Introduction: For the health-care system and for society in general, fractures of the femoral neck are epidemic among the elderly. With increased life expectancy, this type of pathology will continue increasing in the future. The study of possible biological causes of this phenomenon will provide better understanding of the pathology and help us prevent such fractures. Different genes involved in the synthesis of nitric oxide and interleukins are related to the occurrence of fractures of the femoral neck. Materials and methods: We studied 111 patients with fractures of the femoral neck between 2002 and 2004 and a control group of 127 patients operated on for total hip or knee replacement in the same period. In both groups we looked at different genetic polymorphisms of IL-1 alpha, IL-1 beta, IL-1 RA, NOS2 and NOS3. We also measured the levels of IL-1 beta, IL-6 and TNF alpha in patient sera. Results: We found a significant difference for certain genetic polymorphisms related to IL-1 beta and NOS3 and patients with fractures of the femoral neck. Conclusions: There are different genes related to inflammatory reactants which are significantly related to the presence of fractures of the femoral neck

Among elderly Caucasians, fractures of the femoral neck are a common cause of disability. Intertrochanteric and intra-capsular fractures occur equally often, and both are about three times more common in women than in men. Risk factors include neurological impairment, malnutrition, impaired vision, malignancy and decreased activity. We found that in black South Africans femoral neck fractures occur equally often in men and in women. Intracapsular fractures are comparatively rare, occurring in one of every eight female patients and one of every 3.5 male patients. Further, we found that in both black men and black women the femoral neck was consistently and significantly shorter than in whites. These results suggest that a short femoral neck may offer protection not only against intracapsular fracture, but also possibly against fracture of the femoral neck in general. In addition, greater cortical thickness in black people probably offers further protection

The histological findings from the heads of femur or bone biopsy taken from 90 patients with suspected pathological fractures of the femoral neck were studied to determine the rates of significant abnormal pathological findings.The mean age at the time of fracture was 80.41 years (44–99). 29 patients were males and 71 females. The patients were divided into four groups. Group I: 34 patients with fracture without history of fall or trauma. Group II: 21 patients with suspicious radiology of pelvis. Group III: 27 patients with past history of malignancy without known bone metastases. Group IV: 8 patients with past history of malignancy and known bone metastases. None of the patients in groups I and II had significant abnormalities other than osteoporosis. 4 patients (15%) in group III had metastases and 6 patients (75%) in group IV had metastases on histological examination. We conclude that the absence of history of fall or trauma or subtle radiographic findings in patients with fracture of the neck of the femur is usually not associated with sinister pathology and the cause of fracture in these patients is often osteoporosis. Patients with previous history of malignancy without known bone metastases have a 15% risk of finding of metastatic disease even in the absence of radiological abnormalities. Patients with fractured neck of femur with past history of malignancy and who are known to have bone metastases must be considered as having pathological fractures through metastatic disease until unless proven otherwise

Introduction: Fractures of the neck of femurs in amputees have been reported sporadically in literature. We reviewed a series of 19 amputees who presented with a fracture neck of femur to analyse their mobility and pain scores at the end of one year and compared them with other patients presenting with the same condition. Methods: We retrospectively analysed prospectively collected data for fractures of the proximal femur on all patients with amputations of the lower limb. Details on admission of all consecutive admission to one hospital were recorded from 1989 onwards including age, sex, type of amputation, fracture type, mechanism of injury, peri-operative mobility and rehabilitative status up to 1 year post operatively. Results: Nineteen (19) patients with 22 amputations, sustaining 20 fractures of the neck of femurs were treated among approximately 6500 neck of femur fractures in our hip fracture database. Of these 7 were male and 12 were female. The mean age was 79 years with a range of 50–89 years. 17 patients had undergone below knee amputations (BKA) and 5 above knee amputations (AKA). Thirteen patients came from their own homes with thirteen patients being mobile pre-operatively while 6 were bed bound. All patients were alert and scored well on mental test scores. Intracapsular fractures were the most common type with AO Screw fixation being the most common operative management. Hospital stay was an average of 7 days with a range of 1–90 days. Thirteen of our cohort of patients survived more than a year after the fracture operation. Post operative mobility scoring revealed that most of our patients returned to their preoperative mobility level except for those that did not survive for the first year. Discussion: Fractures of the neck of femurs have an increasing incidence in an expanding aging population with nearly 60000 fractures treated in the United Kingdom every year. Amputees suffer from accelerated bone density loss and are at an increased risk for osteoporosis and fragility fractures in the hip. The future prospect with an increasing population of amputees with fracture neck of femurs must be addressed so that appropriate management plans can be implemented to allow such patients to return to full mobility and active lifestyle. This also decreases other co-morbidities such as pressure sores and infection. Approximately one third of our patients survived between 1 to 4 years and another third survived between 5 to 10 years with one patient surviving over 10 years with nearly returning to their pre-injury status. We suggest that satisfactory post operative function is achievable with either internal fixation or hemiarthroplasty. We conclude that these fractures should be treated with the same urgency and expertise as similar fractures in non-amputees as long term survival and good quality of life can be expected

Aim: To assess the functional outcome and longevity of patients who are mentally competent when they sustain an intra-capsular fracture of the femoral neck. Methods: Prospective cohort study of fifty female patients over the age of seventy years of age with a displaced intra-capsular fracture of the femoral neck. Patients with known, cognitive impairment terminal illness or active infection were excluded from the study. Patients were treated with a large head total hip replacement. Functional outcome was assessed using the the Barthel index score and the Charnley-modified Merle d’Aubigne score yearly for five years. The Oxford hip score was also recorded annually from three to ten years post op. The date and cause of death were recorded from hospital notes and death certificates. Results: The mean age at time of femoral neck fracture was 81 years. Three patients died before discharge from hospital. The mortality rates were 18% at twelve months, 28% at two years, 44% at five years and 92% at ten years. Those patients surviving had mean Oxford scores of 24 at 3 years, 26 at 5 years, 23 at 7 years and 25 at ten years. The cause of death was ischaemic heart disease in 22%, cancer in 10%, bronchopneumonia in 12% and simply ‘old age’ in 14%. Conclusion: Elderly female patients who are not cognitively impaired at the time of displaced intra-capsular fracture of the femoral neck have a 56% chance of living five years. Function scores in the survivors are maintained, and are better than would be expected if the patients had undergone hip hemiarthroplasty. Total hip replacement in this population may be justified

Background: Fracture neck of the femur (NOF) is one of the indications for Total Hip Replacement (THR). However, the practice is not the same throughout the world. Aim: We compared the use of THR in the management of the fracture NOF using the annual reports of the National Joint Registries from various countries. Material and Methods: We used the latest available on line annual report of seven national arthroplasty registries to ascertain the rate of use of THR for fractures of the neck of the femur. The registries from Australia, Canada, Norway, Sweden, and the UK gave a detailed breakup of the indications for THR in their reports. Results: 11.9% of the all the THRs performed in Norway since 1987 were for NOFs. · 11.39% of all the THRs performed in Sweden since 1992 were for NOFs. 6.0% of the THRs performed in Canada in 2002–2003 were for NOFs. 2.9% of THRs performed in Australia since 1999 were for NOFs. 1.9% of the THRs performed in the UK in the period April – December 2003 were for NOFs. The registries from Finland and New Zealand had no detailed information on their websites regarding the indications for THA surgery. Discussion: In the Scandinavian countries, THR is performed for the management of a NOF 6 times more often than in the UK, and 4 times more often than in Australia. It is unlikely that the prevalence of patients with previous osteoarthritis of hip who sustain a NOF is higher in the Scandinavian countries than in the UK. Women in Sweden have a higher lifetime risk of hip fracture and live longer, so a procedure providing a good long term results would be beneficial. Provision of health care may also influence surgical management options. The long waiting lists for elective THR in the UK may explain the low number of THRs performed for NOFs

Introduction: We report on the long-term follow up of a previously published randomised controlled trial comparing Hemiarthroplasty (HEMI) and total hip arthroplasty (THA) for the treatment of intracapsular fracture neck of femur. Methods: In this prospectively randomized study, 81 patients who had been mobile and lived independently and who sustained a displaced fracture of the femoral neck were randomized to receive either a fixed acetabular component THA or HEMI. The mean age of the study group was 75 years at fracture. All patients received the same cemented collarless tapered femoral stem and all procedures were performed through a transgluteal approach. Patients were followed up with radiographs, Oxford hip score (OHS), SF-36, Euroqol and their walking distance. Results: At a mean follow-up of 8.6 years (7.18 to 10.27), 19 HEMI patients and 27 THA were alive (p=0.042). The mean walking distance of patients after HEMI was 600m and the OHS 21. After THA, the mean walking distance was 1200m and the OHS was 22. Both groups had a deterioration of their OHS over time. There were no significant differences between the groups with respect to both physical and mental component SF-36 scores and Euroqol visual analogue scores. Of the survivors four of the HEMI group were revised to total hip arthroplasty. One patient had been revised in the THA group. Radiographically six of seven patients in the HEMI group had evidence of acetabular erosion and 13 of 15 patients in the THA group had a lucency around their acetabular component. Discussion: Patients with THA walked further and survived longer. After a mean of nine years follow up there was no difference with respect to function as measured by OHS, Euroqol and SF-36 scores

Literature suggests that joint orthopaedic and geriatric care, and geriatric orthopaedic rehabilitation units, would provide best care for fractured neck of femur (NOF) patients. These are often elderly frail patients with concurrent illnesses and co-morbidities who also have a fracture. There is to date no quantitative data. This completed audit quantifies the care provided on the orthopaedic wards in the first phase solely by orthopaedic team, and in the repeat phase with additional regular geriatric input from an orthogeriatric senior house officer (SHO) and consultant geriatrician ward rounds. A retrospective audit of fractured NOF patients admitted to acute orthopaedic wards under orthopaedics and treated operatively. The first phase analysed 72 patients with sole orthopaedic care. The repeat phase analysed 25 patients after the introduction of an orthogeriatric SHO and geriatric ward rounds. The first audit phase of orthopaedic care alone found that 50% of patients were reviewed each day of the first post op seven-day week. The mean number of reviews in the post-op week was three. A total of 58% patients were operated on the next day. A minority never had post-op bloods or x-rays prior to discharge from the acute bed. Ad hoc medical input by referral occurred in 50% of patients. The repeat audit of combined orthogeriatric care found that 75% of patients were reviewed each day in the post-op week. The mean number of reviews in the post-op week rose to five. Similar to the first phase, 59% proceeded to next day surgery with combined care. All patients had timely bloods and x-rays before discharge from the acute bed. Medical input rose to 80% due to regular ward rounds, and ad hoc referrals decreased in quantity whilst increased in quality. Length of stay and mortality were reduced. The clinical risk of fractured NOF patients was reduced on the appointment of an orthogeriatric SHO in combination with formal reviews by consultant geriatrician. Further models of care are being evaluated. This audit adds evidence that joint care is better for these usually elderly and co-morbid patients

Background: Fracture neck of femur with delayed presentation in young patients can be surgical challenge to any Orthopaedic surgeon. Such scenarios are rare in developed world, but are not uncommon in developing countries. Aim: To present the medium term results of open reduction and internal fixation accompanied by Quadratus femoris muscle pedicle grafting in young patients who presented at least 3 months after sustaining a fracture neck of femur. Materials and Methods: 42 patients with ununited fracture neck of femur with delayed presentation were treated with open reduction and internal fixation and supplemented with Quadratus Femoris muscle pedicle graft. With patient in lateral position, posterior approach was used in all cases. The patients were advised not bear weight till there was clinical and radiological union. Functional recovery was assessed by gait and ability to squat on the floor. Results: The delay in presentation ranged from 3 months to 1year after sustaining the intracapsular fracture. The age of the patients ranged from 24 yrs to 50 yrs. There was male predominance. Radiological union occurred on average at 6 months. 36 patients proceeded to union. 6 patients had non-union and needed revision surgery. Complications included varus union in 9 cases, shortening greater than 2.5 cms in 6 cases. Conclusion: The two staged technique described by Meyer was modified into a single stage open reduction and internal fixation of the fracture neck of femur with quadratus femoris muscle pedicle graft fixation. This helped in promoting the union of the fracture and also preserve the head of the femur (avoiding arthroplasty)

The ideal operative treatment of displaced sub capital femoral fractures in the elderly is controversial. Recently, randomised controlled trials have suggested a better outcome with the use of total hip arthroplasty (THA) to treat displaced intra capsular fractures of the femur for elderly patients in good health. More recently the concept of dual mobility cups is being promoted to avoid dislocations in this cohort of patients. However, overall there is limited evidence to support the choice between different types of arthroplasty. Dislocation remains a main concern with THA, especially when a posterior approach is used. We analysed the outcome of 115 primary THR (112 cements and 3 uncemented) THR using a posterior approach with soft tissue repair in active elderly patients presenting with displaced intra capsular femoral neck fractures. Size 28 mm head was used in 108 and a size 32 mm head in the rest. All surgery was performed by specialist hip surgeons. Satisfactory results were noted in terms of pain control, return to pre-morbid activity and radiological evidence of bone implant osteo-integration. The 30-day mortality was nil. There were two dislocations and only one needed revision surgery due to recurrent dislocation. In conclusion, with optimal patient selection, THA seems to provide a good functional outcome and pain relief in the management of displaced intracapsular femoral neck fractures. Excellent outcome can be achieved when done well using the standard cemented THR and with 28mm head. A good soft tissue repair and a specialist hip surgeon is preferable

Although resurfacing hip replacement (RHR) is associated with a more demanding patient cohort, it has achieved survivorship approaching that of total hip replacement. Occasional failures from femoral neck fracture, or migration and loosening of the femoral head prosthesis have been observed, the causes of which are multifactorial, but predominately biomechanical in nature. Current surgical technique recommends valgus implant orientation and reduction of the femoral offset, reducing joint contact force and the femoral neck fracture risk. Radiographic changes including femoral neck narrowing and ‘pedestal lines’ around the implant stem are present in well performing hips, but more common in failing joints indicating that loosening may involve remodelling. The importance of prosthesis positioning on the biomechanics of the resurfaced joint was investigated using finite element analysis (FEA). Seven FE models were generated from a CT scan of a male patient: the femur in its intact state, and the resurfaced femur with either a 50mm or 52mm prosthesis head in. neutral orientation,. 10° of relative varus or. 10° of relative valgus tilt. The fracture risk during trauma was investigated for stumbling and a sideways fall onto the greater trochanter, by calculating the volume of yielding bone. Remodelling was quantified for normal gait, as the percentage volume of head and neck bone with over 75% post-operative change in strain energy density for an older patient, and 50% for a younger patient. Resurfacing with the smaller, 50mm prosthesis reduced the femoral offset by 3.0mm, 4.3mm and 5.1mm in varus, neutral and valgus orientations. When the 52mm head was used, the natural joint centre could be recreated rrespective of orientation, without notching the femoral neck. The 50mm head reduced the volume of yielding femoral neck bone relative to the intact femur in a linear correlation with femoral offset. When the natural femoral offset was recreated with the 52mm prosthesis, the predicted neck fracture load in stumbling was decreased by 9% and 20% in neutral and varus orientations, but remained in line with the intact bone when implanted with valgus orientation. This agrees with clinical experience and justifies currently recommended techniques. In oblique falling, the neck fracture load was again improved slightly when the femoral offset was reduced, and never fell below 97% of the natural case for the larger implant in all orientations. Predicted patterns of remodelling stimulus were consistent with radiographic clinical evidence. Stress shielding increased slightly from varus to valgus orientation, but was restricted to the superior femoral head in the older patient. Bone densification around the stem was predicted, indicating load transfer. Stress shielding only extended into the femoral neck in the young patient and where the femoral offset was reduced with the 50mm prosthesis. The increase in remodelling correlated with valgus orientation, or reduced femoral offset. The trend would become more marked if this were to reduce the joint contact force, but there was no such correlation for the 52mm prosthesis, when the natural femoral offset was recreated. Only in extreme cases would remodelling alone be sufficient to cause visible femoral neck narrowing, i.e. patients with a high metabolism and considerably reduced femoral offset, implying that other factors including damage from surgery or impingement, inflammatory response or retinacular blood supply interruption may also be involved in femoral neck adaptation. The results of this FEA biomechanical study justify current surgical techniques, indicating improved femoral neck fracture strength in stumbling with valgus position. Fracture risk under oblique falling was less sensitive to resurfacing. Furthermore, the results imply that reduced femoral offset could be linked to narrowing of the femoral neck; however the effects of positioning alone on bone remodelling may be insufficient to account for this. The study suggests that surgical technique should attempt to recreate the natural head centre, but still aim primarily for valgus positioning of the prosthesis, to reduce the femoral neck fracture risk

Purpose: A prospective multicentric study was conducted in a concentric and consecutive series of 204 patients operated on between Mai 1999 and August 2001 for fracture of the proximal femur. The purpose of this study was to assess quality of life after surgery in patients undergoing implantation of the Intermedia® prosthesis.

Material and methods: Mean patient age was 79.6± 8.6 years), 18.8% men. Most of the fractures were Garden III and IV fractures (87.4%) and 90.9% were recent (< 21 d). The intermediary Intermedia® prosthesis was implanted via the posterolateral approach in 73.9% of the patients with acetabular preparation in 13.7%; a head with a restraining skirt was used in 20.8%. The Robinson score for motion, lifestyle, degree of osteoporosis (Singh score), history (ASA), psychomotor index (Hodkinson score) were determined preoperatively (19/26 (±6.89). The Merle d’Aubigné score was calculated at one year. Adaptation of the femoal stem (3 sizes) to the shaft was assessed on standard x-rays. The Kobayashi method was used to study stem to shaft fit; this score gives a rate of shaft filling used to determine whether the self-blocking contact was well achieved with the three stem sizes available.

Results: There were eleven (5.4%) posterior dislocations including four which were reduced orthopaedically. Among the 203 patients, 40 (19.7%) were lost to follow-up and 34 died. The Merle d’Aubigné score at one year showed 84.7% satisfactory results (excellent, very good, good). Preoperatively 59% of the patients were independent and 7% resided in nursing homes, these figures at one year were 55.5% and 5% respectively. Radiologically, the rate of migration (impaction) was 3.9% at one year. Stem-to-shaft fit was, according to Kobayashi for the proximal, middle, and distal portions 73%, 75% and 75% respectively.

Discussion: Mortality due to fracture of the proximal femur is high (16.7% at one year). Morbidity was due to infection (1%) and eleven displacements (5.4%). The difference in motion and lifestyle between the pre- and postoperative period was not significant. Simplification of the implantation procedure by using three stem sizes did not produce any radiological differences at one year.

Long-term prospective RCT comparing hemiarthroplasty (HEMI) and total hip arthroplasty (THA) for the treatment of intracapsular neck of femur fracture. 81 previously mobile, independent, orientated patients were randomised to receive THA or HEMI after sustaining a displaced neck of femur fracture. Patients were followed up with radiographs, Oxford hip score (OHS), SF-36 scores and their walking distance. At a mean follow up of 8.7 years, overall mortality following THA was 32.5% compared to 51.2% following HEMI (p=0.09). Following THA, patients died after a mean of 63.6 months compared to 45 months following HEMI (p=0.093). Patients with THA walked further and had better physical function. No HEMIs dislocated but three (7.5%) THAs did. Four (9.8%) HEMI patients were revised to THA, but only one (2.5%) THA required revision. All surviving HEMI patients had acetabular erosion and all surviving THA patients had wear of the cemented polyethylene cup. Patients with THA have better function in the medium-term and survive longer

Aim: To evaluate the effect of Warfarin, the prevalence of acceptable level of INR by the anaesthetist, leading to delay of surgery in patients with fracture neck of femur and the outcome of such treatment. Material and Methods: We retrospectively reviewed all patients admitted with fracture neck of femur who were on Warfarin in the year 2002. In total 9 out of 135 pt were on Warfarin. Their entire medical records were scrutinised. A control group of similar age, sex and pre- morbid conditions was identified. A telephone survey was then conducted. In warfarin group average delay in surgery was 4 days (1 to 7) , needed 76% more blood test, total morphine 40mg and Codeine 960mg, 60% longer stay and after all 78% had General anaesthesia. The six hospital survey showed the estimated number of such patients averaged 2 (1 to 4) per year, delay in surgery of 2 to 5 days and acceptable INR between 1.5 to under 3. Conclusion: We found that we under estimate the number of patients on Warfarin. These patient had a significant delay in surgery requiring more analgesic both oral and parental, no significant post- op complications but a much longer hospital stay causing significant increase in morbidity, bed block and expenditure. We were surprised that there is no consistently acceptable level of INR to perform the surgery and type of anaesthesia

A new and very unstable intertrochanteric fracture complex is described. The intertrochanteric fracture with extension into the femoral neck is rare but results in an extremely high failure rate because of its instability. A ten-year retrospectic analysis of patients (246) with intertrochanteric fractures treated with a sliding compression hip screw at Hennepin County Medical center was performed. Of these 246 fractures, 20 were classified as fractures with a major intertrochanteric component with extension into the femoral neck. These fractures were similar to intertrochanteric fractures type I-IV described by Kyle and Gustilo in demographics, osteoporosis, and surgical treatment, but this new fracture fracture now described as Type V had a statistically higher rate of mechanical complications 0.0001, reoperation 0.0002, and failure of fixation 0.0001. The overall failure rate was 50%. The majority of these fractures were the result of complete collapse of the hip screw. We feel this higher complication and reoperation rate is secondary to inherent instability in the intertrochanteric fracture which extends into the femoral neck. This instability leads to cmplete collapse of a sliding hip screw result ing in a rigid device that leads to failure of fixation. This fracture complex also has a higher rate of nonunion and avascular necrosis. Although rare, this fracture must be recognized in the fracture classification of intertrochanteric fractures because of its poor prognosis. Other forms of treatment than a sliding hip screw may be considered with this fracture complex because of its high failure rate with standard treatment

The study aims to compare the short-term results of cemented and cementless total hip arthroplasty {THA} in active patients > 80 years of age with femoral neck fractures. Sixty two consecutive patients underwent THA during the study period {cemented -31 and cementless -31}. The mean age was 84 years {81–94 years}. Patients in both groups were comparable in their preoperative variables. Functional and radiological assessments were carried out using validated outcome measures. Complications were recorded. 51 patients were available for final analysis after accounting for deaths and cases lost in follow up. Of the 51 patients, 25 {49%} regained their pre-injury mobility status and 36 {70%} were community ambulant. Cementless THA was associated with significantly less surgical time, blood loss, transfusion rates and hospital stay. The overall mortality rates, complications, functional and radiological results were similar in both groups though the number of deaths in the perioperative period were significantly high in patients undergoing cemented THA. Satisfactory improvement in function with low reoperation rates can be achieved irrespective of the technique used. Complication rates are higher when compared to younger patients undergoing the procedure. Risks and benefits should be carefully assessed and explained before subjecting these patients to THA

Abstract. INTRODUCTION. Fracture neck of femur is aptly called as “the fracture of necessity” owing to the various factors responsible for its non-union. Pauwel's inter-trochantric valgus osteotomy is a useful approach to deal with such fractures. AIM. The aim of this study is to evaluate the functional outcome of valgus osteotomy in treatment of neglected and non-union fracture neck of femur using Harris Hip Scoring system (HHS). MATERIAL AND METHODS. This observational study included 25 patients of the age between 25 years and 50 years with more than 3 weeks since injury and the patients with failed primary fixation. Valgus osteotomy using120° double angled blade plate was done. The patients were followed up till one year. The patients' functional outcome was evaluated with pre-operative and post-operative Harris Hip Score (HHS) at 6 months and one year. RESULTS. Outcome was excellent in 14 patients (HHS>90), good in 8 patients (HHS between 80–90) and fair in one patient (HHS=75.6). Two patients ended up in non-union with blade cut out. The mean HHS at the end of one year was 89.18 + 7.822. The mean change in HHS values pre-operatively and one year post-operatively came out to be 69.58 + 20.032. CONCLUSION. We conclude that for the patients under 50 years of age with neglected fracture of the femoral neck, the Pauwel's osteotomy produces many good results

Introduction. Osteogenesis imperfect (OI) is a geno- and phenotypically heterogeneous group of congenital collagen disorders characterized by fragility and microfractures resulting in long bone deformities. OI can lead to progressive femoral coxa vara from bone and muscular imbalance and continuous microfracture about the proximal femur. If left untreated, patients develop Trendelenburg gait, leg length discrepancy, further stress fracture and acute fracture at the apex of the deformity, impingement and hip joint degeneration. In the OI patient, femoral coxa vara cannot be treated in isolation and consideration must be given to protecting the whole bone with the primary goal of verticalization and improved biomechanical stability to allow early loading, safe standing, re-orientation of the physis and avoidance of untreated sequelae. Implant constructs should therefore be designed to accommodate and protect the whole bone. The normal paediatric femoral neck shaft angle (FNSA) ranges from 135 to 145 degrees. In OI the progressive pathomechanical changes result in FNSA of significantly less than 120 degrees and decreased Hilgenreiner epiphyseal angles (HEA). Proximal femoral valgus osteotomy is considered the standard surgical treatment for coxa vara and multiple surgical techniques have been described, each with their associated complications. In this paper we present the novel technique of controlling femoral version and coronal alignment using a tubular plate and long bone protection with the use of teleoscoping rods. Methodology. After the decision to operate had been made, a CT scan of the femur was performed. A 1:1 scale 3D printed model (AXIAL3D, Belfast, UK) was made from the CT scan to allow for accurate implant templating and osteotomy planning. In all cases a subtrochanteric osteotomy was performed and fixed using a pre-bent 3.5 mm 1/3 tubular plate. The plate was bent to allow one end to be inserted into the proximal femur to act as a blade. A channel into the femoral neck was opened using a flat osteotome. The plate was then tapped into the femoral neck to the predetermined position. The final position needed to allow one of the plate holes to accommodate the growing rod. This had to be determined pre operatively using the 3D printed model and the implants. The femoral canal was reamed, and the growing rod was placed in the femur, passing through the hole in the plate to create a construct that could effectively protect both the femoral neck and the full length of the shaft. The distal part of the plate was then fixed to the shaft using eccentric screws around the nail to complete the construct. Results. Three children ages 5,8 and 13 underwent the procedure. Five coxa vara femurs have undergone this technique with follow-up out to 62 months (41–85 months) from surgery. Improvements in the femoral neck shaft angle (FNSA) were av. 18. o. (10–38. o. ) with pre-op coxa vara FNSA av. 99. o. (range 87–114. o. ) and final FNSA 117. o. (105–125. o. ). Hilgenreiner's epiphyseal angle was improved by av. 29. o. (2–58. o. ). However only one hip was restored to <25. o. In the initial technique employed for 3 hips, the plates were left short in the neck to avoid damaging the physis. This resulted in 2 of 3 hips fracturing through the femoral neck above the plate at approximately 1 year. There were revisions of the 3 hips to longer plates to prevent intra-capsular stress riser. All osteotomies united and both intracapsular fractures healed. No further fractures have occurred within the protected femurs and no other repeat operations have been required. Conclusions. Surgical correction of the OI coxa vara hip is complex. Bone mineral density, multiplanar deformity, a desire to maintain physeal growth and protection of the whole bone all play a role in the surgeon's decision making process. Following modifications, this technique demonstrates a novel method in planning and control of multiplanar proximal femoral deformity, resulting in restoration of the FNSA to a more appropriate anatomical alignment, preventing long bone fracture and improved femoral verticalization in the medium term follow-up

Aims. Evaluate if treating an unstable femoral neck fracture with a locking plate and spring-loaded telescoping screw system would improve construct stability compared to gold standard treatment methods. Methods. A 31B2 Pauwels’ type III osteotomy with additional posterior wedge was cut into 30 fresh-frozen femur cadavers implanted with either: three cannulated screws in an inverted triangle configuration (CS), a sliding hip screw and anti-rotation screw (SHS), or a locking plate system with spring-loaded telescoping screws (LP). Dynamic cyclic compressive testing representative of walking with increasing weight-bearing was applied until failure was observed. Loss of fracture reduction was recorded using a high-resolution optical motion tracking system. Results. LP constructs demonstrated the highest mean values for initial stiffness and failure load. LP and SHS constructs survived on mean over 50% more cycles and to loads 450 N higher than CS. During the early stages of cyclic loading, mean varus collapse of the femoral head was 0.5° (SD 0.8°) for LP, 0.7° (SD 0.7°) for SHS, and 1.9° (SD 2.3°) for CS (p = 0.071). At 30,000 cycles (1,050 N) mean femoral neck shortening was 1.8 mm (SD 1.9) for LP, 2.0 mm (SD 0.9) for SHS, and 3.2 mm (SD 2.5) for CS (p = 0.262). Mean leg shortening at construct failure was 4.9 mm (SD 2.7) for LP, 8.9 mm (SD 3.2) for SHS, and 7.0 mm (SD 4.3) for CS (p = 0.046). Conclusion. Use of the LP system provided similar (hip screw) or better (cannulated screws) biomechanical performance as the current gold standard methods suggesting that the LP system could be a promising alternative for the treatment of unstable fractures of the femoral neck. Cite this article: Bone Joint Res 2020;9(6):314–321

The Nottingham Hip Fracture Score (NHFS) was developed in 2007 as a predictor of 30-day mortality after hip fracture surgery following a neck of femur fracture. The National Hip Fracture Database is the standard used which calculated their own score using national data. The NHF score for 30-day mortality was calculated for 50 patients presenting with a fractured neck femur injury between January 2020 to March 2020. A score <5 was classified as low risk and >/=5 as high risk. Aim was to assess the accuracy in calculating the Nottingham Hip Fracture Score against the National Hip Fracture Database. To explore whether it should it be routinely included during initial assessment to aid clinical management?. There was an increase in the number of mortalities observed in patients who belonged to the high-risk group (>=5) compared to the low risk group. COVID-19 positive patients had worse outcomes with average 30-day mortality of 6.78 compared to the average of 6.06. GEH NHF score per month showed significant accuracy against the NHFD scores. The identification of high-risk groups from their NHF score can allow for targeted optimisations and elucidation of risk factors easily gathered at the point of hospitalisation. The NHFS is a valuable tool and useful predictor to stratify the risk of 30-day mortality and 1-year mortality after hip fracture surgery. Inclusion of the score should be considered as mandatory Trust policy for neck of femur fracture patients to aid clinical management and improve patient safety overall