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

C. Difficile infections in elderly patients with hip fractures is associated with high morbidity and mortality. Antibiotic regimens with penicillin and its derivatives is a leading cause. Antibiotic prophylactic preferences vary across different hospitals within NHS. We compared two antibiotic prophylactic regimens - Cefuroxime only prophylaxis and Teicoplanin with Gentamicin prophylaxis in fracture neck of femur surgery, and evaluated the incidence of C. Difficile diarrhea and Surgical Site Infection (SSI). To assess the Surgical Site Infection and C. Difficile infection rate associated with different regimens of antibiotics prophylaxis in fracture neck of femur surgery. Data was analyzed retrospectively. Neck of femur fracture patients treated surgically from 2009 in our unit were included. Age, gender, co morbidities, type of fracture, operation, ASA grade was collected. 1242 patients received Cefuroxime only prophylaxis between January 2009 and December 2012 (Group 1) and 486 patients received Teicoplanin with Gentamicin between October 2015 and March 2017 (Group 2). There were 353 males and 889 female patients in Group 1 and 138 males and 348 female patients in Group 2. The co morbidities in both groups were comparable. Incidence of C. Difficile diarrhea and Surgical Site Infection (SSI) was noted. Statistical analysis with chi square test was performed to determine the ‘p’ value. C. Diff diarrhea rate in Group 2 was 0.41 % as compared to 1.29 % in Group 1. The Surgical Site Infection (SSI) rate in Group 2 was 0.41 % as compared to 3.06 % in Group 1. The comparative results were statistically significant (p = 0.0009). Prophylactic antibiotic regimen of Teicoplanin with Gentamicin showed significant reduction in C. Difficile diarrhea & Surgical Site Infection in fracture neck of femur patients undergoing surgery

Background: A good hospital guide published in 2006 identified high in-hospital mortality rates in fracture neck of femur patients at the University Hospitals of Leicester NHS trust. The trust was identified as the worst in the country in terms of the percentage of patients having surgery within the recommended 48 hours from admission. The problem had already been identified and a ‘Fracture Neck of femur project’ was launched in January 2006 to improve outcomes in these patients. This included the introduction of trauma coordinators and clinical aides who prepared patients for surgery, a separate fracture neck of femur ward, a discharge nurse, dedicated hip fracture lists and pre and post operative orthogeriatric input. Aim: The aim of this study was to assess the impact of the fracture neck of femur project. Methods: Data on admissions, time to theatre, length of stay and mortality was collected for 3400 patients admitted with fracture neck of femur between January 2003 and September 2007. Mortality rates, length of stay and time to theatre were compared before and after the introduction of the fracture neck of femur project. Results: The length of stay reduced from 32 days to 18 days in 2007 (p< 0.01). The in-hospital mortality reduced from 16.6 % in 2003 to 10.7% in 2007 (p< 0.01). 30 day mortality showed a minor reduction from 12.4% in 2003 to 11.4% in 2007 (p=0.6). 95% of patients had surgery within 48 hours as compared to 47% in 2005–06 and 85% in 2006–07. Conclusions: The high in-hospital mortality rates were reduced. The length of stay was also reduced by effective discharge planning. Measures to reduce time to theatre were highly successful. However, the 30 day mortality did not show a significant reduction. We conclude that in hospital mortality is not a good comparator of hospital performance. 30 day mortality would be more accurate

In 1990 an estimated 1.3 million hip fractures occurred worldwide. Clostridium difficile diarrhoea has emerged as a healthcare associated infection of great clinical and economic significance especially in the frail and vulnerable group of fracture neck of femur patients. The major risk factor is peri-operative antibiotic exposure especially cephalosporins. A retrospective audit was performed to study the effect of C. Difficile in operated fracture neck of femur patients. All the patients who were diagnosed with C. Difficile infection after an operated fracture neck of femur at the District general hospital from April 2004 till March 2007 were included in the present study. All patients received the routine peri-operative antibiotic prophylaxis of three doses of intravenous cefuroxime. Data collected included age, sex, duration between operation and the onset of diarrhoea, length of stay and associated mortality. A total of 1023 patients underwent surgery for fracture neck of femur during the three years of study period. The average age of the patients was 81 years. 80% of the patients were females. A total of 62 patients suffered from C. Difficile diarrhoea (6%) after the arthroplasty procedure, and within this cohort, 29 patients died during the same admission to the hospital (47%). The average length of stay for a patient with fracture neck of femur was increased from 23.4 to 60 days in those affected with C. Difficile. The patients with fracture neck of femur are generally elderly with poor body reserves. C.difficile infection in such patients not only adds to the morbidity, but also causes significant increase in the mortality rate. Propagation of simple infection control measures such as hand-washing and isolation and change of peri-operative antibiotic protocol led to a statistically significant reduction in the incidence of C.Difficile infections after fracture neck of femur surgery

Introduction: In 1990 an estimated 1.3 million hip fractures occurred worldwide, a figure which is expected to double by 2025 and increase to 4.5 million by 2050. Clostridium difficile associated diarrhoea (CDAD) has emerged as a healthcare associated infection of great clinical and economic significance especially in the frail and vulnerable group of fracture neck of femur patients. A major risk factor for the development of CDAD in patients who undergo operation for fracture neck of femur is the perioperative antibiotic exposure, with cephalosporins being particularly implicated. The type ‘027’ strains of C. Difficile are multi-resistant and cause severe morbidity and mortality. A retrospective audit was performed to study the effect of C. Difficile infection in operated fracture neck of femur patients. Material and Methods: All the patients who were diagnosed with C. Difficile after an operated fracture neck of femur at the District general hospital during the three year study period from April 2004 till March 2007 were included in the present study. All patients received the routine peri-operative antibiotic prophylaxis of three doses of intravenous cefuroxime. Data collected included age, sex, duration between operation and the onset of diarrhoea, length of stay and associated mortality. Results: A total of 1023 patients underwent surgery for fracture neck of femur during the three years of study period. The average age of the patients was 81 years. 80% of the patients were females. A total of 62 patients suffered from C. Difficile diarrhoea (6%) after the arthroplasty procedure, and within this cohort, 29 patients died during the same admission to the hospital (47%). The average length of stay for a patient with fracture neck of femur was increased from 23.4 days to 60 days in those affected with C. Difficile diarrhoea. Discussion: The patients with fracture neck of femur are generally elderly, frail and with poor body reserves. C.difficile infection in such patients not only adds to the morbidity, but also causes significant increase in the mortality rate. The broad spectrum peri-operative antibiotics used to prevent infection generally render the patient vulnerable to this highly lethal hospital bug. Introduction of simple infection control measures such as hand-washing and isolation, and change of peri-operative antibiotic protocol led to a statistically significant reduction in the incidence of C. Difficile infections after surgery for fracture neck of femur

Background: Clostridium difficile (C diff) diarrhoea is a growing UK hospital problem. However, it is controversial whether patients die with C diff or of C diff. A series of infection control measures were introduced from August 2006 onwards to reduce the rate of C diff infection and to treat patients suffering from diarrhoea. These included a five-day antibiotic stop policy, a diarrhoea treatment policy, a hand washing campaign, increased investment in environmental cleaning and a change in policy for antimicrobial prophylaxis to coamoxiclav instead of cefuroxime. The aim of this study was to assess the impact of these measures on the incidence of C diff infection and to record the mortality associated with C diff. Fracture neck of femur patients were chosen as they are at particular risk. Method: We assessed data on orthopaedic admissions in particular fracture neck of femur patients, C diff samples, and mortality up to one year. The incidence of C diff was compared between fracture neck of femur patients and other orthopaedic admissions and also before and since the introduction of the infection control policies. This was followed by a comparison of mortality between C diff positive patients and a control group matched by age, sex, ASA grade and place of residence. Mortality data was at 30days, 6 month and 1 year. Results: Clostridium difficile was much more common in patients with fracture neck of femur (72 out of 1800, 4%) than in other orthopaedic admissions (51 out of 10000, 0.5%, p < 0.001). The incidence of C diff in patients with fracture neck of femur decreased from 49 of 548 (9%) in the 9 months pre-policy to 28 of 562 (5%, p=0.009) in the 9 months since policy Introduction: In those with C diff, mortality at 30 days and 6 months was 10/49 (20%) and 35/49 (71%) pre-policy and 9/28 (32%) and 20/28 (71%) since policy Introduction: Regardless of policy introduction, the overall mortality in 168 C diff positive patients at 30days, 6 months and 1 year was 31 (19%), 112 (67%) and 117 (70%) whilst that in the 168 matched controls was 19 (11%), 43 (26%) and 48 (29%). Conclusion: The matched group data indicates that C diff increases mortality. It does not simply colonise the most frail. The percentage of deaths in C diff positive patients was no different after the diarrhoea treatment policy Introduction: The incidence of C diff was reduced by 43% using infection control measures. Our results indicate that the best way to reduce mortality due to C diff is to reduce the incidence, our current treatment policy was ineffective or in other words, ‘prevention was better than cure’. We recommend that similar measures could be introduced in other orthopaedic units in order to reduce the incidence and mortality in fracture neck of femur patients from Clostridium difficile

Fracture neck of femur (NOF) in elderly is a serious debilitating injury and has been presenting in increasing proportions. Some of these patients are unfortunate to come back with a contralateral injury. We attempted at looking into the incidence of these episodes in a cohort attending our trust and compared various parameters. We retrospectively assessed our hospital theatre data for fracture NOF in patients over 60 years in the last 3 years. We reviewed their demographics, mode of injury, time to contralateral injury, incidence of any other insufficiency fracture, operative procedure and any complications. There were 1435 patients who underwent surgery for fracture NOF over the 3 years. Forty-three of these had bilateral fractures. Females had 3 times more incidence as compared to males; average age at first injury was 84 years and at contralateral side was 85 years. Time between the two injuries ranged from 20 to 855 days (Median 242 days). Almost equal incidence of intra / extracapsular fractures was noted. Contralateral fracture pattern (Intra vs Extracapsular) for the was similar in 34 patients. Twelve patients had an associated insufficiency fracture. Fracture NOF in elderly is a rising epidemic. Only 3% of these patients suffer a contralateral fracture NOF which usually occurs within a year. The fracture pattern is frequently similar to the first fracture in and hence similar implants have been used. Only 21% patients were on bone protection medications. It is rather difficult to identify this small group and hence prevent a second contralateral incident

Introduction: Several patients with fracture neck of femur were noted to have alarmingly low postoperative haemoglobin unexplained by the intra-operative and postoperative blood loss. We conducted this study to determine the magnitude of preoperative fall in haemoglobin in patients with hip fractures. Methods: Full blood count was repeated after a minimum of 12 hours of fluid resuscitation in 50 consecutive patients admitted with fracture neck of femur. Patients requiring blood transfusion prior to collection of second specimen were excluded. Patients were grouped according to the type of fracture (intracapsular, inter-trochanteric and sub-tro-chanteric). Results: The average drop in haemoglobin of 0.8 (range,0–2.1), 0.8 (range,0–2.8) and 2.5 (range,0.6–4.9) gm/dl in intracapsular, inter-trochanteric and sub-trochanteric fractures respectively were statistically significant in all three groups (student-t-test, p-value < 0.05) but appears to be clinically significant in only sub-trochanteric group. By close analysis of data it is noted that although average drop in first two groups is low but at least 15 % of patients in both groups dropped their haemoglobin by 2 gm/dl or more. This can be compounded by the drop in haemoglobin following surgery, the average of which was 2.5 gm/dl (range,0–6.4). Discussion and Conclusion: During this study at least 5 patients were saved from going to theatre with dangerously low haemoglobin with no cross-matched blood. There is clinically significant drop in haemoglobin prior to surgery in patients admitted with fracture neck of femur. On admission haemoglobin can be falsely reassuring. We recommend all patients with sub-trochanteric fracture and all patients with intra-capsular and inter-trochanteric fractures with haemoglobin of 12 gm/dl or less to have a repeat haemoglobin check prior to their surgery. This practice may reduce the morbidity and mortality associated with very low haemoglobin in this group of patients with high pre-existent co-morbidities

Prompt mobilisation after the Fracture neck of femur surgery is one of the important key performance index (‘KPI caterpillar charts’ 2021) affecting the overall functional outcome and mortality. Better control of peri-operative blood pressure and minimal alteration of renal profile as a result of surgery and anaesthesia may have an implication on early post-operative mobilisation. Aim was to evaluate perioperative blood pressure measurements (duration of fall of systolic BP below the critical level of 90mmHg) and effect on the post-operative renal profile with the newer short acting spinal anaesthetic agent (prilocaine and chlorprocaine) used alongside the commonly used regional nerve block. 20 patients were randomly selected who were given the newer short acting spinal anaesthetic agent along with a regional nerve block between May 2019 and February 2020. Anaesthetic charts were reviewed from all patients for data collection. The assessment criteria for perioperative hypotension: Duration of systolic blood pressure less than 90 mm of Hg and change of pre and post operative renal functions. Only one patient had a significant drop in systolic BP less than 90mmHg (25 minutes). 3 other patients had a momentary fall of systolic BP of less than 5 minutes. None of the above patients had mortality and had negligible change in pre and post op renal function. Only one patient in this cohort had elevation of post-operative creatinine levels but did not have any mortality. Only 1 patient died on day 3 post operatively who had multiple comorbidities and was under evaluation for GI cancer. Even in this patient the peri-operative blood pressure was well maintained (never below 90mmHg systolic) and post-operative renal function was also shown to have improved (309 pre-operatively to 150 post-operatively) in this patient. The use of short-acting spinal anaesthesia has shown to be associated with a better control of blood pressure and end organ perfusion, less adverse effects on renal function leading to early mobilisation and a more favourable patient outcome with reduced mortality, earlier mobilisation, shorter hospital stay and earlier discharge in this elderly patient cohort

Fracture neck of femur with delayed presentation in young patients can be a surgical challenge. Such scenarios are rare in the developed world but not uncommon in developing countries. To present the medium term results of open reduction and internal fixation accompanied by Quadratus Femoris muscle pedicle grafting in young patients who presented with a delay after sustaining a fracture neck of femur, 42 patients with fracture neck of femur with delayed presentation were treated with open reduction and internal fixation and supplemented with Quadratus Femoris muscle pedicle graft. A posterior approach was used in all cases. The patients were advised not to bear weight until there was clinical and radiological union. Functional recovery was assessed by gait and ability to squat on the floor. The age of the patients, predominantly male, ranged from 24 yrs to 50 yrs. Radiological union occurred on average at 6 months. Thirty-six patients proceeded to union; six patients had non-union and needed revision surgery. Complications included varus union in 9 cases; shortening greater than 2 cms occurred in 6 cases. Quadratus Femoris muscle pedicle grafting described by Meyer in the 1970s is useful in treating fracture neck of femur. Open reduction and internal fixation of the fracture neck of femur when supplemented with Quadratus Femoris muscle pedicle graft fixation promoted the union of fracture and preserved the head the femur

Introduction: Dr Foster data presents mortality rate for fracture neck of femur in acute trusts. We assessed the accuracy of this data in an acute trust in England for a nine-month period. Methods: Fifty-seven patients (17.2%) died due to fracture NOF during our review period according to Dr Foster. Medical notes were retrospectively analysed in detail. There were 20 males with a mean age of 84.5yrs (64–100) and 37 females with a mean age of 85.7yrs (57–100). Data analysis included time and day of admission, admission ward, senior orthopaedic review, anaesthetic review, ASA grade, time to surgery, grade of anaesthetist and operating surgeon, type of anaesthesia, time of anaesthesia and surgery, type of surgery, post-op recovery and cause of death. Results: Seven patients died before their planned surgery due to extensive medical co-morbidity and 50 patients (15.1%) underwent surgery as planned. Thirty-one patients (9.4%) died under the care of the orthopaedic team and were considered by the assessors to be true death due to fracture neck of femur. Eleven patients (3.3%) died in the community after discharge home some several months later. Eight patients (2.4%) died under the care of the rehabilitation team, some months later, the majority from medical causes. The mean time to surgery was 2.7 days (0–13), which was mainly affected by weekend admissions. There were no records of the cause of death in 20 patients including all those that were discharged to the community. Admission time, ward and type and duration of anaesthesia had no effect on mortality rate. Conclusion: In our review Dr Foster overestimated true death rate due to fracture neck of femur. This trend is worrying as such indicators are linked to financial and performance targets for trusts. Accurate data presentation is therefore imperative and Dr Foster does not appear to deliver this

Aims: Hypokalemia is a common electrolyte imbalance with signficent effects. The aim of our study is to identify incidence, causes and prognostic implications of postoperative hypokalemia in elderly patients operated for fracture neck of femur. Methods and material: Retrospective study, of 404 consecutive fracture neck of femur patients who were operated in our hospital between October 2001 and July 2003. Patients identified with postoperative hypo-kalemia the medical notes, fluid charts and anaesthetic notes were analysed for age, preoperative morbidities, medications, mechanism and type of injury, waiting time for operation, pre, peri and postoperative fluid management, type of anaesthesia, operative time, hospital stay and mortality. Results: Out of the 404 patients, 54(13.3%) were hypokalemic (K< 3.5mmol/l) postoperatively. Of the 54 patients 16 (29.6%)had preoperative hypokalemia. Among the hypokalemic group the mean preopera-tive potassium was 3.69mmol/l and the mean postoperative potassium was 3.19mmol/l. The t-test showed a statistically significant difference between mean pre and postoperative potassium levels. (P< 0.0001). High association was found with hypokalemia and post-operative dextrose infusion (38%). 50% of patients on diuretics developed hypokalemia post operatively. Interestingly, only 18% of these were hypokalemic pre operatively. In patients with multiple medical problems, like diabetes, hypertension and CVA, high incidence of hypokalemia was found. (38% had 2 or more medical problems). No significance in the mortality rate was found in fracture neck of femur patients with and without postoperative hypokalemia (40% vs. 39% at 3yrs). Conclusion: There is significant risk of hypokalemia following orthopaedic surgery, especially in the elderly. This avoidable condition, which has serious consequences, should be dealt with care in the orthopaedic units. Fluid infusion regimes and should be formulated and medications reviewed to prevent conditions like hypokalemia

Background. Exeter Trauma Stem (ETS) is a polished tapered collarless monopolar prosthesis used for cemented hemiarthroplasty for fracture neck of femur. Two modular rasps are available on the instrumentation set. The larger rasp, in practice, rarely fits into the femur making trial reduction impossible. Our hypothesis was that the absence of a trial reduction could affect leg length and stability of the prosthesis. Aim. To evaluate the leg length discrepancy following use of Exeter Trauma Stem for intracapsular fracture neck of femur. Methods. All patients who underwent ETS hemiarthroplasty between June 2009 to March 2010 (n = 100) were included in the study. Radiographic assessment of leg length was performed by two independent assessors based on measurements by Woolson et al. Results. Upto half of the patients had equal leg length measurements. Forty four patients had lengthening of the operated leg with a mean of 10mm (5–25). Further complications included four dislocations. There was no statistical significance between leg lengths and dislocations. Conclusion. Care is needed with regards to correct positioning of the ETS prosthesis to achieve equal leg lengths. Following this study a new intermediate sized modular rasp has been introduced to the instrumentation set

Background. Patients with fractured neck of femur have historically received less attention than they deserve and have high morbidity and mortality. Literature suggests that speed to theatre reduces length of in-patient stay and complications. Methodology. Using patients' expressed needs as a basis to redesign the service, a multidisciplinary project team mapped the current process of admission, simulated and mapped an ideal process. This resulted in a fast admission process for patients with suspected fractured proximal femur. Paramedics call a trauma coordinator based on the specialist ward who meets the patient at the door of the Emergency Department, escorting them to X-ray. The fracture is confirmed remotely by an experienced surgeon using PACS. Patients are taken to an optimisation area in the theatre complex for consultant orthopaedic and anaesthetic assessment prior to surgery the same day (utilising spare time on elective and trauma lists), or early the following day. Fascia-iliaca blocks are provided by trauma coordinators to improve pain control and reduce sedative effects of opiates, aiding early mobilisation. Measures include time to theatre, length of stay, and patient experience. Meaningful mortality and morbidity data will become available later. Results. To date we have studied 79 patients (mean age 81 years) over ten weeks. Median time to theatre reduced from 42 hours to 22 hours (Range 2–78 hours). Median length of stay reduced from 10.5 days to 6 days (Range 2–20 days). Secondary improvements include list productivity, communication with relatives, patients' satisfaction. No increase in adverse events has been found and the anaesthetic team felt patients with chronic problems such as cardiac or renal failure were successfully operated on without unnecessary delays. Future Developments. This new process is a permanent change; within six months we will have 250 cases to present, with results of additional metrics

Objectives. to evaluate effect of a dedicated ward for patients with fractured neck of femur on length of acute bed stay and 30 days mortality rate. Design. a retrospective study of two different cohorts of patients with fractured neck of femur, one admitted to a general trauma/surgical ward and the second to a ward dedicated for patients with fractured neck of femur. Setting. a district general hospital affiliated to a University Teaching Foundation Trust. Cohorts. after application of inclusion and exclusion criteria, the first group includes 348 patients who have been diagnosed and admitted with a fractured neck of femur in a 12 months period starting from 01/01/2005. This group have been admitted to a general trauma/surgical ward. The second cohort includes 432 patients who have been diagnosed and admitted with a fractured neck of femur in a 12 months period starting from 01/05/2007. The second group have been admitted into a dedicated ward for patients with fractured neck of femur. Main outcome measures. Lengths of hospital stay in a orthopaedic bed and 30 days mortality rate as main outcome measures. Secondary outcome measures considered to be theatre waiting time and discharge destination improvement. Results. length of acute trauma bed stay has been reduced from 18.3 in the first group to 10.9 (P< 0.01) in the second group. Thirty days mortality rate did not show significant difference (10% vs. 10.8%). There were also some improvements in the secondary outcome measures including reduced theatre waiting time. Conclusion. (with acknowledge of study design limitations) our study has shown a dedicated ward for patients with fractured neck of femur, could shorten acute trauma bed stay, but did not have significant effect on 30 days mortality rate

Aims: Hypokalemia is a common electrolyte imbalance with signficent effects. The aim of our study is to identify incidence, causes and prognostic implications of postoperative hypokalemia in elderly patients operated for fracture neck of femur. Methods and material: Retrospective study, of 404 consecutive fracture neck of femur patients who were operated in our hospital between October 2001 and July 2003. Patients identified with postoperative hypo-kalemia the medical notes, fluid charts and anaesthetic notes were analysed for age, preoperative morbidities, medications, mechanism and type of injury, waiting time for operation, pre, peri and postoperative fluid management, type of anaesthesia, operative time, hospital stay and mortality. Results: Out of the 404 patients, 54(13.3%) were hypokalemic (K< 3.5mmol/l) postoperatively. Of the 54 patients 16 (29.6%)had preoperative hypokalemia. Among the hypokalemic group the mean preopera-tive potassium was 3.69mmol/l and the mean postoperative potassium was 3.19mmol/l. The t-test showed a statistically significant difference between mean pre and postoperative potassium levels (P< 0.0001). High association was found with hypokalemia and post-operative dextrose infusion (38%). 50% of patients on diuretics developed hypokalemia post operatively. Interestingly, only 18% of these were hypokalemic pre operatively. In patients with multiple medical problems, like diabetes, hypertension and CVA, high incidence of hypokalemia was found. (38% had 2 or more medical problems). No significance in the mortality rate was found in fracture neck of femur patients with and without postoperative hypokalemia (40% vs. 39% at 3yrs). Conclusion: There is significant risk of hypokalemia following orthopaedic surgery, especially in the elderly. This avoidable condition, which has serious consequences, should be dealt with care in the orthopaedic units. Fluid infusion regimes and should be formulated and medications reviewed to prevent conditions like hypokalemia

Background: Dr Foster’s Good Hospital Guide 2005–2006 ranked University Hospitals of Leicester NHS Trust amongst the worst in UK for in-hospital mortality and time to theatre in hip fracture patients. The problem had been recognized in early 2005 and the Fracture Neck of Femur (FNOF) project was launched. This included an increase in trauma coordinators and clinical aides, regular orthogeriatric input, daily hip fracture operating lists, a separate hip fracture ward and a dedicated discharge nurse. Aim: The aim of this study was to assess the outcome of the FNOF project. Method: Data on mortality and length of stay was collected from the IM& T department and was cross referenced with the PCT database. Time to theatre data was collected from the trauma coordinators. Study period was five years from January 2003 to December 2007. Results: 3636 patients were admitted with a hip fracture in the five year period. The length of stay reduced from 31 days in 2005 to 19 days in 2007 (p< 0.001). The in-hospital mortality reduced from 17.0 % in 2005 to 11.3% in 2007 (p< 0.01). 1 year mortality dropped from 36.9% to 27.3% (p< 0.001). The 30 day and 4 month mortality were also reduced but this was not statistically significant. 85% of patients had surgery within 48 hours in 2007 as compared to 47% in 2005–06. Conclusions: The FNOF project was successful in reducing In-hospital and 1 year mortality, length of stay and time to theatre. However, the 30 day mortality did not show a significant reduction. In-hospital mortality is not a good comparator of hospital performance as it depends on length of stay; 30 day mortality would be more accurate. The national hip fracture database can be used to obtain accurate data for future studies

Re-positioning osteotomy in the treatment of un-united fracture neck of femur in young patients improves the biomechanical pre-conditions to promote bone union of the Pseudarthrosis. This operative procedure is the method of choice for Pseudarthrosis of the neck of the femur with a viable femoral head. It is also the method of choice in children and in adolescents even if there is avascular necrosis of the femoral head. The operative technique permits exacts planning, stable osteosynthesis both of the un-united fracture of the neck of the femur as well as the osteotomy and allows early mobilisation. In this series of 56 cases, only six (10%) had collapse of the femoral head due to avascular necrosis, six (10%) patients had severe pain in the hip and nine (16%) patients had severe restriction of hip movement. The overall success of the operation in this series was 84%

Treatment of displaced intracapsular fracture of the hip by hemiarthroplasty in old patients is generally satisfactory. Middlemore Hospital’s agreed criteria for hemiarthroplasty were reviewed and tested. Two hundred and thirty three patients who had hemiarthroplasty for displaced intracapsular fracture neck of femur between June 199- June 2001. All the patients’ data collected from the hospital computer system and then a search started for these patients to review their current status regarding pain and mobility. Ninety nine patients (42%) were still alive, of them 13 demented, 13 moved or lost and 7 in a wheel chair. Sixty six patients reviewed for pain and mobility using Sikorski and Barrington scoring criteria for pain and mobility. Thirteen patients had painful hemiarthroplasty. Clinical notes of the most active group of these patients (7 patients) reviewed individually to identify the causes. Two patients had revision to total hip joint replacement within 3 months because of technical errors and two patients placed on the waiting list for revision. The rest had deterioration in their general health that made total hip arthroplasty a risky operation for them. The revision rate was 1.7 %. We concluded that hemiarthroplasty was an acceptable option for these patients. The selection criteria were correct in 98.2% of the cases. Patients who live in their own home will need a careful assessment before deciding on a hemiarthroplasty for them

Fracture neck of femur (NOF) is a significant morbidity in the elderly patient and a significant burden on the healthcare system. Surgery induces a stress response resulting in hyperglycaemia, insulin resistance, and glucose intolerance (Diabetic triad). Furthermore, fasting pre operatively establishes a catabolic state. This diabetic state can last up to 3 weeks following surgery and therefore could be associated with the morbidity of diabetes. Methods. 26 patients with fracture NOF were enrolled in this preliminary study. Exclusion criteria included diabetics. Each underwent hemiarthroplasty or Dynamic Hip Screw fixation. Pre and post operative serum glucose levels were taken. 15 patients were selected to have pre and post operative serum insulin levels because of the expensive nature of the test. Results. Normal glucose range = 4-6 mmol/l. Normal insulin range = 17.8 – 173 pmol/l. 21 of 26 patients exhibited post operative hyperglycaemia (range 5 - 16.4mmol/l). 7 of 15 patients tested for insulin remained in our pilot study where pre and post insulin levels were obtained. Insulin is a technically difficult level to take and samples are easily discarded. 6 of 7 Insulin levels showed marked elevation post operatively (range 17.5 – 595.8). Conclusion. We are able to demonstrate that fracture NOF patients exhibit a postoperative hyperglycaemia and insulin resistance. Insulin levels were significantly elevated in 6 cases and established hyperinsulinaemia was present in 50% of cases. This pilot study determines that a post operative type 2 diabetic state is induced by surgery for fracture neck of femur, perhaps exacerbated by the catabolic state of fasting. If we are able to diminish this we may be able to mitigate morbidity associated with this diabetic state. This in turn may improve the morbidity and burden on our healthcare system