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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIV | Pages 19 - 19
1 Jul 2012
Westacott D McArthur J Bould M
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The femur is a common site for skeletal metastases. The Gamma2 nail has proved effective in relieving pain and restoring function. Little data exists on the use of the Gamma3 Long Nail (GLN) in this condition. Improved instrumentation is suggested to reduce operative time and facilitate minimally invasive surgery. This study reports a series of patients treated in a District General Hospital.

A retrospective casenote review was performed of all patients treated with the GLN for femoral metastatic disease over a five year period. Patients were followed-up for a minimum of one year. Functional level was assessed using the Parker Mobility Score (PMS).

12 patients underwent 15 nailings. Mean age was 75.4 years (median 75.7, range 61-92). In bilateral cases, the operations were performed during the same hospital admission. There were seven prophylactic nailings for impending fracture from proximal femoral lesions, seven procedures for actual fractures distal to the intertrochanteric line, and one basicervical fracture associated with multiple femoral metastases. Primaries were four prostate, two breast, two lung, one bowel, one bladder, one renal, and one myeloma.

Average anaesthetic time for all procedures was 134 mins (median 125, range 90-210). Average peri-operative drop in serum haemoglobin was 2.3g/dL (median 2.1, range 0.6-4.8). Five patients with actual fracture and one patient with impending fracture required blood transfusion, receiving 2.2 units on average.

In-hospital mortality rate was 0.83%, with only one patient not surviving to discharge. One year mortality was 83.3%. Only two patients were alive one year post-operation. Of the remaining patients, average survival was 3.2 months (median 3, range 1-6). Patients spent an average of 17 days on an acute orthopaedic unit (median 14, range 4-80). Two patients required further convalescence in a rehabilitation unit.

There were three surgical complications. Two impending fractures became complete, One intra-operatively and one post-operatively. In the case of basi-cervical fracture, the proximal screw cut out of the femoral head, requiring revision to a long-stem bipolar hemiarthroplasty. This was the only re-operation required in this series.

Average pre-operative PMS was 5.2 (median 4, range 2-9). Average peri-operative drop in PMS was two points (median 1.5, range 0-6). Of the 11 patients who survived to discharge, 10 were independently mobile and returned to their pre-operation residence. Nine required a change in walking aids. Only one patient reported post-operative pain.

This small patient series suggests that the Gamma3 Long Nail is a suitable treatment option for impending and actual metastatic femoral fractures in the District General setting. Length of stay, in-hospital mortality and re-operation rates compare favourably with published data on the Gamma2. There was a significant drop in Parker Mobility Score but all patients bar one were independently mobile and returned to their home. Anaesthetic time was not lower than with the Gamma2, suggesting little tangible benefit of the new instrumentation.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_II | Pages 80 - 80
1 Feb 2012
Sabri O Bosman H Bould M Bannister G
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Nationwide, proximal femoral fractures contribute a significant workload for the NHS and are the commonest trauma admission. Timely discharge from the acute hospital setting is beneficial to both patient and orthopaedic team.

The Community Care Act 2003 formed part of Governmental strategy to reduce ‘bed blocking’. Introduced on 5 January 2004, the scheme enabled Trusts to charge Local Authorities £100 a day where there was delayed transfer of care due to lack of Social Service [SS] provision. The Act brought with it a £250 million package of funding over three years.

We looked at patients admitted to Weston Area Healthcare Trust [WAHT] sustaining fractured neck of femur. These were pre-scheme group A, admitted 08/09/2003-06/10/2003 and post scheme group B, 08/03/2004 – 05/04/2003. Patient numbers, group ‘A’ 33 patients, group ‘B’ 28 patients. Average length of stay, ‘A’ 22.3 days, ‘B’ 16.1 days. The average time spent in hospital after being declared ‘medically fit’, ‘A’ 6.6 days, ‘B’ 2.3 days. Only 13 patients were referred to SS post scheme, with combined delayed discharge of 116 days.

The impact of the scheme in reducing length of stay has not been proven. Few patients were referred to SS even after the implementation of the scheme; however, the delay in discharge for these patients would have amounted to £11600 of funding. To date, WAHT have not received any funds for patients in whom discharge was delayed.

The Act states that lack of SS input must be the ‘sole reason’ for delay in discharge. The scheme is not applicable if delay is due to family choice, lack of equipment or lack of intermediate care package and for these reasons transfer of funds from SS to Trusts has become a multidisciplinary minefield. The impact of the reimbursement scheme will only become apparent if the Act is enforced.


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_III | Pages 288 - 288
1 Mar 2004
Pattison G Bould M Blewitt N
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Background: Posterior dislocation of the elbow with fractures of the radial head and coronoid process is a rare injury which, when treated conservatively, has a high redislocation rate and poor results (7/11 in the largest published series). Methods: Six patients with this injury were treated with triple reconstruction, involving exploration of the joint via a lateral approach with insertion of a radial head prosthesis. The coronoid fracture and anterior capsule was repaired (using an in-to-out technique) and the lateral collateral ligament was reat-tached, using Mitek Super Anchors. All patients were evaluated prospectively. Results: The average age was 52 years (37–75y). At one year follow up all elbows remained in joint and all were pain free or causing slight pain only. The average range of ulno-humeral movement was 55 degrees (range 38–68) and the average forearm rotation was 67 degrees (range 18–104). Functional assessment showed an average Liverpool score of 23/36 (range 17–29) and average Broberg and Morrey score of 74/100 (range 68–84). Conclusions: Triple reconstruction recognises and remedies the three elements of this devastating injury. All of these must be addressed in order to fulþll the short-term goal of restoring and maintaining stability. Our patients have a stable, pain free, though stiff, elbow in contrast to the poor results reported from previous conservative and operative treatments.