To evaluate the impact of routine capsular repair on patient-reported outcomes, survivorship and achievability of clinically important improvement, minimum 5-years post-surgery.

Our prospective institutional registry was reviewed for cases undergoing primary HA for FAI, and stratified into two groups depending on whether the capsule was repaired or not. Routine repair was introduced in late 2013. The No Repair group consisted of patients undergoing HA between Jan 2010-June 2013 while the Repair group consisted of patients undergoing HA between Jan 2015-Sept 2018. Exclusion criteria consisted of >50 years, Tonnis>1, dysplasia(LCEA<25), concomitant hip pathologies. PROMs consisted of mHHS, SF36 and UCLA. Metrics of clinically important improvement was evaluated using MCID and SCB. Rates of repeat HA or THA conversion were recorded.

985 cases were included (359 No Repair; 626 Repair), 86% male, average age 27.4±6.7years. Significant improvement in all PROMs at minimum 5-years was observed for both groups (p<0.001 for all; large effect sizes for mHHS and SF36, medium effect sizes for UCLA). At 5-years post-op there was no significant difference between groups for mHHS(p=0.078) or UCLA(0.794). SF36 was significantly poorer for those cases undergoing routine repair(p<0.001) however effect size was small (0.20). Thresholds of MCID and SCB were calculated as 69% and 86% for mHHS, 64% and 77% for UCLA, 43% and 60% for SF36. Both groups achieved MCID and SCB at similar rates for mHHS and UCLA. A significantly lower proportion of cases in the repair groups achieved MCID for SF36 (53.6% vs 63.5%, p=0.034) and SCB for SF36 (37.3% vs 52.8%, p<0.001). No significant difference between groups for THA conversion (0.6% No Repair vs 0.5% Repair) or repeat HA (9.7% No Repair vs 8.1% Repair).

Routinely repairing the capsule following HA for FAI demonstrates no clinical benefit over not repairing the capsule 5 years post-surgery

Introduction: Bone mineral density (BMD) has been shown to correlate well with strength and bending stiffness of bone. Following tibial diaphyseal fracture, reduction in the optical density of cancellous bony regions is apparent throughout the postoperative period. As much as 70% loss in BMD in the distal tibia and 45% in the proximal tibia has been reported. The process influencing the extent of such posttraumatic osteoporosis is multifactorial: the severity of injury, age of the patient, the effects of the regional acceleratory phenomenon (RAP), fixation type and onset of weight-bearing have all been implicated. Such loss in BMD in most cases is not fully recoverable and has been shown to increase subsequent fracture risk in the ipsilateral tibia and femur. It has been estimated that a 50% reduction in bone mineral content is required before changes are radiologically observed. Such changes in BDM however can be calculated post operatively from standardised orthogonal tibial digital images, following image density calibration and the utilisation of soft tissue subtraction techniques. Using these image density quantification techniques, a study was performed to examine and compare the effects of fixation of tibial fractures, with either Ilizarov or Intramedullary nail, on BMD in cancellous bone.

Method: Twenty-nine patients were recruited in the context of a randomised controlled trial assessing the radiological outcome following the treatment of closed tibial diaphyseal fractures with either an Ilizarov fixator (n=15) or an intramedullary nail (n=14). Informed consent was obtained for AP and Lat radiograph examination at selected postoperative time intervals (1, 3, 6, 12, 26 and 52 weeks). At each visit the rotation of the patients’ limb was standardised using a position control device (jig). The exposure and image acquisition parameters were standardised and digital images analysed. Serial BMD values were calculated and changes throughout the postoperative period compared between treatment groups.

Results: This study demonstrated considerable differences in the extent of disuse osteoporosis in the cancellous regions of the tibia following either Ilizarov fixation or intramedullary nailing. In the proximal metaphysic patients treated with a tibial nail displayed a reduction in BMD by 18.8% at 26 weeks and 25.7% at 42 weeks. In contrast, patients managed with Ilizarov fixation actually increased the BMD at this region at 26 weeks by 11.7% but with a final overall loss of 5.2% at 52 weeks. Each group demonstrated decreases in BMD at both the distal metaphysic and medial malleolar regions over 26 and 52 weeks. The BMD of the distal metaphysic decreased by 15.9% at 26 weeks and 35.3% at 52 weeks for patient treated with a nail, and reduced by 11.1% at 26 weeks and 0.76% at 52 weeks in patients treated with Ilizarov fixation. The medial malleolar region demonstrated the greatest decreases of all with a reduction in BDM of 43.1% and 66.4% in the nail group, and 34.9% and 61.6% in the Ilizarov group, at 26 and 52 weeks, respectively.

Conclusion: The magnitude of disuse osteoporosis following tibial diaphyseal fractures treated with intramedullary nailing, calculated using digital image analysis, and demonstrates changes similar to those reported previously in the literature. The use of Ilizarov fixation however maintains proximal metaphyseal BMD throughout the review period and promotes remineralisation in the distal metaphysic. No difference is observed in the medial malleolus between the two groups. The benefits of axial loading, stability and preservation of intraosseus vascularity with the use of the Ilizarov fixator are clearly demonstrated in the results; preservation of BMD was also shown to correlate well with improved clinical outcome and will reduce future ipsilateral tibial and femoral fracture risk.

Introduction: Many patients admitted to acute fracture units with femoral neck fractures are frail and elderly, dehydrated and malnourished, often with associated medical conditions. Surgery may be delayed for investigation, prolonged management and inadequate review of their medical problems, leading to clinical deterioration with poor outcome. Local anaesthetic techniques have been described for intracapsular fractures. We describe a technique effective for the treatment of the more difficult extracapsular type.

Aims: To provide a safe and effective technique using local anaesthetic and sedation, for the insertion of a dynamic hip screw in high risk elderly patients with extracapsular femoral neck fractures.

Method: Fifty elderly patients who sustained an inter-trochanteric fracture of their femoral neck underwent dynamic hip screw insertion under local anaesthetic and sedation. These patients were medically assessed following admission, all were ASA grade 4, had an additional medical condition (recent MI, CVA, chest infection, aortic stenosis) and were deemed unfit for either general or spinal anaesthesia. All patients not fit for traditional anaesthetic methods were assessed for their suitability for operation under LA, consented and placed on the next available theatre list.

A femoral nerve block was performed, with the aid of a nerve stimulator for accurate location, in the anaesthetic room; skin and periosteal infiltration was performed using a 22g spinal needle, with caution to include the distribution of the lateral cutaneous nerve. The patient was then placed on the fracture table and mild sedation (Ketamine, Diazemul, 02/N20) was administered, titrated against the patients requirements. The fracture was reduced using traction and internal rotation, and the DHS inserted.

Local Anaesthetic: Infiltration; * 20mls O.25% marcaine/1 in 200,000 adrenaline diluted to 40mls with sterile water. (30mls used with 10mls reserved) * 20mls 1% lidocaine diluted in 40mls of sterile water. (10mls used for skin). Local Anaesthetic femoral nerve block; * 10mls 0.25% plain marcaine

The combined amount of local anaesthetic used is well below safe limits recommended by the World Federation of Societies of Anaesthesiologists.

Conclusion: This technique is a safe, simple and effective method of allowing high risk, medically unfit patients to undergo surgery. It reduces operative bleeding and postoperative analgesia requirements, no peri-operative deaths occurred and one patient had evidence of post operative tachycardia that settled within 12 hours.