Background

Isolated fracture of the greater trochanter is an uncommon presentation of hip fracture. Traditional teaching has been to manage these injuries nonoperatively, but modern imaging techniques have made it possible to detect occult intertrochanteric extension of the fracture in up to 90% of cases.

This study aims to review the investigation and management of greater trochanter fractures in a single major trauma centre.

Background

The gradient structure of osteochondral tissue, with bone, calcified and cartilage regions, challenges the design of biomaterials for defect repair. A novel biomimetic tri-layered collagen-based scaffold, designed to replicate these 3 anatomical layers, has been developed within our group and has shown success as an off-the-shelf product in treatment of focal defects in several animal models by recruiting host cells and directing them to form bone and cartilage in the requisite layers. This study aimed to elucidate the mechanism by which the extracellular matrix macromolecules in the scaffold directed stem cell differentiation in each layer.

Introduction:

We report our 10-year experience of post-operative complications of calcaneal fractures treated by internal fixation and attempt to correlate these with previously cited patient risk factors.

Introduction:

Calcaneal fractures are rare but debilitating injuries assumed to affect particular demographic sub groups. This study aimed to relate epidemiological factors (age, gender, smoking status and social deprivation scores) to the incidence of calcaneal fractures requiring operative fixation over a 10-year period.

Background

Orthopaedic surgeons are increasingly pressured to consider thromboprophylaxis for patients when little evidence exists. The aim of this study was to determine the incidence of fatal pulmonary embolism following office attendance in our outpatient fracture clinic.

Symptomatic venous thromboembolism (SVTE) is a potentially significant complication which may occur following injury or surgery. Recent NICE guidelines, and clinical targets have all focused on decreasing in hospital death from acquired SVTE. Despite these guidelines there are no large studies investigating the risk factors for or incidence of SVTE in acute trauma admission.

Data from a prospective series of 9167 consecutive patients with a diagnosis of fractured neck of femur (NOF) at a single institution was used to construct a risk score for SVTE. Twenty three factors were screened with pairwise analysis. The cohort had an event rate of 1.4%. A multiple logistic regression model was used to construct a risk score and correct for confounding variables from nine significant factors identified by the pairwise analysis. Four factors; length of stay; chest infection; cardiac failure and transfusion were used to produce the final risk score. The score was statistically significant (p< 0.0001) and highly predictive (ROC analysis, AUC=0.76) of SVTE.

The score was separately validated in two cohorts from different Level 1 trauma centres. In one prospective consecutive cohort of 1000 NOF patients all components of the Nottingham SVTE score were found to be individually statistically significant (p< 0.0045). The score was further validated in a separate cohort of 3200 patients undergoing elective hip surgery. The score was found to be statistically significantly predictive of SVTE as a whole, and three of the four components were individually predictive in this patient cohort.

Balancing risks and benefits for thromboprophylaxis is key to reducing the risk of thromboembolic events, minimising bleeding and other complications associated with the therapy. Our study of 13,367 prospective patients is the largest of its type and we have successfully constructed and validated a scoring system that can be used to inform patient treatment decisions.

Hypothesis

This study demonstrates the utility of a modified postero-medial surgical approach to the knee in treating a series of patients with complex tibial plateau injuries with associated postero-medial shear fractures.

Postero-medial shear fractures are under-appreciated and their clinical relevance have recently been characterised. Less invasive surgery and indirect reduction techniques are inadequate for treating these postero-medial coronal plane fractures.

Patients presenting with a fractured neck of femur are a fragile group with multiple co-morbidities who are at risk of post-operative complications. As many as 52% of patients are reported to suffer a urinary tract infection post hip fracture surgery. There are little data surrounding the effects of post-operative urinary tract infections on mortality and deep prosthetic infection.

We prospectively investigated the impact of post-operative urinary tract infection (UTI) in 9168 patients admitted to our institution with a diagnosis of proximal femoral fracture over an eleven year period in a prospective population study. We examined the effects of post operative UTI on the incidence of deep infection, survivorship and length of stay.

Post-operative UTI occurred in 6.1% (n=561) and deep infection in 0.89% (n=82). Deep infection was significantly more common in patients complicated with a UTI (3.2% vs 0.74% p< 0.001) with a relative risk of 3.7:1. In 58% of patients the same organisms was cultured in the urine and hip samples. A postoperative UTI did not adversely effect 90 day survival, however was associated with an increased length of stay (ROC analysis AUC=0.79). Delays to surgery and age were not predictive of a post operative UTI.

Recognition of the risks posed by post operative UTI, the risk factors for development of infection and early treatment is essential to reduce the risks of increased subsequent periprosthetic infection.

Introduction

Cemented hemiarthroplasty for neck of femur fractures has been advocated over uncemented hemiarthroplasty due to better post-operative recovery and patient satisfaction. However, studies have shown adverse effects of bone cement on the cardio-respiratory system which may lead to higher morbidity and mortality. Therefore, in some institutes, the use of an uncemented prosthesis has been adopted for patients with a high number of co-morbidities. The aim was to compare early mortality rates for cemented vs. uncemented hemiarthroplasties.

We have identified 69 patients with Vancouver B1 periprosthetic fractures around stable femoral implants. Open reduction internal fixation is the recommended treatment; however recent studies have revealed high rates of nonunion. We have reviewed the fixation techniques utilized to treat these patients, and identified outcomes in relation to rates of union, further surgery and mortality.

Patients were identified from a prospective database of all trauma admissions at Nottingham University Hospitals from 1999 to 2010. Hospital notes were independently reviewed and data retrieved.

69 patients were identified. Mean age 77 years and 63% were female. 51 (74%) occurred around total hip replacements and 18 (26%) around hip hemiarthroplasty after a previous hip fracture.

Periprosthetic fracture occurred around an Exeter stem (n=18), Charnley (n=10), Austin Moore (n=15), other (n=6). 20 patients had undergone previous revision surgery. The mean time from index surgery to fracture was 58 months (median 24) around primary stems, and 48 months (median 22) around revision stems.

6 patients (9%) were treated non-operatively. Five of these had undisplaced fractures (all healed but one required revision due to loosening) and one was too unwell.

63 patients (91%) were treated by open reduction internal fixation. Of these, single plate fixation was performed in 40 cases (64%). In the vast majority of cases, lag screw fixation of the fracture with a long (>12 hole) pre-contoured 4.5mm locking plate was utilised with cables. Both locking and cortical screws were used to achieve stable fixation (Figure 1). A double plate technique was used in 16 cases (25%), where plates were placed perpendicularly to each other (laterally and anteriorly). Strut grafts were used in 13 cases (21%). 7 patients (11%) were treated with cables alone.

23 patients have subsequently died (33%). Two have been lost to follow up and three are awaiting union. There is a mean follow-up of 35 months.

Deep infection occurred in 4 cases (6%). Non-union occurred in four cases (6%). Two of these were infected and one was treated with cables alone. Malunion occurred in one case treated with cables. One patient had a dislocation and two superficial infections occurred.

Further surgery took place in 8 patients (12%). Three of the infected cases were revised and one underwent wound washout. The two other non-unions were revised. Three further revisions were performed: one for malunion, one for aseptic loosening (treated non-operatively) and another for a second periprosthetic fracture. Superficial wound washout was performed in one case.

Mortality was 10% at 3 months, 22% at 1 year and 47% at 3 years.

We have identified that union can be achieved in the majority of cases after periprosthetic fracture fixation. Cable fixation was associated with a high complication rate (7 cases: two requiring revision surgery: one nonunion, one malunion).

We recommend that Vancouver B1 periprosthetic fractures are treated with meticulous technique to achieve anatomical reduction and fracture compression using lag screw technique and plating. Further mechanical support can be provided through the use of a second plate, cables and/or strut grafts.

The clinical results of the cemented Exeter stem in primary hip surgery have been excellent. The Exeter ‘philosophy’ has also been extended into the treatment of displaced intracapsular hip fractures with ‘cemented bipolars’ and the Exeter Trauma Stem (Howmedica).

We have identified an increase in the number of periprosthetic fractures that we see around the Exeter stem. We have also identified a particular group of patients with comminuted fractures around ‘well fixed’ Exeter stems after primary hip surgery that present a particular difficult clinical problem.

Prior to fracture, the stems are not loose, the cement mantle remains sound and bone quality surrounding the reconstruction is good, i.e. classifying it as a Vancouver B1. However the comminuted nature of the fracture makes reduction and fixation with traditional methods difficult. Therefore in these particular circumstances it is often better to manage these as B2 or even B3 fractures, with distal bypass and uncemented reconstruction.

Over an eleven-year period since 1999, 185 patients have been admitted to Nottingham University Hospitals with a periprosthetic femoral fracture around a hip replacement. These patients were identified from a prospective database of all trauma patients admitted to the institution. Of these patients we have identified a cohort of 21 patients (11%) with a periprosthetic fracture around an Exeter polished stem. Hospital notes were independently reviewed and data retrieved. Outcome data was collected with end points of fracture union, re-revision surgery and death. Data was also collected on immediate and long term post-operative complications.

The mean age was 76 years at time of fracture, and 52% were male. The mean duration between primary index surgery and fracture was 18 months (median 11 months).

15 patients were classified as Vancouver B1, and six as B2 fractures. Of the B1 fractures, 14 underwent fixation and one was treated non-operatively. Of the B2 fractures, four were revised, one was revised and fixed using a plate, and one was fixed using a double-plating technique. Prior to fracture, none of the implants were deemed loose although one patient was under review of a stress fracture which subsequently displaced.

One patient died prior to fracture union. All the other patients subsequently went onto unite at a mean of 4 months. There were no deep infections, non- or malunions. No patient underwent further surgery. Dislocation occurred in one patient and a superficial wound infection occurred in one patient which responded to antibiotic treatment. Three other patients have subsequently died at seven, twelve and fifty-three months post fracture due to unrelated causes.

In our series of patients, in addition to the more standard fracture patterns, we have identified a very much more comminuted fracture. Indeed, we have described the appearance as if the tapered stem behaves like an axe, splitting the proximal femur as a consequence of a direct axial load. As a consequence of the injury, the cement mantle itself is severely disrupted. There is significant comminution and soft tissue stripping, calling into question the viability of the residual fragments. Treatment of this type of fracture using a combination of plates, screws and cables is unlikely to provide a sufficiently sound reconstruction. In our experience we believe these fractures around previously ‘well fixed’ Exeter stems should be treated as B2/B3 injuries.

Developments in plate technology have increased interest in the operative fixation of Colles' fracture. The vast majority of patients are treated non-operatively, yet there are few medium or long-term outcome studies.

The aim of this study was to evaluate medium-term outcome of a cohort of patients who previously received treatment in a plaster cast. 236 patients entered two previous prospective, randomised control studies comparing closed reduction techniques or plaster cast type. Both studies showed no difference in clinical or radiological outcome between groups. 43% of this cohort had a final dorsal tilt of > 10° and 44% had final radial shortening of >2mm. All patients now have a minimum follow-up of five years and 60 have died. The remaining 176 patients were contacted by post and asked to complete two validated patient-based questionnaires: a modified Patient Evaluation Measure and a quickDASH. 112 replies were received. The mean age of patients is 67 years (range 23 – 91 years). 31 patients are employed and 57 retired. 77% of patients had a quickDASH score of less than 20. 59% of patients never experience wrist pain whilst 8% of patients have daily pain.

All Patient Evaluation Measures have shown a median score of 12 or less (0=excellent, 100= terrible). The best score was for pain (median 4; IQR 2-12) and the worst for grip strength (median 12; IQR 4 – 41). No radiological outcome 5 weeks after injury correlated with any outcome score, except for dorsal tilt, which correlated with difficulty with fiddly tasks (p=0.04) and carpal malalignment which correlated with interference with work (p=0.04).

In conclusion, our results show a good functional outcome five years after non-operative management of Colles' fracture. A degree of malunion is acceptable and in the light of our results the economic impact of surgery must be evaluated.

The aim of this study was to investigate the risk factors, financial costs and outcomes associated with infection after hip fracture surgery.

Prospective hip fracture data from the University Hospital, Nottingham, was analysed, assessing patients with either deep or superficial wound infections admitted over a five year period.

3605 patients underwent hip fracture surgery. 2.3% of these patients developed a wound infection of which 1.2% were deep wound infections. 75% of infections were due to Staphylococcus aureus and 50% of all infections were caused by methicillin-resistant Staphylococcus aureus.

No statistically significant risk factors for the development of infection were identified in this study.

Length of stay, cost of treatment and pre-discharge mortality were all increased with deep infection. Deep wound infection increased the average length of stay from 28 days to 100 days. This quadrupled the ward costs. The mean overall hospital cost of treating a hip fracture complicated by deep wound infection was £34903 compared to £8979 fro those who did not develop infection. Pre-discharge mortality increased from 24.2% in the control group to 30% in the infected group (p<0.006).

MRSA significantly increased costs, LOS, and pre-discharge mortality compared with non-MRSA infection.

These results show the huge impact that infection after hip fracture surgery has both on mortality and hospital costs.

The aim of the study was to assess the mortality associated with a hip fracture at 5 years in a geriatric population, and to evaluate the influence of age, cognitive state, mobility and residential status on long term survival after hip fracture.

This study forms part of a prospective audit of all patients with a hip fracture admitted to Queen's Medical Centre, Nottingham. Every patient has a detailed admission questionnaire completed including details of the injury, medical history, residence and mobility. All data is collected by independent audit personnel using a detailed proforma. Integration with the database of the Office for National Statistics ensured accurate mortality data for every patient in the study for at least 5 years. All patients admitted in a 2 year period were included and divided into two groups: group B (<80 yrs age, Abbreviated Mental Test score 7/10, admitted from own home, independently mobile) and group A (any patient who did not fulfil all of group B criteria). A multivariate analysis indicated these as important variables that predicted mortality. Exclusion criteria: pathological hip fracture or bilateral hip fractures.

1319 patients fitted the inclusion criteria. 1068 patients fulfilled criteria for group A, 251 patients for group B. Overall mortality was 71% at 5 years. The excess mortality for the first year was 43%. 151 patients (60%) of group B were still alive at 5 years in comparison with only 231 (22%) of group A. Increased survival was shown for each variable: independent mobility RR 2.34 (p<0.05), admitted from home RR 3.81 (p<0.05), age<80 years RR 3.95 (p<0.05) and AMT 7/10 RR 5.45 (p<0.05).

These results facilitate early recognition of those patients with an increased chance of long-term survival that may be suitable for surgical treatment, such as total hip replacement, which have a good long-term outcome.

Methods: We examined prospectively collected data from 6782 consecutive hip fractures to identify 327 fractures in female patients aged 65 years and younger. We report on demographic characteristics, treatment and outcome. We compare this group with a cohort of 4810 consecutive hip fractures in older females.

Results: Not surprisingly, younger women had higher levels of mobility and independence than their older counterparts. However, over 20% mobilised with aids, needed help with activities of daily living and/or had significant co-morbidity. A significantly higher proportion of younger patients were smokers. This had a strong influence on the relative risk of “early” as opposed to “late” fracture (Hazard Ratio 4.7, p< 0.01). Mortality was 0.7% at 30 days and 4.2% at one year.

We calculated age-related incidence of hip fracture in the local population and noted the first significant increase at the interval between 40–44 and 45–49, rather than the age of 50, which is when the onset of screening of hip fracture patients for osteoporosis occurs in most health areas. Lag screw fixation was the most common method of operative fixation. General complication rates were low, as were reoperation rates for cemented prostheses. Intracapsular fractures are an interesting subgroup. When displaced, 39% (61/158) had lag screw fixation and 61% (97/158) were treated by arthroplasty. Kaplan-Meier implant survivorship of displaced intra-capsular fractures treated by reduction and lag screw fixation was 82% at two and 71% at five years.

Conclusion: Hip fractures in females to 65 years of age are sustained by a population at risk as a result of patho-physiology. Treatment in this age group, particularly of intracapsular fractures, remains a topic of debate. Understanding the characteristics of these patients, may lead to an improved opportunity, if not for prevention, at least for intervention.

Aims: Reverse oblique intertrochanteric fractures (OTA/ AO 31-A3) have unique biomechanical properties that confer difficulties in obtaining stable fixation with the conventional sliding dynamic condylar screw. Recent studies have recommended the use of cephalocondylic intramedullary devices for these unstable fractures. Both the Proximal Femoral Nail (PFN) and the Gamma Nail (GN) have shown good outcome results but the results of treatment with the IMHS have not been reported in the literature.

Methods: Between 1999–2008 6724 consecutive hip fractures were treated at our institute. There were 2586 extracapsular fractures and 307 subtrochanteric fractures. 115 of the extracapsular fractures had a reverse oblique pattern and 63 of these were treated with the IMHS. We retrospectively reviewed clinical and radiological records for the reverse oblique intertrochanteric fractures treated with the IMHS. Follow-up duration ranged from 8 months to 6 years.

Results: Among the 63 patients treated with the IMHS, 56 (88%) fractures were reduced satisfactorily with only one poorly positioned hip screw in the femoral head. There were no cases of femoral shaft fracture, screw cut-out or collapse at the fracture site. The orthopaedic complications were two cases of mal-rotation, two cases of non-union, two cases of distal locking bolts backing out, and one cracked nail. 30 day mortality was 6.5%.

Conclusion: Cephalo-medullary nailing devices have been recommended for the treatment of reverse oblique intertrochanteric femoral fractures. Our clinical and radiological outcomes with the IMHS compare favourably to the results in reports where other cephalo-medullary devices have been used. Therefore we consider the IMHS a good option for the treatment of these unstable fractures.

To assess the relationship between preoperative urea concentration and mortality in patients with hip fractures requiring surgery, we carried out a prospective observational study of 1230 consecutive patients admitted to a single trauma unit with a hip fracture, required surgery.

Results: The mean age was 80 years (range 17–101) and 931 (77%) were female. 669 patients (54%) had intracapsular fractures, 547 patients (45%) had extra-capsular fractures and 14 patients (1%) had periprosthetic fractures. 760 (62%) patients were admitted from their own homes, 178 (15%) from residential homes, 150 (12%) from nursing homes and 123 (10%) from warden-aided homes. 644 (53%) were independently mobile before injury, 311 (26%) used walking aids, 241 (20%) were mobile with the use of a frame and 24 (2%) were unable to walk. 371 (32%) patients had a mini mental test score of less than 7. 49 (4%) were known to have renal disease and 106 (9%) had diabetes.

The 30-day mortality was 9.8% and the 90-day mortality was 19.9%. The mortality at 1 year was 29.0% and at 2 years was 30.2%. There is a clear relationship between a raised admission urea concentration and mortality at 90 days, 1 year and 2 years. Abnormalities of serum sodium and potassium concentration did not influence mortality.

Conclusion: Mortality is high following hip fracture. Patients admitted with a raised serum urea and treated with operative methods are at increased risk of death at all the time intervals analysed, up to and including 2 years. This group of patients may require a separate care pathway that provides more intensive management of fluid and electrolyte balance.

Dr Foster, an independent health watchdog, has produced a national league table for hospital performance in hip fracture management. This was published in the Times newspaper in November 2001. No validation of the league table was presented and so we have compared the results of a prospective audit of our hip fractures with the data provided by Dr Foster.

A prospective audit of all patients admitted with hip fracture was undertaken over a 30-month period. An independent research assistant collected data on a standardised questionnaire. Data included basic demographics, comorbidities, mental test score, mobility and social status. Mortality data was obtained from the national office for statistics. Dr Foster’s data was obtained from the Hospital Episode Statistics and they also provided additional information on data and methodology.

Dr Foster reported that our hospital had a standardised mortality ratio of 107 and a one-year mortality per 100,000 population of 112.20. The hospital workload for the year 2000 was given as 400 hip fractures with 40 deaths (10%) within 30 days of surgery. Our prospective audit showed that 738 hip fractures were admitted in the year 2000. 677 were from the local population giving an incidence of hip fracture of 100.3 per 100,000. 63 of these patients died. Thus, the one-year mortality per 100,000 population is 63. The 30-day mortality for all patients admitted during the year was 9.3%.

The league table produced by Dr Foster is based upon inaccurate date. The workload error was 46% with a 10% error for mortality and a 56% error for population mortality statistics. It is completely unacceptable that such data should be published in the public domain without validation.

Funding for the health service is limited and this inevitably leads to rationing. However, the allocation of funding to different specialities and clinical areas often has no rational basis. The aim of this study was to evaluate the health status of patients on the orthopaedic waiting list.

The SF-36 was used as a postal questionnaire and sent to all adult patients on the elective orthopaedic waiting list at our hospital. Demographic data was collected and patients were grouped by intended operation. The health domains of the SF-36 were adjusted for demographic variables and compared to population norms using non-parametric statistical methods.

The SF-36 was sent to 1586 patients and 1155 responded (73%). Analysis was undertaken for hip replacement (n=194), knee replacement (n=291), knee arthroscopy (n=232), foot and ankle (n=147) and cruciate ligament reconstruction (n=46). All diagnostic groups had significantly worse (p< 0.05) scores for all domains of health when compared to population norms. Patients awaiting joint replacement had worse disability (p< 0.001) than other groups, particularly for pain and physical function. Patients over 40 years awaiting arthroscopy had disability approaching these levels and those awaiting ACL reconstruction had poor physical function. In general, patients awaiting foot or ankle surgery had better health than other diagnostic groups but still had significant reductions when compared to normal. Health scores were not related to the Townsend index for social deprivation, indicating equity of access within the health service.

Patients awaiting hip and knee replacement have worse health than others on the waiting list. The SF-36 could be a useful tool if priority on waiting lists were to be determined by pain and disability rather than waiting time.

The New Zealand health score was developed by the New Zealand government to ensure that patients with the greatest needs were given priority. It allows explicit rationing of health care by clinical priority rather than waiting time (the current UK system). The scoring system has not been validated against an accepted measure of health status and the aim of this study was to compare the New Zealand score with the SF-36.

Patients on the orthopaedic waiting list for hip or knee replacement were sent postal questionnaires to collect demographic data and complete an SF-36 and New Zealand score.

581 patients were sent questionnaires. The response rate was 72% and data was available on 243 knee replacement and 168 hip replacement patients. For patients awaiting hip replacement there was good correlation between the NZ and all health domains of the SF-36 (correlation coefficient: 0.19 – 0.62). In contrast, there was poor correlation between the NZ score and the SF-36 for patients awaiting knee replacement with only physical function having a significant correlation (coefficient 0.25). Breakdown of the NZ score into pain and function components did not improve the correlation with SF-36 scores for these patients.

The New Zealand clinical priority scoring system correlates well with health status, as measured by the SF-36, for patients with hip arthritis awaiting hip replacement. However, the NZ score does not correlate with the SF-36 for patients awaiting knee replacement. This system is now being used by some centres in the UK for waiting list management but has been introduced without comparison to any well-established measures of health status. Its use for the prioritisation of patients who require knee replacement should be questioned.