Periprosthetic fractures after total hip arthroplasty are challenging, with potential difficulties associated not only with the fracture but also with implant loosening and bone loss. The incidence of periprosthetic fractures is gradually increasing. We undertook this study to evaluate the periprosthetic fractures presenting to our unit in terms of mechanism of failure, classification and treatment. Charts of patients with periprosthetic fractures presenting within the past six years were retrospectively analysed for demographic and injury details and corresponding radiographs were reviewed to classify the fracture and follow treatment. 45 fractures were identified, with an average age of 78.3 years. The male to female ratio was 5:4. Only 4 fractures occurred in revision prostheses. Two fractures were intraoperative.

The Vancouver system was used to classify the fractures, which can also form a basis for treatment. Three fractures of Vancouver type A were managed conservatively without complication. Thirteen fractures were Vancouver type B1, 12 of which underwent internal fixation, mostly plate osteosynthesis; two of these subsequently failed. Recent fractures have been stabilised using locking plates, with no recorded failures. Fifteen fractures were Vancouver type B2, 11 of which were greater than 5 years post arthroplasty. Most underwent revision of the femoral component. Five of these patients had reported pain for some time preceding fracture. Seven fractures were Vancouver type B3, all occurring greater than 7 years post arthroplasty. Most underwent femoral revision. Seven fractures were Vancouver type C, all underwent plate fixation without failure.

Although there is variability within the group studied, this series demonstrates gradual standardisation of treatment with use of locking plates and a preferred long revision femoral stem. The reports of pain preceding fracture in a proportion of the Vancouver B2 group prompts greater postoperative surveillance in patients with early signs of femoral loosening.

Background: Periprosthetic fractures are now recognised as the second most frequent reason for revision following total hip replacement, less so than aseptic loosening but more so than dislocation and infection. The post-operative incidence of peri-prosthetic fracture is approximately 1% after primary arthroplasty and 4% after revision surgery. 75% of postoperative femoral fractures are associated with prosthetic loosening. The Vancouver system, a reliable and valid classification scheme, sub-classifies fractures around the stem of the prosthesis into three types. B2 is where there is a loose implant but adequate bone stock and B3 is where the implant is loose and bone stock is deficient.

Aim: To assess the outcome of patients with Vancouver type B2 and B3 fractures treated with femoral revision using an uncemented extensively porous coated implant (Solution ® stem).

Methods: A retrospective chart review was performed. Patients in addition attended for a clinical and radiographic assessment. Engh’s criteria for osseointegration of cementless components and the length of time to fracture union were the radiographic endpoints. The Harris hip score was used for clinical assessment with a score of above 80 indicating a satisfactory result.

Results: From July 1999 to present, we identified 22 such patients treated with this method. The mean duration of follow-up was 33.7 months with a minimum of 12 months. The mean age of patients was 78.7 years (range 67–88). The mean time from the index procedure to fracture was 10.8 years (range 7–20 years). The index procedure was a primary total hip replacement in all but 2 cases (revisions). 18 patients had a good result. Four patients had a poor result. The mean Harris Hip Score in the 18 patients was with good results was 82.7 and 69 in those with poor results. The mean duration to fracture union was 5.2 months (range 4–8 months). 17 patients needed concomitant acetabular cup revision. No patient showed any evidence of loosening or subsidence. 2 patients presented with deep seated infection (1 early, 1 late).

Conclusion: Periprosthetic fractures in the setting of a loose prosthesis present a difficult reconstructive challenge. Uncemented extensively porous coated femoral implants incorporate distal with intramedullary fixation of most fractures, permitting fracture healing as well as achieving osseointegration. We report good early survival rates, stable fixation and a low incidence of non union using this implant.

Background: By the end of the current Bone and Joint Decade (2000–2010) the World Health Organisation predicts that 55% of post-menopausal women will have osteoporosis, as defined by fragility fracture and / or BMD. Volume aside, fragility fractures also represent a significant technical challenge in operative care. Current aggressive medical management is aimed to minimize the resource impact of this pandemic.

Study Design: This prospective study of 3000 consecutive fractures treated in a Level 1 trauma unit identified 977 fragility fractures requiring operative management, 803 of which were in patients over the age of 65 years. In every case the GP was informed of the diagnosis of osteoporosis and appropriate recommendations were made regarding medical management. We present the demographic features of this population and the resource impact of their management. We also examine the outcome of our efforts to improve care of the elderly with osteoporotic fractures, as all GP’s were contacted 6 months following discharge to determine the uptake of medical treatment as recommended.

Materials and Methods: Our computerized operative database was utilized to prospectively collect demographic and operative data on all 977 patients. All medical charts were examined to identify medications on admission, GP contact details and other relevant information. GP’s were contacted by telephone and post to determine patient 6-month mortality and the uptake in the use of recommended medication. Data represents the mean ± SD.

Results: Of the 803 patients over the age of 65 years, the average age was 80.5 ± 7.5 years, with a 75% female preponderance. 14% of these had had a previous wrist or vertebral insufficiency fracture, while 2.2% had a previous contralateral hip fracture. Hip fractures accounted for 70% (566 patients) of fragility fractures with 25% AMP, 24% Bipolar, 51% DHS. There were 121 wrist fractures. On admission 23% of hip fracture patients were resident in a Nursing Home. Despite the relatively large number with previous fracture (16.2%) only 3.4% were taking calcium / vitamin D supplementation while only 2.1% were on anti-resorptive therapy, eg a bisphosphonate. The median interval between admission and operation was 1 calendar day with a range of 1–10 days. 57% of all cases were performed outside of routine trauma lists. The average length of stay for this hip fracture population was 11.5 days with a further 16.5 days spent at a step down facility. Only 14.8% went directly home. Of 240 GP’s contacted, 74% replied resulting in complete follow-up data on 730 patients. The inpatient mortality rate was 5.8% while that at 6 months follow up was 19%. By this time 54% of hip fracture patients were living in Nursing Homes. The number of patients taking only calcium / vitamin D was 4%, a bisphosphonate alone 6%, while the use of both had risen dramatically to 16%.

Conclusions: To our knowledge this is the largest reported study documenting the epidemiology, demography and short-term follow-up of hip fractures in an elderly Irish population. Such data is essential to appropriately plan for the impending national health crisis consequent to the predicted dramatic rise in the elderly population with bone fragility. In a short time, we have achieved significant success in improving awareness and treatment of osteoporosis in the elderly following hip fracture.

Aim: We evaluated the Vancouver system of classiþcation and treatment of Periprosthetic fractures. Methods: There were 24 consecutive patients, 17 males and 7 females with a mean age of 78.9 yrs (range 67–88). Two type A fractures were both of the AG type and unstable, were revised with a cemented Exeter stem reinforced with strut grafts. Of the nineteen patients type B fractures, one a B1 that was þxed with the cable grip system and strut graft. The B2 fractures were revised with a long stem cemented Exeter component reinforced with strut grafts. All the B3 fractures were revised with a long stem uncemented component with strut grafts. Of the three type C fractures two were þxed with the plate and cable grip system and the third with a supracondylar nail. Results: The follow up was regular, mean duration being 18.5 months (range 6–26). The review was both clinical using the Harris Hip Score (HHS) and radio-graphic.22 patients had a good result with a mean HHS of 82.7 (range 80–86.4). Two patients had a poor result with a mean HHS of 70 (range69–71). These attributed to progressive Parkinsonñs disease and a loose contra-lateral Hip Replacement. Conclusions: The Vancouver classiþcation system is the only one of its type to be subjected to psychometric testing and show substantial agreement. Based on it appropriate treatment of each fracture can be instituted. It allows a more rational approach to treatment for fracture þxation but also addresses associated problems. Our experiences and results point to this way of treatment.

In Ireland and the United Kingdom, there were 22 deaths as a direct result of blood transfusion during the period October 1996 to September 1998. Added to this there were 366 complications directly related to blood transfusion. With the introduction of a Haemovigilance Nurse and changing surgical personnel we were anxious to review transfusion rates in our Regional Orthopaedic Centre for the period January 1999 to July 2000.

All patients undergoing primary or revision arthroplasty in our Regional Orthopaedic Unit during the study period were reviewed. 459 primary or revision arthroplasties were performed in the study period.

Prior to the introduction of a Haemovigilance Nurse, transfusion rates for primary arthroplasties averaged 1. 41 units/patient, with 74% of patients being transfused. After the introduction, transfusion rates averaged 0. 51 units/patient, with 31% of patients being transfused.

Prior to the introduction of a Haemovigilance Nurse revision arthroplasties averaged 2. 5 units/patient, with 100% of patients being transfused. After the introduction transfusion rates averaged 1. 2 units/patient, with 62% of patients being transfused. There was a statistically significant difference between transfusion rates prior to and post the introduction of a Haemovigilance Nurse (p< 0. 005).

In the current climate post the Finlay Tribunal in Ire-land and the resultant increased public awareness, transfusing a patient without justifiable cause is no longer acceptable. Patients in this Unit are now transfused according to clinical needs and accurate measurement of intra-operative and post-operative blood loss, compared to their calculated maximum allowed blood loss (MABL). Our new transfusion protocol is working well without compromising patient care.

In Ireland and the United Kingdom, there were 22 deaths as a direct result of blood transfusion during the period October 1996 to September 1998. Added to this mortality, there were 366 cases of complications directly related to blood transfusion.

With the introduction of a Haemovigilance Nurse, changing surgical personnel and an increased public awareness of the potential hazards of transfusion, we were anxious to review whether transfusion rates have changed in our Regional Orthopaedic Centre for the period January 1999 to July 2000

All patients undergoing primary or revision arthroplasty in our Regional Orthopaedic Unit during the study period were retrospectively reviewed.

459 primary or revision arthroplasties were performed in the study period. Prior to the introduction of a haemovigilance Nurse, from the period January 1999 to October 1999, transfusion rates for primary arthroplasties averaged 1.41 units/patient with 74% of patients being transfused. After the introduction of a haemovigilance Nurse, from November 1999 to July 2000, transfusion rates for primary arthroplasties averaged 0.51 units/patient, with 31% of patients being transfused.

Prior to the introduction of a haemovigilance Nurse revision arthroplasties averaged 2.5 units/patient, with 100% of patients being transfused. After the introduction of the haemovigilance Nurse transfusion averaged 1.2 units/patient, with 62% of patients being transfused.

There was a statistically significant difference between transfusion rates prior to the introduction of a Haemovigilance Nurse and new surgical personnel and the period after their introduction (p< 0.005).

In the current climate post the Finlay Tribunal and the resultant increased public awareness, transfusing a patient without justifiable cause is no longer acceptable.

Patients in this unit are now transfused according to clinical needs and accurate measurement of intra-operative and post-operative blood loss, compared to their calculated maximum allowed blood loss (MABL). The changing transfusion rates seen in our Unit correspond to the introduction of a Haemovigilance Nurse and a change in surgical personnel. Our new transfusion protocol is working well without compromising patient care.