Sub-trochanteric fractures are challenging to treat due to various anatomical and biomechanical factors. High tensile forces contribute to the challenge of fracture reduction. Intramedullary nailing has become the treatment of choice. If anatomical reduction is not achieved, any mal-alignment will predispose to implant failure. Open reduction with cerclage wires can add to construct stability and improve the quality of reduction. There is no consensus or classification to guide surgeons on when to perform open reduction, which is often performed intra-operatively when closed reduction fails often with no planning. This can lead to intraoperative delays as theatre staff would not have prepared the correct equipment necessary for open reduction The purpose of this study was to assess outcomes of closed and open reduction of traumatic sub-trochanteric fractures treated with intramedullary nailing and to propose a new classification system to dictate management.Background
Objectives
Hip fractures are estimated to cost the NHS over £2 billion per year and, with an ageing society, this is likely to increase. Rehabilitation and discharge planning in this population can be met with significant delays and prolonged hospital stay leading to bed shortages for acute and elective admissions. Planning care for these patients relies on a multidisciplinary approach with allied healthcare providers. The number of hip fracture patients in our hospital averages between 450–500/annum, the second largest number in the North West. The current average length of stay for the hip fracture patients is 22.9 days. We evaluated the impact and performance of a pilot early supported discharge service (ESD) for patients admitted with a hip fracture. The pilot period commenced 22 September 2014 for 3 months and included an initial phase to set up the service and supporting processes, followed by the recruitment of 20 patients during the pilot period. The length of stay and post-discharge care was reviewed. The journey of 20 patients was evaluated. The length of stay was dramatically reduced from an average of 22.9 days to 8.8 days in patients on the ESD pathway. Family feedback showed excellent results with communication regarding the ESD pathway and relatives felt the ESD helped patients return home (100% positive feedback). Prolonged recumbency adversely affects the long-term health of these patients leading to significant morbidity such as pressure sores, respiratory tract infections and loss of muscle mass leading to weakness. Mortality is also a significant risk for these patients. Longer hospital stays lead to disorientation, institutionalisation and loss of motivation. Enhancing self-efficacy has been shown to improve balance, confidence, independence and physical activity. This pilot has proven that the Fracture Neck of Femur ESD service can significantly reduce the length of hospital stay and also deliver excellent patient and family feedback. The benefits of patients with a lower length of stay, with effective rehabilitation in hospital and within the home, will provide significant benefits to the Wirral healthcare economy.
The aim of the study was to assess the clinical, radiological and paedobarographic outcome following modified Silver’s McBride’s procedure, in the treatment of Hallux Valgus. Between 1997 and 1999, Modified Silver’s McBrides procedure for Hallux Valgus was performed on 38 foot in 28 patients (18 unilateral and 10 bilateral). The median age was 60 years. The median follow up was 26 weeks. Clinical outcome measures consisted of pain, deformity, mobility, walking ability and shoe wear. Radiological outcome measures were Hallux Valgus angle, Intermetatarsal angle, 1st to 5th Metatarsal distance, 1st to 2nd metatarsal distance, and the DMAA (Distal Metatarsal Articular Angle). Paedobarographic (Musgrave) outcome of peak pressure, total force, time from heel strike to toe lift off post operatively were analysed. Preoperative visual analogue pain score was 5–8 and 0–4 postoperatively (p<
0.001). 34 feet had pain on walking preoperatively and only 11 had pain post-operatively. 12 were wearing special shoes pre- operatively and 5 post-operatively. Hallux Valgus angle was 34 pre-operatively and 19 post-operatively (p<
0.001). IMT angle was 14.53 pre-op and 10.88 postop (p<
0.001). 1st-5th MT distance was 67mm pre- op and 63mm post-op (p=0.001). 1st-2nd MT distance was 15 pre-op and 10 post-op (p=0.004). DMAA was 24.7 degrees. 21 foot an obliquity of the 1st tarsometatarsal joint was seen indicating an anatomical cause of metatarsus varus. Foot pressure studies showed a peak pressure of 1.37kg/cm2 , heel to toe off- time was 936.9ms and maximum load was 65.2 kg. There were 3 cases of superficial wound problems. One patient developed Hallux varus deformity, with no functional disability.
To report the experience with the new device, the Long Proximal Femoral Nail (Long PFN) in patients with impending pathological femoral fractures to identify the advantages and complications associated with its usage. This is the first in the series on the use of Long PFN for patients with femoral metastases. Between April 2000 and September 2001, twenty-five consecutive patients with femoral pathological lesions were prophylactically stabilised using Long PFN. The nailings were performed using a percutaneous closed technique. Lateral femoral Line (LFL) technique was used for location of the entry point and easy insertion for the nail. Only the proximal one-fifth of the femur was reamed to accommodate the 17 mm diameter of the proximal part of the nail. We had technical problems in three patients. The overall mobility of the patients improved in twenty patients and the mobility remained the same as pre-operative level in five patients. Good to excellent pain relief achieved in eighteen patients. The pain relief was fair in five patients and poor in two patients. We had no mechanical failure of the implant in our series. Long PFN, a modified reconstruction nail, can be inserted percutaneously and has an easy operation technique. Our early experience with Long PFN in the management of impending femoral fractures has been favourable.
A fifty year old lady with history of rheumatoid arthritis (RA) for 24 years and COPD for 10 years was admitted for investigation of persistent chest infection and for the control of RA flare-up. She was on Sulphasalazine, NSAIDs and had completed a course of gold injections and on admission started on methotrexate, folic acid, Calcium, bisphosphonates and alendronate. Urinanalysis was positive for Bence Jones’ Proteins (BJP). Four days after admission patient developed spontaneous pain in the right thigh with inability to move the right leg. Radiographs showed a supracondylar femoral fracture through a lytic lesion, which was stabilised with a Distal femoral nail. At surgery bone quality of right femur was found to be very poor. Radiographs of the left femur showed a lytic lesion in the subtrochanteric region, which was stabilised prophylactically with a Proximal Femoral Nail. Histopathological examination of the marrow reamings from right femur showed no neoplastic changes and from left femur showed occasional plasma cells. 24 hour urinanalysis showed BJP of 0.22g/hour and protein electrophoresis showed monoclonal antibodies. Bone marrow biopsy was performed which showed only reactive cells. A week later 24 hour urine BJP was down to 0.13g/hour. At three weeks, symptoms of RA were under control and the protein electrophoresis showed no monoclonal banding. Chest infection resolved with appropriate antibiotics. Computerised Tomography of chest showed bronchiectasis with no evidence of neoplasm.
A 52 year old male presented with a pathological subtrochanteric femoral fracture secondary to multiple myeloma. While stabilising the fracture with a Long Proximal Femoral Nail (PFN) distal femur fracture occurred, while introducing the distal locking screw, which was fixed with two cables. Partial weight bearing was allowed for the first six weeks. Three months after surgery the distal static locking screw broke. Eighteen months post surgery patient developed sudden spontaneous right hip pain and was treated with further chemotherapy and radiotherapy. Radiographs showed the fracture had not healed but there was no evidence of implant failure. Two years later patient presented with sudden increase in right hip pain with inability to walk. Radiographs showed that the nail had broken at the proximal hip screw hole. At revision surgery, with difficulty the broken distal locking screws were removed and the broken nail was removed by pushing it from below through the knee. The non union was stabilised with another long PFN. At four months post revision surgery there were radiological signs of bone healing and patient had no symptoms.
This is the first reported incidence of failure of long PFN in a pathological femoral fracture stabilisation.
Between April 1999 and December 2001 forty-one patients (forty-five femora) with metastatic lesions in the proximal femur involving intertrochanteric and subtrochanteric regions were stabilised with Proximal Femoral Nail (PFN). Thirty-eight patients (forty-two femora) were followed up for a mean period of 20 months (range 3 weeks to 35 months). There was an overall increase in mobility in 60% of the patients and the rest remained the same. Mean Preoperative Visual analog scale rating for thigh pain was 8.1 versus 3.4 for postoperative score (p<
0.01). There were no complications with respect to PFN. There were three post operative complications – chest infection, superficial wound dehiscence and pulmonary embolism. All these complications resolved without any further deterioration. Since these lesions do not usually heal well a cephalomedullary device is ideal to withstand long-term cyclic loading. Minimal operative trauma, mechanical stability, early mobilisation, pain relief and short hospital stay are the advantages of PFN in stabilising impending fractures of the proximal femur.
Hips and knees are commonly replaced joints for which several types of prostheses are available. As newer versions of the prostheses are brought in, older versions are phased out. When revision is for an isolated component failure as in, wear of acetabular cup, isolated revision of the acetabular cup is an accepted procedure. If the plan is to revise just the isolated component then that particular model of prosthesis should still be available. In an attempt to check the availability of revision components for joint replacements we wrote to ten prostheses manufacturers enquiring the availability of prosthetic components. To have a comparison, we also wrote to eighteen leading car manufacturers enquiring about the duration and any guarantees on the availability of car spare parts. From our survey we found that the availability of the revision implants was satisfactory in that all the prostheses manufacturers were eager to provide as much assistance as possible. The draw back is that there are no regulations to ensure the availability of these prosthetic components for any length of time after discontinuation of a particular model. The car manufacturers are not under any obligation to provide spare parts for discontinued models. The argument put forward by some manufacturers for providing spare parts up to ten years from discontinuing the model was that “it would not reflect well on the company” if it were for any lesser length of time.
Up to 75% of patients develop metalwork related problems following ankle fracture fixation and require further open surgery to remove them. This second procedure can lead to significant morbidity. To minimise these complications, we developed a technique, for removing the metalwork percutaneously. This technique was used in 12 patients with metalwork problems related to malleolar implants. The majority of problems occurred with the distal fibular plate and the screws. One stab incision was placed mid way between every two screws so that two screws could be removed though one incision. The plate was stripped from the distal fibula using a narrow osteotome and extracted through the distal or proximal stab wound. Lag screws were also removed through an anterolateral stab incision. When we were unable to palpate the screw head, we used a guide wire under image intensifier to locate the screw head and railroaded a cannulated screwdriver over the wire to lock into the head of the screw. Medial malleolar screws were removed in a similar fashion. The technique was undertaken as day case surgery. No complications were encountered. All patients remained symptom-free postoperatively. We conclude that percutaneous removal of metalwork around ankle joint is a safe and effective technique, allowing the patient to quickly regain their preoperative level of activity.