Aims

Hip fractures are a major cause of morbidity and mortality, and malnutrition is a crucial determinant of these outcomes. This meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with a hip fracture.

Cite this article: Bone Joint Res 2023;12(8):494–496.

Introduction. Orthopaedic rehabilitation of adolescences and young adults with high dislocation of the femur is rather challenging. The role of palliative salvage procedures is controversial enough in the cohort of patients. Materials and Methods. Treatment outcomes of 10 patients with congenital hip dislocation were analyzed. Mean age at intervention was 17,8 years (15–22). The grade of dislocation were assessed according to Eftekhar: type C − 2, type D − 8. The mean baseline shortening was 4.7±0.36 cm. All subjects underwent PSO with the Ilizarov method. Another osteotomy for lengthening and realignment was produced at the boundary of the upper and middle third of the femur. The mean time in the Ilizarov frame was 5.3 months. Results. The mean follow-up was 2.6±.1 years (range, 15 to 32 years). Limb shortening of 1 cm to 1. 1. /. 2. cm was observed in four cases. Functional outcomes according to d'Aubigne-Postel were: Pain 4,4±0,15 points. ROM − 4,1±0,3 points. Walking ability − 4,5±0,2 points. Two cases had good results (15–17 points), and seven patients had fair outcomes (12–14 points). A poor result (7 points) was recorded in one female patient 28 years after PSO followed by THA. Conclusions. Hip reconstruction with the Ilizarov method can be used in specific clinical situations as an alternative salvage procedure to delay THR in young patients with high dislocation of the femur

Bowel management following joint replacement is often neglected leading lot of patient distress, with the advent of the enhanced orthopedic rehabilitation program, there is a need of a guideline to ensure prompt and quick recovery of bowel habits before discharge. Our aim was to identify the incidence of constipation in joint replacement patients, to evaluate the current practice of bowel management and formulate a protocol for management of constipation to improve the practice. We conducted a prospective study of 50 patients who underwent joint replacement procedures at our institute between September and October 2015. Following initial audit, we formulated a protocol for bowel management, and performed a re-audit by collecting a prospective data of 50 patients. The statistical analysis was done and calculating the mean and standard deviation for continuous variable and Fischer's exact test was used and significance level was set at 0.05. Incidence of constipation was 88% and laxatives were prescribed in 42%. More importantly, there was no correlation between constipation and pre operative fasting (p Value 0.33), post operative fasting (p Value 0.1822), type of surgery (p value 1.00) and type of anaesthesia (p Value 0.27). Following introduction of bowel protocol the laxative prescription increased to 98% (Prophylactic in 81%), consequently the incidence of constipation reduced to 18%. Implementing bowel protocol significantly will improve the patient care and reduce the rate of complications

The Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training. All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded. 53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000). Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training

This study aimed to determine the major diagnoses and needs of children in Rwanda with musculoskeletal conditions to enable the Rwandan government to begin to plan orthopaedic and rehabilitation services. BACKGROUND. When faced with developing orthopaedic services for children in Sub-Saharan Africa, there is little objective evidence-based data on the magnitude and type of services needed. Rwanda is a small country that is in the process of developing orthopaedic and rehabilitation services, and its Ministry of Health supported a survey that would provide information necessary for planning such services. METHODS. A national survey of musculoskeletal impairment (MSI) prevalence was undertaken. Of a population of 8.4 million, 8368 people were enumerated. Four thousand one hundred thirty-four were aged 16 years or less. Cases who failed a screening test for MSI were examined, allocated a diagnostic category, and assessed as to treatment needed. RESULTS. Of 4134 people aged 16 years or less who were enumerated, 3526 (85%) were screened and 91 had MSI, giving a prevalence of MSI among children of 2.58% (95% confidence interval; 2.06-3.10). Twenty-three percent of MSIs were a result of congenital deformity, 14% neurologic conditions, 12% trauma, 3% infection, and 46% other acquired pathology. Of the MSIs, 56.7% were mild, 37.8% moderate, and 5.6% severe. Extrapolated treatment needs suggest that 2% of Rwandan children (approximately 80,000) need orthopaedic physical therapy, 1.2% (50,000) need orthopaedic surgery, and approximately 10,000 need orthopaedic appliances. CONCLUSIONS. These results will be of use in planning future paediatric orthopaedic services in Rwanda, and for comparative studies in other low-income countries

Early prediction of outcome following hip fracture surgery would save valuable time towards arranging post-op rehabilitation benefiting the patient and health economics. The study aim was to develop a prognostic scoring system for elderly hip fracture patients, which on admission is able to predict rehabilitation needs at discharge based on pre-injury factors. A simple and fast prognostic scoring system was developed based on age, pre-injury level of “independence in activities of daily living” (Katz), medical co-morbidities, cognitive functioning (MMSE) and presence of a caregiver, to predict rehabilitation needs at discharge (0–8 points). Rehabilitation options were direct return to pre-injury living situation (group 1), transfer to an orthopaedic rehabilitation unit for a period shorter than 3 months (group 2), or transfer to a psychogeriatric or orthopaedic rehabilitation unit for a period longer than 3 months (group 3). Rehabilitation needs as predicted and the clinical decision by independent, blinded observers were compared. The score was validated in a prospective study on a consecutive cohort of 77 hip fractured patients. Overall positive predictive value (PPV) of the prognostic score was 0.87 (CI 0.77–0.93), a marked improvement compared to previously published scoring systems with a PPV of 0.68 (CI 0.55–0.79). PPV per group (0.80, 0.92, 0.87) was highest for the most critical groups 2 and 3. In-hospital mortality was 1.3 percent. The average length of hospital stay (LOS) was 11.4 days. Using the score fast and reliable prediction of rehabilitation needs could be made already on admission gaining maximum time for the preparation of adequate discharge destinations improving care and reducing costly LOS

A longer stay in the hospital after primary total hip replacement is consistent with an increased morbidity and slower recovery for patients. In addition, it is among the more costly aspects of a total joint replacement. A process, which reduces the length of stay following this procedure and synchronically maintains the high standards of safe care would certainly improve the clinical practice and provide financial benefits. Our objective was to evaluate the efficiency of a holistic perioperative, accelerated recovery programme following this procedure and in particular to assess its impact in the shot term patient’s recovery, morbidity, complications, readmission rate and cost savings for the NHS. Eighty-nine patients participated in our rapid recovery programme, which is a comprehensive approach to patient care, combining individual pre-operative patient education, pain management, infection control, continuous nursing and medical staff motivation as well as intensive physiotherapy in the ward and the community. Forty-eight male and 41 female patients with an average age of 69 (range-50 to 87) underwent a total hip replacement in an NHS District General Hospital. The average BMI was 28 (range-18 to 39) and the average ASA 2.3 (range-1 to 4). The procedure was performed by 3 different surgeons using the same operative standards. A standardised post-operative protocol was followed and the patients were discharged when they were medically fit and had achieved the ward physiotherapy requirements. They were then daily followed up by a community orthopaedic rehabilitation team in patient’s own environment as long as it was required. The average length of stay was reduced from 7.8 days to 5. There was no increase in complications–or readmissions rate while there were significant cost savings. The waiting list for this surgery was reduced and the patient’s satisfaction was high. The rapid recovery programme for primary total hip replacement surgeries has been proved to be an efficient method of reducing the length of stay in hospital and consequently the financial costs while it ensures the safe and effective peri-operative management of patients

In many fields, such as orthopedics and rehabilitation, measurement of segment orientation or three-dimensional (3D) joint rotation is highly required. However, even if laboratory systems (e.g., optical-based tracker) are enough accurate for human movement measurement, they have some limitations (e.g., cost, complexity, capture volume) that exclude their uses in routine practice. Recently, our group proposed an original system fusing a low level magnetic tracker (Minuteman®, Polhemus, USA) and 3D gyroscopes (Physilog®, BioAGM, CH) to measure segments orientation. These complementary devices were selected with the aim to provide real time orientation in clinical environment and without restriction on the acquisition duration. The objective of the present study was to assess the performances of this new system in routine clinical applications. For this evaluation, five healthy young men were enrolled and the orientation of their left thigh was considered. They were asked to perform two times a long scenario (14 min) which included various postures (standing, sitting and lying) and activities (e.g., walking and stairs climbing). These activities were realized both, in the vicinity and far from the magnetic source. Additionally, different metallic objects were inserted and moved in the capture volume to simulate assisted clinical applications. An optical motion capture system (VICON®, UK) was used as reference. In the absence of magnetic distortion and independently of the activity, we obtained a RMS orientation error of 1.2°. Generally, during distortion periods we obtained a slow growing orientation error of about 0.1°/s whatever the activity. In conclusion, the proposed system provided an accurate and real-time measurement of orientation in a large capture volume over a long duration. Furthermore the system performances were tested in an environment including representative distortions of routine clinical uses. In combination with a functional calibration, this system was very promising for routine measurements of 3D joint rotations

Literature suggests that joint orthopaedic and geriatric care, and geriatric orthopaedic rehabilitation units, would provide best care for fractured neck of femur (NOF) patients. These are often elderly frail patients with concurrent illnesses and co-morbidities who also have a fracture. There is to date no quantitative data. This completed audit quantifies the care provided on the orthopaedic wards in the first phase solely by orthopaedic team, and in the repeat phase with additional regular geriatric input from an orthogeriatric senior house officer (SHO) and consultant geriatrician ward rounds. A retrospective audit of fractured NOF patients admitted to acute orthopaedic wards under orthopaedics and treated operatively. The first phase analysed 72 patients with sole orthopaedic care. The repeat phase analysed 25 patients after the introduction of an orthogeriatric SHO and geriatric ward rounds. The first audit phase of orthopaedic care alone found that 50% of patients were reviewed each day of the first post op seven-day week. The mean number of reviews in the post-op week was three. A total of 58% patients were operated on the next day. A minority never had post-op bloods or x-rays prior to discharge from the acute bed. Ad hoc medical input by referral occurred in 50% of patients. The repeat audit of combined orthogeriatric care found that 75% of patients were reviewed each day in the post-op week. The mean number of reviews in the post-op week rose to five. Similar to the first phase, 59% proceeded to next day surgery with combined care. All patients had timely bloods and x-rays before discharge from the acute bed. Medical input rose to 80% due to regular ward rounds, and ad hoc referrals decreased in quantity whilst increased in quality. Length of stay and mortality were reduced. The clinical risk of fractured NOF patients was reduced on the appointment of an orthogeriatric SHO in combination with formal reviews by consultant geriatrician. Further models of care are being evaluated. This audit adds evidence that joint care is better for these usually elderly and co-morbid patients

Introduction: Each year millions of people are treated for hip, knee or foot surgery which require rehabilitation programs that typically involve limited or controlled weight bearing on an affected limb. Weight bearing reduces edema & facilitate rapid rehabilitation. Current weight-bearing instruction protocols involve non-quantitative guidelines, based on the patient’s amount of discomfort while walking or subjective perception. However, the interpretation of these instructions is inaccurate and subjective, and varies among clinicians and patients. New biofeedback technology concepts are beginning to be implemented in the rehabilitation process. The Smart-Step system is a new weight bearing monitoring system that assists clinicians and physical therapists to accurately assess, train and monitor patients’ weight bearing capabilities. Purpose: To assess the effectiveness of the SmartStep system in guiding weight bearing restrictions, and to assess the effectiveness of the SmartStep system as a tool to reeducate full weight bearing. Material and Methods: 8 Patients in the Orthopedic rehabilitation department & 5 patients in the orthopedic physiotherapy out-patient clinic, post orthopedic surgery with FWB instructions were randomly divided into Study & Control groups. During treatment, the patients were trained by the PT in FWB according to the instruction of the surgeon. Data of age and body weight was collected from all patients. Patients in both study groups used the SmartStep System. This system consists of an in-shoe inflatable insole, pressure sensors and a control unit for data storage. The control unit provides also an audio signal whenever the patient was bearing body weight at a recommended and pre-calibrated level. Results: The mean age and body weight were 62±12 years and 76±15 kg in the study group and 65±15 years and 70±13 kg in the control group. Data obtained in both groups (in kg) during the pre-test and during the gait tests was converted into percentage of the patients BW. The means of the differences between the pre-test results and the gait test results in both groups were 9 + 6.7% and 1.5 + 6% in the study and control group, respectably (p=0.0002). Conclusions: The new Smartstep system was proved to be a useful tool in assisting gait rehabilitation since its biofeedback system enhances and improves weight bearing over the affected limb in cases where FWB is recommended

We studied 217 patients with an unstable trochanteric or subtrochanteric fracture who had been randomly allocated to treatment by either internal fixation with a standard Gamma nail (SGN) or a Medoff sliding plate (MSP, biaxial dynamisation mode). Their mean age was 84 years (65 to 99) and they were reviewed at four and 12 months after surgery. Assessments of outcome included general complications, technical failures, revision surgery, activities of daily living (ADL), hip function (Charnley score) and the health-related quality of life (HRQOL, EQ-5D).

The rate of technical failure in patients with unstable trochanteric fractures was 6.5% (6/93) (including intra-operative femoral fractures) in the SGN group and 5.2% (5/96) in the MSP group. In patients with subtrochanteric fractures, there were no failures in the SGN group (n = 16) and two in the MSP group (n = 12). In the SGN group, there were intra-operative femoral fractures in 2.8% (3/109) and no post-operative fractures. There was a reduced need for revision surgery in the SGN group compared with the MSP group (8.3%; 9/108; p = 0.072). The SGN group also showed a lower incidence of severe general complications (p < 0.05) and a trend towards a lower incidence of wound infections (p = 0.05). There were no differences between the groups regarding the outcome of ADL, hip function or the HRQOL. The reduction in the HRQOL (EQ-5D_indexscore) was significant in both groups compared with that before the fracture (p < 0.005).

Our findings indicate that the SGN showed good results in both trochanteric and subtrochanteric fractures. The limited number of intra-operative femoral fractures did not influence the outcome or the need for revision surgery. Moreover, the SGN group had a reduced number of serious general complications and wound infections compared with the MSP group. The MSP in the biaxial dynamisation mode had a low rate of failure in trochanteric fractures but an unacceptably high rate when used in the biaxial dynamisation mode in subtrochanteric fractures.

The negative influence of an unstable trochanteric or subtrochanteric fracture on the quality of life was significant regardless of the surgical method.

Proximal femoral fractures have always been in the centre of attention in terms of their demand on the manpower and resources of the NHS. With an ageing population, the number of these fractures will continue to be a big part of the workload of all the Orthopaedic and rehabilitation units. Hence it is important to be aware of any definite variation in the incidence of proximal femoral fractures for appropriate planning of the available resources. We carried out a study to find out whether there is a definite variation in the incidence of these fractures. The number of operated proximal femoral fractures across 31 hospitals of North-west England and Scotland were collected on a monthly basis from 1994 to 1999. This database of 27, 000 operated proximal femoral fractures was assessed statistically. Our analysis reveals that the incidence of these fractures during December is about 17% higher than the rest of the annual mean with a 2% standard error of the mean (SEM) and in January this increase is about 22% with an SEM of 1%. These trend and pattern were observed for both intra and extra capsular fractures of neck of femur and was consistent over the five years. There was no other significant change in the incidence pattern during other months of the year. This study, one of the largest of its kind ever carried out in Britain, proves that there is an increase in the incidence of hip fractures in the months of December and January. There should be appropriate allocation of manpower and rehabilitation facilities along with a matching reduction in the elective Orthopaedic admissions during the months of December and January to tackle this seasonal variation