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.
We reviewed a consecutive series of 241 uncemented, porous-coated anatomic (PCA) hip replacements at an average follow-up of five years (2 to 9). Of these, 32 had failed (13%), 26 at the acetabular component (11%) and six at the femoral component (2%). Acetabular failure was associated with local osteolysis and excessive polyethylene wear in 20 cases: in these histological examination showed giant macrophages incorporating numerous particles of high-density polyethylene. The femoral failures were related to a poor intramedullary fit with subsequent subsidence. Using the recommendation for revision as the end point, the cumulative survival rate for prostheses was 91% at six years (95% CI +/- 6%), 73% (+/- 11%) at seven years, and 57% (+/- 20%) at eight years. The result of uncemented PCA hip replacement is satisfactory up to six years, but then increasing failure of the acetabular component appears to be due to polyethylene wear, leading to osteolysis, loosening and component migration. At first, failure is often asymptomatic; routine follow-up of uncemented hip replacement is essential, especially after five years.
We made a prospective study of the incidence of fatal pulmonary embolism in patients after total knee replacement with no prophylactic anticoagulation. There were 499 consecutive patients having 527 knee replacements. They all wore anti-thromboembolic stockings and were mobilised 48 hours after surgery. No patient was lost to follow-up. One patient died of pulmonary embolism 22 days after operation. There were no other deaths within three months of operation. The incidence of fatal pulmonary embolism was 0.19% (95% confidence interval: 0 to 0.6%). Fatal pulmonary embolism is rare after total knee replacement without prophylactic anticoagulation and the routine anticoagulation of these patients is of doubtful value.
Exposure to blood is a hazard for all surgeons. We assessed the incidence of glove perforation and needlestick injury from a new blunt taperpoint needle designed to penetrate tissues other than skin with the minimum of force. We performed a prospective, randomised trial comparing the incidence of perforations of surgical gloves with the new needle and a standard cutting needle during wound closure after hip arthroplasties. There was at least one glove perforation in 46 of 69 such procedures (67%). The use of the taperpoint needle produced a significant decrease in perforations (p = 0.049).
Isolated wear of the polyethylene tibial component led to failure in five of a series of 108 uncemented porous-coated knee replacements. The clinical features included pain, effusion and instability with progressive varus deformity. In all cases there was extensive wear on the medial side of the polyethylene surface of the prosthesis. The mechanism of such wear is complex, being due in part to the unconstrained nature of the joint and the incongruity of its surfaces. Other design characteristics may have contributed.
Dislocation is the most frequent serious complication following total hip replacement for subcapital femoral fracture. We report a prospective study, using matched groups, which compared the range of hip movement following hip replacement for arthritis and for fracture. The range of movement was significantly greater in the fracture group. We suggest that this is a predisposing factor for dislocation.
Fractures of the femoral shaft are generally considered to affect young patients, but we have reviewed 24 cases in patients over 60 years who have been treated by locked nailing, usually by closed methods. Most were women with low-velocity injuries, but despite this, 14 fractures were significantly comminuted. The complication rate was 54% with a peri-operative mortality of 17%. Most complications were the general ones of operating on elderly patients. Specific complications included: fractures below an abnormal hip, proximal fracture related to the nail and poor purchase in the distal femur. In all survivors, the femoral shaft fractures united satisfactorily, and the fixation allowed early mobilisation. The locking nail appears to be an effective method of managing femoral shaft fractures in the elderly patient.
