Areal BMD (aBMD) is relatively poor at discriminating those patients at risk of hip fracture. This study tested the hypothesis that a measure of bending resistance, cross section moment of inertia (CSMI) and section modulus, derived from 3D peripheral quantitative computed tomography (pQCT) images made ex-vivo, would discriminate cases of hip fracture from controls better than areal bone mineral density.

The biopsies were from (n = 20, F) subjects that had suffered an intracapsular hip fracture. The control material (n = 23, F) was from post-mortem subjects. Serial pQCT 1mm thick cross-sectional images using the Densiscan 1000 pQCT clinical forearm densitometer were obtained, and matched for location along the neck. The image voxels were converted to units of bone mass, which were then used to derive the mass weighted CSMI (MWCSMI), section modulus and areal bone mineral density, (see Table).

The aBMD results showed that the difference between the means of the fracture cases compared to the controls was 9.9% (−0.061g/cm²; +0.0055g/cm², −0.127g/cm²; 95% confidence interval). However, the MWCSMI was 29.5% (−5966mm⁴; −8868mm⁴,−3066mm⁴; 95% confidence interval) lower in the fracture cases compared to the controls, while section modulus was 32.5% (−242mm³; −133mm³, −352mm³ 95% confidence interval) lower. When presented as Z scores the fracture cases had considerably lower section modulus Z scores (mean −1.27 SD, p=0.0001) than aBMD – Z scores (mean −0.5 SD, p=0.07). To simulate the forces experienced during a sideways fall, the model’s neutral axis was rotated by 210°. The results were similar for section modulus to those at 0°.

This study suggests that biomechanical analysis of the distribution of bone within the femoral neck may offer a marked improvement in the ability to discriminate patients with an increased risk of intracapsular fracture. Progress towards implementing this form of analysis in clinical densitometry should improve its diagnostic value.

Introduction and Aims: Immune suppression induced by blood transfusion may be a determinant in the development of post-operative infectious complications. This study was to determine if blood transfusion was an independent risk factor for mortality and wound infections after hip fracture surgery.

Method: A retrospective cohort study analysing the prospectively collected data for 3571 hip fracture patients undergoing surgery over the last 15 years at one institution. Out of these 1068 patients underwent blood transfusion. Mortality was related to whether the patient was transfused, and adjusted for confounding predictors of mortality (age, sex, pre-operative haemoglobin concentration residential status, ASA grade and mobility).

Results: 3461 cases remained after 290 (7.7%) cases had to be excluded for missing data in the multivariate analysis. The mortality values at 30,120 and 365 days in the transfused group were 95 (8.9%), 247 (23.1%) and 381 (35.7%), whereas corresponding values in the non-transfused group were 181 (7.2%), 374 (14.9%) and 626 (25.0%). This difference at six and 12 months was statistically significant. With adjustment for confounding variables with a Cox regression mode the hazard ratio for mortality at one year was 1.11 (95% CI 0.96–1.29, p value 0.17). Superficial infection occurred in 22 patients (2.0%) in the transfused group and there were 10 deep infections (0.9%). This was not a statistically significant difference from the incidence in the non-transfused group, 48 cases (1.9%) and 15 (0.6%) respectively.

Conclusion: In conclusion, although it appears that blood transfusions are associated with an increased mortality, when this is adjusted for baseline characteristics and confounding variables, the difference is not statistically significant. Neither was there an increased incidence of wound infection in the transfused patients.

Introduction: Despite its common occurrence there is still controversy regarding the choice of treatment for the displaced intracapsular hip fracture in the elderly patient. Aim: To compare internal þxation and hemiar-throplasty in a prospective randomised controlled trial. Method: 455 patients aged over 70 years with a displaced intracapsular hip fracture were randomised to either hemiarthroplasty or internal þxation. Results: Internal þxation has shorter length of anaesthesia (p< 0.0001), lower operative blood loss (p< 0.0001) and lower transfusion requirements (p< 0.0001). Additional surgical procedures were required in 90 patients (39.8%) treated by internal þxation and 12 patients (5.2%) in the arthroplasty group. There was no statistical difference in mortality at one year (p=0.91), however there was a trend to improved survival for the older less mobile patients treated by internal þxation. There was no statistical difference in pain and mobility. Limb shortening was more common after internal þxation (p=0.004). Conclusion: We recommend that displaced intracapsular fractures in the elderly should generally be treated by hemiarthro-plasty, but internal þxation may be appropriate for the frail less mobile patient.

The displaced intracapsular fracture in the elderly has frequently been termed the ‘unsolved’ fracture because of the debate as whether the femoral head should be preserved or replaced. To answer this question 413 patients aged over 70 years with a displaced intracapsular fracture were entered into a prospective randomised trial, to treatment with either an uncemented Austin Moore hemiarthroplasty or reduction and fixation with three cancellous screws. Pathological fractures, Paget’s disease and rheumatoid arthritis patients were excluded. Analysis of pre-operative characteristics of patients showed there was no significant difference between the two groups. Mean follow-up of surviving patients was 827 days.

Internal fixation resulted in a reduced mean operative time (22 versus 47 minutes), operative blood loss (23ml versus 171mls) and transfusion requirements. There was no significant differences in the incidence of post-operative complications between treatment other than and increased risk of wound sepsis for arthroplasty (4/207 versus 0/206 deep wound infections). There was a consistent tendency to a marginally lower mortality following internal fixation (15.5% versus 12.7% at 90 days).

Six patients in the arthroplasty group required revision, four for loosening, one for sepsis and one for fracture around the implant. Non-union occurred in 64(31%) of those treated by internal fixation. Most of these patients had conversion to arthroplasty. Other complications of internal fixation requiring secondary operations were avascular necrosis (4 cases), fracture below implant (1 cases) and removal for painful screw heads (7 cases). Functional assessment of the survivors at one year from injury showed no significant difference between the two groups for pain or change in mobility.

These results indicate that arthroplasty for displaced intracapsular fractures in the elderly is associated with a reduced re-operation rate but at the expense of a marginally increased mortality.

We assessed 882 patients presenting with a proximal femoral fracture by a new mobility score and by a mental test score, to determine which was of the most value in forecasting mortality at one year. Both scores gave a highly significant prediction, but the mobility score had a greater predictive value and is easier to perform.

We studied prospectively a consecutive series of 765 patients with proximal femoral fractures to determine if the time interval between injury and surgery influenced the outcome. Patients in whom surgery had been delayed for medical reasons were excluded. We divided the patients into four groups depending on the delay to surgery. Analysis of pre- and postoperative characteristics showed the groups to be similar. Mortality in the four groups was not significantly different but morbidity was increased by delay, particularly with regard to the incidence of pressure sores.

We have determined the quality-adjusted-life-years and cost of such in several types of hip fracture and various treatment options. Operative treatment proved more cost-effective than other methods for displaced subcapital fractures and for extracapsular fractures. For undisplaced subcapital fractures conservative treatment was almost as cost-effective as surgery.

The results of treatment in 242 patients with intracapsular fractures of the neck of femur treated with Garden screws are presented with reference as to whether the screws were crossed or parallel. The incidence both of nonunion and of avascular necrosis was less in those fractures treated with parallel screws. The outcome was also superior if the reduction was good.