Aim: Intracapsular hip fractures in young adults have a significant risk of fracture healing complications. Consequently, some authors advocate urgent and/or open fracture reduction. Our aim was to analyse outcomes following such fractures with reference to influence of fracture displacement, timing of surgery and method of reduction (open/closed) on the incidence of non-union (NU) and avascular necrosis (AVN).

Methods: Specific search terms were used to retrieve relevant published studies from 1966 to May 2003.

Results: Eighteen studies involving 564 fractures were analysed. The overall incidence of NU was 50/564 (8.9%) and AVN was 130/564 (23.0%). There was a higher incidence of NU and AVN following displaced than undisplaced fractures. NU occurred more frequently after open reduction than closed reduction (10/89 [11.2%] versus 13/275 [4.7%])

There was an increased incidence of AVN after closed than open reduction but this became not statistically significant when one study with a markedly higher reported incidence of AVN was excluded.

The difference in the incidence of NU and AVN following early (< 12 hours) or late (> 12 hours) surgery was not significant for either NU or AVN.

Conclusion: Early or open reduction of these fractures may not reduce the risk of NU or AVN. There is a suggestion of a higher incidence of NU following open reduction than closed reduction. Randomised studies with two year follow-up are required to report on a larger number of patients before definite conclusions on treatment can be made.

Introduction: This study was conducted to find out whether blood transfusion was an independent risk factor for mortality and wound infection after hip fracture surgery.

Materials and Methods: A retrospective cohort study analysed prospectively collected data for 3571 hip fracture patients undergoing surgery over the last 15 years in one institution. Out of these 1068 patients underwent blood transfusion.

Results: There were no significant differences in the mortality values at 30, 120 and 365 days and in the rates of infection (superficial and deep) in the two groups(transfused and non-transfused).

Conclusion: Blood transfusion does not significantly increase mortality or infection following hip fracture surgery.

Introduction and aim There are different methods of internal fixation of intracapsular fractures of the hip of which three AO screws is one of the more popular. There have been no evidence-based publications describing the optimal position for screws. The aim was to establish the relationship between screw position and angle, and subsequent failure of union.

Method Using computer software we studied the position of AO screws in 395 consecutive patients inserted between 1989 and 2003. Follow-up was prospective and for a minimum of 100 days. The diagnosis of non-union was made clinically and confirmed radiographically.

Results The mean age of our population was 73.9 years (range 22–96). Eighty-six (21.8%) were male. Three hundred and twenty seven (82.8%) came from their own home. The mean time between fall and surgery was 37.0 hours and between admission and surgery 20.9 hours. The mean length of radiographic follow-up for those fractures that did not develop non-union was 454 days (range 94–1898). Of the 395 patients 242 (61%) fractures united and 153 (39%) fractures suffered non-union.

Radiographic analysis suggests that the position of the screws on the AP view (superior, middle, inferior or spread) did not alter the outcome significantly. However three factors were related to lower risk of non-union on the lateral view: the closer the middle screw to the center of the head (p< 0.04), the more anterior the anterior screw (p< 0.008), and the greater the ‘spread’ between the anterior and posterior screws (p< 0.005).

Conclusions We conclude that to reduce the risk of non-union with screw fixation of intracapsular fractures of the hip, in the lateral view the middle screw must be positioned as close to the centre of the femoral head as possible, and the anterior and posterior screws achieve maximal spread.

Conventional treatment for nondisplaced intracapsular hip fractures is with cannulated screws. Some authors have argued that in the older patient a hemiarthroplasty offers a better outcome even in the case of a nondisplaced fracture. We have compared the outcomes of an age, sex & co-morbidity matched cohort of 346 patients who have had their nondisplaced hip fracture treated using cannulated screws with a group of 346 patients who have had a displaced fracture treated with a hemi-arthroplasty. The average age of the patients studied was 80.8 years. All operations were carried out at Peter-borough District Hospital and the follow up data was collected as part of the hip fracture project. Operation time, hospital stay and peroperative complication rate are less for the fixation group. They also have better outcomes in terms of pain, use of walking aids and mobility scores at one year. Mortality is 4% less at one year in the patients treated with screws and this, again, is statistically significant. There is no difference in terms of residential status at one year. In patients where the fracture is initially treated with cannulated screws the reoperation rate is considerably higher (17 % versus 6%) but length of stay is less for secondary procedures. We feel that there is little evidence to justify the use of hemi-arthroplasty in nondisplaced femoral neck fractures in patients of any age.

Background: Reverse obliquity and transverse fractures of the proximal femur represent a distinct fracture pattern in which the mechanical forces displace the femur medially thus increasing the risk of fixation failure. There is a paucity of published literature in this area of trauma. This study constitutes the largest series of such fractures.

Methods: Using the hip fracture registry at this institution 101 reverse obliquity and transverse fracture patterns were identified from 3336 consecutive hip fractures. All surviving patients were followed up for 1 year.

Results: Of 100 patients treated operatively, 59 were treated with 1350 sliding hip screws (SHS), 22 were treated with 1350 sliding hip screw devices designed to resist medialization (3 sliding hip screws with trochanteric plate and 19 Medoff plates), and 19 were treated with intramedullary sliding hip screw devices (1 short Gamma nail, 9 long Gamma nails, 6 Reconstruction nails, 6 long Targon nails, 1 short Targon nail). The SHS had 4 failures (6.8%), and the intramedullary devices one failure (5.3%). Those extramedullary devices augmented to prevent medialization had higher failure rates (1 of 3 SHS with trochanteric plate and 3 of 19 Medoff plates), with combined failure rate of 15.8%.

Conclusion: The 1350 SHS and the intramedullary devices had similar failure rates of 6.8% and 5.2% respectively. Those extramedullary devices designed to prevent medialization had higher failure rates (combined failure rate of 4/22 or 18%). This is similar to the high failure rate in 950 devices reported elsewhere. This suggests that extramedullary devices attempting to combat the difficult biomechanics of these fractures are unsuccessful. Better results can be obtained by using the standard 1350 SHS or with intramedullary sliding hip screw devices.

Introduction: Treatment for ruptured Achilles tendon can be classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing); post-operative splintage can be with a rigid cast or functional brace. The aim was to identify and summarise the evidence from randomised trials of the effectiveness of different interventions.

Methods: We searched the Cochrane specialised register, MEDLINE, reference lists of articles and contacted trialists directly for all randomised and quasiran-domised trials comparing different treatment regimes for acute Achilles tendon ruptures.

Results: Fourteen trials involving 891 patients were included.

Open operative treatment compared with non-operative treatment was associated with a lower risk of re-rupture (odds ratio (OR) = 0.25, 95% confidence interval (CI) = 0.1–0.6, p=0.003) but a higher risk of other complications including infection, adhesions and disturbed sensibility (OR = 14.1, 95%CI = 6.3–31.7, p< 0.00001).

Open versus percutaneous operative surgical repair was associated with a longer operation duration and higher risk of infection (OR = 12.9, 95%CI = 1.6–105.6, p=0.02).

Patients splinted with a functional brace rather than a cast post-operatively tended to have a shorter in-patient stay, less time off work, quicker return to sporting activities and fewer reported complications (p=0.0003).

Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques and different non-operative regimes.

Conclusions: Open operative treatment significantly reduces the risk of re-rupture but has the drawback of a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay and time off work and sports.

Previous studies on the timing of hip fracture surgery provide limited and conflicting evidence as to whether early operative intervention influences length of hospital stay, functional outcome and mortality rate. The aim of this study was to determine in a large, consecutive and prospectively followed group of patients the effect of a delay to surgery other than for medical reason. Patients who met the following criteria were included in the study: 1) Fragility fracture of the proximal femur. 2) Age over 60. 3) Complete data sets. 4) Complete follow up. Excluded patients were: 1) Younger than 60 years of age. 2) Conservative fracture treatment. 3) Pathological fracture. 4) Delay from admission to surgery for any medical reason. All patients were subdivided into six groups according to the delay between admission and operation (A:1–12 hours, B:13–24 hours, C:25–36 hours, D:37–48 hours, E:49–72 hours, F:73 + hours). All patients were followed up for one year or until death. Data on the mean length of hospital stay and the discharge destination as a parameter for the functional outcome were analysed in each of the six groups. A total of 3628 patients met the inclusion criteria. The average age was 81 years. 95.2% of patients were operated on between 1 and 48 hours after the admission, and 4.8% between 49 or more hours after the admission. Reason for delay was either lack of theatre time or unavailability of a surgeon or an anaesthetist. Statistical analysis with the unpaired t-test showed a significant difference in the hospital length of stay of 21 days for patients operated within 48 hours of admission versus 32 days for patients operated after 48 hours (p The functional outcome was significantly worse in the group with a delay of more than 48 hours with only 71% of patients discharged to their own home (86% in the early group, p< 0.0001). This study provides further and conclusive evidence that early operative intervention in elderly patients with fragility fractures of the proximal femur results in a decreased hospital stay and a better functional outcome.

Background: Intracapsular hip fractures in young adults under 50 years of age have a significant risk of fracture healing complications which has led some authors to advocate urgent fracture reduction and/or open reduction. As these fractures are infrequent, limited information is available from published studies to advocate a particular method of treatment to reduce the risk of complications. The purpose of this study is to analyze outcomes following such fractures with particular reference to the influence of the degree of fracture displacement, timing of surgery, method of reduction (open/closed) on the incidence of non-union and avascular necrosis.

Methods: Specific search terms were used to retrieve relevant studies from MEDLINE, EMBASE, and CINAHL extending from 1966 to May 2003. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed.

Results: Eighteen studies with 564 fractures were identified for analysis. The overall incidence of non-union was 50/564 (8.9%) and avascular necrosis (AVN) was 130/564 (23.0%). There was a higher incidence of non-union and AVN following displaced than undisplaced fractures. Non-union occurred more frequently after open reduction than closed reduction (10/89 [11.2%] versus 13/275 [4.7%], P=0.04, RR=0.42, 95% CI: 0.19 to 0.93).

There was an increased incidence of AVN after closed than open reduction (P= 0.0005, RR = 2.77, 95% CI: 1.45 to 5.29) but this became not statistically significant when one study with a markedly higher reported incidence of AVN was excluded (P = 0.07, RR= 1.85, 95% CI: 0.93 to 3.68).

The difference in the incidence of non-union and AVN following early (< 12 hours) or late (> 12 hours) surgery was not significant for either non-union or AVN (13/110 [11.8%] versus 3/60 [5.0%], p=0.18, RR2.36, CI 0.70 to 7.97 for non-union, 15/110 [13.6%] versus 9/60 [15.0%], p=0.82, RR=0.91, CI 0.42 to 1.95 for AVN).

Conclusion: Early (< 12 hours) or open reduction of these fractures may not reduce the risk of non-union or avascular necrosis. There is a suggestion of a higher incidence of non-union following open reduction than closed reduction. Randomized studies or prospective observational studies with a minimum follow-up of two years are required to report on a larger number of patients in this age group before definite conclusions on treatment can be made.

Aim: Compressive forces on the medial femoral cortex and tensile forces at the lateral femoral cortex along with cortical comminution lead to a high risk of failure of surgical fixation of subtrochanteric fractures. The purpose of the study was to correlate the incidence of fracture healing complications to the surgical stabilisation method used.

Methods: A comprehensive search of various data sources extending from 1966 to October 2003 was conducted to identify appropriate studies using specific search terms. We also scanned the reference lists of eligible studies for potentially relevant reports. Articles of all languages were considered. Studies with a follow-up of less than six months, pathological fractures, fractures treated non-operatively and studies reporting on less than ten fractures were excluded. Abstracts were also excluded. Each eligible study was independently reviewed by authors for methodological quality. A methodological scoring system adapted from that of Detsky was used. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed.

Results: 39 studies including 1835 fractures were analysed. For extramedullary devices, the incidence of non-union (35/673 – 5.2%), delayed union (11/221 – 4.7%), implant breakage ( 24/444 – 5.1%) and deep infection (14/459 – 3.0%) was statistically significantly higher than non-union (14/506 – 2.7%), delayed union (5/529 – 0.94%), implant breakage (12/628 –1.9%) and deep infection (9/764 – 1.2%) for intramedullary devices. Mortality and superficial infection were higher for extramedullary than intramedullary devices. However, this was not statistically significant. Malunion, shortening and implant cut out were higher for intramedullary than extramedullary devices. This was not statistically significant.

Conclusion: The incidence of fracture healing complications appear to be significantly less with intramedullary than extramedullary devices. Based on this study, we advocate the use of intramedullary surgical fixation devices for subtrochanteric fractures.

Background: The most commonly used implant for the internal fixation of an extracapsular proximal femoral fracture is a sliding hip screw (SHS). More recently short intramedullary nails (IMN) have been advocated as an alternative, particularly for unstable fractures due to possible biomechanical advantages. The purpose of this meta-analysis was to compare, on the basis of evidence from randomised controlled trials, the fixation outcome with these two types of implant in stable and unstable fractures

Method: All randomised controlled studies comparing intramedullary nails with a SHS were considered for inclusion. Studies were identified using the search strategy of the Cochrane Collaboration, with no restriction on languages or source. Two authors independently extracted the data, and assessed trial methodology.

Results: 24 randomised trials involving 3202 patients with 3279 fractures were included in the analysis. Pooled results gave no statistically significant difference in the cut-out rate between the IMN or SHS 41/1556 and 37/1626 (Relative risk 1.19; 95% confidence interval 0.78 to 1.82). There was an increased total failure rate (103/1495 and 58/1565, Relative risk 1.83; 95% confidence interval 1.35 to 2.50) and re-operation rate (57/1357 and 35/1415, Relative risk 1.63; 95% confidence interval 1.11 to 2.40) with the IMN compared the SHS when all fractures were considered. Fracture healing complications were much less frequent for stable fractures. No evidence for a reduced failure rate for IMN’s in unstable fractures patterns could be found.

Conclusions: The results from studies to date indicate an increased fixation failure rate for trochanteric fractures fixed with an intramedullary nail, and show no benefit to the use of a nail in unstable fractures. Therefore the use of intramedullary nails for trochanteric fractures cannot be recommended.

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.