The management of hip fractures has advanced on all aspects from prevention, specialised hip fracture units, early operative intervention and rehabilitation in line with increasing incidence in an aging population. Accurate data analysis on the incidence and trends of hip fractures is imperative to guide future management planning. A review of all articles published on mortality after hip fracture over a twenty year period (1999–2018) was undertaken to determine any changes that had occurred in the demographics and mortality over this period. This article complements and expands upon the findings of a previous article by the authors assessing a four decade period (1959 – 1998) and attempts to present trends and geographical variations over sixty years.Abstract
Introduction
Methods
Dislocation of a hip hemiarthroplasty is a devastating complication with a high mortality rate in elderly patients. Previous studies have suggested a higher dislocation rate in patients with neuromuscular conditions. In this study, we have reviewed our larger cohort of patients to identify whether there is any association between neuromuscular disorders and prosthetic dislocation in patients treated with hip hemiarthroplasty for femoral neck fractures. Our study is a retrospective analysis of data collected over 34 years for patients with intracapsular neck of femur fracture who underwent hip hemiarthroplasty. The study population is composed of four groups: patients with no neuromuscular disorders, patients with Parkinson's disease, patients with previous stroke, and patients with dementia.Abstract
Background
Patients and Methods
The effectiveness of anti-embolic graduated compression stockings (GCSs) has recently been questioned. The aim of this study is to systematically review all the relevant randomised controlled trials published to date. We systematically reviewed all the randomised controlled trials comparing anti-embolism stockings with no stockings. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL, Cochrane Musculoskeletal Injuries Group specialized register and the reference lists of articles as well as hand search results. Trials were independently assessed and data for the main outcome measures; deep vein thrombosis (DVT), pulmonary embolism and skin ulceration, were extracted by two reviewers.Abstract
BACKGROUND
PATIENTS AND METHODS
Dislocation of a hip hemiarthroplasty is a significant complication with a high mortality rate in elderly patients. Previous studies have shown a higher risk of dislocation in patients with neuromuscular conditions. In this study, we reviewed our larger cohort of patients to identify if there is a link between neuromuscular disorders and dislocation of hip hemiarthroplasty in patients with neuromuscular conditions. We have retrospectively analysed a single-centre data that was collected over 34 years for patients with intracapsular neck of femur fracture who underwent hip hemiarthroplasty. The study population was composed of four groups: patients with no neuromuscular disorders, patients with Parkinson's disease, patients with previous stroke, and patients with mental impairment.Introduction and Objective
Materials and Methods
The effectiveness of anti-embolic graduated compression stockings (GCSs) has recently been questioned. The aim of this study is to systematically review all the relevant randomised controlled trials published to date. We systematically reviewed all the randomised controlled trials comparing anti-embolism stockings with no stockings. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL, Cochrane Musculoskeletal Injuries Group specialized register and the reference lists of articles as well as hand search results. Trials were independently assessed and data for the main outcome measures; deep vein thrombosis (DVT), pulmonary embolism and skin ulceration, were extracted by two reviewers.Introduction and Objective
Materials and Methods
Continued controversy exists between cemented versus uncemented hemiarthroplasty for an intracapsular hip fracture. To assist in resolving this controversy, 400 patients were randomised between a cemented polished tapered stem hemiarthroplasty and an uncemented Furlong hydroxyapatite coated hemiarthroplasty. Follow-up was by a nurse blinded to the implant used for up to three years from surgery. Results indicate no difference in the pain scores between implants but a tendency to an improved regain of mobility for those treated with the cemented arthroplasty (1.2 score versus 1.7 at 6 months, p=0.03). There was no difference in early mortality but a tendency to a higher later mortality for the uncemented implants (29% versus 24% at one year, p=0.3). Later peri-prosthetic fracture was more common in the uncemented group (3% versus 1.5%). Revision arthroplasty was required for 2% of cemented cases and 3% of uncemented cases. Surgery for an uncemented hemiarthroplasty was 5 minutes shorter but these patients were more likely to need a blood transfusion (14% versus 7%). Three patients in the cemented group had a major adverse reaction to bone cement leading to their death. These results indicated that a cemented stem hemiarthroplasty give marginally improved regain of mobility in comparison to a contemporary uncemented hemiarthroplasty. An uncemented hemiarthroplasty still has a place for those considered to be at a high risk of bone cement implantation syndrome.
A consecutive series of 320 patients with an
intracapsular fracture of the hip treated with a dynamic locking
plate (Targon Femoral Neck (TFN)) were reviewed. All surviving patients
were followed for a minimum of two years. During the follow-up period
109 patients died. There were 112 undisplaced fractures, of which three (2.7%) developed
nonunion or re-displacement and five (4.5%) developed avascular
necrosis of the femoral head. Revision to an arthroplasty was required
for five patients (4.5%). A further six patients (5.4%) had elective
removal of the plate and screws. There were 208 displaced fractures, of which 32 (15.4%) developed
nonunion or re-displacement and 23 (11.1%) developed avascular necrosis.
A further four patients (1.9%) developed a secondary fracture around
the TFN. Revision to a hip replacement was required for 43 patients
(20.7%) patients and a further seven (3.3%) had elective removal
of the plate and screws. It is suggested that the stronger distal fixation combined with
rotational stability may lead to a reduced incidence of complications
related to the healing of the fracture when compared with other
contemporary fixation devices but this needs to be confirmed in
further studies. Cite this article:
When treating a patient admitted with hip fracture it is useful to have a simple scoring system to predict outcomes, based on admission clerking and routine investigations. The Nottingham Hip Fracture Score (NHFS) is one such measure. Its use has been described by Wiles et al (Br J. Anaes. Jan. 2001) for risk stratification in predicting 30-day and 1-year mortality. Our aim was to use the hip fracture database at Peterborough City Hospital, UK to conduct an independent validation study of the NHFS stratification system.Introduction
Objective
The incidence of distal femoral fractures amongst elderly patients is likely to rise due to increased life expectancy. This study reports on the outcome of a series of distal femoral fractures treated by retrograde femoral nailing and then to compare the results for these patients with a series of patients with a proximal femoral fracture. In this longitudinal cohort study, 36 patients with extra-articular distal femoral fractures were treated with a solid retrograde femoral nail. Data was collected prospectively and then compared to proximal femoral fractures (2426) treated by the same surgeon treated over the same time period.Introduction
Materials and/Methods
The aim of this study was to determine the correlation between body weight and fracture union for displaced intracapsular fracture neck of femur treated by closed reduction and internal fixation. A total of 197 patients with displaced intracapsular fracture of neck of femur, all of whom have been treated with closed reduction and internal fixation, were studied. The mean age was 71 years and 79% were female. Patients were followed up until fracture endpoint (union or non-union) with minimum follow up of 200 days.Objective
Patients and methods
Debate still exists as to the optimum method of fixation for subtrochanteric femoral fractures. Meta-analysis of studies comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures have suggested that further investigation is required in this area. We present the outcome of the largest series to date of subtrochanteric fractures treated by both methods and with a minimum of one year follow-up. 244 patients with a subtrochanteric femur fracture were treated at one centre over a 21 year period were prospectively studied. 75 were treated with an extramedullary fixation implant and 168 with an intramedullary nail. Surviving patients were followed up till one year from injury.Introduction
Methods
There has been little research into the effect of suffering a simultaneous hip and upper limb fragility fracture. The aim of this study is to describe the characteristics of this important group of patients and to define the effect on outcomes such as mortality and length of stay. Hip fracture data in our unit is collected prospectively and entered into a database. All study data was taken from this database. Patients under 60 years of age were excluded from the study.Introduction
Materials and methods
The purpose of the study was to identify factors that affect the incidence of deep wound infection after hip fracture surgery. Data from a hip fracture database of 7057 consecutively treated patients at a single centre was used to determine the relationship between deep wound sepsis and a number of factors. Fisher's exact test and the unpaired T test were used. All patients were initially followed up in a specialist clinic. In addition a phone call assessment was made at one year from injury to check that no later wound healing complications had occurred. There were 50 cases of deep infection (rate of 0.7%). There was no significant difference in the rate of deep sepsis with regards to the age, sex, pre-operative residential status, mobility or mental test score of the patient. Specialist hip surgeons and Consultants have a lower infection rate compared with surgeons below Consultant grade, p=0.01. The mean length of anaesthesia was longer in the sepsis group (76minutes) compared to the no sepsis group (65minutes), this was significant, p=0.01. The patient's ASA grade and fracture type were not significant factors. The rate of infection in intracapsular fractures treated by hemiarthroplasty was significantly greater than those that had internal fixation, p=0.001. The rate of infection in extracapsular fractures fixed with an extra-medullary device was significantly greater than those fixed with an intra-medullary device, p=0.021. The presence of an infected ulcer on the same leg as the fracture was not associated with a higher rate of deep infection. In conclusion we have found that the experience (seniority) of the surgeon, the length of anaesthesia and the type of fixation used are all significant factors in the development of deep sepsis. These are all potentially modifiable risk factors and should be considered in the treatment of hip fracture patients.
Maintaining femoral neck cortical thickness may help prevent hip fracture. Fracture initiation probably starts superiorly at flaws, ie where the cortex is thinnest. Whole body computed tomography (QCT) is now being used to study cortical thickness but limited resolution (> 300 micrometers) makes in vivo estimates imprecise, whereas microscopy s resolution approaches 1 micrometer. We have therefore extended our microscopic studies on femoral neck biopsies to include men (14 cases, 26 controls) and women (50 cases, 23 controls), and here provide data on true cortical thickness in subjects with and without hip fracture. Whole femoral neck cross-sections obtained at hemiarthroplasty (or at post-mortem in controls) were embedded in methacrylate, cut, stained and imaged at medium power. Image-J was used to define cortical boundaries and to measure cortical thicknesses at 5 degree intervals of arc from the cross-sections centre of area. We confirmed that the mid-femoral neck (or narrow neck) site, defined as where the ratio of maximum to minimum neck diameter (max:min) is 1.4, shows great asymmetry, with the thick inferior cortical octant averaging over 3mm thickness (mean age 79 years inter-quartile range 74-85). In the superior 3 octants cortical thickness averaged 26% of that seen inferiorly. To assess statistical determinants of cortical thickness, the data were modelled with linear regression in octants after adjusting for subjects age, sex, max:min, and hip fracture status. To achieve normality of residuals the cortical thickness data were log-transformed. 95% of measured cortical thicknesses fell between 45% and 220% of the mean for octant. In the thinner, superior three octants, minimum thicknesses were just under 0.3 mm in the fracture cases ie close to 35% of the subjects mean for octant. Cases had about 17% thinner cortical thicknesses in all octants than controls, while female controls had cortical thicknesses that uniformly averaged 90% of male. In conclusion, compared to gender and age-matched controls, intra-capsular hip facture cases had generalized cortical thinning in all mid-neck octants. This disease effect contrasts markedly with the effect of normal ageing, which thins preferentially the mechanically under-loaded superior cortex and spares the infero-anterior cortex.
Hip fractures are common injuries in the elderly, with significant mortality and morbidity from several factors. Many of these patients have cardiac disease, and some develop cardiac complications which may increase mortality. Troponin T is a marker of myocardial injury but can be raised in other conditions. Patients over 60 years old admitted with hip fracture during the study period had their troponin T measured on admission and following surgery. Assay was performed after the patient had completed their treatment. We report the results of this study one year after the last patient was admitted. 108 patients were recruited. The average age was 84 years; 86% were female. This study found that 27% of hip fracture patients had some increase in the troponin T levels in the peri-operative period. This increase was not associated with an increase in early mortality, but there was an increase in one-year mortality for those with an increase in troponin T (45% versus 22%, p=0.03). These findings indicate that the routine measurement of troponin T after a hip fracture is unnecessary.
In order to define the optimum timing of surgery for a hip fracture, we undertook a systematic review of all previously published studies on this topic. Data from the retrieved studies were extracted by two independent reviews and the methodology of each study assessed. In total, 43 studies involving 265,137 patients were identified. Outcomes considered were mortality, post-operative complications, length of hospital stay and return of patients back home. There were no randomised trials on this topic. Six studies of 8535 patients have the most appropriate methodology, which was prospective collection of data with adjustment for confounding variables. These studies found no effect on mortality for any delays in surgery. One of these studies found fewer complications for those operated on early but this was not found in the other study to report on these outcomes. Two of these studies reported on hospital stay, which was reduced for those operated on early. Six studies of 229,418 patients were retrospective reviews of patient administration databases with an attempt at adjusting for confounding factors. They reported a reduced mortality, hospital stay and complications for those operated on early. Thirty-one other studies of variable methodology reported similar findings of reduced complications with early surgery, apart from one study of 399 patients which reported an increased mortality and morbidity for those operated on within 24 hours of admission. In conclusion those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. But early surgery (within 48 hours of admission) does seem to reduce complications such as pressure sores and reduces hospital stay.
1133 patients with an intracapsular fracture of femoral neck treated by internal fixation were prospectively studied. All surviving patients were followed up for a minimum of one year from injury. The overall incidence of non-union was 229 (20.2%) and the incidence of avascular necrosis was 61 (5.4%). Fracture non-union was less common for undisplaced fracture in comparison to displaced fractures (48 out of 565 (8.5%) versus 181 out of 568 (31.9%)) and in males than females (45 out of 271 (16.6%) versus 184 out of 862 (21.3%)). The incidence of non-union progressively increased with age from one out of 17 (5.9%) in those aged below 40 years to 84 out of 337 (24.9%) in those in their seventies. For those in their eighties the incidence of non-union began to fall, but if those patients who died within one year from injury were excluded, then the incidence was found to continue to increase. For avascular necrosis there was a falling incidence with age from 9 out of 68 (13.2%) in those aged less than 50 years to 10 out of 388 (2.6%) in those aged over 80 years. The information from this large series of patients treated by contemporary methods enables the surgeon to use the three factors of age, sex and presence of fracture displacement to predict the risk of non-union or avascular necrosis occurring.
The two commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. To determine if any difference in outcome exists between these implants we undertook a prospective randomised controlled trial of 300 patients with a displaced intracapsular hip fractures. All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility. The average age of the patients was 83 years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups, with 34/151 having died at one year in the cemented group and 45/149 in the uncemented group. Pain scores (grade 1-6) were less for those treated by a cemented prosthesis (mean score 1.8 versus 2.4, p value <0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay. Operative complications are as listed. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group. In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended.
Fractures of the proximal femur at the level of the lesser trochanter (reversed and transverse fracture lines, Evans classification type II, AO classification 31. A3 fractures) are known to have an increased risk of fixation failure. 53 patients with such a fracture were randomised to have the fracture fixed with either an intramedullary nail (220 mm Targon Proximal Femoral nail) or a Sliding Hip Screw (SHS). The mean age of the patients was 82 and 11% were male. All patients were followed up for one year by a research nurse blinded to the treatment groups. Mean length of surgery was 51 minutes for the nail versus 53 minutes for the SHS. There were no differences between groups in the need for blood transfusion. Operative complications tended to be less for the nail group (1/27 versus 5/26). Mean hospital stay was 17 days for the nail group versus 29 days for those treated with the SHS (p<
0.0001). The only fracture healing complications were one case of cut-out in each group requiring revision surgery. During follow-up those patient treated with the nail reported significantly lower pain scores than those treated with the SHS (p=0.08). This difference persisted even at one year from injury. In addition there was a tendency to a better regain of mobility in the first nine months from injury for those treated with the nail. These results indicate that for these difficult fractures types an intramedullary nails produces superior results to the Sliding Hip Screw.
The Targon Femoral Neck Hip Screw has been designed to improve the fixation of intracapsular hip fractures. Fracture healing complications after internal fixation occur in approximately 30–40% of displaced fractures and 5–10% of undisplaced fractures. The new implant consists of a small plate with six locking screw ports. The two distal holes are used to fix the plate to the lateral cortex of the femur. Three of four screws are passes through the proximal holes and across the fracture site. These 6.5mm screws are dynamic to allow for collapse of the fracture across the femoral neck. A jig is used to aid insertion of the device with minimal surgical exposure of the femur. For the first 200 patients treated with this implant at the first centre to use this implant, the mean age of the patients was 77 years (range 39–103), 58% were female. The mean length of surgery was 46 minutes and the mean length of anaesthesia 59 minutes. The median length of institutional stay till discharge home was 9 days (mean 13 days, range 3–107). Four telescoping screws were used in 55% of patients, three in 44% and two in 1% of patients. Follow-up of patients at present is a minimum of six months. For the 74 undisplaced fractures there has been one case of non-union and one case of avascular necrosis. For the 121 displaced fractures (Garden III and IV) there have been eleven cases of fracture non-union, six cases of avascular necrosis and two cases of plate detachment from the femur treated by repeat fixation. In addition there was one deep wound sepsis treated by removal of the implant and girdlestone arthroplasty. For the four basal fractures treated there has been one case of plate detachment from the femur. Observation of those fractures that have healed shows there has been between 0 to 22mm of collapse at the fracture site which occurs along the line of the femoral neck. There has been no tilting of the fracture into varus as occurs with a parallel screw method. The results to date show an incidence of fracture healing complications is about a third that which is to be expected with a parallel screw method. This new implant may be a significant advance in the treatment of this difficult and common fracture.
To determine if any notable differences between a cemented Thompson stem hemiarthroplasty and a cemented Exeter stem hemiarthroplasty (ETS), 200 patients with a displaced intracapsular fracture were randomised between the two prosthesis. Surviving patients were followed-up for one year by a nurse blinded to the treatment allocation. The mean age of patients was 84 years and 13% were male. There were no differences between groups for the length of surgery, need for blood transfusion or hospital stay. Implant related complications were three minor operative fractures of the femur in each group. Two patients in the Thompson group had dislocation of the prosthesis requiring revision surgery and one further patient in the Thompson group had late acetabular wear requiring conversion to a total hip replacement. One further patient in the Thompson group had cement retained in the acetabulum. In total therefore only three patients, all in the Thompson group, which required revision surgery. Easy of surgery was assessed subjectively by the surgeon and reported to be easier for the ETS group (p=0.0002). During follow-up there was no significant difference in the degree of residual pain between groups. Conclusions are that the cemented Exeter stem hemiarthroplasty has some advantages over the traditional cemented Thompson hemiarthroplasty.
400 patients with a trochanteric hip fracture were randomised to fixation with either a 220mm long Targon PF (proximal femoral) nail or a Sliding Hip Screw. All surgery was undertaken or supervised by one surgeon. All patients were followed up for a minimum of one year by a blinded observer. The mean age was 82 years (range 27 to 104 years), 20% were male. Mean length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p<
0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality. Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There were only once compilations in the nailed a case of cut-out which required secondary surgery. At follow-up there was no difference in pain scores between groups but there was a tendency to improved mobility in the nailed group (p=0.004). These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails. Intramedullary fixation can result in a lower re-operation rate (3.5% versus 0.5%) and improved mobility in comparison to the sliding hip screw.
There is continuing debate regarding the merits of internal fixation versus arthroplasty for intracapsular hip fractures. For displaced fractures there is a higher risk of fracture healing complications but many of the studies reporting on this are now from some years ago using surgical methods that are now outdated. The aim of our study was to determine the incidence of avascular necrosis (AVN) related to age, gender, displacement and operation delay for a large series of patients with intra-capsular fractures treated with internal fixation using contemporary methods. We prospectively studied 1023 patients, 988 fractures were internally fixed with three cannulated screws and 35 with a sliding hip screw. The average length of radiographic follow-up for those patients who survived to one year was 337 days (range 25 to 3521 days). The average age of the patients was 75.4 years (range 16–100); 243 (23.8%) were male. The overall incidence of AVN was 6.6%. AVN was less common (p=0.0004) for undisplaced fractures than for displaced fractures (21 of 528 [4.0%] vs 47 of 495 [9.5%]) and in men than women (p=0.03) who had a displaced fracture (7 of 143 [4.9%] vs 40 of 352 [11.4%]). The incidence of AVN for those aged less than 60 years and who sustained a displaced fracture was 20.6%, compared to 12.5% for those aged 60–80 years and 2.5% for those aged more than 80 years (p<
0.0001). We found no association between the incidence of AVN and operation delay. Our study showed an increased risk of AVN with younger age and in females with a displaced fracture. This is in contrast to the decreased incidence of non-union seen with younger age. Knowledge of the predicted incidence of fracture healing complications should help surgeons make a more balanced decision between internal fixation and arthroplasty for this condition.
The Targon Femoral Neck Hip Screw has been designed to improve the fixation of intracapsular hip fractures. The new implant consists of a small plate with six locking screw ports. The two distal holes are used to fix the plate to the lateral cortex of the femur. Three of four 6.5mm cancellous screws are passes through the proximal holes and across the fracture site. The proximal screws are dynamic to allow for collapse of the fracture across the femoral neck. A jig is used to aid insertion of the device with minimal surgical exposure of the femur. For the first 91 patients treated with this implant, the mean age of the patients was 75 years (range 46–103). The mean length of surgery was 45 minutes. The median length of hospital stay till discharge home was 8 days). For the 43 undisplaced fractures there has been one case of non-union and one case of avascular necrosis. For the 48 displaced fractures (Garden III and IV) there have been five cases of fracture non-union and one case of plate detachment from the femur treated by repeat fixation. In addition there was one deep wound sepsis treated by removal of the implant and girdlestone arthroplasty. Observation of those fractures that have healed shows there has been between 4 to 18mm of collapse at the fracture site which occurs along the line of the femoral neck. There has been no tilting of the fracture into varus as occurs with a parallel screw method. The results to date show an incidence of fracture non-union that is about a third that which is to be expected with a parallel screw method. This new implant may be a significant advance in the treatment of this difficult and common fracture.
The Sliding Hip Screw (SHS) is currently the treatment of choice for all trochanteric hip fractures. An alternative treatment is the short femoral nail. Earlier designs of these nails were associated with an increased fracture healing complication rate in comparison to the sliding hip screw. The new designs of nails (third generation nails) may however be as good as or even superior to sliding hip screw fixation. We conducted a large randomised trial to compare the Targon Proximal Femoral Nail with the Sliding Hip Screw. Patients with trochanteric hip fractures as per the AO classification (A1–A3) were randomised to either implant. All surgery was supervised by one surgeon. All patients were followed up for a minimum of one year months by a blinded observer. The mean age was 82 years, range 27 to 104 years), 20% were male. Length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p<
0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality. Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There was only one compilation in the nailed a case of cut-out which required secondary surgery. At follow-up no difference in pain scores but there was a tendency to improved mobility in the nailed group (p=0.004). These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails. Intramedullary fixation can result in a lower re-operation rate (3.5% versus 0.5%) and improved mobility in comparison to the sliding hip screw.
Approximately one third of our patients survived between 1 to 4 years and another third survived between 5 to 10 years with one patient surviving over 10 years with nearly returning to their pre-injury status. We suggest that satisfactory post operative function is achievable with either internal fixation or hemiarthroplasty. We conclude that these fractures should be treated with the same urgency and expertise as similar fractures in non-amputees as long term survival and good quality of life can be expected.
To determine the optimum choice of treatment for the displaced intracapsular fracture in the elderly, 455 patients aged over 70 years with a displaced intracapsular fracture were entered into a prospective randomised trial. Treatment was either an uncemented Austin Moore hemiarthroplasty or reduction and internal fixation with three AO cancellous screws. Analysis of pre-operative characteristics of patients showed there was no significant difference between the two groups. Follow-up of surviving patients was continued for between seven to 15 years to determine the long-term outcome for the two treatment Methods: 90% of patients died during this follow-up period. Regarding short term outcomes, internal fixation resulted in a reduced mean operative time, operative blood loss and transfusion requirements. There was no significant difference in the length of hospital stay or incidence of general post-operative complications. There was no difference in either the short term or long-term mortality between the two procedures. The need for revision surgery to the hip was increased for those treated by internal fixation (7% versus 38% implant revision rate). There was no difference in the degree of residual pain between groups neither was there any difference in the number of patients requiring institutional care. There was a tendency to slightly better mobility for those treated by internal fixation although the Results: were not statistically significant. These results demonstrate that both treatment methods produce comparable final outcomes but internal fixation is associated with an increased re-operation rate.
A hip fracture may lead to anaemia after surgery due to blood loss from the fracture site and operative blood loss. The value of iron supplementation for this group of patients remains controversial. A randomised trial was undertaken for 300 patients who had a haemoglobin of less than 110g/l after surgery. Patients were randomised to take either ferrous sulphate, (200mg twice daily for four weeks) or had no iron therapy. Patients were followed up to one year after surgery. The mean age of patients was 82 years. 19% were male. The mean difference between admission haemoglobin and the haemoglobin taken 6 weeks after discharge was 7.3g/l in the iron supplementation group and 8.3g/l in the group that did not receive iron supplementation (p value 0.5). There was also no statistically significant difference between groups for hospital stay (19 versus 21 days) or mortality. 18% of those allocated to iron therapy reported side effects from the medication. This study indicates that routine oral iron supplementation for anaemia after hip fracture surgery is not appropriate.
A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores by analysing prospectively collected data of 4654 consecutive patients (1003 males/3473 females). 3.8% developed pressure sores in the sacral, buttock or heel areas. Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (4.65 versus 5.76), diabetes mellitus (pressure sore incidence 10.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor. While the time interval between fall and admission was not significant, the time interval between admission and surgery was found to be an extremely significant risk factor. A fall in blood pressure during surgery (5.6%) was found to increase risk. Patients who underwent a dynamic hip screw were more likely to develop pressure sores (incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery or type of anaesthesia. Our incidence of pressure sores is lower than previously reported (30%). Whilst determining factors that increase the risk of pressure sores may not be sufficiently reliable to be used for the individual patient, taking appropriate preventative measures can reduce the incidence, particularly with reference to (optimising the patient pre-operatively and) reducing delays to surgery.
It is unclear which length of thread may be most advantageous for the internal fixation of an intracapsular fracture with cancellous screws. We have compared the 16mm versus the 32mm threads on cancellous screws within a randomised trial for 432 patients. All fractures were fixed with three screws and patients followed-up for a minimum of one year from injury. The characteristics of the patients in the two groups was similar with a mean age of 76 years. 23% were male. The most common complication encountered was non-union of the fracture which for undisplaced fractures occurred in 7/107(6.5%) of short threaded screws versus 11/133(8.3%) of long threaded screws. For displaced fractures the figures were 29/104(27.9%) versus 24/89(27.0%). Other complications for the short versus long threaded group were avascular necrosis (two cases versus five cases) and fracture below the implant (two cases in each group). Elective removal of the screws for discomfort was undertaken in five and three cases respectively. None of these differences between groups was statistically significant. In summary there is no difference in fracture healing complications related to the length of the screw threads.
Hip fractures are one of the leading causes of morbidity in the elderly population. A large reduction in morbidity can be achieved if these individuals can have definitive treatment rapidly. However, this is not always achievable to a multi factorial host of contributing factors. Therefore, to enable us to understand some aspect of why these delays, if any occur, the following study was undertaken. The purpose of the study is to relate the place at which the patient fell, to the time of day for admission to casualty. This will enable us to ascertain whether there is a relationship between the location of injury and the time taken to admission into hospital; if there is such a correlation, then it will enable us to identify factors which will expedite an individuals attendance to hospital.
A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores We have analysed prospectively collected data of 4654 consecutive patients (1003 males/3473 females). 3.8% developed pressure sores in the sacral, buttock or heel areas. Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (5.7 versus 6.7), diabetes mellitus (pressure sore incidence 9.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor. Among surgical factors related to an increased risk was a fall in blood pressure during surgery (5.6%). Patients who underwent a dynamic hip screw were more likely to develop pressure sores (pressure sore incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery of type of anaesthesia. Our study indicates that the current incidence of pressure sores is lower that that previously reported (30%). Whilst it is possible in a large population of patients to determine factors that increase the risk of pressure sores, these are not sufficiently reliable to be used for an individual patient.
1133 patients with an intracapsular fractures of femoral neck treated by internal fixation were prospectively studied. All surviving patients were followed up for a minimum of one year from injury. The overall incidence of non-union was 229(20.2%) and the incidence of avascular necrosis was 61(5.4%). Fracture non-union was less common for undisplaced fracture in comparison to displaced fractures [48 out of 565(8.5%) versus 181 out of 568(31.9%)] and in males than females [45 out of 271(16.6%) versus 184 out of 862(21.3%)]. The incidence of non-union progressively increased with age from one out of 17(5.9%) in those aged below 40 years to 84 out of 337(24.9%) in those in their seventies. For those in their eighties the incidence of non-union began to fall, but if those patients who died within one year from injury were excluded, then the incidence was found to continue to increase. For avascular necrosis there was a falling incidence with age from 9 out of 68(13.2%) in those aged less than 50 years to 10 out of 388(2.6%) in those aged over 80 years. The information from this large series of patients treated by contemporary methods enables to surgeon to use the three factors of age, sex and present of fracture displacement to predict the risk of non-union or avascular necrosis occurring.
In order to define the optimum timing of surgery for a hip fracture, we undertook a systematic review of all previously published studies on this topic. Data from the retrieved studies was extracted by two independent reviews and the methodology of each study assessed. In total, 43 studies involving 265137 patients were identified. Outcomes considered were mortality, post-operative complications, length of hospital stay and return of patients back home. There were no randomised trials on this topic. Six studies of 8535 patients have the most appropriate methodology, which was prospective collection of data with adjustment for confounding variables. These studies found no effect on mortality for any delays in surgery. One of these studies found fewer complications for those operated on early but this was not found in the other study to report on these outcomes. Two of these studies reported on hospital stay, which was reduced for those operated on early. Six studies of 229418 patients were retrospective reviews of patient administration databases with an attempt at adjusting for confounding factors. They reported a reduce mortality, hospital stay and complications for those operated on early. Thirty-one other studies of variable methodology reported similar findings of reduced complications with early surgery apart from one study of 399 patients, which reported an increased mortality and morbidity for those operated on within 24 hours of admission. In conclusion those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. But early surgery (within 48 hours of admission) does seem to reduce complications such as pressure sores and reduces hospital stay.
This study was conducted to find out whether blood transfusion was an independent risk factor for mortality and wound infections after hip fracture surgery. 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. 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).
One of the most common early complications after hemiarthroplasty is dislocation, with an incidence of 2 to 4%. After dislocation the mortality and morbidity are significantly increased to in excess of 50%. It has been claimed that a bipolar hemiarthroplasty has a lower risk of dislocation than a unipolar implant. In addition it has been suggested that patients with either Parkinson’s disease or a previous stroke are at increased risk of dislocation. We investigated these claims by performing a comprehensive literature search of articles published in the last 40 years and data obtained from our own hip fracture database. From the literature review, 133 reports involving 21,872 patients were retrieved. A further 1235 hip fractures treated by hemiarthroplasty were recorded from our database. 791 (3.4%) dislocations were recorded. Dislocation rate for unipolar prosthesis was higher than bipolar prosthesis (3.9% versus 2.5%). Dislocation rate for posterior surgical approach was higher than for anterior approach (5.1% versus 2.4%). Dislocation rate for cemented prosthesis was 3.6% versus 2.3% in un-cemented prosthesis. However, the effect of the type of implant becomes non-significant on adjusting for the use of cement and surgical approach. The incidence of open reduction after dislocation was increased with bipolar implants. Patients with Parkinson’s disease showed a highly statistically significant increase in dislocation rate (8.7% to 3.4%). The dislocation rate with respect to ipsilateral hemiplegia was 1.6%. This study indicates there is no difference in the dislocation rate between a unipolar and bipolar prosthesis but if a bipolar prosthesis dislocates, there is an increased risk of failure to reduce the prosthesis by closed means. Patients with Parkinson’s disease are at an increased risk of dislocation but this is not the case for those with a hemiplegia. To minimise the risk of dislocation of a hemiarthroplasty, particularly in those patients with Parkinson’s disease, a unipolar hemiarthroplasty inserted via an antero-lateral approach is recommended.
We report the results of a consecutive series of 500 patients treated with a follow-up range from 5–12 years. Ten patients were lost to follow-up and 398 patients [81%] died. The mean age was 82 years, with 85% being women. Forty-six patients [9.2%] required a second operation of any type, with revision performed in 23 [4.6%]. Of the long-term survivors 66 [81%] had none or minimal pain, whilst 5 [6%] had reported constant pain in the hip. This is the largest consecutive series, with the following follow-up, reported and for the frail elderly patient this prosthesis can still be recommended.
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.
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.
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).
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.
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.
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).