There is currently no information regarding long-term outcomes following total hip replacement (THR) for hip fracture in patients selected in accordance with national guidelines. We define the long-term outcomes and compare these to short-term outcomes in the same previously reported cohort.

We prospectively identified patients who underwent THR for a displaced hip fracture over a 3-year period from 2007–2010. These patients were followed up at 10 years using the Oxford hip score(OHS), the Short-form 12(SF-12) questionnaire and satisfaction questionnaire. These outcomes were compared to the short-term outcomes previously assessed at 2 years. We identified 128 patients. Mean follow up was 10.4 years. 60 patients(48%) died by the time of review and 5 patients(4%) developed dementia and were unable to respond. 3 patients were untraceable. This left a study group of 60 patients with a mean age of 81.2.

Patients reported excellent outcomes at 10 year follow up and, when compared with short-term outcomes, there was no statistically significant change in levels of satisfaction, OHS, or SF-12. The rates of dislocation(2%), deep infection(2%) and revision(3%) were comparable to those in the literature for elective THR. Mortality in the hip fracture group at 10 years is lower than that of elective registry data.

Long-term outcomes for THR after hip fracture in selected patients are excellent and the early proven benefits are sustained. Our data validates the selection process of national guidelines and confirms low complication rates. THR is a safe and highly effective treatment for fit elderly patients with displaced hip fractures.

The management of distal humeral fractures in low-demand patients with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for cases where achieving stable ORIF can be difficult. The ‘bag of bones’ technique, (early movement with fragments accepted in their displaced position), is now rarely considered as it is commonly believed to confer a poor functional result. The aim of this study was to present the short- and medium-term functional outcomes following the primary conservative treatment of distal humeral fractures in elderly and low-demand patients.

We carried out a retrospective case note and radiograph review of all patients (n=40) aged 50 years or more, with distal humeral fractures treated conservatively at our institution over a six-year period. Short-term function was assessed using the Broberg and Morrey (B&M) score. Medium term function was assessed by telephone interview (n=20) using the Oxford Elbow Score (OES), QuickDASH and a pain questionnaire.

The mean post-injury B&M score improved from 42 points at 6 weeks to 67 points by 3 months. By four years, surviving patients had a mean OES of 30 points, a mean QuickDASH of 38 points, and 95% reported a functional range of elbow flexion. Those with fracture non-union experienced greater pain on repetitive elbow activities, but no difference in rest pain, compared with patients whose fractures had united. The cumulative 1-year rate of fracture union was 53%, while the 5-year mortality approached 40%.

Conservative management of distal humeral fractures confers a reasonable functional result to the patient whilst avoiding the substantial surgical risks associated with primary ORIF or TEA.

We define the medium-term outcomes following total hip replacement (THR) for hip fracture. There is currently no information regarding longer term clinical and patient reported outcomes in this group of patients selected in accordance with national guidelines.

We prospectively identified patients who underwent THR for a displaced hip fracture over a three year period between 2007 and 2010. These patients were followed up at 5 years using the Oxford hip score, Short-form 12(SF-12) questionnaire and satisfaction questionnaire.

We identified 128 patients. Mean follow up was at 5.4 years with a mean age of 76.5 years. 21 patients (16%) had died, 12 patients (9%) had developed dementia and 3 patients had no contact details, leaving a study group of 92 patients. 74 patients(80%) responded. Patients reported excellent functional outcomes and satisfaction at 5 years (mean Oxford Hip Score 40.3; SF-12 Physical Health Composite Score 44.0; SF-12 Mental Health Composite Score 46.2; mean satisfaction 90%). The rates of dislocation (2%), deep infection (2%) and revision (3%) were comparable to those quoted for elective THR. When compared with 2 year follow up, there was no statistically significant change in outcome.

Medium-term outcomes for THR after hip fracture are excellent and the early proven benefits of this surgery are sustained. Mortality rates are equivalent to elective THR registry data and significantly lower than overall mortality rates following hip fracture. Our data validates the selection process detailed in national guidelines and confirms the low complication rate. THR is a safe and highly effective treatment for fit elderly patients with displaced hip fractures.

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls.

Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively.

Cite this article: Bone Joint J 2014;96-B:366–72.

Proximal femoral fractures remain the most common reason for admission to hospital following orthopaedic injury, with an annual cost of £1.7 billion to the National Health Service and social care services. Fragility fractures of the hip in the elderly are a substantial cause of mortality and morbidity. Revision surgery for any cause carries a higher morbidity, mortality, healthcare- and social economic burden. Which patients suffer failed surgery and the reasons for failure have not been established. The aim of this study was to determine which patients are at risk of failed proximal femoral fracture surgery, the mechanism and cause fo failed surgery and modifiable patient factors associated with failure of hip fracture surgery.

From prospectively collected data of 795 consecutive proximal femoral fractures admitted between July 2007 and July 2008, all peri-operative and post-operative complications were identified.

55 (6.9%) patients were found to have developed a surgical complication requiring further intervention. Risk factors included younger age (p=0.01), smoking (p=0.01) and cannulated screw fixation (p<0.01). Cannulated screw fixation was associated with a 30.9% complication rate. Mechanical cause was the most common reason for cannulated screw failure. Hip hemiarthroplasty most commonly failed by infective causes. Inter-trochanteric and subtrochanteric fracture fixation had very low failure rates. Surgical complication was not found to be associated with an increased mortality but a post-operative medical complication (21.8%) was associated with higher rate of mortality at 4-years (78.5%) and shorter time to mortality. (Median time 0.16 years (95% CI 0.00–0.33).

The relationship between advancing patient age, decreasing bone mineral density and increasing distal radial fracture incidence is well established. Biomechanical and clinical work has shown that the radiographic severity of distal radial fractures is greater in patients with poor bone quality. Between 1991 and 2007, the number of elderly Scots (aged 75 years or more) increased by 18%, and population projections predict a further 82% increase by 2035. This study was conducted to investigate the effect of recent changes in the demographics of our population on the pattern and radiographic severity of distal radial fractures encountered at our institution.

The epidemiology of two distinct series of patients (1991–93; 2007–08) suffering distal radial fractures was compared. The patient and radiographic fracture characteristics known to be predictive of fracture instability and severity were compared using the MacKenney formulae, and a subgroup analysis of distal radial fragility fractures was performed.

The life expectancy of our catchment population has improved since 1991, and we have encountered a larger number of distal radial fractures occurring in older, more active and functionally independent patients. We identified an increase in the proportion of AO type B fractures, particularly in the oldest patient groups. The radiographic severity of distal radial fractures, especially low energy metaphyseal injuries, has increased.

If the current trend in population demographics continues, it seems likely that orthopaedic surgeons will encounter an increasing number of severe distal radial fractures deemed unsuitable for treatment by closed methods.

To describe the treatment and morbidity of lower limb (LL) football fractures in regard to returning to football in a known UK population at all skill levels.

All football fractures during 2007–2008 sustained by the Lothian population were prospectively collected with the diagnosis being confirmed by the senior author when patients attended the only adult orthopaedic service in Lothian. Patients living outside the region were excluded from the study. Patients were contacted in August 2010 to ascertain their progress in return to football.

There were 424 fractures in 414 patients. 366 fractures (86%) in 357 patients (86%) were followed up with a mean interval of 30 months (range 24–36 months). Of these 32% were sustained in the LL. 88% of LL injuries returned to football compared to 85% of upper limb (UL) fractures (p=0.4). 60% of LL patients were treated as outpatients. 35% were operated on −26% had ORIF and 9% IM Nailing. The most common LL fractures were Ankle 38%, Tibial Diaphysis 14%, 5th Metatarsal 11%, Fibula 9% and Great Toe 7%. Only one of the fractures was an open injury - Gustillo Class 1 2nd Phallanx Foot. Three of the 12 patients who underwent IM nailing required fasciotomy. One patient in the operative cohort developed a significant infection. The mean time for return to football for conservative treatment was 17 weeks (range 3–104 weeks), and for operative treatment 41 weeks (range 10–104 weeks). 91% of patients treated conservatively returned to football, compared to 84% of the operative cohort (p=0.3). 43% of patients had ongoing symptoms from their injury. 9% of the operative cohort required removal of metal work or further operative intervention. 83% of patients returned to the same level of football or higher following injury. Patients under 30 were 1.4 times more likely to return to sport than those over 30 (p<0.05).

We have previously demonstrated that football is the most common cause of sporting fracture(1), yet little is known about patient outcome following fractures. LL fractures are less common than UL fractures, and there is no difference in the proportion of patients returning to football following LL fractures and UL fractures. Over half of LL fractures are treated as outpatients and the incidence of open fractures is very low. There is no significant difference between the operative and conservative groups in their return to football. In the over 30 age group, sustaining a fracture may act as a catalyst to quit football. This may explain the higher non-return rate compared to the under 30 age group. 43% of patients perceive that they have ongoing problems with their fracture over 24 months post-injury reflecting the considerable morbidity of football-related fractures.

Introduction

This study investigates the epidemiology of proximal radial fractures and potential links to social deprivation.

We present the prevalence of multiple fractures in the elderly in a single catchment population of 780 000 treated over a 12-month period and describe the mechanisms of injury, common patterns of occurrence, management, and the associated mortality rate. A total of 2335 patients, aged ≥ 65 years of age, were prospectively assessed and of these 119 patients (5.1%) presented with multiple fractures. Distal radial (odds ratio (OR) 5.1, p <  0.0001), proximal humeral (OR 2.2, p < 0.0001) and pelvic (OR 4.9, p < 0.0001) fractures were associated with an increased risk of sustaining associated fractures. Only 4.5% of patients sustained multiple fractures after a simple fall, but due to the frequency of falls in the elderly this mechanism resulted in 80.7% of all multiple fractures. Most patients required admission (> 80%), of whom 42% did not need an operation but more than half needed an increased level of care before discharge (54%). The standardised mortality rate at one year was significantly greater after sustaining multiple fractures that included fractures of the pelvis, proximal humerus or proximal femur (p < 0.001). This mortality risk increased further if patients were < 80 years of age, indicating that the existence of multiple fractures after low-energy trauma is a marker of mortality.