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The Bone & Joint Journal
Vol. 97-B, Issue 2 | Pages 246 - 251
1 Feb 2015
Chatterton BD Moores TS Ahmad S Cattell A Roberts PJ

The aims of this study were to identify the early in-hospital mortality rate after hip fracture, identify factors associated with this mortality, and identify the cause of death in these patients. A retrospective cohort study was performed on 4426 patients admitted to our institution between the 1 January 2006 and 31 December 2013 with a hip fracture (1128 male (26%), mean age 82.0 years (60 to 105)). Admissions increased annually, but despite this 30-day mortality decreased from 12.1% to 6.5%; 77% of these were in-hospital deaths. Male gender (odds ratio (OR) 2.0, 95% confidence interval (CI) 1.3 to 3.0), increasing age (age ≥ 91; OR 4.1, 95% CI 1.4 to 12.2) and comorbidity (American Society of Anesthesiologists grades 3 to 5; OR 4.2, 95% CI 2.0 to 8.7) were independently and significantly associated with increased odds of in-hospital mortality. From 220 post-mortem reports, the most common causes of death were respiratory infections (35%), ischaemic heart disease (21%), and cardiac failure (13%). A sub-group of hip fracture patients at highest risk of early death can be identified with these risk factors, and the knowledge of the causes of death can be used to inform service improvements and the development of a more didactic care pathway, so that multidisciplinary intervention can be focused for this sub-group in order to improve their outcome. Cite this article: Bone Joint J 2015;97-B:246–51


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_8 | Pages 1 - 1
1 Feb 2013
Singleton J Gibb I Bull A Clasper J
Full Access

Recent advances in combat casualty care have enabled survival following battlefield injuries that would have been lethal in past conflicts. While some injuries remain beyond our current capability to treat, they have the potential to be future ‘unexpected’ survivors. The greatest threat to deployed coalition troops currently and for the foreseeable future is the improvised explosive device (IED) Therefore, the aim of this study was to conduct an analysis of causes of death and injury patterns in recent explosive blast fatalities in order to focus research and mitigation strategies, to further improve survival rates. Since November 2007, UK Armed Forces personnel killed whilst deployed on combat operations undergo both a post mortem computed tomography (PMCT) scan and an autopsy. With the permission of the coroners, we analysed casualties with PMCTs between November 2007 and July 2010. Injury data were analysed by a pathology-forensic radiology-orthopaedic multidisciplinary team. Cause of death was attributed to the injuries with the highest AIS scores contributing to the NISS score. Injuries with an AIS < 4 were excluded. During the study period 227 PMCT scans were performed; 211 were suitable for inclusion, containing 145 fatalities due to explosive blast from IEDs. These formed the study group. 24 cases had such severe injuries (disruptions) that further study was inappropriate. Of the remaining 121, 79 were dismounted, and 42 were mounted (in vehicles). Leading causes of death were head CNS injury (47.6%), followed by intra-cavity haemorrhage (21.7%) in the mounted group, and extremity haemorrhage (42.6%), junctional haemorrhage (22.2%) and head CNS injury (18.7%) in the dismounted group. The severity of head trauma in both mounted and dismounted IED fatalites would indicate that prevention and mitigation of these injuries is likely to be the most effective strategy to decrease their resultant mortality. Two thirds of dismounted fatalities have haemorrhage implicated as a cause of death that may have been amenable to prehospital treatment strategies. One fifth of mounted fatalites have haemorrhagic trauma which currently could only be addressed surgically. Maintaining the drive to improve all haemostatic techniques for combat casualties from point of wounding to definitive surgical proximal control alongside development and application of novel haemostatics could yield a significant survival benefit


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_8 | Pages 13 - 13
1 Feb 2013
Walker N Eardley W Bonner T Clasper J
Full Access

In a recent publication, 4.6% of 6450 Coalition deaths over ten years were reported to be due to junctional bleeding. The authors suggested that some of these deaths could have been avoided with a junctional hemorrhage control device. Prospectively collected data on all injuries sustained in Afghanistan by UK military personnel over a 2 year period were reviewed. All fatalities with significant pelvic injuries were identified and analysed, and the cause of death established. Significant upper thigh, groin or pelvic injuries were recorded in 124 casualties, of which 92 died. Pelvic injury was the cause of death in 42; only 1 casualty was identified where death was at least in part due to a vascular injury below the inguinal ligament, not controlled by a tourniquet, representing <1% of all deaths. Twenty one deaths were due to vascular injury between the aortic bifurcation and the inguinal ligament, of which 4 survived to a medical facility. Some potentially survivable deaths due to exsanguination may be amenable to more proximal vascular control. We cannot substantiate previous conclusions that this can be achieved through use of a groin junctional tourniquet. There may be a role for more proximal vascular control of pelvic bleeding


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 3 | Pages 393 - 398
1 Mar 2011
Findlay JM Keogh MJ Boulton C Forward DP Moran CG

We performed a retrospective study of a departmental database to assess the efficacy of a new model of orthopaedic care on the outcome of patients with a fracture of the proximal femur. All 1578 patients admitted to a university teaching hospital with a fracture of the proximal femur between December 2007 and December 2009 were included. The allocation of Foundation doctors years 1 and 2 was restructured from individual teams covering several wards to pairs covering individual wards. No alterations were made in the numbers of doctors, their hours, out-of-hours cover, or any other aspect of standard patient care. Outcome measures comprised 30-day mortality and cause, complications and length of stay. Mortality was reduced from 11.7% to 7.6% (p = 0.007, Cox’s regression analysis); adjusted odds ratio was 1.559 (95% confidence interval 1.128 to 2.156). Reductions were seen in Clostridium difficile colitis (p = 0.017), deep wound infection (p = 0.043) and gastrointestinal haemorrhage (p = 0.033). There were no differences in any patient risk factors (except the prevalence of chronic obstructive pulmonary disease), cause of death and length of stay before and after intervention. The underlying mechanisms are unclear, but may include improved efficiency and medical contact time. These findings may have implications for all specialties caring for patients on several wards, and we believe they justify a prospective trial to further assess this effect


The Bone & Joint Journal
Vol. 104-B, Issue 10 | Pages 1156 - 1167
1 Oct 2022
Holleyman RJ Khan SK Charlett A Inman DS Johansen A Brown C Barnard S Fox S Baker PN Deehan D Burton P Gregson CL

Aims

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

Methods

We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England’s SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models.


The Bone & Joint Journal
Vol. 104-B, Issue 12 | Pages 1362 - 1368
1 Dec 2022
Rashid F Mahmood A Hawkes DH Harrison WJ

Aims

Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era.

Methods

A multicentre observational study was carried out at 19 NHS Trusts in England. The study period for the data collection was 1 February 2021 until 28 February 2022, with mortality tracing until 28 March 2022. Data collection included demographic details, data points to calculate the Nottingham Hip Fracture Score, COVID-19 status, 30-day mortality, and vaccination status.


The Bone & Joint Journal
Vol. 104-B, Issue 6 | Pages 729 - 735
1 Jun 2022
Craxford S Marson BA Nightingale J Forward DP Taylor A Ollivere B

Aims

The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries.

Methods

A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 376 - 376
1 Sep 2012
Cortina Gualdo J Barastegui Fernandez D Teixidor Serra J Tomàs Hernández J Molero Garcia V Fernández Bautista A Monforte Alemany R Nardi Vilardaga J Cáceres Palou E
Full Access

Introduction and objectives. High-energy pelvic fractures are life-threatening injuries. Approximately 15% to 30% of patients with high-energy pelvic injuries are hemodynamic unstable, hemorrhagic shock remains the main cause of death in patients with pelvic fractures, with an overall mortality rate from 6% to 35%. The correlation between fracture pattern and mortality in polytrauma with pelvic fracture has been previously investigated. However, the purpose of our investigation was to evaluate the relationship of hemodynamic instability with the pelvic fracture pattern according to different classifications. Materials and Methods. A retrospective study of high-energy pelvic fractures was performed for consecutive patients admitted to the emergency Level I trauma center in the polytrauma unit of our institution from June 2007 to June 2010. A total of 759 patients polytrauma were attended, whom 100 had a pelvic fracture and were included in our study. Demographic data, mechanism of injury and associated injuries were recorded. The patients were classified as hemodynamic stable or unstable according to the ATLS protocol. The pelvic fracture patterns were divided into stable and unstable according to Young-Burgess and Tile classifications. Statistical analysis was performed to determine the relationship between fracture pattern and hemodynamic stability. Secondary outcomes were obtained: the relationship with TCE and pulmonary injury, usefulness of the external fixation, relationship between fracture pattern and embolization requests. Chi-square test was used for the analysis and OR test. Results. Male was the gender most frequent (70%), the average age was 45.2 years and the mortality rate was 24%, the main mechanism of injury was motor vehicle injury (41%). Pelvic fracture pattern (neither Tile classification nor Young-Burgess classification) showed no correlation with hemodynamic situation (p>0.05). Neither death could not be predicted on the basis of pelvic fracture pattern (p>0.05). We found statistical association between patients affected by pelvic fracture in polytrauma and head injury, and death (p<0.01). Conclusion. Pelvic fracture pattern is not useful to predict hemodynamic instability in polytrauma, regardless the classification system used. Pelvic fracture is not significantly associated with high risk of mortality; however it contributes to increase mortality risk in cases of head injury associated


Bone & Joint Open
Vol. 2, Issue 11 | Pages 958 - 965
16 Nov 2021
Craxford S Marson BA Nightingale J Ikram A Agrawal Y Deakin D Ollivere B

Aims

Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.

Methods

Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 60 - 60
1 Sep 2012
Yousri T Yichientsaia A Thyagarajen D Livingstone J Bradley R
Full Access

Introduction. Over 300,000 patients present with fragility fractures each year. Following a hip fracture, the 30 days mortality is around 8.3 to 9.3%. Mortality increases to 20–24% after the first year and this risk may persist for at least 5 years. The most significant variables that influence mortality are age, gender, fracture type, prefracture residence, prefracture mobility and ASA scores. Common reported postoperative complications responsible for mortality in hip fracture patients include; heart failure, bronchopneumonia and infections. Most of the studies in the literature focus on management variables influencing mortality rather than the encountered postoperative medical problems leading to death. The aim of this study is to retrospectively analyze the postoperative medical complications which led to death in a cohort of patients, following a hip fracture. Methodology. This is a retrospective analysis of a cohort of 82, out of 648, patients with hip fractures who died over a period of 2 years (December 2006–January 2009). Forty nine females and 33 males (ratio 1.5:1) were included in the study with a mean age of 87.8 years (range 59–98 years). For mortality analysis, patients' co-morbidities and medical events leading to death were categorized according to the involved organ system. This included cardiovascular, respiratory, renal, gastrointestinal, neurological and musculoskeletal systems). The timing and decision of DNAR and palliation was noted for each patient. The 30 days and the overall mortality were the set outcome measures to be reviewed. Results. The 30 days mortality was 9.4% and 13.6% overall. The majority of patients had multiple co-morbidities; 75.6% had cardiac morbidities, 28% had respiratory problems, 19.5% had renal problems, 22% had neurological problems, 22% had endocrine problems and 34.1% had miscellaneous problems including cancer in 9 patients. Out of the 82 patients, 67 died postoperatively and 15 died preoperatively. Of the 67 postoperative deaths the main reported events that led to death were; respiratory in 59.7% (90% of which had chest infection), cardiac in 29.9% (60% of which had pulmonary edema) and sepsis in 35.8% (62.5% of which had chest infection). Of the 15 preoperative deaths the lead cause of death was the respiratory problems, reported in 73.3%, of which 81.8% were due to chest infection. X% of the patients had DNAR decision and x% were palliated. Documented decisions for DNAR and palliation were done by a senior house officers and registrars in the majority of cases (x%). Conclusion. The majority of deaths in our series were related to chest infection (54.9%), cardiac failure (15.9%) and sepsis mainly secondary to chest infection (32.9%, of which 62.9% were related to chest infection). Increased awareness of the encountered medical problems that can lead to death consolidates the need of a pre and postoperative orthogeriatric input to optimize these frail patients


The Bone & Joint Journal
Vol. 103-B, Issue 11 | Pages 1648 - 1655
1 Nov 2021
Jeong S Hwang K Oh C Kim J Sohn OJ Kim JW Cho Y Park KC

Aims

The incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years.

Methods

From January 2003 to January 2016, 305 patients who underwent surgery for AFFs at six hospitals were enrolled. After exclusion, a total of 147 patients were included with a mean age of 71.6 years (48 to 89) and 146 of whom were female. We retrospectively evaluated medical records, and reviewed radiographs to investigate the fracture site, femur bowing angle, presence of delayed union or nonunion, contralateral AFFs, and peri-implant fracture. A statistical analysis was performed to identify the significance of associated factors.


The Bone & Joint Journal
Vol. 103-B, Issue 9 | Pages 1526 - 1533
1 Sep 2021
Schoeneberg C Pass B Oberkircher L Rascher K Knobe M Neuerburg C Lendemans S Aigner R

Aims

The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures.

Methods

A retrospective, multicentre registry-based study was undertaken. Between 1 January 2016 and 31 December 2019, data for 24,919 patients from 100 hospitals were collected in the Registry for Geriatric Trauma. This information was queried and patient groups with and without concomitant injury were compared using linear and logistic regression models. In addition, we analyzed the influence of the different types of additional injuries.


The Bone & Joint Journal
Vol. 103-B, Issue 2 | Pages 264 - 270
1 Feb 2021
Nilsen SM Asheim A Carlsen F Anthun KS Johnsen LG Vatten LJ Bjørngaard JH

Aims

Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients.

Methods

This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_10 | Pages 17 - 17
1 Feb 2013
Smith I Milto K Doherty C Amyes S Simpson A Hall A
Full Access

Staphylococcus aureus is a highly virulent pathogen and is implicated in approximately 50% of cases of septic arthritis. Studies investigating other S. aureus-related infections have suggested that alpha (Hla), beta (Hlb) and gamma (Hlg) toxins are key virulence factors. In particular, the ‘pore-forming’ alpha toxin is believed to be most potent. In this study, we have assessed the influence of alpha toxin on in situ chondrocyte viability. Osteochondral explants were harvested from the metacarpophalangeal joints of 3-year-old cows and placed into flasks containing Dulbecco's Modified Eagle's Medium. The flasks were then inoculated with the following isogenic ‘knockout’ strains of S. aureus: DU5946 (Hla+Hlb-Hlg-) or DU1090 (Hla-Hlb+Hlg+). The explants were incubated (37°C) and stained after 18, 24 and 40hrs with chloromethylfluorescein di-acetate and propidium iodide, labelling living chondrocytes green and dead cells red, respectively. Axial sections were imaged by confocal microscopy and the percentage cell death obtained using Volocity 4 software. The alpha toxin-producing S. aureus caused rapid cell death, with 24.8+/−3.7% at 18hrs and 44.6+/−7.2% at 24hrs. At 40hrs, there was significantly more chondrocyte death (87.4+/−3.6%; p<0.001) compared to the alpha toxin knockout strain (4.1+/−1.7%; means +/− SEM; n=4). In situ chondrocyte viability was significantly compromised by alpha toxin, with beta and gamma toxins having minimal effect. Further work will clarify the exact mechanism through which this important toxin induces chondrocyte death. Thereafter, it is hoped that targeted treatments can be developed to reduce the extent of cartilage destruction during, and after, an episode of septic arthritis


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XV | Pages 15 - 15
1 Apr 2012
Taylor D Vater G Parker P
Full Access

Haemorrhage is the main cause of preventable death on the modern battlefield. As IEDs in Afghanistan become increasingly powerful, more proximal limb injuries occur. Significant concerns now exist about the ability of the CAT tourniquet to control distal haemorrhage following mid thigh application. Aim. To evaluate the efficacy of the CAT windlass tourniquet in comparison to the newer EMT pneumatic tourniquet. Method. Serving soldiers were recruited from a military orthopaedic outpatient clinic. Participants' demographics and blood pressure were recorded and a short medical history obtained to exclude any arteriopathic conditions. Doppler ultrasound was used to identify the popliteal pulses bilaterally. The CAT was randomly self-applied by the participant at mid thigh level and the presence or absence of the popliteal pulse on Doppler was recorded. The process was repeated on the contralateral leg with the CAT now applied by a trained researcher. Finally the EMT tourniquet was self applied to the first leg and popliteal pulse change Doppler recorded again. Results. 40 consecutive patients were invited to participate in the study. 15 declined to participate. 1 was excluded via pre-determined exclusion criteria. A total of 24 participants were recruited. The self applied CAT occluded popliteal flow in only 4 subjects (16.6%). The CAT applied by a researcher occluded popliteal flow in 2 subjects (8.3%). The EMT prevented all popliteal flow in 18 subjects (75%). Discussion. This study demonstrates that the CAT tourniquet is ineffective in controlling arterial blood flow when applied at mid thigh level. The EMT was successful in a significantly larger number of participants


The Bone & Joint Journal
Vol. 101-B, Issue 8 | Pages 1015 - 1023
1 Aug 2019
Metcalfe D Zogg CK Judge A Perry DC Gabbe B Willett K Costa ML

Aims

Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control.

Materials and Methods

We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay.


The Bone & Joint Journal
Vol. 100-B, Issue 6 | Pages 780 - 786
1 Jun 2018
Chang C Lai EC Yeh M

Aims

A high rate of suicide has been reported in patients who sustain fractures, but the association remains uncertain in the context of other factors. The aim of this study was to examine the association between fractures and the risk of suicide in this contextual setting.

Patients and Methods

We performed a case-control study of patients aged 40 years or older who died by suicide between 2000 and 2011. We included patients’ demographics, physical and mental health problems, and socioeconomic factors. We performed conditional logistic regression to evaluate the associations between fractures and the risk of suicide.


The Bone & Joint Journal
Vol. 101-B, Issue 1 | Pages 83 - 91
1 Jan 2019
Whitehouse MR Berstock JR Kelly MB Gregson CL Judge A Sayers A Chesser TJ

Aims. The aim of this study was to investigate the association between the type of operation used to treat a trochanteric fracture of the hip and 30-day mortality. Patients and Methods. Data on 82 990 patients from the National Hip Fracture Database were analyzed using generalized linear models with incremental case-mix adjustment for patient, non-surgical and surgical characteristics, and socioeconomic factors. Results. The use of short and long intramedullary nails was associated with an increase in 30-day mortality (adjusted odds ratio (OR) 1.125, 95% confidence interval (CI) 1.040 to 1.218; p = 0.004) compared with the use of sliding hip screws (12.5% increase). If this were causative, it would represent 98 excess deaths over the four-year period of the study and one excess death would be caused by treating 112 patients with an intramedullary nail rather than a sliding hip screw. Conclusion. There is a 12.5% increase in the risk of 30-day mortality associated with the use of an intramedullary nail compared with a sliding hip screw in the treatment of a trochanteric fractures of the hip


The Bone & Joint Journal
Vol. 100-B, Issue 7 | Pages 973 - 983
1 Jul 2018
Schmal H Froberg L S. Larsen M Südkamp NP Pohlemann T Aghayev E Goodwin Burri K

Aims

The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization.

Patients and Methods

The study used data from the German Pelvic Trauma Registry and compared patients undergoing conservative management (n = 2394), surgical treatment (n = 1345) and transpubic surgery, including posterior stabilization (n = 730) with isolated posterior osteosynthesis (n = 405) in non-complex Type B and C fractures that only involved the obturator ring anteriorly. Calculated odds ratios were adjusted for potential confounders. Outcome criteria were intraoperative and general short-term complications, the incidence of nerve injuries, and mortality.


The Bone & Joint Journal
Vol. 100-B, Issue 9 | Pages 1234 - 1240
1 Sep 2018
Brady J Hardy BM Yoshino O Buxton A Quail A Balogh ZJ

Aims

Little is known about the effect of haemorrhagic shock and resuscitation on fracture healing. This study used a rabbit model with a femoral osteotomy and fixation to examine this relationship.

Materials and Methods

A total of 18 male New Zealand white rabbits underwent femoral osteotomy with intramedullary fixation with ‘shock’ (n = 9) and control (n = 9) groups. Shock was induced in the study group by removal of 35% of the total blood volume 45 minutes before resuscitation with blood and crystalloid. Fracture healing was monitored for eight weeks using serum markers of healing and radiographs.