Background. Dynamic Hip Screw (DHS) is the most frequently used implant in management of intertrochanteric femoral fractures. There is a known statistical relationship between a tip-apex distance (TAD) >25mm and higher rate of implant failure. Our aim was to analyse all DHS procedures performed in our trust from seventeen months and compare their TAD values to the acceptable standard of ≤25mm. Methods. All patients undergoing DHS between April 2020-August 2021 were identified from our theatre system. Additionally, those presenting to hospital with implant failures were included. Patient demographics, date of surgery, fracture classification (AO) and date/mode of failure were recorded. Intraoperative fluoroscopy images were reviewed to calculate TAD, screw location and neck shaft angles by two independent observers. Results. 215 patients were identified, five of which were excluded due to inadequate fluoroscopy. Failure was seen in 3.3% of the cohort (n=7), of which 71.4% had an unacceptable TAD. In total, 21 patients (10%) had TAD >25mm, of whom 12 had superiorly and 15 had posteriorly placed screws. There were no failures in patients with a TAD of <20mm whereas a TAD >30mm had 50% failure rate. Conclusion. This audit reinforces the importance of aiming for a low TAD (preferably <20mm) intraoperatively. It is also desirable to avoid superiorly and significantly posteriorly placed screws. Implications. Complex hip revision surgery in the elderly bears substantial financial implications to the NHS and, more importantly, causes prolonged morbidity to the patient. Adhering to established standards will ensure reduced implant failure and best patient care

The aim of this study is to analyse the radiological outcomes and predictors of avascular necrosis following 2-hole DHS in Garden I and II neck of femur fractures in patients more than 60 years with a minimum follow up of one year.

We retrospectively reviewed 51 consecutive patients aged more than 60 years who underwent DHS fixation for Garden I and II fractures. Demographics, fracture classification, time to surgery, pre-operative AMTS, preoperative posterior tilt angle, quality of reduction, pre and post-operative haemoglobin(hb), creatinine and comorbidities were analysed for correlation with AVN using Chi-Square test, Independent Sample and paired t test.

There were 40 (78.4%) females and the mean age of the cohort was 77 years. 28 and 23 were Garden I and II NOF fractures respectively. Union was observed in all our patients except one(kappa =1). 12/51(23.5%) developed AVN of the femoral head. Statistically significant higher incidence of AVN was noted in patients with a pre-op tilt angle > 200 (p = 0.006). The mean drop in Hb was higher in patients who developed AVN (21.5 g/L) versus the non-AVN group (15.9 g/L) (p = 0.001). There was no difference in AVN rates with respect to laterality, mean time to surgery, pre-op AMTS and Charlson comorbidity index. 4/52 (7.6%) had re-operations (one hardware prominence, two conversions to arthroplasty, one fixation failure during the immediate post-op period). The 30-day and one year mortality rates were 1.9 % and 11.7 % respectively.

2-hole DHS fixation in undisplaced NOF fractures has excellent union rates. A pre-operative posterior tilt angle of >200 and a greater difference in pre and post operative haemoglobin were found to correlate positively with the progression to AVN . No correlation was observed between AVN and time to surgery, laterality, quality of reduction and comorbidities.

Abstract

Introduction

Failure of intertrochanteric fracture fixation often occurs in patients, who have poor bone quality, severe osteoporosis, or unstable fracture patterns. Hip arthroplasty is a good replacement procedure even though it involves technical issues such as implant removal, bone loss, poor bone quality, trochanteric nonunion and difficulty of surgical exposure. The purpose of this study is to evaluate the outcomes of total hip arthroplasty (THA) as the replacement for failed fixation of intertrochanteric fractures of the femur.

Introduction

Lag screw cut-out following fixation of unstable intertrochanteric fractures in osteoporotic bone remains an unsolved challenge. A novel new device is the X-Bolt which is an expanding type bolt that may offer superior fixation in osteoporotic bone compared to the standard DHS screw type device.

A prospective, randomized, controlled trial was performed to compare the outcome of treatment of unstable fractures of the proximal part of the femur with either a sliding hip screw or a short proximal femoral nail antirotation (PFNA-XS, Synthes).

Eighty one patients (April 2007 – May 2008) presenting with unstable fracture of the proximal part of the femur were randomized, at the time of admission, to fixation with use of either a short proximal femoral nail antirotation (n=42) or a sliding hip screw (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Follow-up was undertaken at 3, 6, and 12 postoperative months and yearly thereafter. Plain AP and lateral radiographs were obtained at all visits. All changes in the position of the implant, complications, or fixation failure were recorded. Hip range of motion, pain about the hip and the thigh, walking ability score and return to work status were used to compare the outcomes.

There was no significant difference between 1 year mortality rates for the two groups. Mean Operative time was significantly less in PFNA group (Mean 25 min, range 19 – 56 min) than DHS group (Mean 38 min, range 28 – 70 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. 6 patients in DHS group had implant failure as compared to none in PFNA group. The functional outcome was also better in PFNA group.

When compared to DHS, PFNA-XS provides better functional outcome for unstable trochanteric fractures with less operative time, less blood loss and less complications, however one year mortality rate remains the same.

Surgical training has been greatly affected by the challenges of reduced training opportunities, shortened working hours, and financial pressures. There is an increased need for the use of training system in developing psychomotor skills of the surgical trainee for fracture fixation. The training system was developed to simulate dynamic hip screw fixation. 12 orthopaedic senior house officers performed dynamic hip screw fixation before and after the training on training system. The results were assessed based on the scoring system that included the amount of time taken, accuracy of guide wire placement and the number of exposures requested to complete the procedure. The result shows a significant improvement in amount of time taken, accuracy of fixation and the number of exposures after the training on simulator system. This was statistically significant using paired student t-test (p-value <0.05). Computer navigated training system appears to be a good training tool for young orthopaedic trainees The system has the potential to be used in various other orthopaedic procedures for learning of technical skills aimed at ensuring a smooth escalation in task complexity leading to the better performance of procedures in the operating theatre

Introduction. Osteoporotic intertrochanteric fracture (ITF) is frequent injuries affecting elderly, osteoporotic patients leading to significant morbidity and mortality. Successful prognosis including union and alignment is challenging even though initial successful reduction with internal fixation. Although many factors are related to the patient's final prognosis. Well reduction with stable fracture fixation is still the goal of treatment to improve the quality of life and decrease morbidity in patients with hip fractures, but this in turn depends on the type of fracture and bone quality. Poor bone quality is responsible for common complications, such as failure of fixation, varus collapse and lag screw cut-out, in elderly patients. Kim et al. found that the complication rate when using conventional DHS in unstable ITFs can be as high as 50% because of screw cut-out. We used the dynamic hip screws (DHS) strengthened by calcium phosphate cement (CPC) for treatment femoral intertrochanteric fracture and review the prognosis of our patients. Materials and Methods. From January of 2011 to January of 2014, 42 patients with femoral intertrochanteric fracture underwent surgery with DHS strengthened by CPC. Comparisons were made between the DHS plus CPC group with the other patients with only DHS used in our department. All patients were followed up for an average time of 14.8(6 to 24) months. X-ray was reviewed for the conditions of union and implant failure. Results. In DHS group, fixation failure happened in 3 case, delayed union and coax varus deformity in 2 cases. IN DHS plus CPC group, all fractures healed uneventfully, there is no non-union or malunion in this group. There is only 1 fixation cut-out and 1 secondary lag screw sliding was noted, however, union was still well over fracture site in this case, the patient had no clinical symptoms. Discussion. Residual bony defects present after DHS fixation in intertrochanteric fracture may lead to postoperative complications, including nonunion or implant failure. DHS strengthened by CPC is reliable fixation for old patients with intertrochanteric fracture, We demonstrated that augmentation of the bony defect with dynamic hip screw by reinforced calcium phosphate cement significantly improved the strength of osteoporotic bone, prevent screw loosening, and promote early healing of fracture. The patients can be decreased the risk of refracture and allow early weight bearing, especially in elderly patients with osteoporotic bone

Background. Despite studies into patient consent and their understanding of the potential risks of trauma surgery, no study has looked at the patient's understanding of the procedure involved with neck of femur fracture surgery. Method. Prospective analysis of 150 patients who had operative fixation of neck of femur fractures in a district general hospital. Patients were asked on the third post-operative day to select which procedure they had undergone from a diagram of four different neck of femur surgeries (cannulated screws, cephalomedullary nail, dynamic hip screw and hemiarthroplasty). Exclusion criteria for patient selection - mini mental score of < 20 and confusion secondary to delirium. Results. All patients had signed consent form 1 which was matched to the procedure. All patients were consented by an FP2, CT1 or other SHO. The mean age of patients was 83years. 5% had cannulated screw fixation, 45% had a hemiarthroplasty, 42% had a dynamic hip screw and 8% had a cephalomedullary nail. 47% of patients could correctly identify the procedure they had undergone on the 3. rd. post-operative day. Conclusions. This study shows that there are questions about the effectiveness of informed consent and patient understanding of the procedure before and after hip fracture surgery. We suggest that further detailed studies may highlight the need for alternative ways of communicating procedures to the patients or that more specialised training is required for those explaining hip fracture surgery to patients. Improvements in these areas might help ensure the true informed consent required

Introduction. A recent meta-analysis published in the British Medical Journal suggested an increased risk of infection, but none of the studies were large enough to reach statistical significance. A prospective, randomised trial was designed at our institution to investigate the wound healing and complications related to surgery following fracture neck of femur in the elderly. Objectives. The primary aim was to compare the wound problems and infection following two different methods of skin closure: Subcuticular monocryl suture to metal clips for closure of skin. The secondary aim was to look at the duration of surgery after both types of closure. We received ethical approval for this study. We screened and recruited all eligible patients admitted with acute hip fracture undergoing hemi-arthroplasty or dynamic hip screw. We recruited 541 patients in the study over the period of 3.5 years at our institution. Methods. The study was approved by ethics committee. Inclusion Criteria: Age 18 years and above undergoing DHS/ Hemiarthroplasty and with full mental capacity. Exclusion criteria: Patients with no capacity or undergoing Total Hip Replacement or Nailing of femur. The randomisation was done by using the sealed envelopes. The wound review was done on post op days 2, 5, 7, 10 & 14. Results. 516 patients were included in the study. They were divided in to two groups, 252 Hemiarthroplasty and 264 DHS. Average age was 79.48 yrs. (range 31–100 yrs.), 357 Females and 159 males. Total 196 patients were followed up till day 14 and rest of the patients were discharged by the 10. th. post op day. Out of 516 patients, 278 patients had clips and 238 patients had sub cut monocryl suture for the wound closure. The average score was 1.20 (range 1–3) for the wounds (the group of 278 patients) closed with clips mainly due to bruising and oozing. The average score was 0.71(range 0–1) for the wounds (the 238 group of patients) closed with sub cut monocryl mainly due to bruising. We did not find any significant wound infection in either of these groups. Conclusion. The final review of our study showed that the wounds closed with sub cut monocryl had less wound healing issues (average score 0.71) as compared to the wounds closed with clips (average score 1.20)

The aim of this retrospective study was to evaluate the failure rate among different fixation devices for undisplaced fracture neck of femur. All 52 patients with Garden I and II hip fractures who underwent surgery in a teaching hospital in London from January 2007 to June 2012 were included. Electronic patient records were accessed to collect the patient data. There were 52% females and the mean age of patients was 70 years. Thirty patients had cannulated screws, 18 – dynamic hip screw (DHS) with de-rotation screw and 4 had DHS alone. Initial results showed that 36% patients had re-operation. 7(77%) had total hip replacement and 1(11%) had metal work removal. The reason for revision was failure of fixation in 8 (88%) and avascular necrosis in 1 (11%). There was significantly higher failure rate in the DHS with derotation screw group (50%) compared to the cannulated screw group (35%) and the DHS alone group (0%). Average time to planned revision was 11.1 months. Traditionally undisplaced intra capsular hip fractures are treated by in-situ fixation using different devices. Biomechanically DHS with de-rotation screw achieves better rotational and axial stability compared to other fixation devices. However, our study showed a higher failure rate in this group. Inability to achieve a perfectly parallel screw position seems to be a significant factor responsible for high failure. Higher failure rates with fixation may boost the role of replacement arthroplasty as one off surgical treatment in elderly patients

Intra-operative Tip-Apex Distance (TAD) estimation optimises dynamic hip screw (DHS) placement during hip fracture fixation, reducing risk of cut-out. Thread-width of a standard DHS screw measures approximately 12.5 millimetres. We assessed the effect of introducing screw thread-width as an intra-operative distance reference to surgeons. The null hypothesis was that there were no differences between hip fracture fixation before and after this intervention. Primary outcome measure was TAD. Secondary outcome measures included position of the screw in the femoral head, quality of reduction, cut-out and surgeon accuracy of estimating TAD. 150 intra-operative DHS radiographs were assessed before and after introducing screw thread-width distance reference to surgeons. Mean TAD reduced from 19.37mm in the control group to 16.49mm in the prospective group (p=<0.001). The number of DHS with a TAD > 25mm reduced from 14% to 6%. Screw position on lateral radiographs was significantly improved (p=0.004). There were no significant differences in screw position on antero-posterior radiographs, quality of reduction, or rate of cut-out. Significant improvement in accuracy (p=0.05) and precision (p=0.005) of TAD estimation was demonstrated. Awareness and use of screw-thread width improves estimation and positioning of a DHS screw in the femoral head during fixation of hip fractures

Femoral neck stress fractures (FNSF) are uncommon, representing 3.5% to 8% of all stress fractures in military recruits. The majority of displaced FNSF undergo operative fixation and are at risk of avascular necrosis (AVN) and non union with a 40–100% medical discharge rate. We aimed to review the incidence and outcome of displaced FNSF in Royal Marine Recruits. Retrospective review identified 6 Royal Marine recruits, aged 17 to 25, who had suffered a displaced FNSF over a 6 and a half year period. Incidence was 0.93 per 1000 recruits. Patients were treated urgently by operative fixation with a 2 hole dynamic hip screw device, in 3 cases supplemented with an anti-rotation screw. There were no cases of AVN, no surgical complications and no further procedures were required. All united with a mean time to union of 11 months. 50% had a union time greater than 1 year. 2 completed training, 2 are still in rehabilitation and 2 (33%) were discharged before completion of training. These fractures are slow to unite compared to other fractures at this site or stress fractures elsewhere. With urgent surgical intervention and stable fixation all however went onto successful union with time and all returned to rehabilitation or training with minimal complications. Awareness of the length of time to union has been invaluable in guiding treatment and rehabilitation. It can help avoid the risks of unnecessary secondary interventions for delay to union

Hemiarthroplasty and proximal femoral fixation are common procedures performed in trauma units, but there is very little information regarding post-operative pain experience. Pain control is a keystone in the successful management of hip fractures. A sound strategy of pain management is easier to implement in patients where pain levels can be predicted, allowing for an effective balanced analgesic regime. Analysis was performed on patients presenting with a hip fracture in two hospitals. Patients with a diagnosis of dementia were excluded. Post-operative pain scores were taken from patient observation charts using a verbal analogue scale. Post-operative opiate consumption was calculated from inpatient drug charts. 357 patients were included, 205 patients underwent a cemented hemiarthroplasty (HG) and 152 had fixation with a dynamic hip screw (DG). No significant difference was found in the length of hospital stay. HG patients recorded a mean morphine requirement of 20.2mg compared with 40.3mg for the DG group. Although the early pain score difference was significant (p=0.009), after 4 days, the scores were equivalent. This may support the notion of non-surgical factors determining the total length of hospital stay. The reason for the elevated pain scores and higher morphine requirement in the DHS group remains unclear. One theory is the fracture site still exists, and it is possible that pre-existing hip arthritis may continue to be symptomatic. It is important to recognise the difference in pain experienced between the groups and analgesia should be tailored towards the individual, allowing for improved peri-operative surgical care and patient experience

Aims

The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery.

Introduction. Failed operated intertrochanteric fractures (with screw cutout, joint penetration, varus collapse, nonunion, or femoral head avascular necrosis) pose treatment dilemmas. The ideal approach is re-osteosynthesis with autologous bone grafting. When the femoral head is unsalvageable, conversion to a prosthetic hip replacement is necessary. Materials/Methods. Thirty-seven patients with failed dynamic hip screw fixation (and unsalvageable femoral heads) were treated with cementless hip arthroplasty (13 underwent Bipolar Arthroplasty, 24 had Total Hip Arthroplasty) over a 5-year period (Dec 2005 to Nov 2010). Seven needed a modified trochanteric split, and the rest were managed by standard anterolateral approach. Abductor mechanism was reconstructed using strong nonabsorbable sutures (ethibond 5) or stainless steel wires. The calcar was partially reconstructed using remnant femoral head and cerclage wiring in a few cases. Results. Clinico-radiological assessment was done at three, six, 12 months and yearly thereafter over an average 36 months (range, three to 60 months). Stem loosening, lysis, subsidence and trochanteric union were studied. At last follow-up, one patient had died, and there were two instances each of stem subsidence and trochanteric nonunion. Clinical results using Harris hip scores were good or excellent. Conclusion. Management of nonsalvageable femoral heads after failed intertrochanteric fracture fixation is possible with cementless hip arthroplasty. Successful outcomes depend on functional abductor reconstruction, fracture and femoral shaft penetration prevention. Autograft, allograft or head/neck replacement components are necessary sometimes

The aim of this study was to establish any association between implant cut-out and a Tip Apex Distance (TAD), ≥25mm, in proximal femoral fractures, following closed reduction and stabilisation, with either a Dynamic Hip Screw (DHS) or Intramedullary Hip Screw (IMHS) device. Furthermore, we investigated whether any difference in cut-out rate was related to fracture configuration or implant type. WE conducted a retrospective review of the full clinical records and radiographs of 65 consecutive patients, who underwent either DHS or IMHS fixation of proximal femoral fractures. The TAD was measured in the standard fashion using the combined measured AP and lateral radiograph distances. Fractures were classified according to the Muller AO classification. 35 patients underwent DHS fixation and 30 patients had IMHS fixation. 5 in each group had a TAD≥25mm. There were no cut-outs in the DHS group and 3 in the IMHS group. 2 of the cut-outs had a TAD≥25mm. The 3 cut-outs in the IMHS group had a fracture classification of 31-A2, 31-A3 and 32-A3.1 respectively. In addition, the fractures were inadequately reduced and fixed into a varus position. A TAD<25mm would appear to be associated with a lower rate of cut-out. The cut-out rate in the IMHS group was higher than the DHS group. Contributing factors may have included an unstable fracture configuration and inadequate closed fracture reduction at the time of surgery

Failed internal fixation of hip fracture is a problem with varied aetiology. This becomes more complex when associated with infection. Total hip arthroplasty (THA) remains the only option to restore hip biomechanics when there is partial/complete head destruction associated with it. A retrospective review was performed for 22 consecutive patients of THA following failed infected internal fixation between Sept. 2001 and Nov. 2007. There were 11 dynamic hip screw failures for intertrochanteric fractures, six failed osteotomies following proximal femoral fractures and five failed screw fixations for transcervical fractures. The average age of the patients was 48.5 years and average follow up period was 3.5 years (16 months–7.5 years). All the patients have undergone two stage revision surgeries. The average Harris Hip Score improved from 35.5 to 82.8 at the latest follow up. None of the patients had recurrence of infection. One patient developed sciatic nerve palsy, recovered partially at one year following surgery. The results were comparable to primary arthroplasty in femoral neck fractures. THA is a useful salvage procedure for failed infected internal fixation of hip fractures. Extreme care must be taken to avoid fracture and penetration of femoral shaft in such cases. Auto graft, allograft and special components like multihole cup, narrow stem should be available for reconstruction in difficult cases

Introduction. Fracture of the proximal femur frequently occur in children with osteogenesis imperfecta(O.I.) or fibrous dysplasia and may lead to progressive coxa vara and a “shepherds crook” deformity. In adults, these changes introduce difficulties that are not ordinarily encountered with routine osteosynthesis. There is minimal literature on this topic and the cases reported are few in number. Objective. The purpose of this case report was to describe a intertrochanteric fracture in a elderly woman with O.I. successfully treated by 115 degrees hip osteotomy plate and cannulated screws. Methods. We present a case of a 82-year-old female who was injured by falling. She had O.I. type â�£ A according to Sillence. Radiographs showed a intertrochanteric fracture of the femur with severe deformity. The femoral shaft had 25 degrees angular deformity and moderate rotation at the proximal. The angle between femoral neck and shaft was 105 degrees (severe coxa vara) and the proximal femur had a “shepherds crook” deformity (See Figure 1). She had presented 70 years previously ipsilateral fractures of the femur which had healed. These mal-united fracture involved anatomical changes such as medicalization of the femoral canal and intramedullary remodeling and sclerosis (See Figure 2). Recognizing the anatomical changes before and during surgery, standard dynamic hip screw or AO angled blade plate could not fit the femur and not provide stability. Using 115 degrees hip osteotomy plate and cannulated screws, osteosynthesis was performed (See Figure 3). Results. Twelve months postoperatively, the fracture united without complications and the patient felt comfortable and satisfied with gait. Conclusion. An unusual case was presented in which a 82-year-old woman was successfully treated with 115 degrees hip osteotomy plate and cannulated screws for a intertrochanteric fracture of the femur with osteogenesis imperfecta. Standard plate osteosynthesis was unlikely to provide sufficient stable fixation in this case

Introduction. Intracapsular fractures of the femoral neck in young adults are a surgical emergency. Recent literature reviews have questioned whether the timing of surgery reduces the incidence of avascular necrosis, non-union and revision. A study was performed to determine how many patients met a 12-hour target for operative fixation with this injury. Possible sources of delay to theatre were reviewed. Methods. A Fractures Outcomes Research Database was used to identify patients aged 18–64 who were admitted to the Royal Victoria Hospital in Belfast between 1. st. Jan 2008 and 31. st. Dec 2009. Intracapsular fractures of the femoral neck which were treated with a 2-hole dynamic hip screw were included. Time of injury, time of presentation in A&E, time of admission to fracture ward, operation time, demographic data, and the mechanism of injury were extracted from the database. Results. 81 patients were identified who met the inclusion criteria. Median age was 56 years (range 26–64y). 64 injuries were low energy. 16 patients were alcoholics, 34 smoked cigarettes. 31 of 81 operations were performed within 12 hours of the injury. Of the delayed 50 patients, 25 sustained their injury between 1700–2359. 51 of 81 operations were performed on daytime lists (0900–1659), 23 in the evening (1700–2359) and 7 overnight (0000–0859). Median time from injury to presentation at A&E was 1 hour 39 minutes. Time from A&E presentation to ward admission was 4 hours. Time from ward admission to surgery was 8 hours 13 minutes. Conclusions. The time from ward admission to arrival in theatre accounted for the greatest delay, and is modifiable. Injuries which occur in the evening are often operated on the next day. The majority of the patients had low energy injuries, and a minority smoke cigarettes and abuse alcohol. The long-term implications of this delay will require further work