Introduction. Application of an external fixator for type B and C pelvic fractures can be life saving. Anteriorly the fixator half pins can be placed in the long and thick corridor of bone in the supra-acetabular region often referred to as the low anterior ex-fix. Pins in this location are favoured as they are more stable biomechanically. The bone tunnel for the low anterior ex-fix can be visualised with an iliac oblique projection intra-operatively. In some cases despite being outside the articular surface it may still be low enough to pass through the capsular attachment of the hip joint on the anterior inferior iliac spine. We aim to provide radiological markers for the most superior fibres of the capsule to help accurate extra-capsular pin placement within the supra-acetabular bone tunnel. Materials and Methods. Thirteen cadaveric pelves, embalmed with the method of Thiel, were used for this study. An image intensifier was positioned to acquire an iliac oblique outlet view, such that the supra acetabular bone tunnel was visualised. This was achieved by positioning the beam 30 degrees cephalad and 20 degrees medial. Both left and right hemipelves were examined in this way. A standard size metallic disc was included in all images with in the acetabulum to allow for image calibration. The proximal most fibres of the hip joint capsule were marked with a K-wire so that their relation to the bone tunnel could be clearly seen on the images. Once all images were acquired they were calibrated and analysed using ImageJ Software to estimate the height and maximum width of the bone tunnel as seen on the images and the vertical distance of the superior most fibres of the capsule from the dome of the acetabulum. Results. The mean height of the bone tunnel was 24.9 mm (SD 4.3 mm, Range 18.9–33.2 mm) and the maximum width of the tunnel was 11.7 mm (SD 2.6 mm, Range 7.6–16.3 mm). The inferior margin of the bone tunnel was on average 7.4 mm (SD 3.4 mm, Range 1.1–14.4 mm) superior to the acetabular dome and the most proximal fibres of the capsule were on average 9.2 mm (SD 2.4 mm, Range 4.7–16.1 mm) superior to the acetabular dome. This meant that on average 3.6 mm (SD 2.1 mm, Range 0.3–8.9 mm) of the inferior portion of the tunnel is within the joint. There was no statistically significant difference between the left and right sides. Conclusion. There is adequate space for two long external fixator pins within the described tunnel. These should be placed in the upper half of the anterior inferior iliac spine. Below this level there is risk of being intra-capsular which can lead to septic arthritis. For this reason we recommend that supra-acetabular pins should be placed at least 16 mm superior to the acetabular dome as visualised on the iliac oblique outlet view

Introduction Intermediate and long-term results following extracapsular fracture neck of femur have been evaluated in the past. However the precise effect of the type and the stability of the fracture on the early outcome is not known. This study evaluates the correlations between type and stability of the fracture, length of stay and predictors of early functional outcome.

Methods Ninety-five consecutive cases admitted with intertrochanteric fractures were reviewed retrospectively. Eight patients died during the hospital stay and were excluded from the study. Revision surgery for implant failure was excluded from the study. The medical records were reviewed to determine the pre-operative functional status and the outcome. Radiographs were reviewed by one of the authors to classify the fracture according to AO and Tronzo classification. Statistical analysis was performed using bivariate analysis and multistep logistic regression analysis.

Results The factors influencing the post-operative length of stay most were age and AO classification. The factors influencing post-operative mobility were pre-operative mobility, accommodation and presence of complications. The factors predicting post-operative accommodation were pre-injury accommodation and mobility. The mean difference in the pre and post-operative mobility grade was 1.9. The mean difference in the pre and postoperative accommodation grade was 1.31.

Conclusions One of the reasons for classification is to predict the prognosis. Our study showed that age and AO classification can predict length of stay in hospital. This can be used to pre-empt the discharge strategy.

Fixation of extracapsular proximal femoral fractures with intra/extramedullary device is common operation in any trauma theatre. We audited our results of fixation of 307 similar fractures over the period of Feb’03 to Jan’06. Final analysis was on 252 cases (191 female and 61 male) with mean age of 86.7 years. The fractures were classified by AO classification (A1=116, A2=84, A3=52) and the implants used were DHS (204 cases) and Gamma nail (52 cases). Fixation failure was noted in 38 cases (15.07% failure rate). Failure incidence was higher in female patients and unstable fractures (A3). There was no difference in failure rate of DHS or Gamma nail fixation. The reasons identified for failures were inappropriate implant selection, inadequate reduction (p< 0.007), poor implant placement (screw head in anterior/superior quadrant p< 0.0029, TAD> 25mm p< 0.0037, oblique placement in relation to neck axis in lateral view). Multivariate logistic regression was used to identify the effect of each individual contributing factor. More than one factor was identified in all cases of failure. Out of 38 failures 3 patients died within 6 weeks after primary surgery, conservative treatment was done in 7 cases due to co-morbid conditions, 13 cases were treated by revised fixation, and 15 cases arthroplasty was carried out. The outcome after the second surgery was no different in revision fixation or arthroplasty. We conclude that failure of fixation of these fractures are serious event with disastrous consequences, so every effort should be made to produce a stable construct with any device during primary fixation.

In March 2012, an algorithm for the treatment of intertrochanteric fractures of the hip was introduced in our academic department of Orthopaedic Surgery. It included the use of specified implants for particular patterns of fracture. In this cohort study, 102 consecutive patients presenting with an intertrochanteric fracture were followed prospectively (post-algorithm group). Another 117 consecutive patients who had been treated immediately prior to the implementation of the algorithm were identified retrospectively as a control group (pre-algorithm group). The total cost of the implants prior to implementation of the algorithm was $357 457 (mean: $3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052 to 4133)) after its implementation. There was a trend toward fewer complications in patients who were treated using the algorithm (33% pre- versus 22.5% post-algorithm; p = 0.088). Application of the algorithm to the pre-algorithm group revealed a potential overall cost saving of $70 295.

The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions.

Cite this article: Bone Joint J 2014;96-B:1192–7.

Aims. We chose unstable extra-capsular hip fractures as our study group because these types of fractures suffer the largest blood loss. We hypothesised that tranexamic acid (TXA) would reduce total blood loss (TBL) in extra-capsular fractures of the hip. . Patients and Methods. A single-centre placebo-controlled double-blinded randomised clinical trial was performed to test the hypothesis on patients undergoing surgery for extra-capsular hip fractures. For reasons outside the control of the investigators, the trial was stopped before reaching the 120 included patients as planned in the protocol. . Results. In all 72 patients (51 women, 21 men; 33 patients in the TXA group, 39 in the placebo group) were included in the final analysis, with a significant mean reduction of 570.8 ml (p = 0.029) in TBL from 2100.4 ml (standard deviation (. sd). = 1152.6) in the placebo group to 1529.6 ml (. sd. = 1012.7) in the TXA group. . The 90-day mortality was 27.2% (n = 9) in the TXA group and 10.2% (n = 4) in the placebo group (p = 0.07). We were not able to ascertain a reliable cause of death in these patients. . Discussion. TXA significantly reduced TBL in extra-capsular hip fractures, but concerns regarding its safety in this patient group must be investigated further before the use of TXA can be recommended. Take home message: We present a randomised clinical trial that is unique in the literature. We evaluate the effect of TXA in very homogenous population - extra-capsular fractures operated with short intramedullary nails. Cite this article: Bone Joint J 2016;98-B:747–53

Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3rd body wear and resultant arthritis, plus lead arthropathy and systemic lead poisoning. The literature is sparse on this subject, with mostly sporadic case reports utilizing hip arthroscopy. We report on the largest series of removal of bullets from the hip joints using open surgical. We reviewed prospectively collected data of patients who presented to a single institution with civilian gunshot injuries that breached the hip joint between 01 January 2009 and 31 December 2022. We included all cases where the bullet was retained within the hip joint area. Exclusion criteria: cases where the hip joint was not breached, bullets were not retained around the hip area or cases with isolated acetabulum involvement. One hundred and eighteen (118) patients were identified. One patient was excluded as the bullet embedded in the femur neck was sustained 10 years earlier. Of the remaining 117 patients, 70 had retained bullets around the hip joint. In 44 patients we undertook bullet removal using the followingsurgical hip dislocation (n = 18), hip arthrotomy (n = 18), removal at site of fracture fixation/replacement (n = 2), posterior wall osteotomy (n = 1), direct removal without capsulotomy (tractotomy) (n = 5). In 26 patients we did not remove bullets for the following reasons: final location was extra-capsular embedded in the soft tissues (n=17), clinical decision to not remove (n=4), patients’ clinical condition did not allow for further surgery (n= 4) and patient refusal (n=1). No patients underwent hip arthroscopy. With adequate pre-operative imaging and surgical planning, safe surgical removal of retained bullets in the hip joint can be achieved without the use of hip arthroscopy; using the traditional open surgical approaches of arthrotomy, tractotomy and surgical hip dislocation

Regional anaesthesia is integral to best practice analgesia for patients with neck of femur fractures (NOFFs). These patients are generally frail and are vulnerable to side effects of opioid analgesia. Femoral nerve block (FNB) or fascia-iliaca block (FIB) can reduce opioid requirement. Literature supports good efficacy for extra-capsular NOFFs however it is acknowledged to be suboptimal for intracapsular fractures. We present a novel technique, using point of care ultrasound guidance to perform hip ultrasound guided haematoma (HUSH) aspiration, and injection of local anaesthetic (block) for intracapsular NOFFs. This a case control series. A consecutive series of cognitively intact patients, with an isolated intra-capsular NOFF, received a HUSH block using 10mls of 0.75% Ropivicaine. Haematoma was aspirated and volume recorded. This was performed in addition to standard NOFF pathway analgesia that includes a FIB and multimodal analgesia including opioids. Visual Analogue Scale (VAS)pain scores at rest and on movement were recorded pre and post procedure as well as combined morphine equivalent units administered post HUSH block. The control arm was a retrospective group of similar patients who followed the routine care pathway including a FIB. VAS pain scores from observation charts and usage of morphine equivalent units were calculated. Ten patients consented to receive HUSH blocks and we included thirty-eight patients in our control series. The HUSH block group showed mean VAS pain score of 4.2/10 at rest and 8.6 on movement prior to block. In the time after the block, VAS pain scores reduced to 1.5 at rest (p=0.007) and 3.1 on movement (p=0.0001) with a mean total morphine equivalent use of 8.75mg. This is significantly different from the control group's mean VAS pain at rest score 6.9 (p=0.0001) and 24.1mg total morphine equivalent (p=0.07). HUSH Block in addition to fascia iliaca block appears to significantly better pain relief in intracapsular neck of femur fracture patients when compared to fascia iliaca block alone. We believe it is relatively easy to perform with readily available ultrasound scanners in emergency departments

Fragility fractures are an increasing cause of morbidity and mortality in the elderly population. Their association with reduced bone mineral density (BMD) is well documented. It is a reasonable assumption that hip fracture severity is linked to the magnitude of bone loss, (the lower the BMD, the more severe the fracture), however it is not known whether this correlation exists. Our aim therefore was to investigate the relationship between BMD and hip fracture severity. We reviewed 142 patients, 96 females and 46 males, mean age 74 years (49-92), who had sustained a hip fracture following a simple ground level fall. All had subsequently undergone DEXA bone scanning of the contralateral hip and lumbar spine. Fractures were classified as intra-capsular, extra-capsular or subtrochanteric, then sub-classified using the Garden, Jensen and Seinsheimer classifications respectively. They were grouped into simple (stable) or comminuted (unstable) fracture patterns. Risk factors for osteoporosis were recorded. A low hip BMD (<2.5) was associated with an increased risk of extra-capsular fracture (p=0.025). However, no association with fracture type (extra vs. intra-capsular, p>0.05) was identified with the following variables; age, gender, BMI <25, smoking, and excess alcohol intake. We did not find any statistically significant associations between fracture severity and the nine principle variables tested for: age; gender; smoking; BMI < 25; alcohol excess and low hip or lumbar BMD T or Z score <-2.5. Although the association between BMD and risk of fragility fractures is well documented, the results of this study would suggest that severity of hip fractures does not follow this correlation. Therefore, no assumption can be made about BMD of the proximal femur based on the severity of fracture observed on plain radiographs alone

Introduction Patients sustaining fractures of the proximal femur, with co-morbid medical problems, have increased rates of morbidity and mortality. Chronic renal failure is one such co-morbidity. This study examines the outcome in patients with chronic renal failure who sustain fractures of the proximal femur. Patients and Methods All patients with a fractured neck of femur who presented to our department from September 1997 to March 2004 were retrospectively reviewed. Eighteen of these patients were found to have chronic renal failure requiring dialysis. Medical records were reviewed and information was collected and analysed. A full literature review was conducted. Results There were nine intra-capsular fractures and nine extra-capsular fractures. Four patients with intra-capsular fractures were treated by internal fixation and four by arthroplasty. One patient with an intra-capsular fracture was treated non-operatively. Eight patients with extra-capsular fractures were treated with a dynamic hip screw device and one was treated using a cephalo-medullary nail. There were sixteen deaths at a mean of seven months post-operatively (range 0 to 24). Factors that may influence outcome and the relevant literature are discussed. Conclusions Patients with chronic renal failure who sustain fractures of the proximal femur appear to have a poor outcome regardless of type of fracture or its subsequent management

To investigate whether stopping clopidogrel on admission and subsequently delaying surgery in patients with hip fracture increases the risk of cerebrovascular complications and in-hospital mortality. Retrospectively studied patients with hip fractures on clopidogrel admitted to our trauma unit between January 1, 2006 and May 31, 2007. Fifteen patients aged over 65 years with intra-capsular and extra-capsular hip fracture were reviewed. Demographic details of patients were recorded including the primary diagnosis on admission, timing of surgical intervention performed, pre-and post-operative haemoglobin and classification according to the American Society of Anesthesiologists (ASA) and in hospital mortality. Eight fractures were intra-capsular and seven extra-capsular. The mean preoperative haemoglobin levels were 12.4 (range 9.9 to 14.1), the mean postoperative haemoglobin level were 9.7 (range 8 to 12.3). Four patients required blood transfusions, 8 unit of blood were transfused in total postoperatively. The mean delay in surgery were 9.1 days (range 7 to 14 days). The mean duration of hospital stay was 21 days (range, 8 to 45 days). The 30-day mortalities were 3/15 (20%). Mortalities were secondary to cerebrovascular events. In summary, we found increase mortality and requirement for blood transfusion in patients on clopidogrel in whom surgery were delayed. A well designed research is needed to achieve evidence based management, but this may require several years due to the small, but increasing, number patients seen at present. We suggest early surgery for elderly hip fracture patients on clopidogrel. Patients on clopidogrel should be cross matched pre-operatively for red blood cells and platelets and experienced surgeon should perform the procedure

Fundaments: The surgical management of proximal femoral extra-capsular fractures in the elderly remains controversial. Bone quality and purchase of the cephalic screw are the main limitations of the currently available therapeutic options, dynamic hip screws-blade and proximal femoral nailing systems being the standard fixation Methods: which however report a revision rate of 7% due to mechanical failures. Main complications include implant-related fractures and cut out of the head-neck device with subsequent penetration into the acetabulum. The new PFNATM helical blade appears to improve the stability of the whole construct by providing better compaction of the cephalic cancellous bone around the blade. Hypothesis, Type of Study: We conducted a retrospective radiographic-clinical study of a series of PFNATM osteosyntheses. Assessment of the mid-term results was based on the hypothesis that the PFNATM would reduce the occurrence of secondary deviations. Materials and Methods: Between 2006 and 2008, 108 osteosyntheses were performed. Only traumatic fractures were included in this study. Parker’s quality of life scoring system (0 to 9) and Harris hip score (0 to 100) were used for functional evaluation. The PFNA blade position was assessed using intraoperative radiographs while a postoperative radiographic control was performed during follow-up to evaluate the occurrence of complications. Results: 98 patients (98 hips) were reviewed at a mean follow-up of 5.3 months +/− 1.5. At last follow-up, the mean Parker score had decreased by 2.3 points and the Harris hip score by 24 points. All fractures united at an average time of 10.4 weeks (+/− 2.1). Six complications were reported (6.1%). They included 3 infections of the operative site and 3 cut-out of the femoral head. Three patients required reoperation for removal of the helical blade (3%): Two for significant migration and one for intra-acetabular penetration. No statistically significant risk factors could be observed. However, the three cut-out of the femoral head occurred in unstable fractures (type 31-A.2 and 31-A.3 according to the AO classification) with mispositioning of the helical blade. Discussion: Extra-capsular proximal femoral fractures are common in the elderly population but there is currently no ideal implant available. Unstable fractures as well as mispositioning of the head/neck device are considered risk factors for secondary varus deviation and external rotation. The new PFNATM helical blade has been rarely studied. It appears as a reliable osteosynthesis option since it reports encouraging results at a mean follow-up of 6 months. However, our results do not give evidence of the superiority of the helical blade over the neck screw

Background. Isolated fracture of the greater trochanter is an uncommon presentation of hip fracture. Traditional teaching has been to manage these injuries nonoperatively, but modern imaging techniques have made it possible to detect occult intertrochanteric extension of the fracture in up to 90% of cases. This study aims to review the investigation and management of greater trochanter fractures in a single major trauma centre. Methods. A retrospective review was completed of patients admitted with greater trochanter fractures. These were matched to cases with 2-part extracapsular fractures. Initial management and clinical outcome was established using electronic notes and radiographs. Mortality and length of stay was calculated for both groups. Results. 85 isolated greater trochanter fractures in 84 patients were identified from 2006–2017. 81/85 patients were treated non-operatively. 78 were mobilised full weight bearing. None required readmission or operation due to fracture displacement. 58 of these patients had cross-sectional imaging with MRI or CT and 15 of those scanned had intertrochanteric extension of the fracture. In the same time period, 998 2-part extra-capsular fractures were treated, using a sliding hip screw. Length of stay was shorter in patients with greater trochanter fractures than 2-part extracapsular fractures (median 7 days vs 14 days, P<0.0001). 30-day mortality was 11.9%, with no significant difference to patients with 2-part extracapsular fractures. Discussion. Cross sectional imaging rarely changed the treatment protocol for isolated greater trochanter fractures. The outcome following non-operative treatment is good even in the presence of occult fractures identified on CT or MRI. We advocate a treatment protocol that encourages early mobilisation and repeat plain radiographs if patients fail to progress. This will reduce unnecessary morbidity from fixation of stable occult fractures

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year. We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip

Introduction. Upper femoral fractures include intra and extra-capsular fracture (ECF). For intra-capsular fracture (ICF), hemi-arthroplasty (HA) is the most commonly used treatment. Interest in total hip arthroplasty (THA) is growing because THA yields less revision (4% versus 7%) associated to better functional results despite higher dislocation rate (9% versus 3%). Regarding ECF, internal fixation is the reference treatment. THA could represent a relevant alternative. This study evaluates the efficiency of THA using dual mobility cup (THA-DMC) as treatment of these fractures specially in elderly patients. Material and method. 70 patients were operated on for upper femoral fractures with Quattro THA-DMC between May 2012 and October 2013. Minimum follow-up is one year. Seven surgeons in 4 institutions were involved. Data collected were: age, gender, type of fracture, surgical approach, mortality, revision rate and dislocation rate. Results. Seventy patients were included. 83.3 % were women. Mean age was 82.8 (51–99). 43% were ECF and 57% ICF. Postero-lateral approach represented 51% of cases, trans-trochanteric 43% and Hardinge 6%. Mortality rate was 10%. One dislocation (1.4%) occurred at one month postoperative treated by closed reduction. No revision was performed. Discussion. Even though THA is widely used to treat ICF, two recent meta-analyses concluded that THAs bring better survivorship as well as better functional results despite a higher dislocation rates. THA-DMC is a way to decrease dislocation risk as confirmed by our study. There is a lack of studies published on the treatment of ECF, precluding a proper assessment. Conclusion. Given the studies identified, the gold standard in the treatment of ICF is moving toward THA. THA-DMC could overcome the higher dislocation rate observed with standard THA

Introduction. Dislocation is one of the most common orthopaedic complications after primary total hip replacement (THR). The reported dislocation rate in elective THR is 5–8%. This number increases up to 22% for THR done for neck of femur fractures. Due to the reported increase in dislocation for trauma, some surgeons prefer to do a hemi-arthroplasty or open reduction and internal fixation (ORIF). Hemi-arthroplasty is known to have poorer functional outcomes. Failure of ORIF is as high as 43%, and revision of failed ORIF to THR has reported dislocation rates of up to 42%. Materials and methods. A retrospective review of all THR done for neck of femur fractures during 2006–2011 was undertaken. The patients in our institution who are considered for a THR must have an active life-style. Records were reviewed for delay to surgery, surgical approaches, articulations, bearing surfaces, follow up periods and cemented versus uncemented implants. We excluded all pathological fractures, extra-capsular fractures, failed ORIF, patients with incomplete data and patients with a follow-up period less than 3 months. Hip dislocation was the end-point of the review and we did not study other causes of revision e.g. loosening of components or infection. Results. A total of 115 cases were identified as suitable for analysis. Average age at surgery was 73.2 years (range 30–81). Delay to surgery was 5.3 days (range 1–63). Average follow up period was 18.3 months (range 3 months-4,3years). Four patients (3.4%) had a confirmed dislocation. Three of these patients had successful closed reduction and one patient required revision surgery and change of component orientation. Conclusion. Our early dislocation rate of 3.4% is within the published results and shows that primary THR is an acceptable and safe option for displaced intracapsular NOF in active patients. Most recent studies have shown superior functional outcomes of THR compared to hemi-arthroplasty or poorly performed ORIF. NO DISCLOSURES

The surgical treatment options for patients who have sustained an intra-capsular hip fracture can vary depending on a number of patient and fracture related factors. Currently most national guidelines support the use of cemented prostheses for patient undergoing hemi-arthroplasty surgery. Uncemented prostheses are commonly used for a variety of indications including those patients who have significant medical co-morbidities. To determine whether cemented hemi-arthroplasty is associated with a higher post operative mortality when compared to uncemented procedures. Data was extracted from the Scottish SMR01 database from 01/04/1997 from all patients who were admitted to hospital after sustaining a hip fracture. We investigated mortality at day 1, 2, 4, 7, 30, 120 and 1 year from surgery vs. that on day 0. In order to control for the effects of confounding variables between patients cohorts, 12 case-mix variable were used to construct a multivariable logistic regression analysis model to determine the independent effect of prosthesis fixation method. There were 64,979 patients were included in the study. Mortality for osteosynthesis of extra-capsular fractures was consistently lower when compared to that for surgical procedures for intra-capsular fractures. At day 0, uncemented hemi-arthroplasty operations had a lower associated mortality (p<0.001) when compared to cemented implant designs. Unadjusted figures showed an increased mortality equal to 1 extra death per 424 procedures. By day 1 this had become 1 extra death per 338 procedures. By day 7 cumulative mortality was less for cemented than for uncemented procedures though this did not reach significance until day 120. When compared to uncemented fixation techniques, cemented hemiarthroplasty is associated with a higher mortality in the immediate postoperative period. However, by day 120 and beyond the trend is reversed

The surgical treatment options for patients who have sustained an intra-capsular hip fracture can vary depending on a number of patient and fracture related factors. Currently most national guidelines support the use of cemented prostheses for patient undergoing hemiarthroplasty surgery. Uncemented prostheses are commonly used for a variety of indications including those patients who have significant medical co-morbidities. To determine whether cemented hemiarthroplasty is associated with a higher post operative mortality when compared to uncemented procedures. Data were extracted from the Scottish SMR01 database from 01/04/1997 from all patients who were admitted to hospital after sustaining a hip fracture. We investigated mortality at day 1,2,4,7,30, 120 and 1 year from surgery vs. that on day 0. In order to control for the effects of confounding variables between patients cohorts, 12 case-mix variable were used to construct a multivariable logistic regression analysis model to determine the independent effect of prosthesis design. There were 52283 patients included in the study. Mortality for osteosynthesis of extra-capsular fractures was consistently lower when compared to that for surgical procedures for intra-capsular fractures. At day 0, uncemented hemiarthroplasty had a lower associated mortality (p<0.001) when compared to cemented implant designs. However, this increased mortality was equal to 1 extra death per 2000 procedures. From day 1 onward mortality for cemented procedures was equal to or lower than that of uncemented. By day 4, cumulative mortality was less for cemented than for uncemented procedures. Complication and re-operation rate was significantly higher in the uncemented cohort. The use of uncemented hemiarthroplasty for the treatment of intra-capsular hip fractures cannot be justified in terms of early/late post-operative mortality

Total hip replacement (THR) is an option in a subset of patients with a neck of femur (NOF) fracture. The Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for Clinical Excellence (NICE) provide guidance on the use of THR in patients with a NOF fracture. We compare our experience and recommend changes at a local level to allow successful implementation of the guideline to improve patient care. From July 2008 to July 2011, 36 THRs preformed for trauma were identified retrospectively by cross-referencing several databases (Bluespier, Worcestershire, UK and surveillance of Surgical Site Infection (SSI), Scotland). 7 exclusions (3 failed internal fixation, 1 chronic NOF fracture, and 2 extra-capsular fractures) leaving 29 patients. All operations were carried out under the supervision of a hip surgeon. Outcome data (see results) was collected from electronic sources. Statistical analysis preformed using Fisher's exact test for categorical data. Median age 62 years (44–88), time to surgery 4 days (2–8), American association of anaesthesia grade 2 (2–4) and hospital stay was 12 days (6–18). The first operator was a consultant in 23 cases and registrar in 6. 9 hips were cemented, 5 uncemented and 15 hybrid. 13 (44.8%) patients had a complication including 8 major (27.6%) complications. A blood transfusion was required in 11 (37.9%) patients. There were 2 (6.9%) deaths. A delay to surgery of more than 2 days was associated with increased risk of major complication (p< 0.03). ASA, Age, Grade of surgeon or Cement not associated with major complications. Our results are inferior to those in the literature. We have identified potential causes; mainly a delay to surgery increasing risk of major complication. In keeping with the current guidelines we recommend that local pathways are instigated to ensure THRs for trauma may be preformed in a timely fashion

Introduction: To quantify the magnitude and incidence of haemodynamic changes that occurs during the fixation of extracapsular proximal femoral fractures when using either intra-medullary or extra-medullary fixation device. Methods: A prospective group of 31 patients with extra-capsular proximal femoral fractures were randomised to either fixation using an extra-medullary compression hip screw or an intra-medullary hip screw. All patients received a general anaesthetic adhering to a standardised anaesthetic protocol including invasive blood pressure monitoring and arterial blood gas sampling. Trans-oesophageal Doppler probe and monitor was used to record pre-operative hypovolaemia and peri-operative changes in cardiac output, stroke volume and corrected flow time (FTc – a reflection of left ventricular end diastolic pressure) during placement of implants. Results: 77% of patients were hypovolaemic preoperatively, which was corrected with an average of 439 mls of colloid replacement fluid. Application of the extra-medullary CHS produced no change in haemodynamic function. However on insertion of the IMHS we found a statistically significant reduction in stroke volume, cardiac output and FTc without changes in pulse rate or mean arterial pressure. The changes were transient with normal cardiac function returning by 5 mins post operatively. Conclusion: The transient fall in cardiac function during insertion of the intramedullary hip screw may be caused by fat embolism entering the venous circulation. As these changes are not detected with standard non-invasive monitoring we would recommend that intramedullary devices be used with caution in elderly patients who tend to have poor physiological reserve

Patients and Methods: We conducted a retrospective study of neck of femur fractures over a period of two years. Variables analysed were the perioperative haemoglobin levels, type of fracture and surgery, age, gender and blood transfusion in the perioperative period. Results: Out of a total of 310 patients 49 required a postoperative blood transfusion. The mean preoperative Hb of patients who required blood transfusion was 11; S.D. 1.49 while those who did not require a transfusion it was 12.5; S.D.1.42. Transfusion was required in 23% of patients having extra-capsular neck of femur fractures fixed with a DHS and in 9.5% of patients having intracapsular neck of femur fractures undergoing a hemiarthroplasty. The univariate analysis showed a significant relationship between post-operative transfusion and the pre-operative Hb level (p=0.0001) and the type of fracture (p=0.001). However no relationship was found between transfusion and age (p=0.423) and the gender of the patient (p=0.611). Discussion: The results of our study indicate that the most important factor in the prediction for blood transfusion in fracture neck of femur is the preoperative level of Hb as well as the type of fracture. Predicting a priori, the target population at a higher risk of requiring blood transfusion would enable us to establish appropriate prophylactic measures