Aims. Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines. Methods. We used the NHFD to identify all operations for fixation of trochanteric fractures in England and Wales between 1 January 2021 and 31 December 2021. A uniform price band from each of three hip fracture implant manufacturers was used to set cost implications alongside variation in implant use. Results. We identified 18,156 A1 and A2 trochanteric hip fractures in 162 centres. Of these, 13,483 (74.3%) underwent SHS fixation, 2,352 (13.0%) were managed with short IMN, and 2,321 (12.8%) were managed with long IMN. Total cost of IMN added up to £1.89 million in 2021, and the clinical justification for this is unclear since rates of IMN use varied from 0% to 97% in different centres. Conclusion. Most trochanteric hip fractures are managed with SHS, in keeping with national guidelines. There is considerable variance between hospitals for implant choice, despite the lack of evidence for clinical benefit and cost-effectiveness of more expensive nailing systems. This suggests either a lack of awareness of national guidelines or a choice not to follow them. We encourage provider units to reassess their practice if outwith the national norm. Funding bodies should examine implant use closely in this population to prevent resource waste at a time of considerable health austerity. Cite this article: Bone Jt Open 2022;3(10):741–745

Aims. This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)). Methods. A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant. Results. The overall agreement between surgeons on implant choice was fair (kappa = 0.27 (95% confidence interval (CI) 0.25 to 0.28)). Factors associated with preference for IMN included USA compared to Europe or the UK (Europe odds ratio (OR) 0.56 (95% CI 0.47 to 0.67); UK OR 0.16 (95% CI 0.12 to 0.22); p < 0.001); exposure to IMN only during training compared to surgeons that were exposed to both (only IMN during training OR 2.6 (95% CI 2.0 to 3.4); p < 0.001); and A2 compared to A1 fractures (Type A2 OR 10 (95% CI 8.4 to 12); p < 0.001). Conclusion. In an international cohort of orthopaedic surgeons, there was a large variation in implant preference for patients with A1 and A2 trochanteric fractures. This is due to surgeon bias (country of practice and aspects of training). The observation that surgeons favoured the more expensive implant (IMN) in the absence of convincing evidence of its superiority suggests that surgeon de-biasing strategies may be a useful focus for optimizing patient outcomes and promoting value-based healthcare. Cite this article: Bone Joint J 2021;103-B(4):775–781

Aims

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance.

Aims

National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

Limb length deficiency, secondary to trauma or infection, is a common reason for referral to our tertiary service. After experiencing troubles with the Intramedullary Skeletal Kinetic Distractor (ISKD), we changed implant to the magnet operated Precice nail. We evaluated the safety and reliability of this novel device and compared it to our early ISKD results. To minimise variables, we selected femurs only. In total, we reviewed medical and radiographic records of 20 cases (8 ISKD, 12 Precise) from 2010–2015. At each postoperative visit, the accuracy and precision of distraction and complications were recorded. Accuracy reflected how close the measured lengthening was to the prescribed distraction at each postoperative visit. Precision reflected how close the repeated measurements were to each other over the course of total lengthening period. No patients were lost to follow-up (1–3.5 years). With the Precice nail (2012–2015), 11/12 were male and 10/12 were caused by trauma. The mean age was 34. Mean total lengthening was 38mm (range, 29–53mm), with an accuracy of 98percnt; and precision of 92percnt;. All patients achieved target lengthening at a rate of 1mm lengthening per day. In one case, the Precice nail fractured and this was revised successfully. With the ISKD group (2010–2012), 8/8 had complications (magnet jamming, nail breakage, equinus contractures and claw toes), with 25percnt; achieving accurate lengthening and precision of 38percnt;. Our results so far have justified our change in implant choice and, in our experience, support the Precice nail as being safe and precise

PURPOSE. To evaluate the late radiographic and functional complications occurring after treatment of reverse oblique trochanteric fractures with the proximal femoral nail. PATIENTS. This is a retrospective study which was conducted between October 2004 and October 2009. 55 patients with a reverse oblique trochanteric fracture were treated with the Gamma 3 nail. According to the AO classification, there were 36 type AIII-1, 8 AIII-2, 11 AIII-3 fractures. Closed reduction was achieved in all patients. The long gamma 3 nail was used in 34 fractures. The mean follow up was 18 months (range 9 to 32 months). The patients were evaluated clinically (Harris hip score) and radiographically. RESULTS. No intraoperative complications were recorded. During surgery, satisfactory reduction and acceptable nail insertion was assessed in all patients. No early postoperative technical failures were noticed. Complete union was achieved in 51 patients. The mean Harris hip score was 80.2. The results were excellent in 23 patients (41.8%), good in 19 (34.5%), fair in 9 (16.3%), and poor in 4 patients (7%). Late radiographic complications included secondary varus displacement due to cut-out of the proximal screw in three patients (5.4%), and calcification at the tip of the greater trochanter in nine patients (16%). Stress shielding as evidenced by the lack of cortical hypertrophy at the level of the tip of the implant were detected in 5 patients. Patients treated with a long gamma 3 nail achieved a statistically significant better result (p< 0.005). Three patients (5.5%) required a reconstructive procedure. CONCLUSION. Proximal femoral nailing provides stronger fixation of the proximal part in reverse oblique trochanteric fractures reducing mechanical complications. The implant choice, the accuracy of fracture reduction, and the correct placement of the nail are the key factors influencing the final outcome

Aims. The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability. Methods. We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. Results. Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). Conclusion. This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN. Cite this article: Bone Joint J 2022;104-B(2):274–282

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.

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Hip fractures in patients < 60 years old currently account for only 3% to 4% of all hip fractures in England, but this proportion is increasing. Little is known about the longer-term patient-reported outcomes in this potentially more active population. The primary aim is to examine patient-reported outcomes following isolated hip fracture in patients aged < 60 years. The secondary aim is to determine an association between outcomes and different types of fracture pattern and/or treatment implants.

Aims

A lack of supporting clinical studies have been published to determine the ideal length of intramedullary nail in fixation of trochanteric fractures of the hip. Nevertheless, there has been a trend to use shorter intramedullary nails for the internal fixation of trochanteric hip fractures. Our aim was to determine if the length of nail affected the outcome.

Aims

Debate continues about whether it is better to use a cemented or uncemented hemiarthroplasty to treat a displaced intracapsular fracture of the hip. The aim of this study was to attempt to resolve this issue for contemporary prostheses.

Introduction. The sliding hip screw is the implant of choice for the operative treatment of stable trochanteric femur fractures. Surgeons have been using widely the four-hole side plate DHS (Dynamic Hip screw) with four bicortical screws, which allows adequate weight bearing after operation. However, there is lacking of scientific studies that support the use of such long plate and we question ourselves if we can accomplish the same results with the use of a smaller plate. The objective of this study is to compare the results accomplished with a four-hole and a two-hole DHS side plate in the treatment of transtrochanteric fractures. Material and Methods. This study included 140 patients (43 male and 97 female) that had stable transtrochanteric fractures between 1/01/2005 and 31/12/2008 and were submitted to osteossynthesis with DHS side-plate. 32 (22.9%) were treated with a two-hole DHS (group DHS2) and 108 (77.1%) with four-hole. The fractures were evaluated according to the AO/OTA classification and Evans for stability. The fracture reduction was assessed according to Sernbo criteria and was recorded also patient demographics, fracture patterns and fixation, comorbilities, mortality rate, capacity of ambulation and complications. Results. The patients had in medium 77.74 ± 49.52 years and 18 months of follow-up (range 6–36 months). Both groups had similar patient demographics. The etiology of the fracture was fall in 120 (85.7%) and 20 (14.3%) from traffic accident, 10 (7.1%) were patological. 15 (10.7%) died during hospital stay: 13 (12.0%) in DHS4 group and 2 (6.3%) in DHS2. In terms of capacity of ambulation in the group DHS2 15.6% didn't ambulate and 25% had walking aid; in the group DHS4 20.4% didn't ambulate and 29.7% had walking aid. Concerning fracture reduction there was varus (<125°) in 9.4% of DHS2 group and 9.3% in DHS4. Also in the group DHS4 there were 15 (13.9%) complications: 3 cut-out, 3 device failure, 8 infections and 1 pseudarthrosis. In the group DHS2 there were 4 (12.5%) complications: 1 cut-out, 2 infections and 1 device failure. 121 (28 group DHS2 and 93 group DHS4) fractures healed without complications in anatomical position with good function of the hip joint. Discussion. We found no significant differences between the two groups regarding reduction or percentage of complications. However we could observe that in the group DHS2 there was a lesser rate of mortality during hospital stay and a higher capacity of ambulation without walking aid. So the fixation of stable transtrochanteric fractures with a two-hole DHS side-plate is safe, less invasive, less surgical time and less blood loss than a four-hole. As our study reveled in these stable fractures there is lacking of benefit with the use of a larger slide-plate, the two-hole is adequate and its use should be increasing in our clinical practice

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.