Aim: To assess the functional outcome and longevity of patients who are mentally competent when they sustain an intra-capsular fracture of the femoral neck. Methods: Prospective cohort study of fifty female patients over the age of seventy years of age with a displaced intra-capsular fracture of the femoral neck. Patients with known, cognitive impairment terminal illness or active infection were excluded from the study. Patients were treated with a large head total hip replacement. Functional outcome was assessed using the the Barthel index score and the Charnley-modified Merle d’Aubigne score yearly for five years. The Oxford hip score was also recorded annually from three to ten years post op. The date and cause of death were recorded from hospital notes and death certificates. Results: The mean age at time of femoral neck fracture was 81 years. Three patients died before discharge from hospital. The mortality rates were 18% at twelve months, 28% at two years, 44% at five years and 92% at ten years. Those patients surviving had mean Oxford scores of 24 at 3 years, 26 at 5 years, 23 at 7 years and 25 at ten years. The cause of death was ischaemic heart disease in 22%, cancer in 10%, bronchopneumonia in 12% and simply ‘old age’ in 14%. Conclusion: Elderly female patients who are not cognitively impaired at the time of displaced intra-capsular fracture of the femoral neck have a 56% chance of living five years. Function scores in the survivors are maintained, and are better than would be expected if the patients had undergone hip hemiarthroplasty. Total hip replacement in this population may be justified

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.

Objective

To evaluate the volume of cases, causes of failure, complications in patients with a failed Thompson hemiarthroplasty.

Intoduction: There is a general consensus with regard to the treatment of extacapsular fractures of the hip, however the surgical treatment and the choice of implant in displaced intracapsular fractures remains controversial. Evidence has not definitively established the relative merits of the optimal device for internal fixation. The management of displaced intracapsular femoral neck fractures depends on surgeon’s preference.

Methods: We have done a study using synbone (Corticocancellous with similar properties of natural bone) comparing three methods of fixation (three parallel cannulated screws, two hole dynamic hip screw with and without a derotation screw, four constructs of each fixation). We looked at the ultimate peak loads that a construct can withstand before failure.

Results: There is a significant difference between the cannulated screws and two hole Dynamic hip screw, the latter being stronger of the two. However there is no biomechanical advantage of using the derotation screw.

Discussion: Although this study provides evidence of superiority of dynamic hip screw over cannulated screws, this is limited to the biomechanical properties of the construct. The ultimate clinical failure can depend on numerous other factors. Based on our study we recommend two-holed Dynamic Hip Screw fixation for displaced intracapsular fractures of proximal femur.

Aims

The optimal management of intracapsular fractures of the femoral neck in independently mobile patients remains open to debate. Successful fixation obviates the limitations of arthroplasty for this group of patients. However, with fixation failure rates as high as 30%, the outcome of revision surgery to salvage total hip arthroplasty (THA) must be considered. We carried out a systematic review to compare the outcomes of salvage THA and primary THA for intracapsular fractures of the femoral neck.

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

Introduction. The vascular anatomy of the femoral head and neck has been previously reported, with the primary blood supply attributed to the deep branch of the Medial Femoral Circumflex Artery (MFCA). This understanding has led to development of improved techniques for surgical hip dislocation for multiple intra-capsular hip procedures including Hip Resurfacing Arthroplasty (HRA). However, there is a lack of information in the literature on quantitative analysis of the contributions of the Lateral Femoral Circumflex Artery (LFCA) to femoral head and neck. Additionally, there is a lack of detailed descriptions in the literature of the anatomic course of the LFCA from its origin to its terminal branches. Materials & Methods. Twelve fresh-frozen human pelvic cadaveric specimens were studied (mean age 54.3 years, range 28–69). One hip per specimen was randomly assigned as the experimental hip, with the contralateral used as a control. Bilateral vascular dissection was performed to cannulate the MFCA and LFCA. Specimens were assigned as either LFCA-experimental or MFCA-experimental. All specimens underwent a validated quantitative-MRI protocol: 2mm slice thickness with pre- and post- MRI contrast sequences (Gd-DTPA diluted with saline at 3:1). In the LFCA-experimental group 15ml of MRI contrast solution was injected into the LFCA cannula. In the MFCA-experimental group 15ml of contrast solution was injected into the MFCA cannula. On the control hip contrast solution was injected into both MFCA and LFCA cannulas, 15ml each (30ml total for the control hip). Following MRI, the MFCA and LFCA were injected with polyurethane compound mixed with barium sulfate (barium sulfate only present in either MFCA or LFCA on each hip). Once polymerization had occurred, hips underwent thin-slice CT scan to document the extra- and intra-capsular course of the LFCA and MFCA. Gross dissection was performed to visually assess all intra-capsular branches of both the MFCA and LFCA and assess for extravasation. Quantitative-MRI analysis was performed based on Region of Interest (ROI) assessment. Femoral heads were osteotomized at the level of the largest diameter proximal to the articular margin and perpendicular to the femoral neck, for placement of a 360° scale. Measurements using the 360° scale were recorded. For data processing, we used right-side equivalents and integrated our 360° data into the more commonly used imaginary clock face. Results. Quantitative analysis of contributions of the MFCA and LFCA are detailed (Table 1). Thin slice CT scan graphical analysis of the LFCA provided (Figure 1). Topographic 360° scale (and imaginary clock face) results are also detailed in a diagram (Figure 2). Discussion. This study provides the first comparative results for quantitative assessment of arterial contributions from both the MFCA and LFCA for the femoral head and neck. The MFCA is the dominant vessel for both the femoral head and neck, supplying 82% of the femoral head and 67% of the femoral neck. The LFCA plays its largest role in the inferoanterior femoral neck (with a 48% arterial contribution). This finding highlights the importance of protecting the LFCA in addition to the MFCA during intra-capsular hip procedures including Hip Resurfacing Arthroplasty

Introduction. Osteogenesis imperfect (OI) is a geno- and phenotypically heterogeneous group of congenital collagen disorders characterized by fragility and microfractures resulting in long bone deformities. OI can lead to progressive femoral coxa vara from bone and muscular imbalance and continuous microfracture about the proximal femur. If left untreated, patients develop Trendelenburg gait, leg length discrepancy, further stress fracture and acute fracture at the apex of the deformity, impingement and hip joint degeneration. In the OI patient, femoral coxa vara cannot be treated in isolation and consideration must be given to protecting the whole bone with the primary goal of verticalization and improved biomechanical stability to allow early loading, safe standing, re-orientation of the physis and avoidance of untreated sequelae. Implant constructs should therefore be designed to accommodate and protect the whole bone. The normal paediatric femoral neck shaft angle (FNSA) ranges from 135 to 145 degrees. In OI the progressive pathomechanical changes result in FNSA of significantly less than 120 degrees and decreased Hilgenreiner epiphyseal angles (HEA). Proximal femoral valgus osteotomy is considered the standard surgical treatment for coxa vara and multiple surgical techniques have been described, each with their associated complications. In this paper we present the novel technique of controlling femoral version and coronal alignment using a tubular plate and long bone protection with the use of teleoscoping rods. Methodology. After the decision to operate had been made, a CT scan of the femur was performed. A 1:1 scale 3D printed model (AXIAL3D, Belfast, UK) was made from the CT scan to allow for accurate implant templating and osteotomy planning. In all cases a subtrochanteric osteotomy was performed and fixed using a pre-bent 3.5 mm 1/3 tubular plate. The plate was bent to allow one end to be inserted into the proximal femur to act as a blade. A channel into the femoral neck was opened using a flat osteotome. The plate was then tapped into the femoral neck to the predetermined position. The final position needed to allow one of the plate holes to accommodate the growing rod. This had to be determined pre operatively using the 3D printed model and the implants. The femoral canal was reamed, and the growing rod was placed in the femur, passing through the hole in the plate to create a construct that could effectively protect both the femoral neck and the full length of the shaft. The distal part of the plate was then fixed to the shaft using eccentric screws around the nail to complete the construct. Results. Three children ages 5,8 and 13 underwent the procedure. Five coxa vara femurs have undergone this technique with follow-up out to 62 months (41–85 months) from surgery. Improvements in the femoral neck shaft angle (FNSA) were av. 18. o. (10–38. o. ) with pre-op coxa vara FNSA av. 99. o. (range 87–114. o. ) and final FNSA 117. o. (105–125. o. ). Hilgenreiner's epiphyseal angle was improved by av. 29. o. (2–58. o. ). However only one hip was restored to <25. o. In the initial technique employed for 3 hips, the plates were left short in the neck to avoid damaging the physis. This resulted in 2 of 3 hips fracturing through the femoral neck above the plate at approximately 1 year. There were revisions of the 3 hips to longer plates to prevent intra-capsular stress riser. All osteotomies united and both intracapsular fractures healed. No further fractures have occurred within the protected femurs and no other repeat operations have been required. Conclusions. Surgical correction of the OI coxa vara hip is complex. Bone mineral density, multiplanar deformity, a desire to maintain physeal growth and protection of the whole bone all play a role in the surgeon's decision making process. Following modifications, this technique demonstrates a novel method in planning and control of multiplanar proximal femoral deformity, resulting in restoration of the FNSA to a more appropriate anatomical alignment, preventing long bone fracture and improved femoral verticalization in the medium term follow-up

Aims. In UK there are around 76,000 hip fractures occur each year 10% to 15% of which are undisplaced intracapsular. There is considerable debate whether internal fixation is the most appropriate treatment for undisplaced fractures in older patients. This study describes cannulated hip screws survivorship analysis for patients aged ≥ 60 years with undisplaced intra-capsular fractures. Methods. This was a retrospective cohort study of consecutive patients aged ≥ 60 years who had cannulated screws fixation for Garden I and II fractures in a teaching hospital between March 2013 and March 2016. The primary outcome was further same-side hip surgery. Descriptive statistics were used and Kaplan-Meier estimates calculated for implant survival. Results. A total of 114 operations were performed on 112 patients with a mean age of 80.2 years (SD 8.9). The 30-day and one-year mortality were 1% (n = 1) and 13% (n = 15), respectively. Median follow-up was 6.6 years (interquartile range 6.0 to 7.3). Kaplan-Meier estimates showed a survivorship of 95% at one year and 90% at five years (95% confidence interval 84% to 95%) for cannulated screws. Nine patients underwent further hip surgery: four revision to total hip arthroplasty, one revision to hemiarthroplasty, three removals of screws, and one haematoma washout. Posterior tilt was assessable in 106 patients; subsequent surgery was required in two of the six patients identified with a posterior angle > 20° (p = 0.035 vs angle < 20°). Of the 100 patients with angle < 20°, five-year survivorship was 91%, with seven patients requiring further surgery. Conclusion. This study of cannulated hip screw fixation for undisplaced fractures in patients aged ≥ 60 years reveals a construct survivorship without further operation of 90% at five years. Cannulated screws can be considered a safe reliable treatment option for Garden I and II fractures. Caution should be taken if posterior tilt angle on lateral view exceeds 20°, due to a higher failure rate and reoperation, and considered for similar management to Garden III and IV injuries. Cite this article: Bone Jt Open 2022;3(3):182–188

Introduction. Precise knowledge of the Femoral Head (FH) arterial supply is critical to avoid FH avascular necrosis following open and arthroscopic intra-capsular surgical procedures about the hip. The Medial Femoral Circumflex Artery (MFCA) provides the primary FH vascular contribution. Distribution of vascular foramina at the Femoral Head-Neck Junction (FHNJ) has been reported previously using an imaginary clock face. However, no quantitative information exists on the precise Capsular Insertion (CI) and intra-capsular course of the MFCA Terminal Branches (TBs) supplying the FH. This study seeks to determine the precise anatomic location of the MFCA's TBs supplying the FH, in order to help avoid iatrogenic vascular damage during surgical intervention. Methods. In 14 fresh-frozen cadaveric hips (9 left and 5 right), we cannulated the MFCA and injected a polyurethane compound. Using a posterior approach, careful dissection of the MFCA allowed us to identify and document the extra- and intra-capsular course of the TBs penetrating the FHNJ and supplying the FH. An H-type capsulotomy provided joint access while preserving the intracapsular Retinaculum of Weitbrecht (RW), followed by circumferential capsulotomy at the acetabular margin exposing the FH. The dome of the FH was osteotomized 5 mm proximal to the Articular Border (AB) providing a flat surface for our 360° scale. Right-side equivalents were used for data processing. Results. Gross dissection revealed a constant single branch arising from the transverse MFCA penetrating the capsule at the level of the anterior-inferior neck at 177° (range 167–187°), then courses within the medial RW obliquely (elevated from the neck) to the posterior-inferior FHNJ (Figure 1). This vessel was found to have an average of 5 TBs (range 3–9) penetrating the inferior FHNJ 4 mm (range 1–7 mm) from the AB at 204° (range 145–244°; 14% . 10. /. 69. anterior; 86% . 59. /. 69. posterior). In 79% (. 11. /. 14. ) of specimens, an average of 1.5 branches (range 1–3) arising from the ascending MFCA entered the Femoral Capsular Attachment (FCA) at 244° (range 216–269°), running subsynovial through the neck, and terminating in 2 TBs (range 1–3) penetrating the inferior-posterior FHNJ 5 mm (range 3–9) from the AB at 254° (range 207–281°). The deep branch of the MFCA penetrated the FCA at 327° (range 310–335°) providing an average of 6 TBs (range 4–9) running subsynovial and within the lateral RW, finally penetrating the superior FHNJ 6 mm (range 4–9) from the AB at 339° (range 286–25°; 20%. 15/74. anterior; 80%. 59/74. posterior). Discussion and Conclusion. This study demonstrates that TBs of the MFCA penetrate the joint through the mid-substance of the capsule (from the transverse MFCA) or the FCA (from the ascending or deep MFCA). Once intra-capsular, these vessels course subsynovial or within the RW and terminate at the posterior FHNJ superiorly (from the deep MFCA) and inferiorly (from the ascending and transverse MFCA). Any surgical hip intervention should preserve the posterior FCA, and lateral and medial RW in order to preserve the FH vascular supply. These results illustrate a vascular danger zone that should be respected during surgery and can be easily interpreted with the commonly used clock face

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

Reported rates of dislocation in hip hemiarthroplasty (HA) for the treatment of intra-capsular fractures of the hip, range between 1% and 10%. HA is frequently performed through a direct lateral surgical approach. The aim of this study is to determine the contribution of the anterior capsule to the stability of a cemented HA through a direct lateral approach. . A total of five whole-body cadavers were thawed at room temperature, providing ten hip joints for investigation. A Thompson HA was cemented in place via a direct lateral approach. The cadavers were then positioned supine, both knee joints were disarticulated and a digital torque wrench was attached to the femur using a circular frame with three half pins. The wrench applied an external rotation force with the hip in extension to allow the hip to dislocate anteriorly. Each hip was dislocated twice; once with a capsular repair and once without repairing the capsule. Stratified sampling ensured the order in which this was performed was alternated for the paired hips on each cadaver. . Comparing peak torque force in hips with the capsule repaired and peak torque force in hips without repair of the capsule, revealed a significant difference between the ‘capsule repaired’ (mean 22.96 Nm, standard deviation (. sd. ) 4.61) and the ‘capsule not repaired’ group (mean 5.6 Nm, . sd. 2.81) (p < 0.001). Capsular repair may help reduce the risk of hip dislocation following HA. Cite this article: Bone Joint J 2015;97-B:141–4

Introduction. Current literature supports the use of total hip replacement (THR) for the treatment of displaced intra-capsular proximal femoral fractures (DIPFF). Case series of patients receiving this treatment show dislocation rates higher than that of patients who have THR to treat osteoarthritis. Large diameter THR have mechanical advantages in terms of dislocation and their role in PFF has yet to be assessed. Objectives. To assess the role of large-diameter total hip replacements on the rate of dislocation when used to treat displaced intra-capsular proximal femoral fractures. Design: Single surgeon, case series. Setting: Level I trauma centre. Inclusion criteria:. Displaced intra-capsular proximal femoral fracture (Garden III & IV). Independently mobile pre-operatively for distances greater than a mile, with no more than 1 stick as a mobility aid. Abbreviated mental test score of 9/10 or greater. Exclusion criteria:. Patient under 60. Pathological fractures. Additional fractures of the femur. Outcomes. Mortality. Morbidity (Including dislocation). Oxford Hip Score. SF12. Patients/Participants: Retrospective study to assess patients who presented between May 2006 and December 2008 and met the requirements had a CPTÒ (Zimmer) cemented femoral stem, using 3. rd. generation cementation techniques, and large diameter Duronò (Zimmer) head and cup (uncemented) inserted as a primary procedure via a modified Hardinge technique. Follow up was via routine clinic appointments, letter to GP and phone conversation with patient. Results. 67 patients were selected (49 female) average age was 74.6 (67–87). Follow-up was for an average of 14 months (3–39 months). No dislocations or deaths were recorded for this period of time. Conclusions. This study suggests that the high rates of dislocation associated with THR for PPF can be limited by the use of large diameter components. This study should be followed up by a multi-centre multi-surgeon study

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

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

Following the recommendation of NICE guidelines (CG124) we have recently started using cemented smooth tapered stem hemiarthroplasty as our standard management of intra-capsular neck of femur fractures. Prior to publication of the above guidelines the standard implant utilised was Thompson Hemiarthroplasty prosthesis. The cost implications of this change have not been fully appreciated and the benefit of these changes in ASA grade 3–4 patients has not previously been analysed. We identified a cohort of 89 patients admitted with displaced intra-capsular neck of femur fracture with an ASA grade 3–4. These underwent hip hemiarthroplaties at our centre over a period of 12 months (before and after guideline implementation). Data regarding in-hospital mortality, dislocation, reoperation and place of discharge were retrospectively collected and analysed. Our cohort included 46 patients who underwent a Thompsons Hemiarthroplasty, 30 patients who had a cemented smooth tapered stem hemiarthroplasty and 13 patients who had an Austin-moore Hemiarthroplasty. In-patient mortality rates were highest in the Austin-moore group, followed by the Thompsons group compared to none in the smooth tapered stem group. However, this was not statistically significant. One patient in the Thompsons group and one patient in the smooth tapered group had multiple dislocations and re-operations, compared with none in the Austin-moore group. In terms of percentage of patients who were discharged home from hospital the smooth tapered stem group had a percentage that was more than twice that of the Thompson's which was in turn higher than that found in the Austin-moore group. In conclusion, our data suggests that in patients with an ASA grade of 3–4 there is no significant benefit from using cemented smooth tapper stems when performing a Hip Hemiarthroplasty compared with a well performed Thompsons and that the cost savings of this is significant. We accept that our current numbers are relatively small and further work is needed

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

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

Fractures of the proximal humerus can lead to malalignment of the humeral head, necrosis and post-traumatic osteoarthritis. In such cases surface replacement might be a promising option. A total of 28 shoulders with glenohumeral arthritis subsequent to a fracture underwent surface replacement arthroplasty of the humeral head in patients with a mean age of 60 years (35 to 83). On the basis of the inclination of the impacted head, post-traumatic arthritis was divided into three types: type 1, an impacted fracture of the head in an anatomical position (seven cases); type 2, a valgus impacted fracture (13 cases); type 3, a varus impacted fracture (eight cases). The outcome was measured by means of the Constant score. According to the Boileau classification of the sequelae of fractures of the proximal humerus, all 28 patients had a final result of intra-capsular category 1. The mean Constant score for the 28 shoulders increased from 23.2 points (2 to 45) pre-operatively to 55.1 points (20 to 89) at a mean of 31 months (24 to 66) post-operatively. Valgus impacted fractures had significantly better results (p < 0.039). Surface replacement arthroplasty can provide good results for patients with post-traumatic osteoarthritis of the shoulder. Their use avoids post-operative complications of the humeral shaft, such as peri-prosthetic fractures. Further surgery can be undertaken more easily as the bone stock is preserved

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