Background. Exeter Trauma Stem (ETS) is a polished tapered collarless monopolar prosthesis used for cemented hemiarthroplasty for fracture neck of femur. Two modular rasps are available on the instrumentation set. The larger rasp, in practice, rarely fits into the femur making trial reduction impossible. Our hypothesis was that the absence of a trial reduction could affect leg length and stability of the prosthesis. Aim. To evaluate the leg length discrepancy following use of Exeter Trauma Stem for intracapsular fracture neck of femur. Methods. All patients who underwent ETS hemiarthroplasty between June 2009 to March 2010 (n = 100) were included in the study. Radiographic assessment of leg length was performed by two independent assessors based on measurements by Woolson et al. Results. Upto half of the patients had equal leg length measurements. Forty four patients had lengthening of the operated leg with a mean of 10mm (5–25). Further complications included four dislocations. There was no statistical significance between leg lengths and dislocations. Conclusion. Care is needed with regards to correct positioning of the ETS prosthesis to achieve equal leg lengths. Following this study a new intermediate sized modular rasp has been introduced to the instrumentation set

Objective. The aim of this study was to determine the correlation between body weight and fracture union for displaced intracapsular fracture neck of femur treated by closed reduction and internal fixation. Patients and methods. A total of 197 patients with displaced intracapsular fracture of neck of femur, all of whom have been treated with closed reduction and internal fixation, were studied. The mean age was 71 years and 79% were female. Patients were followed up until fracture endpoint (union or non-union) with minimum follow up of 200 days. Results and conclusion. 118 (60%) of the fractures achieved clinical and radiological union. The mean body weight for the patients achieved fracture union was 64.6 kilograms versus 61.6 kilograms for those who developed fracture non union or avascular necrosis of the femoral head (p value for the difference p=0.15, not statistically significant). This study is the largest study indicates that the patient's weight is not an indicator of later fracture healing complications

Introduction. Neck of femur (NOF) fractures are one of the predominant reasons for hospital admissions in patients >65 year. These fractures are associated with a poor outcome; end to independent living in 60% of patients and a 6 month mortality of 30%. Previous studies have shown show elements of under/mal-nutrition on admission. In addition, their nutritional status shows some deterioration thereafter. The aim of this present study is to examine if the nutritional status of patients with NOF fracture admitted at our institution is associated with a larger post-operative haemoglobin drop. This is compared to an independent living age matched control group from the same geographical area. Methods. A retrospective audit of pathology results for three hundred fracture patients (n = 300) and one hundred age matched home living group pre-assessed of total hip replacement (n = 100). Total serum protein, albumin, total lymphocyte count levels were determined at the time of admission to assess nutritional status. Pre/post-operative haemoglobin, resultant haemoglobin drop, and 6 month mortality was assessed in NOF fracture patients. The nutritional parameters were correlated with the haemoglobin levels and mortality. Results. Fracture patients were found to be malnourished on hospital admission. 10% showed a total serum protein level of <60g/L, 21% showed an albumin level of <35 g/L and 66% had on a total lymphocyte count of <1,200 cells/ml. When compared to an age matched home living group, fracture patients had a significantly (p = <0.0001) lower protein (67.4 vs 74.5), albumin (38.8 vs 43.9) and total lymphocyte counts (1173.3 vs 1840.8). Pre/post-operative haemoglobin showed a positive correlation with albumin and protein levels (p = <0.01). Haemoglobin drop post-operatively showed a negative correlation with albumin and protein levels (p = <0.01). 6 month mortality was correlated with albumin, protein, and total lymphocyte count levels. Discussion. This study confirms that patients admitted with NOF fractures are malnourished on admission. In addition, we report that not only pre-operative haemoglobin is correlated to the malnourishment but also the post-operative haemoglobin drop is correlated to albumin/protein levels on admission. This leads us to hypothesise that these malnourished patients have a higher bleeding tendency. Thus, we propose that malnourishment can be identified by the orthopaedic team using relatively inexpensive laboratory tests such as albumin, protein and total lymphocyte count. Thereafter, appropriate measures should be instituted to prepare for intra/post-operative bleeding and higher need for blood transfusion

We evaluated the outcome of treatment of nonunion of an intracapsular fracture of the femoral neck in young patients using two cannulated screws and a vascularised bone graft. A total of 32 patients (15 women and 17 men, with a mean age of 36.5 years; 20 to 50) with failed internal fixation of an intracapsular fracture were included in the study. Following removal of the primary fixation, two cannulated compression screws were inserted with a vascularised iliac crest bone graft based on the ascending branch of the lateral femoral circumflex artery.

At a mean follow-up of 6.8 years (4 to 10), union was achieved in 27 hips (84%). A total of five patients with a mean age of 40.5 years (35 to 50) had a persistent nonunion and underwent total hip arthroplasty as also did two patients whose fracture united but who developed osteonecrosis of the femoral head two years post-operatively. Statistical analysis showed that younger patients achieved earlier and more reliable union (p < 0.001). The functional outcome, as assessed by the Harris Hip score, was better in patients aged < 45 years compared with those aged > 45 years (p < 0.001).

These findings suggest that further fixation using two cannulated compression screws and a vascularised iliac crest bone graft is an effective salvage treatment in patients aged <  45 years, in whom osteosynthesis of a displaced intracapsular fractures of the femoral neck has failed.

Cite this article: Bone Joint J 2015; 97-B:988–91.

Aims. It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site. Methods. The primary outcome measure was 30-day mortality. Secondary measures included complications of surgery, COVID-19 infection, and length of stay. Multiple variables were assessed for their contribution to the 30-day mortality. In total, 433 patients were included with a mean age of 65 years; 45% were male, and 90% were Caucasian. Results. Overall mortality was 7.6% for all patients and 15.9% for femoral neck fractures. The mortality rate increased from 7.5% to 44.2% in patients with fracture neck of femur and a COVID-19 infection. The COVID-19 rate in the 30-day postoperative period was 11%. COVID-19 infection, age, and Charlson Comorbidity Index were independent risk factor for mortality. Conclusion. There was a significant risk of contracting COVID-19 due to being admitted to hospital. Using a site which was not treating COVID-19 respiratory patients for surgery did not identify a difference with respect to mortality, nosocomial COVID-19 infection, or length of stay. The COVID-19 pandemic significantly increases perioperative mortality risk in patients with fractured neck of femora but patients with other injuries were not at increased risk. Cite this article: Bone Jt Open 2021;2(5):330–336

National guidelines encourage the use of total hip arthroplasty (THA) to treat intracapsular neck of femur fractures. There have been no population based studies appraising the surgical outcomes for this indication across an entire population. This study aims to calculate the complication rates for THA when performed for a fractured neck of femur and compare them to THA performed for primary osteoarthritis in the same population. The Scottish Arthroplasty Project identified all THAs performed in Scotland for neck of femur fracture and osteoarthritis between 1st of January 2009 and 31st December 2014. Dislocation, periprosthetic infection and revision rates at 1 year were calculated. The rate of dislocation, periprosthetic infection and revision at 1 year were all significantly increased among the fracture neck of femur cohort. In total 44046 THAs were performed, 38316 for OA and 2715 for a neck of femur fracture. 2.1% of patients (n=57) who underwent a THA for a neck of femur fracture suffered a dislocation in the 1st year postoperatively, compared to 0.9% (n=337) when the THA was performed for osteoarthritis. Relative Risk of dislocation: 2.4 (95% C.I. 1.8077–3.1252, p value <0.0001). Relative Risk of infection: 1.5 (95% C.I. 1.0496–2.0200, p value 0.0245) Relative Risk of revision: 1.5 (95% C.I. 1.0308–2.1268, p value 0.0336). This is the first time a dislocation rate for THA performed for a neck of femur fracture has been calculated for an entire population. As the number of THAs for neck of femur fracture increases this dislocation rate will have clinical implications

Objectives. To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care. Methods. We performed a retrospective observational study of 185 consecutive adult patients admitted to an Australian metropolitan teaching hospital with fractured neck of femur between 2009 and 2010. The main outcome measures were 30-day and one-year mortality rates, major complications and factors influencing mortality. . Results. The majority of patients were elderly, female and had multiple comorbidities. Multiple peri-operative medical complications were observed, including pre-operative hypoxia (17%), post-operative delirium (25%), anaemia requiring blood transfusion (28%), representation within 30 days of discharge (18%), congestive cardiac failure (14%), acute renal impairment (12%) and myocardial infarction (4%). Mortality rates were 8.1% at 30 days and 21.6% at one year. Factors predictive of one-year mortality were American Society of Anesthesiologists (ASA) score (odds ratio (OR) 4.2 (95% confidence interval (CI) 1.5 to 12.2)), general anaesthesia (OR 3.1 (95% CI 1.1 to 8.5)), age > 90 years (OR 4.5 (95% CI 1.5 to 13.1)) and post-operative oliguria (OR 3.6 (95% CI 1.1 to 11.7)). Conclusions. Results from an Australian metropolitan teaching hospital confirm the persistently high morbidity and mortality in patients presenting with a fractured neck of femur. Efforts should be aimed at medically optimising patients pre-operatively and correction of pre-operative hypoxia. This study provides planning data for future interventional studies. Cite this article: Bone Joint Res 2013;2:162–8

Aims. This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation. Patients and Methods. Of 3326 consecutive patients treated with hemiarthroplasty for fractured neck of femur, 46 (1.4%) sustained dislocations. Of the 46 dislocations, there were 37 female patients (80.4%) and nine male patients (19.6%) with a mean age of 83.8 years (66 to 100). Operative intervention for each, and subsequent dislocations, were recorded. The following outcome measures were recorded: dislocation; mortality up to one-year post-injury; additional surgery; residential status; mobility; and pain score at one year. Results. Of 43 dislocations, 30 (70%) occurred within one month and 42 (98%) occurred within three months of hip fracture surgery. Seven (16%) of these patients were treated with a single closed reduction and sustained no further dislocations. Four (9%) were treated with open reduction and experienced no further dislocations. Three (7%) hips were left dislocated and the remaining 32 (74%) patients required additional surgery of further closed reduction, revision, or excision arthroplasty. The one-year mortality rates for patients treated with two or fewer reductions (open or closed), successful revision arthroplasty, and excision arthroplasty were 3/14 (21%), 1/7 (14%), and 8/14 (57%) respectively. The only statistically significant difference in mortality was the difference between patients who did not sustain a dislocation and those who did and were treated by excision arthroplasty (p = 0.03). Patients treated by excision arthroplasty had the greatest reduction in mobility scores and highest pain scores. The excision arthroplasty group also included the greatest proportion of patients not able to mobilize and the smallest proportion of patients remaining in their own home. Conclusion. Most dislocations of hemiarthroplasties of the hip occur within one month of surgery. Closed reduction is generally unsuccessful. For those patients with unsuccessful closed reduction, revision arthroplasty should be considered when possible, as this results in a better functional outcome with a lower mortality than excision arthroplasty

Aims

To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment.

Aims

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

Aims

The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone.

Introduction. More than 60% of patients presenting with a hip fracture have significant medical co-morbidities and a one year mortality rate between 14% and 47%. The rating scale for the American Society of Anaesthetists (ASA) is a reliable predictor of both surgical risk and mortality with ASA 4 patients having 100% mortality at one year.1,2. Aims. Our aim was to establish a mortality rate for fractured neck of femur patients at three months and twelve months, and to ascertain the mortality of patients with an ASA 4 grading. Ultimately, should we be operating on this high risk cohort of patients'. We also chose to analyse our current practice in the management of displaced intracapsular neck of femur fractures in patients 90 years of age and over. Methods. Over 300 patients with a fractured neck of femur were identified between the 1st January 2007 and the 1st January 2008. A retrospective case note review of 151 patients was performed in conjunction with the NHS mortality database to establish whether each patient was alive or deceased. Our findings were compared to the standards set which included an overall mortality of 20% at three months, 30% at twelve months and 100% mortality for ASA 4 patients at twelve months. Results. Five patients were excluded from the study as one patient had incomplete data and four patients died prior to intended surgery. Only one of these patients had an ASA 4 grading. 146 patients were included and 23 patients (15.7%) were ASA 4. The overall mortality was 16% at three months and 23% at twelve months which was within the limits of the standards set. ASA 4 patients had a mortality of 57% at three months and 65% at twelve months which compared favourably with the limited literature available. There were 11 patients who were 90 years of age and over with intracapsular neck of femur fractures. Three of these patients were treated with a cemented hemiarthroplasty and were all alive at twelve months. Conclusions. Our study demonstrates a much better mortality rate in the ASA 4 patients than the limited literature available would suggest. We believe that ASA 4 patients should continue to be offered surgical intervention and that this data provides us with information to allow the patient and family to reach an informed decision with regard to their treatment. Intracapsular neck of femur fractures in patients 90 years of age and over can be treated with a cemented hemiarthroplasty provided they are deemed fit

Aims

To assess the safety of tranexamic acid (TXA) in a large cohort of patients aged over 65 years who have sustained a hip fracture, with a focus on transfusion rates, mortality, and thromboembolic events.

The cement used for hemiarthroplasties by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty. We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group. The demographics and co-morbid conditions were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point. Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial

The aim of this study was to quantify the stability of fracture-implant complex in fractures after fixation. A total of 15 patients with an undisplaced fracture of the femoral neck, treated with either a dynamic hip screw or three cannulated hip screws, and 16 patients with an AO31-A2 trochanteric fracture treated with a dynamic hip screw or a Gamma Nail, were included. Radiostereometric analysis was used at six weeks, four months and 12 months post-operatively to evaluate shortening and rotation. Migration could be assessed in ten patients with a fracture of the femoral neck and seven with a trochanteric fracture. By four months post-operatively, a mean shortening of 5.4 mm (-0.04 to 16.1) had occurred in the fracture of the femoral neck group and 5.0 mm (-0.13 to 12.9) in the trochanteric fracture group. A wide range of rotation occurred in both types of fracture. Right-sided trochanteric fractures seem more rotationally stable than left-sided fractures. This prospective study shows that migration at the fracture site occurs continuously during the first four post-operative months, after which stabilisation occurs. This information may allow the early recognition of patients at risk of failure of fixation. Cite this article: Bone Joint J 2015;97-B:391–7

Total hip replacements have been shown to give superior outcomes in patients with intracapsular fractures of the neck of femur compared with hemiarthroplasty. Collarless uncemented femoral stems give excellent long term results in elective hip replacements but there are few studies looking at their outcomes in fractured neck of femur patients. There is some concern that in trauma patients bone quality maybe inferior as most neck of femur fractures are secondary to osteoporosis. The presence of osteoporosis and subsequent widened femoral canal may compromise the mechanical stability of uncemented femoral stems and result in early subsidence, which can lead to altered leg length and decreased hip stability. The aim of this study was to assess whether early subsidence occurred when collarless uncemented stems were used to treat patients with fractures of the neck of femur. Post-operative radiographs of 33 patients, mean age 71, who underwent an uncemented collarless total hip replacement for a fracture, were reviewed. The distance from the calcar to the tip of the prosthesis was measured for each patient on the initial post operative radiograph and again on the follow-up radiograph at 6 months post operation. Any subsidence was recorded and magnification for each radiograph was calculated by measuring the diameter of the femoral head, which was known to be 36mm. Distances were then adjusted for magnification. The same procedure was performed on 36 age-matched patients, mean age 71, who underwent elective uncemented total hip replacements for osteoarthritis. Hospital notes for each patient were reviewed to assess for complications and DEXA scan results for trauma patients were also evaluated where available. The mean femoral stem subsidence was significantly greater in the fracture cohort than in elective patients (p = 0.001) with mean subsidence of 4.07mm (range 0.02–18.5mm) and 1.57mm (range 0–5.5mm) respectively. In the fracture cohort there were 3 revisions within 6 months of surgery, 1 for infection and 2 for femoral stem subsidence leading to dislocation. There were no revisions in the elective cohort. DEXA scan results were available for 21 of the 33 fracture cohort patients. All these patients had abnormal bone density with 52% being osteoporotic and 48% osteopenic. This study showed that collarless uncemented stems subsided significantly when performed for fractures and had a high early revision rate. We therefore recommend that cemented or collared femoral stems be used in patients with femoral neck fractures requiring total hip replacement to reduce the risk of femoral stem subsidence

Aims. Patients who sustain neck of femur fractures are at high risk of malnutrition. Our intention was to assess to what extent malnutrition was associated with worse patient outcomes. Methods. A total of 1,199 patients with femoral neck fractures presented to a large UK teaching hospital over a three-year period. All patients had nutritional assessments performed using the Malnutrition Universal Screening Tool (MUST). Malnutrition risk was compared to mortality, length of hospital stay, and discharge destination using logistic regression. Adjustments were made for covariates to identify whether malnutrition risk independently affected these outcomes. Results. Inpatient mortality was 5.2% (35/678) in the group at low risk of malnutrition, 11.3% (46/408) in the medium-risk group, and 17.7% (20/113) in the high-risk group. Multivariate analysis showed each categorical increase in malnutrition risk independently predicted inpatient mortality with an odds ratio (OR) of 1.59 (95% confidence interval (CI) 1.14 to 2.21; p = 0.006). An increased mortality rate persisted at 120 days post-injury (OR 1.64, 95% CI 1.20 to 2.22; p = 0.002). There was a stepwise increase in the proportion of patients discharged to a residence offering a greater level of supported living. Multivariate analysis produced an OR of 1.34 (95% CI 1.03 to 1.75; p = 0.030) for each category of MUST score. Median length of hospital stay increased with a worse MUST score: 13.9 days (interquartile range (IQR) 8.2 to 23.8) in the low-risk group; 16.6 days (IQR 9.0 to 31.5) in the medium-risk group; and 22.8 days (IQR 10.1 to 41.1) in the high-risk group. Adjustment for covariates revealed a partial correlation coefficient of 0.072 (p = 0.008). Conclusion. A higher risk of malnutrition independently predicted increased mortality, length of hospital stay, and discharge to a residence offering greater supported living after femoral neck fracture. Cite this article: Bone Joint J 2021;103-B(1):164–169

Aims

Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery.

Aims

Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees.

The management of patients with displaced intra-capsular hip fractures is usually a hip hemiarthoplasty procedure. NICE guideline 124 published in 2011 suggested that Total Hip Replacement (THR) surgery should be considered in a sub group of patients with no cognitive impairment, who walk independently and are medically fit for a major surgical procedure. The Royal Devon and Exeter Hospital manages approximately 550 patients every year who have sustained a fracture of neck of femur, of which approximately 90 patients fit the above criteria. Prior to the guideline less than 20% of this sub-group were treated with a THR whereas after the guideline over 50% of patients were treated with THR, performed by sub-specialist Hip surgeons. This practice is financially viable; there is no apparent difference in the overall cost of treating patients with THR. The effect of adoption of the NICE guideline was examined using 100 % complete data from 12 month post operative follow up. Only the Hemi-arthroplasty patients were significantly less likely to have stepped down a rung of independent living. Both THR and Hemi-arthroplasty patients were significantly less likely to have stepped down a rung of walking ability, but there was no significant difference between THR and Hemi-arthroplasty groups. Revision rates remained negligible