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

Introduction

Internal fixation of pertrochanteric fractures is evolving as newer implants are being developed. Proximal Femoral Nail Antirotation (PFNA) is a recently introduced implant from AO/ASIF designed to compact the cancellous bone and may be particularly useful in unstable and osteoporotic hip fractures. This study is a single and independent centre experience of this implant used in management of acute hip fractures.

The benefit of using a long intramedullary device for the treatment of geriatric intertrochanteric hip fractures is unknown. The InterTAN device (Smith and Nephew, Memphis TN) is offered in either Short (180–200 mm) or Long (260–460 mm) constructs and was designed to provide stable compression across primary intertrochanteric fracture fragments. The objective of our study was to determine whether Short InterTANs are equivalent to Long InterTANs in terms of functional and adverse outcomes for the treatment of geriatric intertrochanteric hip fractures. 108 patients with OTA classification 31A–1 and 31A–2 intertrochanteric hip fractures were included in our study and prospectively followed at one of four Canadian Level-1 Trauma Centres. Our primary outcomes included two validated primary outcome measures: the Functional Independence Measure (FIM), to measure function, and the Timed Up and Go (TUG), to measure motor performance. Secondary outcome measures included blood loss, length of procedure, length of stay and adverse events. A pre-injury FIM was measured by retrospective recall and all postoperative outcomes were assessed on postoperative day 3, at discharge, at 6 weeks, 3 months, 6 months and 12 months postoperatively. Unpaired t-tests and Chi-square tests were used for the comparison of continuous and categorical variables respectively between the Short and Long InterTAN groups. A statistically significant difference was defined as p<0.05. Our study included 71 Short InterTAN and 37 Long InterTAN patients with 31A–1 and 31A–2 intertrochanteric hip fractures. Age, sex, BMI, side, living status and comorbidities were similar between the two groups. The mean operative time was significantly lower in the Short InterTAN group (61 mins) as compared to the Long InterTAN group (71 mins)(p0.05). There were 5 periprosthetic femur fractures in the short InterTAN group versus 1 in the long InterTAN group. Non-mechanical adverse outcomes such as myocardial infarction, pulmonary embolism, urinary tract infections, pneumonia and death all had similar incidence rates between the two InterTAN groups. Both the Short and Long InterTAN patient cohorts displayed similar improvements in performance and overall function over the course of a year following intertrochanteric hip fracture fixation. The recorded operative times for Short InterTAN fixation were significantly shorter than those recorded for the Long InterTAN patients. Alternatively, a significantly higher proportion of Short InterTAN patients sustained periprosthetic femur fractures within a year of implantation as compared to the Long InterTAN group

Introduction. It is estimated 5% of patients over 65 years receive warfarin therapy. This paper aims to analyse whether a time delay to hip fracture fixation while waiting for the patients International Normalised Ratio (INR) to return to normal increases the mortality risk. Methods. A prospective database of 937 hip fractures was analysed. Patient demographics and time from admission to operation were recorded. The patients' INR on admission and during the preoperative period, the need for vitamin K reversal, and any postoperative thromboembolic compilations were recorded. Thirty-day mortality was obtained from the General Register Office for Scotland. Patients with a therapeutic INR were categorised into two groups: those who received vitamin K within 24 hours of admission and those who did not. Results. There were 27 patients (74% female, mean age 80.9 years) receiving warfarin for atrial fibrillation. Two patients had a subtherapeutic INR on admission and were excluded from further analysis. Nine of eleven patients receiving vitamin K (mean dose 1.3mg) had surgery within 48 hours of admission, whereas only five of the fourteen patients who did not receive vitamin K had surgery within this time (OR3.6, p=0.047). There were no thromboembolic complications during admission for either group. Thirty-day mortality was increased for both groups relative to standard rate (OR1.5, p=0.5, and OR2.4 p=0.2 respectively), but there was no significant difference between the groups (p=0.9). Conclusion. Patients with a fractured hip who are receiving warfarin for atrial fibrillation and have a therapeutic INR should receive low dose vitamin K on admission to facilitate early operative intervention and rehabilitation

Geriatric hip fracture patients have a 14-fold higher 30-day mortality than their age matched peers. Up to 50% of these patients receive blood transfusion perioperatively. Both restrictive and liberal transfusion policies are controversial in this population. Aim: The longitudinal description of transfusion practice in geriatric hip fracture patients in a major trauma centre. An 8-year (2002–2009) retrospective study was performed on patients over the age of 65 undergoing hip fracture fixation. Yearly transfusion rate; the influence of transfusion on 30-day, 90-day and 1-year mortality and length of stay (LOS) was investigated. On admission haemoglobin (Hb), pre-transfusion Hb and post-transfusion Hb and their effect on transfusion requirement and mortality was also reviewed. The yearly changes in on-admission and pre-transfusion Hb were also examined. The influence of comorbidities, timing, procedure performed and operation duration on transfusion requirement and mortality was also studied. From the 3412 patients, 35% (1195) received transfusion during their hospital stay. There was no change in age, gender and co-morbidities during the study. Thirty-day mortality improved from 12.4% in 2002 to 7% in 2009. The transfusion rate showed a gradual decrease from the highest of 48.3% (2003) to 22.9% (2009) (Pearson correlation - R2 = −0.707, p=0.05). There was no change during the study period in on-admission and pre-transfusion Hb. The mortality for non-transfused and transfused patients was [9.6% vs. 10.3 % (30-day)], [17.2% vs. 18.4%(90-day)] and [27% vs. 30.5%(1-year), p=0.031]. LOS was 11±9 for non-transfused patients and 13±10 (p<0.001) for transfused patients. Patients with more comorbidities experienced a higher transfusion rate, (0 – 31%, 1 – 38%, 2 – 46%, 3 – 57%), (Pearson Chi-squared, p<0.001). The need for transfusion by different procedures in decreasing order was 47.6% intramedullary device, 44.0% DHS, 25.2% cemented hemiarthroplasty, 23.6% Austin-Moore, and 5.5% cannulated screws. The length of the operation increases the chance of transfusion (<1hrs, – 33%, 1–2hrs – 35%, 2–3hrs – 41%, >3 hours – 65%), (Pearson Chi-squared, p=0.010). Preoperative waiting time had no influence on transfusion frequency (<24hrs – 36%, 24–48hrs – 34%, 48–96hrs – 36%, >96hrs – 33%), (Pearson Chi-squared, p=0.823). The percentage of transfused geriatric hip fracture patients halved during the eight-year period without changes in demographics and co-morbidities. Perioperative transfusion of hip fracture patients is associated with higher 1-year mortality and increased LOS. A more restrictive transfusion practice has been safe and may be a factor in the improved 30-day mortality

Purpose. Primary internal fixation of uncomplicated scaphoid fractures offers many advantages compared to conventional casting. However, ideal fixation placement along the central scaphoid axis can be challenging, especially if the procedure is performed percutaneously. Because of the lack of direct visualization, percutaneous procedures demand liberal use of imaging, thereby increasing exposure to harmful radiation. It has been demonstrated that computer-assisted navigation can improve the accuracy of guidewire placement and reduce X-ray exposure in procedures such as hip fracture fixation. Adapting the conventional computer-assist paradigm, with preoperative imaging and intraoperative registration, to scaphoid fixation is not straightforward, and thus a novel tactic must be conceived. Method. Our navigation procedure made use of a flatpanel C-arm (Innova, GE Healthcare) to obtain a 3D cone-beam CT (CBCT) scan of the wrist from which volumetrically-rendered images were created. The relationship between the Innova imager and an optical tracking system (OptoTrak Certus, Northern Digital Inc.) was calibrated preoperatively so that an intraoperatively-acquired image could be used for real-time navigation. Optical markers fitted to a drill guide were used to track its orientation, which was displayed on a computer monitor relative to the wrist images for navigation. Randomized trials were conducted comparing our 3D navigated technique to two alternatives: one using a standard portable C-arm, and the other using the Innova flatpanel C-arm with 2D views and image intensification. A model forearm with an exchangeable scaphoid was constructed to provide consistency between the trials. The surgical objective was to insert a K-wire along the central axis of a model scaphoid. An exposure meter placed adjacent to the wrist model was used to record X-ray exposure. Procedure time and drill passes were also noted. CT scans of the drilled scaphoids were used to determine the shortest distance from the drill path to the scaphoid surface. Results. The closest distance from the drill path to the scaphoid surface was significantly larger using navigation compared to the 2D Innova method (p<0.05). Fewer drill passes were required using navigation compared to a conventional C-arm (p<0.01). Navigated procedures were significantly longer, although the overall time remained clinically acceptable (∼4min). There was no significant difference in radiation exposure to the patient between the three methods. The 3D CBCT image was acquired remotely in the navigated approach, so conceivably the exposure to the surgeon was much less than the other techniques. Conclusion. Computer-assisted navigation was successfully adapted to percutaneous scaphoid fixation without requiring the tedious preoperative imaging and intraoperative registration that typically plague these procedures. Navigation resulted in superior central screw placement with fewer drilling attempts in comparison to conventional techniques

Purpose. Femoroacetabular impingement (FAI) may contribute to the development of early onset hip osteoarthritis (OA). A cam lesion (or pistol grip deformity) of the proximal femur reduces head-neck offset resulting in cam type FAI. The alpha angle is a radiographic measurement recommended for diagnosis of cam type FAI. The purpose of this study was to determine if patients that develop end stage hip OA prior to 55 years of age have radiographic evidence of cam type FAI. Method. The anteroposterior (AP) pelvis and lateral hip radiographs of 244 patients (261 hips) who presented to our institution for hip arthroplasty or hip fracture fixation between 2006 and 2008 were retrospectively reviewed. Three cohorts were compared: 1) patients with end stage hip OA < 55 years old (N=76); 2) patients with end stage hip OA > 55 years old (N=84); 3) hip fracture patients > 65 years old without radiographic evidence of hip arthritis were used as controls (N=101). Patients with inflammatory arthritis, avascular necrosis and post-traumatic hip OA were excluded. Alpha angles were measured on the AP pelvis and lateral radiographs by three coauthors using ImageJ 1.43 software (National Institutes of Health, USA). For patients with end stage hip OA, AP alpha angles were measured on both the hip with OA and the contralateral hip. Lateral alpha angles were measured only on the hip with OA. For patients with hip fracture, AP alpha angles were measured on the non-fractured hip and lateral alpha angles were measured on the fractured hip. A one-way ANOVA with post hoc Tukeys HSD test was used to compare the AP and lateral alpha angles for the three cohorts. Results. The intraclass correlation coefficient (ICC) for the three coauthors measuring AP and lateral alpha angles was 0.85 and 0.86 respectively, indicating excellent inter-rater agreement. Patients < 55 years old with end stage hip OA had the largest AP and lateral alpha angles (82.711.6 degrees AP and 63.918.5 degrees lateral). These angles were significantly larger (p<0.01 for both comparisons) than patients > 55 years old with end stage hip OA (71.717.8 degrees AP and 55.518.0 degrees lateral) and hip fracture patients without hip OA (52.710.9 degrees AP and 44.411.4 degrees lateral). Comparing AP alpha angles of the contralateral hips, the mean AP alpha angle for patients < 55 years old with hip OA (70.813.2 degrees) was significantly larger (p=0.04) than patients > 55 years old with hip OA (64.516.2 degrees) which in turn was significantly larger (p<0.01) than the hip fracture patients (52.710.9 degrees). Conclusion. Patients < 55 years old with hip OA had the largest mean AP and lateral alpha angles, significantly larger than patients > 55 years old with hip OA and hip fracture patients without hip OA. Thus young patients with end stage hip OA do have radiographic evidence of cam type FAI. Furthermore, this case-controlled study suggests that cam type FAI may contribute to the development of early onset hip OA