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. Methods. We randomized 229 patients with a trochanteric hip fracture between two implants: a ‘standard’ nail of 220 mm and a shorter nail of 175 mm, which had decreased proximal angulation (4° vs 7°) and a reduced diameter at the level of the lesser trochanter. Patients were followed up for one year by a nurse blinded to the type of implant used to determine if there were differences in mobility and pain with two nail designs. Pain was assessed on a scale of 1 (none) to 8 (severe and constant) and mobility on a scale of 1 (full mobility) to 9 (immobile). Results. The shorter nail did not require any reaming of the femur and was quicker to insert (mean difference 5.1 minutes; p < 0.001, 95% confidence interval (CI) of the difference 3.16 to 7.04). Those treated by the shorter nail were less mobile (mean difference in reduction in mobility score at one year 0.80; p = 0.007, 95% CI 1.38 to 0.22). In addition, there was a trend toward greater residual pain for those treated with the shorter nail, although this was not statistically significant (mean difference in pain score at one year 0.24; p = 0.064, 95% CI -0.01 to 0.49). Conclusion. These results suggest that the increasing use of this very short intramedullary nail with its design modification may not be appropriate. Cite this article: Bone Joint J 2020;102-B(3):394–399

Introduction. The treatment of trochanteric femoral fractures with the use of short femoral nails has become an established method. The fixation is required that lag screw be centered to prevent complications. But correct positioning of the device may difficult because of anatomical feature. This study evaluated the femoral morphology three-dimensionally using computed tomography (CT) images. Methods. Seventy eight patients (mean age 75)who underwent total knee arthroplasty were included. After three-dimensional reconstruction of the CT images, the anterior deviation from the femoral neck axis to proximal shaft axis was measured. The proximal shaft axis was defined as a line between center of the cross-section underneath the lesser trochanter and the center of diaphysis. The connection of center in narrow section of the neck and femoral head center was defined as neck axis. Results. The femoral neck axis and shaft axis were not coplanar. The anterior deviation of the axes was 7.5 mm (1.7 to 18.4 mm). The neck-shaft angle was 124° (110–142°). Discussion. Our results indicate that the nail and screw could not be center in current nail system, because of the non-crossing of the femoral axes. The large variation of neck-shaft angle would lead error in preoperative planning using traditional 2-D template system. Our study suggests needs for three-dimensional template system and newly femoral nail device

Fracture classification of femoral trochanteric fracture is usually based on plain X-ray. However, complications such as delayed union, non-union, and cut out are seen in stable fracture on X-ray. In this study, fracture was classified by 3D-CT and relationship to X-ray classification was investigated. 48 femoral trochanteric fractures (15 males, 33 female, average age: 82.6) treated with PFNA-II were investigated. Fracture was classified to 2part, 3part(5 subgroups), and 4part with combination of 4 fragments in CT; Head (H), Greater trochanter (G), Lesser trochanter (L), and Shaft (S). 5 subgroups of 3 part fracture were (1) H+G (S: small fragment) + L-S, (2) H + G (B:big fragment) + L-S, (3) H + G-L + S, (4) H + G (W:whole) + S, and (5) H + L + G-S. Numbers of each group were as follows; 2 part: 11, 3 part (1) : 7, 3 part (2) : 12, 3 part (3) : 10, 3 part (4) : 2, 3 part (5) : 3, 4 part : 3. 3 part (3), (4), (5) and 4 part are considered as unstable, however, 6 cases in these groups were classified in A1–1 or A1–2 stable fracture in AO classification. 10 fractures in Evans and 5 fractures in Jensen classification classified as stable were unstable in CT evaluation. It is sometimes very difficult to classify the femoral trochanteric fracture by plain X-ray. Classification with 3D-CT is very useful to distinguish which fracture is stable or unstable

Background. It is unclear which form of anaesthesia is the most favourable in primary total hip replacement (THR) surgery. A recently published systematic review of modern anaesthesia techniques in primary THR surgery (Macfarlane 2009) was not able to show any convincing benefit of regional or general anaesthesia. One retrospective study that examined anaesthesia and leg length (Sathappan 2008), found an increased incidence of leg length difference > 5 mm in those patients who were operated with regional anaesthesia. Our department used a mini invasive approach in supine as standard procedure in THR. The type of anaesthesia that is chosen is up to the individual anaesthetist. Purpose. We wanted to see if there was any correlation between type of anaesthesia and leg length, total time spent in theatre and recovery room, postoperative hospital stay, blood loss or operating time in primary THR surgery with a mini invasive approach in supine. Materials and Methods. Our study was a retrospective study of 170 primary THR patients. All patients received an uncemented Corail stem and a cemented Marathon cup. Patients with abnormal anatomy, BMI > 46, simultaneous removal of internal fixation or incomplete data were excluded in the analysis. Radiograpic leg length was measured using the inter teardrop line and the lesser trochanter. Results. 99 patients were operated on with spinal anaesthesia and 71 with total intravenous anaesthesia (TIVA). There were 65% women in both groups. Average age was 74 years (32–95) in the spinal anaesthesia group and 67 years (38–93) in the TIVA group. We found no significant difference in the average operating time (spinal 65 min, TIVA 64 min), drop in haemoglobin to the first postoperative day (spinal 16%, TIVA 16%), postoperative hospital stay (Spinal 1.4 days, TIVA 1.4) or in transfusion rate (spinal 1%, TIVA 1.4%). We found a significant difference in the proportion of patients with a leg length difference of more than 7 mm (Spinal 22%, TIVA 6%, p = 0.02) and the average total time spent in theatre and post-operative department (spinal 325 min, TIVA 293 min, p < 001). Discussion. The study is retrospective and is therefore fettered by the limitations inherent in such a study. Our study seems to confirm the earlier findings that the type of anaesthesia can affect leg length in primary THR. It is speculated that spinal anaesthesia has a more unpredictable effect on muscular tension which could explain this

Introduction. The origins of the uncemented tapered wedge hip stem design currently offered by several orthopaedic device companies can be linked back to the cemented Straight Mueller type stem design first used in 1977. The design, a wedge shape with a taper angle of 6 degrees, maintains a single medial curvature for all sizes and increases laterally in the width to accommodate different size femurs. Although evolutionary improvements have been made over the years the basic body geometry of the stem has stayed mainly unchanged with excellent clinical survivorship. Over the past decade, the demographics of hip replacement have changed, with a large increase in younger male patients in the age range of 40 to 60 years. In this study the femoral fit of a novel tapered stem, designed to fit a wide array of patient types, is compared to a standard predicate tapered stem design. Methods. A bone morphology study was performed on a patient population of 556 patients using three dimensional digital data from CT-scans. To characterize the fit of the stem designs we analyzed the ratio of a distal (60mm below lesser trochanter) and a proximal (10mm above lesser trochanter) cross section. The same measurements were taken with the standard tapered stem design and the novel tapered stem design, with a given constant implantation height of 20mm above the lesser trochanter. The fit of the stems was classified as Type 1, where there was both proximal and distal engagement, Type 2, proximal engagement only, Type 3, distal engagement only. The distal and proximal engagement, Type 1, was specified with a maximum engagement difference of 2mm proximal to distal. Results. The standard tapered stem showed a well balanced distal to proximal ratio in the median sizes. However, with increasing stem size the distal engagement increases. The novel tapered stem design showed a well balanced proximal to distal ratio throughout the complete size range. With respect to Type 3 fit classification the novel tapered stem design showed a reduced percentage of distal engagements (2.8%) compared to the predicate standard stem (17.2%). In the 40 to 60 year old male group the distal engagements for the standard stem increases (28.2%), whereas the distal engagements for the novel stem remains unchanged (1.3%). Discussion. The cementless, tapered wedge stem design is used in large numbers globally due to its ease of use and reproducibility. However, changing patient demographics and associated bone morphology represents a challenge for existing designs to achieve a proximal fit. The novel tapered stem design presented here was adapted to these influencing factors by optimizing the proximal to distal ratio with respect to the whole patient group resulting in a particularly marked improvement in proximal fit in the male 40–60 age group compared to predicate stem designs

Aims

Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

Aims

Current levels of hip fracture morbidity contribute greatly to the overall burden on health and social care services. Given the anticipated ageing of the population over the coming decade, there is potential for this burden to increase further, although the exact scale of impact has not been identified in contemporary literature. We therefore set out to predict the future incidence of hip fracture and help inform appropriate service provision to maintain an adequate standard of care.

Aims

To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.

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.

Aims

The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment.

Aims

The aim of this paper is to review the evidence relating to the anatomy of the proximal femur, the geometry of the fracture and the characteristics of implants and methods of fixation of intertrochanteric fractures of the hip.

Aims

To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries.

Aims

To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture.

Management of bisphosphonate-associated subtrochanteric fractures remains opinion- or consensus-based. There are limited data regarding the outcomes of this fracture.

We retrospectively reviewed 33 consecutive female patients with a mean age of 67.5 years (47 to 91) who were treated surgically between May 2004 and October 2009. The mean follow-up was 21.7 months (0 to 53). Medical records and radiographs were reviewed to determine the post-operative ambulatory status, time to clinical and radiological union and post-fixation complications such as implant failure and need for second surgery.

The predominant fixation method was with an extramedullary device in 23 patients. 25 (75%) patients were placed on wheelchair mobilisation or no weight-bearing initially. The mean time to full weight-bearing was 7.1 months (2.2 to 29.7). The mean time for fracture site pain to cease was 6.2 months (1.2 to 17.1). The mean time to radiological union was 10.0 months (2.2 to 27.5). Implant failure was seen in seven patients (23%, 95 confidence interval (CI) 11.8 to 40.9). Revision surgery was required in ten patients (33%, 95 CI 19.2 to 51.2).

A large proportion of the patients required revision surgery and suffered implant failure. This fracture is associated with slow healing and prolonged post-operative immobility.

Cite this article: Bone Joint J 2014;96-B:658–64.

Fractures of the proximal femur are one of the greatest challenges facing the medical community, constituting a heavy socioeconomic burden worldwide. The National Hip Fracture Audit currently provides a framework for service evaluation. This evaluation is based upon the assessment of process rather than assessment of patient-centred outcome and therefore it fails to provide meaningful data regarding the clinical effectiveness of treatments. This study aims to capture data from the cohort of patients who present with a fracture of the proximal femur at a single United Kingdom Major Trauma Centre. Patient-centred outcomes will be recorded and provide a baseline cohort within which to test the clinical effectiveness of experimental interventions.

Background

Approximately half of all hip fractures are displaced intracapsular fractures. The standard treatment for these fractures is either hemiarthroplasty or total hip arthroplasty. The recent National Institute for Health and Care Excellence (NICE) guidance on hip fracture management recommends the use of ‘proven’ cemented stem arthroplasty with an Orthopaedic Device Evaluation Panel (ODEP) rating of at least 3B (97% survival at three years). The Thompsons prosthesis is currently lacking an ODEP rating despite over 50 years of clinical use, likely due to the paucity of implant survival data. Nationally, adherence to these guidelines is varied as there is debate as to which prosthesis optimises patient outcomes.

The purpose of this study was to identify changing trends in the pattern of distribution of the type and demographics of fractures of the hip in the elderly between 2001 and 2010. A retrospective cross-sectional comparison was conducted between 179 fractures of the hip treated in 2001, 357 treated in 2006 and 454 treated in 2010. Patients aged < 60 years and those with pathological and peri-prosthetic fractures were excluded. Fractures were classified as stable extracapsular, unstable extracapsular or intracapsular fractures.

The mean age of the 179 patients (132 women (73.7%)) treated in 2001 was 80.8 years (60 to 96), 81.8 years (61 to 101) in the 357 patients (251 women (70.3%)) treated in 2006 and 82.0 years (61 to 102) in the 454 patients (321 women (70.1%)) treated in 2010 (p = 0.17). There was no difference in the gender distribution between the three study years (p = 0.68).

The main finding was a steep rise in the proportion of unstable peritrochanteric fractures. The proportion of unstable extracapsular fractures was 32% (n = 57) in 2001, 35% (n = 125) in 2006 and 45% (n = 204) in 2010 (p < 0.001). This increase was not significant in patients aged between 60 and 69 years (p = 0.84), marginally significant in those aged between 70 and 79 years (p = 0.04) and very significant in those aged > 80 years (p < 0.001). The proportion of intracapsular fractures did not change (p = 0.94).

At present, we face not only an increasing number of fractures of the hip, but more demanding and complex fractures in older patients than a decade ago. This study does not provide an explanation for this change.

Cite this article: Bone Joint J 2013;95-B:1250–4.

The Gamma nail is frequently used in unstable peri-trochanteric hip fractures. We hypothesised that mechanical failure of the Gamma nail was associated with inadequate proximal three-point fixation. We identified a consecutive series of 299 Gamma nails implanted in 299 patients over a five-year period, 223 of whom fulfilled our inclusion criteria for investigation. The series included 61 men and 162 women with a mean age of 81 years (20 to 101). Their fractures were classified according to the Modified Evans’ classification and the quality of fracture reduction was graded. The technical adequacy of three points of proximal fixation was recorded from intra-operative fluoroscopic images, and technical inadequacy for each point was defined. All patients were followed to final follow-up and mechanical failures were identified. A multivariate statistical analysis was performed, adjusting for confounders. A total of 16 failures (7.2%) were identified. The position of the lag screw relative to the lateral cortex was the most important point of proximal fixation, and when inadequate the failure rate was 25.8% (eight of 31: odds ratio 7.5 (95% confidence interval 2.5 to 22.7), p < 0.001).

Mechanical failure of the Gamma nail in peri-trochanteric femoral fractures is rare (< 1%) when three-point proximal fixation is achieved. However, when proximal fixation is inadequate, failure rates increase. The strongest predictor of failure is positioning the lateral end of the lag screw short of the lateral cortex. Adherence to simple technical points minimises the risk of fixation failure in this vulnerable patient group.

Cite this article: Bone Joint J 2013;95-B:825–30.

An MR scan was performed on all patients who presented to our hospital with a clinical diagnosis of a fracture of the proximal femur, but who had no abnormality on plain radiographs. This was a prospective study of 102 consecutive patients over a ten-year period. There were 98 patients who fulfilled our inclusion criteria, of whom 75 were scanned within 48 hours of admission, with an overall mean time between admission and scanning of 2.4 days (0 to 10). A total of 81 patients (83%) had abnormalities detected on MRI; 23 (23%) required operative management.

The use of MRI led to the early diagnosis and treatment of occult hip pathology. We recommend that incomplete intertrochanteric fractures are managed non-operatively with protected weight-bearing. The study illustrates the high incidence of fractures which are not apparent on plain radiographs, and shows that MRI is useful when diagnosing other pathology such as malignancy, which may not be apparent on plain films.

There have been recent reports linking alendronate and a specific pattern of subtrochanteric insufficiency fracture. We performed a retrospective review of all subtrochanteric fractures admitted to our institution between 2001 and 2007. There were 20 patients who met the inclusion criteria, 12 of whom were on long-term alendronate. Alendronate-associated fractures tend to be bilateral (Fisher’s exact test, p = 0.018), have unique radiological features (p < 0.0005), be associated radiologically with a pre-existing ellipsoid thickening of the lateral femoral cortex and are likely to be preceded by prodromal pain. Biomechanical investigations did not suggest overt metabolic bone disease. Only one patient on alendronate had osteoporosis prior to the start of therapy. We used these findings to develop a management protocol to optimise fracture healing. We also advocate careful surveillance in individuals at-risk, and present our experience with screening and prophylactic fixation in selected patients.