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
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
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
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
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
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. Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries.Aims
Methods
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. Historical data from the Scottish Hip Fracture Audit (2017 to 2021) were used to identify monthly incidence rates. Established time series forecasting techniques (Exponential Smoothing and Autoregressive Integrated Moving Average) were then used to predict the annual number of hip fractures from 2022 to 2029, including adjustment for predicted changes in national population demographics. Predicted differences in service-level outcomes (length of stay and discharge destination) were analyzed, including the associated financial cost of any changes.Aims
Methods
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. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty).Aims
Methods
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. We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score.Aims
Methods
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. Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale.Aims
Patients and Methods
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. Relevant papers were identified from appropriate clinical databases
and a narrative review was undertaken.Aims
Materials and Methods
To compare the early management and mortality of older patients
sustaining major orthopaedic trauma with that of a younger population
with similar injuries. The Trauma Audit Research Network database was reviewed to identify
eligible patients admitted between April 2012 and June 2015. Distribution
and severity of injury, interventions, comorbidity, critical care
episodes and mortality were recorded. The population was divided
into young (64 years or younger) and older (65 years and older) patients.Aims
Patients and Methods
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. Between 1992 and 2016, 49 patients (33 male) with mean age of
57 years (25 to 87) underwent cemented THA at a mean of 6.5 years
(0.1 to 25) following acetabular fracture. A total of 38 had undergone
surgical fixation and 11 had been treated non-operatively; 13 patients
died at a mean of 10.2 years after THA (0.6 to 19). Patients were
assessed pre-operatively, at one year and at final follow-up (mean
9.1 years, 0.5 to 23) using the Oxford Hip Score (OHS). Implant
survivorship was assessed. An age and gender-matched cohort of THAs
performed for non-traumatic osteoarthritis (OA) or avascular necrosis
(AVN) (n = 98) were used to compare complications and patient-reported outcome
measures (PROMs).Aims
Patients and Methods
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:
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.
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. This study design is a multi-centre, multi-surgeon, parallel, two arm, standard-of-care pragmatic randomised controlled trial. It will be embedded within the WHiTE Comprehensive Cohort Study (ISRCTN63982700). The main analysis is a two-way equivalence comparison between Hemi-Thompson and Hemi-Exeter polished taper with Unitrax head. Secondary outcomes will include radiological leg length discrepancy measured as per Bidwai and Willett, mortality, re-operation rate and indication for re-operation, length of index hospital stay and revision at four months. This study will be supplemented by the NHFD (National Hip Fracture Database) dataset.Background
Design
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:
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:
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.