Proximal femur fractures are increasing in prevalence, with femoral neck (FN) and intertrochanteric (IT) fractures representing the majority of these injuries. The salvage procedure for failed open reduction internal fixation (ORIF) is often a conversion to total hip arthroplasty (THA). The use of THA for failed ORIF improves pain and function, however the procedure is more challenging. The aim of this study was to investigate the clinical and radiographic outcomes in patients who have undergone THA after ORIF. This retrospective case-control study compared patients who underwent THA after failed ORIF to a matched cohort undergoing primary THA for non-traumatic osteoarthritis. From 2004 to 2014, 40 patients were identified. The matched cohort was matched for date of operation, age, gender, and type of implant. Preoperative, intraoperative, and postoperative data were collected and statistical analysis was performed. The cohort of patients with a salvage THA included 18 male and 22 female patients with a mean age of 73 years and mean follow up of 3.1 years. Those with failed fixation included 12 IT fractures and 28 FN fractures. The mean time between ORIF and THA was 2.1 years for IT fractures and 8.5 years for FN fractures (p=0.03). The failed fixation group had longer procedures, greater drop in hemoglobin, and greater blood transfusion rate (p<0.05). There was one revision and one dislocation in the failed fixation group with no revisions or dislocations in the primary THA group. Length of admission, medical complications, and functional outcome as assessed with a standardised hip score and were found not to be statistically different between the groups. Salvage THA for failed initial fixation of proximal femur fractures yields comparable clinical results to primary THA with an increased operative time, blood loss, and blood transfusion rate

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

Fractures of the Proximal Femur are a common and disabling injury requiring hospital admission and surgical treatment leading to approximately 86,000 inpatient episodes annually in the UK, with such patients occupying more than 20% of NHS orthopaedic beds. Based on current trends the number of hip fractures may rise to 120,000 per annum by 2015. As the age of the population increases, so does the prevalence of concomitant medical conditions. Atrial Fibrillation is rising in the general population. Recently, the benefit of treating these patients with warfarin to prevent stroke has been shown; as a consequence, the number of patients being treated with warfarin is on the increase. We have performed a retrospective study of all patients admitted to our unit with Fractures of the neck of the femur between 2001 and 2006, from the Accident and Emergency department with a primary diagnosis of Proximal Femoral Fracture (1987 patients). 138 patients were on long term warfarin at the time of their admission (6.9% of admissions). 90.4% were being warfarinised for AF, 7.6% for DVT and the rest for other indications. Of these Patients only 12 (8.7%) received active reversal to their warfarin. (All received vitamin K either orally or Intravenously). The average delay to theatre attributable to warfarin therapy was 41.1 hours (p-0.001). Active reversal allowed this delay to be negated (p-0.01), and did not delay the reloading of warfarin post-operatively (p-0.012). It also allowed an average of 10.2 days earlier discharge from the orthopaedic unit (p-0.001). This study shows that significant delays occur because of Warfarinisation of these patients and that active reversal seems to be beneficial in expediting surgical treatment and discharge from the orthopaedic unit

Patients presenting with a fractured neck of femur are a fragile group with multiple co-morbidities who are at risk of post-operative complications. As many as 52% of patients are reported to suffer a urinary tract infection post hip fracture surgery. There are little data surrounding the effects of post-operative urinary tract infections on mortality and deep prosthetic infection. We prospectively investigated the impact of post-operative urinary tract infection (UTI) in 9168 patients admitted to our institution with a diagnosis of proximal femoral fracture over an eleven year period in a prospective population study. We examined the effects of post operative UTI on the incidence of deep infection, survivorship and length of stay. Post-operative UTI occurred in 6.1% (n=561) and deep infection in 0.89% (n=82). Deep infection was significantly more common in patients complicated with a UTI (3.2% vs 0.74% p< 0.001) with a relative risk of 3.7:1. In 58% of patients the same organisms was cultured in the urine and hip samples. A postoperative UTI did not adversely effect 90 day survival, however was associated with an increased length of stay (ROC analysis AUC=0.79). Delays to surgery and age were not predictive of a post operative UTI. Recognition of the risks posed by post operative UTI, the risk factors for development of infection and early treatment is essential to reduce the risks of increased subsequent periprosthetic infection

Nationwide, proximal femoral fractures contribute a significant workload for the NHS and are the commonest trauma admission. Timely discharge from the acute hospital setting is beneficial to both patient and orthopaedic team. The Community Care Act 2003 formed part of Governmental strategy to reduce ‘bed blocking’. Introduced on 5 January 2004, the scheme enabled Trusts to charge Local Authorities £100 a day where there was delayed transfer of care due to lack of Social Service [SS] provision. The Act brought with it a £250 million package of funding over three years. We looked at patients admitted to Weston Area Healthcare Trust [WAHT] sustaining fractured neck of femur. These were pre-scheme group A, admitted 08/09/2003-06/10/2003 and post scheme group B, 08/03/2004 – 05/04/2003. Patient numbers, group ‘A’ 33 patients, group ‘B’ 28 patients. Average length of stay, ‘A’ 22.3 days, ‘B’ 16.1 days. The average time spent in hospital after being declared ‘medically fit’, ‘A’ 6.6 days, ‘B’ 2.3 days. Only 13 patients were referred to SS post scheme, with combined delayed discharge of 116 days. The impact of the scheme in reducing length of stay has not been proven. Few patients were referred to SS even after the implementation of the scheme; however, the delay in discharge for these patients would have amounted to £11600 of funding. To date, WAHT have not received any funds for patients in whom discharge was delayed. The Act states that lack of SS input must be the ‘sole reason’ for delay in discharge. The scheme is not applicable if delay is due to family choice, lack of equipment or lack of intermediate care package and for these reasons transfer of funds from SS to Trusts has become a multidisciplinary minefield. The impact of the reimbursement scheme will only become apparent if the Act is enforced

Hip fractures frequently occur in elderly patients with osteoporosis and are rapidly increasing in prevalence owing to an increase in the elderly population and social activities. We experienced several recent presentations of TFNA nails failed through proximal locking aperture which requires significant revision surgery in often highly co-morbid patient population.

The study was done by retrospective data collection from 2013 to 2023 of all the hip fractures which had been fixed with Cephalomedullary nails to review and compare Gamma (2013–2017) and TFNA (2017–2023) failure rates and the timing of the failures. Infected and Elective revision to Arthroplasty cases were excluded.

The results are 1034 cases had been included, 784 fixed with TFNA and 250 cases fixed Gamma nails. Out of the 784 patients fixed with TFNA, 19 fixation failed (2.45%). Out of the 250 cases fixed with Gamma nails, 15 fixation failed (6%). Mean days for fixation failure were 323 and 244 days in TFNA and Gamma nails respectively.

We conclude that TFNA showed remarkable less failure rates if compared to Gamma nails. At point of launch, testing was limited and no proof of superiority of TFNA over Gamma nail. Several failures identified with proximal locking aperture in TFNA which can be related to the new design which had Substantial reduction in lateral thickness at compression screw aperture.

Introduction

Mortality rates following hip fracture are high. There are several scoring systems which aim to predict morbidity and mortality in hospital in-patients. The Nottingham Hip Fracture Score (NHFS) was devised to predict 30 day mortality following hip fracture. Methods: All patients with hip fractures admitted over a 6 month period were reviewed. The NHFS was calculated for each patient and any associations between patient factors, NHFS, and outcome were investigated.

There is conjecture on the optimal timing to administer bisphosphonate therapy following operative fixation of low- trauma hip fractures. Factors include recommendations for early opportunistic commencement of osteoporosis treatment, and clinician concern regarding the effect of bisphosphonates on fracture healing. We performed a systematic review and meta-analysis to determine if early administration of bisphosphonate therapy within the first month post-operatively following proximal femur fracture fixation is associated with delay in fracture healing or rates of delayed or non-union. We included randomised controlled trials examining fracture healing and union rates in adults with proximal femoral fractures undergoing osteosynthesis fixation methods and administered bisphosphonates within one month of operation with a control group. Data was pooled in meta-analyses where possible. The Cochrane Risk of Bias Tool and the GRADE approach were used to assess validity. For the outcome of time to fracture union, meta-analysis of three studies (n= 233) found evidence for earlier average time to union for patients receiving early bisphosphonate intervention (MD = −1.06 weeks, 95% CI −2.01 – −0.12, I. 2. = 8%). There was no evidence from two included studies comprising 718 patients of any difference in rates of delayed union (RR 0.61, 95% CI 0.25–1.46). Meta-analyses did not demonstrate a difference in outcomes of mortality, function, or pain. We provide low-level evidence that there is no reduction in time to healing or delay in bony union for patients receiving bisphosphonates within one month of proximal femur fixation

Gunshot-induced fractures of the proximal femur typically present with severe comminution and bone loss. These fractures may also be associated with local damage to soft tissue, neurovascular structures and injuries to abdominal organs. The aim was to evaluate the outcomes of civilian gunshot injuries to the proximal femur at a major trauma center in South Africa. A retrospective review of all patients who sustained gunshot-induced proximal femur fractures between January 2014 and December 2017 was performed. Patients with gunshot injuries involving the hip joint, neck of femur or pertrochanteric fractures were included. Patient demographics, clinical- treatment and outcome data were collected. Results are reported as appropriate given the distribution of continuous data or as frequencies and counts. Our study included 78 patients who sustained 79 gunshot-induced proximal femur fractures. The mean age of patients was 31 ± 112, and the majority of patients were male (93.6%). Pertrochantenteric fractures were the most common injuries encountered (73.4%). Treatment included cephalomedullary nail (60.8%), arthrotomy and internal fixation (16.4%) and interfragmentary fixation with cannulated screws (6%). One case of complete neck of femur fracture had fixation failure, which required conversion to total hip arthroplasty. The overall union rate was 69.6%, and 6.3% of patients developed a fracture-related infection in cases who completed follow-up. The study shows an acceptable union rate when managing these fractures and a low risk of infection. As challenging as they are, individual approaches for each fracture and managing each fracture according to their merits yield acceptable outcomes

Failure of cephalomedullary fixation for proximal femur fractures is an uncommon event associated with significant morbidity to the patient and cost to the healthcare system. This institution changed nailing system from the PFNA (DePuy Synthes) to InterTan (Smith and Nephew) in February 2020. To assess for non-inferiority, a retrospective review was performed on 247 patients treated for unstable proximal femur fractures (AO 31 A2; A3). Patients were identified through manual review of fluoroscopic images. Stable fracture patterns were excluded (AO 31 A1). Pre/post operative imaging, demographic data, operative time and ASA scores assessed. Internal/external imaging and national joint registry data were reviewed for follow up. No significant difference was found in overall failure rate of PFNA vs InterTan (4.84% vs 3.23%; p = 0.748). Overall, short nails were more likely to fail by cut-out than long nails (7.5% vs 1.2%; p = 0.015). Nails which failed by varus cut-out had a higher tip/apex distance (TAD) (26.2mm vs 17.0mm; p < 0.001). Of concern, varus cut-out occurred in two InterTan nails with TAD of <25mm. The PFNA enjoyed a shorter operative time for both the short (59.1 vs 71.8 mins; p = 0.022) and long nails (98.8 vs 114.3 mins; p = 0.016) with no difference in 120-day survival rate. Overall failure rates of the PFNA and InterTan nailing systems were comparable. However, the failure rate of short nails in this study is concerning. Using long nails with a lag screw design for unstable intertrochanteric femoral fractures may reduce failure rates. Cumulative frequency analysis suggests stringent tip-apex distances of less than 21mm may reduce failure rates in lag-screw design cephulomedullary nails. This dataset suggests that unstable intertrochanteric fractures may be more reliably managed with a long cephalomedullary device

Aims. COVID-19 represents one of the greatest global healthcare challenges in a generation. Orthopaedic departments within the UK have shifted care to manage trauma in ways that minimize exposure to COVID-19. As the incidence of COVID-19 decreases, we explore the impact and risk factors of COVID-19 on patient outcomes within our department. Methods. We retrospectively included all patients who underwent a trauma or urgent orthopaedic procedure from 23 March to 23 April 2020. Electronic records were reviewed for COVID-19 swab results and mortality, and patients were screened by telephone a minimum 14 days postoperatively for symptoms of COVID-19. Results. A total of 214 patients had orthopaedic surgical procedures, with 166 included for analysis. Patients undergoing procedures under general or spinal anaesthesia had a higher risk of contracting perioperative COVID-19 compared to regional/local anaesthesia (p = 0.0058 and p = 0.0007, respectively). In all, 15 patients (9%) had a perioperative diagnosis of COVID-19, 14 of whom had fragility fractures; six died within 30 days of their procedure (40%, 30-day mortality). For proximal femoral fractures, our 30-day mortality was 18.2%, compared to 7% in 2019. Conclusion. Based on our findings, patients undergoing procedures under regional or local anaesthesia have minimal risk of developing COVID-19 perioperatively. Those with multiple comorbidities and fragility fractures have a higher morbidity and mortality if they contract COVID-19 perioperatively; therefore, protective care pathways could go some way to mitigate the risk. Our 30-day mortality of proximal femoral fractures was 18.2% during the COVID-19 pandemic in comparison to the annual national average of 6.1% in 2018 and the University Hospital Coventry average of 7% for the same period in 2019, as reported in the National Hip Fracture Database. Patients undergoing procedures under general or spinal anaesthesia at the peak of the pandemic had a higher risk of contracting perioperative COVID-19 compared to regional block or local anaesthesia. We question whether young patients undergoing day-case procedures under regional block or local anaesthesia with minimal comorbidities require fourteen days self-isolation; instead, we advocate that compliance with personal protective equipment, a negative COVID-19 swab three days prior to surgery, and screening questionnaire may be sufficient. Cite this article: Bone Joint Open 2020;1-9:520–529

Long femoral nails for neck of femur fractures and prophylactic fixation have a risk of anterior cortex perforation. Previous studies have demonstrated the radius of curvature (ROC) of a femoral nail influencing the finishing point of a nail and the risk of anterior cortex perforation. This study aims to calculate a patients femoral ROC using preoperative XR and CT and therefore nail finishing position. We conducted a retrospective study review of patients with long femoral cephalomedullary nailing for proximal femur fractures (OTA/AO 31(A) and OTA/AO 32) or impending pathological fractures at a level 1 trauma centre between January 1, 2015 and December 31, 2020 with both full length lateral X-ray and CT imaging. Femoral ROC was calculated on both imaging modalities. Outcomes measured including nail finishing position, anterior cortex encroachment and impingement. The mean femoral ROC was 1026mm on CT and 1244mm on XR. CT femoral ROC strongly correlated with nail finishing point with a spearmans coefficient of 0.77. Additionally, femurs with a ROC <1000mm were associated with a higher risk of anterior encroachment (OR 6.12) and femurs with a ROC <900mm were associated with a higher risk of anterior cortex impingement (OR 6.47). To our knowledge this is the first study to compare a measured femoral ROC to nail finishing position. The use of CT to measure femoral ROC and to a lesser extent XR was able to predict both nail finishing position and risk of anterior cortex encroachment. Preoperative XRs and CTs were able to identify patients with a small femoral ROC. This predicted patients at risk of anterior cortex impingement, anterior cortex encroachment and nail finishing position. We may be able to select femoral nails that resemble the native femoral ROC and mitigate the risk of anterior cortex perforation

Aim. The most frequent mechanical failure in the osteosynthesis of intertrochanteric fractures is the cut-out. Fracture pattern, reduction quality, tip-apex distance or the position of the cervico-cephalic screw are some of the factors that have been associated with higher cut-out rates. To date, it has not been established whether underlying bacterial colonization or concomitant infection may be the cause of osteosynthesis failure in proximal femur fractures (PFF). The primary objective of this study is to assess the incidence of infection in patients with cut-out after PFF osteosynthesis. Method. Retrospective cohort study on patients with cut-out after PFF osteosynthesis with endomedullary nail, from January 2007 to December 2020. Demographic data of patients (such as sex, age, ASA), fracture characteristics (pattern, laterality, causal mechanism) and initial surgery parameters were collected (time from fall to intervention, duration of surgery, intraoperative complications). Radiographic parameters were also analyzed (tip-apex distance and Chang criteria). In all cut-out cases, 5 microbiological cultures and 1 anatomopathological sample were taken and the osteosynthesis material was sent for sonication. Fracture-related infection (FRI) was diagnosed based on Metsemakers et al (2018) and McNally et al (2020) diagnostic criteria. Results. Of the 67 cut-out cases, 16 (23.9%) presented clinical, analytical or microbiological criteria of infection. Of these sixteen patients, only in 3 of them the presence of an underlying infection was suspected preoperatively. A new osteosynthesis was performed in 24 cases (35.8%) and a conversion to arthroplasty in the remaining 43 (64.2%). A comparative analysis was performed between cases with and without infection. The groups were comparable in terms of demographic data and postoperative radiological data (using Chang criteria and tip-apex distance). Patients with underlying infection had a higher rate of surgical wound complication (56.3% vs 22%, p = 0.014), higher rates of leukocytes counts (11.560 vs 7.890, p = 0.023) and time to surgery (5.88 vs 3.88 days, p = 0.072). Conclusions. One out of four osteosynthesis failure in PFF is due to underlying FRI and in almost 20% were not unsuspected before surgery. In PFF osteosynthesis failures, underlying infection should be taken into account as a possible etiological factor and thus a preoperative and intraoperative infection study should be always performed

Few studies have examined the socio-economic impact of complications requiring surgery following initial surgical management of proximal femoral fractures. Our hypothesis was that there would be a significant difference in the cost, mortality rate and ultimate discharge location in patients requiring further surgery after their index procedure for a proximal femoral fracture compared to a matched control group. This was a retrospective matched cohort study of all proximal femoral fractures presenting to the John Radcliffe Hospital over a five year period. Data had been collected prospectively in a standard manner. The total cost of treatment for each patient was calculated by separating the treatment costs into its components. Mortality data was retrieved from the Office of National Statistics and data were analysed using SPSS statistics software, with a p value of less than 0.05 considered significant. There were 2360 proximal femoral fractures in 2257 patients. Of this group, 144 (6.1%) required further surgical intervention due to a complication of the primary procedure. Mean age at time of fracture was 82.59 years; 81.6% women. Mean cost of treatment in those cases with complications was £18,731 compared to £8,575 for uncomplicated cases (p=0.00) with a mean length of stay of 62.8 days and 32.7 days respectively (p=0.00). Mortality probability of cases was significantly higher than the control group with a mean survival of 209 days versus 496 days for controls (p= 0.035) and patients with complications were statistically less likely to return to their own home (p< 0.01). The socio-economic impact of complications following treatment of proximal femoral fractures is important in this current economic climate. Greater awareness and understanding are warranted. Recognition of potential risk factors for complications may allow earlier detection of potential cases and thereby reduce their number and in turn the socioeconomic cost

Introduction. In our institution, we started to perform THA with SuperPATH approach, including preservation of soft tissue around the hip (James Chow et al. Musculoskelet Med 2011) since July 2014, aiming for fast recovery and prevention of hip dislocation. For minimally-invasive approaches, however, there have been a few reports on malalignment of the implants related to shortage of operative field. The purpose of this study is to examine the short-term results of THA using SuperPATH, especially implant alignment. Materials and methods. We performed a study of 45 patients (45 hips) with osteoarthritis of the hip joint who had a THA with SuperPATH approach. There were 8 men and 37 women with an average age of 73 years, which were minimally 24 months followed. Dynasty Bioform cup and Profemur Z stem (Microport Orthopaedics) were used for all cases. Patients were clinically assessed with Merle d'Aubigne score and complications. Implant alignment and stability were radiologically evaluated by annual X-ray and CT acquired two months after surgery. Results. Merle d'Aubigne score was 10.2 (pain:2.8, mobility:4.4 walking ability:3.0) preoperatively and 16.6(pain:5.8, mobility:5.8, walking ability:5.0) at the latest follow-up. There were no dislocation and infection, but intraoperative proximal femoral fracture was found for two cases, which was managed to treat with additional circulating wire intraoperatively. Latest follow-up X-ray image showed 95% of the stem A-P alignment to be within 2 degrees and 5% to be more than 2 degrees and less than 5 degrees, while 44% of the stem lateral alignment to be within 2 degrees, 47% to be more than 2 degrees and less than 5 degrees, and 8% to be more than 5 degrees. From CT images averaged cup position found to be 40±5 degrees for inclination, and 19±5 degrees for anatomic anteversion, averaged stem anteversion to be 33±9 degrees. Annual X-ray evaluation showed no radiolucent line and less than Grade 2 stress-shielding (Engh classification) around the implants for all cases. One case had more than 5mm subsidence of the stem in early postoperative period, but not progressively subsided. No loosening of components was evident. Discussion and Conclusion. Many minimally-invasive approaches have developed, there have been many reports on fast recovery and low incidence of postoperative hip dislocation, however, the risk of complications or malalignment related to shortage of operative field has been pointed out. In this study, intraoperative proximal femoral fracture occurred for two cases. Also, though there were no loosening and the components position seemed excellent but lateral view of the X-ray showed 8% to be more than 5 degrees tilting alignment, resulting from femoral broaching required before femoral neck resection. SuperPATH approach, including pass way from between the Gluteus Medius and the piriformis tendon, can preserve the whole short external rotators and capsule of the hip joint, leading to fast recovery and low incidence of postoperative dislocation. Moreover, this approach may be friendly to the surgeons familiar with the posterior approach because of easily conversion to the conventional posterior approach

Introduction. Many minimally-invasive approaches have been described in an effort to improve short-term results of total hip arthroplasty (THA), aiming for fast recovery and prevention of dislocation. In our institution, we started to perform THA with SuperPATH approach, including preservation of soft tissue around the hip (James Chow et al. Musculoskelet Med 2011) since July 2014. The purpose of this study is to examine the short-term results of THA using SuperPATH, especially treatment progress of rehabilitation. Materials and methods. We performed a study of 30 patients (30 hips) with osteoarthritis of the hip joint who had a THA with SuperPATH approach. There were 4 men and 26 women with an average age of 71 years, which were followed up for 24 months. Patients were clinically assessed with Merle d'Aubigne score, postoperative hip pain during walking by Numerical Rating Scale (NRS:0–10), complications and treatment progress of rehabilitation in regard to moving and activities of daily living. Implant alignment and stability were radiologically evaluated by annual X-ray and CT acquired two months after surgery. Results. Merle d'Aubigne score was 10.4 (pain:2.9, mobility:4.5 walking ability:3.0) preoperatively and 16.8(pain:5.9, mobility:5.9, walking ability:5.0) at the latest follow-up. NRS showed less than 3 points for more than 50% of the THA patients next day postoperatively. For more than 80%, NRS showed less than 1 point at 7 days after surgery, and most patients acquired the ability of level ground walking for 100 meters independently by 4 days postoperatively, climbing up and down stairs independently by 5 days and wearing/taking off their socks independently by 7 days. There were no dislocation and infection, but intraoperative proximal femoral fracture was found for two cases, which was managed to treat with additional circulating wire intraoperatively. From CT images averaged cup position found to be 39±5 degrees for inclination, and 21±6 degrees for anatomic anteversion, averaged stem anteversion to be 33±9 degrees. No loosening of components was evident. Discussion and Conclusion. Many minimally-invasive approaches have developed, there have been many reports on fast recovery and low incidence of postoperative hip dislocation, however, the risk of complications related to shortage of operative field has been pointed out. In this study, intraoperative proximal femoral fracture occurred for two cases, but the components position seemed excellent and NRS showed less pain postoperatively and most of the patients acquired walking ability in a few days. SuperPATH approach, including pass way from between the Gluteus Medius and the piriformis tendon, can preserve the whole short external rotators and capsule of the hip joint, leading to fast rehabilitation progress. Moreover, this approach may be friendly to the surgeons familiar with the posterior approach because of easily conversion to the conventional posterior approach

Acute postoperative periprosthetic joint infection (PJI) is a serious complication after any hemiarthroplasty (HHA) implanted due to a proximal hip fracture. The growing number of chronic institutionalized geriatric patients (CIGP) colonized with multi-drug resistant bacteria (e.g.: MRSA), not covered by usual antibiotic prophylaxis, has been identified as a risk factor for PJI after HHA. We therefore sought to compare the HHA infection characteristics between non-institutionalized patients (NIP) with proximal hip fractures and CIGP. We investigate (1) the rate of compliance with a new proposed protocol, (2) the acute infection rate, 3) the microbiologic characteristics of the infection, and 4) the success of the new protocol. We gathered clinical, operative and infection data on all patients who underwent HHA due to a proximal femoral fracture in our center, during a 3-year period. We focus in the cases of acute postoperative infection (Zimmerli´s criteria). The new proposed antibiotic prophylaxis is cefazolin except in CIGP in which co-trimoxazole is used. During the study period a total of 385 HHA in 385 patients were performed. In all cases the HHA was performed after a proximal femoral fracture. Overall, 109 patients (28,2%) were CIGP. We found an acute postoperative PJI in 21 out 385 HHA procedures, that is, a global acute infection rate of 5.43%. Ten out 109 (9.17%) CIGP patients resulted infected compared to 11 out 278 (3.9%) non-institutionalized patients (p: 0.049). One or more causative microorganisms were identified in 20/21 (95%) of PJI. Globally the Gram-Negative bacilli group accounted for the majority of the infections (60%). Staphylococus aureus was isolated in 3 cases (8.6%) with only a single MRSA infection. The percentage of polymicrobial infections was 47% (10 out of 21). Co-trimoxazole was used in the prophylaxis in 80.1% of the CIGP. In the infected cases a non-effective drug against the microorganism was used in the prophylaxis in 17 (81%) of the acute infected HHA. We confirm that institutionalized patients are more prone to acute infections after a HHA. Our current strategy of antibiotic prophylaxis has showed to be effective in preventing MRSA PJI in CIGP. However, we found an increased rate of infection due to gram-negative bacilli non-covered by the current antibiotic prophylaxis. According our data an extended antibiotic prophylaxis on gram-negative drug will be proposed to be implemented in CIGP scheduled to a HHA because a proximal femoral fracture

Introduction. Premature cessation of clopidogrel in certain patients with cardiac conditions is associated with an increased risk of recurrent coronary events. Such patients often present with proximal femoral fractures requiring surgical intervention. Our aim was to ascertain whether it is necessary to stop clopidogrel preoperatively to avoid postoperative complications following hip hemiarthroplasty surgery. Methods. A retrospective review of 102 patients with ongoing clopidogrel therapy and patients not on clopidogrel who underwent hip hemiarthroplasty for an intracapsular proximal femoral fracture was undertaken. Statistical comparison on pre- and postoperative haemoglobin (Hb), ASA grades, comorbidities, operative times, transfusion requirements, hospital length of stay (LOS), wound infection, haematoma and reoperation rates between the two groups was undertaken. Results. There were 50 patients in the clopidogrel group (CG) and 52 in the non-clopidogrel group (NCG). The mean age was 83 years. There was no difference with respect to ASA grade, comorbidities (except cardiac comorbidities), age, gender and operation times between the two groups. The mean preoperative Hb was 12.5 g/dl and 12.6 g/dl respectively in the CG and NCG (p=0.72). The mean postoperative Hb was 10.8 g/dl and 11.1 g/dl respectively in the CG and NCG (p= 0.37). 4 and 2 patients respectively required transfusions postoperatively in the CG and NCG (p= 0.37). A total of 8 and 5 units were utilised in the CG and NCG groups respectively (p= 0.54). There was no difference with respect to LOS, wound infection, haematoma and reoperation rates between the two groups postoperatively. Conclusion. Maintaining clopidogrel therapy throughout the perioperative period in high risk patients with intracapsular proximal femoral fractures is not associated with an increased risk of bleeding or complications following hip hemiarthroplasty surgery

Perioperative fracture during routine THA represents one of the “not so fresh” feelings that occur for both patients and surgeons. With the increase in the use of uncemented implants and MIS techniques this truly is a problem on the rise. We have examined and quantified the risk factors associated with proximal femoral fracture during THA. Risk factors (risk ratios) identified were: uncemented stems (8.9), anterolateral approach (7.4) and female gender (2.2). Fortunately, treatment with cerclage wiring for uncemented stems has facilitated excellent stem stability and acceptable survivorship with many different femoral component designs. Reduced proximal geometry stems that better match the endosteal osseous anatomy have reduced fracture rates at our institution and maintained excellent stem survivorship. New data examining this design will be presented. In our series, cemented stems, however, had decreased survivorship in the presence of a proximal femoral fracture. MIS techniques may accelerate rehabilitation but they certainly permit limited visibility of the proximal femoral and acetabular anatomy and may result in less accurate component position. Relatively high fracture rates in series of MIS-THA have been reported. A bigger concern, however, is the unrecognised fracture that displaces postoperatively and requires a return to surgery for treatment with or without revision and mandates that we “see it before it sees us!” Cerclage wiring with looped Luque wires has been our treatment of choice for many years. Wires are significantly less expensive than cables and have proven to be durable in our series. This technique allows intraoperative repositioning and variable tightening in multiple locations. Cable fretting and breakage have been common in our experience with braided cable devices. Acetabular fracture during uncemented THA is most likely an under-reported occurrence and has been associated with elliptical component designs and under-reaming. In the presence of a stable cup, long-term performance has been acceptable

Introduction. The gamma nail is a cephalomedullary implant used in proximal femoral fracture management. Short gamma nails are technically less demanding, but there is concern over potentially higher complication rate. Objectives. To determine differences in implant related complications between the short and long gamma nail. Methods. 54 patients were identified who had either short or long gamma nail for a proximal femoral fracture. Case notes and radiographs were reviewed retrospectively to determine the complication rate due to implant failure. Fisher's exact test was used for testing the significance. Results. Out of 54 patients, 20 patients had short gamma and 34 patients had long gamma nail. 4 (20%) patients with short gamma nail had implant related complications whereas none in the long gamma nail group (P<.05). 2 (10%) patients had fracture of the nail at the level of proximal screw, 1 (5%) patient had cut out of the screw from the femoral head and 1 (5%) patient had fracture below the tip of the nail. Conclusions. Our study suggests short gamma nails are associated with higher rate of implant related complications and we now routinely use long gamma nails whenever indicated