Little data exists on predicting the actual outcome of patients with fracture neck of femur when aged over 90. This group represents a complex of medical problems and where a delay in surgery can impact on patient recovery. In this study we evaluated the POSSUM scores at time of admission and time of surgery. We aim to define the actual mortality and morbidity of this group, if the possum had any predictive value, and any correlation with outcome.

132 patients over 90 with a fracture where followed from 2005–7, and a control cohort were followed up in 2005–6. A collection form was prepared to collect standard data on physiological status, with a standard scoring system on admission (Ortho possum), at the time of operation, comparing their progress and clinical outcome post-op. It also recorded co-morbidities and other outcomes. Statistical analysis was conducted using SPSS.

132 patient notes were reviewed and 130 patients in the control group. 5 had no surgery and the average age was 93 (90–103) vs. 76 in the control group. The majority of over 90’s were admitted from home by ambulance (n=99); and the cause of the fracture was recorded as a fall (n=68). 74 patients at admission were using a stick or a frame (24 were independent). Only 2 patients were on warfain.

At the point of admission the physiological POSSUM score on average was 23.48 (18–44) and at surgery it was 23.52 (16–38). This meant that the predicted mortality increased from 0.103 to 0.104. The average time to surgery was 1.5 days (0–12 days). However delays in surgery increased the POSSUM score and higher Possum scores were correlated with increased number of complications (p> 0.002), increased time to mobilisation (p> 0.003), and reduced mobility as compared to admission at day 15 and longer hospital admissions (p> 0.005).

In hospital mortality was 0.068 with a higher total POSSUM score prior to surgery of 36.29 for these patients compared to those patients who died after discharge. 35 patients died in total at 2 years post discharge (36%). Of these patients those within the 30 day mortality post discharge was 0.087 with a higher Total POSSUM score of 28.55 compared with the 120 day mortality post discharge of 0.194 with Total POSSUM score of 27.55; predicted mortality for the whole group was 0.28 using the Possum score (actual 0.27). Of the 35 patients that died 22 had higher Possum scores at surgery than admission.

In summary we found that there was no significant difference in the mortality and morbidity in the over 90’s fracture neck of femur group than the control. The Possum scoring system over predicted overall mortality and morbidity. Our results indicate a dedicated team to deal with these patients may well be of benefit to improve surgical Possum scores and outcome.

Eighteen porous coated posterior stabilized prostheses, inserted without cement or screws have been reviewed. Six were revised within two years. One was infected. The remaining five were revised for persistent symptoms considered to be due to tibial component loosening. Three of the four improved after revision with cementing of the tibial component, the other has remained symptomatic. One patient was lost to follow-up. Clinical review of the remaining eleven was good or excellent at two years. Radiographs at two years, available in eight, revealed that all had a non progressive I mm radio-lucent line at the bone- tibial prosthesis interface. The lack of bony ingrowth and apparent symptomatic early loosening in the four revised, suggests that posterior stabilised tibial prostheses may require additional initial fixation. From our experience in this short series, it is recommend that the tibial component of this prosthesis and perhaps any other posterior stabilized design, be cemented or fixed with screws.

Early failures have seen titanium fall from favour as a material for cemented femoral stems. Between 1989 and 1994, we performed a prospective review of a consecutive series of 122 cemented total hip replacements using the Ultima straight textured titanium stem, and report the five- to ten-year clinical and radiological outcomes. There were no revisions for loosening of the femoral stem. Revision surgery was undertaken for other reasons such as dislocation, infection and loosening of the cup in 7.3%. Of those patients without revision all but two were satisfied with their hip, with 74% graded good or excellent using a modified Harris hip score. Radiological assessment revealed probable loosening in two. Although slight vertical subsidence was found in one-third of patients it had not progressed to loosening. It is not clear whether this represents debonding. Non-progressive radiolucent lines (1 to 2 mm) were present in zone 1 at the cement-prosthesis interface in 14.7%. Calcar resorption and hypertrophy around the distal stem were not often seen. With 97% survival at a mean of 7.5 years, the medium-term results of this specific cemented titanium stem are reassuring so far, but we are concerned about debonding and future failure.