Controversy exists whether to treat unstable pertrochanteric hip fractures with either intra-medullary or extra-medullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw or long Gamma Nail. The hypothesis was that there is no difference in outcome between the two modes of treatment. Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2) were recruited into the study. Eligible patients were randomised on admission to either long Gamma Nail or sliding hip screw. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure or ‘cut-out’. Secondary measures included mortality, length of hospital stay, transfusion rate, change in mobility and residence, and EuroQol outcome score. Five patients required revision surgery for implant cut-out (2.5%), of which three were long Gamma Nails and two were sliding hip screws (no significant difference). There were no incidences of implant failure or deep infection. Tip apex distance was found to correlate with implant cut-out. There was no statistically significant difference in either the EuroQol outcome scores or mortality rates between the two groups when corrected for mini mental score. There was no difference in transfusion rates, length of hospital stay, and change in mobility or residence. There was a clear cost difference between the implants. The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur.
Controversy exists whether to treat unstable pertrochanteric hip fractures with either intramedullary or extramedullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw (SHS) or Long Gamma Nail (LGN). The hypothesis was that there is no difference in outcome between the two modes of treatment. Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2.1/A2.2/A2.3) were recruited into the study. Eligible patients were randomised on admission to either LGN or SHS. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure and implant ‘cut-out’. Secondary measures included mortality, length of hospital stay, and EuroQol outcome score. Five patients required revision surgery for implant cutout, of which three were LGNs and two were SHSs (no significant difference). There was a significant correlation between tip apex distance and the need for revision surgery. There were no incidences of implant failure or deep infection. Mortality rates between the two groups were similar when corrected for mini mental score. There was no difference between the two groups with respect to tip apex distance, hospital length of stay, blood transfusion requirement, and EuroQol outcome score. The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur.
Regional anaesthesia, and the supplementation of either general or spinal anaesthesia with nerve block is well established and becoming increasingly more popular. Femoral, sciatic and obturator nerve blockade, in alone or in combination, by means of single shot or continuous infusion has been shown to significantly improve pain control and post operative nausea and vomiting (PONV). We identify equally significant morbidity associated with this practice, with delayed post operative rehabilitation, increase in length of stay, reduction in range of movement and local adverse symptoms at the site of injection and paraesthesia at 3 months post operatively. 2 surgeons were recruited to contribute 100 consecutive total knee replacements each to this study. Each worked exclusively with a one anaesthetist. Each had a predictable and different practice. One employed either spinal or general anaesthesia which the surgeon supplemented with end of operation infiltration of soft tissues in the surgical field including the capsule and skin incision with ropivacaine 300mg, adrenaline 500μg and ketorolac 30mg with normal saline added to make a volume of 100ml. The second employed either spinal or general anaesthesia but supplemented this with a single combined femoral and sciatic nerve block performed pre-operatively. Intravenous opiate analgesia administed via patient controlled analgesia pump for 24 hours post operatively, paracetamol 1g 6 hourly and ibuprofen 300mg 8 hourly where appropriate were prescribed by both anaesthetists. We recorded the incidence of insertion of urinary catheter, deep venous thrombosis diagnosed within 3 and 12 weeks, recovery of lower limb power to grade 5/5, range of movement achieved in each postoperative day and at 12 weeks post operatively, length of stay in addition to PONV and pain scores using the visual analogue scale (VAS) and collected every 6 hours. Localised pain and tenderness at the site of injection was noted at 12 weeks, and persistent paraesthesia. As predicted patients in the group receiving nerve block has significantly less pain and post operative nausea and vomiting (p<
0.05). There was no statistically significant difference in the use of urinary catheters (p = 0.052) or the incidence of deep venous thrombosis (p=0.58). There was however a significant difference in the recovery of lower limb power (p = 0.023), range of movement recorded at 24hr intervals (p=0.038) (at 12 weeks p=0.54) and length of stay in hospital (0.038). One patient had an almost complete femoral nerve palsy at 12 weeks and required a manipulation under anaesthesia of her knee following recovery of same. Nerve blockade is an increasingly popular method of controlling post-operative pain. We demonstrate some adverse effects on rehabilitation following this practice in addition to the increased financial and logistical burden of a longer inpatient stay.
To investigate whether stopping clopidogrel on admission and subsequently delaying surgery in patients with hip fracture increases the risk of cerebrovascular complications and in-hospital mortality. Retrospectively studied patients with hip fractures on clopidogrel admitted to our trauma unit between January 1, 2006 and May 31, 2007. Fifteen patients aged over 65 years with intra-capsular and extra-capsular hip fracture were reviewed. Demographic details of patients were recorded including the primary diagnosis on admission, timing of surgical intervention performed, pre-and post-operative haemoglobin and classification according to the American Society of Anesthesiologists (ASA) and in hospital mortality. Eight fractures were intra-capsular and seven extra-capsular. The mean preoperative haemoglobin levels were 12.4 (range 9.9 to 14.1), the mean postoperative haemoglobin level were 9.7 (range 8 to 12.3). Four patients required blood transfusions, 8 unit of blood were transfused in total postoperatively. The mean delay in surgery were 9.1 days (range 7 to 14 days). The mean duration of hospital stay was 21 days (range, 8 to 45 days). The 30-day mortalities were 3/15 (20%). Mortalities were secondary to cerebrovascular events. In summary, we found increase mortality and requirement for blood transfusion in patients on clopidogrel in whom surgery were delayed. A well designed research is needed to achieve evidence based management, but this may require several years due to the small, but increasing, number patients seen at present. We suggest early surgery for elderly hip fracture patients on clopidogrel. Patients on clopidogrel should be cross matched pre-operatively for red blood cells and platelets and experienced surgeon should perform the procedure.
Allogenic blood is becoming a scarce commodity, with many advocating autologous retransfusion systems to reduce the transfusion burden post primary arthroplasty. Many units have not embraced this, as the costs involved are perceived to be prohibitively expensive. The inpatient stays of 149 consecutive patients undergoing primary total knee arthroplasty, performed in a single unit by multiple surgeons, were reviewed. Length of post-operative stays and blood transfusion requirements were noted, and cost implications of allogenic and autologous transfusion determined. The total post-operative transfusion requirement was 28 units of allogenic blood in 12 patients (8%). The total transfusion cost per patient was £28.80. With the cheapest autologous re-infusion system costing £60.08 per patient, a marginal cost of £31.28 would need to be offset, to make such a system viable solely from an economic point of view. The average post operative stay was increased from 5.6 to7.7 days in those requiring blood transfusion. This extra bed occupancy was estimated to cost a minimum of £42.68 per patient. Autologous drainage systems not only lessen the risks associated with allogenic blood, but have been shown previously to shorten hospital stay and significantly reduce allogenic transfusion requirement. By doing so, they would easily offset the increased expenditure needed to institute such a system.
