Hip fractures are a leading cause of hospital admission and an increasing problem within the ageing population. The two main treatment options for displaced intracapsular fractures are total hip arthroplasty and hemiarthroplasty. This service evaluation aims to compare the outcomes of patients over 80 years old with a younger cohort undergoing the two main treatment modalities. The study included 378 patients admitted to a major UK trauma centre between April 2011 and March 2013. The main outcome measures were: mortality rate at 30 days and 1 year; reoperation rate at 30 days; proportion living in their own home/sheltered accommodation at 30 days, 1 year and upon NHS discharge; change in walking ability indoors and outdoors at 30 days and 1 year. All patients receiving THA were discharged home compared to 74.3% under 80 receiving hemiarthroplasty and 57.3% over 80 receiving hemiarthroplasty. No THA patients required reoperation at 30 days. 4.4% under 80 receiving hemiarthroplasty required reoperation, as did 2.0% over 80 receiving hemiarthroplasty. Mortality rates were higher following hemiarthroplasty. Patients receiving THA in both age groups were more likely to retain their pre-injury walking ability at 1 year; however loss of walking ability was similar at 30 days regardless of age or treatment. Patients receiving THA in the trust had less risk of mortality and reoperation with an increased chance of retaining pre-injury walking ability and place of residence; however these patients were healthier prior to the operation. Age had a larger impact on walking ability for those receiving hemiarthroplasty.
There were 70000 people admitted to hospital with fractured hips in 2007 and the incidence is rising by 2% each year. Hip fractures represent significant morbidity and mortality to patients and cost the NHS £1.8 billion annually. In 2008 the British Orthopaedic Association Standards for Trauma (BOAST) issued a 14-point guideline to be followed for the management of hip fractures. The aim was to improve secondary prevention of osteoporosis, reduce the falls risk and further fractures. This aimed to provide better care to improve the outcomes for patients and reduce the burden of hip fractures on society. The aim of the audit was to see if the BOAST guidelines are met before and after the transition to a level 1 MTC (Major Trauma Centre) and to measure any impact the change had. Methods: Prospective data was collected for three months in 2010, 2011 and 2012. 94 case notes were reviewed and compared to the outcomes laid out in the BOAST guidelines to see if standards were met. Overall adherence to the guideline's recommendations was high throughout the 3 sample months. For each of the 3 sample months 100% adherence was seen in all of the following criteria: further imaging if x-rays unclear, appropriate analgesia, pre-op assessment, seniority of surgeon, orthogeriatrician involvement, seniority of surgeons and submission to the National Hip Fracture Database. The main common area where adherence was less than 100% was with A and E breaches (i.e. greater than 4 hours referral to the ward). Despite relocation and transition to a level 1 MTC, the management of fractured neck of femur patients compared to the BOAST guidelines remained of a high standard. Further improvements have also been made since moving to the new hospital site where shortcomings in management have been identified. Improvements from year one to three include prophylactic antibiotics and warfarin reversal; there is now a new trust protocol in place for warfarin reversal in the case of hip fractures. Elsewhere adherence to the guidelines remains high across the sample months. Confirming that despite moving to a level 1 status the trauma team continues to be performing well and managing this group appropriately. In January 2012 BOAST published a second version of the hip fracture guidelines: A and E breaches were removed from the guidelines. There have also been several new additions to the guidelines, which prompt a further re-audit in the future.
Recent NICE guidelines suggest that Total Hip Arthroplasty (THA) be offered to all patients with a displaced intracapsular neck of femur fracture who: are able to walk independently; not cognitively impaired and are medically fit for the anaesthesia and procedure. This is likely to have significant logistical implications for individual departments. Data from the National Hip Fracture Database was analysed retrospectively between January 2009 and November 2011. The aim was to determine if patients with displaced intracapsular neck of femur fractures admitted to a single tertiary referral orthopaedic trauma unit received a THA if they met NICE criteria. Case notes were then reviewed to obtain outcome and complication rates after surgery. Five hundred and forty-six patients were admitted with a displaced intracapsular neck of femur fracture over the described time period. Sixty-five patients met the NICE criteria to receive a THA (mean age 74 years, M:F = 16: 49); however, 21 patients had a THA. The other patients received either a cemented Thompson or bipolar hemiarthroplasty. Within the THA cohort there were no episodes of dislocation, venous thromboembolism, significant wound complications or infections that required further surgery. Within the hemiarthroplasty cohort there was 2 mortalities, 2 implant related infections, 1 dislocation and 2 required revision to a THA. There is evidence to suggest better outcomes in this cohort of patients, in terms pain and function. There is also a forecasted cost saving for departments, largely due to the relative reduction in complications. However, there were many cases (44) in our department, which would have been eligible for a THA, according to the NICE guidelines, who received a hemiarthroplasty. This is likely a reflection of the increased technical demand, and larger logistical difficulties faced by the department. We did note more complications within the hemiarthroplasty group, however, the numbers are too small to address statistical significance, and a longer follow up would be needed to further evaluate this. There is a clear scope for optimisation and improvement of infrastructure to develop time and resources to cope with the increased demand for THA for displaced intracapsular neck of femur fractures, in order to closely adhere to the NICE guidelines.
Renal homeostasis has been shown to influence mortality after hip fractures; this is true for patients with both chronic kidney disease, and those who develop acute renal dysfunction after surgery. We have examined the influence of impaired renal function upon mortality and length of stay. We investigated this relationship through accurate mathematical modelling of available biochemistry data on a cohort of hip fracture patients. Complete data were available for 566 patients treated over a 27-month period. All patients had urea and creatinine checked on admission, and at 24–48 hours after surgery. Post-operative analgesia, fluid therapy, transfusion protocols and orthogeriatric reviews were standardised. Generalised Linear Models and correlation matrices were used. Cox-proportional hazards analyses investigated the association between serum concentrations of urea and creatinine on admission and length of stay and mortality after surgery.Introduction
Methods
The coronoid and collateral ligaments are key elbow stabilizers. When repair of comminuted coronoid fractures is not possible, prosthetic replacement may restore elbow stability. A coronoid prosthesis has been designed with an extended tip in an effort to augment elbow stability in the setting of residual collateral ligament insufficiency. The purpose of this biomechanical study, therefore, was to compare an anatomic coronoid replacement with an extended tip implant both with and without ligament insufficiency. Two coronoid prostheses were designed and developed based on CT-derived images adjusted for cartilage thickness: an anatomical implant and an extended-tip implant. Passive elbow extension was performed in 7 cadaveric arms in the varus and valgus positions. Varus-valgus laxity of the ulna relative to the humerus was quantified with a tracking system with an intact coronoid, a 40% coronoid deficiency, an anatomical prosthesis, and an extended prosthesis, with the collateral ligaments sectioned and repaired.Purpose
Method
There have been a number of described techniques for sizing the diameter of radial head implants. All of these techniques, however, are dependent on measurements of the excised native radial head. When accurate sizing is not possible due to extensive comminution or due to a previous radial head excision, it has been postulated that the proximal radioulnar joint (PRUJ) may be used as an intraoperative landmark for correct sizing. The purpose of this study was to: 1) determine if the PRUJ could be used as a reliable landmark for radial head implant diameter sizing when the native radial head in unavailable, and (2) determine the reliability of measurements of the excised radial head. Twenty-seven fresh-frozen denuded ulnae and their corresponding radial heads (18 males, 9 females) were examined. The maximum diameter (MaxD), minimum diameter (MinD) and dish diameter (DD) of the radial heads were measured twice, 3–5 weeks apart, using digital calipers. Two fellowship-trained upper extremity surgeons, an upper extremity fellow and a senior orthopedic resident were then asked to independently select a radial head implant diameter based on the congruency of the radius of curvature of the PRUJ to that of the radial head trial implants. The examiners were blinded to the native radial head dimensions. This selection was repeated 3–5 weeks later by two of the investigators. Correlation between radial head measurements and radial head implant diameter sizes was assessed using Pearsons correlation coefficient (PCC) and inter and intra-observer reliability were assessed using intra-class correlation coefficient (ICC).Purpose
Method
There are concerns with regard to the physiological effects of reamed intramedullary femoral fracture stabilisation in patients who have received a pulmonary injury. This large animal study used invasive monitoring techniques to obtain sensitive cardiopulmonary measurements and compared the responses to Early Total Care (reamed intramedullary femoral fracture fixation) to Damage Control Orthopaedics (external fixation), after the induction of acute lung injury. We hypothesised a greater cardiopulmonary response to intramedullary fracture fixation. Acute lung injury (PaO2/FiO2 < 200 mmHg) was induced in 12 invasively monitored and terminally anaesthetised male sheep via the infusion of oleic acid into the right atrium. Each animal underwent surgical femoral osteotomy and fixation with either reamed intramedullary (n=6) or external fixation (n=6). Simultaneous haemodynamic and arterial blood-gas measurements were recorded at baseline and at 5, 30 and 60 minutes after fracture stabilisation.Purpose
Method
The coronoid process is an integral component for elbow stability. In the setting of a comminuted coronoid fracture, where repair is not possible, a prosthetic device may be beneficial in restoring elbow stability. The hypothesis of this in-vitro biomechanical study was that an anatomic coronoid prosthesis would restore stability to the coronoid deficient elbow. A metal coronoid prosthesis was designed and developed based on CT-derived images adjusted for cartilage thickness. The kinematics and stability of eight fresh-frozen male cadaveric arms (mean age 77.4 years, range 69–92 years) were quantified in the intact state; after collateral ligament sectioning and repair (control state); after a simulated 40% transverse coronoid fracture; and after implantation of a coronoid prosthesis. Elbow flexion was simulated passively with the arm oriented in the varus position and the forearm in pronation. Varus-valgus angulation (VV) and internal-external rotation (IE) of the ulna relative to the humerus were quantified with an electromagnetic tracking system (Flock of Birds, Ascension Technologies, Burlington, VT, static accuracy: 1.8mm position, 0.5 orientation).Purpose
Method
The aim of this study was to establish any association between implant cut-out and a Tip Apex Distance (TAD), ≥25mm, in proximal femoral fractures, following closed reduction and stabilisation, with either a Dynamic Hip Screw (DHS) or Intramedullary Hip Screw (IMHS) device. Furthermore, we investigated whether any difference in cut-out rate was related to fracture configuration or implant type. WE conducted a retrospective review of the full clinical records and radiographs of 65 consecutive patients, who underwent either DHS or IMHS fixation of proximal femoral fractures. The TAD was measured in the standard fashion using the combined measured AP and lateral radiograph distances. Fractures were classified according to the Muller AO classification. 35 patients underwent DHS fixation and 30 patients had IMHS fixation. 5 in each group had a TAD≥25mm. There were no cut-outs in the DHS group and 3 in the IMHS group. 2 of the cut-outs had a TAD≥25mm. The 3 cut-outs in the IMHS group had a fracture classification of 31-A2, 31-A3 and 32-A3.1 respectively. In addition, the fractures were inadequately reduced and fixed into a varus position. A TAD<25mm would appear to be associated with a lower rate of cut-out. The cut-out rate in the IMHS group was higher than the DHS group. Contributing factors may have included an unstable fracture configuration and inadequate closed fracture reduction at the time of surgery.
The Western Infirmary/Gartnavel General Hospital orthopaedic department is geographically located next to the Beatson Oncology Centre, a specialist regional oncology unit. Pathological femoral fractures are the commonest reason for surgical intervention in patients referred from the Beatson and we have used them as a model to establish the demographic data, referral patterns, treatment results, and survival characteristics in such a group of patients. We have collected prospective data for the last 4 years on referrals from patients under the care of oncology services.Introduction
Methods
Damage Control techniques involve primary external fracture fixation to reduce the ‘second hit’ of surgery. This study used a large animal (ovine) trauma model to compare pathophysiological responses of primary external femoral fixation and intramedullary stabilisation. Under terminal anaesthesia bilateral femoral fractures and hypovolaemia were produced using a pneumatic ram. 24 sheep were randomised into 4 groups and monitored for 24 hours. Group 1 – Control; Group 2 – Trauma only; Group 3 – Trauma and external fixation; Group 4 – Trauma and reamed intramedullary stabilisation. Outcome measures: pulmonary embolic load (transoesophageal echocardiography); plasma coagulation markers; bronchoalveolar lavage differential cell counts (neutrophils, lymphocytes and macrophages). Total embolic load was significantly higher (p<0.001) in the intramedullary fixation group (median score 42 versus 20). All trauma groups had a significant increase (p < 0.05) in prothrombin time with a fall in antithrombin III and fibrinogen levels. No significant differences occurred between trauma groups with any coagulation or alveolar lavage marker. Intramedullary femoral fracture fixation produced a relatively higher pulmonary embolic load. However, the initial fracture fixation method did not affect any of the changes seen in the measured coagulation or inflammatory markers during the first 24 hours of injury.
