Hip precautions are currently practiced in three-quarters of trauma hospitals in the UK, despite national recommendations from the ‘Blue Book’ not stating it as a requirement. Valuable therapist time is utilised alongside the need for specialised equipment, which can potentially delay discharge whilst it is being arranged. Objective of this study was to explore the current practice of the use of hip precautions on discharge following hemiarthroplasty for hip fractures. To also explore whether they are necessary and to identify areas for improvement to benefit patient care overall.

Online survey distributed to various Trauma and Orthopaedic Departments across the UK. Survey was available over a 4-month period, collecting 55 responses overall.

Majority of responses were from trauma and orthopaedic consultants who were aware of the ‘Blue Book’ recommendations. The majority of trusts who responded did not practice hip precautions and did not feel this increased the risk of dislocations on discharge. Recommendations included integration of hip precautions in the post-op advice in coordination with the physiotherapist and information leaflets on discharge regarding hip precautions. Hip precautions were not commonly practiced, for reasons including patient compliance and the inherently stable procedure of a hemiarthroplasty compared to a THR, reducing the need for hip precautions.

Hip precautions are not widely regarded as a useful practice for post-hip hemiarthroplasty, viewed as utilising more resources and increasing costs and risk due to increased hospital stay. Thus, this potentially delays discharge overall. A consistent approach should be implemented in treating patients post-hip hemiarthroplasty.

Background: Delay in operative fixation of neck of femur fracture is associated with increased morbidity and mortality. Apart from medical reasons, inadequate facilities or poor organization has also shown to delay neck of femur fracture patients going to theatre.

Methods: In the year 2005, the Orthopaedic Directorate of University Hospitals of Leicester formed a fractured neck of femur project group to look at achieving a mean 48 hour wait (from clinical fitness to surgery) for this group to get to theatre. The salient changes effected by the group included assigning a dedicated fractured neck of femur ward where patients can be fast tracked from A & E. A dedicated half-day theatre hip list 7 days a week was instituted staffed by senior anaesthetist and surgeons. Ortho geriatricians were designated for each day to pre- and post-operatively assess fractured neck of femur patients and optimize their medical condition. The number of Trauma Coordinators and clinical aides were increased to provide 7 days a week cover. Also various services were integrated and specialist discharge coordinator assigned for early discharge. These measures were implemented from June 2006.

Results: As a result of these measures the mean time to theatre of fit fractured neck of femur patients increased from 35% in 2005 to 75% in 2007 and 90% for the first 6 months of 2008. The mortality decreased from 18.5% in 2005 to 13.2% in 2007 and 9.3% for first 6 months of 2008. 28.7% of patients were deemed unfit for surgery in 2005. This figure dropped to 6 – 7% in the following years. Also percentage of patients staying longer in hospital decreased from 30.5% in 2005 to 13.4% in 2008.

Conclusion: Reorganisation of available resources leads to better service provision and decreased mortality rate in fractured neck of femur patients.

Delay in operative fixation of neck of femur fracture is associated with increased morbidity and mortality, and has reduced chance of successful internal fixation and rehabilitation. Apart from medical reasons, inadequate facilities or poor organization has also shown to delay neck of femur fracture patients going to theatre.

In the year 2005, the Orthopaedic Directorate of University Hospitals of Leicester formed a #NOF project group to look at achieving a mean 24 hour wait (from clinical fitness to surgery) for this group to get to theatre. This group identified the areas of deficiencies and suggested organizational changes to overcome these.

The salient changes effected by the group are as follows.

Assigning a dedicated #NOF ward where patients can be fast tracked from A & E, promptly assessed and pre operative management instituted.

These measures were implemented in total from June 2006.

As a result of these measures the mean time to theatre of fit #NOF patients increased from 35% in 2005 to 75% in 2007 and 90% for the first 6 months of 2008. The mortality decreased from 18.5% in 2005 to 13.2% in 2007 and 11.3% for first 6 months of 2008. Relative risk of death decreased from 123 in 2005 to 107.9 in 2007 and 79.8 for Jan – June 2008. Also percentage of patients staying longer in hospital decreased from 30.5% in 2005 to 19.3% in 2007 and 13.4% in 2008.

In conclusion, identifying deficiencies and re organization to over come them has resulted in a better service provision and decreased mortality rate in #NOF patients. This is also a model for other hospitals to follow to improve on their care of #NOF patients.

Introduction: Intramedullary humeral nailing (IMHN) is appropriate for metastatic lesions and fractures as it stabilizes the whole bone and allows immediate mobilization. We report the results of a patient cohort with metastatic lesions/fractures treated by IMHN.

Methods: We included patients who were treated with IMHN between June 2001 and December 2007 for metastatic lesions/fractures. We noted the source of referrals, site of fracture/lesion, primary lesion, metastasis elsewhere, operative complications, post-operative patient satisfaction and pain control, fracture healing and post-operative survivorship.

Results: We identified 38 patients. The median age was 71 years (50–87). Four patients presented with lytic lesions involving more than 50% of cortical diameter while 34 patients had a fracture. 10 patients had pain in their arm for at least 2 weeks before presentation. Primary malignancies were breast (9), Non-Hodgkins B-cell Lymphoma (4), prostate (4), kidney (5), myeloma and lung (2 each), bladder, leiomyosarcoma and oesophagus (1 each) and unknown (9). There were 22 proximal, 13 midshaft and 3 distal humeral lesions. All had metastasis elsewhere in addition to the humerus except six. 12 patients were without co-morbidities. Senior grade surgeons operated on all the patients. There were no intra-operative complications. Post-operative complications included sepsis (2), frozen shoulder(1), elbow stiff-ness(1), pneumonia(2), and transient radial nerve palsy (2). Three patients developed a second fracture distal to the first one and had revision surgery. Post-operative pain control was satisfactory in 34 and unsatisfactory in 3 patients. Difficulty in pain assessment occurred in 1 patient with brain metastasis. 36 patients died, with median survival from date of surgery of 12 weeks (range 1 – 62 weeks). Two patients are alive 2.5 and 1.7 years after surgery. The median follow-up period by the orthopaedic outpatient department was 2 months (1–26.5) for 33 patients as 5 patients died with in two weeks of operation. At follow up; 9 fractures had healed, 17 were healing, 2 had not united, and 5 patients did not have x-ray at follow up.

5 Out of 8 patients, who died with in 4 weeks of surgery, had a combination of at least one co morbidity, one area of metastasis other than the humerus and were in - patients. There was no co relation between mortality and sex, age, type of tumour, or presence of metastasis.

Conclusion: IMHN for metastatic lesions and fractures is effective for pain relief and fracture healing. However a long IM nail should be used and the whole arm should be radiated. Deviations from these principles lead to 3 surgical revisions in our cohort of patients. Also one group of patient had a high mortality rate and in this specific group non-operative treatment should be thought about.

Between 1st March 1995 and 31st December 2002 we treated 69 patients for pedal ganglia. Review was carried out through a research clinic or by questionnaire by an independent reviewer. One patient had died of unrelated causes and one was housebound and deaf. Fourteen were lost to follow-up; final results are pending in 15.

Of the patients reviewed, 13 were treated by observation. Six were male, seven female, aged 16–76, median follow-up 59 months (range 40–106). Eight had no pain and five had occasional pain. None had interference with activities of daily living (ADL). Four chose shoes for comfort and nine could wear any. All had residual ganglia 3–5 mm in diameter but only five were bothered by them. One patient had undergone excision of the ganglion.

Twenty-one had aspiration and injection of ganglia. Eleven were male and ten female, aged 33–80, median follow-up 58 months (range 20–92). Ten had no pain and 11 occasional pain. Sixteen had no problems with ADL, four had interference with recreational activities and one interference with all ADL. Fourteen could wear any shoe and seven chose shoes for comfort. Eighteen were not bothered by their ganglion, two were occasionally bothered and one bothered often. Ten had no treatment other than aspiration and injection, four had repeat aspiration (one twice) and nine had the ganglion excised (two repeat excisions). Five had residual ganglia (three after surgery), two had tender scars and two altered sensation.

Four patients had primary excision. None had any pain, problems with ADL or shoe wear restrictions; one was occasionally bothered by the ganglion site. There were no recurrent ganglia but two had uncomfortable scars.

Many ganglia can be managed by simple treatment and surgery is often followed by minor residual symptoms.