Hip fractures are a significant cause of mortality and morbidity in the elderly. Malnutrition is a major element of this but no consensus exists as to the detection or management of this condition. Reported incidence in elderly hip fracture patients varies widely between 9.0% and 88.6%.

The aim of this study was to evaluate the nutritional status of 415 patients with operatively managed hip fractures and determine the prognostic relevance of admission serum albumin and total lymphocyte count (TLC) assays. Protein-energy malnutrition (PEM) was defined as serum albumin < 3.5g/dl and a TLC < 1,500 cells/mm3. Delay to operation, duration of in-patient stay, re-admission (< 3 months) and in-patient, 3- and 12-month mortality were assessed as outcome variables.

Survival data was available for 377 patients at 12 months. Of 377 patients, 53% (n=200) had both a serum albumin and TLC levels taken at admission, while 47% (n=177) had not. The incidence of PEM was 51%. Inhospital mortality for PEM patients was 9.8%, compared with 0% for patients with normal values of both laboratory parameters. Older patients were more likely to have lower albumin (p=0.017) and TLC (p=0.023). Nursing home patients were also more likely to have lower albumin (p=0.033). Multivariate analysis revealed a significant difference in 12-month mortality, with patients who had both a low albumin and a low TLC 4.6 times (95% CI: 1.0–21.3) more likely to die within 12 months postoperatively than patients who had normal values of both laboratory parameters. This was significant after adjusting for age, gender and domicile (p=0.049).

Serum albumin and TLC in combination are accurate predictors of 12-month mortality in hip fracture patients. These results highlight the relevance of assessing the nutritional status of patients with hip fractures at the time of admission and emphasises the relationship between nutrition and outcome.

Aim: To prospectively compare the quantity of bone removed from the acetabulum in hip resurfacing arthroplasty and uncemented total hip replacements.

Methods: Sixty four patients were prospectively enrolled in the study. We compared 32 birmingham hip resurfacing acetabular components with 32 trident uncemented acetabular cups. To assess the pre-reaming size of the acetabulum, and to allow comparison between acetabular sizes, the size of the femoral head was assessed to the nearest millimetre intraoperatively with the use of a measuring calliper. The reamings from the acetabulum were collected. This bone was then dehydrated and defatted with five washes of acetone followed by five washes of diethyl ether. The bone was then placed in a furnace at 200 degrees Celsius until a consistent dry weight was achieved. The size of acetabular component used was recorded in all cases.

Results: The mean weight of bone removed from the acetubulum of the resurfacing group was 13.79 g. The corresponding mean weight of bone removed from the acetabulum of the total hip replacement group was 11.71g. Using a non-parametric analysis of covariance (ANCOVA) to account for the covariate of acetabular size, regression analysis indicated no evidence of a difference between the mean bone weight removed in the two groups (p-value of 0.57).

Conclusions: Close attention to surgical technique in preparing the femoral head during resurfacing will allow the use of an appropriately small femoral component. If performed accurately this will avoid oversizing the acetabular component and removal of excess bone stock.

Background: Protein energy malnutrition (PEM) is an accepted predictor of poor outcome in hip fracture patients. There is no universally accepted definition of PEM. Admission screening for PEM is not routinely performed for hip fracture patients. The reported incidence in elderly hip fracture patients varies widely between 9.0% and 88.6%.

Aims: To determine the prognostic relevance of admission serum albumin and total lymphocyte count (TLC), as clinical markers of PEM and predictors of outcome for hip fracture patients.

Methods: Retrospective review of 415 patients with operatively managed hip fracture. Protein-energy malnutrition was defined as albumin < 3.5g/dl and TLC < 1,500cells/mm3. Delay to operation, duration of in-patient stay, readmission (< 3 months) and in-patient, 3- and 12-month mortality were assessed as outcome variables.

Results: Survival data was available for 377 patients at 12 months. Of 377 patients, 53% (n=200) had both a serum albumin and TLC levels taken at admission (study), while 47% (n=177) had not (control). Incidence of PEM was 51%. Older patients were more likely to have lower albumin (p=0.03) and TLC (p=0.012). Nursing home patients were also more likely to have lower albumin (p=0.049). In-hospital mortality for PEM patients was 9.8%, compared with 0% for patients with normal values of both laboratory parameters. Patients with PEM had a higher 12-month mortality compared to patients who had normal values of both laboratory parameters (Odds Ratio=4.52; p=0.049).

Conclusion: Serum albumin and TLC in combination are accurate predictors of 12-month mortality in hip fracture patients. These results underscore the clinical relevance of assessing the nutritional status of patients with hip fractures at the time of admission and emphasises the relationship between nutrition and outcome in these patients.

In the past autogenous bone grafting has been the mainstay of treatment in patients with fracture non-unions. The harvesting of bone graft is, however associated with significant donor site morbidity. Recently there has been much interest in the use of synthetic osteo-inductive agents.

We performed a review series of thirteen patients with sixteen non-unions in whom op-1, a bone morphogenetic protein (available commercially as Osigraft) was used to promote union.

This was a retrospective chart review and union was judged on the basis of radiological union as reported by the radiology department and documented by the surgeon responsible and clinical union based on the ability to weight bear with minimal or no pain as documented in the patients’ records.

At nine months twelve of sixteen non-unions (75%) had achieved clinical and radiographic union. Three patients had repeat grafting, all of whom went on to union. Mean time to grafting after initial treatment for all patients was 8.9 +/−6.1 months. Mean time to union was 5.1 +/− 1.6 months.

We conclude that the use of osteo-inductive agents, in particular BMP-7 (op-1) results in good clinical and radiological outcomes. What remains unclear is whether they are superior to the traditional approach of autogenous grafting.

Aim: An epidemiological analysis of spontaneous community acquired septic arthritis cases in an elderly population at a university teaching hospital

Method: We studied confirmed cases of spontaneous septic arthritis in the over 65 population. Patients with prosthetic joint infections were excluded from the study. We analysed data relating to initial presenting complaint and clinical examination, haematological and microbio-logical tests along with ultimate patient outcome.

Results: There were 7 confirmed cases of spontaneous septic arthritis in over 65 population in the last 6 months (2 hips, 5 knees). The mean age was 72.14 (range 65–82) with a mean length of stay of 49 days. Those with septic arthritis of the knee presented with swelling, pain and immobility. Hip cases presented with pain and immobility. All patients were systemically well at time of presentation, with no other foci of infection detected after septic screening. All patients had aspirate and arthroscopic/arthrotomy confirmed infection. Staphylococcus Aureus was isolated from 6 joint aspirations and Pseaudomonas Auruginosa from one patient. Complications of treatment included acute renal failure, cardio/respiratory failure, disseminated infection and death (1 case).

Conclusion: Septic arthritis must be considered as a differential diagnosis in all patients with joint pain, swelling and immobility. This diagnosis is not confined to the paediatric population. A backround of degenerative disease and the occult presentation in the elderly may delay diagnosis. Sepsis must be considered in the elderly with joint pathology, with treatment initiated in a prompt and aggressive manner to prevent the sequelae that ensues.

There is little published data concerning long-term outcome in pyogenic spinal infection. Previous studies have used either neurological outcome in isolation, or non-validated quality of life measure instruments yielding data that is difficult to interpret.

To assess long-term outcome following pyogenic spinal infection through standardised outcome measures, Oswestry Disability Index (ODI) and Short Form-36 (SF-36) were utilised.

All cases of pyogenic spinal infection presenting to a single institution over the period 1993–2003 were retrospectively identified. Inclusion in each case was based on consistent clinical, imaging and microbiology criteria. The follow-up was by clinical review, American Spinal Injury Association (ASIA) classification, ODI and SF-36. The outcome was compared to normative data for the Irish population.

Twenty-nine cases of pyogenic spinal infection were identified. Nineteen patients (66%) had an adverse outcome at a median follow-up of 61 months, despite only 5 patients (17%) who had persistent neurological deficit according to ASIA classification. A significant difference in SF-36 PF (physical function) scores was observed between patients with adverse outcome and those who recovered (p=0.003). SF-36 scores failed to reach those of a normative population, even after apparent full recovery. A strong correlation was observed between ODI and SF-36 Physical Function scores (rho=0.61, p< 0.05). Seventeen percent (n= 5) of admissions resulted in acute sepsis-related death. Delay in diagnosis of spinal infection (p= 0.025) and neurological impairment at diagnosis (p< 0.001) were associated with neurological deficit at follow-up examination. Previous spinal surgery was a significant predictor of adverse outcome in patients requiring readmission < 1 year (p= 0.018).

The finding of high rates of adverse outcome and using SF-36 and ODI suggests under-reporting of poor outcome in other series. We advocate use of validated standardised spinal outcome questionnaires to accurately assess long-term outcome and facilitate comparison between case series.

Background: Nonagenarian patients with hip fractures present many challenges to the clinician, both in terms of their advanced age and medical co-morbidities with potential orthopaedic complications. Our aims were to assess outcome of hip fractures in a nonagenarian population with respect to pre-operative predictors of outcome, immediate and long-term morbidity, and survival rates.

Methods: All nonagenarian patients with a hip fracture admitted to our unit between January 2000 and Decem-ber 2003 were considered. Eighty-one patients were included, the majority being female (M: F 14: 67). Ages ranged from 90 to 98 years for female patients (mean 92.5 years, SD 2.2) compared to 90 to 95 years for male patients (mean 92.7 years, SD 2).

Results: Delay to surgery was 1.25 days and the median ASA grade was III. The method of anaesthesia used was spinal in 78% and general in 22%. The majority of patients had intertrochanteric fractures and methods of fixation involved internal fixation in 63% and hemiarthroplasty in the remaining 36% of the group deemed fit for surgery. The rate of complications during inpatient stay was 19% and there were eight in-patient post-operative mortalities due to medical complications. Mean survival post hip fracture in our patient group was 474.7 days (median 372.5 days). Within forty days of surgery 25% of patients died, including our inpatient mortality of 10%. However, 50% of the patients were still alive 126 days post-operatively.

Conclusion: Hip fractures must be given special attention in the nonagenarian population because of their advanced age and medical co-morbidities. Careful pre-operative assessment and medical maximisation combined with prompt surgical intervention yielded a good outcome and return to pre-injury status for most patients. Lower ASA grades, surgery within 48 hours, and increased pre-operative haemoglobin levels were all associated with favourable outcomes. Medical complications were the major cause of morbidity and mortality with a low rate of orthopaedic complications. The majority of patients were able to return to their previous residence and continued to be mobile with various levels of assistance.

Introduction: The optimal management of ankle fractures in the elderly is controversial, with wide variation in the complication rates reported in the literature. Achieving a satisfactory outcome is essential as reduced mobility exacerbates pre-existing morbidity and diminishes the likelihood of independent living. However, in elderly patients surgery carries increased risks due to osteoporosis, poor skin condition and decreased vascularity.

Methods: We performed a retrospective review of outcome and complications in patients over 70 years of age with ankle fractures. Patients were admitted for manipulation under anaesthetic and application of cast (MUA) or open reduction and internal fixation (ORIF). Data were retrieved from medical and nursing notes relating to pre-operative functioning, type of injury, operative procedure and outcome. All X-rays were also reviewed to confirm fracture grade and union.

Results: A total of 134 patients over the age of 70 were admitted for management of ankle fractures during January 1995 and December 2003 and 117 of these were included in the study. 84 were operatively treated for ankle fractures and a further 27 patients underwent MUA. The mean age in both groups was 76 and there was a female predominance in both groups (89% in MUA, 79% in ORIF). 14.8% of the conservatively managed group were nursing home residents compared to 2.4% of the operatively treated group. The groups were similar with respect to ASA grade and co-morbidities. The median length of stay was shorter for the conservatively managed group (4 vs. 6 days). 7.5% of the MUA group required a second intervention compared to 4.5% of the operatively managed group. There were two below knee amputations in the operatively managed group, both related to open fractures, and one arthrodesis in each group. There were three wound complications in the operatively managed group. The rate of postoperative medical complications was the same in both cohorts. 7.4% of patients treated with MUA and 1.1% of patients treated operatively had reduced mobility at final follow-up.

Conclusion: The decision-making process for treatment of ankle fractures in the geriatric population is challenging. We observed significantly better functional results in the ORIF group than the MUA group. These results indicate that open reduction and internal fixation of ankle fractures in geriatric patients is efficacious and safe in selected patients

Injuries to the sciatic nerve are an occasional complication of surgery to the hip and acetabulum, and traction is frequently the causative mechanism. In vitro and animal experiments have shown that increased tensile strain on peripheral nerves, when applied for prolonged periods, impairs nerve function.

We have used video-extensometry to measure strain on the human sciatic nerve during total hip replacement (THR). Ten consecutive patients with a mean age of 72 years undergoing primary THR by the posterior approach were recruited, and strains in the sciatic nerve were measured in different combinations of flexion and extension of the hip and knee, before dislocation of the hip. Significant increases (p = 0.02) in strain in the sciatic nerve were observed in flexion of the hip and extension of the knee. The mean increase was 26% (19% to 30%). In animal studies increases of this magnitude have been shown to impair electrophysiological function in peripheral nerves. Our results suggest that excessive flexion of the hip and extension of the knee should be avoided during THR.