To determine the outcome of subtrochanteric fractures treated by intramedullary (IM) nailing and identify causes for implant failure. We performed a retrospective analysis of all subtrochanteric fractures treated by intramedullary nailing in Belfast trauma units between February 2006 and 2009. This subgroup of patients was identified using the Fractures Outcome Research Database (FORD). Demographic data, implant type, operative details, duration of surgery and level of operator were collected and presented. Post-operative X-rays were assessed for accuracy of reduction. One hundred and twenty two (122) patients were identified as having a subtrochanteric fracture treated by IM nailing. There were 79 females and 43 males. Age range was 16 to 93 (mean 78). 95 (78%) cases were performed by training grades and 27 (22%) by consultants. Duration of surgery ranged from 73–129mins (mean 87mins). 47 patients (38.5%) were found to have a suboptimal reduction and 75 patients (61.5%) had an anatomical reduction on immediate post-operative x-ray. One year from surgery 73/122 patients were available for follow up. Of those patients with suboptimal reduction, 13/47 (27.7%) required further surgery. 8 required complete revision with bone grafting, and 5 underwent dynamisation. A further 6 patients had incomplete union. In the anatomical group, 4 patients underwent further surgery (5%). 3 required dynamisation and one had exchange nailing for an infected non-union. 3 patients had incomplete union at last follow up. 5/47 (10.6%) had open reduction in the suboptimal group compared to 25/75 (33.3%) in the anatomical group. Of the 27 cases performed by consultants, 13 (48%) were open reduction, compared to 17/93 (18%) by training grades. This study has shown that inadequate reduction of subtrochanteric fractures, leads to increased rates of non union and ultimately implant failure. We recommend a low threshold for performing open reduction to ensure anatomical reduction is achieved in all cases.
Currently there is an elevated public awareness of the consequences of nosocomial infection, of which, 14.5% is due to surgical site infection (SSI). Hip fracture patients are at increased risk of SSI due to their age related poor medical health, immune response impairments and decreased capacity of wound healing. Superficial SSI following hip fracture surgery can affect up to 16.9% with deep infection affecting 3.7%. Deep infection represents a major complication, from which hip fracture patients are 4.5 times less likely to survive to discharge and carries a 50% mortality at 1 year, compared to 33% without infection. Treatment requires a prolonged hospital stay, additional diagnostic testing, antibiotic therapy and surgery, resulting in the total cost of treating deep infection to be more than double that of non-infected hip fracture surgery. Wound closure aims to accurately appose the skin edges thereby promoting rapid healing and restoration of the protective dermal barrier. Failure to provide accurate skin apposition can result in delayed wound healing which has been shown to have a 3 fold risk of developing late infection. Importantly, delayed wound healing is reflected by prolonged wound ooze. We hypothesized that skin closure via sutures is better at achieving skin edge apposition than wounds closed with staples, providing more rapid wound healing. We compared staples and sutures for wound closure in hip fracture patients by using ooze duration as an outcome measure for wound healing. Duration of wound ooze was recorded in 170 patients. 65 wounds, closed with sutures, had an average duration of ooze of 1.82 days. 105 wounds, closed with staples, had an average duration of ooze of 4.97 days. This study suggests that sutures are superior to staples with regard to early wound healing in hip fracture patients.
Recently a great amount of research has been conducted into fatigability of paraspinal muscles in relation to Lower Back Pain (LBP). Additionally relationships have been observed between a general level of “fitness” and LBP. This research project aimed to evaluate the influence of aerobic fitness and health on lower back muscle function as measured by Electromyographic (EMG) spectral parameters. Participants undertake a series of psychometric tests, anthropometric data collection, EMG spectral analysis of the paraspinal muscles at lumbar and thoracic regions, and an aerobic fitness test. The EMG test involves a 30-sec isometric pull against a load normalised for weight. The spectral half-width, initial median frequency and median frequency slope are calculated. Participants are given biofeedback and exercise advice. Participants in this study were of above average fitness level compared to normative data. Other anthropometric data were similar to previous work conducted within this department. Preliminary regression analysis results have revealed no relationships between aerobic fitness level and EMG parameters, a finding that is counter to current beliefs on LBP and fitness, however it was observed that age did significantly influence lumbar spectral variable values (p = .002). A similar psychological profile was observed for all fitness levels.
Due to the disproportionate prevalence of Lower Back Pain (LBP) amongst the socially excluded a Health Action Zone (HAZ) funded population based research project was implemented to evaluate LBP, using EMG spectral analysis, physical fitness and health status amongst this cohort. A large representative sample (n = 300) was required, however the study has been confounded in obtaining its’ prospective sample due to recruitment problems. Initial recruitment techniques utilised health promotion roadshows held in prominent public locations throughout Teesside and a large-scale media campaign. The ‘roadshows’ promote a positive message relating to LBP and the importance of exercise. Each person receives the opportunity to obtain unique individual information relating to back muscle function from EMG testing as a motivator to participate. Secondary recruitment took the form of purposive sampling amongst selected professional groups (teachers, police, prison officers), testing taking place in the workplace but employing the same research “message”. The project had been unsuccessful in i) recruiting the general public within the public domain and ii) specifically recruiting the socially excluded. Population based research, especially that which intends to target difficult to access populations may encounter difficulties in recruitment. Why? Distrust and suspicion towards positions of “authority”, low perceived importance of research to this cohort, simple apathy? These reasons are anecdotal and we would be very interested in any ideas and welcome any input on this frustrating issue.
Serum 1.25 dihydroxyvitamin D concentrations were reduced in elderly patients with femoral neck fractures, irrespective of the presence of osteomalacia. This reduction was not attributable to a decrease in vitamin D binding protein. The low rate of bone turnover in these elderly patients might reduce the requirement for vitamin D and protect against the development of osteomalacia. Serum vitamin D metabolite concentration cannot be used as a screening test for osteomalacia in these patients.
