Aims

We present an audit comparing our level I major trauma centre’s data for a cohort of patients with hip fractures in the National Hip Fracture Database (NHFD) with locally held data on these patients.

United Kingdom National Institute for Health and Clinical Excellence guidelines recommend the use of total hip replacement (THR) for displaced intracapsular fractures of the femoral neck in cognitively intact patients, who were independently mobile prior to the injury. This study aimed to analyse the risk factors associated with revision of the implant and mortality following THR, and to quantify risk. National Joint Registry data recording a THR performed for acute fracture of the femoral neck between 2003 and 2010 were analysed. Cox proportional hazards models were used to investigate the extent to which risk of revision was related to specific covariates. Multivariable logistic regression was used to analyse factors affecting peri-operative mortality (< 90 days). A total of 4323 procedures were studied. There were 80 patients who had undergone revision surgery at the time of censoring (five-year revision rate 3.25%, 95% confidence interval 2.44 to 4.07) and 137 patients (3.2%) patients died within 90 days. After adjusting for patient and surgeon characteristics, an increased risk of revision was associated with the use of cementless prostheses compared with cemented (hazard ratio (HR) 1.33, p = 0.021). Revision was independent of bearing surface and head size. The risk of mortality within 90 days was significantly increased with higher American Society of Anesthesiologists (ASA) grade (grade 3: odds ratio (OR) 4.04, p < 0.001; grade 4/5: OR 20.26, p < 0.001; both compared with grades 1/2) and older age (≥ 75 years: OR 1.65, p = 0.025), but reduced over the study period (9% relative risk reduction per year).

THR is a good option in patients aged < 75 years and with ASA 1/2. Cementation of the femoral component does not adversely affect peri-operative mortality but improves survival of the implant in the mid-term when compared with cementless femoral components. There are no benefits of using head sizes > 28 mm or bearings other than metal-on-polyethylene. More research is required to determine the benefits of THR over hemiarthroplasty in older patients and those with ASA grades > 2.

The October 2015 Trauma Roundup³⁶⁰ looks at: PCA not the best in resuscitation; Impact of trauma centre care; Quality of life after a hip fracture; Recovery and severity of injury: open tibial fractures in the spotlight; Assessment of the triplane fractures; Signs of an unstable paediatric pelvis; Safe insertion of SI screws: are two views required?; Post-operative delirium under the spotlight; Psychological effects of fractures; K-wires cost effective in DRAFFT

The aims of this study were to identify the early in-hospital mortality rate after hip fracture, identify factors associated with this mortality, and identify the cause of death in these patients. A retrospective cohort study was performed on 4426 patients admitted to our institution between the 1 January 2006 and 31 December 2013 with a hip fracture (1128 male (26%), mean age 82.0 years (60 to 105)).

Admissions increased annually, but despite this 30-day mortality decreased from 12.1% to 6.5%; 77% of these were in-hospital deaths. Male gender (odds ratio (OR) 2.0, 95% confidence interval (CI) 1.3 to 3.0), increasing age (age ≥ 91; OR 4.1, 95% CI 1.4 to 12.2) and comorbidity (American Society of Anesthesiologists grades 3 to 5; OR 4.2, 95% CI 2.0 to 8.7) were independently and significantly associated with increased odds of in-hospital mortality. From 220 post-mortem reports, the most common causes of death were respiratory infections (35%), ischaemic heart disease (21%), and cardiac failure (13%). A sub-group of hip fracture patients at highest risk of early death can be identified with these risk factors, and the knowledge of the causes of death can be used to inform service improvements and the development of a more didactic care pathway, so that multidisciplinary intervention can be focused for this sub-group in order to improve their outcome.

Cite this article: Bone Joint J 2015;97-B:246–51.

We report the outcome of 39 patients who underwent a modified Pauwels’ intertrochanteric osteotomy for nonunion of a femoral neck fracture following failed osteosynthesis. There were 31 men and eight women with a mean age of 47.2 years (34 to 59). By Pauwels’ classification, there were 11 Type II fractures and 28 Type III fractures. The mean follow-up was 7.9 years (2 to 19). In the 11 patients whose initial treatment had been osteotomy, union was achieved in nine (81.8%). In 28 patients whose initial treatment had been with a lag screw or a dynamic hip screw, union was achieved in 27 (96.4%). Limb lengths were equalised in 14 of 16 patients (87.5%) with pre-operative shortening. The mean neck-shaft angle improved significantly from 100.5° (80° to 120°) to 131.6° (120° to 155°) (p = 0.004). The mean modified Harris hip score was 85.6 points (70 to 97) and the mean modified Merle d’Aubigné score was 14.3 (11 to 18). Good to excellent functional outcomes were achieved in 32 patients (88.8%). A modified Pauwels’ intertrochanteric osteotomy is a reliable method of treating ununited fractures of the femoral neck following failed osteosynthesis: coxa vara and shortening can also simultaneously be addressed. Cite this article: Bone Joint J 2014;96-B:1198–1201

The aim of this randomised controlled study was to compare functional and radiological outcomes between modern cemented and uncemented hydroxyapatite coated stems after one year in patients treated surgically for a fracture of the femoral neck. A total of 141 patients aged > 65 years were included. Patients were randomised to be treated with a cemented Exeter stem or an uncemented Bimetric stem. The patients were reviewed at four and 12 months.

The cemented group performed better than the uncemented group for the Harris hip score (78 vs 70.7, p = 0.004) at four months and for the Short Musculoskeletal Function Assesment Questionnaire dysfunction score at four (29.8 vs 39.2, p = 0.007) and 12 months (22.3 vs 34.9, p = 0.001). The mean EQ-5D index score was better in the cemented group at four (0.68 vs 0.53, p = 0.001) and 12 months (0.75 vs 0.58, p = < 0.001) follow-up. There were nine intra-operative fractures in the uncemented group and none in the cemented group.

In conclusion, our data do not support the use of an uncemented hydroxyapatite coated stem for the treatment of displaced fractures of the femoral neck in the elderly.

Cite this article: Bone Joint J 2015;97-B:1475–80.

The August 2012 Hip & Pelvis Roundup³⁶⁰ looks at: whether cemented hip replacement might be bad for your health; highly cross-linked polyethylene; iHOT-33 - a new hip outcome measure; hamstring injuries; total hip replacement; stemmed metal-on-metal THR; bipolar hemiarthroplasty, neuromuscular disease and dislocation; the high risk of secondary hemiarthroplasty; and whether we have to repair the labrum after all?

Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail.

The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open.

The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture.

A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices.

Cite this article: Bone Joint J 2014; 96-B:817–22.

We undertook a retrospective cohort study to determine clinical outcomes following the revision of metal-on-metal (MoM) hip replacements for adverse reaction to metal debris (ARMD), and to identify predictors of time to revision and outcomes following revision. Between 1998 and 2012 a total of 64 MoM hips (mean age at revision of 57.8 years; 46 (72%) female; 46 (72%) hip resurfacings and 18 (28%) total hip replacements) were revised for ARMD at one specialist centre. At a mean follow-up of 4.5 years (1.0 to 14.6) from revision for ARMD there were 13 hips (20.3%) with post-operative complications and eight (12.5%) requiring re-revision.

The Kaplan–Meier five-year survival rate for ARMD revision was 87.9% (95% confidence interval 78.9 to 98.0; 19 hips at risk). Excluding re-revisions, the median absolute Oxford hip score (OHS) following ARMD revision using the percentage method (0% best outcome and 100% worst outcome) was 18.8% (interquartile range (IQR) 7.8% to 48.3%), which is equivalent to 39/48 (IQR 24.8/48 to 44.3/48) when using the modified OHS. Histopathological response did not affect time to revision for ARMD (p = 0.334) or the subsequent risk of re-revision (p = 0.879). Similarly, the presence or absence of a contralateral MoM hip bearing did not affect time to revision for ARMD (p = 0.066) or the subsequent risk of re-revision (p = 0.178).

Patients revised to MoM bearings had higher rates of re-revision (five of 16 MoM hips re-revised; p = 0.046), but those not requiring re-revision had good functional results (median absolute OHS 14.6% or 41.0/48). Short-term morbidity following revision for ARMD was comparable with previous reports. Caution should be exercised when choosing bearing surfaces for ARMD revisions.

Cite this article: Bone Joint J 2014;96-B:1600–9.

A number of studies have reported satisfactory results from the isolated revision of an acetabular component. However, many of these studies reported only the short- to intermediate-term results of heterogeneous bearing surfaces in a mixed age group.

We present our experience of using a ceramic-on-ceramic (CoC) bearing for isolated revision of an uncemented acetabular component in 166 patients (187 hips) who were under the age of 50 years at the time of revision. There were 78 men and 88 women with a mean age of 47.4 years (28 to 49). The most common reason for revision was polyethylene wear and acetabular osteolysis in 123 hips (66%), followed by aseptic loosening in 49 hips (26%).

We report the clinical and radiological outcome, complication rate, and survivorship of this group. The mean duration of follow-up was 15.6 years (11 to 19).

The mean pre-operative Harris hip score was 33 points (1 to 58), and improved to a mean of 88 points (51 to 100) at follow-up. The mean pre-operative total Western Ontario and McMaster Universities Osteoarthritis Index score was 63.2 (43 to 91) and improved to 19.8 points (9 to 61) post-operatively. Overall, 153 of 166 patients (92%) were satisfied with their outcome. Kaplan–Meier survivorship analysis, with revision or radiological evidence of implant failure (13 patients, 8%) as end-points, was 92% at 15 years (95% confidence interval 0.89 to 0.97).

Isolated revision of a cementless acetabular component using a CoC bearing gives good results in patients under 50 years of age.

Cite this article: Bone Joint J 2015;97-B:1197–1203.

The April 2014 Trauma Roundup. 360 . looks at: is it safe to primarily close dog bite wounds?; conservative transfusion evidence based in hip fracture surgery; tibial nonunion is devastating to quality of life; sexual dysfunction after traumatic pelvic fracture; hemiarthroplasty versus fixation in displaced femoral neck fractures; silver VAC dressings “Gold Standard” in massive wounds; dual plating for talar neck fracture; syndesmosis and fibular length easiest errors in ankle fracture surgery; and dual mobility: stable as a rock in fracture

We retrospectively reviewed 2989 consecutive patients with a mean age of 81 (21 to 105) and a female to male ratio of 5:2 who were admitted to our hip fracture unit between July 2009 and February 2013. We compared weekday and weekend admission and weekday and weekend surgery 30-day mortality rates for hip fractures treated both surgically and conservatively. After adjusting for confounders, weekend admission was independently and significantly associated with a rise in 30-day mortality (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.02 to 1.9; p = 0.039) for patients undergoing hip fracture surgery. There was no increase in mortality associated with weekend surgery (OR 1.2, 95% CI 0.8 to 1.7; p = 0.39). All hip fracture patients, whether managed surgically or conservatively, were more likely to die as an inpatient when admitted at the weekend (OR 1.4, 95% CI 1.02 to 1.80; p = 0.032), despite our unit having a comparatively low overall inpatient mortality (8.7%). Hip fracture patients admitted over the weekend appear to have a greater risk of death despite having a consultant-led service.

Cite this article: Bone Joint J 2014;96-B:373–8.

The February 2014 Hip & Pelvis Roundup³⁶⁰ looks at: length of stay; cementless metaphyseal fixation; mortality trends in over 400,000 total hip replacements; antibiotics in hip fracture surgery; blood supply to the femoral head after dislocation; resurfacing and THR in metal-on-metal replacement; diabetes and hip replacement; bone remodelling over two decades following hip replacement; and whether bisphosphonates affect acetabular fixation.

We performed a case–control study to compare the rates of further surgery, revision and complications, operating time and survival in patients who were treated with either an uncemented hydroxyapatite-coated Corail bipolar femoral stem or a cemented Exeter stem for a displaced intracapsular fracture of the hip. The mean age of the patients in the uncemented group was 82.5 years (53 to 97) and in the cemented group was 82.7 years (51 to 99) We used propensity score matching, adjusting for age, gender and the presence or absence of dementia and comorbidities, to produce a matched cohort receiving an Exeter stem (n = 69) with which to compare the outcome of patients receiving a Corail stem (n = 69). The Corail had a significantly lower all-cause rate of further surgery (p = 0.016; odds ratio (OR) 0.18, 95% CI 0.04 to 0.84) and number of hips undergoing major further surgery (p = 0.029; OR 0.13, 95% CI 0.01 to 1.09). The mean operating time was significantly less for the Corail group than for the cemented Exeter group (59 min [12 to 136] vs 70 min [40 to 175], p = 0.001). The Corail group also had a lower risk of a peri-prosthetic fracture (p = 0.042; OR 0.19, 95% CI 0.01 to 1.42) . There was no difference in the mortality rate between the groups. There were significantly fewer complications in the uncemented group, suggesting that the use of this stem would result in a decreased rate of morbidity in these frail patients. Whether this relates to an improved functional outcome remains unknown.

Cite this article: Bone Joint J 2014;96-B:299–305.

The August 2013 Trauma Roundup³⁶⁰ looks at: reverse oblique fractures do better with a cephalomedullary device; locking screws confer no advantage in tibial plateau fractures; it’s all about the radius of curvature; radius of curvature revisited; radial head replacement in complex elbow reconstruction; stem cells in early fracture haematoma; heterotrophic ossification in forearms; and Boston in perspective.

The purpose of this study was twofold: first, to determine whether the five-year results of hip resurfacing arthroplasty (HRA) in Canada justified the continued use of HRA; and second, to identify whether greater refinement of patient selection was warranted.

This was a retrospective cohort study that involved a review of 2773 HRAs performed between January 2001 and December 2008 at 11 Canadian centres. Cox’s proportional hazards models were used to analyse the predictors of failure of HRA. Kaplan–Meier survival analysis was performed to predict the cumulative survival rate at five years. The factors analysed included age, gender, body mass index, pre-operative hip pathology, surgeon’s experience, surgical approach, implant sizes and implant types. The most common modes of failure were also analysed.

The 2773 HRAs were undertaken in 2450 patients: 2127 in men and 646 in women. The mean age at operation was 50.5 years (sd 8.72; 18 to 82) and mean follow-up was 3.4 years (sd 2.1; 2.0 to 10.1). At the last follow-up a total of 101 HRAs (3.6%) required revision. Using revision for all causes of failure as the endpoint, Kaplan–Meier survival analysis showed a cumulative survival of 96.4% (95% confidence interval (CI) 96.1 to 96.9) at five years. With regard to gender, the five-year overall survival was 97.4% in men (95% CI 97.1 to 97.7) and 93.6% in women (95% CI 92.6 to 94.6). Female gender, smaller femoral components, specific implant types and a diagnosis of childhood hip problems were associated with higher rates of failure. The most common cause of failure was fracture of the femoral neck, followed by loosening of the femoral component.

The failure rates of HRA at five years justify the ongoing use of this technique in men. Female gender is an independent predictor of failure, and a higher failure rate at five years in women leads the authors to recommend this technique only in exceptional circumstances for women.

Cite this article: Bone Joint J 2013;95-B:1044–50.

The April 2013 Research Roundup³⁶⁰ looks at: when the ‘residency cake’ is done; steroids, stem cells and tendons; what exactly is osteoarthritis; platelet-rich plasma; CRPS; d-Dimer for DVT; reducing bacterial adhesion; and fin or limb?

We describe the outcome of tibial diaphyseal fractures in the elderly (≥ 65 years of age). We prospectively followed 233 fractures in 225 elderly patients over a minimum ten-year period. Demographic and descriptive data were acquired from a prospective trauma database. Mortality status was obtained from the General Register Office database for Scotland. Diaphyseal fractures of the tibia in the elderly occurred predominantly in women (73%) and after a fall (61%). During the study period the incidence of these fractures decreased, nearly halving in number. The 120-day and one-year unadjusted mortality rates were 17% and 27%, respectively, and were significantly greater in patients with an open fracture (p < 0.001). The overall standardised mortality ratio (SMR) was significantly increased (SMR 4.4, p < 0.001) relative to the population at risk, and was greatest for elderly women (SMR 8.1, p < 0.001). These frailer patients had more severe injuries, with an increased rate of open fractures (30%), and suffered a greater rate of nonunion (10%).

Tibial diaphyseal fractures in the elderly are most common in women after a fall, are more likely to be open than in the rest of the population, and are associated with a high incidence of nonunion and mortality.

Cite this article: Bone Joint J 2013;95-B:1255–62.