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The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 5 | Pages 690 - 697
1 May 2012
Khan MA Hossain FS Dashti Z Muthukumar N

The aim of this study was to examine the rates and potential risk factors for 28-day re-admission following a fracture of the hip at a high-volume tertiary care hospital. We retrospectively reviewed 467 consecutive patients with a fracture of the hip treated in the course of one year. Causes and risk factors for unplanned 28-day re-admissions were examined using univariate and multivariate analysis, including the difference in one-year mortality. A total of 55 patients (11.8%) were re-admitted within 28 days of discharge. The most common causes were pneumonia in 15 patients (27.3%), dehydration and renal dysfunction in ten (18.2%) and deteriorating mobility in ten (18.2%). A moderate correlation was found between chest infection during the initial admission and subsequent re-admission with pneumonia (r = 0.44, p < 0.001). A significantly higher mortality rate at one year was seen in the re-admission group (41.8% (23 of 55) vs 18.7% (77 of 412), p < 0.001). Logistic regression analysis identified advancing age, admission source, and the comorbidities of diabetes and neurological disorders as the strongest predictors for re-admission. Early re-admission following hip fracture surgery is predominantly due to medical causes and is associated with higher one-year mortality. The risk factors for re-admission can have implications for performance-based pay initiatives in the NHS. Multidisciplinary management in reducing post-operative active clinical problems may reduce early re-admission.


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 8 | Pages 1064 - 1068
1 Aug 2009
Sankey RA Turner J Lee J Healy J Gibbons CER

An MR scan was performed on all patients who presented to our hospital with a clinical diagnosis of a fracture of the proximal femur, but who had no abnormality on plain radiographs. This was a prospective study of 102 consecutive patients over a ten-year period. There were 98 patients who fulfilled our inclusion criteria, of whom 75 were scanned within 48 hours of admission, with an overall mean time between admission and scanning of 2.4 days (0 to 10). A total of 81 patients (83%) had abnormalities detected on MRI; 23 (23%) required operative management.

The use of MRI led to the early diagnosis and treatment of occult hip pathology. We recommend that incomplete intertrochanteric fractures are managed non-operatively with protected weight-bearing. The study illustrates the high incidence of fractures which are not apparent on plain radiographs, and shows that MRI is useful when diagnosing other pathology such as malignancy, which may not be apparent on plain films.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 10 | Pages 1435 - 1441
1 Oct 2010
Bischel OE Böhm PM

Endoprosthetic reconstruction following resection of 31 tumours of the proximal femur in 30 patients was performed using a Wagner SL femoral revision stem. The mean follow-up was 25.6 months (0.6 to 130.0). Of the 28 patients with a metastasis, 27 died within a mean follow-up period of 18.1 months (0.6 to 56.3) after the operation, and the remaining patient was excluded from the study 44.4 months post-operatively when the stem was removed. The two patients with primary bone tumours were still alive at the latest follow-up of 81.0 and 130.0 months, respectively. One stem only was removed for suspected low-grade infection 44.4 months post-operatively. The worst-case survival rate with removal of the stem for any cause and/or loss to follow-up was 80.0% (95% confidence interval 44.9 to 100) at 130.0 months. The mean Karnofsky index increased from 44.2% (20% to 70%) pre-operatively to 59.7% (0% to 100%) post-operatively, and the mean Merle d’Aubigné score improved from 4.5 (0 to 15) to 12.0 (0 to 18). The mean post-operative Musculoskeletal Tumour Society score was 62.4% (3.3% to 100%).

The Wagner SL femoral revision stem offers an alternative to special tumour prostheses for the treatment of primary and secondary tumours of the proximal femur. The mid-term results are very promising, but long-term experience is necessary.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 5 | Pages 679 - 686
1 May 2010
Das De S Setiobudi T Shen L Das De S

There have been recent reports linking alendronate and a specific pattern of subtrochanteric insufficiency fracture. We performed a retrospective review of all subtrochanteric fractures admitted to our institution between 2001 and 2007. There were 20 patients who met the inclusion criteria, 12 of whom were on long-term alendronate. Alendronate-associated fractures tend to be bilateral (Fisher’s exact test, p = 0.018), have unique radiological features (p < 0.0005), be associated radiologically with a pre-existing ellipsoid thickening of the lateral femoral cortex and are likely to be preceded by prodromal pain. Biomechanical investigations did not suggest overt metabolic bone disease. Only one patient on alendronate had osteoporosis prior to the start of therapy. We used these findings to develop a management protocol to optimise fracture healing. We also advocate careful surveillance in individuals at-risk, and present our experience with screening and prophylactic fixation in selected patients.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 7 | Pages 949 - 950
1 Jul 2006
Lloyd JM Calder JDF

The Thompson hemiarthroplasty is a popular hip prosthesis. We present two case reports highlighting a significant alteration in the design of the implant which compromised the success of the operations.

In recent years the manufacturing process of this prosthesis has changed, with a resultant increase in the volume of the stem of 10 ml.

It is essential that manufacturers inform orthopaedic surgeons of any alteration in the design of the implant and supply compatible instrumentation to minimise surgical errors. Surgeons must remain vigilant when checking the compatibility of the trial and definitive prostheses.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 3 | Pages 418 - 418
1 Mar 2006
Tucker K


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 1 | Pages 112 - 114
1 Jan 2007
Giannoudis PV Tsiridis E

We report the management of an adult patient with septic sacroiliitis. This is an uncommon condition. Debridement, decompression and spontaneous fusion are the treatment of choice when symptoms do not resolve with routine initial intravenous antibiotic therapy. A percutaneous technique is described, using the principles of sacroiliac screw insertion commonly used for pelvic reconstruction surgery. After successful evacuation of the infected joint, fusion was observed in our patient.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 1 | Pages 110 - 115
1 Jan 2010
Bosma E de Jongh MAC Verhofstad MHJ

This retrospective cohort study was conducted to investigate whether operative treatment of patients with a pertrochanteric femoral fracture outside working hours is associated with an increased risk of complications and higher mortality. During the study period 165 patients were operated on outside working hours and 123 were operated on during working hours (08.00 to 17.00). There was no difference in the rate of early complications (outside working hours 33% versus working hours 33%, p = 0.91) or total complications during follow-up (outside working hours 40% versus working hours 41%, p = 0.91). Both in-hospital mortality (outside working hours 12% versus working hours 11%, p = 0.97) and mortality after one year (outside working hours 29% versus working hours 27%, p = 0.67) were comparable. Adjustment for possible confounders by multivariate logistic regression analysis revealed no increased risk of complications when patients were operated on outside working hours.

On the basis of these data, there is no medical reason to postpone operative reduction and fixation in patients with a proximal femoral fracture until working hours.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 3 | Pages 392 - 393
1 Mar 2006
Kejariwal D

Heparin is a drug widely used for thromboprophylaxis or treatment in many clinical situations. However, it can cause serious adverse effects, including thrombocytopenia, which is a potentially life-threatening condition. Unfortunately, heparin-induced thrombocytopenia is generally under-recognised and under-diagnosed. A case of heparin-induced thrombocytopenia occurring in a post-operative orthopaedic patient in association with prophylactic low-molecular-weight heparin is described.


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 1 | Pages 131 - 137
1 Jan 2009
Boraiah S Dyke JP Hettrich C Parker RJ Miller A Helfet D Lorich D

In spite of extensive accounts describing the blood supply to the femoral head, the prediction of avascular necrosis is elusive. Current opinion emphasises the contributions of the superior retinacular artery but may not explain the clinical outcome in many situations, including intramedullary nailing of the femur and resurfacing of the hip. We considered that significant additional contribution to the vascularity of the femoral head may exist. A total of 14 fresh-frozen hips were dissected and the medial circumflex femoral artery was cannulated in the femoral triangle. On the test side, this vessel was ligated, with the femoral head receiving its blood supply from the inferior vincular artery alone. Gadolinium contrast-enhanced MRI was then performed simultaneously on both control and test specimens. Polyurethane was injected, and gross dissection of the specimens was performed to confirm the extraosseous anatomy and the injection of contrast. The inferior vincular artery was found in every specimen and had a significant contribution to the vascularity of the femoral head. The head was divided into four quadrants: medial (0), superior (1), lateral (2) and inferior (3). In our study specimens the inferior vincular artery contributed a mean of 56% (25% to 90%) of blood flow in quadrant 0, 34% (14% to 80%) of quadrant 1, 37% (18% to 48%) of quadrant 2 and 68% (20% to 98%) in quadrant 3. Extensive intra-osseous anastomoses existed between the superior retinacular arteries, the inferior vincular artery and the subfoveal plexus.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 9 | Pages 1253 - 1255
1 Sep 2005
Alam A Willett K Ostlere S

Incomplete intertrochanteric fractures do not extend across to the medial femoral cortex and are stable, without rotational deformity or shortening of the lower limb. The aim of our study was to establish whether they can be successfully managed conservatively. A total of 68 patients over a five-year period presented with a suspected fracture of the femoral neck and underwent an MRI scan for further assessment. From these, we retrospectively reviewed eight patients with normal plain radiographs but with an incomplete, intertrochanteric fracture on MRI scan. Five were managed conservatively and three operatively.

The mean length of hospital stay was 16 days for the conservatively-treated group and 15 days for those who underwent surgery; this was not statistically significant (p > 0.5) and all patients were mobilised on discharge. Although five patients were readmitted at a mean of 3.2 years after discharge, none had progressed to a complete fracture. We believe that patients with incomplete intertrochanteric fractures should be considered for conservative treatment.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 12 | Pages 1669 - 1674
1 Dec 2005
Mullins MM Sood M Hashemi-Nejad A Catterall A

Avascular necrosis is a serious complication of slipped capital femoral epiphysis and is difficult to treat. The reported incidence varies from 3% to 47% of patients. The aims of treatment are to maintain the range of movement of the hip and to prevent collapse of the femoral head. At present there are no clear guidelines for the management of this condition and treatment can be difficult and unrewarding.

We have used examination under anaesthesia and dynamic arthrography to investigate avascular necrosis and to determine the appropriate method of treatment. We present 20 consecutive cases of avascular necrosis in patients presenting with slipped capital femoral epiphysis and describe the results of treatment with a mean follow-up of over eight years (71 to 121 months). In patients who were suitable for joint preservation (14), we report a ten-year survivorship of the hip joint of 75% and a mean Harris hip score of 82 (44 to 98).


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 9 | Pages 1216 - 1219
1 Sep 2005
Hogan N Azhar A Brady O

We have evaluated the effect of vacuum aspiration of the iliac wing on the osseointegration of cement into the acetabulum. We entered a total of 40 patients undergoing primary total hip arthroplasty into two consecutive study groups. Group 1 underwent acetabular cement pressurisation for 60 seconds before insertion of the acetabular component. Group 2 had the same pressurisation with simultaneous vacuum suction of the ilium using an iliac-wing aspirator. Standard post-operative radiographs were reviewed blindly to assess the penetration of cement into the iliac wing. Penetration was significantly greater in the group with aspiration of the iliac wing.


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 11 | Pages 1488 - 1494
1 Nov 2007
Gorodetskyi IG Gorodnichenko AI Tursin PS Reshetnyak VK Uskov ON

We undertook a trial on 60 patients with AO 31A2 fractures of the hip who were randomised after stabilisation of the fracture into two equal groups, one of which received post-operative treatment using a non-invasive interactive neurostimulation device and the other with a sham device. All other aspects of their rehabilitation were the same. The treatment was continued for ten days after operation.

Outcome measurements included the use of a visual analogue scale for pain, the brief pain inventory and Ketorolac for post-operative control of pain, and an overall assessment of outcome by the surgeon. There were significantly better results for the patients receiving treatment by active electrical stimulation (repeated measures analysis of variance, p < 0.001). The findings of this pilot trial justify a larger study to determine if these results are more generally applicable.


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 3 | Pages 294 - 303
1 Mar 2009
Lindner T Kanakaris NK Marx B Cockbain A Kontakis G Giannoudis PV

Failure of fixation is a common problem in the treatment of osteoporotic fractures around the hip. The reinforcement of bone stock or of fixation of the implant may be a solution. Our study assesses the existing evidence for the use of bone substitutes in the management of these fractures in osteoporotic patients. Relevant publications were retrieved through Medline research and further scrutinised. Of 411 studies identified, 22 met the inclusion criteria, comprising 12 experimental and ten clinical reports. The clinical studies were evaluated with regard to their level of evidence. Only four were prospective and randomised.

Polymethylmethacrylate and calcium-phosphate cements increased the primary stability of the implant-bone construct in all experimental and clinical studies, although there was considerable variation in the design of the studies. In randomised, controlled studies, augmentation of intracapsular fractures of the neck of the femur with calcium-phosphate cement was associated with poor long-term results. There was a lack of data on the long-term outcome for trochanteric fractures. Because there were only a few, randomised, controlled studies, there is currently poor evidence for the use of bone cement in the treatment of fractures of the hip.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 8 | Pages 1123 - 1126
1 Aug 2005
Siegmeth AW Gurusamy K Parker MJ

Previous studies on the timing of surgery for fracture of the hip provide conflicting evidence as to the effect of prolonged delay before operation. We have prospectively reviewed 3628 such fractures in patients older than 60 years of age. Those for whom the delay was for medical reasons were excluded. Patients were followed up for one year or until death. Operation was undertaken within 48 hours in 95.2% and after this in 4.8%. A significant increase in length of stay was found in patients operated on after 48 hours when compared with those in the earlier group (21.6 vs 32.5 days). No increase in hospital stay was found for lesser delays.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 8 | Pages 1065 - 1070
1 Aug 2006
Appleton P Moran M Houshian S Robinson CM

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile.

Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low.

A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 9 | Pages 1210 - 1217
1 Sep 2007
Peyser A Weil YA Brocke L Sela Y Mosheiff R Mattan Y Manor O Liebergall M

Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function. The percutaneous compression plate (PCCP) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure. It has several potential mechanical advantages over the conventional compression hip screw (CHS). Our aim in this prospective, randomised, controlled study was to compare the outcome of patients operated on using these two devices.

We randomised 104 patients with intertrochanteric fractures (AO/OTA 31.A1–A2) to surgical treatment with either the PCCP or CHS and followed them for one year postoperatively.

The mean operating blood loss was 161.0 ml (8 to 450) in the PCCP group and 374.0 ml (11 to 980) in the CHS group (Student’s t-test, p < 0.0001). The pain score and ability to bear weight were significantly better in the PCCP group at six weeks post-operatively. Analysis of the radiographs in a proportion of the patients revealed a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients, 18.9%); Fisher’s exact test, p < 0.02.

The PCCP device was associated with reduced intra-operative blood loss, less postoperative pain and a reduced incidence of collapse of the fracture.