Aims. The aim of this investigation was to compare risk of infection in both cemented and uncemented hemiarthroplasty (HA) as well as in total hip arthroplasty (THA) following femoral neck fracture. Methods. Data collection was performed using the German Arthroplasty Registry (EPRD). In HA and THA following femoral neck fracture, fixation method was divided into cemented and uncemented prostheses and paired according to age, sex, BMI, and the Elixhauser Comorbidity Index using Mahalanobis distance matching. Results. Overall in 13,612 cases of intracapsular femoral neck fracture, 9,110 (66.9%) HAs and 4,502 (33.1%) THAs were analyzed. Infection rate in HA was significantly reduced in cases with use of antibiotic-loaded cement compared with uncemented fixated prosthesis (p = 0.013). In patients with THA no statistical difference between cemented and uncemented prosthesis was registered, however after one year 2.4% of infections were detected in uncemented and 2.1% in cemented THA. In the subpopulation of HA after one year, 1.9% of infections were registered in cemented and 2.8% in uncemented HA. BMI (p = 0.001) and Elixhauser Comorbidity Index (p < 0.003) were identified as risk factors of periprosthetic joint infection (PJI), while in THA cemented prosthesis also demonstrated an increased risk within the first 30 days (hazard ratio (HR) = 2.73; p = 0.010). Conclusion. The rate of infection after intracapsular femoral neck fracture was statistically significantly reduced in patients treated by antibiotic-loaded cemented HA. Particularly for patients with multiple risk factors for the development of a PJI, the usage of antibiotic-loaded bone cement seems to be a reasonable procedure for prevention of infection. Cite this article: Bone Joint Res 2023;12(5):331–338

Aims. Evaluate if treating an unstable femoral neck fracture with a locking plate and spring-loaded telescoping screw system would improve construct stability compared to gold standard treatment methods. Methods. A 31B2 Pauwels’ type III osteotomy with additional posterior wedge was cut into 30 fresh-frozen femur cadavers implanted with either: three cannulated screws in an inverted triangle configuration (CS), a sliding hip screw and anti-rotation screw (SHS), or a locking plate system with spring-loaded telescoping screws (LP). Dynamic cyclic compressive testing representative of walking with increasing weight-bearing was applied until failure was observed. Loss of fracture reduction was recorded using a high-resolution optical motion tracking system. Results. LP constructs demonstrated the highest mean values for initial stiffness and failure load. LP and SHS constructs survived on mean over 50% more cycles and to loads 450 N higher than CS. During the early stages of cyclic loading, mean varus collapse of the femoral head was 0.5° (SD 0.8°) for LP, 0.7° (SD 0.7°) for SHS, and 1.9° (SD 2.3°) for CS (p = 0.071). At 30,000 cycles (1,050 N) mean femoral neck shortening was 1.8 mm (SD 1.9) for LP, 2.0 mm (SD 0.9) for SHS, and 3.2 mm (SD 2.5) for CS (p = 0.262). Mean leg shortening at construct failure was 4.9 mm (SD 2.7) for LP, 8.9 mm (SD 3.2) for SHS, and 7.0 mm (SD 4.3) for CS (p = 0.046). Conclusion. Use of the LP system provided similar (hip screw) or better (cannulated screws) biomechanical performance as the current gold standard methods suggesting that the LP system could be a promising alternative for the treatment of unstable fractures of the femoral neck. Cite this article: Bone Joint Res 2020;9(6):314–321

Aims. In this study, we aimed to explore surgical variations in the Femoral Neck System (FNS) used for stable fixation of Pauwels type III femoral neck fractures. Methods. Finite element models were established with surgical variations in the distance between the implant tip and subchondral bone, the gap between the plate and lateral femoral cortex, and inferior implant positioning. The models were subjected to physiological load. Results. Under a load of single-leg stance, Pauwels type III femoral neck fractures fixed with 10 mm shorter bolts revealed a 7% increase of the interfragmentary gap. The interfragmentary sliding, compressive, and shear stress remained similar to models with bolt tips positioned close to the subchondral bone. Inferior positioning of FNS provided a similar interfragmentary distance, but with 6% increase of the interfragmentary sliding distance compared to central positioning of bolts. Inferior positioning resulted in a one-third increase in interfragmentary compressive and shear stress. A 5 mm gap placed between the diaphysis and plate provided stability comparable to standard fixation, with a 7% decrease of interfragmentary gap and sliding distance, but similar compressive and shear stress. Conclusion. Finite element analysis with FNS on Pauwels type III femoral neck fractures revealed that placement of the bolt tip close to subchondral bone provides increased stability. Inferior positioning of FNS bolt increased interfragmentary sliding distance, compressive, and shear stress. The comparable stability of the fixation model with the standard model suggests that a 5 mm gap placed between the plate and diaphysis could viably adjust the depth of the bolt. Cite this article: Bone Joint Res 2022;11(2):102–111

The Femoral Neck System (FNS) was introduced as an alternative device for the fixation of neck of femur fractures (NOFFs). The purported advantages include superior angular and rotatory stability compared to multiple cancellous screws, via a minimally invasive instrumentation that is simpler than conventional fixed angle devices. There were limited clinical studies regarding the utility of this device. We aimed to study the outcomes of NOFFs fixed with the FNS. This was a single-institution, retrospective review of all undisplaced elderly (≥60 years old) undisplaced young, and displaced young NOFFs fixed with the FNS. Demographics, surgical parameters, radiographic parameters, and clinical outcomes including complications were reviewed. Thirty-six subjects with a median age of 75 [44,89] years old, had NOFF fixation using the FNS. Thirty-one (86.1%) had undisplaced fractures. There were 6 (16.7%), 26 (72.2%), and 4 (11.1%) subjects with Pauwels types 1, 2, and 3 respectively. Thirty-two (88.9%) had posterior tilt of <20º. The mean duration of surgery was 71±18 minutes. Excluding 4 patients whom required revision surgery, 2 patients whom demised, and 10 patients whom defaulted reviews, the mean follow-up duration was 55±13 weeks. Four complications were recorded, namely implant cut out at the femoral head at week 8, breaking of the locking screw at the run-off region at week 22, avascular necrosis at week 25, and a refracture following near fall, causing the fracture to fail in varus at week 7 postoperation. While reasonably fast to instrument, failures still occur and it is likely multifactorial. However, the rate of reoperation is lower than what has been reported for NOFFs fixed with the a fixed-angle device or 3 cancellous screws. In conclusion, the FNS is a reasonably safe instrument to use. Surgeons’ discretion is still needed in patient selection, keeping in mind the need for satisfactory radiological parameters

Aims. Traditionally, total hip arthroplasty (THA) templating has been performed on anteroposterior (AP) pelvis radiographs. Recently, additional AP hip radiographs have been recommended for accurate measurement of the femoral offset (FO). To verify this claim, this study aimed to establish quantitative data of the measurement error of the FO in relation to leg position and X-ray source position using a newly developed geometric model and clinical data. Methods. We analyzed the FOs measured on AP hip and pelvis radiographs in a prospective consecutive series of 55 patients undergoing unilateral primary THA for hip osteoarthritis. To determine sample size, a power analysis was performed. Patients’ position and X-ray beam setting followed a standardized protocol to achieve reproducible projections. All images were calibrated with the KingMark calibration system. In addition, a geometric model was created to evaluate both the effects of leg position (rotation and abduction/adduction) and the effects of X-ray source position on FO measurement. Results. The mean FOs measured on AP hip and pelvis radiographs were 38.0 mm (SD 6.4) and 36.6 mm (SD 6.3) (p < 0.001), respectively. Radiological view had a smaller effect on FO measurement than inaccurate leg positioning. The model showed a non-linear relationship between projected FO and femoral neck orientation; at 30° external neck rotation (with reference to the detector plane), a true FO of 40 mm was underestimated by up to 20% (7.8 mm). With a neutral to mild external neck rotation (≤ 15°), the underestimation was less than 7% (2.7 mm). The effect of abduction and adduction was negligible. Conclusion. For routine THA templating, an AP pelvis radiograph remains the gold standard. Only patients with femoral neck malrotation > 15° on the AP pelvis view, e.g. due to external rotation contracture, should receive further imaging. Options include an additional AP hip view with elevation of the entire affected hip to align the femoral neck more parallel to the detector, or a CT scan in more severe cases. Cite this article: Bone Jt Open 2022;3(10):795–803

Osteonecrosis of the femoral head after femoral neck fracture (ONFHpoFNFx) poses challenges in children, particularly at Ficat III stage. Limited effective treatments are available. This study explores basicervical femoral neck rotational osteotomy (BFNRO) for ONFHpoFNFx in children and adolescents and evaluates its outcomes. Children and adolescents with ONFHpoFNFx (Ficat stage III) underwent BFNRO at our center from June 2017 to September 2022 were included. Follow-up exceeded 1 year, with data on modified-Harris-hip-score (mHHS), range of motion (ROM), patient satisfaction, femoral head collapse, necrotic area repair, leg-length, and osteoarthritis progression recorded. This study included 15 cases (15 hips), with 8 males and 7 females, averaging 12.9 years in age (range: 10–17 years). Nine cases had BFNRO alone, and six had combined PAO. Rotation angles varied from 70° to 90° for anterior rotation and 110° to 135° for posterior rotation. Nine patients had femoral neck fixation in a varus position (10° to 30°). The postoperative contour of the weight-bearing area of the femoral head has significantly improved in all patients. With an average follow-up of 28.6 months (range: 12.2–72.7 months), mHHS significantly improved (65.2 to 90.2, P<0.001). Only one patient showed femoral head collapse. Patients experienced no/mild hip pain (VAS=0-3), slight restriction in range of motion, and mild limb shortening. Two patients showed osteoarthritis progression. No infections, joint replacements, or nerve injuries were observed. Even in cases of ONFHpoFNFx in the late stage, BFNRO in children and adolescents can still yield positive early to mid-term results by relocating the necrotic area and restoring the integrity of the anterior-lateral column of the femoral head, thereby preventing femoral head collapse and delaying the onset of severe osteoarthritis

Femoral neck fractures account for half of all hip fractures and are recognized as a major public health problem associated with a high socioeconomic burden. Whilst internal fixation is preferred over arthroplasty for physiologically younger patients, no consensus exists about the optimal fixation device yet. The recently introduced implant Femoral Neck System (FNS) (DePuy Synthes, Zuchwil, Switzerland) was developed for dynamic fixation of femoral neck fractures and provides angular stability in combination with a minimally invasive surgical technique. Alternatively, the Hansson Pin System (HPS) (Swemac, Linköping, Sweden) exploits the advantages of internal buttressing. However, the obligate peripheral placement of the pins, adjacent to either the inferior or posterior cortex, renders the instrumentation more challenging. The aim of this study was to evaluate the biomechanical performance of FNS versus HPS in a Pauwels II femoral neck fracture model with simulated posterior comminution. Forty-degree Pauwels II femoral neck fractures AO 31-B2.1 with 15° posterior wedge were simulated in fourteen paired fresh-frozen human cadaveric femora, followed by instrumentation with either FNS or HPS in pair-matched fashion. Implant positioning was quantified by measuring the shortest distances between implant and inferior cortex (DI) as well as posterior cortex (DP) on anteroposterior and axial X-rays, respectively. Biomechanical testing was performed in 20° adduction and 10° flexion of the specimens in a novel setup with simulated iliopsoas muscle tension. Progressively increasing cyclic loading was applied until construct failure. Interfragmentary femoral head-to-shaft movements, namely varus deformation, dorsal tilting and rotation around the neck axis were measured by means of motion tracking and compared between the two implants. In addition, varus deformation and dorsal tilting were correlated with DI and DP. Cycles to 5/10° varus deformation were significantly higher for FNS (22490±5729/23007±5496) versus HPS (16351±4469/17289±4686), P=0.043. Cycles to 5/10° femoral head dorsal tilting (FNS: 10968±3052/12765±3425; HPS: 12244±5895/13357±6104) and cycles to 5/10° rotation around the femoral neck axis (FNS: 15727±7737/24453±5073; HPS: 15682±10414/20185±11065) were comparable between the implants, P≥0.314. For HPS, the outcomes for varus deformation and dorsal tilting correlated significantly with DI and DP, respectively (P=0.025), whereas these correlations were not significant for FNS (P≥0.148). From a biomechanical perspective, by providing superior resistance against varus deformation and performing in a less sensitive way to variations in implant placement, the angular stable Femoral Neck System can be considered as a valid alternative to the Hansson Pin System for the treatment of Pauwels II femoral neck fractures

Aims. Accumulated evidence indicates that local cell origins may ingrain differences in the phenotypic activity of human osteoblasts. We hypothesized that these differences may also exist in osteoblasts harvested from the same bone type at periarticular sites, including those adjacent to the fixation sites for total joint implant components. Methods. Human osteoblasts were obtained from the acetabulum and femoral neck of seven patients undergoing total hip arthroplasty (THA) and from the femoral and tibial cuts of six patients undergoing total knee arthroplasty (TKA). Osteoblasts were extracted from the usually discarded bone via enzyme digestion, characterized by flow cytometry, and cultured to passage three before measurement of metabolic activity, collagen production, alkaline phosphatase (ALP) expression, and mineralization. Results. Osteoblasts from the acetabulum showed lower proliferation (p = 0.034), cumulative collagen release (p < 0.001), and ALP expression (p = 0.009), and produced less mineral (p = 0.006) than those from the femoral neck. Osteoblasts from the tibia produced significantly less collagen (p = 0.021) and showed lower ALP expression than those from the distal femur. Conclusion. We have demonstrated for the first time an anatomical regional variation in the biological behaviours of osteoblasts on either side of the hip and knee joint. The lower osteoblast proliferation, matrix production, and mineralization from the acetabulum compared to those from the proximal femur may be reflected in differences in bone formation and implant fixation at these sites. Cite this article: Bone Joint Res 2021;10(9):611–618

Aims. The aim of this study was to determine the association between knee alignment and the vertical orientation of the femoral neck in relation to the floor. This could be clinically important because changes of femoral neck orientation might alter chondral joint contact zones and joint reaction forces, potentially inducing problems like pain in pre-existing chondral degeneration. Further, the femoral neck orientation influences the ischiofemoral space and a small ischiofemoral distance can lead to impingement. We hypothesized that a valgus knee alignment is associated with a more vertical orientation of the femoral neck in standing position, compared to a varus knee. We further hypothesized that realignment surgery around the knee alters the vertical orientation of the femoral neck. Methods. Long-leg standing radiographs of patients undergoing realignment surgery around the knee were used. The hip-knee-ankle angle (HKA) and the vertical orientation of the femoral neck in relation to the floor were measured, prior to surgery and after osteotomy-site-union. Linear regression was performed to determine the influence of knee alignment on the vertical orientation of the femoral neck. Results. The cohort included 147 patients who underwent knee realignment-surgery. The mean age was 51.5 years (SD 11). Overall, 106 patients underwent a valgisation-osteotomy, while 41 underwent varisation osteotomy. There was a significant association between the orientation of the knee and the coronal neck-orientation. In the varus group, the median orientation of the femoral neck was 46.5° (interquartile range (IQR) 49.7° to 50.0°), while in the valgus group, the orientation was 52.0° (IQR 46.5° to 56.7°; p < 0.001). Linear regression analysis revealed that HKA demonstrated a direct influence on the coronal neck-orientation (β = 0.5 (95% confidence interval (CI) 0.2 to 0.7); p = 0.002). Linear regression also showed that realignment surgery was associated with a significant influence on the change in the coronal femoral neck orientation (β = 5.6 (95% CI 1.5 to 9.8); p = 0.008). Conclusion. Varus or valgus knee alignment is associated with either a more horizontal or a more vertical femoral neck orientation in standing position, respectively. Subsequently, osteotomies around the knee alter the vertical orientation of the femoral neck. These aspects are of importance when planning osteotomies around the knee in order to appreciate the effects on the adjacent hip joint. The concept may be of even more relevance in dysplastic hips. Cite this article: Bone Jt Open 2021;2(12):1057–1061

Aims. Surgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck. Methods. A Hueter approach and capsulotomy were performed bilaterally in six cadaveric hips. In the experimental group, a one-third tubular plate was secured to the inferomedial femoral neck at 6:00 on the clockface. The contralateral hip served as a control with surgical approach and capsulotomy without fixation. Pre- and post-contrast MRI was then performed to quantify signal intensity in the femoral head and neck. Qualitative assessment of the terminal arterial branches to the femoral head, specifically the inferior retinacular artery (IRA), was also performed. Results. Quantitative MRI revealed a mean reduction of 1.8% (SD 3.1%) of arterial contribution in the femoral head and a mean reduction of 7.1% (SD 10.6%) in the femoral neck in the plating group compared to non-plated controls. Based on femoral head quadrant analysis, the largest mean decrease in arterial contribution was in the inferomedial quadrant (4.0%, SD 6.6%). No significant differences were found between control and experimental hips for any femoral neck or femoral head regions. The inferior retinaculum of Weitbrecht (containing the IRA) was directly visualized in six of 12 specimens. Qualitative MRI assessment confirmed IRA integrity in all specimens. Conclusion. Calcar femoral neck plating at the 6:00 position on the clockface resulted in minimal decrease in femoral head and neck vascularity, and therefore it may be considered as an adjunct to laterally-based fixation for reduction and fixation of femoral neck fractures, especially in younger patients. Cite this article: Bone Jt Open 2021;2(8):611–617

Three Cannulated Screws (3CS), Dynamic Hip Screw (DHS) with antirotation screw (DHS–Screw) or with a Blade (DHS–Blade) are the gold standards for fixation of unstable femoral neck fractures. Compared to 3CS, both DHS systems require larger skin incision with more extensive soft tissue dissection while providing the benefit of superior stability. The newly designed Femoral Neck System (FNS) for dynamic fixation combines the advantages of angular stability with a less invasive surgical technique. The aim of this study is to evaluate the biomechanical performance of FNS in comparison to established methods for fixation of the femoral neck in a human cadaveric model. Twenty pairs of fresh–frozen human cadaveric femora were instrumented with either DHS–Screw, DHS–Blade, 3CS or FNS. A reduced unstable femoral neck fracture 70° Pauwels III, AO/OTA31–B2.3 was simulated with 30° distal and 15° posterior wedges. Cyclic axial loading was applied in 16° adduction, starting at 500N and with progressive peak force increase of 0.1N/cycle until construct failure. Relative interfragmentary movements were evaluated with motion tracking. Highest axial stiffness was observed for FNS (748.9 ± 66.8 N/mm), followed by DHS–Screw (688.8 ± 44.2 N/mm), DHS–Blade (629.1 ± 31.4 N/mm) and 3CS (584.1 ± 47.2 N/mm) with no statistical significances between the implant constructs. Cycles until 15 mm leg shortening were comparable for DHS–Screw (20542 ± 2488), DHS–Blade (19161 ± 1264) and FNS (17372 ± 947), and significantly higher than 3CS (7293 ± 850), p<0.001. Similarly, cycles until 15 mm femoral neck shortening were comparable between DHS–Screw (20846 ± 2446), DHS–Blade (18974 ± 1344) and FNS (18171 ± 818), and significantly higher than 3CS (8039 ± 838), p<0.001. From a biomechanical point of view, the Femoral Neck System is a valid alternative to treat unstable femoral neck fractures, representing the advantages of a minimal invasive angle–stable implant for dynamic fixation with comparable stability to the two DHS systems with blade or screw, and superior to Three Cannulated Screws

Abstract. INTRODUCTION. Fracture neck of femur is aptly called as “the fracture of necessity” owing to the various factors responsible for its non-union. Pauwel's inter-trochantric valgus osteotomy is a useful approach to deal with such fractures. AIM. The aim of this study is to evaluate the functional outcome of valgus osteotomy in treatment of neglected and non-union fracture neck of femur using Harris Hip Scoring system (HHS). MATERIAL AND METHODS. This observational study included 25 patients of the age between 25 years and 50 years with more than 3 weeks since injury and the patients with failed primary fixation. Valgus osteotomy using120° double angled blade plate was done. The patients were followed up till one year. The patients' functional outcome was evaluated with pre-operative and post-operative Harris Hip Score (HHS) at 6 months and one year. RESULTS. Outcome was excellent in 14 patients (HHS>90), good in 8 patients (HHS between 80–90) and fair in one patient (HHS=75.6). Two patients ended up in non-union with blade cut out. The mean HHS at the end of one year was 89.18 + 7.822. The mean change in HHS values pre-operatively and one year post-operatively came out to be 69.58 + 20.032. CONCLUSION. We conclude that for the patients under 50 years of age with neglected fracture of the femoral neck, the Pauwel's osteotomy produces many good results

The current evidence favors replacement for the treatment of displaced femoral neck fractures in the older patients. Controversies remain whether total hip replacement (THR), or hemiarthroplasty (HA) would result in better outcomes. The purpose of this study is to compare the outcomes, and the complications in patients who underwent THR or HA for displaced femoral neck fractures. There were 345 consecutive patients who had undergone either a THR or HA at a single institution. THR was done in 137, and HA was done in 208 patients, respectively. Standard peri-operative data were collected. The mean values for the data in the THR group are: age 69 years, ASA 2.7, OR time was 99 minutes, estimated blood loss 354 ml, and the length of stay 8 days. The mean values for the data in the HA group are: age 75 years, ASA 3.0, OR time 88 minutes, estimated blood loss 200 ml, and the length of stay 10 days. The overall complications were 8.8% (THR), and 9.1% (HA), respectively. The mortality rates for the patients were: at the 1-year (9.5% THR vs 16.3% HA), at the 3-year (15.3% THR vs 24.0% HA), and at the 5-year (19.7% THR vs 26.9% HA), respectively. Our data demonstrated similar peri-operative data and short-term complications between the two groups. There was a difference in the mortality rates between the two groups at all 3-time intervals following the surgery. This could be a reflection of the patient selection bias for each of the operations

The covid-19 pandemic had a great impact in the daily clinical and surgical practice. Concerning patients with a femoral neck fracture, there is the need of a negative Sars-CoV-2 test or an established isolation period for the positive cases, pre-operatively. The goal of this study was to evaluate the impact of the pandemic in the management of patients with femoral neck fractures, who were submitted to surgical treatment with hemiarthroplasty, in our hospital. A retrospective, observational study was performed, analysing the patients with femoral neck fractures submitted to hip hemiarthroplasty, during the years 2019 (before the pandemic) and 2020 (first year of the pandemic). We analysed the first 5 patients operated in each month of the mentioned years. We analysed 56 and 60 patients submitted to surgery in the years 2019 and 2020, respectively. The inpatient days were, in average, 14.1 and 13.1. Patients were operated, in average, 3.0 and 3.8 days after admission (corrected to 2.5 and 3.6 days if the time of discontinuation of anticoagulants or antiplatelets needed before surgery is deducted). There were peri-operative complications in 53.6% and 46.7% of the patients, in 2019 and 2020 respectively. The most common complication in both groups was a low postoperative haemoglobin level needing red blood cell transfusion. One-year postoperative mortality rate was 17.9% and 13.3%, respectively. Despite the changes triggered by the new pandemic, there was an overall maintenance of the quality of the management of these patients, with only a slight increase in the interval between admission and surgery. Some of the remaining variables even showed an improvement when comparing the two groups of patients. Nevertheless, it is important to mention that there were patients infected with Covid-19 who died before being submitted to surgery, therefore not being present in these statistics

Introduction. Neck of femur (NoF) fractures have an inherent 6.5% 30-day mortality as per National hip fracture database(2019). Several studies have demonstrated a higher mortality rate in covid positive NoFs but have been unable to demonstrate whether there are risk factors that contribute to the risk of mortality in this patient group or whether COVID is solely responsible for the higher mortality. Aims. To assess risk factors that are concurrently present in a fracture NoF cohort that may contribute to higher mortality in COVID positive patients. Methods. A cross sectional, retrospective study was performed for a period of 1 year starting from 1st March 2020. All surgically treated neck of femur fracture patients having an isolated intra/extracapsular fracture were included in the study. Data fields recorded- patient demographics, date and time of admission, ward discharge, surgery, mode of surgery (fixation/arthroplasty), prehospital AMTS score, residential status and mobility, ASA grade as per anaesthetist's records, date of death (if deceased), cause of death (as per death certificate/ postmortem / coroner's report). Analysis of mortality was carried out by creating a matched comparison group for each risk factor as well as some combinations. Results. 344 patients were surgically treated for a neck of femur fracture in our DGH during the period of 1st March 2020 to 28th February 2021. 46 patients did not receive a COVID swab (reasons unknown) and were excluded from the study. 35 patients had a COVID-19 RT PCR positive test during their hospital stay and 264 patients remained negative. There were 12 deaths in COVID positive patients (34%) and 53 deaths in COVID negative patients (20%) within the time frame of the study. For each risk factor matched group COVID was seen to confer higher mortality in general. There was no mortality in ASA 1 or 2 patients. Mortality rates in matched groups for age and ASA revealed 23.8% mortality in COVID positive as opposed to 17.3% in COVID negative for ASA 3 and 33.3% mortality in COVID positive vs. 28% in ASA 4. 11 out of the 12 COVID positive patients who died had an AMTS score >6. No correlation was seen between COVID positive deaths and preinjury residential status, type of fracture or surgery offered, or preinjury mobility. The average length of hospital stay was much higher for COVID positive patients (19.5days) as compared to 9.5 days for COVID negative patients. Conclusion. Matched group analysis show that there is a 37.5% increase in COVID positive neck of femur fracture mortality in ASA 3 patients, the same number falls to 17.8% for ASA 4 patients. These figures are much lower compared to other studies in the UK. There is a need to understand the real cause of death in this subset and to improve death certification so that we can differentiate between patients whose mortality is ‘due to’ or ‘With’ COVID

Aims. The localization of necrotic areas has been reported to impact the prognosis and treatment strategy for osteonecrosis of the femoral head (ONFH). Anteroposterior localization of the necrotic area after a femoral neck fracture (FNF) has not been properly investigated. We hypothesize that the change of the weight loading direction on the femoral head due to residual posterior tilt caused by malunited FNF may affect the location of ONFH. We investigate the relationship between the posterior tilt angle (PTA) and anteroposterior localization of osteonecrosis using lateral hip radiographs. Methods. Patients aged younger than 55 years diagnosed with ONFH after FNF were retrospectively reviewed. Overall, 65 hips (38 males and 27 females; mean age 32.6 years (SD 12.2)) met the inclusion criteria. Patients with stage 1 or 4 ONFH, as per the Association Research Circulation Osseous classification, were excluded. The ratios of anterior and posterior viable areas and necrotic areas of the femoral head to the articular surface were calculated by setting the femoral head centre as the reference point. The PTA was measured using Palm’s method. The association between the PTA and viable or necrotic areas of the femoral head was assessed using Spearman’s rank correlation analysis (median PTA 6.0° (interquartile range 3 to 11.5)). Results. We identified a negative correlation between PTA and anterior viable areas (rho −0.477; p = 0.001), and no correlation between PTA and necrotic (rho 0.229; p = 0.067) or posterior viable areas (rho 0.204; p = 0.132). Conclusion. Our results suggest that residual posterior tilt after FNF could affect the anteroposterior localization of necrosis. Cite this article: Bone Jt Open 2024;5(5):394–400

C. Difficile infections in elderly patients with hip fractures is associated with high morbidity and mortality. Antibiotic regimens with penicillin and its derivatives is a leading cause. Antibiotic prophylactic preferences vary across different hospitals within NHS. We compared two antibiotic prophylactic regimens - Cefuroxime only prophylaxis and Teicoplanin with Gentamicin prophylaxis in fracture neck of femur surgery, and evaluated the incidence of C. Difficile diarrhea and Surgical Site Infection (SSI). To assess the Surgical Site Infection and C. Difficile infection rate associated with different regimens of antibiotics prophylaxis in fracture neck of femur surgery. Data was analyzed retrospectively. Neck of femur fracture patients treated surgically from 2009 in our unit were included. Age, gender, co morbidities, type of fracture, operation, ASA grade was collected. 1242 patients received Cefuroxime only prophylaxis between January 2009 and December 2012 (Group 1) and 486 patients received Teicoplanin with Gentamicin between October 2015 and March 2017 (Group 2). There were 353 males and 889 female patients in Group 1 and 138 males and 348 female patients in Group 2. The co morbidities in both groups were comparable. Incidence of C. Difficile diarrhea and Surgical Site Infection (SSI) was noted. Statistical analysis with chi square test was performed to determine the ‘p’ value. C. Diff diarrhea rate in Group 2 was 0.41 % as compared to 1.29 % in Group 1. The Surgical Site Infection (SSI) rate in Group 2 was 0.41 % as compared to 3.06 % in Group 1. The comparative results were statistically significant (p = 0.0009). Prophylactic antibiotic regimen of Teicoplanin with Gentamicin showed significant reduction in C. Difficile diarrhea & Surgical Site Infection in fracture neck of femur patients undergoing surgery

Aims. Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs). Methods. In the first series, 98 hip fixation procedures were performed using CCS. After fluoroscopic reduction of the fracture, three CCSs were placed. In the second series, 105 VOOF procedures were performed using a closing wedge intertrochanteric osteotomy with a compression lag screw and lateral femoral plate. The alignment goal was to create a modified Pauwel’s fracture angle of 30°. After fluoroscopic reduction of fracture, lag screw was placed to achieve the calculated correction angle, followed by inter-trochanteric osteotomy and placement of barrel plate. Patients were followed for a minimum of two years. Results. Mean follow-up was 4.6 years (4.1 to 5.0) in the CCS group and 5.5 years (5.25 to 5.75) in the VOOF group. The mean Harris Hip Score at two-year follow-up was 83.85 in the CCS group versus 88.00 in the VOOF group (p < 0.001). At the latest follow-up, all-cause failure rate was 29.1% in the CCS group and 11.7% in the VOOF group (p = 0.003). The total cost of the VOOF technique was 7.2% of a THA, and total cost of the CCS technique was 6.3% of a THA. Conclusion. The VOOF technique decreased all-cause failure rate compared to CCS. The total cost of VOOF was 13.5% greater than CCS, but 92.8% less than a THA. Increased cost of VOOF was considered acceptable to all patients in this series. VOOF technique provides a reasonable alternative to THA in patients who cannot afford a THA procedure. Cite this article: Bone Jt Open 2023;4(5):329–337

Neck of femur fracture (NOF#) is the commonest reason for admission to an orthopaedic ward with 70-75,000 cases each year in the UK. 1. The femoral head is often sent to pathology if there is clinical suspicion of a malignant cause. There is limited evidence in the literature to support the efficacy of this. 2. The purpose of this project was to study the incidence of femoral head pathology analysis in NOF # patients with a background of malignancy and evaluate the impact this investigation has on guiding future management. Retrospective analysis of all neck of femur fractures admitted to the Queen Elizabeth University Hospital between 01/01/2021 and 31/12/2021. The electronic notes were accessed and for patients with past medical history of malignancy, it was confirmed whether femoral head or bone reamings were sent to pathology, resultant findings and the impact on subsequent management. In 2021, 784 patients were admitted to the QEUH with a NOF#. Of these, 770 (98.2%) underwent operative management, 138 (17.3%) of whom had a past medical history (PMH) of malignancy. Intra-operative pathology was sent from 19 (13.7%) of these 138 patients. No malignant cells were found in 13 (69%) samples, and in 6 (31%), the known active malignancy was confirmed. In all cases where samples were sent for pathology, none caused any change in management. In this retrospective study, pathological investigations in NOF# patients with a PMH of malignancy had no impact on further management. The authors would not advocate for sending pathology results in this cohort group

Aims. Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately. Methods. We retrieved data on all patients aged ≥ 75 years with an uFNF registered in the Swedish Fracture Register from 2011 to 2018. The database was linked to the Swedish Arthroplasty Register and the National Patient Register to obtain information on comorbidity, mortality, and reoperations. Our primary outcome, reoperation, or death at one year was analyzed using restricted mean survival time, which gives the mean time to either event for each group separately. Results. Overall, 3,909 patients presenting with uFNFs were included. Of these patients, 3,604 were treated with IF and 305 with primary arthroplasty. There were no relevant differences in age, sex, or comorbidities between groups. In the IF group 58% received cannulated screws and 39% hook pins. In the arthroplasty group 81% were treated with hemiarthroplasty and 19% with total hip arthroplasty. At one year, 32% were dead or had been reoperated in both groups. The reoperation-free survival time over one year of follow-up was 288 days (95% confidence interval (CI) 284 to 292) in the IF group and 279 days (95% CI 264 to 295) in the arthroplasty group, with p = 0.305 for the difference. Mortality was 26% in the IF group and 31% in the arthroplasty group at one year. Reoperation rates were 7.1% in the IF group and 2.3% in the arthroplasty group. Conclusion. In older patients with a uFNF, reoperation-free survival at one year seems similar, regardless of whether IF or arthroplasty is the primary surgery. However, this comparison depends on the choice of follow-up time in that reoperations were more common after IF. In contrast, we found more early deaths after arthroplasty. Our study calls for a randomized trial comparing these two methods. Cite this article: Bone Jt Open 2024;5(2):86–92