More than half of patients with neck of femur (NOF) fractures report their pain as severe to very severe in the first 24hrs. Opioids remain the most commonly used analgesia and are effective for static pain but not dynamic pain. Opioids provide suboptimal analgesia when patients are in a dynamic transition state and their side-effects are a source of morbidity in these patients. The Fascia Iliaca Compartment Block (FICB) involves infiltration of the fascia iliaca compartment with a large volume of low concentrated local anaesthetic to reduce pain by affecting the femoral and lateral cutaneous nerve of the thigh. The London Quality Standards for Fractured neck of femur services (2013) stated that the FICB should be routinely offered to patients. We performed an audit of patient outcomes following the introduction of the FICB across three centres. We performed a two-cycle audit across two hospitals in 2014/15. The first cycle audited compliance with the NICE guidance in the management and documentation of pain and AMTS (Abbreviated Mental Test Scores) in patients. The second cycle was conducted following the integration of the FICB into the multidisciplinary NOF fracture protocol across three hospital sites. Data was collected on numeric pain scores, pre and post-op AMTS and opioid requirements. There were 40 patients audited with 20 in the first cycle prior to the introduction of the FICB and 20 following this. In the second cycle, there was a statistically significant improvement (p<0.001) in the difference between the pre and post-op AMTS. The preliminary findings in this audit support the use of the FICB adjunct to analgesia in the pre-operative management of NOF fracture patients. The FICB is a safe procedure and the organisational learning of this procedure through a multidisciplinary approach can significantly improve the outcomes of NOF fracture patients

Background. Fractured neck of femurs cause substantial morbidity and mortality in elderly patients and represent a huge financial burden to the NHS. Hip fracture patients are generally malnourished on admission, often having poor nutritional inpatient intake, hindering recovery and increasing chances of “unfavourable outcome.” Nutritional care is included in intercollegiate guidelines for management of fractured neck of femur patients, but is nutrition a management priority in clinical practice?. Study Aim. To evaluate protein and energy intake of acute fractured neck of femur patients depending on admission MMSE, and compare these to department of health targets. Method. 40 acute fractured neck of femur admissions were recruited between December 08-March 09 and put into three groups depending on admission MMSE. Initial nutrition screening information (mid-arm circumference, grip strength, MUST score) was recorded and through food charts daily kcal and protein intake were calculated for a three day period. Results. 100% of patients recruited were high risk of malnutrition on admission. Overall average daily calorie intake over 3 days was 385.9 kCal, average protein intake was 14.1g. Intake for each group was well below recommended target intake of 1810kCal and 46.5g, p<0.05. Discussion. On admission all 40 patients included were classified high risk for malnutrition, therefore in need of dietetic and nutritional intervention. Two patients received dietician input and oral supplementation. Recorded nutritional intake was very low, well below target nutrient intakes for this population even before extra requirement due to the stress response is accounted for. Whilst there is a paucity of hard evidence linking poor nutrition to clinical outcome, this is likely to be detrimental to rehabilitation from surgery. Conclusion. Despite attempted adherence to NICE nutrition guidance, involving screening tools, care plans and protected mealtimes; acutely unwell, malnourished patients are not receiving their basic nutritional requirements

It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts.

Cite this article: Bone Joint Open 2020;1-6:198–202.

National guidelines encourage the use of total hip arthroplasty (THA) to treat intracapsular neck of femur fractures. There have been no population based studies appraising the surgical outcomes for this indication across an entire population. This study aims to calculate the complication rates for THA when performed for a fractured neck of femur and compare them to THA performed for primary osteoarthritis in the same population.

The Scottish Arthroplasty Project identified all THAs performed in Scotland for neck of femur fracture and osteoarthritis between 1st of January 2009 and 31st December 2014. Dislocation, periprosthetic infection and revision rates at 1 year were calculated.

The rate of dislocation, periprosthetic infection and revision at 1 year were all significantly increased among the fracture neck of femur cohort. In total 44046 THAs were performed, 38316 for OA and 2715 for a neck of femur fracture. 2.1% of patients (n=57) who underwent a THA for a neck of femur fracture suffered a dislocation in the 1st year postoperatively, compared to 0.9% (n=337) when the THA was performed for osteoarthritis. Relative Risk of dislocation: 2.4 (95% C.I. 1.8077–3.1252, p value <0.0001). Relative Risk of infection: 1.5 (95% C.I. 1.0496–2.0200, p value 0.0245) Relative Risk of revision: 1.5 (95% C.I. 1.0308–2.1268, p value 0.0336).

This is the first time a dislocation rate for THA performed for a neck of femur fracture has been calculated for an entire population. As the number of THAs for neck of femur fracture increases this dislocation rate will have clinical implications.

Statistics New Zealand states “Over the next five decades the 65+ dependency ratio is projected to more than double, from 18 (people aged 65+ years) per 100 (people aged 15 – 64 years) in 2006 to 45 per 100 in 2061. This means that for every person aged 65+ years, there will be 2.2 people in the working-age group in 2061, compared with 5.4 people in 2006 “. This will have a profound impact on health care, specifically in those fractures sustained by the elderly e.g. fractured neck of femur (#NOF).

Also at present little is proven regarding outcome following #NOF in the New Zealand population. These two factors (population change and patient outcome) led to disagreement and healthy debate at the 2008 NZOA ASM. After a pilot study in Dunedin we have examined national electronic records of 52,456 patients presenting with a first admission due to #NOF over the last 20 years.

The mean age at which a patient sustained their first #NOF was around 80 and 71% of these patients have since died. Approximately 10% of patients had a subsequent readmission for #NOF. There was a trend for increasing age over the last twenty years proportional to the increased average age of the general population. One year survival was 75% and mean survival was 3½ years with a third of patients living longer than six years. We found differences in outcome for gender and fracture type (intracapsular vs. extracapsular). Our patients also showed a trend to higher survival risk ratios (i.e. they are clinically “sicker” than they used to be). The incidence of #NOF has increased over the last 20 years with a projected doubling in the number of cases (to 5600 per year) at around 25yrs from now based on the most conservative estimates.

Introduction

More than 60% of patients presenting with a hip fracture have significant medical co-morbidities and a one year mortality rate between 14% and 47%. The rating scale for the American Society of Anaesthetists (ASA) is a reliable predictor of both surgical risk and mortality with ASA 4 patients having 100% mortality at one year.1,2

Since the introduction of national guidelines in 2009 encouraging the use of total hip arthroplasty (THA) to treat intracapsular neck of femur fractures there has been no population-based studies into the surgical outcomes for this indication. This study aims to calculate the complication rates for THA when performed for a fractured neck of femur and compare them to THA performed for primary osteoarthritis in the same population.

The Scottish Arthroplasty Project was used to identify all THAs performed in Scotland for neck of femur fracture and osteoarthritis between 1st of January 2009 and 31st December 2014. Dislocation, infection and revision rates at 1 year were calculated.

The rate of dislocation, infection and revision at 1 year were all significantly increased among the fracture neck of femur cohort. In total 44046 THAs were performed, 38316 for OA and 2715 for a neck of femur fracture. 2.1% of patients (n=57) who underwent a THA for a neck of femur fracture suffered a dislocation in the 1st year postoperatively, compared to 0.9% (n=337) when the THA was performed for osteoarthritis. Relative Risk of dislocation: 2.3870 (95% C.I. 1.8077–3.1252, p value <0.0001). Relative Risk of infection: 1.4561 (95% C.I. 1.0496–2.0200, p value 0.0245) Relative Risk of revision: 1.4807 (95% C.I. 1.0308–2.1268, p value 0.0336).

This is the first time a dislocation rate for THA performed for a neck of femur fracture has been calculated for an entire population. As the number of THAs for neck of femur fracture increases this dislocation rate will have clinical implications.

Contrary to NICE guidance there remains a role for Austin-Moore hemiarthroplasty (AM) for patients with significant pre-existing comorbidities who are at higher risk of death and complications following cemented hemiarthroplasty.

We analysed prospectively-collected data comparing uncemented AM hemiarthroplasty in frail, poorly-mobile patients, and cemented hemiarthroplasty. We analysed age, pre-operative morbidity, duration of operation, death rate and complication rate.

AM patients were significantly older with significantly higher ASA grades. It took significantly longer to optimise them before surgery. AM was significantly shorter to perform. There was no significant difference in complications requiring re-operation. Twice as many AM patients developed post-operative pneumonia despite absence of cement. Twice as many AM patients died after surgery and a significant proportion died within the first month despite no increased risk of repeat operation, shorter operating time and no risk of cement-disease. We infer that these patients would likely have fared badly had they undergone a longer, cemented procedure. A modern cemented prosthesis costs £691 more than AM.

There exists a subset of patients within the neck of femur cohort who are significantly more unwell. Contrary to guidelines, we suggest that the cheaper, user-friendly Austin-Moore can be a reasonable prosthesis to use for this cohort.

Hip fractures are estimated to cost the NHS over £2 billion per year and, with an ageing society, this is likely to increase. Rehabilitation and discharge planning in this population can be met with significant delays and prolonged hospital stay leading to bed shortages for acute and elective admissions. Planning care for these patients relies on a multidisciplinary approach with allied healthcare providers. The number of hip fracture patients in our hospital averages between 450–500/annum, the second largest number in the North West. The current average length of stay for the hip fracture patients is 22.9 days.

We evaluated the impact and performance of a pilot early supported discharge service (ESD) for patients admitted with a hip fracture. The pilot period commenced 22 September 2014 for 3 months and included an initial phase to set up the service and supporting processes, followed by the recruitment of 20 patients during the pilot period. The length of stay and post-discharge care was reviewed.

The journey of 20 patients was evaluated. The length of stay was dramatically reduced from an average of 22.9 days to 8.8 days in patients on the ESD pathway. Family feedback showed excellent results with communication regarding the ESD pathway and relatives felt the ESD helped patients return home (100% positive feedback).

Prolonged recumbency adversely affects the long-term health of these patients leading to significant morbidity such as pressure sores, respiratory tract infections and loss of muscle mass leading to weakness. Mortality is also a significant risk for these patients. Longer hospital stays lead to disorientation, institutionalisation and loss of motivation. Enhancing self-efficacy has been shown to improve balance, confidence, independence and physical activity. This pilot has proven that the Fracture Neck of Femur ESD service can significantly reduce the length of hospital stay and also deliver excellent patient and family feedback. The benefits of patients with a lower length of stay, with effective rehabilitation in hospital and within the home, will provide significant benefits to the Wirral healthcare economy.

Patients who suffer a fracture of the proximal femur are high risk for developing venous thromboembolism. They require effective anti-thrombotic prophylaxis. In an audit of 11,900 patients a mortality of 17% occurred 3 months after the injury. Although post mortem examination was rare, it was estimated that nearly 50% of 753 deaths were thrombosis related, 6.9% specifically attributed to pulmonary embolus. It is likely that many of the other deaths, attributed to various respiratory problems were also at least in part due to PE. Comparing the data with actuarial tables demonstrated an excess mortality in both gender and in nearly all age groups. In a second audit, although many patients were receiving some form of prophylaxis, many were given ineffective agents and probably using an ineffective regime. In many patients a fracture of the proximal femur is regarded as a terminal event. However, the data from these 2 audits would suggest that many of these patients are dying unnecessarily and that effective prophylaxis would reduce the risk of death. Chemical prophylaxis commenced immediately after surgery and continued for 5 weeks would be appropriate.

Echocardiograms are requested in patients presenting with hip fractures and the finding of a cardiac murmur. The opinion amongst anaesthetists in our department is that general anaesthetic (GA) is safer in patients with significant aortic stenosis, mitral regurgitation, or left ventricular impairment compared to spinal anaesthetic (SA).

A retrospective review was carried out and data on fifty patients were collected, who had presented with fractured neck of femur with the finding of a heart murmur and required an echocardiogram pre-operatively.

Our results demonstrated :

Focussed history and examination was rarely performed;

Our audit suggests that many echocardiograms are ordered unnecessarily. Effective use of clinical skills and investigations are rarely utilised by orthopaedic doctors, in requesting an echocardiogram. There is delayed operating times, cost implications and increased workload for the cardiology department. There is no indication that the results of these echocardiograms significantly influences anaesthetic choice.

A second audit cycle was performed prospectively with the use of a proforma. An echocardiogram was not ordered if a recent echocardiogram (within last the last year) was normal or if the history, examination and ECG findings in a patient were all insignificant. This demonstrated a reduction in ordering of echocardiograms by 40%. Local guidelines have been implemented in our department.

This study aims to assess prospectively whether measurement of perioperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur.

All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post-surgery. According to local protocol, a level of >0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay.

108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T >0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p<0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p<0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (7.6%) in the group with no rise (p<0.05).

The principal causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity.

We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment.

The aim of this study was to investigate the use of large diameter head THR to treat fractured neck of femur, and to demonstrate if this conferred greater stability.

46 independent, mentally alert patients with displaced intracapsular fractures underwent THR. Mean age was 72.1 years. Outcome measures were dislocation, reoperation/ revision rate, Oxford hip score (OHS), Euroqol (EQ-5D) and residential status. Data was collected prospectively, with review being carried out at 3 months and 1 year.

At mean follow-up (12.5 months) there were no dislocations. Reoperation, revision and infection rate were all 0%. Two patients died (4.3%). Mean pre-injury and postoperative OHS were 12.1 and 17.9 respectively. Mean pre-injury and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. Mean postoperative walking distance was 2.5 miles. There were no changes in residential status.

This is the first published series utilising 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur. We have demonstrated that it affords patients excellent stability with no recorded dislocations.

Dislocation is a major concern following total hip replacement (THR) for fractured neck of femur. The aim of this prospective study was to investigate the use of large diameter femoral head uncemented THR to treat fractured neck of femur, and to demonstrate if the improved stability seen in previous clinical situations with these designs, can be used to benefit this difficult subgroup of patients that are particularly prone to dislocation.

Forty-six consecutive independent, active and mentally alert patients with displaced intracapsular fractured neck of femur underwent large diameter head uncemented THR. The mean age of patients was 72.1 years. The outcome measures used were the dislocation rate, reoperation and revision rate, Oxford hip score (OHS), Euroqol (EQ-5D) and residential status.

Clinical and radiological data were available on all 46 patients. At a mean follow-up of 12.5 months there were no dislocations. The reoperation, revision and infection rate were all 0%. Two patients died (4.3%) from unrelated causes. Mean pre- and postoperative OHS were 12.1 and 17.9 respectively. The mean pre- and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. The mean postoperative walking distance was 2.5 miles and there were no changes in residential status.

This is the first published series utilising a 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur in mobile, independent patients. We have demonstrated that it affords patients excellent stability with no recorded dislocations.

Introduction – Patients who have sustained a fracture of the hip should have their surgical treatment with 48 hours of admission to hospital. A delay results in increased morbidity and mortality.

This elderly cohort of patients often have confounding co-morbidities. A pre-operative echocardiographic assessment to guide the anaesthetic is frequently requested upon clinical grounds. A delay in acquiring the echocardiogram was observed thus delaying surgery. This instigated a change in policy within the department whereby all patients over 70 years old who sustained a hip fracture underwent echocardiographic assessment with 24 hours of admission.

Method: An audit was performed assessing delays in acquiring the echocardiograms and measuring the time taken to perform the operation.

Results: Period 1 – Selective Echo: Mean time to echo 5 days, mean time to theatre 7 days. Period 2 – Unselective Echo: Mean time to echo 1 day, mean time to theatre 2 days.

Conclusion: As a result of the unselective policy to perform echo cardiograms on all patients admitted with a fractured neck hip, the delay to perform surgery has been reduced significantly.

Dislocation is a major concern following THR for fractured neck of femur. The aim of this prospective study was to investigate the use of large diameter femoral head uncemented THR to treat fractured neck of femur, and to demonstrate if the improved stability seen in previous clinical situations with these designs, can be used to benefit this difficult subgroup of patients that are particularly prone to dislocation.

Forty-six consecutive independent, active and mentally alert patients with displaced intracapsular fractured neck of femur underwent large diameter head uncemented THR. The mean age of patients was 72.1 years. The outcome measures used were the dislocation rate, reoperation and revision rate, Oxford hip score (OHS), EuroQol (EQ-5D) and residential status.

Clinical and radiological data were available on all 46 patients. At a mean follow-up of 12.5 months there were no dislocations. There were no reoperations, revisions or infections. Two patients died (4.3%) from unrelated causes. Mean pre- and postoperative OHS were 12.1 and 17.9 respectively. The mean pre- and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. The mean postoperative walking distance was 2.5 miles and there were no changes in residential status.

This is the first published series utilising a 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur in mobile, independent patients. We have demonstrated that it affords patients excellent stability with no recorded dislocations.

Parker et al examined the effect that delay to surgery has on patients with proximal femoral fractures. They found that a delay of more than 48 hours to surgery significantly increased the patient’s length of stay. They examined delays due to lack of theatre resource only.

Therefore an audit was proposed at the RUH Bath to set a standard of care that fracture neck of femur patients should be operated on within 48 hours. One month of data was collected (August 2005) and analysed. Of 52 fracture neck of femur patients 23% were waiting longer than 48 hours. The recommendation was made to have extra lists made available for fracture neck of femur patients.

In January 2006 the elective orthopaedic ward was closed (for 12 days) due to diarrhoea and vomiting. Therefore elective lists were utilised for trauma. The audit was repeated comparing these 12 days with 12 in December. In the December cohort seven neck of femur fracture patients waited more than 48 hours, in the January cohort no neck of femur patient waited more than 48 hours. A further recommendation was made for increased theatre capacity for neck of femur patients.

Subsequent to these recommendations 2 half day fracture neck of femur lists have been added to the rota at the RUH Bath. (Tuesday and Thursday pm). The patients can be assessed and worked up as planned trauma and can be seen in advance by the anaesthetist. Audit of January 2007 fractured neck of femur patients showed that there were 46 patients treated with only 1 waiting more than 48 hours due to theatre capacity.

In conclusion the audit process can work and achieve beneficial results as shown here. An accepted standard of care was taken from the literature, department performance analysed, changes implemented and closure of the audit loop has shown that it has worked.

Introduction: The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive and specific enzymatic marker of myocardial injury. This study aims to assess prospectively whether Troponin T may be used as a predictor of morbidity and mortality in admissions with fractured neck of femur.

Methods: All patients aged 65 years and over presenting with a fractured neck of femur over 4 months were included. Exclusion criteria of polymyositis, renal failure and conservative fracture management were applied. Troponin T levels were measured on admission, and days 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures were defined as adverse cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay.

Results: 108 patients were recruited over the 4 months. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least one of the outcome complications including death, as opposed to 7 (10.6%) from the group with no Troponin rise (p< 0.001). The mean inpatient stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (10.6%) in the group with no rise (p< 0.05).

Discussion: The association between raised Troponin and hip fractures has not previously been made. Many patients appear to be having silent cardiorespiratory or related events, which may be a significant cause of perioperative morbidity and mortality. We propose measurement of Troponin levels as part of the standard perioperative screening for hip fracture patients to identify this risk and initiate appropriate treatment measures.

Nosocomial infection with methicillin-resistant Staphylococcus aureus (MRSA) is on the increase and is expensive to treat. MRSA surgical wound infection may have disastrous consequences, particularly in an orthopaedic setting. We studied the rate of MRSA colonization in an important subgroup of orthopaedic patients. 50 nursing home residents were retrospectively reviewed with regard to their MRSA status on admission to an orthopaedic ward with fractured neck of femur. As is policy in our institution, all patients from nursing homes or other institutions are screened for MRSA on admission.

Of the 50 nursing home patients requiring a hemi-arthroplasty, 16%(8) were MRSA positive. 2%(1/50) acquired MRSA infection while I hospital, while the remaining 14%(7/50) were carriers on admission. 4%(2/50) developed sepsis postoperatively, followed by multiorgan failure and death. 4% had their MRSA cleared prior to discharge, while 8% remained positive on discharge. All patients undergoing hemiarthroplasty received cefuroxime, unless allergic, as prophylaxis at induction. These findings of considerable MRSA carriage in nursing home patients is particularly relevant today, as the number of patients in nursing homes continues to grow as the population ages. The patient population in nursing homes is susceptible to infection because of the physiological changes that occur with ageing, the underlying chronic diseases of the patients and the institutional environment within which residents socialize and live.

Nursing home residents presenting to orthopaedic units for surgery are a unique group in repairing careful consideration.

We studied the histomorphometry of the trabecular bone of 19 black men and 15 black women over the age of 60 years who had sustained fractured neck of femur (FNF) as a result of minor trauma. The findings were correlated with indicators of iron overload (ferritin and vitamin C).

A striking feature was the presence of iron granules in the bone marrow of 16 of the men and nine of the women, together with fibrosis. Present in large numbers, the granules were quantitated. There were significantly more iron granules in the men than in the women (p =0.05). Ferritin levels were higher in those patients with large numbers of granules than in those with few or no granules. There was no clear correlation with the indicators, bone formation or resorption.

We concluded that iron overload is a strong aetiological factor in black male FNF patients. In postmenopausal female FNF patients, the possible aetiological role of iron overload is complicated by hormone deficiency.