The aim of this study was to determine the incidence of second hip fracture.

A prospective cohort study include 2682 patients aged 50 years or more admitted with a hip fracture over a 4 year period. Mortality data were available for all patients and survival analysis was performed to determine the incidence of second hip fracture. The mean age-specific incidence rates of primary hip fracture in the population were calculated to serve as a baseline.

95 patients (3.5%) sustained a sequential, contralateral hip fracture within the study period. The mean age at first hip fracture was 82 years and the mean interval between fractures was 316 days. Fracture morphology was similar on both sides in 69% of cases. Survival analysis demonstrated that the incidence of second hip fracture at 1 year was 2.8% (95% CI: 2.0–3.6), 2 years was 5.7% (95% CI: 4.3–7.1) and 3 years was 7.3% (95% CI: 5.4–9.2). The relative risk of hip fracture in patients who had already sustained one hip fracture was 2.4 times above that of matched controls. Assistance with activities of daily living was identified as a risk for second hip fracture (p=0.026, 95% CI: 1.058, 2.466). The odds ratio for sustaining a second hip fracture compared with the incidence of primary hip fracture in the normal population aged 55–64 years was 47.5 xs; 65–74 years was 15 xs; 75–84 years was 3.7x and 85+ years was 1x.

The risk of sustaining a second contralateral hip fracture is substantial. In younger patients preventative measures can be targeted at the individual who has sustained a fracture whereas in more elderly patients, preventative measures need to address the population as a whole.

The aim of this study was to assess patient-based outcome two years following non-operative management of displaced Colles fractures.

100 patients were evaluated at a minimum of two years after displaced Colles fracture. Fractures were reduced under regional anaesthesia and immobilised in a Colles-type cast for five weeks. The fractures were assessed radiographically by measurement of radial angle, dorsal tilt, radial shortening and carpal malalignment at the time of injury, post-manipulation, and after one and five weeks. The fractures were classified according to Frykman classification. A validated patient-based outcome questionnaire, using a visual analogue score, was used to assess outcome at the end of two years.

7 patients had died, 8 patients were unable to complete the questionnaire because of confusion and 5 were lost to follow-up. Complete outcome data were available on 80 patients.

The median age was 61 years. The median pain score was 5 (25%-2 and 75%-12, range 0–100). There was loss of reduction, with more than 5° dorsal angulation and/or 5mm radial shortening in 70% cases. We found that age had no effect on patient outcome except that patients over 50 years complained of more finger stiffness The Frykman classification was an important prognostic factor and a higher grade resulted in worse outcome in a number of areas. Dorsal angulation had no significant effect and carpal malalignment correlated with poor visual appearance. Radial angle and radial shortening were both associated with increased complaints of wrist pain and stiffness

This prospective patient based outcome study has demonstrated that patients make a good functional recovery following nonoperative management of Colles fracture. 70% of our patients had a poor radiological outcome but few reported problems with pain and function at 2 years. Extra-articular malunion due to radial angulation and shortening was common and correlated with wrist pain and stiffness at two years. Frykman classification correlated with pain and functional outcome.

Generally ankle fractures in the very elderly are treated by non-operative methods but some fractures can be highly unstable and are difficult to treat in a plaster.

During a 10-year period, 74 patients over the age of 70 years were retrospectively studied to identify the early complications, length of stay, return to pre-injury mobility and residential status. There were 58 females and 16 males with an average age of 76 years (70–91years). 57(77%) fractures were at the level of the syndesmosis (Type B) and 17(33%) were above the level of the syndesmosis (Type C). All but one injury was due to a simple fall. All patients had initial manipulation and plaster immobilisation. They underwent ORIF after the reduction in the plaster was lost. Plate and screws were used in 53 patients (72%), rush pins in 12 patients (16%) and external fixation was used in 2 patients. All patients were immobilised in a below knee plaster after surgery for 6–8 weeks.

Following surgery, 1% deep infection, 9% delayed wound healing, 5% malunion, and 3% mortality were recorded. In 12% of patients, soft bone and communition precluded fixation of one malleolus. The average length of stay for patients who walked with a Zimmer frame before injury was significantly longer than for those who walked independently or with sticks. However, the majority (85%) of patients regained their pre-injury mobility and residential status.

We conclude that ORIF of ankle fractures in the elderly carries a significant risk of wound edge necrosis with delayed wound healing but the incidence of deep infection is relatively low. ORIF should be reserved for patients where non-operative management has failed. Poor bone quality presents technical difficulties but the majority of patients can expect a good outcome.

To investigate the incidence of PTS in patients with veno-graphically proven DVT following hip or knee replacement surgery, patients were derived from a randomised controlled trial of LMWH versus unfractionated heparin prophylaxis in 500 total hip or knee replacement patients. Surveillance venogram at 10 days detected DVT in 93 patients, and these were warfarinised for 3–6 months. At a minimum follow-up of 7 years, patients were assessed by clinical examination, questionnaire and application of two scoring systems; a modified PTS score based on the Browse score, and the clinical component of the International Consensus Committee on Chronic Venous Disease classification (ICC-CVD).

70 patients (21 deaths and 2 non-responders, follow-up rate 97%) with 32 THR and 38 TKR were studied. 63% patients were female, and average age was 74 years. Leg ache (46%) and swelling (42%) were the most common subjective complaints, but 40% patients had no complaints. Objectively, leg swelling was observed in 52% of patients, varicose veins in 26%, but ulceration was seen in only 3% of patients. The modified PTS score showed 14% patients had no symptoms, 64% mild symptoms, 19% moderate and 3% severe symptoms of PTS. The ICC-CVD score revealed 27% with no symptoms, 53% mild symptoms, 17% moderate and 3% severe symptoms of PTS. There was good correlation between the scoring systems for moderate and severe disease, but the modified PTS may have overestimated the incidence of mild PTS.

Severe symptomatic PTS is rare following early detection and treatment of DVT after total hip and knee replacement.

This study investigates the role of pre-operative mental health on outcome following Total Knee Replacement.

Patients were recruited as part of a prospective, observational study of the outcomes of primary total knee replacement for osteothritis in centres in the United Kingdom (6 centres), United States (4 centres) and Australia (2 centres). Independent, research assistants recruited eligible patients, collecting clinical history and examination data pre-operatively, 3 and 12 month post surgery. The SF-36, WOMAC, patient satisfaction and demographic data were obtained by self-administered questionnaires.

We recruited 862 eligible patients and have completed 12-month data on 742 patients (86%). Mean age was 70 years (SD 10), 59% were female, 50% were from the UK, 30% from the USA and 20% from Australia. In linear regression models, the significant correlates of preoperative mental health (in decreasing order of significance) were: low preoperative WOMAC function (Std B 8, 2; p< 0. 0001), self reported depression (Std 8 7. 6; p< 0, 0001), female gender (Std 13 2. 9 p=0, 004), older age (Std 13 2, 9; p=0. 004), other comorbid conditions (Std 3 2. 8; p=0, 005) and low income (Std B 23; p-0, 03). 12 months following surgery, low pre-operative mental health was a significance predictor of worse WOMAC pain and function (p< 0. 0001). The linear regression models adjusted for preoperative pain and function, age, sex, comorbid conditions, country and centre within country. With the exception of the pre-operative WOMAC pain and function score, low pre-operative mental health was the strongest of worse outcome 12 months after TKR.

Low pre-operative mental health is a highly significant predictor of worse outcome one year after Total Knee Replacement. It may be possible to identify patients with poor mental health before surgery using the SF36 mental health score as well as self-reported depression. This may allow for effective treatment of their mental health problems prior to TKR and/or highlight the need for extra rehabilitation input to improve outcome following surgery.

The aim of this study was to evaluate the peri-operative (30-day) mortality following hip fracture and look at the variables which influence early mortality after this injury. A prospective audit of all patients admitted with hip fracture was undertaken over an 18-month period. An independent research assistant collected data on a standardised questionnaire. Data included basic demographics, comorbidities, mental test score, mobility and social status, All patients received prophylactic antibiotics and thromboprophylaxis and surgery was undertaken on dedicated trauma and hip fracture operating lists.

There were 1072 patients admitted with hip fracture: 829 females (77%) and 240 males (23%) with a mean age of 80 years (range 24–103 years). The basic fracture types were intracapsular (n=616; 58%); extracapsular (n=414; 38%); subtrochanteric (n=29; 3%) and periprosthetic (n=12; 1%). 69 patients (7%) had acute medical problems which delayed anaesthesia. Delays to surgery, because of a lack of theatre resources, were common and only 314 patients (29%) had their hip fracture fixed on the day of admission or the following day. There were 9 deep infections (0. 8%) and 69 patients (6%) died within 30 days of surgery. Linear regression analysis showed that the 30-day mortality was not associated with pre-injury mobility or mental test score (p=0. 224). Any delay to surgery (2 days or more) resulted in a significant increase in mortality (p=0. 0042) and the risk of death increased 21% for every day surgery was delayed. Subgroup analysis showed that acute medical comorbidity was the most important factor influencing mortality with an odds ratio for death of 4. 9 (p=0, 0007). Delay to surgery in medically fit patients (n= 633) gave an odds ratio for death of 1. 6. In this group, the risk of death increased 16% for every day surgery was delayed with an 85% probability (p=O. 125) that this trend was significant.

The peri-operative mortality for hip fractures is now quite low (6%). Acute medical comorbidities are the most important cause of early post-operative death. Delay to surgery may be a factor in medically fit patients and our data suggests that the ideal time for surgery is the day after admission.

To assess the prevalence of anterior knee pain more than 5 years after closed intramedullary nailing of the tibia and evaluate the long-term socioeconomic impact of this complication in terms of knee function and employment.

A retrospective, cohort study of 298 consecutive tibial intramedullary nailings in 295 patients. Minimum follow-up was 5 years and patients were assessed using a questionnaire and the Lysholm knee score. 26 patients are known to have died, 22 patients, greater than 60 years at the tune of their injury, were excluded, Thus, 251 knees in 248 patients were available for review.

The mean age at follow-up was 40. 8 years. The male to female ratio was SA:1 and mean follow-up was 7. 9 years. Anterior knee sensory disturbance was reported by 58% of patients. This interfered with activities of daily living (ADLs) in 29%, work in 25% and sport in 37%. Anterior knee pain was reported by 47% of patients. This interfered with ADLs in 37%, work in 36% and sport in 57%, Anterior knee pain was present all the time in 4%, often in 12%, sometimes in 27%, rarely in 21% and never in 37%, Pain on kneeling was rated on a visual analogue scale as mild in 54%, moderate in 34% and severe 12%. AKP improved with time in 73% patients and became worse in 4%. The Lysholm score rated 4 1 % knees as excellent, 19% as good, 26% as fair and 14% as poor. 86% of patients have been able to return to work, 9% are currently unemployed and 5% disabled. The presence of anterior knee pain was felt by the patient to prevent return to previous work in 10%.

Anterior knee pain persists in 47% of patients after intramedullary nailing of the tibia- There is some decrease in symptoms with time and the majority of patients are able to return to work and activities of daily living. However, anterior knee pain causes significant disability in a small number and all patients should be warned of this problem prior to surgery.

The aim of this study was to evaluate the early results and complications of internal fixation for displaced fractures of the talar neck.

A retrospective review was undertaken of displaced talar neck fractures. 35 patients had open reduction and lag screw fixation during a 16-year period. All patients were followed with serial radiographs for at least three years.

There were 25 males and 10 females with a mean age of 31 years (range 15–61 years). The most common mechanism of injury was fall from height (n=13) and motor vehicle accidents (n=l1). There was one bilateral fracture. Ipsilateral ankle fractures occurred in 5 patients (14%) and 8 patients (23%) had multiple injuries. There were 31 Hawkins’ type II fractures and 5 Hawkins’ type III fractures. 25 patients (71%) had no complications as a result of their injuries or surgery. All fractures united within 6 months. There was one deep infection (3%) in a IIIB open fracture that required early amputation. 8 patients developed avascular necrosis: 6 Hawkins’ type II fractures (19%) and 2 Hawkins’ type III fractures (40%). Avascular necrosis was more common if surgery was delayed beyond 24 hours but this may reflect the severity of injury rather than the timing of surgery. The outcome following avascular necrosis was poor in general and 5 patients (63%) required hindfoot fusion.

Talar neck fractures are rare. This is the first study from the UK to evaluate this injury and it is the first to look specifically at one method of operative treatment. In general, the early results were good with only 1 deep infection (3%) and all fractures united following lag screw fixation. Avascular necrosis remains the most common complication but, compared with other studies, we report low rates of this problem.

Good results can be obtained following lag screw fixation of displaced talar neck fractures. The complication rate is low but avascular necrosis remains a serious problem.