Abstract

Abstract

Abstract

Introduction and Objective

Dislocation of a hip hemiarthroplasty is a significant complication with a high mortality rate in elderly patients. Previous studies have shown a higher risk of dislocation in patients with neuromuscular conditions. In this study, we reviewed our larger cohort of patients to identify if there is a link between neuromuscular disorders and dislocation of hip hemiarthroplasty in patients with neuromuscular conditions.

Introduction and Objective

The effectiveness of anti-embolic graduated compression stockings (GCSs) has recently been questioned. The aim of this study is to systematically review all the relevant randomised controlled trials published to date.

Continued controversy exists between cemented versus uncemented hemiarthroplasty for an intracapsular hip fracture. To assist in resolving this controversy, 400 patients were randomised between a cemented polished tapered stem hemiarthroplasty and an uncemented Furlong hydroxyapatite coated hemiarthroplasty. Follow-up was by a nurse blinded to the implant used for up to three years from surgery.

Results indicate no difference in the pain scores between implants but a tendency to an improved regain of mobility for those treated with the cemented arthroplasty (1.2 score versus 1.7 at 6 months, p=0.03). There was no difference in early mortality but a tendency to a higher later mortality for the uncemented implants (29% versus 24% at one year, p=0.3). Later peri-prosthetic fracture was more common in the uncemented group (3% versus 1.5%). Revision arthroplasty was required for 2% of cemented cases and 3% of uncemented cases. Surgery for an uncemented hemiarthroplasty was 5 minutes shorter but these patients were more likely to need a blood transfusion (14% versus 7%). Three patients in the cemented group had a major adverse reaction to bone cement leading to their death.

These results indicated that a cemented stem hemiarthroplasty give marginally improved regain of mobility in comparison to a contemporary uncemented hemiarthroplasty. An uncemented hemiarthroplasty still has a place for those considered to be at a high risk of bone cement implantation syndrome.

Introduction

When treating a patient admitted with hip fracture it is useful to have a simple scoring system to predict outcomes, based on admission clerking and routine investigations. The Nottingham Hip Fracture Score (NHFS) is one such measure. Its use has been described by Wiles et al (Br J. Anaes. Jan. 2001) for risk stratification in predicting 30-day and 1-year mortality.

Introduction

The incidence of distal femoral fractures amongst elderly patients is likely to rise due to increased life expectancy. This study reports on the outcome of a series of distal femoral fractures treated by retrograde femoral nailing and then to compare the results for these patients with a series of patients with a proximal femoral fracture.

Objective

The aim of this study was to determine the correlation between body weight and fracture union for displaced intracapsular fracture neck of femur treated by closed reduction and internal fixation.

Introduction

Debate still exists as to the optimum method of fixation for subtrochanteric femoral fractures. Meta-analysis of studies comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures have suggested that further investigation is required in this area. We present the outcome of the largest series to date of subtrochanteric fractures treated by both methods and with a minimum of one year follow-up.

Introduction

There has been little research into the effect of suffering a simultaneous hip and upper limb fragility fracture. The aim of this study is to describe the characteristics of this important group of patients and to define the effect on outcomes such as mortality and length of stay.

The purpose of the study was to identify factors that affect the incidence of deep wound infection after hip fracture surgery.

Data from a hip fracture database of 7057 consecutively treated patients at a single centre was used to determine the relationship between deep wound sepsis and a number of factors. Fisher's exact test and the unpaired T test were used. All patients were initially followed up in a specialist clinic. In addition a phone call assessment was made at one year from injury to check that no later wound healing complications had occurred.

There were 50 cases of deep infection (rate of 0.7%). There was no significant difference in the rate of deep sepsis with regards to the age, sex, pre-operative residential status, mobility or mental test score of the patient. Specialist hip surgeons and Consultants have a lower infection rate compared with surgeons below Consultant grade, p=0.01. The mean length of anaesthesia was longer in the sepsis group (76minutes) compared to the no sepsis group (65minutes), this was significant, p=0.01. The patient's ASA grade and fracture type were not significant factors. The rate of infection in intracapsular fractures treated by hemiarthroplasty was significantly greater than those that had internal fixation, p=0.001. The rate of infection in extracapsular fractures fixed with an extra-medullary device was significantly greater than those fixed with an intra-medullary device, p=0.021. The presence of an infected ulcer on the same leg as the fracture was not associated with a higher rate of deep infection. In conclusion we have found that the experience (seniority) of the surgeon, the length of anaesthesia and the type of fixation used are all significant factors in the development of deep sepsis. These are all potentially modifiable risk factors and should be considered in the treatment of hip fracture patients.

Maintaining femoral neck cortical thickness may help prevent hip fracture. Fracture initiation probably starts superiorly at flaws, ie where the cortex is thinnest. Whole body computed tomography (QCT) is now being used to study cortical thickness but limited resolution (> 300 micrometers) makes in vivo estimates imprecise, whereas microscopy s resolution approaches 1 micrometer. We have therefore extended our microscopic studies on femoral neck biopsies to include men (14 cases, 26 controls) and women (50 cases, 23 controls), and here provide data on true cortical thickness in subjects with and without hip fracture.

Whole femoral neck cross-sections obtained at hemiarthroplasty (or at post-mortem in controls) were embedded in methacrylate, cut, stained and imaged at medium power. Image-J was used to define cortical boundaries and to measure cortical thicknesses at 5 degree intervals of arc from the cross-sections centre of area.

We confirmed that the mid-femoral neck (or narrow neck) site, defined as where the ratio of maximum to minimum neck diameter (max:min) is 1.4, shows great asymmetry, with the thick inferior cortical octant averaging over 3mm thickness (mean age 79 years inter-quartile range 74-85). In the superior 3 octants cortical thickness averaged 26% of that seen inferiorly. To assess statistical determinants of cortical thickness, the data were modelled with linear regression in octants after adjusting for subjects age, sex, max:min, and hip fracture status. To achieve normality of residuals the cortical thickness data were log-transformed. 95% of measured cortical thicknesses fell between 45% and 220% of the mean for octant. In the thinner, superior three octants, minimum thicknesses were just under 0.3 mm in the fracture cases ie close to 35% of the subjects mean for octant. Cases had about 17% thinner cortical thicknesses in all octants than controls, while female controls had cortical thicknesses that uniformly averaged 90% of male. In conclusion, compared to gender and age-matched controls, intra-capsular hip facture cases had generalized cortical thinning in all mid-neck octants. This disease effect contrasts markedly with the effect of normal ageing, which thins preferentially the mechanically under-loaded superior cortex and spares the infero-anterior cortex.

Hip fractures are common injuries in the elderly, with significant mortality and morbidity from several factors. Many of these patients have cardiac disease, and some develop cardiac complications which may increase mortality.

Troponin T is a marker of myocardial injury but can be raised in other conditions. Patients over 60 years old admitted with hip fracture during the study period had their troponin T measured on admission and following surgery. Assay was performed after the patient had completed their treatment. We report the results of this study one year after the last patient was admitted.

108 patients were recruited. The average age was 84 years; 86% were female. This study found that 27% of hip fracture patients had some increase in the troponin T levels in the peri-operative period. This increase was not associated with an increase in early mortality, but there was an increase in one-year mortality for those with an increase in troponin T (45% versus 22%, p=0.03). These findings indicate that the routine measurement of troponin T after a hip fracture is unnecessary.

In order to define the optimum timing of surgery for a hip fracture, we undertook a systematic review of all previously published studies on this topic. Data from the retrieved studies were extracted by two independent reviews and the methodology of each study assessed. In total, 43 studies involving 265,137 patients were identified. Outcomes considered were mortality, post-operative complications, length of hospital stay and return of patients back home.

There were no randomised trials on this topic. Six studies of 8535 patients have the most appropriate methodology, which was prospective collection of data with adjustment for confounding variables. These studies found no effect on mortality for any delays in surgery. One of these studies found fewer complications for those operated on early but this was not found in the other study to report on these outcomes. Two of these studies reported on hospital stay, which was reduced for those operated on early. Six studies of 229,418 patients were retrospective reviews of patient administration databases with an attempt at adjusting for confounding factors. They reported a reduced mortality, hospital stay and complications for those operated on early. Thirty-one other studies of variable methodology reported similar findings of reduced complications with early surgery, apart from one study of 399 patients which reported an increased mortality and morbidity for those operated on within 24 hours of admission.

In conclusion those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. But early surgery (within 48 hours of admission) does seem to reduce complications such as pressure sores and reduces hospital stay.

1133 patients with an intracapsular fracture of femoral neck treated by internal fixation were prospectively studied. All surviving patients were followed up for a minimum of one year from injury. The overall incidence of non-union was 229 (20.2%) and the incidence of avascular necrosis was 61 (5.4%). Fracture non-union was less common for undisplaced fracture in comparison to displaced fractures (48 out of 565 (8.5%) versus 181 out of 568 (31.9%)) and in males than females (45 out of 271 (16.6%) versus 184 out of 862 (21.3%)). The incidence of non-union progressively increased with age from one out of 17 (5.9%) in those aged below 40 years to 84 out of 337 (24.9%) in those in their seventies. For those in their eighties the incidence of non-union began to fall, but if those patients who died within one year from injury were excluded, then the incidence was found to continue to increase. For avascular necrosis there was a falling incidence with age from 9 out of 68 (13.2%) in those aged less than 50 years to 10 out of 388 (2.6%) in those aged over 80 years.

The information from this large series of patients treated by contemporary methods enables the surgeon to use the three factors of age, sex and presence of fracture displacement to predict the risk of non-union or avascular necrosis occurring.

The two commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. To determine if any difference in outcome exists between these implants we undertook a prospective randomised controlled trial of 300 patients with a displaced intracapsular hip fractures.

All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility.

The average age of the patients was 83 years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups, with 34/151 having died at one year in the cemented group and 45/149 in the uncemented group. Pain scores (grade 1-6) were less for those treated by a cemented prosthesis (mean score 1.8 versus 2.4, p value <0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay. Operative complications are as listed. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group.

In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended.

Fractures of the proximal femur at the level of the lesser trochanter (reversed and transverse fracture lines, Evans classification type II, AO classification 31. A3 fractures) are known to have an increased risk of fixation failure. 53 patients with such a fracture were randomised to have the fracture fixed with either an intramedullary nail (220 mm Targon Proximal Femoral nail) or a Sliding Hip Screw (SHS). The mean age of the patients was 82 and 11% were male. All patients were followed up for one year by a research nurse blinded to the treatment groups.

Mean length of surgery was 51 minutes for the nail versus 53 minutes for the SHS. There were no differences between groups in the need for blood transfusion. Operative complications tended to be less for the nail group (1/27 versus 5/26). Mean hospital stay was 17 days for the nail group versus 29 days for those treated with the SHS (p< 0.0001). The only fracture healing complications were one case of cut-out in each group requiring revision surgery. During follow-up those patient treated with the nail reported significantly lower pain scores than those treated with the SHS (p=0.08). This difference persisted even at one year from injury. In addition there was a tendency to a better regain of mobility in the first nine months from injury for those treated with the nail.

These results indicate that for these difficult fractures types an intramedullary nails produces superior results to the Sliding Hip Screw.

The Targon Femoral Neck Hip Screw has been designed to improve the fixation of intracapsular hip fractures. Fracture healing complications after internal fixation occur in approximately 30–40% of displaced fractures and 5–10% of undisplaced fractures. The new implant consists of a small plate with six locking screw ports. The two distal holes are used to fix the plate to the lateral cortex of the femur. Three of four screws are passes through the proximal holes and across the fracture site. These 6.5mm screws are dynamic to allow for collapse of the fracture across the femoral neck. A jig is used to aid insertion of the device with minimal surgical exposure of the femur.

For the first 200 patients treated with this implant at the first centre to use this implant, the mean age of the patients was 77 years (range 39–103), 58% were female. The mean length of surgery was 46 minutes and the mean length of anaesthesia 59 minutes. The median length of institutional stay till discharge home was 9 days (mean 13 days, range 3–107). Four telescoping screws were used in 55% of patients, three in 44% and two in 1% of patients.

Follow-up of patients at present is a minimum of six months. For the 74 undisplaced fractures there has been one case of non-union and one case of avascular necrosis. For the 121 displaced fractures (Garden III and IV) there have been eleven cases of fracture non-union, six cases of avascular necrosis and two cases of plate detachment from the femur treated by repeat fixation. In addition there was one deep wound sepsis treated by removal of the implant and girdlestone arthroplasty. For the four basal fractures treated there has been one case of plate detachment from the femur.

Observation of those fractures that have healed shows there has been between 0 to 22mm of collapse at the fracture site which occurs along the line of the femoral neck. There has been no tilting of the fracture into varus as occurs with a parallel screw method.

The results to date show an incidence of fracture healing complications is about a third that which is to be expected with a parallel screw method. This new implant may be a significant advance in the treatment of this difficult and common fracture.

To determine if any notable differences between a cemented Thompson stem hemiarthroplasty and a cemented Exeter stem hemiarthroplasty (ETS), 200 patients with a displaced intracapsular fracture were randomised between the two prosthesis. Surviving patients were followed-up for one year by a nurse blinded to the treatment allocation. The mean age of patients was 84 years and 13% were male.

There were no differences between groups for the length of surgery, need for blood transfusion or hospital stay. Implant related complications were three minor operative fractures of the femur in each group. Two patients in the Thompson group had dislocation of the prosthesis requiring revision surgery and one further patient in the Thompson group had late acetabular wear requiring conversion to a total hip replacement. One further patient in the Thompson group had cement retained in the acetabulum. In total therefore only three patients, all in the Thompson group, which required revision surgery. Easy of surgery was assessed subjectively by the surgeon and reported to be easier for the ETS group (p=0.0002). During follow-up there was no significant difference in the degree of residual pain between groups.

Conclusions are that the cemented Exeter stem hemiarthroplasty has some advantages over the traditional cemented Thompson hemiarthroplasty.