Introduction. Four parts inter trochanteric fracture of femur are commonest in elderly people. DHS fixation is gold standard treatment of such fractures. Various Complications of DHS implant are reported in the literature. However, Hip Instability: Subluxation and Dislocation is very rare. We report, five cases of Hip instability following DHS fixation surgery. Materials and Methods. This is a retrospective study conducted at ACPM Medical College, Dhule. We found only five cases that developed hip instability after DHS fixation since 1997. Available clinical notes and X-rays of these patients were studied to get the relevant information. Results and Observations. Three patients were male, two female, four had right sided fracture and one had left sided. Three had instability after six weeks and remaining two developed dislocation after eight months which were associated with infection. 1 patient refused further investigations & treatment, 2 other died with due course of time 1 lost to follow-up and one patient with deep infection underwent excision arthroplasty. We could only speculate cause for dislocation / subluxation on the basis of clinical examination, X-ray, Investigations and review of literature. In these cases it appeared that the factors responsible for instability could be mechanical factors and pyogenic infection. Review of literature and possible aetiological factors, investigations and various aspects of management of such cases are discussed. Conclusions. Mechanical factors such as intra-operative femoral head rotation, avulsion of greater trochanter, excessive medialisation, valgus reduction, excessive collapse, soft tissue injury, and infection are contributing factors for hip instability

The aim of this study is to analyse the radiological outcomes and predictors of avascular necrosis following 2-hole DHS in Garden I and II neck of femur fractures in patients more than 60 years with a minimum follow up of one year. We retrospectively reviewed 51 consecutive patients aged more than 60 years who underwent DHS fixation for Garden I and II fractures. Demographics, fracture classification, time to surgery, pre-operative AMTS, preoperative posterior tilt angle, quality of reduction, pre and post-operative haemoglobin(hb), creatinine and comorbidities were analysed for correlation with AVN using Chi-Square test, Independent Sample and paired t test. There were 40 (78.4%) females and the mean age of the cohort was 77 years. 28 and 23 were Garden I and II NOF fractures respectively. Union was observed in all our patients except one(kappa =1). 12/51(23.5%) developed AVN of the femoral head. Statistically significant higher incidence of AVN was noted in patients with a pre-op tilt angle > 200 (p = 0.006). The mean drop in Hb was higher in patients who developed AVN (21.5 g/L) versus the non-AVN group (15.9 g/L) (p = 0.001). There was no difference in AVN rates with respect to laterality, mean time to surgery, pre-op AMTS and Charlson comorbidity index. 4/52 (7.6%) had re-operations (one hardware prominence, two conversions to arthroplasty, one fixation failure during the immediate post-op period). The 30-day and one year mortality rates were 1.9 % and 11.7 % respectively. 2-hole DHS fixation in undisplaced NOF fractures has excellent union rates. A pre-operative posterior tilt angle of >200 and a greater difference in pre and post operative haemoglobin were found to correlate positively with the progression to AVN . No correlation was observed between AVN and time to surgery, laterality, quality of reduction and comorbidities

Background. Dynamic Hip Screw (DHS) is the most frequently used implant in management of intertrochanteric femoral fractures. There is a known statistical relationship between a tip-apex distance (TAD) >25mm and higher rate of implant failure. Our aim was to analyse all DHS procedures performed in our trust from seventeen months and compare their TAD values to the acceptable standard of ≤25mm. Methods. All patients undergoing DHS between April 2020-August 2021 were identified from our theatre system. Additionally, those presenting to hospital with implant failures were included. Patient demographics, date of surgery, fracture classification (AO) and date/mode of failure were recorded. Intraoperative fluoroscopy images were reviewed to calculate TAD, screw location and neck shaft angles by two independent observers. Results. 215 patients were identified, five of which were excluded due to inadequate fluoroscopy. Failure was seen in 3.3% of the cohort (n=7), of which 71.4% had an unacceptable TAD. In total, 21 patients (10%) had TAD >25mm, of whom 12 had superiorly and 15 had posteriorly placed screws. There were no failures in patients with a TAD of <20mm whereas a TAD >30mm had 50% failure rate. Conclusion. This audit reinforces the importance of aiming for a low TAD (preferably <20mm) intraoperatively. It is also desirable to avoid superiorly and significantly posteriorly placed screws. Implications. Complex hip revision surgery in the elderly bears substantial financial implications to the NHS and, more importantly, causes prolonged morbidity to the patient. Adhering to established standards will ensure reduced implant failure and best patient care

Abstract. Background. The aim of this study is to analyse the radiological outcomes and predictors of avascular necrosis following 2-hole DHS in Garden I and II neck of femur fractures in patients >60 years with a minimum follow up of one year. Methods. We retrospectively reviewed 51 consecutive patients >60 years who underwent DHS fixation for Garden I and II fractures. Demographics, fracture classification, time to surgery, pre-operative AMTS, preoperative posterior tilt angle, quality of reduction, pre and post-operative haemoglobin (hb), creatinine and comorbidities were analysed. Results. There were 40 (78.4%) females and the mean age was 77 years. 28 and 23 were Garden I and II NOF fractures respectively. Union was observed in all our patients except one. 12/51(23.5%) developed AVN of the femoral head. Statistically significant higher incidence of AVN was noted in patients with a pre-op tilt angle > 20. 0. (p = 0.006). The mean drop in Hb was higher in patients who developed AVN (21.5 g/L) versus the non-AVN group (15.9 g/L) (p = 0.001). There was no difference in AVN with respect to laterality, mean time to surgery, pre-operative AMTS and Charlson comorbidity index. 4/52 (7.6%) had re-operations. The 30-day and one year mortality were 1.9 % and 11.7 % respectively. Conclusion. In our series a preoperative posterior tilt angle of >20. 0. and a drop in haemoglobin were found to correlate with the progression to AVN. No correlation was observed between AVN and time to surgery, laterality, quality of reduction and comorbidities

Introduction. Osteoporotic intertrochanteric fracture (ITF) is frequent injuries affecting elderly, osteoporotic patients leading to significant morbidity and mortality. Successful prognosis including union and alignment is challenging even though initial successful reduction with internal fixation. Although many factors are related to the patient's final prognosis. Well reduction with stable fracture fixation is still the goal of treatment to improve the quality of life and decrease morbidity in patients with hip fractures, but this in turn depends on the type of fracture and bone quality. Poor bone quality is responsible for common complications, such as failure of fixation, varus collapse and lag screw cut-out, in elderly patients. Kim et al. found that the complication rate when using conventional DHS in unstable ITFs can be as high as 50% because of screw cut-out. We used the dynamic hip screws (DHS) strengthened by calcium phosphate cement (CPC) for treatment femoral intertrochanteric fracture and review the prognosis of our patients. Materials and Methods. From January of 2011 to January of 2014, 42 patients with femoral intertrochanteric fracture underwent surgery with DHS strengthened by CPC. Comparisons were made between the DHS plus CPC group with the other patients with only DHS used in our department. All patients were followed up for an average time of 14.8(6 to 24) months. X-ray was reviewed for the conditions of union and implant failure. Results. In DHS group, fixation failure happened in 3 case, delayed union and coax varus deformity in 2 cases. IN DHS plus CPC group, all fractures healed uneventfully, there is no non-union or malunion in this group. There is only 1 fixation cut-out and 1 secondary lag screw sliding was noted, however, union was still well over fracture site in this case, the patient had no clinical symptoms. Discussion. Residual bony defects present after DHS fixation in intertrochanteric fracture may lead to postoperative complications, including nonunion or implant failure. DHS strengthened by CPC is reliable fixation for old patients with intertrochanteric fracture, We demonstrated that augmentation of the bony defect with dynamic hip screw by reinforced calcium phosphate cement significantly improved the strength of osteoporotic bone, prevent screw loosening, and promote early healing of fracture. The patients can be decreased the risk of refracture and allow early weight bearing, especially in elderly patients with osteoporotic bone

Introduction. Lag screw cut-out following fixation of unstable intertrochanteric fractures in osteoporotic bone remains an unsolved challenge. A novel new device is the X-Bolt which is an expanding type bolt that may offer superior fixation in osteoporotic bone compared to the standard DHS screw type device. Aims. The aim of this study was to test if there was a difference in cut-out using the X-Bolt implant compared with the standard DHS system. Methods. Specimens of low density surrogate bone (5pcf) were inserted into a simplified biomechanical fracture model and had either an X-Bolt or DHS implant inserted. There were eight samples in each group. The fracture model was tested with an incremental cyclical loading programme in a Material Test System. Displacement, cycle count and force exerted were continuously recorded until cut-out of the implant. Results. All of the specimens failed by varus collapse with superior cut-out and resulted in an automatic stop of the MTS. Specimens with the X-Bolt implant inserted lasted longer on cyclical count and withstood a greater force at cut-out compared with DHS specimens. The mean number of cycles to cutout in the DHS specimens was 4345 and in specimens with the X-Bolt inserted was 6898. The mean force at which cutout occurred in the DHS group was 1.025kN and in specimens with the X-Bolt inserted was 1.275kN. A statistically significant difference was observed with a P-value of 0.005 and a power of 87.2% with respect to cycle count and a P-value of 0.008 and power 84.8% with respect to force exerted at failure when comparing between the two groups. Conclusion. This study shows that the X-Bolt device demonstrated superior cut-out resistance and withstood greater loads compared to the DHS in low density surrogate bone in an unstable fracture model under cyclical axial loading

The aim of this retrospective study was to evaluate the failure rate among different fixation devices for undisplaced fracture neck of femur. All 52 patients with Garden I and II hip fractures who underwent surgery in a teaching hospital in London from January 2007 to June 2012 were included. Electronic patient records were accessed to collect the patient data. There were 52% females and the mean age of patients was 70 years. Thirty patients had cannulated screws, 18 – dynamic hip screw (DHS) with de-rotation screw and 4 had DHS alone. Initial results showed that 36% patients had re-operation. 7(77%) had total hip replacement and 1(11%) had metal work removal. The reason for revision was failure of fixation in 8 (88%) and avascular necrosis in 1 (11%). There was significantly higher failure rate in the DHS with derotation screw group (50%) compared to the cannulated screw group (35%) and the DHS alone group (0%). Average time to planned revision was 11.1 months. Traditionally undisplaced intra capsular hip fractures are treated by in-situ fixation using different devices. Biomechanically DHS with de-rotation screw achieves better rotational and axial stability compared to other fixation devices. However, our study showed a higher failure rate in this group. Inability to achieve a perfectly parallel screw position seems to be a significant factor responsible for high failure. Higher failure rates with fixation may boost the role of replacement arthroplasty as one off surgical treatment in elderly patients

Intra-operative Tip-Apex Distance (TAD) estimation optimises dynamic hip screw (DHS) placement during hip fracture fixation, reducing risk of cut-out. Thread-width of a standard DHS screw measures approximately 12.5 millimetres. We assessed the effect of introducing screw thread-width as an intra-operative distance reference to surgeons. The null hypothesis was that there were no differences between hip fracture fixation before and after this intervention. Primary outcome measure was TAD. Secondary outcome measures included position of the screw in the femoral head, quality of reduction, cut-out and surgeon accuracy of estimating TAD. 150 intra-operative DHS radiographs were assessed before and after introducing screw thread-width distance reference to surgeons. Mean TAD reduced from 19.37mm in the control group to 16.49mm in the prospective group (p=<0.001). The number of DHS with a TAD > 25mm reduced from 14% to 6%. Screw position on lateral radiographs was significantly improved (p=0.004). There were no significant differences in screw position on antero-posterior radiographs, quality of reduction, or rate of cut-out. Significant improvement in accuracy (p=0.05) and precision (p=0.005) of TAD estimation was demonstrated. Awareness and use of screw-thread width improves estimation and positioning of a DHS screw in the femoral head during fixation of hip fractures

The aim of this study was to establish any association between implant cut-out and a Tip Apex Distance (TAD), ≥25mm, in proximal femoral fractures, following closed reduction and stabilisation, with either a Dynamic Hip Screw (DHS) or Intramedullary Hip Screw (IMHS) device. Furthermore, we investigated whether any difference in cut-out rate was related to fracture configuration or implant type. WE conducted a retrospective review of the full clinical records and radiographs of 65 consecutive patients, who underwent either DHS or IMHS fixation of proximal femoral fractures. The TAD was measured in the standard fashion using the combined measured AP and lateral radiograph distances. Fractures were classified according to the Muller AO classification. 35 patients underwent DHS fixation and 30 patients had IMHS fixation. 5 in each group had a TAD≥25mm. There were no cut-outs in the DHS group and 3 in the IMHS group. 2 of the cut-outs had a TAD≥25mm. The 3 cut-outs in the IMHS group had a fracture classification of 31-A2, 31-A3 and 32-A3.1 respectively. In addition, the fractures were inadequately reduced and fixed into a varus position. A TAD<25mm would appear to be associated with a lower rate of cut-out. The cut-out rate in the IMHS group was higher than the DHS group. Contributing factors may have included an unstable fracture configuration and inadequate closed fracture reduction at the time of surgery

A prospective, randomized, controlled trial was performed to compare the outcome of treatment of unstable fractures of the proximal part of the femur with either a sliding hip screw or a short proximal femoral nail antirotation (PFNA-XS, Synthes). Eighty one patients (April 2007 – May 2008) presenting with unstable fracture of the proximal part of the femur were randomized, at the time of admission, to fixation with use of either a short proximal femoral nail antirotation (n=42) or a sliding hip screw (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Follow-up was undertaken at 3, 6, and 12 postoperative months and yearly thereafter. Plain AP and lateral radiographs were obtained at all visits. All changes in the position of the implant, complications, or fixation failure were recorded. Hip range of motion, pain about the hip and the thigh, walking ability score and return to work status were used to compare the outcomes. There was no significant difference between 1 year mortality rates for the two groups. Mean Operative time was significantly less in PFNA group (Mean 25 min, range 19 – 56 min) than DHS group (Mean 38 min, range 28 – 70 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. 6 patients in DHS group had implant failure as compared to none in PFNA group. The functional outcome was also better in PFNA group. When compared to DHS, PFNA-XS provides better functional outcome for unstable trochanteric fractures with less operative time, less blood loss and less complications, however one year mortality rate remains the same

The availability and usage of portable image intensifiers has revolutionised routine orthopaedic practice. Many procedures have become simpler, easier, less invasive and less time-consuming. Extensive use of fluoroscopy can, however, result in significant radiation exposure to operating staff. An accumulated dose of 65 (Sv after multiple exposures has been reported to increase the risk of thyroid cancer many years later. Previous studies have shown that it is possible to exceed this dose during various orthopaedic procedures. Though thyroid shields are extensively available most orthopaedic surgeons do not use them. The present study was aimed at measuring the scattered dose to thyroid during DHS/IMHS for neck of femur fractures and IM nailing for long bone fractures and thereby emphasise the need for operating theatre personnel to wear a thyroid shield. A prospective study of 32 consecutive procedures was carried out. The EDD Unfors dosimeter was used to measure the tissue specific exposure dose to thyroid. Measurements were also obtained from the mobile C-arm fluoroscope unit, which calculated the total number of images and the total dose and duration of radiation for each procedure. Other factors including the grade of surgeon, the total number of theatre personnel wearing the lead gown and/or the thyroid shield and the duration of surgery were also recorded. In 32 procedures, the dose of 65 (Sv was exceeded 13 times; 8 times during DHS/IMHS and 5 times during IMN. The average thyroid dose was 142 (Sv during IMN and 55 (Sv during DHS. Only 9 of 223 (4%) theatre personnel were using a thyroid shield in spite of its availability. The results suggest that the thyroid is frequently exposed to potentially harmful radiation during these procedures. Strict inclusion of a thyroid shield as a part of routine radiation protection is recommended

Introduction. A recent meta-analysis published in the British Medical Journal suggested an increased risk of infection, but none of the studies were large enough to reach statistical significance. A prospective, randomised trial was designed at our institution to investigate the wound healing and complications related to surgery following fracture neck of femur in the elderly. Objectives. The primary aim was to compare the wound problems and infection following two different methods of skin closure: Subcuticular monocryl suture to metal clips for closure of skin. The secondary aim was to look at the duration of surgery after both types of closure. We received ethical approval for this study. We screened and recruited all eligible patients admitted with acute hip fracture undergoing hemi-arthroplasty or dynamic hip screw. We recruited 541 patients in the study over the period of 3.5 years at our institution. Methods. The study was approved by ethics committee. Inclusion Criteria: Age 18 years and above undergoing DHS/ Hemiarthroplasty and with full mental capacity. Exclusion criteria: Patients with no capacity or undergoing Total Hip Replacement or Nailing of femur. The randomisation was done by using the sealed envelopes. The wound review was done on post op days 2, 5, 7, 10 & 14. Results. 516 patients were included in the study. They were divided in to two groups, 252 Hemiarthroplasty and 264 DHS. Average age was 79.48 yrs. (range 31–100 yrs.), 357 Females and 159 males. Total 196 patients were followed up till day 14 and rest of the patients were discharged by the 10. th. post op day. Out of 516 patients, 278 patients had clips and 238 patients had sub cut monocryl suture for the wound closure. The average score was 1.20 (range 1–3) for the wounds (the group of 278 patients) closed with clips mainly due to bruising and oozing. The average score was 0.71(range 0–1) for the wounds (the 238 group of patients) closed with sub cut monocryl mainly due to bruising. We did not find any significant wound infection in either of these groups. Conclusion. The final review of our study showed that the wounds closed with sub cut monocryl had less wound healing issues (average score 0.71) as compared to the wounds closed with clips (average score 1.20)

Aim. This study aimed to identify risk factors for development of deep periprosthetic joint infection (PJI) in patients following surgical treatment of neck of femur fracture. Method. This study identified a consecutive series of 2,822 (2,052 female, 73%) patients who underwent either hemiarthroplasty (n=1,825, 65%) or fixation (DHS) (n=997, 35%) for fractured neck of femur performed between January 2009 and June 2015 at our institution. Full patient demographics, co-morbidity and peri-operative complication data were determined. The majority of patients were either ASA 2 (n=663, 23%) or ASA 3 (n=1,521, 54%), mean age = 81.3 years (SD 10.3). All patients were followed up post-operatively by a dedicated surgical site infection (SSI) monitoring team in order to identify patients who developed a PJI within 1 year. A stepwise multivariable logistic regression model was used to identify patient and surgical factors associated with increased risk of infection. Predictors with a p-value of <0.20 in the univariate analysis were included in the multivariate analysis. Results. Thirty-nine (39) cases of deep periprosthetic infection were identified (hemiarthroplasty n=35, DHS n=4) representing an overall deep infection rate of 1.4% (hemiarthroplasty 1.9%, DHS 0.4%). The most common infecting pathogen was a pure growth of coagulase negative Staphylococcus (n=9, 23%) followed by a pure growth of Staphylococcus aureus (n=7, 18%). An increased risk of PJI was observed in patients who underwent hemiarthroplasty compared to those treated by fixation (odds ratio (OR) 6.50, 95%CI 2.26 – 18.7, p=0.001). Of patient factors, only blood transfusion within 30 days (OR 3.51, 95%CI 1.72 – 7.13, p=0.001) and the presence or development of pressure sores on or during admission (OR 2.99, 95%CI 1.24 – 7.19, p=0.015) were significantly associated with an increased risk of development of PJI. Use of high-dose dual antibiotic cement (gentamicin and clindamycin) was associated with a two-fold reduction in the risk of PJI (OR 0.39, 95%CI 0.20 – 0.76, p=0.005) vs standard dose gentamicin antibiotic cement. Conclusions. This study found: 1) a deep infection rate similar to that reported earlier from large number studies from the UK, 2) a six-fold higher deep infection rate in hemiarthroplasties, compared to internal fixations, and 3) a three-fold higher infection rate in patients who suffer concomitant pressure sores or receive a blood transfusion up to 30 days post-operatively

Recent reports observe that orthopaedic surgeons lack essential knowledge about ionising radiation. We aim to demonstrate perceived use of image-intensifiers by surgeons and awareness of radiation doses used during fractured neck of femur surgery. Surgeons at a regional trauma centre were sent an online questionnaire. They were shown two neck of femur fracture radiographs and asked the total number of images they would use to reduce and fix the fracture with a dynamic-hip-screw / inter-medullary nail respectively. They were asked the maximum safe radiation dose, and that of ‘hip pining’ compared to CXR as outlined by the Ionising Radiation Regulations 1999. For a DHS, consultants and registrars estimate their image use similarly. For IM nailing, consultants estimated higher image use than registrars, and double the number of X-rays taken for IM nailing compared to DHS. Knowledge levels regarding radiation doses during orthopaedic hip procedures are very low. There is an expectation that more images will be used in IM nailing procedures. We plan to educate orthopaedic surgeons about radiation dose and safety. Correlating our findings with actual use of image in theatre when performing hip fracture surgery would extend the use of this study

Aims

The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery.

In June 2012 the Orthopaedic Speciality Advisory of the Joint Committee on Surgical Training defined ‘minimum indicative numbers’ that trainees would have to meet before completion of specialist training. It has been speculated that regions have varied in their ability to provide operative opportunities to their trainees. This study aims to test the hypothesis that there are regional differences in operative training experience. The eLogbook database was interrogated for cases over a 12 month period from 7 August 2013 to 5 August 2015. Within each region, the mean of the cases registered by orthopaedic trainees in each year of training during the study period was calculated and summed to give a representative surgical experience for the years ST3-8. First surgeon only cases were analysed for 11 index procedures in 30 T&O rotations. Considerable variation in training existed across rotations. In three index procedures, including DHS, no rotation achieved the minimum indicative number required. All rotations achieved the minimum indicative number of external fixator applications. This study proves the extent of the significant regional variation in surgical training in Trauma and Orthopaedics in the UK and raises concerns regarding the volume of operative training currently achieved

Hemiarthroplasty and proximal femoral fixation are common procedures performed in trauma units, but there is very little information regarding post-operative pain experience. Pain control is a keystone in the successful management of hip fractures. A sound strategy of pain management is easier to implement in patients where pain levels can be predicted, allowing for an effective balanced analgesic regime. Analysis was performed on patients presenting with a hip fracture in two hospitals. Patients with a diagnosis of dementia were excluded. Post-operative pain scores were taken from patient observation charts using a verbal analogue scale. Post-operative opiate consumption was calculated from inpatient drug charts. 357 patients were included, 205 patients underwent a cemented hemiarthroplasty (HG) and 152 had fixation with a dynamic hip screw (DG). No significant difference was found in the length of hospital stay. HG patients recorded a mean morphine requirement of 20.2mg compared with 40.3mg for the DG group. Although the early pain score difference was significant (p=0.009), after 4 days, the scores were equivalent. This may support the notion of non-surgical factors determining the total length of hospital stay. The reason for the elevated pain scores and higher morphine requirement in the DHS group remains unclear. One theory is the fracture site still exists, and it is possible that pre-existing hip arthritis may continue to be symptomatic. It is important to recognise the difference in pain experienced between the groups and analgesia should be tailored towards the individual, allowing for improved peri-operative surgical care and patient experience

Introduction. The aim of the study was to analyze the outcome of AO cannulated screws for fractures neck of femur at our institute. Methods. 412 patients (101 males/311 females) who underwent AO screws for fracture neck of femur over 5 years (2000 -2004) and followed-up for a minimum of 2 yrs formed the study population. A retrospective review of data from electronic patient record (EPR), clinical coding, clinic and GP letters was made. Age, residential placement, Garden's classification, mode of injury, associated comorbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. Reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions were critically analysed. Post-op physiotherapy, proportion of patients sustaining contra-lateral fracture NOF and its management and mortality statistics were reviewed. Results. The mean age of patients was 68 yrs (range 18-96 yrs). Mean length of stay in hospital was 12.3 days (range2- 51 days) and mean time to operate from admission was 51 hrs (median 24 hrs). Second Surgery in form of hemiarthroplasty was required in 36, DHS in 7, Implant removal in 15 and Total hip replacement in 29 patients. Non-union occurred in 25 pts (7.93%)and avascular necrosis (AVN) in 61 Pts (19.36%) and overall 2 years mortality rate was 66 pts(16%). Conclusion. AVN and Non union was high in patients with displaced fractures, patients more than 80 yrs and patients with co-morbidities like Renal Failure, Diabetes Mellitus, Osteoporosis and Steroid intake etc. Outcome is influenced by complex interplay of multiple factors so we should treat the physiological age and not the chronological age

Introduction. There is conflicting evidence in the literature regarding outcome of patients living in their own home prior to a fracture neck of femur, when using discharge destination and rehabilitation as measures of outcome. We investigated the factors predicting outcome following neck of femur (NOF) fractures, in patients previously living in their own home. Method. Medical records of all 292 patients admitted to Royal Derby Hospital between January and October 2010 with a fractured NOF (who lived in their own home prior to admission) were obtained retrospectively. Data included patient demographics; type of surgical intervention; mobility status and level of independence before admission; nature of fracture and patients' ASA grade. Outcome measures including: number of days spent in hospital; number of days spent in rehabilitation; mortality; mobility on discharge; and discharge destination, were also sought. Data was analysed using SPSS Version 18. Results. On discharge from the trust 101 (34.6%) patients returned to their own home. Twelve patients died before discharge from the trust. 5 patients (1.7%) needed nursing home care and one patient (0.3%) needed residential home care. Prior to their fracture 164 (56.2%) patients were able to walk indoors with no aids, which dropped dramatically to four (1.4%) patients at discharge.150 patients needed a median number of 28 days of extended rehabilitation period. Higher pre-operative ASA grades were associated with a higher median number of days spent in hospital. Conclusion. A delay in surgery due to the patient being medically unfit was associated with a longer hospital stay, delay in surgery for administrative and logistical reasons however did not increase the median number of days spent in hospital. A longer extended rehabilitation period was associated with internal fixation with DHS/IM Nail, a higher pre-operative ASA grade, and a greater number of days from fracture to mobilisation

Epidemiologic studies project an increase of hip fractures worldwide. They are an important cause of morbidity and mortality in the elderly and represent an increasing burden on a country's health service. The aim of the study was to evaluate the mortality of hip fractures admitted to a regional hospital in Australia and calculate the relative risk ratio of morbidity variables on mortality. This retrospective review included all patients admitted from 2003 to 2008 to a regional Queensland hospital with a hip fracture. The relative risk ratio for the probability of death was calculated for the following variables: previous mobility (independent, home with help, nursing home), type of treatment (hemiarthroplasty, ORIF, DHS/Nail, total hip arthroplasty, conservative), ASA, comorbidities (dementia, hypertension, cardiac, respiratory, renal, previous hip fractures, diabetes), pre-operative haemoglobin, BUN ratio, length of stay, operative time, anaesthetic time and type (general, spinal) and, gender. A total of 211 patients (136 female, 75 male) with an average age of 79.1 years were admitted. Seventy-six patients died during the specified interval. The average 30 day mortality was 6.2% and the average time of survival was 318 days. The relative risk of death was above one for the following variables: female gender 1,16; nursing home 1,11; more than 1 comorbidity 1,38; more than 4 comorbidities 1,78; dementia 1,12; diabetes 1,3; hypertension 1,35, previous fractures 1,43; ASA 4 1,5; operating time more than 120 minutes 7,4; length of stay more than 20 days 2,16, BUN ratio>0.1 1,38 and BUN ration<0.04 1,78. This retrospective project identified a number of variables influencing mortality of hip fractures. These results demonstrate that the relative risk substantially increases with length of surgical time, length of hospital stay in excess of 20 days and more than four associated comorbidities