Background. Prosthetic implants used in primary total hip replacements have a range of bearing surface combinations (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, metal-on-metal); head sizes (small <36mm, large 36mm+); and fixation techniques (cemented, uncemented, hybrid, reverse hybrid), which influence prosthesis survival, patient quality of life, and healthcare costs. This study compared the lifetime cost-effectiveness of implants to determine the optimal choice for patients of different age and gender profiles. Methods. In an economic decision Markov model, the probability that patients required one or more revision surgeries was estimated from analyses of UK and Swedish hip joint registries, for males and females aged <55, 55–64, 65–74, 75–84, and 85+ years. Implant and healthcare costs were estimated from hospital procurement prices, national tariffs, and the literature. Quality-adjusted life years were calculated using utility estimates, taken from Patient-Reported Outcome Measures data for hip procedures in the UK. Results. Optimal choices varied between traditionally used cemented metal-on-polyethylene and cemented ceramic-on-polyethylene implants. Small head cemented ceramic-on-polyethylene implants were optimal for males and females aged under 65. The optimal choice for adults aged 65 and older was small head cemented metal-on-polyethylene implants. Conclusions. The older the patient, the higher the probability that small head cemented metal-on-polyethylene implants are optimal. Small head cemented ceramic-on-polyethelyne implants are optimal for adults aged under 65. Our findings can influence NICE guidance, clinical practice, and commissioning of services. Funding. NIHR Research for Patient Benefit programme PB-PG-0613-31032

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

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

Recent NICE guidance recommends use of a well proven cemented femoral stem for hip hemiarthroplasty in management of fractured neck of femur. The Exeter Trauma Stem (ETS) has been designed based on the well proven Exeter hip stem. It has a double taper polished stem design, proclaimed to share geometry and surface finish with the Exeter hip. This study investigated the surface finish of the two stems in order to investigate the hypothesis that they were different. Two ETS and two Exeter stems were examined using a profilometer with a sensitivity of one nanometer. Macroscopic visual inspection showed that the two Exeter stems had significantly smoother surface finish than the ETS stems. The roughness average (RA) values on the ETS stems were approximately an order of magnitude higher than those of the Exeter stems, mean of 0.235μm compared with 0.025μm (p<0.0001). This difference in surface finish has implications for the biomechanical functioning of the stem. Previous change of the Exeter stem to a matt surface-finish in 1976 resulted in a significant increase in stem failure rates and an understanding of the importance of the polished surface-finish in order to function within a taper-slip philosophy. By changing the surface finish in the ETS stem, longevity of the implant may similarly be affected. Clinical results have yet to be published demonstrating this. We recommend the manufacturer reconsiders the surface finish of the ETS stem to ensure it functions as well as the Exeter primary stem with which it shares a design philosophy

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

Objectives

To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice.