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.

Abstract

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

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

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

Aims

Despite the COVID-19 pandemic, incidence of hip fracture has not changed. Evidence has shown increased mortality rates associated with COVID-19 infection. However, little is known about the outcomes of COVID-19 negative patients in a pandemic environment. In addition, the impact of vitamin D levels on mortality in COVID-19 hip fracture patients has yet to be determined.

Aims

We aim to objectively assess the impact of COVID-19 on mean total operative cases for all indicative procedures (as outlined by the Joint Committee on Surgical Training (JCST)) experienced by orthopaedic trainees in the deanery of the Republic of Ireland. Subjective experiences were reported for each trainee using questionnaires.