Controversy exists whether to treat unstable pertrochanteric hip fractures with either intra-medullary or extra-medullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw or long Gamma Nail. The hypothesis was that there is no difference in outcome between the two modes of treatment. Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2) were recruited into the study. Eligible patients were randomised on admission to either long Gamma Nail or sliding hip screw. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure or ‘cut-out’. Secondary measures included mortality, length of hospital stay, transfusion rate, change in mobility and residence, and EuroQol outcome score. Five patients required revision surgery for implant cut-out (2.5%), of which three were long Gamma Nails and two were sliding hip screws (no significant difference). There were no incidences of implant failure or deep infection. Tip apex distance was found to correlate with implant cut-out. There was no statistically significant difference in either the EuroQol outcome scores or mortality rates between the two groups when corrected for mini mental score. There was no difference in transfusion rates, length of hospital stay, and change in mobility or residence. There was a clear cost difference between the implants. The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur

Awareness that minimising tip apex distance (TAD) when inserting a sliding hip screw reduces the risk of screw cut out is important for orthopaedic trainees. The advent of the Picture Archive and Communication System (PACS) has made the accurate measurement of TAD from x-rays and image intensifier films much easier. This study was to determine whether TAD would be reduced if a surgeon knew that his performance was being continually monitored. 31 consecutive cases of sliding hip screw insertion by a single group of surgeons were identified and the TAD measured. The mean TAD was 16.11mm (8.87mm-25.47mm). The same surgeons were then re-educated as to the importance of the TAD and informed that their results would be monitored and discussed. The next 34 consecutive cases were collected prospectively. The mean TAD in these cases was 13.83mm (6.72mm-21.51mm). There was a significant difference between the TAD for the two groups using the two-tailed t-test (p=0.034). There was one implant failure in the pre education group and none in the post education group. These results suggest that awareness of surveillance improves surgical performance even if the importance of the variable being assessed is already known

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

Internal fixation is currently the standard of care for Garden I and II femoral neck fractures in the elderly. However, there may be a degree of posterior tilt on the preoperative lateral radiograph above which failure is likely, and primary arthroplasty would be preferred. The purpose of this study was to determine the association between posterior tilt and the risk of subsequent arthroplasty following internal fixation of Garden I and II femoral neck fractures in the elderly. This study represents a secondary analysis of data collected in the FAITH trial, an international multicenter randomized controlled trial comparing the sliding hip screw to cannulated screws in the management of femoral neck fractures in patients aged 50 years or older. For each patient who sustained a Garden I or II femoral neck fracture and had an adequate preoperative lateral radiograph, the amount of posterior tilt was categorized as < 2 0 degrees or ≥20 degrees. Multivariable Cox proportional hazards analysis was used to assess the association between posterior tilt and subsequent arthroplasty during the two-year follow-up period, while controlling for potential confounders. Of the 555 patients in the study sample, posterior tilt was classified as ≥20 degrees for 67 (12.1%) and < 2 0 degrees for 488 (87.9%). Overall, 13.2% (73/555) of patients underwent subsequent arthroplasty in the 24-month follow-up period. In the multivariable analysis, patients with posterior tilt ≥20 degrees had a significantly increased risk of subsequent arthroplasty compared to those with posterior tilt < 2 0 degrees (22.4% (15/67) vs 11.9% (58/488), Hazard Ratio (HR) 2.22, 95% confidence interval (CI) 1.24–4, p=0.008). The other factor associated with subsequent arthroplasty was age ≥80 (p=0.03). In this study of patients with Garden I and II femoral neck fractures, posterior tilt ≥20 degrees was associated with a significantly increased risk of subsequent arthroplasty. Primary arthroplasty should be considered for Garden I and II femoral neck fractures with posterior tilt ≥20 degrees, especially among older patients

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end-stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels Type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilisation with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

The Radiographic Union Score for Hip (RUSH) is an outcome instrument designed to describe radiographic healing of femoral neck fractures. The ability to identify fractures that have not healed is important for defining non-union in clinical trials and predicting patients that likely require additional surgery to promote fracture healing. We sought to determine a RUSH threshold score that defines nonunion at 6-months post-injury. Our secondary objective was to determine if this threshold was associated with increased risk for non-union surgery. A sample of 248 patients with adequate six-month hip radiographs and complete two-year clinical follow-up were analysed from a multi-national hip fracture trial (FAITH). All patients had a femoral neck fracture and were treated with either multiple cancellous screws or a sliding hip screw. Two reviewers independently determined the RUSH score based on the six-month post-injury radiographs, and agreement was assessed using the Interclass Correlation Coefficient (ICC). Fracture healing was determined by two independent methods: 1) prospectively by the treating surgeon using clinical and radiographic assessments, and 2) retrospectively by a Central Adjudication Committee using radiographs alone. Receiver Operator Curve analysis was used to define a RUSH threshold score that was specific for fracture nonunion. RUSH score inter-rater agreement was high (ICC: 0.81, 95% CI 0.76 to 0.85). The mean six-month RUSH score for all included patients was 24.4 (SD 3.4). A threshold score of <18 was associated with a greater than 98% specificity for nonunion. Furthermore, patients with a six-month RUSH score below 18 were more the seven-times more likely to require revision surgery for nonunion (Relative Risk: 7.25, 95% CI 2.62 to 20.00). The six-month RUSH score can effectively be used to communicate when a femoral neck fracture has not healed. The validity of our conclusions was further supported by the increased risk of nonunion surgery for patients below the RUSH threshold. We believe our findings can standardise a definition of nonunion for clinical trials and recommend the use of the RUSH and its <18-point threshold when describing femoral neck nonunion

Fractures of the proximal femur at the level of the lesser trochanter (reversed and transverse fracture lines, Evans classification type II, AO classification A3 fractures) are known to have an increased risk of fixation failure. 58 patients with such a fracture were randomised to have the fracture fixed with either an intramedullary nail (220 mm Targon PF 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 50 minutes for the nail versus 52 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 18 days for the nail group versus 29 days for those treated with the SHS. The only fracture healing complications were one case of cut-out in the SHS group and two cut-outs in the nail group, two of which required revision surgery. During follow-up those patients treated with the nail reported a tendency to lower pain scores than those treated with the SHS (p=0.04 at two months). This difference persisted even at one year from injury. Mortality and regain of mobility was similar between groups. These results indicate that for these difficult fractures types both types of fixation produce comparable outcomes

Introduction. Intracapsular hip fractures in young adults are treated with internal fixation, often as a surgical emergency to reduce the vascular insult to the femoral head. Avascular necrosis and non-union often require revision surgery. Methods. A prospective trauma database was retrospectively searched from 1. st. August 2008 to 31. st. December 2010. Intracapsular hip fracture admissions to the Regional Trauma Centre, in adults under sixty-five years, were studied. Ninety-eight intracapsular fractures internally fixed with sliding hip screw underwent radiographic review for quality of fixation, and evidence of complications at a mean of thirteen months. Co-morbid medical conditions and quality of fixation were assessed for association with revision rates. Results. Avascular necrosis developed in eighteen fractures, and seven proceeded to non-union. Seventeen of ninety-eight fractures underwent revision to total hip arthroplasty. Three individuals were deceased at final review. Six of thirty-four fractures (18%) fixed within twelve hours of injury required revision, compared with eleven of sixty-four (17%) fixed after twelve hours. None of the four fractures fixed within six hours required revision, although this was not statistically significant (p=0.32). Revision was required for three of six individuals with chronic respiratory disease (50%) excluding asthma, one of two with rheumatoid arthritis (50%), and three of six with varus reduction (50%), and each were significant on multiple regression. Residual translation and eccentric screw placement approached significance on chi-squared analysis. Only two of twenty (10%) fractures fixed using an additional anti-rotation screw required revision. Conclusions. Internal fixation of intracapsular hip fractures within twelve hours in young adults did not statistically reduce revision rates. Accurate reduction and internal fixation is paramount, and anti-rotation screws may reduce complication rates. Certain co-morbid conditions predict revision, and should be taken into consideration when selecting the primary operative procedure

The last decade has seen a rise in the use of the gamma nail for managing inter-trochanteric and subtrochanteric hip fractures. Patients with multiple co-morbidities are under high anaesthetic risk of mortality and are usually not suitable for general or regional anaesthesia. However, there can be a strong case for fixing these fractures despite these risks. Apart from aiming to return patients to their pre-morbid mobility, other advantages include pain relief and reducing the complications of being bed bound (e.g. pressure ulcers, psychosocial factors). While operative use of local anaesthesia and sedation has been documented for insertion of extra-medullary femoral implants such as the sliding hip screw, currently no literature is present for the insertion of the gamma nail. We studied intra-operative and post-operative outcomes of three patients aged between 64 and 83 with right inter-trochanteric hip fractures and American Society of Anesthesiologists (ASA) scores of 4 or more. Consent for each case was obtained after discussion with the patient and family, or conducted with the patient's best interests in mind. All patients received a short unlocked gamma nail, and were operated on within 24 hours of admission. Each patient underwent local injections of Bupivacaine or Lignocaine or both, with Epinephrine, and with one patient receiving nerve block of the fascia iliaca. Each patient received a combination of sedatives under the discretion of the anaesthetist including Midazolam, Ketamine, Propofol, Fentanyl, and/or Haloperidol. Operating time ranged from 30–90 minutes. Patients were managed post-operatively with analgesia based on the WHO pain ladder and physiotherapy. Our results showed no intra-operative complications in any of the cases. All patients noted improvement in their pain and comfort post-operatively without complications of the operation site. Two patients achieved their pre-morbid level of mobility after undergoing physiotherapy and were subsequently discharged from the orthopaedic team. One patient with ongoing pre-operative medical complications died 5 days after the operation. This study provides a glimpse into the use of local anaesthetic and sedation on high operative risk patients, and this may be a viable alternative to extra-medullary implants or non-operation. Further research is needed to quantify the risks and benefits of operating within this patient group

Introduction. Total knee arthroplasty is effective for the management of osteoarthritis of the knee. Conventional techniques utilizing manual instrumentation (MI) make use of intramedullary femoral guides and either extramedullary or intramedullary tibial guides. While MI techniques can achieve excellent results in the majority of patients, those with ipsilateral hardware, post-traumatic deformity or abnormal anatomy may be technically more challenging, resulting in poorer outcomes. Computer-assisted navigation (CAN) is an alternative that utilizes fixed trackers and anatomic registration points, foregoing the need for intramedullary guides. This technique has been shown to yield excellent results including superior alignment outcomes compared to MI with fewer outliers. However, studies report a high learning curve, increased expenses and increased operative times. As a result, few surgeons are trained and comfortable utilizing CAN. Patient-specific instrumentation is an alternative innovation for total knee arthroplasty. Custom guide blocks are fabricated based on a patient's unique anatomy, allowing for the benefits of CAN but without the increased operative times or the high learning curve. In this study we sought to evaluate the accuracy of PSI techniques in patients with previous ipsilateral hardware of the femur. Methods. After reviewing our database of 300 PSI total knee arthroplasty patients, 16 were identified (10 male, 6 female) using the Zimmer NexGen Patient Specific Instrumentation System. Fourteen patients included in the study had a preexisting total hip arthroplasty on the ipsilateral side [Figure 1], 1 had a sliding hip screw, and 1 patient had a cephalomedullary nail. Postoperative mechanical axis alignment measurements were performed using plain long-standing radiographs [Figure 2]. The American Knee Society Score was used to evaluate clinical outcomes postoperatively. Results. Sixteen total knee arthroplasties were performed using PSI, all in the setting of previous ipsilateral hardware placement. The average age at the time of surgery was 72, with patients ranging from 56 to 85 years of age [Table 1]. 11 of the included knees had a preoperative varus alignment and 5 had valgus alignment. The average value of a deformity identified via the preoperative planning software was 7.9°(1.5°–15.7°). The average value of a deformity identified via preoperative radiographs was 10.1°(2.2°–14.7°). Average postoperative mechanical axis was 3.1° (1°–5.3°) measured from plain radiographs. Average angle between the FMA and femoral component was 90.0° (85.3°–94.1°). The average angle between the TMA and tibial component was 90.6°(87.6°–92.9°). The average difference between the femoral mechanical and anatomic axes was 5.9°(3.4°–7.0°). The average discrepancy between medial and lateral joint space on an anterior-posterior standing radiograph was 0.4mm(0.0mm–1.1mm). At an average of 4.5 months follow-up, American Knee Society knee scores show an aggregate average score of 82.94. Conclusions. Patient specific instrumentation (PSI) is an innovative technology in TKA that replaces the use of intramedullary femoral guides and either extramedullary or intramedullary tibial guides. This study demonstrates that PSI is capable of producing favorable radiographic and clinical outcomes despite preexisting ipsilateral hardware, which may otherwise preclude the use of customary manual instrumentation. We believe PSI is an accurate and effective tool for use in patients with preexisting ipsilateral hardware

Introduction:. Total knee arthroplasty (TKA) is an effective operation for the management of osteoarthritis of the knee. Conventional technique utilizing manual instrumentation (MI) allows for reproducible and accurate execution of the procedure. The most common techniques make use of intramedullary femoral guides and either extrameduallary or intrameduallary tibial guides. While these methods can achieve excellent results in the majority of patients, those with ipsilateral hardware, post-traumatic deformity or abnormal anatomy may preclude the accurate use of these techniques. Patient-specific instrumentation (PSI) is an alternative innovation for total knee arthroplasty. Utilizing magnetic resonance imaging (MRI) or computed tomography (CT), custom guide blocks are fabricated based on a patient's unique anatomy. This allows for the benefits of computer assisted navigation (CAN) but without the increased operative times or the high learning curve associated with it. Furthermore it allows the use of familiar cutting blocks and guides to check the accuracy of the PSI guide blocks. In this study we sought to evaluate the accuracy of PSI techniques in patients with previous ipsilateral hardware, which would make the use of MI technically challenging and possibly subject to inaccuracy. Methods:. After reviewing our database of 300 PSI total knee arthroplasty patients, 16 patients were identified (10 male, 6 female) using the Zimmer NexGen Patient Specific Instrumentation System. Fourteen patients included in the study had a preexisting total hip arthroplasty on the ipsilateral side, 1 had a preexisting sliding hip screw, and 1 patient had a preexisting cephalomedullary nail. Postoperative mechanical axis alignment measurements were performed using plain long-standing radiographs. The American Knee Society Score was used to evaluate clinical outcomes postoperatively. Results:. Sixteen total knee arthroplasties were performed using PSI, all in the setting of previous ipsilateral hardware placement. The average age at the time of surgery was 72, with patients ranging from 56 to 85 years of age. Eleven of the included knees had a preoperative varus alignment and 5 had valgus alignment. The average value of a deformity identified via the preoperative planning software was 7.85°. The average value of a deformity identified via preoperative radiographs was 10.1°. Average postoperative mechanical axis was 3.1° measured from plain radiographs. Average angle between the femoral mechanical axis and femoral component was 90.0°. The average angle between the tibial mechanical axis and tibial component was 90.6°. The average difference between the femoral mechanical and anatomic axes was 5.9°. The average discrepancy between medial and lateral joint space on an anterior-posterior standing radiograph was 0.4 mm. At an average of 4.5 months follow-up, American Knee Society knee scores show an aggregate average score of 82.94. Conclusion:. Patient specific instrumentation is an innovative technology in TKA that replaces the use of intramedullary femoral guides and either extramedullary or intramedullary tibial guides. This study demonstrates that PSI is capable of producing favorable radiographic and clinical outcomes despite preexisting ipsilateral hardware, which may preclude the use of customary manual instrumentation. We believe PSI is an accurate and effective tool for use in patients with preexisting ipsilateral hardware

It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts.

Cite this article: Bone Joint Open 2020;1-6:198–202.

Aims

COVID-19 has changed the practice of orthopaedics across the globe. The medical workforce has dealt with this outbreak with varying strategies and adaptations, which are relevant to its field and to the region. As one of the ‘hotspots’ in the UK , the surgical branch of trauma and orthopaedics need strategies to adapt to the ever-changing landscape of COVID-19.

We report the results of six trauma and orthopaedic projects to Kenya in the last three years. The aims are to deliver both a trauma service and teaching within two hospitals; one a district hospital near Mount Kenya in Nanyuki, the other the largest public hospital in Kenya in Mombasa. The Kenya Orthopaedic Project team consists of a wide range of multidisciplinary professionals that allows the experience to be shared across those specialties. A follow-up clinic is held three months after each mission to review the patients. To our knowledge there are no reported outcomes in the literature for similar projects.

A total of 211 operations have been performed and 400 patients seen during the projects. Most cases were fractures of the lower limb; we have been able to follow up 163 patients (77%) who underwent surgical treatment. We reflect on the results so far and discuss potential improvements for future missions.