Objectives

Acetabular fractures with quadrilateral plate involvement have been shown to have a high rate of complications. Anatomic suprapectineal plating systems have been developed to manage these injuries with good short-term outcomes, however long-term maintenance of anatomical reduction and functional outcomes is yet to be established. Efficacy of maintenance of reduction and functional outcomes at a minimum of 5-years follow-up is the aim of this study.

Traditionally, unstable anterior pelvic ring injuries have been stabilised with an external fixator or by internal fixation. Recently, a new percutaneous technique of placement of bilateral supraacetabular polyaxial screws and subcutaneous connecting bar to assemble an “internal fixator” has been described.

We present the surgical technique and early clinical results of using this technique in twenty-five consecutive patients with a rotationally unstable pelvic ring injury and no diastasis of the symphysis pubis treated between April 2010 and December 2013. Additional posterior pelvic stabilisation with percutaneous iliosacral screws was used in 23 of these patients. The anterior device was routinely removed after three months.

Radiological evidence of union of the anterior pelvic ring was seen in 24 of 25 patients at a minimum 6 month follow-up. Thirteen patients developed sensory deficits in the lateral femoral cutaneous nerve (five bilateral) and only one fully recovered.

The anterior pelvic internal fixator is a reliable, safe and easy percutaneous technique for the treatment of anterior pelvic ring injuries, facilitating the reduction and stabilisation of rotational displacement. However, lateral femoral cutaneous nerve dysfunction is common. The technique is recommended in cases with bilateral or unilateral pubic rami fractures and no diastasis of the symphysis pubis.

Stable, anatomical fixation of acetabular fractures gives the best chance of a good outcome. We performed a biomechanical study to compare fracture stability and construct stiffness of three methods of fixation of posterior wall acetabular fractures.

Two-dimensional motion analysis was used to measure fracture fragment displacement and the construct stiffness for each fixation method was calculated from the force / displacement data.

Following 2 cyclic loading protocols of 6000 cycles, to a maximum 1.5kN, the mean fracture displacement was 0.154mm for the rim plate model, 0.326mm for the buttress plate and 0.254mm for the spring plate model. Mean maximum displacement was significantly less for the rim plate fixation than the buttress plate (p=0.015) and spring plate fixation (p=0.02).

The rim plate was the stiffest construct 10962N/mm (SD 3351.8), followed by the spring plate model 5637N/mm (SD 832.6) and the buttress plate model 4882N/mm (SD 387.3).

Where possible a rim plate with inter-fragmentary lag screws should be used for isolated posterior wall fracture fixation as this is the most stable and stiffest construct. However, when this method is not possible, spring plate fixation is a safe and superior alternative to a posterior buttress plate method.

Aim

To determine the rate of recurrence of coronal plane deformity in children treated with ‘guided growth’ using 8-plates, from the time of implant removal to skeletal maturity.

Introduction

Pelvic and acetabular injuries are relatively rare and surgical reconstruction usually occurs only in specialist centres. As part of their work up there is a local protocol for radiological investigations including Judet oblique views for acetabular fractures, pelvic inlet and outlet for pelvic ring fractures and urethrograms for sustaining anterior pelvic injury. The aim of this service evaluation was to assess whether patients had these radiological investigations prior to transfer.

The literature is filled with reports of various studies identifying perioperative factors that adversely affect survival. The aim of this study was to identify perioperative factors associated with an increased risk of death at 5 years.

All patients admitted to our unit in 2002 with a proximal femoral fracture were included. Demographic details, physiological parameters and biochemical parameters on admission were documented. Survival data at five years was available for all patients and was used to perform survival analyses. 633 patients with a proximal femoral fracture were admitted to our unit between January 2002 to December 2002. Data for all patients was available for analysis. There were 118 men and 515 women, M:F =1:1.4. Average age of the patients was 81.2±9.4 years (range 45–105 years).

Univariate analysis showed that patient age, mental test score, number of days delayed to surgery, number of comorbidities, ASA grade, if the patient lived in an institution, had a previous stroke, suffered from congestive cardiac failure or valvular heart disease, heart rate, serum haemoglobin, serum urea and whether the patient developed a post operative complication were all significant factors that affected survival. Multivariate analysis showed that mental test score (Exp B=0.939 95%CI=0.901–0.978 p= 0.002), age (Exp B = 1.031 95%CI= 1.004–1.058 p= 0.025) and ASA grade (Exp B = 1.458 95%CI= 1.039–2.046 p= 0.029) were all independent variables that affected five year survival.

Various independent factors affect five year survival in patients with proximal femoral fracture. It is important that these factors are identified firstly, so that patients and relatives can be given information about survival and secondly, so that high risk patient groups can be allocated adequate resources in order that their peri and postoperative care is optimised. This may improve outcome in these subgroups of patients.

It is has been suggested that as a result of the skewed age distribution, the incidence of hip fracture will increase disproportionately among Asians. The epidemiology of hip fracture among the Asian and White populations in Leicestershire the five year survival between the two groups was investigated.

All patients in Leicestershire with hip fracture between 2001–2 were studied. Demographic data, type of fracture, and treatment was recorded. Ethnic origin was noted as White, Asian, or other. Survival at 5 years was documented as number of days survived. The results were analysed statistically.

On thousand one hundred and thirty-four patients were admitted to our unit with hip fracture, 617 intracapsular fractures and 517 extracapsular fractures. Leicestershire Census data in 2002 showed that 85.7% of the population was white, 11.9% Asian and the remaining 2.4% of other ethnic group. The percentage of Asians > 65 years was 8.8% compared to 18.9% of whites. The number of Asian patients < 65 years with a hip fracture was significantly greater than the number of whites < 65 years (p =0.002, Fishers exact test). Five year survival of Asian patients < 65 years with hip fracture was significantly lower than white counterparts in the same age group (p = 0.002)

Over the last decade there has been a 30% increase in the Asian population in Leicestershire (9.3% to 11.9%). The proportion of Asians over 65 years doubled over the last decade from 4.3% to 8.8%. The proportion of Whites over 65 years increased from 16.3% to 18.9%. The 5 year survival of Asians with hip fracture under 65 years old is significantly reduced when compared to Whites. This suggests that Asians under the age of 65 years that sustain hip fracture may have other risk factors that may contribute to their earlier demise.

Clopidogrel, an anti-platelet agent is used in the secondary prevention of ischaemic events in high risk patients. Recent studies suggest that there are no National guidelines on when to stop clopidogrel in patients with hip fracture. It is suggested that stopping clopidogrel and waiting up to 1 week or more before surgery may have adverse effects on the patient.

This study is aimed at identifying factors predicting outcome in these patients. All patients admitted to our unit in 2006 with proximal femoral fracture were included. Patients on clopidogrel were identified for further investigation. Demographic, perioperative and postoperative data including complications and death were documented.

Thirty one of 586 patients with proximal femoral fracture were on clopidogrel on admission. Mean delay to surgery was 8.4 days (range 2–16 days SD 2.5). The mean age was 81 years (64–97) with a male to female ratio of 1:2.4. Of the 31 patients, 8 (25.8%) had died at 1 year. The standardised mortality ratio was higher in patients less than 65 years old and lower in all patients over 65 years.

Significant predictors of death on univariate analysis at one year were spinal anaesthesia (p = 0.04), postoperative blood transfusion (p = 0.03), postoperative complication (p = 0.03) and delay to surgery (p = 0.03). There was a positive correlation between delay to surgery and developing a postoperative complication (Pearson’s correlation 0.33 p = 0.04). Multivariate analysis revealed that delay to surgery was the only independent factor predicting death at one year.

No evidence exists to suggest that clopidogrel should be stopped 1 week prior to surgery for proximal femoral fracture. Waiting for 1 week or more prior to surgery is directly correlated to developing postoperative complications and subsequent death at one year.

We examined rates of MRSA wound infection in patients admitted to the Leicester Royal Infirmary Trauma Unit between January 2004 and June 2006. The influence of MRSA status at the time of their admission, together with age, sex and diagnosis were examined using multivariant analysis.

3.2%(79/2473)) were MRSA carriers at time of admission and 96.8%(2394/2473) were MRSA negative. Those carrying MRSA at the time of admission were more likely to develop MRSA surgical site infections [8.8% (7/79)] as compared to non MRSA carrier at the time of admission [2.2% (54/2394), p< 0.001]. Further analysis revealed that hip fracture and increasing age (linear increase in relative risk of 1.8% per year) were also risk factors.

MRSA carriage at admission, age and pathology are all associated with an increased rate of developing MRSA wound infections. Identification of such risk factors at admission helps to target health care resources such as the use of glycopeptides at induction and increased vigilance for wound infection in the post operative phase

We examined the incidence of infection with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to the Leicester Royal Infirmary Trauma Unit between January 2004 and June 2006. The influence of MRSA status at the time of their admission was examined, together with age, gender and diagnosis, using multi-variant analysis. Of 2473 patients, 79 (3.2%) were MRSA carriers at the time of admission and 2394 (96.8%) were MRSA-negative. Those carrying MRSA at the time of admission were more likely to develop surgical site infection with MRSA (7 of 79 patients, 8.8%) than non-MRSA carriers (54 of 2394 patients, 2.2%, p < 0.001). Further analysis showed that hip fracture and increasing age were also risk factors with a linear increase in relative risk of 1.8% per year.

MRSA carriage at admission, age and the pathology are all associated with an increased rate of developing MRSA wound infection. Identification of such risk factors at admission helps to target health-care resources, such the use of glycopeptide antibiotics at induction and the ‘building-in’ of increased vigilance for wound infection pre-operatively.

Cerebral micro emboli have been noted to occur during both total hip and knee arthroplasty. These micro emboli have been implicated in the causation of postoperative cognitive impairment. The aim of this study was to determine whether cerebral micro emboli occur during hip fracture surgery.

28 patients undergoing hip fracture surgery had transcranial doppler assessment of the middle cerebral artery to detect cerebral micro emboli. Micro embolic signals (MESs) were recorded during the operative procedure.

Successful monitoring was carried out in 26 patients. MES were recorded in 16 out of 26 patients. 12 out of 16 patients who had MESs had undergone a cemented hemiarthroplasty; the remainder had a sliding hip screw for an extracapsular hip fracture. 75% (9/12) of patients who had a cemented hemiarthroplasty had the majority of MESs after reaming and cementing. MESs in the patients who had a sliding hip screw occurred throughout the operative procedure.

Conclusion: Cerebral micro emboli do occur during hip fracture surgery. These emboli may be responsible for the cognitive dysfunction that occurs in this susceptible group of patients.

Introduction The 2002 NCEPOD report recommended that autopsies should be the subject of a formal external audit process. It is thought that a post mortem would improve the understanding of the pathological events leading up to the death of a patient. The aims of this study were to find out the number of post mortems requested for patients with hip fracture and to establish the cause of death of all hip fracture patients as documented on the death certificate by medical practitioners and the coroner.

Patients and Methods A retrospective review of all hip fracture deaths in the year 2000 was performed. The number of cases referred to the coroner for a post mortem and the given verdict was documented. Data regarding the cause of death (as per part 1a on the death certificate) recorded by the medical practitioner and the coroner was established.

Results 83 patients with a hip fracture died in hospital in 2000 (mean age 83.6 years, range 58–97 years). There were 30 male and 53 female deaths. 37 patients (44.6%) were referred to the coroner for a post mortem examination. The common causes of death documented by the medical practitioner were: Bronchopneumonia; 27.9%, Congestive cardiac failure; 11.6%, Left ventricular failure; 9.3%, Cerebrovascular accident; 14%, and Carcinomatosis; 4.6%. The common causes of death documented by the coroner were: Bronchopneumonia; 35.1%, Congestive cardiac failure; 16.2%, Left ventricular failure; 10.8%, Cerebrovascular accident; 2.7%, carcinomatosis; 8.1%, and Pulmonary embolism; 8.1%.

Conclusion Approximately 45% of hip fracture deaths are referred to the coroner. Apart from PE, the cause of death documented by medical practitioners and the coroner was no different in terms of frequency and spectrum. Cardiac and respiratory causes account for nearly 2/3 of hospital hip fracture deaths. Resources need to be targeted accordingly in an attempt to improve in hospital morbidity and mortality.

Introduction and Aims: Cerebral micro emboli have been noted to occur during both total hip and knee arthroplasty. These micro emboli have been implicated in the causation of post-operative cognitive impairment. The aim of this study was to determine whether cerebral micro emboli occur during hip fracture surgery.

Method: Twenty-eight patients undergoing hip fracture surgery had transcranial doppler assessment of the middle cerebral artery to detect cerebral micro emboli. Micro embolic signals (MESs) were recorded during the operative procedure.

Results: Successful monitoring was carried out in 26 patients. MES were recorded in 16 out of 26 patients. Twelve out of 16 patients who had MESs had undergone a cemented hemiarthroplasty, the remainder had a sliding hip screw for an extracapsular hip fracture. Seventy-five percent (9/12) of patients that had a cemented hemiarthroplasty, had the majority of MESs after reaming and cementing. MESs in the patients that had a sliding hip screw occurred throughout the operative procedure.

Conclusion: Cerebral micro emboli do occur during hip fracture surgery. These emboli may be responsible for the cognitive dysfunction that occurs in this susceptible group of patients.

Introduction: Estimates suggest that 50% of new cases of invasive cancer diagnosed each year will eventually metastasise to bone. The proximal end of the femur is the most common site of long bone involvement by metastatic disease. Accepted principles for the treatment of metastatic disease of the proximal femur have been published. The results of 31 consecutive patients treated with a long intramedullary hip screw for metastatic disease of the proximal femur are reported.

Patients and Methods: Retrospective case note review of all patients that had a long intramedullary hip screw for metastatic disease affecting the proximal femur over a four-year period 1998–2002.

Results: The case notes of 31 patients (33 femurs) were reviewed. There were 21 females and 12 males with a mean age of 71 years. 31 femurs were Zickel group Ia or Ib, the remaining 2 were impending pathological fractures (Zickel group II) that were fixed prophylactically.

Post operatively all patients were allowed to fully weight bear. 70 % of patients regained their initial level of mobility or increased their level of dependence by a factor of one. Mean hospital stay was 20.8 days (mode 7 days). Patients that died post operatively had a mean survival of 299 days (range 2–1034). Those patients that were still alive at the last follow up had a mean survival of 475 days (range 7–1384). There were no cases of fixation or implant failure. There was one case of deep infection that was treated by implant removal.

Conclusion: On the basis of these findings, the long intramedullary hip screw fulfils the principles for treatment of metastatic disease and can be recommended for the treatment of pathological or impending pathological fractures of the proximal femur.

Background: The majority of extracapsular proximal femoral fractures are treated with a sliding hip screw. The barrel of the plate can slide over the shaft of the screw in two modes; keyed (locked) or unkeyed (unlocked). The purpose of the study was to determine whether there is a difference in outcome following þxation using a sliding hip screw in the locked and unlocked modes.

Methods: A prospective randomised controlled trial of patients requiring a sliding hip screw for a proximal femoral fracture. Patients were randomised to receive a sliding hip screw either in the locked or unlocked mode. 20 patients were randomised to each group. Patients were assessed clinically and radiologically post-operatively and at three months following discharge from hospital. Screw slide and þxation failure were used as primary outcomes. A Visual analogue scoring system (VAS) was used to assess pain.

Results: 40 patients were recruited in this study. Mean age of patients in the locked group was 74.05 years (range 55–90) and 78.0 years (range 65–97) in the unlocked group. There was one case of þxation failure in the locked group compared to two in the unlocked group. The mean screw slide was 10.98mm (range 1.04–37.62) in the locked group and 12.94mm (range 1.91–20.82) in the unlocked group. The pain score according to the VAS improved over the three months. There was no signiþcant difference in pain score between the two groups.

Conclusion:When comparing screw slide, þxation failure and pain, the results show there is no signiþcant difference between using the sliding hip screw in the locked and unlocked mode.