Background

To conduct a systematic review and network meta-analysis of RCTs with the aims of comparing relevant clinical outcomes (i.e. VAS, WOMAC total and sub-score score, Lequesne Algofunctional index, joint space width change and adverse events) between diacerein, glucosamine and placebo.

There is a high rate of mortality in elderly patients who sustain a fracture of the hip. We aimed to determine the rate of preventable mortality and errors during the management of these patients. A 12 month prospective study was performed on patients aged > 65 years who had sustained a fracture of the hip. This was conducted at a Level 1 Trauma Centre with no orthogeriatric service. A multidisciplinary review of the medical records by four specialists was performed to analyse errors of management and elements of preventable mortality. During 2011, there were 437 patients aged > 65 years admitted with a fracture of the hip (85 years (66 to 99)) and 20 died while in hospital (86.3 years (67 to 96)). A total of 152 errors were identified in the 80 individual reviews of the 20 deaths. A total of 99 errors (65%) were thought to have at least a moderate effect on death; 45 reviews considering death (57%) were thought to have potentially been preventable. Agreement between the panel of reviewers on the preventability of death was fair. A larger-scale assessment of preventable mortality in elderly patients who sustain a fracture of the hip is required. Multidisciplinary review panels could be considered as part of the quality assurance process in the management of these patients.

Cite this article: Bone Joint J 2014;96-B:1178–84.

International and national predictions from the late 1990s warned of alarming increases in hip fracture incidence due to an ageing population globally. Our study aimed to describe contemporary, population-based longitudinal trends in outcomes and epidemiology of hip fracture patients in a tertiary referral trauma centre.

A retrospective review was performed of all patients aged 65 years and over with a diagnosis of fractured neck of femur (AO classification 31 group A and B) admitted to the John Hunter Hospital, Newcastle, New South Wales between 1st January 2002 and 30th December 2009. Datawas collated and cross referenced from several databases (Prospective Long Bone Fracture Database, Operating Theatre Database and the Hospital Coding Unit). Mortality data was obtained via linkage with the Cardiac and Stroke Outcomes Unit, Planning and Performance, Division of Population Health. Main outcome measures were 30-day mortality, in-hospital mortality, length of stay.

The JHH admitted (427 ± 20/year, range: 391–455) patients with hip fractures over the 9 year study period. The number of admissions per year increased over the study period (p = 0.002), with no change in the age-standardised incidence (p = 0.1). The average age (83.5 ± 0.2) and average percentage female (73.7%) did not change. There was an overall trend to decreased 30-day mortality from 12.4% in 2002 to 7% in 2009 (p = 0.05). The factors that were associated with increased mortality were age (p < 0.0001), male gender (p = 0.0004), time to operating theatre (p = 0.0428) and length of stay (p < 0.0001).

In accordance with national and international projections on increased incidence of geriatric hip fractures, the incidence of fractured neck of femur in our institution increased from 2002–2009, reflecting our ageing population. 30-day mortality improved and longer length of stay corresponded with increased 30-day mortality.

Standard imaging of complex intra-articular distal radius fractures consists of posterior-anterior, lateral and oblique x-rays. Recently the liberal use of CT scan in this area became widely accepted as an additional imaging tool in pre-operative evaluation. The aim of this study was to evaluate whether CT scanning of complex distal radius fractures changed the management of these fractures compared to plain films.

A series of 20 closed distal radius complex intra-articular fractures AO 12-C which had both plain PA, lateral and oblique films and CT scans were selected from our long bone trauma database. The plain films were blindly reviewed by five observers. A management plan was then formulated. Options provided were: closed manipulation, closed manipulation with percutaneous K wire fixation, open reduction and internal fixation, external fixature or bone graft/substitute. The same patients' CT scans (in randomised order) were blindly reviewed at the one week interval by the same clinicians with the same management options decided upon. Kappa statistic was used to measure the intra-individual agreement between x-ray and CT, as well as inter-individual agreement within each imagining modality.

The agreement between individual observer's management decisions, based on the x-rays and on the CT scan was poor; with an average Kappa score of 0.038 (range 0.006 to 0.19). A regression model with management as a graded 5 level variable ranging from least invasive to most invasive and imaging modality as the predictor gave an estimated coefficient of 0.163, (p=-0.267); this indicates a trend towards a slightly higher level of invasiveness when the management decision was based on the CT compared to the plain x-rays. The agreement on management decisions between the observers based on x-ray alone was higher than that based on CT alone (kapa=0.174 vs 0.03)

This study indicates a very poor level of agreement between decision-making, based on x-ray and on CT. Even within individual's ‘interindividual’ agreement appears higher with x-ray than CT. This study also raises the possibility that the use of CT scans increases the level of invasiveness in the surgical management of complex distal radius fractures.