Aims

Falls are a common occurrence among hospital inpatients and can lead to injury, prolonged hospitalisation and delayed rehabilitation. There is major economic burden associated with this. Post operative orthopaedic patients have certain risk factors that predispose them to falls including decreased mobility, use of opioids and, in some cases, history of previous falls.

Many osteoporosis units are now identifying low impact fracture patients at presentation and assessing them for osteoporosis risk using a nurse led fracture liaison service (FLS); we established such a service in July 2002. Unfortunately many patients previously admitted with hip fractures have never been assessed, but are at high risk of future fracture. Outlined below is an audit of case finding using the theatre database to identify these patients.

All fractured neck of femur cases from 1999 to 2002 were identified on a theatre excel database. We utilised our Hospital Information Services System (HISS) to exclude those who had subsequently died. Current address and other personal/GP details were also found using HISS. Patients under 80 years of age received a questionnaire on osteoporosis risk factors, treatment and subsequent fractures and were invited for a Dexa scan.

Results: 675 patients were identified, of which 291 (43%) died. We were unable to obtain details on 74 (11%) patients. 96 patients under 80 years were invited for a Dexa. 45/96 replied to the letter, 36/45 agreed to a scan. 9/45 declined. Only 6/96 had a scan from GP previously & 8 had been commenced on therapy since fracture (3: Calcium/D3 supplements, 4: bisphosphonates and 1: both). 32 had a Dexa following the audit (M/F – 9:23). 4 (11%) did not attend. 21 (65%) were osteo-porotic, of which only 2 were taking bisphosphonates & 1 calcium/D3. 11 (34%) were osteopenic of which 1 was on Calcium/D3 and 10 had no treatment.

Although this is quite a labour intensive intervention, it did identify many untreated osteoporotic patients who were a high risk of future fracture. It also highlighted the small number of patients who are referred for Dexa or commenced on treatment by their GP following the fragility fracture. We would recommend this strategy to other units for case finding. This emphasizes the importance of a FLS and the need to have active ways to implement NICE guidance.

Primary disc space infections are thought to occur in children because of the abundant vascularity of the disc prior to skeletal maturity, and while they generally resolve with treatment, little is known about the long-term consequences on the spine.

An ovine model of discitis was used to investigate the effects of discitis on spinal development in the growing sheep. Six-week-old lambs underwent lumbar discography at multiple spinal levels using either radiographic contrast inoculated with Staphylococcus epidermidis (inoculated group) or radiographic contrast only (control group). Plain x-rays of the spines were taken at intervals up to 18 months before the animals were killed and the spines removed for histologic and morphometric analysis.

Discs from animals in the control group were radiologically and histologically normal at all time points, and as expected there was a steady increase in vertebral body and disc dimensions. Although not all inoculated animals showed histologic evidence of discitis, disc abnormalities were evident from an early stage. In particular disc height was significantly reduced from 2 weeks after inoculation and vertebral body dimensions were significantly reduced from one year.

Infection of discs at a young age, whether or not it progresses to discitis, has a significant effect on spinal development.

Objective: To assess the factors which result in increased mortality following a femoral neck fracture.

Design: Patients were sequentially recruited on admission to the fracture units and followed up at 2 weeks, 3 months, 6 months and 1 year.

Setting: The fracture units of two major Belfast teaching hospitals, The Royal Victoria and Belfast City Hospital (which have since amalgamated)

Subjects: All patients over the age of 65 years between 27th October 1997 and 30th November 1998 and who were admitted to the fracture units within 28 days of having sustained a fracture.

Outcome measures: Patients were assessed by: Barthel score, mental score, home circumstances. Mobility and mortality

Results: 748 patients (male/female 153/595). Mean age 82.1 years ± s.d. 7.4 years.

The overall 1-year mortality was 31.4% (235/748) and the sex distribution (male 73/153 [47.7%] female 162/595 [27.2%]).

27/748 patients who did not undergo surgical intervention had a 1-year mortality of 85.2%.

Factors which were associated with an increased 1 year mortality were: male sex (p< 0.0005), High ASA score (p< 0.0005), low Barthel score (p< 0.0005), poor mental score (p< 0.0005), decreased mobility (p< 0.0005), increased dependency in home circumstances (p< 0.0005), increased age (p< 0.0005), increased delay to surgery (p< 0.0005) and living alone (p< 0.0005).

Marital status, fracture type and type of operative intervention had no statistical effect on mortality.

Using logistic regression male sex, high ASA score, increased age, increased delay to surgery and poor mental score all remained independently associated with an increased mortality at 1 year.

Conclusion: The majority of factors which are associated with increased mortality following a femoral neck fracture are outside our control, namely age, sex and mental score. It should however be possible to reduce surgical delay and improve the patients pre-operative medical status (ASA score). A balance has to be struck between optimisation of the patient and delaying surgery unduly. The optimal timing of surgery requires further investigation.