Management of Distal Femur Fractures: Replacement Versus Surgical Fixation Versus Conservative Management.

INTRODUCTION: Distal femur fractures are a frequently encountered injury, especially among the ageing population. Previous studies have identified that these fractures can be managed with a variety of methods and techniques which has led to an ongoing debate and investigation to decipher the optimal approach to manage these fractures. AIM: The purpose of this study was to compare outcomes of patients managed with either distal femur replacements (DFRs), surgical fixation (SF) or conservative management. Outcomes measured included length of hospital stay, readmission rates, 30-day mortality and Oxford Knee Score. METHODS: A retrospective review was conducted, of patients admitted with distal femur fractures between June 2020 and October 2022 at Huddersfield Royal Infirmary Hospital. Patients with both native and peri-prosthetic joints were included. All patient's medical data, including imaging and operative records, were reviewed. RESULTS: A total of 42 patients were identified. There were six males and 36 females with a mean age of 78 years, a median age of 76 and a range of 35-102 years. Of these fractures, 15 were peri-prosthetic, and 27 were native joints. Of the patients, 30 had an SF, five had a DFR and the remaining seven were conservatively managed. Those managed with an SF had an average length of stay of 18 days, an Oxford score of 24 and two patients were readmitted within 30 days of discharge. For the DFR, the average length of stay was 16 days, an Oxford score of 22 and no patients were readmitted within 30 days. For the conservatively managed patients 21 days, an Oxford score of 25 and two patients were readmitted within 30 days of discharge. There was no 30-day mortality across all groups. CONCLUSIONS: From our study, we can conclude that patients who managed with a DFR had the shortest length of stay in a hospital and the lowest readmission rates when compared to alternative management techniques. There was minimal difference found between the Oxford scores between all three groups. This study shows that DFR can be a safe and reliable strategy to manage distal femur fractures. Additional research is required to further compare the outcomes of these different methods of repair.

The impact of reducing the femoral stem length in total hip arthroplasty during gait.

AIM: The length of the femoral stem in total hip arthroplasty (THA) is a practical consideration to prevent gait impairment. The aim of this study was to determine if reducing the femoral stem length in THA would lead to impaired gait biomechanics. METHODS: Patients uniformly with the same brand implant of differing lengths (100 mm vs 140-166 mm) were taken retrospectively from a prospective trial introducing a new short stem. Twelve patients without any other disorder to alter gait besides contralateral differing length stem THA were tested at differing gradients and speed on a validated instrumented treadmill measuring ground reaction forces. An anthropometrically similar group of healthy controls were analysed to compare. RESULTS: With the same posterior surgical approach, the offset and length of both hips were reconstructed within 5 mm of each other with an identical mean head size of 36 mm. The short stem was the last procedure for all the hips with gait analysis occurring at a mean of 31 and 79 months postoperatively for the short and long stem THA, respectively. Gait analysis between limbs of both stem lengths demonstrated no statistical difference during any walking condition. In the 90 gait assessments with three loading variables, the short stem was the favoured side 51% of the time compared 49% for the long stem. CONCLUSION: By testing a range of practical walking activities, no lower limb loading differences can be observed by reducing the femoral stem length. A shorter stem demonstrates equivalence in preference during gait when compared to a reputable conventional stem in total hip arthroplasty.

Length of hospital stay following hip fracture and risk of 30 and 90 day mortality in a United Kingdom cohort.

A recent study identified a length of stay (LOS) of 10 days or less following hip fracture is associated with increased risk of 30-day mortality. This effect has not been previously studied for 90-day mortality or in the United Kingdom (UK). Our aim was to investigate the effect of LOS on 30-day and 90-day mortality following hip fracture in a UK population. In this single-centre study, we retrospectively identified consecutive patients with a hip fracture from the National Hip Fracture Database over 3 years. We excluded patients who died as inpatient during their index admission. The main end-points were 30-day and 90-day mortalities and risk factors for these were examined using stepwise univariate and multivariate Cox regression analyses. Of 1228 patients, mortality at 30-days was 1.2% (15 patients) and 7.8% (96 patients) at 90-days. Mean LOS was 24 days and a total of 206 patients had a LOS of 10 days or less. Following cariate analysis, the highest risk factor for 30-day mortality was a LOS of 10 days or less with a hazard ratio of 7.26 (95% confidence interval 2.56-20.51). Other risk factors for 30-day mortality included increasing age, male gender and chest infection. A LOS of 10 days or less was not associated with increased mortality at 90-days. A short LOS was associated with higher risk of early mortality. We recommend that hip fracture patients be fully rehabilitated prior to discharge to reduce the risk of early mortality.

Study to Assess the Rate of Adverse Reaction to Metal Debris in Hip Resurfacing at a Minimum 13-year Follow-up.

BACKGROUND: Hip Resurfacing (HR), although reducing in popularity, is still used in the younger male population. Excellent medium-term results have been published; however, the use of metal on metal has reduced with increased awareness of adverse reactions to metal debris (ARMD). ARMD has been shown to often be clinically "silent" following large Head MoM total hip replacement (THR). The purpose of our study was to report the incidence of ARMD following HR with a minimum follow-up of 13 years. METHODS: We performed a retrospective study of a consecutive series of patients who underwent HR between January 1, 2000 and August 1, 2005. All patients were entered into our hospital MoM hip replacement surveillance program database. Patients were reviewed yearly for symptoms and blood ion levels. Patients had Magnetic Resonance (MR) imaging to assess for ARMD. RESULTS: A total of 102 patients with 123 hip replacements were included in the study. Eight hips in 7 patients were revised: two for fracture, one for avascular necrosis, and five for ARMD. A best-case scenario of 109 (93.2%) resurfacings were surviving at 13 years. With regard to the radiological analysis, 34% were found to have ARMD on MR. CONCLUSION: While the implant survivorship in our series is acceptable, we found a high incidence of ARMD. Surgeons and patients with or considering a HR should be aware of the risk of ARMD developing. This allows an informed choice as to the best implant for their personal requirement and informs of the potential modes of failure and need for long-term screening.

The 2nd Metacarpal Cortical Index as a Simple Screening Tool for Osteopenia.

BACKGROUND: Osteopenia is a known risk factor for sustaining skeletal fractures. Prevention of fragility fractures has obvious clinical and economic advantages, however screening all patients using a dual energy X-ray absorptiometry (DXA) is controversial not only because of the cost implications but also because it would potentially involve exposing a percentage of normal patients to unnecessary radiation. We wished to assess whether a simple hand X-ray measuring the 2nd metacarpal cortical index (2MCI) could be used as a simple screening tool for identifying patients with osteopenia. METHODS: We retrospectively collected the radiographic data of 206 patients who had a simple radiograph of the hand and a DXA scan within one year of each other from our picture archiving and communication system database. The 2MCI was calculated for all patients. As data was parametric, a Pearson's correlation was performed to assess association between Tscores and 2MCI. Further analysis involved the construction of receiver operating characteristic (ROC) curves to identify a 2MCI index, which would give the most appropriate sensitivity and specificity values for identifying the presence of osteopenia. RESULTS: A statistically significant and moderate correlation between DXA T-scores and 2MCI values was found (r=0.54, n=206, P<0.001). Further ROC curve analysis of normal and osteopenic subjects identified that a 2MCI of 41.5 had a sensitivity of 100% and specificity of 53% for detecting osteopenia. CONCLUSIONS: Our results support the use of the 2MCI as a simple screening tool for identifying patients with osteopenia.

Improving patient and staff safety by minimising radiation exposure during trauma surgery: A simple and validated predictive model.

INTRODUCTION: Minimising radiation exposure, from fluoroscopic equipment during trauma surgery is crucial to safe-guarding patients and staff. This aim of this study was to identify variables associated with increased radiation exposure for 3 of the most common trauma procedures. Secondly, we aimed to derive an internally and externally validated mathematical model for predicting radiation exposure for these procedures. MATERIALS AND METHODS: We prospectively recorded radiation exposure from 270 sliding hip screw (SHS), ankle and wrist fixation procedures. Patient demographics, fracture severity, surgeon and radiographer grade were assessed using univariate and multivariate analyses. A mathematical model was then created and externally assessed for validity from another unit. RESULTS: With regards to the analysis of radiation exposure when fixing wrist fractures, a significant regression equation was found (F (3, 86) = 62.2, p < 0.001), with an adjusted R2 of 0.69. Patients' predicted radiation exposure (cGY/cm2) was therefore equal to the positive result of: 81.916(Fracture severity) + 43.426(Surgical grade) + 23.490 (radiographer grade)-203.89.With regards to the analysis of radiation exposure when fixing ankle fractures, a significant regression equation was found, (F (3, 83) = 15.49, p < 0.001), with an adjusted R2 of 0.34. Patients' predicted radiation exposure (cGY/cm2) was therefore equal to the positive result of: 39.541(Fracture severity) + 51.937(Surgical grade) + 37.702 (radiographer grade)-124.558 SHS (F (3, 89) = 25.29, p < 0.001), R2 of 0.44.61.338(Fracture severity) + 60.945(Surgical grade) + 35.491 (radiographer grade)-105.501. These predictive models were successfully externally validated. CONCLUSION: This study has demonstrated a workable and externally validated model for accurately predicting the likely radiation exposure using common and easily collectable variables. These models could be used to modify practuce and minimise the radiation exposure to patients and staff.

Epsilon-aminocaproic acid versus tranexamic acid in total knee arthroplasty: a meta-analysis study.

INTRODUCTION: Total knee arthroplasty (TKA) surgery can be associated with significant blood loss. Among the problems associated with such blood loss is the need for transfusions of banked blood [1]. Transfusions not only have a financial consequence but also carry a small risk of disease transmission to the patient. Antifibrinolytics have been successfully used to reduce transfusion requirements in elective arthroplasty patients. The objective of this meta-analysis is to determine which of tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) is more effective for reducing peri-operative blood loss, and lessening the need for blood transfusion following knee arthroplasty surgery. MATERIALS AND METHODS: MEDLINE, Embase and CINAHL databases were searched for relevant articles published between January 1980 to January 2018 for the purpose of identifying studies comparing TXA and EACA for TKA surgery. A double-extraction technique was used, and included studies were assessed regarding their methodological quality prior to analysis. Outcomes analysed included blood loss, pre- and post-operative haemoglobin, number of patients requiring transfusion, number of units transfused, operative and tourniquet time, and complications associated with antifibrinolytics. RESULTS: Three studies contributed to the quantitative analysis of 1691 patients, with 743 patients included in the TXA group and 948 in the EACA group. Estimated blood loss was similar between the two groups [95% confidence interval (CI) -0.50, 0.04; Z = 1.69; P = 0.09]. There were no differences between the two groups regarding the percentage of patients requiring transfusion (95% CI 0.14, 4.13; Z = 0.31; P = 0.76). There was no difference in the pre- and post-operative haemoglobin difference between the two groups (95% CI -0.36, 0.24; Z = 0.38; P = 0.70). There was no difference in the average number of transfused units (95% CI -0.53, 0.25; Z = 0.71; P = 0.48). There was no difference in the operative (95% CI -0.35, 0.36; Z = 0.04; P = 0.97) or tourniquet time (95% CI -0.16, 0.34; Z = 0.72; P = 0.47). Similarly, there was no difference in the percentage of venous thromboembolism between the two groups (95% CI 0.17, 2.80; Z = 0.51; P = 0.61). CONCLUSIONS: This study did not demonstrate TXA to be superior to EACA. In fact, both antifibrinolytic therapies demonstrated similar efficacy in terms of intra-operative blood loss, transfusion requirements and complication rates. Currently EACA has a lower cost, which makes it an appealing alternative to TXA for TKA surgery. LEVEL OF EVIDENCE: 3.

Short-term risk factors for a second hip fracture in a UK population.

INTRODUCTION: A hip fracture carries significant morbidity and mortality-a second fracture of the contralateral hip carries even higher complications. Most second hip fractures occur within 48 months of the first. The aim of this study was to comprehensively analyse all identifiable variables that may increase the risk of a contralateral hip fracture within this time period. METHODS: We retrospectively analysed 1242 consecutive patients with hip fractures presenting to our institution. All patient-related, surgery-related and inpatient variables were collected from the index admission. We then identified patients with a subsequent contralateral hip fracture in the following 2 years. Univariate and multivariate analyses were performed to identify risk factors associated with a second fracture. RESULTS: A total of 66 patients (5.3%) had a contralateral hip fracture in the 2 years following initial hip fracture. Mean age at first presentation was 81 years, and mean time to second fracture was 305 days. Following multivariate analysis, the patients at highest risk of a second fracture were those with dementia, acute inpatient chest infection, urinary tract infection and multiple comorbidities as measured by the Charlson score. Discharge destination after initial fracture was not associated with the risk of a second fracture. CONCLUSIONS: We have identified a number of discrete risk factors that are associated with a short- to medium-term risk of contralateral hip fracture that may be useful in screening for patients at risk and provide them with focused medical rehabilitation.

Patient-specific guides improve hip arthroplasty surgical accuracy.

The role of patient-specific (PS) technology in total hip arthroplasty remains relatively unexplored. We asked whether PS guides: (1) Reduced average surgical errors? (2) Reduced outlier error frequencies? (3) Could predict the size of implants used? A single surgeon implanted femurs using either standard or PS guides and was blinded to the pre-operative plans. There were significant differences in median leg length errors between standard (3.3 mm) and PS groups (1.4 mm), U = 110, z = -2.3, p = 0.02. In contrast to the PS group, the standard group had significantly more outlier errors and frequently undersized implants. PS guides improve hip arthroplasty surgical accuracy.Abbreviations: PS: patient specific; THA: total hip arthroplasty; LLD: leg length discrepancies; HRA: hip resurfacing arthroplasty.

The loading patterns of a short femoral stem in total hip arthroplasty: gait analysis at increasing walking speeds and inclines.

BACKGROUND: The purpose of this study was to examine the gait pattern of total hip arthroplasty (THA) patients with a new short femoral stem at different speeds and inclinations. MATERIALS AND METHODS: A total of 40 unilateral THA patients were tested on an instrumented treadmill. They comprised two groups (shorter stemmed THA n = 20, longer stemmed THA n = 20), both which had the same surgical posterior approach. The shorter femoral stemmed patients were taken from an ongoing hip trial with minimum 12 months postop. The comparative longer THR group with similar disease and severity were taken from a gait database along with a demographically similar group of healthy controls (n = 35). All subjects were tested through their entire range of gait speeds and inclines with ground reaction forces collected. Body weight scaling was applied and a symmetry index to compare the implanted hip to the contralateral normal hip. An analysis of variance with significance set at α = 0.05 was used. RESULTS: The experimental groups were matched demographically and implant groups for patient reported outcome measures and radiological disease. Both THA groups walked slower than controls, but symmetry at all intervals for all groups were not significantly different. Push-off loading was less favourable for both the shorter and longer stemmed THR groups (p < 0.05) depending on speed. CONCLUSIONS: Irrespective of femoral stem length, symmetry for ground reaction forces for both THA groups were returned to a normal range when compared to controls. However individual implant performance showed inferior (p < 0.05) push-off forces and normalised step length in both THR groups when compared to controls. LEVEL OF EVIDENCE: III.

There is no 'weekend effect' in elective orthopaedic surgery.

Introduction The 'weekend effect' is said to occur when patient outcomes are adversely affected by the day of the week on which they present to hospital or have surgery. However, it is uncertain whether such a phenomenon exists for elective orthopaedic surgery. We investigated whether there is a 'weekend effect' in elective orthopaedic patients. Methods Retrospectively collected data were obtained from our institution's electronic patient records. We collected demographic and International Statistical Classification of Diseases and Related Health Problems tenth revision coding data for all included patients. Multivariate analyses identified covariate-adjusted risk factors, associated with prolonged stays. Thirty-day mortality data were assessed according to the day on which surgery occurred. Results We analysed data for 892 patients over a one-year period. During the year, 457 patients had a total hip and 435 had a total knee replacement; 814 patients (91.3%) underwent surgery during the week, while 78 (8.7%) had surgery on a Saturday. There was no difference in average length of stay between the groups (5.0, 2.6 vs 5.0, 3.4, P = 0.95). Variables associated with prolonged hospitalisation included increasing age (covariate adjusted relative risk 1.02, 95% confidence interval 1.01-1.03, P < 0.001) and an American Society of Anesthesiologists score of 2, (relative risk 1.6, 95% confidence interval 1.15-2.20, P = 0.005). There was one death in a patient who underwent surgery on a Monday. Conclusions There is no 'weekend effect' for elective orthopaedic surgery.

There is no weekend effect in hip fracture surgery - A comprehensive analysis of outcomes.

BACKGROUND: Previous studies have shown that some patient groups suffer adverse outcomes if they are acutely admitted to hospital over a weekend. We aimed to investigate this 'weekend effect' at our centre in patients presenting with a hip fracture. METHODS: Consecutive patients undergoing acute hip fracture surgery were identified from a prospective database. Patient demographics, co-morbidities, fracture type, admission blood parameters were examined. Outcomes analysed included 30-day, 90-day and 1-year mortality as well as length of stay, re-operations and delay to surgery. The data were analysed with regards to day of admission and day of surgery separately. RESULTS: A total of 1326 patients were included, of which 368 patients were admitted over a weekend and 411 patients had their operation over a weekend. Overall 30-day mortality was 7.6% (101 patients), whilst the 90-day and 1-year mortalities were 15.3% and 26.8% (203 and 356 patients). There were no significant differences in any of the outcomes based on the day of admission or the day of surgery. Multivariate analysis for 30-day mortality demonstrated the following variables to be significant predictors: admission urea levels (hazard ratio (HR) 1.042, p = 0.027), age (HR 1.058, p < 0.001), admission source (HR 1.428, p < 0.001), surgical delay >48 h (HR 1.853, p = 0.004), male gender (HR 1.967, p = 0.003), previous stroke (HR 2.261, p = 0.038), acute chest infection (4.240, p < 0.001) and chronic liver disease (HR 4.581, p = 0.014). CONCLUSION: This data suggests that there is no significant weekend effect in hip fracture surgery and mortality is affected by patient co-morbidities and delay to surgery.

Quadriceps Tendon-Bone or Patellar Tendon-Bone Autografts When Reconstructing the Anterior Cruciate Ligament: A Meta-analysis.

OBJECTIVE: We aimed to quantitatively assess the outcomes of studies, comparing the use of Bone-patellar tendon-bone (BPTB) and the quadriceps tendon-bone (QTB) autografts when reconstructing the anterior cruciate ligament (ACL). DATA SOURCES: MEDLINE, Embase, and CINAHL databases were searched for relevant articles published between January 1980 and January 2015 for the purpose of identifying studies comparing BPTB and QTB autografts for ACL reconstruction. Included studies were assessed regarding their methodological quality before analysis. Outcomes analyzed were graft failure rates, objective and subjective stability assessments, as well as the presence and severity of donor site morbidity. MAIN RESULTS: Five studies contributed to the quantitative analysis of 806 patients with 452 patients included in the BPTB group and 354 patients in the QTB group. Graft failure rates were similar between the 2 groups [odds ratio (OR) = 0.61; confidence interval (CI) = 0.17-2.15; Z = 0.78, P = 0.44]. There were no significant differences between the 2 groups when testing anteroposterior stability using an arthrometer (standardized mean difference = 0.07; CI = -0.12-0.25; Z = 0.70, P = 0.48). At 1 year postoperatively, there was no difference in the percentage of patients with a positive pivot shift test between the 2 groups (OR = 1.0; CI = 0.85-1.18; Z = 0.01, P = 0.99). However, significantly less patients had graft site pain 1 year after surgery in the QTB group (OR = 0.10; CI = 0.02-0.43; Z = 3.12, P = 0.002). Similarly, fewer patients reported moderate to severe pain while kneeling, in the QTB group (OR = 0.16; CI = 0.07-0.37; Z = 4.26, P < 0.001). CONCLUSIONS: This study demonstrates comparable survival rates and joint stability when BPTB and QTB grafts are used. However, fewer adverse donor site symptoms are evident with QTB grafts. LEVEL OF EVIDENCE: III.

(in vivo Gastrocnemius Muscle) Tendon Ratio in Patients with Cerebral Palsy.

BACKGROUND: The position of the gastrocnemius tendon in relation to the leg length may be different in children with cerebral palsy as compared to normal children. The palpation of muscle bellies or previous experience of the operating surgeon is employed to place the surgical incision for lengthening of the gastrocnemius aponeurosis. Inaccurate localisation may cause incorrect incisions and a risk of iatrogenic damage to the vital structures (i.e. sural nerve). OBJECTIVES: The aim of our study is to compare gastrocnemius length in-vivo between paretic and unaffected children and create a formula to localise the muscle-tendon junction accurately. METHODS: 10 children with di/hemiplegia (range 2-14y) were recruited. None of them had received any conventional medical treatment. An equal number of age/sex matched, typically developing children (range 4-14y) were recruited. Ultrasound scanning of the gastrocnemius muscle at rest was performed to measure the length of gastrocnemius bellies. We also measured the heights and leg lengths in all the children. RESULTS: The gastrocnemius medial muscles were shorter in Cerebral Palsy children when compared to similar aged normal children. In cerebral palsy children, the gastrocnemius muscle and leg ratio ranged between 35 to 50% (average ratio of 45%). CONCLUSION: Using these figures, we created an average percentage for gastrocnemius muscle length that may be used clinically to identify the tendon for open/endoscopic lengthening and also to make simple and accurate localisation of gastrocnemius muscle-tendon junction for surgical access. This decreases the length of the surgical incision and may reduce the risk of iatrogenic injuries.

Abnormal ground reaction forces lead to a general decline in gait speed in knee osteoarthritis patients.

AIM: To analyse ground reaction forces at higher speeds using another method to be more sensitive in assessing significant gait abnormalities. METHODS: A total of 44 subjects, consisting of 24 knee osteoarthritis (OA) patients and 20 healthy controls were analysed. The knee OA patients were recruited from an orthopaedic clinic that were awaiting knee replacement. All subjects had their gait patterns during stance phase at top walking speed assessed on a validated treadmill instrumented with tandem force plates. Temporal measurements and ground reaction forces (GRFs) along with a novel impulse technique were collected for both limbs and a symmetry ratio was applied to all variables to assess inter-limb asymmetry. All continuous variables for each group were compared using a student t-test and χ2 analysis for categorical variables with significance set at α = 0.05. Receiver operator characteristics curves were utilised to determine best discriminating ability. RESULTS: The knee OA patients were older (66 ± 7 years vs 53 ± 9 years, P = 0.01) and heavier (body mass index: 31 ± 6 vs 23 ± 7, P < 0.001) but had a similar gender ratio when compared to the control group. Knee OA patients were predictably slower at top walking speed (1.37 ± 0.23 m/s vs 2.00 ± 0.20 m/s, P < 0.0001) with shorter mean step length (79 ± 12 cm vs 99 ± 8 cm, P < 0.0001) and broader gait width (14 ± 5 cm vs 11 ± 3 cm, P = 0.015) than controls without any known lower-limb joint disease. At a matched mean speed (1.37 ± 0.23 vs 1.34 ± 0.07), ground reaction results revealed that push-off forces and impulse were significantly (P < 0.0001) worse (18% and 12% respectively) for the knee OA patients when compared to the controls. Receiver operating characteristic curves analysis demonstrated total impulse to be the best discriminator of asymmetry, with an area under the curve of 0.902, with a cut-off of -3% and a specificity of 95% and sensitivity of 88%. CONCLUSION: Abnormal GRFs in knee osteoarthritis are clearly evident at higher speeds. Analysing GRFs with another method may explain the general decline in knee OA patient's gait.

A Comprehensive Analysis of the Causes and Predictors of 30-Day Mortality Following Hip Fracture Surgery.

BACKGROUND: A fracture neck of femur is the leading cause of injury-related mortality in the elderly population. The 30-day mortality figure is a well utilised marker of clinical outcome following a fracture neck of femur. Current studies fail to analyse all patient demographic, biochemical and comorbid parameters associated with increased 30-day mortality. We aimed to assess medical risk factors for mortality, which are easily identifiable on admission for patients presenting with a fractured neck of femur. METHODS: A retrospective review of a prospectively populated database was undertaken to identify all consecutive patients with a fracture neck of femur between October 2008 and March 2011. All factors related to the patient, injury and surgery were identified. The primary outcome of interest was 30-day mortality. Univariate and subsequent multivariate analyses using a backward stepwise likelihood ratio Cox regression model were performed in order to establish all parameters that significantly increased the risk of death. RESULTS: A total of 1,356 patients were included in the study. The 30-day mortality was 8.7%. The most common causes of death included pneumonia, sepsis and acute myocardial infarction. Multiple regression analysis revealed male gender, increasing age, admission source other than the patient's own home, admission haemoglobin of less than 10 g/dL, a history of myocardial infarction, concomitant chest infection during admission, increasing Charlson comorbidity score and liver disease to be significant predictors of mortality. CONCLUSIONS: This study has elucidated risk factors for mortality using clinical and biochemical information which are easily gathered at the point of hospitalization. These results allow for identification of vulnerable patients who may benefit from a prioritisation of resources.

Predicting intertrochanteric extension of greater trochanter fractures of the hip on plain radiographs.

INTRODUCTION: It is important to distinct between isolated greater trochanter (GT) fractures and complete intertrochanteric (IT) extension to prevent unwanted morbidities. Aim of this study was to determine if there was any particular fracture pattern, of GT fractures on a plain radiograph of the hip which could predict IT extension. METHOD: Retrospective review of radiographs of 49 patients with a GT fracture who presented in the last 10 years (January 2005-December 2015). All images were reviewed by a consultant musculoskeletal radiologist and an orthopaedic surgeon. The AP plain radiographs were assessed to look for fracture angle and length of the fracture. The fracture length was taken as a percentage and was measured as the length of the fracture crossing the intertrochanteric line/the total length of the intertrochanteric line. The fracture angle was measured as the angle between a line drawn from the most superior point of the fracture on the lateral cortex of the GT, to a perpendicular line along the medial cortex of the femoral shaft. The subsequent MRI and CT scans were assessed to see if there was true intertrochanteric extension. RESULTS: 32 patient were female and 17 male. 27 CT scans of which 8 showed complete IT extension. 22 had MRI scan of which 6 showed complete extension. The mean fracture length of patients with complete extension was 56% with a range of 50%-63%. The mean fracture length of patients with incomplete extension was 33% with a range of 12%-55%. The mean fracture angle for patients with complete extension was 39° with a range of 35-42°. The mean fracture angle for patients with incomplete extension was 58° with a range of 44-124°. CONCLUSION: For greater trochanter fractures that do not cross >50% of the IT line and do not have a fracture angle between 35 and 42° do not require further imaging as they will not have complete intertrochanteric extension.

The Effect of Hip Arthroplasty on Osteoarthritic Gait: A Blinded, Prospective and Controlled Gait Study at Fast Walking Speeds.

BACKGROUND: Painful unilateral cox arthrosis results in excessive forces passing through the "good leg." The impact of hip arthroplasty on contralateral leg gait has not been fully explored. We measured patients gait before and after arthroplasty, to answer 3 questions: (1) Are peak forces for the good legs outside the normal range? (2) Does arthroplasty protect contralateral limbs by reducing peak forces? and (3) Does arthroplasty result in a more symmetric and normal gait at fast walking speeds? METHODS: This prospective, controlled study, assessed ground reaction forces before and 13 months (range, 6-21 months) after hip arthroplasty. RESULTS: Peak ground reaction force in contralateral hips fell (1.45-1.38 times body weight, P = .04), whereas symmetry index maximum weight acceptance improved postoperatively (12.2 ± 11 vs 1.3 ± 6, P < .001). CONCLUSION: Although gait becomes more symmetrical, patients still experience higher peak loads than matched controls. These high forces may offer an explanation to the progression of arthrosis in lower limbs.

Achieving hip fracture surgery within 36 hours: an investigation of risk factors to surgical delay and recommendations for practice.

BACKGROUND: The UK hip fracture best practice tariff (BPT) aims to deliver hip fracture surgery within 36 h of admission. Ensuring that delays are reserved for conditions which compromise survival, but are responsive to medical optimisation, would help to achieve this target. We aimed to identify medical risk factors of surgical delay, and assess their impact on mortality. MATERIALS AND METHODS: Prospectively collected patient data was obtained from the National Hip Fracture Database (NHFD). Medical determinants of surgical delay were identified and analysed using a multivariate regression analysis. The mortality risk associated with each factor contributing to surgical delay was then calculated. RESULTS: A total 1361 patients underwent hip fracture surgery, of which 537 patients (39.5 %) received surgery within 36 h of admission. Following multivariate analyses, only hyponatraemia was deduced to be a significant risk factor for delay RR = 1.24 (95 % CI 1.06-1.44). However, following a validated propensity score matching process, a Pearson chi-square test failed to demonstrate a statistical difference in mortality incidence between the hypo- and normonatraemic patients [χ (2) (1, N = 512) = 0.10, p = 0.757]. CONCLUSIONS: Hip fracture surgery should not be delayed in the presence of non-severe and isolated hyponatraemia. Instead, surgical delay may only be warranted in the presence of medical conditions which contribute to mortality and are optimisable. LEVEL OF EVIDENCE: III.