Nottingham Hip Fracture Score: Does It Predict Mortality in Distal Femoral Fracture Patients?

Background Patients with distal femur fractures are associated with mortality rates comparable to neck of femur fractures. Identifying high-risk patients is crucial in terms of orthogeriatric input, pre-operative medical optimisation and risk stratification for anaesthetics. The Nottingham Hip Fracture Score (NHFS) is a validated predictor of 30-day mortality in neck of femur fracture patients. In this study, we aim to investigate and evaluate the suitability of the NHFS in predicting 30-day as well as one-year mortality of patients who have sustained distal femur fractures. Methods Patients admitted to a level 1 major trauma centre with distal femur fractures were retrospectively reviewed between June 2012 and October 2017. NHFSs were recorded using parameters immediately pre-operatively. Results Ninety-one patients were included for analysis with a mean follow-up of 32 months. The mean age was 69, 56 (61%) patients were female, 10 (11%) were open fractures and 32 (35%) were peri-prosthetic fractures with 85% of patients being surgically managed. Forty-one patients were found to have an NHFS >4. Overall mortality at 30 days was 7.7% and at 1 year was 21%. Patients with an NHFS of ≤4 had a lower mortality rate at 30 days of 6% compared with those with >4 at 9.8% (p=0.422). On Kaplan-Meier plotting and log-rank test, patients with an NHFS of >4 were associated with a higher mortality rate at 1 year at 36.6% compared to patients with an NHFS of ≤4 at 8% (p=0.001). Conclusion NHFS is a promising tool not only in neck of femur fractures but also distal femur fractures in risk-stratifying patients for pre-operative optimisation as well as a predictor of mortality.

Cost analysis on virtual clinic follow-up after primary joint arthroplasty.

BACKGROUND: As previously reported, a virtual clinic (VC) effectively manages the increasing need to review and monitor patients after primary joint replacement. Such procedure is increasing steadily in number, with more than 200,000 procedures performed annually in the UK. Considering that face-to-face review following routine uncomplicated primary joint arthroplasty is costly and time consuming, guidelines suggest reviewing patients at regular intervals through radiographs and patient-reported outcome measures (PROMs). METHODS: We reviewed our VC experience in a large teaching hospital. A single surgeon established the VC, and all primary hip and knee replacements over an 18-month period (January 2016 to July 2017) were included in the study. We evaluated all clinical records, PROMs, patient satisfaction, and outcome of VC at one-year follow-up. Additionally, we conducted a safety and cost analysis. RESULTS: This study included 154 primary joints (70 total knee replacements and 84 total hip replacements) in 148 patients (89 females, 59 males). The mean age at surgery was 65.3 years. Of the patients, 93% completed the postoperative PROMs, whereas <40% completed the PROM during regular clinical follow-up. All the patients had follow-up radiographs. After VC assessment, which included radiographies and PROMs, 59% of the patients were directly discharged. Of the remaining 41% patients who had face-to-face review, one-third were examined for the same arthroplasty issue, and two-thirds were examined for unrelated or other joint problems. Although the postoperative PROM was below the national average, the improvement in PROM (from pre-operative to post-operative scores) was higher than the national average. The cost analysis demonstrated an average cost savings of £10.449 per year and consultant. CONCLUSIONS: VC follow-up after primary joint replacement is a safe and cost-effective option to manage postoperative follow-up visits and identify those patients who require additional face-to-face reviews and who can be safely discharged. The discharge criteria included satisfactory improvement in PROM scores, review of follow-up radiographs, and no concerns raised by patients. Considering the increasing number of primary joint arthroplasty and the financial pressure on the National Health Service, VC offers an excellent alternative to conventional clinics.

Poor nutritional status correlates with mortality and worse postoperative outcomes in patients with femoral neck fractures.

AIMS: Patients who sustain neck of femur fractures are at high risk of malnutrition. Our intention was to assess to what extent malnutrition was associated with worse patient outcomes. METHODS: A total of 1,199 patients with femoral neck fractures presented to a large UK teaching hospital over a three-year period. All patients had nutritional assessments performed using the Malnutrition Universal Screening Tool (MUST). Malnutrition risk was compared to mortality, length of hospital stay, and discharge destination using logistic regression. Adjustments were made for covariates to identify whether malnutrition risk independently affected these outcomes. RESULTS: Inpatient mortality was 5.2% (35/678) in the group at low risk of malnutrition, 11.3% (46/408) in the medium-risk group, and 17.7% (20/113) in the high-risk group. Multivariate analysis showed each categorical increase in malnutrition risk independently predicted inpatient mortality with an odds ratio (OR) of 1.59 (95% confidence interval (CI) 1.14 to 2.21; p = 0.006). An increased mortality rate persisted at 120 days post-injury (OR 1.64, 95% CI 1.20 to 2.22; p = 0.002). There was a stepwise increase in the proportion of patients discharged to a residence offering a greater level of supported living. Multivariate analysis produced an OR of 1.34 (95% CI 1.03 to 1.75; p = 0.030) for each category of MUST score. Median length of hospital stay increased with a worse MUST score: 13.9 days (interquartile range (IQR) 8.2 to 23.8) in the low-risk group; 16.6 days (IQR 9.0 to 31.5) in the medium-risk group; and 22.8 days (IQR 10.1 to 41.1) in the high-risk group. Adjustment for covariates revealed a partial correlation coefficient of 0.072 (p = 0.008). CONCLUSION: A higher risk of malnutrition independently predicted increased mortality, length of hospital stay, and discharge to a residence offering greater supported living after femoral neck fracture. Cite this article: Bone Joint J 2021;103-B(1):164-169.

Infection versus ALVAL: acute presentation with abdominal pain.

A 52-year-old man underwent bilateral articular surface replacement (ASR) DePuy in June 2006. Following a right femoral neck fracture 4 days postoperatively, he underwent revision to a cemented C-stem DePuy, a taper sleeve adaptor and a 47 mm diameter cobalt chromium femoral head. The patient recovered well with satisfactory 5-year follow-up. In September 2011 the patient presented to the accident and emergency department with a 5-day history of feeling unwell with right lower quadrant pain. Examination of the right hip was unremarkable apart from painful adduction. Blood tests showed raised inflammatory markers and white cell count. MRI scan showed a right iliopsoas collection which appeared to communicate with the hip joint. The patient underwent a direct exchange of the right hip prosthesis. The intraoperative clinical picture was suggestive of atypical lymphocytic vasculitis and associated lesions. The patient recovered well and was discharged home. At his last clinic visit he was well and pain free.

The effect of bolus administration of tranexamic acid in revision hip arthroplasty.

We assessed the efficacy of tranexamic acid in reducing transfusion requirements in patients undergoing revision hip arthroplasty. A prospective cohort study was designed comparing Tranexamic acid administration in 30 patients compared to 30 patients in a control group. Blood loss was measured in theatre, pre- and postoperative haemoglobin measurements were recorded and postoperative haemodynamic parameters were evaluated. The mean postoperative haemoglobin was 9.5 g/dl in the tranexamic acid group and 8.2 g/dl in the control group (p<0.01). The mean haemoglobin reduction was 2.7 g/dl in the tranexamic acid group and 3.4 g/dl in the control group (p = 0.47). Mean transfusion requirements were 2.76 units in the study group and 4.0 units in the control group (p = 0.49) and the frequency of transfusion was reduced (p = 0.032). Infected revisions showed no reduction in transfusion requirements with tranexamic acid administration (p = 0.25). There was a reduced frequency of transfusion in patients when revision was performed for aseptic loosening (p = 0.027). This group of patients may benefit from tranexamic acid administration.

Wrist MRI Arthrogram v Wrist Arthroscopy: What are we Finding?

The aim of the study was to compare the radiological findings of wrist arthrogram with wrist arthroscopy. This allowed us to establish the accuracy (sensitivity, specificity) of MRI arthrogram as a diagnostic tool. Thirty patients (20 female and 10 male) have undergone both wrist MRI arthrogram and wrist arthroscopy over the last 3 years at a District General Hospital. The mean age at arthrogram was 42.4 years with an average 6.7 month interval between the two procedures.The MRI arthrogram was reported by a consultant radiologist with an interest in musculoskeletal imaging and the arthroscopies performed by two upper limb surgeons. Patients who underwent both procedures were identified. The arthrogram reports and operation notes were examined for correlation. Three main areas of pathology were consistently examined: TFCC (triangular fibrocartilage complex), scapholunate and lunotriquetral ligament tears. The sensitivity and specificity of arthrogram was calculated for each. Other areas of pathology were also noted.In the case of TFCC tears MRI arthrogram had 90% sensitivity and 75% specificity. The lunotriquetral ligament examination with this technique was 100% sensitivity and specificity. However for scapholunate ligament tears it only had 91% sensitivity and 88% specificity.Wrist arthrogram and arthroscopy are both invasive techniques. In cost terms the arthrogram remains cheaper but is superseded by arthroscopy as it is both diagnostic and therapeutic.

The use of total femoral arthroplasty as a limb salvage procedure: the Sheffield experience.

Over the last 25 years, 14 patients have undergone total femoral arthroplasty (TFA) after complications of revision arthroplasty surgery. These patients had previously undergone extensive surgery, which had failed, and required salvage surgery. The alternatives would have been amputation or hip disarticulation. A retrospective review of medical records and radiographs was undertaken, and clinical outcome was evaluated using the Musculoskeletal Tumour Society criteria. Before TFA, all patients had previously undergone multiple operations (range, 2-10). In 88% of cases, reconstructive options were not only limited by the availability of minimal host bone but also by deep sepsis. Results were encouraging, with most of the patients having greater mobility and less pain after surgery. A third of the patients achieved a 75% improvement in function. We believe that TFA has a definite role in the management of complex problems after extensive hip and knee revision arthroplasty surgery.