Improved adherence to hip fracture standards reduces mortality after hip fractures.

BACKGROUND: Hip fractures are increasing in incidence due to increasing life expectancy. Mortality continues to improve but it is important to explore which factors are responsible for driving improvements. METHODS: A cohort of hip fracture patients predating SARS-CoV-2 was examined to determine the predictors of adherence to the six Irish Hip Fracture Standards (IHFS) and the impact of adherence on short (30 day) and long term (1 year) mortality. Our primary aim was assess the impact of a single HFS and cumulative number of HFS on mortality after hip fracture. Our secondary aim was to determine the impact of the HFS which are intrinsically linked to specialist Geriatric care. RESULTS: Across 962 patients, over 5 years, the factors which were associated with adherence to HFS were female gender, increasing ASA grade and being nursed on an orthopaedic ward. Patients with increasing ASA were more likely to have met HFS 4-6 (Geriatrician review HFS4, bone health HFS5 & specialist falls assessment HFS6), less likely to have surgery within 48 h are more likely to develop a pressure ulcer. If the patient was not nursed on an orthopaedic ward all HFS were less likely to be met. At 30 days HFS 4-6 were associated with a statistically significant odds ratio (OR) of being alive, while at one year HFS 1 (admitted to an orthopaedic ward within 4 h), 5 and 6 were associated with a statistically significant OR of being alive. As increasing numbers of hip fracture standards were met patients were more likely to be alive at 30 days and one year. CONCLUSION: This study has identified that improved adherence to hip fracture standards are associated with improved mortality at 30 days and one year.

Trends in hip fracture care in the Republic of Ireland from 2013 to 2018: results from the Irish Hip Fracture Database.

Hip fractures continue to be one of the most serious and costly injuries suffered by older people globally. This paper describes the development of a national hip fracture audit and summarises the first 6 years of data from the Republic of Ireland. This can help inform care, standards and outcomes of hip fracture patients. INTRODUCTION: Ireland has one of the highest standardised rates of hip fracture in the world behind northern European countries. The Irish Hip Fracture Database (IHFD) was established in 2012 to drive clinical and organisational improvements in quality and effectiveness of hip fracture care. This paper describes the progression of the IHFD between 2013 and 2018 and identifies trends and areas for improvement. METHODS: The IHFD is a clinically led, web-based audit, with data collected through the national Hospital Inpatient Enquiry (HIPE) electronic system, the principal source of information from publicly funded acute hospitals in Ireland. Eligible cases are aged ≥ 60 years with hip fracture as defined by IHFD or with other specified hip fracture excluding periprosthetic fractures. As of 2015, all 16 trauma-receiving hospitals within Ireland submitted data. Demographics and adherence to six national quality standards are described. RESULTS: A total of 17,983 cases were included in the analysis. National coverage has increased from 63% in 2013 to 99% in 2018. Demographic characteristics are unchanged, but higher levels of comorbidity are seen. Internal fixation and hemiarthroplasty are the most common modes of surgical repair with two-thirds of cases receiving spinal rather than general anaesthesia. Increasingly patients are being assessed by a geriatrician (11% in 2013 to 69% in 2018) and receive a bone health assessment (65% in 2013 to 84% in 2018). CONCLUSION: While some hip fracture standards have improved, further improvements are required to compare favourably internationally. Reduction of surgical delay and ensuring early mobilisation post-operatively are immediate priorities for the IHFD.

Knowledge, Attitudes and Practices of Non-Consultant Hospital Doctors In The Immediate Post-Fall Period

Aim The aim of this study is to determine the knowledge, attitudes and practices of Non-Consultant Hospital Doctors (NCHDs) in the immediate post-fall period. Methods A survey study design was employed using an online questionnaire of all NCHDs in SVUH comprising 15 questions that blend dichotomous, multiple choice, scaled and open-ended questions to determine knowledge, attitudes and practices of NCHDs across three constructs; injury management, falls prevention and fracture prevention. Descriptive statistics was used to analyse data. Results There was a 40% response rate (n=105). The respondents reported dissatisfaction with their standard of falls assessment training (mean 4/10). Between 60-70% of NCHDs do not routinely determine hip trauma, joint tenderness, syncope, use of anti-coagulants, visual symptoms, amnesia or vomiting. Half of respondents (n=57) rarely or never rationalised medications. The main reasons for this are lack of knowledge of alternatives (63%), time constraints (65%), benefits outweighing the risks (80%) and reluctance to interfere with care of another medical team (86%). Only 9% always consider a bone health review. Discussion A targeted education programme in the areas of hip assessment, neurological assessment, syncope management, medication rationalisation and bone protection is warranted.

Factors influencing radiation exposure during internal fixation of hip fractures.

The use of fluoroscopy is of great importance for operative fixation of fractures. Previous studies have shown an increased fluoroscopy time for intramedullary nails and with junior surgeons in comparison with more experienced surgeons. We examined the impact of operation length on fluoroscopy dose, cumulative fluoroscopy time between consultant and registrar surgeons and cumulative fluoroscopy time between dynamic hip screw and intramedullary nailing. We performed a retrospective cohort study of all patients admitted to our centre over the period of 1 year. Patients who underwent dynamic hip screw (DHS) or intramedullary (IM) nailing were identified from our in-hospital hip fracture database. Intraoperative fluoroscopy images were then accessed through our hospital's medical imaging software. A total of 137 patients were identified. Fluoroscopy reports were not available for 49 patients, resulting in a final total of 88 patients. Patients whose operation lasted longer than 1 h received a statistically significant higher dose of radiation (183.83 cGYM2 vs. 368.22 cGYM2; p value 0.0002). Operations performed by a consultant resulted in less cumulative fluoroscopy time in comparison with those performed by a registrar or specialist registrar although this was not statistically significant (00:00:53 vs. 00:00:45; p vaue 0.38). Cumulative fluoroscopy time was less in dynamic hip screw compared to long intramedullary nails (00:00:39 vs. 00:01:29; p value <0.001) and short intramedullary nails (00:00:39 vs. 00:01:52; p value 0.387). Studies, which had a cumulative fluoroscopy time exceeding 50 secs, delivered a higher radiation dose (434.34cGYM2 vs. 150.51cGYM2; p value <0.001). We concluded that there is no significant impact in cumulative fluoroscopy time in operations performed by either a registrar or consultant. Dynamic hip screws have a lower fluoroscopy time in comparison with long intramedullary nails.

Multiple Looser zones of osteomalacia in Byler disease with associated vitamin D deficiency, phosphaturia, and elevated FGF23.

INTRODUCTION: Byler disease (progressive familial intrahepatic cholestasis) is associated metabolic bone disease as a consequence of chronic malabsorption. CASE PRESENTATION: A 33-year-old man with decompensated liver disease secondary to Byler disease was referred to the orthopaedic department with progressive pain over this right proximal tibia. On examination, he had an antalgic gait. Tenderness was localised to the proximal tibia just distal to the tibial tubercle and bilateral foot swelling. Radiographs showed multiple stress fractures characteristic of Looser zones at various stages of healing in both tibia, metatarsals (third, fourth, and fifth on the right side, and second and fourth on the left) and left femur. Bone mineral density was extremely low. Subsequent investigations were consistent with severe osteomalacia due to a combination of vitamin D deficiency and phosphaturia with elevated fibroblast factor 23 (FGF23). A good clinical response was achieved following supplementation with calcium 1000mg and vitamin D 20µg daily. DISCUSSION: Stress fractures are often associated with delay in diagnosis. Our patient presented to the orthopaedic service with multiple Looser zones that had not been previously detected. As expected, there was biochemical evidence of vitamin D deficiency. An unexpected finding was phosphaturia that was associated with marked elevation in FGF23, which has never been reported previously. CONCLUSION: Byler disease may result in Looser zones of osteomalacia due to chronic malabsorption. Renal phosphorus wasting as a consequence of unexplained marked elevation in FGF23 is thought to have contributed to the onset of osteomalacia.

Clinician approach to diagnosis of stress fractures including bisphosphonate-associated fractures.

Stress fractures are repetitive strain injuries that occur in normal bones and in abnormal bones. Stress fractures share many features in common but differences depend on the status of the underlying bone. This review article for clinicians addresses aspects about stress fractures with particular respect to fatigue fractures, Looser zones of osteomalacia, atypical Looser zones, atypical femoral fractures associated with bisphosphonate therapy and stress fractures in Paget's disease of bone.

The long-term functional outcome of type II odontoid fractures managed non-operatively.

Odontoid fractures currently account for 9-15% of all adult cervical spine fractures, with type II fractures accounting for the majority of these injuries. Despite recent advances in internal fixation techniques, the management of type II fractures still remains controversial with advocates still supporting non-rigid immobilization as the definitive treatment of these injuries. At the NSIU, over an 11-year period between 1 July 1996 and 30 June 2006, 66 patients (n = 66) were treated by external immobilization for type II odontoid fractures. The medical records, radiographs and CT scans of all patients identified were reviewed. Clinical follow-up evaluation was performed using the Cervical Spine Outcomes Questionnaire (CSOQ). The objectives of this study were to evaluate the long-term functional outcome of patients suffering isolated type II odontoid fractures managed non-operatively and to correlate patient age and device type with clinical and functional outcome. Of the 66 patients, there were 42 males and 24 females (M:F = 1.75:1) managed non-operatively for type II odontoid fractures. The mean follow-up time was 66 months. Advancing age was highly correlated with poorer long-term functional outcomes when assessing neck pain (r = 0.19, P = 0.1219), shoulder and arm pain (r = 0.41, P = 0.0007), physical symptoms (r = 0.25, P = 0.472), functional disability (r = 0.24, P = 0.0476) and psychological distress (r = 0.41, P = 0.0007). Patients >65 years displayed a higher rate of pseudoarthrosis (21.43 vs. 1.92%) and established non-union (7.14 vs. 0%) than patients <65 years. The non-operative management of type II odontoid fractures is an effective and satisfactory method of treating type II odontoid fractures, particularly those of a stable nature. However, patients of advancing age have been demonstrated to have significantly poorer functional outcomes in the long term. This may be linked to higher rates of non-union.

Lung tissue storage: optimizing conditions for future use in molecular research.

The quality of tissue studied impacts greatly on oligonucleotide microarray results, emphasizing the importance of harvesting techniques. The analyzed RNA extracted from human lung samples preserved via 4 different storage conditions (RNAlater, phosphate-buffered saline, TRIzol, liquid nitrogen). RNA was assessed by denaturing gel electrophoresis, Agilent bioanalysis, real-time polymerase chain reaction (PCR), and Test3 Affymetrix chip hybridization. Results revealed better quality RNA from RNAlater samples on gel electrophoresis and bioanalysis. RNAlater samples also showed greater yield (r18s via PCR P < .05) and resulted in better Test3 chips hybridization (p < .05), suggesting RNAlater was superior at preserving lung tissue nucleic acid.

Rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures.

AIM: To evaluate the use of rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures. INTRODUCTION: The complex three-dimensional anatomy of the pelvis and acetabulum make assessment, classification and treatment of fractures of these structures notoriously difficult. Conventional imaging only provides two-dimensional images of these fractures. While interpretation of traditional imaging techniques becomes better with experience, novel techniques may assist in the understanding of these complex injuries. METHODS: Twenty patients with acetabular fractures were studied. Life size three-dimensional models were manufactured from standardised CT scans, using the rapid prototyping process, selective laser sintering. Each model was presented to the operating surgeon prior to surgery. The surgeons found that the models greatly assisted in their understanding of the personality of the fracture. Three consultant orthopaedic surgeons and three senior trainees were asked to classify each fracture using conventional radiographs (AP pelvis, Judet views and CT scans) and then using the model. The kappa statistic was used to evaluate inter- and intraobserver agreement. RESULTS: Interobserver agreement was not absolute using either conventional radiographs or the models. For the consultants the kappa statistic using conventional radiographs was 0.61 while the kappa value using the model was 0.76 (p<0.05). For the trainees the kappa value was 0.42, using conventional radiographs and 0.71 using the model (p<0.01). CONCLUSION: Full sized models of acetabular fractures greatly assisted surgeons understand the personality of complex fractures prior to surgery and have been shown in this study to significantly reduced the degree of interobserver variability in fracture classification. This effect is particularly evident for less experienced surgeons. This technique is available and relatively inexpensive. The use of these models should prove invaluable as a tool to aid clinical practice.

Abdominal aortic aneurysm repair and colonic infarction: a risk factor appraisal.

OBJECTIVE: Colonic infarction is a recognized complication of abdominal aortic aneurysm (AAA) surgery. The clinical difficulty in establishing the diagnosis combined with the patient's poor physiological status is usually associated with a fatal outcome. We assessed our experience with this problem to identify a possible risk factor profile for these patients. METHOD: Patients records were identified from the operative logs, intensive care unit, Hospital Inpatient Enquiry system and vascular unit databases over a 6-year period. RESULTS: A total of 405 patients underwent AAA repair during this period; 140 as emergency ruptures. Nine patients were identified from the databases with known colonic infarction (2.2%). One was a woman. The mean age was 70 years. Seven patients had emergency ruptures (5%). Twenty independent risk factors were analysed using univariate and multivariate logistic regression models. Significant risk factors identified by using a multivariate analysis included the nature of the presenting patient, preoperative hypotension, prolonged cross-clamp time, intra-operative ischaemia and postoperative acidosis. Confirmatory diagnosis was made by colonoscopy in eight patients. One patient survived following the salvage surgery. The mean duration of survival was 10.5 days. The overall mortality was 89% of patients. CONCLUSION: In our unit infrarenal AAA repair has a 2.2% rate of colonic infarction. A definitive diagnosis is best made by colonoscopy. A risk factor profile for the development of colonic infarction may be constructed on the basis of specific clinical parameters. Earlier intervention on the basis of this profile may ultimately reduce the current excessive mortality.

Revision of the Sheehan total knee arthroplasty.

The use of the Sheehan knee prosthesis extended from 1971 to 2002. It incorporated a semi-constrained hinge with intra-medullary stems cemented into the femur and tibia. While some authors have reported excellent short-term results, others have reported revision rates of up to 31% at 5--10 years. The aim of this study was to review the senior author's experience in revising these arthroplasties. We review 54 Sheehan total knee replacements and discuss the difficulties encountered during first and subsequent revisions and the often-complex reconstruction techniques used to overcome these.

Above-knee Ilizarov external fixation for early periprosthetic supracondylar femoral fracture--a case report.

Supracondylar femoral fractures above a total knee replacement are rare injuries that may be challenging to treat. We present a 60-year-old woman who sustained a supracondylar femoral fracture 10 days following a total knee replacement. This patient had multiple risk factors. The fracture was not deemed amenable to conventional treatment. This patient underwent fixation of her femoral fracture above a total knee replacement using a two-ring above-knee Ilizarov external fixator. This allowed full mobilization of the affected limb during fracture healing. The fixator was removed at 10 weeks, at which time the fracture was solidly healed. At the most recent follow-up, 14 months from injury, she was fully weight-bearing without walking aids and had a knee range of motion of 0-120 degrees .

The natural history of the periacetabular fragment following Ganz osteotomy.

The vascularity of the acetabular free fragment in Ganz osteotomies has remained a concern. This study aims to assess the role of MR imaging in the postoperative evaluation of Ganz osteotomies. Twenty patients (19 females, 1 male), average age 24 years (range, 12-36 years), had sequential magnetic resonance imaging studies of the pelvis at 6 weeks and 6 months following Ganz osteotomies. Normal healing with no evidence of periosteotomy edema was seen in 17 patients at 6 weeks. Three patients showed evidence of reduced vascularity. In two of these, there were focal changes suggestive of subclinical ischemia. The other had gross signal changes in the osteotomy fragment suggestive of diffuse ischemia. The patients with focal changes were asymptomatic and had normal 6-month scans. The patient with diffuse changes complained of persistent groin pain, which resolved after 4 months. The 6-month scan showed some persistent vascular changes. The scan at 1 year showed complete resolution. The study suggests that Ganz osteotomy has minimal effect on the vascularity of the acetabular free fragment.

Thoracoscopic management of primary spontaneous pneumothorax.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is the preferred option for the surgical management of primary spontaneous pneumothorax (PSP). AIMS: To evaluate the role of thoracoscopic blebectomy with and without chemical pleurodesis. METHODS: A retrospective study was performed on 113 consecutive cases carried out in one unit. RESULTS; One hundred and thirteen VATS procedures were performed on 108 patients. The mean age was 23 years (range 14-45). The male to female ratio was 82:26. Recurrent pneumothorax was the indication for surgery in 80%. Conversion to an open procedure was required in 10 cases (9%), most commonly due to severe adhesions. Successful endoscopic blebectomy was performed in 98 cases (87%), 48 of which had an additional chemical pleurodesis. Follow-up is currently to a mean of 28 months. Recurrence has occurred in eight cases, including only three in the group managed with additional chemical pleurodesis (6.25%). CONCLUSION: VATS with blebectomy and chemical pleurodesis is a safe and effective procedure in the management of PSP.