The timing of surgery for proximal femoral fractures.

We studied prospectively a consecutive series of 765 patients with proximal femoral fractures to determine if the time interval between injury and surgery influenced the outcome. Patients in whom surgery had been delayed for medical reasons were excluded. We divided the patients into four groups depending on the delay to surgery. Analysis of pre- and postoperative characteristics showed the groups to be similar. Mortality in the four groups was not significantly different but morbidity was increased by delay, particularly with regard to the incidence of pressure sores.

Rehabilitation after hip fractures. Home and hospital management compared.

The rehabilitation of elderly patients after hip fractures is important: we report a prospective study which compares supported home rehabilitation with management in hospital in two similar groups of patients. Our results show that early discharge from hospital and home rehabilitation produces substantial savings in bed days, and also provides quicker and more effective recovery.

Seasonal variation in the incidence of congenital talipes equinovarus.

A review of 77 neonates who presented with congenital talipes equinovarus over a seven-year period revealed an increase in the condition amongst babies born in the winter quarter. This finding was particularly apparent among the less severe cases of club-foot. Possible reasons for this seasonal variation are discussed.

Assessment of the AO classification of intracapsular fractures of the proximal femur.

There are a number of classification systems for intracapsular fractures of the proximal femur, but none has been shown to be practical with satisfactory reproducibility and accurate predictive value. We have investigated the AO classification and evaluated intra- and interobserver accuracy and its value in predicting treatment and outcome. We found it to have very poor intra- and interobserver reliability and to be of limited predictive use for the outcome of treatment. A simplified system in which the subdivisions were allocated to one of three groups of undisplaced, displaced and basal fractures was found to be of value. We conclude that this is the only division which is appropriate for these fractures and that the AO system for intracapsular fractures is too complicated and should not be used.

Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients.

A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail.

A comparison of presenting characteristics of patients with intracapsular and extracapsular proximal femoral fractures.

The presenting characteristics of 1423 consecutive admissions with proximal femoral fractures were prospectively studied, to determine any differences that may exist between patients, dependent on the radiological site of the fracture. Patients with intracapsular fractures were of a lower average age, more mobile, less likely to use walking aids or live in residential accommodation, they also had a considerably shorter length of hospital stay than for those patients with extracapsular fractures. Comparison against previous series shows that the average age of hip fracture patients and the proportion of trochanteric fractures is increasing.

Mortality and morbidity after hip fractures.

OBJECTIVE: To study the mortality and morbidity associated with proximal femoral fractures with reference to fracture type (intracapsular and extracapsular). DESIGN: Consecutive prospective study with 12 month follow ups. SETTING: Two British trauma receiving centres. PATIENTS: 1000 consecutive acute proximal femoral fractures (fractured necks of femur) in 972 patients. RESULTS: Significantly higher mortality at one year was seen in patients with extracapsular fractures (188/490; 38%) than in those with intracapsular fractures (147/510; 29%; p < 0.01). Greater morbidity was experienced during the study period by patients with extracapsular fractures, who were less mobile and less independent at the time of their injury. CONCLUSIONS: The rise in average age of presentation with proximal femoral fracture is associated with a persistently high mortality (33%) and morbidity, greater in patients with an extracapsular fracture. Comparison with other studies, principally from outside Britain, is difficult, but despite advancing standards of care the mortality and morbidity of femoral neck fractures remains high, placing an ever increasing burden on the health service.

Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip: a randomised trial of 600 fractures.

In a randomised trial involving 598 patients with 600 trochanteric fractures of the hip, the fractures were treated with either a sliding hip screw (n = 300) or a Targon PF intramedullary nail (n = 300). The mean age of the patients was 82 years (26 to 104). All surviving patients were reviewed at one year with functional outcome assessed by a research nurse blinded to the treatment used. The intramedullary nail was found to have a slightly increased mean operative time (46 minutes (sd 12.3) versus 49 minutes (sd 12.7), p < 0.001) and an increased mean radiological screening time (0.3 minutes (sd 0.2) versus 0.5 minutes (sd 0.3), p < 0.001). Operative difficulties were more common with the intramedullary nail. There was no statistically significant difference between implants for wound healing complications (p = 1), or need for post-operative blood transfusion (p = 1), and medical complications were similarly distributed in both groups. There was a tendency to fewer revisions of fixation or conversion to an arthroplasty in the nail group, although the difference was not statistically significant (nine versus three cases, p = 0.14). The extent of shortening, loss of hip flexion, mortality and degree of residual pain were similar in both groups. The recovery of mobility was superior for those treated with the intramedullary nails (p = 0.01 at one year from injury). In summary, both implants produced comparable results but there was a tendency to better return of mobility for those treated with the intramedullary nail.

Classification of subtrochanteric femoral fractures.

A review of the literature identified 15 different classification methods for subtrochanteric femoral fractures. Only eight of those classifications defined the area of bone, which constituted a subtrochanteric fracture. The actual length of femur defined as the subtrochanteric zone varied from 3 cm up to the level of the femoral isthmus. There was no agreement between the different classifications regarding the proximal and distal border or for those fractures, which traverse anatomical boundaries. In the various classifications, fractures were subdivided into 2-15 subgroups. The majority of the identified studies were unable to find the classifications useful in either determining treatment or predicting the outcome after treatment. We subdivided subtrochanteric fractures into three types based on the degree of fracture comminution. We examined the inter- and intra-observer agreement of our recommended classification. One orthopaedic consultant, one specialist hip fracture surgeon, two trainee registrar orthopaedic surgeons and one specialty trainee in orthopaedics, on two different occasions, 8 weeks apart, independently classified the radiographs of 20 patients with a subtrochanteric fracture. The mean kappa value for inter- and intra-observer variation was 0.71 and 0.79, respectively, with both showing substantial agreement and, therefore, this simpler classification is recommended. Based on the review of previous classification methods, we also recommend that the subtrochanteric zone be defined as the one in which the fracture line crossing the femur is predominantly within the area of bone extending 5 cm below the lower border of the lesser trochanter.

A study of the influence of technical adequacy on the clinical result of Moore hemiarthroplasty.

The Moore and Thompson hemiarthroplasties are still commonly used for the displaced subcapital fracture in the elderly. The cemented Thompson has been claimed to be superior to the uncemented Moore prosthesis. However, the use of cement is associated with greater risks and the uncemented Moore appears to give good results in approximately two-thirds of patients. The technical adequacy of uncemented hemiarthroplasty has rarely been considered in assessing the outcome. This study indicates that, on the basis of four radiological criteria, incorrect insertion of the prosthesis leads to a high chance of a poor clinical result at 6 months. Good results are more likely when the postoperative radiograph shows the prosthesis to have been inserted accurately. This is possible in most cases, except where the femur is grossly osteoporotic with a wide intramedullary canal. Uncemented hemiarthroplasty can produce satisfactory results but, like uncemented total joint replacement, is a more demanding procedure.

Internal fixation or arthroplasty for displaced cervical hip fractures in the elderly: a randomised controlled trial of 208 patients.

208 patients aged over 70 years with a displaced cervical hip fracture were admitted to a prospective randomised trial of internal fixation using 3 parallel cannulated screws or an uncemented Austin Moore hemiarthroplasty. All surviving patients were followed for a minimum of 3 years. Functional assessment of survivors at 1, 2 and 3 years from injury showed no significant difference between groups. Patients treated by the fixation had a marginally lower mortality rate. Other outcomes which favoured internal fixation were a lower risk of wound infection, reduced length of surgery (22 minutes versus 47 minutes), lower operative blood loss (23 mL versus 172 mL), and lower transfusion requirements (4/102 patients versus 18/106). However, internal fixation had a significantly greater re-admission rate (24/102 versus 7/106) and re-operation rate. Following internal fixation, 44 re-operations were required in 36 patients, while re-operation was required in only 4 patients treated with arthroplasty. The results of this randomised trial indicate that both procedures produce comparable final functional outcomes for the survivors.

Fractures of the distal femur: the role of the Zickel supracondylar fixation device.

Supracondylar fractures of the femur are often difficult to manage, especially in the elderly whose osteoporotic bone renders internal fixation tenuous. The Zickel supracondylar device provides a dynamic, medullary fracture fixation secure enough to allow unsupported early mobilization even in the elderly. The device can be inserted through small incisions, minimizing surgical injury. Interlocking screws prevent shortening and rotation and allow its use even in comminuted fractures. In 16 patients with non-pathological fractures, follow-up was possible on 14. There were 7 excellent, 5 satisfactory and 2 unsatisfactory results. There were no failures. Follow-up ranged from 6 months to 2 years. The device also proved effective in four patients with pathological fractures, the closed insertion allowing the benefit of early radiotherapy. This small but varied series shows the value of the Zickel supracondylar device in this difficult fracture.

Treatment of undisplaced subcapital fractures.

A total of 157 patients with undisplaced subcapital fractures was studied with reference to outcome depending on the method of treatment; 135 were treated surgically and 22 were treated conservatively. The main complication of treatment was non-union, with an overall incidence of 5.7%. Conservative treatment resulted in an incidence of non-union which was approximately twice that of patients who were treated surgically. Patients treated surgically, however, had significant postoperative complications in 14.8% of cases. Although conservative treatment has an increased incidence of non-union, it is a safe method of treatment and we feel it still has a place in selected patients.

Gamma versus DHS nailing for extracapsular femoral fractures. Meta-analysis of ten randomised trials.

A meta-analysis has been carried out of all published randomised trials which compare the gamma with the DHS nail, giving in a total of 1794 patients with extracapsular femoral fractures. Results showed that the Gamma nail had a significantly increased risk of fracture of the femoral shaft and an increased reoperation rate. There was no difference in the lag screw cut-out rates, incidence of wound infection or length of stay in hospital. The gamma nail cannot be recommended for routine use in trochanteric fractures until the problem of femoral shaft fracture is resolved.

Early discharge after hip fracture. Prospective 3-year study of 645 patients.

The effectiveness of providing additional community resources to enable early discharge following hip fracture surgery has been prospectively evaluated in a consecutive series of 645 patients. For those discharged under the scheme, the average hospital stay was 9.3 days, and this resulted in a substantial saving of hospital bed days.