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.

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.

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.

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.