Protecting my injured child: a qualitative study of parents' experience of caring for a child with a displaced distal radius fracture.

BACKGROUND: Childhood fractures can have a significant impact on the daily lives of families affecting children's normal activities and parent's work. Wrist fractures are the most common childhood fracture. The more serious wrist fractures, that can look visibly bent, are often treated with surgery to realign the bones; but this may not be necessary as bent bones straighten in growing children. The children's radius acute fracture fixation trial (CRAFFT) is a multicentre randomised trial of surgery versus a cast without surgery for displaced wrist fractures. Little is known about how families experience these wrist fractures and how they manage treatment uncertainty. This study aimed to understand families' experience of this injury and what it is like to be asked to include their child in a clinical trial. METHODS: Nineteen families (13 mothers, 7 fathers, 2 children) from across the UK participated in telephone interviews. Interviews were audio recorded, transcribed and analysed using reflexive thematic analysis. RESULTS: Our findings highlight parents' desire to be a good parent through the overarching theme "protecting my injured child". To protect their child after injury, parents endeavoured to make the right decisions about treatment and provide comfort to their child but they experienced ongoing worry about their child's recovery. Our findings show that parents felt responsible for the decision about their child's treatment and their child's recovery. They also reveal the extent to which parents worried about the look of their child's wrist and their need for reassurance that the wrist was healing. CONCLUSION: Our findings show that protecting their child after injury can be challenging for parents who need support to make decisions about treatment and confidently facilitate their child's recovery. They also highlight the importance of providing information about treatments, acknowledging parents' concerns and their desire to do the right thing for their child, reassuring parents that their child's wrist will heal and ensuring parents understand what to expect as their child recovers.

Protocol for the Weight-bearing in Ankle Fractures (WAX) trial: a multicentre prospective non-inferiority trial of early versus delayed weight-bearing after operatively managed ankle fracture.

BACKGROUND: Unstable ankle fractures represent a substantial burden of disease, accounting for a mean hospital stay of nine days, a mean cost of £4,491 per patient and 20,000 operations per year. There is variation in UK practice around weight-bearing instructions after operatively managed ankle fracture. Early weight-bearing may reduce reliance on health services, time off work, and improve functional outcomes. However, concerns remain about the potential for complications such as implant failure. This is the protocol of a multicentre randomised non-inferiority clinical trial of weight-bearing following operatively treated ankle fracture. METHODS: Adults aged 18 years and over who have been managed operatively for ankle fracture will be assessed for eligibility. Baseline function (Olerud and Molander Ankle Score [OMAS]), health-related quality of life (EQ-5D-5L), and complications will be collected after informed consent has been obtained. A randomisation sequence has been prepared by a trial statistician to allow for 1:1 allocation to receive either instruction to weight-bear as pain allows from the point of randomisation, two weeks after the time of surgery ('early weight-bearing' group) or to not weight-bear for a further four weeks ('delayed weight -bearing' group). All other treatment will be as per the guidance of the treating clinician. Participants will be asked about their weight-bearing status weekly until four weeks post-randomisation. At four weeks post-randomisation complications will be collected. At six weeks, four months, and 12 months post-randomisation, the OMAS, EQ-5D-5L, complications, physiotherapy input, and resource use will be collected. The primary outcome measure is ankle function (OMAS) at four months post-randomisation. A minimum of 436 participants will be recruited to obtain 80% power to detect a non-inferiority margin of -6 points on the OMAS 4 months post-randomisation. A within-trial health economic evaluation will be conducted to estimate the cost-effectiveness of the treatment options. DISCUSSION: The results of this study will inform national guidance with regards to the most clinically and cost-effective strategy for weight-bearing after surgery for unstable ankle fractures. TRIAL REGISTRATION: ISRCTN12883981 , Registered 02 December 2019.

SPiRIT study protocol (Shoulder Pain: Randomised trial of Injectable Treatments): a randomised feasibility and pilot study of autologous protein solution (APS) vs corticosteroids for treating subacromial shoulder pain.

BACKGROUND: The management of subacromial shoulder pain represents a significant challenge and is typically managed through either physiotherapy, joint injection or surgical intervention. Recent surgical trials have questioned the efficacy and there is a need to improve the evidence base for the non-surgical management of this condition. The study aims to provide evidence of the feasibility of conducting a randomised controlled trial to compare the efficacy of autologous protein solution (APS) against the current standard of care, corticosteroid injection (CSI) for subacromial shoulder pain. Autologous protein solution (APS) is a blood-derived biological injection which has been shown to have anti-inflammatory effects. METHODS: A parallel-group two-arm randomised control trial will be conducted, comparing APS and CSI for shoulder pain. Fifty patients will be recruited. Feasibility will be assessed by examination of the conversion rate of eligible participants to the total number of participants recruited, whether it is possible to collect the appropriate outcome measures and the levels of retention/data compliance at follow-up dates. DISCUSSION: CSI is the mainstay of conservative management of subacromial shoulder pain. Trials and systematic reviews have reported differing conclusions, but the consensus view is that any benefits seen from CSI use are most likely to be short-term and there remains a significant number of patients who go on to have surgical intervention despite CSI. Biological injections, such as APS are being increasingly used, in the anticipation they may offer improved longer lasting outcomes for shoulder pain. However, the evidence to demonstrate the comparative efficacy of CSI versus APS does not currently exist. If feasible, a fully powered study will offer clarity to the treatment pathway of thousands of patients each year with subacromial pain. TRIAL REGISTRATION: The study is funded by the National Institute for Health Research-Research for Patient Benefit, NIHR 201473, Trial Registration Number (ISRCTN12536844: SPiRIT. Shoulder pain: randomised trial of injectable treatments-date of Registration 15/9/2021). Protocol Version V1.0_30Jul2021. IRAS Project ID: 294,982.

Self-management behaviour after a physiotherapist guided blended self-management intervention in patients with chronic low back pain: A qualitative study.

BACKGROUND: Self-management support is considered an important component in the physiotherapeutic treatment of people with chronic low back pain. The stratified blended physiotherapy intervention e-Exercise Low Back Pain is an example of a self-management intervention. More insight may contribute to improving blended interventions to stimulate self-management after treatment and thus hopefully prevent chronicity and/or relapses in patients with chronic low back pain. OBJECTIVES: The aim of this study was to gain an in-depth understanding of the self-management behaviour after a physiotherapist guided blended self-management intervention in people with chronic low back pain. DESIGN: A qualitative study with semi-structured interviews nested within a randomized controlled trial on the (cost-)effectiveness of e-Exercise Low Back Pain was conducted. METHOD: Thematic analysis was used to analyse the transcriptions. A hybrid process of both deductive and inductive approaches was used. RESULTS: After 12 interviews, data saturation was reached. Analysis of the data yielded six themes related to self-management behaviour: illness beliefs, coping, cognitions, social support and resource utilization, physiotherapeutic involvement and motivation. CONCLUSIONS: In our study the majority of the participants seemed to show adequate self-management behaviour when experiencing low back pain. Most participants first try to gain control over their low back pain themselves when experiencing a relapse before contacting the physiotherapist. Participants struggle in continuing health behaviour in pain free periods between relapses of low back pain. Physiotherapists are recommended to encourage long-term behaviour change. Additionally, better facilitation by the physiotherapist or additional functionalities in the app to stimulate social support might have a useful contribution.

Utilization and costs of formal and informal care, home adaptations, and physiotherapy among older patients with hip fracture.

AIMS: This feasibility study investigates the utilization and cost of health resources related to formal and informal care, home adaptations, and physiotherapy among patients aged 60 years and above after hip fracture from a multicentre cohort study (World Hip Trauma Evaluation (WHiTE)) in the UK. METHODS: A questionnaire containing health resource use was completed at baseline and four months post-injury by patients or their carer. Completion rate and mean cost of each health resource item were assessed and sensitivity analysis was performed to derive a conservative estimate of the informal care cost. All costs are presented in 2017/18 pound sterling. RESULTS: A total of 4,183 patients from the WHiTE cohort completed the baseline questionnaire between May 2017 and April 2018, of whom 3,524 (84.2%) completed the four-month health resource section. Estimated mean costs of formal and informal care, home adaptations, and physiotherapy during the four months following injury were £2,843 (SD 5,467), £6,613 (SD 15,146), £706 (SD 1,706) and £9 (SD 33), respectively. Mean cost of informal care decreased to £660 (SD £1,040) in the sensitivity analysis when informal care was capped at 17.2 hours per day. CONCLUSION: Informal care is a significant source of costs after hip fracture and should therefore be included in future economical analyses of this patient group. Our results show that there is considerable variation in the interpretation of time-use of informal care among patients and further work is needed to improve how data regarding informal care are collected in order to obtain a more accurate cost estimate.Cite this article: Bone Joint Res. 2020;9(5):250-257.

Percutaneous fixation with Kirschner wires versus volar locking-plate fixation in adults with dorsally displaced fracture of distal radius: five-year follow-up of a randomized controlled trial.

AIMS: The aim of this study was to compare the clinical effectiveness of Kirschner wire (K-wire) fixation with locking-plate fixation for patients with a dorsally displaced fracture of the distal radius in the five years after injury. PATIENTS AND METHODS: We report the five-year follow-up of a multicentre, two-arm, parallel-group randomized controlled trial. A total of 461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation were recruited from 18 trauma centres in the United Kingdom. Patients were excluded if the surface of the wrist joint was so badly displaced it required open reduction. In all, 448 patients were randomized to receive either K-wire fixation or locking-plate fixation. In the K-wire group, there were 179 female and 38 male patients with a mean age of 59.1 years (19 to 89). In the locking-plate group, there were 194 female and 37 male patients with a mean age of 58.3 years (20 to 89). The primary outcome measure was the patient-rated wrist evaluation (PRWE). Secondary outcomes were health-related quality of life using the EuroQol five-dimension three-level (EQ-5D-3L) assessment, and further surgery related to the index fracture. RESULTS: At 12 months, 402/448 participants (90%) recruited into the main study provided PRWE scores. At year two, 294 participants (66%) provided scores; at year five, 198 participants (44%) provided scores. There was no clinically relevant difference in the PRWE at any point during the five-year follow-up; at five years, the PRWE score was 8.3 (12.5) in the wire group and 11.3 (15.6) in the plate group (95% confidence interval -6.99 to 0.99; p = 0.139). Nor was there a clinically relevant difference in health-related quality of life. Only three participants had further surgery in the five years after their injury (one in the wire group and two in the plate group). CONCLUSION: This follow-up study continues to show no evidence of a difference in wrist pain, wrist function, or quality of life for patients treated with wires versus locking plates in the five years following a dorsally displaced fracture of the distal radius. Cite this article: Bone Joint J 2019;101-B:978-983.

Cost-effectiveness of negative-pressure wound therapy in adults with severe open fractures of the lower limb: evidence from the WOLLF randomized controlled trial.

AIMS: The aim of this study was to estimate the cost-effectiveness of negative-pressure wound therapy (NPWT) in comparison with standard wound management after initial surgical wound debridement in adults with severe open fractures of the lower limb. PATIENTS AND METHODS: An economic evaluation was conducted from the perspective of the United Kingdom NHS and Personal Social Services, based on evidence from the 460 participants in the Wound Management of Open Lower Limb Fractures (WOLLF) trial. Economic outcomes were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Bivariate regression of costs (given in £, 2014 to 2015 prices) and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained associated with NPWT dressings. Sensitivity and subgroup analyses were undertaken to assess the impacts of uncertainty and heterogeneity, respectively, surrounding aspects of the economic evaluation. RESULTS: The base case analysis produced an incremental cost-effectiveness ratio of £267 910 per QALY gained, reflecting higher costs on average (£678; 95% confidence interval (CI) -£1082 to £2438) and only marginally higher QALYS (0.002; 95% CI -0.054 to 0.059) in the NPWT group. The probability that NPWT is cost-effective in this patient population did not exceed 27% regardless of the value of the cost-effectiveness threshold. This result remained robust to several sensitivity and subgroup analyses. CONCLUSION: This trial-based economic evaluation suggests that NPWT is unlikely to be a cost-effective strategy for improving outcomes in adult patients with severe open fractures of the lower limb. Cite this article: Bone Joint J 2019;101-B:1392-1401.

Validation of a prospective cohort study of older adults with hip fractures.

AIMS: This study sought to determine the proportion of older adults with hip fractures captured by a multicentre prospective cohort, the World Hip Trauma Evaluation (WHiTE), whether there was evidence of selection bias during WHiTE recruitment, and the extent to which the WHiTE cohort is representative of the broader population of older adults with hip fractures. PATIENTS AND METHODS: The characteristics of patients recruited into the WHiTE cohort study were compared with those treated at WHiTE hospitals during the same timeframe and submitted to the National Hip Fracture Database (NHFD). RESULTS: Patients recruited to WHiTE were more likely to be admitted from their own home (83.5% vs 80.2%; p < 0.001) and to have a higher median Abbreviated Mental Test Score (AMTS) (9 (interquartile range (IQR) 6 to 10) vs 9 (IQR 5 to 10); p < 0.001) than those who were not recruited. In terms of WHiTE cohort generalizability, participating hospitals included a greater proportion of Major Trauma Centres (47.8% vs 7.8%) and large hospitals (997 (IQR 873 to 1290) vs 707 (459 to 903) beds) with high-volume Emergency Departments (median annual attendances of 43 981 (IQR 37 147 to 54 385) vs 35 964 (IQR 26 229 to 50 551)). However, there were few differences in baseline characteristics between patients in the WHiTE cohort and those recorded in the NHFD. CONCLUSION: There is evidence of a weak selection bias towards recruiting fitter patients within the WHiTE cohort, which will help to put into context the findings of future studies. We conclude that the patients within the WHiTE cohort are representative of the national population of older adults with hip fractures throughout England, Wales, and Northern Ireland. Cite this article: Bone Joint J 2019;101-B:708-714.

A qualitative study of patient experience of an open fracture of the lower limb during acute care.

Aims: The aim of this study was to explore the patients' experience of recovery from open fracture of the lower limb in acute care. Patients and Methods: A purposeful sample of 20 participants with a mean age of 40 years (20 to 82) (16 males, four females) were interviewed a mean of 12 days (five to 35) after their first surgical intervention took place between July 2012 and July 2013 in two National Health Service (NHS) trusts in England, United Kingdom. The qualitative interviews drew on phenomenology and analysis identified codes, which were drawn together into categories and themes. Results: The findings identify the vulnerability of the patients expressed through three themes; being emotionally fragile, being injured and living with injury. The participants felt a closeness to death and continued uncertainty regarding loss of their limb. They experienced strong emotions while also trying to contain their emotions for the benefit of others. Their sense of self changed as they became a person with visible wounds, needed intimate help, and endured pain. When ready, they imagined what it would be like to live with injury. Conclusion: Recovery activities require an increased focus on emotional wellbeing. Surgeons are aware of the need for clinical expertise and for adequate pain relief but may not be as aware that their patients require support regarding their body image and help to imagine their future life. Cite this article: Bone Joint J 2018;100-B:522-6.

A comparison of the cost-effectiveness of intramedullary nail fixation and locking plate fixation in the treatment of adult patients with an extra-articular fracture of the distal tibia: economic evaluation based on the FixDT trial.

Aims: The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and 'locking' plate fixation in the treatment of extra-articular fractures of the distal tibia. Patients and Methods: An economic evaluation was conducted from the perspective of the United Kingdom National Health Service (NHS) and personal social services (PSS), based on evidence from the Fixation of Distal Tibia Fractures (UK FixDT) multicentre parallel trial. Data from 321 patients were available for analysis. Costs were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality adjusted life year (QALY) gained, and net monetary benefit. Sensitivity analyses were conducted to test the robustness of cost-effectiveness estimates. Results: Mean NHS and PSS costs were significantly lower for patients treated with an intramedullary nail than for those treated with a locking plate (-£970, 95% confidence interval (CI) -1685 to -256; p = 0.05). There was a small increase in QALYs gained in the nail fixation group (0.01, 95% CI -0.03 to 0.06; p = 0.52). The probability of cost-effectiveness for nail fixation exceeded 90% at cost-effectiveness thresholds as low as £15 000 per additional QALY. The cost-effectiveness results remained robust to several sensitivity analyses. Conclusion: This trial-based economic evaluation suggests that nail fixation is a cost-effective alternative to locking plate fixation. Cite this article: Bone Joint J 2018;100-B:624-33.

A randomized controlled trial comparing the Thompson hemiarthroplasty with the Exeter polished tapered stem and Unitrax modular head in the treatment of displaced intracapsular fractures of the hip: the WHiTE 3: HEMI Trial.

Aims: This study aimed to compare the change in health-related quality of life of patients receiving a traditional cemented monoblock Thompson hemiarthroplasty compared with a modern cemented modular polished-taper stemmed hemiarthroplasty for displaced intracapsular hip fractures. Patients and Methods: This was a pragmatic, multicentre, multisurgeon, two-arm, parallel group, randomized standard-of-care controlled trial. It was embedded within the WHiTE Comprehensive Cohort Study. The sample size was 964 patients. The setting was five National Health Service Trauma Hospitals in England. A total of 964 patients over 60 years of age who required hemiarthroplasty of the hip between February 2015 and March 2016 were included. A standardized measure of health outcome, the EuroQol (EQ-5D-5L) questionnaire, was carried out on admission and at four months following the operation. Results: Of the 964 patients enrolled, 482 died or were lost to follow-up (50%). No significant differences were noted in EQ-5D between groups, with a mean difference at four months of 0.037 in favour of the Exeter/Unitrax implant (95% confidence interval (CI) 0.014 to 0.087, p = 0.156), rising to 0.045 (95% CI 0.007 to 0.098, p = 0.09) when patients who died were excluded. The minimum clinically important difference for EQ-5D-5L used in this study is 0.08, therefore any benefit between implants is unlikely to be noticeable to the patient. There was no difference in mortality or mobility score. Conclusion: Allowing for the high rate of loss to follow-up, the use of the traditional Thompson hemiarthroplasty in the treatment of the displaced intracapsular hip fracture shows no difference in health outcome when compared with a modern cemented hemiarthroplasty. Cite this article: Bone Joint J 2018;100-B:352-60.

Modelling and estimation of health-related quality of life after hip fracture: A re-analysis of data from a prospective cohort study.

OBJECTIVES: This study investigates the reporting of health-related quality of life (HRQoL) in patients following hip fracture. We compare the relative merits and make recommendations for the use for two methods of measuring HRQoL; (i) including patients who died during follow-up and (ii) including survivors only. METHODS: The World Hip Trauma Evaluation has previously reported changes in HRQoL using EuroQol-5D for patients with hip fractures. We performed additional analysis to investigate the effect of including or excluding those patients who died during the first four months of the follow-up period. RESULTS: The dataset included 503 patients, 25 of whom died between 30 days and four months of injury. There was a statistically significant difference in 30-day HRQoL between those alive (mean 0.331 and standard deviation (sd) 0.360) and those dead (mean 0.156 and sd 0.421) by four months (independent-samples t-test; p 0.022). The estimated difference of 0.175 in HRQoL (95% confidence interval 0.025 to 0.325) was also highly clinically significant. CONCLUSION: When reporting HRQoL for patients after a hip fracture, excluding patients who die during follow-up leads to an overestimate of the effects of the intervention or treatment pathway. We would recommend that death-adjusted estimates should be used routinely when reporting HRQoL in this population.Cite this article: N. Parsons, X. L. Griffin, J. Achten, T. J. Chesser, S. E. Lamb, M. L. Costa. Modelling and estimation of health-related quality of life after hip fracture: A re-analysis of data from a prospective cohort study. Bone Joint Res 2018;7:1-5.

Informed consent in the context of research involving acute injuries and emergencies.

Traditionally, informed consent for clinical research involves the patient reading an approved Participant Information Sheet, considering the information presented and having as much time as they need to discuss the study information with their friends and relatives, their clinical care and the research teams. This system works well in the 'planned' or 'elective' setting. But what happens if the patient requires urgent treatment for an injury or emergency? This article reviews the legal framework which governs informed consent in the emergency setting, discusses how the approach taken may vary according to the details of the emergency and the treatment required, and reports on the patients' view of providing consent following a serious injury. We then provide some practical tips for managing the process of informed consent in the context of injuries and emergencies. Cite this article: Bone Joint J 2017;99-B:147-150.

A pragmatic randomised controlled trial comparing the efficacy of a femoral nerve block and periarticular infiltration for early pain relief following total knee arthroplasty.

AIMS: The aim of this study was to compare the effectiveness of a femoral nerve block and a periarticular infiltration in the management of early post-operative pain after total knee arthroplasty (TKA). PATIENTS AND METHODS: A pragmatic, single centre, two arm parallel group, patient blinded, randomised controlled trial was undertaken. All patients due for TKA were eligible. Exclusion criteria included contraindications to the medications involved in the study and patients with a neurological abnormality of the lower limb. Patients received either a femoral nerve block with 75 mg of 0.25% levobupivacaine hydrochloride around the nerve, or periarticular infiltration with 150 mg of 0.25% levobupivacaine hydrochloride, 10 mg morphine sulphate, 30 mg ketorolac trometamol and 0.25 mg of adrenaline all diluted with 0.9% saline to make a volume of 150 ml. RESULTS: A total of 264 patients were recruited and data from 230 (88%) were available for the primary analysis. Intention-to-treat analysis of the primary outcome measure of a visual analogue score for pain on the first post-operative day, prior to physiotherapy, was similar in both groups. The mean difference was -0.7 (95% confidence interval (CI) -5.9 to 4.5; p = 0.834). The periarticular group used less morphine in the first post-operative day compared with the femoral nerve block group (74%, 95% CI 55 to 99). The femoral nerve block group reported 39 adverse events, of which 27 were serious, in 31 patients and the periarticular group reported 51 adverse events, of which 38 were serious, in 42 patients up to six weeks post-operatively. None of the adverse events were directly attributed to either of the interventions under investigation. CONCLUSION: Periarticular infiltration is a viable and safe alternative to femoral nerve block for the early post-operative relief of pain following TKA. Cite this article: Bone Joint J 2017;99-B:904-11.

The tip-apex distance in the X-Bolt dynamic plating system.

OBJECTIVES: The Sliding Hip Screw (SHS) is commonly used to treat trochanteric hip fractures. Fixation failure is a devastating complication requiring complex revision surgery. One mode of fixation failure is lag screw cut-out which is greatest in unstable fracture patterns and when the tip-apex distance of the lag screw is > 25 mm. The X-Bolt Dynamic Hip Plating System (X-Bolt Orthopaedics, Dublin, Ireland) is a new device which aims to reduce this risk of cut-out. However, some surgeons have reported difficulty minimising the tip-apex distance with subsequent concerns that this may lead to an increased risk of cut-out. PATIENTS AND METHODS: We measured the tip-apex distance from the intra-operative radiographs of 93 unstable trochanteric hip fractures enrolled in a randomised controlled trial (Warwick Hip Trauma Evaluation, WHiTE One trial). Participants were treated with either the sliding hip screw or the X-Bolt dynamic hip plating system. We also recorded the incidence of cut-out in both groups, at a median follow-up time of 17 months. RESULTS: There was a significantly increased tip-apex distance with the use of the X-Bolt (mean difference 3.7mm (95% confidence interval 1.58 to 5.73); SHS mean 17.1 mm, X-Bolt mean 20.8; p = 0.001. However, this was not associated with an increased incidence of cut-out at a median follow-up time of 17 months, with three cut-outs (6%) in the SHS group and 0 (0%) in the X-Bolt group. CONCLUSION: The X-Bolt is a safe implant with no increased risk for cut-out. Concerns about minimising the tip-apex distance may be justified but do not appear to be clinically important.Cite this article: M. A. Fernandez, A. Aquilina, J. Achten, N. Parsons, M. L. Costa, X. L. Griffin. The tip-apex distance in the X-Bolt dynamic plating system. Bone Joint Res 2017;6:-207. DOI: 10.1302/2046-3758.64.BJR-2015-0016.R2.

A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS?

OBJECTIVES: The annual incidence of hip fracture is 620 000 in the European Union. The cost of this clinical problem has been estimated at 1.75 million disability-adjusted life years lost, equating to 1.4% of the total healthcare burden in established market economies. Recent guidance from The National Institute for Health and Clinical Excellence (NICE) states that research into the clinical and cost effectiveness of total hip arthroplasty (THA) as a treatment for hip fracture is a priority. We asked the question: can a trial investigating THA for hip fracture currently be delivered in the NHS? METHODS: We performed a contemporaneous process evaluation that provides a context for the interpretation of the findings of WHiTE Two - a randomised study of THA for hip fracture. We developed a mixed methods approach to situate the trial centre within the context of wider United Kingdom clinical practice. We focused on fidelity, implementation, acceptability and feasibility of both the trial processes and interventions to stakeholder groups, such as healthcare providers and patients. RESULTS: We have shown that patients are willing to participate in this type of research and that surgeons value being part of a team that has a strong research ethos. However, surgical practice does not currently reflect NICE guidance. Current models of service delivery for hip fractures are unlikely to be able to provide timely total hip arthroplasty for suitable patients. CONCLUSIONS: Further observational research should be conducted to define the population of interest before future interventional studies are performed.Cite this article: C. Huxley, J. Achten, M. L. Costa, F. Griffiths, X. L. Griffin. A process evaluation of the WHiTE Two trial comparing total hip artroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS? Bone Joint Res 2016;5:444-452. DOI: 10.1302/2046-3758.510.BJR-2015-0008.R1.

The Warwick Hip Trauma Evaluation One: a randomised pilot trial comparing the X-Bolt Dynamic Hip Plating System with sliding hip screw fixation in complex extracapsular hip fractures: WHiTE (One).

AIMS: The aim of this study was to inform a definitive trial which could determine the clinical effectiveness of the X-Bolt Dynamic Hip Plating System compared with the sliding hip screw for patients with complex pertrochanteric fragility fractures of the femur. PATIENTS AND METHODS: This was a single centre, participant blinded, randomised, standard-of-care controlled pilot trial. Patients aged 60 years and over with AO/ASIF A2 and A3 type femoral pertrochanteric fractures were eligible. RESULTS: The primary outcome was the EuroQoL 5 Dimension Score (EQ-5D-3L) at one year following index fixation. A total of 100 participants were recruited, and primary outcome data were available for 88 patients following losses to follow-up and withdrawals. The mean difference in EQ-5D was 0.03 (95% confidence interval -0.17, 0.120; p = 0.720.) There were no significant differences in any of the secondary outcomes measures. The recruitment and follow-up rates from this feasibility study were as predicted. CONCLUSION: A definitive trial with 90% power to find a clinically important difference in EQ-5D would require 964 participants based upon the data from this study. We plan to start recruitment to this trial in Spring 2016. TAKE HOME MESSAGE: A definitive trial of X-Bolt Dynamic Hip Plating System is feasible and should be conducted now in order to quantify the clinical effectiveness of this novel implant. Cite this article: Bone Joint J 2016;98-B:686-9.

A randomised feasibility study comparing total hip arthroplasty with and without dual mobility acetabular component in the treatment of displaced intracapsular fractures of the proximal femur : The Warwick Hip Trauma Evaluation Two : WHiTE Two.

AIMS: The optimal treatment for independent patients with a displaced intracapsular fracture of the hip remains controversial. The recognised alternatives are hemiarthroplasty and total hip arthroplasty. At present there is no established standard of care, with both types of arthroplasty being used in many centres. PATIENTS AND METHODS: We conducted a feasibility study comparing the clinical effectiveness of a dual mobility acetabular component compared with standard polyethylene component in total hip arthroplasty for independent patients with a displaced intracapsular fracture of the hip, for a 12-month period beginning in June 2013. The primary outcome was the risk of dislocation one year post-operatively. Secondary outcome measures were EuroQol 5 Dimensions, ICEpop CAPability measure for Older people, Oxford hip score, mortality and re-operation. RESULTS: Only 20 patients were recruited during this time. The baseline demographics were similar in the two groups and no patient suffered a dislocation. Differences in secondary outcomes were not analysed due to the small sample. CONCLUSION: This feasibility study suggests that any trial investigating the effectiveness of total hip arthroplasty for fracture of the hip might not be deliverable within the constraints of current systems of care in the United Kingdom. Cite this article: Bone Joint J 2016;98-B:1431-5.

The World Hip Trauma Evaluation Study 3: Hemiarthroplasty Evaluation by Multicentre Investigation - WHITE 3: HEMI - An Abridged Protocol.

BACKGROUND: Approximately half of all hip fractures are displaced intracapsular fractures. The standard treatment for these fractures is either hemiarthroplasty or total hip arthroplasty. The recent National Institute for Health and Care Excellence (NICE) guidance on hip fracture management recommends the use of 'proven' cemented stem arthroplasty with an Orthopaedic Device Evaluation Panel (ODEP) rating of at least 3B (97% survival at three years). The Thompsons prosthesis is currently lacking an ODEP rating despite over 50 years of clinical use, likely due to the paucity of implant survival data. Nationally, adherence to these guidelines is varied as there is debate as to which prosthesis optimises patient outcomes. DESIGN: This study design is a multi-centre, multi-surgeon, parallel, two arm, standard-of-care pragmatic randomised controlled trial. It will be embedded within the WHiTE Comprehensive Cohort Study (ISRCTN63982700). The main analysis is a two-way equivalence comparison between Hemi-Thompson and Hemi-Exeter polished taper with Unitrax head. Secondary outcomes will include radiological leg length discrepancy measured as per Bidwai and Willett, mortality, re-operation rate and indication for re-operation, length of index hospital stay and revision at four months. This study will be supplemented by the NHFD (National Hip Fracture Database) dataset. DISCUSSION: Evidence on the optimum choice of prosthesis for hemiarthroplasty of the hip is lacking. National guidance is currently based on expert opinion rather than empirical evidence. The incidence of hip fracture is likely to continue to increase and providing high quality evidence on the optimumCite this article: A. L. Sims. The World Hip Trauma Evaluation Study 3: Hemiarthroplasty Evaluation by Multicentre Investigation - WHITE 3: HEMI - An Abridged Protocol. Bone Joint Res 2016;5:18-25. doi: 10.1302/2046-3758.51.2000473.