Spinal or general anaesthesia for surgical repair of hip fracture and subsequent risk of mortality and morbidity: a database analysis using propensity score-matching.

Around 76,000 people fracture their hip annually in the UK at a considerable personal, social and financial cost. Despite longstanding debate, the optimal mode of anaesthesia (general or spinal) remains unclear. Our aim was to assess whether there is a significant difference in mortality and morbidity between patients undergoing spinal anaesthesia compared with general anaesthesia during hip fracture surgery. A secondary analysis examined whether a difference exists in mortality for patients with pre-existing cardiovascular disease or chronic obstructive pulmonary disease. This was a clinical database analysis of patients treated for hip fracture in Nottingham, UK between 2004 and 2015. Propensity score-matching was used to generate matched pairs of patients, one of whom underwent each mode of anaesthesia. Data were analysed using conditional logistic regression, with 7164 patients successfully matched. There was no difference in 30- or 90-day mortality in patients who had spinal rather than general anaesthesia (OR [95%CI] 0.97 [0.8-1.15]; p = 0.764 and 0.93 [0.82-1.05]; p = 0.247 respectively). Patients who had a spinal anaesthetic had a lower-risk of blood transfusion (OR [95%CI] 0.84 [0.75-0.94]; p = 0.003) and urinary tract infection (OR [95%CI] 0.72 [0.61-0.84]; p < 0.001), but were more likely to develop a chest infection (OR [95%CI] 1.23 [1.07-1.42]; p = 0.004), deep vein thrombosis (OR [95%CI] 2.18 [1.07-4.45]; p = 0.032) or pulmonary embolism (OR [95%CI] 2.23 [1.16-4.29]; p = 0.016). The mode of anaesthesia for hip fracture surgery resulted in no significant difference in mortality, but there was a significant difference in several measures of postoperative morbidity.

Managing failed fixation: valgus osteotomy for femoral neck nonunion.

Femoral neck non union is a relatively uncommon complication following intracapsular hip fracture in the young patient. Almost all patients with femoral neck non union are symptomatic for which they will require some form of revision surgery. This review discusses the role of valgus osteotomy in managing the younger patient with femoral neck non union.

Lead contamination of surgical gloves by contact with a lead hand.

Background. "Lead hands" are frequently used to maintain hand and finger position in hand surgery. The malleability and strength of lead make it ideal for this purpose. The aim of this study was to determine the amount of lead transferred to a surgeon's glove during handling of a lead hand. Method. Sterile surgical gloves were wiped over the surface of a lead hand. The number of wipes was varied, the gloves were then sent to a trace elements laboratory, and the lead content transferred to each glove was determined. Results. The amount of lead transferred to each glove increased with increasing exposure to the lead hand. After twenty wipes, up to 2 mg of lead was transferred to the surgeon's glove. Covering the lead hand with a sterile drape markedly reduced the lead transferred to the surgeon's glove. Conclusion. Significant amount of lead is transferred on to the gloves after handling a lead hand. This risks wound contamination and a foreign body reaction. Covering the lead hand with a sterile drape may minimise the risk of surgical wound contamination.

The triceps-flexor carpi ulnaris (TRIFCU) approach to the elbow.

INTRODUCTION: Intra-articular fractures of the distal humerus frequently require internal fixation. Several approaches have been described, with the posterior approaches being most common. We present a new approach to the distal humerus via the lateral border of the triceps muscle. PATIENTS AND METHODS: The senior author has used this technique for fixation of intra-articular fractures of the distal humerus in 12 patients. RESULTS: The approach is equally useful for intra- and extra-articular fractures. No cases of postoperative ulna nerve neuropraxia have been encountered. There have been no postoperative wound complications. The exposure has allowed sufficient access to allow anatomically contoured plates to be easily applied to both sides of the distal humerus with confirmation of intra-articular fracture reduction. CONCLUSIONS: The approach has the advantages of leaving the muscular bed of the ulna nerve undisturbed, whilst still providing excellent exposure of the distal humerus. The triceps mechanism is not divided or split allowing rapid recovery of extensor function. Additionally, because of the natural carrying angle of the elbow, repositioning of the reflected triceps aponeurosis is easy.

Malunion following flexible intramedullary nails for tibial and femoral fractures in adolescents.

PURPOSE: Flexible intramedullary nails (FIN) are increasingly used in the management of paediatric tibial and femoral fractures. Concerns have recently been raised regarding the use of FIN in older children. The aim of this study was to determine how effective FIN is in treating tibial and femoral fractures in adolescents. METHODS: Patients aged 11 years or older undergoing FIN for tibial and femoral fractures between 2003 and 2009 were identified. Radiographs and case notes were reviewed to identify complications. RESULTS: Thirty-five consecutive adolescent patients underwent FIN for tibial (n = 21) and femoral fractures (n = 15), with a mean age of 12.9 years. The mean radiographic follow up was 29 weeks. Sixty percent (60%, n = 9) and 38% (n = 9) of femoral and tibial fractures, respectively, malunited. Fracture severity was associated with increased malunion for both tibial and femoral fractures (P = 0.046 and P = 0.044, respectively). Two femoral fractures took longer than 20 weeks to unite and seven tibial fractures took longer than 16 weeks to unite. CONCLUSION: The higher than expected rates of malunion and delayed union in this study suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures.

Factors influencing discharge location following hip fracture.

INTRODUCTION: Outcome measures following hip fracture usually consider morbidity and mortality following injury.(5) Few studies have looked at post injury discharge location as an outcome measure following hip fracture. Discharging patients to a different location frequently delays discharge whilst the necessary social arrangements are made. Early identification of these patients could reduce these delays. The aim of this study was to determine factors influencing discharge location following hip fracture. METHODS: Three thousand two hundred and forty consecutive patients were admitted to our centre with a fractured neck of femur. Data was prospectively collected by independent audit clerks on a standardised proforma. Our outcome measure was whether the patient was discharged from hospital either to their place of normal residence or to an alternative location. Factors influencing discharge location were identified using multivariate logistic regression analysis. RESULTS: Increasing age was associated with increasing risk of requiring discharge to an alternative location (DAL) (p<0.001). This risk rose from 13% in the sixth decade by approximately 10% every additional decade. Males were 2.5 times more likely than females to require DAL. Patients who were more independent prior to injury were less likely to require DAL. Patients who sustained their injury whilst in hospital were 2.3 times more likely to require DAL compared to those who fell in their own homes. CONCLUSION: The following risk factors are associated with increased risk of requiring discharge to an alternative location: (1) pre-injury dependence, (2) increasing age, (3) male sex, (4) injury sustained whilst in hospital. Early identification of patients requiring DAL could reduce inpatient delays.

Childhood fractures requiring inpatient management.

INTRODUCTION: Fractures account for significant morbidity during childhood. Children requiring inpatient management for their fractures represent the most serious injuries. The aim of this study was to identify injury patterns in childhood fractures requiring inpatient management at a regional trauma centre. METHODS: Three thousand and forty two consecutive injured children were admitted to our orthopaedic centre over a 4-year period. Data was prospectively collected by independent audit clerks and entered onto a database. Data recorded included type of injury, mechanism of injury and place of injury. This was then used to assess injury patterns and trends. RESULTS: Upper limb and lower limb fractures accounted for 51% (n=1,565) and 21% (n=637) of all emergency admissions, respectively. Other causes included soft tissue injury, Infections, Polytrauma and Dislocations. Twice as many males were admitted with upper or lower limb fractures compared to females (67% versus 33%) (P<0.001). Males were more likely to be older (P<0.001) compared to females. Distal radial fractures accounted for 60% of upper limb fractures. Distal and midshaft tibial fractures accounted for 52% of lower limb fractures. Sports injuries were responsible for the majority of lower limb fractures with falls accounting for the majority of upper limb fractures. Fracture incidence peaked during summer months. CONCLUSION: Males are twice as likely to require inpatient management for fractures as females. Male adolescents are particularly at risk. Distal radial fractures following falls and distal tibial fractures following sports injuries are the most common fractures requiring admission. Identifying ways of minimising risk of these injuries would reduce childhood morbidity.

Interval appendicectomy after resolution of adult inflammatory appendix mass--is it necessary?

INTRODUCTION: The management of adult inflammatory appendix mass is evolving. Traditional management has been shown to be initially conservative, with interval appendicectomy performed after the mass resolved. This remains the most common approach in UK surgical practice. Recently, an increasing number of studies have challenged this approach. This review looks at the management of the inflammatory appendix mass in the adult in light of these recent changes and suggests a management approach based on the current evidence. METHODS: A Medline, Pubmed and Cochrane database search was performed using key words including combinations of; appendix, appendiceal, interval, appendectomy, appendicectomy, mass, abscess, phlegmon, and appendicitis. All articles were cross-referenced. FINDINGS: A conservative management approach will be successful in the majority of patients presenting with an appendix mass. The incidence of recurrence of symptoms following successful conservative management is low. CONCLUSION: After initial successful conservative management, routine use of interval appendicectomy is not justified in asymptomatic patients.

Mortality and causes of death among patients with isolated limb and pelvic fractures.

Between May 2001 and May 2005, all 8834 adults admitted to our hospital with fractures to the limbs and pelvis were prospectively entered onto a database. Information was cross-referenced with the Office of National Statistics, and all patients who died during the study period were identified. Mortality rates were adjusted for age, gender and type of injury and cause of death was identified from hospital records. Neck of femur fractures accounted for 32% of admissions. Younger patients were more likely to be male and older patients more likely to be female. Overall 30-day and 1-year mortalities were 4.5 and 13%, respectively. Increased mortality was associated with age, male gender and fractures of the femur or pelvis.