Characteristics and outcomes of hip fractures in lower limb amputees

INTRODUCTION

Lower limb amputees, regardless of age are at an increased risk of developing fragility fractures of the neck of femur. The characteristics and outcomes of the fractures of the neck of femur in lower limb amputees have not been studied in detail.

METHODS

We undertook a retrospective review of a prospectively collected single centre and single surgeon database between March 1996 and January 2017, using a standard proforma to identify patients who required surgical intervention for fracture neck of femur and had sustained a previous lower limb amputation and compared them with a cohort of standard hip fracture patients.

RESULTS

Twenty-seven patients, sustaining 28 fractures of the neck of femurs were identified of which 16 were females with mean age of 78 years (50-89). Nineteen fractures were sustained on the ipsilateral side of the amputation. Results showed that seventy percent of amputees returned to their previous level of mobility and prior residence. Mortality in this group is higher as compared to a standard hip fracture patient but pain and mobility were comparable in both groups.

DISCUSSION

The incidence of both hip fractures and amputations in increasing worldwide but no study has compared outcomes of hip fractures in amputees and compared them to a standard hip fracture patient. Amputees exhibit reduced bone density both at the hip and stump end which increases risk for osteoporosis and fragility fractures in the hip. The management of our patients followed orthopaedic principles, well established surgical interventions and rehabilitation.

CONCLUSION

This study reveals that hip fractures in amputees can have comparable results to a standard hip fracture cohort if preoperative optimisation, planning and postoperative rehabilitation is carried out.

Management and outcome of the dislocated hip hemiarthroplasty

AIMS

This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation.

PATIENTS AND METHODS

Of 3326 consecutive patients treated with hemiarthroplasty for fractured neck of femur, 46 (1.4%) sustained dislocations. Of the 46 dislocations, there were 37 female patients (80.4%) and nine male patients (19.6%) with a mean age of 83.8 years (66 to 100). Operative intervention for each, and subsequent dislocations, were recorded. The following outcome measures were recorded: dislocation; mortality up to one-year post-injury; additional surgery; residential status; mobility; and pain score at one year.

RESULTS

Of 43 dislocations, 30 (70%) occurred within one month and 42 (98%) occurred within three months of hip fracture surgery. Seven (16%) of these patients were treated with a single closed reduction and sustained no further dislocations. Four (9%) were treated with open reduction and experienced no further dislocations. Three (7%) hips were left dislocated and the remaining 32 (74%) patients required additional surgery of further closed reduction, revision, or excision arthroplasty. The one-year mortality rates for patients treated with two or fewer reductions (open or closed), successful revision arthroplasty, and excision arthroplasty were 3/14 (21%), 1/7 (14%), and 8/14 (57%) respectively. The only statistically significant difference in mortality was the difference between patients who did not sustain a dislocation and those who did and were treated by excision arthroplasty (p = 0.03). Patients treated by excision arthroplasty had the greatest reduction in mobility scores and highest pain scores. The excision arthroplasty group also included the greatest proportion of patients not able to mobilize and the smallest proportion of patients remaining in their own home.

CONCLUSION

Most dislocations of hemiarthroplasties of the hip occur within one month of surgery. Closed reduction is generally unsuccessful. For those patients with unsuccessful closed reduction, revision arthroplasty should be considered when possible, as this results in a better functional outcome with a lower mortality than excision arthroplasty.

Sliding hip screw versus the Targon PFT nail for trochanteric hip fractures

Aims

To compare the outcomes for trochanteric fractures treated with a sliding hip screw (SHS) or a cephalomedullary nail.

Patients and Methods

A total of 400 patients with a trochanteric hip fracture were randomised to receive a SHS or a cephalomedullary nail (Targon PFT). All surviving patients were followed up to one year from injury. Functional outcome was assessed by a research nurse blinded to the implant used.

Results

Recovery of mobility, as assessed by a mobility scale, was superior for those treated with the intramedullary nail compared with the SHS at eight weeks, three and nine months (p-values between 0.01 and 0.04), the difference at six and 12 months was not statistically significant (p = 0.15 and p = 0.18 respectively). The mean difference was around 0.4 points (0.3 to 0.5) on a nine point scale. Surgical time for the nail was four minutes less than that for the SHS (p < 0.001). Fracture healing complications were similar for the two groups. There were no statistically significant differences between implants for any other recorded outcomes including the need for post-operative blood transfusion, wound healing complications, general medical complications, hospital stay or mortality.

Conclusion

This study confirms the findings of a previous study that both methods of treatment produce similar results, although intramedullary fixation does result in marginally improved regain of mobility in comparison with the SHS. Cite this article: Bone Joint J 2017;99-B:1210–15.

Compound heterozygous variants in NBAS as a cause of atypical osteogenesis imperfecta

BACKGROUND

Osteogenesis imperfecta (OI), the commonest inherited bone fragility disorder, affects 1 in 15,000 live births resulting in frequent fractures and reduced mobility, with significant impact on quality of life. Early diagnosis is important, as therapeutic advances can lead to improved clinical outcome and patient benefit.

REPORT

Whole exome sequencing in patients with OI identified, in two patients with a multi-system phenotype, compound heterozygous variants in NBAS (neuroblastoma amplified sequence). Patient 1: NBAS c.5741G>A p.(Arg1914His); c.3010C>T p.(Arg1004*) in a 10-year old boy with significant short stature, bone fragility requiring treatment with bisphosphonates, developmental delay and immunodeficiency. Patient 2: NBAS c.5741G>A p.(Arg1914His); c.2032C>T p.(Gln678*) in a 5-year old boy with similar presenting features, bone fragility, mild developmental delay, abnormal liver function tests and immunodeficiency.

DISCUSSION

Homozygous missense NBAS variants cause SOPH syndrome (short stature; optic atrophy; Pelger-Huet anomaly), the same missense variant was found in our patients on one allele and a nonsense variant in the other allele. Recent literature suggests a multi-system phenotype. In this study, patient fibroblasts have shown reduced collagen expression, compared to control cells and RNAseq studies, in bone cells show that NBAS is expressed in osteoblasts and osteocytes of rodents and primates. These findings provide proof-of-concept that NBAS mutations have mechanistic effects in bone, and that NBAS variants are a novel cause of bone fragility, which is distinguishable from 'Classical' OI.

CONCLUSIONS

Here we report on variants in NBAS, as a cause of bone fragility in humans, and expand the phenotypic spectrum associated with NBAS. We explore the mechanism underlying NBAS and the striking skeletal phenotype in our patients.

Defining Significant Events for Neonatal and Pediatric Transport: Results of a Combined Delphi and Consensus Meeting Process

Objective  To develop standardized definitions for a list of indicators that represent significant events during pediatric transport, which were previously identified by a national Delphi study. Methods  We designed a three-phase consensus process that applied Delphi methodology to a combination of electronic questionnaires and a live consensus meeting. Results  Thirty-one pediatric transport experts evaluated a total of 59 indicators. Twenty-four indicators represented events or interventions that did not require definition. One indicator was removed from the list. Definitions for the remaining 34 indicators were developed. Conclusion  This standardized indicator list is intended for application to quality improvement and clinical research initiatives.

ASPP2 deficiency causes features of 1q41q42 microdeletion syndrome

Chromosomal abnormalities are implicated in a substantial number of human developmental syndromes, but for many such disorders little is known about the causative genes. The recently described 1q41q42 microdeletion syndrome is characterized by characteristic dysmorphic features, intellectual disability and brain morphological abnormalities, but the precise genetic basis for these abnormalities remains unknown. Here, our detailed analysis of the genetic abnormalities of 1q41q42 microdeletion cases identified TP53BP2, which encodes apoptosis-stimulating protein of p53 2 (ASPP2), as a candidate gene for brain abnormalities. Consistent with this, Trp53bp2-deficient mice show dilation of lateral ventricles resembling the phenotype of 1q41q42 microdeletion patients. Trp53bp2 deficiency causes 100% neonatal lethality in the C57BL/6 background associated with a high incidence of neural tube defects and a range of developmental abnormalities such as congenital heart defects, coloboma, microphthalmia, urogenital and craniofacial abnormalities. Interestingly, abnormalities show a high degree of overlap with 1q41q42 microdeletion-associated abnormalities. These findings identify TP53BP2 as a strong candidate causative gene for central nervous system (CNS) defects in 1q41q42 microdeletion syndrome, and open new avenues for investigation of the mechanisms underlying CNS abnormalities.

Atypical femur fractures - Patient characteristics and results of intramedullary nailing for a series of 21 patients

Atypical femoral fractures have been associated with long term use of bisphosphonates. Our study plan was to report the outcome of treatment for a series of -patients with an atypical femoral fracture and to compare the characteristics of those patients with a proximal femoral fracture. 21 atypical fractures were identified over a seven year period and these were compared with those of 2.547 hip fracture patients treated over the same time period at a single centre. The mean age of patients with an atypical fracture was on average nine years less than that for the hip fracture patients (72 as against 81 years, p = 0.002). Four (19.0%) of the patients with atypical fracture had no injury associated with the fracture and nine (42.9%) patients had pain prior to presentation at hospital for a mean of 31 days. Patients with atypical fractures were more likely to be smokers (9/21(42.9%) versus 319/2547 (12.5%), p = 0.0001) and more likely to be on long term oral steroid therapy (8/21 (38.1%) versus 131/2547 (5.1%), p < 0.0001) in comparison to other hip fracture patients. All the atypical fractures were treated by intramedullary nailing and healed uneventfully apart from one fracture that developed non-union requiring revision nailing. Residual pain at one year from injury was more prevalent for patients with atypical fractures.

Hemiarthroplasty versus internal fixation for displaced intracapsular fractures of the hip in elderly men: a pilot randomised trial

A total of 56 male patients with a displaced intracapsular fracture of the hip and a mean age of 81 years (62 to 94), were randomised to be treated with either a cemented hemiarthroplasty (the Exeter Trauma Stem) or reduction and internal fixation using the Targon Femoral Plate. All surviving patients were reviewed one year after the injury, at which time restoration of function and pain in the hip was assessed. There was no statistically significant difference in mortality between the two groups (7/26; 26.9% for hemiarthroplasty vs 10/30; 33.3% for internal fixation). No patient treated with a hemiarthroplasty required further surgery, but eight patients treated by internal fixation did (p = 0.005), five requiring hemiarthroplasty and three requiring total hip arthroplasty. Those treated by internal fixation had significantly more pain (p = 0.02). The restoration of mobility and independence were similar in the two groups. These results indicate that cemented hemiarthroplasty gives better results than internal fixation in elderly men with a displaced intracapsular fracture of the hip.

Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015: Association of Anaesthetists of Great Britain and Ireland British Orthopaedic Association British Geriatric Society

Concise guidelines are presented for the preparation and conduct of anaesthesia and surgery in patients undergoing cemented hemiarthroplasty for hip fracture. The Working Party specifically considered recent publications highlighting complications occurring during the peri‐operative period 1, 2. The advice presented is based on previously published advice and clinical studies.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

Early surgery for patients with a fracture of the hip decreases 30-day mortality

There has been extensive discussion about the effect of delay to surgery on mortality in patients sustaining a fracture of the hip. Despite the low level of evidence provided by many studies, a consensus has been accepted that delay of > 48 hours is detrimental to survival. The aim of this prospective observational study was to determine if early surgery confers a survival benefit at 30 days.

Between 1989 and 2013, data were prospectively collected on patients sustaining a fracture of the hip at Peterborough City Hospital. They were divided into groups according to the time interval between admission and surgery. These thresholds ranged from <  6 hours to between 49 and 72 hours. The outcome which was assessed was the 30-day mortality. Adjustment for confounders was performed using multivariate binary logistic regression analysis. In all, 6638 patients aged > 60 years were included.

Worsening American Society of Anaesthesiologists grade (p < 0.001), increased age (p <  0.001) and extracapsular fracture (p < 0.019) increased the risk of 30-day mortality.

Increasing mobility score (p = 0.014), mini mental test score (p < 0.001) and female gender (p = 0.014) improved survival. After adjusting for these confounders, surgery before 12 hours improved survival compared with surgery after 12 hours (p = 0.013). Beyond this the increasing delay to surgery did not significantly affect the 30-day mortality.

Cite this article: Bone Joint J 2015;97-B:104–8.

Cardiopulmonary exercise testing for preoperative risk assessment before pancreaticoduodenectomy for cancer

OBJECTIVE

Pancreaticoduodenectomy is the standard of care for tumors confined to the head of pancreas and can be undertaken with low operative mortality. The procedure has a high morbidity, particularly in older patient populations with preexisting comorbidities. This study evaluated the role of cardiopulmonary exercise testing to predict postoperative morbidity and outcome in high-risk patients undergoing pancreaticoduodenectomy.

METHODS

In a prospective cohort of consecutive patients undergoing pancreaticoduodenectomy, those aged over 65 years (or younger with comorbidity) were categorized as high risk and underwent preoperative assessment by cardiopulmonary exercise testing (CPET) according to a predefined protocol. Data were collected on functional status, postoperative complications, and survival.

RESULTS

A total of 143 patients underwent preoperative assessment, 50 of whom were deemed to be at low risk for surgery per study protocol. Of 93 high-risk patients, 64 proceeded to surgery after preoperative CPET. Neither anaerobic threshold (AT) nor maximal oxygen consumption ([Formula: see text] O 2 MAX) predicted patient mortality or morbidity. However, ventilatory equivalent of carbon dioxide ([Formula: see text] E/[Formula: see text] CO 2) at AT was a predictive marker of postoperative mortality, with an area under the curve (AUC) of 0.84 (95 % confidence interval [CI] 0.63-1.00, p = 0.020); a threshold of 41 was 75 % sensitive and 95 % specific (positive predictive value 50 %, negative predictive value 98 %). Above this threshold, raised [Formula: see text] E/[Formula: see text] CO 2 predicted poor long-term survival (hazard ratio 2.05, 95 % CI 1.09-3.86, p = 0.026).

CONCLUSIONS

CPET is a useful adjunctive test for predicting postoperative outcome in patients being assessed for pancreaticoduodenectomy. Raised CPET-derived [Formula: see text] E/[Formula: see text] CO 2 predicts early postoperative death and poor long-term survival.

Clopidogrel has no effect on mortality from hip fracture

Over 76,000 patients in the UK sustain a proximal femoral fracture. Clopidogrel is currently the world's second best selling drug. There has been much recent controversy surrounding the optimal time for surgical intervention in this medically challenging group of patients. This consecutive series of 1225 patients from our unit over six years included thirty patients concurrently taking clopidogrel whilst sustaining a hip fracture. Our study demonstrated no significant difference in ASA grade, intra-operative blood loss or subsequent transfusion, post-operative wound complication, or mortality to one year in those taking clopidogrel. The authors therefore advocate timely surgical intervention as rapidly as circumstances allow.

Orthopaedic injuries associated with hip fractures in those aged over 60 years: a study of patterns of injury and outcomes for 1971 patients

INTRODUCTION

There has been little research into the consequence of suffering a hip fracture and associated orthopaedic injures. The aim of this research paper is to describe the patient characteristics, patterns of injury and to define the effect on outcomes of orthopaedic injuries occurring simultaneously with hip fractures.

PATIENTS AND METHODS

Hip fracture data was collected prospectively. Patients under 60 years of age were excluded from the study. Between 2004 and 2010 we treated 1971 consecutive patients aged 60 years or older with a hip fracture.

RESULTS

81 (4.1%) patients sustained a simultaneous fracture or dislocation. 90% (73/81) of these injuries were in the upper limb and 88% (71/81) were ipsilateral, with the wrist (34 cases) and the proximal humerus (21 cases) being the commonest site of injury. Median hospital stay was significantly longer for those with additional injures. Pubic rami fractures were not seen in association with a hip fracture. Those patients who sustained a concomitant wrist fracture tended to be slightly fitter than those without associated injuries whist those with an associated humeral fracture were slightly frailer. Mortality was increased for those with an associated proximal humeral fracture but was lower with an associated wrist fracture.

DISCUSSION AND CONCLUSION

Simultaneous injuries occurring with hip fractures are mainly seen in the ipsilateral upper limb. They present a greater challenge to the multidisciplinary team than a solitary hip fracture, experiencing a longer hospital stay and inevitably a higher financial cost. Those patients with wrist fractures have the best prognosis in terms of mortality, whereas a proximal humerus fracture may indicate a higher risk of mortality.

Cardiopulmonary exercise testing for preoperative risk assessment before hepatic resection

BACKGROUND

Contemporary liver surgery practice must accurately assess operative risk in increasingly elderly populations with greater co-morbidity. This study evaluated preoperative cardiopulmonary exercise testing (CPET) in high-risk patients undergoing hepatic resection.

METHODS

In a prospective cohort referred for liver resection, patients aged over 65 years (or younger with co-morbidity) were evaluated by preoperative CPET. Data were collected prospectively on functional status, postoperative complications and survival.

RESULTS

Two hundred and four patients were assessed for hepatic resection, of whom 108 had preoperative CPET. An anaerobic threshold (AT) of 9·9 ml O(2) per kg per min predicted in-hospital death and subsequent survival. Below this value, AT was 100 per cent sensitive and 76 per cent specific for in-hospital mortality, with a positive predictive value (PPV) of 19 per cent and a negative predictive value (NPV) of 100 per cent: no deaths occurred above the threshold. Age and respiratory efficiency in the elimination of carbon dioxide (VE/VCO(2)) at AT were statistically significant predictors of postoperative complications. Receiver operating characteristic (ROC) curve analysis showed that a threshold of 34·5 for VE/VCO(2) at AT provided a specificity of 84 per cent and a sensitivity of 47 per cent, with a PPV of 76 (95 per cent confidence interval (c.i.) 58 to 88) per cent and a NPV of 60 (48 to 72) per cent for postoperative complications. Long-term survival of those with an AT of less than 9·9 ml O(2) per kg per min was significantly worse than that of patients with a higher AT (hazard ratio for mortality 1·81, 95 per cent c.i. 1·04 to 3·17; P = 0·036).

CONCLUSION

CPET provides a useful prognostic adjunct in the preoperative assessment of patients undergoing hepatic resection.

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.

Characteristics and outcome in patients sustaining a second contralateral fracture of the hip

We compared 5341 patients with an initial fracture of the hip with 633 patients who sustained a second fracture of the contralateral hip. Patients presenting with a second fracture were more likely to be institutionalised, female, older, and have lower mobility and mental test scores. There was no significant difference between the two groups with regards to the change in the level of mobility or return to their original residence at one year follow-up. However, the mortality rate in the second fracture group was significantly higher at one year (31.6% vs 27.3%, p = 0.024). In two thirds of patients, the second fracture was in the same anatomical location as the first. In an analysis of 293 patients, approximately 70% of second fractures occurred within three years of the first. This is the largest study to investigate the outcome of patients who sustain a second contralateral hip fracture. Despite the higher mortality rate at one year, the outcome for surviving patients is not significantly different from those after initial hip fractures.

Factors affecting the incidence of deep wound infection after hip fracture surgery

Prospective data on 6905 consecutive hip fracture patients at a district general hospital were analysed to identify the risk factors for the development of deep infection post-operatively. The main outcome measure was infection beneath the fascia lata.

A total of 50 patients (0.7%) had deep infection. Operations by consultants or a specialist hip fracture surgeon had half the rate of deep infection compared with junior grades (p = 0.01). Increased duration of anaesthesia was significantly associated with deep infection (p = 0.01). The method of fracture fixation was also significant. Intracapsular fractures treated with a hemiarthroplasty had seven times the rate of deep infection compared with those treated by internal fixation (p = 0.001). Extracapsular fractures treated with an extramedullary device had a deep infection rate of 0.78% compared with 0% for those treated with intramedullary devices (p = 0.02).

The management of hip fracture patients by a specialist hip fracture surgeon using appropriate fixation could significantly reduce the rate of deep infection and associated morbidity, along with extended hospitalisation and associated costs.

Case series: 2q33.1 microdeletion syndrome--further delineation of the phenotype

Recurrent deletions of 2q32q33 have recently been reported as a new microdeletion syndrome, clinical features of which include significant learning difficulties, growth retardation, dysmorphic features, thin and sparse hair, feeding difficulties, and cleft or high palate. Haploinsufficiency of one gene within the deleted region, SATB2, has been suggested to be responsible for most of the features of the syndrome. This article describes seven previously unreported patients with deletions at 2q33.1, all partially overlapping the previously described critical region for the 2q33.1 microdeletion syndrome. The deletions ranged in size from 35 kb to 10.4 Mb, with the smallest deletion entirely within the SATB2 gene. Patients demonstrated significant developmental delay and challenging behaviour, a particular behavioural phenotype that seems to be emerging with more reported patients with this condition. One patient in this cohort has a deletion entirely within SATB2 and has a cleft palate, whereas several patients with larger deletions have a high arched palate. In addition, one other patient has significant orthopaedic problems with ligamentous laxity. Interestingly, this patient has a deletion that lies just distal to SATB2. The orthopaedic problems have not been reported previously and are possibly an additional feature of this syndrome. Overall, this report provides further evidence that the SATB2 gene is the critical gene in this microdeletion syndrome. In addition, because the individuals in this study range in age from 3-19 years, these patients will help define the natural progression of the phenotype in patients with this microdeletion.

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.

Avascular necrosis after internal fixation of intracapsular hip fractures; a study of the outcome for 1023 patients

We prospectively studied 1023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using contemporary methods. The overall incidence of avascular necrosis (AVN) was 6.6%. AVN was less common for undisplaced (4.0%) than for displaced fractures (9.5%) and in men (4.9%) than women (11.4%) who had a displaced fracture. The incidence of AVN for those aged less than 60 years and who sustained a displaced fracture was 20.6%, compared to 12.5% for those aged 60-80 years and 2.5% for those aged more than 80 years. Our study showed an increased risk of AVN with younger age and in females with a displaced fracture. We found no association between the incidence of AVN and the interval between injury to surgery.

Mortality following hip fracture: trends and geographical variations over the last 40 years

Hip fractures are an ever increasing cause of morbidity and mortality. Treatment of this condition requires an all-encompassing approach from prevention to post-operative care. It is important in such a situation to gather data on the incidence and trends of hip fractures to aid in the future treatment planning of this important condition. A review of all articles published on the outcome after hip fracture over a four decade period (1959-1998) was undertaken to determine any changes that had occurred in the demographics of patients and mortality over this time period. The mean age of patients sustaining hip fractures was found to be steadily increasing over the study period at a rate of 1 year of age for every 5-year time period. The mean age in the 1960s was 73 years to a mean of 79 years in the 1990s. No notable differences were seen in the proportion of male patients over the years but a definite downward trend was noticed with regard to intracapsular fractures. The mortality at 6 and 12 months after injury remained essentially unchanged over the four decades reviewed. Mortality after a hip fracture remains significant, being 11-23% at 6 months and 22-29% at 1 year from injury. Geographical variations exist in the mortality after hip fracture. More detailed international comparisons are required to determine if these differences in outcome are accounted for by the variations in the demographics of patients or due to diversities in treatment methods.

Pressure sores and hip fractures

Development of pressure sores during hospital admission causes morbidity and distress to the patient, increases strain on nursing resources, delaying discharge and possibly increasing mortality. A hip fracture in elderly patients is a known high-risk factor for development of pressure sores. We aimed to determine the current incidence of pressure sores and identify those factors which were associated with an increased risk of pressure sores. We retrospectively analysed prospectively collected data of 4654 consecutive patients admitted to a single unit. One hundred and seventy-eight (3.8%) of our patients developed pressure sores. Patient factors that increased the risk of pressure sores were increased age, diabetes mellitus, a lower mental test score, a lower mobility score, a higher ASA score, lower admission haemoglobin and an intra-operative drop in blood pressure. The risk was higher in patients with an extracapsular neck of femur fracture and patients with an increased time interval between admission to hospital and surgery. Our studies indicate that while co-morbidities constitute a substantial risk in an elderly population, the increase in incidence of pressure sores can be reduced by minimising delays to surgery.

Intramedullary osteosynthesis of complex proximal femoral fractures with the Targon PF nail

We evaluated the performance of the Targon PF nailing system in the treatment of complex proximal femoral fractures with a retrospective analysis of prospectively collected data for 94 patients with a complex proximal femoral fracture (subtrochanteric fracture or fracture with reversed fracture line pattern) treated with a Targon PF nail. There were no intra-operative femoral fractures. Late complications requiring reoperation were one femoral fracture and one fracture around the nail secondary to tumour. Seven nails had to be dynamised and a further six 'self-dynamised' at the site of the distal locking screw. One patient required revision of the distal locking. Only one other patient required secondary surgery for a wound haematoma. There were no cases of implant cut-out or non-union. The Targon PF nail represents a progressive development in the design of intramedullary nails for proximal femoral fractures and the results compare favourably with other intramedullary systems used to treat complex proximal femoral fractures.

Closed suction surgical wound drainage after anterior cruciate ligament reconstruction: a systematic review of randomised controlled trials

There is still debate over the use of drains following anterior cruciate ligament reconstruction surgery. We have performed a systematic review of the literature for randomised trials that related to the use of closed suction drains following anterior cruciate ligament reconstruction surgery. Five studies involving 349 patients were identified. There was no significant difference in the occurrence of wound healing complications, infections or the number of aspirations for haemarthrosis. There was also no difference in post-operative range of movement, functional score or incidence of limb swelling. The difference in pain scores varied between authors with some reporting increased pain in the drained group. All other outcomes reported failed to show any benefit for the use of drains. The authors recommend not using a drain following anterior cruciate ligament reconstruction with either Bone-Patellar Tendon-Bone or Quadrupled Hamstring graft.

Closed suction surgical wound drainage after hip fracture surgery: a systematic review and meta-analysis of randomised controlled trials

There is still debate over the use of drains following hip fracture surgery. We have performed a systematic review and meta-analysis of the literature for randomised trials that related to the use of closed suction drains following hip fracture surgery. Six studies involving 664 patients were identified. There was no statistically significant difference in the occurrence of wound healing complications, re-operations or requirement for blood transfusion between drained and un-drained wounds. All other outcomes reported failed to show any benefit from the use of drains. Further randomised trials are required and until they have been undertaken the efficacy of closed surgical drainage systems in hip fracture surgery is unknown.

Closed suction surgical wound drainage after orthopaedic surgery

BACKGROUND

Closed suction drainage systems are frequently used to drain fluids, particularly blood, from surgical wounds. The aim of these systems is to reduce the occurrence of wound haematomas and infection.

OBJECTIVES

To evaluate the effectiveness of closed suction drainage systems for orthopaedic surgery.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2006), and contacted the Cochrane Wounds Group. We also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), and MEDLINE (1966 to March 2006). Articles of all languages were considered.

SELECTION CRITERIA

All randomised or quasi-randomised trials comparing the use of closed suction drainage systems with no drainage systems for all types of elective and emergency orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality, using a nine item scale, and extracted data. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Thirty-six studies involving 5464 participants with 5697 surgical wounds were identified. The types of surgery involved were hip and knee replacement, shoulder surgery, hip fracture surgery, spinal surgery, cruciate ligament reconstruction, open meniscectomy and fracture fixation surgery. Pooling of results indicated no statistically significant difference in the incidence of wound infection, haematoma, dehiscence or re-operations between those allocated to drains and the un-drained wounds. Blood transfusion was required more frequently in those who received drains. The need for reinforcement of wound dressings and the occurrence of bruising were more common in the group without drains.

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised trials to support the routine use of closed suction drainage in orthopaedic surgery. Further randomised trials with larger patient numbers are required for different operations before definite conclusions can be made for all types of orthopaedic operations.

The t(4;8) is mediated by homologous recombination between olfactory receptor gene clusters, but other 4p16 translocations occur at random

The t(4;8)(p16;p23) is the second most common constitutional chromosomal translocation and is caused by an ectopic meiotic recombination between the olfactory receptor gene clusters (ORGC), located on chromosome 4p and 8p. Given that ORGCs are scattered across the genome and make-up about 0.1% of the human genome we reasoned that translocations between 4p16 and other chromosomes might be mediated by ectopic recombination between different ORGC. In 13 patients, we mapped the breakpoints of either a balanced or unbalanced translocation between chromosome 4p16 and different chromosomes. For all four t(4;8) cases, the breakpoints fall within the 4p and 8pter ORGC, confirming that non-allelic homologous recombination (NAHR) between the ORGC is the main mechanism of the t(4;8) formation. For the nine other translocations, the breakpoints on chromosome 4 mapped to different loci, one of them within the ORGC and in two flanking the ORGC. In these three cases, the translocation breakpoint at the reciprocal chromosome did not contain ORGC sequences. We conclude that only the t(4;8) is mediated by NAHR between ORGC.

Is perioperative blood transfusion a risk factor for mortality or infection after hip fracture?

OBJECTIVES

To assess whether allogeneic blood transfusion in the perioperative period is associated with changes in mortality or complication rates in patients undergoing surgical treatment for hip fracture (proximal femoral fracture).

DESIGN

Retrospective case-control series, all patients followed up for 1 year or until death.

SETTING

District General Hospital in Peterborough, UK. PATIENTS PARTICIPANTS: Three thousand six hundred twenty-five consecutive patients admitted and operated for hip fracture (proximal femoral fracture) during July 1989 to January 2002 (151 months); 1068 (29.9%) received a perioperative allogeneic blood transfusion.

MAIN OUTCOME MEASURES

Thirty- 120-, and 365-day mortality, deep and superficial wound infection rates.

RESULTS

Overall mortality for all patients at 1 year post fracture was 28.2% (1007 patients). Transfusion was associated with a statistically significant increase in mortality from 120 days onward after hip fracture. However, when this was adjusted with a statistical regression model for baseline characteristics and confounding variables, this difference became statistically insignificant (P = 0.17). Infection rates in the transfusion group were 2.0% for superficial infection and 0.9% for deep infection compared with 1.9% and 0.6%, respectively, in the nontransfusion group. These figures were not statistically significantly different. Other complications of deep venous thrombosis, chest infection, and congestive cardiac failure showed no statistically significant increase in those patients who received transfusion.

CONCLUSIONS

Our data suggest that transfusion is not associated with a change in mortality or infection rates in the hip-fracture patient.

Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults

BACKGROUND

Displaced intracapsular fractures may be treated by either reduction and internal fixation, which preserves the femoral head, or by replacement of the femoral head with an arthroplasty.

OBJECTIVES

To review all randomised controlled trials that have compared internal fixation with arthroplasty for intracapsular femoral fractures in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 4), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles. We contacted trialists where possible.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials comparing internal fixation with arthroplasty for intracapsular hip fractures in adults.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed by use of a 10 item scale. At least two review authors independently assessed trial quality and extracted data. Additional information was sought from trialists. After grouping into three broad categories, comparable groups of trials were subgrouped and where appropriate, data were pooled using the fixed-effect model.

MAIN RESULTS

Seventeen trials involving 2694 participants were included. Length of surgery, operative blood loss, need for blood transfusion and risk of deep wound infection were significantly less for internal fixation compared with arthroplasty. Arthroplasty had a significantly lower re-operation rate in comparison with fixation. No definite differences for hospital stay, mortality, or regain of same residential state were found. Limited information from some studies suggested pain was less and function was better for a cemented arthroplasty in comparison to fixation.

AUTHORS' CONCLUSIONS

Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip. Definite conclusions cannot be made for differences in pain and residual disability between the two groups. Future studies should concentrate on better reporting of final outcome measures and there is still a need for studies to define which patient groups are better served by the different treatment methods.

Intramedullary nails for extracapsular hip fractures in adults

BACKGROUND

Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. They may be inserted from the top (cephalocondylic) or from the bottom (condylocephalic) end of the femur.

OBJECTIVES

To compare different types or design modifications of intramedullary nails used in the fixation of extracapsular hip fractures.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2006), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials comparing different types of intramedullary nails or modifications to the design of intramedullary nails in the treatment of extracapsular hip fractures in adults.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed trial quality and extracted data. Additional information was sought from all trialists.

MAIN RESULTS

Six studies, involving a total of 1071 predominantly female and older people with mainly unstable trochanteric fractures, were included. Allocation concealment was likely in one trial, not described in three and not done in the other two trials. Four studies, with 910 participants, compared the proximal femoral nail with the Gamma nail. Though there was increased risk of comminution (fragmentation) at the fracture site when inserting a Gamma nail, there was no statistically significant difference in operative fracture of the femur (1/455 versus 5/455; relative risk 0.33, 95% confidence interval 0.07 to 1.63). No notable differences were seen between implants for fracture healing complications, reoperations and other post-operative complications. Pooled data showed no significant difference between implants for mortality (relative risk 1.08, 95% confidence interval 0.82 to 1.41) or function assessment outcomes. One study, with 80 participants, found no differences between a gliding nail versus a standard Gamma nail. Another study, with 81 participants, found no difference between a dynamically versus a statically locked intramedullary hip screw.

AUTHORS' CONCLUSIONS

The limited evidence from the randomised trials undertaken to date is insufficient to determine whether there are important differences in outcome between different designs of intramedullary nails used in the internal fixation of extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.

Pre-operative traction for fractures of the proximal femur in adults

BACKGROUND

Following a hip fracture, traction may be applied to the injured limb before surgery.

OBJECTIVES

To evaluate the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1988 to 2006 Week 11), CINAHL (1982 to March 2006), the UK National Research Register (Issue 1, 2006), conference proceedings and reference lists of articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials comparing either skin or skeletal traction with no traction, or skin with skeletal traction for patients with an acute hip fracture prior to surgery.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, data were pooled.

MAIN RESULTS

Ten randomised trials, mainly of moderate quality, involving a total of 1546 predominantly elderly patients with hip fractures, were identified and included in the review. Nine trials compared traction with no traction. Although limited data pooling was possible, overall this provided no evidence of benefit from traction, either in the relief of pain before surgery or ease of fracture reduction or quality of fracture reduction at time of surgery. One of these trials included both skin and skeletal traction groups. This trial and one other compared skeletal traction with skin traction and found no important differences between these two methods, although the initial application of skeletal traction was noted as being more painful and more costly.

AUTHORS' CONCLUSIONS

From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. However, the evidence is also insufficient to rule out the potential advantages for traction, in particular for specific fracture types, or to confirm additional complications due to traction use. Further, high quality trials would be required to confirm or refute the absence of benefits of traction.

Arthroplasties (with and without bone cement) for proximal femoral fractures in adults

BACKGROUND

Numerous types of arthroplasties may be used in the surgical treatment of a hip fracture (proximal femoral fracture). The main differences between the implants are in the design of the stems, whether the stem is fixed in place with or without cement, whether a second articulating joint is included within the prosthesis (bipolar prosthesis) or whether a partial (hemiarthroplasty) or total whole hip replacement is used.

OBJECTIVES

To review all randomised controlled trials that have compared different arthroplasties for the treatment of hip fractures in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials comparing different arthroplasties and their insertion with or without cement, for the treatment of hip fractures.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality, by use of a ten-item checklist, and extracted data.

MAIN RESULTS

Seventeen trials involving 1920 patients were included. One trial involved two comparisons. Cemented prostheses, when compared with uncemented (six trials, 549 participants) were associated with less pain at a year or later (16/52 versus 28/52; RR 0.51, 95% CI 0.31 to 0.81) and a tendency to better mobility. No significant difference in surgical complications was found. Comparison of unipolar hemiarthroplasty with bipolar hemiarthroplasty (seven trials, 857 participants, 863 fractures) showed no significant differences between the two types of implant. Two trials involving 232 patients compared uncemented hemiarthroplasty with a total hip replacement. Both studies reported increased pain for the uncemented prosthesis and one study found better mobility and a lower long-term revision rate for those treated with a THR. Two trials involving 214 participants compared cemented hemiarthroplasty versus total hip replacement. Both trials generally found little difference between prostheses. THR was associated with a slightly longer surgical time but a tendency to better functional outcome in one trial.

AUTHORS' CONCLUSIONS

There is limited evidence that cementing a prosthesis in place may reduce post-operative pain and lead to better mobility. There is insufficient evidence to determine the roles of bipolar prostheses and total hip replacement. Further well-conducted randomised trials are required.

Paediatric emergency department staff perceptions of infection control measures against severe acute respiratory syndrome

OBJECTIVES

To determine paediatric emergency department (ED) staff perceptions of the effectiveness and practice of infection control measures against a novel virulent pathogen.

METHODS

All medical staff of the paediatric ED in a tertiary medical centre completed a written questionnaire near the onset of the severe acute respiratory syndrome (SARS) outbreak. Level of concern regarding SARS, and perceptions of effectiveness and use of infection control measures were assessed on a 5 point scale. Statistical analysis was performed using chi2 test and one way analysis of variance with significance at p<0.05.

RESULTS

Response rate was 97% (116/120). All scores were given out of 5 possible points. Using isolation rooms (mean score 4.6), wearing a mask when examining patients (4.5), and handwashing (4.5) were considered most effective. Staff physicians reported handwashing more than nurses and trainees (4.9 v 4.5 and 4.5, respectively; p<0.05) while other measures were reported equally. Respondents considering SARS a high public health threat reported higher compliance with handwashing (4.8 v 4.4), always wearing a mask (3.9 vs 3.2) and gloves (3.6 v 2.9) in the ED (p<0.05), but not eye protection (3.4 v 3.0), gown use (4.9 v 4.7), or wearing a mask when examining patients (5.0 v 4.8). Staff who considered combined infection control measures effective in protecting patients and healthcare workers did not report increased compliance.

CONCLUSIONS

Eye protection was perceived as only moderately effective in protecting against the spread of SARS, and reported compliance was relatively poor among ED staff. Concern of SARS as a public health threat rather than perceived effectiveness of infection control measures appears to have a greater impact on compliance.

Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults

BACKGROUND

Internal fixation, commonly used for extracapsular hip fractures, may fail particularly in unstable fractures. Replacement of the hip using arthroplasty, often used for intracapsular fractures, has been used as an alternative.

OBJECTIVES

To compare replacement arthroplasty with internal fixation for the treatment of extracapsular hip fractures in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing replacement arthroplasty with an internal fixation implant for adults with an extracapsular hip fracture.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed 10 aspects of trial quality and extracted data. We requested additional information from trial investigators. Where appropriate, limited pooling of data was performed.

MAIN RESULTS

Two randomised controlled trials including a total of 148 people aged 70 years or over with unstable extracapsular hip fractures in the trochanteric region were identified and included in this review. Both had methodological limitations, including inadequate assessment of longer-term outcome. One trial compared a cemented arthroplasty with a sliding hip screw. This found no significant differences between the two methods of treatment for operating time, local wound complications, mechanical complications, reoperation, mortality or loss of independence of previously independent patients at one year. There was, however, a higher blood transfusion need in the arthroplasty group. The other trial compared a cementless arthroplasty versus a proximal femoral nail. It also found a higher blood transfusion need in the arthroplasty group, together with a greater operative blood loss, and a longer length of surgery. There were no significant differences between the two interventions for mechanical complications, local wound complications, reoperation, general complications, mortality at one year or long-term function. None of the pooled outcome data yielded statistically significant differences between the arthroplasty and internal fixation, with the exception of the significantly higher numbers of participants in the arthroplasty group requiring blood transfusion (relative risk 1.71, 95% confidence interval 1.05 to 2.77).

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised trials to determine whether replacement arthroplasty has any advantage over internal fixation for extracapsular hip fractures. Further larger well-designed randomised trials comparing arthroplasty versus internal fixation for the treatment of unstable fractures are required.

Smoking and hip fracture; a study of 3617 cases

We analysed the characteristics and outcome for 467 hip fracture patients, who reported that they were currently smoking at the time of admission, against 3150 non-smoking hip fracture patients. Those patients who smoked were younger (72 years versus 81 years mean age), more likely to be male (35.3% versus 19.5%), more mobile and less likely to be living in institutional care (7.5% versus 25.0%). Preoperative outcomes and complication rates were similar, despite the smokers' relative youth. Mortality at 30 days was similar for the two groups (6.2% versus 7.6%), but lower for the smokers at one year (22.7% versus 27.6%). However, with adjustment for the younger age and sex of these patients, this difference in mortality was not statistically significant. These findings suggest that smoking results in hip fracture occurring at a younger age. Despite this, the outcome for smokers was similar to that for the average hip fracture patient.

Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults

BACKGROUND

Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone.

OBJECTIVES

To compare different types of extramedullary fixation implants and external fixators for fixing extracapsular hip fracture in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2005), various other databases, conference proceedings and reference lists.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing extramedullary implants or external fixators for fixing extracapsular hip fracture in adults.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed trial quality and extracted data. Data were pooled where appropriate.

MAIN RESULTS

The 14 included trials tested seven comparisons in a total of 2222 mainly female and older participants. All trials had methodological flaws that may affect the validity of their results. Three trials comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS) found an increased risk of fixation failure for fixed nail plates. The two trials comparing the Resistance Augmented Bateaux (RAB) plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration. One trial comparing the Pugh nail and the SHS found no significant difference between implants. Two trials compared the Medoff plate with the SHS. One trial reported higher blood losses and longer operation times for the Medoff plate. There was a lower risk of fixation failure with the Medoff plate for unstable trochanteric fractures. Two trials compared the Medoff plate with three different screw-plate systems. There were no statistically significant differences in outcome for trochanteric fractures. For subtrochanteric fractures, there was a lower fixation failure rate for the Medoff plate, but no evidence for differences in longer-term outcomes. Two trials comparing the Gotfried percutaneous plate with a SHS found a reduced blood loss with the Gotfried plate. A higher intra-operative fixation failure rate of the Gotfried plate may indicate some restriction to its use. Two trials found less operative trauma for external fixation when compared with the SHS. Final outcome appeared similar.

AUTHORS' CONCLUSIONS

The markedly increased fixation failure rate of fixed nail plates compared with the SHS is a major consideration and thus the SHS appears preferable. There was insufficient evidence from other comparisons to draw definite conclusions.

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults

BACKGROUND

Two types of implants used for the surgical fixation of extracapsular hip fractures are cephalocondylic intramedullary nails, which are inserted into the femoral canal proximally to distally across the fracture, and extramedullary implants.

OBJECTIVES

To compare cephalocondylic intramedullary nails with extramedullary implants (e.g. the sliding hip screw) for extracapsular hip fractures in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2005), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the UK National Research Register, orthopaedic journals, conference proceedings and reference lists of articles.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed trial quality and extracted data. Wherever appropriate, results were pooled.

MAIN RESULTS

Predominantly older people with mainly trochanteric fractures were treated in the 32 included trials. Twenty trials, involving 3646 people, compared the Gamma nail with the sliding hip screw (SHS). The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased reoperation rate. There were no major differences between implants in the wound infection, mortality or medical complications. Data were inadequate for other outcomes. Five trials, involving 623 people, compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. Two trials involving 314 people showed no difference in fracture fixation complications, reoperation, wound infection and length of hospital stay for proximal femoral nail (PFN) compared with the SHS. Single trial comparisons (experimental mini-invasive static intramedullary nail compared with the SHS: 60 participants; Kuntscher-Y nail with the SHS: 230 participants; Gamma nail and the Medoff sliding plate: 217 participants) failed to provide sufficient evidence to establish differences between implants in outcome. Two trials, involving 65 people with reverse and transverse fractures at the level of the lesser trochanter, found intramedullary nails (Gamma nail or PFN) were associated with better intra-operative results and fewer fracture fixation complications than extramedullary implants (a 90-degree blade plate or dynamic condylar plate) for these fractures.

AUTHORS' CONCLUSIONS

Given the lower complication rate of the SHS in comparison with intramedullary nails, SHS appears superior for trochanteric fractures. Further studies are required to determine if different types of intramedullary nail produce similar results, or if intramedullary nails have advantages for selected fracture types (for example, subtrochanteric fractures).

Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur

Previous studies on the timing of surgery for fracture of the hip provide conflicting evidence as to the effect of prolonged delay before operation. We have prospectively reviewed 3628 such fractures in patients older than 60 years of age. Those for whom the delay was for medical reasons were excluded. Patients were followed up for one year or until death. Operation was undertaken within 48 hours in 95.2% and after this in 4.8%. A significant increase in length of stay was found in patients operated on after 48 hours when compared with those in the earlier group (21.6 vs 32.5 days). No increase in hospital stay was found for lesser delays.

Hip protectors for preventing hip fractures in older people

BACKGROUND

Hip fracture in older people usually results from a fall on the hip. Hip protectors have been advocated as a means to reduce the risk of sustaining a hip fracture.

OBJECTIVES

To determine if external hip protectors reduce the incidence of hip fractures in older people following a fall.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group trials register (January 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to January Week 2, 2005), EMBASE (1988 to 2005 Week 02), CINAHL (1982 to December Week 2 2004), other databases and reference lists of relevant articles. We also contacted trialists.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing the use of hip protectors with a control group.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We sought additional information from trialists. Pooling of uncorrected data from cluster-randomised trials was only done on an exploratory basis.

MAIN RESULTS

Fifteen included trials contributed data to this updated review. One trial, which was a study of compliance (adherence) lasting 12 weeks, contributed no fracture outcome data. Pooling of data from eleven trials conducted in nursing or residential care settings, including six cluster-randomised studies, showed evidence of a marginally statistically significant reduction in hip fracture incidence (relative risk (RR) 0.77, 95% confidence interval (CI) 0.62 to 0.97). This analysis showed significant statistical heterogeneity. Pooling of data from three individually randomised trials involving 5135 community dwelling participants, showed no reduction in hip fracture incidence from the provision of hip protectors (RR 1.16, 95% CI 0.85 to 1.59). There was no evidence of any significant effect of hip protectors on incidence of pelvic or other fractures. No important adverse effects of the hip protectors were reported but compliance, particularly in the long term, was poor.

AUTHORS' CONCLUSIONS

Accumulating evidence casts some doubt on the effectiveness of the provision of hip protectors in reducing the incidence of hip in older people. Acceptance and adherence by users of the protectors remain poor due to discomfort and practicality.

The complications of displaced intracapsular fractures of the hip

We have studied the placement of three screws within the femoral head and the degree of angulation of the screws in 395 patients with displaced intracapsular fracture of the hip to see if either was related to the risk of failure of the fracture to unite. No relationship between nonunion of the fracture was found regarding the position of the screws on the anteroposterior radiograph. However, we found that a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.

Intramedullary nails for extracapsular hip fractures in adults

BACKGROUND

Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. They may be inserted from the top (cephalocondylic) or from the bottom (condylocephalic) end of the femur.

OBJECTIVES

To compare different types or design modifications of intramedullary nails used in the fixation of extracapsular hip fractures.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to September week 1 2004), EMBASE (1988 to 2004 Week 37), the UK National Research Register Issue 2, 2004, several orthopaedic journals, conference proceedings and reference lists of articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials comparing different types of intramedullary nails or modifications to the design of intramedullary nails in the treatment of extracapsular hip fractures in adults.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed trial quality and extracted data. Additional information was sought from all trialists.

MAIN RESULTS

Four studies, involving a total of 834 predominantly female and older patients with mainly unstable trochanteric fractures, were included. All trials compared different designs of cephalocondylic nail. Allocation concealment was likely in one trial, not described in two and not done in the fourth. Two studies, with 674 participants, compared the proximal femoral nail versus the Gamma nail. Blood transfusion was greater for the proximal femoral nail group in one trial, yet blood loss was less in this group in the other trial. Pooled data for re-operation (relative risk 1.08, 95% confidence interval 0.65 to 1.81) and mortality (relative risk 1.24, 95% confidence interval 0.90 to 1.71) showed no statistically significant differences between the two groups. Limited data for long term function also showed no statistically significant differences. The two other studies, with 80 participants each, found respectively no differences between a gliding nail versus a Gamma nail; and a dynamically versus a statically locked intramedullary hip screw.

AUTHORS' CONCLUSIONS

The limited evidence from the randomised trials undertaken to date is insufficient to determine if there are important differences in outcome between different designs of intramedullary nails used in the internal fixation of extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.

Surgical approaches and ancillary techniques for internal fixation of intracapsular proximal femoral fractures

BACKGROUND

In the fixation of intracapsular hip fractures, different implants, surgical approaches and ancillary manoeuvres have been employed to improve the reduction, and the stability of the reconstruction, in an attempt to reduce the frequency of non-union and aseptic necrosis of the femoral head.

OBJECTIVES

To compare alternative surgical approaches and ancillary techniques in internal fixation of intracapsular hip fractures which have been subjected to randomised and quasi-randomised trials in adults.

SEARCH STRATEGY

The Cochrane Musculoskeletal Injuries Group Specialised Register, MEDLINE, and reference lists of relevant articles were searched. Date of the most recent search: November 2004.

SELECTION CRITERIA

All randomised and quasi-randomised trials investigating operative technique for the treatment of intracapsular hip fractures.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality, by use of a 10 item checklist, and extracted data.

MAIN RESULTS

One trial with 103 participants studied the effect of impaction of the fracture at the time of surgery. The only outcome measure reported was bone scintimetry. There was some evidence that impaction, particularly of displaced fractures, resulted in a reduction of blood flow to the femoral head as assessed by bone scintimetry. One quasi-randomised trial with 220 participants compared compression of the fracture with no compression. Results for 156 individuals at one year showed a tendency to a lower incidence of non-union for those fractures treated without compression.Two trials, one involving 102 young adults under 50 years old and the other involving 49 older people aged 65 years or over, compared open versus closed reduction of the fracture. Both found open reduction significantly increased length of surgery. None of the other differences between open and closed reduction in the outcomes reported by the two trials were statistically significant.

AUTHORS' CONCLUSIONS

Insufficient evidence exists from randomised trials to confirm the relative effects of open versus closed reduction of intracapsular fractures, or the effects of intra-operative impaction or compression of an intracapsular fracture treated by internal fixation.

Mobilisation strategies after hip fracture surgery in adults

BACKGROUND

Hip fracture, which happens in predominantly elderly populations, often results in a reduction in mobility. Care programmes after hip fracture surgery include strategies for mobilisation, such as early weight bearing and gait retraining. Other mobilisation strategies, such as exercises and physical training, are used at various stages in rehabilitation including after discharge from hospital.

OBJECTIVES

To evaluate the effects of different mobilisation strategies and programmes after hip fracture surgery.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (May 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2004), MEDLINE and other databases, conference proceedings and reference lists of articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials comparing different mobilisation strategies/programmes after hip fracture surgery.

DATA COLLECTION AND ANALYSIS

The reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Our third update, which extended the review scope to cover the whole rehabilitation period, included four new trials. Most of the 10 included trials were small and all had methodological limitations, including inadequate follow up. Seven trials evaluated mobilisation strategies started soon after hip fracture surgery. One trial (273 participants) found no statistically significant differences in unfavourable outcomes for weight bearing started at two versus 12 weeks after internal fixation of a displaced intracapsular fracture. Of two trials (188 participants) comparing a more with a less intensive regimen of physiotherapy, one reported a lack of demonstrable difference in recovery of the two patient groups, and the other found a higher level of drop-out in the more intensive group with no difference in length of hospital stay. One trial (80 participants) comparing two-week programmes of weight-bearing versus non-weight-bearing exercise found some short-term improvement in mobility and balance in the weight-bearing exercise group. One trial (80 participants) found improved mobility, leg extension power and Barthel score in those given a quadriceps muscle strengthening exercise programme. One trial (40 participants) found no statistically significant difference in recovery of mobility and time to hospital discharge after a treadmill versus conventional gait retraining programme. One trial (27 participants) comparing neuromuscular stimulation of the quadriceps muscle with placebo found a greater recovery of pre-fracture mobility in the stimulation group. The interventions tested by the three remaining trials started after hospital discharge. One trial (28 participants) found improved outcome after 12 weeks of intensive physical training. One trial (120 participants) found improved outcome after home-based exercises started around 22 weeks from injury. One trial (44 participants) found home-based weight-bearing exercises starting at seven months produced no statistically significant differences aside, perhaps, for greater quadriceps strength.

REVIEWERS' CONCLUSIONS

There is insufficient evidence from randomised trials to determine the effectiveness of the various mobilisation strategies examined in this review that start either in the early post-operative period or during the later rehabilitation period. Further research is required to establish the possible benefits of the additional provision of interventions primarily aimed at enhancing mobility.