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Does delay to surgery affect outcomes and 1 year mortality rates in peri prosthetic femur fractures?
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Abstracts / Injury Extra 42 (2011) 95–169
1A.18 Conversion of failed hemiarthroplasty to total hip replacement L. Bayam, H. Nagai, P. Kay Wrightington Hospital, United Kingdom Purpose: We aimed to study clinical and radiological outcomes of conversion from hemiarthroplasty to total hip replacement (THR) with a particular concern over reported increased dislocation rates. Methods and results: The study included 42 patients, who underwent the procedure above. The operations were carried out by a single unit with Charnley-type of cemented THR primarily using 22 mm diameter of femoral heads through a transtrochanteric approach. The average follow-up was 75.7 months (range 25–171). The outcome was assessed with postoperative pain, function and complications and implant survivorship as well as radiological evaluation. Charnley’s modified pain and mobility scoring system was used for clinical outcome and Hodgkinson and Harris criteria for radiological assessment. Functionally, all of the patients showed improvement in their pain level by average of 2.7. On mobility assessment, two patients (4.8%) with persistent deep infection from previous operations, and two others (4.8%) with CVA did not have any improvement in their mobility. But, all the rest showed improvement by average of 2.2 in their walk score. Only three cases (7.1%) sustained a single isolated postoperative dislocation, all of which were conservatively treated. One case (2.4%) had painful subluxations. There was no recurrent dislocation. Three cases (7.1%) showed clinical sign of resistant or recurrent infection, with other two (4.8%) wound dehiscence and two (4.8%) trochanteric bursitis. On radiological evaluation, one case (2.4%) showed cup demarcation without bone loss, two (4.8%) cup migration, and one stem (2.4%) demarcation. But, on implant survivorship, only one case (2.4%) had implants revised due to infection. Conclusion: All the patients without deep infection or major disabling problems had dramatic improvement following this conversion operation. The dislocation rate with this technique was comparable to the other revision total hip replacements even though 22 mm heads were primarily used in this group of revision surgeries. doi:10.1016/j.injury.2011.06.225
1A.19 Cemented hemiarthroplasty is associated with a higher early mortality rate than un-cemented hemiarthroplasty—Fact or fiction? T. Al-Atassi, D.T.S. Chou, C. Boulton, C.G. Moran Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom Introduction: Cemented hemiarthroplasty for neck of femur fractures has been advocated over uncemented hemiarthroplasty due to better post-operative recovery and patient satisfaction. However, studies have shown adverse effects of bone cement on the cardio-respiratory system which may lead to higher morbidity and mortality. Therefore, in some institutes, the use of an uncemented prosthesis has been adopted for patients with a high number of co-morbidities. The aim was to compare early mortality rates for cemented vs. uncemented hemiarthroplasties. Method: Cohort study of displaced intracapsular hip fractures treated with hemiarthroplasty between 1999 and 2009 at one institute. A total of 3094 hemiarthroplasties performed; out of which
1002 (32.4%) were cemented and 2092 (67.6%) were uncemented. 48 h and 30 day mortality rates for the two groups were compared and a multivariate Cox regression model used to eliminate confounding factors. Significant confounding factor included age, sex, mini mental test score, medical co-morbidities, Nottingham Hip Fracture Score and delay to surgery. Results: The study showed that, after eliminating confounding factors, 48 h mortality in the cemented group was 0.3% compared to 0.5% in the uncemented group (p = 0.388). However, the adjusted 30-day mortality rate for the cemented group (4%) was shown to be significantly lower than for the uncemented group (10.8%) (p < 0.001). Conclusion: The use of cement in hip hemiarthroplasty is not associated with an increased rate of mortality at 48 h or at 30 days. Along with emerging evidence of better post-op recovery and patient satisfaction with the use of a cemented prosthesis, we support the use of cement for all patients undergoing hip hemiarthroplasty. doi:10.1016/j.injury.2011.06.226 1A.20 Does delay to surgery affect outcomes and 1 year mortality rates in peri prosthetic femur fractures? M. Ramappa, A. Jennings University Hospital of North Durham, United Kingdom Introduction: With increasing number of arthroplasty procedures and life expectancy, peri-prosthetic fractures are currently on the rise. Due to complexity of these injuries, often their treatment can be delayed. In hip fracture surgery, it is clear that delay to surgery can have adverse outcomes. However literature is not clear with regards to the effect of timing and type of surgery for peri prosthetic fractures on the 1 year mortality rates and complications. Aim: To assess whether delay in surgery of >48 h affected the 1 year mortality rates, length of inpatient stay and complications. Also to assess whether replacement and fixation provided similar outcomes. Methods: All patients who underwent surgical treatment for peri-prosthetic femur fractures between January 2007 and December 2009 were reviewed. Data was obtained from our coding department as well as radiographic and case note review, utilising a pre-determined questionnaire. A subgroup analysis was performed based on time to surgery and type of surgery. Co-morbidities were also assessed quantitatively by Charlson’s co-morbidity index across the subgroups. Results: 37 patients were included for the final review. Average age was 77 years (±5). Overall 1 year mortality rate was 5%. Comparative analysis of early versus delayed surgery showed that only 35% were operated within 48 h from admission, out of which 85% underwent fixation. Therefore fractures requiring fixation generally underwent early surgery. The 1 year mortality rates were 0% and 8% for early and delayed surgery groups respectively. Similarly complication rates were 30% and 41% for the two groups. Average Charlson’s co-morbidity index scores and average age were similar across both groups. Average length of inpatient stay was unaffected by time to surgery. Comparative analysis of fixation group versus replacement group showed 1 year mortality rates of 8% and 0% respectively. Similarly, complication rates were 44% and 25% for the two groups respectively. Average Charlson’s co-morbidity index scores and average age were similar across both groups. Length of inpatient stay was on an average 7 days less for the replacement group. Due to small numbers, a statistical analysis was not considered.
Abstracts / Injury Extra 42 (2011) 95–169
Discussion: Our low 1 year mortality rate could have been due to adequate optimisation of both surgeon and patient related factors. Regular input from Orthogeriatric team has improved medical optimisation perioperatively. Due to complexity of these injuries, delayed surgery can be inevitable. Our experience has shown best outcomes for patients operated within 48 h and patients having replacement surgery. Patient co-morbidity did not seem to be the main reason for delayed surgery. In contrary it was often due to Surgeon related factors. doi:10.1016/j.injury.2011.06.227 1A.21 The outcome of displaced intracapsular hip fractures treated with cemented compared to uncemented hemiarthroplasty. Systematic review M. Al-Najjim University of Warwick, Scunthorpe General Hospital, Scunthorpe, UK Aims: The aim of this study is to conduct a scientific evaluation of the available literature to provide evidence to compare the outcome of displaced intracapsular hip fractures treated with cemented compared to uncemented hemiarthroplasty in elderly patients. Methods: Systematic search of Medline and EMBASE databases for English language articles from 2008 to June 2010. Articles were considered for review if they satisfied the following inclusion criteria: original articles on the treatment of displaced intracapsular femoral neck fractures in adult patients above 60 years of age, including both genders, described treatment consisting exclusively of randomised controlled trials comparing cemented and uncemented hemiarthroplasties, reported at least 1 of the following outcomes of interest: residual pain; mobility; mortality; implant related complication; post operative medical complication and functional outcome. Critical appraisal of the selected studies was carried out using Critical Appraisal Skills Programme (CASP) checklist. Results: 3 studies were identified from searching databases; only 2 papers met the inclusion criteria. Both papers were looking for functional outcome of displaced femoral neck fractures treated with cemented versus uncemented hemiarthroplasty. Primary outcome was set as functional scoring systems like Harris hip score, Barthel index, EQ-5D, activities of daily living and residual pain. Secondary outcome was set as length of surgery, operative blood loss, hospital stay and mortality. One trail reported there were no differences in the functional outcome between both groups, while the other trail reported better pain control, mobility and return to daily living with cemented than uncemented hemiarthroplasties. Both trails reported shorter time of surgery and less blood loss intraoperatively with the uncemented group. Conclusion: Uncemented prosthesis can be used for old, frail patients with high comorbidities as it has less operative time and blood loss. Cemented prosthesis can be used for more fit and mobile patients as it has got superior outcome to the uncemented prosthesis. doi:10.1016/j.injury.2011.06.228
105
1A.22 Improvements to the management of patients suffering a fractured neck of femur in Torbay hospital as compared to local and national BOA guidelines: Closure of an audit loop E. Stinton, C. Jones, T. Whiter, T. Woodacre Torbay Hospital, United Kingdom Purpose of study: To assess the impact of changes to local policy on the management of patients suffering a fractured neck of femur (NOF) at Torbay Hospital. Methods: In 2009 an audit was completed assessing the management of patients suffering a fractured NOF in Torbay hospital as compared to BOA guidance. Significant changes to local guidelines have subsequently been implemented. These include: • Introduction of a “fast-track” service of patients from ambulance to assessment within the theatre complex, and if appropriate an operation on the day of admission. • Assessment by an anaesthetist of all patients not immediately operated on to facilitate their operation the following day. • Application of local nerve blockades for symptom control to patients not immediately operated on by appropriately trained staff. • Assessment of all patients by an ortho-geriatrician for assisted medical care and the suitability of anti-resorptive therapy. The audit cycle was completed over an equal time period in 2010 to assess compliance with BOA and local guidelines. Results: Since implementation of changes: • 91% of patients were operated on within 48 h (an improvement of 18%); 68% were operated on within 24 h. • 81% of patients were reviewed by the orthopaedic team within 4 h of arrival at hospital; 50% within 1 h. • All patients not operated upon on the day of admission were reviewed by a member of the anaesthetic team the same day and received appropriate local nerve blockade. • Average length of stay improved from 10 to 6 days. • All other assessed areas were BOA compliant. • Universally positive staff and patient feedback. Conclusions: Key changes to local guidelines have dramatically improved the care of patients suffering a fractured NOF in Torbay, reducing time to theatre, time to discharge and improving overall inpatient care. doi:10.1016/j.injury.2011.06.229 1A.23 Exeter trauma stem—An early experience in a DGH M.D.J. Sinclair, P. Pavlou, S. Stuart, T. Salter, A.R. Harvey Poole Hospital Foundation Trust, United Kingdom Purpose: We present our early experience of the Exeter Trauma Stem in a single surgeon series of 83 hip hemiarthroplasties. Methods and results: This prospective cohort study included 82 patients (62 females and 22 males) with a mean age of 83.6 years, presenting with intracapsular fracture neck of femur. We analyzed time to surgery with date to discharge using the Wilcoxon two sample test. The mean operation date post day of admission was day 3.4. The mean number of days between day of surgery and date of discharge was 14.9. There was no statistically
Abstracts / Injury Extra 42 (2011) 95–169
1A.18 Conversion of failed hemiarthroplasty to total hip replacement L. Bayam, H. Nagai, P. Kay Wrightington Hospital, United Kingdom Purpose: We aimed to study clinical and radiological outcomes of conversion from hemiarthroplasty to total hip replacement (THR) with a particular concern over reported increased dislocation rates. Methods and results: The study included 42 patients, who underwent the procedure above. The operations were carried out by a single unit with Charnley-type of cemented THR primarily using 22 mm diameter of femoral heads through a transtrochanteric approach. The average follow-up was 75.7 months (range 25–171). The outcome was assessed with postoperative pain, function and complications and implant survivorship as well as radiological evaluation. Charnley’s modified pain and mobility scoring system was used for clinical outcome and Hodgkinson and Harris criteria for radiological assessment. Functionally, all of the patients showed improvement in their pain level by average of 2.7. On mobility assessment, two patients (4.8%) with persistent deep infection from previous operations, and two others (4.8%) with CVA did not have any improvement in their mobility. But, all the rest showed improvement by average of 2.2 in their walk score. Only three cases (7.1%) sustained a single isolated postoperative dislocation, all of which were conservatively treated. One case (2.4%) had painful subluxations. There was no recurrent dislocation. Three cases (7.1%) showed clinical sign of resistant or recurrent infection, with other two (4.8%) wound dehiscence and two (4.8%) trochanteric bursitis. On radiological evaluation, one case (2.4%) showed cup demarcation without bone loss, two (4.8%) cup migration, and one stem (2.4%) demarcation. But, on implant survivorship, only one case (2.4%) had implants revised due to infection. Conclusion: All the patients without deep infection or major disabling problems had dramatic improvement following this conversion operation. The dislocation rate with this technique was comparable to the other revision total hip replacements even though 22 mm heads were primarily used in this group of revision surgeries. doi:10.1016/j.injury.2011.06.225
1A.19 Cemented hemiarthroplasty is associated with a higher early mortality rate than un-cemented hemiarthroplasty—Fact or fiction? T. Al-Atassi, D.T.S. Chou, C. Boulton, C.G. Moran Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom Introduction: Cemented hemiarthroplasty for neck of femur fractures has been advocated over uncemented hemiarthroplasty due to better post-operative recovery and patient satisfaction. However, studies have shown adverse effects of bone cement on the cardio-respiratory system which may lead to higher morbidity and mortality. Therefore, in some institutes, the use of an uncemented prosthesis has been adopted for patients with a high number of co-morbidities. The aim was to compare early mortality rates for cemented vs. uncemented hemiarthroplasties. Method: Cohort study of displaced intracapsular hip fractures treated with hemiarthroplasty between 1999 and 2009 at one institute. A total of 3094 hemiarthroplasties performed; out of which
1002 (32.4%) were cemented and 2092 (67.6%) were uncemented. 48 h and 30 day mortality rates for the two groups were compared and a multivariate Cox regression model used to eliminate confounding factors. Significant confounding factor included age, sex, mini mental test score, medical co-morbidities, Nottingham Hip Fracture Score and delay to surgery. Results: The study showed that, after eliminating confounding factors, 48 h mortality in the cemented group was 0.3% compared to 0.5% in the uncemented group (p = 0.388). However, the adjusted 30-day mortality rate for the cemented group (4%) was shown to be significantly lower than for the uncemented group (10.8%) (p < 0.001). Conclusion: The use of cement in hip hemiarthroplasty is not associated with an increased rate of mortality at 48 h or at 30 days. Along with emerging evidence of better post-op recovery and patient satisfaction with the use of a cemented prosthesis, we support the use of cement for all patients undergoing hip hemiarthroplasty. doi:10.1016/j.injury.2011.06.226 1A.20 Does delay to surgery affect outcomes and 1 year mortality rates in peri prosthetic femur fractures? M. Ramappa, A. Jennings University Hospital of North Durham, United Kingdom Introduction: With increasing number of arthroplasty procedures and life expectancy, peri-prosthetic fractures are currently on the rise. Due to complexity of these injuries, often their treatment can be delayed. In hip fracture surgery, it is clear that delay to surgery can have adverse outcomes. However literature is not clear with regards to the effect of timing and type of surgery for peri prosthetic fractures on the 1 year mortality rates and complications. Aim: To assess whether delay in surgery of >48 h affected the 1 year mortality rates, length of inpatient stay and complications. Also to assess whether replacement and fixation provided similar outcomes. Methods: All patients who underwent surgical treatment for peri-prosthetic femur fractures between January 2007 and December 2009 were reviewed. Data was obtained from our coding department as well as radiographic and case note review, utilising a pre-determined questionnaire. A subgroup analysis was performed based on time to surgery and type of surgery. Co-morbidities were also assessed quantitatively by Charlson’s co-morbidity index across the subgroups. Results: 37 patients were included for the final review. Average age was 77 years (±5). Overall 1 year mortality rate was 5%. Comparative analysis of early versus delayed surgery showed that only 35% were operated within 48 h from admission, out of which 85% underwent fixation. Therefore fractures requiring fixation generally underwent early surgery. The 1 year mortality rates were 0% and 8% for early and delayed surgery groups respectively. Similarly complication rates were 30% and 41% for the two groups. Average Charlson’s co-morbidity index scores and average age were similar across both groups. Average length of inpatient stay was unaffected by time to surgery. Comparative analysis of fixation group versus replacement group showed 1 year mortality rates of 8% and 0% respectively. Similarly, complication rates were 44% and 25% for the two groups respectively. Average Charlson’s co-morbidity index scores and average age were similar across both groups. Length of inpatient stay was on an average 7 days less for the replacement group. Due to small numbers, a statistical analysis was not considered.
Abstracts / Injury Extra 42 (2011) 95–169
Discussion: Our low 1 year mortality rate could have been due to adequate optimisation of both surgeon and patient related factors. Regular input from Orthogeriatric team has improved medical optimisation perioperatively. Due to complexity of these injuries, delayed surgery can be inevitable. Our experience has shown best outcomes for patients operated within 48 h and patients having replacement surgery. Patient co-morbidity did not seem to be the main reason for delayed surgery. In contrary it was often due to Surgeon related factors. doi:10.1016/j.injury.2011.06.227 1A.21 The outcome of displaced intracapsular hip fractures treated with cemented compared to uncemented hemiarthroplasty. Systematic review M. Al-Najjim University of Warwick, Scunthorpe General Hospital, Scunthorpe, UK Aims: The aim of this study is to conduct a scientific evaluation of the available literature to provide evidence to compare the outcome of displaced intracapsular hip fractures treated with cemented compared to uncemented hemiarthroplasty in elderly patients. Methods: Systematic search of Medline and EMBASE databases for English language articles from 2008 to June 2010. Articles were considered for review if they satisfied the following inclusion criteria: original articles on the treatment of displaced intracapsular femoral neck fractures in adult patients above 60 years of age, including both genders, described treatment consisting exclusively of randomised controlled trials comparing cemented and uncemented hemiarthroplasties, reported at least 1 of the following outcomes of interest: residual pain; mobility; mortality; implant related complication; post operative medical complication and functional outcome. Critical appraisal of the selected studies was carried out using Critical Appraisal Skills Programme (CASP) checklist. Results: 3 studies were identified from searching databases; only 2 papers met the inclusion criteria. Both papers were looking for functional outcome of displaced femoral neck fractures treated with cemented versus uncemented hemiarthroplasty. Primary outcome was set as functional scoring systems like Harris hip score, Barthel index, EQ-5D, activities of daily living and residual pain. Secondary outcome was set as length of surgery, operative blood loss, hospital stay and mortality. One trail reported there were no differences in the functional outcome between both groups, while the other trail reported better pain control, mobility and return to daily living with cemented than uncemented hemiarthroplasties. Both trails reported shorter time of surgery and less blood loss intraoperatively with the uncemented group. Conclusion: Uncemented prosthesis can be used for old, frail patients with high comorbidities as it has less operative time and blood loss. Cemented prosthesis can be used for more fit and mobile patients as it has got superior outcome to the uncemented prosthesis. doi:10.1016/j.injury.2011.06.228
105
1A.22 Improvements to the management of patients suffering a fractured neck of femur in Torbay hospital as compared to local and national BOA guidelines: Closure of an audit loop E. Stinton, C. Jones, T. Whiter, T. Woodacre Torbay Hospital, United Kingdom Purpose of study: To assess the impact of changes to local policy on the management of patients suffering a fractured neck of femur (NOF) at Torbay Hospital. Methods: In 2009 an audit was completed assessing the management of patients suffering a fractured NOF in Torbay hospital as compared to BOA guidance. Significant changes to local guidelines have subsequently been implemented. These include: • Introduction of a “fast-track” service of patients from ambulance to assessment within the theatre complex, and if appropriate an operation on the day of admission. • Assessment by an anaesthetist of all patients not immediately operated on to facilitate their operation the following day. • Application of local nerve blockades for symptom control to patients not immediately operated on by appropriately trained staff. • Assessment of all patients by an ortho-geriatrician for assisted medical care and the suitability of anti-resorptive therapy. The audit cycle was completed over an equal time period in 2010 to assess compliance with BOA and local guidelines. Results: Since implementation of changes: • 91% of patients were operated on within 48 h (an improvement of 18%); 68% were operated on within 24 h. • 81% of patients were reviewed by the orthopaedic team within 4 h of arrival at hospital; 50% within 1 h. • All patients not operated upon on the day of admission were reviewed by a member of the anaesthetic team the same day and received appropriate local nerve blockade. • Average length of stay improved from 10 to 6 days. • All other assessed areas were BOA compliant. • Universally positive staff and patient feedback. Conclusions: Key changes to local guidelines have dramatically improved the care of patients suffering a fractured NOF in Torbay, reducing time to theatre, time to discharge and improving overall inpatient care. doi:10.1016/j.injury.2011.06.229 1A.23 Exeter trauma stem—An early experience in a DGH M.D.J. Sinclair, P. Pavlou, S. Stuart, T. Salter, A.R. Harvey Poole Hospital Foundation Trust, United Kingdom Purpose: We present our early experience of the Exeter Trauma Stem in a single surgeon series of 83 hip hemiarthroplasties. Methods and results: This prospective cohort study included 82 patients (62 females and 22 males) with a mean age of 83.6 years, presenting with intracapsular fracture neck of femur. We analyzed time to surgery with date to discharge using the Wilcoxon two sample test. The mean operation date post day of admission was day 3.4. The mean number of days between day of surgery and date of discharge was 14.9. There was no statistically