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Exeter trauma stem—An early experience in a DGH
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
106
Abstracts / Injury Extra 42 (2011) 95–169
significant difference (P 0.63) in date to discharge between surgery within 2 days (14.7 days) and surgery after 2 days (15.5 days). Pre-morbid mobility and place of residence were recorded on admission and compared post discharge via a telephone interview at 30 days and 120 days, respectively. Pre admission 93% of patients were living in their own home, compared to 62% at 30 days and 81% at 120 days. Pre admission 51% of patients were mobilizing independently with no aids, compared to <1% at 30 days and 25% at 120 days. A further 65% were walking but required the assistance of a stick or frame. There were 4 dislocations, 2 of which were long when postoperative implant position was assessed. Four patients died, 2 within 30 days and a further two within 120 days. Conclusions: The Exeter Trauma Stem is associated with a low mortality rate and facilitates the return of a high proportion of out patients to their usual residence. There was no significant association between early surgery and early discharge. Care must be taken to ensure the implant is not left long to minimize the risk of dislocation. doi:10.1016/j.injury.2011.06.230 1A.24 The role of CT and MRI in the diagnosis of occult hip fractures S.K. Gill, J. Smith, T.J.S. Chesser Dept of Trauma and Orthopaedics, Frenchay Hospital, Bristol, UK Aim: The aim of this study was to retrospectively compare the reports of patients sent for MRI or CT with negative radiographs and a clinical suspicion of a fractured neck of femur. Methods: All patients presenting to the hospital with a clinical suspicion of a hip fracture but initial negative radiographs over a two-year period were included. Patients were either investigated with an MRI scan, or if not immediately available with a multi-slice CT scan. The presence of a fracture, the requirement for surgery and any further requirement for imaging were recorded Results: Over two years 92 patients were included of which 61 were referred for a CT and 31 were referred for an MRI to rule out an occult fractured neck of femur. Of these, MRI picked up a fracture in 35% of referrals and CT picked up a fracture in 38% of referrals. 83% of the fractures found on CT and 73% of the fractures found on MRI were operated on. The patients were followed up radiologically for 6 weeks post scan and no patients with a negative CT or MRI returned with a fractured neck of femur. Discussion: About 70–75,000 fractured neck of femurs occur annually in the UK. Up to 10% of these may be missed on initial radiographs and require further imaging if there is clinical suspicion of a fractured neck of femur. Current guidelines state patients should be offered MRI if hip fracture is suspected despite negative anteroposterior pelvis and lateral hip X-rays. However MRIs may not be readily available in all hospitals, is expensive and is contraindicated in confused patients and patients with cardiac pacemakers. Our findings show that modern multi-slice CT may be comparable with MRI for detecting occult fracture. doi:10.1016/j.injury.2011.06.231
1A.25 The impact of Clostridium Difficile infection on recovery potential in elderly patients after emergency proximal femoral fracture surgery A.L. Ramavath, T. Okoro, P. Sathyamoorthy Department of Orthopaedics, Ysbyty Gwynedd, Betsi Cadwaladr University Health Board, Penrhosgarnedd, Bangor, United Kingdom Introduction: Clostridium difficile associated diarrhoea (CDAD) is a recognised complication of antibiotic administration1 . Proximal femoral fractures in the elderly are the commonest cause of acute admission to Trauma and Orthopaedic Wards2 . The aims of this study were to assess whether CDAD decreases the recovery potential of elderly patients undergoing emergency proximal femoral surgery and quantify the added risk to patient mortality. Material and methods: Retrospective analysis of 3141 proximal hip fracture patients admitted from January 2004 to June 2008. 19 cases of CDAD mean age 83.9 (±10.9) identified and compared to 38 normal controls. Recovery potential (inpatient stay, mobility and discharge destination), and mortality data collated. Results: The CDAD group had a higher inpatient hospital stay period compared to controls (average 53 days (±48.46) vs. 13 days (±5.08); t test p = 0.002). A significant difference existed in the inpatient 30-day mortality with the CDAD group also higher than the controls (42% (8/19) vs. 13.15% (5/38); Fishers exact p = 0.018). None of the CDAD patients achieved a home return in comparison to 7.9% of the control group whilst a higher proportion of the control group made it to rehabilitation (CDAD vs. Control – Residential home 21% vs. 52%; Nursing home 21% vs. 26%). For mobility a higher percentage of control patients retained independence compared to the CDAD group and more patients ended up bedbound after contracting CDAD (CDAD vs. Control – Independence 0% vs. 34%; Stick 5.2% vs. 31.5%; Hoist 10.5% vs. 2.63% Frame 15.8% vs. 18.4%; Bedbound 10.5% vs. 2.6%). Discussion: CDAD in elderly patients after emergency proximal hip fracture surgery increases inpatient stay and impacts significantly on patient recovery. Postoperative management should focus on preventing this debilitating complication. References 1 Yam FK, et al. Collateral damage: antibiotics and the risk of clostridium difficile infection. Orthopaedics 2005;28:275–9. 2 Clarke HJ, et al. Clostridium difficile infection in orthopaedic patients. J Bone Joint Surg 1990;72-A:1056–9.
doi:10.1016/j.injury.2011.06.232 1A.26 Improved component alignment in hip hemiarthroplasty results in improved functional outcome at 12 months C.M. Stevenson, A. Johnston, K. Dane, M.G. McAlinden Trauma Unit, Ulster Hospital, Belfast, Northern Ireland, United Kingdom Introduction: Hip fracture is a painful debilitating condition that seriously affects quality of life. Only half of survivors will return to their previous level of independence. In 2007, our unit changed from using a Thompson implant to an Exeter Trauma Stem. We investigated whether the change in implant could result in improved positioning and concluded that the ETS implant was more likely to be inserted in neutral alignment with better restora-
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
106
Abstracts / Injury Extra 42 (2011) 95–169
significant difference (P 0.63) in date to discharge between surgery within 2 days (14.7 days) and surgery after 2 days (15.5 days). Pre-morbid mobility and place of residence were recorded on admission and compared post discharge via a telephone interview at 30 days and 120 days, respectively. Pre admission 93% of patients were living in their own home, compared to 62% at 30 days and 81% at 120 days. Pre admission 51% of patients were mobilizing independently with no aids, compared to <1% at 30 days and 25% at 120 days. A further 65% were walking but required the assistance of a stick or frame. There were 4 dislocations, 2 of which were long when postoperative implant position was assessed. Four patients died, 2 within 30 days and a further two within 120 days. Conclusions: The Exeter Trauma Stem is associated with a low mortality rate and facilitates the return of a high proportion of out patients to their usual residence. There was no significant association between early surgery and early discharge. Care must be taken to ensure the implant is not left long to minimize the risk of dislocation. doi:10.1016/j.injury.2011.06.230 1A.24 The role of CT and MRI in the diagnosis of occult hip fractures S.K. Gill, J. Smith, T.J.S. Chesser Dept of Trauma and Orthopaedics, Frenchay Hospital, Bristol, UK Aim: The aim of this study was to retrospectively compare the reports of patients sent for MRI or CT with negative radiographs and a clinical suspicion of a fractured neck of femur. Methods: All patients presenting to the hospital with a clinical suspicion of a hip fracture but initial negative radiographs over a two-year period were included. Patients were either investigated with an MRI scan, or if not immediately available with a multi-slice CT scan. The presence of a fracture, the requirement for surgery and any further requirement for imaging were recorded Results: Over two years 92 patients were included of which 61 were referred for a CT and 31 were referred for an MRI to rule out an occult fractured neck of femur. Of these, MRI picked up a fracture in 35% of referrals and CT picked up a fracture in 38% of referrals. 83% of the fractures found on CT and 73% of the fractures found on MRI were operated on. The patients were followed up radiologically for 6 weeks post scan and no patients with a negative CT or MRI returned with a fractured neck of femur. Discussion: About 70–75,000 fractured neck of femurs occur annually in the UK. Up to 10% of these may be missed on initial radiographs and require further imaging if there is clinical suspicion of a fractured neck of femur. Current guidelines state patients should be offered MRI if hip fracture is suspected despite negative anteroposterior pelvis and lateral hip X-rays. However MRIs may not be readily available in all hospitals, is expensive and is contraindicated in confused patients and patients with cardiac pacemakers. Our findings show that modern multi-slice CT may be comparable with MRI for detecting occult fracture. doi:10.1016/j.injury.2011.06.231
1A.25 The impact of Clostridium Difficile infection on recovery potential in elderly patients after emergency proximal femoral fracture surgery A.L. Ramavath, T. Okoro, P. Sathyamoorthy Department of Orthopaedics, Ysbyty Gwynedd, Betsi Cadwaladr University Health Board, Penrhosgarnedd, Bangor, United Kingdom Introduction: Clostridium difficile associated diarrhoea (CDAD) is a recognised complication of antibiotic administration1 . Proximal femoral fractures in the elderly are the commonest cause of acute admission to Trauma and Orthopaedic Wards2 . The aims of this study were to assess whether CDAD decreases the recovery potential of elderly patients undergoing emergency proximal femoral surgery and quantify the added risk to patient mortality. Material and methods: Retrospective analysis of 3141 proximal hip fracture patients admitted from January 2004 to June 2008. 19 cases of CDAD mean age 83.9 (±10.9) identified and compared to 38 normal controls. Recovery potential (inpatient stay, mobility and discharge destination), and mortality data collated. Results: The CDAD group had a higher inpatient hospital stay period compared to controls (average 53 days (±48.46) vs. 13 days (±5.08); t test p = 0.002). A significant difference existed in the inpatient 30-day mortality with the CDAD group also higher than the controls (42% (8/19) vs. 13.15% (5/38); Fishers exact p = 0.018). None of the CDAD patients achieved a home return in comparison to 7.9% of the control group whilst a higher proportion of the control group made it to rehabilitation (CDAD vs. Control – Residential home 21% vs. 52%; Nursing home 21% vs. 26%). For mobility a higher percentage of control patients retained independence compared to the CDAD group and more patients ended up bedbound after contracting CDAD (CDAD vs. Control – Independence 0% vs. 34%; Stick 5.2% vs. 31.5%; Hoist 10.5% vs. 2.63% Frame 15.8% vs. 18.4%; Bedbound 10.5% vs. 2.6%). Discussion: CDAD in elderly patients after emergency proximal hip fracture surgery increases inpatient stay and impacts significantly on patient recovery. Postoperative management should focus on preventing this debilitating complication. References 1 Yam FK, et al. Collateral damage: antibiotics and the risk of clostridium difficile infection. Orthopaedics 2005;28:275–9. 2 Clarke HJ, et al. Clostridium difficile infection in orthopaedic patients. J Bone Joint Surg 1990;72-A:1056–9.
doi:10.1016/j.injury.2011.06.232 1A.26 Improved component alignment in hip hemiarthroplasty results in improved functional outcome at 12 months C.M. Stevenson, A. Johnston, K. Dane, M.G. McAlinden Trauma Unit, Ulster Hospital, Belfast, Northern Ireland, United Kingdom Introduction: Hip fracture is a painful debilitating condition that seriously affects quality of life. Only half of survivors will return to their previous level of independence. In 2007, our unit changed from using a Thompson implant to an Exeter Trauma Stem. We investigated whether the change in implant could result in improved positioning and concluded that the ETS implant was more likely to be inserted in neutral alignment with better restora-