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A randomised controlled trial to compare the haemodynamic changes during the fixation of extracapsular proximal femoral fractures using the compression hip screw versus the intramedullary hip screw
206
Abstracts / Injury Extra 40 (2009) 183–235
time, admission into trauma beds, pre- and post-operative medical assessment by the orthogeriatricians. Keywords: Lean; Value; Fracture; Hip doi:10.1016/j.injury.2009.06.227 5A.8 Progressive change in femoral neck shaft angle with age J. Wilson a , W. Eardley b , S. Odak a,∗ , A. Jennings a a b
County Durham and Darlington Foundation Trust, UK Northern Deanery, UK
Introduction: The geometry of the proximal femur has important implications for femoral neck fracture risk, planning of osteotomy or fracture fixation and precise knowledge is essential for successful arthroplasty. This study aims to identify any variation in femoral neck shaft angle (NSA) in relation to age or gender. Methods: NSA was measured from AP, pelvic radiographs. Three age categories were considered: adolescence to mid-twenties (after closure of the proximal femoral physes) 40–50-year olds, 70–80year olds. Images were included if both hips showed no radiological evidence of hip pathology. Using the digital callipers and the angle measuring tools from the CentricityTM software (GE Medical Systems, web-version 1.0), the neck shaft angle (NSA) was then determined for both proximal femora. The mean NSA of each age group was compared using a one-way ANOVA. The difference between sides and gender were compared using T tests. Results: A total of 229 radiographs were studied, the mean NSA was 130.3◦ (129.6–131.1◦ ). A significant difference was found between the mean NSA of the different age groups. The youngest age group had a mean of 133.6◦ (132.1–135.2◦ ), the middle group 130.6◦ (129.3–132.0◦ ) and the oldest group’s mean was 129.2 (128.2–131.1◦ ). The differences between the young and middle group and young and old group were significant. (p = 0.021 and p < 0.001 respectively) There was no significant gender difference (p = 0.12). Discussion and conclusion: This study has identified a progressive reduction in the NSA with increasing age. This has implications for implant design and choice within different age groups, and highlights the need to pay attention to the specific geometry of the hip on an individualised basis. It should also be noted that the mean NSA is 130.3◦ , not 135◦ which is the angle of many proximal femur fixation devices. Keywords: Neck shaft angle; Proximal femur doi:10.1016/j.injury.2009.06.228 5B.1
5B: Proximal Femoral Fractures Femoral head histology after fractured neck of femur—How useful is it? M. Abu Shameh a , S. Masud a,b,∗ , A. Sahu a , A. Shoaib a a b
Stockport NHS Foundation Trust, UK Ysbyty Gwynedd, UK
Introduction: Femoral neck fractures can occur as a result of metastatic disease. Traditionally this has been investigated by histological examination of the excised femoral head. There is no clear guidance on who may clinically benefit from this. A recent study cast doubt on the usefulness of histology in patients without a
history of malignancy. The aims of this study were to determine what factors in the clinical history are associated with positive histology in suspected pathological femoral neck fractures, and whether the histological diagnosis affected subsequent clinical management. Methods: We retrospectively examined the histological findings over 11 consecutive years for femoral heads that had been excised during surgical treatment of femoral neck fractures. We reviewed the clinical history of every patient for causation. This included a history of trauma, suspicious lesions on plain radiographs, and known neoplastic disease. We correlated this with the histology, and investigated whether the histological diagnosis affected patient management. Results: Seventy-four patients were histologically investigated after femoral neck fracture. Ten had a history of metastatic disease and six (60%) had positive histology. Twenty-three had a previous history of cancer without bone metastases of which three (13%) had positive histology. All positive histology in cancer patients confirmed metastatic disease from the known primary malignancy. One patient with no history of trauma and no previous history of neoplastic disease was diagnosed with disseminated adenocarcinoma on the basis of the histology alone. Discussion: Clinical management changed significantly following positive histology in a patient with no previous history of malignancy. Patients with no history of cancer who sustain a fracture without significant trauma should be investigated as they stand to gain the most from it. Patients known to have bone metastases are likely to have a pathological fracture due to metastases from the underlying known primary. doi:10.1016/j.injury.2009.06.229 5B.2 A randomised controlled trial to compare the haemodynamic changes during the fixation of extracapsular proximal femoral fractures using the compression hip screw versus the intramedullary hip screw M. Ahmad ∗ , R. Bhattacharya, R. Nanda, A. Bajwa, G. Danjoux, A. Hui James Cook University Hospital, UK Introduction: To quantify the magnitude and incidence of haemodynamic changes that occurs during the fixation of extracapsular proximal femoral fractures when using either intramedullary or extramedullary fixation device. Methods: A prospective group of 31 patients with extracapsular proximal femoral fractures were randomised to either fixation using an extramedullary compression hip screw or an intramedullary hip screw. All patients received a general anaesthetic adhering to a standardised anaesthetic protocol including invasive blood pressure monitoring and arterial blood gas sampling. Trans-oesophageal Doppler probe and monitor was used to record preoperative hypovolaemia and perioperative changes in cardiac output, stroke volume and corrected flow time (FTc—a reflection of left ventricular end diastolic pressure) during placement of implants. Results: 77% of patients were hypovolaemic preoperatively, which was corrected with an average of 439 ml of colloid replacement fluid. Application of the extramedullary CHS produced no change in haemodynamic function. However on insertion of the IMHS we found a statistically significant reduction in stroke volume, cardiac output and FTc without changes in pulse rate or mean arterial pressure. The changes were transient with normal cardiac function returning by 5 min post-operatively.
Abstracts / Injury Extra 40 (2009) 183–235
Conclusion: The transient fall in cardiac function during insertion of the intramedullary hip screw may be caused by fat embolism entering the venous circulation. As these changes are not detected with standard non-invasive monitoring we would recommend that intramedullary devices be used with caution in elderly patients who tend to have poor physiological reserve. Keywords: RCT; Haemodynamic changes; IMHS; CHS
207
• Surgical plan based on AP views
doi:10.1016/j.injury.2009.06.230 5B.3 Role of lateral view radiographs in the management of intracapsular neck femur fractures
• Surgical decision after viewing lateral views
R. Reddy, T. Korim, C. Wildin, U. Saleem ∗ University Hospitals of Leicester, UK Introduction: Do we need pre-op lateral radiographs in the management/decision making of intra-capsular neck femur fractures. Methods: Admissions of femoral neck fractures recorded in 4 months period. • Surgical decision before and after viewing lateral views
Consultants (C1, C2), senior (S1) and junior registrars (S2) were asked to fill in the questionnaire after seeing AP and LAT views of fracture. Results: Total number of admissions: 168 • Intra-capsular neck femur fractures: 99 • Diagnosis based on AP views
C2—not clear on AP and Lat but still considered Hemi(2) S2—not clear on AP & Lat but still considered Hemi(1), ORIF(1) No change in surgical decisions based on AP views but S2-decision changed for three cases from ORIF to Hemi
• Request for lateral views 3–9% surgical decisions made after viewing lateral views for AP view diagnosed undisplaced and unclear fractures. Discussion: Our study clearly shows there is no clinical significance for doing lateral X rays in intra-capsular fractures neck of femur. Less than 5% of the decisions were changed after viewing lateral X rays. Reducing unnecessary lateral X rays could avoid unnecessary radiation exposure, patient discomfort and saving money for the trust.
Abstracts / Injury Extra 40 (2009) 183–235
time, admission into trauma beds, pre- and post-operative medical assessment by the orthogeriatricians. Keywords: Lean; Value; Fracture; Hip doi:10.1016/j.injury.2009.06.227 5A.8 Progressive change in femoral neck shaft angle with age J. Wilson a , W. Eardley b , S. Odak a,∗ , A. Jennings a a b
County Durham and Darlington Foundation Trust, UK Northern Deanery, UK
Introduction: The geometry of the proximal femur has important implications for femoral neck fracture risk, planning of osteotomy or fracture fixation and precise knowledge is essential for successful arthroplasty. This study aims to identify any variation in femoral neck shaft angle (NSA) in relation to age or gender. Methods: NSA was measured from AP, pelvic radiographs. Three age categories were considered: adolescence to mid-twenties (after closure of the proximal femoral physes) 40–50-year olds, 70–80year olds. Images were included if both hips showed no radiological evidence of hip pathology. Using the digital callipers and the angle measuring tools from the CentricityTM software (GE Medical Systems, web-version 1.0), the neck shaft angle (NSA) was then determined for both proximal femora. The mean NSA of each age group was compared using a one-way ANOVA. The difference between sides and gender were compared using T tests. Results: A total of 229 radiographs were studied, the mean NSA was 130.3◦ (129.6–131.1◦ ). A significant difference was found between the mean NSA of the different age groups. The youngest age group had a mean of 133.6◦ (132.1–135.2◦ ), the middle group 130.6◦ (129.3–132.0◦ ) and the oldest group’s mean was 129.2 (128.2–131.1◦ ). The differences between the young and middle group and young and old group were significant. (p = 0.021 and p < 0.001 respectively) There was no significant gender difference (p = 0.12). Discussion and conclusion: This study has identified a progressive reduction in the NSA with increasing age. This has implications for implant design and choice within different age groups, and highlights the need to pay attention to the specific geometry of the hip on an individualised basis. It should also be noted that the mean NSA is 130.3◦ , not 135◦ which is the angle of many proximal femur fixation devices. Keywords: Neck shaft angle; Proximal femur doi:10.1016/j.injury.2009.06.228 5B.1
5B: Proximal Femoral Fractures Femoral head histology after fractured neck of femur—How useful is it? M. Abu Shameh a , S. Masud a,b,∗ , A. Sahu a , A. Shoaib a a b
Stockport NHS Foundation Trust, UK Ysbyty Gwynedd, UK
Introduction: Femoral neck fractures can occur as a result of metastatic disease. Traditionally this has been investigated by histological examination of the excised femoral head. There is no clear guidance on who may clinically benefit from this. A recent study cast doubt on the usefulness of histology in patients without a
history of malignancy. The aims of this study were to determine what factors in the clinical history are associated with positive histology in suspected pathological femoral neck fractures, and whether the histological diagnosis affected subsequent clinical management. Methods: We retrospectively examined the histological findings over 11 consecutive years for femoral heads that had been excised during surgical treatment of femoral neck fractures. We reviewed the clinical history of every patient for causation. This included a history of trauma, suspicious lesions on plain radiographs, and known neoplastic disease. We correlated this with the histology, and investigated whether the histological diagnosis affected patient management. Results: Seventy-four patients were histologically investigated after femoral neck fracture. Ten had a history of metastatic disease and six (60%) had positive histology. Twenty-three had a previous history of cancer without bone metastases of which three (13%) had positive histology. All positive histology in cancer patients confirmed metastatic disease from the known primary malignancy. One patient with no history of trauma and no previous history of neoplastic disease was diagnosed with disseminated adenocarcinoma on the basis of the histology alone. Discussion: Clinical management changed significantly following positive histology in a patient with no previous history of malignancy. Patients with no history of cancer who sustain a fracture without significant trauma should be investigated as they stand to gain the most from it. Patients known to have bone metastases are likely to have a pathological fracture due to metastases from the underlying known primary. doi:10.1016/j.injury.2009.06.229 5B.2 A randomised controlled trial to compare the haemodynamic changes during the fixation of extracapsular proximal femoral fractures using the compression hip screw versus the intramedullary hip screw M. Ahmad ∗ , R. Bhattacharya, R. Nanda, A. Bajwa, G. Danjoux, A. Hui James Cook University Hospital, UK Introduction: To quantify the magnitude and incidence of haemodynamic changes that occurs during the fixation of extracapsular proximal femoral fractures when using either intramedullary or extramedullary fixation device. Methods: A prospective group of 31 patients with extracapsular proximal femoral fractures were randomised to either fixation using an extramedullary compression hip screw or an intramedullary hip screw. All patients received a general anaesthetic adhering to a standardised anaesthetic protocol including invasive blood pressure monitoring and arterial blood gas sampling. Trans-oesophageal Doppler probe and monitor was used to record preoperative hypovolaemia and perioperative changes in cardiac output, stroke volume and corrected flow time (FTc—a reflection of left ventricular end diastolic pressure) during placement of implants. Results: 77% of patients were hypovolaemic preoperatively, which was corrected with an average of 439 ml of colloid replacement fluid. Application of the extramedullary CHS produced no change in haemodynamic function. However on insertion of the IMHS we found a statistically significant reduction in stroke volume, cardiac output and FTc without changes in pulse rate or mean arterial pressure. The changes were transient with normal cardiac function returning by 5 min post-operatively.
Abstracts / Injury Extra 40 (2009) 183–235
Conclusion: The transient fall in cardiac function during insertion of the intramedullary hip screw may be caused by fat embolism entering the venous circulation. As these changes are not detected with standard non-invasive monitoring we would recommend that intramedullary devices be used with caution in elderly patients who tend to have poor physiological reserve. Keywords: RCT; Haemodynamic changes; IMHS; CHS
207
• Surgical plan based on AP views
doi:10.1016/j.injury.2009.06.230 5B.3 Role of lateral view radiographs in the management of intracapsular neck femur fractures
• Surgical decision after viewing lateral views
R. Reddy, T. Korim, C. Wildin, U. Saleem ∗ University Hospitals of Leicester, UK Introduction: Do we need pre-op lateral radiographs in the management/decision making of intra-capsular neck femur fractures. Methods: Admissions of femoral neck fractures recorded in 4 months period. • Surgical decision before and after viewing lateral views
Consultants (C1, C2), senior (S1) and junior registrars (S2) were asked to fill in the questionnaire after seeing AP and LAT views of fracture. Results: Total number of admissions: 168 • Intra-capsular neck femur fractures: 99 • Diagnosis based on AP views
C2—not clear on AP and Lat but still considered Hemi(2) S2—not clear on AP & Lat but still considered Hemi(1), ORIF(1) No change in surgical decisions based on AP views but S2-decision changed for three cases from ORIF to Hemi
• Request for lateral views 3–9% surgical decisions made after viewing lateral views for AP view diagnosed undisplaced and unclear fractures. Discussion: Our study clearly shows there is no clinical significance for doing lateral X rays in intra-capsular fractures neck of femur. Less than 5% of the decisions were changed after viewing lateral X rays. Reducing unnecessary lateral X rays could avoid unnecessary radiation exposure, patient discomfort and saving money for the trust.