- Email: [email protected]
Improved component alignment in hip hemiarthroplasty results in improved functional outcome at 12 months
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-
Abstracts / Injury Extra 42 (2011) 95–169
tion of the original hip offset. The purpose of the present study was to assess whether this translated into an improved functional outcome. Methods: Our fracture outcomes database prospectively collects functional data on Hip Fracture patients twelve months following surgery. A retrospective analysis was carried out on data gathered from the previously studied cohort. Results: A consecutive series of 126 patients underwent surgery in a seven-month period in 2007. Three were excluded due to incomplete data. 55 received a Thompson stem and 68 an ETS stem. The mean age in each group was 82 years. The group receiving an ETS stem had poorer pre-morbid health (78% ASA 3 or 4) than those receiving a Thompson stem (62% ASA 3 or 4). 68% of ETS patients and 73% of Thompson patients were alive at 12 months. Increased numbers of patients with an ETS stem were mobile and walk unaccompanied at twelve months (70% ETS vs. 63% Thompson). However, of those mobile, increased numbers with a Thompson stem are mobile unaided (20% vs. 17%). Both patient groups had similar Barthel scores at twelve months. Discussion: Despite poorer pre-morbid health, patients receiving an ETS stem appear to be more mobile than those with a Thompson stem. Our study has shown that the ETS stem is inserted in an improved alignment and that this appears to translate to a better functional outcome at twelve months. doi:10.1016/j.injury.2011.06.233 1A.27 What is the association of displacement of intracapsular fracture neck of femur and with gardens classification? A. Qaddori ∗ , S. Lakkol University Hospital North Tees, United Kingdom Aim: To measure the distance between fractured head to lesser trochanter in intracapsular fracture neck of femur and correlate this with Garden classification to facilitate easy interpretation of these injuries. Methods and results: We included all patients who sustained displaced intra-capsular fracture neck of femur in between September 2010 to February 2011. Initially all fractures were classified according to Gardens classification by reviewing the antero-posterior radiographs of pelvis. The distance from the lowest point on the fractured head to a parallel line drawn at the highest point of lesser trochanter was measured and correlated with the garden classification. There were 24 Garden type IV fractures and 14 type III fractures. In type IV group there were 24 females and mean age at injury was 78 years (range 50–91 years). In type III group there were 9 female patients and average age at the time of injury was 79 years (range 64–91 years). The measured distance between the two reference points was 15.88 ± 7.85 mm (Range 0-27.2 mm) among completely displaced Garden IV fractures. Whereas in type III fracture, the measured distance was 31.30 ± 7.66 mm (range 21.4–47.7 mm). The difference mean scores between two groups were 15.42 mm and the minimum distance in type III fracture (21.4 mm) was 5.2 mm more than average for type IV fractures. Conclusion: The results clearly show that as the distance between head and lesser trochanter is more among less displaced Garden III type fractures. Where as in more displaced type IV fractures the distance is very less. This is very useful for trainees while analysing these fractures and valuable additional information diagnosing these injuries. (Values expressed as mean ± standard deviation).
107
(Please note: This ongoing study and we will increase the final numbers to 50:50). doi:10.1016/j.injury.2011.06.234 1A.29 Does size matter. . . Or is bigger better? Impact on hip dislocation rates with larger head bearing total hip arthroplasty for neck of femur fractures S. Yousaf, O.T. Ward, E. Bsis, G. Cooper, R. Hargrove Frimley Park Hospital NHS Trust, United Kingdom Background: Recent advances in larger than 32 mm prosthetic head sizes in primary total hip arthroplasty (THA) for osteoarthritis reportedly enhance stability owing to increased range of motion before impingement and increased jump distance to subluxation hence reducing dislocation rates. However it is not clear whether it influences the dislocation rates of THA for neck of femur (NOF) fractures. Aims: We sought to determine if using larger diameter heads has influenced dislocation rates total hip arthroplasty (THA) for neck of femur (NOF) fractures as it remains one of the commonest reported complication in case series of this treatment. Methods: Details were retrieved from our arthroplasty database regarding all THA’s done for NOF fractures in our unit using 36 mm and 40 mm femoral heads by different surgeons. Follow-up information was obtained from patients by a specialist joint replacement nurse (GC) in follow up clinics and by telephone conversation. Results: The cohort considered 62 consecutive THA’s, between January 2007 to October 2010 with large heads (≥36 mm). All received either highly cross-linked UHMWPE liners or metal on metal or ceramic on ceramic liners. Almost 60% patients were operated by a modified Hardinge technique and 40% by posterior approach. Follow up was for an average of 18 months (3–46 months). No dislocations were reported irrespective of choice of surgical approach or for this period of time (p < 0.001). Conclusions: This study indicates that using a large femoral reduce the incidence of early dislocation and may enable early return to activities postoperatively. Future evaluations of this patient group will elicit longer term follow-up data. doi:10.1016/j.injury.2011.06.235 1A.30 Cemented or uncemented hip patients get which prosthesis?
hemiarthroplasty—Which
F. Quiney 1 , S. Bennet 2 , R. Majkowski 3 1
Bristol University Medical School, United Kingdom Trauma and Orthopaedics, Severn Deanery, United Kingdom 3 Gloucestershire Royal Hospital, Gloucester, United Kingdom 2
Introduction: Hemiarthroplasty is the optimal treatment for displaced femoral neck fractures in the elderly. Recent evidence suggests the use cemented femoral stems results in less pain and better mobility compared to uncemented stems. We sought to investigate what factors were considered when deciding what prosthesis was most suitable for each patient. Methods: We conducted a retrospective review of prospectively collected data of all hip fractures treated in our unit in 2010. This included basic demographics, medical co-morbidites, ASA grade, walking ability both indoors and outdoors and type of prosthesis
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-
Abstracts / Injury Extra 42 (2011) 95–169
tion of the original hip offset. The purpose of the present study was to assess whether this translated into an improved functional outcome. Methods: Our fracture outcomes database prospectively collects functional data on Hip Fracture patients twelve months following surgery. A retrospective analysis was carried out on data gathered from the previously studied cohort. Results: A consecutive series of 126 patients underwent surgery in a seven-month period in 2007. Three were excluded due to incomplete data. 55 received a Thompson stem and 68 an ETS stem. The mean age in each group was 82 years. The group receiving an ETS stem had poorer pre-morbid health (78% ASA 3 or 4) than those receiving a Thompson stem (62% ASA 3 or 4). 68% of ETS patients and 73% of Thompson patients were alive at 12 months. Increased numbers of patients with an ETS stem were mobile and walk unaccompanied at twelve months (70% ETS vs. 63% Thompson). However, of those mobile, increased numbers with a Thompson stem are mobile unaided (20% vs. 17%). Both patient groups had similar Barthel scores at twelve months. Discussion: Despite poorer pre-morbid health, patients receiving an ETS stem appear to be more mobile than those with a Thompson stem. Our study has shown that the ETS stem is inserted in an improved alignment and that this appears to translate to a better functional outcome at twelve months. doi:10.1016/j.injury.2011.06.233 1A.27 What is the association of displacement of intracapsular fracture neck of femur and with gardens classification? A. Qaddori ∗ , S. Lakkol University Hospital North Tees, United Kingdom Aim: To measure the distance between fractured head to lesser trochanter in intracapsular fracture neck of femur and correlate this with Garden classification to facilitate easy interpretation of these injuries. Methods and results: We included all patients who sustained displaced intra-capsular fracture neck of femur in between September 2010 to February 2011. Initially all fractures were classified according to Gardens classification by reviewing the antero-posterior radiographs of pelvis. The distance from the lowest point on the fractured head to a parallel line drawn at the highest point of lesser trochanter was measured and correlated with the garden classification. There were 24 Garden type IV fractures and 14 type III fractures. In type IV group there were 24 females and mean age at injury was 78 years (range 50–91 years). In type III group there were 9 female patients and average age at the time of injury was 79 years (range 64–91 years). The measured distance between the two reference points was 15.88 ± 7.85 mm (Range 0-27.2 mm) among completely displaced Garden IV fractures. Whereas in type III fracture, the measured distance was 31.30 ± 7.66 mm (range 21.4–47.7 mm). The difference mean scores between two groups were 15.42 mm and the minimum distance in type III fracture (21.4 mm) was 5.2 mm more than average for type IV fractures. Conclusion: The results clearly show that as the distance between head and lesser trochanter is more among less displaced Garden III type fractures. Where as in more displaced type IV fractures the distance is very less. This is very useful for trainees while analysing these fractures and valuable additional information diagnosing these injuries. (Values expressed as mean ± standard deviation).
107
(Please note: This ongoing study and we will increase the final numbers to 50:50). doi:10.1016/j.injury.2011.06.234 1A.29 Does size matter. . . Or is bigger better? Impact on hip dislocation rates with larger head bearing total hip arthroplasty for neck of femur fractures S. Yousaf, O.T. Ward, E. Bsis, G. Cooper, R. Hargrove Frimley Park Hospital NHS Trust, United Kingdom Background: Recent advances in larger than 32 mm prosthetic head sizes in primary total hip arthroplasty (THA) for osteoarthritis reportedly enhance stability owing to increased range of motion before impingement and increased jump distance to subluxation hence reducing dislocation rates. However it is not clear whether it influences the dislocation rates of THA for neck of femur (NOF) fractures. Aims: We sought to determine if using larger diameter heads has influenced dislocation rates total hip arthroplasty (THA) for neck of femur (NOF) fractures as it remains one of the commonest reported complication in case series of this treatment. Methods: Details were retrieved from our arthroplasty database regarding all THA’s done for NOF fractures in our unit using 36 mm and 40 mm femoral heads by different surgeons. Follow-up information was obtained from patients by a specialist joint replacement nurse (GC) in follow up clinics and by telephone conversation. Results: The cohort considered 62 consecutive THA’s, between January 2007 to October 2010 with large heads (≥36 mm). All received either highly cross-linked UHMWPE liners or metal on metal or ceramic on ceramic liners. Almost 60% patients were operated by a modified Hardinge technique and 40% by posterior approach. Follow up was for an average of 18 months (3–46 months). No dislocations were reported irrespective of choice of surgical approach or for this period of time (p < 0.001). Conclusions: This study indicates that using a large femoral reduce the incidence of early dislocation and may enable early return to activities postoperatively. Future evaluations of this patient group will elicit longer term follow-up data. doi:10.1016/j.injury.2011.06.235 1A.30 Cemented or uncemented hip patients get which prosthesis?
hemiarthroplasty—Which
F. Quiney 1 , S. Bennet 2 , R. Majkowski 3 1
Bristol University Medical School, United Kingdom Trauma and Orthopaedics, Severn Deanery, United Kingdom 3 Gloucestershire Royal Hospital, Gloucester, United Kingdom 2
Introduction: Hemiarthroplasty is the optimal treatment for displaced femoral neck fractures in the elderly. Recent evidence suggests the use cemented femoral stems results in less pain and better mobility compared to uncemented stems. We sought to investigate what factors were considered when deciding what prosthesis was most suitable for each patient. Methods: We conducted a retrospective review of prospectively collected data of all hip fractures treated in our unit in 2010. This included basic demographics, medical co-morbidites, ASA grade, walking ability both indoors and outdoors and type of prosthesis