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Outcome of primary THR in displaced fracture neck of femur
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Abstracts / Injury Extra 42 (2011) 95–169
Conclusion: There is a strong correlation between SDS and mortality within 30 days of surgery indicating its usefulness in predicting such deaths. Graphs intersect at SDS 5 and this value could be taken as an indicator of high risk (50%) of death within 30 days. Larger data and a prospective study would help derive more accurate values. doi:10.1016/j.injury.2011.06.247 1A.42 Early involvement of a multi-disciplinary team improves outcomes in patients with fractured neck of femurs
The most common sites for the primary tumor were breast (36%), prostate (23%) and lung (17%). Mean survival following operation was 270 days (range 2–3053 days), being longest for those with myeloma (662 days), lymphoma (>312 days) and breast tumours (492 days) and lowest for lung tumours (110 days). 99% of the fractures were treated surgically. Mean hospital stay was 19 days. The commonest fracture healing complication was further fracture of the femur around or immediately below the implant which occurred in 9/143 (6.3%) of operations. This complication appeared to be reduced with a change to cemented arthroplasties and long intramedullary nails. doi:10.1016/j.injury.2011.06.249
R.L. O’Connell, M. Thilagarajah 1A.44 Darent Valley Hospital, Kent, UK Purpose of study: Patients who sustain a fractured neck of femur (NOF) occupy approximately 20% of orthopaedic beds. Our aim in this study was to determine whether early intervention by a multidisciplinary team significantly improves peri-operative care, length of stay and secondary prevention in this high-risk group of patients. Methods: A retrospective study was undertaken to collect information on patients (n = 79) who sustained a fractured NOF over a three-month period. Following this, an integrated care pathway was developed based on guidelines from the National Hip Fracture Database. A multi-disciplinary team was trained on following the pathway, which included early ortho-geriatric involvement. Data was collected prospectively over the next 6 months (n = 151 patients). Results: Prior to implementation, 70% (n = 55) of patients were admitted to a specialist orthopaedic ward following fractured NOF; this improved to 91% (n = 138, 2-tailed Chi-squared test, p < 0.0001). The proportion of patients having an ortho-geriatric review within 72 hours improved from 15% to 57% (p = 0.0001). Without a multi-disciplinary approach only 63% (n = 50/79) of patients were assessed and treated for bone protection when indicated, this improved to 92% (n = 139/151) after involvement of the multi-disciplinary team (p < 0.0001). Overall mortality fell from 22% (n = 17/79) prior to the multi-disciplinary approach to 16% (24/151). Finally, as the percentage of patients seen by an ortho-geriatrician increased from month on month, the length of stay fell significantly (Spearman rank correlation coefficient, r = −0.94, p < 0.05). Conclusion: A multi-disciplinary approach in the management of fractured NOFs results in an increase in the assessment for bone protection, which is essential for secondary prevention. Involvement of an orthogeriatric team also results in a reduction in the length of stay and a fall in mortality. Further multivariate analyses should be carried out to determine other variables which can improve outcomes in this vulnerable group of patients. doi:10.1016/j.injury.2011.06.248
Internal fixation of proximal humeral fractures using the philos plate J. Broomfield, P. Ralte, A. Sinha, Y. Khan, C. Neophytou, J. Fischer, M. Waseem, R. Bassi Macclesfield District General Hospital, United Kingdom Aims: The aim of this study was to assess outcomes and efficacy of the Proximal Humeral Internal Locking System (PHILOS) as a treatment of fractures of the proximal humerus. Method: We retrospectively reviewed all patients who sustained proximal humeral fractures treated with PHILOS plating in a 7-year period from December 2003 to November 2010. There were 51 procedures carried out. Outcomes were assessed using the Oxford Shoulder Score and a 10 cm Visual Analogue Scale (VAS). Results: There were 26 (51%) female and 25 (49%) male patients with an average age of 60.6 (23.0–88.9) years. In 26 (51%) cases the injury affected the dominant side. The indications for surgery were: acute fracture (40, 78.43%), nonunion (8, 15.69%), acute fracture dislocation (1, 1.96%), malunion (1, 1.96%) and revision of failed IM fixation (1, 1.96%). Average inpatient stay was 7.2 days (0–67) and average number of follow up visits before discharge was 4.6 (1–15) over an average duration of 9.8 months (1.8–44.2). We found 48 (94.1%) fractures united without consequence with 1 (1.96%) case of nonunion, 1 (1.96%) case of metalwork cut out and 1 (1.96%) mortality on the first post operative day. The average Oxford Shoulder Score was 28.4 (6–48) and mean VAS was 6.9 (0–10). Conclusion: The PHILOS plate is an effective treatment of proximal humeral fractures and has high patient satisfaction. doi:10.1016/j.injury.2011.06.250 1A.45 Outcome of primary THR in displaced fracture neck of femur S. Chokkalingam, A. Moftah, B. Bhavanasi
1A.43 Sandwell General Hospital, West Bromwich, UK Pathological fractures of the proximal femur: A review of 143 cases A.Z. Khan, M.J. Parker Peterborough City Hospital, United Kingdom We report on the 143 cases of pathological metastatic fractures of the proximal femur with a minimum follow-up for the survivors of three years. 2.5% of all hip fractures were pathological. The average age was 72 years, 61% were females. 47% of fractures were intracapsular, 28% trochanteric and 25% subtrochanteric.
Introduction: Concept of Primary THR in Fracture neck of femur (NOF) is more than acute trauma management. The incidence of displaced intra capsular fracture NOF is over 40%. Controversy exists in the physiologically active group between fixation and replacement. Fixation method has a cumulative risk of failure in over 50% and also salvage THR for failed fixation has inferior results. Total hip replacements carry a high risk of dislocation rate but better outcome. Aim: To study the outcome of Primary THR in Fracture neck of femur.
Abstracts / Injury Extra 42 (2011) 95–169
Materials and methods: A retrospective study of 35 consecutive patients with primary THR following displaced intracapsular fracture between January 2008 and December 2010. More common in females than males. Age range between 51 and 95 years with a mean age of 72.5 years and only 20% of the cases were below 60 years. Most fractures were Garden type 3 and 4. Laminar air flow theatre, antibiotic prophylaxis, Anterolateral approach was followed for all cases. 48% had uncemented type with and only 28.5% cemented type of fixation. Results: All had Follow up at 6 weeks and 3 months. With a mean follow up of 1.8 years all had satisfactory outcome with return to pre fracture level mobility within 2 months. The complications are as follows: 1year mortality in 2 cases (5.7%) due to unrelated causes, deep infection in 2 cases (5.7%) ended up with girdle stone in one and settled with wash out in other case. Periprosthetic fracture in a uncemented THR (2.8%) needed revision within 6 weeks. None of these had a dislocation. Conclusion: THR is a viable option for selected patient group of NOF in the hands of hip surgeons. RCT study will be conclusive. doi:10.1016/j.injury.2011.06.251
113
Method: We have left a 6-month interval between audit cycles to allow the recommendations to become established practice. We are prospectively collecting data for January, February and March 2011. Results: The 2 key areas where we previously did not meet the BPT were; surgery within 36 h and Ortho-Geriatrician review within 72 h. We have now changed the Ortho-Geriatrician ward rounds and with improved awareness of the targets, we hope to demonstrate improved compliance. Discussion: The BPT for NOFs is currently a hot topic in Orthopaedics. It will improve survival and ensure that this vulnerable patient group does not receive delayed treatment. The uplifted tariff price is a cash incentive for Trusts to improve the quality of their service and can generate a substantial source of income. We hope to share our experience and demonstrate that simple solutions can be rewarding. doi:10.1016/j.injury.2011.06.252 1B.1
1A.46
Complex maltreated neglected trauma of the humerus and its revision surgery
Re-auditing compliance with the best practice tariff for fragility hip fractures
I. Shah ∗ , J. Shah, S. Alam, S.M.A. Shah
R. Fawdington, D. Giebaly, A. Marsh Russells Hall Hospital, Dudley, West Midlands, United Kingdom Aim: The purpose of our study is to identify if our previous recommendations to improve compliance with the best practice tariff (BPT) were effective. Background: The BPT for fragility hip fractures (NOFs) was introduced in April 2010. There are 6 criteria which must be met to receive an uplifted tariff price. The Department of Health estimates that 85–90% of patients should meet the BPT. We previously retrospectively audited our April, May and June 2010 data. We found that only 53.2% of patients met the BPT criteria and received an uplifted tariff price. Our recommendations to improve compliance were: • Identify the breach time on admission and state it on the theatre list • Put NOFs early on trauma operating lists • Change the timing of the Ortho-Geriatrician’s ward round • Prospectively collect data • Re-analysing the April, May, June data in light of the above recommendations meant that 81.7% of patients would have met the BPT.
AO CLINIC - Institute of Trauma & Orthopaedics, United Kingdom 483 cases of neglected/maltreated long bone fractures were seen over the last 4 years. 60 of these cases were humeral fractures that required attention and surgical intervention. Humeral revision trauma cases are particularly interesting and the most challenging of long bone neglected fractures due to the close proximity of neurovascular structures especially when they get entangled within the fibrous tissue which forms due to weeks/years of neglect after the initial erroneous management. In this presentation, we cover our principles of management for these complex cases and our results are very encouraging, with one re-infection after revision surgery and no non-unions. All of these infected patients had their external fixators or their IM nail removed and were then treated with a compression plate and autologous bone graft. One patient had his IM humeral fibula removed and also replaced with a compression plate and achieved full bony union. Conclusion: Plating for infected malunited/non united humeral fractures gives predictable excellent results as long as infection is controlled appropriately before embarking on revision trauma surgery.
Abstracts / Injury Extra 42 (2011) 95–169
Conclusion: There is a strong correlation between SDS and mortality within 30 days of surgery indicating its usefulness in predicting such deaths. Graphs intersect at SDS 5 and this value could be taken as an indicator of high risk (50%) of death within 30 days. Larger data and a prospective study would help derive more accurate values. doi:10.1016/j.injury.2011.06.247 1A.42 Early involvement of a multi-disciplinary team improves outcomes in patients with fractured neck of femurs
The most common sites for the primary tumor were breast (36%), prostate (23%) and lung (17%). Mean survival following operation was 270 days (range 2–3053 days), being longest for those with myeloma (662 days), lymphoma (>312 days) and breast tumours (492 days) and lowest for lung tumours (110 days). 99% of the fractures were treated surgically. Mean hospital stay was 19 days. The commonest fracture healing complication was further fracture of the femur around or immediately below the implant which occurred in 9/143 (6.3%) of operations. This complication appeared to be reduced with a change to cemented arthroplasties and long intramedullary nails. doi:10.1016/j.injury.2011.06.249
R.L. O’Connell, M. Thilagarajah 1A.44 Darent Valley Hospital, Kent, UK Purpose of study: Patients who sustain a fractured neck of femur (NOF) occupy approximately 20% of orthopaedic beds. Our aim in this study was to determine whether early intervention by a multidisciplinary team significantly improves peri-operative care, length of stay and secondary prevention in this high-risk group of patients. Methods: A retrospective study was undertaken to collect information on patients (n = 79) who sustained a fractured NOF over a three-month period. Following this, an integrated care pathway was developed based on guidelines from the National Hip Fracture Database. A multi-disciplinary team was trained on following the pathway, which included early ortho-geriatric involvement. Data was collected prospectively over the next 6 months (n = 151 patients). Results: Prior to implementation, 70% (n = 55) of patients were admitted to a specialist orthopaedic ward following fractured NOF; this improved to 91% (n = 138, 2-tailed Chi-squared test, p < 0.0001). The proportion of patients having an ortho-geriatric review within 72 hours improved from 15% to 57% (p = 0.0001). Without a multi-disciplinary approach only 63% (n = 50/79) of patients were assessed and treated for bone protection when indicated, this improved to 92% (n = 139/151) after involvement of the multi-disciplinary team (p < 0.0001). Overall mortality fell from 22% (n = 17/79) prior to the multi-disciplinary approach to 16% (24/151). Finally, as the percentage of patients seen by an ortho-geriatrician increased from month on month, the length of stay fell significantly (Spearman rank correlation coefficient, r = −0.94, p < 0.05). Conclusion: A multi-disciplinary approach in the management of fractured NOFs results in an increase in the assessment for bone protection, which is essential for secondary prevention. Involvement of an orthogeriatric team also results in a reduction in the length of stay and a fall in mortality. Further multivariate analyses should be carried out to determine other variables which can improve outcomes in this vulnerable group of patients. doi:10.1016/j.injury.2011.06.248
Internal fixation of proximal humeral fractures using the philos plate J. Broomfield, P. Ralte, A. Sinha, Y. Khan, C. Neophytou, J. Fischer, M. Waseem, R. Bassi Macclesfield District General Hospital, United Kingdom Aims: The aim of this study was to assess outcomes and efficacy of the Proximal Humeral Internal Locking System (PHILOS) as a treatment of fractures of the proximal humerus. Method: We retrospectively reviewed all patients who sustained proximal humeral fractures treated with PHILOS plating in a 7-year period from December 2003 to November 2010. There were 51 procedures carried out. Outcomes were assessed using the Oxford Shoulder Score and a 10 cm Visual Analogue Scale (VAS). Results: There were 26 (51%) female and 25 (49%) male patients with an average age of 60.6 (23.0–88.9) years. In 26 (51%) cases the injury affected the dominant side. The indications for surgery were: acute fracture (40, 78.43%), nonunion (8, 15.69%), acute fracture dislocation (1, 1.96%), malunion (1, 1.96%) and revision of failed IM fixation (1, 1.96%). Average inpatient stay was 7.2 days (0–67) and average number of follow up visits before discharge was 4.6 (1–15) over an average duration of 9.8 months (1.8–44.2). We found 48 (94.1%) fractures united without consequence with 1 (1.96%) case of nonunion, 1 (1.96%) case of metalwork cut out and 1 (1.96%) mortality on the first post operative day. The average Oxford Shoulder Score was 28.4 (6–48) and mean VAS was 6.9 (0–10). Conclusion: The PHILOS plate is an effective treatment of proximal humeral fractures and has high patient satisfaction. doi:10.1016/j.injury.2011.06.250 1A.45 Outcome of primary THR in displaced fracture neck of femur S. Chokkalingam, A. Moftah, B. Bhavanasi
1A.43 Sandwell General Hospital, West Bromwich, UK Pathological fractures of the proximal femur: A review of 143 cases A.Z. Khan, M.J. Parker Peterborough City Hospital, United Kingdom We report on the 143 cases of pathological metastatic fractures of the proximal femur with a minimum follow-up for the survivors of three years. 2.5% of all hip fractures were pathological. The average age was 72 years, 61% were females. 47% of fractures were intracapsular, 28% trochanteric and 25% subtrochanteric.
Introduction: Concept of Primary THR in Fracture neck of femur (NOF) is more than acute trauma management. The incidence of displaced intra capsular fracture NOF is over 40%. Controversy exists in the physiologically active group between fixation and replacement. Fixation method has a cumulative risk of failure in over 50% and also salvage THR for failed fixation has inferior results. Total hip replacements carry a high risk of dislocation rate but better outcome. Aim: To study the outcome of Primary THR in Fracture neck of femur.
Abstracts / Injury Extra 42 (2011) 95–169
Materials and methods: A retrospective study of 35 consecutive patients with primary THR following displaced intracapsular fracture between January 2008 and December 2010. More common in females than males. Age range between 51 and 95 years with a mean age of 72.5 years and only 20% of the cases were below 60 years. Most fractures were Garden type 3 and 4. Laminar air flow theatre, antibiotic prophylaxis, Anterolateral approach was followed for all cases. 48% had uncemented type with and only 28.5% cemented type of fixation. Results: All had Follow up at 6 weeks and 3 months. With a mean follow up of 1.8 years all had satisfactory outcome with return to pre fracture level mobility within 2 months. The complications are as follows: 1year mortality in 2 cases (5.7%) due to unrelated causes, deep infection in 2 cases (5.7%) ended up with girdle stone in one and settled with wash out in other case. Periprosthetic fracture in a uncemented THR (2.8%) needed revision within 6 weeks. None of these had a dislocation. Conclusion: THR is a viable option for selected patient group of NOF in the hands of hip surgeons. RCT study will be conclusive. doi:10.1016/j.injury.2011.06.251
113
Method: We have left a 6-month interval between audit cycles to allow the recommendations to become established practice. We are prospectively collecting data for January, February and March 2011. Results: The 2 key areas where we previously did not meet the BPT were; surgery within 36 h and Ortho-Geriatrician review within 72 h. We have now changed the Ortho-Geriatrician ward rounds and with improved awareness of the targets, we hope to demonstrate improved compliance. Discussion: The BPT for NOFs is currently a hot topic in Orthopaedics. It will improve survival and ensure that this vulnerable patient group does not receive delayed treatment. The uplifted tariff price is a cash incentive for Trusts to improve the quality of their service and can generate a substantial source of income. We hope to share our experience and demonstrate that simple solutions can be rewarding. doi:10.1016/j.injury.2011.06.252 1B.1
1A.46
Complex maltreated neglected trauma of the humerus and its revision surgery
Re-auditing compliance with the best practice tariff for fragility hip fractures
I. Shah ∗ , J. Shah, S. Alam, S.M.A. Shah
R. Fawdington, D. Giebaly, A. Marsh Russells Hall Hospital, Dudley, West Midlands, United Kingdom Aim: The purpose of our study is to identify if our previous recommendations to improve compliance with the best practice tariff (BPT) were effective. Background: The BPT for fragility hip fractures (NOFs) was introduced in April 2010. There are 6 criteria which must be met to receive an uplifted tariff price. The Department of Health estimates that 85–90% of patients should meet the BPT. We previously retrospectively audited our April, May and June 2010 data. We found that only 53.2% of patients met the BPT criteria and received an uplifted tariff price. Our recommendations to improve compliance were: • Identify the breach time on admission and state it on the theatre list • Put NOFs early on trauma operating lists • Change the timing of the Ortho-Geriatrician’s ward round • Prospectively collect data • Re-analysing the April, May, June data in light of the above recommendations meant that 81.7% of patients would have met the BPT.
AO CLINIC - Institute of Trauma & Orthopaedics, United Kingdom 483 cases of neglected/maltreated long bone fractures were seen over the last 4 years. 60 of these cases were humeral fractures that required attention and surgical intervention. Humeral revision trauma cases are particularly interesting and the most challenging of long bone neglected fractures due to the close proximity of neurovascular structures especially when they get entangled within the fibrous tissue which forms due to weeks/years of neglect after the initial erroneous management. In this presentation, we cover our principles of management for these complex cases and our results are very encouraging, with one re-infection after revision surgery and no non-unions. All of these infected patients had their external fixators or their IM nail removed and were then treated with a compression plate and autologous bone graft. One patient had his IM humeral fibula removed and also replaced with a compression plate and achieved full bony union. Conclusion: Plating for infected malunited/non united humeral fractures gives predictable excellent results as long as infection is controlled appropriately before embarking on revision trauma surgery.