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Predictors of the risk of postopertaive blood transfusion in hip fractures
Abstracts / Injury Extra 43 (2013) 71–127
records, clinic letters and radiographs were reviewed for any further surgical intervention. Results: A total of 341 cannulated hip screws were performed, 18.5% (63 patients) required early reintervention and the overall 90 day mortality was 7.9% (26 patients). The initial Garden classification had a significant effect (p = 0.000) with 31.8% (20 patients) of type IV compared to 4.8% (3 patients) of type I fractures requiring reintervention. Both age (p = 0.026) and successful fracture reduction (p = 0.001) were also shown to be significant factors. The number of screws, their orientation and position in the femoral neck were not shown to have a significant effect on outcome. Conclusion: We have shown that key factors for a successful outcome following cannulated hip screws are a young patient, low grade of initial displacement and good reduction. Our results did not reveal any significance to either the number of screws or their configuration. http://dx.doi.org/10.1016/j.injury.2012.07.294 [2B.22] Analysis of total hip arthroplasty for displaced intracapsular neck of femur fractures in a tertiary referral trauma centre Z. Gamie ∗ , J. Neale, D. Shields, J. Claydon, S. Hazarika, A. Gray Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, United Kingdom Purposes: Recent NICE guidelines suggest that Total Hip Arthroplasty (THA) be offered to all patients with a displaced intracapsular neck of femur fracture who: are able to walk independently; not cognitively impaired and are medically fit for the anaesthesia and procedure. Methods and results: A retrospective review of data collected between Jan 2009–Nov 2011 on all displaced intracapsular neck of femur fractures admitted to a single tertiary referral orthopaedic trauma unit. Data was analysed to determine if patients meeting NICE criteria received a THA. Case notes and radiographs were then reviewed to obtain outcome and complication rates after surgery. 638 patients were admitted with a displaced intracapsular neck of femur fracture over the described time period. 79 patients met the NICE criteria to receive a THA (mean age 74 years, M:F = 16:49); however, only 27 patients had a THA. The other patients received either a cemented Thompson or bipolar hemiarthroplasty. Within the THA cohort there were no episodes of dislocation, venous thromboembolism, significant wound complications or infections that required further surgery. Within the hemiarthroplasty cohort there was 2 mortalities, 2 implant related infections, 3 dislocations and 1 loosening. Of these complications, 3 required revision to a THA. Conclusion: The relative number of THAs performed for displaced intracapsular neck of femur fractures in cognitively intact and previously independently mobile patients admitted to our unit was low and below the current standards set by NICE. Although there is an increasing awareness and published evidence to support improved levels of pain and function after THA in well selected patients, time and resource issues may have caused bias and increased the threshold for the more extensive and technically demanding procedure. There is a need to optimise and improve infrastructure, time and resource to cope with the increased demand for THA after neck of femur fractures. http://dx.doi.org/10.1016/j.injury.2012.07.295
105
[2B.23] Can we justify uncemented hemiarthroplasties? Outcome of 356 consecutive titanium hydroxyapatite coated uncemented stem hemiarthroplasties A. Keightley ∗ , J. Granville-Chapman, C. Bruce, A. Khaleel St. Peter’s Hospital, Chertsey, United Kingdom Aim: To review outcome measures (mortality and revision surgery) in a prospective series of uncemented HAC stem hemiarthroplasties. A Cochrane review influenced new NICE guidelines, which recommended surgeons: ‘Offer cemented implants to patients undergoing surgery with arthroplasty’. However our trust routinely uses HAC uncemented stem (Taperloc® , Biomet) hemiarthroplasties. No HAC uncemented stem studies were analyzed within this Cochrane review. One Randomised Controlled Trial has compared a HAC stem (Corail® ) with a cemented stem (Spectron® ) hemiarthroplasty. This revealed no difference in measured outcomes at one year. Another series of 480 patients, received Furlong HAC LOL® (JRI) hemiarthroplasty. At four years, 88% had slight or no pain and 89% walked independently, or with only a stick. Methods: A series of consecutive uncemented hip hemiarthroplasties were entered prospectively into database between 01 Jan 2008 and 07 Jan 2011. Outcome data were gathered from electronic medical records; radiographs and notes review. Results: 356 consecutive hemiarthroplasties were performed in 344 patients, with 18 month (1–37) follow-up. 356 Taperloc stems were inserted. Mean age 83 years; 71% female. Mean post-operative hospital stay (including in-patient rehabilitation) was 22 (3–153) days. Mean time to operation was 50 h (reduced to 36.7 h since 01 Apr 2010). 30-day mortality: 4.4% (16/356). One-year mortality: 17.5% (45/257). Ipsilateral further surgery: 4.7% (17/356). The stem was removed or revised in 11 of 17 reoperations. Conversion to THR: 2.2% (8/356). Conclusion: Cemented hemiarthroplasty is associated with a 25% one-year mortality; 5.3% further surgery rate and 3% conversion rate to THR (follow-up 3.7 years) (5). Although our follow-up period is shorter, our results are comparable with these and other data (6;7). We believe that uncemented proven stem design hemiarthroplasty remains a safe and reasonable surgical option for displaced intracapsular fractures. http://dx.doi.org/10.1016/j.injury.2012.07.296 [2B.24] Predictors of the risk of postopertaive blood transfusion in hip fractures Z.A. Alshameeri ∗ , M. Derias, P. Williams Chesterfield Royal Hospital, United Kingdom Introduction: The aim was to find out the rate of blood transfusion, the triggering Haemoglobin (Hb) level for transfusion, and the associated predictive factors in the hope of selectively crosshatching the patients who are more likely to need transfusion and reduce transfusion rate. Method: This was a prospective study over three month’s period. Information relating to the fracture type, the method of operative treatment, preoperative (Preop) and postoperative (Postop) Hb and transfusion were recorded. Results: 98 cases were included. 55% had intercapsular fractures the rest (45%) were extracapsular. The surgical treatment involved; 44% hemiarthroplasties, 45% Dynamic hip screws (DHS) and 10% cannulated screws. Mean Preop and Post op Hb was 12.3 and 9.7
106
Abstracts / Injury Extra 43 (2013) 71–127
respectively. 22% had post operative transfusion with a mean Preop and Postop Hb of 10.9 and 7.4, respectively. The triggering Hb level for transfusion was 7.9. Extra capsular fractures and DHS were associated with the highest average in Hb Drop (of 2.9) and higher transfusion rate (36%, p < 0.01). However these patients also had a lower Hb on admission (p = 0.02). Conclusion: A combination of low Hb on admission and extra capsular fractures treated with DHS were associated with the highest post operative transfusion rate in hip fractures. However the interoperative blood loss in the hemiarthroplasty and the DHS group was similar, suggesting that the preoperative Hb is more important in determining the risk of post operative transfusion and this therefore may permit selective crosshatching for these patients. Nevertheless we should not underestimate the impact of reducing blood loss during surgery on the transfusion rate. http://dx.doi.org/10.1016/j.injury.2012.07.297 [2B.25] Acute vs delayed operative intervention in acute clavicle fractures: A comparative case series B.J. Ollivere ∗ , K.E. Rollins, A. Das, P. Johnston, L. van Rensburg, G.M. Tytherleigh-Strong Addenbrooke’s Hospital, Cambridge, United Kingdom Purpose: The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation. Methods: Between August 2006 and May 2010, 97 patients were managed with operative fixation for their clavicular fracture. Sixty eight with initial fixation and 29 delayed fixation for clavicular non- or mal-union. Patients were prospectively followed up to radiographic union, and outcomes were measured with the Oxford Shoulder Score, QuickDASH, EQ5D and a patient interview. Mean follow-up was to 30 months. All patients were managed with Acumed anatomical clavicular plates. Results: The radiographic and clinical outcomes were available for all patients. Scores were available for 62 (62/97). There were no statistically significant differences in age (p > 0.05), sex (p > 0.05), energy of injury (p > 0.05), number of open fractures (p > 0.05) between the two groups. The mean quickDASH was 8.9 early, 9.1 delayed (p < 0.05), Oxford Shoulder score was 15.7 early, 16.1 delayed (p < 0.05). In the early fixation group 5 patients had wound healing complications, and 8 went on subsequently to have removal of prominent metalwork. In the delayed fixation group 2 had wound healing complications and 4 had removal of prominent metalwork. There were no statistically significant differences in the EQ5D quality of life questionnaire. Conclusion: There are no statistically significant differences in shoulder performance, wound or operative complications between early and delayed fixation of clavicular fractures. Our series does not support early fixation of clavicular fractures, as results. http://dx.doi.org/10.1016/j.injury.2012.07.298
[2B.26] Union rates following proximal scaphoid fractures: Metaanalyses and review of available evidence N. Eastley 1,∗ , H.P. Singh 1 , N. Taub 2 , J.J. Dias 1 1
Leicester General Hospital, University Hospitals of Leicester NHS Trust, United Kingdom 2 Division of Orthopaedic Surgery, Department of Health Sciences, University of Leicester, United Kingdom A meta-analysis to calculate the relative risk of nonunion for acute proximal scaphoid fractures managed nonoperatively compared with acute fracture elsewhere in the scaphoid, combined with a literature review to investigate union following operative and non-operative management, and the current surgical techniques available. Electronic databases were searched for relevant articles. Titles and abstracts highlighted were reviewed with their bibliographies, and relevant articles obtained for full text review. Authors’ assorted definitions of the scaphoid’s proximal pole and union were accepted. Our search yielded 82 potential publications, of which eleven met eligibility criteria. Three of these studies investigated union after surgery and eight reported union after non-operative management. 1147 non-operatively managed acute scaphoid fractures were analysed. Of these 67 (5.8%) involved the proximal pole. Meta-analysis revealed a relative risk of non-union of 7.5 for proximal fractures managed non-operatively compared with fractures elsewhere in the bone also managed non-operatively (95% CI 4.9–11.5, p < 0.001). Comparison of operatively and nonoperatively managed acute proximal fractures was attempted, but too few operative studies were available. There is little published on the management of acute proximal scaphoid fractures. Worry of avascular necrosis has led to a tendency towards early surgical fixation. We performed a metaanalysis comparing union rates of non-operatively managed acute proximal pole scaphoid fractures with acute fractures elsewhere in the scaphoid to investigate the magnitude of nonunion. Our new data highlights a clear association between acute proximal scaphoid fractures and non-union shown by the pooled odds ratio calculated. Current literature suggests surgical management of acute proximal fractures may reduce this risk. Retrograde compression screw fixation following open or percutaneous K-wire stabilisation appears a safe technique for such cases. Future work should compare union of acute proximal pole fractures when managed surgically and conservatively. http://dx.doi.org/10.1016/j.injury.2012.07.299 [2B.27] Upper limb non-union treated with BMP-7: Efficacy and clinical results R. Singh ∗ , N. Khan, N. Kanakaris, P.V. Giannoudis Leeds General Infirmary, United Kingdom
Introduction: During impaired bone healing when biological enhancement is desired, besides autologous iliac crest bone grafting other options including the implantation of growth factors have been described in the literature. Objectives: The aim of this study is to present our institutional experience of using human recombinant osteogenic protein-1 (rhBMP-7) in the treatment of upper limb non-unions. Methods: Between 2001 and 2011 all consecutive patients within our institution, which were operated upon with the application of rhBMP-7 were followed up prospectively. Demographic
records, clinic letters and radiographs were reviewed for any further surgical intervention. Results: A total of 341 cannulated hip screws were performed, 18.5% (63 patients) required early reintervention and the overall 90 day mortality was 7.9% (26 patients). The initial Garden classification had a significant effect (p = 0.000) with 31.8% (20 patients) of type IV compared to 4.8% (3 patients) of type I fractures requiring reintervention. Both age (p = 0.026) and successful fracture reduction (p = 0.001) were also shown to be significant factors. The number of screws, their orientation and position in the femoral neck were not shown to have a significant effect on outcome. Conclusion: We have shown that key factors for a successful outcome following cannulated hip screws are a young patient, low grade of initial displacement and good reduction. Our results did not reveal any significance to either the number of screws or their configuration. http://dx.doi.org/10.1016/j.injury.2012.07.294 [2B.22] Analysis of total hip arthroplasty for displaced intracapsular neck of femur fractures in a tertiary referral trauma centre Z. Gamie ∗ , J. Neale, D. Shields, J. Claydon, S. Hazarika, A. Gray Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, United Kingdom Purposes: Recent NICE guidelines suggest that Total Hip Arthroplasty (THA) be offered to all patients with a displaced intracapsular neck of femur fracture who: are able to walk independently; not cognitively impaired and are medically fit for the anaesthesia and procedure. Methods and results: A retrospective review of data collected between Jan 2009–Nov 2011 on all displaced intracapsular neck of femur fractures admitted to a single tertiary referral orthopaedic trauma unit. Data was analysed to determine if patients meeting NICE criteria received a THA. Case notes and radiographs were then reviewed to obtain outcome and complication rates after surgery. 638 patients were admitted with a displaced intracapsular neck of femur fracture over the described time period. 79 patients met the NICE criteria to receive a THA (mean age 74 years, M:F = 16:49); however, only 27 patients had a THA. The other patients received either a cemented Thompson or bipolar hemiarthroplasty. Within the THA cohort there were no episodes of dislocation, venous thromboembolism, significant wound complications or infections that required further surgery. Within the hemiarthroplasty cohort there was 2 mortalities, 2 implant related infections, 3 dislocations and 1 loosening. Of these complications, 3 required revision to a THA. Conclusion: The relative number of THAs performed for displaced intracapsular neck of femur fractures in cognitively intact and previously independently mobile patients admitted to our unit was low and below the current standards set by NICE. Although there is an increasing awareness and published evidence to support improved levels of pain and function after THA in well selected patients, time and resource issues may have caused bias and increased the threshold for the more extensive and technically demanding procedure. There is a need to optimise and improve infrastructure, time and resource to cope with the increased demand for THA after neck of femur fractures. http://dx.doi.org/10.1016/j.injury.2012.07.295
105
[2B.23] Can we justify uncemented hemiarthroplasties? Outcome of 356 consecutive titanium hydroxyapatite coated uncemented stem hemiarthroplasties A. Keightley ∗ , J. Granville-Chapman, C. Bruce, A. Khaleel St. Peter’s Hospital, Chertsey, United Kingdom Aim: To review outcome measures (mortality and revision surgery) in a prospective series of uncemented HAC stem hemiarthroplasties. A Cochrane review influenced new NICE guidelines, which recommended surgeons: ‘Offer cemented implants to patients undergoing surgery with arthroplasty’. However our trust routinely uses HAC uncemented stem (Taperloc® , Biomet) hemiarthroplasties. No HAC uncemented stem studies were analyzed within this Cochrane review. One Randomised Controlled Trial has compared a HAC stem (Corail® ) with a cemented stem (Spectron® ) hemiarthroplasty. This revealed no difference in measured outcomes at one year. Another series of 480 patients, received Furlong HAC LOL® (JRI) hemiarthroplasty. At four years, 88% had slight or no pain and 89% walked independently, or with only a stick. Methods: A series of consecutive uncemented hip hemiarthroplasties were entered prospectively into database between 01 Jan 2008 and 07 Jan 2011. Outcome data were gathered from electronic medical records; radiographs and notes review. Results: 356 consecutive hemiarthroplasties were performed in 344 patients, with 18 month (1–37) follow-up. 356 Taperloc stems were inserted. Mean age 83 years; 71% female. Mean post-operative hospital stay (including in-patient rehabilitation) was 22 (3–153) days. Mean time to operation was 50 h (reduced to 36.7 h since 01 Apr 2010). 30-day mortality: 4.4% (16/356). One-year mortality: 17.5% (45/257). Ipsilateral further surgery: 4.7% (17/356). The stem was removed or revised in 11 of 17 reoperations. Conversion to THR: 2.2% (8/356). Conclusion: Cemented hemiarthroplasty is associated with a 25% one-year mortality; 5.3% further surgery rate and 3% conversion rate to THR (follow-up 3.7 years) (5). Although our follow-up period is shorter, our results are comparable with these and other data (6;7). We believe that uncemented proven stem design hemiarthroplasty remains a safe and reasonable surgical option for displaced intracapsular fractures. http://dx.doi.org/10.1016/j.injury.2012.07.296 [2B.24] Predictors of the risk of postopertaive blood transfusion in hip fractures Z.A. Alshameeri ∗ , M. Derias, P. Williams Chesterfield Royal Hospital, United Kingdom Introduction: The aim was to find out the rate of blood transfusion, the triggering Haemoglobin (Hb) level for transfusion, and the associated predictive factors in the hope of selectively crosshatching the patients who are more likely to need transfusion and reduce transfusion rate. Method: This was a prospective study over three month’s period. Information relating to the fracture type, the method of operative treatment, preoperative (Preop) and postoperative (Postop) Hb and transfusion were recorded. Results: 98 cases were included. 55% had intercapsular fractures the rest (45%) were extracapsular. The surgical treatment involved; 44% hemiarthroplasties, 45% Dynamic hip screws (DHS) and 10% cannulated screws. Mean Preop and Post op Hb was 12.3 and 9.7
106
Abstracts / Injury Extra 43 (2013) 71–127
respectively. 22% had post operative transfusion with a mean Preop and Postop Hb of 10.9 and 7.4, respectively. The triggering Hb level for transfusion was 7.9. Extra capsular fractures and DHS were associated with the highest average in Hb Drop (of 2.9) and higher transfusion rate (36%, p < 0.01). However these patients also had a lower Hb on admission (p = 0.02). Conclusion: A combination of low Hb on admission and extra capsular fractures treated with DHS were associated with the highest post operative transfusion rate in hip fractures. However the interoperative blood loss in the hemiarthroplasty and the DHS group was similar, suggesting that the preoperative Hb is more important in determining the risk of post operative transfusion and this therefore may permit selective crosshatching for these patients. Nevertheless we should not underestimate the impact of reducing blood loss during surgery on the transfusion rate. http://dx.doi.org/10.1016/j.injury.2012.07.297 [2B.25] Acute vs delayed operative intervention in acute clavicle fractures: A comparative case series B.J. Ollivere ∗ , K.E. Rollins, A. Das, P. Johnston, L. van Rensburg, G.M. Tytherleigh-Strong Addenbrooke’s Hospital, Cambridge, United Kingdom Purpose: The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation. Methods: Between August 2006 and May 2010, 97 patients were managed with operative fixation for their clavicular fracture. Sixty eight with initial fixation and 29 delayed fixation for clavicular non- or mal-union. Patients were prospectively followed up to radiographic union, and outcomes were measured with the Oxford Shoulder Score, QuickDASH, EQ5D and a patient interview. Mean follow-up was to 30 months. All patients were managed with Acumed anatomical clavicular plates. Results: The radiographic and clinical outcomes were available for all patients. Scores were available for 62 (62/97). There were no statistically significant differences in age (p > 0.05), sex (p > 0.05), energy of injury (p > 0.05), number of open fractures (p > 0.05) between the two groups. The mean quickDASH was 8.9 early, 9.1 delayed (p < 0.05), Oxford Shoulder score was 15.7 early, 16.1 delayed (p < 0.05). In the early fixation group 5 patients had wound healing complications, and 8 went on subsequently to have removal of prominent metalwork. In the delayed fixation group 2 had wound healing complications and 4 had removal of prominent metalwork. There were no statistically significant differences in the EQ5D quality of life questionnaire. Conclusion: There are no statistically significant differences in shoulder performance, wound or operative complications between early and delayed fixation of clavicular fractures. Our series does not support early fixation of clavicular fractures, as results. http://dx.doi.org/10.1016/j.injury.2012.07.298
[2B.26] Union rates following proximal scaphoid fractures: Metaanalyses and review of available evidence N. Eastley 1,∗ , H.P. Singh 1 , N. Taub 2 , J.J. Dias 1 1
Leicester General Hospital, University Hospitals of Leicester NHS Trust, United Kingdom 2 Division of Orthopaedic Surgery, Department of Health Sciences, University of Leicester, United Kingdom A meta-analysis to calculate the relative risk of nonunion for acute proximal scaphoid fractures managed nonoperatively compared with acute fracture elsewhere in the scaphoid, combined with a literature review to investigate union following operative and non-operative management, and the current surgical techniques available. Electronic databases were searched for relevant articles. Titles and abstracts highlighted were reviewed with their bibliographies, and relevant articles obtained for full text review. Authors’ assorted definitions of the scaphoid’s proximal pole and union were accepted. Our search yielded 82 potential publications, of which eleven met eligibility criteria. Three of these studies investigated union after surgery and eight reported union after non-operative management. 1147 non-operatively managed acute scaphoid fractures were analysed. Of these 67 (5.8%) involved the proximal pole. Meta-analysis revealed a relative risk of non-union of 7.5 for proximal fractures managed non-operatively compared with fractures elsewhere in the bone also managed non-operatively (95% CI 4.9–11.5, p < 0.001). Comparison of operatively and nonoperatively managed acute proximal fractures was attempted, but too few operative studies were available. There is little published on the management of acute proximal scaphoid fractures. Worry of avascular necrosis has led to a tendency towards early surgical fixation. We performed a metaanalysis comparing union rates of non-operatively managed acute proximal pole scaphoid fractures with acute fractures elsewhere in the scaphoid to investigate the magnitude of nonunion. Our new data highlights a clear association between acute proximal scaphoid fractures and non-union shown by the pooled odds ratio calculated. Current literature suggests surgical management of acute proximal fractures may reduce this risk. Retrograde compression screw fixation following open or percutaneous K-wire stabilisation appears a safe technique for such cases. Future work should compare union of acute proximal pole fractures when managed surgically and conservatively. http://dx.doi.org/10.1016/j.injury.2012.07.299 [2B.27] Upper limb non-union treated with BMP-7: Efficacy and clinical results R. Singh ∗ , N. Khan, N. Kanakaris, P.V. Giannoudis Leeds General Infirmary, United Kingdom
Introduction: During impaired bone healing when biological enhancement is desired, besides autologous iliac crest bone grafting other options including the implantation of growth factors have been described in the literature. Objectives: The aim of this study is to present our institutional experience of using human recombinant osteogenic protein-1 (rhBMP-7) in the treatment of upper limb non-unions. Methods: Between 2001 and 2011 all consecutive patients within our institution, which were operated upon with the application of rhBMP-7 were followed up prospectively. Demographic