Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip: a randomised trial of 600 fractures.

In a randomised trial involving 598 patients with 600 trochanteric fractures of the hip, the fractures were treated with either a sliding hip screw (n = 300) or a Targon PF intramedullary nail (n = 300). The mean age of the patients was 82 years (26 to 104). All surviving patients were reviewed at one year with functional outcome assessed by a research nurse blinded to the treatment used. The intramedullary nail was found to have a slightly increased mean operative time (46 minutes (sd 12.3) versus 49 minutes (sd 12.7), p < 0.001) and an increased mean radiological screening time (0.3 minutes (sd 0.2) versus 0.5 minutes (sd 0.3), p < 0.001). Operative difficulties were more common with the intramedullary nail. There was no statistically significant difference between implants for wound healing complications (p = 1), or need for post-operative blood transfusion (p = 1), and medical complications were similarly distributed in both groups. There was a tendency to fewer revisions of fixation or conversion to an arthroplasty in the nail group, although the difference was not statistically significant (nine versus three cases, p = 0.14). The extent of shortening, loss of hip flexion, mortality and degree of residual pain were similar in both groups. The recovery of mobility was superior for those treated with the intramedullary nails (p = 0.01 at one year from injury). In summary, both implants produced comparable results but there was a tendency to better return of mobility for those treated with the intramedullary nail.

Classification of subtrochanteric femoral fractures.

A review of the literature identified 15 different classification methods for subtrochanteric femoral fractures. Only eight of those classifications defined the area of bone, which constituted a subtrochanteric fracture. The actual length of femur defined as the subtrochanteric zone varied from 3 cm up to the level of the femoral isthmus. There was no agreement between the different classifications regarding the proximal and distal border or for those fractures, which traverse anatomical boundaries. In the various classifications, fractures were subdivided into 2-15 subgroups. The majority of the identified studies were unable to find the classifications useful in either determining treatment or predicting the outcome after treatment. We subdivided subtrochanteric fractures into three types based on the degree of fracture comminution. We examined the inter- and intra-observer agreement of our recommended classification. One orthopaedic consultant, one specialist hip fracture surgeon, two trainee registrar orthopaedic surgeons and one specialty trainee in orthopaedics, on two different occasions, 8 weeks apart, independently classified the radiographs of 20 patients with a subtrochanteric fracture. The mean kappa value for inter- and intra-observer variation was 0.71 and 0.79, respectively, with both showing substantial agreement and, therefore, this simpler classification is recommended. Based on the review of previous classification methods, we also recommend that the subtrochanteric zone be defined as the one in which the fracture line crossing the femur is predominantly within the area of bone extending 5 cm below the lower border of the lesser trochanter.

Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients.

A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail.

11-year results in 2,846 patients of the Peterborough Hip Fracture Project: reduced morbidity, mortality and hospital stay.

3,025 consecutive patients presenting over an 11-year period with an acute hip fracture were prospectively studied to determine the effectiveness of a designated hip fracture service. After the introduction of the service, the mean length of hospital stay per patient was reduced from 51 days to 21 days. This reduction was accomplished by a progressive increase in the proportion of patients discharged directly home from the admission ward (50%-86%) and a reduction in the numbers of patients transferred to care of the elderly wards (28%-6%) and other outlying wards (15%-3%). This change was accompanied by a reduction in the 30-day mortality rate from 22% to 7%. There was no significant increase in the re-admission rate or proportion of patients requiring institutional care. We conclude that the provision of designated staff and treatment regimes for hip fracture patients can result in a significant reduction in both mortality and morbidity, combined with substantial savings in patient bed-days.

Internal fixation or arthroplasty for displaced cervical hip fractures in the elderly: a randomised controlled trial of 208 patients.

208 patients aged over 70 years with a displaced cervical hip fracture were admitted to a prospective randomised trial of internal fixation using 3 parallel cannulated screws or an uncemented Austin Moore hemiarthroplasty. All surviving patients were followed for a minimum of 3 years. Functional assessment of survivors at 1, 2 and 3 years from injury showed no significant difference between groups. Patients treated by the fixation had a marginally lower mortality rate. Other outcomes which favoured internal fixation were a lower risk of wound infection, reduced length of surgery (22 minutes versus 47 minutes), lower operative blood loss (23 mL versus 172 mL), and lower transfusion requirements (4/102 patients versus 18/106). However, internal fixation had a significantly greater re-admission rate (24/102 versus 7/106) and re-operation rate. Following internal fixation, 44 re-operations were required in 36 patients, while re-operation was required in only 4 patients treated with arthroplasty. The results of this randomised trial indicate that both procedures produce comparable final functional outcomes for the survivors.

Assessment of the AO classification of intracapsular fractures of the proximal femur.

There are a number of classification systems for intracapsular fractures of the proximal femur, but none has been shown to be practical with satisfactory reproducibility and accurate predictive value. We have investigated the AO classification and evaluated intra- and interobserver accuracy and its value in predicting treatment and outcome. We found it to have very poor intra- and interobserver reliability and to be of limited predictive use for the outcome of treatment. A simplified system in which the subdivisions were allocated to one of three groups of undisplaced, displaced and basal fractures was found to be of value. We conclude that this is the only division which is appropriate for these fractures and that the AO system for intracapsular fractures is too complicated and should not be used.

Delayed diagnosis of femoral neck fractures.

To determine the causes and consequences of any delay from the onset of symptoms to diagnosis, 1108 consecutive patients with an acute proximal femoral fracture were prospectively studied. In 154 cases (13.9 per cent) the diagnosis was delayed more than 24 h from the onset of symptoms. The reason for this was due to failure to seek medical help in 63 patients. For the 91 patients who were seen by a medical practioner, 60 were not X-rayed straight away. For those cases where a radiographic examination was requested, the fracture was invisible in only nine cases, of which six subsequently displaced. The diagnosis was more likely to be delayed if the fracture occurred spontaneously, the patient fell inside, or the fracture was intracapsular. Delay in diagnosis was not associated with an increase in mortality but there was a significant increase in the risk of pressure sores.

Subtrochanteric fractures of the femur.

A consecutive series of 103 patients with a subtrochanteric fracture were prospectively studied. Ten patients were treated non-operatively, whilst the other 93 had operative treatment. The overall fixation failure rate was 12 per cent with a re-operation rate of 6 per cent by 1 year. There were six (8 per cent) failures of fixation for the 74 fractures treated with the sliding hip screw. No method of fracture classification was demonstrated to be of value in predicting either the choice of treatment or the risk of fracture healing complications. Either intramedullary nailing or extramedullary fixation with a dynamic hip screw appear to give the best results for subtrochanteric fractures.

Environmental hazards and hip fractures.

The type of environmental hazards implicated in the aetiology of a consecutive series of 787 hip-fracture patients was prospectively studied. Most falls occurred between 09 h 00 and midday and there was no seasonal variation. Fifty-one different environmental hazards were implicated in the aetiology of the fall for 58% of patients. The nature of environmental hazards was diverse, implying that measures to reduce the risk of falls due to these factors are unlikely to lead to a significant reduction in the incidence of hip fractures.

Gamma versus DHS nailing for extracapsular femoral fractures. Meta-analysis of ten randomised trials.

A meta-analysis has been carried out of all published randomised trials which compare the gamma with the DHS nail, giving in a total of 1794 patients with extracapsular femoral fractures. Results showed that the Gamma nail had a significantly increased risk of fracture of the femoral shaft and an increased reoperation rate. There was no difference in the lag screw cut-out rates, incidence of wound infection or length of stay in hospital. The gamma nail cannot be recommended for routine use in trochanteric fractures until the problem of femoral shaft fracture is resolved.

The value of a special surgical team in preventing complications in the treatment of hip fractures.

The incidence of the major complications of operation have been studied prospectively in 1,722 patients with a proximal femoral fracture treated by either insertion of a hemiarthroplasty, internal fixation with a Dynamic Hip Screw (DHS) or multiple parallel screws. Major complications occurred in 8.0%. A special surgical "Hip Fracture Team" reduced the incidence of major complications from 12.5% to 5.0%. The most significant benefit from employment of the special team was in reducing the incidence of wound sepsis and of failure of fixation following the operative management of displaced intracapsular and extracapsular fractures. Assigning hip fracture surgery to designated personell will result in a significant reduction in morbidity.

Mortality and morbidity after hip fractures.

OBJECTIVE: To study the mortality and morbidity associated with proximal femoral fractures with reference to fracture type (intracapsular and extracapsular). DESIGN: Consecutive prospective study with 12 month follow ups. SETTING: Two British trauma receiving centres. PATIENTS: 1000 consecutive acute proximal femoral fractures (fractured necks of femur) in 972 patients. RESULTS: Significantly higher mortality at one year was seen in patients with extracapsular fractures (188/490; 38%) than in those with intracapsular fractures (147/510; 29%; p < 0.01). Greater morbidity was experienced during the study period by patients with extracapsular fractures, who were less mobile and less independent at the time of their injury. CONCLUSIONS: The rise in average age of presentation with proximal femoral fracture is associated with a persistently high mortality (33%) and morbidity, greater in patients with an extracapsular fracture. Comparison with other studies, principally from outside Britain, is difficult, but despite advancing standards of care the mortality and morbidity of femoral neck fractures remains high, placing an ever increasing burden on the health service.

Treatment of undisplaced subcapital fractures.

A total of 157 patients with undisplaced subcapital fractures was studied with reference to outcome depending on the method of treatment; 135 were treated surgically and 22 were treated conservatively. The main complication of treatment was non-union, with an overall incidence of 5.7%. Conservative treatment resulted in an incidence of non-union which was approximately twice that of patients who were treated surgically. Patients treated surgically, however, had significant postoperative complications in 14.8% of cases. Although conservative treatment has an increased incidence of non-union, it is a safe method of treatment and we feel it still has a place in selected patients.

The timing of surgery for proximal femoral fractures.

We studied prospectively a consecutive series of 765 patients with proximal femoral fractures to determine if the time interval between injury and surgery influenced the outcome. Patients in whom surgery had been delayed for medical reasons were excluded. We divided the patients into four groups depending on the delay to surgery. Analysis of pre- and postoperative characteristics showed the groups to be similar. Mortality in the four groups was not significantly different but morbidity was increased by delay, particularly with regard to the incidence of pressure sores.

A comparison of presenting characteristics of patients with intracapsular and extracapsular proximal femoral fractures.

The presenting characteristics of 1423 consecutive admissions with proximal femoral fractures were prospectively studied, to determine any differences that may exist between patients, dependent on the radiological site of the fracture. Patients with intracapsular fractures were of a lower average age, more mobile, less likely to use walking aids or live in residential accommodation, they also had a considerably shorter length of hospital stay than for those patients with extracapsular fractures. Comparison against previous series shows that the average age of hip fracture patients and the proportion of trochanteric fractures is increasing.

Early discharge after hip fracture. Prospective 3-year study of 645 patients.

The effectiveness of providing additional community resources to enable early discharge following hip fracture surgery has been prospectively evaluated in a consecutive series of 645 patients. For those discharged under the scheme, the average hospital stay was 9.3 days, and this resulted in a substantial saving of hospital bed days.