Hip Hemi-Arthroplasty vs Total Hip Replacement for Displaced Intra-Capsular Hip Fractures: Retrospective Age and Sex Matched Cohort Study.

INTRODUCTION: The Royal Victoria Hospital in Belfast is the largest volume hospital in the UK Hip Fracture Database. Management of displaced intra-capsular hip fractures is evolving in light of NICE2 and BOA guidelines3, with more patients receiving total hip replacement (THR) over hemi-arthroplasty. With current rationing within the NHS, it is vital that principles of the 'Getting It Right First time' (GIRFT) report4 are implemented and the correct treatment choice made. Our aim was to assess Barthel scores5, complication rate, blood transfusion rate and post op functional ability in two age and sex matched cohorts to see if our patient selection was appropriate. METHODS: Between January and December 2013, 2 age and sex matched cohorts each containing 46 hip fracture patients were retrospectively identified. The first group underwent Hip Hemi-Arthroplasty (HHA) and the second group underwent THR. We looked at complication rate, blood transfusion rate, pre- and post-operative locomotor ability as well as Barthel score5. RESULTS: Average age in the HHA group was 69.7 with an average ASA grade of 2.61, compared to 71.2 and 2.43 respectively in the THR group. Complication rate in the HHA group was 45.6% with 2/3 due to chest sepsis or urosepsis. The THR group had a complication rate of 8.7% with 3/4 due to venous thrombembolism, reflecting the better pre-morbid physiological function in this cohort. Blood transfusion rates were similar in both groups. Barthel scores5 showed average reductions of 2.67 in the HHA group and 0.30 in the THR group. CONCLUSIONS: The application of the NICE guidelines2 for arthroplasty choice in hip fracture management has led to judicious patient selection for THR. The THR group had a significantly lower complication rate (p<0.05) and better Barthel scores5 (p<0.05) compared to the HHA group. In addition, having a higher ASA score (III or IV) or lower Barthel score5 pre-operatively were independent predictors of complication occurrence.

Atraumatic Pantalar Avascular Necrosis in a Patient With Alcohol Dependence.

In the United States, an estimated 10,000 to 20,000 new cases of avascular necrosis are diagnosed each year. We present an unusual case of atraumatic avascular necrosis with widespread hindfoot and midfoot involvement. A 62-year-old female with a history of alcohol dependence and smoking, who had previously been treated for avascular necrosis of the knee, presented with right-sided foot pain and difficulty weightbearing. Imaging studies revealed extensive avascular necrosis of the hindfoot and midfoot, which precluded simple surgical intervention. The patient was followed up for 18 months. In the last 8 months of the 18-month period, the patient managed her symptoms using an ankle-foot orthosis. A diagnosis of avascular necrosis should be considered in patients with atraumatic foot and ankle pain, especially in the presence of risk factors such as alcohol excess and smoking.