New NHS Prehospital Major Incident Triage Tool: from MIMMS to MITT.

Triage is a key principle in the effective management of major incidents and is the process by which patients are prioritised on the basis of their clinical acuity. However, work published over the last decade has demonstrated that existing methods of triage perform poorly when trying to identify patients in need of life-saving interventions. As a result, a review of major incident triage was initiated by NHS England with the remit to determine the optimum way in which to triage patients of all ages in a major incident for the UK. This article describes the output from this review, the changes being undertaken to UK major incident triage and the introduction of the new NHS Major Incident Triage Tool from the Spring of 2023.

Implant and patient survival rates using Exeter Trauma Stem hemiarthroplasty in fracture neck of femur patients: The largest study to date.

INTRODUCTION: Exeter Trauma Stems (ETS) femoral hemiarthroplasties are based on Exeter THR stems with a few design changes. Little has been published on ETS survival rates to justify their high cost compared to other cheaper implants. This is the largest prospective study to assess ETS implant failure-free survival rates in fracture neck of femur patients (NOF). This non-developing-centre study examined whether these design differences have altered implant survival (compared with Exeter THR's published survival data). METHODS: Data were prospectively collected by independent audit officers. Dislocation, periprosthetic fracture, re-admission with severe hip pain, deep infection and revision surgery were considered events of interest in implant failure-free survival. RESULTS: This study assessed 1,123 ETS stems (36 patients received bilateral ETS) in NOF patients. The mean patient age at the time of operation was 83 years (range; 49 - 102 years). The mean observation period was 2.5 years (range; 0 days - 8 years). Only 29 implants failed. All failure events were reported within the first year. Stem failure-free survival was 97.2% at eight years (CI 95.9% - 98%). Dislocation occurred in 10 patients (1%), periprosthetic femoral fracture in 4 (0.4%), and deep infection in 11 patients (1.2%). Patient survival rates were 75% and 48% at one and five years respectively. CONCLUSION: ETS has high implant failure-free survival rates when used in hip fractures. ETS design changes have not altered ETS survival when used in hip fractures compared with the published literature of Exeter THR stem when used as a treatment for OA. Exeter Trauma Stems in NOF patients might last these elderly patients their entire short lifetime.

Surgical Stabilization Improves 30-day Mortality in Patients With Traumatic Flail Chest: A Comparative Case Series at a Major Trauma Center.

OBJECTIVES: To evaluate the outcomes including early mortality after surgical rib fixation using a locking plate system as part of a newly introduced chest trauma pathway. DESIGN: Prospective cohort study with retrospective case-controlled matching with a minimum of 1-year follow-up. SETTING: Regional Level 1 trauma center. PATIENTS/PARTICIPANTS: Consecutive patients undergoing surgical rib fixation were prospectively recruited over a 3-year period (56 patients) and matched to similar patients managed nonoperatively (89 patients) using our local trauma registry. Matching was based on injury severity scores and patient demographics. INTERVENTION: Surgical rib fixation with locking plates. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was 30-day mortality with secondary outcomes of hospital length of stay, intensive care unit length of stay, and patient-reported outcome measures including quality of life (EuroQol-EQ-5D-5L). Official causes of death were obtained from the coroner including postmortem results. RESULTS: There was a significant reduction in 30-day mortality in the fixed patients with 1.8% (1/56) compared to 12.4% (11/89) of the nonfixed patients (P = 0.03). This difference remained significant after further exclusion of other nonsurvivable injuries (P = 0.046). Although hospital length of stay was significantly longer in the fixed group, there was no difference on multivariable analysis. Other secondary outcomes were comparable between the groups with no significant differences in any patient-reported measures. CONCLUSIONS: Mortality was significantly lower in patients who underwent rib stabilization. Quality of life and other patient-reported measures were similar, demonstrating no evidence of detrimental longer-term effects of rib stabilization. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evolution of the hip fracture population: time to consider the future? A retrospective observational analysis.

OBJECTIVE: To examine how the population with fractured neck of femur has changed over the last decade and determine whether they have evolved to become a more physically and socially dependent cohort. DESIGN: Retrospective cohort study of prospectively collected Standardised Audit of Hip Fractures of Europe data entered on to an institutional hip fracture registry. PARTICIPANTS: 10 044 consecutive hip fracture admissions (2000-2012). SETTING: A major trauma centre in the UK. RESULTS: There was a generalised increase in the number of admissions between 2000 (n=740) and 2012 (n=810). This increase was non-linear and best described by a quadratic curve. Assuming no change in the prevalence of hip fracture over the next 20 years, our hospital is projected to treat 871 cases in 2020 and 925 in 2030. This represents an approximate year-on-year increase of just over 1%. There was an increase in the proportion of male admissions over the study period (2000: 174 of 740 admissions (23.5%); 2012: 249 of 810 admissions (30.7%)). This mirrored national census changes within the geographical area during the same period. During the study period there were significant increases in the numbers of patients admitted from their own home, the proportion of patients requiring assistance to mobilise, and the proportion of patients requiring help with basic activities of daily living (all p<0.001). There was also a twofold to fourfold increase in the proportion of patients admitted with a diagnosis of cardiovascular disease, renal disease, diabetes and polypharmacy (use of >4 prescribed medications; all p<0.001). CONCLUSIONS: The expanding hip fracture population has increasingly complex medical, social and rehabilitation care needs. This needs to be recognised so that appropriate healthcare strategies and service planning can be implemented. This epidemiological analysis allows projections of future service need in terms of patient numbers and dependency.

Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial.

BACKGROUND: The aim of this study was to compare the outcomes of displaced distal radial fractures treated with a volar locking plate with the results of such fractures treated with a conventional method of closed reduction and percutaneous wire fixation with supplemental bridging external fixation when required. Our aim was to ascertain whether the use of a volar locking plate improves functional outcomes. METHODS: A single-center, pragmatic, randomized controlled trial was conducted in a tertiary care institution. One hundred and thirty patients (eighteen to seventy-three years of age) who had a displaced distal radial fracture were randomized to treatment with either a volar locking plate (n = 66) or a conventional percutaneous fixation method (n = 64). Outcome assessments were conducted at six weeks, twelve weeks, and one year. Outcomes were measured on the basis of scores on the Patient Evaluation Measure (PEM) and QuickDASH questionnaire (a shortened version of the Disabilities of the Arm, Shoulder and Hand, or DASH, Outcome Measure), EuroQol-5D (EQ-5D) scores, wrist range of motion, grip strength, and radiographic parameters. RESULTS: The rate of follow-up at one year was 95%. Patients in the volar locking-plate group had significantly better PEM and QuickDASH scores and range of motion at six weeks compared with patients in the conventional-treatment group, but there were no significant differences between the two groups at twelve weeks or one year. Grip strength was better in the plate group at all time points. The volar locking plate was better at restoring palmar tilt and radial height. Significantly more patients in the plate group were driving at the end of six weeks, but this did not translate to a significant difference between groups in terms of those returning to work by that time. CONCLUSIONS: Use of a volar locking plate resulted in a faster early recovery of function compared with use of conventional methods. However, no functional advantage was demonstrated at or beyond twelve weeks. Use of the volar locking plate resulted in better anatomical reduction and grip strength, but there was no significant difference in function between the groups at twelve weeks or one year. The earlier recovery of function may be of advantage to some patients. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Nottingham Hip Fracture Score as a predictor of early discharge following fractured neck of femur.

BACKGROUND: hip fracture represents a huge medical, social and financial burden on patients, their carers and the health and social care systems. For survivors, return to their own home may be a key outcome. The Nottingham Hip Fracture Score (NHFS) is a validated score, based on admission characteristics, for predicting 30-day and 1-year mortality that may be of benefit in predicting return-to-home, directly from the acute orthopaedic ward. OBJECTIVE: to assess the utility of the NHFS as a predictor of return-to-home in patients following hip fracture. METHODS: the NHFS was calculated for all patients admitted from their own home and the correlation between the NHFS and eventual return-to-home was calculated, as well as the probability of discharge by within 7, 14 and 21 days. RESULTS: a total of 6,123 patients were available for analysis. Of which, 3,699 (60%) were discharged from acute hospital to their own home. Increasing NHFS was negatively correlated with eventual return-to-home (r(2) = 0.949) and with the proportion of patients discharged back to their own home at 7, 14 and 21 postoperative days, respectively (r(2) = 0.84, 0.94, 0.96, respectively). CONCLUSIONS: the NHFS is a reliable tool for predicting return-to-home. It may be useful for discharge planning, and for the design of future research trials.

Reverse oblique intertrochanteric femoral fractures treated with the intramedullary hip screw (IMHS).

AIMS: Recent studies have recommended the use of cephalo-medullary devices for the treatment of reverse oblique intertrochanteric femoral fractures (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen, OTA/AO 31-A3). Both the proximal femoral nail (PFN) and the gamma nail (GN) have shown good outcome results but the results of treatment with the intramedullary hip screw (IMHS) have not been reported in the literature. Our aim was to review the outcomes of these unstable fractures treated with the IMHS implant at our institute. METHODS: Between 1999 and 2008, 6724 consecutive hip fractures were treated at our institute. There were 115 reverse oblique intertrochanteric fractures and 63 of these were treated with the IMHS. We retrospectively reviewed clinical and radiological records for these fractures treated with the IMHS. Follow-up duration ranged from 1 to 6 years. RESULTS: Amongst the 63 patients treated with the IMHS, 57 (90.5%) fractures were reduced satisfactorily with one poorly positioned hip screw and one breach of the anterior femoral cortex. The mean operative time was 115 min, 22 patients required a blood transfusion and 20 had postoperative medical complications. The major orthopaedic complications included two cases of malrotation, three nonunions and one traumatic periprosthetic fracture with a total failure rate of 7.9%. There were four cases of distal locking bolts breaking or backing out. The 30-day mortality was 6.5%. CONCLUSION: The clinical and radiological outcomes achieved with the IMHS compare favourably to the results achieved with other cephalo-medullary devices. We consider the long IMHS a good implant for the treatment of these unstable fractures.

The use of LiDCO based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: neck of femur optimisation therapy - targeted stroke volume (NOTTS): study protocol for a randomized controlled trial.

BACKGROUND: Approximately 70,000 patients/year undergo surgery for repair of a fractured hip in the United Kingdom. This is associated with 30-day mortality of 9% and survivors have a considerable length of acute hospital stay postoperatively (median 26 days). Use of oesophageal Doppler monitoring to guide intra-operative fluid administration in hip fracture repair has previously been associated with a reduction in hospital stay of 4-5 days. Most hip fracture surgery is now performed under spinal anaesthesia. Oesophageal Doppler monitoring may be unreliable in the presence of spinal anaesthesia and most patients would not tolerate the probes. An alternative method of guiding fluid administration (minimally-invasive arterial pulse contour analysis) has been shown to reduce length of stay in high-risk surgical patients but has never been studied in hip fracture surgery. METHODS: Single-centre randomised controlled parallel group trial. Randomisation by website using computer generated concealed tables. SETTING: University hospital in UK. PARTICIPANTS: 128 patients with acute primary hip fracture listed for operative repair under spinal anaesthesia and aged > 65 years. INTERVENTION: Stroke volume guided intra-operative fluid management. Continuous measurement of SV recorded by a calibrated cardiac output monitor (LiDCOplus). Maintenance fluid and 250 ml colloid boluses given to achieve sustained 10% increases in stroke volume. CONTROL GROUP: fluid administration at the responsible (blinded) anaesthetist's discretion. The intervention terminates at the end of the surgical procedure and post-operative fluid management is at the responsible anaesthetist's discretion. PRIMARY OUTCOME: length of acute hospital stay is determined by a blinded team of clinicians. Secondary outcomes include number of complications and total cost of care. Funding NIHR/RfPB: PB-PG-0407-13073. TRIAL REGISTRATION: Current Controlled Trials ISRCTN88284896.

Predictors of 5 year survival following hip fracture.

BACKGROUND: This study aims to assess the mortality associated with hip fracture at 5 years in a geriatric population, and evaluate the influence of age, cognitive state, mobility and residential status on long term survival after hip fracture. METHODS: A prospective audit was carried out of all patients with a hip fracture admitted to a university hospital over a 4 year period. Data from 2640 patients were analysed and multivariate analysis used to indicate the important variables predicting mortality. Patients fulfilling the criteria of age<80 years, Abbreviated Mental Test Score (AMT)≥7/10, independently mobile and admitted from own home were put into group A (low risk group). Patients not meeting the criteria were placed into group B (high risk group). RESULTS: 2640 patients fitted the inclusion criteria, 482 in group A and 2158 in group B. 850 patients (43.1%) died in their first year following hip fracture. 302 patients (63%) of group A were still alive at 5 years in comparison with only 367 (17%) of group B. Overall, 669 (25%) patients survived for 5 years. Increased survival was shown for the following variables: age<80 years RR 5.27 (p<0.01), AMT≥7/10 RR 6.03 (p<0.01), independent mobility RR 2.63 (p<0.01) and admitted from own home RR 4.52 (p<0.01). CONCLUSIONS: These findings will allow for early recognition of those patients with an increased chance of long-term survival following hip fracture. Such patients may be suitable for surgical treatment, such as total hip replacement, which has a good long-term outcome.

All-polyethylene compared with metal-backed tibial components in total knee arthroplasty at ten years. A prospective, randomized controlled trial.

BACKGROUND: Several studies have described equivalent performance on radiostereometric analysis at two years for metal-backed compared with all-polyethylene stemmed tibial implants. The purpose of this study was to determine the ten-year survivorship results of these two designs from a large randomized controlled trial. METHODS: Patients who were fifty years old or more, with no history of infection, and were undergoing primary total knee arthroplasty were randomized at the time of surgery to receive either an all-polyethylene or a metal-backed tibial component. Patients were assessed preoperatively and at one, three, five, eight, and ten years postoperatively. All assessments included a clinical history, a physical examination, and a radiographic evaluation. A total of 510 consecutive patients (566 knees) were recruited from August 1993 to January 1997. The mean age of the patients at the time of the index arthroplasty was 69.3 years, and 299 (59%) were women. The primary diagnosis was osteoarthritis for 458 knees (80.9%) and rheumatoid arthritis for 108 knees (19.1%). RESULTS: Two hundred and ninety-three patients returned for the ten-year follow-up evaluation. A total of twenty-eight knees had been revised. Ten-year survivorship, with revision for any reason (or the time at which patients were documented as requiring revision but were unfit for surgery) as the end point, was 94.5% (95% confidence interval, 90.4% to 96.8%) for the all-polyethylene design and 96% (95% confidence interval, 92.6% to 97.8%) for the metal-backed design. Ten-year survivorship, with aseptic failure as the end point, was 97% (95% confidence interval, 93.3% to 98.7%) for the all-polyethylene design and 96.8% (95% confidence interval, 93.6% to 98.4%) for the metal-backed design. On the basis of the numbers available at ten years, there was no significant difference in survivorship between the two designs (p > 0.05). CONCLUSIONS: The long-term results demonstrate excellent survivorship, with revision as the end point, for both the metal-backed and the all-polyethylene tibial component designs with no differences noted between the two.