The NORSe: changing the way we communicate.

Introduction Rapid, reliable and efficient communication in healthcare systems with finite resources promises to improve patient care. Telephone engagement has effectively monopolised the referral process in the acute setting. Hence, traditional inter-hospital referral networks are potentially time consuming, not expeditious and frustrating. There is often no comprehensive documented communication record or audit trail. Social media, however, suggest that instantaneous, secure and dependable exchanges of information can occur via alternative conduits, potentially transforming the acute clinical referral system. The National On-Call Referral System (NORSe) was established in 2010 as an alternative referral paradigm. We explore the literature evidence surrounding the clinical impact of the NORSe referral system and analogous models. Early evidence suggests that NORSe may minimise delays in obtaining specialist advice and management, particularly in the acute setting. It enables the specialist to receive and address a large number of fact intense referrals that would otherwise be unpalatable and unmanageable. We summarise recent developments with the NORSe and give an overview of its clinical applications and links with clinical governance. NORSe and similar models promise to change the way we communicate as doctors, making the process more efficient, with a robust audit trail facilitating service appraisal and training.

Risk factors for intramedullary nail breakage in proximal femoral fractures: a 10-year retrospective review.

INTRODUCTION Intramedullary nailing is a common treatment for proximal femoral fractures. Fracture of the nail is a rare but devastating complication that exposes often frail patients to complex revision surgery. We investigated which risk factors predict nail failure. METHODS We reviewed all cases of nail breakage seen over a 10-year period in a single busy trauma unit; 22 nail fractures were seen in 19 patients. Comparison was made with a group of 209 consecutive patients who underwent intramedullary fixation of a proximal femur fracture with no nail breakage over a 2-year period. RESULTS In the fractured nail group, mean age was 70.4 years (range 55-88 years).The mean time to fracture was 10 months (range 2.5-23 months). Logistical regression was used to show that low American Society of Anesthesiologists (ASA) score, subtrochanteric fracture and pathological fracture were independent risk factors for nail fracture. CONCLUSIONS Young patients with a low ASA score are at highest risk of nail breakage. We advise close follow-up of patients with these risk factors until bony union has been achieved. In addition, there may be merit in considering other treatment options, such as proximal femoral replacement, especially for those with pathological fracture with a good prognosis.

Wrist function in malunion: Is the distal radius designed to retain function in the face of fracture?

Introduction Fractures of the distal radius are the most common fracture in humans and are the sempiternal hazard of 3.5 million years of bipedalism. Despite the antiquity of the injury, one of the most controversial topics in current orthopaedics is the management of distal radius fractures. It has been suggested that radiographic appearances rarely correlate with functional outcomes. As the success of the human species is predicated almost exclusively on its dexterity and intelligence, it is conceivable that the distal radius has evolved to preserve function even in the face of injury. We therefore hypothesise that the distal radius is designed to accommodate the possibility of fracture. Methods We conducted a review of studies comparing fracture pattern and form with function. We also explore the paleoanthropological evidence and comparative studies with other primates. Findings The evidence points to the human distal radius being highly tolerant of post-fracture deformity in terms of preservation of function. In addition, the distal radius appears to have apparently anatomically 'redundant' features that confer this capability. We believe these phenomena to be an evolved trait that developed with bipedalism, increasing the chances of survival for a species whose success depends upon its dexterity.

New anti-resorptives and antibody mediated anti-resorptive therapy.

UNLABELLED: The ageing population and an increase in both the incidence and prevalence of cancer pose a healthcare challenge, some of which is borne by the orthopaedic community in the form of osteoporotic fractures and metastatic bone disease. In recent years there has been an increasing understanding of the pathways involved in bone metabolism relevant to osteoporosis and metastases in bone. Newer therapies may aid the management of these problems. One group of drugs, the antibody mediated anti-resorptive therapies (AMARTs) use antibodies to block bone resorption pathways. This review seeks to present a synopsis of the guidelines, pharmacology and potential pathophysiology of AMARTs and other new anti-resorptive drugs. We evaluate the literature relating to AMARTs and new anti-resorptives with special attention on those approved for use in clinical practice. Denosumab, a monoclonal antibody against Receptor Activator for Nuclear Factor Kappa-B Ligand. It is the first AMART approved by the National Institute for Health and Clinical Excellence and the US Food and Drug Administration. Other novel anti-resorptives awaiting approval for clinical use include Odanacatib. Denosumab is indicated for the treatment of osteoporosis and prevention of the complications of bone metastases. Recent evidence suggests, however, that denosumab may have an adverse event profile similar to bisphosphonates, including atypical femoral fractures. It is, therefore, essential that orthopaedic surgeons are conversant with these medications and their safe usage. TAKE HOME MESSAGE: Denosumab has important orthopaedic indications and has been shown to significantly reduce patient morbidity in osteoporosis and metastatic bone disease.

Serum lactate as a marker of mortality in patients with hip fracture: A prospective study.

Outcomes from patients suffering hip fracture remain poor, with 9% mortality at 30 days and 35% at 1 year. Despite robust guidelines these mortality rates have undergone little change. Admission serum lactate in patients with sepsis or suffering general trauma has been shown to be an indicator of adverse clinical outcomes. We investigated whether venous lactate can predict mortality for hip fracture patients. Over a 12-month period the admission venous lactate of all patients presenting to our institution with hip fractures was prospectively collated. Demographic and patient survivorship data were also prospectively recorded. Multivariate binary logistic regression and Cox proportional hazards ratio analysis was used to evaluate the relationship between admission venous lactate and 30-day mortality and early survivorship, whilst adjusting for age and gender. 770 patients were included in the study. The mean age was 80 years. The overall 30-day mortality for this cohort was 9.5%. Admission venous lactate was associated with early death. A 1mmol/L increase in venous lactate resulted in a 1.9 (95% CI 1.5-2.3 p<0.0001) fold increase in the odds of 30-day mortality and a 1.4 (95% CI: 1.2-1.6 p<0.0001) factor increase in the risk of death at any time after hip fracture. Admission venous lactate remained a predictor of mortality despite adjustment for patients American Society of Anesthesiologists (ASA) grade. Those with an admission serum lactate of 3mmol/L or greater were particularly at risk. This cohort had a 30-day mortality odds that was 5-fold higher than those whose level was less than 3mmol/L (p<0.0001) and at any-time risk of death that was 1.9 times higher (p<0.0001). Those with a level of less than 3mmol/L had a 30-day mortality of 6.8%. For those with an admission venous lactate of 3mmol/L or greater this was four times higher at 28%. The difference was statistically significant (p<0.0001). Elevated admission venous lactate following hip fracture is a predictor of early death. Venous lactate may be useful as a prognostic indicator or risk stratifier in patients with proximal femoral fractures.

Is there an association between body temperature and serum lactate levels in hip fracture patients?

Introduction Hyperlactataemia is associated with adverse outcomes in trauma cases. It is thought to be the result of anaerobic respiration during hypoperfusion. This produces much less energy than complete aerobic glycolysis. Low body temperature in the injured patient carries an equally poor prognosis. Significant amounts of energy are expended in maintaining euthermia. Consequently, there may be a link between lactate levels and dysthermia. Hyperlactataemia may be indicative of inefficient energy production and therefore insufficient energy to maintain euthermia. Alternatively, significant amounts of available oxygen may be sequestered in thermoregulation, resulting in anaerobic respiration and lactate production. Our study investigated whether there is an association between lactate levels and admission body temperature in hip fracture patients. Furthermore, it looked at whether there is a difference in the mean lactate levels between hip fracture patients with low (<36.5°C), normal (36.5-37.5°C) and high (>37.5°C) body temperature on admission, and for patients who have low body temperature, whether there is a progressive rise in serum lactate levels as body temperature falls. Methods The admission temperature and serum lactate of 1,162 patients presenting with hip fracture were recorded. Patients were divided into the euthermic (body temperature 36.5-37.5°C), the pyrexial (>37.5°C) and those with low body temperature (<36.5°C). Admission lactate and body temperature were compared. Results There was a significant difference in age between the three body temperature groups (p=0.007). The pyrexial cohort was younger than the low body temperature group (mean: 78 vs 82 years). Those with low body temperature had a higher mean lactate level than the euthermic (2.2mmol/l vs 2.0mmol/l, p=0.03). However, there was no progressive rise in serum lactate level as admission temperature fell. Conclusions The findings suggest that in hip fracture patients, the body attempts initially to maintain euthermia, incurring an oxygen debt. This would explain the difference in lactate level between the low body temperature and euthermic cohorts. The fact that there is no correlation with the degree of temperature depression and lactate levels indicates that the body does not fuel thermohomeostasis indefinitely with oxygen. Instead, in part, it abandons thermoregulatory mechanisms. Consequently, in this population, active rewarming may be indicated rather than depending on patients' own thermogenic ability.

Common contra-indications and interactions of drugs in orthopaedic practice.

Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication. In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians. Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care.

Influence of coincident distal radius fracture in patients with hip fracture: single-centre series and meta-analysis.

BACKGROUND: Hip and wrist fractures are the most common orthopaedic injuries. Combined hip and distal radius fractures are an important clinical and public health problem, since mobilisation and rehabilitation is challenging and likely to be prolonged in this setting. Few studies have explored the influence of an associated wrist fracture in patients with hip fracture. We present the largest series of patients with concomitant hip and wrist fractures. We perform the first meta-analysis of the literature on patients with concurrent hip and wrist fractures. MATERIAL AND METHODS: In this single-centre retrospective study we compared 88 consecutive patients with simultaneous hip and wrist fractures with 772 consecutive patients who suffered isolated hip fractures. RESULTS: Patients with the combined fracture were of a similar age compared to those with isolated hip fracture. There were a significantly higher proportion of women in the cohort with both hip and wrist fractures (female:male ratio of 9:1 versus 4:1 p < 0.0001). The combination fracture group had a greater length of hospitalisation (18 vs 13 days p < 0.0001). The survivorship of both groups was not significantly different even after adjustment for age and gender. Meta-analysis of the literature showed female preponderance, increased length of stay but no significant difference in survival in patients with concomitant hip and wrist fractures. CONCLUSION: The combination fracture occurs much more commonly in women and patients require a greater length of hospitalisation. The patients who sustained simultaneous hip and wrist fractures experienced no statistically significant difference in survivorship when compared to those who suffer isolated hip fractures. This is not withstanding the presence of two fractures. This difference in mortality did not reach statistical significance. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

A double mobility acetabular implant for primary hip arthroplasty in patients at high risk of dislocation.

INTRODUCTION: Dislocation following total hip replacement continues to be a problem for which no completely satisfactory solution has been found. Several methods have been proposed to reduce the incidence of hip dislocations with varying degrees of success, including elevated rim liners, constrained liners and large diameter bearings. We present our experience with the double mobility acetabular component in patients at high risk of instability. METHODS: This was a retrospective review of 65 primary total hip arthroplasties in 55 patients (15 men, 40 women), performed between October 2005 and November 2009. The majority (80%) of patients had at least two and 26% had at least three risk factors for instability. The mean age was 76 years (range: 44-92 years). The patients were followed up for a mean duration of 60 months (range: 36-85 months). RESULTS: Fourteen patients died and one was lost to follow-up, leaving fifty hips for final assessment. Until the final follow-up appointment, no patients had dislocation and none required revision surgery. The mean Oxford hip score improved from 45.0 to 26.5 (p<0.0001). The mean Merle d'Aubigné pain score improved from 1.4 to 4.9 (p<0.0001), the walking score from 2.3 to 3.1 (p<0.07) and the absolute hip function score from 5.4 to 10.8 (p<0.0001). There were no clinical or radiographic signs of loosening. CONCLUSIONS: The double mobility acetabular component was successful at preventing dislocation during early to medium-term follow-up. However, as data are still lacking with regard to polyethylene wear rates at the additional bearing surface, it would be prudent to restrict the use of this implant to selected patients at high risk of instability.

Peri-operative mortality after hemiarthroplasty for fracture of the hip: does cement make a difference?

We aimed to determine whether cemented hemiarthroplasty is associated with a higher post-operative mortality and rate of re-operation when compared with uncemented hemiarthroplasty. Data on 19 669 patients, who were treated with a hemiarthroplasty following a fracture of the hip in a nine-year period from 2002 to 2011, were extracted from NHS Scotland's acute admission database (Scottish Morbidity Record, SMR01). We investigated the rate of mortality at day 0, 1, 7, 30, 120 and one-year post-operatively using 12 case-mix variables to determine the independent effect of the method of fixation. At day 0, those with a cemented hemiarthroplasty had a higher rate of mortality (p < 0.001) compared with those with an uncemented hemiarthroplasty, equivalent to one extra death per 424 procedures. By day one this had become one extra death per 338 procedures. Increasing age and the five-year co-morbidity score were noted as independent risk factors. By day seven, the cumulative rate of mortality was less for cemented hemiarthroplasty though this did not reach significance until day 120. The rate of re-operation was significantly higher for uncemented hemiarthroplasty. Despite adjusting for 12 confounding variables, these only accounted for 15% of the observed variability. The debate about the choice of the method of fixation for a hemiarthroplasty with respect to the rate of mortality or the risk of re-operation may be largely superfluous. Our results suggest that uncemented hemiarthroplasties may have a role to play in elderly patients with significant co-morbid disease.

Association of ABO blood group with fracture pattern and mortality in hip fracture patients.

INTRODUCTION: The mechanism of falling has been proposed as the exclusive explanation for hip fracture pattern. Evidence exists that other genetic factors also influence proximal femoral fracture configuration. The ABO blood group serotype has been associated with other pathologies but any role in hip fracture has yet to be definitively characterised. METHODS: Our National Hip Fracture Database was interrogated over a four-year period. All patients had their blood group retrieved, and this was compared with hip fracture pattern and mortality rates. Confounding factors were accounted for using logistic regression and the Cox proportional hazards model. RESULTS: A total of 2,987 consecutive patients presented to our institution. Those with blood group A were significantly more likely to sustain intracapsular fractures than 'non-A' individuals (p=0.009). The blood group distribution of patients with intracapsular fractures was identical to that of the national population of England. However, blood group A was less common in patients with intertrochanteric fractures than in the general population (p=0.0002). Even after correction for age and sex, blood group A was associated with a decrease in the odds of suffering an intertrochanteric fracture to 80% (p=0.002). Blood group A had inferior survivorship correcting for age, sex and hip fracture pattern (hazard ratio: 1.14, p=0.035). This may be due to associated increased prevalence of co-morbid disease in this cohort. CONCLUSIONS: Blood group is an independent predictor of hip fracture pattern, with group A patients more likely to sustain an intracapsular fracture and non-A individuals more likely to sustain an intertrochanteric fracture. The determinants of fracture pattern are likely to be related to complex interactions at a molecular level based on genetic susceptibility. The mechanism of fall may not be the only aetiological determinant of proximal femoral fracture configuration.

The weekend effect: short-term mortality following admission with a hip fracture.

We retrospectively reviewed 2989 consecutive patients with a mean age of 81 (21 to 105) and a female to male ratio of 5:2 who were admitted to our hip fracture unit between July 2009 and February 2013. We compared weekday and weekend admission and weekday and weekend surgery 30-day mortality rates for hip fractures treated both surgically and conservatively. After adjusting for confounders, weekend admission was independently and significantly associated with a rise in 30-day mortality (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.02 to 1.9; p = 0.039) for patients undergoing hip fracture surgery. There was no increase in mortality associated with weekend surgery (OR 1.2, 95% CI 0.8 to 1.7; p = 0.39). All hip fracture patients, whether managed surgically or conservatively, were more likely to die as an inpatient when admitted at the weekend (OR 1.4, 95% CI 1.02 to 1.80; p = 0.032), despite our unit having a comparatively low overall inpatient mortality (8.7%). Hip fracture patients admitted over the weekend appear to have a greater risk of death despite having a consultant-led service.