The hip fracture burden on health and social care services in Scotland is anticipated to increase significantly, primarily driven by an ageing population. This study forecasts future hip fracture incidence and the annual number of hip fractures in Scotland until 2029.

The monthly number of patients with hip fracture aged ≥ 50 admitted to a Scottish hospital between 01/01/2017 and 31/12/2021 was identified through data collected by the Scottish Hip Fracture Audit. This data was analysed using Exponential Smoothing and Auto Regressive Integrated Moving Average forecast modelling to project future hip fracture incidence and the annual number of hip fractures until 2029. Adjustments for population change were accounted for by integrating population projections published by National Records of Scotland.

Between 2017 and 2021 the annual number of hip fractures in Scotland increased from 6675 to 7797, with a respective increase in hip fracture incidence from 313 to 350 per 100,000. By 2029, the averaged projected annual number of hip fractures is 10311, with an incidence rate of 463 per 100,000. The largest percentage increase in hip fracture occurs in the 70-79 age group (57%), with comparable increases in both sexes (30%). Based upon these projections, overall length of stay following hip fracture will increase from 142713 bed days per annum in 2021, to 203412 by 2029, incurring an additional cost of over £25 million.

Forecast modelling demonstrates that the annual number of hip fractures in Scotland will rise substantially by 2029, with considerable implications for health and social care services.

Aims

Iliopsoas pathology is a relatively uncommon cause of pain following total hip arthroplasty (THA), typically presenting with symptoms of groin pain on active flexion and/or extension of the hip. A variety of conservative and surgical treatment options have been reported. In this retrospective cohort study, we report the incidence of iliopsoas pathology and treatment outcomes.

Background

National hip fracture programmes are becoming widespread, but this practice is nascent and varied. The Scottish Hip Fracture Audit (SHFA) was an early adopter of this strategy and is credited with substantial systemic improvements in quality and outcomes.

Hip fracture care is complex multi-disciplinary. We hypothesise that quality of care is affected by variance in resources between ‘in-hours’ (Monday-Friday, 0800–1700) and ‘out-of-hours’ services.

This prospective multicentre national cohort study assessed quality of care by evaluating adherence to the evidence-based Scottish Standards of Care for Hip Fracture Patients. Data was collected by the Scottish Hip Fracture Audit for 15174 patients admitted to any of 22 Scottish hospitals from January 2014-April 2018.

11197/15174 (73.8%) patients were admitted out-of-hours. They were significantly less likely to meet the following Standards: ED Big-6-Bundle (OR 0.85, p= 0.002); Time in ED <4 hours (OR 0.76, p< 0.001); avoidance of repeated fasting (OR 0.80, p< 0.001), and avoidance of prolonged fluid fasting (OR 0.83, p< 0.001). Out-of-hours admissions were more likely to receive: geriatric assessment <3 days (OR 1.16, p< 0.001); OT input <3 days (OR 1.10, p= 0.013), and PT input <2 days (OR 1.44, p< 0.001). There were no significant differences for: Time to Theatre <36 hours; Inpatient Care Bundle <24 hours, and Post-op Day 1 Mobilisation.

Quality of hip fracture care is affected by time of admission. ED care is poorer out-of-hours, which may reflect limited resources, and out-of-hours admissions are more likely to be excessive fasted excessively. Weekday in-hours admissions are less likely to receive geriatric and allied health professional input in the days following admission, which may reflect the reduced weekend services. Examination of out-of-hours service organisation is required for the pursuit of consistent, equitable care for hip fracture patients.

Hip fractures in young adults are rare but represent an important cohort of patients, of which relatively limited data exists. The aim of this study was to evaluate this distinct subgroup of hip fractures from an epidemiological perspective and assess their subsequent outcomes.

Patients aged 18–50 were identified across an 8 year period from a total of 5326 hip fractures. 46 hip fractures met the inclusion criteria and a retrospective case series analysis was conducted.

25/46 (54%) of fractures were intracapsular and 21/46 (46%) were extracapsular. Only 15/46 (33%) of fractures were sustained from a high energy mechanism and 31/46 (67%) low energy. The low energy cohort was significantly more comorbid with a mean Elixhauser comorbidity score of 1.5 compared to the high energy cohort 0.3 (p<0.0005, unpaired t-test). Alcohol excess was the most prevalent comorbidity present in 24% of patients and was a positive predictor in complication (p=0.006, binary regression). Failure of fixation (non-union/avascular necrosis) in displaced intracapsular fractures sustained following low energy trauma managed by internal fixation 5/11 (45%) was markedly higher than the high energy cohort 0/6 (0%). 5 year mortality was 9% for all hip fractures, six times higher than an aged matched cohort of non-hip fractures (p=0.007, Wilcoxon test).

Representing only 0.86% of all hip fractures in the study period, hip fractures in young adults are rare. A clear sub-division of patients is observed between patients with a low and high energy mechanism, both in terms of level of comorbidity and surgical outcome.

Deficiency in the gluteus medius and minimus abductor muscles is a well-recognised cause of hip pain and considerable disability. These patients present a management challenge, with no established consensus for surgical intervention. Whiteside in 2012 described a surgical technique for gluteus maximus tendon transfer, with successful outcomes reported. This study is the largest known case series to date of patients undergoing gluteus maximus tendon transfer with clinical and patient reported outcomes measured.

13 consecutive patients were included in the study. All patients had clinical evidence of abductor dysfunction together with MRI evidence of gluteal atrophy and fat infiltration. All patients underwent gluteus maximus transfer with surgery performed according to the procedure described by Whiteside. Patients were followed up with both clinical assessment and patient questionnaires conducted.

Mean age was 69 (range 54–82) with 9 patients (69%) having previous Hardinge approach to the affected hip. 6 patients (46%) reported they were satisfied overall with the procedure and 5 patients (38%) were unsatisfied. 7 patients (54%) had improvements in visual analogue scale of pain and 5 patients (54%) reported overall improvements in function. Mean Oxford Hip Score on follow up was 20/48 (range 5–48) and trendelenberg test was positive in 11 patients (85%). No differentiating variable could be identified between patients with positive and negative outcomes (Assessed Variables: Age, sex, BMI, aetiology and gluteus maximus muscle thickness).

Clinical outcomes were varied following gluteus maximus tendon transfer for chronic hip abductor dysfunction. Results are considerably less promising than pre-existing studies would suggest.

Due to changes in population demographics, the burden of hip fractures in Scotland is expected to rise dramatically over the coming decades. This study aims to establish the future incidence of hip fracture in Scotland in individuals aged 50 and over.

The number of patients admitted to hospital in Scotland with a hip fracture between 1999 and 2016 were ascertained from discharge coding across NHS Scotland. The annual number of hip fractures were categorised to enable gender and age specific hip fracture incidence rates to be calculated. Through static and variable projection methods, the annual hip fracture incidence up to 2035 was forecast and analysed with respect to specific demographics ascertained from population data provided by the National Records of Scotland.

Between 1999 and 2016 the total number of hip fractures in individuals aged 50 and over increased by 11%, from 7,131 to 7,930, equating to an average year-on-year increase of 0.6%. Patients aged over 75 consistently accounted for more than 85% of recorded hip fractures, with females having a higher incidence rate than males across all age groups. A decreasing incidence in females aged over 70 was observed. Using multiple projection methods, the annual number of hip fractures in Scotland is predicted to increase by 55% from 7,930 in 2016, to an average of 12,316 by 2035.

Projection modelling confirms the annual number of hip fractures in Scotland will rise substantially by 2035 with considerable implications for health and social care provision.

Three distal femoral axes have been described to aid in alignment of the femoral component; the Trans Epicondylar Axis (TEA), the Posterior Condylar Axis (PCA) and the Antero Posterior (AP) axis. Our aim was to identify if there was a reproducible relationship between the axes which would aid alignment of the femoral component. This is the first study compare all three distal femoral axes with each other using magnetic resonance imaging (MRI) in a Caucasian population. Our sample group represents real life patients awaiting total knee arthroplasty (TKA), as opposed non-arthritic or cadaveric knees.

We identified the relationship between these rotational axes by performing MRI scans on 89 patients awaiting TKA with patient-specific instrumentation. Measurements were taken by two observers.

Patients had a mean age of 62.5 years (range 32–91). 51 patients were female. The mean angle between the TEA and the AP axis was 92.78° with a standard deviation of 2.51° (range 88° – 99°). The mean angle between the AP axis and the PCA was 95.43° with a standard deviation of 2.75° (range 85° – 105°). The mean angle between the TEA and the PCA was 2.78° with a standard deviation of 1.91° (range 0° – 10°).

We conclude that while there is a reproducible relationship between the differing femoral axes, there is a significant range in the relationship between the femoral axes. This range may lead to greater inaccuracy than has previously been appreciated when defining the rotation of the femoral component. There is most variation between the PCA and the AP axis. The TEA's relationship with the PCA and AP appears important in defining rotation. Due to the well accepted difficulty in defining the TEA intra-operatively, there may be a role for patient-specific instrumentation in TKA surgery with pre-operative MRI.

Although there is strong evidence that bisphosphonates prevent certain types of osteoporotic fractures, there are concerns that they may be associated with rare atypical femoral fractures.

1480 patients of proximal femur and shaft fractures over a period of 2 years from Jan 2014 to Jan 2016 were retrospectively reviewed in Gloucestershire Hospitals NHS trust. Hospital trauma database was used.195 patients had fractures in subtrochancteric and femoral shaft area.

11 patients had atypical femur fractures as defined by American society for bone and mineral research (ASBMR) task force 2013, revised criteria. Ten were female, one was male. Patients were aged from 68 to 97. In 6 patients, fractures were in the shaft, 5 in subtrochancteric area and 4 patients out of these had bilateral fractures. 10 out of 11 patients were on bisphosphonates. 4 patients had delayed diagnosis. 5 out of 11 patients did not have contralateral femoral x-rays. Treatment, 9 patients had intramedullary nail, one blade plate, and one treated conservatively. One patient in the IM group, had bilateral nailing. Average follow up was 7.6 months (range 1 to 16 months). At the end of the study, only 4 had united, 6 had not united and one not followed up. 4 out of 7 had low Vitamin D levels, 3 out of 7 had their bisphosphonate treatment stopped and 2 had histology which showed necrotic bone with trabeculae surrounded by fibrosis.

Increasing number of patients are on bisphosphonates for osteoporosis. Atypical femur fractures from bisphosphonates are often occult, often bilateral, with delayed healing. Patients on bisphosphonatetreatment should be advised to report any thigh or groin pain. Painful incomplete fractures need treatment with cephalomedullary nailing. Bone biology needs correcting by stopping bisphosphonatesand administering calcium & vitamin D supplements.

Implications: We need to raise awareness amongst treating clinicians and have national guidelines.

Introduction

Acute kidney injury is a recognised post-operative complication in primary joint replacement. Recently it has been demonstrated that antibiotic regimen can significantly impact on the proportion of patients who develop acute kidney impairment post-operatively. Within our unit an increased rate of acute kidney injury had been noted post-operatively over the last 5 years. This increase followed the introduction of a rapid recovery protocol for arthroplasty patients. Our aim was determine whether we could identify a causative factor or those who were at increased risk of post-operative renal impairment.

We evaluated an operative technique, described by the Exeter Hip Unit, to assist accurate introduction of the femoral component. We assessed whether it led to a reduction in the rate of leg-length discrepancy after total hip arthroplasty (THA).

A total of 100 patients undergoing THA were studied retrospectively; 50 were undertaken using the test method and 50 using conventional methods as a control group. The groups were matched with respect to patient demographics and the grade of surgeon. Three observers measured the depth of placement of the femoral component on post-operative radiographs and measured the length of the legs.

There was a strong correlation between the depth of insertion of the femoral component and the templated depth in the test group (R = 0.92), suggesting accuracy of the technique. The mean leg-length discrepancy was 5.1 mm (0.6 to 21.4) pre-operatively and 1.3 mm (0.2 to 9.3) post-operatively. There was no difference between Consultants and Registrars as primary surgeons. Agreement between the templated and post-operative depth of insertion was associated with reduced post-operative leg-length discrepancy. The intra-class coefficient was R ≥ 0.88 for all measurements, indicating high observer agreement. The post-operative leg-length discrepancy was significantly lower in the test group (1.3 mm) compared with the control group (6.3 mm, p < 0.001).

The Exeter technique is reproducible and leads to a lower incidence of leg-length discrepancy after THA.

Cite this article: Bone Joint J 2015;97-B:154–9.

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.

Cite this article: Bone Joint J 2014;96-B:1185–91.

The surgical treatment options for patients who have sustained an intra-capsular hip fracture can vary depending on a number of patient and fracture related factors. Currently most national guidelines support the use of cemented prostheses for patient undergoing hemi-arthroplasty surgery. Uncemented prostheses are commonly used for a variety of indications including those patients who have significant medical co-morbidities.

To determine whether cemented hemi-arthroplasty is associated with a higher post operative mortality when compared to uncemented procedures. Data was extracted from the Scottish SMR01 database from 01/04/1997 from all patients who were admitted to hospital after sustaining a hip fracture. We investigated mortality at day 1, 2, 4, 7, 30, 120 and 1 year from surgery vs. that on day 0. In order to control for the effects of confounding variables between patients cohorts, 12 case-mix variable were used to construct a multivariable logistic regression analysis model to determine the independent effect of prosthesis fixation method.

There were 64,979 patients were included in the study. Mortality for osteosynthesis of extra-capsular fractures was consistently lower when compared to that for surgical procedures for intra-capsular fractures. At day 0, uncemented hemi-arthroplasty operations had a lower associated mortality (p<0.001) when compared to cemented implant designs. Unadjusted figures showed an increased mortality equal to 1 extra death per 424 procedures. By day 1 this had become 1 extra death per 338 procedures. By day 7 cumulative mortality was less for cemented than for uncemented procedures though this did not reach significance until day 120.

When compared to uncemented fixation techniques, cemented hemiarthroplasty is associated with a higher mortality in the immediate postoperative period. However, by day 120 and beyond the trend is reversed.

Three distal femoral axes have been described to aid in alignment of the femoral component; the Trans Epicondylar Axis (TEA), the Posterior Condylar Axis (PCA) and the Antero Posterior (AP) axis. Our aim was to identify if there was a reproducible relationship between the axes. Hopefully this will aid the surgeon to more accurately judge the rotation of the femoral cutting block by using the axes with the least variation. This is the first study compare all three distal femoral axes with each other using magnetic resonance imaging (MRI) in a Caucasian population awaiting total knee arthroplasty (TKA).

We identified the relationship between these axes by performing MRI scans on 89 patients awaiting TKA with patient-specific instrumentation. Measurements were taken by two observers.

Patients had a mean age of 62.5 years (range 32–91). 51 patients were female. The mean angle between the TEA and AP axis was 92.78°, standard deviation (SD) 2.51° (range 88°–99°). The mean angle between the AP axis and PCA was 95.43°, SD 2.75° (range 85°–105°). The mean angle between the TEA and PCA was 2.78°, SD 1.91° (range 0°–10°).

We conclude that while there is a reproducible relationship between the differing femoral axes, there is a significant range in the relationship between the femoral axes. This range may lead to greater inaccuracy than has previously been appreciated when defining the rotation of the femoral component. There is most variation between the PCA and the AP axis. Most systems have a cutting block with 3° of external rotation from the PCA and this would be parallel to the TEA in the majority, but not all, cases in this series. This data suggests that if the surgeon is to pick two axes to reference from, one should include the TEA.

Leg length discrepancy (LLD) can adversely affect functional outcome and patient satisfaction after total hip arthroplasty. We describe a novel intraoperative technique for femoral component insertion.

We aimed to determine if this technique resulted in the desired femoral placement, as templated, and if this was associated with a reduced LLD.

A series of fifty consecutive primary total hip replacements were studied. Preoperative digital templating was performed on standardised PA radiographs of the hips by the senior surgeon. The preoperative LLD was calculated and the distance from the superior tip of the greater trochanter to the predicted shoulder of the stem was calculated (GT-S). Intraoperatively, this length was marked on the rasp handle and the stem inserted to the predetermined level by the surgeon. This level corresponded to the tip of the greater trochanter and formed a continuous line to the mark on the rasp handle. Three independent blinded observers measured the GT-S on the postoperative radiographs. We assessed the relationship between the senior author's GT-S (preoperative) and the observers' GT-S (postoperative) using a Person correlation. The observers also measured the preoperative and postoperative LLD, and the inter-observer variability was calculated as the intra-class correlation coefficient.

There was a strong correlation of preoperative and postoperative GT-S (R=0.87), suggesting that the stem was inserted as planned. The mean preoperative and postoperative LLD were −4.3 mm (−21.4–4) and −0.9 mm (−9.8–8.6), respectively (p<0.001).

This technique consistently minimised LLD in this series. This technique is quick, non-invasive and does not require supplementary equipment.

Reconstruction of severe acetabular defects during revision hip arthroplasty presents a significant surgical challenge. Such defects are associated with significant loss of host bone stock, which must be addressed in order to achieve stable implant fixation. A number of imaging techniques including CT scanning with 3D image reconstruction are available to assist the surgeon in the pre-operative planning of such procedures.

We describe the use of a novel technique to assist the pre-operative planning of severe acetabular defects during revision hip arthroplasty.

Patient and Methods – We present the use of this technique in the case of a 78 year old patient who presented 20 years from index procedure with severe hip pain and inability to weight bear due aseptic loosening of a previously revised total hip arthroplasty. A Paprosky 3B defect was noted with intra-pelvic migration of the acetabular component. Pre-operative investigations included: inflammatory markers, pelvic CT scan with 3D reconstruction, pelvic angiography and hip aspiration.

Using DICOM images obtained from the CT scan, we used free open source software to carry out a 3D surface render of the bony pelvis. This was processed and converted to a suitable format for 3D printing. Using selective laser sintering, a physical 3D model of the pelvis, acetabular component and proximal femur were produced. Using this model the surgeon was able to gain an accurate representation of both the position of the intra-pelvic cup and more accurately assess the loss of bone stock. This novel technique is particularly useful in the pre-operative planning of such complex acetabular defects in order to determine if/which reconstruction technique is most likely to be successful.

3D printing is a relatively recent technology, which has numerous potential clinical applications. This is the first reported case of this technology being used to assess acetabular defects during revision hip arthroplasty. The use of this technology gives the surgeon a 3D model of the pelvis, quickly (7 days from CT) and at a tenth of the cost (£280) of producing such a model through the traditional commercial routes. The model allowed the surgeon to size potential implant, quantify the amount of bone graft required (if applicable) and to more accurately classify the loss of acetabular bone stock.

The aim of this study is to assess the discrepancy between weight bearing long leg radiographs and supine MRI alignment. There is currently increasing interest in the use of MRI to assess knee alignment and develop custom made cutting blocks utilising this data. However in almost all units MRI scans are performed supine and it is recognised that knee alignment can alter with weight bearing. 46 patients underwent MRI scans as pre-operative planning for Biomet signature total knee replacement and the measure of varus or valgus deformity on MRI was obtained from the plan produced by Biomet Signature software system. 41 of these patients had long leg weight bearing radiographs performed. 37 of these radiographs were amenable to measuring the knee alignment on the picture archiving and communication system (PACS). These measurements were performed by two assessors and inter-observer reliability was satisfactory. There was a significant difference between the alignment as measured on supine MRI compared with weight bearing long leg films. In knee arthroplasty one of the aims is to correct the biomechanical axis of the knee and one of the appeals of custom made cutting blocks is that this can be achieved more easily. However it is important to realise that alignment is not a static value and thus correcting supine alignment may not necessarily result in correction of weight bearing alignment.

The surgical treatment options for patients who have sustained an intra-capsular hip fracture can vary depending on a number of patient and fracture related factors. Currently most national guidelines support the use of cemented prostheses for patient undergoing hemiarthroplasty surgery. Uncemented prostheses are commonly used for a variety of indications including those patients who have significant medical co-morbidities.

To determine whether cemented hemiarthroplasty is associated with a higher post operative mortality when compared to uncemented procedures. Data were extracted from the Scottish SMR01 database from 01/04/1997 from all patients who were admitted to hospital after sustaining a hip fracture. We investigated mortality at day 1,2,4,7,30, 120 and 1 year from surgery vs. that on day 0. In order to control for the effects of confounding variables between patients cohorts, 12 case-mix variable were used to construct a multivariable logistic regression analysis model to determine the independent effect of prosthesis design.

There were 52283 patients included in the study. Mortality for osteosynthesis of extra-capsular fractures was consistently lower when compared to that for surgical procedures for intra-capsular fractures. At day 0, uncemented hemiarthroplasty had a lower associated mortality (p<0.001) when compared to cemented implant designs. However, this increased mortality was equal to 1 extra death per 2000 procedures. From day 1 onward mortality for cemented procedures was equal to or lower than that of uncemented. By day 4, cumulative mortality was less for cemented than for uncemented procedures. Complication and re-operation rate was significantly higher in the uncemented cohort.

The use of uncemented hemiarthroplasty for the treatment of intra-capsular hip fractures cannot be justified in terms of early/late post-operative mortality.

The aim of this study is to assess the discrepancy between weight bearing long leg radiographs and supine MRI alignment. There is currently increasing interest in the use of MRI to assess knee alignment and develop custom made cutting blocks utilising this data. However in almost all units MRI scans are performed supine and it is recognised that knee alignment can alter with weight bearing. 46 patients underwent MRI scans as pre-operative planning for Biomet signature total knee replacement and the measure of varus or valgus deformity on MRI was obtained from the plan produced by Biomet Signature software system. 41 of these patients had long leg weight bearing radiographs performed. 33 of these radiographs were amenable to measuring the knee alignment on the picture archiving and communication system (PACS). These measurements were performed by two assessors and inter-observer reliability was satisfactory. There was a significant difference between the alignment as measured on supine MRI compared with weight bearing long leg films. In knee arthroplasty one of the aims is to correct the biomechanical axis of the knee and one of the appeals of custom made cutting blocks is that this can be achieved more easily. However it is important to realise that alignment is not a static value and thus correcting supine alignment may not necessarily result in correction of weight bearing alignment.

Fragility fractures are an increasing cause of morbidity and mortality in the elderly population. Their association with reduced bone mineral density (BMD) is well documented. It is a reasonable assumption that hip fracture severity is linked to the magnitude of bone loss, (the lower the BMD, the more severe the fracture), however it is not known whether this correlation exists. Our aim therefore was to investigate the relationship between BMD and hip fracture severity.

We reviewed 142 patients, 96 females and 46 males, mean age 74 years (49-92), who had sustained a hip fracture following a simple ground level fall. All had subsequently undergone DEXA bone scanning of the contralateral hip and lumbar spine. Fractures were classified as intra-capsular, extra-capsular or subtrochanteric, then sub-classified using the Garden, Jensen and Seinsheimer classifications respectively. They were grouped into simple (stable) or comminuted (unstable) fracture patterns. Risk factors for osteoporosis were recorded.

A low hip BMD (<2.5) was associated with an increased risk of extra-capsular fracture (p=0.025). However, no association with fracture type (extra vs. intra-capsular, p>0.05) was identified with the following variables; age, gender, BMI <25, smoking, and excess alcohol intake. We did not find any statistically significant associations between fracture severity and the nine principle variables tested for: age; gender; smoking; BMI < 25; alcohol excess and low hip or lumbar BMD T or Z score <-2.5.

Although the association between BMD and risk of fragility fractures is well documented, the results of this study would suggest that severity of hip fractures does not follow this correlation. Therefore, no assumption can be made about BMD of the proximal femur based on the severity of fracture observed on plain radiographs alone.

Hyponatraemia is one of the most common electrolyte disorders in the elderly and has considerable associated morbidity and mortality. In this study we report the prevalence and independent risk factors for the development of post-operative hyponatraemia after surgery for hip fracture.

We conducted a retrospective cohort study of 144 consecutive patients who underwent surgery after sustaining a hip fracture. Patient medical case-notes, operative notes and online biochemistry results were used to obtain relevant data which was entered into a database.

Pre-operative (30/144, 21%) and post-operative hyponatraemia (49/144, 34%) was common. However, most cases were mild (plasma sodium >130 mmol/l) and only 1% of pre-operative and 6% of post-operative patients had moderate/severe hyponatraemia (plasma sodium <130mmol/l). One of 3 post-operative deaths involved a patient with moderate hyponatraemia as a consequence of severe congestive cardiac failure. In order to determine the independent relationship between several reported risk factors and hyponatraemia we constructed a multivariable logistic regression model. Female gender, pre-operative hyponatraemia and hypotonic fluid administration were all significantly associated with the development of post-operative hyponatraemia. Age and thiazide diuretics both had positive risk associations however were not statistically significant.

Hyponatraemia is a common problem in hip fracture patients. While the majority of cases in this series were mild, 6% of patients suffered from moderate/severe hyponatraemia post-operatively. Female gender, pre-operative hyponatraemia and hypotonic fluid administration are all important and independent risk factors for the development of hyponatraemia. Hypotonic intravenous fluids should be avoided unless clinically indicated in this patient group.

Delay to theatre after hip fracture is common in order to medically optimise the patient prior to surgery. The association between delay to surgery and mortality after hip fracture remains a contentious issue.

We aimed to investigate how medical postponement, time to surgery and correction of medical abnormalities prior to surgery affect peri-operative mortality after hip fracture.

From February to December 2007 prospective data was collected from all acute trauma units in Scotland relating to hip fracture patients' fitness for theatre, reasons for postponement of surgery and subsequent plans of action. The data-set recorded whether medical abnormalities were identified following criteria reported by McLaughlin et al. Survival at 30-days post-operation was used as primary outcome measure. Multivariable logistic regression models were used to control for differences in case-mix between patients.

Data were available for 4284 patients. Patients postponed for medical reasons were less likely to survive to 30 days compared to patients who were not postponed (87% (122/947) versus 93% (3098/3337)). Survival also decreased as time to theatre increased - 92% of patients operated on during the same/next day vs. 89% of those operated on admission day four. However, after controlling for differences in case-mix variables and co-morbidities, neither variable significantly affected survival. We then analysed whether delaying surgery to resolve medical problems improved survival. Adjusted survival was not significantly different between those patients who had their medical problem resolved prior to surgery compared to those patients who were not postponed. Individuals who were postponed but did not have their clinical abnormality resolved prior to surgery had significantly lower adjusted 30 day survival.

The possible benefits of postponement need to be weighed against prolonged discomfort and the possibility of developing other complications. Postponing patients who cannot be medically improved should be avoided.

Details of orthopaedic implants in Scotland are recorded on a national database. The results are used by the Scottish Arthroplasty Project to record survival and complication rates for both knee and hip replacements.

The aim of our study was to assess the accuracy of recorded data for unicompartmental knee replacements in the West of Scotland. The national database was searched for all unicompartmental knee replacements carried out in the West of Scotland between March 2000 to October 2004. All patient data was then crosschecked with hospital theatre records and case notes for confirmation of accuracy.

A total of 88 cases were coded as unicompartment joint replacements in the study period. 63 cases were confirmed as being accurate (71.6%) and 6 as being inaccurate (6.8%). 19 patient details were not available for review either from notes or theatre records (21.6%). Of those coded inaccurately, five were total knee replacements, one cemented hip hemiarthroplasty and one shoulder replacement. One case of miscoding could be accounted for as an error in documentation while in six cases no cause could be identified. Of the 63 knees confirmed as unicompartmental, seven knees had been revised within 5 years, giving a 5 year survival rate of 87.7%.

The current system used by the Scottish Arthroplasty Project in Scotland has at least a 6.8% inaccuracy rate when recording unicompartmental knee replacements.

We have investigated how medical postponement, the time to surgery and the correction of medical abnormalities, according to McLaughlin criteria, before operation affected peri-operative mortality after fracture of the hip. From February to December 2007, in addition to core data, the Scottish Hip Fracture Audit collected information relating to surgical delay. Data were available for 4284 patients which allowed 30-day survival analysis to be performed. Multivariable logistic regression models were used to control for differences in case-mix.

Patients with major clinical abnormalities were more likely to have a postponement and had a lower unadjusted 30-day survival. The time to operation and postponement were not associated with higher mortality after adjustment for case-mix. Correction of major clinical abnormalities before surgery improved the adjusted survival, but this improvement was not significant (p = 0.10). Postponement without correction of a medical abnormality before surgery was associated with a significantly lower (p = 0.006) 30-day adjusted survival. The possible benefits of postponement need to be weighed against prolonged discomfort for the patient and the possibility of the development of other complications.

The humerus is a common site for skeletal metastases in the adult. Surgical stabilisation of such lesions is often necessary to relieve pain and restore function. These procedures are essentially palliative and should therefore provide effective relief from pain for the remainder of the patient’s life without the need for further surgical intervention.

We report a retrospective analysis of 35 patients (37 nails) with symptomatic metastases in the shaft of the humerus which were treated by locked, antegrade nailing. There were 27 true fractures (73.0%) and ten painful deposits (27.0%). Relief from pain was excellent in four (11.4%), good in 29 (82.9%) and fair in two (5.7%) on discharge. Function was improved in all but one patient. One case of palsy of the radial nerve was noted. The mean postoperative survival was 7.1 months (0.2 to 45.5) which emphasises the poor prognosis in this group of patients. There were no failures of fixation and no case in which further surgery was required.

Antegrade intramedullary nailing is an effective means of stabilising the humerus for the palliative treatment of metastases. It relieves pain and restores function to the upper limb with low attendant morbidity.

We investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18 817 patients were obtained from the Scottish Hip Fracture Audit database. We divided variables into two categories, depending on whether they were case-mix (age; gender; fracture type; pre-fracture residence; pre-fracture mobility and ASA scores) or management variables (time from fracture to surgery; time from admission to surgery; grade of surgical and anaesthetic staff undertaking the procedure and anaesthetic technique).

Multivariate logistic regression analysis showed that all case-mix variables were strongly associated with post-operative mortality, even when controlling for the effects of the remaining variables. Inclusion of the management variables into the case-mix base regression model provided no significant improvement to the model. Patient case-mix variables have the most significant effect on post-operative mortality and unfortunately such variables cannot be modified by pre-operative medical interventions.

Lumps of the foot present relatively infrequently to the orthopaedic service. There have been very few published studies looking at presenting characteristics or the differential diagnosis of such lesions. We report our experience of foot lumps treated surgically looking at the patient demographics, presenting characteristics, diagnoses encountered and the diagnostic accuracy of the surgeon. All patients who underwent excision or biopsy of a foot lump over a period of 4 years were studied; 101 patients were identified. Average age was 47.3 years (range 14–79); there was a significant female preponderance with 73 females and 28 males (p< 0.0001). Pain was the single most common presenting complaint followed by footwear problems. Only three patients attended because of cosmetic reasons and neurological symptoms were very rare with only one patient complaining of paraesthesia. Certain lesions were more commonly encountered in specific zones of the foot. 32 different histological types were identified, ganglion cysts were the most commonly encountered lesions and there was only one malignant lesion encountered in this study. Only 58 out of the l01 lumps were correctly diagnosed prior to surgery.

We have shown that there are a wide variety of potential diagnoses, which have to be considered when examining a patient with a foot lump. There is a low diagnostic accuracy for foot lumps and therefore surgical excision and histological diagnosis should be sought if there is any uncertainty.

Introduction: Patients undergoing surgery to the foot frequently ask when it is safe to return to driving. The ability to drive is important both in social and economical terms. There is currently little data in the literature relevant to foot surgery. We are conducting a prospective cohort control study to asess the effect of forefoot surgey on break-response time. Methods- Individuals attending for first MTP joint arthroplasty and SCARF/Chevron osteotomies for hallux valgus are recruited. A driving simulator was constructed consisting of a steering wheel, foot pedals, an LCD display, a CPU and a control unit. The patient follows an image on the LCD screen using the steering wheel. The examiner then randomly initiates the machine and a stop sign is displyed. The patient would then release the accelerator pedal and depress the brake. The CPU claculates the “respone-time”, the “break-time” and total breaking time. In addition the “stick test” and “stand test” were performed as further measures of lower limb function. Each individual was assessed pre-operatively and at 2 and 6 weeks postoperatively. Both drivers and non-drivers are included and a control population of age and gender matched individuals was included for comparison. Results – 25 individuals are currently enrolled as study cases, 12 of which have 2 week follow-up and 3 have completed the study. Control data is being collected.

Conclusion: Early results indiciate that break response time is increased at 2 weeks post-operatively, however this returns to pre-operative levels by 6 weeks. (204ms vs 256ms vs 206ms) These early results may be validated when all individuals have completed the study. Further study of the period 2–6 weeks after surgery will now be subject to study to assess the optimum time to return to driving.

Introduction: Aseptic osteolysis represents a significant challenge to the orthopaedic surgeon as it limits the long terms survivorship of prosthetic implants.

Aim: To investigate whether the bisphosphonate aledronate alters the cytokine profile in the psuedomembrane excised from individuals undergoing revision hip arthroplasty surgery for aseptic failure.

Methods: A prospective, double-blinded, randomised controlled trial was conducted with relevant ethical approval. 10 patients were randomly assigned to receive a placebo or alendronate 70mg for a 6 week period prior to revision surgery. All individuals had aseptic failure of primary cemented femoral stems and acetabular cups with UHDPE inserts. Infection was excluded in all individuals prior to surgery. Multiple tissue samples were subsequently excised at surgery and sent for histology and culture. If either was subsequently positive for infection the individual was excluded from the study. Tissue samples were preserved using liquid nitrogen and formalin. Frozen tissue was stored at −70^oC pending Polymerase Chain Reaction analysis. Formalin preserved samples were paraffin sectioned for immunohistochemical analysis. PCR was carried out to assess expression of mRNA for Interleukins 1,6,17,18; TNF alpha, RANK-L, OPG and RANK. IHC was performed to confirm protein expression in the pseudomembrane excised from the femur and acetabulum. Multiple samples were used in each patient.

Results: In the 5 individuals who received the placebo there was expression of mRNA and protein for Interleukins 1,6,17,18; TNF alpha; RANK-L; OPG and RANK in all cases. There was no statistically significant difference in the expression of any of the aforementioned cytokines/receptors in the group receiving alendronate.

Discussion: A six seek course of oral alendronate 70mg had no effect upon osteoclastogenic cytokine expression when compared to the placebo group. This would suggest that alendronate may offer little benefit in reversing established particle induced osteolysis.

We report gender differences in the epidemiology and outcome after hip fracture from the Scottish Hip Fracture Audit, with data on admission and at 120 days follow-up from 22 orthopaedic units across the country between 1998 and 2005. Outcome measures included early mortality, length of hospital stay, 120-day residence and mobility. A multivariate logistic regression model compared outcomes between genders. The study comprised 25 649 patients of whom 5674 (22%) were men and 19 975 (78%) were women. The men were in poorer pre-operative health, despite being younger at presentation (mean 77 years (60 to 101) vs 81 years (50 to 106)). Pre-fracture residence and mobility were similar between genders.

Multivariate analysis indicated that the men were less likely to return to their home or mobilise independently at the 120-day follow-up. Mortality at 30 and 120 days was higher for men, even after differences in case-mix variables between genders were considered.

As patients live longer following treatment for soft tissue sarcomas, complications from treatment will continue to emerge. Predicting which patients are at risk allows for improved preoperative planning, treatment, and surveillance. The data presented here suggests that females greater than fifty-five years of age treated with high dose, postoperative radiotherapy in combination with limb salvage surgery for soft tissue sarcomas are at an increased risk of post irradiation fractures. Unlike previous reports, a significantly higher rate of fracture occurred in patients who received higher doses (60 or 66Gy) of radiation versus lower doses (50 Gy).

This retrospective study was performed to determine if the timing and dosage of radiotherapy are related to the risk of post radiation pathologic fracture following combined therapy for lower extremity soft tissue sarcomas. Three hundred sixty-four patients with sarcomas treated with external beam radiation therapy and limb salvage surgery were evaluated. High dose radiation was defined as 60 Gy or 66 Gy; low dose as 50Gy. Radiation timing schedules were preoperative, postoperative, or preoperative with a postoperative boost. Univariate and multivariate analysis was used to determine which factors were associated with fracture risk. Twenty- seven pathologic fractures occurred in twenty-three patients. Twenty- four fractures occurred in twenty patients who were treated with high dose radiation. Sixteen of these patients had postoperative radiation (fourteen patients received 66Gy, two received 60Gy), and four had pre-operative radiation with a postoperative boost (total dose = 66Gy). Three fractures occurred in three patients who received low dose preoperative radiation (50Gy). Both high dose radiation (versus low dose) (p=.001) and preoperative radiation (versus postoperative) (p =0.002) were associated with a risk of fracture. Findings in this study were consistent with previous reports in that females over fifty-five years of age who undergo removal of a thigh sarcoma combined with radiation therapy are at a higher risk of a pathologic fracture, and differs in that there was a significantly higher rate of fracture in patients who received higher doses (60 or 66Gy) of radiation versus lower doses (50 Gy), and when radiation therapy was given postoperatively versus preoperatively.

Despite the increase in numbers of the extreme elderly, little data is available regarding their outcome after surgery for fracture of the hip. We performed a prospective study of 50 patients aged 95 years and over who underwent this procedure. Outcome measures included morbidity, mortality, hospital stay, residential and walking status. Comparison was made with a control group of 200 consecutive patients aged less than 95 years who had a similar operation. The mortality at 28 and 120 days was higher (p = 0.005, p = 0.001) in the patients over 95 years. However, the one-year cumulative post-operative mortality was neither significantly different between the two groups (p = 0.229) nor from the standardised mortality rate for the age-matched population (p = 0.445). Predictors of mortality included the ASA grade, the number of comorbid medical conditions and active medical problems on admission. Patients over 95 were unlikely to recover their independence and at a mean follow-up of 29.3 months (12.1 to 48) 96% required permanent institutional care.

Introduction: Lumps of the foot present relatively infrequently to the orthopaedic service. There have been very few published studies looking at the differential diagnosis of such lesions and there is no clear evidence for the prevalence of malignant lesions in patients presenting with foot lumps.

Aim: To assess the prevalence of malignant lesions identified in patients presenting with a lump on the foot.

Methods: All patients presenting to a regional centre with a foot lump who required surgical excision of their lesion were identified over a 3 year period. All case notes were retrospectively reviewed. Data recorded included patient demographics, presenting characteristics, pre-operative diagnosis and histological diagnosis The centre includes a tumour service and serves a population of 550,000 patients. Tertiary referrals from out-with the direct catchment area of the centre were excluded.

Results: 101 cases presenting during this study period underwent surgery. Average age was 47.3 years (range 14–79) and there was a significant female preponderance with 73 females and 28 males. There was only one malignant tumour although 32 different histological diagnoses were identified. Only 58 out of the 101 lumps were correctly diagnosed prior to surgery.

Conclusions: We have shown that the prevalence of malignant lesion presenting as foot lumps is low but there are a wide variety of potential diagnoses which have to be considered. Pre-operative diagnosis is often inaccurate, therefore surgical excision and histological diagnosis should still be sought if there is any uncertainty.