Abstract

Abstract

Abstract

Introduction and Objective

The effectiveness of anti-embolic graduated compression stockings (GCSs) has recently been questioned. The aim of this study is to systematically review all the relevant randomised controlled trials published to date.

Introduction and Objective

Dislocation of a hip hemiarthroplasty is a significant complication with a high mortality rate in elderly patients. Previous studies have shown a higher risk of dislocation in patients with neuromuscular conditions. In this study, we reviewed our larger cohort of patients to identify if there is a link between neuromuscular disorders and dislocation of hip hemiarthroplasty in patients with neuromuscular conditions.

Continued controversy exists between cemented versus uncemented hemiarthroplasty for an intracapsular hip fracture. To assist in resolving this controversy, 400 patients were randomised between a cemented polished tapered stem hemiarthroplasty and an uncemented Furlong hydroxyapatite coated hemiarthroplasty. Follow-up was by a nurse blinded to the implant used for up to three years from surgery.

Results indicate no difference in the pain scores between implants but a tendency to an improved regain of mobility for those treated with the cemented arthroplasty (1.2 score versus 1.7 at 6 months, p=0.03). There was no difference in early mortality but a tendency to a higher later mortality for the uncemented implants (29% versus 24% at one year, p=0.3). Later peri-prosthetic fracture was more common in the uncemented group (3% versus 1.5%). Revision arthroplasty was required for 2% of cemented cases and 3% of uncemented cases. Surgery for an uncemented hemiarthroplasty was 5 minutes shorter but these patients were more likely to need a blood transfusion (14% versus 7%). Three patients in the cemented group had a major adverse reaction to bone cement leading to their death.

These results indicated that a cemented stem hemiarthroplasty give marginally improved regain of mobility in comparison to a contemporary uncemented hemiarthroplasty. An uncemented hemiarthroplasty still has a place for those considered to be at a high risk of bone cement implantation syndrome.

A consecutive series of 320 patients with an intracapsular fracture of the hip treated with a dynamic locking plate (Targon Femoral Neck (TFN)) were reviewed. All surviving patients were followed for a minimum of two years. During the follow-up period 109 patients died.

There were 112 undisplaced fractures, of which three (2.7%) developed nonunion or re-displacement and five (4.5%) developed avascular necrosis of the femoral head. Revision to an arthroplasty was required for five patients (4.5%). A further six patients (5.4%) had elective removal of the plate and screws.

There were 208 displaced fractures, of which 32 (15.4%) developed nonunion or re-displacement and 23 (11.1%) developed avascular necrosis. A further four patients (1.9%) developed a secondary fracture around the TFN. Revision to a hip replacement was required for 43 patients (20.7%) patients and a further seven (3.3%) had elective removal of the plate and screws.

It is suggested that the stronger distal fixation combined with rotational stability may lead to a reduced incidence of complications related to the healing of the fracture when compared with other contemporary fixation devices but this needs to be confirmed in further studies.

Cite this article: Bone Joint J 2013;95-B:1402–5.

Introduction

When treating a patient admitted with hip fracture it is useful to have a simple scoring system to predict outcomes, based on admission clerking and routine investigations. The Nottingham Hip Fracture Score (NHFS) is one such measure. Its use has been described by Wiles et al (Br J. Anaes. Jan. 2001) for risk stratification in predicting 30-day and 1-year mortality.

Introduction

The incidence of distal femoral fractures amongst elderly patients is likely to rise due to increased life expectancy. This study reports on the outcome of a series of distal femoral fractures treated by retrograde femoral nailing and then to compare the results for these patients with a series of patients with a proximal femoral fracture.

Objective

The aim of this study was to determine the correlation between body weight and fracture union for displaced intracapsular fracture neck of femur treated by closed reduction and internal fixation.

Introduction

Debate still exists as to the optimum method of fixation for subtrochanteric femoral fractures. Meta-analysis of studies comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures have suggested that further investigation is required in this area. We present the outcome of the largest series to date of subtrochanteric fractures treated by both methods and with a minimum of one year follow-up.

Introduction

There has been little research into the effect of suffering a simultaneous hip and upper limb fragility fracture. The aim of this study is to describe the characteristics of this important group of patients and to define the effect on outcomes such as mortality and length of stay.

The purpose of the study was to identify factors that affect the incidence of deep wound infection after hip fracture surgery.

Data from a hip fracture database of 7057 consecutively treated patients at a single centre was used to determine the relationship between deep wound sepsis and a number of factors. Fisher's exact test and the unpaired T test were used. All patients were initially followed up in a specialist clinic. In addition a phone call assessment was made at one year from injury to check that no later wound healing complications had occurred.

There were 50 cases of deep infection (rate of 0.7%). There was no significant difference in the rate of deep sepsis with regards to the age, sex, pre-operative residential status, mobility or mental test score of the patient. Specialist hip surgeons and Consultants have a lower infection rate compared with surgeons below Consultant grade, p=0.01. The mean length of anaesthesia was longer in the sepsis group (76minutes) compared to the no sepsis group (65minutes), this was significant, p=0.01. The patient's ASA grade and fracture type were not significant factors. The rate of infection in intracapsular fractures treated by hemiarthroplasty was significantly greater than those that had internal fixation, p=0.001. The rate of infection in extracapsular fractures fixed with an extra-medullary device was significantly greater than those fixed with an intra-medullary device, p=0.021. The presence of an infected ulcer on the same leg as the fracture was not associated with a higher rate of deep infection. In conclusion we have found that the experience (seniority) of the surgeon, the length of anaesthesia and the type of fixation used are all significant factors in the development of deep sepsis. These are all potentially modifiable risk factors and should be considered in the treatment of hip fracture patients.

Maintaining femoral neck cortical thickness may help prevent hip fracture. Fracture initiation probably starts superiorly at flaws, ie where the cortex is thinnest. Whole body computed tomography (QCT) is now being used to study cortical thickness but limited resolution (> 300 micrometers) makes in vivo estimates imprecise, whereas microscopy s resolution approaches 1 micrometer. We have therefore extended our microscopic studies on femoral neck biopsies to include men (14 cases, 26 controls) and women (50 cases, 23 controls), and here provide data on true cortical thickness in subjects with and without hip fracture.

Whole femoral neck cross-sections obtained at hemiarthroplasty (or at post-mortem in controls) were embedded in methacrylate, cut, stained and imaged at medium power. Image-J was used to define cortical boundaries and to measure cortical thicknesses at 5 degree intervals of arc from the cross-sections centre of area.

We confirmed that the mid-femoral neck (or narrow neck) site, defined as where the ratio of maximum to minimum neck diameter (max:min) is 1.4, shows great asymmetry, with the thick inferior cortical octant averaging over 3mm thickness (mean age 79 years inter-quartile range 74-85). In the superior 3 octants cortical thickness averaged 26% of that seen inferiorly. To assess statistical determinants of cortical thickness, the data were modelled with linear regression in octants after adjusting for subjects age, sex, max:min, and hip fracture status. To achieve normality of residuals the cortical thickness data were log-transformed. 95% of measured cortical thicknesses fell between 45% and 220% of the mean for octant. In the thinner, superior three octants, minimum thicknesses were just under 0.3 mm in the fracture cases ie close to 35% of the subjects mean for octant. Cases had about 17% thinner cortical thicknesses in all octants than controls, while female controls had cortical thicknesses that uniformly averaged 90% of male. In conclusion, compared to gender and age-matched controls, intra-capsular hip facture cases had generalized cortical thinning in all mid-neck octants. This disease effect contrasts markedly with the effect of normal ageing, which thins preferentially the mechanically under-loaded superior cortex and spares the infero-anterior cortex.

Hip fractures are common injuries in the elderly, with significant mortality and morbidity from several factors. Many of these patients have cardiac disease, and some develop cardiac complications which may increase mortality.

Troponin T is a marker of myocardial injury but can be raised in other conditions. Patients over 60 years old admitted with hip fracture during the study period had their troponin T measured on admission and following surgery. Assay was performed after the patient had completed their treatment. We report the results of this study one year after the last patient was admitted.

108 patients were recruited. The average age was 84 years; 86% were female. This study found that 27% of hip fracture patients had some increase in the troponin T levels in the peri-operative period. This increase was not associated with an increase in early mortality, but there was an increase in one-year mortality for those with an increase in troponin T (45% versus 22%, p=0.03). These findings indicate that the routine measurement of troponin T after a hip fracture is unnecessary.

In order to define the optimum timing of surgery for a hip fracture, we undertook a systematic review of all previously published studies on this topic. Data from the retrieved studies were extracted by two independent reviews and the methodology of each study assessed. In total, 43 studies involving 265,137 patients were identified. Outcomes considered were mortality, post-operative complications, length of hospital stay and return of patients back home.

There were no randomised trials on this topic. Six studies of 8535 patients have the most appropriate methodology, which was prospective collection of data with adjustment for confounding variables. These studies found no effect on mortality for any delays in surgery. One of these studies found fewer complications for those operated on early but this was not found in the other study to report on these outcomes. Two of these studies reported on hospital stay, which was reduced for those operated on early. Six studies of 229,418 patients were retrospective reviews of patient administration databases with an attempt at adjusting for confounding factors. They reported a reduced mortality, hospital stay and complications for those operated on early. Thirty-one other studies of variable methodology reported similar findings of reduced complications with early surgery, apart from one study of 399 patients which reported an increased mortality and morbidity for those operated on within 24 hours of admission.

In conclusion those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. But early surgery (within 48 hours of admission) does seem to reduce complications such as pressure sores and reduces hospital stay.

The two commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. To determine if any difference in outcome exists between these implants we undertook a prospective randomised controlled trial of 300 patients with a displaced intracapsular hip fractures.

All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility.

The average age of the patients was 83 years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups, with 34/151 having died at one year in the cemented group and 45/149 in the uncemented group. Pain scores (grade 1-6) were less for those treated by a cemented prosthesis (mean score 1.8 versus 2.4, p value <0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay. Operative complications are as listed. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group.

In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended.

1133 patients with an intracapsular fracture of femoral neck treated by internal fixation were prospectively studied. All surviving patients were followed up for a minimum of one year from injury. The overall incidence of non-union was 229 (20.2%) and the incidence of avascular necrosis was 61 (5.4%). Fracture non-union was less common for undisplaced fracture in comparison to displaced fractures (48 out of 565 (8.5%) versus 181 out of 568 (31.9%)) and in males than females (45 out of 271 (16.6%) versus 184 out of 862 (21.3%)). The incidence of non-union progressively increased with age from one out of 17 (5.9%) in those aged below 40 years to 84 out of 337 (24.9%) in those in their seventies. For those in their eighties the incidence of non-union began to fall, but if those patients who died within one year from injury were excluded, then the incidence was found to continue to increase. For avascular necrosis there was a falling incidence with age from 9 out of 68 (13.2%) in those aged less than 50 years to 10 out of 388 (2.6%) in those aged over 80 years.

The information from this large series of patients treated by contemporary methods enables the surgeon to use the three factors of age, sex and presence of fracture displacement to predict the risk of non-union or avascular necrosis occurring.

Fractures of the proximal femur at the level of the lesser trochanter (reversed and transverse fracture lines, Evans classification type II, AO classification 31. A3 fractures) are known to have an increased risk of fixation failure. 53 patients with such a fracture were randomised to have the fracture fixed with either an intramedullary nail (220 mm Targon Proximal Femoral nail) or a Sliding Hip Screw (SHS). The mean age of the patients was 82 and 11% were male. All patients were followed up for one year by a research nurse blinded to the treatment groups.

Mean length of surgery was 51 minutes for the nail versus 53 minutes for the SHS. There were no differences between groups in the need for blood transfusion. Operative complications tended to be less for the nail group (1/27 versus 5/26). Mean hospital stay was 17 days for the nail group versus 29 days for those treated with the SHS (p< 0.0001). The only fracture healing complications were one case of cut-out in each group requiring revision surgery. During follow-up those patient treated with the nail reported significantly lower pain scores than those treated with the SHS (p=0.08). This difference persisted even at one year from injury. In addition there was a tendency to a better regain of mobility in the first nine months from injury for those treated with the nail.

These results indicate that for these difficult fractures types an intramedullary nails produces superior results to the Sliding Hip Screw.

The Targon Femoral Neck Hip Screw has been designed to improve the fixation of intracapsular hip fractures. Fracture healing complications after internal fixation occur in approximately 30–40% of displaced fractures and 5–10% of undisplaced fractures. The new implant consists of a small plate with six locking screw ports. The two distal holes are used to fix the plate to the lateral cortex of the femur. Three of four screws are passes through the proximal holes and across the fracture site. These 6.5mm screws are dynamic to allow for collapse of the fracture across the femoral neck. A jig is used to aid insertion of the device with minimal surgical exposure of the femur.

For the first 200 patients treated with this implant at the first centre to use this implant, the mean age of the patients was 77 years (range 39–103), 58% were female. The mean length of surgery was 46 minutes and the mean length of anaesthesia 59 minutes. The median length of institutional stay till discharge home was 9 days (mean 13 days, range 3–107). Four telescoping screws were used in 55% of patients, three in 44% and two in 1% of patients.

Follow-up of patients at present is a minimum of six months. For the 74 undisplaced fractures there has been one case of non-union and one case of avascular necrosis. For the 121 displaced fractures (Garden III and IV) there have been eleven cases of fracture non-union, six cases of avascular necrosis and two cases of plate detachment from the femur treated by repeat fixation. In addition there was one deep wound sepsis treated by removal of the implant and girdlestone arthroplasty. For the four basal fractures treated there has been one case of plate detachment from the femur.

Observation of those fractures that have healed shows there has been between 0 to 22mm of collapse at the fracture site which occurs along the line of the femoral neck. There has been no tilting of the fracture into varus as occurs with a parallel screw method.

The results to date show an incidence of fracture healing complications is about a third that which is to be expected with a parallel screw method. This new implant may be a significant advance in the treatment of this difficult and common fracture.

To determine if any notable differences between a cemented Thompson stem hemiarthroplasty and a cemented Exeter stem hemiarthroplasty (ETS), 200 patients with a displaced intracapsular fracture were randomised between the two prosthesis. Surviving patients were followed-up for one year by a nurse blinded to the treatment allocation. The mean age of patients was 84 years and 13% were male.

There were no differences between groups for the length of surgery, need for blood transfusion or hospital stay. Implant related complications were three minor operative fractures of the femur in each group. Two patients in the Thompson group had dislocation of the prosthesis requiring revision surgery and one further patient in the Thompson group had late acetabular wear requiring conversion to a total hip replacement. One further patient in the Thompson group had cement retained in the acetabulum. In total therefore only three patients, all in the Thompson group, which required revision surgery. Easy of surgery was assessed subjectively by the surgeon and reported to be easier for the ETS group (p=0.0002). During follow-up there was no significant difference in the degree of residual pain between groups.

Conclusions are that the cemented Exeter stem hemiarthroplasty has some advantages over the traditional cemented Thompson hemiarthroplasty.

400 patients with a trochanteric hip fracture were randomised to fixation with either a 220mm long Targon PF (proximal femoral) nail or a Sliding Hip Screw. All surgery was undertaken or supervised by one surgeon. All patients were followed up for a minimum of one year by a blinded observer.

The mean age was 82 years (range 27 to 104 years), 20% were male. Mean length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p< 0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality.

Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There were only once compilations in the nailed a case of cut-out which required secondary surgery. At follow-up there was no difference in pain scores between groups but there was a tendency to improved mobility in the nailed group (p=0.004).

These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails. Intramedullary fixation can result in a lower re-operation rate (3.5% versus 0.5%) and improved mobility in comparison to the sliding hip screw.

There is continuing debate regarding the merits of internal fixation versus arthroplasty for intracapsular hip fractures. For displaced fractures there is a higher risk of fracture healing complications but many of the studies reporting on this are now from some years ago using surgical methods that are now outdated. The aim of our study was to determine the incidence of avascular necrosis (AVN) related to age, gender, displacement and operation delay for a large series of patients with intra-capsular fractures treated with internal fixation using contemporary methods.

We prospectively studied 1023 patients, 988 fractures were internally fixed with three cannulated screws and 35 with a sliding hip screw. The average length of radiographic follow-up for those patients who survived to one year was 337 days (range 25 to 3521 days). The average age of the patients was 75.4 years (range 16–100); 243 (23.8%) were male. The overall incidence of AVN was 6.6%. AVN was less common (p=0.0004) for undisplaced fractures than for displaced fractures (21 of 528 [4.0%] vs 47 of 495 [9.5%]) and in men than women (p=0.03) who had a displaced fracture (7 of 143 [4.9%] vs 40 of 352 [11.4%]). The incidence of AVN for those aged less than 60 years and who sustained a displaced fracture was 20.6%, compared to 12.5% for those aged 60–80 years and 2.5% for those aged more than 80 years (p< 0.0001). We found no association between the incidence of AVN and operation delay.

Our study showed an increased risk of AVN with younger age and in females with a displaced fracture. This is in contrast to the decreased incidence of non-union seen with younger age. Knowledge of the predicted incidence of fracture healing complications should help surgeons make a more balanced decision between internal fixation and arthroplasty for this condition.

The Targon Femoral Neck Hip Screw has been designed to improve the fixation of intracapsular hip fractures. The new implant consists of a small plate with six locking screw ports. The two distal holes are used to fix the plate to the lateral cortex of the femur. Three of four 6.5mm cancellous screws are passes through the proximal holes and across the fracture site. The proximal screws are dynamic to allow for collapse of the fracture across the femoral neck. A jig is used to aid insertion of the device with minimal surgical exposure of the femur.

For the first 91 patients treated with this implant, the mean age of the patients was 75 years (range 46–103). The mean length of surgery was 45 minutes. The median length of hospital stay till discharge home was 8 days). For the 43 undisplaced fractures there has been one case of non-union and one case of avascular necrosis. For the 48 displaced fractures (Garden III and IV) there have been five cases of fracture non-union and one case of plate detachment from the femur treated by repeat fixation. In addition there was one deep wound sepsis treated by removal of the implant and girdlestone arthroplasty.

Observation of those fractures that have healed shows there has been between 4 to 18mm of collapse at the fracture site which occurs along the line of the femoral neck. There has been no tilting of the fracture into varus as occurs with a parallel screw method.

The results to date show an incidence of fracture non-union that is about a third that which is to be expected with a parallel screw method. This new implant may be a significant advance in the treatment of this difficult and common fracture.

The Sliding Hip Screw (SHS) is currently the treatment of choice for all trochanteric hip fractures. An alternative treatment is the short femoral nail. Earlier designs of these nails were associated with an increased fracture healing complication rate in comparison to the sliding hip screw. The new designs of nails (third generation nails) may however be as good as or even superior to sliding hip screw fixation.

We conducted a large randomised trial to compare the Targon Proximal Femoral Nail with the Sliding Hip Screw. Patients with trochanteric hip fractures as per the AO classification (A1–A3) were randomised to either implant. All surgery was supervised by one surgeon. All patients were followed up for a minimum of one year months by a blinded observer.

The mean age was 82 years, range 27 to 104 years), 20% were male. Length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p< 0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality. Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There was only one compilation in the nailed a case of cut-out which required secondary surgery. At follow-up no difference in pain scores but there was a tendency to improved mobility in the nailed group (p=0.004).

These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails. Intramedullary fixation can result in a lower re-operation rate (3.5% versus 0.5%) and improved mobility in comparison to the sliding hip screw.

Introduction: Fractures of the neck of femurs in amputees have been reported sporadically in literature. We reviewed a series of 19 amputees who presented with a fracture neck of femur to analyse their mobility and pain scores at the end of one year and compared them with other patients presenting with the same condition.

Methods: We retrospectively analysed prospectively collected data for fractures of the proximal femur on all patients with amputations of the lower limb. Details on admission of all consecutive admission to one hospital were recorded from 1989 onwards including age, sex, type of amputation, fracture type, mechanism of injury, peri-operative mobility and rehabilitative status up to 1 year post operatively.

Results: Nineteen (19) patients with 22 amputations, sustaining 20 fractures of the neck of femurs were treated among approximately 6500 neck of femur fractures in our hip fracture database. Of these 7 were male and 12 were female. The mean age was 79 years with a range of 50–89 years. 17 patients had undergone below knee amputations (BKA) and 5 above knee amputations (AKA). Thirteen patients came from their own homes with thirteen patients being mobile pre-operatively while 6 were bed bound. All patients were alert and scored well on mental test scores. Intracapsular fractures were the most common type with AO Screw fixation being the most common operative management. Hospital stay was an average of 7 days with a range of 1–90 days. Thirteen of our cohort of patients survived more than a year after the fracture operation. Post operative mobility scoring revealed that most of our patients returned to their preoperative mobility level except for those that did not survive for the first year.

Discussion: Fractures of the neck of femurs have an increasing incidence in an expanding aging population with nearly 60000 fractures treated in the United Kingdom every year. Amputees suffer from accelerated bone density loss and are at an increased risk for osteoporosis and fragility fractures in the hip. The future prospect with an increasing population of amputees with fracture neck of femurs must be addressed so that appropriate management plans can be implemented to allow such patients to return to full mobility and active lifestyle. This also decreases other co-morbidities such as pressure sores and infection.

Approximately one third of our patients survived between 1 to 4 years and another third survived between 5 to 10 years with one patient surviving over 10 years with nearly returning to their pre-injury status. We suggest that satisfactory post operative function is achievable with either internal fixation or hemiarthroplasty.

We conclude that these fractures should be treated with the same urgency and expertise as similar fractures in non-amputees as long term survival and good quality of life can be expected.

Background: Venous thromboembolism (VTE) remains a significant cause of morbidity and mortality of patients following hip fracture. It is not known preoperatively which patients are at greater risk of developing VTE complications following their surgery. This study reports the incidence of VTE following neck of femur fracture, the timing of the diagnosis of VTE and any risk factors associated with VTE development.

Materials and Methods: We analysed the prospectively recorded complications of patients that presented with a neck of femur fracture. Those patients that developed VTE were compared to those with no complications and their risk factors compared.

Results: A total of 5300 patients were analysed. The incidence of VTE was 2% despite thromboprophylaxis. The significant risk factors for VTE were poor pre operative mobility (p< 0.01), those preoperatively living in their own home (p< 0.01), low mental test score (p< 0.01), high postoperative haemoglobin (p< 0.03), intertrochanteric fractures and fixation with a dynamic hip screw (p< 0.01).

Conclusions: This is the largest group of patients to be prospectively analysed for risk factors for developing VTE following surgery for neck of femur fractures. There were a number of groups that were at a significantly higher risk of developing VTE than others. Orthopaedic surgeons should be aware of these groups in the management of these vulnerable patients.

To determine the optimum choice of treatment for the displaced intracapsular fracture in the elderly, 455 patients aged over 70 years with a displaced intracapsular fracture were entered into a prospective randomised trial. Treatment was either an uncemented Austin Moore hemiarthroplasty or reduction and internal fixation with three AO cancellous screws. Analysis of pre-operative characteristics of patients showed there was no significant difference between the two groups.

Follow-up of surviving patients was continued for between seven to 15 years to determine the long-term outcome for the two treatment Methods: 90% of patients died during this follow-up period.

Regarding short term outcomes, internal fixation resulted in a reduced mean operative time, operative blood loss and transfusion requirements.

There was no significant difference in the length of hospital stay or incidence of general post-operative complications. There was no difference in either the short term or long-term mortality between the two procedures. The need for revision surgery to the hip was increased for those treated by internal fixation (7% versus 38% implant revision rate). There was no difference in the degree of residual pain between groups neither was there any difference in the number of patients requiring institutional care. There was a tendency to slightly better mobility for those treated by internal fixation although the Results: were not statistically significant. These results demonstrate that both treatment methods produce comparable final outcomes but internal fixation is associated with an increased re-operation rate.

A hip fracture may lead to anaemia after surgery due to blood loss from the fracture site and operative blood loss. The value of iron supplementation for this group of patients remains controversial. A randomised trial was undertaken for 300 patients who had a haemoglobin of less than 110g/l after surgery. Patients were randomised to take either ferrous sulphate, (200mg twice daily for four weeks) or had no iron therapy. Patients were followed up to one year after surgery.

The mean age of patients was 82 years. 19% were male. The mean difference between admission haemoglobin and the haemoglobin taken 6 weeks after discharge was 7.3g/l in the iron supplementation group and 8.3g/l in the group that did not receive iron supplementation (p value 0.5). There was also no statistically significant difference between groups for hospital stay (19 versus 21 days) or mortality. 18% of those allocated to iron therapy reported side effects from the medication.

This study indicates that routine oral iron supplementation for anaemia after hip fracture surgery is not appropriate.

Background: Numerous researchers have documented posterior comminution to confer an increased incidence of non-union and avascular necrosis after internal fixation of both displaced and undisplaced intracpasular hip fractures. This prospective study of 1247 patients questions this association and shows that comminution does not cause a statistically significant increase in these complications of fracture healing.

Methods: Twelve hundred and forty-seven patients with 1247 intracapsular hip fractures (568 undisplaced and 679 displaced fractures) were treated with open reduction and internal fixation. All these had preoperative radiographs, which were evaluated for posterior comminution. All of them were followed up post-operatively for clinical and radiographic evidence of non-union and avascular necrosis. The incidence of complications in comminuted versus non-comminuted fractures was calculated in both undisplaced and displaced groups. These rates were then compared for statistical significance (p value =0.05).

Results: The undisplaced cases (n=568) comprised 557 non-comminuted and 11 comminuted fractures. The complication rates were 10.9% and 18.2% respectively. The difference was not significant, with a p value of 0.38. Displaced fractures (n=679) consisted of 588 non-comminuted and 91 comminuted cases. In this group, complication rates were 33% and 35% respectively, with a p value of 0.82.

Conclusions: For the 1247 patients studied, there was no association between the observation of comminution of the fracture on the pre-operative x-rays and the later development of fracture healing complications.

A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores by analysing prospectively collected data of 4654 consecutive patients (1003 males/3473 females). 3.8% developed pressure sores in the sacral, buttock or heel areas.

Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (4.65 versus 5.76), diabetes mellitus (pressure sore incidence 10.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor.

While the time interval between fall and admission was not significant, the time interval between admission and surgery was found to be an extremely significant risk factor. A fall in blood pressure during surgery (5.6%) was found to increase risk. Patients who underwent a dynamic hip screw were more likely to develop pressure sores (incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery or type of anaesthesia. Our incidence of pressure sores is lower than previously reported (30%). Whilst determining factors that increase the risk of pressure sores may not be sufficiently reliable to be used for the individual patient, taking appropriate preventative measures can reduce the incidence, particularly with reference to (optimising the patient pre-operatively and) reducing delays to surgery.

It is unclear which length of thread may be most advantageous for the internal fixation of an intracapsular fracture with cancellous screws. We have compared the 16mm versus the 32mm threads on cancellous screws within a randomised trial for 432 patients. All fractures were fixed with three screws and patients followed-up for a minimum of one year from injury.

The characteristics of the patients in the two groups was similar with a mean age of 76 years. 23% were male. The most common complication encountered was non-union of the fracture which for undisplaced fractures occurred in 7/107(6.5%) of short threaded screws versus 11/133(8.3%) of long threaded screws. For displaced fractures the figures were 29/104(27.9%) versus 24/89(27.0%). Other complications for the short versus long threaded group were avascular necrosis (two cases versus five cases) and fracture below the implant (two cases in each group). Elective removal of the screws for discomfort was undertaken in five and three cases respectively. None of these differences between groups was statistically significant. In summary there is no difference in fracture healing complications related to the length of the screw threads.

Hip fractures are one of the leading causes of morbidity in the elderly population. A large reduction in morbidity can be achieved if these individuals can have definitive treatment rapidly. However, this is not always achievable to a multi factorial host of contributing factors. Therefore, to enable us to understand some aspect of why these delays, if any occur, the following study was undertaken.

The purpose of the study is to relate the place at which the patient fell, to the time of day for admission to casualty. This will enable us to ascertain whether there is a relationship between the location of injury and the time taken to admission into hospital; if there is such a correlation, then it will enable us to identify factors which will expedite an individuals attendance to hospital.

Designs: Retrospective analysis of prospectively collected data for 5273 consecutive admission to one centre with a confirmed proximal femoral fracture from January 1989 to November 2006.

Setting: Peterborough District Hospital

Results: Individuals who sustained an injury inside their own home living alone were more likely to suffer a delay in attendance to the hospital with a fracture (Median 8 hours), compared to individuals who live in there own home living with one or more individual (Median 3 hours) or those who fell indoors at other locations (Median 5 hours) or outside (Median 2 hours) were their falls were witnessed. Also it was noticed that patients living in there own homes fell during the early hours of the day, while patients who had a fall outside fell mainly during ‘working hours’ where as patients in hospital mainly had a fall during night time or mid day.

Conclusion: There is a quantifiable correlation demonstrated between place of injury and the delay in attendance to hospital.

A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores

We have analysed prospectively collected data of 4654 consecutive patients (1003 males/3473 females).

3.8% developed pressure sores in the sacral, buttock or heel areas. Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (5.7 versus 6.7), diabetes mellitus (pressure sore incidence 9.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor. Among surgical factors related to an increased risk was a fall in blood pressure during surgery (5.6%). Patients who underwent a dynamic hip screw were more likely to develop pressure sores (pressure sore incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery of type of anaesthesia.

Our study indicates that the current incidence of pressure sores is lower that that previously reported (30%). Whilst it is possible in a large population of patients to determine factors that increase the risk of pressure sores, these are not sufficiently reliable to be used for an individual patient.

1133 patients with an intracapsular fractures of femoral neck treated by internal fixation were prospectively studied. All surviving patients were followed up for a minimum of one year from injury. The overall incidence of non-union was 229(20.2%) and the incidence of avascular necrosis was 61(5.4%). Fracture non-union was less common for undisplaced fracture in comparison to displaced fractures [48 out of 565(8.5%) versus 181 out of 568(31.9%)] and in males than females [45 out of 271(16.6%) versus 184 out of 862(21.3%)]. The incidence of non-union progressively increased with age from one out of 17(5.9%) in those aged below 40 years to 84 out of 337(24.9%) in those in their seventies. For those in their eighties the incidence of non-union began to fall, but if those patients who died within one year from injury were excluded, then the incidence was found to continue to increase. For avascular necrosis there was a falling incidence with age from 9 out of 68(13.2%) in those aged less than 50 years to 10 out of 388(2.6%) in those aged over 80 years.

The information from this large series of patients treated by contemporary methods enables to surgeon to use the three factors of age, sex and present of fracture displacement to predict the risk of non-union or avascular necrosis occurring.

In order to define the optimum timing of surgery for a hip fracture, we undertook a systematic review of all previously published studies on this topic. Data from the retrieved studies was extracted by two independent reviews and the methodology of each study assessed. In total, 43 studies involving 265137 patients were identified. Outcomes considered were mortality, post-operative complications, length of hospital stay and return of patients back home.

There were no randomised trials on this topic. Six studies of 8535 patients have the most appropriate methodology, which was prospective collection of data with adjustment for confounding variables. These studies found no effect on mortality for any delays in surgery. One of these studies found fewer complications for those operated on early but this was not found in the other study to report on these outcomes. Two of these studies reported on hospital stay, which was reduced for those operated on early. Six studies of 229418 patients were retrospective reviews of patient administration databases with an attempt at adjusting for confounding factors. They reported a reduce mortality, hospital stay and complications for those operated on early. Thirty-one other studies of variable methodology reported similar findings of reduced complications with early surgery apart from one study of 399 patients, which reported an increased mortality and morbidity for those operated on within 24 hours of admission.

In conclusion those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. But early surgery (within 48 hours of admission) does seem to reduce complications such as pressure sores and reduces hospital stay.

This study was conducted to find out whether blood transfusion was an independent risk factor for mortality and wound infections after hip fracture surgery.

A retrospective cohort study analysed prospectively collected data for 3571 hip fracture patients undergoing surgery over the last 15 years in one institution. Out of these 1068 patients underwent blood transfusion.

There were no significant differences in the mortality values at 30, 120 and 365 days and in the rates of infection (superficial and deep) in the two groups (transfused and non-transfused).

Conclusion: Blood transfusion does not significantly increase mortality or infection following hip fracture surgery.

One of the most common early complications after hemiarthroplasty is dislocation, with an incidence of 2 to 4%. After dislocation the mortality and morbidity are significantly increased to in excess of 50%.

It has been claimed that a bipolar hemiarthroplasty has a lower risk of dislocation than a unipolar implant. In addition it has been suggested that patients with either Parkinson’s disease or a previous stroke are at increased risk of dislocation. We investigated these claims by performing a comprehensive literature search of articles published in the last 40 years and data obtained from our own hip fracture database.

From the literature review, 133 reports involving 21,872 patients were retrieved. A further 1235 hip fractures treated by hemiarthroplasty were recorded from our database. 791 (3.4%) dislocations were recorded. Dislocation rate for unipolar prosthesis was higher than bipolar prosthesis (3.9% versus 2.5%). Dislocation rate for posterior surgical approach was higher than for anterior approach (5.1% versus 2.4%). Dislocation rate for cemented prosthesis was 3.6% versus 2.3% in un-cemented prosthesis. However, the effect of the type of implant becomes non-significant on adjusting for the use of cement and surgical approach. The incidence of open reduction after dislocation was increased with bipolar implants. Patients with Parkinson’s disease showed a highly statistically significant increase in dislocation rate (8.7% to 3.4%). The dislocation rate with respect to ipsilateral hemiplegia was 1.6%.

This study indicates there is no difference in the dislocation rate between a unipolar and bipolar prosthesis but if a bipolar prosthesis dislocates, there is an increased risk of failure to reduce the prosthesis by closed means. Patients with Parkinson’s disease are at an increased risk of dislocation but this is not the case for those with a hemiplegia. To minimise the risk of dislocation of a hemiarthroplasty, particularly in those patients with Parkinson’s disease, a unipolar hemiarthroplasty inserted via an antero-lateral approach is recommended.

We report the results of a consecutive series of 500 patients treated with a follow-up range from 5–12 years.

Ten patients were lost to follow-up and 398 patients [81%] died. The mean age was 82 years, with 85% being women. Forty-six patients [9.2%] required a second operation of any type, with revision performed in 23 [4.6%]. Of the long-term survivors 66 [81%] had none or minimal pain, whilst 5 [6%] had reported constant pain in the hip.

This is the largest consecutive series, with the following follow-up, reported and for the frail elderly patient this prosthesis can still be recommended.

Aim: Intracapsular hip fractures in young adults have a significant risk of fracture healing complications. Consequently, some authors advocate urgent and/or open fracture reduction. Our aim was to analyse outcomes following such fractures with reference to influence of fracture displacement, timing of surgery and method of reduction (open/closed) on the incidence of non-union (NU) and avascular necrosis (AVN).

Methods: Specific search terms were used to retrieve relevant published studies from 1966 to May 2003.

Results: Eighteen studies involving 564 fractures were analysed. The overall incidence of NU was 50/564 (8.9%) and AVN was 130/564 (23.0%). There was a higher incidence of NU and AVN following displaced than undisplaced fractures. NU occurred more frequently after open reduction than closed reduction (10/89 [11.2%] versus 13/275 [4.7%])

There was an increased incidence of AVN after closed than open reduction but this became not statistically significant when one study with a markedly higher reported incidence of AVN was excluded.

The difference in the incidence of NU and AVN following early (< 12 hours) or late (> 12 hours) surgery was not significant for either NU or AVN.

Conclusion: Early or open reduction of these fractures may not reduce the risk of NU or AVN. There is a suggestion of a higher incidence of NU following open reduction than closed reduction. Randomised studies with two year follow-up are required to report on a larger number of patients before definite conclusions on treatment can be made.

Introduction: This study was conducted to find out whether blood transfusion was an independent risk factor for mortality and wound infection after hip fracture surgery.

Materials and Methods: A retrospective cohort study analysed prospectively collected data for 3571 hip fracture patients undergoing surgery over the last 15 years in one institution. Out of these 1068 patients underwent blood transfusion.

Results: There were no significant differences in the mortality values at 30, 120 and 365 days and in the rates of infection (superficial and deep) in the two groups(transfused and non-transfused).

Conclusion: Blood transfusion does not significantly increase mortality or infection following hip fracture surgery.

Introduction and aim There are different methods of internal fixation of intracapsular fractures of the hip of which three AO screws is one of the more popular. There have been no evidence-based publications describing the optimal position for screws. The aim was to establish the relationship between screw position and angle, and subsequent failure of union.

Method Using computer software we studied the position of AO screws in 395 consecutive patients inserted between 1989 and 2003. Follow-up was prospective and for a minimum of 100 days. The diagnosis of non-union was made clinically and confirmed radiographically.

Results The mean age of our population was 73.9 years (range 22–96). Eighty-six (21.8%) were male. Three hundred and twenty seven (82.8%) came from their own home. The mean time between fall and surgery was 37.0 hours and between admission and surgery 20.9 hours. The mean length of radiographic follow-up for those fractures that did not develop non-union was 454 days (range 94–1898). Of the 395 patients 242 (61%) fractures united and 153 (39%) fractures suffered non-union.

Radiographic analysis suggests that the position of the screws on the AP view (superior, middle, inferior or spread) did not alter the outcome significantly. However three factors were related to lower risk of non-union on the lateral view: the closer the middle screw to the center of the head (p< 0.04), the more anterior the anterior screw (p< 0.008), and the greater the ‘spread’ between the anterior and posterior screws (p< 0.005).

Conclusions We conclude that to reduce the risk of non-union with screw fixation of intracapsular fractures of the hip, in the lateral view the middle screw must be positioned as close to the centre of the femoral head as possible, and the anterior and posterior screws achieve maximal spread.

Conventional treatment for nondisplaced intracapsular hip fractures is with cannulated screws. Some authors have argued that in the older patient a hemiarthroplasty offers a better outcome even in the case of a nondisplaced fracture. We have compared the outcomes of an age, sex & co-morbidity matched cohort of 346 patients who have had their nondisplaced hip fracture treated using cannulated screws with a group of 346 patients who have had a displaced fracture treated with a hemi-arthroplasty. The average age of the patients studied was 80.8 years. All operations were carried out at Peter-borough District Hospital and the follow up data was collected as part of the hip fracture project. Operation time, hospital stay and peroperative complication rate are less for the fixation group. They also have better outcomes in terms of pain, use of walking aids and mobility scores at one year. Mortality is 4% less at one year in the patients treated with screws and this, again, is statistically significant. There is no difference in terms of residential status at one year. In patients where the fracture is initially treated with cannulated screws the reoperation rate is considerably higher (17 % versus 6%) but length of stay is less for secondary procedures. We feel that there is little evidence to justify the use of hemi-arthroplasty in nondisplaced femoral neck fractures in patients of any age.

Background: Reverse obliquity and transverse fractures of the proximal femur represent a distinct fracture pattern in which the mechanical forces displace the femur medially thus increasing the risk of fixation failure. There is a paucity of published literature in this area of trauma. This study constitutes the largest series of such fractures.

Methods: Using the hip fracture registry at this institution 101 reverse obliquity and transverse fracture patterns were identified from 3336 consecutive hip fractures. All surviving patients were followed up for 1 year.

Results: Of 100 patients treated operatively, 59 were treated with 1350 sliding hip screws (SHS), 22 were treated with 1350 sliding hip screw devices designed to resist medialization (3 sliding hip screws with trochanteric plate and 19 Medoff plates), and 19 were treated with intramedullary sliding hip screw devices (1 short Gamma nail, 9 long Gamma nails, 6 Reconstruction nails, 6 long Targon nails, 1 short Targon nail). The SHS had 4 failures (6.8%), and the intramedullary devices one failure (5.3%). Those extramedullary devices augmented to prevent medialization had higher failure rates (1 of 3 SHS with trochanteric plate and 3 of 19 Medoff plates), with combined failure rate of 15.8%.

Conclusion: The 1350 SHS and the intramedullary devices had similar failure rates of 6.8% and 5.2% respectively. Those extramedullary devices designed to prevent medialization had higher failure rates (combined failure rate of 4/22 or 18%). This is similar to the high failure rate in 950 devices reported elsewhere. This suggests that extramedullary devices attempting to combat the difficult biomechanics of these fractures are unsuccessful. Better results can be obtained by using the standard 1350 SHS or with intramedullary sliding hip screw devices.

Introduction: Treatment for ruptured Achilles tendon can be classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing); post-operative splintage can be with a rigid cast or functional brace. The aim was to identify and summarise the evidence from randomised trials of the effectiveness of different interventions.

Methods: We searched the Cochrane specialised register, MEDLINE, reference lists of articles and contacted trialists directly for all randomised and quasiran-domised trials comparing different treatment regimes for acute Achilles tendon ruptures.

Results: Fourteen trials involving 891 patients were included.

Open operative treatment compared with non-operative treatment was associated with a lower risk of re-rupture (odds ratio (OR) = 0.25, 95% confidence interval (CI) = 0.1–0.6, p=0.003) but a higher risk of other complications including infection, adhesions and disturbed sensibility (OR = 14.1, 95%CI = 6.3–31.7, p< 0.00001).

Open versus percutaneous operative surgical repair was associated with a longer operation duration and higher risk of infection (OR = 12.9, 95%CI = 1.6–105.6, p=0.02).

Patients splinted with a functional brace rather than a cast post-operatively tended to have a shorter in-patient stay, less time off work, quicker return to sporting activities and fewer reported complications (p=0.0003).

Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques and different non-operative regimes.

Conclusions: Open operative treatment significantly reduces the risk of re-rupture but has the drawback of a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay and time off work and sports.

Previous studies on the timing of hip fracture surgery provide limited and conflicting evidence as to whether early operative intervention influences length of hospital stay, functional outcome and mortality rate. The aim of this study was to determine in a large, consecutive and prospectively followed group of patients the effect of a delay to surgery other than for medical reason. Patients who met the following criteria were included in the study: 1) Fragility fracture of the proximal femur. 2) Age over 60. 3) Complete data sets. 4) Complete follow up. Excluded patients were: 1) Younger than 60 years of age. 2) Conservative fracture treatment. 3) Pathological fracture. 4) Delay from admission to surgery for any medical reason. All patients were subdivided into six groups according to the delay between admission and operation (A:1–12 hours, B:13–24 hours, C:25–36 hours, D:37–48 hours, E:49–72 hours, F:73 + hours). All patients were followed up for one year or until death. Data on the mean length of hospital stay and the discharge destination as a parameter for the functional outcome were analysed in each of the six groups. A total of 3628 patients met the inclusion criteria. The average age was 81 years. 95.2% of patients were operated on between 1 and 48 hours after the admission, and 4.8% between 49 or more hours after the admission. Reason for delay was either lack of theatre time or unavailability of a surgeon or an anaesthetist. Statistical analysis with the unpaired t-test showed a significant difference in the hospital length of stay of 21 days for patients operated within 48 hours of admission versus 32 days for patients operated after 48 hours (p The functional outcome was significantly worse in the group with a delay of more than 48 hours with only 71% of patients discharged to their own home (86% in the early group, p< 0.0001). This study provides further and conclusive evidence that early operative intervention in elderly patients with fragility fractures of the proximal femur results in a decreased hospital stay and a better functional outcome.

Aim: Compressive forces on the medial femoral cortex and tensile forces at the lateral femoral cortex along with cortical comminution lead to a high risk of failure of surgical fixation of subtrochanteric fractures. The purpose of the study was to correlate the incidence of fracture healing complications to the surgical stabilisation method used.

Methods: A comprehensive search of various data sources extending from 1966 to October 2003 was conducted to identify appropriate studies using specific search terms. We also scanned the reference lists of eligible studies for potentially relevant reports. Articles of all languages were considered. Studies with a follow-up of less than six months, pathological fractures, fractures treated non-operatively and studies reporting on less than ten fractures were excluded. Abstracts were also excluded. Each eligible study was independently reviewed by authors for methodological quality. A methodological scoring system adapted from that of Detsky was used. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed.

Results: 39 studies including 1835 fractures were analysed. For extramedullary devices, the incidence of non-union (35/673 – 5.2%), delayed union (11/221 – 4.7%), implant breakage ( 24/444 – 5.1%) and deep infection (14/459 – 3.0%) was statistically significantly higher than non-union (14/506 – 2.7%), delayed union (5/529 – 0.94%), implant breakage (12/628 –1.9%) and deep infection (9/764 – 1.2%) for intramedullary devices. Mortality and superficial infection were higher for extramedullary than intramedullary devices. However, this was not statistically significant. Malunion, shortening and implant cut out were higher for intramedullary than extramedullary devices. This was not statistically significant.

Conclusion: The incidence of fracture healing complications appear to be significantly less with intramedullary than extramedullary devices. Based on this study, we advocate the use of intramedullary surgical fixation devices for subtrochanteric fractures.

Background: The most commonly used implant for the internal fixation of an extracapsular proximal femoral fracture is a sliding hip screw (SHS). More recently short intramedullary nails (IMN) have been advocated as an alternative, particularly for unstable fractures due to possible biomechanical advantages. The purpose of this meta-analysis was to compare, on the basis of evidence from randomised controlled trials, the fixation outcome with these two types of implant in stable and unstable fractures

Method: All randomised controlled studies comparing intramedullary nails with a SHS were considered for inclusion. Studies were identified using the search strategy of the Cochrane Collaboration, with no restriction on languages or source. Two authors independently extracted the data, and assessed trial methodology.

Results: 24 randomised trials involving 3202 patients with 3279 fractures were included in the analysis. Pooled results gave no statistically significant difference in the cut-out rate between the IMN or SHS 41/1556 and 37/1626 (Relative risk 1.19; 95% confidence interval 0.78 to 1.82). There was an increased total failure rate (103/1495 and 58/1565, Relative risk 1.83; 95% confidence interval 1.35 to 2.50) and re-operation rate (57/1357 and 35/1415, Relative risk 1.63; 95% confidence interval 1.11 to 2.40) with the IMN compared the SHS when all fractures were considered. Fracture healing complications were much less frequent for stable fractures. No evidence for a reduced failure rate for IMN’s in unstable fractures patterns could be found.

Conclusions: The results from studies to date indicate an increased fixation failure rate for trochanteric fractures fixed with an intramedullary nail, and show no benefit to the use of a nail in unstable fractures. Therefore the use of intramedullary nails for trochanteric fractures cannot be recommended.

Background: Intracapsular hip fractures in young adults under 50 years of age have a significant risk of fracture healing complications which has led some authors to advocate urgent fracture reduction and/or open reduction. As these fractures are infrequent, limited information is available from published studies to advocate a particular method of treatment to reduce the risk of complications. The purpose of this study is to analyze outcomes following such fractures with particular reference to the influence of the degree of fracture displacement, timing of surgery, method of reduction (open/closed) on the incidence of non-union and avascular necrosis.

Methods: Specific search terms were used to retrieve relevant studies from MEDLINE, EMBASE, and CINAHL extending from 1966 to May 2003. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed.

Results: Eighteen studies with 564 fractures were identified for analysis. The overall incidence of non-union was 50/564 (8.9%) and avascular necrosis (AVN) was 130/564 (23.0%). There was a higher incidence of non-union and AVN following displaced than undisplaced fractures. Non-union occurred more frequently after open reduction than closed reduction (10/89 [11.2%] versus 13/275 [4.7%], P=0.04, RR=0.42, 95% CI: 0.19 to 0.93).

There was an increased incidence of AVN after closed than open reduction (P= 0.0005, RR = 2.77, 95% CI: 1.45 to 5.29) but this became not statistically significant when one study with a markedly higher reported incidence of AVN was excluded (P = 0.07, RR= 1.85, 95% CI: 0.93 to 3.68).

The difference in the incidence of non-union and AVN following early (< 12 hours) or late (> 12 hours) surgery was not significant for either non-union or AVN (13/110 [11.8%] versus 3/60 [5.0%], p=0.18, RR2.36, CI 0.70 to 7.97 for non-union, 15/110 [13.6%] versus 9/60 [15.0%], p=0.82, RR=0.91, CI 0.42 to 1.95 for AVN).

Conclusion: Early (< 12 hours) or open reduction of these fractures may not reduce the risk of non-union or avascular necrosis. There is a suggestion of a higher incidence of non-union following open reduction than closed reduction. Randomized studies or prospective observational studies with a minimum follow-up of two years are required to report on a larger number of patients in this age group before definite conclusions on treatment can be made.