Introduction: The National Institute for Health and Care Excellence (NICE) updated their 2011 hip fracture management guidelines on 6th January 2023, suggesting that clinicians offer extramedullary fixation in preference to intramedullary nails for trochanteric fractures above and including the lesser trochanter except for reverse oblique fractures. This study aimed to assess compliance of our hospital with the updated guidelines while comparing the results with our performance prior to the update together with the national average. Methods: A retrospective observational study was done over three months before (06 October 2022 – 05 January 2023) and after the update (06 January – 05 April 2023) from the hospital hip fracture database. There were 60 eligible patients before and 46 patients following the update. Fractures were classified using the 2018 AO/ OTA classification system independently by 2 experienced authors with a review from a senior consultant if there was any discrepancy. Data was analyzed to determine if surgery was NICE compliant. Results: The non-compliance rate before and after the update was similar at 13.33% (n=8) and 13.04% (n=6) respectively. However, it was significantly better than the national average of about 30% non-compliance before and after the update. There was a higher tendency for 31A2 fractures to be non-compliant and contributed to 87.5% and 50% non-compliant cases before and after the update respectively. Conclusions: Surgeon preferences could interfere with compliance. However, departmental training could help improve adherence. While there is scope for improvement, district general hospitals can exceed national standards.

There is no consensus about the appropriate timing regarding the surgical treatment of per- and subtrochanteric femoral fractures. Therefore, we aimed to assess the effect of an early (< 48 h) or delayed surgery (≥ 48 h) on complication and mortality rates, also focusing on preexisting comorbidities. We retrospectively evaluated 1235 consecutive patients. They all underwent surgery at the level I trauma center of the Medical University of Vienna after suffering a per- or subtrochanteric femoral fracture for the first time. The study population consisted of 349 males and 886 females (71.7%) with a median age of 84.0 (IQR=16.0) years. They were divided into two cohorts according to their time of surgery (cohort 1 < 48 h and cohort 2 ≥ 48 h). The preoperative assessment of comorbidities used the Charlson Comorbidity Index (CCI). Cohort 1 combined 1075 patients (87.0%). For cohort 2, the median inpatient preoperative length of stay was 71.5 (IQR=39.0) hours, predominantly caused by medical reasons. In cohort 1, fewer patients were diagnosed with CCI ≥ 3 compared to cohort 2 (21.4% versus 43.9 %; p<0.001). Patients in cohort 1 had a lower in-hospital overall complication rate (32.6% versus 43.1%; p=0.008), a lower 1-year postdischarge surgical complication rate (8.6% versus 9.4%; p=0.008), a lower in-hospital mortality rate (3.5% versus 9.4%; p<0.001), and a lower 1-year mortality rate (22.2% versus 30.0%; p=0.030). An OR=2.8 (p<0.001) for the in-hospitality mortality and an OR=1.5 (p=0.031) for the 1-year mortality rate indicates higher odds of dying for patients with delayed surgery.

Introduction: Comminuted unstable proximal femoral fractures are very common in high energy injuries both in the young and the elderly. Stabilisation with AFN is the standard of care. An intact lateral wall is one of the pre-requisites for a successful proximal femoral nailing. When the lateral wall is disrupted, there is no support for the cephalic screws and the screws tend to rest on to the nail itself which may not achieve adequate stability. These are challenging situations and we lack implants to augment the lateral wall. We modified the commonly used 4.5 DCP to augment the lateral wall and this is a report of our innovative technique which is simple, cost-effective and successful. Patients & Methods: The conventional 4.5 DCP was modified by enlarging the proximal two holes to accommodate the 6.5mm cephalic screws of the AFN system. The plate was then secured to the distal fragment through conventional cortical screws either anterior or posterior to the nail. From 2018 there were 31 patients were treated with nail plate technique and found to be better than open reduction and circlage wiring in respect to size of incision, operating time and blood loss with minimum follow up of 2 years. In our series 4 patients died of other reasons, one implant failure, other 26 patients had uneventful fracture healing and good Harris hip score. Conclusion: Augmentation of lateral wall with a modified DCP increases stability in an unstable fracture and aids in healing.

Abstract

Implants for internal fixation of trochanteric hip fractures are either an extramedullary plate /lag screw or an intramedullary nail /lag screw. The aim of this study was to summarise the findings of previous randomised trials.

Methods
Recently updated Cochrane review which included randomised trials up to July 2020. Outcomes included mortality, regain of function, residual pain, surgical and fracture complications and medical complications.

Results
76 trials involving 10,979 participants. No difference was found for mortality (nail vs plate, one year mortality 753/3783(19.9%) versus 782/3834(20.4%) respectively, RR 0.99, 95%CI 0.90 to 1.08). Regain of mobility tended to be superior for intramedullary fixation (RR 0.48, 95% CI 0.10-0.87). Studies prior to 2000 reported increased risk of fracture healing complications for nails, yet 2000 onwards difference was no longer apparent (pre 2000 101/1212(8.3%) versus 47/1245(3.8%), RR 1.14, 95%CI 1.65 to 3.35, post 2009 82/1948(4.2%) versus 91/1931(4.7%), RR 0.90, 95% CI 0.66 to 1.22). Increased risk of intra-operative /later peri-prosthetic fractures using nailing compared to extramedullary fixation. However, this increase in periprosthetic fractures was associated with earlier nail designs. No difference in medical complications was apparent between implants but there were less superficial wound infections with intramedullary fixation. (2.9% versus 4.2%, RR 0.71, 95% CI 0.53 to 0.96).

Conclusion
The evidence from randomised trials shows no difference in the overall occurrence of fracture healing complications between contemporary intramedullary and extramedullary fixation implants when used for a trochanteric hip fracture. Intramedullary fixation is associated with better function and less wound infections.

Background:

Dynamic Hip screw (DHS) is a common procedure done for inter-trochanteric fracture Neck of femur representing 24% of all surgically treated Hip fractures in 2020 in the UK. Tip Apex Distance (TAD) has been introduced by Baumgartner et al, in 1995. Then 2 years later, it became the gold standard for DHS position in the femoral head to avoid cut-out failure. Several techniques have been described to evaluate TAD intraoperatively.

Methods:
In this study, we review the different techniques to estimate TAD intraoperatively. we evaluate, describe, and provide actual intraoperative imaging to check which technique is the most applicable.

Results:
Three main techniques are found in the literature. The first is the Baumgartner technique which depends on using the threads portion of the guide wire to measure TAD, the second is using the width of the lag screw threads as a reference which requires the presence of an unscrubbed surgeon in the theatre room, and the third technique depends on the computer-based system to adjust intraoperative imaging which is not available in all general district hospitals. The Baumgartner technique is found to be the easiest and most applicable intra-operative technique to measure TAD.

Conclusions:
The authors recommend using the Baumgartner technique to adequately evaluate and document Tip-Apex Distance in Dynamic hip screw surgery intra-operatively as a standard technique in district general hospitals to decrease the DHS cut-out failure rate.

Introduction: Unstable trochanteric fractures are challenging injueries with a high rate of implant failure and re-operation. Cephalomedullary nails proved to be a rational management choice for these fracture patterns, yet other management options have not been well assessed. The aim of this study is to compare between the DHS with trochanteric stabilizing plate (TSP) and proximal femoral locked plate (PFLP) in unstable pertrochanteric fractures.
Methods: This randomised controlled trial (RCT) included 40 patients (22 males, 18 females) with unstable pertrochanteric fractures (AO/OTA 31A2.2/A2.3). The patients were randomised into group 1 managed by DHS with TSP while group 2 was managed by PFLP. All patients were followed up for 1 year. Patients were assessed radiographically and clinically using Harris hip score (HHS) at 3, 6 and 12 months. Operative time, estimated blood loss and time to union were also compared.
Results: The difference in the intra-operative variables, including operative time and intra-operative blood loss, between both groups was not statistically significant. Time to bony union was faster in the first group with a statistically significant P value (p = 0.04). Functional outcome as per the HHS was significantly better in group 1 (p < 0.01) and implant failure in group 1 occurred statistically lesser (p < 0.01).
Discussion: DHS with TSP appears to be a good option of management for unstable pertrochanteric fractures. In contrast, the use of PFLP in unstable pertrochanteric fractures in the elderly does not appear to be a good alternative.

Objectives: The present study aimed to compare outcomes between Femoral Neck System (FNS) and Cancellous Canulated Screws (CCS). Methods: We evaluated patients with femoral neck fractures surgically intervened in 2021 and results were paired with controls from our database. Studied variables were age, sex, pain, hemoglobin loss, days of hospitalization, gait recovery and need of revision surgery. Results: Among the 85 patients included, 13 and 72 patients were categorized into the FNS and CCS groups, respectively. FNS group average age is 65 ± 13.93 years old. There are 61,5% women and Garden type II is the most frequent grade of fracture. Surgery took place within first 24 hours in 53,84% of cases. CSS group average age is 68,49 ± 15,82 and there are 76.4% of women. Garden type I was the most frequent grade and surgery took place within first 24 hours in 46.47% of patients. Blood loss was higher in FNS group measured with hemoglobin concentration before and after surgery (P<0.000), pain was also higher in this group (P<0.000). However, the number of days of hospitalization were lower (P<0.000). Conclusions: In our experience, FNS can cause a higher loss of blood, probably due to longer surgical time. However, our study is limited due to small FNS group and small experience with this new implant. The number of patients and follow up becomes bigger with the popularization of this implant and new studies with higher grade of evidence will help to determine whether there are relevant differences between both implants.

Aim: Total hip replacement (THR) was thought to give better outcomes in active patients with neck of femur (NOF) fractures compared to hemiarthroplasty (HA). However, there are few studies on the rate of peri-operative complications between the two surgeries. This study evaluates the determinants of peri-operative complications between THR and HA. Methods: A prospective cohort study was conducted on patients with low energy, non-pathological unilateral NOF fracture from 2014 to 2021 and underwent either HA or THR. Covariates assessed include age, gender, co-morbidities, the American Society of Anaesthesiology (ASA) score, operation duration, hemoglobin loss and days before patients started ambulating. Intra-operative and early post-operative (those that occurred before discharge from hospital) complications were recorded. Multi-variable logistic regression analysis was done to determine the factors influencing per-operative complications. Statistical significance was taken to be p < 0.05. Results: A total of 74 THR and 381 HA were included. Patients who underwent THR tend to be younger and better ASA scores (p<0.001). THR had significantly longer operative duration and blood loss (p<0.001). There were no significant differences in the incidence of different peri-operative complications between THR and HA. Patients who ambulated later were more prone to hospital-acquired pneumonia (p=0.037) and deep vein thrombosis (p=0.036), while those that had delay of more than 48 hours before undergoing surgery tend to experience post-operative delirium (p=0.011). Conclusion: THR and HA have similar peri-operative complication rates. Early surgery and post-operative ambulation may reduce the rate of peri-operative patients in patients with NOF fractures.

Purpose:
This literature review aims to examine the available evidence on the morbidity and mortality associated with hip fragility fractures among geriatric populations in developing countries. The main research question is to explore the impact of hip fragility fractures on the health and well-being of geriatric populations in developing countries.

Methods:
A systematic literature review was conducted using the PubMed, Embase, and Cochrane Library databases. Studies published between 2017 and 2022 were included in the review. The search terms included "hip fragility fractures," "geriatric population," "developing countries," "morbidity," and "mortality."

Results:
The review found that the incidence of hip fragility fractures in developing countries is high and expected to increase rapidly due to population aging and urbanization. Hip fragility fractures are associated with significant morbidity, such as prolonged hospitalization, functional decline, and a decreased quality of life. Additionally, hip fragility fractures are associated with high mortality rates, particularly among older adults and those with comorbidities. Prevention and management strategies, such as regular physical activity, adequate calcium and vitamin D intake, fall prevention programs, early surgery, and the use of bone-protecting medications, are essential to reduce the associated morbidity and mortality.

Conclusion:
The review highlights the urgent need for effective prevention and management strategies and further research to evaluate the effectiveness and feasibility of these strategies in developing country settings. The findings of this review could help inform the development of policies and programs aimed at reducing the incidence and impact of hip fragility fractures among geriatric populations in developing countries

Dislocation of a hip hemiarthroplasty used to treat a hip fracture is a serious complication. The aim of this study was to identify whether a delay in the time from fracture to surgery causes an increase in the rate of post-operative hip dislocation. From a single center, data from intracapsular neck of femur patients treated with hip hemiarthroplasty was collected between October 1986 to August 2021. The time from both fall to surgery and admission to surgery was recorded. Surviving patients were followed up for one year.

The overall dislocation rate was 51 out of 4155 patients (1.2%). The 3019 patients who had surgery within two days of the injury had a lower dislocation rate (29 dislocations, 0.96%). For the 197 patients with no history of a fall, there were 5 (2.5%) dislocations (p=0.036, 95% confidence interval of difference 0.15 to 0.97 for comparison with surgery within two days). For the 399 patients with a delay of more than four days from injury till surgery, there were nine dislocations (2.3%) (p=0.045, 95% confidence intervals of difference 0.20 to 0.89 for comparison with surgery within two days). This study demonstrates an increase in the risk of dislocation for those patients with no history of a fall and those with a delay of more than four days from injury to surgery.
 

Introduction: Hip fractures are the commonest fragility fractures and a shorter length of stay has been associated with increased mortality. We aimed to investigate the association of length of inpatient stay on early and late mortality following hip fracture in a UK population. Methods: 1356 consecutive hip fracture patients were included. Data collected included demographic, co-morbidities and admission blood results. Causes and risk factors for 30-day, 90-day and 1-year mortality were examined using stepwise univariate and multivariate Cox regression analyses. Results: Overall mortality was 8.7% at 30 days, 16.4% at 90 days and 27.9% at 1 year. Inpatient stay less than 10 days had a 30-day mortality of 21.6% vs 5.7% in those with a longer inpatient stay (p<0.001). Following multivariate analysis adjusting for demographics and co-morbidities, inpatient stay of under 10 days a significant independent risk factor for 30-day mortality (OR 3.989, CI 2.750-5.787), 90-day mortality (OR 1.897, CI 1.417-2.539) and 1-year mortality (OR 1.370, CI 1.067-1.760). Conclusions: In hip fracture patients, an ‘early’ discharge less than 10 days after admission is independently associated with increased mortality in the short and long-term. This may be due to inadequate rehabilitation post-operatively and under-treatment or non-recognition of sub-clinical comorbidity such as cardiovascular disease. We suggest that these patients have a thorough medical work-up and appropriate post-operative rehabilitation prior to hospital discharge.

Background: Internal fixation of intertrochanteric fractures in geriatric patients with anaesthetic or surgical risks or in patients with open fracture has high complication rate, so external fixation should be considered as a semiconservative method to reduce operative time and complications.

Objective: to evaluate the results of using external fixator in treatment of intertrochanteric fractures regarding union, functional outcome and complications.

Patients and methods: twenty patients with intertrochanteric fracture with a wide range of ages and different physical conditions were treated by Ilizarov external fixator.

Results: All patients were evaluated clinically & radiologically for at least 6 months .Excellent and good (satisfactory) results were found in 15patients and fair results were found in 2 patient and poor (unsatisfactory) results were found in 3 patients. The time of radiological union and fixator removal ranged from 8 to 20 weeks with a Mean of 13.4 weeks. Pin tract infection occurred in all patients but deep pin tract infection occurred in one patient. Varus malalignment occurred in 4 patients and valgus deformity in one. Temporary knee stiffness found in 2 patients.
Conclusion: the study proved that external fixation of intertrochanteric fractures in elderly high risk patients and open fractures is a reliable, effective and safe treatment option. It offers a minimal operative risk, no blood loss, short hospital stay, early mobilization and low morbidity and mortality.