Glyn A. Pryor

Internal fixation or arthroplasty for displaced cervical hip fractures in the elderly: A randomised controlled trial of 208 patients

208 patients aged over 70 years with a displaced cervical hip fracture were admitted to a prospective randomised trial of internal fixation using 3 parallel cannulated screws or an uncemented Austin Moore hemiarthroplasty. All surviving patients were followed for a minimum of 3 years. Functional assessment of survivors at 1, 2 and 3 years from injury showed no significant difference between groups. Patients treated by the fixation had a marginally lower mortality rate. Other outcomes which favoured internal fixation were a lower risk of wound infection, reduced length of surgery (22 minutes versus 47 minutes), lower operative blood loss (23 mL versus 172 mL), and lower transfusion requirements (4/102 patients versus 18/106). However, internal fixation had a significantly greater re-admission rate (24/102 versus 7/106) and re-operation rate. Following internal fixation, 44 re-operations were required in 36 patients, while re-operation was required in only 4 patients treated with arthroplasty. The results of this randomised trial indicate that both procedures produce comparable final functional outcomes for the survivors.

Classification of trochanteric fracture of the proximal femur: a study of the reliability of current systems

Five observers using the Jensen modification of the Evans classification and the AO classification (with and without subgroups) classified the radiographs of 88 trochanteric hip fractures. Each observer classified the radiographs independently on two occasions 3 months apart. Kappa statistical analysis was used for determination of intra- and inter-observer variation. For the Jensen classification, the mean kappa value was 0.52 (range: 0.44-0.60) for intra-observer variation and 0.34 (range: 0.17-0.38) for inter-observer variation. For the AO system with subgroups, the mean kappa value was 0.42 (range: 0.20-0.65) for intra-observer variation and 0.33 (range: 0.14-0.48) for inter-observer variation. For the AO classification system without subgroups, the mean kappa value was 0.71 (range: 0.60-0.81) for intra-observer variation and 0.62 (range: 0.50-0.71) for inter-observer variation. We recommend classifying trochanteric fractures into three groups as that of the AO system without the subgroups. For ease of use, these three groups may be termed stable trochanteric, unstable trochanteric and trans-trochanteric. Neither the Jensen classification nor the AO classification with subgroups is an acceptable classification system for trochanteric hip fractures.

Assessment of the AO classification of intracapsular fractures of the proximal femur

There are a number of classification systems for intracapsular fractures of the proximal femur, but none has been shown to be practical with satisfactory reproducibility and accurate predictive value. We have investigated the AO classification and evaluated intra- and interobserver accuracy and its value in predicting treatment and outcome. We found it to have very poor intra- and interobserver reliability and to be of limited predictive use for the outcome of treatment. A simplified system in which the subdivisions were allocated to one of three groups of undisplaced, displaced and basal fractures was found to be of value. We conclude that this is the only division which is appropriate for these fractures and that the AO system for intracapsular fractures is too complicated and should not be used.

11-year results in 2,846 patients of the Peterborough Hip Fracture Project: reduced morbidity, mortality and hospital stay.

3,025 consecutive patients presenting over an 11-year period with an acute hip fracture were prospectively studied to determine the effectiveness of a designated hip fracture service. After the introduction of the service, the mean length of hospital stay per patient was reduced from 51 days to 21 days. This reduction was accomplished by a progressive increase in the proportion of patients discharged directly home from the admission ward (50%-86%) and a reduction in the numbers of patients transferred to care of the elderly wards (28%-6%) and other outlying wards (15%-3%). This change was accompanied by a reduction in the 30-day mortality rate from 22% to 7%. There was no significant increase in the re-admission rate or proportion of patients requiring institutional care. We conclude that the provision of designated staff and treatment regimes for hip fracture patients can result in a significant reduction in both mortality and morbidity, combined with substantial savings in patient bed-days.

Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures: a long-term follow-up of a randomised trial.

In a prospective randomised trial, 455 patients presenting to one hospital with a displaced intracapsular fracture were randomised to either closed reduction and internal fixation with three cancellous screws or replacement with an uncemented hemiarthroplasty. Follow-up of surviving patients was for between 9 and 15 years to determine the long-term outcome for the two treatment methods. 93% of patients died during this follow-up period. There was no difference in mortality between the two procedures. The need for revision surgery to the hip was increased for those treated by internal fixation (93% versus 62% implant survival rate; hazard ratio: 0.14, 95% CI 0.08-0.24). 91% of revisions operations occurred within 2 years from injury. 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. These results demonstrate that both treatment methods produce comparable final outcomes but internal fixation is associated with an increased re-operation rate.

Early discharge after hip fracture : prospective 3-year study of 645 patients

The effectiveness of providing additional community resources to enable early discharge following hip fracture surgery has been prospectively evaluated in a consecutive series of 645 patients. For those discharged under the scheme, the average hospital stay was 9.3 days, and this resulted in a substantial saving of hospital bed days.

Hospital at home – a review of our experience

Introduction: Hospital at home (HAH) is a service that provides home-based nursing and rehabilitation services whose aim is to prevent admission or to facilitate early discharge from care in an acute hospital. Methods: We evaluated the effectiveness of early discharge hospital at home (HAH) schemes for hip fracture patients over a 27-year period in a district general hospital in the United Kingdom. A long-term database for audit and research purposes is maintained for all hip fracture patients admitted to Peterborough City Hospital. The data were analysed retrospectively and patients were followed up routinely for six weeks after discharge. Results: As many as 8876 patients were admitted with a hip fracture between 1st January 1987 and 31st December 2014, of which 5512 patients were eligible for one of the two available HAH schemes. The proportion of eligible patients discharged to the HAH schemes, and their hospital stay and readmission rates were measured; 1786 patients were discharged to a HAH scheme. The proportion of patients discharged to the scheme progressively reduced from a maximum of 94% to a minimum of 13% over the study period. The length of hospital stay until discharge to the scheme progressively increased from a mean of eight days to 18 days. Discussion: We conclude that HAH schemes can potentially reduce the length of hospital stay of hip fracture patients but continued resources and service organisation have to be provided to match the increasing demand to prevent the service from becoming ineffective.