Tim Chesser

Proximal femoral fractures in the elderly: How are we measuring outcome?

INTRODUCTION Patients with proximal femoral fractures present a difficult problem to health care systems in view of their complex presentations and co-morbidities. Traditionally, the focus of outcome measurement for this patient group has been on mortality and surgical implant success. Increasing recognition of the need to diversify outcome measurements has led to the creation and use of a number of outcome scales. We sought to examine how these scales are being used in the current literature. METHODS Abstracts to over 4000 papers related to proximal femoral fracture research were screened to identify commonly used scales in the five main categories of general quality of life measures (QoL), Activities of Daily Living scales (ADL), mobility and physical performance scales, disease-specific scales and hip-specific scales. The 14 identified scales were then searched for directly, and papers analysed for scale usage, timing and interpretation. RESULTS ADL scales were the most commonly used group, followed by QoL measures, which are validated for elderly patients. Scale timing and use varied widely between studies. A large number of scales were found in addition to the 14 identified scales. None of the 14 identified scales were validated for the proximal femoral fracture population. DISCUSSION A good scale must be appropriate in content, method and clinical utility. Its method of application must be reliable, responsive, and validated for the population in question. Outcome scale usage was difficult to assess in proximal femoral fracture research due to difficulties in isolating the relevant research, and in differences in scale timing and interpretation. Scale prevalence was skewed by use by specific research groups. CONCLUSION There is no single unifying scale in widespread use for proximal femoral fracture patients. We would recommend the validation of commonly used scales for this population, and would advise the use of scales from more than one category to assess outcome.

The outcome following fixation of bicondylar tibial plateau fractures

Unstable bicondylar tibial plateau fractures are rare and there is little guidance in the literature as to the best form of treatment. We examined the short- to medium-term outcome of this injury in a consecutive series of patients presenting to two trauma centres. Between December 2005 and May 2010, a total of 55 fractures in 54 patients were treated by fixation, 34 with peri-articular locking plates and 21 with limited access direct internal fixation in combination with circular external fixation using a Taylor Spatial Frame (TSF). At a minimum of one year post-operatively, patient-reported outcome measures including the WOMAC index and SF-36 scores showed functional deficits, although there was no significant difference between the two forms of treatment. Despite low outcome scores, patients were generally satisfied with the outcome. We achieved good clinical and radiological outcomes, with low rates of complication. In total, only three patients (5%) had collapse of the joint of > 4 mm, and metaphysis to diaphysis angulation of 75º, and five patients (9%) with displacement of > 4 mm. All patients in our study went on to achieve full union. This study highlights the serious nature of this injury and generally poor patient-reported outcome measures following surgery, despite treatment by experienced surgeons using modern surgical techniques. Our findings suggest that treatment of complex bicondylar tibial plateau fractures with either a locking plate or a TSF gives similar clinical and radiological outcomes.

Smoking status and the Disabilities of the Arm Shoulder and Hand score are early predictors of symptomatic nonunion of displaced midshaft fractures of the clavicle.

AIMS This study identifies early risk factors for symptomatic nonunion of displaced midshaft fractures of the clavicle that aid identification of an at risk group who may benefit from surgery. METHODS We performed a retrospective study of 88 patients aged between 16 and 60 years that were managed non-operatively. RESULTS The rate of symptomatic nonunion requiring surgery was 14% (n = 13). Smoking (odds ratio (OR) 40.76, 95% confidence intervals (CI) 1.38 to 120.30) and the six week Disabilities of the Arm Shoulder and Hand (DASH) score (OR 1.11, 95% CI 1.01 to 1.22, for each point increase) were independent predictors of nonunion. A six week DASH score of 35 or more was identified as a threshold value to predict nonunion using receiver operating characteristic curve analysis. Smoking and the threshold value in the DASH and were additive risk factors for nonunion, when neither were present the risk of nonunion was 2%, if one or the other were present the nonunion rate was between 17% to 20%, and if both were present the rate increased to 44%. DISCUSSION Patients with either of these risk factors, which include approximately half of all patients sustaining displaced midshaft fractures of the clavicle, are at an increased risk of developing a symptomatic non-union. TAKE HOME MESSAGE Smoking and failure of functional return at six weeks are significant predictors of nonunion of the midshaft of the clavicle. Such patients warrant further investigation as to whether they would benefit from early surgical fixation in order to avoid the morbidity of a nonunion.

The use of LISS femoral locking plates and cabling in the treatment of periprosthetic fractures around stable proximal femoral implants in elderly patients.

A retrospective review was performed of Vancouver type C periprosthetic femoral fractures treated using the Less Invasive Stabilisation System (LISS) femoral locking plate system. Five patients with stable hip prostheses (only one of which was an uncomplicated primary arthroplasty) were treated with the LISS plating system in combination with bone grafting and cables. The average age at the time of fixation was 87 years (range 83-93). All fractures united and all but one of the patients was able to mobilise independently. One case was complicated by superficial wound infection, but there were no other significant complications. One patient is still alive 50 months after surgery; the remaining four died a mean of 27 months postoperatively. Our results indicate that the LISS system is effective in the management of Type C periprosthetic fractures around well-fixed proximal femoral implants in the elderly, even in complex cases.

Survival of ceramic bearings in total hip replacement after high-energy trauma and periprosthetic acetabular fracture

Surgeons remain concerned that ceramic hip prostheses may fail catastrophically if either the head or the liner is fractured. We report two patients, each with a ceramic-on-ceramic total hip replacement who sustained high-energy trauma sufficient to cause a displaced periprosthetic acetabular fracture in whom the ceramic bearings survived intact. Simultaneous fixation of the acetabular fracture, revision of the cementless acetabular prosthesis and exchange of the ceramic bearings were performed successfully in both patients. Improved methods of manufacture of new types of alumina ceramic with a smaller grain size, and lower porosity, have produced much stronger bearings. Whether patients should be advised to restrict high-impact activities in order to protect these modern ceramic bearings from fracture remains controversial.

The modified ilioinguinal and anterior intrapelvic approaches for acetabular fracture fixation: indications, quality of reduction, and early outcome.

Objectives: Traditionally, the anterior surgical approach of choice for acetabular reconstruction was ilioinguinal. There has been an increasing usage of the midline “Stoppa” or “anterior intrapelvic approach.” The aim is to report the techniques, early results (minimum 1 year), and complications of anterior approaches for acetabular reconstruction. Design: Retrospective case-note review. Setting: Pelvic and acetabular tertiary center. Patients: A consecutive series of acetabular fractures treated at 1 tertiary specialist unit were retrospectively reviewed. The fracture patterns, incisions used, intraoperative and postoperative complications, reduction achieved (measured on postoperative radiographs and computed tomography scans), and early postoperative results (minimum 1-year follow-up), were recorded. Main Outcome Measurements: Postoperative reduction (measured by postoperative plain radiographs and computed tomography). Results: Of 160 consecutive patients who underwent acetabular reconstruction, 56 (mean age, 44 years) underwent reconstruction using only anterior approaches (mean of 7 days after injury). Iatrogenic complications, postoperative infection, arthritis, and avascular necrosis rates are comparable with the literature. Overall, anatomic reduction was seen in 71% of cases and concentric reconstruction of the dome in over 90%. Thirty-six of the 56 patients (64%) were symptom-free at the latest follow-up and 34 (61%) had returned to work. Conclusions: The results reported suggest the use of dual approaches using the lateral 2 windows, and/or a midline anterior intrapelvic approach in anterior acetabular reconstructions has a relatively low complication rate and can lead to anatomic reconstructions in 71%. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The role of total hip replacement in the treatment of displaced intracapsular hip fractures in the elderly

Replacement arthroplasty is the treatment of choice in patients sustaining a displaced intracapsular fragility hip fracture. Recently, total hip replacement (THR) has been advocated for ‘‘fit’’ patients with this injury. Presently in the UK, 46% of the total hip fractures are recorded in the National Hip Fracture Database as displaced intracapsular of which 92% are treated by replacement arthroplasty including 12.5% treated by THR (5.75% of the total hip fracture population). However, several questions remain unanswered. What is the definition of the ‘‘fit’’ patient? What is the optimal fixation method of the implant? What is the optimal diameter of the femoral head prosthesis and material of the bearing surface? What is the best surgical approach? This article aims to examine the current evidence pertaining to these questions and thus clarify the value of THR in this patient population. The present literature comprises eight randomised control trials (RCTs), as well as meta-analyses of prospective and retrospective studies. The number of hip fractures is increasing worldwide, yet the number of patients studied is small, with just over 1500 patients reported in the eight RCTs performed. The studies are often biased by inclusion and exclusion criteria and report differing outcomes and lengths of follow up. It is also recognised that the initial cost of a total hip replacement is greater than other treatment modalities (such as fixation or hemiarthroplasty) yet many studies do not include any health economics or cost-effectiveness analysis. The eight randomised control trials comparing THR with other treatment modalities in fragility hip fractures involving the neck of femur, reported that THR led to better function with increased walking distance compared to hemiarthroplasty (2.23 miles vs. 1.09 miles, 57% walking independently vs. 41%) and an improvement in the Harris Hip Score (ranging from 80 to87 for THA group and from 55 to 79 in HA group). In addition, decreased re-operation rates were reported, but with a higher dislocation rate (ranging from 0 to 20%) and a slightly longer operation time. All but one study supports the use of THR in the selected population. Only one study included a health economic analysis, which showed THR to be cost effective when compared to other treatments, when revision surgery was included. This has led to the current guidance in the UK and other countries that THR should be offered as treatment in this selected patient group (independently mobile patients, no cognitive impairment and medicallyfit for the anaesthesia and operation). It is important to highlight the inclusion and exclusion criteria for these trials. All studies excluded those who had cognitive or physical impairment (previous arthritis, unable to walk with more than one aid or medically unfit) but only one study randomised patients over the age of 90. Other RCTS had patients with a mean age of 65 years (range 60–90 years), but with far fewer older patients. This suggests there may have been recruitment bias favouring the younger patient.

The use of an anterior pelvic internal fixator to treat disruptions of the anterior pelvic ring: a report of technique, indications and complications

Aims The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications. Patients and Methods We reviewed the case notes and radiographs of 50 patients treated with an anterior pelvic internal fixator between April 2010 and December 2015 at a major trauma centre in the United Kingdom. The median follow‐up time was 38 months (interquartile range 24 to 51). Results Three patients were excluded from the analysis leaving 47 patients with complete follow‐up data. Of the 47 patients, 46 achieved radiological union and one progressed to an asymptomatic nonunion. Of the remaining patients, 45 required supplementary posterior fixation with percutaneous iliosacral screws, 2 of which required sacral plating. The incidence of injury to the lateral femoral cutaneous nerve (LFCN) was 34%. The rate of infection was 2%. There were no other significant complications. Without this treatment, 44 patients (94%) would have needed unilateral or bilateral open reduction and plate fixation extending laterally to the hip joint. Conclusion The anterior pelvic internal fixator reduces the need for extensive open surgery and is a useful addition to the armamentarium for the treatment of anterior pelvic injuries. It is associated with injury to the LFCN in a third of patients.

Modelling and estimation of health-related quality of life after hip fracture: A re-analysis of data from a prospective cohort study.

Objectives This study investigates the reporting of health-related quality of life (HRQoL) in patients following hip fracture. We compare the relative merits and make recommendations for the use for two methods of measuring HRQoL; (i) including patients who died during follow-up and (ii) including survivors only. Methods The World Hip Trauma Evaluation has previously reported changes in HRQoL using EuroQol-5D for patients with hip fractures. We performed additional analysis to investigate the effect of including or excluding those patients who died during the first four months of the follow-up period. Results The dataset included 503 patients, 25 of whom died between 30 days and four months of injury. There was a statistically significant difference in 30-day HRQoL between those alive (mean 0.331 and standard deviation (sd) 0.360) and those dead (mean 0.156 and sd 0.421) by four months (independent-samples t-test; p 0.022). The estimated difference of 0.175 in HRQoL (95% confidence interval 0.025 to 0.325) was also highly clinically significant. Conclusion When reporting HRQoL for patients after a hip fracture, excluding patients who die during follow-up leads to an overestimate of the effects of the intervention or treatment pathway. We would recommend that death-adjusted estimates should be used routinely when reporting HRQoL in this population. Cite this article: N. Parsons, X. L. Griffin, J. Achten, T. J. Chesser, S. E. Lamb, M. L. Costa. Modelling and estimation of health-related quality of life after hip fracture: A re-analysis of data from a prospective cohort study. Bone Joint Res 2018;7:1–5.

Research priorities in fragility fractures of the lower limb and pelvis: a UK priority setting partnership with the James Lind Alliance

Objective To determine research priorities in fragility fractures of the lower limb and pelvis which represent the shared priorities of patients, their friends and families, carers and healthcare professionals. Design/setting A national (UK) research priority setting partnership. Participants Patients over 60 years of age who have experienced a fragility fracture of the lower limb or pelvis; carers involved in their care (both in and out of hospital); family and friends of patients; healthcare professionals involved in the treatment of these patients including but not limited to surgeons, anaesthetists, paramedics, nurses, general practitioners, physicians, physiotherapists and occupational therapists. Methods Using a multiphase methodology in partnership with the James Lind Alliance over 18 months (August 2016–January 2018), a national scoping survey asked respondents to submit their research uncertainties. These were amalgamated into a smaller number of research questions. The existing evidence was searched to ensure that the questions had not been answered. A second national survey asked respondents to prioritise the research questions. A final shortlist of 25 questions was taken to a multistakeholder workshop where a consensus was reached on the top 10 priorities. Results There were 963 original uncertainties submitted by 365 respondents to the first survey. These original uncertainties were refined into 88 research questions of which 76 were judged to be true uncertainties following a review of the research evidence. Healthcare professionals and other stakeholders (patients, carers, friends and families) were represented equally in the responses. The top 10 represent uncertainties in rehabilitation, pain management, anaesthesia and surgery. Conclusions We report the top 10 UK research priorities in patients with fragility fractures of the lower limb and pelvis. The priorities highlight uncertainties in rehabilitation, postoperative physiotherapy, pain, weight-bearing, infection and thromboprophylaxis. The challenge now is to refine and deliver answers to these research priorities.