The importance of perioperative optimisation to facilitate safe regional anaesthesia and their improved outcomes in fracture neck of femur patients

Background: Hip fractures are common presentations to orthopaedic departments, and their surgical management often results in blood transfusions. Compared with general anaesthesia, regional anaesthesia reduces the need for transfusions and mortality in the wider surgical population. Aims: In hip fracture patients, our primary outcome measure was to examine any relationship between anaesthetic modality and transfusion rates. The secondary outcome measure was to assess the relationship between anaesthetic modality and one-year mortality. Methods: A retrospective cohort study of 280 patients was carried out in 2017 and 2018. Data were collected from patient records, local transfusion laboratory and the national hip fracture database. Results: A total of 59.6% had regional and 40.4% general anaesthesia. Regional anaesthesia patients were younger with fewer comorbidities (p < .05). About 19.8% regional and 34.5% general anaesthesia patients received transfusions (odds ratio (OR) = 0.47, p < .05); 13.6% were taking anticoagulants and were less likely to receive a regional anaesthetic (31.6% versus 64%, OR = 0.26, p < .05). One-year mortality was 27% for regional and 37% for general anaesthetic patients (OR = 0.64, p = .09). Conclusion: Regional anaesthesia halved the risk of blood transfusion. Anticoagulated patients were 74% less likely to receive regional anaesthetics, but had no additional transfusion risk. With optimisation, a larger proportion of patients could have regional anaesthesia.

Does the Nottingham Hip Fracture Score Help Predict Which Patients Will Benefit From a Modern Modular Hemiarthroplasty for the Treatment of Intracapsular Proximal Femoral Fractures?

Introduction: Hemiarthroplasty for the management of intracapsular neck of femur fractures is common but current practice in the UK still varies regionally and individually. Guided by the National Institute of Health and Care Excellence (NICE) we have observed a move towards modern, modular prostheses such as the Exeter V40 Stem but the use of older, monoblock prostheses such as the Thompsons Hemiarthroplasty remains controversial. Use of the Nottingham Hip Fracture Scores (NHFS) can help surgeons stratify patients according to risk and select the most appropriate prosthesis to meet their individual needs. Materials and Methods: 765 hip hemiarthroplasties were analysed over a 28-month period at a single, high-volume, orthopaedic department in the UK. We calculated the NHFS and recorded the choice of prosthesis. Patients were then followed up for at least a year. Outcomes were mortality and change in residential status. Results: Six hundred and forty-six (446) patients were treated with monoblock prostheses (mean age=85.6; range 62-105). 319 patients received modular prostheses (mean age=81.0; range 61-98). Patients who were selected to receive a monoblock prosthesis were over twice as likely to be dead at a year (32.87% vs. 13.65%) and over twice as likely to require increased assistance with living (50.12% vs. 23.81%). Amongst patients with equivocal NHFS, those who receive a monoblock stem suffered worse outcomes in all but the very highest risk group, who experienced lower mortality (OR=0.71, CI 0.52-0.96) and change in residential status (OR=0.76, CI 0.58-0.99). Conclusion: Nottingham Hip Fracture Score (NHFS) can confer predictable outcomes in hip fracture patients treated with modular stems. Modular stems should be the default choice when performing hemiarthroplasties for intracapsular neck of femur fractures. However, in keeping with other studies, we found that in very old, frail, or co-morbid patients, modular stems are not associated with better survival or return to pre-morbid function.

A comparative study between anterior and posterior approach for bipolar hemiarthroplasty in intracapsular fracture neck of femur

<ul><li><p class="abstract"><strong>Background:</strong> The present study was undertaken to to compare the efficacy of treatment of intracapsular neck of femur fracture operated by anterior and posterior approaches.</p><p class="abstract"><strong>Methods:</strong> A total 100 patients of either sex, aged &gt;65 years with intracapsular neck femur fracture were operated with hemiarthroplasty. The patients were divided into two equal groups and patients were operated alternatively one with anterior approach and the second with posterior approach. Functional outcomes were compared using Harris hip score and range of movements assessed clinically. Hip function and final outcome measures were noted and compared between two groups.<strong></strong></p><p class="abstract"><strong>Results:</strong> The mean age of patients was 63.1±5.3 years in group A and 65.8±5.4 years in group B with female to male ratio was 1.7:1 for group A and 1.8:1 for group B. Operating time for group A and for group B was 65 and 78 minutes respectively. Mean intraoperative blood loss was 120 ml in group A and 150 ml in group B. The most common complication in both the groups were infection and rate in group A was 9.70% and in group B was 13.50%. Posterior approach carried an increased risk of prosthetic dislocation as compared to anterior approach. There was no intraoperative mortality seen in follow up period.</p><p class="abstract"><strong>Conclusions:</strong> Anterior approach for hip hemiarthroplasty in elderly population with intracapsular femoral neck fractures provided significant benefit in early postoperative period when compared to the posterior approach in terms of duration of surgery, intraoperative blood loss, time of recovery, hip dislocation rate.</p></li></ul>

Cytokine Changes in Cerebrospinal Fluid and Plasma Post-Emergency Orthopaedic Surgery

Background: The process of neuroinflammation after surgery and how it may contribute to post-operative neurocognitive disorders (PND) is not well understood. Studying the association between central and peripheral cytokines and neuroinflammation is a prelude to the development of treatments for PND. Here, we investigate the hypotheses that there is a greater cytokine response in cerebrospinal fluid (CSF) than plasma after orthopaedic surgery, and that plasma cytokine levels are directly related to CSF cytokine levels, enabling plasma cytokine levels to be used as markers of neuroinflammation. Methods: Patients admitted with a fractured neck of femur were invited to participate in this study. Participants had a spinal catheter inserted just prior to induction of anaesthesia. Samples of blood and CSF were taken before, immediately after, and on the first day following emergency surgery. The catheter was then removed. Samples were analysed for the presence of ten cytokines by immunoassay. Results: A spinal catheter was successfully inserted in 11 participants during the 18-month study period. Five plasma cytokines (IL-4, IL-6, IL-10, IL-12p70 and IL-13) rose significantly following surgery, whereas all ten CSF cytokines rose significantly (IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IFN-γ and TNF-α) (adjusted-p <0.05). Central (CSF) cytokine levels were consistently higher than their peripheral (plasma) counterparts after surgery, with some patients having a particularly marked neuroinflammatory response. The greatest increases occurred in IL-8 in CSF and IL-6 in plasma. There were significant, strong positive correlations between several of the measured cytokines in the CSF after surgery, but far fewer in plasma. There was no significant correlation between cytokine levels in the plasma and CSF at each of the three time points.Conclusions: To our knowledge, this is the first study to analyse paired samples of plasma and CSF for cytokine levels before and after emergency orthopaedic surgery. This study demonstrates that following surgery for a fractured neck of femur, there is a far greater rise in cytokines in the CSF compared to plasma. The lack of correlation between peripheral and central cytokines suggests measurement of peripheral cytokines are not necessarily related to which patients may have a large neuroinflammatory response.

Cemented Bipolar Hemiarthroplasty for Fracture Neck of Femur and Unstable Intertrochanteric Fractures - Prospective and Retrospective Study

Hip fractures in elderly patients are becoming a major social problem from various perspectives, including the progressive aging of global societies. The elderly have a high risk of hip fracture, even with minor injuries because of osteoporosis, while early surgical treatment may be difficult due to comorbidities and medication. In this study, significant risk factors were identified. Patients over age 70 had three times the mortality of younger patients. Greater than three pre-existing medical conditions is associated with a 25 percent mortality rate, more than twice that of healthier patients. Surgery performed on the first day of admission and beyond the fifth day was associated with a 34 percent mortality rate. Those patients operated in during days 2 through 5 had a 5.8 percent mortality rate. There was no failures related to inadequate stem or mechanical loosening. The tendency to dislocation can be clinically identifiable by major discrepancy in length, there was no failures related to inadequate stem or mechanical loosening. The tendency to dislocation can be clinically identifiable by major discrepancy in length and only 1 patient had shortening of about 2 cms post operatively which was slightly better than that of James et al (11%).

Cemented Bipolar Hemiarthroplasty for Fracture

Ashley Cooper recognized fractures in the proximal femur distal to the insertion of capsule. He noted that they invariably united without difficulty often with external rotation and shortening leading to coxa vara. Till the 1940s the standard treatment was reduction of the fracture and immobilization in plaster spica or in traction. The long period of immobility required for this treatment carried considerable morbidity, particularly in elderly patients. In addition to problems of prolonged bed rest, reports about various management strategies were not satisfactory. The justification for early rehabilitation in this group was accurately summed up by this quotation by Evans. '' The very old patients who sustain this injury tolerate pain and immobility badly; their mental state is often precarious and is quick to develop bed sores or pulmonary complications. We believe that they should be treated as surgical emergency and the older and more feebler the patient the more urgent is the need for the operation" The aim of this prospective and retrospective study is to analyse the short term follow up results of cemented bipolar hemi arthroplasty in neck of femur fracture and unstable intetrochanteric fractures of the elderly done in our institution.