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Background: The incidence of femoral neck fractures in older adults is increasing each year. Active and reasonable postoperative rehabilitation exercises can restore the activity of geriatric patients with femoral neck fractures to a great extent, while also avoiding bedridden complications and re-fractures. This study explores the perspectives, experiences, and recommendations of medical staff regarding the implementation status, existing problems, promoting factors, and hindering factors of post-surgical rehabilitation exercises for geriatric patients with femoral neck fractures. The ultimate goal is to further optimize rehabilitation exercise programs and to expedite this process for patients., Methods: A qualitative, descriptive phenomenological study was conducted. A total of 21 clinical medical staff were selected using the purposive sampling method for semi-structured interviews. A content analysis method was used to collate and analyze the collected interview data., Results: A total of 2 themes and 6 sub-themes were defined. The themes consisted of multiple obstacles occurring during the implementation of rehabilitation exercises and the scientific cognition of medical staff on these exercises. Respondents found that patient initiative during rehabilitation exercises was insufficient, that the comprehensiveness and continuity of exercises could not be guaranteed, and that unification between textbook theory and clinical practice was incomplete. Moreover, respondents believed that their professional quality should be excellent, but that staffing and organizational management required optimization, and that support was required for the implementation of rehabilitation exercises., Conclusion: This study investigated the opinions and experiences of medical staff during postoperative rehabilitation exercises in geriatric patients with femoral neck fractures. Collaborative efforts should fully engage hospitals, communities, and families, enhance the alignment of health education with patient needs, advance the scientific development of an integrated medical model by refining the curriculum and teaching system, and significantly elevate the level of medical science and technology. This study will serve as a valuable reference for the establishment of future professional, and personalized rehabilitation programs tailored for geriatric patients with femoral neck fractures., (© 2024. The Author(s).)

Purpose: To compare the postoperative rehabilitation of femoral neck fractures treated with robot-assisted nailing and freehand nailing., Methods: We systematically searched the PubMed, EMBASE, Cochrane, China National Knowledge Infrastructure(CNKI), WanFang database, China Science and Technology Journal Database (VIP) and Web of Science databases to identify potentially eligible articles. Indispensable data such as the year of publication, country, study type, robot type, age, number of patients, sex distribution, study design, and outcome indicators were extracted. The outcome indicators of interest included healing rate, length of healing time, Harris score, operation time, frequency of X-ray fluoroscopy, frequency of guide pin insertion, and intraoperative blood loss. RevMan 5.4.1 was used for the meta-analysis., Results: Fourteen studies with 908 participants were included in this meta-analysis. The results showed that in terms of healing rate (SMD = 2.75, 95% CI, 1.03 to 7.32, P = 0.04) and Harris score (SMD = 2.27, 95% CI, 0.79 to 3.75, P = 0.003), robot-assisted screw placement technique scores were higher than the traditional freehand technique. Additionally, operative time (SMD = -12.72, 95% CI, -19.74 to -5.70, P = 0.0004), healing time (SMD = -13.63, 95% CI, -20.18 to -7.08, P < 0.0001), frequency of X-ray fluoroscopy (SMD = - 13.64, 95% CI, - 18.32 to - 8.95, P < 0.00001), frequency of guide pin insertion (SMD = - 7.95, 95% CI, - 10.13 to - 5.76, P < 0.00001), and intraoperative blood loss (SMD = - 17.33, 95% CI, - 23.66 to - 11.00, P < 0.00001) were lower for patients who underwent robotic-assisted screw placement than those for patients who underwent the conventional freehand technique., Conclusion: Compared to the freehand nailing technique, robot-assisted nailing helps improve postoperative healing rates in patients with femoral neck fractures; shortens healing times; better restores hip function; reduces the number of intraoperative fluoroscopies, guides pin placements; reduces intraoperative bleeding; and increases perioperative safety., (© 2024. The Author(s).)

Abstract: To retrospectively analyze the functional outcomes and complications in patients who underwent hip arthroplasty with enhanced recovery after surgery (ERAS) program for femoral neck fractures.Between June 2015 and May 2019, 1138 patients with femoral neck fractures were treated in our department. According to the Garden classification system, 467 cases were type III and 671 cases were type IV with an average age of 74.9 ± 8.8 years (range, 59-96 years). All patients underwent hip arthroplasty with ERAS. The clinical outcomes of these patients were retrospectively analyzed at the final follow-up using the Harris hip score (HHS).The median follow-up was 21.2 months (range, 6-36 months). The mean time to surgery and the length of hospitalization after surgery were 2.4 and 2.2 days, respectively. Eight hundred and fifty-two patients (74.9%) were operated within 48 hours from admission, 1052 cases (92.4%) were discharged within 48 hours after surgery. Twelve patients (1.05%) were readmitted for prosthetic dislocation. None of the patients suffered from infection, periprosthetic fractures, and/or prosthetic loosening. The HHS at the final follow-up was 92.7 ± 7.6, with an excellent or good rate of 90.2%.Patient-oriented ERAS optimizes the interventional measures during the perioperative period for geriatric patients with femoral neck fractures and can improve their short-term clinical outcomes without increased readmission rates., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Femoral neck fracture is a common type of hip fracture, which has a high morbidity and mortality. Surgical treatment is the first choice. However, the functional rehabilitation after operation has not been paid enough attention. In addition, the quality of exercise is difficult to quantify, and the rehabilitation is lack of standards. Therefore, the intelligent rehabilitation assistant system which could record exercise details, might be used to evaluate the quality and adherence to the prescribed exercise to this fragile group of patients has great relevance, so as to provide new ideas for postoperative rehabilitation of hip fracture., Methods: This is an opening, prospective, double-dummy RCT. Fifty femoral neck fractures patients, older than 65 years and are about to hospitalize for HA, will be invited to study. The sample will be divided into monitoring group and control group randomly at a 1:1 ratio. The prescribed exercises need to be done continuously for 2 weeks. The monitoring group needs additional use intelligent rehabilitation assistant system. Each subject will receive a total of 4 follow-up visits at the designated time (2 weeks, 4 weeks, 12 weeks, and 24 weeks). The following factors will be talked as dependent variables:Each subject will receive a total of 4 follow-up visits at the designated time, and the findings will be analyzed statistically considering a 5% significance level (P < .05)., Discussion: Exercise under monitor may improve patients compliance and exercise quality, and accelerate the rehabilitation process. This protocol reported in accordance with the CONSORT 2010 checklist and SPIRIT 2013 Checklist., Trial Registration: The trial is registered at Chinese Clinical Trials Registry (ChiCTR2000033213, May 24, 2020).

Background: Hip fractures are common with a UK incidence of over 70,000 cases and total healthcare costs of over £2 billion per year. Mortality rates of 10% at 30 days and up to 30% at 1-year have been reported. We wanted to assess the outcome of hip fracture surgery in patients with reduced pre-fracture mobility as this has not been exclusively studied previously., Methods: We retrospectively reviewed 168 hip fracture patients with reduced pre-fracture mobility (wheelchair bound, bed bound, walking with 2 aids or a frame) who underwent hip fracture surgery at our institution between 2008 and 2013 using case notes, discharge letters, outpatient clinic letters and laboratory test results. Measured outcomes included 30-day renal, cardiac and respiratory morbidity as well as 30-day and 1-year mortality., Results: Our study comprised 27% males and 73% females with a mean age of 82 years. The 30-day chest infection, acute renal failure and acute coronary syndrome rates were 26%, 7.7% and 4% respectively. In those patients who were either wheelchair or bed bound, 30-day and 1-year mortality rates were 11.8% and 52% respectively whereas in those who could mobilise with the help of 2 aids or frame, 30-day and 1-year mortality rates were 4.34% and 39.70% respectively., Conclusion: Our study highlighted increased 30-day and 1-year morbidity and mortality rates following hip fracture surgery with notable high rates of respiratory and renal complications in patients with reduced pre-fracture mobility. We would recommend pre- and postoperative optimisation with orthogeriatric review, chest physiotherapy and intravenous fluid hydration to reduce complication rates and improve morbidity and mortality.

Objectives: This study aims to translate and investigate the inter- rater reliability, agreement and validity of the Turkish version of the Cumulated Ambulation Score (CAS-TR) in patients with hip fracture., Patients and Methods: This study included patients with a hip fracture of the femoral neck between July 2019 and March 2020 at the Dr. Lütfi Kırdar Kartal Training and Education Hospital, Department of Orthopedics and Traumatology, Istanbul. The CAS manual and score-sheet were translated into Turkish. An orthopedician and a physiotherapist independently administered the CAS-TR to 36 patients (12 males, 24 females; mean age 78.7 years; range, 65 to 90 years) at postoperative days one, two, three and 30. Weighted Cohen's kappa coefficient was used to measure inter-rater reliability. Turkish version of modified Barthel Index was used for analysis of validity., Results: The majority of the patients had type III fracture (72.2%) according to Garden's classification. The kappa value was ≥0.90 for days one-three, the total and 30th day score of CAS-TR. The observed agreement ranged between 91.6% and 100% for all assessments. Validity analysis showed a significantly positive correlation between day two and day 30 CAS-TR and Barthel scores., Conclusion: We found almost perfect reliability, high percentage agreement and acceptable convergent validity of the CAS-TR. We recommend the CAS to be used as an easily applicable instrument to assess basic mobility status in Turkish patients with hip fracture. Orthopedic and geriatric patients and patients undergoing any type of surgery can be assessed with CAS for early evaluation of mobility status.

Aims: The aim of this study was to determine if different patient groups have superior mobility regain following intertrochanteric hip fracture fixation with a cephomedullary nail compared to a sliding hip screw (SHS)., Patients and Methods: The present study is a subgroup analysis of patients which were enrolled into a randomized controlled trial which randomized 1000 patients with an intertrochanteric hip fracture to fixation with either a short cephomedullary nail (Targon® PF or PFT) or a SHS. In the present study the two treatment groups were dicotomised on the basis of six variables determined at the time of admission; age (<80; ≥80 years), sex, residence (admitted from own home; institutional care), mobility (mobility score ≥7 [good]; <7 [poor]), mental status (AMTS < 7 [cognitively impaired]; ≥7) and health status (ASA < 3; ≥3). The primary outcome measure was the difference between mobility score pre-fracture and mobility score during the year after hip fracture fixation., Results: Patients less than 80 years of age, those admitted from their own home, cognitively intact patients and patients who mobilised without assistance pre-fracture, recovered superior mobility when fracture fixation was performed with a nail compared to a SHS. Those patients admitted from institutional care, those with significant cognitive or mobility impairment at the time of the injury did not have any significantly improved benefit in mobility regain with a nail compared to a SHS., Conclusion: Fixation of an intertrochanteric hip fracture with a cephomedullary nail results in superior recovery of mobility for younger patients who prior to the injury were more mobile, cognitively intact and living at home., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Early mobilization following hip fracture surgery is of superior importance especially in elderly hip fracture patients. Reduced mobilization can result in complications and increased mortality. In this study a gait analysis was performed using force-measuring insoles. We hypothesized, that patients with femoral neck fractures treated with hip replacement surgery load the affected limb more compared to patients with pertrochanteric fractures treated with fracture fixation. All patients (> 65 years) treated for a femoral neck fracture with hip replacement or a pertrochanteric fracture, respectively using fracture fixation with intramedullary nailing, were consecutively included in this study. For gait analysis, specific insole forcesensors (Loadsol®) were inserted into the footwear. Five days after surgery gait analysis was performed with a defined walking distance and all patients were instructed to transpose full weight. 20 patients following hip replacement surgery and 27 patients following intramedullary nailing were included. The hip replacement group loaded the affected limb with an average of 74.01% (SD 13.6) of bodyweight, while the fracture fixation group loaded a significantly reduced average of 62.70% (SD 8.3; p = 0.002). The results of the present study indicate that patients suffering from pertrochanteric fractures following fracture fixation are struggling to fully load the affected leg compared to patients suffering from femoral neck fractures treated with hip replacement surgery. The focus of further studies should concentrate on alternative analgesia and verify the cause of the observed difference in order to facilitate early full weight bearing especially in hip fracture patients following fracture fixation. The results indicate that in elderly patients, the fracture pattern and thus the surgical approach lead to a different weight bearing pattern. The primary therapeutic goal for elderly patients must be early mobilization at full weight bearing., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the effect of early preoperative mobilization on the rehabilitation of the elderly patients with hip fractures after operation., Methods: The clinical data of 16 elderly patients with hip fractures between February 2017 and April 2018 who met the selection criteria was retrospectively analyzed. There were 8 males and 8 females, with an average age of 80.3 years (range, 69-90 years). There were 8 cases of intertrochanteric fracture and 8 cases of femoral neck fracture. The preoperative American Society of Anesthesiologists (ASA) scored 2.94±0.43. There were 3 cases of cardiovascular and cerebrovascular diseases, 6 cases of essential hypertension, 5 cases of respiratory diseases, 3 cases of diabetes, and 2 cases of other system diseases. The time from injury to admission was 4 hours to 14 days with an average of 39.5 hours. On the day of admission or on the first day after admission, the patient started to exercise on the floor underwent analgesia treatment. And the patients were treated with closed reduction (9 cases) or artificial hip arthroplasty (7 cases). The time from admission to operation was 4 to 25 days, with an average of 7.4 days. At the time of admission, after the first ground movement before operation, on the second day after operation, and at last follow-up, the Barthel Index was used to assess the patients' self-care ability, and Barthel effectiveness (BE) was calculated. The complications were observed and recorded during follow-up., Results: All 16 patients underwent operation successfully. The hospital stay was 8 to 24 days, with an average of 14.1 days. All patients were followed up 2.5-16.0 months with an average of 6.5 months. One patient developed postoperative pulmonary infection; the remaining patients had no surgical-related complications. No patient died during the follow-up. The Barthel Index scored 30.63±5.56 at admission, 53.13±9.50 after the first ground movement before operation, 60.63±6.09 on the second day after operation, and 96.25±4.84 at last follow-up. There were significant differences in Barthel Index scores between different time points ( P <0.05). The BE was 0.23±0.06 after the first ground movement before operation, 0.30±0.04 on the second day after operation, and 0.66±0.06 at last follow-up. There were significant differences in BE between different time points ( P <0.05)., Conclusion: For elderly patients with hip fractures who have long waiting time before operation, early preoperative mobilization has a positive impact on patients' activities of daily living.

Aims: Our aim was to investigate function, health status and satisfaction in patients treated with primary dual mobility (DM) total hip arthroplasty (THA) after displaced femoral neck fracture (FNF)., Patients and Methods: From 2005-2011, 414 consecutive FNF patients received Saturne DM THA. At a minimum of 1-year follow-up, 124 (95 women) were evaluated with Oxford Hip Score (OHS), Harris Hip Score (HHS), health-related quality of life (HRQoL) measure (EQ-5D) and two functional tests: Timed Up and Go (TUG) and Sit to Stand 10 times (STS). The FNF patients were matched 1:2 by age, sex and surgery date with patients receiving THA due to osteoarthrosis (OA group) and 1-year OHS and EQ5D were compared. FNF patients were matched by age and sex with the general population index (GPI) for EQ-5D comparison., Results: Patient age at surgery after FNF was mean 74.8 (range 30-92) years. At mean follow-up of 2.8 (range 1.0-7.7) years, mean EQ-5D score was 0.79 (SD 0.15) in the FNF group, which was similar to the matched GPI ( p = 0.4), but lower ( p = 0.014) compared to the OA group. Mean OHS was 36.4 (SD 9.5) in the FNF group and 38.4 (SD 7.2) in the OA group ( p = 0.18). HHS in the FNF group was 78.7 (SD 15.5). Mean TUG time was 13.5 (SD 4.9) secs, and mean STS was 37.9 (SD 15.3) secs. Eighty nine percent (n = 111) of FNF patients were satisfied with the operation result., Conclusion: DM THA following displaced FNF provides a good functional result and quality of life in addition to high patient satisfaction., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

A 23-year-old woman was referred to physical therapy by her primary care physician for a 4-week history of right groin pain that had progressively worsened while training for a half-marathon. Before the physical therapy referral, the primary care physician ordered radiography of the right hip, which was unremarkable for fracture. Following examination, the physical therapist suspected osseous or soft tissue abnormality and requested that the primary care physician order magnetic resonance imaging without contrast, which revealed a femoral neck stress fracture. J Orthop Sports Phys Ther 2018;48(4):343. doi:10.2519/jospt.2018.7479.

Background and Purpose: Prospective studies on patient related outcome in patients <70years with a femoral neck fracture (FNF) are few. We aimed to investigate functional outcome and health-related quality of life (HRQoL) in 20-69years old patients with a FNF treated with internal fixation., Patients and Methods: 182 patients, 20-69years with a FNF treated with internal fixation were prospectively included in a multicenter study. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and SF-36), fracture healing and re-operations., Results: At 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85% of the patients with a non-displaced fracture (p=0.15). Of the patients with displaced fracture (n=120), 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of the patients with non-displaced fracture (n=50) had an NU, 12% had a radiographic AVN and 8% needed a re-operation. The mean EQ-5D index in patients with displaced fracture decreased from 0.81 to 0.59 at 4 months, 0.63 at 12 months and 0.65 at 24 months (p<0.001). The corresponding values for patients with non-displaced fracture were 0.88, 0.69, 0.75 and 0.74 respectively (p<0.001). The mean SF-total score in patients with displaced fracture decreased from 76 to 55 at 4 months, 63 at 12 months and 65 at 24 months (p<0.001). The corresponding values for patients with non-displaced fracture were 80, 67, 74 and 76 respectively (p<0.001)., Interpretation: Two thirds of the patients with displaced femoral neck fracture healed after one operation and three quarters reported good or excellent functional outcome at 24 months. However, they did not regain their pre-fracture level of HRQoL., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Hip fractures in the elderly are a major cause of morbidity and mortality. The treatment settings of these patients may change their outcomes. The aim of this study is to compare the outcomes of patients with displaced femoral neck fractures who were admitted to the orthopedic vs. geriatric wards., Patients and Methods: A retrospective study was conducted on 217 consecutive older patients with 219 displaced femoral neck fractures admitted either to the orthopedic or the geriatric ward between Jan. 2013 and Jun. 2015. Information regarding demographic, medical history, surgical management, hospitalization, and one year readmissions and mortality data was retrieved from electronic charts., Results: 102 hemiarthroplasty patients were admitted to the orthopedic ward and 117 to the geriatric ward. Patients' characteristics, including age, living arrangements, mobility status and the Charlson Comorbidity Index were similar between groups. Patients from the orthopedic ward had shorter hospitalization time (9±5.1 vs. 10.8±6.7days, p=0.022) and presented a lower in-hospital complication rates (0.6±0.96 vs. 1±1.9, p=0.022), namely fewer events of urinary retentions, urinary tract infections and pneumonias (8.8% vs. 23.9%, p=0.004, 3.9% vs. 14.5%, p=0.010 and 2.9% vs. 12.2%, p=0.034, respectfully). Readmission rates were similar. Neither in hospital nor one year mortality rates differed between groups., Conclusions: Our study found that geriatric care was not superior to orthopedic directed management in the treatment of elderly patients with hip fractures in terms of in-hospital complications, and hospitalization times., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Hip joint replacement (endoprosthesis, alloplasty) has become one of the most frequent surgery interventions of the 20th century., Aim: To conduct rehabilitation therapy in the late post-surgery period of hospital rehabilitation (45 days after surgery), to track patients' progress and measure the results., Materials and Methods: One hundred and fifty-two patients with hip joint endoprosthesis were included in the study. All underwent surgery and rehabilitation at the Department of Clinical Rehabilitation of the Physical and Rehabilitation Medicine Clinic at Doctor G. Stranski University Hospital, Pleven. Kinesitherapy included therapeutic massage, isometric exercises for gluteal and hip muscles, isotonic exercises for the hip and the knee joint, breathing exercises, analytical gymnastics, exercises for balance and posture stability; gait control, exercises with gym equipment; occupational exercises included all activities of daily living (ADL) that were practiced at home; treatment with performed physical factors included applying magnetic field, interferential current therapy, electrostimulation of the m. quadriceps femoris and the gluteal muscles., Results: The scores from the pain visual analog scale (VAS), the muscle strength test and the test for the movement volume of the hip joint were obtained at the beginning and at the end of the rehabilitation process and stored in an individual file for each patient., Conclusion: The results of the present study suggest that the complex rehabilitation program (kinesitherapy, performed physical factors and occupational therapy) can result in a considerably faster recovery and ensures that patients reach optimal functional results.

Objectives: To determine if early surgery before 12h confers a survival or length of stay benefit for patients with neck of femur (NOF) fractures., Design: Retrospective review of prospectively collected data., Setting: District general hospital., Patients: 1913 patients aged over 60 admitted with a fractured NOF who underwent surgery between 2011 and 2015. Mean age was 83.9 years. 73.7% were female., Intervention: Patients had surgery for fractured NOF with data collected on demographics, mortality and length of stay., Main Outcome Measurements: Data collected included gender, age, ASA grade, fracture anatomy, surgery, time to surgery, days spent in acute hospital and rehabilitation settings and 30-day mortality. Statistical analysis was used to identify independent predictors of mortality and length of stay., Results: 30-day mortality was 6.1% and the mean hospitalisation time was 13±11.3days for the acute hospital and 20.2±17.2days for the trust. Operations were performed at a mean of 23.8±14.8h after presentation. Age, gender, ASA grade and type of fracture were independent predictors of either mortality or length of stay. Timing of surgery had an association with mortality but this only reached statistical significance at 24h. In line with previous studies we analysed time to surgery in 12h blocks. We also used logistic regression, recognizing time as a continuous variable, which revealed that every hour of delay to surgery increased the mortality risk by 1.8%., Conclusions: While every hour of delay increased mortality risk, the association with mortality only became statistically significant when delaying over 24h. This supports a pragmatic approach, with surgery as soon as medically possible without a race to theatre., Level of Evidence: Level III retrospective cohort study., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Hip fractures in the elderly are a common reason for admission to the department of orthopaedic surgery, this condition asks an important part of health resources and is associated with high levels of co-morbidity and mortality. Many improvements have been introduced in the treatment of these patients, preoperative regional analgesia, intensive physical therapy, interdisciplinary care program; but still remain unresolved gaps. The aim of this study is to document the natural history of early versus delayed surgical intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge., Methods: A sample of 499 patients admitted in our Institution was prospectively reviewed between February 2008 and February 2013. Preoperatively characteristics and functional data were assessed in relation with time to surgery (focused on mortality and ability to walk at first year)., Results: The ability to walk and activities of daily living (functional results) were not associated with surgical delays (surgery before 24h from admission, surgery among 24h and 72h from admission and surgery later than 72h). However, ASA class, Parkinson disease and age were significantly associated with poor functional results. In the same way, mortality at 1year was not associated with time to surgery, but ASA class was associated with significant risk factor of 1 year-mortality., Conclusions: ASA class, Parkinson disease and age are independent predictor of poor functional outcomes after intracapsular hip fracture. In addition, ASA class is an independent predictor of mortality. Patients with poor functional status before fracture and older than 75 years would benefit from geriatric and rehabilitation intervention immediately after surgery., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Here, we assessed the prognostic value of the early sliding length (ESL) for predicting the risk of non-union after internal fixation of femoral neck fractures (FNFs) by Dual SC Screws (DSCS)., Methods: A retrospective analysis of 86 patients with intra-capsular FNFs was performed. They underwent osteosynthesis by DSCS at our institution between 2008 and 2013 with a minimum follow-up duration of 6 months. Preoperative displacement, fracture reduction quality, ESL of screws at 2 weeks postoperatively, and correlation of non-union with the ESL of screws were evaluated., Results: Bone union without complications was achieved in 74 patients (86.0%), whereas 12 patients (14.0%) showed non-union. The ESL was significantly longer in the non-union group (proximal 3.94 ± 2.79 mm, distal 4.03 ± 3.16 mm) than in the union group (proximal 0.98 ± 1.85 mm, distal 1.01 ± 1.84 mm, P = 0.0001* for proximal, P < 0.0001* for distal). The ESL was significantly associated with non-union, both in the proximal [P = 0.0002, unit odds ratio (OR) 1.58, 95% confidence interval (CI) 1.23-2.16] and distal screws (P = 0.0002, unit OR 1.53, 95% CI 1.21-2.02). The areas under the ROC curves for the ESL of proximal and distal screws were 0.845 and 0.867, respectively; the cut-off values to predict non-union were 1.0 mm (sensitivity 91.7% and specificity 74.3%) and 1.4 mm (sensitivity 83.3% and specificity 81.1%), respectively., Conclusions: In this study, the ESL was a good predictor of postoperative non-union in patients with FNFs fixed by DSCS.

Background: Swallowing difficulties challenge patient safety due to the increased risk of malnutrition, dehydration and aspiration pneumonia. A theoretically driven study was undertaken to examine the spread and sustainability of a locally developed innovation that involved using the Inter-Professional Dysphagia Framework to structure education for the workforce. A conceptual framework with 3 spread strategies (hierarchical control, participatory adaptation and facilitated evolution) was blended with a processual approach to sustaining organisational change. The aim was to understand the processes, mechanism and outcomes associated with the spread and sustainability of this safety initiative., Methods: An instrumental case study, prospectively tracked a dysphagia innovation for 34 months (April 2011 to January 2014) in a large health care organisation in England. A train-the-trainer intervention (as participatory adaptation) was deployed on care pathways for stroke and fractured neck of femur. Data were collected at the organisational and clinical level through interviews (n = 30) and document review. The coding frame combined the processual approach with the spread mechanisms. Pre-determined outcomes included the number of staff trained about dysphagia and impact related to changes in practice., Results: The features and processes associated with hierarchical control and participatory adaptation were identified. Leadership, critical junctures, temporality and making the innovation routine were aspects of hierarchical control. Participatory adaptation was evident on the care pathways through stakeholder responses, workload and resource pressures. Six of the 25 ward based trainers cascaded the dysphagia training. The expected outcomes were achieved when the top-down mandate (hierarchical control) was supplemented by local engagement and support (participatory adaptation)., Conclusions: Frameworks for spread and sustainability were combined to create a 'small theory' that described the interventions, the processes and desired outcomes a priori. This novel methodological approach confirmed what is known about spread and sustainability, highlighted the particularity of change and offered new insights into the factors associated with hierarchical control and participatory adaptation. The findings illustrate the dualities of organisational change as universal and context specific; as particular and amendable to theoretical generalisation. Appreciating these dualities may contribute to understanding why many innovations fail to become routine.

Aims: The aims of this audit were to collect the Minimum Data Set outlined by the Australia New Zealand Hip Fracture Registry (ANZHFR), assess patient characteristics, analyse process of care, and evaluate how this compares to NICE guidelines for hip fracture care, as well as to Auckland Hospital data from 2007., Method: Retrospective case record audit of patients with fractured neck of femur aged 65 years and over admitted under Orthopaedics over a 4-month period in 2013., Results: Ninety-one patients were audited; mean age was 83 years, 68% were female. Both inpatient and 30-day mortality was 5%. 120-day mortality was 15%. Seventy-six percent of patients were admitted from ED within the national health target prescribed period of 6 hours. Only one patient was treated non-surgically. Eighty-six percent had surgery within 48 hours of admission. Eighty-two percent of patients had rehabilitation and treatment by Older People's Health. Of those living at home pre-fracture, 76% returned home on discharge. Thirty-seven percent of patients were able to walk unaided prior to hip fracture, but only 1% on discharge. Average overall length of stay was 22 days. Bisphosphonates were prescribed for 56% of patients., Conclusions: Compared to 2007, Auckland City Hospital has demonstrated a significant improvement in the rate of provision of timely surgery for hip fracture patients. Most patients are receiving the guideline recommended fracture-specific surgical interventions. The assessment and treatment of osteoporosis needs further attention.

Background: The average length of stay (LOS) following a hip fracture in hospitals around the UK has been approximately 20 days in recent years. This can vary between hospitals and there are numerous factors that can affect LOS. We had the impression that LOS varied by Clinical Commissioning Group (CCG) from which the patient originates. The aim of our study was to discover whether the concern was valid, and if so, what the reasons may be., Methods: We analysed hip fracture data collected at our Trust between September 2008 and December 2014. LOS was compared for each of three CCGs in our Trust's catchment areas, and those patients admitted from outlying CCGs. Sub-analysis was performed by patient age, ASA grade, abbreviated mental test score, procedure type and discharge destination to determine which factors influence LOS., Results: 1847 patients were identified. After excluding deaths, missing data and extreme outliers, 1603 patients were included in the analysis. The median LOS varied from 14.9 to 23.4 days across CCGs. The major reason for this variation was discharge destination. CCGs associated with longer LOS had a significantly higher rate of discharge to the patient's own home, rather than institutional care. This was independent of patient age, mental status, ASA grade and promptness of surgery., Conclusion: We have shown that CCGs vary in their performance to aid discharge. This directly influences a Trust's performance on the National Hip Fracture Database. Compared with other hospitals, our results show a poor outcome in terms of length of stay, but much better performance regarding home discharge. We recommend that more emphasis in future be placed on discharge destination than LOS., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The aim of this randomised controlled study was to compare functional and radiological outcomes between modern cemented and uncemented hydroxyapatite coated stems after one year in patients treated surgically for a fracture of the femoral neck. A total of 141 patients aged > 65 years were included. Patients were randomised to be treated with a cemented Exeter stem or an uncemented Bimetric stem. The patients were reviewed at four and 12 months. The cemented group performed better than the uncemented group for the Harris hip score (78 vs 70.7, p = 0.004) at four months and for the Short Musculoskeletal Function Assesment Questionnaire dysfunction score at four (29.8 vs 39.2, p = 0.007) and 12 months (22.3 vs 34.9, p = 0.001). The mean EQ-5D index score was better in the cemented group at four (0.68 vs 0.53, p = 0.001) and 12 months (0.75 vs 0.58, p = < 0.001) follow-up. There were nine intra-operative fractures in the uncemented group and none in the cemented group. In conclusion, our data do not support the use of an uncemented hydroxyapatite coated stem for the treatment of displaced fractures of the femoral neck in the elderly., (©2015 The British Editorial Society of Bone & Joint Surgery.)

Purpose: To estimate functional capability and attendant falls-risk in older institutionalized people after total hip arthroplasty (THA) for femoral neck fractures., Methods: The study population comprised 149 consecutive patients (F104, M45; mean age 83.4 years) who were permanent residents of nursing care facilities four weeks after THA for femoral neck fractures. Individual mental and functional capability status was assessed using the Mini Mental State Examination (MMSE), Timed Up and Go test (TUG) and Tinetti's Performance Oriented Mobility Assessment (POMA) which includes sub-scales for balance (B) and gait (G), in conjunction with identifying any concomitant disorders, reviewing individual pharmacotherapy and leisure time activities., Results: The subjects' mean MMSE was 23.1 points, whereas in Tinetti's POMA they scored 19 points on average, which translated into a five-fold greater falls-risk, whereas average TUG scores of 23.9s effectively corroborated this assertion. Multiple regression analysis effectively highlighted that TUG scores were strongly correlated with the actual number of concomitant disorders, number of regularly taken medications, and usual manner of spending leisure time., Conclusions: Institutionalized older people after THA for femoral neck fracture continue to be exposed to high risk of recurrent, possibly injurious falls, which is closely correlated with significantly diminished individual functional capabilities., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Femoral neck fractures have been reported as a cause for failure in patients with a hip resurfacing arthroplasty. However, the incidence and management of fractures of the femoral shaft with an ipsilateral hip resurfacing arthroplasty is relatively absent in current literature. Although, the gold standard for the fixation of a closed femoral shaft fracture is with the use of an intramedullary nail, this can be a challenge in the presence of a hip resurfacing arthroplasty. We describe the case of anterograde intramedullary nail fixation for a femoral shaft fracture in a patient with an ipsilateral hip resurfacing arthroplasty in situ., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Hip fracture care has evolved, largely due to standardisation of practice, measurement of outcomes and the introduction of the Best Practice Tariff, leading to the sustained improvements documented by the National Hip Fracture Database (NHFD). The treatment of distal femoral fractures in this population has not had the same emphasis. This study defines the epidemiology, current practice and outcomes of distal femoral fractures in four English centres., Patients and Methods: 105 patients aged 50 years or greater with a distal femoral fracture, presenting to four UK major trauma centres between October 2010 and September 2011 were identified. Data was collected using an adapted NHFD data collection tool via retrospective case note and radiograph review. Local ethics approval was obtained., Results: Mean age was 77 years (range 50-99), with 86% female. 95% of injuries were sustained from a low energy mechanism, and 72% were classified as either 33-A1 or 33-C1. The mean Parker mobility score and Barthel Independence Index were 5.37 (0-9) and 75.5 (0-100) respectively. Operative management was performed in 84%, and 86% had their surgery within 36 h. Three quarters were fixed with a peri-articuar locking plate. There was no consensus on post operative rehabilitation, but no excess of complications in the centres where weight bearing as tolerated was the standard. 45% were seen by an orthogeriatrician during their admission. Mean length of stay was 29 days. Mortality at 30 days, 6 months, and 1 year was 7%, 16% and 18% respectively., Discussion: This study demonstrates that the distal femoral and hip fracture populations are similar, and highlights the current disparity in their management. The metrics and standards of care currently applied to hip fractures should be applied to the treatment of distal femoral fractures. Optimal operative treatment and rehabilitation remains unclear, and is in need of further research., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Unlabelled: The purpose of our case presentation was to reveal effectiveness of medical massage in the therapy for obturator nerve dysfunction as a complication of hip joint alloplasty., Design: Medical massage was carried out in a 58-year-old man after hip joint alloplasty. The aim was to normalize tension of muscle-ligament-fascia apparatus within pelvic girdle and reconstruct correct structural conditions in the course of obturator nerve., Methods: The methodology included correct positioning and medical massage with individually designed procedures., Findings: Full normalization of muscular tone and subsidence of pain complaints were obtained., Conclusions: Massage has a positive influence on subsidence of pain complaints; however, effectiveness of the procedure depends on an appropriate methodology., Clinical Relevance: The presented massage procedure is an effective therapy in obturator nerve dysfunction as complication after alloplasty and it can be one of elements of complex improvement after surgical joint procedures within the scope of nursing rehabilitation., (© 2013 Association of Rehabilitation Nurses.)

Background: Hip fractures frequently occur in older persons and severely decrease life expectancy and independence. Several care pathways have been developed to lower the risk of negative outcomes but most pathways are limited to only one aspect of care. The aim of this study was therefore to develop a comprehensive care pathway for older persons with a hip fracture and to conduct a preliminary analysis of its effect., Methods: A comprehensive multidisciplinary care pathway for patients aged 60 years or older with a hip fracture was developed by a multidisciplinary team. The new care pathway was evaluated in a clinical trial with historical controls. The data of the intervention group were collected prospectively. The intervention group included all patients with a hip fracture who were admitted to University Medical Center Groningen between 1 July 2009 and 1 July 2011. The data of the control group were collected retrospectively. The control group comprised all patients with a hip fracture who were admitted between 1 January 2006 and 1 January 2008. The groups were compared with the independent sample t-test, the Mann-Whitney U-test or the Chi-squared test (Phi test). The effect of the intervention on fasting time and length of stay was adjusted by linear regression analysis for differences between the intervention and control group., Results: The intervention group included 256 persons (women, 68%; mean age (SD), 78 (9) years) and the control group 145 persons (women, 72%; mean age (SD), 80 (10) years). Median preoperative fasting time and median length of hospital stay were significantly lower in the intervention group: 9 vs. 17 hours (p < 0.001), and 7 vs. 11 days (p < 0.001), respectively. A similar result was found after adjustment for age, gender, living condition and American Society of Anesthesiologists (ASA) classification. In-hospital mortality was also lower in the intervention group: 2% vs. 6% (p < 0.05). There were no statistically significant differences in other outcome measures., Conclusions: The new comprehensive care pathway was associated with a significant decrease in preoperative fasting time and length of hospital stay.

Objective: To describe the most common characteristics of elderly people who fell and fractured their femoral neck and who were admitted to our rehabilitation setting after surgery by an orthopedic surgeon., Setting: A rehabilitation department in a general regional hospital., Participants: A cohort of 100 patients, 37 men and 63 women, hospitalized for rehabilitation after surgery for a fracture in the femoral neck., Methods: All the patients were interviewed by a physician from the rehabilitation department about the circumstances of their fall injuries, examined by an ophthalmologist for ocular problems, and evaluated by an occupational therapist for cognitive function. Data about background diseases were retrieved from the patients' medical records., Main Outcome Measurements: Age of the patients, place and time of the fall, the circumstances of the fall event, the footwear used at the time of the fall, ophthalmic problems, cognitive disorders, eyeglasses use, walking aids use, medication used that may affect the central nervous system, and the presence of diseases that may influence patients' equilibrium., Results: The mean age of the patients was 78 years, with a mean weight of 69 kg. Seventy-eight percent had 1-5 diseases that could influence their balance during weight bearing; 67% had an ophthalmic disease. For 70% of the patients, the cause of the fall appeared to be intrinsic (personal). Seventy-two percent wore socks or slippers, or were barefoot at the time of the fall. Sixty-four percent of the patients who used a walking aid did not use it during the fall event. Seventy-one percent of falls occurred indoors and 29% outdoors. Fifty-five percent of the patients were with another person when they fell. Fifty-one percent were taking tranquilizers or medications for sleep disorders. Sixty-eight percent fell during the daylight hours, between 6 AM and 6 PM. Of the patients who wore eyeglasses, 77.6% were not wearing them when they fell. Seventy percent had a short-term memory disorder, 57% had a concentration disorder, and 49% had an orientation disorder., Conclusions: Characteristics common to patients who fell and fractured their femoral neck included age older than 78 years, cognitive impairment, nonuse of eyeglasses that were prescribed, and inappropriate footwear., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: To examine how the population with fractured neck of femur has changed over the last decade and determine whether they have evolved to become a more physically and socially dependent cohort., Design: Retrospective cohort study of prospectively collected Standardised Audit of Hip Fractures of Europe data entered on to an institutional hip fracture registry., Participants: 10 044 consecutive hip fracture admissions (2000-2012)., Setting: A major trauma centre in the UK., Results: There was a generalised increase in the number of admissions between 2000 (n=740) and 2012 (n=810). This increase was non-linear and best described by a quadratic curve. Assuming no change in the prevalence of hip fracture over the next 20 years, our hospital is projected to treat 871 cases in 2020 and 925 in 2030. This represents an approximate year-on-year increase of just over 1%. There was an increase in the proportion of male admissions over the study period (2000: 174 of 740 admissions (23.5%); 2012: 249 of 810 admissions (30.7%)). This mirrored national census changes within the geographical area during the same period. During the study period there were significant increases in the numbers of patients admitted from their own home, the proportion of patients requiring assistance to mobilise, and the proportion of patients requiring help with basic activities of daily living (all p<0.001). There was also a twofold to fourfold increase in the proportion of patients admitted with a diagnosis of cardiovascular disease, renal disease, diabetes and polypharmacy (use of >4 prescribed medications; all p<0.001)., Conclusions: The expanding hip fracture population has increasingly complex medical, social and rehabilitation care needs. This needs to be recognised so that appropriate healthcare strategies and service planning can be implemented. This epidemiological analysis allows projections of future service need in terms of patient numbers and dependency.

Summary: The study rationale was to provide a detailed overview of the costs for femoral neck fracture treatment with internal fixation in the Netherlands. Mean total costs per patient at 2-years follow-up were 19,425. Costs were higher for older, less healthy patients. Results are comparable to internationally published costs., Introduction: The aim of this study was to provide a detailed overview of the cost and healthcare consumption of patients treated for a hip fracture with internal fixation. A secondary aim was to compare costs of patients who underwent a revision surgery with patients who did not., Methods: The study was performed alongside the Dutch sample of an international randomized controlled trial, concerning femoral neck fracture patients treated with internal fixation. Patient characteristics and healthcare consumption were collected. Total follow-up was 2 years. A societal perspective was adopted. Costs included hospital costs during primary stay and follow-up, and costs related to rehabilitation and changes in living situation. Costs were compared between non-revision surgery patients, implant removal patients, and revision arthroplasty patients., Results: A total of 248 patients were included (mean age 71 years). Mean total costs per patient at 2-years follow-up were 19,425. In the non-revision surgery patients total costs were 17,405 (N = 137), in the implant removal patients 10,066 (N = 38), and in the revision arthroplasty patients 26,733 (N = 67). The main contributing costs were related to the primary surgery, admission days, physical therapy, and revision surgeries., Conclusions: The main determinant was the costs of admission to a rehabilitation center/nursing home. Costs were specifically high in elderly with comorbidity, who were less independent pre-fracture, and have a longer admission to the hospital and/or a nursing home. Costs were also higher in revision surgery patients. The 2-years follow-up costs in our study were comparable to published costs in other Western societies.

Background: Hip fractures are common injuries in the elderly, with significant associated morbidity and mortality rates. The National Hip Fracture Database (NHFD) was implemented to audit care according to national standards thus improving its clinical and cost-effectiveness., Patients and Methods: We retrospectively examined the care pathway for all hip fractures after its introduction at our centre over 1 year, with an audit of care according to the BOA-BGS 'Blue Book' guidelines. Data between the first (period 1: initial audit) and second (period 2: re-audit) six months of the study period were compared., Results: There were 372 patients (28% male, 72% female) in total with 190 in period 1 and 182 in period 2. For all patients, the median age was 85 years (range 33-101) and the median time to surgery was 24.5h (1-519.3), with 251 (67.5%) within 36h. Surgical delay was mainly due to lack of theatre space (37.6%) and medical reasons (54.7%). The median length of stay was 11 days (2-92) and the inpatient mortality rate was 6.2% (23). When comparing the two study periods, there were significantly more patients undergoing falls (p<0.01) and bone protection (p<0.01) assessments in period 2. Lack of theatre space was a significantly less common (p<0.01), with a significantly shorter median time to surgery (p=0.01) and length of stay (p<0.01) in period 2. More patients were discharged to rehabilitation units and the mortality rate was non-significantly lower in period 2 (7.4% vs. 5%). The best practice tariff was met in 45.3% and 70.3% (p<0.001) of patients in periods 1 and 2 respectively providing a total income of £95230.00 (GBP)., Conclusions: Implementing the NHFD has led to an improvement the quality of hip fracture care according to national guidelines. More patients were assessed by an orthogeriatrician, with a shorter time to surgery and length of stay following re-audit. There is potential for an improvement in mortality rates as well as significant financial income for hospitals., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

We present a patient with no dementia, depression or apathy, who had difficulty in learning self-exercise instructions. The patient was an 80-year-old right-handed woman who was admitted to a rehabilitation unit to receive postoperative rehabilitation after a femoral neck fracture. She was instructed quadriceps isometric exercises to perform 10 repetitions and to hold each stretch for 10 s. She performed the exercise correctly with motivation, but she had difficulty in learning the number of repetitions and the duration of each stretch. She had no history of cerebrovascular accident and the neurological examination was normal. Neuropsychological testing, MRI and (18)F-fluoro- D-glucose-positron emission tomography (FDG-PET) were performed to examine the neural mechanisms associated with this difficulty in learning instructions. Neuropsychological tests revealed dysfunction of working memory while other cognitive domains were relatively preserved. Her neuropsychological tests scores were (1) Mini-Mental State Examination: 24 (mild cognitive impairment), (2) Geriatric Depression Scale-15: 2 (no depression), (3) Apathy Scale: 2 (no apathy), (4) digit span forward: 5 (normal), (5) digit span backward: 2 (impaired), (6) visuospatial span forward: 4 (normal), (7) visuospatial span backward: 2 (impaired), (8) frontal assessment battery: 11 (normal), (9) Weigl test: 0 (impaired), (10) trail making test A: 52 s (normal), (11) train making test B: failed (impaired). T2-weighted and fluid-attenuated inversion recovery MRI showed high signal-intensity lesions in the cerebral deep white matter. FDG-PET revealed hypometabolic areas in the bilateral frontal lobes, particularly in the bilateral dorsolateral frontal area, anterior cingulate cortex and orbitofrontal cortex. One of the possible neural mechanisms underlying the learning difficulties in this patient may have been partial blockage of the cingulofrontal network by deep white matter lesions.

Concomitant ipsilateral fractures of the neck and shaft of the femur in children are rare. The most recent report in this context found a total of only nine reported cases (<12 years of age) following a search of the indexed English literature. These injuries occur in children due to high-velocity trauma, and there is no generally accepted method of treatment. We report three additional cases from the literature and two cases of our own. In our cases, one had a residual 10° varus deformity at the subtrochanteric level in the femur, but this did not affect hip function. Another patient exhibited a limp at final follow-up due to leg length discrepancy, and peroneal nerve palsy at the time of injury. We advocate operative stabilization of the femoral shaft fracture first to reduce the risk of further displacement and simplify the subsequent reduction of the femoral neck. The series shows that these rare injuries have a poor prognosis, with high rates of incidence of avascular necrosis, coxa vara, and leg length discrepancy.

Background: both acute and chronic renal dysfunction (ARD and CRD) have been reported to influence outcomes after neck of femur fractures. We have examined the relationship between the length of stay, mortality and renal dysfunction using biomarkers. These included pre-operative (admission) serum concentrations of urea, creatinine and albumin, and estimated glomerular filtration rates (eGFR) derived from four- and six-variable Modification of Diet in Renal Disease (MDRD) study equations., Methods: complete outcomes data for 566 patients and the patterns of variations in the biomarkers were analysed using generalised linear models. Cox-proportional hazard analyses investigated the association between kidney function (as assessed by the above-mentioned biochemical data) and post-operative length of stay and mortality. All patients were stratified for CRD according to their eGFR., Results: serum urea and creatinine were significantly, positively correlated with age. After adjusting for age and sex, risk of mortality was positively related to six-variable eGFR and creatinine, and marginally so for urea. One-year mortality risk thus worsened with stages of CRD (1-4), increasing age and male gender. Risk of discharge from trauma ward, the length of stay in trauma ward and the overall length of stay were not related to urea and creatinine, but were negatively related to both four- and six-variable eGFR., Conclusions: the study has identified elderly renal-impaired males as the subgroup of patients most at risk for poor survival. This subgroup may require a more targeted approach to the management of their fluid and electrolyte homoeostasis to help improve their outcomes.

Background: The ability to predict the long-term physical function and prognosis of hip fracture patients during the early postoperative period is essential for surgeons and physical therapists as well as for patients and their families. The purpose of this study was to determine whether early functional assessment correlated with and/or predicted long-term function after surgery to treat a displaced femoral neck fracture., Methods: Sixty-two patients undergoing hemiarthroplasty for a displaced femoral neck fracture were evaluated prospectively; a minimum follow-up of two years was required. Validated functional assessments, including the Lower Extremity Measure and the Timed Up and Go test, were utilized, and scores were analyzed with respect to patient baseline data., Results: The functional level of patients decreased significantly after the injury, with the mean Lower Extremity Measure score decreasing from 87.7 to 62.4 and the need for a walking aid increasing from 36% to 54% at two years postoperatively (p < 0.05 for both). The Timed Up and Go test scores at four days and three weeks postoperatively were significantly higher in patients who needed a walking aid at two years compared with independently walking patients (p < 0.05). Receiver operating characteristic curve analysis of the Timed Up and Go test scores revealed that the optimal threshold for predicting the need for a walking aid at two years was fifty-eight seconds at four days postoperatively and twenty-six seconds at three weeks. Also, the need for a walking aid at two years was ninetyfold higher when the Timed Up and Go test score at three weeks postoperatively exceeded the twenty-six seconds threshold., Conclusions: The Timed Up and Go test was an early clinical indicator of future physical function in patients with a hip fracture treated with hemiarthroplasty. Innovative clinical approaches to anticipate future function will contribute to increasing the efficiency of overall management of this growing set of patients.

Introduction: Enhanced Recovery after Surgery protocols are associated with reduced length of stay and morbidity in patients undergoing major surgery. The aim of this audit was to assess the impact of a multimodal optimisation protocol in patients admitted with fractured neck of femur., Patients and Methods: A multimodal optimisation protocol was introduced for the care of patients with proximal femoral fractures. The short-term effects of the optimised perioperative care programme was assessed and compared with the conventional perioperative care before the intervention., Results: A total of 232 patients were included in this audit, 117 optimised care and 115 conventional care. Patients were similar with regards to age, gender, domicile, mental status and the type of operation. The optimised group suffered from fewer post-operative complications (36 out of 117 vs 48 out of 115, P = 0.04, Chi square test). There was no significant difference between two groups with regards to the length of hospital stay and 30-day mortality., Conclusion: Multimodal optimisation may be associated with a decline in post-operative morbidity in patients with proximal hip fracture. It does not have any significant impact on the length of hospital stay and 30-day mortality., (Copyright © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Mobility impairments, joint deformations, osteoporosis, weakening of sensory functions and orientation in space, which are quite common in senility expose elderly individuals to various kinds of falls and accidents. Femoral neck fractures and pertrochanteric fractures are the most frequent traumatic injuries among the elderly patients. During the post-surgical period or rehabilitation process it is of vital importance that treatment activities should enable patients to function in social and family environment in the same way as before the accident. Furthermore, it is crucial that rehabilitation procedures be of multi-faceted character - owing to the psycho-physical unity of the human being, they should not focus merely on physical treatment of the patient, but also on their psychological condition which is particularly significant in the whole treatment process. Apart from that, it is essential to consider the level of anxiety and motivation of the patient and to offer them professional psychological support and assistance.

We report the delay in diagnosis of a Neck of Femur (NOF) stress fracture in mixed sex basic military training. Stress fractures are common in military training with the incidence reported as ranging between 3.2-31%. NOF stress fractures, whilst only representing around 8% of stress fractures are associated with a high morbidity. It is imperative that medical officers looking after military recruits have a sound knowledge of the potential signs, symptoms and presentation of these injuries. Medical officers should always remains vigilant for stress fractures especially in mixed military training.

Surgical treatment of femoral neck fractures is associated with a significant impact on quality of life. The aim of this study was to determine the long-term influence of displaced femoral neck fractures treated by bipolar hemiarthroplasty on the activities of daily living, quality of life and social dependency. We studied 487 geriatric patients treated in the years 1989 to 2003. At the beginning of follow-up in 2004, 166 patients were alive and evaluation was carried out on 145 patients (87.3%) at 91.3 (14 - 244) months postoperatively by a standardized questionnaire. All enrolled patients had been treated with cemented bipolar hemiarthroplasty for a displaced femoral neck fracture. Patients were evaluated concerning their average pre- and postoperative ability to walk, the need for assisting devices, type of residency and the SF-12® Score. Femoral neck fracture and hemiarthroplasty had a significant influence on all recorded aspects of quality of life. Even though almost two thirds of the patients needed assisting devices to walk after surgery, about two thirds returned to their original type of accommodation and the majority reached their original degree of mobility. Compared to a normal population no significant impact was observed on the quality of life measured by the SF-12® score. We consider bipolar hemiarthroplasty an effective treatment option for displaced femoral neck fractures in geriatric patients. Most patients returned to their original type of accommodation and level of mobility, even though the majority required a number of assisting devices to do so.

The femoral neck fracture in elderly patient is an entity that is within the scope of "disease causing a femoral neck fracture". The specific factors for successful management of these elderly patients are centered around patient's comorbidities, specific management in a clinical pathway, and more or less early rehabilitation after surgery. The type of fracture, surgery, specific treatment, early active recovery for the patients lying in bed after surgery optimize the functional outcome at mean term. The improvement of nutritional status, equilibrium for comorbidities and early rehabilitation with walking activities and physiotherapy significantly improve functional outcome at short and medium terms and postoperative mortality. The use of multimodal analgesia and regional analgesia primarily by perioperative continuous femoral nerve blocks also improve the medical prognosis and functional outcome of the patient., (2011. Published by Elsevier SAS.)

The femoral neck fracture is a major cause of morbidity and mortality in the elderly. The etiology of cognitive impairment observed in this population of aged patient seems to be multifactorial. In the strategy of prevention, elderly patient must have the clearer information dealing with the postoperative cognitive dysfunction. This would reduce the incidence of POCD and some cognitive complaints, which often reflect the anxiety of the elderly patient facing the possibility of cognitive impairment. During the anaesthesia consultation, it seems important to assess the cognitive function of this elderly patient (like using neuropsycholgical scale as the MMSE) and to identify associated risk factors of cognitive dysfunction. The management of cognitive disorders should be multidisciplinary, the anesthesiologist being the main referent, in collaboration with the geriatrician and the surgeon. In the clinical setting of femoral neck fracture in the elderly, this multimodal management (pain, nutrition, functional rehabilitation to make these patients autonomous as quickly as possible), seems to improve the functional prognosis and to have the observed POCD decreased., (2011. Published by Elsevier SAS.)

We reviewed the seven- to ten-year results of our previously reported prospective randomised controlled trial comparing total hip replacement and hemiarthroplasty for the treatment of displaced intracapsular fracture of the femoral neck. Of our original study group of 81 patients, 47 were still alive. After a mean follow up of nine years (7 to 10) overall mortality was 32.5% and 51.2% after total hip replacement and hemiarthroplasty, respectively (p = 0.09). At 100 months postoperatively a significantly greater proportion of hemiarthroplasty patients had died (p = 0.026). Three hips dislocated following total hip replacement and none after hemiarthroplasty. In both the total hip replacement and hemiarthroplasty groups a deterioration had occurred in walking distance (p = 0.02 and p < 0.001, respectively). One total hip replacement required revision compared with four hemiarthroplasties which were revised to total hip replacements. All surviving patients with a total hip replacement demonstrated wear of the cemented polyethylene component and all hemiarthroplasties had produced acetabular erosion. There was lower mortality (p = 0.013) and a trend towards superior function in patients with a total hip replacement in the medium term.

Background: The process of care of older patients with fractured neck of femur at Auckland City Hospital has recently changed with selected patients "fast-tracked" as soon as possible postoperatively to a specialised Older People's Health (OPH) ward., Aims: The aims of this study were: to evaluate patient characteristics; to analyse process of care; to compare outcomes in those "fast-tracked" patients with those receiving usual care; and to compare this information with previous data from Auckland City Hospital and other centres in New Zealand., Method: Prospective case record audit of patients with fractured neck of femur aged 65 years and over admitted under Orthopaedics over a 4-month period., Results: 115 patients were audited; mean age was 84 years, 77% were female. Inpatient mortality was 5%. Twenty-four percent of patients had surgery within 24 hours of admission. Of those who did not have surgery within 24 hours, 39% were awaiting operating theatre availability. Median overall length of stay (LOS) was 27 days. Eighty-four percent of patients were transferred to Older Peoples Health. Considering all patients, 70% of those living at home pre-fracture returned home on discharge. However, only 26% of those in Rest Home returned to Rest Home. Overall, 35% of patients were discharged to a higher level of care. Forty-four percent of the group were able to walk unaided prior to hip fracture, but only 1% on discharge. Forty-three patients were "fast-tracked" to Older Peoples Health. Their median overall LOS was 23 days compared to 28 days for those receiving usual care. This was due to the shorter time in Orthopaedics. Thirty-three percent of this group went to a higher level of care on discharge compared to 35% in the group that received usual care., Conclusions: Many patients experience a delay to surgery for non-medical reasons. The percentage transferred to Older Peoples Health is high. Fast-tracking to Older Peoples Health shortens overall length of stay due to fewer days in Orthopaedics. Many patients require a higher level of care after hip fracture, particularly if already resident in Rest Home. Demographics and inpatient mortality are comparable, but total length of stay is longer than similar New Zealand studies due to a longer length of stay in Older Peoples Health. Review of previous data from Auckland City Hospital and from other New Zealand centres shows significant variability in process of care for older patients with hip fracture.

Background: Little is known about risk factors that may prevent hip fracture patients from being discharged to home. The present study was developed to investigate possible prognostic factors., Materials and Methods: We studied 345 patients with hip fracture treated at our hospital since 1997, who were living at home before the injury. There were 84 males and 261 females. Mean age at injury was 81.6 years. Fracture type was femoral neck fracture in 152 patients and trochanteric fracture in 193. Patients were divided into those who were discharged to home (home discharge group) and those who were discharged to rehabilitation facilities or died in hospital (non-home discharge group). Gender, age at admission, fracture type, and other factors were investigated. Multivariate analysis was conducted on these variables for the home discharge and non-home discharge groups., Results: There were 202 patients (58.6%) in the home discharge group and 143 patients (41.4%) in the non-home discharge group. The factors significantly associated with not achieving the goal of discharge to home were age 85 years or above [odds ratio (OR) = 1.79, P = 0.0204], chronic systemic diseases (OR = 1.77, p = 0.0225), dementia (OR = 3.17, P < 0.0001), and walking disability before injury (OR = 5.70, P = 0.0328)., Conclusions: In elderly patients with hip fracture, the risk factors that predict difficulties with discharge to home include age at admission, concomitant chronic systemic diseases and dementia, and walking disability before injury.

Surgical treatment for medial femoral neck fracture was two options. One is osteosynthesis, and another is femoral head replacement. There are advantages and disadvantages. In terms of early rehabilitation, femoral head replacement is recommended. Muscle sparing small invasive surgery should be performed to avoid dislocation.

Purpose: The purpose of this study was to develop a decision-making process to assess the conditions for predicting gait independence in patients with femoral neck fracture., Methods: A total of 108 patients were divided into 2 groups on the basis of their walking abilities at discharge for an unrelated illness; an independent (n=55) and dependent group (n=53). Details regarding age, sex, length of hospital therapy, operative procedures, classification of fracture, past history of stroke and fracture were collected from medical records. Body mass index (BMI), knee extension power, maximum walking speed, functional reach test (FRT) and the mini-mental state examination (MMSE) were measured to evaluate motor ability and cognitive status at discharge. Student's t-test and the chi-squared test were used to test for statistical differences between the 2 groups. On multivariate analysis, classification and regression trees (CART) was used to determine the predictive value of those measures that differed significantly between the 2 groups., Results: On bivariable analysis, significant differences were found in nearly all variables, except for BMI and length of hospital therapy. As a result of this analysis, the decision tree, which consists of knee extension power, FRT, MMSE and a past history of stroke, was created. CART analyses showed that when knee extension power was >0.34 kgf/kg, the MMSE score was >13.5; with no past history of stroke, the rate of independent walking at discharge was 93.8%. In contrast, when knee extension power was ≤0.33 kgf/kg, FRT was ≤25.5 cm, the MMSE score was ≤13.5, and the rate of dependent walking at discharge was 100%., Conclusions: Our findings indicate that the decision tree can be helpful in predicting gait independence in patients with femoral neck fracture.

Purpose: To find out whether patients with femoral neck fracture treated with hemiarthroplasty differ from those treated with internal fixation regarding functional outcome, walking ability, pain or short-term mortality., Method: Sixty-six patients aged 64 years or more with femoral neck fracture were included in a prospective non-randomised trial with two equal-sized groups recruited consecutively within each group. All patients were treated operatively and encouraged to pursue an active rehabilitation. They were reviewed at admission, before discharge and 3 months after surgery. Assessments included demographic data, length of hospitalisation, post-operative medical complications, activities of daily living, walking ability, pain and mortality., Results: There were no significant differences between the two groups in terms of age, gender, ability to walk, functional status or at admission. The patients treated with hemiarthroplasty had a longer total hospital stay due to longer waiting time to operation. They started to walk sooner after operation and walked better during hospitalisation. Their walking distance at discharge was longer; their improvement in functional independence, as measured by the Functional Independence Measure, was also higher, but this difference was not statistically significant. Observed mortality in the hemiarthroplasty group was lower., Conclusion: A longer follow-up would be necessary to determine whether the preferable outcomes of hemiarthroplasty persist in the long-term.

Purpose: To assess rehabilitation, type of follow-up visits and outcome after bipolar hemiarthroplasty for femoral neck fracture., Method: Two hundred thirty-six consecutive patients with femoral neck fractures treated with hemiarthroplasty were followed for 30 months., Results: One hundred sixty-eight (71%) were women, 175 (74%) over 80 years old and 53 (22%) were demented. Of 150 patients with available 3-month data, 7 patients (5%) had not regained their walking ability. Seventy (47%) were pain-free and 112 (75%) were back in their original habitat. A hip-related complication leading to a contact with the orthopaedic department occurred in 20 of all patients (8%), and 7 (3%) of these underwent a revision surgery. One hundred eighty-seven patients (79%) received occupational therapy (OT). Demented patients received OT more seldom (p < 0.001), as did patients aged 90 and older (p = 0.049)., Conclusion: Due to the low rate of orthopaedic complications, these patients are now referred to their general practitioners, without any further follow-up at the orthopaedic department. Rehabilitation efforts are unevenly distributed. The need of increased rehabilitation efforts for demented or 'old old' patients is discussed.