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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.

Background Lateral compression type1 (LC-1) fragility fractures are a common, painful injury in older adults resulting in reduced mobility. The incidence of these fractures is increasing with the growing older adult population. The current standard of care is non-surgical management; however, patients with this injury are at risk of long-term immobility and related complications. INFIX is a pelvic fixation device used in younger patients with high-energy fractures. The device is fitted via a percutaneous technique with no external pin sites and has good purchase even in osteoporotic bone. It therefore has the potential to be well tolerated in patients with LC-1 fragility fractures. INFIX could improve patients’ ability to mobilise and reduce the risk of immobility-related complications. However, there is a risk of complications related to surgery, and robust evidence is required on patient outcomes. This study will investigate the clinical and cost-effectiveness of surgical fixation with INFIX compared to non-surgical management of LC-1 fragility fractures in older adults. Methods A multi-centre randomised controlled trial of 600 patients allocated 1:1 to non-surgical management or INFIX surgery. The study will have a 12-month internal pilot to assess recruitment and trial feasibility. The primary outcome will be the patient quality of life over 6 months, measured by the patient-reported EQ-5D-5L. The secondary outcomes will include physical function, mental health, pain, delirium, imaging assessment, resource use, and complications. Discussion The L1FE study aims to compare the clinical and cost-effectiveness of surgical and non-surgical management of people aged 60 years and older with LC-1 fragility fractures. The trial is sufficiently powered and rigorously designed to inform future clinical and patient decision-making and allocation of NHS resources. Trial registration International Standard Randomised Controlled Trial Number Registry ISRCTN16478561. Registered on 8 April 2019

Background Anaemia following hip fracture is common. Approximately 30 to 45% of patients have haemoglobin concentrations below population norms on admission, and around 10% are severely anaemic. Anaemia on admission, and in the postoperative period, is associated with poor outcomes with regard to mobility, postoperative mortality and readmission. There is currently no clear consensus on the optimal method of managing perioperative anaemia in this group of frail patients with frequent comorbidity. Liberal red cell transfusion in the postoperative period does not appear to improve outcome, whereas tranexamic acid appears to reduce transfusion rate at the expense of increased cardiovascular morbidity. There are encouraging results from one centre with the use of agents to stimulate red cell production, including intravenous iron and erythropoietin. UK practice differs significantly from these patients and these studies, and it is not clear whether these promising results will translate to the UK population. Methods/Design This is a single-centre randomized controlled parallel group trial, in a British university hospital.Randomization is achieved using a website and computer-generated concealed tables. Participants are 80 patients 70 years or over with acute hip fracture undergoing operative repair. The intervention group receive three daily infusions of 200 mg iron sucrose, starting within 24 hours of admission. The control group receive standard hospital care at the discretion of the clinical team. Red cell transfusions for each group are given in accordance with standard clinical triggers. The primary outcome is an increase in mean reticulocyte count in the intervention group at day 7. Secondary outcome measures include haemoglobin concentrations, early and late transfusion rates, infectious and cardiovascular complications, mobility and 30-day mortality. Discussion This is a pilot study to demonstrate haematopoietic efficacy of intravenous iron in this setting. Hence, we have chosen to measure change in reticulocyte count rather than the more clinically relevant differences in haemoglobin concentration or transfusion rate. If our results are positive, the study will provide the necessary information for development of a full-scale trial of intravenous iron. Trial registration Current Controlled Trials ISRCTN76424792 ; UK Medicines and Healthcare products Regulatory Authority (EuDRACT: 2011-003233-34).

Aim Reconstructing or augmenting the lumbo-pelvic junction after resection of L5 and part of the sacrum is challenging. Numerous lumbo-pelvic reconstruction methods based on posterior construct and anterior cages have been proposed for cases involving total sacrectomy and lumbar vertebrectomy. These constructs create long lever arms and generate high cantilever forces across the lumbo-sacral junction, resulting in implant failure or breakage. Biomechanical studies have shown that placing implants anterior to lumbo-sacral pivot point provides a more effective moment arm to resist flexion force and improves the ultimate strength of the construct. We present here a novel method to augment a lumbo-pelvic construction using a pelvic ring construct. Methods A 69-year-old lady presented with implant failure of her two previous posterior lumbo-pelvic reconstructions performed by the authors. She initially presented, two and a half years previously with 6 months history of back pain with normal neurological function. MRI scans of her whole spine showed isolated secondaries in the lumbar spine (L4, L5) and sacrum (S1). An abdominal CT scan revealed a primary tumour in her right kidney. Briefly, the first surgery involved a single-stage removal of posterior elements of L4 and L5 and posterior stabilisation from L2 to pelvis, anterior resection of L4 and L5 and partially S1 with implantation of an expandable Synex II cage. The cage was replaced with an anterior rod construct from L2 and L3 to a trans-sacral screw a week later as it had dislodged. The second revision, 9 months later, involved removal of two posterior broken rods which were replaced and converted into a modified four-rod construct. While monitoring her progress, it was subsequently noted that the trans-sacral rod had broken. Therefore, it was decided to augment her lumbo-pelvic construct to prevent eventual catastrophic posterior construct failure. From a posterior approach, contoured rods were passed bilaterally along the inner table of the pelvis under the iliacus muscle up to the anterior border of the pelvis. Using T-connectors, the rods were connected to the posterior lumbo-pelvic construct. Thereafter, two anterior supra-acetabular pelvic screws were connected to a subcutaneously placed rod matched to the shape of the anterior abdominal wall. The pelvic ring construct was completed on connecting this rod with T-connectors to the free ends of the contoured iliac rods. Results and conclusion There were no intra-operative complications. At the end of 12 months, she was mobilising with a frame, with no radiological evidence of failure of the construct. However, she died due to disease progression at the end of 15 months. Experience from one clinical case shows that such a construct is feasible and adds a technical option to the difficult reconstruction of lumbo-pelvic junction after tumour surgery.

Background Lateral compression type1 (LC-1) fragility fractures are a common, painful injury in older adults resulting in reduced mobility. The incidence of these fractures is increasing with the growing older adult population. The current standard of care is non-surgical management; however, patients with this injury are at risk of long-term immobility and related complications. INFIX is a pelvic fixation device used in younger patients with high-energy fractures. The device is fitted via a percutaneous technique with no external pin sites and has good purchase even in osteoporotic bone. It therefore has the potential to be well tolerated in patients with LC-1 fragility fractures. INFIX could improve patients' ability to mobilise and reduce the risk of immobility-related complications. However, there is a risk of complications related to surgery, and robust evidence is required on patient outcomes. This study will investigate the clinical and cost-effectiveness of surgical fixation with INFIX compared to non-surgical management of LC-1 fragility fractures in older adults. Methods A multi-centre randomised controlled trial of 600 patients allocated 1:1 to non-surgical management or INFIX surgery. The study will have a 12-month internal pilot to assess recruitment and trial feasibility. The primary outcome will be the patient quality of life over 6 months, measured by the patient-reported EQ-5D-5L. The secondary outcomes will include physical function, mental health, pain, delirium, imaging assessment, resource use, and complications. Discussion The L1FE study aims to compare the clinical and cost-effectiveness of surgical and non-surgical management of people aged 60 years and older with LC-1 fragility fractures. The trial is sufficiently powered and rigorously designed to inform future clinical and patient decision-making and allocation of NHS resources. Trial registration International Standard Randomised Controlled Trial Number Registry ISRCTN16478561. Registered on 8 April 2019 Keywords: INFIX surgery, Lateral compression type 1, LC-1, Pelvic fracture fixation, Elderly patients, Older adults, Fragility fracture, Osteoporotic bone, Pubic ramus fracture, Immobility-related complications

A 62-year-old man presented to the emergency department, having fallen 6 ft from a ladder, with pain over his left hip and shoulder. He was managed according to the Advanced Trauma Life Support (ATLS) protocol, and his primary survey showed no haemodynamic compromise. Initial radiographs showed a unilateral left superior and inferior pubic rami fracture, which was treated conservatively. Forty-eight hours post-admission, the patient became tachycardic and hypotensive and was found to have dropped his haemoglobin from 125 to 89 g/L. After resuscitation, a repeat contrast CT scan revealed an enlarging haematoma in his pelvis. This was treated with urgent angioembolisation and the patient was further stabilised in the intensive care unit. This report shows the need for a low threshold in suspecting intrapelvic bleeds in patients with pubic rami fractures, and the need for prompt treatment of such patients, either surgically or radiologically.

Injury to the thoracic duct following blunt trauma can rarely result in tension chylothorax. We report a case of traumatic tension chylothorax in a young man with cervical and thoracic spine injuries after he was hit by the open luggage compartment of a passing bus. Diagnosis was made on the fourth day following injury when he became short of breath during physiotherapy, and then deteriorated rapidly with haemodynamic compromise. The tension chylothorax was treated with intercostal drainage leading to immediate resolution of cardiorespiratory function. No further surgical intervention was required. This case highlights three important learning points: pleural fluid, not just air, can cause tension; seriously injured patients should have a multidisciplinary trauma team assessment on arrival to hospital and when reviewing radiographs, all the structures should be carefully examined, not just those that the study was performed to examine.

The UK Hospital at Night (H@N) programme is hypothesised to improve efficiency of out-of-hours care. No studies have assessed a surgical programme or mechanisms of effect. This prospective study aimed to do so in a trauma and orthopaedic department over 10 weeks. Senior house officers recorded night shift activity. Mean time to attend referrals reduced from 29 to 15 minutes as a result of the programme (p=0.007). Workload and 30 day mortality and morbidity for hip fracture remained unchanged. The mechanisms underlying improvements are unclear, but may represent central organisation of workload.