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.

Level IV (observational cohort study).

-Prescriptions for intravenous (iv)fluids in hospitals may not be closely adhered to. This study prospectively examined whether prescribed iv fluids are administered at the correct rate. During a four-week period, the iv infusion rates in patients requiring continuous iv fluids and cared for by a single medical team in a district hospital were studied. The periods over which iv crystalloid fluid bags were administered were compared with the time prescribed. Of a total 207 bags, 53 (26%) were correctly administered at the prescribed rate (percentage error 10% to -10%), 138 bags (67%) were infused too slowly and 16 bags (8%) were infused too fast. Overall, the median (interquartile range) absolute percentage error (positive or negative) for all infused bags was 23% (9.7-50). Thirtynine per cent of bags were infused accurately when a metered pump was used, compared to 21% of bags infused accurately when a metered pump was not used (p<0.01). Marked inaccuracies in iv fluid infusion rates are common, and do not seem to be perceived by staff as important. Metered pumps improve accuracy. Increased awareness of such errors, and the routine use of metered pumps should help improve the accuracy of iv fluid infusion rates.

Multidisciplinary management of severe open tibial diaphyseal may not be feasible at presentation of injury depending on local hospital specialist services available. Our results highlight the need for robust assessment, triage and senior orthopaedic review in the early post-injury phase. However, broader improvements in the management of lower limb trauma will additionally require further development of combined specialist trauma centres.

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