Добірка наукової літератури з теми "Mount Royal Hospital"

Original Research Paper FUNCTIONAL OUTCOME OF BIPOLAR HEMIARTHROPLASTY IN DISPLACED INTRACAPSULAR FEMORAL NECK FRACTURE IN ELDERLY IN RURAL TERTIARY HOSPITAL <strong>Authors:</strong> <strong>¹</strong><strong>Dr. Saikrishna Rengerla</strong><strong>, </strong><strong>²</strong><strong>Dr. Akhil Lohkare, ³Dr. CM Badole</strong> <em>^1,2</em><em>Senior Resident, Dept of Orthopaedics, MGIMS Sevagram</em> <em>³</em><em>Director-Professor &amp; HOD, Dept of Orthopaedics, MGIMS Sevagram</em> Corresponding Author: Dr. Saikrishna Rengerla, Dept of Orthopaedics, MGIMS Sevagram <strong>Article Received:</strong>&nbsp; 10-08-2022&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <strong>Revised:</strong>&nbsp; 31-08-2022&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <strong>Accepted:</strong> 21-09-2022 <strong>ABSTRACT: </strong> Femoral neck fractures, one of the most common injuries in the elderly have always presented great challenges to orthopaedic surgeons. The present study was conducted in 42 elderly patients with closed displaced intracapsular fracture of femoral neck following all inclusion and exclusion criteria who were present to the Orthopaedics department from October 2019-May 2021 to evaluate functional outcome of bipolar hemiarthroplasty in displaced intracapsular femoral neck fracture in elderly who were followed for duration of 6 months at an interval of 6 weeks, 3 months and 6 months. Most of the patients were belonging to 65-69 years of age group accounting to 33.33%. Females outnumbered males accounting to 59.52% with female to male ratio of 1.47:1. Transcervical fractures outnumbered and accounted for 90.48%. There were more left sided fractures accounting for 71.43%. Most of the patients were operated within 7 days of fracture accounting for 45.24% with average hospital stay of 14.71&plusmn;4.79 days. Most common mode of injury was trivial trauma i.e.92.86%. 41mm Bipolar prosthesis size accounted for maximum of 28.6%. Harris Hip Score was used to evaluate the functional outcome of Bipolar Hemiarthroplasty was noted at regular follow ups. &nbsp;Mean Harris Hip score at 6 weeks was 74.21&plusmn;10.07, at 3 months was 77.66&plusmn;10.59, at 6 months was 80.40&plusmn;10.60 with upward trend in the mean score over follow up period. There was 2.38% cases of posterior dislocation noted at 1 month in Uncemented Bipolar Hemiathroplasty postoperatively, 4.76% cases of infection and 7.14% cases of lengthening, 7.14% cases of Bedsores. The final functional outcome at 6 months of follow up revealed excellent results in 13 patients(30.95%), Good in 11 patients(26.19), Fair in 12 patients(28.57%) and Poor results in 6 patients(14.29%). Our study concludes that Bipolar Hemiarthroplasty offers excellent, painless mobility and ease in rehabilitation and return to function. <strong><em>Key words: Bipolar hemiarthroplasty, Elderly patients, Harris hip score, Intracapsular femoral neck fracture, Complications, Functional Outcome.</em></strong> &nbsp; &nbsp; <strong>INTRODUCTION:</strong> Femoral neck fractures, one of the most common injuries in the elderly have always presented great challenges to orthopaedic surgeons. The prevalence of these fractures has increased with improvement in life expectancy, increased incidence of osteoporosis, poor vision, neuro-muscular incoordination and changes in lifestyle leading to sedentary habits⁽¹⁾. In the elderly with osteoporotic bones, a trivial fall is the cause of hip fractures in about 90% of cases⁽²⁾. The prevalence of the fracture also doubles for each decade of life after fifth decade⁽³⁾. Treatment of displaced femoral neck fractures in elderly has been controversial. Open reduction and internal fixation of these fractures in the elderly have poor outcome including high rate of nonunion and avascular necrosis⁽¹⁾. Various prosthesis have been designed which can be broadly divided into two types- unipolar and bipolar. Of unipolar prosthesis, the most commonly used are the THOMPSONS and AUSTIN MOORES prosthesis. Main problems with these prosthesis were stem loosening and migration⁽⁴⁾. In modern days the bipolar prosthesis with cement is the best option wherein they can be more active⁽⁵⁾. PMMA cement offers advantages as its use as a grouting agent to replace thinning trabecular bone thus greatly simplifying rehabilitation. The Bipolar prosthesis was introduced to prevent and retard acetabular wear. These prosthesis have a 22 to 32mm head that articulates with ultra-high-density polyethylene inner liner which is covered with a polished metal outer head that articulates with acetabular cartilage. It causes less articular wear⁽⁴⁾. Advantages of uncemented femoral components is including faster implantation and potential lower risk of fat and marrow embolism compared to cemented implants. Disadvantages of uncemented implants in elderly are potential for retarded osteointegration, osteopenia and concern for fracture and in patients with wide femoral canal has mismatch of proximal/distal diameters^(6,7,8). There was no significant difference in using cemented and uncemented bipolar prosthesis⁽⁹⁾. The aim of the study is to evaluate the functional outcome of Bipolar hemiarthroplasty in closed displaced intracapsular femoral neck fracture in elderly. <strong>METHODOLOGY: </strong> This was a follow up study and conducted in 42 elderly patients with closed displaced intracapsular fracture of femoral neck reported to the Orthopaedics Department of MGIMS and Kasturba hospital following all inclusion and exclusion criteria from October 2019-May 2021. Inclusion criteria was patients of age 60 years and above, nonunited/old fracture neck of femur. Exclusion criteria was pathological fractures of neck of femur, medically unfit for surgery, Bilateral fracture neck femur, Previously operated fracture neck femur of same and opposite side, Non ambulators, those who would not complete 6 months of final follow up. Informed consent was taken at the initiation of study, in English and in regional language, after explaining the procedure in detail. Preoperative Protocol consisted of thorough history taking and clinical examination and evaluation was done and then Anteroposterior radiographs of pelvis with both hip. All study Patients were put on skin traction, given oral or parenteral analgesics to relieve pain. Adequate medical management of associated comorbid conditions like diabetes mellitus, systemic hypertension, COPD and heart diseases was initialized to optimize patient&rsquo;s fitness for anaesthesia. All measures were taken so that the patient could be taken up for surgery at the earliest. Operative Approach was Moore&rsquo;s posterior approach for all patients in Lateral decubitus position on the operating table with the affected side facing up. A curved incision taken from a point 10cm distal to posterior superior iliac spine and extended distally and laterally parallel to the fibres of gluteus maximus to the posterior margin of greater trochanter. Deep fascia was exposed over gluteus maximus, was then split in the direction of its fibres by blunt dissection. By retracting the proximal fibres of the muscle proximally, the greater trochanter was exposed after trochanteric bursa excised. Distal fibres were retracted distally and divided at their insertion over linea aspera. The sciatic nerve was not usually exposed . It was protected with the finger in the lateral part of the incision and gently retracted out of the way. The gemelli and obturator internus and piriformis tendon were divided at their insertions after tagging them for easier identification and reattachment. The posterior part of the capsule thus exposed was incised from distal to proximal along the line of neck of femur and at right angle to it, thus making a L shaped opening in the capsule. The fractured head and neck of the femur were levered out of the acetabulum and size measured using femoral head gauge. The size was confirmed using trial prosthesis by its suction fit in the acetabulum. The acetabulum was prepared by excising remnants of ligamentum teres and soft tissue. The femoral shaft was rasped using a broach(rasp) and prepared for the insertion of the prosthesis. Femoral neck if long was nibbled keeping 2 to 2.5cm of calcar above the lesser trochanter. The appropriate sized prosthesis was then inserted into the femoral shaft(reamed canal) in taking care to place in 10⁰ to 15⁰ of anteversion and impacted into the femur. The reduction of prosthesis done using gentle traction of the thigh. If Prosthesis became loose intraoperatively, cemented procedure were performed. In these cases, the stem was cemented in place using standard cementing technique- lavage, cleaning, drying and plugging of the canal. Absolute haemostasis obtained. After suturing the capsule, the external rotators sutured. The wound closed in layers over a suction drain, were removed at the first changing of dressing after 48hours. Post operatively, patients were kept in the ward with limbs in wide abduction with the help of abduction pillow. Adduction, internal rotation and flexion were avoided. Static exercise in bed for quadriceps and breathing exercises along with active limb movement to decrease limb edema. Ambulation started within a week with walker and progressive weight bearing. Postoperatively DVT prophylaxis was added to high risk patients according to the advice given by Physician/Anaesthetist. Patients were advised not to sit cross legged or squat. All patients were followed up monthly for first 3 months and then at 6 months. Minimum follow up of 6 months and HARRIS HIP SCORE⁽¹⁰⁾was noted and radiographs of the affected hip were taken. Final evaluation of the study was done after completion of study according to criteria. <strong>RESULTS:</strong> 42 study participants fulfilling inclusion and exclusion criteria were selected and evaluated for associated comorbidities and operated by Bipolar Hemiarthroplasty and&nbsp; followed for duration of 6 months at an interval of 6 weeks, 3 months and 6 months during the study period. <strong>Age distribution:</strong> majority of the patients were belonging to 65-69 years of age group accounting to 33.33%, followed by 60-64 years of age group accounting 26.19%, followed by 70-74 years of age group accounting 21.43%, followed by 75-79 years of age group and 80-84 years of age group accounting 7.14% each and followed by &gt;84 years of age group accounting 4.76%. Mean age in general was 68.66 &plusmn; 7.03 with range of 60-85 years. <strong>Gender:</strong> In the present study, females outnumbered males accounting to 25(59.52%) and males proportion was 17(40.48%). Female to male ratio in our study was 1.47:1 <strong>Fracture side distribution:</strong> There were more left sided fractures accounting for 30 cases (71.43%) Garden classification: Patients with Type 4 of Garden classification accounted for maximum of 83.33%, followed by Type 3 for 9.52% and Type 2 for 7.14%. <strong>Anatomical Classification:</strong> Patients with Transcervical fractures outnumbered and accounted for 90.48%, followed by Subcapital fracture for 7.14% and followed by Basicervical for 2.38% <strong>Distribution of patients according to duration between fracture and surgery:</strong> Duration(days) No of patients Percentage &lt;7 days 19 45.24 7-30 days 18 42.86 &gt;30 days 5 11.90 Total 42 100 Mean&plusmn;SD 13.11 &plusmn; 16.20(2-95 days) <strong>Table 1</strong> <strong>Duration between admission and surgery: </strong>In our study, majority of the patients operated within 3-7 days of admission i.e. 26(61.90%) followed by more than 7days i.e. 9(21.43%) and within 3 days in only 7 patients i.e.16.67% <strong>Mode of injury: </strong>In our study most of the patients had trivial trauma which accounted for 39 cases (92.86%) followed by road traffic accident of 3 cases(7.14%) <strong>Distribution of patients according to comorbidities</strong> Comorbidities No of patients Percentage Asthma 4 9.52 Diabetes Mellitus 8 19.05 Chronic Kidney Disease 3 7.14 Hypertension 16 38.10 &nbsp;Rheumatoid Arthritis 1 2.38 Thyroid Disease 1 2.38 Ischemic heart disease 1 2.38 Lung consolidation 1 2.38 <strong>Table 2</strong> <strong>Average hospital stay:</strong> was 14.71&plusmn;4.79 days with maximum of 28 days and minimum of 4 days. <strong>Prosthesis Size:</strong> 41mm Bipolar prosthesis accounted for maximum of 28.6% in 12 cases and least used was 53mm Bipolar prosthesis in 1 case (2.4%) &nbsp; Frequency Percent P R O S T H E S I S 37 mm 2 4.8 39 mm 3 7.1 41 mm 12 28.6 43 mm 7 16.7 45 mm 5 11.9 47 mm 4 9.5 49 mm 6 14.3 51 mm 2 4.8 53 mm 1 2.4 Total 42 100.0 <strong>Table 3</strong> &nbsp; &nbsp; &nbsp; <strong>Position of stem:</strong> Position of stem No of patients Percentage Valgus 5 11.90 Varus 6 14.29 Neutral 31 73.81 Total 42 100 <strong>Table 4</strong> <strong>Intraoperative time and blood loss: </strong>average blood loss was 326.66 &plusmn; 109.18ml with range of 150-750ml and average intraoperative time was 63.45 &plusmn; 11.64 min with range of 45-90 min. <strong>Harris Hip Score: </strong>used to evaluate the functional outcome of Bipolar Hemiarthroplasty which was noted at regular follow ups at 6 weeks, 3 months and 6 months. The Mean Harris Hip score at 6 weeks was 74.21&plusmn;10.07 with range of 47-87. The Mean Harris Hip score at 3 months was 77.66&plusmn;10.59 with range of 50-90. The Mean Harris Hip score at 6 months was 80.40&plusmn;10.60 with range of 52-90. There was an upward trend in the mean score over follow up period. &nbsp; N Minimum Maximum Mean Std. Deviation 6 weeks 42 47.00 87.00 74.21 10.07 3 months 42 50.00 90.00 77.66 10.59 6 months 42 52.00 92.00 80.40 10.60 <strong>Table 5</strong> Graph 1: Distribution of patients according to Harris Hip Score &nbsp; &nbsp; <strong>Distribution of patients according to complications:</strong> Complications No of patients Percentage Dislocation 1 2.38 Infection 2 4.76 Lengthening 3 7.14 Other(Bed Sore) 3 7.14 <strong>Table 6</strong> &nbsp; <strong>Functional outcome: </strong>In our study, the final functional outcome at 6 months of follow up using Harris Hip Score. We observed excellent results in 13 patients(30.95%), Good in 11 patients(26.19), Fair in 12 patients(28.57%) and Poor results in 6 cases(14.29%). &nbsp; &nbsp; <strong>Distribution of patients according to functional outcome at final follow up(6 months)</strong> Functional Outcome No of patients Percentage Poor 6 14.29 Fair 12 28.57 Good 11 26.19 Excellent 13 30.95 Total 42 100 <strong>Table: 7</strong> <strong>DISCUSSION:</strong> Elderly patients with fracture neck of femur who were mobile before injury should be able to restore to their preoperative functional and ambulatory status. In active older patients especially needing early mobilization, conservative method of treatment is not acceptable because it results in non union with unstable hip and limitation of hip movement as well as complications of prolonged immobilization like bedsores, deep vein thrombosis and respiratory infections. Result for femoral neck fracture treatment illustrated by Leighton et al⁽¹¹⁾recommended prosthetic replacement for patients more than 60 years old having femur neck fracture. Bateman and Giliberty in 1974 introduced Bipolar hemiarthroplasty, which is a self articulating prosthesis. Advantage of Bipolar prosthesis is that erosion and protrusion of acetabulum would be less because, there is dual articulation between inner head and shell and acetabulum⁽¹²⁾. The Aim of present study was to evaluate the functional outcome of Bipolar Hemiarthroplasty in displaced intracapsular femoral neck fracture in elderly. 42 patients of fracture neck femur were treated using Bipolar Hemiarthroplasty, both cemented and uncemented. A concept that has been generally held by Orthopaedic surgeons is that Cemented femoral fixation is required in elderly patients because of poor bone stock⁽¹³⁾. However, cemented technique has also been associated with greater risk of fat embolization and hypotension⁽¹³⁾. Many Orthopaedic surgeons feel that stable femoral fixation can be achieved in elderly patients with cementless femoral stem⁽¹⁴⁾. The complications following the Bipolar Hemiarthroplasty is reported in varying incidences. Early surgical complications after Bipolar Hemiarthroplasty may be the origin of cascades leading to general complications and increased mortality. That is why their prevention is very important⁽¹⁵⁾. In present study, there was 1(2.38%) case of posterior dislocation noted in <em>(CASE 1)</em> 76 years old female with multiple co morbidities like right lower lung consolidation, Diabetes Mellitus, Hypertension, Chronic Kidney Disease, Asthma admitted on the same day of trauma with transcervical neck femur fracture of left side due to trivial trauma operated with Uncemented Bipolar Hemiathroplasty and postoperatively at 1 month there was posterior dislocation occurred due to sudden adduction of hip, which was managed by revision Cemented Bipolar Hemiarthroplasty immediately and later after 12 weeks she developed deep infection in wound which was managed by debridement which eventually healed with final Harris Hip Score of 72 at 6 months of follow up. In our study all cases were operated by posterior approaches. Dislocation of the Hip Hemiarthroplasty have been a concern for Orthopaedic surgeons since the advent of the procedure. Furthermore, early dislocation is associated with increased mortality rate⁽¹⁶⁾. Dislocation of the Bipolar prosthesis is a rare phenomenon. It has been reported in literature ranging from 1.1% at one year follow up to 5% at 20 years⁽¹⁷⁾. Saberi S et al⁽¹⁸⁾, in his study related to the complications following Bipolar Hemiarthroplasty amongst the 150 patients at 1 year follow up reported 6.5% dislocation rate. Rajak MK et al⁽¹⁹⁾, reported 3% prosthesis dislocation following Bipolar Hemiarthroplasty. Unwin et al⁽²⁰⁾, reported 6.5% of dislocation rate among all their patients with those having posterior approach being three times more likely to dislocate. &nbsp; <strong><em>CASE 1</em></strong> &nbsp; <strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Pre-operative X-RAY&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Post-operative X-RAY</strong> &nbsp; <strong>Dislocation At 1 Month</strong> &nbsp; <strong>Open Reduction of Dislocation with Revision Cemented Prosthesis and Drain Placement</strong> <strong>X-RAY At 3 Months&nbsp; of Revision Procedure</strong> &nbsp; <strong>X-RAY At 6 Months</strong> &nbsp; In our study there were 2(4.76%) cases of infection out of which 1 was superficial wound infection and 1 deep wound infection. 73 year old male patient with no comorbidities observed superficial infection after 4 months of Uncemented Bipolar Hemiarthroplasty who was managed by antibiotic and dressing. Another patient, 76 year old female with multiple comorbidities including Diabetes had developed deep wound infection after cemented Bipolar Hemiarthroplasty as a revision procedure following posterior dislocation after 6 weeks which was managed by debridement and appropriate antibiotic after culture and sensitivity and diabetic control. Naidu KA et al⁽²¹⁾, observed superficial wound infection in 2 patients in the 1^st week of operation, of which 1 patient was diabetic. Treated with proper antibiotic and dressing which resulted in prolongation of their hospital stay. The organism isolated in the above cases were Staphylococcus Aureus. Maruthi CV and Shivanna⁽⁵⁾, observed 1 patient(2%) had a superficial wound infection in the 1^st week of operation which led to the prolongation of the hospital stay treated with proper antibiotics and dressing. The organism isolated was Staphylococcus Aureus. In present study, we observed lengthening of the operated limb in 3 patients upto 1 cm(7.14%). Ponraj RK et al⁽⁹⁾, observed in two cases had limb lengthening(1 cm). Naidu KA et al⁽²¹⁾, reported limb length discrepancy seen in 2 patients(9.09%) of which lengthening was noted in both patients. Rajak MK et al⁽¹⁹⁾, observed limb lengthening in 1(3%) patient about 1.5cm which was managed by compensatory footwear in the opposite limb. While Marya SKS et al⁽²²⁾, observed limb lengthening in 7% of the cases. Limb lengthening of less than 3.5cm was not significant and did not affect outcome. Patel KC et al⁽²³⁾, in 84% of the patient there was no limb length discrepancy. No case showed limb shortening while 16% showed limb lengthening. All the cases in our series were assessed according to Harris Hip Score and graded accordingly as Excellent , Good, Fair and Poor. In present study, we evaluated mean Harris Hip score at the end of 6 months follow up which was 80.4 points. Our findings are consistent with the study of Rajak MR et al⁽¹⁹⁾,Bezwada HP et al⁽²⁴⁾, Ponraj RK et al⁽⁹⁾, Maruthi CV and Shivanna⁽⁵⁾<strong>. </strong> &nbsp; <strong>&nbsp;Studies with Harris Hip Score</strong> STUDIES MEAN HARRIS HIP SCORE Bezwada HP et al⁽²⁴⁾ At 3.5 years 82 points with range of 54-92 Shukla R et al⁽²⁾ At 6 months 74.68 points At 1 year 78.24 points At 2 years 81.40 Saberi S et al⁽¹⁸⁾ At 6 months 74.5 points At 1 year 80.7 points Maruthi CV and Shivanna⁽⁵⁾ At 6 months range of 35 to 94.6 Reddy YH et al⁽²⁵⁾ At 1 year 90.36points Rajak MK et al⁽¹⁹⁾ At 6 months 82.1 points At 1 year 83.1 points Ebrahimpour A et al⁽²⁶⁾ At 1 year 83.5 points Ponraj RK et al⁽⁹⁾ At 6 months 84.2 points Our study At 6 weeks 74.21 points At 3 months 77.66 points At 6 months 80.4 points <strong>Table 8</strong> <strong>Studies with Functional Outcome</strong> Study Duration Excellent Good Fair Poor Naidu KA et al⁽²¹⁾ 22 cases for 6 months 31.82% 54.55% 9.09% 4.54% Kalantri A et al⁽²⁷⁾ 30 cases for 6 months 53.33% 33.3% 16.67% 6.67% Ponraj RK et al⁽⁹⁾ 30 cases for minimum 6 months 23.33% 56.66% 13.33% 6.66% Jindal RC et al⁽²⁸⁾ 30 cases for 6 months 40% 40% 6.7% 13.3% Patel KC et al⁽²³⁾ 50 cases for 12 months 64% 28% 8% 0% Bezwada HP et al⁽²⁰⁾ 248 cases for 3.5 years 10% 55% 30% 5% Rajak MK et al⁽¹⁹⁾ 30 cases for 12 months 33.33% 43.33% 16.66% 6.66% Malhotra R et al⁽²⁹⁾ 32 cases 75% 15.6% 6.3% 3.1% Our study 42 cases for 6 months 30.95% 26.19% 28.57% 14.29% <strong>Table 9</strong> &nbsp; <strong>CONCLUSION:</strong> Our study concludes that Bipolar Hemiarthroplasty is a good method to manage intracapsular fracture neck femur in elderly patients . It offers excellent, painless mobility and ease in rehabilitation and return to function. The surgery is relatively easy to perform, takes less operating time and less blood loss with low complication rate. <strong>REFERENCES:</strong> Adapureddi HT, Kamareddy SB, Kumar A, Paturi SK, Anne S, Reddy JP. Prospective study of management of fracture neck of femur by Hemiarthroplasty with cemented Bipolar. Journal of Evolution of Medical and Dental Sciences. 2015; 4(98): 16309-16314. Shukla R, Singh M, Jain RK, Mahajan P, Kumar R. Functional Outcome of Bipolar Prosthesis versus Total Hip Replacement in the Treatment of Femoral Neck Fracture in Elderly Patients. Malaysian Orthopaedic Journal<em>.</em> 2017; 11(1): 1 -5. Leighton RK: Fractures of the Neck Femur. In: Bucholz RW, Heckman JD,Court-Brown CM. (eds.) Rockwood and Green&rsquo;s fracture in adults. 6^th edition. Philadelphia, Lippincott Williams &amp; Wilkins 2006; 1753-1791. Sharoff L, Nazeer M, Unnikrishnan R. 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Biber R, Brem M, Singler K, Moellers M, Sieber C, Bail HJ. Dorsal versus transgluteal approach for hip hemiarthroplasty: an analysis of early complications in seven hundred and four consecutive cases. International Orthopaedics<em>.</em> 2012; 36(11): 2219-23. Peterson MB, Jorgenson HL, Hansen K, Duus BR. Factors affecting postoperative mortality of patients with displaced femoral neck fracture<em>. </em>Injury<em>. 2006</em>; 37(8): 705-11. Sierra, Rafael J et al. Dislocation of Bipolar Hemiarthroplasty: Rate, Contributing Factors, and Outcome. Clinical Orthopaedics &amp; Related Research. 2006; 442: 230-238. Saberi S, Arabzadeh A, Khomeisi B, Berehnegard E, Mortazavi SMJ. Early Complications Following Bipolar Hemiarthroplasty for Femoral Neck Fracture in Elderly Patients. Academic Journal of Surgery. 2014; 1(3-4): 45-48. Rajak MK, Jha R, Kumar P, Thakur R. Bipolar hemiarthroplasty for intracapsular femorla neck fracturres in elderly patients. 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Cementless Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures in the Elderly<em>. </em>The Journal of Arthroplasty<em>. </em>2004; 19(7): 73-77. Reddy YH, Vishnu K. A study of management of intracapsular fracture neck femur using bipolar prosthesis. Indian Archives of Integrated Medicine. 2018; 5(1): 28-35. Ebrahimpour A, Zandi R, Ayazi M, Safdari F. The Outcomes of Treating Femoral Neck Fractures Using Bipolar Hemiarthroplasty. Trauma Monthly. 2017; 22(1): e61806. Kalantri A, Barod S, Kothari D, Kothari A, Nagla A, Bhambani P. Hemiarthroplasty for intra-capsular fracture neck of femur in elderly patients: a prospective observational study. International Journal of Research in Orthopaedics. 2017; 3(5): 991-997. Jindal RC, Gill SS, Singh M, Gautam RK. Functional Outcome of Bipolar Arthroplasty for Fracture Neck Femur in Elderly People. Indian Journal of Research. 2016; 5(11): 7-10. Malhotra R, Arya R, Bhan S. Bipolar hemiarthyroplasty in femoral neck fractures. 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Egon Orowan died in the Mount Auburn Hospital in Cambridge, Massachusetts, on 3 August 1989, a day after his 87th birthday. He is buried in the Mount Auburn Cemetery. Together with G. I. Taylor and Michael Polanyi, he was responsible for the introduction of the crystal dislocation into physics as the essential mediator of plastic deformation. Though he occasionally spoke at meetings concerned with science and technology policy, and wrote letters to the press on a number of topics, he was an essentially private person and left no biographical notes. In compiling this memoir, F. R. N. Nabarro has been principally responsible for the period 1902-1951, which Orowan spent mainly in Europe, and Ali S. Argon for the period 1951-1989, when Orowan was affiliated with the Massachusetts Institute of Technology. An extended version of the memoir is held in the archives of the Royal Society, the US National Academy of Sciences and the Massachusetts Institute of Technology.

1909–22: Turkey exterminated over 1.5 million of its ethnically Armenian, and hundreds of thousands of its ethnically Greek and Assyrian, citizens. Most died in 1915. This period of decimation in now widely called the Armenian Genocide (Balakian 179-80).1910: Siamanto first published his poem, The Dance: “The corpses were piled as trees, / and from the springs, from the streams and the road, / the blood was a stubborn murmur.” When springs run red, when the dead are stacked tree-high, when “everything that could happen has already happened,” then time is nothing: “there is no future [and] the language of civilised humanity is not our language” (Nichanian 142).2007: In my novel The Edge of the World a ceramic bowl, luminous blue, recurs as motif. Imagine you are tiny: the bowl is broken but you don’t remember breaking it. You’re awash with tears. You sit on the floor, gather shards but, no matter how you try, you can’t fix it. Imagine, now, that the bowl is the sky, huge and upturned above your head. You have always known, through every wash of your blood, that life is shockingly precarious. Silence—between heartbeats, between the words your parents speak—tells you: something inside you is terribly wrong; home is not home but there is no other home; you “can never be fully grounded in a community which does not share or empathise with the experience of persecution” (Wajnryb 130). This is the stubborn murmur of your body.Because time is nothing, this essay is fragmented, non-linear. Its main characters: my mother, grandmother (Hovsanna), grandfather (Benyamin), some of my mother’s older siblings (Krikor, Maree, Hovsep, Arusiak), and Mustafa Kemal Ataturk (Ottoman military officer, Young Turk leader, first president of Turkey). 1915–2013: Turkey invests much energy in genocide denial, minimisation and deflection of responsibility. 24 April 2012: Barack Obama refers to the Medz Yeghern (Great Calamity). The use of this term is decried as appeasement, privileging political alliance with Turkey over human rights. 2003: Between Genocide and Catastrophe, letters between Armenian-American theorist David Kazanjian and Armenian-French theorist Marc Nichanian, contest the naming of the “event” (126). Nichanian says those who call it the Genocide are:repeating every day, everywhere, in all places, the original denial of the Catastrophe. But this is part of the catastrophic structure of the survivor. By using the word “Genocide”, we survivors are only repeating […] the denial of the loss. We probably cannot help it. We are doing what the executioner wanted us to do […] we claim all over the world that we have been “genocided;” we relentlessly need to prove our own death. We are still in the claws of the executioner. We still belong to the logic of the executioner. (127)1992: In Revolution and Genocide, historian Robert Melson identifies the Armenian Genocide as “total” because it was public policy intended to exterminate a large fraction of Armenian society, “including the families of its members, and the destruction of its social and cultural identity in most or all aspects” (26).1986: Boyajian and Grigorian assert that the Genocide “is still operative” because, without full acknowledgement, “the ghosts won’t go away” (qtd. in Hovannisian 183). They rise up from earth, silence, water, dreams: Armenian literature, Armenian homes haunted by them. 2013: My heart pounds: Medz Yeghern, Aksor (Exile), Anashmaneli (Indefinable), Darakrutiun (Deportation), Chart (Massacre), Brnagaght (Forced migration), Aghed (Catastrophe), Genocide. I am awash. Time is nothing.1909–15: Mustafa Kemal Ataturk was both a serving Ottoman officer and a leader of the revolutionary Young Turks. He led Ottoman troops in the repulsion of the Allied invasion before dawn on 25 April at Gallipoli and other sites. Many troops died in a series of battles that eventually saw the Ottomans triumph. Out of this was born one of Australia’s founding myths: Australian and New Zealand Army Corps (ANZACs), courageous in the face of certain defeat. They are commemorated yearly on 25 April, ANZAC Day. To question this myth is to risk being labelled traitor.1919–23: Ataturk began a nationalist revolution against the occupying Allies, the nascent neighbouring Republic of Armenia, and others. The Allies withdrew two years later. Ataturk was installed as unofficial leader, becoming President in 1923. 1920–1922: The last waves of the Genocide. 2007: Robert Manne published A Turkish Tale: Gallipoli and the Armenian Genocide, calling for a recontextualisation of the cultural view of the Gallipoli landings in light of the concurrence of the Armenian Genocide, which had taken place just over the rise, had been witnessed by many military personnel and widely reported by international media at the time. Armenian networks across Australia were abuzz. There were media discussions. I listened, stared out of my office window at the horizon, imagined Armenian communities in Sydney and Melbourne. Did they feel like me—like they were holding their breath?Then it all went quiet. Manne wrote: “It is a wonderful thing when, at the end of warfare, hatred dies. But I struggle to understand why Gallipoli and the Armenian Genocide continue to exist for Australians in parallel moral universes.” 1992: I bought an old house to make a home for me and my two small children. The rooms were large, the ceilings high, and behind it was a jacaranda with a sturdy tree house built high up in its fork. One of my mother’s Armenian friends kindly offered to help with repairs. He and my mother would spend Saturdays with us, working, looking after the kids. Mum would stay the night; her friend would go home. But one night he took a sleeping bag up the ladder to the tree house, saying it reminded him of growing up in Lebanon. The following morning he was subdued; I suspect there were not as many mosquitoes in Lebanon as we had in our garden. But at dinner the previous night he had been in high spirits. The conversation had turned, as always, to politics. He and my mother had argued about Turkey and Russia, Britain’s role in the development of the Middle East conflict, the USA’s roughshod foreign policy and its effect on the world—and, of course, the Armenian Genocide, and the killingof Turkish governmental representatives by Armenians, in Australia and across the world, during the 1980s. He had intimated he knew the attackers and had materially supported them. But surely it was the beer talking. Later, when I asked my mother, she looked at me with round eyes and shrugged, uncharacteristically silent. 2002: Greek-American diva Diamanda Galas performed Dexifiones: Will and Testament at the Perth Concert Hall, her operatic work for “the forgotten victims of the Armenian and Anatolian Greek Genocide” (Galas).Her voice is so powerful it alters me.1925: My grandmother, Hovsanna, and my grandfather, Benyamin, had twice been separated in the Genocide (1915 and 1922) and twice reunited. But in early 1925, she had buried him, once a prosperous businessman, in a swamp. Armenians were not permitted burial in cemeteries. Once they had lived together in a big house with their dozen children; now there were only three with her. Maree, half-mad and 18 years old, and quiet Hovsep, aged seven,walked. Then five-year-old aunt, Arusiak—small, hungry, tired—had been carried by Hovsanna for months. They were walking from Cilicia to Jerusalem and its Armenian Quarter. Someone had said they had seen Krikor, her eldest son, there. Hovsanna was pregnant for the last time. Together the four reached Aleppo in Syria, found a Christian orphanage for girls, and Hovsanna, her pregnancy near its end, could carry Arusiak no further. She left her, promising to return. Hovsanna’s pains began in Beirut’s busy streets. She found privacy in the only place she could, under a house, crawled in. Whenever my mother spoke of her birth she described it like this: I was born under a stranger’s house like a dog.1975: My friend and I travelled to Albany by bus. After six hours we were looking down York Street, between Mount Clarence and Mount Melville, and beyond to Princess Royal Harbour, sapphire blue, and against which the town’s prosperous life—its shopfronts, hotels, cars, tourists, historic buildings—played out. It took away my breath: the deep harbour, whaling history, fishing boats. Rain and sun and scudding cloud; cliffs and swells; rocky points and the white curves of bays. It was from Albany that young Western Australian men, volunteers for World War I, embarked on ships for the Middle East, Gallipoli, sailing out of Princess Royal Harbour.1985: The Australian Government announced that Turkey had agreed to have the site of the 1915 Gallipoli landings renamed Anzac Cove. Commentators and politicians acknowledged it as historic praised Turkey for her generosity, expressed satisfaction that, 70 years on, former foes were able to embrace the shared human experience of war. We were justifiably proud of ourselves.2005: Turkey made her own requests. The entrance to Albany’s Princess Royal Harbour was renamed Ataturk Channel. A large bronze statue of Ataturk was erected on the headland overlooking the Harbour entrance. 24 April 1915: In the town of Hasan Beyli, in Cilicia, southwest Turkey, my great grandfather, a successful and respected businessman in his 50s, was asleep in his bed beside his wife. He had been born in that house, as had his father, grandfather, and all his children. His brother, my great uncle, had bought the house next door as a young man, brought his bride home to it, lived there ever since; between the two households there had been one child after another. All the cousins grew up together. My great grandfather and great uncle had gone to work that morning, despite their wives’ concerns, but had returned home early. The women had been relieved to see them. They made coffee, talked. Everyone had heard the rumours. Enemy ships were massing off the coast. 1978: The second time in Albany was my honeymoon. We had driven into the Goldfields then headed south. Such distance, such beautiful strangeness: red earth, red rocks; scant forests of low trees, thin arms outstretched; the dry, pale, flat land of Norseman. Shimmering heat. Then the big, wild coast.On our second morning—a cool, overcast day—we took our handline to a jetty. The ocean was mercury; a line of cormorants settled and bobbed. Suddenly fish bit; we reeled them in. I leaned over the jetty’s side, looked down into the deep. The water was clear and undisturbed save the twirling of a pike that looked like it had reversed gravity and was shooting straight up to me. Its scales flashed silver as itbroke the surface.1982: How could I concentrate on splicing a film with this story in my head? Besides the desk, the only other furniture in the editing suite was a whiteboard. I took a marker and divided the board into three columns for the three generations: my grandparents, Hovsanna and Benyamin; my mother; someone like me. There was a lot in the first column, some in the second, nothing in the third. I stared at the blankness of my then-young life.A teacher came in to check my editing. I tried to explain what I had been doing. “I think,” he said, stony-faced, “that should be your third film, not your first.”When he had gone I stared at the reels of film, the white board blankness, the wall. It took 25 years to find the form, the words to say it: a novel not a film, prose not pictures.2007: Ten minutes before the launch of The Edge of the World, the venue was empty. I made myself busy, told myself: what do you expect? Your research has shown, over and over, this is a story about which few know or very much care, an inconvenient, unfashionable story; it is perfectly in keeping that no-one will come. When I stepped onto the rostrum to speak, there were so many people that they crowded the doorway, spilled onto the pavement. “I want to thank my mother,” I said, “who, pretending to do her homework, listened instead to the story her mother told other Armenian survivor-women, kept that story for 50 years, and then passed it on to me.” 2013: There is a section of The Edge of the World I needed to find because it had really happened and, when it happened, I knew, there in my living room, that Boyajian and Grigorian (183) were right about the Armenian Genocide being “still operative.” But I knew even more than that: I knew that the Diaspora triggered by genocide is both rescue and weapon, the new life in this host nation both sanctuary and betrayal. I picked up a copy, paced, flicked, followed my nose, found it:On 25 April, the day after Genocide memorial-day, I am watching television. The Prime Minister stands at the ANZAC memorial in western Turkey and delivers a poetic and moving speech. My eyes fill with tears, and I moan a little and cover them. In his speech he talks about the heroism of the Turkish soldiers in their defence of their homeland, about the extent of their losses – sixty thousand men. I glance at my son. He raises his eyebrows at me. I lose count of how many times Kemal Ataturk is mentioned as the Father of Modern Turkey. I think of my grandmother and grandfather, and all my baby aunts and uncles […] I curl over like a mollusc; the ache in my chest draws me in. I feel small and very tired; I feel like I need to wash.Is it true that if we repeat something often enough and loud enough it becomes the truth? The Prime Minister quotes Kemal Ataturk: the ANZACS who died and are buried on that western coast are deemed ‘sons of Turkey’. My son turns my grandfather’s, my mother’s, my eyes to me and says, It is amazing they can be so friendly after we attacked them.I draw up my knees to my chest, lay my head and arms down. My limbs feel weak and useless. My throat hurts. I look at my Australian son with his Armenian face (325-6).24 April 1915 cont: There had been trouble all my great grandfather’s life: pogrom here, massacre there. But this land was accustomed to colonisers: the Mongols, the Persians, latterly the Ottomans. They invade, conquer, rise, fall; Armenians stay. This had been Armenian homeland for thousands of years.No-one masses ships off a coast unless planning an invasion. So be it. These Europeans could not be worse than the Ottomans. That night, were my great grandfather and great uncle awoken by the pounding at each door, or by the horses and gendarmes’ boots? They were seized, each family herded at gunpoint into its garden, and made to watch. Hanging is slow. There could be no mistakes. The gendarmes used the stoutest branches, stayed until they were sure the men weredead. This happened to hundreds of prominent Armenian men all over Turkey that night.Before dawn, the Allies made landfall.Each year those lost in the Genocide are remembered on 24 April, the day before ANZAC Day.1969: I asked my mother if she had any brothers and sisters. She froze, her hands in the sink. I stared at her, then slipped from the room.1915: The Ottoman government decreed: all Armenians were to surrender their documents and report to authorities. Able-bodied men were taken away, my grandfather among them. Women and children, the elderly and disabled, were told to prepare to walk to a safe camp where they would stay for the duration of the war. They would be accompanied by armed soldiers for their protection. They were permitted to take with them what they could carry (Bryce 1916).It began immediately, pretty young women and children first. There are so many ways to kill. Months later, a few dazed, starved survivors stumbled into the Syrian desert, were driven into lakes, or herded into churches and set alight.Most husbands and fathers were never seen again. 2003: I arrived early at my son’s school, parked in the shade, opened The Silence: How Tragedy Shapes Talk, and began to read. Soon I was annotating furiously. Ruth Wajnryb writes of “growing up among innocent peers in an innocent landscape” and also that the notion of “freedom of speech” in Australia “seems often, to derive from that innocent landscape where reside people who have no personal scars or who have little relevant historical knowledge” (141).1984: I travelled to Vancouver, Canada, and knocked on Arusiak’s door. Afraid she would not agree to meet me, I hadn’t told her I was coming. She was welcoming and gracious. This was my first experience of extended family and I felt loved in a new and important way, a way I had read about, had observed in my friends, had longed for. One afternoon she said, “You know our mother left me in an orphanage…When I saw her again, it was too late. I didn’t know who they were, what a family was. I felt nothing.” “Yes, I know,” I replied, my heart full and hurting. The next morning, over breakfast, she quietly asked me to leave. 1926: When my mother was a baby, her 18 year-old sister, Maree, tried to drown her in the sea. My mother clearly recalled Maree’s face had been disfigured by a sword. Hovsanna, would ask my mother to forgive Maree’s constant abuse and bad behaviour, saying, “She is only half a person.”1930: Someone gave Hovsanna the money to travel to Aleppo and reclaim Arusiak, by then 10 years old. My mother was intrigued by the appearance of this sister but Arusiak was watchful and withdrawn. When she finally did speak to my then five-year-old mother, she hissed: “Why did she leave me behind and keep you?”Soon after Arusiak appeared, Maree, “only half a person,” disappeared. My mother was happy about that.1935: At 15, Arusiak found a live-in job and left. My mother was 10 years old; her brother Hovsep, who cared for her before and after school every day while their mother worked, and always had, was seventeen. She adored him. He had just finished high school and was going to study medicine. One day he fell ill. He died within a week.1980: My mother told me she never saw her mother laugh or, once Hovsep died, in anything other than black. Two or three times before Hovsep died, she saw her smile a little, and twice she heard her singing when she thought she was alone: “A very sad song,” my mother would say, “that made me cry.”1942: At seventeen, my mother had been working as a live-in nanny for three years. Every week on her only half-day off she had caught the bus home. But now Hovsanna was in hospital, so my mother had been visiting her there. One day her employer told her she must go to the hospital immediately. She ran. Hovsanna was lying alone and very still. Something wasn’t right. My mother searched the hospital corridors but found no-one. She picked up a phone. When someone answered she told them to send help. Then she ran all the way home, grabbed Arusiak’s photograph and ran all the way back. She laid it on her mother’s chest, said, “It’s all right, Mama, Arusiak’s here.”1976: My mother said she didn’t like my boyfriend; I was not to go out with him. She said she never disobeyed her own mother because she really loved her mother. I went out with my boyfriend. When I came home, my belongings were on the front porch. The door was bolted. I was seventeen.2003: I read Wajnryb who identifies violent eruptions of anger and frozen silences as some of the behaviours consistent in families with a genocidal history (126). 1970: My father had been dead over a year. My brothers and I were, all under 12, made too much noise. My mother picked up the phone: she can’t stand us, she screamed; she will call an orphanage to take us away. We begged.I fled to my room. I couldn’t sit down. I couldn’t keep still. I paced, pressed my face into a corner; shook and cried, knowing (because she had always told us so) that she didn’t make idle threats, knowing that this was what I had sometimes glimpsed on her face when she looked at us.2012: The Internet reveals images of Ataturk’s bronze statue overlooking Princess Royal Harbour. Of course, it’s outsized, imposing. The inscription on its plinth reads: "Peace at Home/ Peace in the World." He wears a suit, looks like a scholar, is moving towards us, a scroll in his hand. The look in his eyes is all intensity. Something distant has arrested him – a receding or re-emerging vision. Perhaps a murmur that builds, subsides, builds again. (Medz Yeghern, Aksor, Aghed, Genocide). And what is written on that scroll?2013: My partner suggested we go to Albany, escape Perth’s brutal summer. I tried to explain why it’s impossible. There is no memorial in Albany, or anywhere else in Western Australia, to the 1.5 million victims of the Armenian Genocide. ReferencesAkcam, Taner. “The Politics of Genocide.” Online Video Clip. YouTube. YouTube, 11 Dec. 2011. 6 Mar. 2013 ‹http://www.youtube.com/watchv=OxAJaaw81eU&amp;noredirect=1genocide›.Balakian, Peter. The Burning Tigress: The Armenian Genocide. London: William Heinemann, 2004.BBC. “Kemal Ataturk (1881–1938).” BBC History. 2013. 6 Mar. 2013 ‹http://www.bbc.co.uk/history/historic_figures/ataturk_kemal.shtml›.Boyajian, Levon, and Haigaz Grigorian. “Psychological Sequelae of the Armenian Genocide.”The Armenian Genocide in Perspective. Ed. Richard Hovannisian. New Brunswick: Transaction, 1987. 177–85.Bryce, Viscount. The Treatment of the Armenians in the Ottoman Empire. London: Hodder and Stoughton, 1916.Galas, Diamanda. Program Notes. Dexifiones: Will and Testament. Perth Concert Hall, Perth, Australia. 2001.———.“Dexifiones: Will and Testament FULL Live Lisboa 2001 Part 1.” Online Video Clip. YouTube, 5 Nov. 2011. Web. 6 Mar. 2013 ‹http://www.youtube.com/watch?v=mvVnYbxWArM›.Kazanjian, David, and Marc Nichanian. “Between Genocide and Catastrophe.” Loss. Eds. David Eng and David Kazanjian. Los Angeles: U of California P, 2003. 125–47.Manne, Robert. “A Turkish Tale: Gallipoli and the Armenian Genocide.” The Monthly Feb. 2007. 6 Mar. 2013 ‹http://www.themonthly.com.au/turkish-tale-gallipoli-and-armenian-genocide-robert-manne-459›.Matiossian, Vartan. “When Dictionaries Are Left Unopened: How ‘Medz Yeghern’ Turned into a Terminology of Denial.” The Armenian Weekly 27 Nov. 2012. 6 Mar. 2013 ‹http://www.armenianweekly.com/2012/11/27/when-dictionaries-are-left-unopened-how-medz-yeghern-turned-into-terminology-of-denial/›.Melson, Robert. Revolution and Genocide. Chicago: U of Chicago P, 1996.Nicholson, Brendan. “ASIO Detected Bomb Plot by Armenian Terrorists.” The Australian 2 Jan. 2012. 6 Mar. 2013 ‹http://www.theaustralian.com.au/in-depth/cabinet-papers/asio-detected-bomb-plot-by-armenian-terrorists/story-fnbkqb54-1226234411154›.“President Obama Issues Statement on Armenian Remembrance Day.” The Armenian Weekly 24 Apr. 2012. 5 Mar. 2013 ‹http://www.armenianweekly.com/2012/04/24/president-obama-issues-statement-on-armenian-remembrance-day/›.Polain, Marcella. The Edge of the World. Fremantle: Fremantle Press, 2007.Siamanto. “The Dance.” Trans. Peter Balakian and Nervart Yaghlian. Adonias Dalgas Memorial Page 5 Mar. 2013 ‹http://www.terezakis.com/dalgas.html›.Stockings, Craig. “Let’s Have a Truce in the Battle of the Anzac Myth.” The Australian 25 Apr. 2012. 6 Mar. 2013 ‹http://www.theaustralian.com.au/national-affairs/opinion/lets-have-a-truce-in-the-battle-of-the-anzac-myth/story-e6frgd0x-1226337486382›.Wajnryb, Ruth. The Silence: How Tragedy Shapes Talk. Crows Nest: Allen and Unwin, 2001.

Edith and John Power were a wealthy expatriate Australian couple who lived in England and Europe from the early years of the 20th century until their deaths. In 1915 John Power married Edith Lee in London before serving as a surgeon on the Western Front in the Royal Army Medical Corps. After the war Edith and John left Britain to live in Paris and Brussels in the centre of a large international group of avant-garde artists. Edith, who was twelve years older than her husband, and had been married twice before (once widowed and once divorced), was to all accounts the driving force behind John's success as an artist -- he exhibited alongside Picasso, Braque and Kandinsky -- and the great love of his life. The following comes from a book-length fictionalised biography of their lives, narrated by Edith in the early 1960s when she was ninety-two years old. This extract comes from the part of the manuscript dealing with the Nazi Occupation of the Channel Island of Jersey in the second world war; the 'safe haven' to which the Powers had fled in 1938 when war threatened. The first winter under the Germans was very hard and there were reports of old people dying of starvation and exposure. Jack had terrible chilblains and we were both very thin. Cooking fat was only available for doctors to give to invalids, and one poor chap was so desperate that he used sump oil from his car to fry up some gull eggs, and poisoned himself. Sitting down to a plate of boiled potatoes I couldn't sometimes help but reminisce about the wonderful meals we had eaten in Paris and Brussels. How decadent they seemed -- oysters, poached salmon, grilled tournedos with asparagus or a roasted duck, then a glass of champagne, a slice or two of Ange à Cheval and some wild strawberries to finish off with. I also realised how petty all our worries had been up 'til then. We would be upset if the hotel we fancied was booked out for the summer, the bath water cold or a soufflé heavy. When the stock market dropped a point or two we were devastated, and Jack used to sulk for days when he had trouble with a painting or if his frames were not exactly as ordered, the moulding wrong, the gilding scratched or too bright. Such concerns seemed absurd when we faced death every day and misery and fear were all around us. Then the prisoners-of-war arrived from Russia, dressed in rags and even thinner than us. They suffered terribly, working impossibly hard every day on the railway and underground hospital, with nowhere proper to sleep and very little to eat. We felt so sorry for them, and admired those Islanders who, although it was a serious crime, sheltered them if they managed to escape. We had another dreadful reminder of just how awful the Germans could be when they started shooting anyone caught with a crystal radio set. By the summer of 1942 Jack was very ill, although he continued to deny anything was wrong. He finally confided in me just how dire things were one afternoon when we were sitting on the terrace. We were drinking the last of our English tea and discussing how wild the garden had become. One minute Jack was saying how much he enjoyed watching everything return to its natural state, the next he was telling me that he thought he had a cancerous tumour in his kidneys and should see a doctor. I listened in a daze as he detailed the possible treatments and his prognosis, which he anticipated to be poor. Then he stood, drank the dregs in his cup, kissed me and said he had to return to the studio. He had salvaged a piece of wood from somewhere to paint on and didn't want to lose the last light. I was stunned, not wanting to believe what he had told me. I never found out whether Jack suspected the cancer before the Occupation, but if he did, I can't understand why he didn't tell me. We could have gone back to England or over to Switzerland and seen the best doctors. This still puzzles me for Jack was never reticent to seek medical treatment. Tony even laughingly called Jack a hypochondriac, he was so careful with his health, but then again, I know Jack's father had hidden the same condition from his family some forty years before. For many years after the war Ceylon tea only ever tasted of trouble and dismay to me. Nowadays everyone wants to give me tea all the time, especially the nurses. I tell them I'd really like a stiff gin and tonic, but alcohol is another of life's pleasures denied to the elderly. If I could only get out of this bed, I'd get one for myself -- a big one. I have forgotten the name of that doctor we consulted a few days later, but I remember exactly what he said. He confirmed what Jack thought, that the tumours were in his kidneys, but added that they had possibly settled in his lungs as well. In a last (but futile) effort, my poor darling was operated on by this old fashioned surgeon who had to work in the most primitive conditions; without the drugs, anaesthetics or antiseptics he needed. By that time it was difficult to find soap whatever price you were willing to pay, and I gave him some fancy little rose scented tablets to wash up with before he cut Jack open. Jack had never been a fast healer and all the odds were against him; the strain of the advancing cancer, the inadequacy of our diet and the lack of proper medicines. The only foods we could obtain were quite coarse, there was no lean meat to make beef tea or eggs for milk puddings. Jack once said to me something to the effect that the ghastly jokes of fate are not always in the best of taste but they could be extremely witty. I never, however, found anything except the most savage cruelty in his situation, that such a highly trained surgeon had to endure such a crude assault on his body, and that a wealthy philanthropist could suffer so for the want of the most basic requirements of food, firewood and pain killers. My darling, who had been so dreadful when struck down with the slightest illness, was a model patient. It took a long time, but eventually he was able to leave his bed, and the first thing he did was to boil up his own analgesics, potent narcotics which he followed with a stiff whisky. When his condition deteriorated and I had to tend to all his most intimate needs, he was always good tempered and never made me feel I was humiliating or demeaning him. We grew closer than ever, but I knew our time was running out. In another cruel twist of fate Jack was only exempted from deportation to a German internment camp by the sick certificate. An order of 1942 decreed that all the British men not born on the Channel Islands, from the young boys of sixteen to poor old men of seventy, would be transferred to Germany. Thinking about it now, it seems bizarre that such a reasonable bureaucratic rule could regulate the Germans' inhumanity. My darling's last days are as clear in my memory as if they were yesterday. He lay in our yellow bedroom, looking out over the garden to the sea. I only left his side for the briefest periods, and slept in a chair by his bed. Early one morning I woke from an uneasy doze. I looked over to Jack. His face was grey and much too old for his sixty-two years, he was no longer the boy he had always been in my heart. Lying stiffly in the middle of the bed, arms by his side, eyes and lips closed, his breathing was so shallow that his chest hardly rose or fell. I wondered if he felt the weight of the blankets or heard the wind outside. Did he even know how I sat with him? I looked out over the garden. The vegetable patches dug in the chamomile lawn were flourishing, but the grass was long, the roses run to briars, the pond filled with sludge and rotting weeds. I wanted to lie beside my darling and hold him, just as I had each night for so many years, so after I had removed my shoes and placed them together under the bed, I pulled back the sheets and lay on my side facing Jack. He didn't move. I traced my finger across his cheekbones and down his nose to the mouth I had kissed so often. His skin was cool and very dry. I moved over and pressed my body close to his and as he made no sign that this was uncomfortable, I began to relax. The house was quiet and, for the first time in weeks, I sank into a peaceful sleep. When I woke, the soft light of late afternoon was filtering through the curtains. The breeze had dropped outside and I heard a lone bird calling for its mate. Most of the birds had been killed and I thought I would put out some potato bread for him. What depths we were reduced to in those days, eating the gentle creatures around us. It was rumoured that some desperate soul had roasted and eaten a hedgehog, but I still can't believe that was true. There were so many dreadful stories in those days, you never knew what to believe. My hand found Jack's. It was icy. I willed myself not to think of it, but I knew he was gone. I touched his cheek, my fingers slightly warming the cold flesh, then I put my arms right around him and pressed my face into his neck. We lay like that for a long time. Eventually I got up, tucked the blankets around him and closed the window. Downstairs I washed in cold water and dressed in black stockings, black slip and my best black dress. My black shoes were still under Jack's bed, so I laced on my tan brogues. I found my veiled black hat and put it on the sideboard. Even though I knew it was ridiculous, I felt uncomfortable wearing brown shoes with black and returned them to the cupboard. I looked around for my pearls, and realised I had left them upstairs too. I stood outside the bedroom door for some time before I could enter. Then I went in, raised the window and sat on the chair. I don't know what I thought about, but after some time the chirping of the little bird brought me back to the present. I bent and retrieved my shoes from under the bed and placed them beside the door. I could see my pearls lying in a shining mound on top of the blankets just below his hip. As I was picking them up I finally looked at Jack properly. His eyes were closed and his face was relaxed as if in a deep dreamless sleep. He looked years younger. He wore his favourite blue striped pyjamas from Jeremyn Street, but he was a stranger to me. I kissed him for the last time, then lifted the linen sheet to cover the face I had loved so much. I turned away, picked up my shoes and left the room, closing the door behind me. Although I hadn't noticed, that dreadful Sunday, the 1st of August 1943, had been a beautifully hot summer's day, just the sort of day Jack had always loved. Citation reference for this article MLA style: Donna Lee Brien. "Just the Sort of Day Jack Had Always Loved." M/C: A Journal of Media and Culture 2.8 (1999). [your date of access] &lt;http://www.uq.edu.au/mc/9912/day.php&gt;. Chicago style: Donna Lee Brien, "Just the Sort of Day Jack Had Always Loved," M/C: A Journal of Media and Culture 2, no. 8 (1999), &lt;http://www.uq.edu.au/mc/9912/day.php&gt; ([your date of access]). APA style: Donna Lee Brien. (1999) Just the sort of day Jack had always loved. M/C: A Journal of Media and Culture 2(8). &lt;http://www.uq.edu.au/mc/9912/day.php&gt; ([your date of access]).