Trochanteric fractures in the elderly: the influence of primary hip arthroplasty on 1-year mortality

[How does the preoperative waiting time affect hospital mortality and complication rates in geriatric patients with medial femoral neck fractures?]

BACKGROUND

The current guidelines of the German Federal Joint Committee on the treatment of proximal femoral fractures require that patients with a proximal femoral fracture receive surgical treatment as soon as possible and within 24 h of admission. This is intended to reduce perioperative complication rate and mortality.

OBJECTIVE

The aim of this study was to analyze the hospital mortality as well as complication rates and types in relation to the preoperative waiting time.

METHODOLOGY

From 2010 to 2020, a total of 575 patients with femoral neck fractures treated with a bipolar prosthesis were retrospectively analyzed with respect to hospital mortality and the occurrence of complications. Patients with pathological fractures, femoral neck fractures more than 4 weeks old and those treated with osteosynthesis were excluded. Patient-specific data, hospital mortality and complication rates and types were recorded.

RESULTS

During the study period, the implementation of the given guidelines resulted in a reduction in the preoperative waiting time from a median of 38 h in 2010 to 19 h in 2020. Surgical treatment was performed on average after 14.2 h in patients who had surgery within 24 h after admission and on average after 40.2 h for those who had surgery after 24 h. The average American Society of Anesthesiologists (ASA) score for all 575 patients was 2.76. The group of patients who had surgery after more than 24 h had a significantly higher ASA classification (p = 0.024). A total of 12 (4.2%) patients in the group surgically treated within 24 h died, compared to 24 (8.5%) deaths in the group surgically treated after 24 h (p = 0.035). The complication rate for the entire cohort was 15% (88 patients). There was no difference in the occurrence of complications and the overall complication rate with respect to the timing of surgery.

CONCLUSION

During the study period the preoperative waiting time was halved from 39h to 19 h. Patients who were surgically treated within 24 h had a significantly lower hospital mortality than those surgically treated after 24 h; however, the group surgically treated after 24 h simultaneously showed higher baseline comorbidities and in the adjusted analysis for age and ASA score, the 24‑h threshold no longer emerged as an independent risk factor for hospital mortality. Regarding complication rates, no significant differences were found between the groups based on the timing of surgery.

Cost-effectiveness analysis of proximal femoral nail versus bipolar hemiarthroplasty for femoral neck fracture

BACKGROUND

Hip fractures are a serious public health problem with high rates of morbidity, mortality, disability and care costs. The aim of the research was to perform cost effectiveness analysis of hip fracture treatments using proximal femoral nail and bipolar hemiarthroplasty surgeries.

METHODS

The analysis was completed based on the perspectives of the paying institution and patient. A decision tree model was used to determine whether proximal femoral nail or bipolar arthroplasty was most cost effective for the management of a femoral neck fracture in this patient population.

RESULTS

The findings from the decision tree model suggested that ICERs for BHP were TRY 43,164.53 TL/QALY based on reimbursement and TRY 3,977.35 TL/QALY based on patient expenditures. Compared to the calculated threshold value of TRY 60.575 TL, we concluded BHP to be a cost-effective option. Moreover, all parameter changes yielded stable results on the one-way sensitivity analysis. When it comes to the probabilistic sensitivity analysis, BHP with specified threshold value was found to be cost-effective in all the comparisons. Currently available data the use of bipolar hemiarthroplasty as the more cost- effective treatment strategy in this specific population.

CONCLUSION

Overall, our findings showed HA as a cost-effective surgical technique at the calculated threshold in a population over 60 years of age. The impacts of HA on patients' quality of life and costs are remarkable.

Fractures of the proximal femur and hip osteoarthrosis - coincidence or coherence?

PURPOSE

The current study aimed to investigate the correlation between the grade of radiographic hip osteoarthritis (OA) and the fracture pattern observed in fragility fractures of the proximal femur. The information may help in cases of occult hip fractures.

METHODS

In this retrospective study all 448 patients treated with fragility fractures of the proximal femur in the years 2014-2018 were included. Patients were allocated into two groups: Group I) intracapsular (femoral neck) fractures and Group II) extracapsular (pertrochanteric and subtrochanteric) femoral fractures. The radiographic grade of OA was determined according to Kellgren and Lawrence's classification. One single observer examined all radiographs.

RESULTS

Patients' age ranged between 52 and 104 years with a mean of 80.0 years. There was a significant difference in mean age between the two groups (76.9 years intracapsular vs. 83.1 years extracapsular fractures). A total of 250 (55.8%) fractures were intracapsular (femoral neck) and 198 (44.2%) were located extracapsular (pertrochanteric, subtrochanteric). A significant correlation between the degree of OA to fracture pattern was observed: Higher degrees of OA were related to extracapsular fractures and lower degrees of OA to intracapsular fractures.

CONCLUSION

The results of this study support the hypothesis that hip osteoarthritis affects the fracture pattern in proximal femur fractures. More severe hip OA is associated with extracapsular fractures that can be treated surgically with lower complication rates compared to intracapsular fractures.

Should trochanteric fractures in elderly patients be treated by arthroplasty or internal fixation?

Most trochanteric fractures are treated by fixation, most often intramedullary. Nevertheless, the desire to have patients walk as soon as possible and the fear of fixation failure has driven some surgeons to carry out an arthroplasty instead, especially for unstable fractures and/or in patients with severe osteoporosis, in order to avoid the difficult conversion to arthroplasty later on if the fixation fails. The aim of this review was to specify the role, technique and results of performing arthroplasty in this context. In which fractures? Unstable fractures (A2.2, A2.3 and A3), especially in osteoporotic bone, which are the most difficult to reduce and fix, and in cases with associated osteoarthritis. For which patients? Arthroplasty should not be done in patients who have ASA≤3 due to greater blood loss and longer operative time. Since the postoperative Parker score often drops, arthroplasty should not be done in patients having a Parker score<6. What are the technical problems? Arthroplasty must be done by an experienced surgeon because of the lack of anatomical landmarks, although fracture fixation has its own demands (satisfactory reduction, appropriate length and position of cervicocephalic screw). What are the results and complications? Despite several comparative studies (randomized trials, meta-analysis and prospective studies), it is difficult to draw any conclusions. These studies show worse performance of dynamic hip screws relative to intramedullary nails. The complication and revision rates were higher for nails than arthroplasty, but not in every study, while the functional outcomes with nails (with or without immediate weightbearing) were better than those of arthroplasty beyond 6 months. What is the mortality rate? It was lower after nailing in a few studies but was mainly determined by the patient's comorbidities and preoperative Parker score. The best indication for arthroplasty may be self-sufficient patients over 70 years of age who have an unstable fracture with severe osteoporosis. Nevertheless, new studies should be done to compare arthroplasty to nailing with immediate return to weightbearing in patients having the same type of fracture, defined using 3D CT scan. Level of evidence: Expert advice.

The Korean hip fracture registry study

BACKGROUND

The purpose of the Korean Hip Fracture Registry (KHFR) Study is to establish a nationwide, hospital-based prospective cohort study of adults with hip fracture to explore the incidence and risk factors of second osteoporotic fractures for a Fracture Liaison Service (FLS) model.

METHODS

The KHFR, a prospective multicenter longitudinal study, was launched in 2014. Sixteen centers recruited participants who were treated for hip fracture. The inclusion criteria were patients, who were treated for proximal femur fracture due to low-energy trauma and aged 50 or more at the time of injury. Until 2018, 5,841 patients were enrolled in this study. Follow-up surveys were conducted annually to determine occurrence of second osteoporotic fracture, and 4,803 participants completed at least one follow-up survey.

DISCUSSION

KHFR is a unique resource of individual level on osteoporotic hip fracture with radiological, medical, and laboratory information including DXA (dual energy x-ray absorptiometry), bone turnover marker, body composition, and hand grip strength for future analyses for FLS model. Modifiable factors for mortality after hip surgery is planned to be identified with nutritional assessment and multi-disciplinary interventions from hospitalization to follow-ups. The proportions of femoral neck, intertrochanteric, and subtrochanteric fractures were 517 (42.0%), 730 (53.6%), and 60 (4.4%), respectively, from 2014 to 2016, which was similar in other studies. Radiologic definition of atypical subtrochanteric fracture was adopted and 17 (1.2%) fractures among 1,361 proximal femoral fractures were identified. Internal fixation showed higher reoperation rate compared to arthroplasty in unstable intertrochanteric fractures (6.1% vs. 2.4%, p = 0.046) with no significant difference in mortality. The KHFR plans to identify outcomes and risk factors associated with second fracture by conducting a 10-year cohort study, with a follow-up every year, using 5,841 baseline participants.

TRIAL REGISTRATION

Present study was registered on Internet-based Clinical Research and Trial management system (iCReaT) as multicenter prospective observational cohort study (Project number: C160022, Date of registration: 22th, Apr, 2016).

Conversion arthroplasty after failed extracapsular hip fracture fixation is associated with high complication rates

Background/Aim: There is no standard treatment of choice that addresses all extracapsular fractures, which account for approximately half of the elderly hip fractures. Arthroplasty is mostly favored secondary to unsuccessful fixation or unstable primary fractures. However, conversion arthroplasty complication rates are high in the literature. This study compares arthroplasty performed after unsuccessful fixation and primary arthroplasty for unstable extracapsular hip fractures. Methods: In this retrospective study, we compared the first-year results of the groups that underwent conversion arthroplasty (cHA) and the primary arthroplasties (pHA) for extracapsular hip fractures. In the cHA group, patients were indicated for operation if there was a failure of fixation after extracapsular hip fractures (n=44). In the pHA group, patients were for unstable extracapsular hip fractures (n=44). In the cHA group, failure of fixation causes were cut-out of lag screws (54.5%), cut-through of lag screws (9.1%), non-union of fractures (27.3%), and osteonecrosis of femoral heads (9.1%). While total hip replacement was applied to all patients in the cHA group, total hip replacement was applied to ten patients in the pHA group and hemiarthroplasty to 34 patients. In comparing groups, duration of operation, amount of bleeding, intraoperative complications, post-operative complications, mobilization capacities, functional status, and mortality rates were used. Results: There were 44 patients in both groups. The surgical time (134.3 [34.5)] vs. 66 [16], [P<0.001]), the amount of bleeding (1000 ml [400] vs. 300ml [200], [P<0.001]), the need for red blood cell transfusion in the operations (80% vs. 32%, [P<0.001]), and the frequency of intraoperative femur fracture (30% vs. 0%, [P<0.001]) were larger or longer in the cHA group compared to pHA group (P<0.001). While 14 complications requiring surgical intervention were observed in 12 of 44 patients in the CHA group in the post-operative 1st year, four complications were observed in four of 44 patients in the pHA group. There was no difference in mortality rates (3 vs. 3, [P =1]), mobilization capacities (5.9 [2.1] vs. 5.7 [2.0], [P=0.597]), and functional status (12.5 [3.3] vs. 13.0 [2.7], [P=0.434]) between the groups. Conclusion: Arthroplasty performed as conversion surgery after unsuccessful fixation has a higher risk of intraoperative and post-operative complications than primary arthroplasty performed after extracapsular hip fractures. We believe the cases prone to implant failure, non-union, or restricted mobilization because of the patient and fracture-type reasons should be treated with primary arthroplasty.

Mortality and functional consequences after revision osteosynthesis for peritrochanteric fractures treated by intramedullary nail: A retrospective study of 312 patients

INTRODUCTION

Osteosynthesis of peritrochanteric fractures by intramedullary nail is associated with a 3 to 15% rate of complications requiring revision surgery. The objective of our study was to compare mortality and autonomy between patients who required revision surgery after osteosynthesis, and patients without revision surgery.

HYPOTHESES

Patients who underwent revision surgery after osteosynthesis of a peritrochanteric fracture by intramedullary nail did not exhibit excess mortality or loss of autonomy compared to those who did not undergo revision surgery.

METHODS

Between January 2017 and October 2019, 312 consecutive patients were operated on for a peritrochanteric fracture by intramedullary nail. Among them, 23 patients (7.4%) required revision surgery (change, nail removal, total hip arthroplasty). Mortality at 90 days and at one year was evaluated and compared between the group of "revision" patients and "no revision" patients. The level of autonomy was assessed by the Parker and Palmer score, one year postoperatively and compared between the 2 groups.

RESULTS

The patients requiring revision surgery were younger: 73 years old vs. 86 years old (p<0.011). The overall mortality was 7.25% at 90 days after surgery and 15% at one year. Mortality was zero at 90 days, and at 1 year, postoperatively for patients requiring revision surgery. There was no significant difference for the mortality at 90 days (p=0.39) between the 2 groups, however at 1 year, it was significantly less for the revision patients (0% vs. 17%, p=0.032). There was no significant difference for the Parker score between the "revision" group; 5 (4-9) and the "no revision" group; 4 (3-7), at one year postoperatively (p=0.24).

CONCLUSION

This study did not show any excess mortality, nor loss of autonomy at 1 year postoperatively, for patients who required osteosynthesis for a trochanteric fracture, and who presented with a complication requiring revision surgery.

LEVEL OF EVIDENCE

III, comparative retrospective study.

Do breaks from surgery improve the performance of orthopaedic surgeons?

This paper explores whether breaks from surgical practice impact surgeons' performance. Using a large panel of orthopaedic surgeons in England, I estimate the effect of surgeons' breaks, measured by the number of days since their last surgery, on the health outcomes of emergency patients admitted after a hip fracture. To identify a causal effect, I implement a surgeon fixed effects model and exploit the quasi-exogenous variation in breaks from unanticipated emergency hip fracture admissions. Results show that short breaks of four to six days reduce 30-day mortality rates by around six percent relative to no breaks. Notably, short breaks also affect the type of surgery carried out, holding patient characteristics fixed. Overall, these findings show that the organisation of surgeons' activity is a possible determinant of the quality of care provided.

Intramedullary Nail or Primary Arthroplasty? A System Review and Meta-Analysis on the Prognosis of Intertrochanteric Femoral Fractures Based on Randomized Controlled Trials

Introduction

There is no consensus regarding the superiority between intramedullary nailing and primary arthroplasty in the management of intertrochanteric femoral fractures. This systematic review was performed to investigate and compare the clinical efficacy of intertrochanteric femoral fractures treated with these 2 methods.

Materials and methods

We systematically searched PubMed, Embase, Cochrane, Web of science core collection and ClinicalTrials.gov for randomized controlled trials which compared the clinical outcomes of intertrochanteric fractures treated with either intramedullary nails or primary arthroplasty. Relevant data of the postoperative complications, reoperations, mortality and functional assessment, were pooled and presented graphically.

Results

A total of 6 trials with 427 participants were identified and included in the analyses. The pooled estimates suggested these 2 techniques have comparable risks in terms of overall complications (pooled risk ratio [RR] .80; 95% confidence interval [CI] .43 to 1.43; I2 = 79.94%), the rate of patients with orthopedic complications (RR .71, 95% CI .40 to 1.27; I2 = .00%), reoperations (RR 1.33, 95% CI .48 to 3.71; I2 = .00%), the overall mortality (RR .52; 95%CI .26 to 1.02; I2 = 31.35%) and 1-year mortality (RR .67; 95%CI .38 to 1.19; I2 = .00%). Primary arthroplasty associated with higher HHS at 3 months postoperatively (MD -21.95, 95% CI -28.29 to -15.60; I2 = 70.44%). While the difference was not significant at 6 months (MD 2.32, 95% CI -1.55 to 6.18; I2 = .00%), and even reversed at 12 months postoperatively (MD 13.02, 95% CI 8.14 to 17.90; I2 = 73.42%).

Conclusions

Meta-analytic pooling of current evidences demonstrated that primary arthroplasty is related to a better early functional recovery at the early stage postoperatively, but the long-term result tends to favor to intramedullary nailing. The differences in overall complications, the rate of patients with orthopedic complications, reoperations, overall and 1-year mortality did not reach a significant level.

Analysis of risk factors affecting mortality in elderly patients operated on for hip fractures: A retrospective comparative study

OBJECTIVE

The aims of this study were (1) to investigate the effects of different demographic and perioperative modalities on mortality rates and (2) to compare mortality rates between different implants in elderly patients operated on for hip fractures.

METHODS

In this retrospective study, a total of 314 patients who were operated on for hip fractures were included study. Patients were then divided into four groups based in their implant types: long-stem cementless bipolar hemiarthroplasty (n = 124; 102 female, 22 male; mean age = 84.2 ± 6.4 years), standard-stem cementless bipolar hemiarthroplasty (n = 74; 48 female, 26 male; mean age = 83.5 ± 6.9 years), antegrade intertrochanteric nail (n = 61; 35 female, 26 male; mean age = 78.5 ± 6.8 years), and total hip arthroplasty (n = 55; 34 female, 21 male; mean age = 72.5 ± 4.3 years). Data including gender, age, duration from injury to surgery, American Society of Anesthesiologists (ASA) score, comorbidities, use of antiplatelet agents, Barthel Index of Activities of Daily Living, type of anesthesia, operation time, preoperative hemoglobin values, blood transfusions given, duration of hospital stay, complications, and type of fracture were recorded.

RESULTS

Overall, the mean follow-up was 36.5 (range = 0 - 107) months. The overall mortality rate was 53.2%. The median survival duration was 44.2 ± 5 months (range = 34.3 - 54). Survival rates were found significantly different among the groups (P = 0.001). In the first three years postoperatively, the mortality rate was higher in the standard-stem bipolar hemiarthroplasty group, but in the long-term follow-up, the long-stem bipolar hemiarthroplasty group exhibited the higher mortality rates. It was observed that some parameters had statistically significant effects on the mortality rates. Male gender, higher age, lower hemoglobin values, increased number of blood transfusions, ASA scores ≥3, the existence of ≥ 3 comorbidities were found as main predictors of increased mortality rates.

CONCLUSION

The results of this study have shown that age, gender, preoperative hemoglobin levels, ASA scores, and comorbidities are significant factors affecting mortality in elderly patients operated on for hip fractures. Long-stem cementless bipolar hemiarthroplasty appears to show similar rates of mortality with standard-stem cementless bipolar hemiarthroplasty.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Lower 1-Year Postoperative Mortality After Acetabular Versus Proximal Femoral Fractures in Elderly Patients

BACKGROUND

Geriatric acetabular fractures are becoming more common due to demographic changes. Compared with proximal femoral fractures, surgical treatment is more complex and often does not allow full-weight-bearing. The aims of this study were to compare operatively treated acetabular and proximal femoral fractures with regard to (1) cumulative 1-year mortality, (2) perioperative complications, and (3) predictive factors associated with a higher 1-year mortality.

METHODS

This institutional review board-approved comparative study included 486 consecutive surgically treated elderly patients (136 acetabular and 350 proximal femoral fractures). After matching, 2 comparable groups of 129 acetabular and 129 proximal femoral fractures were analyzed. Cumulative 1-year mortality was evaluated through Kaplan-Meier survivorship analysis, and perioperative complications were documented and graded. After confirming that the proportionality assumption was met, Cox proportional hazard modeling was conducted to identify factors associated with increased 1-year mortality.

RESULTS

The acetabular fracture group had a significantly lower cumulative 1-year mortality before matching (18% compared with 33% for proximal femoral fractures, log-rank p = 0.001) and after matching (18% compared with 36%, log-rank p = 0.005). Nevertheless, it had a significantly higher overall perioperative complication rate (68% compared with 48%, p < 0.001). In our multivariable Cox regression analysis, older age, perioperative blood loss of >1 L, and wheelchair mobilization were associated with lower survival rates after acetabular fracture surgery. Older age and a higher 5-item modified frailty index were associated with a higher 1-year mortality rate after proximal femoral fractures, whereas postoperative full weight-bearing was protective.

CONCLUSIONS

Despite the complexity of operative treatment and a higher complication rate after acetabular fractures in the elderly, the 1-year mortality rate is lower than that after operative treatment of proximal femoral fractures, even after adjustment for comorbidities.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Intertrochanteric Femur Fractures with Hip Arthroplasty in Older Patients: A Narrative Review of Indications and Outcomes

Intertrochanteric femur fractures are common in older patients and often have a significant impact on disability. The treatment aims to achieve a rapid return to the prior functional level with a low rate of complications and mortality. Surgical management by internal fixation is the mainstay of treatment for most of these fractures. Even when treated with intramedullary nails, the overall complication rates are high, especially for unstable or highly comminuted fractures or in the presence of poor bone quality. Hip arthroplasty is an alternative in older patients with intertrochanteric femur fractures at high risk of fixation failure or with concomitant intraarticular pathologies. Especially patients whose condition precludes prolonged bedrest and who are at risk of significant deterioration if their locomotor function cannot be restored rapidly are likely to benefit from hip arthroplasty. The choice of the surgical technique mainly depends on the surgeon’s preferences and the fracture characteristics. Bipolar hemiarthroplasty is the most common type of prosthesis used with primary or revision femoral stems. Compared with intramedullary nails, hip arthroplasty has a better early functional outcome and lower rates of surgical complications as well as reoperations. However, the functional outcome and the mortality rate in the longer term tend to favor intramedullary nails, even though the results are inconsistent, and a statistically significant difference cannot always be obtained. Currently, there are no guidelines that define the role of hip arthroplasty in the treatment of intertrochanteric femur fractures in older patients. The literature only offers an overview of the possibilities of the usage of hip arthroplasty, but methodological limitations are common, and evidence levels are low. Further studies are needed to identify the intertrochanteric fractures that are at high risk of internal fixation failure, the characteristics that determine which patients may benefit most from hip arthroplasty, and the optimal surgical technique.

[Endoprosthetic treatment of pertrochanteric femoral fractures with concomitant coxarthrosis : A consecutive observational study with a control group]

INTRODUCTION

Hip replacement for pertrochanteric femoral fractures (PF) is challenging due to its complexity. Studies regarding this procedures are limited, therefore this monocentric study was conducted. The null hypothesis was no effect between replacement and internal fixation according to revision and mortality.

MATERIAL AND METHODS

Using an electronic database, patients who had received a hip replacement between 2007 and 2016 for a PF with a concomitant coxarthrosis were included in the study. The comparison group consisted of 1000 osteosyntheses for the treatment of PF. With the exception of coxarthrosis, the same inclusion and exclusion criteria were defined. Surgical revision and mortality with endpoint 2 years after the operation were the primary outcomes. At least 2 years postoperatively, a telephone follow-up was done with living patients who underwent replacement.

RESULTS

Records of 90 hip replacements and 15 baseline characteristics were reviewed (e.g., age, sex, body mass index, preoperative blood values, ASA classification, dementia, fracture classification). Replacement was significantly associated with a delay to operation (p < 0.001), a longer duration of operation (p < 0.001), an increased blood loss (p < 0.001), more blood transfusions (p < 0.001), and a longer inpatient stay (p = 0.026). According to the primary outcome, the mortality rate (p = 0.002) and the rate of infection in a subgroup analysis (p = 0.031) were also significantly increased. Using Cox regression, replacement was associated with a significantly higher probability of a shorter survival rate (odds ratio: 1.438, confidence interval: 1.054-1.962). Therefore, the null hypothesis was rejected. At the follow-up 6.1 years postoperatively (3.2-8.6 years), only 17 patients with replacement (20%) were still alive. The mean Parker mobility score was 5.0 points (range 3-9 points).

CONCLUSION

In this study, a significantly higher rate of infection and mortality was observed in patients with hip replacement for a PF and with a concomitant coxarthrosis; compared to osteosynthesis of PF without coxarthrosis. Further studies are mandatory to provide the appropriate treatment for patients with this fracture pattern.

Analysis of factors among 30-day and 1-year mortality rates in patients with borderline stable-unstable intertrochanteric hip fracture

OBJECTIVE

This study aimed to evaluate the possible effects of surgical procedures on mortality and to identify the possible risk factors for mortality in the management of geriatric hip fractures.

METHODS

A total of 191 patients (105 women and 86 men; mean age 82.26±9.681 [60-108] years) with AO/OTA 31A2.2 intertrochanteric fractures and treated with sliding hip screw, proximal femoral nail, or hemiarthroplasty were included in this retrospective cohort study. The treatment type was decided by the responsible surgeon according to the patients' pre-injury activity level, bone quality, and features of the fracture. Age, sex, type of fracture, type of surgery performed, American society of anesthesiology (ASA) grade, type of anesthesia, time to surgery, type of physical therapy, length of hospital stay, and number of comorbidities were documented. We evaluated the 30-day and 1-year mortality of patients treated with sliding hip screw (SHS), proximal femoral nail antirotation (PFN-A), or hemiarthroplasty and identified the possible risk factors for mortality.

RESULTS

A total of 49 patients underwent SHS, 58 underwent PFN-A, and 84 underwent hemiarthroplasty. Of these, 2 patients with SHS, 2 with PFN-A, and 11 with hemiarthroplasty died within 30 days after surgery, whereas 7 patients with SHS, 15 with PFN-A, and 23 with hemiarthroplasty died 1 year after surgery. The 30-day and 1-year overall mortality rates were 7.9% and 23.6%, respectively. Both the 30-day and 1-year mortality risks were higher in patients undergoing hemiarthroplasty than in patients undergoing SHS (p=0.068 versus 0.058). The 30-day mortality was higher in patients receiving general anesthesia than in those receiving combined spinal and epidural anesthesia (p=0.009). The 1-year mortality risk was higher in patients with ASA grade 4 than in those with grade 1 and 2 (p=0.045). Advanced age (p=0.022) and male sex (p=0.007) were also found to be the risk factors for 1-year mortality.

CONCLUSION

We demonstrated that higher ASA grade, male sex, general anesthesia, and hemiarthroplasty procedures are associated with higher mortality rates in elderly patients with hip fractures. Thus, we highly recommend orthopedic surgeons to consider all these factors in the management of intertrochanteric hip fractures in the geriatric population.

LEVEL OF EVIDENCE

Level IV, Prognostic Study.

The Role of Stem Modularity in the Failure of Internal Fixation in Geriatric Patients With Distally Fixed Hemiarthroplasty

The aim of this study was to compare the radiological and clinical outcomes of the same make of modular and monoblock tapered fluted stems in patients with failure of internal fixation following osteoporotic intertrochanteric fracture. This retrospective, comparative study included patients older than 65 years who underwent hemiarthroplasty with a modular or monoblock distally fixed fluted stem and had failed treatment with proximal femoral nailing between 2012 and 2017, with at least a 2-year follow-up period. Radiographic and clinical evaluations of the groups were compared. The modular group comprised 22 males and 18 females with a mean age of 85.05±7.1 years, and the monoblock group comprised 27 males and 17 females with a mean age of 83.27±7.0 years. No significant difference was observed between the groups regarding the preoperative and final-visit Harris Hip Score and Parker and Palmer Mobility Score values (P>.05 for both). More patients showed osseous restoration in the monoblock group, but not to a significant level. The groups were similar regarding mortality rates. Stem length was greater in the modular group, but the proximal femoral part and stem size were similar in the groups (P<.05 for all). Canal filling at levels A, B, and C was negatively correlated (weak) with the proximal femoral bone restoration (P<.001 for all). Canal filling at level B was negatively correlated (weak) with the stress shielding of the femur (P<.05 for all). When comparing the modularity of the stem by minimizing the variations of both prostheses, such as brand and geometric design, there was no significant difference in either clinical or radiological evaluations. [Orthopedics. 2021;44(1):e119-e124.].

Medical and economic consequences of perioperative complications in older hip fracture patients

Patients suffering from complications during inpatient treatment after hip fracture surgery are associated with a worse mid-term outcome. While surgically treatable complications only delay the healing process, internal complications seem to worsen the outcome in the long run. All complications come with significant increased costs during the hospital stay.

PURPOSE

Due to the demographic changes, the importance of hip fractures is still increasing nowadays. Not only surgical but also medical complications represent a major challenge in the treatment of those patients. Nevertheless, only few is known about the functional, medical, and economic consequences of complications.

METHODS

A total of 402 hip fracture patients ≥ 60 years were observed prospectively at a German university hospital. Complications were assessed during the inpatient stay and classified by Clavien and Dindo. Afterwards their influence on acute care costs was examined as well as their influence on the mortality, health-related quality of life (HRQL) (EQ5D), functional capacities (Barthel index), and mobility (Tinetti score) in the follow-up periods of 6 and 12 months.

RESULTS

Complications that required surgical revision/treatment (type III) were associated with an increased 6 months' mortality, while type II and IV complications did not influence mortality after 6 and 12 months. Six months after surgery, HRQL, Barthel score, and Tinetti score were reduced in patients suffering from all different types of complications. After 12 months however, HRQL, Barthel score, and Tinetti score following type II and IV complications remained reduced, while the scores improved in patients suffering from type III complication. All types of complications led to significantly increased acute care costs.

CONCLUSIONS

The results of the present study emphasize the crucial role of perioperative complications in older patients with hip fractures. Therefore, special attention has to be given to the prevention of those complications, e.g., with orthogeriatric treatment models, which have been shown to be effective in the reduction of complications.

Primary Cementless Bipolar Long Stem Hemiarthroplasty for Unstable Osteoporotic Intertrochanteric Fracture in the Elderly Patients

BACKGROUND

Intertrochanteric fracture (ITF) is a major part of fracture in femoral head fracture. 95% of ITF are found in elderly patients. Osteosynthese is the preferred method of choice. However, elderly patients had osteoporotic, combined with many of chronic disease conditions that increase the rate of osteosynthese failure. Hemiarthroplasty bipolar long-stem is a surgical method that helps patients relieve pain, facilitate early rehabilitation, limit long-term complications, and improve quality of life for patients.

AIM

The aim of our study is to evaluate the clinical of result of primary cementless bipolar long stem hemiarthroplasty in treatment for unstable ITF in the elderly patients who have severe osteoporosis.

METHODS

Between 01/2016 and 12/2017, 35 patients with ITF type A2.2 and A2.3 (AO) were included in our prospective study. These patients were over 70 years old and treatment by hemiarthroplasty cementless long stem at E hospital and Saint Paul hospital by one group surgeons.

RESULTS

Mean age of studied subjects was 84.29 ± 6.17, the lowest was 71, the highest was 96; ratio male/female was 1/4. Follow-up of 35 patients for at least 6 months showed 88.6% caused by a low-energy injury; Average rehabilitation time was 4.63 ± 1.7 days. The average Harris point at the end was 90.4 ± 4.72.

CONCLUSION

Primary cementless bipolar long stem hemiarthroplasty is one of good choices in treatment unstable ITF in elderly patients with severe osteoporosis helped patients improve the quality of life.

Predictors of long-term survival after hip fractures?-5-year results of a prospective study in Germany

The incidence of hip fractures is increasing due to demographic transition. Data on long-term survival and influencing factors are sparse. Our prospective observational study with 395 patients shows a survival of 38% after 5 years. Significant risk factors were male gender, higher age, lower Barthel Index, lower Charlson Comorbidity Score, lower Mini-Mental State Examination, and delirium during hospitalization.

PURPOSE

The incidence of hip fractures is increasing due to demographic transition. Until now, they are associated with poor results and high mortality rates. Data on long-term survival and influencing factors are sparse. Therefore, a prospective observational study was conducted.

METHODS

Patients ≥ 60 years with hip fracture were included in this prospective study between 2009 and 2011. Demographic parameters, as well as ASA Score, pre-fracture Barthel Index and EQ-5D, Mini-Mental State Examination, Charlson Comorbidity Score, fracture type, type of surgical treatment, place of discharge, and arising complications were registered. Outcome parameter was survival during a 5-year follow-up period.

RESULTS

A total of 539 patients attended to our emergency room during the period of recruitment. The recruitment rate was 75%. A total of 402 patients were included; 7 were lost to follow-up, and 152 (38%) survived the study period. The mortality was more than 25% in the first year after fracture. Subsequently, it was between 7 and 9% per year. In the multivariate analysis, significant risk factors for dying were male gender (p = 0.002), higher age (p < 0.001), lower Charlson Comorbidity Score (p = 0.033), lower Barthel Index (p = 0.024), lower Mini-Mental State Examination (p = 0.002), and occurrence of delirium during hospitalization (p = 0.008).

CONCLUSION

Our results confirm poor results of geriatric patients after hip fracture. While early results might be influenced by optimal fracture care, long-term results seem to be determined by not changeable patient factors. Nevertheless, more than one third of surviving patients after 5 years justify the elaborate treatment algorithms for these fragile patients.

High comorbidity index is not associated with high morbidity and mortality when employing constrained arthroplasty as a primary treatment for intertrochanteric fractures in elderly patients

AIM

The aim of our study is to investigate the results of constrained total hip arthroplasty as a primary treatment of intertrochanteric fractures (ITF) in elderly patients with high comorbidities.

MATERIALS AND METHODS

Total hip replacement (THR) with a retentive cup was performed on 73 patients with ITF over the age of 54 years who had high comorbidities and a Charlson score above five. Short- and long-term complications were determined by follow-up. Bivariate analysis was conducted in order to determine the possible determinants of mortality and factors associated with comorbidity as measured by the Charlson comorbidities index.

RESULTS

Patient demographics that consisted of females (58.9%) (p < 0.04) with the mean age of both males and females demonstrated no statistical significance. The mean hospitalization time and weight bearing time were 11 and 2.67 days, respectively. Only 4.1% needed re-intervention due to re-fracture and none due to prosthesis failure. There was a statistical significance between the comorbidity index and the mortality rate. However, no statistical significance was identified between the comorbidity index and the functional status after constrained THR.

CONCLUSION

High comorbidity index is not associated with high morbidity and mortality when employing constrained arthroplasty as a primary treatment for ITF in elderly patients.

Evaluating Postoperative Complications and Outcomes of Orthopedic Fracture Repair in Nonagenarian Patients

Introduction:

The United States and the world are currently experiencing a tremendous growth in the elderly population. Moreover, individuals surpassing the ages of 80 and 90 are also continuing to increase. As this unique division of society expands, it is critical that the medical community best understands how to assess, diagnose, and treat this population. The purpose of this study was to analyze morbidity, mortality, and overall outcome of patients aged 90 years and older after orthopedic surgical fracture repair. Such knowledge will guide patients and their families in making decisions when surgery is required among nonagenarians.

Methods:

The trauma registry of our level I academic medical center was queried to identify potential study participants over the past decade. Two hundred and thirty-three surgical procedures among 227 patients were included and retrospectively assessed. Parameters of specific interest were injury type, mechanism of injury (including high energy vs low energy and height of falls), injury severity score, preoperative comorbidities, postoperative complications, length of hospital stay, discharge destination, and postoperative mortality rate.

Results:

Overall, 4.3% of the cohort died in the hospital following surgery. Of the patients who survived, 89.7% were discharged to a professionally supervised setting. The nonagenarian population displayed a considerable follow-up rate, as 82.8% of individuals returned for their first postoperative office visit.

Discussion:

Historically, surgical morbidity and mortality are highly associated with this age group. However, the number of nonagenarians in the United States is increasing, as are these surgical procedures. The epidemiologic and clinical findings of our study support this trend and add further insight into the matter.

Conclusion:

This investigation demonstrates that orthopedic surgery is an appropriate treatment in this population with an acceptable complication rate. Furthermore, nonagenarians have the potential to demonstrate a substantial follow-up rate, but postoperative discharge to a professionally supervised setting may be necessary.

What Are the Determinants of Mortality After Cemented Bipolar Hemiarthroplasty for Unstable Intertrochanteric Fractures in Elderly Patients?

BACKGROUND

Primary hemiarthroplasty is proposed for the treatment of unstable intertrochanteric fractures in elderly patients with the advantages of early mobilization, acceptable functional results, and lower failure rates. The 1-year mortality rates demonstrated high variance in the literature, whereas, the factors related to 1-year mortality were not widely investigated. The main purpose of the present study was to determine predictive factors related to 1-year mortality after primary cemented calcar-replacement bipolar hemiarthroplasty performed for unstable intertrochanteric fracture.

METHODS

One hundred six patients with the mean age of 80.7 years were included in this retrospective study. Age, gender, body mass index, comorbid diseases, American Society of Anesthesiologists score, total hospitalization time, time from injury to surgery, operation time, estimated blood loss, postoperative mobilization time, and decrease in Koval ambulatory categories were evaluated. Univariate and multivariate analyses were performed to determine major predictors of 1-year mortality. The Kaplan-Meier survival analysis was used to construct the cumulative survival rate.

RESULTS

Three or more American Society of Anesthesiologists scores, presence of ≥3 comorbid diseases, and postoperative mobilization time of ≥2 days were significantly correlated with 1-year mortality. Presence of ≥3 comorbid systemic diseases was identified as the major predictive factor for 1-year mortality. The overall 5-year cumulative survival rate was 5.6%.

CONCLUSION

Having three or more comorbid systemic diseases has been detected as the major determinant of 1-year mortality after primary cemented calcar-replacement bipolar hemiarthroplasty performed for unstable intertrochanteric fracture in elderly patients.

Proximal femoral nail antirotation versus hemiarthroplasty in the treatment of senile intertrochanteric fractures: Case report

•

PFNA is an effective method in treating senile intertrochanteric fractures with low rates of internal fixation failure and related reoperation.

•

Hemiarthroplasty in treating these fractures is associated with greater surgical trauma and higher incidence of postoperative medical complications.

•

Hip arthroplasty should be used as a salvage procedure for internal fixation failure in treating senile intertrochanteric fractures.

Background

Primary hemiarthroplasty was recommended by some surgeons as the preferred choice in treating unstable senile intertrochanteric fractures with osteoporosis. However, many studies reported that proximal femoral nail antirotation (PFNA) currently was as an optimal implant for the treatment of different type of intertrochanteric fractures. Which method is better for treating senile intertrochanteric fractures remains controversial due to the insufficient clinical evidences.

Methods

We reviewed all consecutive senile intertrochanteric fractures treated with PFNA or cemented hemiarthroplasty at our institution between July 2010 and March 2015. The primary outcome measures were postoperative complications, reoperation rate and hip function. The secondary outcome measures were intraoperative blood loss, transfusion rate, surgical time, postoperative hemoglobin, hospital stay and 1- year mortality.

Results

Seventy-one patients in PFNA group and 52 patients in hemiarthroplasty group were included for analysis. There were no significant differences between the two groups regarding to the orthopaedic complications, reoperation rate, surgical time and Harris Hip Score at 1 year follow-up. Significant differences were found between PFNA and hemiarthroplasty group in comparison of intraoperative blood loss (P < 0.001), transfusion rate, medical complications (P = 0.037) and hospital stay (P = 0.001). Patients treated with hemiarthroplasty had a trend of higher postoperative 1- year mortality compared to those underwent PFNA but this was statistically not significant (P = 0.134).

Conclusions

These findings indicate that PFNA has obvious advantages over hemiarthroplasty in the treatment of senile intertrochanteric fractures. Hemiarthroplasty in treating these fractures is associated with greater surgical trauma and higher incidence of postoperative medical complications.

Comparison of intramedullary fixation and arthroplasty for the treatment of intertrochanteric hip fractures in the elderly: A meta-analysis

BACKGROUND

More and more studies conduct to compare intramedullary fixation (IMF) with arthroplasty in treating intertrochanteric hip fractures, but it remains controversy. The aim of this meta-analysis was to find out whether IMF or arthroplasty was more appropriate for treating intertrochanteric hip fractures in elderly patients.

METHODS

Relevant studies were searched in the electronic databases of PubMed, Embase, and The Cochrane Central Register of Controlled Trials from January 1980 to September 2016 with English language restriction. Surgical information and postoperative outcomes were analyzed using RevMan 5.3 version.

RESULTS

A total of 1239 patients from 11 studies which satisfied the eligibility criteria were included. Compared with IMF, the use of arthroplasty reduced implant-related complications (odds ratio [OR]: 2.05, P = .02) and reoperation rate (OR: 7.06, P < .001), and had similar length of hospital stay (weighted mean difference [WMD]: -0.41, P = .63). However, IMF reduced blood loss (WMD: -375.01, P = .001) and transfusion requirement (OR: 0.07, P < .001), shorter operation time (WMD: -18.92, P = .010), higher Harris hip score (WMD: 4.19, P < .001), and lower rate of 1-year mortality (OR: 0.67, P = .02) compared with arthroplasty.

CONCLUSION

The main treatment of intertrochanteric hip fractures is internal fixation using IMF. In the absence of concrete evidence, arthroplasty should be undertaken with caution in carefully selected patient and surgeon should be aware of the increased complexity of doing the arthroplasty in these elderly patients. Further high-quality randomized controlled trials (RCTs) are needed to provide robust evidence and evaluate the treatment options.

Comparison of Post-Operative Muscular Strength Between Gamma Nailing and Hemiarthroplasty System in Femoral Intertrochanteric Fractures

Background:

The current study focuses on the comparison of postoperative muscular strength around the hip joint of patients with femoral intertrochanteric fractures treated either by cephalo-medullary (CM) nailing or a new bipolar hip prosthesis (BHP), an especially attached device to secure displaced greater trochanteric fragment.

Methods:

Twenty patients treated with CM nailing were age- and sex- matched with a control group of 20 patients treated with BHP. Maximum isometric forces at the bilateral hip joint were measured during the follow up period. Means of 3 measurements were represented.

Results:

The mean and standard deviation values (kg) of muscle strength at the non-operative/ operative side in the CM nailing group were as follows: flexion strength 9.5±4.7/8.5±4.9 (P=0.06), extension strength 6.2±3.5/5.5±3.7 (P=0.08), abduction strength at 0 degrees 7.7±3.5/6.2±2.8 (p=0.002), abduction strength at 10 degrees 5.5±2.0/4.2±2.0 (p=0.001). In the BHP group, mean and standard deviation values of muscle strength at the non-operative/ operative side were as follows: flexion strength 6.5±2.8/6.0±3.4 (P=0.08), extension strength 4.4±0.9/4.4±0.6 (P=0.83), abduction strength at 0 degrees 5.1±1.9/5.0±1.6 (p=0.12), and that at 10 degrees 4.7±1.4/4.6±1.3 (p=0.10).

Conclusion:

Our results demonstrate that CM nailing may cause a 25-30% decrease in postoperative muscle strength around the hip joint, particularly during hip abduction. With the new BHP, greater trochanter reduction is achieved allowing early weight bearing and maintaining strength in abduction. Surgeons should consider postoperative muscular strength as one of the necessary factors for selection of the appropriate surgical procedure.

Level of Evidence:

Therapeutic Level III.

Early Clinical Efficacy Comparison Study of Gamma3 Nail, Percutaneous Compression Plate (PCCP) and Femoral Head Replacement (FHR) Treatment on Senile Unstable Intertrochanteric Fractures

PURPOSE

This study aimed to analyze the early clinical efficacy of Gamma 3 nail, percutaneous compression plate (PCCP) and femoral head replacement (FHR) treatments on senile unstable intertrochanteric fractures.

MATERIALS AND METHODS

Totally 116 patients were included to perform an retrospective study, which involved analysis of the operation time, intraoperative blood loss, and hemoglobin reduction on the first postoperative day compared with preoperative levels, fracture gap, neck shaft angle and tip apex distance on the first postoperative X-ray, hospital stay, time from surgery to mobilization, Harris hip scores and Barthel index six months after operation, and complications postoperative meanwhile were evaluated respectively among three groups.

RESULTS

The Harris hip score and Barthel index and time from surgery to mobilization after FHR treatment were superior to another two surgical methods, but had more blood loss and greater hemoglobin reduction. The mean PCCP hemoglobin reduction was notably shorter than that of the other two groups. Gamma 3 treatment had a lower operation time and blood loss than those treated with PCCP and FHR.

CONCLUSIONS

Gamma 3 and PCCP treatments are a priority for senile unstable intertrochanteric fractures if patients are in good health and perform fair activities of daily living prior to the operation, but had a significantly longer mobilization time than that in FHR. Therefore, considering the senile patients who unable to tolerate long immobilization time, FHR treatment is a considerable choice for faster recovery of independent function and achieve a good clinical efficacy as well as improve quality of life.

Efficacy of Kirschner-wires and tension band in hip arthroplasty for aged patients with unstable intertrochanteric osteoporotic fracture: A 2-to-11-year follow-up

The aim of this study was to evaluate the efficacy of supplementary fixation in hip arthroplasty with the use of Kirschner-wires and tension band for geriatric patients suffering unstable intertrochanteric osteoporotic fractures. A total of 103 patients aged more than 75 years were recruited. A bipolar or total hip replacement was performed with additional application of Kirschner-wires and tension band, and the participants were followed up for 2 to 11 years. Physical component summary (PCS), mental component summary (MCS), visual analog scale (VAS), and Harris hip score were utilized to evaluate patients' hip pain and function, as well as the mental condition postoperatively after 1.5 months, 3 months, 6 months, 1 year, and annually thereafter until the latest follow-up in 2015. Patients showed a significant improvement in all scores between 1.5 months and 1 year (P < 0.001), with the good efficacy lasting at least until the 2-year follow-up. None of the patients showed dislocation, implant loosening, or nonunion of the fracture throughout the follow-up period. In conclusion, it was beneficial to treat unstable intertrochanteric osteoporotic fractures in aged patients with hip arthroplasty coupled with Kirschner-wires and tension band.

Hip Arthroplasty for Treatment of Atypical Femoral Fracture with Pre-existing Hip Osteoarthritis

A 72-year-old woman with bilateral hip dysplasia sustained atypical femoral fracture of the left subtrochanteric region. She underwent left total hip replacement with a long extensively porous coated femoral stem. The fracture healed with incorporation of the strut allograft after 8 months. A painful horizontal radiolucent line at the tip of the femoral stem was noted after 4 years, with resolution of symptoms after a period of protected weight bearing. We believe that total hip replacement for subtrochanteric atypical femoral fracture with pre-existing hip dysplasia is a feasible option and avoids a second operation for the treatment of osteoarthritis.

Is arthroplasty preferable to internal fixation for the treatment of extracapsular fracture of the upper femur in the elderly?

INTRODUCTION

Although internal fixation is the reference treatment for extracapsular fracture of the upper femur, indications for arthroplasty are broadening, especially in unstable comminutive fracture in fragile bone. The present study hypothesis was that arthroplasty reduces early mortality and morbidity and provides better recovery of autonomy in over-80 year-old patients than does internal fixation.

MATERIAL AND METHODS

A prospective multicenter study was conducted on 8 sites. Internal fixation was systematically used in 5 centers; arthroplasty was used systematically in 1 center, and reserved for unstable fracture in 2 centers. A total of 697 patients aged over 80 years (mean age, 85±5 years), presenting with extracapsular fracture, were included; 521 were treated by internal fixation and 176 by arthroplasty. Results were studied on multivariate analysis of ASA score, blood loss, transfusion, and also of treatment modality as an independent factor for early (first 6 months) mortality and morbidity (mechanical, general and nutritional complications) and functional outcome (autonomy and dependence).

RESULTS

Overall mortality was 19.2%. Autonomy deteriorated in 56% of patients alive at 6 months and dependence worsened in 44%. Two percent of those managed by internal fixation underwent revision for disassembly (n=8) or infection (n=1). Eight percent of those managed by arthroplasty underwent revision for dislocation (n=4), implant loosening (n=3) or infection (n=7). On univariate analysis, mortality was higher in the arthroplasty group (25%) than with internal fixation (17%; P=0.002), as were blood loss (425±286mL versus 333±223mL; P<0.0001), transfusion rate (61% versus 32%; P<0.0001) and infection (4% versus 0.2%; P<0.001). On multivariate analysis, however, treatment modality no longer showed impact on mortality or on morbidity and autonomy at 6 months. Nutritional status was better conserved at 6 months following arthroplasty, but dependence worsened. Poor preoperative autonomy, ASA score, and nutritional status and time to treatment were independent factors for mortality. Transfusion, associated with onset of mechanical complications, significantly increased dependence.

CONCLUSION

Type of treatment had little impact on mortality, morbidity or functional outcome. Differences seemed more related to preoperative functional and nutritional status.

LEVEL OF EVIDENCE

III, prospective case-control study.

Unstable intertrochanteric versus displaced femoral neck fractures treated with cementless bipolar hemiarthroplasty in elderly patients; a comparison of 80 matched patients

BACKGROUND

While hemiarthroplasty (HA) is considered the treatment of choice for displaced femoral neck (FN) fractures in elderly patients, HA has been partly performed as an alternative treatment option for unstable intertrochanteric (IT) fractures. However, there is a paucity of data regarding the risk and availability of HA for unstable IT fractures compared to HA for displaced FN fractures in elderly patients. Therefore, we performed this case-control study to determine whether HA for unstable IT fractures provides clinical results and survival comparable to HA for displaced FN fractures in elderly patients.

HYPOTHESIS

HA for unstable IT fractures in elderly patients provides clinical results and 1-year survival comparable to HA for displaced FN fractures in the same aging group.

MATERIALS AND METHODS

We identified 80 patients aged 75years or older, who underwent cementless bipolar HA for unstable IT fracture (AO/OTA type 31-A2.2/3 and A3.3). Their clinical results and 1-year survival were compared to the matched control group of 80 patients with displaced FN fractures (Garden type 3 and 4) treated with the same procedure. Perioperative results, postoperative complications, and 1-year survival were investigated between the two groups. Functional outcome was assessed by walking status and Harris hip score (HHS) 6months after surgery.

RESULTS

Operating time was significantly longer in the IT group than the FN group (97.3min [50 to 255] vs. 79.3min [40 to 175], P=0.016). However, the two groups did not significantly differ regarding perioperative results, such as total blood loss, transfusion, intraoperative fracture, length of hospital stay, and postoperative complication. No statistically significant differences in walking status and HHS were observed between the groups. No significant difference in cumulative survival was observed between the two groups (P=0.836), with a 1-year survival rate of 80% (95% confidence interval [CI], 71.8 to 87.5) in the IT group and 82% (95% CI, 73.1 to 89.4) in the FN group.

CONCLUSION

HA for unstable IT fractures in elderly patients showed clinical results and 1-year survival comparable to HA as the treatment of choice for displaced FN fractures in the same aging group.

LEVEL OF EVIDENCE

Level III, case-control study.

Risk factors for mortality in geriatric hip fractures: a compressional study of different surgical procedures in 785 consecutive patients

BACKGROUND

Only a little is known about whether type of surgical intervention has an effect on mortality of these patients. Our primary objective was to assess whether different type of surgical procedures has an effect on mortality among elderly patients with hip fracture. A secondary objective was to examine factors that are related to mortality in our patient population. Our hypothesis is that type of surgical procedure, especially external fixation, should have an influence on mortality outcomes.

METHODS

We included 785 patients age 65 years or older, with hip fractures. Operative treatment consisted of external fixation, internal fixation, total hip arthroplasty and hip hemiarthroplasty. Age, gender, type of fracture, type of surgery performed, American Society of Anesthesiology (ASA) grade, clinical comorbidities, anesthesia type, blood transfusion requirement, time to surgery, intensive care unit requirement, operation length and length of hospital stay and number of comorbidities were documented.

RESULTS

During the study period, 785 patients (262 male, 523 female) were included to study, Overall mortality rate was 37.2 % (292/785). Their age ranged between 65 and 100 years (mean 81). Surgery type Kaplan-Meier cumulative mortality curves suggested no significant difference between four different types of surgery groups (p = 0.064). Transfusion requirement was significantly lower in external fixation group comparing to other groups (p = 0.014). Cox regression analysis showed the number of comorbidities 2 and ≥ 3 (p = 0.0027, p = 0.015), transfusion requirement (p = 0.0001), ASA 4 (p = 0.016) to be significant predictors of mortality.

CONCLUSIONS

Transfusion requirement, ASA grade 4 and having more than two comorbidities are risk factors for mortality in geriatric hip fractures. Type of surgical intervention and fracture type had similar mortality rates in our patient population.

Comparison of treatment of unstable intertrochanteric fracture with different arthroplasty methods

Background:

Intertrochanteric femur fractures are elderly is very common and can be treated by different fixation methods such as internal fixation and arthroplasty. In our study, we investigated the correlation between the hemiarthroplasty treatment method and functional results.

Materials and Methods:

The study consists of 121 patients with intertrochanteric fractures and these patients are divided into three groups. Eighty-five were male and 36 were female. Group I was uncemented bipolar hemiarthroplasty patients, Group II was cemented bipolar hemiarthroplasty and Group III was cemented calcar preserving bipolar hemiarthroplasty. Mean follow-up period was 16 months. Harris hip score was used to evaluate functional outcome of the patients.

Results:

There were no significant differences between three groups when comparing the mortality rate in the 1^st month and 1^st year but all time mortality was proportionally lower in Group I comparing to the two other groups. There were no significant differences between three groups when comparing the functional results in 1^st month and 1^st year.

Conclusion:

In our study, uncemented bipolar hemiarthroplasty is a preferable treatment over the two other arthroplasty treatment model (cemented bipolar and calcar preserving) regarding to the mortality rate since there is no significant difference between. This conclusion needs further studies with greater number of patients.

Damage Control Orthopedics Management as Vital Procedure in Elderly Patients with Femoral Neck Fractures Complicated with Chronic Renal Failure: A Retrospective Cohort Study

Background

Chronic renal failure (CRF) predisposes to hip fractures in elderly patients, with high subsequent mortality. Selection and timing of the surgical procedure of such patients is a serious challenge. Many clinicians believe in earlier surgery as preferable and providing better outcomes. Damage control orthopedics (DCO) aids to adjust and optimize the overall condition of patients.

Methods

In 32 patients with femoral neck fractures complicated with CRF, we evaluated how the timing of the surgery determines the mortality rates if the DCO approach is applied. Preoperative ASA grading, POSSUM score, P-POSSUM score and DCO were carried out. Based on the assessment, timing of the surgery was ascertained.

Results

Of a total of 32 patients, twenty-nine patients were accepted for either early (< 48 hours; n = 18) or delayed (3–10 days; n = 10) surgery. Hip arthroplasty (total hip arthroplasty and hemiarthroplasty) was the principal surgery option. All patients survived operation and were followed up postoperatively with the average time of 30 days. Postoperative complications tended to occur at higher rates in the early vs. delayed surgery group (7/18 vs. 5/10). During follow up, a total of 3 patients died in both groups (2/18 in the early surgery and 1/10 in the delayed surgery group), mostly from multi-organ failures and acute respiratory distress syndrome. There was no significant difference in complication rates and Harris hip score between both groups.

Conclusion

In patients with femoral neck fracture complicated with CRF, delaying the surgery for several days does not increase the incidence of postoperative adverse events.

Calcar Preservation Arthroplasty for Unstable Intertrochanteric Femoral Fractures in Elderly

BACKGROUND

The treatment of unstable intertrochanteric fractures in elderly is still controversial. The purpose of this study is to present treatment strategies for unstable intertrochanteric fractures with hemiarthroplasty using standard uncemented collared femoral stems and at the same time preserving the fractured calcar fragment.

METHODS

Fifty-four patients aged 75 years or older with unstable intertrochanteric fractures were included in this prospective cohort study. All patients were treated with calcar preserving hemiarthroplasty using cementless collored femoral stems. Fractured calcar fragment was stabilized either by compaction between the implant and femur or fixed with cable grip system. Follow-up evaluations were performed at least 24 months and later. Palmer and Parker mobility score and visual analogue scale (VAS) pain score were assessed. We also analyzed radiographs of the operated hip at each follow-up visit.

RESULTS

The patients were 15 males and 39 females with a mean age of 81.3 years (range, 75 to 93 years). The average operative time was 86.6 minutes. The mean transfused blood units were 1.2 units. The average duration of hospital stay was 5.3 days. The preoperative mean mobility score was 6.20. This score was found to be 4.96 on postoperative third day and 5.90 at 24 months postoperatively. The results of the statistical analysis revealed significant increase in the mobility scores at each follow-up after three days. Radiological interpretation revealed no loosening in the cable-grip systems, and no significant subsidence (> 5 mm) of prosthesis was observed.

CONCLUSIONS

Calcar preservation arthroplasty is a good option for elderly patients with severe osteoporosis, frail constitution and the patients who are at higher risk for second operation due to unstable intertrochanteric fractures.

Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture

Thirty one patients were treated with salvage total hip arthroplasty (THA) for failed internal fixation of intertrochanteric fracture. After a mean follow-up of 47.5 months, all patients reported remarkable pain relief and return to ambulation. Twenty five patients had no pain, and 6 patients complained of residual trochanteric low-grade pain without compromise of activities. The Harris Hip score increased from a preoperative average of 28.4 points to a postoperative average of 85.6 points. All patients demonstrated successful bony union and five had Brooker I or II heterotopic ossification. Seven patients had intraoperative or early complications and were treated successfully. There was no infection, re-fracture, loosening, or revision for any reason. Salvage THA using non-modular cementless long-stem prosthesis represents an effective procedure after failed intertrochanteric fixation.

Is cemented bipolar hemiarthroplasty a safe treatment for femoral neck fracture in elderly patients?

OBJECTIVES

Controversy exists regarding the use of cement in hemiarthroplasty when treating a displaced femoral neck fracture in elderly patients. The primary hypothesis of this study was that the use of cement would afford better visual analog pain and activity scores in elderly patients.

METHODS

This study included 133 patients over 65 years of age admitted to our clinics from 2006 to 2012 for the surgical treatment of a displaced femoral neck fracture. All patients were treated via hemiarthroplasty. The patients (66 males, 67 females; mean age: 78.16 years; range: 60-110 years) were followed-up regularly. All patients were divided into one of two groups: group A was treated with cement; and group B without. Both groups were compared in terms of preoperative features (demographics and associated diseases), pre- and postoperative complications, mortality rates, pain and activity levels, and hip scores. Hospitalization time, average surgical duration, and time from fracture to operation were also recorded. Mean follow-up duration was 30.9 (range: 5-51) months.

RESULTS

We found no significant between-groups differences in terms of length of hospital stay, Harris Hip Score, complications, or follow-up mortality rates. Walking ability and pain scores were better in the cemented group in the early follow-up period. Duration of surgery and perioperative mortality rates were somewhat lower in the cementless group, but the difference was not statistically significant.

CONCLUSION

The use of cement during hip hemiarthroplasty in patients over 65 years of age had no negative impact on mortality or morbidity. Hemodynamic changes during cement application are important, but it is noteworthy that patients fitted with cemented endoprostheses had increased levels of activity and lower pain levels.

Salvage of failed hip osteosynthesis for fractures with modular hip prosthesis

BACKGROUND/PURPOSE

Treating options of failed internal fixation include revision fixation and salvage arthroplasty. The purpose of this study was to evaluate the results, complications and the final functional outcome associated with modular hip arthroplasty.

METHODS

Modular arthroplasty was performed in 11 patients due to failed treatment of peritrochanteric fracture. Each patient examination included Trendelenburg test, Harris Hip Score, SF-36, and X-rays of the hip. Examinations were recorded and a paired t test was applied for further statistic analysis.

RESULTS

Two years postoperatively, four patients referred no hip pain, seven patients claimed for slight or mild pain, and three patients presented with moderate pain. Statistical analysis revealed a statistically significant difference equally for Harris Hip Score and SF-36.

CONCLUSION

The use of modular stems during salvage arthroplasty can decrease the risk of intraoperative and postoperative complications. The final outcome for the patient is satisfactory with functional improvement of the hip.

The hip prosthesis in lateral femur fracture: current concepts and surgical technique

The third proximal femur fractures are divided into medial and lateral ones. For medial fractures already exists unanimity of thought for the choice of treatment that involves the prosthetic replacement of the hip joint in patients over 60 without indications to the synthesis. Regarding the lateral femur fractures this unanimity does not exist yet even if the majority of surgeons practice treatment with osteosynthesis. We want to highlight if there are any types of lateral fractures associated with patient's clinical condition in which it might be more useful to a prosthetic replacement with the aim of being able to allow a total load and earlier deambulation, reducing complications related to a possible patient immobilization.

How to Treat the Complex Unstable Intertrochanteric Fractures in Elderly Patients? DHS or Arthroplasty

BACKGROUND

Due to difficulty in obtaining anatomical reduction, management of the unstable intertrochanteric fractures in elderly osteoporotic patients is challenging. The purpose of this study is to compare the results of hip arthroplasty (total, hemi, or bipolar) with DHS in the elderly patients with unstable intertrochanteric fractures.

METHODS

We prospectively studied and followed-up 80 old patients with complex unstable intertrochanteric fracture from January 2007 to December 2010. Depending on the time of the patients' admission, we alternatively treated them by DHS and arthroplasty, and placed them in Groups A and B, respectively. We followed them up radiologically and also clinically by Harris Hip Score for more than 24 months. Statistical analysis was performed using SPSS version 11.5 for Windows.

RESULTS

The mean length of follow-up and age were 34.3±4.1 months (ranged; 24-59) and the 75.2±5.2 years (ranged; 58-96), respectively. Comparing Group A with B, demographic data, mean blood loss, duration of operation, time to walking and duration of hospital stay had no significant difference but overall device related complications were significantly higher in Group A. Functional scores were also higher in Group B, but this difference was not significant statistically. In both groups, the patients with Type A3 compared with Type A2, had more duration of surgery and blood loss.

CONCLUSIONS

Arthroplasty is an alternative treatment in elderly patients with unstable intertrochanteric fractures and can provide good and satisfactory clinical outcomes associated with low complication and mortality rates.

Treatment of recent trochanteric fracture in adults

Recent trochanteric fracture is frequent in adults, and mainly affects elderly patients who risk loss of independence. Treatment is surgical, of various sorts. Open reduction internal fixation (ORIF) with intra- or extra-medullary implants is the most frequent attitude in these fractures, which usually heal easily. In elderly patients, arthroplasty is an alternative of choice for some authors. These different treatment modalities are presented, focusing on technical details. Possible technical difficulties and the means of dealing with them are considered. Published results help in choosing the treatment most suitable for a particular type of fracture in a particular patient.

Artificial neural network models for predicting 1-year mortality in elderly patients with intertrochanteric fractures in China

The mortality rate of older patients with intertrochanteric fractures has been increasing with the aging of populations in China. The purpose of this study was: 1) to develop an artificial neural network (ANN) using clinical information to predict the 1-year mortality of elderly patients with intertrochanteric fractures, and 2) to compare the ANN's predictive ability with that of logistic regression models. The ANN model was tested against actual outcomes of an intertrochanteric femoral fracture database in China. The ANN model was generated with eight clinical inputs and a single output. ANN's performance was compared with a logistic regression model created with the same inputs in terms of accuracy, sensitivity, specificity, and discriminability. The study population was composed of 2150 patients (679 males and 1471 females): 1432 in the training group and 718 new patients in the testing group. The ANN model that had eight neurons in the hidden layer had the highest accuracies among the four ANN models: 92.46 and 85.79% in both training and testing datasets, respectively. The areas under the receiver operating characteristic curves of the automatically selected ANN model for both datasets were 0.901 (95%CI=0.814-0.988) and 0.869 (95%CI=0.748-0.990), higher than the 0.745 (95%CI=0.612-0.879) and 0.728 (95%CI=0.595-0.862) of the logistic regression model. The ANN model can be used for predicting 1-year mortality in elderly patients with intertrochanteric fractures. It outperformed a logistic regression on multiple performance measures when given the same variables.

Intramedullary nail versus extramedullary plate fixation for unstable intertrochanteric fractures: decision analysis

BACKGROUND

The best options of internal fixation for unstable intertrochanteric femoral fractures in elderly osteoporotic patients remain controversial. We determined whether intramedullary nail or extramedullary plate provides better treatment for unstable intertrochanteric fractures using a decision analysis tool that considers quality of life.

METHODS

A decision analysis model was constructed containing final outcome score and the probability of mortality within 1 year, infection, and mechanical complications. Final outcome was defined as health-related quality of life and was used as a utility in the decision tree. Probabilities were obtained by literature review, and health-related quality of life was evaluated by asking 30 orthopedic experts to complete a questionnaire. A roll back tool was used to determine the best surgical option, and sensitivity analysis was performed to compensate for decision model uncertainty.

RESULTS

The decision model favored intramedullary nailing in terms of quality of life. In one-way sensitivity analysis, intramedullary nailing was more beneficial than the extramedullary plating, when probability of mechanical complication after intramedullary nailing was below 0.258.

CONCLUSIONS

In terms of quality of life, the decision analysis model showed that intramedullary nailing was more beneficial for patients with an unstable intertrochanteric fracture.

Bipolar hemiarthroplasty compared with internal fixation for unstable intertrochanteric fractures in elderly patients

BACKGROUND

The optimal treatment for unstable intertrochanteric fractures in elderly patients remains controversial. We aimed to compare internal fixation and bipolar hemiarthroplasty for the treatment of unstable intertrochanteric fractures in elderly patients.

METHODS

124 patients aged over 70 years were enrolled into this study (64 internal fixations, 60 bipolar hemiarthroplasties). Patients were followed for two years, and had a clinical, radiological, and functional review at three, six, and twelve months as well as two years.

RESULTS

In the internal fixation group, the fracture reduction and internal fixation were regarded as satisfactory in 44 cases and unsatisfactory in 20 cases. Five patients in the internal fixation group (two with satisfactory results and three with unsatisfactory results) and three patients in the arthroplasty group died before the final two-year follow-up. Five patients in the internal fixation group who had unsatisfactory results suffered complications. At 24 months post-operation, patients who were treated satisfactorily with internal fixation had higher Harris scores, less pain, and better walking ability than those treated with hemiarthroplasty and unsatisfactory internal fixation.

CONCLUSIONS

Internal fixation with good reduction and fixation quality should be the preferred therapeutic method for elderly unstable intertrochanteric fractures, even when severe osteoporosis is present.

[Treatment results after cemented hemiprosthesis for care of unstable pertrochanteric femoral fractures in the elderly]

BACKGROUND

The optimal treatment strategy for unstable trochanteric fractures in the elderly is still controversial because of the frequent failure of osteosynthesis.

METHODS

A cohort of patients with unstable trochanteric fractures who were treated with cemented hemiarthroplasty and presented in our department during the period 2003-2009 was analyzed. Complications, reoperations, walking ability and full weight bearing were documented.

RESULTS

A total of 91 patients were included (mean age 87.7±6.8 years) and predominantly 31A2 fractures (89%) were treated. There were 3.3% reoperations in the cohort and the 30 day mortality was 5.5%. At least 1 general complication occurred in over 50% of the patients. However, 30% of the patients had lower urinary tract infections, disturbances of electrolyte balance or transitory psychotic symptoms. On average full weight bearing could be performed at 3.5 (±3) days after the operation.

CONCLUSION

Cemented hemiarthroplasty is a safe treatment strategy for unstable trochanteric fractures in the elderly, which allows early full weight bearing. Because of frequent general complications, more interdisciplinary units and centres of excellence are needed to handle this challenging cohort.