Trends in surgical management of femoral neck fractures in the United States

Comparison of the Reliability of Three Scoring Systems Used to Decide Whether to Apply Cement in Hip Arthroplasty Among Fracture Patients and the Effect of Surgical Experience: The Spotorno, Dorr, and Canal Flare Indices

BACKGROUND

No consensus has been reached regarding the best index to decide whether to use cement during hip replacement surgery. Therefore, this study compared the reliability of three frequently used scoring systems. The secondary purpose was to evaluate the effect of surgical experience on the decision to use cement.

METHODS

Anteroposterior radiographs of 60 hips were assessed by four orthopedic surgeons and four orthopedic residents. The observers were asked to make measurements using the Spotorno criteria, the Dorr index, and the canal flare index, and to decide whether to use a cemented or cementless femoral stem. The same X-rays were sent to all participants, in a different order, 4 weeks later, for a second evaluation. The SPSS software (version 24.0) was used for the statistical analysis. Intraobserver agreement was determined for all observers via the intraclass correlation coefficient (ICC), and interobserver reliability was calculated using the weighted kappa (κ) statistic.

RESULTS

The average age of the patients were 73.1 ± 12.1 years. Thirty-three (55%) patients were female and thirty-two (53.3%) had fractures on the right side. Intraobserver agreement was "excellent" for all participants according to the Spotorno criteria. The canal flare index had the lowest intra-observer agreement. The highest interobserver agreement was found using the Spotorno criteria.

CONCLUSION

The intra- and interobserver reliabilities of the Spotorno criteria were higher than those of the Dorr index and the canal flare index. The Spotorno criteria was more useful for deciding between cemented and un-cemented hip arthroplasty.

Nationwide Analysis of Lower Extremity Periprosthetic Fractures

BACKGROUND

Although the annual incidence of primary total joint arthroplasty is increasing, trends in the annual incidence of periprosthetic fractures have not been established. This study aimed to define the annual incidence of periprosthetic fractures in the United States.

METHODS

Inpatient admission data for 60,887 surgically treated lower extremity periprosthetic fractures between 2006 and 2015 were obtained from the National Inpatient Sample database. The annual incidence of periprosthetic fractures was defined as the number of new cases per year and presented as a population-adjusted rate per 100,000 US individuals. Univariable methods were used for trend analysis and comparisons between groups.

RESULTS

The national annual incidence of periprosthetic fractures presented as a population-adjusted rate of new cases per year peaked in 2008 (2.72; 95% confidence interval [95% CI], 2.39-3.05), remained stable from 2010 (1.65; 95% CI, 1.45-1.86) through 2013 (1.67; 95% CI, 1.55-1.8) and increased in 2014 (1.99; 95% CI, 1.85-2.13) and 2015 (2.47; 95% CI, 2.31-2.62). The proportion of femoral periprosthetic fractures managed with total knee arthroplasty revision remained stable (P_trend = .97) with an increase in total hip arthroplasty (THA) revision (P_trend < .001) and concurrent decrease in open reduction and internal fixation (ORIF) (P_trend < .001). Revision THA was significantly more costly than revision total knee arthroplasty (P = .004), and both were significantly more costly than ORIF (P < .001 for both).

CONCLUSION

The annual incidence of periprosthetic fractures remained relatively stable throughout our study period. The proportion of periprosthetic fractures managed with revision THA increased, whereas ORIF decreased. Our findings are encouraging considering the significant burden an increase in periprosthetic fracture incidence would present to the health care system in terms of both expense and patient morbidity.

Hemiarthroplasty vs Total Hip Arthroplasty for Femoral Neck Fractures: 2010-2017 Trends in Complication Rates

BACKGROUND

Optimal treatment of femoral neck fractures (FNFs) remains debated. Recent data suggest that total hip arthroplasty (THA) confers improved functional outcomes compared to hemiarthroplasty (HA) in active patients. However, temporal trends in complication rates between these treatments lack study.

METHODS

The National Surgical Quality Improvement Program database was retrospectively queried to compare differences between HA and THA over time (2010-2012, 2013-2015, and 2016-2017) in blood transfusions, operation time, major complications, minor complications, and 30-day readmission, among FNF patients aged ≥50 years. Analyses adjusted for age, gender, anesthesia type, smoking, body mass index, hypertension, bleeding disorder, steroid use, and American Society of Anesthesiologists classification.

RESULTS

In total, 16,213 patients were identified. THA was associated with higher transfusion rates in 2010-2012 (mean = 0.34 vs 0.28, P = .001) and 2013-2015 (mean = 0.21 vs 0.19, P = .002), but not in 2016-2017 (mean = 0.13 vs 0.14, P = .146). Operation time was significantly higher for THA across all periods (P's < .001), but declined over time. In recent years, THA was associated with less major (2016-2017: 5.4% vs 10.2%, P = .02; 2013-2015: 5.3% vs 10.3%, P < .001) and minor (2016-2017: 6.2% vs 9.8%, P = .02; 2013-2015: 7.2% vs 12.4%, P < .001) complications compared to 2010-2012 (major: 7.2% vs 10.6%, P = .87; minor: 12.6% vs 10.1%, P = .89). No differences in 30-day readmission were noted.

CONCLUSION

THA was associated with less major and minor complications in recent time periods compared to HA for the treatment of FNF, controlling for comorbidities. THA trends in transfusions and operation duration have improved over time compared to HA.

National trends in total hip arthroplasty for traumatic hip fractures: An analysis of a nationwide all-payer database

BACKGROUND

Hemiarthroplasty (HA) has traditionally been the treatment of choice for elderly patients with displaced femoral neck fractures. Ideal treatment for younger, ambulatory patients is not as clear. Total hip arthroplasty (THA) has been increasingly utilized in this population however the factors associated with undergoing HA or THA have not been fully elucidated.

AIM

To examine what patient characteristics are associated with undergoing THA or HA. To determine if outcomes differ between the groups.

METHODS

We queried the Nationwide Inpatient Sample (NIS) for patients that underwent HA or THA for a femoral neck fracture between 2005 and 2014. The NIS comprises a large representative sample of inpatient hospitalizations in the United States. International Classifications of Disease, Ninth Edition (ICD-9) codes were used to identify patients in our sample. Demographic variables, hospital characteristics, payer status, medical comorbidities and mortality rates were compared between the two procedures. Multivariate logistic regression analysis was then performed to identify independent risk factors of treatment utilized.

RESULTS

Of the total 502060 patients who were treated for femoral neck fracture, 51568 (10.3%) underwent THA and the incidence of THA rose from 8.3% to 13.7%. Private insurance accounted for a higher percentage of THA than hemiarthroplasty. THA increased most in urban teaching hospitals relative to urban non-teaching hospitals. Mean length of stay (LOS) was longer for HA. The mean charges were less for HA, however charges decreased steadily for both groups. HA had a higher mortality rate, however, after adjusting for age and comorbidities HA was not an independent risk factor for mortality. Interestingly, private insurance was an independent predictor for treatment with THA.

CONLUSION

There has been an increase in the use of THA for the treatment of femoral neck fractures in the United States, most notably in urban hospitals. HA and THA are decreasing in total charges and LOS.

The rising use of total hip arthroplasty for femoral neck fractures in the United States

BACKGROUND

We examined the trends in the treatment of femoral neck fractures with arthroplasty in the United States from 2004-2013.

METHODS

We used the National Inpatient Sample database in conjunction with codes from the International Classification of Diseases, Ninth Revision, to identify patients receiving hemiarthroplasty (HA) or total hip arthroplasty (THA) for the treatment of closed femoral neck fracture from 2004-2013. We evaluated the trend of these 2 treatments along with demographics, comorbidities, length of stay and same admission mortality.

RESULTS

Our study identified 1,059,414 patients who underwent arthroplasty for the treatment of femoral neck fracture. We found a 42% increase in the use of THA during the study period from 8.4% in 2004 to 12.9% in 2013. While the large majority of patients received HA (87.1%), there was an overall decline in the use of HA (89,132 in 2004 to 85,635 in 2013) and increase in the use of THA (8,177 in 2004 to 11,375 in 2013). Patients receiving THA were younger (mean age 74.7 THA vs. 80.4 HA, p < 0.001) with fewer comorbidities, higher likelihood of discharge to home (24% THA vs. 10% HA, p < 0.001) and lower inpatient mortality rates (1.5 % THA vs. 2.4 % HA, p < 0.001) in comparison to HA.

CONCLUSION

There has been a significant increase in the use of THA over the last decade. Patients receiving THA were younger and healthier with fewer comorbidities, less likely to sustain a same admission mortality and more likely to discharge to home in comparison to HA patients.

Sliding hip screws versus cancellous screws for femoral neck fractures: a systematic review and meta-analysis

PURPOSE

Both sliding hip screws (SHS) and cancellous screws are used in the surgical management of intracapsular femoral neck fracture. However, there is paucity of information as to which is the superior treatment modality. We performed this systematic review and meta-analysis study to compare the clinical outcomes of SHS and cancellous screws for the treatment of femoral neck fractures in adult patients.

METHODS

We searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL, up to December 2017. Randomized controlled trials (RCTs) directly comparing the clinical outcomes of SHS and cancellous screws for femoral neck fractures were retrieved with no language or publication year restrictions. Data retrieved included operative details, nonunion rate, avascular necrosis, reoperation, infection and mortality, hip pain, functional hip scores, and medical complications. These were pooled as risk ratio or mean difference (MD) with their corresponding 95% confidence interval (CI). Heterogeneity was assessed by Chi-square test.

RESULTS

Ten RCTs involving 1934 patients were included in the final analysis. The pooled estimate showed that the SHS group was associated with more intraoperative blood loss (MD = 110.01 ml, 95% CI [52.42, 167.60], p = 0.00002) than the cancellous screws. There was no significant difference in terms of operative time, postoperative hip function, nonunion, avascular necrosis, reoperation rate, infection, fracture healing, hip pain, medical complications, and mortality rate.

CONCLUSION

Based on our study, the cancellous screws group was associated with less intraoperative blood loss in comparison with the SHS group. No other significant differences were found between the two interventions.

Trends in the surgical treatment of pathological proximal femur fractures in the United States

BACKGROUND AND OBJECTIVES

Large scale data on the treatment of pathologic proximal femur fractures (PPFFs) are lacking. The purpose of this study was to evaluate trends in patient demographics, complication rates, and relative utilization rates of various techniques associated with PPFFs.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database was queried for PPFFs from 2009 to 2017. Patient demographics, 30-day complications, and utilization rates were recorded. Trends in these variables were determined over the study period.

RESULTS

Most patient demographics did not change during the study period. There were no trends toward decreasing rates of major complications (P = .82), reoperations (P = .65), non-home discharges (P = .17), readmissions (P = .07), or deaths (P = .75); transfusion rates significantly decreased (P < .001). Rates of hemiarthroplasty decreased (P = .03) and rates of intramedullary nailing increased (P = .001).

DISCUSSION

Despite advances in cancer therapeutics, the average PPFF patient has not significantly changed over the past decade. Similarly, most short-term outcomes after PPFF surgery have not improved, demonstrating a need for improved perioperative protocols. Finally, rates of IMN fixation are increasing while rates of HA are falling at NSQIP hospitals. Given that orthopedic oncologists favor endoprosthetic reconstruction in most cases, there may be a need for increased communication between orthopedic oncologists and other members of the orthopedic community treating PPFFs.

Hemiarthroplasty for Femoral Neck Fracture

Hemiarthroplasty is a common treatment for femoral neck fractures in the elderly population. The main complications are periprosthetic dislocation and infection, which potentially impact morbidity and quality of life and may contribute to mortality. This procedure can be technically demanding, and adequate closure of the capsule and soft tissue cannot be emphasized enough. One advantage of a bipolar prosthesis is that it can be easily converted to a total hip arthroplasty without replacing the femoral component and with approximately the same complication rates as a revision total hip arthroplasty. Cement should be used when the patient is osteoporotic or has a Dorr type-C canal because there is a significant reduction in risk of fracture. The addition of a collared stem is helpful if there is a crack in the calcar extending from the fracture. The procedure is as follows. (1) The patient is placed in the lateral decubitus position. (2) The surgical site is prepared and draped to above the iliac crest and mid-sacrum. (3) A posterior approach is utilized. (4) The hip is dislocated. (5) A cut is made at the femoral neck. (6) The implant is templated with the femoral head. (7) The femur is broached. (8) The trial implant is placed. (9) The femur is cemented. (10) Trial implants are removed and cement is placed. (11) The final stem implant is placed in 5° to 10° of anteversion. (12) The final head and neck implants are trialed and then placed. (13) Implant position and range of motion are tested. (14) The surgical wound is irrigated. (15) Short external rotators are repaired. The posterior approach, which is often used, is known for increased rates of dislocation. The rate of dislocation can be minimized with repair of the posterior capsule and posterior soft tissue. Proper placement of the implants is of the utmost importance to minimize complications. Other contributing factors that lead to dislocation are implant malpositioning and patient factors.

Trends in surgical treatment of femoral neck fractures in the elderly

Objective

To analyze recent demographic and medical billing trends in treatment of femoral neck fracture of American elderly patients.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2006 to 2015, for patients aged 65 years and older, using the Current Procedural Terminology codes 27130, 27125, 27235, and 27236. Patient demographics, postoperative complications, and frequency of codes were compared and analyzed over time. Our sample had 17,122 elderly patients, in that, 70% were female, mean age of 80.1 years (standard deviation±6.6 years).

Results

The number of cases increased, but age, gender, body mass index, rates of diabetes and smoking did not change over time. Open reduction internal fixation was the most commonly billed code, with 9,169 patients (53.6%), followed by hemiarthroplasty with 5,861 (34.2%) patients. Combined estimated probability of morbidity was 9.8% (standard deviation±5.2%), and did not change significantly over time. Postoperative complication rates were similar between treatments.

Conclusion

Demographics and morbidity rates in femoral neck fractures of elderly patients did not change significantly from 2006 to 2015. Open reduction internal fixation was the most common treatment followed by hemiarthroplasty.

[Effectiveness analysis of surgical treatment of ipsilateral femoral neck fracture and subtrochanteric fracture]

Objective

To discuss the effectiveness of intramedullary nail fixation with selective cable wiring in the treatment of ipsilateral femoral neck fracture and subtrochanteric fracture.

Methods

Between June 2012 and December 2015, a total of 19 patients with ipsilateral femoral neck fracture and subtrochanteric fracture underwent closed reduction of femoral neck fracture and intramedullary nail fixation combined with selective cable wiring. There were 5 males and 14 females with a median age of 52 years (range, 35-77 years). The cause of injury included traffic accident injury in 17 cases and falling injury in 2 cases. According to Garden classification for femoral neck fractures, 7 cases were rated as type Ⅱ, 8 as type Ⅲ, and 4 as type Ⅳ. Femoral subtrochanteric fractures were classified by Seinsheimer classification, with 9 cases as type Ⅱ, 5 as type Ⅲ, 3 as type Ⅳ, and 2 as type V. The interval from injury to operation ranged from 2 to 7 days with an average of 3.7 days.

Results

The operation time was 58-125 minutes (mean, 82.4 minutes) and the intraoperative blood loss was 225-725 mL (mean, 289.5 mL). All incisions achieved healing by first intention and no early complication such as infection was observed. All patients were followed up 12-18 months (mean, 13.9 months). At 1 month after operation, the tip apex distance was 9-23 mm (mean, 15.2 mm). All patients achieved bone union with the healing time of 18-42 weeks (mean, 27.4 weeks). One case of hip varus and femoral neck re-displacement (femoral neck shaft angle was 122°) occurred at 3 months after operation, which achieved bone union at 42 weeks after operation. Five patients complained of postoperative pain with the visual analogue scale (VAS) score of 1-3 (mean, 1.8), which did not influence normal life. A total of 16 patients recovered preoperative hip function. During follow-up, no fracture nonunion, femoral head necrosis, implant failure, screw cut-out, and loosening of cable wiring was observed. The Harris hip score (HSS) was 72-92 (mean, 82.8) at last follow-up and 15 patients (78.9%) achieved good hip function.

Conclusion

Intramedullary nail fixation combined with selective cable wiring was effective in the treatment of ipsilateral femoral neck fracture and subtrochanteric fracture.

Operative Trends in the Treatment of Hip Fractures and the Role of Arthroplasty

Introduction:

There is a projected exponential increase in the number of hip fractures in the United States. Trends in patient demographics and the role of total hip arthroplasty (THA) and its associated outcomes following hip fractures surgery have not been well studied.

Methods:

Patients with proximal femur fractures between 1990 and 2007 were identified in the National Hospital Discharge Survey database. Demographics, comorbidities, perioperative complications, and discharge status for patients undergoing THA, hemiarthroplasty, or internal fixation were examined. Multivariable regression was performed to determine independent risk factors for perioperative complications.

Results:

Between 1990 and 2007, there was a statistically significant increase in patient age, adverse events, medical comorbidities, surgical complications, medical complications, and nonroutine discharge across all surgical treatment modalities. In the same time period, the utilization of THA for all fracture types decreased significantly.

Discussion:

Total hip arthroplasty was found to be an independent risk factor for perioperative complications. Orthopedic surgeons should be aware that the hip fracture population continues to get older, with more medical comorbidities and are at higher risk for perioperative complications.

Conclusion:

Total hip arthroplasty is associated with a higher rate of perioperative complications in the hip fracture population.

Nationwide Analysis of Femoral Neck Fractures in Elderly Patients: A Receding Tide

BACKGROUND

Geriatric femoral neck fractures are associated with substantial morbidity and medical cost. We evaluated the incidence and management trends of femoral neck fractures in recent years in the U.S.

METHODS

Patient data from 2003 through 2013 were obtained from the Nationwide Inpatient Sample database. Femoral neck fractures in patients ≥65 years old were identified and grouped using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for internal fixation, hemiarthroplasty, or total hip arthroplasty (THA). The nationwide incidence of femoral neck fractures was calculated and presented as an age-adjusted population rate. Univariable methods were used for trend analysis and comparisons between groups. Logistic regression modeling was used to analyze complications.

RESULTS

From 2003 to 2013, we identified 808,940 femoral neck fractures in patients ≥65 years old. The national age-adjusted incidence of femoral neck fractures decreased from 242 per 100,000 U.S. adults in 2003 to 146 in 2013. The proportion of fractures managed operatively with THA increased over time (5.9% in 2003 versus 7.4% in 2013; p < 0.001). Concurrently, the use of hemiarthroplasty declined (65.1% versus 63.6%; p < 0.001). In 2013, the median age of the patients treated with THA was significantly younger (77.3 years) compared with that in the hemiarthroplasty and internal fixation groups (83.2 and 82.0 years). The THA group had significantly higher median initial hospital costs ($17,097) compared with the hemiarthroplasty and internal fixation groups ($14,776 and $10,462).

CONCLUSIONS

In the last decade, the total number and population rate of femoral neck fractures in the elderly declined significantly. There was a modest but significant increase in the utilization of THA.

CLINICAL RELEVANCE

This report identifies the changing trends in clinical practice in the treatment of geriatric femoral neck fractures in the U.S. Treating physicians should be aware of these trends, which include a decreasing national incidence of geriatric femoral neck fractures as well as an increase in the use of THA.

Intramedullary Fixation With Minimally Invasive Clamp-Assisted Reduction for the Treatment of Ipsilateral Femoral Neck and Subtrochanteric Fractures: A Technical Trick

The purpose of this study is to describe a surgical technique for intramedullary fixation and minimally invasive clamp-assisted reduction with selective cerclage wiring for the management of combined ipsilateral femoral neck and subtrochanteric fractures and to present the clinical outcomes in 17 patients after treatment using this technique.

Disparities in Total Hip Arthroplasty Versus Hemiarthroplasty in the Management of Geriatric Femoral Neck Fractures

Introduction:

Recent clinical evidence suggests that total hip arthroplasty (THA) provides improved clinical outcomes as compared to hemiarthroplasty (HA) for displaced femoral neck fractures in elderly individuals. However, THA is still utilized relatively infrequently. Few studies have evaluated the factors affecting utilization and the role socioeconomics plays in THA versus HA.

Methods:

In the United States, the National Inpatient Sample (NIS) database was used to identify patients treated surgically for femoral neck fracture, between 2009 and 2010. Patients were identified using International Classification of Diseases, Ninth Revision, codes for closed, transcervical femoral neck fractures and closed fractures at unspecified parts of the femoral neck. All candidate predictors of THA versus HA were entered into a multilevel mixed-effect regression model.

Results:

Older patient age, being Asian or Pacific Islander, and having Medicaid payer status were all associated with lower odds of receiving THA. Patients with private insurance including Health Maintenance organization (HMO) had higher odds of THA as did patients with other insurance. Odds of THA were significantly lower among patients in teaching hospitals and higher at hospitals with greater THA volume.

Discussion:

Ethnicity, payer status, hospital size, and institutional THA volume were all associated with the utilization of THA versus HA in the treatment of geriatric femoral neck fractures.

Level of Evidence:

Level III Retrospective Cohort study.

Relationship between socioeconomic status and mortality after femur fracture in a Korean population aged 65 years and older: Nationwide retrospective cohort study

Femur fracture is an emerging public health concern in aging societies, owing to the substantially high morbidity and mortality. Because the recent increase in femur fracture incidence in Asian populations is comparable to that in the West, it is necessary to investigate the association between socioeconomic status (SES) and mortality after femur fracture in developed Asian societies.Data were obtained from the National Health Insurance Claims Database. During 2002 to 2013, femur fractures were newly diagnosed in 5441 patients among 1025,340 enrollees. Multiple logistic regression and the Cox proportional model were used to investigate the associations between individual SES and probability of surgery and mortality after femur fracture.Of 5441 patients, 1928 (35.4%) received surgery. Patients with low (odds ratio [OR] = 0.87, 95% confidence interval [CI]: 0.75-0.99) and middle (OR = 0.85, 95% CI: 0.74-0.98) income were less likely to undergo surgery than high-income patients. Patients with low (hazard ratio [HR] = 1.12, 95% CI: 1.01-1.24) and middle (HR = 1.20, 95% CI: 1.08-1.33) income had a higher HR for mortality. This difference was more prominent in patients who underwent surgery (low income: HR = 1.07, 95% CI: 0.94-1.21; middle income: HR = 1.18, 95% CI: 1.04-1.33) than in patients with conservative treatment (low income: HR = 1.24, 95% CI: 1.04-1.49; middle income: HR = 1.30, 95% CI: 1.08-1.56).Femur-fracture patients with low SES are less likely to receive surgery for and more likely to die after femur fracture. The difference in mortality risk remained even when only the patients who received surgery were considered, suggesting that we need to consider support measures for these deprived patients.

Is surgeons' experience important on intra- and inter-observer reliability of classifications used for adult femoral neck fracture?

PURPOSE

To evaluate whether surgeons' experience affect inter- and intra-observer reliability among mostly used classification systems for femoral neck fractures.

MATERIAL AND METHODS

A power point presentation was prepared with 107 slides which were antero-posterior radiographs of each femoral neck fracture. Five residents, 5 orthopaedic surgeons and 5 senior orthopaedic surgeons reviewed this presentation and classified the fractures according to Garden, Pauwels and AO classifications. The order of the slides was changed and reviews were repeated after 3 months. Fleiss kappa and intraclass correlation coefficient values were calculated to evaluate inter and intra-observer reliability.

RESULTS

Garden and AO classifications' inter-observer reliabilities were similar and higher than Pauwels classification. Among three experience groups, the inter-observer reliability for Garden classification was highest in senior surgeon group, the interobserver reliability for AO classification was highest in surgeon group, and interobserver reliability of Pauwels classification was highest in low experienced groups (residents and surgeons). Intra-observer reliability was highest for Garden and lowest for Pauwels classifications. Surgical experience was found to be not effective for intraobserver reliability.

CONCLUSION

Both Garden and AO classifications were more reliable than Pauwels classification. Surgical experience was not significantly important on these three classification systems' evaluation.

LEVEL OF EVIDENCE

Level IV, Diagnostic study.

Evaluation of Contemporary Trends in Femoral Neck Fracture Management Reveals Discrepancies in Treatment

Background:

Recent evidence supports total hip arthroplasty (THA) as compared to hemiarthroplasty (HA) for the management of displaced femoral neck fractures in a significant subset of elderly patients. The purpose of this study was to examine trends in femoral neck fracture management over the last 12 years.

Methods:

Using the National Inpatient Sample database, we identified patients treated for femoral neck fractures between 1998 and 2010 with THA, HA, or internal fixation (IF). We examined treatment trends and demographic variables including patient age, gender, socioeconomic status, and payer and hospital characteristics.

Results:

We identified 362 127 femoral neck fracture patients treated between 1998 and 2010. Overall, there were statistically significant increases in rates of THA and HA, whereas rates of IF decreased. Total hip arthroplasty varied based on patient age, with significant increases occurring in age-groups 0 to 49 years, 50 to 59 years, 60 to 69 years, and 70 to 79 years. Utilization of THA varied significantly based on socioeconomic status and race. Patient sex, urban versus rural hospital location, and teaching versus nonteaching hospital status were not related to rates of THA.

Conclusion:

Rates of THA for femoral neck fractures increased between 1998 and 2010 in patients younger than 80 years, suggesting that surgeons are responding to clinical evidence supporting THA for the treatment of elderly femoral neck fractures. This is the first study to demonstrate this change and expose disparities in practice patterns over time in response to this evidence in the United States. Further research is indicated to explore the effect of socioeconomic status and race on femoral neck fracture management.

Does Teriparatide Improve Femoral Neck Fracture Healing: Results From A Randomized Placebo-controlled Trial

BACKGROUND

There is a medical need for therapies that improve hip fracture healing. Teriparatide (Forteo(®)/ Forsteo(®), recombinant human parathyroid hormone) is a bone anabolic drug that is approved for treatment of osteoporosis and glucocorticoid-induced osteoporosis in men and postmenopausal women at high fracture risk. Preclinical and preliminary clinical data also suggest that teriparatide may enhance bone healing.

QUESTIONS/PURPOSES

We wished to test the hypotheses that treatment with teriparatide versus placebo would improve femoral neck fracture healing after internal fixation as measured by (1) frequency of revision surgery, (2) radiographic fracture healing, and (3) other outcomes including pain control, gait speed, and safety.

METHODS

We initiated two separate, but identically designed, clinical trials to meet FDA requirements to provide substantial evidence to support approval of a new indication. The two prospective, randomized double-blind, placebo-controlled Phase III studies were designed to evaluate the effect of subcutaneous teriparatide (20 μg/day) for 6 months versus placebo on fracture healing at 24 months. The trials were conducted concurrently with a planned enrollment of 1220 patients per trial. However, enrollment was stopped owing to very slow patient accrual, and an a priori decision was made to pool the results of those studies for statistical analyses before study completion; pooling was specified in both protocols. Randomization was stratified by fixation (sliding hip screw or multiple cancellous screws) and fracture type (displaced or nondisplaced). An independent Central Adjudication Committee reviewed revision surgical procedures and radiographs. A total of 159 patients were randomized in the two trials (81 placebo, 78 teriparatide). The combined program had very low power to detect the originally expected treatment effect but had approximately 80% power to detect a larger difference of 12% between treatment groups for risk of revision surgery.

RESULTS

The proportion of patients undergoing revision surgery at 12 months was 14% (11 of 81) in the placebo group versus 17% (13 of 78) in the teriparatide group. Central Adjudication Committee review excluded two of these patients treated with placebo from the primary analysis. After exclusions, the proportion of patients who did not undergo revision surgery at 12 months (primary endpoint) was not different between the study and placebo groups, at 88% in the placebo group (90% CI, 0.79-0.93) versus 84% in the teriparatide group (90% CI, 0.75-0.90; p = 0.743). There also were no differences between groups in the proportion of patients achieving radiographic fracture healing at 12 months (75% [61 of 81] placebo versus 73% [57 of 78] teriparatide; odds ratio, 0.89; 90% CI, 0.46-1.72; p = 0.692) or in measures of pain control (such as pain during ambulation, 92% [55 of 62] placebo versus 91% [52 of 57] teriparatide; odds ratio, 0.91; 90% CI, 0.25-3.37; p = 0.681). The frequency of patients reporting adverse events was 49% [40 of 81] in the placebo group versus 45% [35 of 78] in the teriparatide group (p = 0.634) during the 6-month treatment period.

CONCLUSIONS

The small sample size limited this study's power to detect potential differences, and the results are exploratory. With the patients available, teriparatide did not decrease the risk of revision surgery, improve radiographic signs of fracture healing, or decrease pain compared with the placebo. The adverse event data observed were consistent with the teriparatide safety profile. Functional and health outcome data from the studies may help improve our understanding of patients recovering from femoral neck fractures. Further large controlled studies are required to determine the effect of teriparatide on fracture healing.

LEVEL OF EVIDENCE

Level II, prospective study.

Clinical results of treatment of garden type 1 and 2 femoral neck fractures in patients over 70-year old

INTRODUCTION

We retrospectively analyzed the clinical results of treatment of impacted or undisplaced femoral neck fractures (Garden types 1 and 2) by osteosynthesis in elderly patients >70-year old.

MATERIALS AND METHODS

We retrospectively reviewed the radiological results of 52 patients who were followed up for at least 6 months from April 2002 to December 2008. The average age of the patients was 77.6 years (range 70-97 years), and 38 patients were females. The mean follow-up period was 11.7 months (range 6-19 months). Thirteen cases were Garden type 1 fractures, and 39 were Garden type 2 fractures. We assessed the relationships between the occurrence of complications and age, sex, Garden stage, bone mineral density (BMD), history of contralateral hip fracture, and any additional hip injury.

RESULTS

Major complications occurred in 18 cases (34.6 %), including nonunion (8 cases), osteonecrosis (6 cases), stress fracture of the subtrochanter (2 cases), excessive pull-out of a screw (1 case), and deep infection (1 case). The development of complications was associated with Garden stage 2, BMD, and additional hip injury. However, other factors were not associated with complications. Reoperations were performed in 16 cases (30.1 %), and 2 of the patients died during follow-up.

CONCLUSION

A relatively high rate of complications or reoperations developed after treatment of Garden 2 femoral neck fractures in senile patients >70 years of age with osteoporosis. Although internal fixation has been recommended in the literature for undisplaced femoral neck fractures, primary arthroplasty may be a better option for treatment of Garden type 2 fractures in elderly patients.

Changing trends in the treatment of femoral neck fractures: a review of the american board of orthopaedic surgery database

BACKGROUND

The purpose of this study was to investigate the trends in operative management of femoral neck fractures by orthopaedic surgeons applying for board certification.

METHODS

We queried the American Board of Orthopaedic Surgery database to identify all femoral neck fractures that had been treated and reported by candidates taking Part II of the licensing examination from 1999 to 2011 to determine the utilization of internal fixation, hemiarthroplasty, and total hip arthroplasty. The longitudinal trends were then stratified by patient age (younger than sixty-five, sixty-five to seventy-nine, eighty and older) and the declared subspecialty of the candidate.

RESULTS

There were 19,541 femoral neck fractures that had been treated by 4450 board certification candidates. The use of total hip arthroplasty increased over time (0.7% of fractures in 1999, 7.7% in 2011, p < 0.001); use of hemiarthroplasty (67.1% in 1999, 63.1% in 2011, p = 0.020) and internal fixation (32.2% in 1999, 29.2% in 2011, p = 0.064) declined slightly. All geographic regions showed an increase in utilization of total hip arthroplasty, with substantial variation between locations. The proportion of patients younger than age sixty-five who were managed with total hip arthroplasty increased from 1.4% to 13.1% (p < 0.001). Candidates with a declared subspecialty of "adult reconstruction" showed a strong trend toward the use of total hip arthroplasty (4.3% from 1999 to 2002, 21.1% from 2009 to 2011, p < 0.001), while "trauma" subspecialty candidates demonstrated decreasing utilization of internal fixation (40.9% from 1999 to 2002, 32.9% from 2009 to 2011, p = 0.012). The percentage of candidates treating at least one femoral neck fracture decreased from 54.8% from 1999 to 2002 to 46.3% from 2009 to 2011 (p < 0.001).

CONCLUSIONS

The most substantial changes in treatment of femoral neck fractures were seen in the younger group of patients. Currently, a smaller percentage of board certification candidates are treating femoral neck fractures than those in the past, possibly reflecting a trend toward specialty care.

Primary total hip arthroplasty versus internal fixation in displaced fracture of femoral neck in sexa- and septuagenarians

BACKGROUND

The optimal treatment of femoral neck fracture in the elderly patient is still under debate. In patients aged 60-80 years, the decision between internal fixation and arthroplasty remains controversial. The primary aim of the present study is to evaluate the functional outcome of patients aged 60-80 years with femoral neck fracture treated with total hip arthroplasty or closed reduction and internal fixation. The secondary aim is to evaluate the incidence of nonunion and avascular necrosis in femoral neck fracture in different age groups.

MATERIALS AND METHODS

We studied 100 patients affected by displaced fracture of the femoral neck from May 2007 through June 2010. There were 60 men and 40 women with mean age of 66 years. Fifty patients were treated with closed reduction and internal fixation with cannulated screws (group A), and the other 50 patients with total hip arthroplasty (group B). Mean surgical time, blood loss, duration of hospital stay, Harris hip score, complications, and need for reoperation were recorded.

RESULTS

Harris hip score was significantly higher in group B at 3-, 6-, 12-, and 18-month follow-up evaluation. The overall complication rate was 28 % in group A and 32 % in group B, which was not statistically significant. A statistically significant difference was found regarding patients who required reoperation in group A (20 %) compared with group B (no one). The average Harris hip score in the internal fixation group was 90.6 and in the total hip arthroplasty group was 93.7, which was statistically significant (p < 0.05). Our study showed an increased risk for intracapsular hip fracture developing nonunion with older age.

CONCLUSIONS

Primary total hip arthroplasty compared with internal fixation appears to be a reasonably safe method of treating displaced fracture of femoral neck in elderly patients. We also concluded that outcome regarding hip function is generally better after total hip arthroplasty compared with internal fixation.

LEVEL OF EVIDENCE

Level II-Prospective cohort study.

Computed tomographic evaluation of the proximal femur: A predictive classification in displaced femoral neck fracture management

BACKGROUND

Femoral neck fracture is truly an enigma due to the high incidence of avascular necrosis and nonunion. Different methods have been described to determine the size of the femoral head fragment, as a small head has been said to be associated with poor outcome and nonunion due to inadequate implant purchase in the proximal fragment. These methods were two dimensional and were affected by radiography techniques, therefore did not determine true head size. Computed tomography (CT) is an important option to measure true head size as images can be obtained in three dimensions. Henceforth, we subjected patients to CT scan of hip in cases with displaced fracture neck of femur. The study aims to define the term small head or inadequate size femoral head" objectively for its prognostic significance.

MATERIALS AND METHODS

70 cases of displaced femoral neck fractures underwent CT scan preoperatively for proximal femoral geometric measurements of both hips. Dual energy X-ray absorptiometry scan was done in all cases. Patients were treated with either intertrochanteric osteotomy or lag screw osteosynthesis based on the size of the head fragment on plain radiographs.

RESULTS

The average femoral head fragment volume was 57 cu cm (range 28.3-84.91 cu cm; standard deviation 14 cu cm). Proximal fragment volume of >43 cu cm was termed adequate size (type I) and of ≤43 cu cm as small femoral head (type II). Fractures which united (n = 54) had a relatively large average head size (59 cu cm) when compared to fractures that did not (n = 16), which had a small average head size (49 cu cm) and this difference was statistically significant. In type I fractures union rate was comparable in both osteotomy and lag screw groups (P > 0.05). Lag screw fixation failed invariably, while osteotomy showed good results in type II fractures (P < 0.05).

CONCLUSION

Computed tomography scan of the proximal femur is advisable for measuring true size of head fragment. An objective classification based on the femoral head size (type I and type II) is proposed. Osteosynthesis should be the preferred method of treatment in type I and osteotomy or prosthetic replacement is the method of choice for type II femoral neck fractures.

Trends of surgical treatment in femoral neck fracture: a nationwide study based on claim registry

We evaluated current trends of surgical treatment, such as internal fixation and hip arthroplasty, in femoral neck fracture. We assessed annual proportion of the each procedure in patients aged 50 years or more from 2006 to 2011, using the data of Health Insurance Review and Assessment Service (HIRA), which is a national claim registry. The proportion of hip arthroplasty increased while that of internal fixation decreased annually during the 5 years. The proportion of total hip arthroplasty increased in patients aged ≤ 65 years, and that of hemiarthroplasty increased in patients aged ≥ 65 years. The proportional increase of hip arthroplasty seemed to conform to the recent evidence regarding the outcomes of surgical treatments for the femoral neck fracture.

The natural history of the hemiarthroplasty for displaced intracapsular femoral neck fractures

BACKGROUND

Numerous papers have been published on the medium- and long-term results of hemiarthroplasties (HAs) after femoral neck fracture in the elderly. We were not aware of any articles that describe the outcome of HA until the patient dies.

METHODS

Between 1975 and 1989, 307 bipolar hemiarthroplasties were performed in 302 consecutive patients with a displaced femoral neck facture. Patients with osteoarthritis of the hip, rheumatoid arthritis (RA), or senile dementia were not included in the study. All patients were followed annually until they died or until they needed a revision operation.

RESULTS

The mortality rate was 28% after 1 year, and 63% after 5 years. The last patient who did not need a revision operation died in October 2010. Revision operations for aseptic loosening, protrusion, or both had to be performed in 34 patients (16%). A difference in reoperation rate was observed between patients less than 75 years of age (38%) and those who were older (6%).

INTERPRETATION

Apart from age below 75 years, male sex appeared to be predictive of a revision operation. HA is a safe and relatively inexpensive treatment for patients over 75 years of age with a displaced femoral neck fracture.

The trends in treatment of femoral neck fractures in the Medicare population from 1991 to 2008

BACKGROUND

We examined trends in the treatment of femoral neck fractures over the last two decades.

METHODS

We used Medicare Part A administrative data to identify patients hospitalized for closed femoral neck fracture from 1991 to 2008. We used codes from the International Classification of Diseases, Ninth Revision, to categorize treatment as nonoperative, internal fixation, hemiarthroplasty, and total hip arthroplasty. We examined differences in treatment according to hospital hip fracture volume, hospital location (rural or urban), and teaching status.

RESULTS

Our sample consisted of 1,119,423 patients with intracapsular hip fractures occurring from 1991 to 2008. We found a generally stable trend over time in the percentage of patients managed with nonoperative treatment, internal fixation, hemiarthroplasty, and total hip arthroplasty. We found little difference in surgical treatment across different groups of hospitals (high volume compared with low volume, urban compared with rural, and teaching compared with nonteaching). The percentage of acute care hospitals treating hip fractures remained fairly constant (74.8% in 1991 to 1993 and 69.0% in 2006 to 2008). The median number of hip fractures treated per hospital did not change (thirty-three in 1991 to 1993 and thirty-three in 2006 to 2008). There was no increase in the percentage of fractures treated in high-volume hospitals over time (57.7% in 1991 to 1993 and 57.1% in 2006 to 2008) and little reduction in the percentage of fractures treated in low-volume hospitals (5.8% in 1991 to 1993 and 5.5% in 2006 to 2008).

CONCLUSIONS

There has been little change in the trends of operative and nonoperative treatment for proximal femoral fractures over the last two decades, and there was little evidence of regionalization of hip fracture treatment to higher-volume hospitals.

Treatment and displacement affect the reoperation rate for femoral neck fracture

BACKGROUND

Femoral neck fractures (FNFs) comprise 50% of geriatric hip fractures. Appropriate management requires surgeons to balance potential risks and associated healthcare costs with surgical treatment. Treatment complications can lead to reoperation resulting in increased patient risks and costs. Understanding etiologies of treatment failure and the population at risk may decrease reoperation rates.

QUESTIONS/PURPOSES

We therefore (1) determined if treatment modality and/or displacement affected reoperation rates after FNF; and (2) identified factors associated with increased reoperation and timing and reasons for reoperation.

METHODS

We reviewed 1411 records of patients older than 60 years treated for FNF with internal fixation or hemiarthroplasty between 1998 and 2009. We extracted patient age, sex, fracture classification, treatment modality and date, occurrence of and reasons for reoperation, comorbid conditions at the time of each surgery, and dates of death or last contact. Minimum followup was 12 months (median, 45 months; range, 12-157 months).

RESULTS

Internal fixation (hazard ratio [HR], 6.38) and displacement (HR, 2.92) were independently associated with increased reoperation rates. The reoperation rate for nondisplaced fractures treated with fixation was 15% and for displaced fractures 38% after fixation and 7% after hemiarthroplasty. Most fractures treated with fixation underwent reoperation within 1 year primarily for nonunion. Most fractures treated with hemiarthroplasty underwent reoperation within 3 months, primarily for infection.

CONCLUSIONS

Overall, hemiarthroplasty resulted in fewer reoperations versus internal fixation and displaced fractures underwent reoperation more than nondisplaced. Our data suggest there are fewer reoperations when treating elderly patients with displaced FNFs with hemiarthroplasty than with internal fixation.

Valgus intertrochanteric osteotomy and fibular strut graft in the management of neglected femoral neck fracture

PURPOSE

A prospective study of neglected femoral neck fractures in mostly young patients was conducted to evaluate whether our technique of valgus intertrochanteric osteotomy with fibular strut grafting and osteosynthesis with dynamic hip screw and double-angle side plate can facilitate union with consistent satisfactory clinical outcomes.

METHODS

Forty-one consecutive patients (27 males, 14 females) of neglected femoral neck fractures treated between April 2002 and December 2009 were studied. The average age of patients was 45.41 years (±11.67, range 20-62 years). The average interval since injury was 14 weeks (±10.21, range 4-44 weeks). The cases were evaluated radiographically and clinically.

RESULTS

The average follow-up period was 32.5 months (±8, range 24-54 months). Radiographically union was seen in 39 patients at the nonunion site. The average time to radiographic union was 16.82 weeks (±3 weeks, range 12-24 weeks). Average Harris Hip Score (HHS) was 19.9 (±7.9, range 10-35) preoperatively and 90.9 (±10.35, range 62-100) at the latest follow-up. At that time clinical outcomes were excellent in 31, good in four, fair in three and poor in three patients.

CONCLUSION

Our mechanobiological surgical technique is reproducible with radiographic union achieved in 95.12% cases (39 patients) at the nonunion site and consistent excellent or good functional outcome in 85% of patients over a 32-month average follow-up. We recommend this procedure for neglected femoral neck fractures.

Quantitative score system for the surgical decision on adult femoral neck fractures

Surgical decision making for femoral neck fractures is currently based on factors such as patient age, fracture type, and medical condition, lacking a quantitative standard. The treatment protocol based on such qualitative assessment has poor operability, greatly affected by the surgeon's subjective factors. As a result, a quantitative score system (QSS) focusing on 5 factors--age, fracture type, bone mineral density, activities of daily living, and medical comorbidities--with a total score of 25 is designed to deal with adult femoral neck fractures. The higher the score, the worse the patient's physiological condition. According to our clinical experience, patients with 1 to 11 points should be treated with internal fixation; patients with 12 to 17 points with total hip arthroplasty (THA), and patients with 18 to 22 points with hemiarthroplasty. Patients with 22 to 25 points should be treated with internal fixation due to the high surgical risk of arthroplasty caused by poor physiological condition. Three hundred seventy-five adult femoral neck fractures were treated on the basis of QSS for this 2-year prospective study. Of these, 242 were treated with low-score internal fixation, 60 with THA, 55 with hemiarthroplasty, and 18 with high-score internal fixation. The revision rates 2 years postoperatively in the low-score internal fixation, THA, and hemiarthroplasty groups were 15.3%, 5.0%, and 5.5%, respectively, which were lower than those from a meta-analysis (internal fixation, 35%; THA, 16%). This QSS helps surgical decision making regarding the treatment choice for adult patients with femoral neck fractures, and good results in preliminary clinical practice have been achieved.

Treatment of displaced neck fractures of the femur with total hip arthroplasty

We report our experience in unstable fractures of the femoral neck in a consecutive series of patients who underwent total hip arthroplasty. Over a period of 12 years, 88 patients were treated with a cemented total hip arthroplasty; 3 patients were lost to follow-up, leaving 86 fractures (85 patients) for retrospective analysis. Seven patients had dislocations, all but 1 of which were treated successfully without reoperation. Four patients required reoperation in the same hip undergoing arthroplasty. There was a graded increase in mortality rates across the continuum of risk groups at the time of surgery. The low incidence (4.6%) of a second procedure on the hip repaired initially, as well as low mortality rates, makes this treatment strategy quite satisfactory.

Femoral stem dislodgement during bipolar hemiarthroplasty dislocation

Bipolar hemiarthroplasty remains a treatment option for displaced femoral neck fractures in elderly patients without pre-existing hip disease. Implant-related complications associated with this procedure include acetabular erosion, dislocation, disassembly of the modular components, polyethylene debris-induced osteolysis, metallosis from outer cup impingement, and femoral component loosening. This article presents a case of a patient in whom the polished collarless tapered femoral stem dislodged out of the cement mantle during traumatic bipolar hemiarthroplasty dislocation, 28 days after the index procedure. This complication, associated with bipolar hemiarthroplasty dislocation, was adequately managed by driving the stem back to the original cement mantle, followed by reduction of bipolar component dislocation and placing bone cement over the shoulder of the femoral stem to prevent a new dislodgement episode. Although rare, dislodgement of cemented polished collarless tapered stems from the cement mantle has been recently reported either during dislocation or, more frequently, as a complication of reduction of a dislocated total hip arthroplasty. However, its occurrence in association with bipolar hemiarthroplasty dislocation was not found to have been reported in the literature. The occurrence of femoral stem dislodgement during bipolar hemiarthroplasty dislocation should be considered as a possible complication of such a procedure and may be prevented by routinely placing bone cement over the shoulder of the femoral implant.

Arthroplasty versus internal fixation for femoral neck fractures in the elderly

We studied 140 patients with femoral neck fractures treated from January 1999 to December 2006. There were 68 men and 72 women with a mean age of 72 years (range 60-80 years). Seventy patients were treated with closed reduction and internal fixation (group A), and 70 patients with hip arthroplasty (group B). The duration of surgery, length of hospitalization, complications, postoperative Harris hip score, and need for reoperation were recorded. Group B had significantly higher blood loss, increased surgical time and length of hospitalization compared to group A patients. The Harris hip score was significantly higher in group B at the 3, 6, and 12-month follow-up evaluations; however, the differences were no longer significant at the 24-month evaluation. The overall complications rate was 18.6% (13 patients) in group A compared to 25.7% (18 patients) in group B; this was not statistically significant (P = 0.309). A statistically significant difference was found regarding reoperation rate in group A (11.4%, eight patients) compared to group B (1.4%, one patient) (P = 0.016). Arthroplasty compared to internal fixation for displaced femoral neck fractures is associated with a significantly higher functional score and lower risk of reoperation at the cost of greater infection rates, blood loss, and operative time.