Proximal Femoral Plate, Intramedullary Nail Fixation Versus Hip Arthroplasty for Unstable Intertrochanteric Femoral Fracture in the Elderly: A Meta-analysis

Anemia, Abnormal Body Mass Index, and Sarcopenia Increase Complication Risk in Patients Undergoing Surgical Treatment for Metastatic Bone Disease

BACKGROUND AND OBJECTIVES

Metastatic bone disease (MBD) is a common complication of primary cancers and is typically managed surgically. Overall health status and nutritional optimization are essential in surgical outcomes. The objective of this study was to report the intersectionality of previously studied laboratory, imaging, and clinical characteristics on postoperative complications.

METHODS

Patients treated surgically for metastatic disease of the femur or tibia from 2001 to 2022 were reviewed. Age, gender, diagnosis, perioperative BMI, hemoglobin, albumin, method of surgical treatment, history of chemotherapy, history of radiation to the site, return to the operating room (OR), and complication type were collected for analysis. Psoas cross-sectional area was measured.

RESULTS

Following review, 119 patients (61 F, 58 M) treated at 128 anatomic sites, with mean age 61.9 ± 15.6 and mean follow-up 23.7 ± 9.3 met the inclusion criteria. The rate of wound dehiscence was 7/128 (5.47%) and infection was 7/128 (5.47%). Hemoglobin < 12 [OR 1.091 (95% CI 1.023-1.164, p < 0.05)] and abnormal BMI [OR 9.000 (95% CI 0.962-84.208, p < 0.05)] were both associated with an increased risk of deep infection. Hemoglobin < 12 [OR 1.091 (95% CI 1.023-1.164, p < 0.05)] was also associated with increased risk in superficial infection. Abnormal BMI [OR 3.783 (95% CI 1.209-11.831, p < 0.05)] was associated with an increased risk of return to the OR. History of chemotherapy [OR 2.965 (95% CI 1.173-7.493, p < 0.05)] was associated with an increased risk in overall complications. There was no association found between history of diabetes and complications. No statistically significant difference was found between the method of fixation when comparing complications between those that received an endoprosthesis, intramedullary nail (IMN), or plate.

CONCLUSIONS

The complication risk for patients with metastatic disease is multifactorial, with anemia, abnormal BMI, and sarcopenia as measured by psoas cross-sectional area increasing risk for nononcologic complications. In the future, large-scale studies can help quantify the impact of each factor to allow for preoperative optimization to reduce complications.

Numerical comparison of the intramedullary nail for the fixation of different proximal femoral fractures

BACKGROUND

This study aimed to compare the mechanical responses, including the stability and implant stress, of different proximal femoral fractures stabilized with an intramedullary system by finite element simulation. Furthermore, the effect of number of the lag screws, including one and two screws, was also investigated.

METHODS

A numerical hip model was created first, and then four different types of proximal femoral fractures-namely femoral neck, intertrochanteric, reverse intertrochanteric, and subtrochanteric fractures-were employed in this study. An intramedullary nail system was used to fix the four fracture types. Furthermore, two different number of lag screws, either one bigger or two smaller, was also compared. The peak loading of the femur in level walking was used for comparison.

FINDINGS

The results showed that both the peak displacement and the gap opening distance in the reversed intertrochanteric fracture were obviously higher than in the other fractures. Additionally, the peak equivalent stress of the intramedullary nail in the reversed intertrochanteric fracture was the highest among all the fractures. The stress on the nail in cases of reversed intertrochanteric fracture was 4.6 times (ranging from 132.9 to 616.8 MPa) and 4.4 times (ranging from 126 to 556 MPa) higher than in intertrochanteric fractures with one and two lag screws, respectively.

INTERPRETATION

The intramedullary nail is a mechanically effective device for the fixation of proximal femoral fractures. However, to avoid the nail breakage the postoperative rehabilitation process for reversed intertrochanteric fracture should be slower compared to the neck, intertrochanteric and subtrochanteric fractures.

Surgical glove perforation during intramedullary nailing of intertrochanteric fractures

Intramedullary nail fixation is a routine procedure for treatment of intertrochanteric fractures. Aseptic technique is vital for reducing postoperative complications, as intraoperative glove perforations increase the risk of surgical site infections. The aim of this study was to determine the incidence of surgical glove perforation during intramedullary nailing of intertrochanteric fractures and to identify surgery-specific steps at risk. A prospective series of 148 short intramedullary nail implantations was analysed. Intraoperative glove perforations and causative events were recorded. All gloves from the scrubbed surgical team were collected and examined for micro- and macroperforations. 1771 gloves were tested. A total of 341 perforations in 309 gloves were detected, resulting in an overall glove perforation rate of 17%. Surgeon experience had no influence on the overall incidence of glove perforations. Usage of the awl and insertion of the proximal locking screw resulted in 33.9% of all detected glove perforations. Perforation rate significantly increased with operative time (p = 0.003). Regular glove changing after surgery-specific risk-steps and during longer surgeries could decrease the rate of glove perforations during intramedullary nailing of intertrochanteric fractures and reduce the risk of potential septic contamination or even disease transmission for both, the surgeon, and the patient.

Exploring the Efficacy of Computer-Assisted Navigation in Improving Lag Screw Placement and Preventing Cut-Out in Intramedullary Nail Fixation of Femoral Fractures: A Meta-Analysis

Femoral neck fractures are a common complication treated by orthopedic surgeons. Exploring the role of computer-assisted orthopedic programs in femoral fracture treatment is of particular interest given the technological advances in computer-assisted programs in the medical field. Notably, systems such as Stryker's Adaptive Positioning Technology (ADAPT) may allow for more precision in determining the tip-apex distance (TAD) when treating intertrochanter femur fractures. Such innovations hold the potential to reduce complication rates, including the incidence of lag screw cut-out, which could improve clinical outcomes in intertrochanter femur fracture treatment. This meta-analysis aims to evaluate the effectiveness of computer-assisted orthopedic systems in improving lag screw placement, as determined by the TAD and, ultimately, screw cut-out. Three studies were compared that reported continuous data for TAD in groups that did and did not use Stryker's ADAPT computer-assisted system. A random effects model was utilized to identify heterogeneity between studies. This was determined by variation and calculated through Cochran's Q-test, I2 statistic, and Tau2. Operative time was also reported in these studies and was evaluated as a secondary outcome. Each study analyzed showed that ADAPT had a statistically significant improvement in TAD with an overall effect size of -5.06. However, with an I2 value of 89% (p<0.01), there was notable heterogeneity between the three studies compared in this meta-analysis. While it is clear that there are benefits to using computer-assisted technology for internal femur fixation, more research is needed to understand the implications, including operative time and possible improvements in screw position.

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.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.