Mid-Term Survivals After Cementless Bipolar Hemiarthroplasty for Unstable Intertrochanteric Fractures in Elderly Patients

Screening risk factors for the occurrence of wedge effects in intramedullary nail fixation for intertrochanteric fractures in older people via machine learning and constructing a prediction model: a retrospective study

PURPOSE

The wedge effect (V-effect) is a common complication in intramedullary nailing surgery for intertrochanteric fractures and can significantly affect postoperative outcomes. The purpose of this study was to screen risk factors for the intraoperative V-effect in intertrochanteric fractures and to develop a clinical prediction model.

METHODS

A total of 319 patients (77 patients who developed V-effects) from China were randomly divided into a training set (n = 223) and a validation set (n = 96) at a ratio of 7:3. The variables were screened via 3 machine learning methods, including least absolute shrinkage and selection operator (LASSO) regression, the Boruta algorithm, and recursive feature elimination (RFE). Variables that appeared in the three machine learning methods were included in multivariate logistic regression to construct predictive models. Spearman correlation analysis was used to exclude covariance between variables. Restricted cubic splines (RCSs) were used to analyze the relationships among femoral lateral wall thickness, BMI, and the V effect. The differentiation, calibration and clinical applicability of the model were assessed, and the reasonability of the model was analyzed.

RESULTS

Machine learning identified 8 variables that appeared in these 3 machine learning methods, and the covariance between these 8 variables was excluded (r < 0.6). BMI, surgical experience, a lesser trochanteric fracture, the thickness of the lateral wall, the insertion point, bone density, fracture classification, and holiday surgery were found to be risk factors for the occurrence of the V-effect via multivariate logistic regression. The RCS analysis revealed that the lateral wall thickness, BMI, and occurrence of the V effect were linearly related. The final predictive model had good differentiation, calibration and clinical applicability, and it had better predictive efficacy than the other models did.

CONCLUSION

This study employed three machine learning variable selection methods-the LASSO, RFE, and Boruta algorithms-to construct a V-effect predictive model. The model enables orthopedic surgeons to better understand the risk factors associated with the V-effect and provides a reference for surgeons to implement appropriate measures to reduce the incidence of the V-effect.

Changing treatment of hip fractures in Finland

INTRODUCTION

Hip fracture treatment should be as standardized and effective as possible, with emphasis on fast recovery and avoidance of complications, especially those leading to reoperations. There is accumulating evidence regarding the optimal treatment of hip fractures but reports of whether this has influenced treatment in the clinical setting are sparse. The objective of this study was to determine the trends of hip fracture incidence and treatment in Finland, with special regard to how we treat older patients compared to younger ones.

MATERIALS AND METHODS

All operatively treated hip fractures in Finland between 1997 and 2018 were identified from a national administrative register. The incidence of these fractures and operations performed to treat them were calculated based on the adult population size.

RESULTS

Apart from a decline in the elderly age groups during the first half of the study period, the incidence of hip fractures remained relatively constant. However, the incidences of different operations changed significantly. In treatment of femoral neck fractures from 1997 to 2018, the incidence of cemented hemiarthroplasty (HA) increased from 41.1 to 59.9 per 100,000 person-years (105) and hybrid total hip arthroplasty (THA) from 0.56 to 5.93 per 105, while the incidence of internal fixation (IF) decreased, for instance screw fixation from 12.5 to 2.7 per 105. The incidence of cementless HA decreased from 13.3 to 1.2 per 105. These changes were much more pronounced in the elderly population and there was a statistically significant difference in the proportion of patients aged > 59 treated with cemented HA and IF in 1997 compared to 2018. For trochanteric and subtrochanteric fractures, treatment with intramedullary nails replaced extramedullary devices as the most common treatment method.

CONCLUSIONS

The changes in treatment methods in Finland correspond to the increasing knowledge available about the optimal treatment of hip fractures and global treatment trends.

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.

Mid-Term Follow-Up Results After Hemiarthroplasty Using Long Femoral Stem Prosthesis (Peerless-160) for Intertrochanteric Fractures in Octogenarians

Purpose

To analyze the clinical effect and imaging data of cementless bipolar hemiarthroplasty employing a long femoral stem (peerless-160) and 2 reconstructed femoral titanium wires to repair intertrochanteric fractures among the octogenarians.

Methods

Between June 2014 and August 2016, 58 octogenarians with femoral intertrochanteric fractures underwent the long femoral stem (peerless-160) cementless bipolar hemiarthroplasty by the same surgeon. We assessed clinical and radiological outcomes such as operative time, bleeding volume, blood transfusion volume, length of hospital stay, full weight-bearing walking time, walking ability calculated by Koval classification and Harris Hip Score (HHS), including fracture healing and greater trochanter fragments subsidence.

Result

The surgery was successfully performed in all patients. The average operation time was 72.8 ± 13.2 min, the average blood loss during surgery was 225.0 ± 91.4 mL, 200 mL of blood was transfused, the mean duration of hospitalization was 11.9 ± 4.0 days, the mean time of full weight bearing was 12.5 ± 3.8 days. Patients were followed up for 24-68 months, averagely 49.4 ± 10.3 months. During follow-up, 4 (6.9%) patients died, and 1 (1.7%) was completely lost to ask about the recent situation. The average Harris Hip Score at the last follow-up was 87.8 ± 6.1, most of the patients recovered walking ability, under radiological examination, the prosthesis showed no signs of loosening. All trochanteric fractures gradually healed, the clinical and radiographic signs of healing occurred at average of 4.0 ± 1.1 months postoperatively.

Conclusion

For osteoporotic unstable intertrochanteric fractures in octogenarians, this study confirmed that the Cementless Bipolar Hemiarthroplasty Using a Long Femoral stem (peerless-160) with double cross binding technique is a satisfactory and safe choice for the octogenarians.

COMPARING GAIT AND HIP SCORES IN FEMORAL NECK AND INTERTROCHANTERIC FRACTURES

Objective

Treatment modality is controversial in the unstable IT fractures. Ideal hemiarthroplasty treatment for unstable IT fractures should be comparable to that for FN fractures. Therefore, the aim of this study was to compare patients who underwent cementless hemiarthroplasty for a diagnosis of FN and unstable IT in terms of clinical outcomes, functional scores, and smartphone-based gait analysis data.

Methods

Case matching was applied to 50 patients with FN fracture and 133 patients with IT fracture who underwent hemiarthroplasty treatment, they were compared in terms of, preoperative and postoperative walking status, and Harris hip scores. Smartphone-based gait analysis was applied to 12 patients in the IT group and 14 patients in the FN group who could walk without support.

Results

There was no significant difference between patients with IT and FN fractures regarding Harris hip scores, preoperative, and postoperative walking status. In the gait analysis, gait velocity, cadence, step time, step length, and step time symmetry values were observed to be significantly better in patients in the FN group.

Conclusion

Cementless hemiarthroplasty operations for unstable IT fractures have similar hip scores to FN fractures. However, the walking speed and walking symmetry data were seen to be worse. This result should be considered in the selection of appropriate treatment. Level of evidence III; Retrospective study.

A bone-conserving revision stem for unstable intertrochanteric fractures of the geriatric osteoporotic population

Purpose

Primary hemiarthroplasty is gaining popularity for the treatment of unstable intertrochanteric fractures in geriatric patients with severe osteoporosis. This study evaluated early clinical and radiographic outcomes by using a bone-conserving revision stem for unstable intertrochanteric fractures in the geriatric osteoporotic population.

Methods

A retrospective study involving 31 patients with unstable intertrochanteric fractures was conducted. The patients were aged 82.1 years on average. All patients underwent primary hemiarthroplasty using bone-conserving, fully porous-coated revision stem. The operative time, intraoperative blood loss, length of hospitalization, and need for blood transfusion were noted during the hospital stay. Postoperative complications, including dislocations, deep venous thrombosis, infections, peri-prosthetic fractures, and frontal thigh pain were also recorded. Koval's category was used to quantify activity level, and Harris hip score (HHS) was used for functional assessment. Radiographic outcomes, including osteolysis, bone ingrowth, subsidence of the femoral component, lower limb length discrepancy, and heterotopic ossification, were collected at each follow-up.

Results

The 31 patients were followed for an average time of 23 months postoperatively. The average operative time lasted for 74.2 min, while the mean intraoperative blood loss was 200.1 ml, with an average hemoglobin decrease of 11.1 g/L after the procedure. The mean visual analog scale (VAS) score for pain dropped from 7.4 preoperatively to 2.4 at the 4-week follow-up. At the latest follow-up, the mean Harris hip score was 82.1, and the VAS was 1.7. No intraoperative or postoperative peri-prosthetic fractures were noted. Postoperative complications included one case of thrombosis formation in the posterior tibial vein and one case of congestive heart failure. Both patients were discharged uneventfully after treatment. Radiographically, none of the hips had evidence of stem loosening or osteolysis. Within the follow-up period of 23 months, the mortality rate was 3.2% (1/31), and no revision surgeries were required.

Conclusion

Primary hemiarthroplasty using a bone-conserving, cementless revision stem could serve as a reliable alternative for the treatment of unstable intertrochanteric fractures in the geriatric population with osteoporosis.

Bipolar hemiarthroplasty in unstable intertrochanteric fractures in elderly patients. The predictive value of the Charlson Comorbidity Index in 1-year mortality

BACKGROUND

Hip fractures have a significant impact on morbidity and mortality in the elderly. Aims: We retrospectively evaluated the predictive role of the Charlson Comorbidity Index (CCI) for 1-year mortality in elderly patients with unstable intertrochanteric hip fractures (ITHF) treated with bipolar hemiarthroplasty. The secondary objective was to identify other relationships, if any, between the variables recorded and mortality.

METHODS

We included ≥75-year-old patients with unstable ITHF treated with bipolar hemiarthroplasty. We recorded patient gender, age, Body Mass Index, pre-fracture walking ability (Parker Mobility score, modified Harris Hip Score), America Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), time to surgery, time to mobilization, hospital stay, and postoperative complications. Uni- and multivariate logistic regression analysis were performed. Sensitivity and specificity were calculated using a ROC curve.

RESULTS

A total of 135 patients with a mean age of 87.34 ± 5.5 years were included. The overall 1-year mortality rate was 18.5%. The CCI (OR 1.64 CI 95% 1.21-2.23; p 0.00821) and postoperative complications (OR 3.5 CI 95% 1.19-10.23 p 0.0202) were identified as independent predictors of 1-year mortality in the univariate regression and confirmed in the multivariate regression. CCI sensitivity to predict 1-year mortality was 80%.

CONCLUSION

CCI has shown acceptable sensitivity in the prediction of 1-year mortality in elderly patients with unstable ITHF treated with bipolar hemiarthroplasty. It is of utmost importance to prevent postoperative complications due to their significant impact on 1-year mortality.

PFNA-II Internal Fixation Helps Hip Joint Recovery and Improves Quality of Life of Patients with Lateral-Wall Dangerous Type of Intertrochanteric Fracture

Objective

To analyze the effect of PFNA-II internal fixation on hip joint recovery and quality of life (QOL) in patients with lateral-wall dangerous type of intertrochanteric fracture.

Methods

One hundred and twelve patients with lateral-wall dangerous type of intertrochanteric fracture who underwent surgical treatment in our hospital from May 2017 to May 2019 were selected as the participants of the study. Based on the treatment method, all the enrolled patients were divided into two groups: proximal femoral nail antirotation (PFNA group; n = 59) who received closed reduction and minimally invasive PFNA internal fixation and dynamic hip screw group (DHS; n = 53) who received internal fixation. The clinical indicators, curative effect, hip function score, pain degree, postoperative QOL score, and complications were compared between the two groups.

Results

The operation time, intraoperative blood loss, postoperative drainage volume, and the incidence of postoperative complications in PFNA group were statistically lower than those in DHS group (P < 0.05). The curative effect in PFNA group was notably better than that in DHS group. There were no significant differences in scores of hip function, visual analogue scale (VAS), and QOL between the two groups before operation (P > 0.05). However, the hip function score and QOL score increased in both groups after surgery, and the increase was more significant in the PFNA group, while the VAS score decreased in both groups, and the decrease in PFNA group was more significant (P < 0.05).

Conclusion

PFNA internal fixation for the treatment of lateral-wall dangerous type of intertrochanteric fracture has the advantages of short operation time, less intraoperative blood loss, effective improvement of hip joint function, and fewer postoperative complications, which is worthy of clinical application.

Cemented hemiarthroplasty versus proximal femoral nail antirotation in the management of intertrochanteric femoral fractures in the elderly: a case control study

Background

The treatment for intertrochanteric femoral fractures (IFF) among the elderly has been a controversial topic. Hemiarthroplasty (HA) and proximal femoral nail antirotation (PFNA) have their own advantages in the management of IFF. Hence, this study aims to compare and analyze differences in the effectiveness of both procedures on IFF among the elderly.

Methods

Overall, 99 patients (81.09 ± 8.29 years; 68 women) underwent HA or PFNA from January 2016 to May 2020. IFF were classified according to the Arbeitsgemeins für Osteosynthesefragen (AO) classification. The difference in underlying diseases, the American Society of Anesthesiologists (ASA) grade, Singh index, Harris scores, surgical time, intraoperative bleeding, postoperative blood test results, postoperative number of days to partially bearing weight, and survival outcomes were analyzed. Postoperative follow-ups were performed every 3 months.

Results

There was no significant difference in the AO classification, underlying diseases, ASA grade, Singh index, surgical time, and survival outcomes of the HA (45 patients) group and PFNA group (54 patients). The HA group was associated with earlier partial weight-bearing (HA: 4 [2 ~ 4.5] days, PFNA: 10 [8~14] days). It also had a higher total Harris score than the PFNA group at the 6-month follow-up visit (HA: 86.8 [81.90 ~ 90.23], PFNA: 83.48 [75.13 ~ 88.23]). Harris scores decreased more in patients aged ≥90 years in the PFNA group than in the HA group. The postoperative stress recovery rate in the HA group was faster based on postoperative blood test results.

Conclusions

PFNA and HA have good therapeutic effects in the treatment of IFF. The advantages of HA were reflected in short-term weight bearing, faster recovery from stress, and better joint function in the long term. This advantage is more obvious in the patient population aged over 90 years. Therefore, we suggest that surgeons should consider the benefit of HA in the treatment of IFF among the elderly.

Trial registration

Chinese Clinical Trial Registry, ChiCTR2000035814. Registered 17 August 2020, https://www.chictr.org.cn/showproj.aspx?proj=57083

Fixation options for reconstruction of the greater trochanter in unstable intertrochanteric fracture with arthroplasty

INTRODUCTION

With the aggravation of population aging, the incidence of intertrochanteric fracture also increases dramatically. Patients are often elderly accompany with severe osteoporosis and various complications. Therefore, we should select an individualized treatment based on the each patient's state. Arthroplasty is recommended for unstable fractures with obvious osteoporosis, ipsilateral femoral head necrosis or arthritis. Rigid fixation of the greater trochanter with arthroplasty is challenging because of the powerful pulling forces created by multiple muscles being transmitted to the greater trochanter. Currently, there are few contemporary literatures on the evaluation of unstable intertrochanteric fracture with efficient fixation of the greater trochanter. Moreover, there is no consensus to choose which implant to immobilize the greater trochanter. The purpose of this study was to review previous literatures and provide a valuable guidance.

CONCLUSIONS

The locking plate, which not only provides rigid fixation but also results in lower rate of postoperative complications. However, further prospective randomized and cohort studies are needed.

Primary hemiarthroplasty after unstable trochanteric fracture in elderly patients: mortality, readmission and reoperation

Background

Most unstable trochanteric fractures are treated with internal fixation and often with high complication rates. Hemiarthroplasty might be an alternative method in difficult condition, especially in unstable comminuted fracture in fragile bone. However, few have investigated the long-term outcomes after hemiarthroplasty for unstable trochanteric fracture. We conducted a population-based retrospective cohort study of trochanteric fracture after primary hemiarthroplasty using competing risk analysis on their long-term outcomes, including mortality, readmission and reoperation.

Methods

We studied a total of 2798 patients over 60 years old, with a mean age of 79 years, of which 68% are females and 67.23% have at least one comorbidity. They underwent a hemiarthroplasty for unstable trochanteric fracture during the period between January 1, 2000 and December 31, 2010 and were follow-up until the end of 2012, or death. Survival analysis and Cox model were used to characterize mortality. Competing risk analysis and Fine and Gray model were used to estimate the cumulative incidences of the first readmission and the first reoperation.

Results

The follow-up mortality rate for 1-year was 17.94%; 2-year, 29.76%; 5-year, 56.8%; and 10-year, 83.38%. The cumulative incidence of the first readmission was 16.4% for 1-year and 22.44% for 3-year. The cumulative incidence of the first reoperation was 13.87% for 1-year, 18.11% for 2-year, 25.79% for 5-year, and 38.24% for 10-year. Male gender, older age, higher Charlson Comorbidity Index (CCI) and lower insured amount were all risk factors for the overall mortality. Older age and higher CCI were risk factors for the first readmission. Older age was a protective factor for reoperation, which is likely due to the competing death.

Conclusions

The mortality and revision rates after hemiarthroplasty for unstable trochanteric fracture are acceptable as a salvage procedure for this fragile sub-population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04277-7.

Mid-term survivals of cemented calcar-replacement bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients

BACKGROUND

The literature has limited evidence regarding the mid-term survivals of cemented calcar-replacement bipolar hemiarthroplasty (HA) in elderly patients with unstable intertrochanteric (IT) fracture. The purpose of the present study was to evaluate clinical and radiological outcomes of cemented calcar-replacement bipolar HA for unstable IT fractures in elderly patients.

METHODS

One hundred and twenty-two patients with the mean age of 80.6 years were enrolled in this retrospective study after they met the selection criteria. Demographics, main clinical characteristics, and operative data were recorded for all patients. Functional outcomes were assessed according to Koval's categories. Clinical and radiological evaluations were performed. Kaplan-Meier survival analysis was used to construct the cumulative survival rate. The mean follow-up time was 25.7 ± 2.9 months (ranges 0-72 months).

RESULTS

Based on Koval's categories, 3 or 4-level decrease was detected in 21 patients (17%). Three patients (2 periprosthetic infections, 1 periprosthetic fracture) underwent reoperation during follow-up. No patient underwent revision of bipolar HA prosthesis. Femoral stem loosening and stem subsidence was the most common complication, observed in 22 patients (18%), followed by acetabular erosion that was seen in 12 patients (9.8%). The mean cumulative survival rate of prosthesis was 56.5% (95% confidence interval: 51.3-61.6).

CONCLUSION

Based on the results of our study, cemented calcar-replacement HA is an appropriate treatment option in elderly patients with unstable IT fractures owing to the advantages of satisfactory functional outcomes and lower reoperation rates. However, orthopedic surgeons should consider the low survival rates of cemented calcar-replacement HA prosthesis because of the increased femoral loosening in osteoporotic elderly patients.

[Effectiveness comparison between proximal femoral nail anti-rotation and proximal femoral locking compression plate for intertrochanteric fracture in elderly patients combined with hemiplegia due to cerebral infarction]

Objective

To investigate the difference in the effectiveness between proximal femoral nail anti-rotation (PFNA) and proximal femoral locking compression plate (PFLCP) for intertrochanteric fracture in elderly patients combined with hemiplegia due to cerebral infarction.

Methods

The clinical data of 67 cases of intertrochanteric femoral fractures combined with hemiplegia due to cerebral infarction between October 2013 and January 2017 were retrospectively analyzed. Among them, 32 cases were treated with PFNA internal fixation (PFNA group), and 35 cases were treated with PFLCP internal fixation (PFLCP group). There was no significant difference in gender, age, injury side, modified Evans classification of fracture, preoperative medical disease, and interval from injury to operation between 2 groups ( P>0.05). The operation time, intraoperative blood loss, postoperative bed time, incidence of perioperative complications, time of fracture healing, and hip Harris score at 6 months and 1 year after operation were recorded and compared.

Results

Both groups were followed up 12-24 months with an average of 14 months. Compared with the PFLCP group, the PFNA group had shorter operation time, less intraoperative blood loss, and shorter bed time, and the differences were significant ( P<0.05). X-ray films showed that the fractures healed in both groups. The fracture healing time of the PFNA group was shorter than that of the PFLCP group, but the difference was not significant ( t=0.743, P=0.460). During hospitalization, there were 3 cases of pulmonary infection, 2 cases of deep venous thrombosis of lower limbs, and 1 case of urinary tract infection in the PFNA group; and the incidence of perioperative complications was 18.8% (6/32). There were 4 cases of pulmonary infection, 6 cases of deep venous thrombosis of lower limbs, 1 case of recurrent cerebral infarction, and 1 case of stress ulcer in the PFLCP group; and the incidence of perioperative complications was 34.3% (12/35). There was no significant difference in the incidence of perioperative complications between 2 groups ( χ ²=2.053, P=0.152). At 6 months after operation, the Harris total score and individual scores in the PFNA group were higher than those in the PFLCP group ( P<0.05). At 1 year after operation, there was no significant difference in the Harris total score and pain score, life ability score, and walking ability score between the PFNA group and the PFLCP group ( P>0.05); However, the joint deformity and activity score of the PFNA group was significantly better than that of the PFLCP group ( t=4.112, P=0.000).

Conclusion

For intertrochanteric fracture in elderly patients with cerebral infarction hemiplegia, the PFNA has shorter operative time, less intraoperative blood loss, shorter bed time after operation, and better short-term hip function when compared with the PFLCP.