Outcomes after fixation for undisplaced femoral neck fracture compared to hemiarthroplasty for displaced femoral neck fracture among the elderly

Comparing total medical costs of surgical treatment versus nonoperative care for femoral neck fractures among Alzheimer's disease patients: A retrospective cohort study

OBJECTIVES

To compare the total medical costs associated with operative versus non-operative medical procedures for femoral neck fractures in older adults with Alzheimer's disease (AD).

METHODS

This retrospective cohort study examined 4,157 Optum beneficiaries diagnosed with AD who filed an initial claim for femoral neck fracture between January 1, 2012, and December 31, 2017. Generalized linear regression with Gamma log link function was performed to evaluate total medical costs between surgical treatment and non-operative care while controlling for covariates.

RESULTS

The adjusted total medical costs per patient for arthroplasty and internal fixation were $207,392 and $170,210, exceeding the total medical costs for non-operative cases ($63,041). Comorbidities such as history of falls, sarcopenia/muscle weakness, abnormal weight loss, depression, and fatigue also had a significant impact on the overall medical costs.

CONCLUSIONS

Surgical intervention for femoral neck fractures incurs higher costs but offers better clinical outcomes than non-operative care.

Predictors of long-term mortality in older patients with hip fractures managed by hemiarthroplasty: a 10-year study based on a population registry in Saxony, Germany

BACKGROUND

Mortality of patients with a femoral neck fracture is high, especially within the first year after surgery, but also remains elevated thereafter. The aim of this study was to identify factors potentially associated with long-term mortality in patients homogeneously treated with hemiarthroplasty for femoral neck fracture.

METHODS

This retrospective cohort study was performed at a single level 1 national trauma center at the university hospital of Leipzig (Saxony, Germany). The study time-window was January 1, 2010 to December 31, 2020. Primary outcome measure was mortality depending on individual patient-related characteristics and perioperative risk factors. Inclusion criteria was a low-energy femoral neck fracture (Garden I-IV) in geriatric patients 60 years of age or older that were primarily treated with bipolar hemiarthroplasty. Date of death or actual residence of patients alive was obtained from the population register of the eastern German state of Saxony, Germany. The outcome was tested using the log-rank test and plotted using Kaplan-Meier curves. Unadjusted and adjusted for other risk factors such as sex and age, hazard ratios were calculated using Cox proportional hazards models and presented with 95% confidence intervals (CI).

RESULTS

The 458 included patients had a median age of 83 (IQR 77-89) years, 346 (75%) were female and 113 (25%) male patients. Mortality rates after 30 days, 1, 5 and 10 years were 13%, 25%, 60% and 80%, respectively. Multivariate regression analysis revealed age (HR = 1.1; p < 0.001), male gender (HR = 1.6; p < 0.001), ASA-Score 3-4 vs. 1-2 (HR = 1.3; p < 0.001), dementia (HR = 1.9; p < 0.001) and a history of malignancy (HR = 1.6; p = 0.002) as independent predictors for a higher long-term mortality risk. Perioperative factors such as preoperative waiting time, early surgical complications, or experience of the surgeon were not associated with a higher overall mortality.

CONCLUSIONS

In the present study based on data from the population registry from Saxony, Germany the 10-year mortality of older patients above 60 years of age managed with hemiarthroplasty for femoral neck fracture was 80%. Independent risk factors for increased long-term mortality were higher patient age, male gender, severe comorbidity, a history of cancer and in particular dementia. Perioperative factors did not affect long-term mortality.

Comparing survival rates and mortality in operative versus nonoperative treatment for femoral neck fractures among Alzheimer's disease patients: A retrospective cohort study

Introduction

Addressing femoral neck fractures resulting from ground-level falls in older adults with Alzheimer's disease (AD) involves a personalized treatment plan. There is considerable ongoing debate concerning the relative advantages and disadvantages of surgical treatment (internal fixation or arthroplasty) vs nonoperative treatment for femoral neck fractures in older persons with AD.

Methods

This retrospective cohort study compared the mortality, hazard ratio, and survival rate between operative and nonoperative treatments, controlling for patients' demographic information and baseline health status. The study population consisted of Optum beneficiaries diagnosed with AD who experienced an initial femoral neck fracture claim between January 1, 2012, and December 31, 2017. Kaplan-Meier survival curves were applied to compare the treatment groups' post-fracture survival rates and mortality. Cox regression was used to examine the survival period by controlling the covariates.

Results

Out of the 4157 patients with AD with femoral neck fractures, 59.8% were women (n = 2487). The median age was 81 years. The 1-year survival rate for nonoperative treatment (70.19%) was lower than that for internal fixation (75.27%) and arthroplasty treatment (82.32%). Compared with the nonoperative group, arthroplasty surgical treatment had significant lower hazard risk of death (arthroplasty hazard ratio: 0.850, 95% CI: 0.728-0.991, P < 0.05).

Discussion

The findings suggest that the operative treatment group experiences higher survival rates and lower mortality rates than the nonoperative group. This paper provides insights into treatment outcomes of older adults with AD receiving medical care for femoral neck fractures.

Canal Fill Ratio in Hemiarthroplasty Compared to Total Hip Arthroplasty: A Case Control Study

Background

Cementless stems are commonly used in hemiarthroplasty (HA) for femoral neck fractures. Recent studies have reported increased risk of periprosthetic fracture with cementless stems compared to cemented HA. In elective total hip arthroplasty (THA), lower proximal canal fill ratios (CFR) of cementless stems have been associated with worse outcomes. The purpose of this study was to compare CFRs and complications following HA for femoral neck fracture compared to THA for arthritis. We hypothesized that HA would have lower CFRs.

Methods

130 patients undergoing cementless hemiarthroplasty for femoral neck fracture were identified and matched by age, sex, and BMI to 328 patients undergoing elective cementless THA. Postoperative radiographs were independently evaluated by two investigators to determine Dorr femur type and CFR at four points. Interrater agreement was calculated for CFR and Dorr type. Complication rates were compared between HA and THA groups.

Results

Dorr type and CFR measurements showed strong agreement between investigators. Dorr type was similar between groups. Hemiarthroplasties had significantly lower CFR at each level, with the greatest difference at the lesser trochanter. Dorr C femurs had worse CFR, specifically in the HA group. Complications rates were similar between HA and THA.

Conclusion

Worse CFR in HA compared to THA further suggests that cemented stems should be considered in HA. Suboptimal CFR represents a potential cause of complications including periprosthetic fracture following HA. Level of Evidence: III.

High Complication Rate After Percutaneous Screw Fixation for Valgus-Impacted Femoral Neck Fractures Without Sagittal Malalignment

OBJECTIVES

To evaluate the rate of reoperation in patients without sagittal plane malalignment who underwent percutaneous screw fixation of a valgus-impacted femoral neck fracture.

DESIGN

Retrospective case series.

SETTING

Two Level 1 academic trauma centers.

PATIENTS AND INTERVENTION

Two hundred seven patients >50 years of age with valgus-impacted femoral neck fractures treated with at least 3 large-diameter (>6.5 mm) cancellous screws from 2013 to 2019. Patients were excluded if there was a sagittal plane fracture deformity.

MAIN OUTCOME MEASUREMENTS

The primary outcome was reoperation. Secondary outcomes considered "major complications" included: avascular necrosis, varus collapse or implant cutout, nonunion, deep infection, and hematoma requiring reoperation. Surgical fixation strategies (screw configuration, aim) and implant type (partial vs. fully threaded cancellous screws) were secondarily compared.

RESULTS

Average patient age was 77 years, and median clinical follow-up was 658 days. Thirty-one patients (15%) required reoperation, and the major complication rate was 17.3% (36 complications in 33 patients). Logistic regression analysis demonstrated a higher risk of reoperation with constructs consisting of all partially threaded screws (17.0%) compared with the use of at least 1 fully threaded screw (7.5%) when an inverted triangle configuration was used (odds ratio, 2.50; 95% CI, 0.81-7.77).

CONCLUSIONS

This study demonstrated a relatively high rate of reoperation and major complications in patients with valgus-impacted femoral neck fractures without sagittal malalignment treated with in situ percutaneous screw fixation.

LEVEL OF EVIDENCE

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

Internal Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare internal fixation (IF) versus hemiarthroplasty (HA) for elderly individuals (ie, older than 65 years) with nondisplaced (ie, Garden type I or II) femoral neck fracture (FNF).

DATA SOURCE

We searched English literature of MEDLINE, PubMed, and Embase from inception to December 4, 2021.

STUDY SELECTION

Eligibility criteria were randomized controlled trials (RCTs) compared IF versus HA for elderly individuals with nondisplaced FNF. Primary outcomes were Harris hip score (HHS), quality of life per European Quality of Life 5 Dimension (EQ-5D), and mortality. Secondary outcomes were complications, reoperation, intraoperative bleeding, operation duration, and length of hospital stay.

DATA EXTRACTION

Two authors separately extracted data and assessed the risk of bias of the included studies using Cochrane risk-of-bias tool.

DATA SYNTHESIS

Three RCTs yielding 400 patients were enrolled, of which 203 (50.7%) underwent IF. Internal fixation was inferior to HA with respect to 6-month HHS [mean difference (MD) = -8.28 (-14.46, -2.10), P = 0.009] and 1-year EQ-5D [MD = -0.07 (-0.14, -0.00), P = 0.04]. The 2 techniques were comparable regarding length of hospital stay (day), HHS at 1 and 2 years, EQ-5D at 2 years, and mortality. IF was inferior to HA in implant-related complication [20.1% vs. 6.0%, relative risk (RR) = 3.18 (1.72, 5.88), P = 0.0002] and reoperation rate [20.1% vs. 6.0%, RR = 3.30 (1.79, 6.08), P = 0.0001]. Hemiarthroplasty had a greater blood loss (mL) [MD = -138.88 (-209.58, -68.18), P = 0.001] and operation duration (min) [MD = -23.27 (-44.95, -1.60), P = 0.04] compared with IF.

CONCLUSION

HA is the preferred technique for nondisplaced FNF if early recovery, higher mobility, and better quality of life are priorities. The choice of fixation should be weighed on an individual patient level.

LEVEL OF EVIDENCE

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

An overview on the treatment strategies of non-displaced femoral neck fracture in the elderly

Background

This paper aimed to review the databases on non-displaced femoral neck fractures in elderly patients. We also discussed the surgical and non-surgical treatments and selection of implants.

Methods

Reviewed was the literature on non-displaced femoral neck fractures in elderly patients. Four major medical databases and a combination of the search terms of “femoral neck fractures”, “nondisplaced”, “undisplaced”, “non-displaced”, “un-displaced”, “aged”, “the elderly”, and “geriatric” were used to search the literature relevant to the topic of the review.

Results

Patients who were unable to tolerate the operation and anesthesia could be treated conservatively. Otherwise, surgical treatment was a better choice. Specific surgical strategies and implant selection were important for the patient’s functional recovery.

Conclusions

The non-displaced femoral neck fractures are relatively stable but carry a risk of secondary displacement. Surgical treatments may be a better option because the implants provide additional stability and allow early exercise and ambulation. Hemiarthroplasty is also an alternative for old patients with higher risks of displacement and avascular necrosis of the femoral head.

Comparison of the survivorship between arthroplasty and ORIF for basi-cervical femoral neck fractures in the overall population and in polymorbid patients

BACKGROUND

Femoral neck fractures (FNFs) are associated with high mortality and can be treated with arthroplasty or open reduction and internal fixation (ORIF). For basi-cervical FNFs, there is no agreement on which procedure is better. Do arthroplasty and open reduction with internal fixation (ORIF) have different rates of survival? Do age and comorbidities influence survivorship?

HYPOTHESIS

Patients who underwent arthroplasty and patients who underwent ORIF have different rates of survival.

PATIENTS AND METHODS

Survivorship curves, complications, and hospitalisation length were analysed in 154 patients who received hip arthroplasty, and in 72 patients who received ORIF. Age and ASA score were used to divide the patients into sub-groups and perform secondary analyses.

RESULTS

At 4.9±2.4 years after surgery, 74 patients in the arthroplasty group (48%) and 33 in the ORIF group (45%) had died. The survivorship curves of the two groups showed a non-significant difference. The hospitalisation length was 13.5±8.9 days, with a non-significant difference between groups. There were 130 complications in total: 97 in the arthroplasty patients (19 patients had multiple complications, 52 had only one), 33 in the ORIF patients (4 patients had multiple complications, 29 had only one); the odds ratio was therefore 2.1 (p=0.02). Age, ASA score, Sernbo score, Charlson comorbidity index, and sex (male) were the best predictors of mortality. In the ASA 3-4 sub-group, the survivorship curves showed a lower mortality in the arthroplasty group (p=0.02).

DISCUSSION

Arthroplasty and ORIF are both valid procedures for the treatment of basi-cervical FNFs, but a high mortality rate is associated with either procedures. There is no difference in terms of survivorship between arthroplasty and ORIF in the overall population, but the presence of comorbidities may favour arthroplasty, which should be considered when managing patients with basi-cervical FNFs.

LEVEL OF EVIDENCE

III; retrospective, observational study.

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.

Long-Term Efficacy of Screw Fixation vs Hemiarthroplasty for Undisplaced Femoral Neck Fracture in Patients over 65 Years of Age: A Systematic Review and Meta-Analysis

Objective

To compare the long‐term efficacy of screw fixation and hemiarthroplasty in elderly patients with undisplaced femoral neck fractures.

Methods

We searched Cochrane Library, EMBASE, and MEDLINE from inception to 10 June 2020 to identify studies about undisplaced femoral neck fracture in elderly patients over 65 years of age. The included studies were assessed by two researchers according to the Cochrane risk‐of‐bias criteria and Newcastle–Ottawa Scale. Meta‐analysis was performed with Revman 5.3 software. The odds ratios (OR) and mean differences (MD) were used to compare dichotomous and continuous variables.

Results

A total of 750 patients were included in this meta‐analysis. In elderly patients, undisplaced femoral neck fracture treated with hemiarthroplasty had a lower implant‐related complication rate (OR, 4.05 [95% CI, 2.38 to 6.89]; P < 0.00001; I² = 0), lower reoperation rate (OR, 4.88 [95% CI, 2.84 to 8.38]; P < 0.00001; I² = 0), and superior Harris score (WMD, −5.05 [95% CI, −7.30 to −2.80]; P < 0.0001; I² = 0) in the early postoperative period. Although screw fixation was associated with shorter operative time (WMD, −36.22 [95% CI, −50.72 to −21.73]; P < 0.00001; I² = 98%) and less blood loss (WMD, −165.84 [95% CI, −209.29 to −122.38]; P < 0.00001; I² = 96%), there was no significant difference in long‐term mortality (OR, 0.65 [95% CI, 0.28 to 1.48]; P < 0.31; I² = 75%) between these two treatments.

Conclusion

In elderly patients with undisplaced femoral neck fractures, hemiarthroplasty provided a lower implant‐related complication rate, lower reoperation rate, superior hip function without increased long‐term mortality. Hemiarthroplasty should be recommended as a better alternative in such patients compared with multiple cannulated screws.

Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in the Elderly: A Cost-Effectiveness Analysis

OBJECTIVE

To evaluate the cost-effectiveness of screw fixation versus hemiarthroplasty for nondisplaced femoral neck fractures in low-demand elderly patients.

METHODS

We constructed a Markov decision model using a low-demand, 80-year-old patient as the base case. Costs, health-state utilities, mortality rates, and transition probabilities were obtained from published literature. The simulation model was cycled until all patients were deceased to estimate lifetime costs and quality-adjusted life years (QALYs). The primary outcome was the incremental cost-effectiveness ratio with a willingness-to-pay threshold set at $100,000 per QALY. We performed sensitivity analyses to assess our parameter assumptions.

RESULTS

For the base case, hemiarthroplasty was associated with greater quality of life (2.96 QALYs) compared with screw fixation (2.73 QALYs) with lower cost ($23,467 vs. $25,356). Cost per QALY for hemiarthroplasty was $7925 compared with $9303 in screw fixation. Hemiarthroplasty provided better outcomes at lower cost, indicating dominance over screw fixation.

CONCLUSIONS

Hemiarthroplasty is a cost-effective option compared with screw fixation for the treatment of nondisplaced femoral neck fractures in the low-demand elderly. Medical comorbidities and other factors that impact perioperative mortality should also be considered in the treatment decision.

LEVEL OF EVIDENCE

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

Lower rates of mortality, readmission and reoperation in patients receiving acupuncture after hip fracture: a population-based analysis

BACKGROUND

Studies on the effects of acupuncture on mortality and complication rates in hip fracture patients are limited by small sample size and short follow-up time. We aimed to assess the associations of acupuncture use with mortality, readmission and reoperation rates in hip fracture patients using a longitudinal population-based database.

METHODS

A retrospective matched cohort study was conducted using data for the years 1996-2012 from Taiwan's National Health Insurance Research Database. Hip fracture patients were divided into an acupuncture group consisting of 292 subjects who received at least 6 acupuncture treatments within 183 days of hip fracture, and a propensity score matched "no acupuncture" group of 876 subjects who did not receive any acupuncture treatment and who functioned as controls. The two groups were compared using survival analysis and competing risk analysis.

RESULTS

Compared to non-treated subjects, subjects treated with acupuncture had a lower risk of overall death (hazard ratio (HR): 0.41, 95% confidence interval (CI): 0.24-0.73, p = 0.002), a lower risk of readmission due to medical complications (subdistribution HR (sHR): 0.64, 95% CI: 0.44-0.93, p = 0.019) and a lower risk of reoperation due to surgical complications (sHR: 0.62, 95% CI: 0.40-0.96, p = 0.034).

CONCLUSION

This is the first study to suggest that postoperative acupuncture in hip fracture patients is associated with significantly lower mortality, readmission and reoperation rates compared with those of matched controls.

Hemiarthroplasty compared with internal fixation for treatment of nondisplaced femoral neck fractures in elderly patients: a retrospective study

INTRODUCTION

Internal fixation (IF) with cannulated screws is the most widely accepted operation method for nondisplaced femoral neck fractures (FNFs) in elderly patients. However, there were higher rate of reoperation, severe complications and poorer functional outcomes reported in these patients treated with IF. The purpose of this research is to compare the prognosis, complications, reoperation and mortality of bipolar hemiarthroplasty (HA) with IF of cannulated screws in elderly patients.

METHODS

All elderly patients (>75 years of age) with nondisplaced FNFs from January 2010 to December 2015 at our institution were included in this study. Patients treated with HA and IF with cannulated screws were compared. Outcome measures included the surgical complications, perioperative parameters, hip joint function, reoperation and mortality.

RESULTS

The blood loss of HA group (150.0 ± 55.1 mL) was statistically more than IF group (40.5 ± 15.7 mL, p = 0.001). However, the blood transfusion rate was similar between two groups (p = 0.102). At the last follow-up, there were total 14 (34.1%) severe surgical complications in the IF group, compared to 9 (10.1%) in the HA group (P = 0.001). No difference was detected between two groups with respect to the HHS and VAS at the last follow-up. Compared with the HA group, the IF group had much more reoperation in the follow up period (p = 0.001). There was no statistically differences of mortality rate between HA group (39.3%, 35/89) and IF group (34.1%, 14/41) (p=0.571).

CONCLUSIONS

As a treatment option for nondisplaced intracapsular FNFs in elderly patients, HA showed the merits of a less surgical complications and less reoperations, while IF demonstrated a shorter surgical time and less intraoperative blood loss. Meanwhile, there was no significant difference in the hip joint function and mortality rate in midterm follow-up. Further evaluation with a longer follow-up is recommended to strengthen these findings.

Predictors of early failure of the cannulated screw system in patients, 65 years and older, with non-displaced femoral neck fractures

BACKGROUND

Hip fractures represent the most common injury and the main cause of morbidity and mortality among patients 65 years and older. About 20% of all femoral neck fractures (FNFs) are non-displaced or valgus impacted, for which internal fixation with the cannulated screws system (CSS) is indicated.

AIMS

The aim of this study was to identify predictors of early failure of CSS.

METHODS

Patients with non-displaced FNFs (Garden type I and II) treated operatively using the CSS were enrolled. Their characteristics, Pauwels angle, and posterior tilt were assessed and related with outcomes. The primary outcome was fixation failure within 6 months.

RESULTS

259 patients were included with a mean age of 81.44 years. Most patients were female with ASA 3. The majority of fractures were classified as Garden I and Pauwels I. On average, Pauwels angle was 27°, while posterior tilt was 12°. A linear correlation between Pauwels angle and posterior tilt was found; the failure rate was 9.7%. Using the adjusted Cox competing risk regression analysis, posterior tilt was found to be independently associated with failure rate (sub-distribution hazard ratio or SHR 1.14 [95% CI 1.05-1.24], p = 0.0020). A posterior tilt greater than 18° resulted predictive of failure. The 1-year mortality rate was 12%.

CONCLUSIONS

Non-displaced Garden type II fractures, Pauwels type II or III fractures, and a posterior tilt greater than 18° represent radiographic predictors of CSS early failure in the elderly.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Internal Fixation Versus Arthroplasty for the Treatment of Nondisplaced Femoral Neck Fractures in the Elderly: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the outcomes of elderly patients with nondisplaced and minimally displaced femoral neck fractures treated with internal fixation versus arthroplasty.

DATA SOURCES

A comprehensive search of the MEDLINE, Embase, and central databases was conducted through June 25, 2019.

STUDY SELECTION

Studies were included if the sample population was (1) 60 years of age or older, (2) had nondisplaced or minimally displaced (Garden I or II) femoral neck fractures, and (3) if the study compared internal fixation versus arthroplasty. Only full-text English manuscripts were included. The primary outcome was reoperation. Secondary outcomes included mortality, patient-reported outcomes, length of hospital stay, infection, and blood transfusions.

DATA EXTRACTION

Two authors independently extracted data from the included studies. Each study was independently evaluated for quality using the Cochrane risk of bias assessment.

DATA SYNTHESIS

Of the 1597 identified articles, 4 manuscripts met the eligibility criteria with a total of 579 patients (236 treated with hemiarthroplasty and 343 treated with internal fixation). Patients treated with arthroplasty had a significantly lower risk of reoperation when compared with those treated with internal fixation [relative risk: 0.30 (95% CI, 0.16-0.55, P < 0.01)]. There was no significant difference detected in 1-year mortality risk between the 2 treatment groups.

CONCLUSIONS

In elderly patients with nondisplaced and minimally displaced femoral neck fractures, treatment with hemiarthroplasty may reduce the relative risk of reoperation by 70% when compared with internal fixation.

LEVEL OF EVIDENCE

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

Cementless Bipolar Hemiarthroplasty for Low-energy Intracapsular Proximal Femoral Fracture in Elderly East-Asian Patients: A Longitudinal 10-year Follow-up Study

Purpose

Short-term outcomes following cemented and cementless hemiarthroplasties (HAs) are reported to be comparable, however, long-term outcomes of cementless HA—especially among Asian patients—is limited. We aimed to assess long-term outcomes in elderly East-Asian patients with intracapsular proximal femoral fractures treated with cementless HA.

Materials and Methods

We enrolled 135 patients treated with cementless HA who met our inclusion criteria. We documented bone/implant-related complications (e.g., incidences of revision hip surgery, femoral stem subsidence, dislocation, intraoperative and postoperative periprosthetic fractures, contralateral hip fractures). We included those patients who are still alive 10 years after the index surgery in the final functional analysis of the existence of pain, ambulatory status, and residential status.

Results

The mean age at injury was 78.3 years (range: 60–85 years). At the 10-year follow-up, 26 of the original patients (19.3%) had survived. During follow-up, revision hip surgery was conducted in two patients (1.5%). We recorded the incidence of intraoperative fractures, postoperative periprosthetic fractures, and contralateral fractures in two (1.5%), eight (5.9%), and six patients (4.4%), respectively. Among the 10-year survivors, six patients (23.1% of the survivors) complained of groin pain, but generally reported the pain to be tolerable.

Conclusion

Among elderly East-Asian patients, the incidence of revision surgery after cementless HA may be lower than that in their European counterparts, whereas the incidence of periprosthetic fractures can still be considerably higher. For patients undergoing cementless HA, prevention of such secondary fractures is of critical importance.

[Research progress in treatment of femoral neck fracture in the elderly]

OBJECTIVE

To introduce the research progress of conservative treatment, internal fixation, hip arthroplasty, and multidisciplinary team (MDT) modes in the treatment of femoral neck fracture in the elderly.

METHODS

By consulting domestic and foreign literature in recent years, the characteristics and application of various treatment methods and new treatment modes for femoral neck fracture in the elderly were summarized and analyzed.

RESULTS

The elderly non-displaced femoral neck fracture should be treated surgically, and conservative treatment has a high risk of secondary displacement. The displaced fracture should be operated as soon as possible. There is no difference in long-term functional outcome between hemiarthroplasty and total hip arthroplasty. Hemiarthroplasty has less intraoperative blood loss, shorter operation time, and is suitable for the elderly patients with poor basic condition. Total hip arthroplasty is suitable for the elderly patients with better basic condition and higher demand of life quality. MDT can effectively reduce preoperative waiting time and length of stay, reduce the incidence of medical complications, improve the nutritional status of patients, and reduce the mortality of patients.

CONCLUSION

Significant results have been achieved in the treatment of femoral neck fractures in the elderly by methods such as internal fixation, hip arthroplasty, and MDT.

Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in Elderly Patients: A Multicenter Randomized Controlled Trial

BACKGROUND

Elderly patients with a displaced femoral neck fracture treated with hip arthroplasty may have better function than those treated with internal fixation. We hypothesized that hemiarthroplasty would be superior to screw fixation with regard to hip function, mobility, pain, quality of life, and the risk of a reoperation in elderly patients with a nondisplaced femoral neck fracture.

METHODS

In a multicenter randomized controlled trial (RCT), Norwegian patients ≥70 years of age with a nondisplaced (valgus impacted or truly nondisplaced) femoral neck fracture were allocated to screw fixation or hemiarthroplasty. Assessors blinded to the type of treatment evaluated hip function with the Harris hip score (HHS) as the primary outcome as well as on the basis of mobility assessed with the timed "Up & Go" (TUG) test, pain as assessed on a numerical rating scale, and quality of life as assessed with the EuroQol-5 Dimension-3 Level (EQ-5D) at 3, 12, and 24 months postsurgery. Results, including reoperations, were assessed with intention-to-treat analysis.

RESULTS

Between February 6, 2012, and February 6, 2015, 111 patients were allocated to screw fixation and 108, to hemiarthroplasty. At the time of follow-up, there was no significant difference in hip function between the screw fixation and hemiarthroplasty groups, with a 24-month HHS (and standard deviation) of 74 ± 19 and 76 ± 17, respectively, and an adjusted mean difference of -2 (95% confidence interval [CI] = -6 to 3; p = 0.499). Patients allocated to hemiarthroplasty were more mobile than those allocated to screw fixation (24-month TUG = 16.6 ± 9.5 versus 20.4 ± 12.8 seconds; adjusted mean difference = 6.2 seconds [95% CI = 1.9 to 10.5 seconds]; p = 0.004). Furthermore, screw fixation was a risk factor for a major reoperation, which was performed in 20% (22) of 110 patients who underwent screw fixation versus 5% (5) of 108 who underwent hemiarthroplasty (relative risk reduction [RRR] = 3.3 [95% CI = 0.7 to 10.0]; number needed to harm [NNH] = 6.5; p = 0.002). The 24-month mortality rate was 36% (40 of 111) for patients allocated to internal fixation and 26% (28 of 108) for those allocated to hemiarthroplasty (RRR = 0.4 [95% CI = -0.1 to 1.1]; p = 0.11). Two patients were lost to follow-up.

CONCLUSIONS

In this multicenter RCT, hemiarthroplasty was not found to be superior to screw fixation in reestablishing hip function as measured by the HHS (the primary outcome). However, hemiarthroplasty led to improved mobility and fewer major reoperations. The findings suggest that certain elderly patients with a nondisplaced femoral neck fracture may benefit from being treated with a latest-generation hemiarthroplasty rather than screw fixation.

LEVEL OF EVIDENCE

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

Factors Associated With Revision Surgery After Internal Fixation of Hip Fractures

BACKGROUND

Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device.

METHODS

We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation.

RESULTS

Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (for every 5-point increase) (HR 1.19, 95% CI 1.02-1.39; P = 0.027), displaced fracture (HR 2.16, 95% CI 1.44-3.23; P < 0.001), unacceptable quality of implant placement (HR 2.70, 95% CI 1.59-4.55; P < 0.001), and smokers treated with cancellous screws versus smokers treated with a sliding hip screw (HR 2.94, 95% CI 1.35-6.25; P = 0.006). Additionally, for every 10-year decrease in age, participants experienced an average increased risk of 39% for hardware removal.

CONCLUSIONS

Results of this study may inform future research by identifying high-risk patients who may be better treated with arthroplasty and may benefit from adjuncts to care (HR 1.39, 95% CI 1.05-1.85; P = 0.020).

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Incidence of and Factors Influencing Femoral Neck Shortening in Elderly Patients After Fracture Fixation with Multiple Cancellous Screws

BACKGROUND To study the incidence of and factors influencing "neck shortening" in elderly patients treated for femoral neck fractures using multiple cancellous screws. MATERIAL AND METHODS Of the 197 femoral neck fracture cases treated via closed reduction and cancellous screws fixation from January 2006 to February 2010, 110 were followed up. Patient age, gender, operative time, implantation method, reduction quality, fracture type, bone mineral density, loading time, length of hospital stay, and Harris hip score 12 months after operation were recorded. The patients were divided into two groups (shortening and non-shortening) based on their X-ray performance during follow-up. The healing rates and Harris hip scores of the two groups were compared, and the influencing factors of femoral neck shortening were analyzed. RESULTS Of the 110 cases followed up, 94.5% (104/110) were healed and neck shortening occurred in 41.8% (46/110) within 12.5 months (mean) after treatment. The Harris hip score of the shortening group was lower than that of the non-shortening group (78±17 vs. 86±23, p=0.048). The fracture healing rates of the two groups were not significantly different (p=0.068). The factors influencing neck shortening were significantly correlated with bone mineral density, patient age, gender, and type of fracture. CONCLUSIONS The incidence of neck shortening in elderly patients treated for femoral neck fracture using cancellous screws was high. Bone mineral density, patient age, gender, and type of fracture were the influencing factors of neck shortening.

Internal fixation of intra-capsular proximal femoral fractures in patients older than 80 years: Still relevant? Multivariate analysis of a prospective multicentre cohort

BACKGROUND

Arthroplasty is now widely used to treat intra-capsular proximal femoral fractures (PFFs) in older patients, even when there is little or no displacement. However, whether arthroplasty is associated with lower mortality and complication rates in non-displaced or mildly displaced PFFs is unknown. The objectives of this prospective study were: (1) to evaluate early mortality rates with the two treatment methods, (2) to identify risk factors for complications, (3) and to identify predictors of functional decline.

HYPOTHESIS

Arthroplasty and internal fixation produce similar outcomes in non-displaced fractures of patients older than 80 years with PFFs.

MATERIAL AND METHODS

This multicentre prospective study included consecutive patients older than 80 years who were managed for intra-capsular PFFs at eight centres in 2014. Biometric data and geriatric assessment scores (Parker Mobility Score, Katz Index of Independence, and Mini-Nutritional Assessment [MNA] score) were collected before and 6 months after surgery. Independent risk factors were sought by multivariate analysis. We included 418 females and 124 males with a mean age of 87±4years. The distribution of Garden stages was stage I, n=56; stage II, n=33; stage III, n=130; and stage IV, n=323. Arthroplasty was performed in 494 patients and internal fixation in 48 patients with non-displaced intra-capsular PFFs.

RESULTS

Mortality after 6 months was 16.4% overall, with no significant difference between the two groups. By multivariate analysis, two factors were significantly associated with higher mortality, namely, male gender (odds ratio [OR], 3.24; 95% confidence interval [95% CI], 2.0-5.84; P<0.0001) and high ASA score (OR, 1.56; 95% CI, 1.07-2.26; P=0.019). Two factors were independently associated with lower mortality, with 75% predictive value, namely, high haematocrit (OR, 0.8; 95% CI, 0.7-0.9; P=0.001) and better Parker score (OR, 0.5; 95% CI, 0.3-0.8; P=0.01). The cut-off values associated with a significant risk increase were 2 for the Parker score (OR, 1.8; 95% CI, 1.1-2.3; P=0.001) and 37% for the haematocrit (OR, 3.3; 95% CI, 1.9-5.5; P=0.02). Complications occurred in 5.5% of patients. Surgical site infections were seen in 1.4% of patients, all of whom had had arthroplasty. Blood loss was significantly greater with arthroplasty (311±197mL versus 201±165mL, P<0.0002). Dependency worsened in 39% of patients, and 31% of patients lost self-sufficiency. A higher preoperative Parker score was associated with a lower risk of high postoperative dependency (OR, 0.86; 95% CI, 0.76-0.97; P=0.014).

DISCUSSION

Neither treatment method was associated with decreased mortality or better function after intra-capsular PFFs in patients older than 80 years. Early mortality rates were consistent with previous reports. Among the risk factors identified in this study, age, preoperative self-sufficiency, and gender are not amenable to modification, in contrast to haematocrit and blood loss.

CONCLUSION

Internal fixation remains warranted in patients older than 80 years with non-displaced intra-capsular PFFs.

LEVEL OF EVIDENCE

III, prospective case-control study.