Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register

Classification and segmentation of hip fractures in x-rays: highlighting fracture regions for interpretable diagnosis

OBJECTIVE

To develop an artificial intelligence (AI) system capable of classifying and segmenting femoral fractures. To compare its performance against existing state-of-the-art methods.

METHODS

This Institutional Review Board (IRB)-approved retrospective study did not require informed consent. 10,308 hip x-rays from 2618 patients were retrieved from the hospital PACS. 986 were randomly selected for annotation and randomly split into training, validation, and test sets at the patient level. Two radiologists segmented and classified femoral fractures based on their location (femoral neck, pertrochanteric region, or subtrochanteric region) and grade, using the Evans and Garden scales for neck and pertrochanteric regions, respectively. A YOLOv8 segmentation convolutional neural network (CNN) was trained to generate fracture masks and indicate their class and grade. Classification CNNs were trained in the same dataset for method comparison.

RESULTS

On the test set, YOLOv8 achieved a Dice coefficient of 0.77 (95% CI: 0.56-0.98) for segmenting fractures, an accuracy of 86.2% (95% CI: 80.77-90.55) for classification and grading, and an AUC of 0.981 (95% CI: 0.965-0.997) for fracture detection. These metrics are on par with or exceed those of previously published AI methods, demonstrating the efficacy of our approach.

CONCLUSIONS

The high accuracy and AUC values demonstrate the potential of the proposed neural network as a reliable tool in clinical settings. Further, it is the first to provide a precise segmentation of femoral fractures, as indicated by the Dice scores, which may enhance interpretability. A formal evaluation is planned to further assess its clinical applicability.

CRITICAL RELEVANCE STATEMENT

The proposed system offers high granularity in fracture classification and is the first to segment femoral fractures, ensuring interpretability.

KEY POINTS

We present the first AI method that segments and grades femoral fractures. The method classifies fractures with fracture location and type. High accuracy and interpretability promise utility in clinical practice.

Lag Screw Design Is a Predictor for Cut-Out Complication After Intertrochanteric Femur Fracture Treatment in Elderly. A Comparative Analysis

Background: Hip fractures are common in older adults and are associated with significant morbidity and mortality. Surgical fixation with intramedullary devices, such as proximal femoral nails (PFN), is a common treatment method. However, complications such as implant cut-out remain a challenge despite advancements in implant designs. The objective of this study was to evaluate the clinical experience with different PFN designs and lag screws and to compare implant cut-out rates. Additionally, the study aimed to identify the most important factors that could prevent complications and predict cut-out. Methods: This retrospective study included 145 patients with trochanteric fractures who had undergone surgical treatment with PFN devices between January 2015 and December 2018. Patients younger than 65 years, those with pathological fractures, ipsilateral pelvic and knee fractures, subtrochanteric fractures, and multiple traumas were excluded. Radiographs were evaluated to determine osteoporosis, fracture type, implant type, fracture reduction quality, early and late neck shaft angle (NSA), lag screw position in the femoral head, tip-apex distance (TAD), and cut-out. Fractures were classified according to the AO/OTA classification system, and the quality of fracture reduction was assessed using the Baumgaertner classification. The Cleveland method was used to record the location of the screw/blade within the head. Results: The study compared the implant features of four different PFN devices, including Double lag screw PFN, Wedge wing lag screw PFN nail, Helical blade PFN, and Integrated Dual Screw PFN. The statistical analysis indicated that early and late NSA, TAD, Reduction quality of fracture, Cleveland index, and the difference between PFN types were risk factors for Cut-out. (P ≤ .001). Patients with helical blade PFN had a significantly higher rate of cut-out compared to other PFN devices. Univariate and multivariate regression analyses identified the Cleveland Index, fracture reduction quality (P ≤ .001), TAD, and early and late NSA as significant predictors for cut-out complications (P ≤ .001). Patients with poor Cleveland Index, poor fracture reduction quality, low TAD, and low NSA had a higher risk of cut-out (P ≤ .001). Conclusion: In conclusion, careful consideration of patient and surgical factors, including implant design and placement, is crucial in minimizing the risk of complications such as cut-out.

Risk factors of postoperative complications and in-hospital mortality after hip fracture among patients older than 80 years old: a retrospective study

INDUCTION

The mortality and morbidity in hip fracture is a big healthcare burden. How to identify risk patients preoperatively is important. The aim of study was to evaluate the risk factors of postoperative complications and mortality in patients older than 80 years old after hip fracture surgery.

METHODS

Patients older than 80 years old with the diagnosis of hip fracture who had surgical treatment from February 2013 to June 2021 at a single center in China were included for analysis. The primary outcome were postoperative complications and in-hospital mortality. Binary logistic regression was used to confirm the relationship between preoperative factors and postoperative complications/mortality.

RESULTS

498 patients were included for analysis. 176 patients developed 265 episodes of complications and the incidence of postoperative complication was 35.3%. Postoperative pulmonary infection was the most common complication, followed by cardiovascular complications and postoperative delirium. And there were 10 postoperative in-hospital deaths (2.0%). Preoperative Charlson comorbidity index(CCI) was associated with postoperative complications (OR = 1.243, 95%CI 1.020-1.516, P = 0.031) and mortality (OR = 2.303, 95%CI 1.351-3.925, P = 0.002). However, American society of Anesthesiologists (ASA) score was not an independent risk factor for postoperative complication and mortality.

CONCLUSION

CCI was the risk factor of poor postoperative outcome for patients older than 80 years old after hip fracture surgery. And CCI can be used as the potential tool of risk stratification for this group of patients.

TRIAL REGISTRATION

This study had been registered in www.chictr.org.cn and the registration ID was ChiCTR2400085291 on June 4th 2024.

Fractures sustained by slipping on ice or snow: an epidemiological study of 50,500 fractures from the Swedish Fracture Register

BACKGROUND AND PURPOSE

 Despite numerous patients sustaining fractures annually due to slipping on ice or snow, descriptive studies are scarce, which may result in less systematic management and prevention. We aimed to analyze fractures in adults sustained by slipping on ice and snow in Sweden using data from the Swedish Fracture Register (SFR).

METHODS

 Data on all patients ≥ 18 years registered in the SFR between January 1, 2015 and December 31, 2022, with a fracture sustained by slipping on ice or snow was extracted. Descriptive statistical analyses were performed.

RESULTS

 During the study period, 50,500 fractures were registered as sustained by slipping on ice or snow, representing 9% of all registered fractures in the SFR during the same period. 60% of the fractures affected the upper extremity. The mean age at the time of fracture was 61 years (18-105) and almost 70% of fractures were seen in women. The most common fractures were to the wrist (34%), ankle (18%), proximal humerus (11%), and hip (10%).

CONCLUSION

 Almost 1 in 10 fractures is sustained by slipping on ice or snow. The most common fractures are related to the wrist and the ankle. The majority of fractures affect the upper extremity, and two-thirds are sustained by women. Protective shoe wear, and better snow and ice clearance, could potentially have a large effect on injury prevention.

Effects of different reduction patterns on stress distribution in patients with intertrochanteric fractures with intramedullary nail fixation: a finite element analysis

Objective

Positive medial cortical support is a reliable fracture reduction pattern, but existing research on its use is mainly qualitative. We conducted this finite element analysis study to quantitatively evaluate the usefulness of positive cortical support for intertrochanteric fracture reduction.

Methods

Twenty-five models of intramedullary nail fixation for AO type 31-A1.2 intertrochanteric fractures subjected to different reduction patterns were established. The peak von Mises stress at the femoral fracture surface, proximal intersection of the intramedullary nail, and distal intersection of the intramedullary nail, as well as the maximum fracture displacement, were determined by finite element analysis under the three working conditions of standing, walking, and walking stairs.

Results

As the head-neck fragment moved forward, the von Mises stress at the fracture surface, the proximal intersection point of the intramedullary nail, and the distal intersection point gradually decreased. This resulted in reduced fracture displacement, a significant decrease in trabecular bone volume, and a slight increase in the risk of screw cut-out. As the head-neck fragment moved medially, the fracture gained positive support from the medial cortex, leading to a gradual decrease in von Mises stress at the fracture surface and the proximal intersection point of the intramedullary nail, as well as reduced fracture displacement. However, the von Mises stress at the distal intersection point gradually increased.

Conclusion

The reduction pattern involving positive medial, anteromedial, and anterior cortical support may be an effective alternative to anatomical reduction for the treatment of difficult-to-reduce intertrochanteric fractures.

Trochanteric hip fractures with subtrochanteric extension. Does the cephalomedullary nail length matter?

INTRODUCTION

Short or standard nails are widely accepted as the treatment of choice for unstable intertrochanteric fractures, while long nails are preferred for the treatment of subtrochanteric fractures. There is no consensus on the optimal implant length for peri/intertrochanteric fractures with subtrochanteric extension. Determining whether to opt for a standard or a long intramedullary nail (IMN) is often unclear and tends to be subjective. The aim of this study was to compare functional outcomes before and 1 year after the surgical fixation of trochanteric fractures with subtrochanteric extension, reoperation rates, 1-year mortality rates, surgical time, blood loss, quality of fracture reduction, and tip-apex distance (TAD) in patients treated with either standard or long cephalomedullary nails.

MATERIALS AND METHODS

A retrospective cohort study was conducted using our Institutional Fragility Hip Fracture Registry. All patients over 65 years old who underwent hip surgery due to an intertrochanteric fracture with subtrochanteric extension > 2 cm from the lesser trochanter between January 1, 2015, and December 31, 2021, were included. Patients were divided based on the length of the cephalomedullary nails used to treat the trochanteric fractures (standard vs. long nails).

RESULTS

Competing risk analyses showed significant differences in the subdistribution hazard ratio (SHR) for PMS reduction in the unadjusted SHR = 0.37 (95% CI 0.15, 0.88) and adjusted SHR = 0.4 (95% CI 0.17, 0.94) in favor of the long nail group. No differences were detected in 1-year mortality rates, which were 16.29%. There were also no differences in TAD, reoperations, quality of reduction, or blood loss, although surgical time was longer for the long nail group.

CONCLUSION

Of 1533 peri-intertrochanteric fractures, 11.6% exhibited subtrochanteric extension of more than 2 cm. While long nails demonstrated advantages in PMS reduction and fracture extension management, standard nails had the advantage of reducing surgical time. Both standard and long nails exhibited comparable outcomes in terms of mortality, surgical complications, and hematological parameters.

Finite Element Analysis of Proximal Femoral Bionic Nail (PFBN), Proximal Femoral Nail Antirotation and InterTan for Treatment of Reverse Obliquity Intertrochanteric Fractures

OBJECTIVE

Reverse obliquity intertrochanteric fracture is an unstable type of fracture. Current guidelines recommend intramedullary fixation, but there are still complications such as screw removal, hip varus, nail withdrawal, and nail fracture. The objective of this study was to use finite element analysis to compare the biomechanical properties of the novel proximal femoral bionic nail (PFBN), proximal femoral nail antirotation (PFNA), and combined compression interlocking intramedullary nail (InterTan) in the treatment of reverse obliquity intertrochanteric fractures (AO/OTA 31-A3.1).

METHODS

The three-dimensional models of PFBN, PFNA, InterTan, and the A3.1 type intertrochanteric fracture model were established by using modeling software such as Mimics and Unigraphics. Different force loads were implemented using ANSYS software to compare finite element biomechanical parameters, such as maximum stress in the implant and maximum stress and displacement at the proximal femur.

RESULTS

In this finite element study, we found that the distribution trend of maximum femoral stress and displacement in the femoral models of the three internal fixation groups was similar, but the maximum stress and maximum displacement were the lowest in the PFBN group, and the maximum stress of the internal fixation implant in the PFBN group was lower than that in the PFNA group and the InterTan group. The maximum stress and displacement of the femur in the PFNA group were 403.71 MPa and 14.274 mm, respectively, the maximum stress and displacement in the InterTan group were 362.72 MPa and 10.678 mm, and the maximum stress and displacement in the PFBN group were 186.23 MPa and 9.7068 mm. In the internal fixation implant model, the maximum stress of the PFNA group was 1445 MPa, the maximum stress of the InterTan group was 919.62 MPa, and the maximum stress of the PFBN group was the lowest, at 911.77 MPa.

CONCLUSION

Compared to PFNA and InterTan, PFBN designed by the "lever - reconstruction - balance" hypothesis can provide better biomechanical stability. It is a feasible choice for the future treatment of reverse intertrochanteric fracture, and additional clinical studies are required to substantiate its efficacy.

Safety of Cement-augmented Femoral Cephalomedullary Nails: A Meta-analysis and Systematic Review

Trochanteric fractures of the femur pose an increasing burden for elderly people. The standard treatment for these types of fractures includes cephalomedullary nailing, which can be augmented with cement. Although many studies have reported on the stability of this augmented construct, few studies have examined its clinical benefit and safety. Therefore, the objective of this meta-analysis is to examine the perioperative complications and postoperative mortality associated with cement-augmented nails in the management of intertrochanteric and pertrochanteric fractures of the hip. A search of PubMed, Cochrane, and Google Scholar (pages 1-20) until January 2024 was conducted. Analysis of the outcomes included perioperative complications and postoperative mortality. Seven studies were included in this meta-analysis. Fewer perioperative complications were observed when using a cemented femoral nail (P=0.002), although there was no difference in postoperative mortality (P=0.30). This meta-analysis is the first to assess the safety of a cement-augmented femoral nail in management of intertrochanteric and pertrochanteric fractures. The results showed a reduced rate of perioperative complications, which may be attributed to a more a solid construct, which reduced the duration of postoperative immobilization as well as use of a proper augmentation technique, resulting in a reduced rate of cement-associated complications.

Evaluation of Functional and Radiological Outcome of Different Cephalomedullary Nail Designs in Intertrochanteric Fractures of Femur

Introduction

The incidence of intertrochanteric (IT) fracture is rising because of increase in the survival of the elderly population with osteoporosis and also the increase in the number of motor vehicle accidents. The treatment of choice is normally surgical with internal fixation. The surgical options for these fractures commonly include fixation with dynamic hip screw (DHS) or cephalomedullary nailing. Due to its advantages over DHS, cephalomedullary nailing is the predominant procedure in many parts of the world. Various varieties of cephalomedullary nails are available. Short cephalomedullary nails are indicated for IT fractures not extending beyond lesser trochanter. There are limited studies on the comparison of short cephalomedullary nails for IT fracture. In this study, we are evaluating functional outcome, radiological union and complications of inter-trochanteric fractures of femur treated with three different short cephalomedullary nails: (1) Proximal femoral nail (PFN)-standard, (2) modified short PFN (MS-PFN) and (3) PFN-A2 of 240 mm.

Materials and Methods

Our study is a randomized control trial. Subjects are patients with IT fracture presenting to Srinivas Institute of Medical Sciences and Research Centre. After obtaining informed and written consent, as per inclusion and exclusion criteria, subjects are randomized into three groups (simple randomization) and treated with standard PFN (240 mm length), MS-PFN (180 mm length), and PFN-A2 of length 240 mm as per randomisation. Duration of the surgery and total intraoperative blood loss is noted. Patients are followed up till 1-year post-operative period, in different intervals. Functional outcome using Harris hip score, fracture union, complications are assessed and compared. Considering the lost to follow-up, the final study size obtained is 75 (25 in each group).

Results

In our study, the average age of the patients is 71.29 years with male predominance and right-side predominance. Majority of the fractures belong to Type 1 Group 2 and type 1 Group 4 of Evan's classification. The average operating time and average intraoperative blood loss is less in PFN-A2 group compared to PFN and MS-PFN groups. The fracture union time is earlier in PFN A2 group compared to PFN and MS-PFN group. Functional outcome is better in PFN-A2 group compared to PFN and MS-PFN groups. In PFN group and PFN A2 of 240 mm length group, there were significant patients with anterior thigh pain. Among 75 patients, 3 in PFN group, 2 in MS-PFN group, and 1 in PFN-A2 group had >1 cm of shortening. 2 patients in PFN group and 1 in MS-PFN group had complication of screw cut-out; 2 in PFN group and 2 in PFN-A2 group had surgical site infection; 1 in PFN group and 1 in PFN-A2 group had varus collapse; and 1 in PFN group and 2 in MS-PFN group had Z effect/reverse Z effect.

Conclusion

In our study, on comparing three short nails - PFN, MF-PFN, and PFN-A2, PFN-A2 is superior in terms of operating time, intraoperative blood loss, functional outcome and fracture union. MS-PFN is next to PFN-A2 in the above parameters. Hence, PFN-A2 is superior to MS-PFN and MS-PFN is superior to PFN. Moreover, to avoid anterior thigh pain, we recommend the use of shorter nails (180 mm).

Postoperative outcomes in patients operated for extra- and intracapsular hip fractures - a secondary analysis of two randomized controlled trials

BACKGROUND

Hip fractures are among the most common and serious injuries in older adults. There has been a perception that extracapsular hip fractures have worse outcome than intracapsular hip fractures. We aimed to examine postoperative outcomes in patients operated for extra- and intracapsular hip fractures.

METHODS

This is a secondary analysis of data from two randomized controlled trials evaluating the effect of orthogeriatric care. Bivariate analyses were conducted, comparing patients with extracapsular fracture to patients with intracapsular fracture. Mortality, length of hospital stay (LOS), new nursing home admissions, operative data and measures of functional and cognitive performance were assessed as endpoints.

RESULTS

The primary analysis included 711 patients; 283 patients had an extracapsular fracture and 428 an intracapsular fracture. At four months follow-up, the intracapsular fracture group had significantly better Short Physical Performance Battery (SPPB) (5.0 vs. 4.0, p = 0.007), personal Activities of Daily Living (p-ADL) (17.0 vs. 16.0, p = 0.007) and instrumental ADL (i-ADL) (32.5 vs. 28.0, p = 0.049). There were no statistically significant differences between the groups at 12 months.

CONCLUSIONS

Patients with an extracapsular fracture had worse mobility and ADL levels four months postoperatively, but there were no clinically relevant differences at 12 months postoperatively.

Risk of Falls, Fear of Falling, and Rates of Visual Field Progression in Glaucoma in the African Descent and Glaucoma Evaluation Study

PURPOSE

To assess the relationships between rates of glaucomatous visual field (VF) progression, fear of falling (FoF), history of falls, and ancestry.

DESIGN

Prospective, multicenter, longitudinal cohort.

SUBJECTS

Patients followed in the multisite African Descent and Glaucoma Evaluation Study with primary open-angle glaucoma and who completed a validated fear of falling questionnaire along with a self-reported history of falls in the past year were enrolled.

METHODS

Baseline VF severity and VF progression rates were assessed using 24-2 VF mean deviation (MD). We used univariable and multivariable models adjusting for confounders (age, sex, ancestry, and baseline MD) using clustered robust logistic regression and linear regression.

MAIN OUTCOME MEASURES

The primary outcome measure was the relationship between history of falls (yes vs. no) as a dependent variable and MD slopes (dB/year). The secondary outcome measure was the relationship between FoF scores (continuous) as a dependent variable and MD slopes (dB/year).

RESULTS

There were 4453 patient encounters, including at least 5 VF tests per patient with a minimum of 2 years of follow-up in 277 eyes of 183 individuals. Faster MD slopes were significantly associated with a history of falls in both univariable (odds ratio [OR]: 2.68 per dB/year faster rates; 95% confidence interval [CI]: 1.35-5.33; P = 0.005) and multivariable models (OR: 2.55; 95% CI: 1.29-5.04; P = 0.007). Rapid progressors (MD slope less than -0.5 dB/year) were 2.45-fold more likely to have a positive history of falls (95% CI: 1.22-4.91, P = 0.012). Faster MD slopes were significantly associated with worse FoF in both univariable (β: 2.97 per dB/year faster rates; 95% CI: 0.41-5.54; P = 0.023) and multivariable (β: 2.27; 95% CI: 0.17-4.36; P = 0.034) models. Patients of African descent (AD) were as likely to have a history of falls and had similar FoF scores as those of European descent (ED) (all P > 0.40).

CONCLUSIONS

A faster rate of MD progression is associated with a greater fear of falling and history of falls among AD and ED treated glaucoma patients. Rapid progressors were almost threefold more likely to have a history of falls. The 2 ancestry groups also experienced similar rates of falls and fear of fall scores.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Admission deep venous thromboembolism of the lower extremity in patients of subtrochanteric fractures: a retrospective study

BACKGROUND

Subtrochanteric fractures, which constitute 5-10% of proximal femoral fractures, are particularly challenging due to their high incidence of nonunion and failure of internal fixation. The incidence of deep venous thrombosis (DVT) in the lower extremities is notably higher among patients with orthopedic trauma, leading to significantly increased healthcare costs and prolonged hospitalization. The number of studies focusing on the incidence and risk factors among the patients with subtrochanteric fractures was quite limited. Therefore, there is a lack of effective methods of identification and predication. The study aimed to examine the occurrence and contributing factors of DVT in the lower limbs following subtrochanteric fractures in patients.

MATERIALS AND METHODS

Retrospective analysis was performed on the patients with subtrochanteric fracture who were admitted from August 2019 to October 2022. All patients received ultrasound doppler scanning to detect lower extremity DVT. Demographic information, comorbid conditions, and serum markers levels from patients including red blood cell (RBC), hemoglobin (HGB), lymphocyte (LYM), triglyceride (TG) and etc. were collected for analysis. Variables that demonstrated significant differences were subsequently introduced into multiple regression models to identify the independent risk factors associated with DVT.

RESULTS

A total of 120 patients were included, including 80 males and 40 females, with an average age of 58.3 ± 16.14years. A total of 51 patients were diagnosed to have DVT, with an incidence of 42.50%. There was significant difference between two groups in terms of albumin (ALB) (P = 0.0008), total protein (TP)(P = 0.019), RBC(P = 0.013), HGB (P = 0.032) and D-dimer levels (P = 0.007). However, multivariate analyses identified increased D-dimer level(>750 ng/ml) and reduced serum albumin as independent factors. The ROC curve indicated that a D-dimer level of 750 ng/ml was the optimal cut-off value for diagnosing DVT in patients with subtrochanteric fractures, with a sensitivity of 56.52% and specificity of 82.35%. The optimal cut-off value of ALB was determined to be 36.6 g/L, with a sensitivity of 73.2% and the specificity of 41.2%. The area under the curve of 0.63 indicates that this cut-off moderately effectively distinguishes between conditions related to ALB levels.

CONCLUSIONS

D-dimer level and serum albumin are independent factors of DVT in patients with subtrochanteric fractures. These data are helpful in assessing risks of DVT, and guiding the subsequent individualized intervention program.

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.

Are Process Changes Measurable? An Analysis of 4136 Proximal Femur Fractures over 16 Year

Prozessänderungen im perioperativen Setting werden selten analysiert, weil ihre Ergebnisse nicht unmittelbar fassbar sind und es einer hohen Fallzahl bedarf. Primäres Ziel war es, Prozessänderungen retrospektiv anhand proximaler Femurfrakturen (PF) zu evaluieren und deren Effekt mit verschiedenen Zielkriterien zu überprüfen. Sekundäres Ziel war die Definition möglicher Qualitätskriterien für die Versorgung von PF.Retrospektive Analyse der Datenbank eines Level-1-Traumazentrums zu PF. Eingeschlossen wurden alle osteosynthetisch und endoprothetisch versorgten PF im Behandlungszeitraum vom 01.01.2006 bis 31.12.2021. Der Zeitraum von 16 Jahren wurde für die Statistik trichotom aufgeteilt und die ersten 6 Jahre als Ausgangsbasis verwendet. Insgesamt 10 Prozessänderungen wurden in den folgenden 10 Jahren vorgenommen. Die Auswirkungen dieser Änderungen wurden anhand 1. der operativen Revisionsrate, 2. der Infektionsrate, 3. der perioperativen Transfusionsrate sowie 4. der 1-Jahres-Letalität überprüft.Insgesamt 4163 PF wurden analysiert. Hinsichtlich der Zielkriterien zeigten die Änderungen der ersten 5 Jahre (2012-2016; intramedulläres Verfahren für Osteosynthesen sowie Einwegabdeckung und Einwegkittel) den stärksten Effekt mit einer erstmaligen Senkung der operativen Revisionsrate unter 10% auf Dauer. Weitere Prozessoptimierungen der letzten 5 Jahre (2017-2021) erbrachten ebenfalls messbare Verbesserungen (Senkung der Infektions- und Transfusionsrate). Die 1-Jahres-Letalität blieb unverändert, auch während der COVID-19-Pandemie.Prozessänderungen bei PF führen nicht unmittelbar zu objektiv messbaren Verbesserungen. Rückblickend erscheint der Paradigmenwechsel von extra- auf intramedulläre Osteosynthese den höchsten Effekt erzielt zu haben, wenngleich über die letzten 10 Jahre eine schrittweise Besserung aller Zielkriterien eintrat - mit Ausnahme der Letalität. Als objektive Qualitätskontrolle sollte eine 1-Jahres-Revisionsrate unter 10% angestrebt sein.

Narrow DCP application during intertrochanteric fracture fixation to serve as a fracture reduction maintenance tool and a trochanteric stabilization plate

Intertrochanteric fractures (ITFs) could be treated efficiently using various devices, including dynamic hip screws, proximal femoral nails, and proximal femoral locking plates. To guard against femoral shaft medialization in unstable ITFs, a trochanteric stabilization plate (TSP) could be added as a supplementary fixation, produced by different companies and in various shapes. We describe a simplified technique using a narrow dynamic compression plate (DCP) (applied anterolaterally or posterolaterally) to act as a preliminary or permanent fracture reduction maintenance tool and serve as a TSP. The technique is simple and affordable, as a narrow DCP is available in most orthopedic operating theaters. Furthermore, this option could be a rescue plan if an original TSP is unavailable or cannot be applied.

Evaluating ChatGPT's Performance in Classifying Pertrochanteric Fractures Based on Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) Standards

Introduction Generative Pre-Training Transformer (ChatGPT) has become widely recognized for its capability to generate text, synthesize complex information, and perform a variety of tasks without requiring human specialists for data collection. The latest iteration, ChatGPT-4, is a large multimodal model capable of integrating both text and image inputs, rendering it particularly promising for medical applications. However, its efficacy in analyzing radiographic images remains largely unexplored. Aim This study aims to (i) address the lack of data on the accuracy of ChatGPT in radiographic fracture classification into stable or unstable under the revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification system, and this procedure is also performed by surgeons, and (ii) compare the agreement between surgeons or ChatGPT-based performance. The study hypothesizes that the use of ChatGPT would achieve moderate agreement with orthopedic surgeons. Materials and methods Patients diagnosed with pertrochanteric fractures were retrospectively collected. Patients with both preoperative two-directional plain radiographs and CT scans (3D-CT) images were conditioned for enrollment into the study. Two orthopedic surgeons (observer 1 and observer 2, respectively) and one resident (observer 3) were once assigned to dichotomized groups into A1 (stable) or A2 (unstable) based on AO/OTA classification using two-directional plain radiographs. Prior to the ChatGPT study, all the anteroposterior images trimmed at the fractured side, attached with figure names including gender, and age, were inputted into OpenAI ChatGPT-4. Radiological evaluation prompts were designed to initiate ChatGPT's classification analysis of the uploaded radiographic images. A single observer (MN) decided the classification patterns by examining 3D CT scan images as well as plain radiographs. This judgment of A1 (stable) and A2 (unstable) was set as a benchmark to mark the results of observers and ChatGPT based on plain radiographs. Results The cohort consisted of 29 males and 90 females, with a mean age of 87 years after the data exclusion. The fractures were classified into A1 (stable) and A2 (unstable) groups based on CT imaging. The A1 group included 50 patients (13 males, 37 females; mean age: 86.2 ± 7.8 years), while the A2 group included 69 patients (16 males, 53 females; mean age: 87.0 ± 7.9 years). Kappa values for fracture classification between plain radiographs evaluated by the three observers and ChatGPT, compared to the CT-based gold standard, showed fair to moderate agreement: Observer 1: 0.494 (95% CI: 0.337-0.650), Observer 2: 0.390 (95% CI: 0.227-0.553), Observer 3: 0.360 (95% CI: 0.198-0.521), and ChatGPT: 0.420 (95% CI: 0.255-0.585). ChatGPT demonstrated accuracy, sensitivity, specificity, and positive and negative predictable values comparable to the human observers, suggesting moderate reliability. Conclusion This study demonstrates that ChatGPT can classify pertrochanteric fractures into A1 (stable) and A2 (unstable) under the Revised AO/OTA Classification System. Its moderate agreement with CT-based assessments (κ = 0.420) is comparable to the performance of orthopedic surgeons. Moreover, ChatGPT is straightforward to integrate into clinical workflows, requiring minimal data collection for training.

Human fall simulation testing method: where we are

Falls pose a significant threat to human health and safety. Accurately assessing the protective effectiveness of fall protection products can significantly reduce the occurrence of fall accidents. This paper systematically reviews the types and risk factors of human falls and then discusses the current research status and future prospects of various test methods for human fall protection. A literature search was conducted in databases such as Web of Science, Google Scholar, and Scopus. This study focuses on experimental methods for human fall testing, simulation model experiments, and finite element simulations, providing an outlook on future development trends. In the discussion of three different fall testing methods, research indicates that human fall simulation testing faces limitations such as ethical concerns and safety issues. Although simulation experiments allow for multiple tests in a short period, the complexity and accuracy of the models may affect the reliability of the results. By integrating more experimental data, optimizing the design of human models, and incorporating finite element simulation technology, the scope of testing applications can be expanded, thereby improving the effectiveness of protective product designs. In conclusion, future research on fall protection testing methods should aim to establish unified international standards, which will enhance consistency and repeatability in testing, facilitating better comparison and evaluation of the effectiveness of various protective measures. Furthermore, the integration of more experimental data with real-world scenarios, the optimization of human models and test environments, and the promotion of finite element simulation technology will be crucial in enhancing the precision of protective assessments.

La survie après fracture ostéoporotique de l’extrémité supérieure du fémur

OBJECTIVES

To evaluate survival after osteoporotic fractures of the upper femur and determine its associated factors.

METHODS

Cross-sectional study of patients hospitalized for fractures of the upper end of the femur during 2020 at Monastir University Hospital. Outcome was determined up to 2 years. The Kaplan-Meier curve is used for survival analysis.

RESULTS

Eighty one patients with mean age of 77.46 ± 17,36 years and a sex ratio of 0.61 were evaluated. The femoral neck fracture was observed in54% of cases. Overall survival was 84.6% at 6 months, 75.4% at 1 year and 63.4% at 2 years. Median survival was 30 months. Patients older than 75 years had a shorter survival (68% versus 83% at one year and 55% versus 72% at 2 years ; p < 10-3).

CONCLUSION

The osteoporotic fracture of the upper femur is serious due to its severe outcome. One-year mortality was aboutt 25%. Increased mortality was associated to elderly population.

Cost-effectiveness and budget impact of cement augmentation for the fixation of unstable trochanteric fractures from a European perspective: Cost-effectiveness and budget impact of cement augmentation in Europe

INTRODUCTION

Hip fractures have a high patient burden and mortality rate, particularly following revision surgery. Cement augmentation of cephalomedullary nails has been shown to lower the risk of cut-out, aiming to reduce the need and expense of revision surgeries. The aim of this study was to assess the economic impact of cement augmentation for the fixation of trochanteric hip fractures in fragile, elderly patients, across a range of European countries (UK, Spain, Italy, Germany, and France), from both a provider (hospital) and a payer perspective.

METHOD

The budget impact (hospital perspective) and cost-effectiveness (payer perspective) analyses were informed by clinical outcomes from a meta-analysis published in 2021, additional published literature, registries, and clinical experts. Economic inputs included length of stay and operating time for the hospital perspective, revision surgery, outpatient, and rehabilitation days costs for the payer perspective. Outcomes included the breakeven cost below which using cement augmentation would begin to generate cost savings for the hospital, and potential cost savings for the payer with incremental costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Deterministic and probabilistic sensitivity analyses were conducted to assess model uncertainty.

RESULTS

From a hospital perspective, the breakeven cost below which the hospital would start saving money using cement augmentation was £491 (UK), €1490 (Spain), €1075 (Italy), €852 (Germany), and €834 (France) per patient, driven by reduced length of hospital stay. From a payer perspective, cost savings were £1675 (UK), €2202 (Spain), €993 (Italy), €944 (Germany), and €892 (France) per patient, mainly driven by fewer revision surgeries. Payer cost savings, coupled with incremental QALY gain of 0.004 across all regions, led to cement augmentation being the dominant strategy. These budget impact and cost-effectiveness results were rigorously tested in sensitivity analyses and were found to be robust.

CONCLUSION

These models support the wider adoption of cement augmentation to reduce the healthcare system costs associated with length of stay and revision surgery. These results provide useful information to providers, payers, and policymakers to ultimately influence choice surrounding the 'gold-standard' treatment of an unstable trochanteric fracture following low energy trauma.

Intramedullary Nail Failure in a Subtrochanteric Fracture in a 62-Year-Old Woman

Subtrochanteric fractures in older patients are typically due to low-energy falls. The standard of care is intramedullary nailing. The Smith & Nephew Trigen Intertan (Memphis, TN, US) is an intramedullary nail with a novel design that incorporates two integrated compression screws. We present a case of intramedullary nail failure in a patient with a subtrochanteric fracture. A 62-year-old woman with osteoporosis, a 40-year history of smoking, and consumption of two to three alcoholic beverages daily, weighing 177 pounds and five feet two inches tall (BMI 32.4), experienced a low-energy fall in her home. She presented to the emergency department (ED) with a shortened and externally rotated right leg with pain on manipulation. Her neurovasculature was intact. An X-ray revealed a comminuted, right subtrochanteric femur fracture. The patient underwent open reduction and internal fixation with a Trigen Intertan nail with no intraoperative complications. Her leg returned to pre-injury length, and she resumed ambulating at her pre-injury level. Six weeks later, the patient experienced pain upon standing. She was transported to the ED by ambulance where she presented with a shortened externally rotated right leg with pain on manipulation. An X-ray revealed failure of the intramedullary nail with breakage at the lag screw hole. Her care was transferred to another orthopedic surgeon (JC), where she underwent hardware removal and conversion to a total hip arthroplasty. Postoperatively, her legs were of equal length, and her neurovasculature remained intact. Four months later, at her final follow-up, she was ambulating unassisted at her pre-fracture level. Subtrochanteric fractures in elderly patients pose serious threats to morbidity, mortality, and quality of life. Surgery with intramedullary nail placement and rapid ambulation have generally favorable outcomes. Failure rates are generally very low. Such circumstances generally require hardware removal and total hip arthroplasty, which are generally curative but can confer small risks of morbidity and mortality.

The Impact of Rotational Malalignment Following Intramedullary Nailing for Intertrochanteric Fractures on Patients' Functional Outcomes: A Prospective Study

Background & Aims: Rotational malalignment after intramedullary nailing of intertrochanteric fractures is a relatively common complication that may have a crucial impact on both functional outcome and a fracture's healing properties, ultimately affecting the patient's postoperative morbidity and mortality. Methods: 74 patients treated with intramedullary nailing due to an intertrochanteric fracture underwent a postoperative computed tomography (CT) scan of the hips and knees. The femoral anteversion difference (D angle) between the operated and healthy hip was calculated using the technique described by Jeanmart et al. The patients were divided into two groups according to their D angle values: a D angle less than 15° was considered an acceptable rotational alignment (group A), while a D angle equal to or more than 15° was considered a rotational deformity (group B). Postoperatively, the functional level of each patient was evaluated at the 6-month and 1-year follow-up visits and compared to the pre-fracture status using the modified Harris hip score (mHHS). Also, fracture union, other postoperative complications, and patient mortality were noted. Results: The mean femoral anteversion difference was 12.3° with a standard deviation of 10.3°. Of the 74 patients, 51 (68.9%) were assigned to group A and 23 (31.1%) to group B. At the 6-month postoperative follow-up, 67 (90.5%) patients had survived and 7 (9.5%) were deceased, with our statistical analysis indicating a linear trend (p-value = 0.048) between the presence of rotational malalignment and 6-month mortality. At the 1-year postoperative follow-up, 63 (85.1%) patients survived and 11 (14.9%) were deceased, with the statistical analysis indicating a significant relationship (p-value = 0.031) between the presence of rotational malalignment and the 1-year mortality. Regarding the functional outcome six months after the operation, the difference between the pre-fracture and the postoperative mHHS was 8.7/100 with a standard deviation of 6.1 for the 49 patients in group A and 14.5/100 with a standard deviation of 12.4 for the 18 patients in group B, with the statistical analysis indicating a significant difference (t = -2.536, significance < 0.05) in the functional level between the two groups. As for the functional outcome one year after the operation, the difference between the pre-fracture and the postoperative mHHS was 4.9/100 with a standard deviation of 7.8 for the 47 patients in group A and 8.3/100 with a standard deviation of 13 for the 16 patients in group B, with the statistical analysis indicating no significant difference (t = -1.266, significance > 0.05) in the functional level between the two groups. The only postoperative complication noted was fracture non-union, presenting in two patients (3%), with the statistical analysis indicating no significant relationship (p-value = 0.698) between this complication and the presence of rotational malalignment. Conclusions: In this study, rotational malalignment after intertrochanteric fracture intramedullary nailing presents in 31.1% of cases. The correlation between this malalignment and functional outcomes shows a decline in patients' functional abilities during the first six postoperative months, a condition that improves over time, with most patients returning to their preoperative functional status one year after the operation. Furthermore, our results indicate a possible relationship between rotational malalignment and mortality within one year. Future research should focus on creating a more detailed, functional evaluation system for the elderly and applying it to a larger sample to confirm these findings.

Palliative care of proximal femur metastatic disease and osteolytic lesions: results following surgical and radiation treatment

BACKGROUND

Femoral bone metastases (FBM) or lesions (FBL) can lead to loss of mobility and independence due to skeletal-related events (SRE), e.g. pain, deformity and pathological fractures. Aim of this study was to analyze effects of radiotherapy and surgery, different surgical techniques and complications on disease-specific survival (DSS).

METHODS

Patients who underwent palliative therapy for FBM or FBL between 2014 and 2020 were retrospectively analyzed. Chi-square test was used to detect intergroup differences. Survival was calculated using Kaplan-Meier method, Cox regression and compared using log-rank test. Complications were evaluated using Chi-Square test.

RESULTS

145 patients were treated for proximal femoral BM/BL or pathologic fractures (10 bilaterally). Three groups were classified: surgery only (S, n = 53), surgery with adjuvant radiation (S + RT, n = 58), and primary radiation only (RT, n = 44). Most common primary tumors were breast (n = 31), prostate (n = 27), and non-small cell lung cancer (n = 27). 47 patients underwent surgery for an impending, 61 for a manifest pathological fracture. There were no significant differences in DSS between the 3 groups (S = 29.8, S + RT = 32.2, RT = 27.1 months), with the S + RT group having the longest one-year survival. Local complications occurred in 25 of 145 patients after a mean interval of 9.9 months.

CONCLUSION

Due to the steadily increasing incidence and survival of patients with FBM/FBL, indication for prevention and treatment of painful and immobilizing SREs should be critically assessed. Surgical treatment should always be performed with maximum stability and, whenever possible, adjuvant RT.

Intensive Multiprofessional Rehabilitation Is Superior to Standard Orthogeriatric Care in Patients with Proximal Femur Fractures-A Matched Pair Study of 9580 Patients from the Registry for Geriatric Trauma (ATR-DGU)

Background: Orthogeriatric treatment, which involves a collaborative approach between orthopedic surgeons and geriatricians, is generally considered to be superior to standard care following hip fractures. The aim of this study was to investigate additional effects of a geriatrician-led multidisciplinary rehabilitation program. Methods: In this matched paired observational cohort study, patients aged 70 years and older with a proximal femur fracture requiring surgery were included. Between 1 January 2016 and 31 December 2022 data were recorded from hospital admission to 120-day follow-up in the Registry for Geriatric Trauma (ATR-DGU), a registry of older adults with hip fractures. Out of 60,254 patients, 9580 patients met the inclusion criteria, 4669 patients received early multiprofessional rehabilitation (EMR) and 4911 patients were treated by standard orthogeriatric co-management (OGC). Results: Compared to standard orthogeriatric treatment, multiprofessional therapy significantly lowered the 7-day mortality rate (2.89% vs. 5.11%) and had a significant impact on walking ability seven days after surgery (86.44% vs. 77.78%). Conclusions: In summary, a geriatrician-led multiprofessional rehabilitation program resulted in lower mortality and improved walking ability than standard orthogeriatric care.

Change in Femoral Offset after Closed Reduction and Dynamic Hip Screw Osteosynthesis Via Lateral Approach in Patients with Medial Femoral Neck Fracture: A Retrospective Analysis

OBJECTIVE

Closed reduction and dynamic hip screw (DHS) osteosynthesis are preferred as joint-preserving therapy in case of medial femoral neck fractures (MFNFs). A change in the femoral offset (CFO) can cause gait abnormality, impingement, or greater trochanteric pain syndrome. It is unknown whether the femoral offset (FO) can be postoperatively fully restored. The aim of the study was to investigate the extent of a possible CFO in hip joints after DHS osteosynthesis in the case of an MFNF.

METHODS

In this retrospective study, 104 patients (mean age: 71.02 years, men: n = 50, women: n = 54) with MFNF who underwent closed reduction and DHS osteosynthesis were analyzed by postoperative x-rays to assess CFO between the operated (OS) and nonoperated joint side (NOS). The studies covered the time period 2010-2020. A statistical comparison was performed between the mean values of FO between OS and NOS, taking into account patient age, gender, and fracture severity.

RESULTS

All operated hip joints showed a CFO. In 76.0% (79 of 104), the FO decreased (FOD), and in 24.0% (25 of 104), the FO increased (FOI). A critical CFO (>15% CFO) was detected in 52.9% (55 of 104). In hip joints with postoperative FOD, the mean FO between NOS (49.15 mm [±6.56]) and OS (39.32 mm [±7.87]) and in hip joints with postoperative FOI the mean FO between NOS (41.59 [±8.21]) and OS (47.27 [±6.68]) differed significantly (p < 0.001). Preoperative FO (rS: -0.41; p > 0.001) and caput-collum-diaphyseal angle (CCD; rS: 0.34; p > 0.001) correlated with postoperative CFO. FOD was found in hip joints with a preoperative FO >44 mm and CCD <134° vice versa FOI in hip joints with a preoperative FO <44 mm and CCD >134°.

CONCLUSION

Closed reduction and DHS osteosynthesis in patients with MFNF result in a clustered significant CFO. The individual FO should be taken into account pre- and intraoperatively to avoid a postoperative extensive CFO.

Impact of lateral cortical notching on biomechanical performance in cephalomedullary nailing for unstable pertrochanteric fractures

PURPOSE

In pertrochanteric femur fractures the risk for fracture healing complications increases with the complexity of the fracture. In addition to dynamization along the lag screw, successful fracture healing may also be facilitated by further dynamization along the shaft axis. The aim of this study was to investigate the mechanical stability of additional axial notch dynamization compared to the standard treatment in an unstable pertrochanteric femur fracture treated with cephalomedullary nailing.

METHODS

In 14 human cadaver femora, an unstable pertrochanteric fracture was stabilized with a cephalomedullary nail. Additional axial notch dynamization was enabled in half of the samples and compared against the standard treatment (n = 7). Interfragmentary motion, axial construct stiffness and load to failure were investigated in a stepwise increasing cyclic load protocol.

RESULTS

Mean load to failure (1414 ± 234 N vs. 1428 ± 149 N, p = 0.89) and mean cycles to failure (197,129 ± 45,087 vs. 191,708 ± 30,490, p = 0.81) were equivalent for axial notch dynamization and standard treatment, respectively. Initial construct stiffness was comparable for both groups (axial notch dynamization 684 [593-775] N/mm, standard treatment 618 [497-740] N/mm, p = 0.44). In six out of seven specimens the additional axial dynamization facilitated interfragmentary compression, while maintaining its mechanical stability. After initial settling of the constructs, there were no statistically significant differences between the groups for either subsidence or rotation of the femoral head fragment (p ≤ 0.30).

CONCLUSION

Axial notch dynamization provided equivalent mechanical stability compared to standard treatment in an unstable pertrochanteric fracture. Whether the interfragmentary compression generated by axial notch dynamization will promote fracture healing through improved fracture reduction needs to be evaluated clinically.

Assessment of trochanteric vascularity using quantitative magnetic resonance imaging in a cadaveric model

Purpose

Few studies have assessed trochanteric vascularity despite its implications for bone healing and surgical approaches. This study aimed to assess the regional arterial contributions of the medial femoral circumflex artery (MFCA) versus the lateral femoral circumflex artery (LFCA) to trochanteric vascularity.

Methods

Ten adult human cadaveric pelvises to mid-femur specimens were obtained. One hip was randomly assigned experimental (either MFCA or LFCA MRI-contrast infusion) and contralateral as control (MFCA and LFCA magnetic resonance imaging [MRI]-contrast infusion). Vascular dissection was performed for MFCA and LFCA cannulation. Pre- and post-contrast 3T MRI was completed, and intra-osseous contributions were quantified by region: greater trochanter (GT), intertrochanteric (IT), lesser trochanter (LT) and subtrochanteric (ST). A polyurethane compound mixed with barium sulfate was injected into the LFCA cannula, and into the MFCA cannula for the contralateral hip. Computed tomography (CT) imaging was completed to assess terminal branch locations.

Results

MFCA provided the majority of arterial contributions to the full trochanteric region (68.5% MFCA, 31.5% LFCA; standard deviation [SD]: 10.7%, p < 0.001). Over 70% of arterial contributions to ST, LT and IT regions are derived from MFCA. GT contributions were more balanced (52.5% MFCA, 47.5% LFCA; SD: 33.7%; p = 0.853). Significant differences were found between MFCA and LFCA contributions in all regions except for the GT. CT revealed multiple consistent MFCA and LFCA trochanteric terminal branches.

Conclusions

MFCA provided the dominant trochanteric arterial supply, which highlights MFCA's importance to overall hip vascularity. LFCA's trochanteric contribution was smaller but still provided trochanteric contributions, especially the GT region. Knowledge of trochanteric arterial contributions can be beneficial for optimizing surgical approaches and fixation to protect terminal branches during trochanteric fracture, nonunion treatment and trochanteric osteotomies.

Level of Evidence

Not applicable.

Increased risk of hip and major osteoporotic fractures in 8463 patients who have undergone stem cell transplantation, a Swedish population-based study

In this retrospective cohort study of adult stem cell transplanted patients (n = 8463), a significant increased risk of both MOF and hip fractures was seen compared with the Swedish population and occurred in mean more than 2 years after stem cell transplantation.

PURPOSE

To explore the risk for osteoporotic fracture in patients who have undergone hematopoietic stem cell transplantation (HSCT) compared with the Swedish population.

METHODS

The risk of osteoporotic fractures was determined in a retrospective population cohort study of adult (≥ 18 years) Swedish patients (n = 8463), who were transplanted with HSCT 1997-2016 and compared with all adults living in Sweden during the same period.

RESULTS

In the total study group (n = 8463), 90 hip fractures (1.1% both in males and females) and 361 major osteoporotic fractures (MOF) (3.2% in men and 6.0% in women) were identified. In the total study population, the ratio of observed and expected number of hip fracture for women was 1.99 (95% CI 1.39-2.75) and for men 2.54 (95% CI 1.91-3.31). The corresponding ratio for MOF in women was 1.36 (CI 1.18-1.56) and for men 1.61 (CI 1.37-1.88). From 2005 onwards, when differentiation in the registry between allo- and auto-HSCT was possible, the observed number of hip fracture and MOF in allo-HSCT (n = 1865) were significantly increased (observed/expected hip fracture 5.24 (95% CI 3.28-7.93) and observed/expected MOF 2.08 (95% CI 1.63-2.62)). Fractures occurred in mean 2.7 (hip) and 2.5 (MOF) years after allo-HSCT. Graft-versus-host disease (GVHD) was not associated with an increased risk of fracture.

CONCLUSION

Patients who underwent HSCT had an increased risk of both hip and major osteoporotic fracture compared with the Swedish population and occurred in 4.3% of patients. GVHD was not statistically significantly associated with fracture risk.

A Look Into How the "Blue Zone" Lifestyle May Affect Patients' Lives Before and After Hip Fracture: A Propensity-Matched Cohort Study

INTRODUCTION

Hip fractures are life-changing injuries with associated one-year mortality up to 30%. Five locations in the world have been termed "blue zones," where the longevity of the population is markedly higher than that of surrounding areas and there are 10 times more centenarians. The United States has one blue zone (Loma Linda, California), which is believed to be because of the lifestyle of the Seventh-day Adventist population living there. We hypothesized that patients from the blue zone experience low-energy, frailty-driven, osteoporotic hip fractures later in life and an increased postinjury longevity relative to non-blue zone control subjects.

METHODS

A review of patients treated for hip fracture between January 2010 and August 2020 from a single institution was conducted. Demographic data were collected, and the end point of mortality was assessed using death registry information, queried in April 2024. Groups were divided into blue zone and non-blue zone. Statistical analysis was conducted with P < 0.05 considered significant.

RESULTS

Complete data were available for 1,032 patients. The blue zone cohort sustained low-energy hip fractures 12 years later in life (83.2 versus 71.1, P < 0.01). Propensity score matching was used to account for this difference. After propensity score matching, age, body mass index, American Society of Anesthesiologists score, surgery performed, sex, mechanism, ethnicity, diabetes, chronic obstructive pulmonary disease, CHF, chronic kidney disease grade, dementia, surgical time, and drug/tobacco/marijuana use were similar between groups. Blue zone patients had lower mortality at both 1 and 2 years postoperatively (12% versus 24%, P = 0.03 and 20% versus 33%, P = 0.03, respectively), had more hypertension (76% versus 62%, P = 0.03), reported lower alcohol use (7% versus 20%, P < 0.01), and included more Seventh-day Adventists (64% versus 15%, P < 0.01).

CONCLUSION

The blue zone lifestyle affected the onset of frailty and delayed osteoporotic hip fracture by 12 years in this propensity-matched cohort study. Postoperative mortality was also markedly lower in the blue zone cohort.

Pulmonary Embolism Post-Femoral Neck Fracture Surgery: A Critical Predictor of Five-Year Mortality

Objectives

This study examines the impact of pulmonary embolism (PE) on mortality among patients with femoral neck fractures, exploring the predictive value of preoperative PE for postoperative occurrences and associated mortality over a 5-year follow-up period.

Methods

We analyzed 2256 patients over 60 years old admitted with femoral neck fractures, focusing on those who developed DVT or PE postoperatively. Surgical intervention aimed within 48 hours without pharmacological thromboprophylaxis, utilizing mechanical prophylaxis instead. Postoperative management included Enoxaparin administration. Data analysis employed SPSS 21, with chi-squared tests, T-tests, and multivariate logistic regression to explore mortality and PE incidence.

Results

PE was diagnosed in 1.4% of patients, with a notable mortality contrast between patients with PE (87%) and those without (59.7%) over 5 years. A history of preoperative PE emerged as a significant risk factor for postoperative PE. Despite surgical variations, no significant correlation was found between surgery type and PE incidence. Early postoperative weight-bearing and institutional rehabilitation did not significantly alter PE incidence rates.

Conclusions

The study underscores the significant mortality risk associated with preoperative PE in femoral neck fracture patients. It highlights the necessity for vigilant PE risk assessment and management, challenging assumptions about the protective role of early mobility and rehabilitation in PE incidence. Further research is essential to refine patient care strategies and improve outcomes.

Association of Serum Lactate Levels Measured in the Emergency Department with 30-Day Mortality in Older Patients with Unilateral Hip Fractures

BACKGROUND

Hip fractures are frequent injuries in older patients and are associated with high mortality rates. This study assessed the association between serum lactate level and 30-day mortality in older patients with unilateral hip fractures and examined the prognostic value of this association on the clinical outcomes of these patients.

METHODS

This retrospective, single-center study included patients aged ≥65 years admitted to the emergency department due to low-energy trauma and diagnosed with unilateral hip fracture upon admission. The additional inclusion criteria were patients with independent ambulation or walker or cane assistance before the injury, with available data on serum lactate levels on venous blood gas analysis, and who underwent surgery.

RESULTS

Among the 330 included patients, 30.9% experienced postoperative complications and 10.3% died within 30 days. Using a lactate cut-off value of 2 mmol/L to distinguish between living and deceased patients, the sensitivity and specificity were 41% and 88%, respectively. Multivariate logistic regression analysis revealed that high lactate and low albumin levels and male sex were associated with mortality.

CONCLUSION

Identifying risk factors for mortality in geriatric patients with hip fractures is important. Male sex, low albumin levels, and particularly increased lactate levels were independent predictors of short-term mortality in these patients.

Uric acid-to-high-density lipoprotein cholesterol ratio and osteoporosis: Evidence from the national health and nutrition examination survey

Background: The uric acid-to-high-density lipoprotein cholesterol ratio (UHR) has emerged as a novel indicator of inflammatory and metabolic status. This study aims to examine the association between UHR and bone mineral density (BMD), as well as the risk of osteoporosis, in individuals aged ≥50 years. Methods: This cross-sectional study used data from the National Health and Nutrition Examination Survey, focusing on participants aged ≥50 years. Femoral neck BMD (FN-BMD) was measured using dual-energy X-ray absorptiometry. Linear regression models were employed to examine the association between UHR and FN-BMD. Additionally, generalised additive models were used to assess the nonlinear relationship between UHR and FN-BMD. Logistic regression models were employed to evaluate the association between UHR and the risk of osteoporosis. Results: Finally, the study included 2963 adults with a mean age of 64.16 ± 8.92 years. Linear regression analyses revealed a positive association between UHR and FN-BMD, regardless of covariate adjustments. Logistic regression analyses indicated that elevated UHR was associated with a reduced risk of osteoporosis with or without covariate adjustments. Subgroup analyses revealed that the positive association between UHR and BMD was significant in individuals aged ≥65 years but not in those aged 50 to 64 years. Interaction analyses by age showed significant differences after adjusting for all covariates. Conclusions: Clinicians should be vigilant regarding the potential risk of osteoporosis in individuals with a low UHR. UHR might serve as a risk indicator for osteoporosis.

The influence of COVID-19 epidemic on the number of orthopaedic surgeries in Japan

BACKGROUND

There is limited data on the impact of COVID-19 epidemic on the number of orthopaedic surgeries in Japan.

METHODS

We conducted a nationwide hospital survey asking for the monthly number of orthopaedic surgeries performed at each facility from January 2019 to June 2021. Those facilities that had performed at least 100 surgeries in 2019 were included for analyses. The facilities were further grouped by prefecture and by hospital characteristics. A brief health economic evaluation was also performed. Risk ratios were compared using univariate analyses with P < 0.05 considered statistically significant.

RESULTS

Questionnaire was sent to 1988 hospitals with 1671 hospitals (84%) responding. The survey data indicated a total number of orthopaedic surgeries decreased in 2020 compared to 2019 (1,061,541 vs 1,119,955 P < 0.01), and also for the first six months of 2021 compared to the same period in 2019 (530,388 vs 550,378 P < 0.01). In 2020, over 50% of all facilities in nearly all of the prefectures saw a decline in surgical procedures. The risk of incurring more than a 25% decease in the number of surgeries was significantly higher in 2020 for class I designated medical institutions compared to those that were not designated for any types of infectious diseases among the institutions with a tertiary emergency medical center in 2020 (crude risk ratio 2.9: 95% CI 1.2-7.4, p = 0.02) and in 2021 (crude risk ratio 4.7: 95% CI 1 0.9-12.1, p < 0.01). The estimated total nationwide decrease of revenue were in the range of approximately ¥29.2 to ¥116.8 billion per year for orthopaedic surgeries alone.

CONCLUSION

There was a statistically significant decrease in the number of orthopaedic surgeries in Japan. The magnitude of the decline varied by prefectures and hospital characteristics, with the greater impact imposed on medical institutions with higher classification functions. The estimated immediate health economic impact was sizable.

Treatment Outcomes of Dynamic Hip Screws Versus Short Intramedullary Nails for Extra-capsular Fragility Hip Fractures and Their Coding Audit

Introduction In the UK, hip fractures are a common reason for presentations to the emergency departments, which places significant pressure on NHS hospitals, appropriate choice of an implant to treat the hip fracture is one among many other factors that affect patients' outcomes. This audit aims to identify and compare the outcome difference between the dynamic hip screws (DHS) and short cephalomedullary nails in the treatment of extracapsular hip fractures. Methods In a retrospective study of 52 patients admitted as a result of hip fractures in one NHS trust, data collection was done from the patients' records using the trust's online system, we studied different variables to compare the outcome difference between DHS and short intramedullary (IM) nails, two senior authors interpreted the patients' X-rays and verified the coding and classification of the neck of femur fractures. Results This retrospective study examined 52 extracapsular hip fracture cases, including 37 females and 15 males. Forty-six (88%) of the included patients were ASA 3 and 4 (American Society of Anesthesiologists), and the average days to discharge from therapies were 8.4 (SD-+ 4) days compared to 11 (SD-+ 5.2) days for short IM nails and DHS, respectively (P= 0.03), the 30-day mortality rate for short nails was 7% (n= 4/52) patients and 6% (n= 3/52) for DHS (P =0.69). The mean operating times for the different implants were 58.11 (SD-+ 15.1) minutes for DHS and 58.03 (SD-+ 23.2) minutes for the short nail (P =0.98). Compliance with the national guidelines for providing an appropriate operation to treat hip fractures initially went from 63% (n=33/52) initially to 73% (n=38/52). This means that more patients who are appropriate for nailing are being treated with IM nails. Conclusion Short IM nails are associated with faster hospital discharge; this fact may be reflecting the lower postoperative pain as a result of avoiding soft tissue dissection associated with extramedullary devices. keeping in mind that IM devices have mechanical advantages over sliding hip screws; hence, they are more commonly used for more complex fracture patterns, leading to nearly similar outcomes when compared to extramedullary devices, this can be a source of bias in retrospective studies, larger randomized trials may lead to different outcomes.

Characterization of patient population receiving bioactive glass bone graft substitute as intraoperative treatment for orthopaedic trauma fractures

Background

Bioactive glass synthetic bone grafts are used to treat osseous defects in orthopaedic surgery. Characterization of the clinical scenarios associated with bioactive glass use in the context of orthopaedic trauma, are not well established. This study aims to characterize population demographics, operative variables, as well as postoperative variables, for patients who required bone grafting for treatment of traumatic orthopaedic injuries and received a bioactive glass bone substitute intraoperatively.

Methods

The electronic medical record at a large Level I trauma center was queried for fracture patients between January 1st, 2019, and April 30th, 2022. Our retrospective cohort included fracture patients who received Fibergraft Matrix or Fibergraft Putty intraoperatively, and their respective control groups. This study ascertained patient demographic variables, operative variables, and postoperative variables. Differences in categorical variables were tested with Fischer's Exact Tests, while differences in continuous variables were tested with ANOVA. Statistical significance was determined as P < 0.05. If the overall Group model was significant for a given variable, post-hoc Fischer's Exact or Tukey HSD tests were used to assess pairwise significance between individual Group pairs.

Results

A total of four categories across our analysis of demographic, operative, and postoperative variables displayed significant differences amongst subject Groups (P ≤ 0.03). Individual groups were compared such that significant differences between subject groups could be appreciated for a specific variable. FM subjects had greater length of surgery, billable costs, and vitamin D supplementation at the time of surgery compared to FM controls. Similarly, FP subjects had greater length of surgery, billable cost, and implants used intraoperatively compared to FP controls.

Conclusion

This analysis revealed Fibergraft patients to have greater length of surgery and billable cost, with respect to their matched controls. These data suggest that Fibergraft patients had more severe orthopaedic fractures compared to matched controls.

The hip fracture incidence in the high-risk area Oslo continues to decline

Oslo in Norway has had the highest incidence of hip fractures in the world. The incidence in Oslo has been thoroughly described every decade since the late 1970s. The incidence in Oslo has previously been higher compared to the rest of Norway but has now decreased to a level below the country average.

PURPOSE

The purpose of this study was to report the incidence of hip fractures in Oslo in 2019 and compare it with the incidence rates from the previous four decades.

METHODS

Patients residing in Oslo in 2019 with a new hip fracture identified by searching the Oslo hospital's patient administrative systems and protocols from the operating theaters. The diagnosis was verified through medical records and/or radiographs. To compare with previous studies, the direct standardization method was used with the population of Oslo in 2019 as the standard.

RESULTS

A total of 758 hip fractures, 70% women, were identified in 2019. The age-standardized incidence rates per 10,000 person-years in 2019 (95% CI) were 45 (41.1-48.8) for women and 30 (25.8-33.8) for men. In women, there has been a continuous decline in age-standardized rates the last three decades and in men the last two decades. The most pronounced decline was seen in the oldest age groups over 70 years. There has been a secular decline in both cervical and trochanteric fractures; however, the decrease in trochanteric fractures was most distinct for males, with more than two times higher risk in 1996/1997 compared to 2019.

CONCLUSION

Incidence rates for hip fractures in Oslo in 2019 were the lowest rate reported since 1978. The decrease was significant for both men and women. For the first time, the incidence rates are below the national rates of Norway. However, the rates are still among the highest worldwide.

Biocompatibility and bone regeneration with elastin-like recombinamer-based catalyst-free click gels

Large bone defects are a significant health problem today with various origins, including extensive trauma, tumours, or congenital musculoskeletal disorders. Tissue engineering, and in particular bone tissue engineering, aims to respond to this demand. As such, we propose a specific model based on Elastin-Like Recombinamers-based click-chemistry hydrogels given their high biocompatibility and their potent on bone regeneration effect conferred by different bioactive sequences. In this work we demonstrate, using biochemistry, histology, histomorphometry and imaging techniques, the biocompatibility of our matrix and its potent effect on bone regeneration in a model of bone parietal lesion in female New Zealand rabbits.

Incidence and risk factors for hip fractures among U.S. Armed Forces active component women compared to men, 2018-2022

Women, who comprise approximately 18% of the U.S. Armed Forces, suffer disproportionately higher rates of musculoskeletal injuries among active component service members. Using a retrospective study design, this study calculated incidence rates and rate ratios for acute hip fractures and hip stress fractures from January 1, 2018 through September 30, 2022 among female and male active component U.S. military members. Women who were younger than age 20 years, in recruit training, serving in the Army or Marine Corps, engaged in combat-related occupations, and with body mass indexes in the underweight or normal weight categories had the highest rates of both types of fractures. Women who had progressed beyond the recruit training phase had a higher female-to-male rate ratios of hip stress fractures than recruits. Despite an overall decline during the surveillance period, rates of acute hip fracture and hip stress fracture were higher among women than men. Changes in training and fitness policies may have contributed to the hip fracture rate declines among women. Continued efforts are needed to further reduce injuries among women.

The Impact of the COVID-19 Pandemic on One-Year Mortality in Geriatric Hip Fracture: A Retrospective Cohort Study

Introduction

The COVID-19 pandemic has profoundly impacted global healthcare systems, necessitating substantial shifts in patient care strategies. The pandemic's onset led to drastic operational changes in hospitals, including reduced bed capacity and staffing levels, which could have further influenced the mortality outcomes for geriatric patients. The study aimed to assess the impact of the COVID-19 pandemic on 1-year mortality rates of surgically treated geriatric hip fractures.

Methods

This retrospective, single-center cohort study included 346 participants aged 65 and above who underwent surgical treatment for hip fractures. We compared mortality rates between the pre-COVID and COVID eras. Data included demographics, treatment, complications, and COVID-19 status. The independent samples t test and Chi-square tests (or Fisher's exact test) were used for comparisons for era cohorts. Survival probabilities were assessed using Kaplan-Meier, while multivariate analysis identified mortality predictors.

Results

175 patients were included in the pre-COVID era, and 171 patients were included in the COVID era. During the COVID era, the 30-day mortality rate was 11.7% (compared to 13.7% in the pre-COVID era, p = 0.573), and the 1-year mortality rate was 43.9% (compared to 49.1% in the pre-COVID era, p = 0.325). The overall 1-year mortality rate was 46.5%. Patients who underwent surgery within 48 hours had a higher 1-year survival rate (60.5%) compared to those with delayed surgery (51.2%), p = 0.031. Additionally, patients not admitted to the ICU had a higher 1-year survival rate (74.7%) than those who were admitted (44.9%), p < 0.001. 70.1% of the total deaths occurred within the first 90 days.

Conclusion

Elderly patients with hip fractures experienced high mortality rates before and during the pandemic. This study demonstrates that the 1-year mortality rates of geriatric hip fractures were not significantly affected by the pandemic. The findings emphasize the importance of pandemic preparedness and prompt surgeries and attentive ICU care in reducing mortality rates.

Experimental Analysis of a Failed Gamma Nail: A Case Report and Literature Review

The Gamma Nail represents one of the most popular and efficient implants for treating proximal femoral fractures. Our paper reports a case of a failed Gamma Nail which was used for the surgical treatment of a 69-year-old woman with a right femoral trochanteric fracture due to a car accident. After the surgical intervention, 6 months later, the patient presented to the hospital reporting pain and limited mobility of the right hip. An X-ray was performed at the level of the pelvis, which highlighted the fracture nonunion and the implant failure. The implant removal and its replacement with a dynamic condylar screw system (DCS) was decided. Because Gamma Nail failures are rare occurrences, the implant was subjected to analyses and experimental determinations to find out the cause. For the implant analyses, a stereomicroscope, an optical microscope, and scanning electron microscopy were used. After the tests were conducted, preparation and processing irregularities as causes of the implant failure were eliminated. Also, the experimental analyses showed that the Gamma Nail did comply with chemical composition and microstructure regulations. Thus, it was concluded that the implant failed due to the mechanical overloading caused by surgical technique errors.

A New Postoperative Stability Score to Predict Loss of Reduction in Intertrochanteric Fractures in Elderly Patients

The study aimed to validate a newly developed postoperative stability score for evaluating clinical follow-up in elderly patients with low-energy hip fractures. From 1 January 2020 to 31 December 2021, we enrolled patients aged over 65 who underwent cephalomedullary nail fixation using proximal femoral nail antirotation II (PFNAII) and had at least 6 months of follow-up; excluding multiple fractures, pathological fractures, and periprosthetic fractures. We collected general patient data. Parameters such as TAD, Parker's ratio (AP and lateral), and the new postoperative stability score were recorded. A loss of reduction was defined using the decline in the Chang reduction quality criteria (CRQC) score within one month. Among the 108 enrolled patients, 23 (21.3%) experienced a loss of reduction, with a mean age of 82.1 years and a mean follow-up time of 7.4 months. Univariate analysis showed no significant association between loss of reduction and general data. However, the new postoperative stability score correlated significantly with loss of reduction (mean scores: 6.68 vs. 4.83, p = 0.045). Multivariate analysis confirmed this association (odds ratio: 0.076, 95% confidence interval: 0.022-0.263, p < 0.05). The newly developed postoperative stability score, incorporating surgical technique assessment, improves prediction accuracy for loss of reduction in elderly intertrochanteric fracture (ITF) patients.

Osteoporotic Fractures: Diagnosis, Evaluation, and Significance From the International Working Group on DXA Best Practices

Osteoporotic fractures, also known as fragility fractures, are reflective of compromised bone strength and are associated with significant morbidity and mortality. Such fractures may be clinically silent, and others may present clinically with pain and deformity at the time of the injury. Unfortunately, and even at the time of detection, most individuals sustaining fragility fractures are not identified as having underlying metabolic bone disease and are not evaluated or treated to reduce the incidence of future fractures. A multidisciplinary international working group with representation from international societies dedicated to advancing the care of patients with metabolic bone disease has developed best practice recommendations for the diagnosis and evaluation of individuals with fragility fractures. A comprehensive narrative review was conducted to identify key articles on fragility fractures and their impact on the incidence of further fractures, morbidity, and mortality. This document represents consensus among the supporting societies and harmonizes best practice recommendations consistent with advances in research. A fragility fracture in an adult is an important predictor of future fractures and requires further evaluation and treatment of the underlying osteoporosis. It is important to recognize that most fragility fractures occur in patients with bone mineral density T scores higher than -2.5, and these fractures confirm the presence of skeletal fragility even in the presence of a well-maintained bone mineral density. Fragility fractures require further evaluation with exclusion of contributing factors for osteoporosis and assessment of clinical risk factors for fracture followed by appropriate pharmacological intervention designed to reduce the risk of future fracture. Because most low-trauma vertebral fractures do not present with pain, dedicated vertebral imaging and review of past imaging is useful in identifying fractures in patients at high risk for vertebral fractures. Given the importance of fractures in confirming skeletal fragility and predicting future events, it is recommended that an established classification system be used for fracture identification and reporting.

Development of Prediction Model for 1-year Mortality after Hip Fracture Surgery

Purpose

Hip fractures are associated with increased mortality. The identification of risk factors of mortality could improve patient care. The aim of the study was to identify risk factors of mortality after surgery for a hip fracture and construct a mortality model.

Materials and Methods

A cohort study was conducted on patients with hip fractures at two institutions. Five hundred and ninety-seven patients with hip fractures that were treated in the tertiary hospital, and another 147 patients that were treated in a secondary hospital. The perioperative data were collected from medical charts and interviews. Functional Assessment Measure score, Short Form-12 and mortality were recorded at 12 months. Patients and surgery variables that were associated with increased mortality were used to develop a mortality model.

Results

Mortality for the whole cohort was 19.4% at one year. From the variables tested only age >80 years, American Society of Anesthesiologists category, time to surgery (>48 hours), Charlson comorbidity index, sex, use of anti-coagulants, and body mass index <25 kg/m2 were associated with increased mortality and used to construct the mortality model. The area under the curve for the prediction model was 0.814. Functional outcome at one year was similar to preoperative status, even though their level of physical function dropped after the hip surgery and slowly recovered.

Conclusion

The mortality prediction model that was developed in this study calculates the risk of death at one year for patients with hip fractures, is simple, and could detect high risk patients that need special management.

Risk of peri‑implant femoral fracture after cephalomedullary nailing in older patients with trochanteric fractures

INTRODUCTION

Despite the recent increase in the use of cephalomedullary nails for trochanteric hip fractures, factors that may be associated with peri‑implant femoral fracture (PIFF) after cephalomedullary nailing for trochanteric fractures remain unknown. We investigated the factors associated with PIFF after cephalomedullary nailing of trochanteric hip fractures in older patients.

METHODS

A nested case-control study was conducted using a database of patients aged ≥65 years who underwent surgery with cephalomedullary nails for trochanteric fractures caused by low-energy trauma during 2005-2021. The cases were defined as patients who developed PIFF after surgery, while controls were patients who did not develop PIFF and who were followed up for ≥3 years after surgery. Four controls were randomly matched to each case for sex and age. First, potential factors associated with PIFF were compared between cases and controls. Second, multivariable conditional logistic regression analysis was employed to assess factors possibly associated with PIFF, controlling for potential confounding factors.

RESULTS

Of 1531 patients who underwent surgery with cephalomedullary nails because of trochanteric fractures, we assessed 34 cases and 136 controls (N = 170; mean age 85.7 ± 7 years; and females, 94 %). PIFF was significantly associated with patients having undergone total knee arthroplasty (adjusted odds ratios [95 % confidence intervals], 4.41 [1.16-16.8]) and those with AO/OTA classification 31A3 fracture (A3 fracture) (2.3 [1.12-4.76]), after adjusting for potential confounding factors.

CONCLUSIONS

Our results showed that PIFF was more likely to develop among older patients with a clinical history of total knee arthroplasty and A3 fracture. These findings suggest that such patients may require careful follow-up with rigorous assessments after cephalomedullary nailing for trochanteric fractures.

Migration of the Gamma Nail Neck Screw into the Pelvis with Bladder Damage

Background

Medial migration of the cervical screw is a frequent complication of Gamma nails and is observed in 4.3% - 6% of cases. The reasons are a violation of the surgical technique of osteosynthesis of a trochanter fracture, including an unrepaired fracture, a breach of the insertion point of the fixator, and a suboptimal position of the cervical screw. However, the migration of the Gamma nail neck screw into the pelvic cavity is sporadic, and only a few cases have been published in the literature.

Case description

This is the case of a patient born in 1952 who was admitted to the hospital with pain syndrome in the pelvis and dysuric phenomena. As a result of clinical X-ray examination, CT, and MRT examination of the pelvis, medial migration of the Gamma nail cervical screw with damage to the bladder was revealed. The patient was urgently operated on the day of admission. The cervical screw from the bladder was removed, the bladder was sutured, and an epicystostomy was installed. The Gamma nail from the right femur was also released. There were no intraoperative complications. In the postoperative period, the patient was prescribed antibiotics and analgesics. The duration of hospitalization was six days. Being examined for five weeks after the operation, the patient does not make any particular complaints, walks without means of support, and the intertrochanteric fracture of the right femur fused incorrectly. The patient was offered an endoprosthesis of the right hip joint, but he and his relatives refused.

Conclusion

The traumatologist should be aware of the possibility of such complications after osteosynthesis and its associated risks. They should be able to recognize the etiological factors causing the medial migration of the cervical screw of the intramedullary retainer. If medial screw migration is detected, the traumatologist should assess the function of internal organs and the condition of the main vessels and take measures to safely remove the migrated fixator from the anatomical cavity of the body in one team with a surgeon, urologist and vascular surgeon.

Biomechanical comparison of an intramedullary nail combined with a reconstruction plate combination versus a single intramedullary nail in unstable intertrochanteric fractures with lateral femoral wall fracture: A finite element analysis

This study aimed to compare the biomechanical performance of an intramedullary nail combined with a reconstruction plate and a single intramedullary nail in the treatment of unstable intertrochanteric femoral fractures with a fracture of the lateral femoral wall (LFW). A three-dimensional finite element (FE) femur model was established from computed tomography images of a healthy male volunteer. A major reverse obliquity fracture line, associated with a lesser trochanteric fragment defect and a free bone fragment of the LFW, was developed to create an AO/OTA type 31-A3.3 unstable intertrochanteric fracture mode. Two fixation styles were simulated: a long InterTAN nail (ITN) with or without a reconstruction plate (RP). A vertical load of 2100 N was applied to the femoral head to simulate normal walking. The construct stiffness, von Mises stress, and model displacement were assessed. The ITN with RP fixation (ITN/RP) provided higher axial stiffness (804 N/mm) than the ITN construct (621 N/mm). The construct stiffness of ITN/RP fixation was 29% higher than that of ITN fixation. The peak von Mises stress of the implants in the ITN/RP and ITN models was 994.46 MPa and 1235.24 MPa, respectively. The peak stress of the implants in the ITN/RP model decreased by 24% compared to that of the ITN model. The peak von Mises stress of the femur in the ITN/RP model was 269.06 MPa, which was lower than that of the ITN model (331.37 MPa). The peak stress of the femur in the ITN/RP model was 23% lower than that of the ITN model. The maximum displacements of the ITN/RP and ITN models were 12.12 mm and 13.53 mm, respectively. The maximum displacement of the ITN/RP model decreased by 12% compared with that of the ITN model. The study suggested that an additional plate fixation could increase the construct stiffness, reduce the stresses in the implant and femur, and decrease displacement after intramedullary nailing. Therefore, the intramedullary nail and reconstruction plate combination may provide biomechanical advantages over the single intramedullary nail in unstable intertrochanteric fractures with a fractured LFW.

Development of early complications after treatment of trochanteric fractures with an intramedullary sliding hip screw in a geriatric population

PURPOSE

Although trochanteric fractures (TF) are a frequent event in the geriatric population, studies reporting on complication rates associated with surgical treatment are sparse. Thus, this study investigated the relevance of fracture-, implant-, and surgery-associated complications in TF. Furthermore, the role of possible risk factors for the before mentioned complications was investigated.

METHODS

A consecutive series of patients with TF treated by intramedullary nailing with a sliding screw device was evaluated. Data were sampled retrospectively from the hospital patient information system and anonymized at the source. Demographic data and information regarding fracture pattern, the treatment performed, hospital stay, and evaluation of operative and follow-up radiographs were analyzed. Intraoperative problems (i.e., technical problems with the implant, intraoperative fracture) and postoperative complications were investigated.

RESULTS

Postoperative surgical complications were noted in 11.7%. The most frequent surgical problem was a difficult fracture reduction (13%) and intraoperative fracture dislocation (3.6%). The most frequent postoperative complication was intra-hospital mortality (3.6%), delayed/non-union (2.7%), and a cut-out of the lag screw in the femoral head (2.3%). Implant failure (1,4%) was significantly associated with morbid obesity while cut-out (2,3%) correlated with a higher tip-apex distance (TAD). A complex fracture type and a suboptimal screw position significantly increased the cut-out rate to 5% (p = 0.018).

CONCLUSION

Complications after TF treatment occur frequently. While patient-associated variables such as morbid obesity cannot be influenced by the surgeon, correct fracture reduction and implant positioning remain to be of highest importance.

Risk prediction models of mortality after hip fracture surgery in older individuals: a systematic review

OBJECTIVE

This study aimed to critically assess existing risk prediction models for postoperative mortality in older individuals with hip fractures, with the objective of offering substantive insights for their clinical application.

DESIGN

A comprehensive search was conducted across prominent databases, including PubMed, Embase, Cochrane Library, SinoMed, CNKI, VIP, and Wanfang, spanning original articles in both Chinese and English up until 1 December 2023. Two researchers independently extracted pertinent research characteristics, such as predictors, model performance metrics, and modeling methodologies. Additionally, the bias risk and applicability of the incorporated risk prediction models were systematically evaluated using the Prediction Model Risk of Bias Assessment Tool (PROBAST).

RESULTS

Within the purview of this investigation, a total of 21 studies were identified, constituting 21 original risk prediction models. The discriminatory capacity of the included risk prediction models, as denoted by the minimum and maximum areas under the subject operating characteristic curve, ranged from 0.710 to 0.964. Noteworthy predictors, recurrent across various models, included age, sex, comorbidities, and nutritional status. However, among the models assessed through the PROBAST framework, only one was deemed to exhibit a low risk of bias. Beyond this assessment, the principal limitations observed in risk prediction models pertain to deficiencies in data analysis, encompassing insufficient sample size and suboptimal handling of missing data.

CONCLUSION

Subsequent research endeavors should adopt more stringent experimental designs and employ advanced statistical methodologies in the construction of risk prediction models. Moreover, large-scale external validation studies are warranted to rigorously assess the generalizability and clinical utility of existing models, thereby enhancing their relevance as valuable clinical references.

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.

Is there a difference between preoperative and postoperative delirium in elderly hip fracture patients?: A retrospective case control study

Delirium is associated with greater morbidity, higher mortality, and longer periods of hospital day after hip fracture. There are number of studies on postoperative delirium after a hip fracture. However, few studies have made a distinction between preoperative and postoperative delirium. The purpose of this study is to compare risk factors and clinical outcome between preoperative and postoperative delirium in elderly patients with a hip fracture surgery. A total of 382 consecutive patients aged > 65 years who underwent operation for hip fracture were enrolled. Among them, the patients diagnosed with delirium were divided into 2 groups (a preoperative delirium group and a postoperative delirium group) according to the onset time of delirium. To evaluate risk factors for preoperative and postoperative delirium, we analyzed demographic data, preoperative laboratory data, and perioperative data. To compare clinical outcomes between preoperative and postoperative delirium, we analyzed postoperative complications, KOVAL score, regression, readmission, and 2-year survival rate. Delirium was diagnosed in 150 (39.3%) patients during hospitalization. Preoperative and postoperative delirium occurred in 67 (44.6%) and 83 (55.4%) patients, respectively. Independent risk factors of preoperative delirium included age (odds ratio: 1.47, 95% confidential interval [CI]: 1.13-2.23, P = .004), stroke (odds ratio [OR]: 2.70, 95% CI: 1.11-6.01, P = .015), American Society of Anesthesiologist (OR: 1.68, 95% CI: 1.137-2.24, P = .033), and time from admission to operation (OR: 1.08, 95% CI: 1.01-1.16, P = .031). There was no significant difference in preoperative KOVAL score between the 2 groups. However, postoperative KOVAL score (5.1 ± 2.0 vs 4.4 ± 2.1, P = .027) and regression rate (68.7% vs 44.6%, P = .029) were significantly higher in the preoperative delirium group than in the postoperative delirium group. Moreover, the 2-year survival rate was significantly lower in the preoperative delirium group than in the postoperative delirium group (62.7% vs 78.3%, P = .046). Characteristics, risk factors, and prognosis are different for patients with preoperative delirium and postoperative delirium. Preoperative delirium patients showed different risk factors with poorer prognosis and higher mortality. Therefore, hip fracture patients with risk factors for preoperative delirium should be monitored more carefully due to their greater risk of mortality.

Subtrochanteric fracture of the femur following knee replacement surgery: A case series and review of the literature

INTRODUCTION AND IMPORTANCE

Knee arthroplasties as an effective intervention is primarily performed in patients with primary osteoarthritis and rheumatoid arthritis. Risk of hip fracture may be either decreased or increased in patients with Knee arthroplasties. There is conflicting evidence in this regard. Over the years, some studies have reported the occurrence of hip fractures following this operation as a rare but severe complication. The aim of the present case series was to report diagnosis and treatment of the mentioned five cases.

CASE PRESENTATION

During a period of two years, five patients with a diagnosis of a subtrochanteric fracture and history of total knee arthroplasty who referred to hospital were selected to include in the present case series. CLINICAL DISCUSSION: the presence of RA and treatment with glucocorticoids, a reduction of BMD following knee replacement surgery, and ultimately, an increase in physical activity and movement after the arthroplasty due to the improvement of preoperational pain, may all contribute in a complex manner to the observed outcome of increased fracture risk in the hip following TKA.

CONCLUSION

In summary, special care including using medications to improve BMD should be taken to minimize the risk of such an event.