Epidemiology, classification, treatment, and mortality of adult femoral neck and basicervical fractures: an observational study of 40,049 fractures from the Swedish Fracture Register

Impact of femoral head size on the localization of proximal femur fractures: Retrospective analysis of 400 cases

Background

Proximal femur fractures are prevalent among the elderly, leading to high mortality, reduced quality of life, and significant healthcare burdens. The incidence is rising with demographic ageing, with osteoporotic fractures projected to reach 6 million annually by 2050, costing $25.4 billion. A 351 % increase in proximal femur fractures among individuals over 85 years is expected. Accurate fracture localization through imaging, combined with understanding femoral head size and patient-specific factors, improves preoperative planning and outcomes. This study explores the relationship between femoral head size and fracture localization.

Methods

A retrospective cohort study analyzed data from 400 patients with proximal femur fractures treated between 2010 and 2022. Fractures were classified as medial, lateral, pertrochanteric, or subtrochanteric. Radiographs measured femoral head morphology, and statistical analyses, including chi-square tests, t-tests, ANOVA, and logistic regression, identified predictors of fracture localization.

Results

Femoral head area (FHA) varied significantly across fracture types, with lateral fractures having the largest mean FHA (2355.95 mm2/cm2, p = 0.047). Osteoarthritis prevalence differed (p = 0.028), being highest in subtrochanteric fractures (17 %, Kellgren & Lawrence grade 3-4). Lateral fractures had a younger mean age of 71.05 years (p < 0.001), while pertrochanteric fractures averaged 79.52 years (p < 0.001). Vertical (p < 0.001) and horizontal (p = 0.028) femoral head diameters also differed significantly.

Conclusion

Larger femoral heads are associated with lateral fractures, whereas pertrochanteric fractures occur in older patients. Subtrochanteric fractures correlate with smaller femoral heads and advanced osteoarthritis.

Direct anterior approach enhances early recovery outcomes in total hip arthroplasty among elderly individuals with femoral neck fractures: a propensity-matched cohort study

Objective Enhanced recovery after surgery protocols have been increasingly adopted to optimize postoperative functional restoration. This propensity score-matched cohort study quantified the impact of the direct anterior approach during THA on ERAS efficacy in patients with femoral neck fractures and analyzed outcomes such as functional recovery acceleration and perioperative complications. Methods The consecutive cohort comprised 231 patients who underwent primary arthroplasty for femoral neck fractures and were stratified by surgical approach: direct anterior (DAA, n = 59) versus posterolateral (PLA, n = 172). The clinical outcomes, such as patient statistics, details of perioperative management, length of stay, pain, Harris hip score, and in-hospital complications, were recorded. This retrospective observational study mitigated the risk of confounding bias by applying propensity score matching. Results With PSM, 51 pairs of well-matched patients were generated for comparison between the DAA group and the PLA group. The incision length decreased to 10.7 ± 1.4 cm in the DAA group, whereas it was 13.1 ± 1.3 cm in the PLA group. Compared with the PLA cohort, the DAA cohort had a significantly shorter postoperative length of stay (P = 0.001) but superior limb-length discrepancy control (P < 0.001). Compared with the PLA group, the DAA group demonstrated superior early pain control (VAS score reduction: 3/7/14 days, P < 0.05) and accelerated functional gains (HHS improvement: 7/14 days/1 month, P < 0.05), although the 6-month outcomes were similar between groups (P = 0.675). The DAA group exhibited superior 1-month outcomes in terms of pain control, device independence, and ambulation (P < 0.05), but there were similar complication profiles between the groups. Conclusions Compared with the posterolateral approach, DAA enhances early recovery outcomes in THA among elderly patients with femoral neck fractures undergoing ERAS protocols. DAA demonstrated superior short-term functional gains and similar long-term outcomes compared with the posterolateral approach. These findings support the strategic use of DAA for optimizing early recovery for this patient population.

The use of both conventional and dual-mobility components in primary total hip arthroplasty is safe in a university hospital practice

Aims

Dislocation after total hip arthroplasty (THA) is a frequent cause of revision. Patients with intrinsic risk factors have been identified. The use of a dual-mobility (DM) acetabular component has shown great effectiveness in preventing dislocation, with questions regarding selective or absolute use. The aim of this study was to compare the outcome of conventional THA (C-THA) and DM-THA, when used for selected patients.

Methods

This retrospective continuous cohort study evaluated 531 patients, of whom 313 received C-THA and 218 DM-THA. There were 354 primary osteoarthritis (67%), 121 femoral neck fractures (FNFs) (23%), and 56 other indications (10%). The surgical approach was anterior (AA) in 75% cases (398) and posterior (PA) in 25% of cases (133). In the DM-THA group, 189 patients (87%) presented at least one dislocation risk factor compared to 151 patients (48%) in the C-THA group (p < 0.001). The primary outcome was major surgical complications within two years (including deep infection requiring surgery, dislocation requiring closed or open reduction, or revision surgery). Secondary outcomes included length of hospital stay and component positioning.

Results

There were no differences in major complications at two years' follow-up, with six patients (2.7%) in the DM-THA group and eight in the C-THA group (2.6%) (p = 0.301). There were four dislocations in the DM-THA group (three PA and one AA) and three in the C-THA group (three AA) (p = 0.402). The length of stay was significantly longer in the DM-THA group, with seven days (2 to 12) compared to four days (1 to 7) in the C-THA group (p = 0.001).

Conclusion

C-THA and DM-THA are complementary devices in the management of patients requiring primary THA. C-THA associated with AA is a safe option for patients with or without dislocation risk factors, excluding FNF. The selective implantation of the DM component was associated with a low rate of dislocation when THA was undertaken for FNF. The identification of dislocation risk factors is important to select patients requiring DM-THA and provide reproducible outcomes in a university hospital practice with various levels of surgeon experience.

Epidemiology, treatment, and mortality of femoral neck fractures in patients over the age of 65 years: a nationwide retrospective cohort study of 83,789 cases in Turkey

BACKGROUND

A population-based study delineating the epidemiologic, clinical, and treatment characteristics of femoral neck fractures (FNFs) in elderly patients has not yet been conducted in Turkey. In this nationwide study, the epidemiologic, clinical, and treatment characteristics of patients aged ⩾65 years with FNFs who underwent osteosynthesis, hemiarthroplasty (HA), or total hip arthroplasty (THA) were examined.

METHODS

Patients aged ⩾65 years with FNFs were identified in this retrospective, nationwide study. Then, the patients who underwent osteosynthesis or total/hemiarthroplasty from 2016 to 2021 were included. All the outcome variables were collected from patient medical records stored in the e-health database of the Republic of Turkey Ministry of Health.

RESULTS

A total of 83,789 FNFs treated surgically were analysed. Osteosynthesis was performed on 21,130 FNFs (25.2%), HA on 56,378 FNFs (67.3%), and THA on 6281 FNFs (7.5%). From 2016 to 2021, the overall revision rates for THA and HA were 14.6% (914/5367 patients) and 5.9% (3301/53,077 patients), respectively. The rate of revision prosthetic surgery was significantly higher after THA than after HA (p < 0.001). Mortality rates at 1 year were 25% (n = 5293) for osteosynthesis, 14.7% (n = 924) for THA, and 71.1% (n = 40,109) for HA (p = 0.001). The multivariate model of 1-year postoperative mortality revealed 7 independent predictors: male sex (odds ratio [OR] 1.694; 95% confidence interval [CI], 1.640-1.751), use of a cemented femoral stem (OR 1.182; 95% CI, 1.117-1.250), acute myocardial infarction (AMI) (OR 1.317; 95% CI, 1.240-1.400), cerebrovascular accident (CVA) (OR 1.379; 95% CI, 1.333-1.425), chronic liver disease (CLD) (OR 2.188; 95% CI, 1.802-2.489), diabetes mellitus (DM) (OR, 1.160; 95% CI, 1.122-1.200), and age >81.50 years (OR 2.654; 95% CI, 2.569-2.742).

CONCLUSIONS

Our study suggested that a hemiarthroplasty is the most common treatment modality for FNF followed by osteosynthesis (25.2%) and THA (7.5%) in Turkey. Revision rates after THA for FNF are concerning. The 1-year mortality rates are highest after HA, followed by osteosynthesis and THA. Male sex, cemented fixation, CVA, CLD, liver failure, DM, and age >81.50 are the independent predictive factors for postoperative 1-year mortality in this specific group of patients.

Risk factors for mortality in periprosthetic femur fractures about the hip-a retrospective analysis

PURPOSE

Fractures around the hip are known to be an indicator for fragility and are associated with high mortality and various complications. A special type of fractures around the hip are periprosthetic femur fractures (PPF) after Total Hip Arthroplasty (THA). The aim of this study was to investigate the mortality rate associated with PPF after THA and to identify risk factors that may increase it.

METHODS

Consecutive patients (N = 158) who were treated for a PPF after THA in our university hospital between 2010 and 2020 were identified and mortality was assessed using the residential registry. Univariate (Kaplan-Meier-Estimator) and multivariate (Cox-Regression) statistical analysis was performed to identify risk factors influencing mortality.

RESULTS

One-year-mortality rate was 23.4% and 2-year mortality was 29.2%. Mortality was significantly influenced by age, gender, treatment, type of comorbidity and time of surgery (p < 0.05). Surgical treatment during regular working hours (8 to 18 h) reduced mortality by 53.2% compared to surgery on call (OR: 0.468, 95% CI 0.223, 0.986; p = 0.046). For every year of age, mortality risk increased by 12.9% (OR: 1,129, 95% CI 1.078, 1.182; p < 0.001). The type of fracture according to the Vancouver classification had no influence on mortality (p = 0.179). Plate fixation and conservative treatment were associated with a higher mortality compared to revision arthroplasty (plate: OR 2.8, 95% CI 1.318, 5.998; p = 0.007; conservative: OR 2.5, 95% CI 1.421, 4.507; p = 0.002).

CONCLUSION

Surgical treatment during regular working hours is associated with lower mortality compared to surgery outside these hours. In this retrospective cohort, time to surgery showed no significant impact on all-cause mortality, and revision arthroplasty was associated with lower mortality than conservative treatment or plate fixation.

LEVEL OF EVIDENCE

IV (Retrospective cohort study).

A Systematic Review and Meta-Analysis of Supercapsular Percutaneously Assisted Total Hip Arthroplasty Versus Standard Posterior Approach for Femoral Neck Fracture in Elderly Patients

INTRODUCTION

This meta-analysis aimed to evaluate the efficacy and safety of the supercapsular percutaneously assisted total hip arthroplasty (SuperPATH) and the standard posterior approach in hip arthroplasty in treating femoral neck fractures in elderly patients.

METHOD

A systematic search was conducted for studies from 2012 to December 2022. Meta-analysis was conducted using Review Manager 5.3 on surgical time, intraoperative blood loss, Harris hip scores, and visual analog scale scores.

RESULT

A total of 26 studies involving 2,236 patients with femoral neck fractures were included. The SuperPATH group performed better than traditional posterior approach group in reducing intraoperative blood loss (in ml), shortening incision length (in cm), length of hospitalization period (in days) and improving Harris Hip score (HHS). The operation time took longer than the traditional posterior approach, with statistically significant differences. The VAS scores at 1 week and 3 months after surgery in the SuperPATH group were lower than those of the traditional posterior approach, with statistically significant differences. There was no statistical significance between the two groups in VAS scores 2 weeks and 1 month after surgery.

CONCLUSION

The SuperPATH group resulted in better effects in reducing intraoperative blood loss (in ml), shortening incision length (in cm), length of hospitalization period (in days), and improving Harris hip score (HHS), which is conducive to the rapid postoperative recovery of patients.

Classification of AO/OTA 31A/B femur fractures in X-ray images using YOLOv8 and advanced data augmentation techniques

Femur fractures are a significant worldwide public health concern that affects patients as well as their families because of their high frequency, morbidity, and mortality. When employing computer-aided diagnostic (CAD) technologies, promising results have been shown in the efficiency and accuracy of fracture classification, particularly with the growing use of Deep Learning (DL) approaches. Nevertheless, the complexity is further increased by the need to collect enough input data to train these algorithms and the challenge of interpreting the findings. By improving on the results of the most recent deep learning-based Arbeitsgemeinschaft für Osteosynthesefragen and Orthopaedic Trauma Association (AO/OTA) system classification of femur fractures, this study intends to support physicians in making correct and timely decisions regarding patient care. A state-of-the-art architecture, YOLOv8, was used and refined while paying close attention to the interpretability of the model. Furthermore, data augmentation techniques were involved during preprocessing, increasing the dataset samples through image processing alterations. The fine-tuned YOLOv8 model achieved remarkable results, with 0.9 accuracy, 0.85 precision, 0.85 recall, and 0.85 F1-score, computed by averaging the values among all the individual classes for each metric. This study shows the proposed architecture's effectiveness in enhancing the AO/OTA system's classification of femur fractures, assisting physicians in making prompt and accurate diagnoses.

Factors that influence surgical decision-making for geriatric displaced femoral neck fractures: Bullet Health Analysis (BHA) I : Worldwide Orthopaedic Research Collaboration: Leveraging Big Data (WORLD) I

PURPOSE

The management of geriatric femoral neck fractures, which includes options like hemiarthroplasty (HA), total hip arthroplasty (THA), and fixation, exhibits regional and healthcare setting variations. However, there is a lack of information on global variations in practice patterns and surgical decision factors for this injury.

METHODS

Survey data were collected from April 2020 to June 2023 via Orthobullets Case Studies, a global clinical case collaboration platform hosted on a prominent orthopedic educational website. Collaboratively developed standardized polls, based on the best available evidence and a comprehensive, peer-reviewed, evidence-based item list, were used to capture surgeons' treatment preferences worldwide. Subsequent analyses explored preferences within subspecialties and practice settings. Multivariable regression analysis identified associations between subspecialty, practice type, the likelihood of choosing THA, and the preferred femoral fixation method.

RESULTS

Our study encompassed 2595 respondents from 76 countries. Notably, 51.5% of participants (n = 1328; 51.5%, 95% CI 49.6-53.4%) leaned towards THA and 44.9% for HA, while 3.6% favoured surgical fixation. Respondents affiliated with academic institutions and large non-university-affiliated hospitals were 1.74 times more likely to favour THA, and arthroplasty specialists exhibited a 1.77-fold preference for THA. There was a 19-fold variation for cemented femoral fixation between the United Kingdom (UK) and USA with the UK favouring cemented fixation.

CONCLUSION

Our study reveals a significant shift towards THA preference for managing geriatric femoral neck fractures, influenced by subspecialty and practice settings. We also observed a pronounced predominance of cement fixation in specific geographic locations. These findings highlight the evolving fracture management landscape, emphasizing the need for standardization and comprehensive understanding across diverse healthcare settings.

Comparison of femoral neck shortening after femoral neck system and cannulated cancellous screw fixation for displaced femoral neck fractures in young adults

BACKGROUND

The purpose of this study was to compare the outcomes of femoral neck shortening between the femoral neck system (FNS) and the cannulated cancellous screws (CCS) for displaced femoral neck fractures in young adults PATIENTS AND METHODS: In this retrospective analysis, 225 patients aged 18-65 years with displaced femoral neck fracture were divided into two groups according to internal fixation: 135 patients in the FNS group and 90 patients in the CCS group. The length of hospital stay, duration of surgery, intraoperative blood loss, quality of reduction, extent of femoral neck shortening, incidence of femoral neck shortening, femoral neck shortening at each follow-up visit, Harris hip score (HHS), reoperation, and complications were compared between the two groups.

RESULTS

The median follow-up time was 28.2 (26.0, 31.2) months in the FNS group and 30.2 (26.3, 34.7) months in the CCS group. The follow-up time, age, sex distribution, body mass index (BMI), mechanism of injury, injured side, length of hospital stay, time from injury to surgery, and fracture classification were similar between the groups. Duration of surgery was longer in the FNS group (65.0 (55.0, 87.0) min versus 55.0 (50.0, 65.0) min, P<0.001); intraoperative blood loss was greater in the FNS group (50.0 (20.0, 60.0) ml versus 20.0 (10.0, 35.0) ml, P<0.001). Femoral neck shortening was 2.4 (1.0, 4.5) mm in the FNS group versus 0.6 (0.0, 2.6) mm in the CCS group at 1 month postoperatively (P<0.001); 3.7 (1.8, 6.4) mm in the FNS group versus 1.2 (0.6, 3.8) mm in the CCS group at 3 months (P<0.001); 4.1(2.4, 7.7) mm in the FNS group versus 2.3 (1.1, 4.4) mm in the CCS group at 6 months (P<0.001); 4.2 (2.6, 7.7) mm in the FNS group versus 2.6 (1.3, 4.6) mm in the CCS group at 12 months (P<0.001); and 4.5 (2.8, 8.0) mm in the FNS group versus 2.8 (1.5, 4.8) mm in the CCS group at 18 months (P<0.001). The two groups showed no significant differences in HHS, reoperation, and reduction quality.

CONCLUSION

Compared to CCS, FNS is deficient in preventing femoral neck shortening. Future research should focus on improving FNS in terms of preventing femoral neck shortening.

Basicervical femoral neck fractures: an observational study derived from the Swedish Fracture Register

BACKGROUND AND PURPOSE

Limited research has been conducted on basicervical femoral neck fractures (bFNFs). The importance of displacement in clinical outcomes remains unclear. We aimed to characterize patient demographics, degree of displacement, treatment, treatment failures, and reoperations in a cohort of fractures from the Swedish Fracture Register (SFR).

METHODS

1,260 fractures in 1,185 individuals ≥ 60 years who had a bFNF registered in the SFR at 6 orthopedic departments from 2011 to 2020 were screened through radiographic review. The final sample included 291 patients with a confirmed bFNF. The medical records of these 291 patients were reviewed. We assessed baseline characteristics, initial fracture dislocation, treatment methods, tip-apex distance, failures, reoperations, and mortality.

RESULTS

The mean age was 82 years (range 60-101, 55% women). 98 (34%) were undisplaced and 193 (66%) displaced. All patients underwent operative treatment. In the undisplaced group 95 (97%) patients received internal fixation (IF) and 3 (3%) had primary hip arthroplasty. In the displaced group 149 (77%) received IF and 41 (21%) had primary hip arthroplasty. 33 (11%) suffered treatment failure. When treating an undisplaced bFNF with IF, only 3 (3%) experienced treatment failure, in contrast to the 24 (16%) failure rate for a displaced bFNF.

CONCLUSION

Undisplaced bFNFs have a low failure rate when treated with IF. For displaced bFNF treated with IF the failure rate is considerably higher. There is a need for further investigation of classification, treatment, and outcome of bFNF.

Comparison of the Surgical Outcome between the Multiple Screw Fixation and Fixed Angle Devices for the Basicervical Femoral Neck Fractures

Introduction: Basicervical femoral neck fracture (FNF) is an uncommon type of femoral neck fracture and is associated with an increased risk of fixation failure due to its inherent instability. The purpose of this study was to compare the surgical parameters and reoperation rate between the use of a multiple cannulated screw (MCS) and fixed angle device (FAD) in treating basicervical FNFs. Methods: We retrospectively reviewed the records of 885 patients who underwent internal fixation between May 2004 and August 2019 to determine basicervical FNF with at least 12 months of follow-up. Among the identified 77 patients with basicervical FNF, 17 patients who underwent multiple cannulated screw (MCS) fixation and 36 patients who underwent fixed angle device (FAD) fixation were included. We compared the rates of fracture-site collapse and reoperations according to the fixation device. Results: Among the 53 patients with basicervical FNF, 13 patients (24.5%) sustained surgical complications (8 collapses of fracture site and 5 reoperations). The reoperation rate in the MCS group was significantly higher than that in the FAD group (23.5% vs. 2.8%, p = 0.016), without any significant difference in the collapse of the fracture site (11.8% vs. 16.7%, p = 0.642). Conclusions: Although basicervical FNF was rare among hip fractures, fracture site collapse was prevalent and prone to fixation failure. Surgeons should keep this in mind, and consider FAD for basicervical FNF.

Elderly awareness and perception of neck femur fracture in Saudi Arabia

Background

Femoral neck fractures are prevalent and make up the highest per cent of proximal femur fractures. The femoral neck is the most common location for a hip fracture. This study aims to assess elderly awareness and perception of neck femur fracture in Saudi Arabia.

Methods

A descriptive cross-sectional web-based study was conducted targeting all persons aged 60 years or above. An online questionnaire was developed by the study researchers based on literature review and after consultation of the field experts. The anonymous questionnaire was published using the social media platforms from October 2022 to January 2023 by the researchers and their families.

Results

A total of 410 elderly completed the study questionnaire. Elderly age ranged from 60 to 89 years with mean age of 68.2 ± 10.9 years old. A total of 44 (10.7%) of the study elderly had an overall good awareness regarding NFF. The most reported sources were physician (61.7%), social media (41.2%), mass media (33.4%) and books and magazines reading (20.5%).

Conclusion

In conclusion, elderly awareness regarding femur neck fracture was very low especially among male elderly and those with no history of trauma. Poor awareness for clinical presentation and complications of NFF was reported.

Comparison of reconstruction nails versus dual implants in the treatment of ipsilateral femoral neck and shaft fractures in adults: a meta-analysis and systematic review

OBJECTIVE

There is no consensus on the optimal treatment for ipsilateral femoral neck and shaft fractures. This meta-analysis aims to assess the effectiveness of reconstruction nails and dual implants in treating ipsilateral femoral neck and shaft fractures to provide a basis for decision-making when selecting the optimal approach.

METHODS

Relevant articles were retrieved from Pubmed, Embase, and Cochrane databases using the keywords "neck of femur", "shaft" and "fracture fixation" from inception until November 17, 2022. The screening process of the studies was conducted independently by two assessors, who assessed each study's eligibility and two assessors assessed the quality. Then compared differences in outcome measures using RevMan 5.3 software.

RESULTS

A total of ten retrospective cohort studies were included. There were no significant differences in union time, union rate, union-related complications (malunion, nonunion, delayed union) of femoral neck and shaft fractures, osteonecrosis of the femoral head, and functional outcomes (Friedman-Wyman scoring system) (P > 0.05).

CONCLUSION

Our pooled estimates indicated that reconstruction nails and dual implants for ipsilateral femoral neck and shaft fractures could yield satisfactory surgical results, and that there is no difference between the two treatment methods.

TRIAL REGISTRATION

This meta-analysis was registered on the PROSPERO website (registration number: CRD42022379606).

Acetabular Morphology Predicts the Risk of Dislocation Following Hemiarthroplasty for Femoral Neck Fractures in the Elderly

BACKGROUND

Hip hemiarthroplasty dislocation is a devastating complication. Among other preoperative risk factors, acetabular morphology has been rarely studied. The purpose of the study was to evaluate the influence of preoperative native acetabular morphology on hemiarthroplasty dislocation.

METHODS

We retrospectively reviewed 867 patients who underwent hip hemiarthroplasty for femoral neck fracture between January 1, 2014 and January 1, 2019. The 380 included patients were treated with an anterior-based muscle-sparing approach. The central-edge angle (CEA) and acetabular depth-to-width ratio (ADWR) of the fractured hip were measured preoperatively on the anteroposterior pelvic view. Receiver operating characteristic curves were performed to analyze the optimal cutoff for CEA and ADWR. Hemiarthroplasty dislocation occurred in 18 patients (4.7%), and the remaining 362 patients were used as the control group.

RESULTS

No significant differences in terms of sex, age, dementia, neuromuscular disease, and body mass index were found between the 2 groups. The 18 patients who had a hip dislocation had significantly smaller mean CEA than the control group (P = .0001) (mean 36.1 ± 7.5° and 43.2 ± 5.6°, respectively) as well as ADWR (mean 34 ± 6 versus 37 ± 4, respectively) (P = .001). Using the receiver operating characteristic analysis, we report significant cutoffs of 38.5° for CEA (P = .0001) and 34.5 for the ADWR (P = .017).

CONCLUSION

Higher rates of hemiarthroplasty dislocation were observed in patients who had a preoperative CEA of less than 38.5° and an ADWR of less than 34.5. Patients who have preoperative acetabular morphological risk factors for dislocation might be better candidates for a total hip arthroplasty.

Direct Anterior vs. Direct Lateral Approach Total Hip Arthroplasty for Displaced Femoral Neck Fracture

BACKGROUND

This study compared outcomes of the direct anterior approach (DAA) and direct lateral approach (DLA) for treating displaced femoral neck fractures in active elderly patients.

METHODS

This retrospective study included active elderly patients who sustained a displaced femoral neck fracture and underwent a cementless total hip arthroplasty either with a supine DAA or a decubitus DLA. Patients were assessed using the Harris hip score at discharge and at a 6-week follow-up.

RESULTS

A total of 41 women and 18 men were included in the study. Of those, 22 underwent DLA and 37 received DAA, all performed by the same team. In both groups, 69% were women, mean age was 70 years, and mean BMI was 25.2. Mean hemoglobin loss was 2.3 g/dl between admission and the first post-operative day in both groups. Similar numbers in each cohort were discharged home rather than to a rehabilitation center. The patients who underwent the DAA experienced a 2-day reduction in their hospital stay compared to the DLA group (4.2 ± 1.9 vs. 6.8 ± 3.7, respectively; p < 0.001). The Harris hip score in the DAA group was significantly higher at the 6-week follow-up than in the DLA group (87.23 ± 7.75 vs. 81.23 ± 7.67, respectively; p < 0.031).

CONCLUSIONS

The patients who underwent THA with the DAA demonstrated better short term outcomes compared to the alternative approach for displaced femoral neck fractures in active elderly patients. DAA helped patients regain independence faster and might decrease hospitalization and rehabilitation costs. Based on these results, we recommend using the DAA for active elderly patients with a displaced femoral neck fracture.

Association of depressive disorders and dementia with mortality among older people with hip fracture

BACKGROUND

Hip fracture (HF) is a significant cause of mortality among older people. Almost half of the patients with HF have dementia, which increases the mortality risk further. Cognitive impairment is associated with depressive disorders (DDs) and both dementia and DDs are independent risk factors for poor outcome after HF. However, most studies that evaluate mortality risk after HF separate these conditions.

AIMS

To investigate whether dementia with depressive disorders (DDwD) affects the mortality risk at 12, 24, and 36 months after HF among older people.

METHODS

Patients with acute HF (n = 404) were included in this retrospective analysis of two randomized controlled trials performed in orthopedic and geriatric departments. Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive function was assessed using the Mini-Mental State Examination. A consultant geriatrician made final depressive disorder and dementia diagnoses using the Diagnostic and Statistical Manual of Mental Disorders criteria, with support from assessments and medical records. The 12-, 24- and 36-month mortality after HF was analyzed using logistic regression models adjusted for covariates.

RESULTS

In analyses adjusted for age, sex, comorbidity, pre-fracture walking ability, and fracture type, patients with DDwD had increased mortality risks at 12 [odds ratio (OR) 4.67, 95% confidence interval (CI) 1.75-12.51], 24 (OR 3.61, 95% CI 1.71-7.60), and 36 (OR 4.53, 95% CI 2.24-9.14) months. Similar results were obtained for patients with dementia, but not depressive disorders, alone.

CONCLUSION

DDwD is an important risk factor for increased mortality at 12, 24, and 36 months after HF among older people. Routinely assessments after HF for cognitive- and depressive disorders could identify patients at risk for increased mortality, and enable early interventions.

TRIAL REGISTRATION

RCT2: International Standard Randomized Controlled Trial Number Register, trial registration number: ISRCTN15738119.

Characteristics of subsequent contralateral proximal femoral fracture: more convenient access is needed to treat osteoporosis

BACKGROUND

Patients with proximal femoral fracture (PFF) have high mortality and many complications. Osteoporosis increases the risk of subsequent fractures, leading to subsequent contralateral PFF. This study was performed to analyze the features of individuals with subsequent PFF following surgical therapy of first PFF and to ascertain whether such patients received an examination or treatment of osteoporosis. The reasons for lack of examination or treatment were also analyzed.

METHODS

This retrospective study involved 181 patients with subsequent contralateral PFF who underwent surgical treatment in Xi'an Honghui hospital from September 2012 to October 2021. The patients' sex, age, hospital day, mechanism of injury, surgical procedure, fracture interval, fracture type, fracture classification, and Singh index of the contralateral hip at the time of the initial and subsequent fractures were recorded. Whether the patients took calcium and vitamin D supplements, used anti-osteoporosis medication, or underwent a dual X-ray absorptiometry (DXA) scan was recorded, as was the start time of each. Patients who had never undergone a DXA scan or received anti-osteoporosis medication took part in a questionnaire.

RESULTS

The 181 patients in this study comprised 60 (33.1%) men and 121 (66.9%) women. Patients with initial PFF and subsequent contralateral PFF had a median age of 80 years (range 49-96 years) and 82 years (range 52-96 years), respectively. The median fracture interval was 24 (7-36) months. Contralateral fractures occurred at the highest incidence between 3 months and 1 year (28.7%). The Singh index was not significantly different between the two fractures. In 130 (71.8%) patients, the fracture type was the same. No significant difference was found in the fracture type or fracture stability classification. A total of 144 (79.6%) patients had never received a DXA scan or anti-osteoporosis medication. The main reason for not treating osteoporosis further was concern about the safety of drug interactions (67.4%).

CONCLUSIONS

Patients with subsequent contralateral PFF were of advanced age, had a higher proportion of intertrochanteric femoral fractures, had more severe osteoporosis, and had longer hospital stays. The difficulty managing such patients requires multidisciplinary involvement. Most of these patients were not screened or formally treated for osteoporosis. Advanced-age patients with osteoporosis need reasonable treatment and management.

Proportion of stable femoral neck fracture types in different age groups: a population-based study

OBJECTIVE

The treatment and incidence of femoral neck fracture (FNF) in older patients is controversial. We investigated the new AO (Arbeitsgemeinschaft für Osteosynthese) classification in patients with FNF by age to determine the proportions of stable fracture and change trends according to patients' age.

METHODS

We divided patients with FNF hospitalized in Xi'an Honghui Hospital from 2018 to 2020 into five groups according to age: young (<50 years), middle-aged (50-59 years), young-elderly (60-69 years), middle-elderly (70-79 years), and very elderly (≥80 years) groups. We retrospectively collected data of patients' sex, admission date, fracture side, mechanism of injury, and new AO classification.

RESULTS

In total, 2071 patients were included for analysis, with 1329 women (64.2%); 1106 patients (53.4%) had left-side fracture. The main mechanism of injury was falling. In the young-elderly, middle-elderly, and very-elderly groups, 33.3%, 29.2%, and 24.1% had stable fracture type, respectively). The proportion of patients with FNF did not show a change trend by age during the 3-year investigation period.

CONCLUSION

In our study, the proportion of older patients with FNF did not increase, and as many as a third of patients with FNF aged 50 to 70 years had stable fracture.

Study protocol: The DAICY trial-dual versus single-antibiotic impregnated cement in primary hemiarthroplasty for femoral neck fracture-a register-based cluster-randomized crossover-controlled trial

BACKGROUND AND PURPOSE

Older patients with a displaced femoral neck fracture (FNF) are often treated with a cemented primary hemiarthroplasty (HA). The DAICY trial investigates whether high-dose dual-impregnated antibioticloaded cement (DIAC) including gentamicin and clindamycin can reduce the risk of periprosthetic joint infection (PJI) in comparison with low-dose single-impregnated gentamicin antibiotic-loaded cement (SIAC), in patients ≥ 60 years treated with a cemented HA for a displaced FNF.

STUDY DESIGN

The trial is a national, multicenter, register-based, cluster-randomized, crossover trial. Patients ≥ 60 years with a non-pathological, displaced FNF (Type Garden 3-4/AO 31-B2 or B3) suitable for HA according to local guidelines are eligible for inclusion. Participating orthopedic departments will be randomized to start with either SIAC (control group) or DIAC treatment (intervention group) for 2 years. After 2 years, the study departments will then change to the other treatment arm for the remaining 2 years of the study. Approximately 7,000 patients will be included. The study is pragmatic in that the choice of implant brands, surgical approach and peri- and postoperative protocols follow the local routines of each participating department. All outcome variables will be retrieved after linkage of the study cohort to the following Swedish registers: the Fracture Register, the Arthroplasty Register, the National Patient Register and the Prescribed Drug Registry Outcome: The primary outcome will be periprosthetic joint infection of the index joint within 1 year after surgery. Secondary outcomes will be any reoperation on the index joint, mortality within 90 days and 1 year, resistance patterns of causative bacteria in cases of PJI, and health economics. Potential added value: This trial is designed to support or refute the efficacy of DIAC used in patients with a displaced FNF, potentially reducing PJI and resource allocation. Start of the trial and estimated duration - The DAICY trial started recruiting patients in January 2022 and will continue recruiting for approximately 4 years. Complete follow-up expected in 5 years.

Direct Anterior Approach in Hip Hemiarthroplasty for Femoral Neck Fractures: Do Short-Term Outcomes Differ with Approach?: A Systematic Review and Meta-Analysis

BACKGROUND

Hip hemiarthroplasty (HA) is commonly used to treat femoral neck fractures, but it remains unclear if the surgical approach impacts patient outcomes for this commonly performed procedure. The objective of this systematic review and meta-analysis was to assess early postoperative outcomes in patients undergoing HA for femoral neck fracture with the direct anterior approach (DAA) compared with other approaches.

METHODS

The Cochrane Central Registry of Controlled Trials, MEDLINE, and Google Scholar databases were searched for randomized controlled trials, prospective nonrandomized trials, and retrospective studies published prior to September 7, 2021, comparing DAA with other approaches (anterolateral approach [ALA], direct lateral approach [DLA], and posterior-based approach [PA]) in HA for femoral neck fractures. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes included functional outcomes, total complications, prosthetic dislocation, periprosthetic fracture, periprosthetic joint infection (PJI), reoperation, mortality, pain, operative time, and perioperative blood loss. Fixed effect odds ratios, along with their 95% confidence intervals, were used to analyze dichotomous variables. Significance was set at p < 0.05. Meta-analysis was conducted with Review Manager 5.4.

RESULTS

In total, 19 studies were included for qualitative analysis and 16 studies were included for quantitative analysis, with a total of 1,604 cases analyzed (723 DAA, 215 ALA, 301 DLA, and 365 PA). Compared with other approaches, the use of the DAA for HA was associated with improved early postoperative functional outcomes, lower early postoperative pain scores, fewer total complications, and fewer prosthetic hip dislocations. The rates of periprosthetic fracture, PJI, and reoperation, pain scores beyond 40 days, operative time, perioperative blood loss, and mortality were not significantly different between surgical approaches.

CONCLUSIONS

Utilizing the DAA while performing HA for femoral neck fractures is associated with improved functional outcomes, lower early postoperative pain scores, lower incidence of prosthetic hip dislocation, and potentially fewer total complications.

LEVEL OF EVIDENCE

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

Stress fractures of the femoral neck in adults: an observational study on epidemiology, treatment, and reoperations from the Swedish Fracture Register

BACKGROUND AND PURPOSE

Stress fractures of the femoral neck (sFNFs) are uncommon injuries. Studies on sFNFs are rare. We describe the demographics, classification, treatment, reoperation rates, and mortality in a cohort of sFNF patients from the Swedish Fracture Register (SFR).

PATIENTS AND METHODS

We included 146 patients ≥ 18 years of age with an sFNF registered in the SFR between 2011 and 2020. The cohort was linked with the Swedish Arthroplasty Register and reviewed using medical records and radiographs. We assessed the presence of disorders of bone remodeling, duration of symptoms, fracture classification, treatment, reoperations, and mortality.

RESULTS

The mean age was 58 years (21-96), 75% were women and the median duration of symptoms was 23 days (1-266). 40% of patients had disorders of bone remodeling. 54% were undisplaced (uFNF), 30% displaced (dFNF), and 16% basicervical (bFNF). 14% of patients < 60 years were treated nonoperatively, by internal fixation (IF) in 77% and by arthroplasty in 10%. Patients ≥ 60 years were treated nonoperatively in 10%, IF in 40%, and arthroplasty in 49%. Nonoperative treatment was reserved for uFNFs or bFNFs, resulting in 35% receiving late surgery. The overall secondary or late surgery rate was 19%. Mortality was 2% at 90 days and increased to 3% at 1 year.

INTERPRETATION

sFNF has a biphasic age distribution. One-third of patients presented with a displaced FNF and those managed nonoperatively for an undisplaced sFNF were at risk of late surgery. The mortality rates for patients with these injuries was low.