Management of proximal femur fractures in the elderly: current concepts and treatment options

Structural characteristics, biomechanics and clinical significance of calcar femorale: A review

The calcar femorale, first identified by Merkel in 1874, plays a pivotal role in the weight-bearing capacity of the proximal femur, and its structural integrity is crucial for the efficient distribution of mechanical loads. Originating at the vertical ridge where the pubofemoral ligament anchors, this bony prominence extends laterally behind the neutral axis from the medial to lateral aspects. Its presence is not merely an anatomical curiosity but significantly influences the biomechanics of the hip joint by providing additional strength and support against compressive forces encountered during activities such as walking or jumping. Despite its clear description in orthopedic texts, misconceptions persist about its exact function and importance. This article delves into the nuanced anatomy and biomechanical properties of the calcar femorale, offering a detailed literature-based examination that demonstrates its relevance in clinical practice. The review highlights how the robustness of the calcar femorale contributes to the prevention of femoral neck fractures as well as the stabilization of hip prostheses. Furthermore, the indispensable role of the calcar femorale in surgical outcomes is discussed, especially in the context of fracture repair and joint replacement, thus illustrating its enduring significance in contemporary medical applications.

[Nonunions after intertrochanteric and subtrochanteric femoral fractures]

INTRODUCTION

The overall frequency of proximal femoral fractures means that we are repeatedly confronted with failed healing and implant failure, despite a relatively low nonunion rate especially in intertrochanteric fractures (< 5%). The aim of this paper is to present our approach to treating these nonunions of the proximal femur and discuss the treatment results.

MATERIAL AND METHODS

Between 2009 and 2023, patients with nonunion of the proximal femur were retrospectively identified and analyzed. Age, gender, time to revision, the Weber-Cech classification of pseudarthrosis and radiographic imaging before and after revision were analyzed.

RESULTS

A total of 66 patients were analyzed. The mean age was 58 years (range 25-88 years). The overall healing rate was 88% with a mean consolidation time of 8 months (range 2-29 months). The main osteosynthesis procedures were plate osteosynthesis (n = 45, of which 44 were blade plates), and nail replacement (n = 12). Other procedures included augmentative plate osteosyntheses (n = 4), isolated cancellous bone graft (n = 2), nail dynamization (n = 2), and the use of a dynamic hip screw (n = 1).

DISCUSSION

The analysis of our treatment data as well as the current literature, revealed a trend towards intramedullary revision procedures. Implants that can be used to correct the CCD angle, such as the blade plate, remain a predictable option to achieve correction, especially in nonunions with an increased degree of varus. Particularly in the subtrochanteric region, fractures can also be treated in a targeted manner by a combination of mechanical and biological methods with a reamed nail change to a larger caliber implant.

[Treatment of proximal femoral fractures : Principles, tips and tricks]

Proximal femoral fractures occur at an annual incidence of approximately 200/100,000 inhabitants and mortality rates range up to 30% especially in geriatric patients where complications are not necessarily associated to surgery. In nearly all cases surgical treatment is required. Procedures to preserve the femoral head have to be performed as early as possible (as specified by the Federal Joint Committee, GBA, within 24 h). For joint-preserving approaches in medial femoral neck fractures a time to surgery within 6 h is considered to be advantageous. Perioperative patient care is of high importance regarding the prevention of pneumonia, renal failure, delirium and further complications. Postoperatively full weight bearing enables for early mobilization and prevention of surgery-related complications. Nonunions, avascular necrosis of the femoral head, cut-out and prosthetic dislocation must be avoided by the selection of the appropriate procedure. Minimally displaced femoral neck fractures are primarily treated by osteosynthesis and conservative management is only considered in isolated cases. For displaced femoral neck fractures, factors such as a young biological age with high activity levels, the absence of arthritis and good bone quality with a successful reduction favor for a femoral head-preserving osteosynthesis. Otherwise, (hybrid) total hip replacement (THR) is the preferred method for unstable and displaced fractures, whereby hemiarthroplasty should only be considered for very old and patients with pre-existing diseases. Fractures in the trochanteric region are treated with a proximal femoral nail and subtrochanteric fractures are managed using a long proximal femoral nail. To avoid secondary complications, the choice of optimal treatment should be based on a good understanding of the injury pattern, biomechanical and technical aspects of each procedure.

Geriatric proximal femur fracture updates

Proximal femur fractures in the aging population present a variety of challenges. Physiologically, patients incurring this fracture are typically frail, with significant medical comorbidities, yet require early surgical treatment to restore mobility to prevent deterioration. Socioeconomically, the occurrence of a fragility fracture may be the beginning of the loss of independence, and the burdens of rehabilitation and support are borne by the individual patient and health care systems.

Mechanical Complications of Proximal Femur Fractures Treated with Intramedullary Nailing: A Retrospective Study

Background and Objectives: This retrospective cohort study analyzes mechanical complications in hip fracture surgery using the Trochanteric Fixation Nail-Advanced (TFNA) implant. It investigates the correlation of these complications with demographic, intraoperative, and radiological factors, aiming to identify associated risk factors and suggest improvements in clinical surveillance and treatment strategies. Materials and Methods: We enrolled 253 patients diagnosed with pertrochanteric hip fractures treated between 2017 and 2021, with 126 meeting the criteria for a minimum 6-month follow-up. Data on demographics, American Anesthesia Association Classification (ASA), comorbidities, AO/OTA [AO (Arbeitsgemeinschaft für Osteosynthesefragen)/OTA (Orthopedic Trauma Association)] fracture classification, procedural details, and time to failure were collected. Radiographs were evaluated for reduction quality, the tip-apex distance (TAD), progressive varus deviation, and identification of mechanical complications. Statistical analysis was performed using SPSS software. Results: The predominant AO/OTA fracture classification was 31A2 in 67 cases (52.7%). Reduction quality was deemed good or acceptable in 123 cases (97.6%). The mean time to failure was 4.5 months (range: 2.2-6). The average TAD was 18 mm (range: 1.2-36), with a mean progressive varus deviation of 2.44° (range: 1.30-4.14). A good or acceptable reduction quality was observed in 97.6% of cases. Mechanical complications occurred in 21.4% of patients, with significant associations found with the lateral cortex fracture, use of a TFNA implant with a 130° angle, open reduction, and absence of prior osteoporosis treatment. Conclusions: The study provides insights into mechanical complications in proximal femur fractures treated with the TFNA nail, emphasizing the need for enhanced clinical and radiographic surveillance, especially in patients without osteoporosis treatment. Our findings support the necessity for further clinical studies comparing these outcomes with other implant designs and underscore the importance of personalized treatment strategies to reduce complication rates.

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.

A complementary analytical tool for hip prosthesis dislocation: Thermal imaging in rehabilitation

The use of routine ionizing imaging in identify and classify patients with dislocation or infection after surgery has some medical contraindication, in addition to risks associated with the ionizing load and elevated costs. A novel, less expensive and non-ionizing imaging technique, called infrared thermal imaging, can be proposed as a complementary method to routinely evaluate hip prosthesis patients and track their inflammation response following serious complications. Here we report a case of a total hip prosthesis which was dislocated during inpatient rehabilitation, and ultimately reduced without surgical procedure. During the process, routine clinical and radiographic diagnosis was complemented with an infrared examination. The infrared images were easy to take bedside, without direct contact with the area of surgery, and well tolerated. After the dislocation reduction, the thermal imaging procedure provided important feedbacks on the local inflammation, helping to exclude other complications such as the infections.

Meta-analysis of the clinical efficacy of the Gamma3 nail vs Gamma3U-blade system in the treatment of intertrochanteric fractures

BACKGROUND

The traditional Gamma3 nail is a mainstream treatment for femoral intertrochanteric fractures. Literature reports that the Gamma3U-blade system can increase the stability of the Gamma3 nail and reduce complication incidence. However, comparative studies between the Gamma3U-blade and Gamma3 systems are limited; hence, this meta-analysis was performed to explore the clinical efficacy of these two surgical methods.

AIM

To investigate the clinical efficacy of Gamma3 and Gamma3 U-blade for intertrochanteric fractures.

METHODS

A computerized search for Chinese and English literature published from 2010 to 2022 was conducted in PubMed, Cochrane, CNKI, Wanfang, and VIP databases. The search keywords were gamma 3, gamma 3 U blade, and intertrochanteric fracture. Additionally, literature tracking was performed on the references of published literature. The data were analyzed using Revman 5.3 software. Two individuals checked the inputs for accuracy. Continuous variables were described using mean difference and standard deviation, and outcome effect sizes were expressed using ratio OR and 95% confidence interval (CI). High heterogeneity was considered at (P < 0.05, I2 > 50%), moderate heterogeneity at I2 from 25% to 50%, and low heterogeneity at (P ≥ 0.05, I2 < 50%).

RESULTS

Following a comprehensive literature search, review, and analysis, six articles were selected for inclusion in this study. This selection comprised five articles in English and one in Chinese, with publication years spanning from 2016 to 2022. The study with the largest sample size, conducted by Seungbae in 2021, included a total of 304 cases. Statistical analysis: A total of 1063 patients were included in this meta-analysis. The main outcome indicators were: Surgical time: The Gamma3U blade system had a longer surgical time compared to Gamma3 nails (P = 0.006, I2 = 76%). Tip-apex distance: No statistical significance or heterogeneity was observed (P = 0.65, I2 = 0%). Harris Hip score: No statistical significance was found, and low heterogeneity was detected (P = 0.26, I2 = 22%). Union time: No statistical significance was found, and high heterogeneity was detected (P = 0.05, I2 = 75%).

CONCLUSION

Our study indicated that the Gamma3 system reduces operative time compared to the Gamma3 U-blade system in treating intertrochanteric fractures. Both surgical methods proved to be safe and effective for this patient group. These findings may offer valuable insights and guidance for future surgical protocols in hip fracture patients.

Benefits of surgical treatment within 48 h of proximal femoral fracture in centenarians: a retrospective cohort study

Introduction

Proximal femoral fractures in aging populations represent a significant concern, with an increasing prevalence among individuals aged ≥100 years. The existing research does not provide robust guidance for clinicians managing older patients aged ≥100 years with proximal femoral fractures. We investigated the safety and efficacy of surgical treatment in patients aged ≥100 years with proximal femoral fractures and evaluated the impact of early surgery on their outcomes.

Methods

This retrospective cohort study involved 15 patients aged ≥100 years who underwent surgical treatment of proximal femoral fractures; the control group included 137 patients in their 90s. Data were collected between January 2010 and December 2017. Evaluation items included patient characteristics, surgical details, perioperative complication rates, length of hospital stay, the proportion of patients discharged to the same facility or home, rate of regaining walking ability, and 1-year survival rate.

Results

The patients aged ≥100 years and those in their 90s had comparable outcomes. Thus, age alone does not dictate surgical success. Early surgery (≤48 h) was associated with trends toward improved perioperative complications, ambulatory ability, and return to original living environment.

Discussion

This study underscores the potential benefits of surgical intervention for proximal femoral fractures in patients aged ≥100 years, indicating the relevance of early surgery (≤48 h). Our findings emphasized the importance of timely intervention and evidence-based decision-making for this demographic. Clinicians, policymakers, and patients could benefit from our insights to enhance fracture management strategies, along with future research endeavors to validate and expand our results in larger multicenter cohorts.

Comparison of Bone-setting Robots and Conventional Reduction in the Treatment of Intertrochanteric Fracture: A Retrospective Study

OBJECTIVE

Intertrochanteric fracture of the femur is a common fracture in older people. Due to the poor systemic condition and prognosis of elderly patients, it is prone to more complications. We introduce the bone-setting concept in the design of the robots, which are used for intertrochanteric fracture of the femur reduction. The purpose of this study is to compare the effect of bone-setting robots and conventional reduction in the treatment of intertrochanteric fracture of the femur (IFF).

METHODS

From June 2021 to January 2023, 60 patients with IFF who were treated surgically were assigned to bone-setting robots group and conventional reduction methods group in this retrospective study. The reduction time, operation time, total time, intraoperative blood loss, incision length, fluoroscopy time, and the follow-up time were reviewed. The visual analogue scale (VAS) and Harris scores were used for functional assessment. For continuous variables, independent t-tests were applied; for categorical data, the chi-square test was applied. The significance level as p < 0.05.

RESULTS

Among the 60 patients with IFF, 31 were assigned to the bone-setting robots group, and 29 were assigned to the conventional reduction methods group. Both groups with a similar baseline in the number, gender, age, and classification (p > 0.05). The reduction time, operation time, total time, intraoperative blood loss, and fluoroscopy time were less than those in the bone-setting robots reduction group compared to the conventional reduction group. In the bone-setting robots reduction group, the preoperative VAS score was 6.2 ± 1.3, the Harris score was 35.3 ± 3.1, 1 week after surgery VAS score was 3.3 ± 1.2, the Harris score was 57.3 ± 3.7, and at the last follow-up VAS score was 2.4 ± 0.8, and the Harris score was 88.7 ± 3.4. While in the conventional reduction group, the preoperative VAS score was 6.3 ± 1.3, the Harris score was 35.9 ± 2.9, 1 week after surgery VAS score was 4.8 ± 1.4, the Harris score was 46.8 ± 2.8, and at the last follow-up VAS score was 2.6 ± 0.8, and the Harris score was 87.3 ± 3.3. There were no significant differences between the two groups at the preoperative and 6-month postoperative follow-ups in VAS score and Harris score (p > 0.05, p > 0.05, respectively). But the difference was statistically significant at the one-week postoperative follow-up in VAS and Harris scores (p < 0.001).

CONCLUSION

The bone-setting robots can better protect the "fracture environment" and have the advantages of being precise, minimally invasive, simple, short time, low radiation, and rapid fracture recovery. The clinical effect of closed repair of IFF is ideal.

Unipolar Hip Hemiarthroplasty in Geriatric Patients: A Prospective Study and Analysis of Clinical and Radiological Outcomes

Introduction

Femoral neck fractures (FNF) in the geriatric population are commonly treated with hip replacement procedures, such as total hip arthroplasty, unipolar hip hemiarthroplasty (UHA), and bipolar hip hemiarthroplasty (BHA). The optimal treatment remains controversial, considering outcomes and cost-effectiveness, with UHA often being cheaper. This prospective observational study aims to evaluate UHA's clinical and radiological outcomes, safety, and survivorship compared to existing literature.

Methods

We followed 90 elderly patients who underwent UHA following FNF. We assessed patients using the Parker score before and after surgery, as well as Harris Hip Score (HHS), and Postel-Merle d'Aubigné (PMA) scores postoperatively. All complications, acetabular erosions and heterotopic ossifications (HO), were documented.

Results

One year post-surgery, 26.7% of patients had passed away, mostly due to declining general health status. Systemic complications occurred in 14.4% of cases, with a 1.1% rate of deep surgical site infections. A single dislocation resulted from excessive stem anteversion. UHA implant survival rate was 97.8% after 4 years. The Parker score remained stable, and HHS at 6 and 12 months was 71.5 ± 12.9 and 70.9 ± 11.8, respectively, while PMA score was 14.3 ± 2.4 and 14.5 ± 2.1, respectively. Five hips showed Baker I acetabular wear. HO were noted as Brooker I in 12 patients, II in 4 patients, and IV in 1 patient.

Discussion

UHA exhibited comparable systemic complication rates, implant survivorship, and dislocation rates to those in the literature for both UHA and BHA. The deep surgical site infection rate was lower than reported for BHA. Patients' functional and mental abilities did not decline based on clinical scores. Acetabular wear in UHA was similar to its bipolar counterpart, while HO were only minor findings with no clinical implications.

Conclusion

In elderly patients, UHA demonstrated clinical and radiological outcomes similar to BHA in existing literature. UHA may represent a cost-effective alternative for patients with limited life expectancy.

Outcomes in very elderly ICU patients surgically treated for proximal femur fractures

Proximal femur fractures (PFF) are a common injury in elderly patients that significantly impact mobility and daily living activities. Mortality rates in this population are also high, making effective treatment essential. Recent advances in intensive and geriatric care have enabled complex surgical interventions that were previously not feasible. However, there is a lack of studies focusing on outcome parameters in very elderly patients (≥ 90 years) who receive intensive care treatment following PFFs. In this retrospective study, we analyzed multi-layered data of 148 patients who were 90 years or older and received intensive care after trauma and orthopedic surgical treatment for PFFs or periprosthetic fractures between 2009 and 2019. All patients received a 365-day follow-up. To identify potential predictors of mortality, all deceased and surviving patients were subjected to multiple logistic regression analyses. We found that 22% of patients deceased during in-hospital care, and one-year survival was 44%. Independent predictors of one-year all-cause mortality included higher CCI and SOFA scores at ICU admission. Overall, 53% of patients who resided in private dwellings prior to admission were able to return home. Our study highlights the utility of using CCI and SOFA scores at ICU admission as prognostic indicators in critically ill very elderly patients who undergo surgical treatment for PFFs. These scores can provide valuable insight into the severity of illness and potential outcomes, which can inform resource allocation, prioritize endangered patients, and aid in end-of-life discussions and planning with patients and their families. Our findings can help improve the management of PFFs in very elderly patients and contribute to optimized patient care.

Femoral insufficiency fracture related to bisphosphonate use

This case report details the symptoms, diagnostic results, and surgical treatment of a 66-year-old woman who presented to the emergency department complaining of excruciating pain in her right leg after being injured while doing Pilates. After an accident involving a ball during a Pilates exercise, the patient reported feeling pain. Upon physical examination, the right leg was found to be shortened and externally rotated, with the foot's sensation and mobility unaffected. A displaced proximal subtrochanteric femur fracture was detected via plain film radiography.

Anticoagulation management in elderly patients with proximal femur fractures - overview of current concepts

Objectives

Proximal femur fractures (PFF) are common injuries in elderly patients and can have considerable effects on their quality of life, morbidity, and mortality. Due to pre-existing comorbidities, the prevalence of anticoagulated patients is increasing. The right timing for surgery and perioperative anticoagulation treatment remains controversial.

Content

This overview aims to summarize current practices in the pre- and postoperative anticoagulation management and the recommended time to surgery in elderly patients with PFF.

Summary and Outlook

Time to surgery for anticoagulated patients is often prolonged due to worries about serious perioperative bleeding and higher transfusion demands. But the delay of surgical PFF treatment increases the risk for perioperative complications like pulmonary embolism, pneumonia, deep vein thrombosis and urinary tract infections. Early surgery can be achieved with a consistent and interdisciplinary perioperative anticoagulation management. Antiplatelets do not have to be discontinued and surgery should be performed early without delay. For patients taking vitamin K antagonists (VKA) an INR less than 1.5 is recommended prior to surgery, which can be achieved by pausing VKA intake or by administering vitamin K, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). For the treatment with direct oral anticoagulants (DOAC) a plasma drug level of under 50 pg/mL is considered safe for surgery. If the plasma level can not be determined, a gap of 24 h between the last DOAC dose and surgery is recommended. The systemic administration of tranexamic acid can reduce overall blood loss and transfusion rates in anticoagulated patients with PFF. Surgical treatment of PFF should be performed within 24 h, as delayed surgery increases the risk for perioperative complications. This also applies to anticoagulated patients, when clinically appropriate. International and interdisciplinary guidelines are necessary to ensure early and appropriate treatment of anticoagulated elderly patients with PFF.

Lateral cortical notching facilitates dynamization of proximal femoral nailing - A finite element analysis

INTRODUCTION

Dynamization of proximal femoral nailing by removal of distal interlocking is one of the recommended treatment options for nonunions of femur fractures. However, in certain inter-/subtrochanteric fractures, gliding of the nail along the femoral shaft is blocked by lateral femoral cortical support of the lag screw. For these cases, Biber et al. proposed lateral cortical notching (LCN), in which the supporting lateral bone is removed. This study investigates the biomechanical effect of LCN on gliding of proximal femoral nailing and stress distribution at the bone/implant interface.

MATERIALS AND METHODS

In this finite element analysis a three-dimensional model of an unstable intertrochanteric fracture with proximal femoral nailing without distal interlocking was simulated using the FebioStudio software suite. To simulate LCN, the lag screw hole was lengthened to 15.34 mm at the lateral cortex. Displacement of the nail along the femoral shaft axis and von Mises stress distribution were compared between LCN model and standard implantation model.

RESULTS

Displacement of the nail along the femoral shaft axis was higher in the LCN model than in the standard implantation model (0.48 mm vs. 0.07 mm). Highest von Mises stresses of 176-178 MPa at the implant and of 52-81 MPa at the proximal femur were detected. Maximum von Mises stresses of the implant were comparable at all sides, except for a reduced von Mises stress at the lateral inferior side in the LCN model (80 vs. 102 MPa). At the inferior lateral screw hole and the anterior/posterior lateral screw hole maximum von Mises stress was reduced in the LCN model (2 vs. 49 MPa and 52 vs. 81 MPa), whereas the maximum von Mises stress at the inferior medial screw hole was higher in the LCN model than in the standard implantation model (53 vs. 27 MPa).

CONCLUSIONS

Lateral cortical notching facilitates gliding of a distally dynamized proximal femoral nail along the femoral shaft axis in intertrochanteric fractures. Additionally, the lack of lateral cortical bone support at the lag screw reduces von Mises stress at the bone/implant interface and thus could lower the risk for implant breakage and peri‑implant fractures.

Restoration of Hip Geometry after Femoral Neck Fracture: A Comparison of the Femoral Neck System (FNS) and the Dynamic Hip Screw (DHS)

BACKGROUND

The femoral neck system (FNS) was introduced as a minimally invasive fixation device for managing femoral neck fractures.

OBJECTIVE

To compare radiographic, clinical, and patient-reported outcome measures (PROMs) of femoral neck fracture patients following FNS compared to dynamic hip screw (DHS) implantation combined with an anti-rotational screw.

METHODS

Patients who underwent closed reduction and internal fixation of a femoral neck fracture between 2020 and 2022 were retrospectively included. We measured leg length, femoral offset, and centrum-collum-diaphyseal (CCD) angle in plain radiographs. Scar length, Harris Hip Score, short-form health survey 36-item score (SF-36), and Numeric Rating Scale (NRS) were assessed during follow-up visits.

RESULTS

We included 43 patients (22 females) with a median age of 66 (IQR 57, 75). In both groups, leg length differences between the injured and the contralateral side increased, and femoral offset and CCD angle differences were maintained over time. FNS patients had shorter scars and reported fewer emotional problems and more energy. There were no differences between groups regarding the remaining SF-36 sub-scores, Harris Hip Score, and NRS.

CONCLUSIONS

The FNS allows for a comparable leg length, femoral offset, and CCD angle reconstruction while achieving similarly high functional and global health scores to the DHS.

Outcomes of direct anterior approach for uncemented total hip replacement in medial femoral neck fractures: a retrospective comparative study on the first 100 consecutive patients

BACKGROUND

With the aging of the population, the incidence of medial femoral neck fractures is likely to increase, and along them the need for total hip replacement. The present study aimed to analyze whether the use of the direct anterior hip approach, compared with posterolateral approach in medial proximal femur fracture patients, results in any advantage in terms of complications rate and functional recovery.

METHODS

A total of 162 patients were included in the study, and divided by approach: 100 performed with direct anterior approach (group A) and 62 with posterolateral approach (group B). The two populations were overlapping in age (75 vs 74 years; p = 0.13), sex (58F 42M vs 46F 16M; p = 0.12) and BMI (24 vs 24; p = 0.77).

RESULTS

Group A showed a higher ASA score compared to group B (3 vs 2; p = 0.04). Similar hospital stays (7 vs 7 days; p = 0.55) and complication rates (6% vs 8%; p = 0.61) were observed among groups, the most frequent being periprosthetic fractures, and need for allogeneic blood transfusion (20% vs 13%; p = 0.25). Patients in group A (96 vs 85 min; p = 0.10) showed a slightly, longer surgical time and a faster postoperative functional recovery witnessed by the ability to climb stairs at hospital discharge (37% vs 21%; p = 0.041).

CONCLUSION

The use of the direct anterior hip approach was effective in the management of frail patients with medial femoral neck fractures managed by total hip arthroplasty, allowing faster functional recovery in the elderly population.

Changes in physical activity in older adult patients with postoperative hip fractures in convalescent rehabilitation wards during rehabilitation time and during daily activities in the ward: a prospective cohort study

As the older adult population increases, the number of patients with hip fractures is expected to increase. Hip fractures are a major factor in bedridden patients and decreased activities of daily living. Older adults may have multiple comorbidities, and improving their physical function under comprehensive care is better to meet their needs. Convalescent rehabilitation wards provide comprehensive care and aim to improve the activities of daily living and physical activity in older adults. This study aimed to identify the time of day, including rehabilitation, when physical activities improve in inpatients with subacute postoperative hip fracture, among the many comorbidities of older adults, in comprehensive care, including rehabilitation. This prospective cohort study was conducted in a comprehensive care setting in a subacute rehabilitation ward in a Japanese hospital. Older adult inpatients with a musculoskeletal disease in a subacute rehabilitation ward were divided into the postoperative hip fracture and non-hip fracture patients to examine age, frailty, activities of daily living, and longitudinal physical activity data from objective measures at admission and discharge. Physical activity increased in older adult inpatients with postoperative hip fractures not only during personalized rehabilitation time ( P  < 0.001) but also during free activity in the ward ( P  < 0.001), despite their tendency to be older, frailer, and lower activities of daily living. In conclusion, postoperative hip fracture inpatients may improve their fitness after receiving comprehensive care.

Correlation between Inflammatory Systemic Biomarkers and Surgical Trauma in Elderly Patients with Hip Fractures

The treatment for hip fractures consists of a wide variety of orthopedic implants ranging from prosthesis to intramedullary nails. The purpose of this study is to determine the correlation between blood-count-derived biomarkers such as the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), the monocyte-to-lymphocyte ratio (MLR) and the systemic immune-inflammation index (SII) and the level of aggression sustained by elderly patients during these surgical procedures. A total of 129 patients aged over 70 and diagnosed with acute hip fractures who underwent surgical treatment between November 2021 and February 2023 were included in our observational retrospective cohort study. Two groups were formed depending on the anatomic location of the fracture for statistical comparison: group 1 with extracapsular fractures, who received a closed reduction internal fixation (CRIF) with a gamma nail (GN) as treatment, and group 2 with intracapsular fractures, who received a bipolar hemiarthroplasty (BHA) as treatment. The length of hospital stay (LHS), duration of surgery, preoperative days, pre- and postoperative red blood count (RBC) and hemoglobin (HGB) levels and postoperative NLR, PLR and SII were significantly different between the two groups (p < 0.05). Furthermore, the multivariate analysis indicated that the postoperative NLR (p = 0.029), PLR (p = 0.009), SII (p = 0.001) and duration of surgery (p < 0.0001) were independently related to the invasiveness of the procedures. The ROC curve analysis demonstrated that a postoperative SII > 1564.74 is a more reliable predictor of surgical trauma in terms of specificity (58.1%) and sensitivity (56.7%). Postoperative SII as a biomarker appears to be closely correlated with surgical trauma sustained by an older population with hip fractures.

Orthogeriatric Assessment of the Elderly Patient with Fragility Hip Fracture: Preliminary Results of a Prospective Study

Nowadays, more studies deal with "OrthoGeriatrics", for the co-management of elderly patients suffering fractures, from the admission to the discharge and beyond. For the first time at Cagliari University Hospital, we introduced an orthogeriatric service, in which trained geriatricians stay in orthopedic unit alongside trained orthopedics. The primary aim of the study was to analyze the rate of death and rehospitalization in elderly femur-fractured people of 65 or more years of age, identifying possible predictive factors. The secondary aim of the study was to analyze the recovery of daily living autonomies during the months following surgery. To reach the aim, we designed a prospective study, which is currently ongoing. We evaluated femur-fractured patients aged 65 years or more with a comprehensive geriatric assessment before surgery. The most common fractures were lateral hip ones, treated with osteosynthesis. Cognitive-affective, functional, and nutritional status, mood, and comorbidities were less impaired than in the outpatient service of the same hospital devoted to frail elderly. Pain control was excellent. A significantly low delirium incidence was found. More than a third of the sample were recognized as frail (according to the Survey of Health, Ageing and Retirement in Europe-Frailty Instrument (SHARE-FI)), and over a third of the sample were identified as a moderate-high risk of hospitalization and death (according to Multidimensional Prognostic Index (MPI)). Overall mortality rate was 13.87%, and rehospitalization rate was 11.84%. Frail people were more likely to die than non-frail (HR: 5.64), and pre-frail ones (HR: 3.97); similarly, high-risk patients were more likely to die than low-risk (HR: 8.04), and moderate-risk ones (HR: 5.46). Conversely, neither SHARE-FI nor MPI predicted rehospitalization. Creatinine (OR: 2.66, p = 0.003) and folate (OR: 0.75, p = 0.03) levels were independently associated with death and rehospitalization, respectively. Finally, the patients did recover the lost autonomies later, 6 months after surgery. Our study demonstrated that SHARE-FI and MPI are reliable tools to predict mortality in an orthogeriatric setting, and that creatinine and folate levels should also be measured given their independent association with negative outcomes.

The development, incidence and treatment trends of trochanteric fractures in Germany: a cohort study

BACKGROUND

Hip fractures are a major public health problem worldwide and can lead to disability, increased mortality, and reduced quality of life. We aim to provide a nationwide epidemiological analysis of trochanteric and subtrochanteric fractures and their respective surgical treatments.

METHODS

Data were retrieved from the national database of the German Department of the Interior. ICD-10-GM and OPS data from the period of 2006 to 2020 were analysed and all patients with trochanteric and subtrochanteric fractures as their main diagnosis, who were treated in a German hospital, were included. Patients were grouped by age and gender and linear regression was performed where suitable to calculate statistically significant correlations between variables and incidences.

RESULTS

985,104 pertrochanteric fractures and 178,810 subtrochanteric fractures were reported during the analysed period. We calculated a mean incidence of 80.08 ± 6.34 for pertrochanteric and 14.53 ± 1.50 for subtrochanteric fractures per million inhabitants. In both fracture types, a distinct dependence of incidence on age can be determined. Incidence rates equally rise in both sexes through the age groups with an increase of about 288-fold from those under the age of 60 to those over the age of 90 in pertrochanteric fractures, and about 123-fold in subtrochanteric fractures. Intramedullary nailing was the most common kind of treatment for both fracture types with augmentative cerclages on the rise throughout the whole period. Plate and dynamic compression screws were decreasing in frequency over the analysed period in both fractures.

CONCLUSIONS

We provided incidence data on per- and subtrochanteric fractures and their treatment. We calculated an economic impact of approximately 1.563 billion € per year in Germany. With regards to recent literature on costs of treatment and our findings regarding the implementation and utilization of different treatment methods, we conclude that the reinforcement of nationwide prevention programs is a relevant step in lessening the economic burden. We welcome the increased utilisation of intramedullary nailing as many studies show beneficiary outcomes and cost effectiveness in most of the included fracture types.

Retrospective evaluation of radiological and clinical outcomes after surgical treatment of proximal femur fractures utilizing TFNA

INTRODUCTION

The aim of this study was to evaluate the clinical and radiological outcomes of patients treated with the TFN-Advanced™ Proximal Femoral Nailing system (TFNA¸ DePuy Synthes, West Chester, PA) including intra- and postoperative complications.

MATERIALS AND METHODS

All patients with an acute proximal femur fracture consequently treated with a TFNA between September 2014 and December 2018 were evaluated. Clinical and radiological data were assessed for intra- and postoperative complications, including treatment failure. In addition, intra- and postoperative X-rays were used to determine the position of the implant, and any migration, via tip-apex-distance (TAD) and the caput-collum-diaphyseal angle (CCD). The accuracy of the fracture reduction was rated by both observers according to Baumgartners criteria.

RESULTS

275 consecutive patients (mean age 77.5 ± 14.1; 70.2% female) were included. The predominant OTA/AO fracture classification was 31A2 (140 cases, 50.7%). The average surgical time was 69 min (± 39.8). The reduction quality was good in 253 cases (92.0%) and acceptable in 22 cases (8.0%). In 18 cases, a pre-defined primary outcome parameter (6.5%) was recorded after a mean of 8.2 ± 8.0 months. During the observational period, 19 patients (6.9%) required a total of 23 additional surgeries. Implant removal was not considered a failure in the absence of pain. Significant group differences were observed with younger age (p = 0.001), lower Charlson Comorbidity Index (CCI)-score (p = 0.041) and lower rate of osteoporosis (p = 0.015) in the failure group. There were no cases of cut-out or cut-through among the patients who underwent augmentation as part of osteosynthesis.

CONCLUSIONS

Proximal femur fractures treated with the TFNA show low complication rates and high levels of radiological healing. Implant-related complications might be more common in patients with younger age, a lower CCI-score and lower frequency of osteoporosis. Usage of cement augmentation could potentially be beneficial to reduce postoperative cut-through and cut-out.

Post-Fracture Care Program: Pharmacological Treatment of Osteoporosis in Older Adults with Fragility Fractures

PURPOSE OF REVIEW

To present and discuss the recently published scientific evidence on the approach, mode of action, and timing of osteoporosis therapy initiation after fragility fractures.

RECENT FINDINGS

A comprehensive management approach is required to reduce mortality and morbidity associated with fragility fractures. This will help to reduce the risk of missing the diagnosis of osteoporosis as the underlying disorder while at the same time promoting the timely treatment of osteoporosis. The target is to minimize the incidence of post-traumatic disability and to reduce the imminent fracture risk. This article will present a Bone-Care algorithm for the diagnosis and management of fragility fractures in patients presenting for trauma surgery. This algorithm has been developed based on recently published national as well as international guidelines for implementation in standard clinical practice. International figures revealed that only a small proportion of those patients at high risk of sustaining a fragility fracture receive osteoporosis therapy. Based on the best currently available evidence, it is safe to start osteoporosis therapy in the acute post-fracture period (the optimal therapeutic window of romosozumab is the late endochondral phase/throughout bone remodeling). The right Bone-Care pathway ensures the delivery of a comprehensive management approach that meets the global call to action. All parameters including risk, benefit, compliance, and cost should be considered on an individual base for all kinds of therapy.

Postoperative Delirium in Patients Receiving Hip Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures: The Risk Factors and Further Clinical Outcomes

BACKGROUND

Postoperative delirium in patients who have hip fractures may lead to poor outcomes. This study aimed to determine perioperative risk factors and clinical outcomes of postoperative delirium in patients undergoing hip bipolar hemiarthroplasty for displaced femoral neck fractures.

METHODS

Among 1,353 patients who underwent hemiarthroplasty at our institution during 2013-2021, we identified 78 patients with postoperative delirium diagnosed with the confusion assessment method. The mean delirium duration was 28 hours (range: 15-520). We also included 1:2 sex- and age-matched patients who did not have postoperative delirium after the same surgery as a matching cohort for comparison. Patient comorbidities, perioperative data, delirium occurrence, and outcomes were collected for analyses.

RESULTS

A Charlson Comorbidity Index (CCI) score ≥6 (odds ratio (OR): 2.08, P = .017), nighttime surgery (OR: 3.47, p =<.001), surgical delays (OR: 1.01, P = .012), preoperative anemia (OR: 2.1, P = .012), and blood transfusions (OR: 2.47, P = .01) may increase the risk of postoperative delirium. The presentation of delirium was associated with sepsis (OR: 3.77, P = .04), longer hospital stays (P < .001), higher 1-year mortality (OR: 3.97, P = .002), and overall mortality (OR: 2.1, P = .02).

CONCLUSION

Postoperative delirium predicted poor outcomes. Our results emphasized the importance of early identification of patients at risk and optimization of the medical conditions before and after surgery.

A comparison of internal fixation and hemiarthroplasty in the management of un- or minimally displaced hip fractures in patients over 60 years old

BACKGROUND

The incidence of hip fractures in the elderly is increasing. Minimally displaced and undisplaced hip fractures can be treated with either internal fixation or hemiarthroplasty.

OBJECTIVES

To identify the revision rate of internal fixation and hemiarthroplasty in patients 60 years or older with Garden I or II hip fractures and to identify risk factors associated with each method.

METHOD

A retrospective analysis was conducted from 2 Major Trauma Centres and 9 Trauma Units between 01/01/2015 and 31/12/2020. Patients managed conservatively, treated with a total hip replacement and missing data were excluded from the study.

RESULTS

1273 patients were included of which 26.2% (n = 334) had cannulated hip fixation (CHF), 19.4% (n = 247) had a dynamic hip screw (DHS) and 54.7% (n = 692) had a hemiarthroplasty. 66 patients in total (5.2%) required revision surgery. The revision rates for CHF, DHS and hemiarthroplasty were 14.4%, 4%, 1.2% (p<0.001) respectively. Failed fixation was the most common reason for revision with the incidence increasing by 7-fold in the CHF group [45.8% (n = 23) vs. 33.3% (n = 3) in DHS; p<0.01]. The risk factors identified for CHF revision were age >80 (p<0.05), female gender (p<0.05) and smoking (p<0.05). The average length of hospital stay was decreased when using CHF compared to DHS and hemiarthroplasty (12.6 days vs 14.9 days vs 18.1 days respectively, p<0.001) and the 1 year mortality rate for CHF, DHS and hemiarthroplasty was 2.5%, 2% and 9% respectively.

CONCLUSIONS

Fixation methods for Garden I and II hip fractures in elderly patients are associated with a higher revision rate than hemiarthroplasty. CHF has the highest revision rate at 14.4% followed by DHS and hemiarthroplasty. Female patients, patients over the age of 80 and patients with poor bone quality are considered high risk for fixation failure with CHF. Hemiarthroplasty is a suitable alternative with lowest revision rates. When considering an internal fixation method, DHS is more robust than a screw construct.

Excellent Long-Term Results of an Austin Moore Hemiarthroplasty After Half a Century: A Case Report

CASE

We present the unique case of a 73-year-old man who was treated 50 years ago with a hemiarthroplasty (HA) for avascular necrosis after a femoral neck fracture (FNF) of his left hip and who has developed only mild osteoarthritis since and has reported satisfactory clinical and functional outcomes with no acetabular erosion.

CONCLUSION

HA for FNFs can provide durable long-term results and can, therefore, be considered as an option in the treatment of FNFs in younger patients. We describe a case with good results after 50 years, which, to our knowledge, is the longest reported follow-up of HA.

Intertrochanteric Femoral Fractures: A Comparison of Clinical and Radiographic Results with the Proximal Femoral Intramedullary Nail (PROFIN), the Anti-Rotation Proximal Femoral Nail (A-PFN), and the InterTAN Nail

Background and Objectives: The aim of this study was to evaluate retrospectively the radiological and functional outcomes of closed reduction and internal fixation for intertrochanteric femoral fractures (IFF) using three different proximal femoral nails (PFN). Materials and Methods: In total, 309 individuals (143 males and 166 females) who underwent surgery for IFF using a PFN between January 2018 and January 2021 were included in the study. Our surgical team conducted osteosynthesis using the A-PFN® (TST, Istanbul, Turkey) nail, the PROFIN® (TST, Istanbul, Turkey), and the Trigen InterTAN (Smith & Nephew, Memphis, TN, USA) nail. The PFNs were compared based on age, gender, body mass index (BMI), length of stay (LOS) in intensive care, whether to be admitted to intensive care, mortality in the first year, amount of transfusion, preoperative time to surgery, hospitalisation time, duration of surgery and fluoroscopy, fracture type and reduction quality, complication ratio, and clinical and radiological outcomes. The patients’ function was measured with the Harris Hip Score (HHS) and the Katz Index of Independence in Activities of Daily Living (ADL). Results: Pain in the hip and thigh is the most common complication, followed by the V-effect. The Z-effect was seen in 5.7% of PROFIN patients. A-PFN was shown to have longer surgical and fluoroscopy durations, lower HHS values, and much lower Katz ADL Index values compared to the other two PFNs. The V-effect occurrence was significantly higher in the A-PFN group (36.7%) than in the InterTAN group. The V-effect was seen in 33.1% of 31A2-type fractures but in none of the 31A3-type fractures. Conclusions: InterTAN nails are the best choice for IFFs because they have high clinical scores after surgery, there is no chance of Z-effect, and the rate of V-effect is low.

Factors affecting the quality of life in the chronic phase of thoracolumbar osteoporotic vertebral fracture managed conservatively with a brace

BACKGROUND CONTEXT

Although osteoporotic vertebral fractures (OVFs) are the most common type of osteoporotic fracture, few reports have closely investigated the factors contributing to the quality of life (QOL) in the chronic phase after thoracolumbar OVFs using detailed radiographic evaluation.

PURPOSE

This study aimed to identify factors associated with the QOL in the chronic phase after thoracolumbar OVF.

DESIGN

Post hoc analysis of a prospective randomized study.

PATIENT SAMPLE

Participants included 195 patients with fresh thoracolumbar OVF managed conservatively with a brace who were available for radiographic analysis 48 weeks after injury.

OUTCOME MEASURES

The degree of QOL impairment at 48 weeks after thoracolumbar OVF was assessed using the Japanese three-level version of the EuroQol five-dimensional questionnaire (EQ-5D) score.

METHODS

Univariate and multivariate regression analyses were used to evaluate the relationships between the QOL and radiographic factors.

RESULTS

The univariate analysis showed that age, analgesic use, T10/L5 Cobb angle on magnetic resonance imaging (MRI), subsequent vertebral fracture, and nonunion were significantly associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. The multiple regression analysis showed that nonunion, analgesic use, subsequent vertebral fracture, and sacral slope on MRI were independently associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. Receiver operating characteristic analysis for the deterioration of QOL showed that the cutoff value for sacral slope on MRI was 35 degrees.

CONCLUSIONS

This study demonstrated that nonunion, subsequent vertebral fracture, and lower sacral slope were independently associated with poorer QOL in the chronic phase of thoracolumbar OVF managed conservatively with a brace. Therefore, improving or preventing these factors in patients with thoracolumbar OVF in the chronic phase may improve the QOL of the affected patients.

Novel screw fixation placement configuration for the treatment of Pauwels type III femoral neck fractures: a finite element analysis

Verticality of transcervical hip fractures in young patients is usually connected with typically high-energy fractures which are known as Pauwels type III. Artificial femoral head replacement surgery is mostly not considered for treating femoral neck fractures in such patients. The commonly used devices for the fixation of vertical femoral neck fractures are multiple screws or a sliding hip screw with or without an antirotation screw. Size, location and length of the screws are the most effective parameters in terms of the structural performance of internal fixation implants, but the optimal configuration of the screws is necessary to be investigated to direct the clinical practice. The aim of this study is to compare the biomechanical stability of the standard inverted triangle configuration with the various newly proposed x-crossed screw configurations. FEA simulations carried out in this study demonstrated that using an x-crossed-right assembly in treating Pauwels type III femoral neck fractures satisfies the biomechanical stability in terms of maximum von Mises stresses and maximum femoral head displacement. However, in terms of maximum relative neck fracture displacement, the x-crossed-right assembly would not entirely suffice the desired biomechanical stability. Therefore, using an x-crossed screw assembly in treating femoral neck fractures would provide the needed biomechanical stability.

Evaluation of impact of epidural volume extension on the quality of spinal anaesthesia in patients undergoing proximal femoral nailing surgeries - randomized controlled study

INTRODUCTION

Epidural volume extension is technique aiming to mitigate spinal anaesthesia induced hypotension, by reducing the dose of local anaesthetics. The present study was executed to determine the effect of epidural volume extension subarachnoid block with 0.5% hyperbaric bupivacaine in patients undergoing proximal femoral nailing (PFN) regarding characteristics of sensory-motor block and postoperative analgesia.

MATERIAL AND METHODS

In this prospective, double-blind trial conducted from October 2021 to April 2022, 105 adult patients scheduled to undergo PFN were randomised into groups: control (C), 10 mL NS (E1), and 20 mL NS (E2), to receive 10 mg hyperbaric bupivacaine intrathecally plus additional epidural volume extension with 10 and 20 mL normal saline in groups E1 and E2, respectively. The primary outcome measured was the duration of postoperative analgesia. The secondary outcomes measured included onset of sensory- motor block and duration of sensory block. P < 0.05 was considered statistically significant.

RESULTS

A significantly longer duration of postoperative analgesia was noted in patients receiving 10 and 20 mL epidural volume extension (365.09 ± 101.83 and 330.06 ± 35.22 vs. 265.77 ± 38.01 min in the control group, P < 0.01). Patients who received any epidural volume extension with either 10 or 20 mL had significantly quicker onset of sensory and motor block as well as prolonged duration of sensory block. No significant difference in duration of postoperative analgesia, and onset and duration of block was observed between patients receiving either 10 or 20 mL epidural volume extension.

CONCLUSIONS

Epidural volume extension significantly shortened the onset of sensory-motor block and increased the duration of sensory block and postoperative analgesia in patients undergoing PFN under subarachnoid block; however, no such difference was observed between 10 and 20 mL epidural volume extension.

Hip replacement in femoral neck fractures: the role of cementation and its technical difficulties

Hip fractures in elderly patients are an arising problem due to aging of population and still represent a controversial challenge for orthopedic surgeon who should help achieve the best functional recovery in the shortest time. Cementation in hip replacement plays an important role, but it should be carefully planned considering the possible risks. According to the literature, there are still no certainties regarding the superiority of an uncemented implant compared to a cemented one. The purpose of this work is to conduct an overview of the scientific literature that can clarify the advantages and disadvantages of cemented and non-cemented implants from a biological and biomechanical point of view.

Postoperative delirium in geriatric patients with hip fractures

Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.

What Is the Best Treatment Choice for Concomitant Ipsilateral Femoral Neck and Intertrochanteric Fracture? A Retrospective Comparative Analysis of 115 Consecutive Patients

PURPOSE

Although a concomitant ipsilateral femoral neck and intertrochanteric fracture has been considered to be a rare type of injury, its incidence has been increasing, especially among elderly hip fracture patients. However, there is limited evidence on the optimal treatment option. This study surveys surgical outcomes of different implants in order to assist in selecting the best possible implant for a combined femoral neck and intertrochanteric fracture.

METHODS

The postoperative complications after the treatment of a concomitant ipsilateral femoral neck and intertrochanteric fracture via cephalomedullary nail (CMN), dynamic hip screw (DHS), and hip arthroplasty groups were analyzed by retrospectively reviewing the electronic medical records of 115 consecutive patients.

RESULTS

The patient demographics and perioperative details showed no significant discrepancies amongst different surgical groups, except for the operative time; a CMN had the shortest mean operative time (standard deviation) of 85.6 min (31.1), followed by 94.7 min (22.3) during a DHS, and 107.3 min (37.2) during an HR (p = 0.021). Of the 84 osteosynthesis patients, 77 (91.7%) achieved a fracture union. Only one (3.2%) of the 31 HR cases had a dislocation. The sub-analysis of the different osteosynthesis methods showed a higher incidence of excessive sliding and the nonunion of the fracture fragment in the DHS group than that in the CMN group (p = 0.004 and p = 0.022, respectively). The different surgical methods did not significantly vary in other outcome variables, such as the re-operation rate, mortality, and hip function.

CONCLUSIONS

For the surgical treatment of combined femoral neck and trochanteric fractures, osteosynthesis did not differ significantly from an HR in terms of the overall postoperative complications, reoperation and mortality rate, and hip function, however, the risk of nonunion and more mechanical complications should be considered when choosing a DHS. Our suggestion for the treatment of a femoral neck and ipsilateral trochanteric fracture is that a surgeon should choose wisely between an HR and a CMN depending on the patient's age, the displacement of the femoral neck, and one's expertise.

A review of Risk Factors for Post-traumatic hip and knee osteoarthritis following musculoskeletal injuries other than anterior cruciate ligament rupture

Post-traumatic osteoarthritis (PTOA) is a common form of osteoarthritis that might occur after any joint trauma. Most PTOA publications mainly focus on anterior cruciate ligament (ACL) injuries. However, many other traumatic injuries are associated with PTOA, not only for the knee but also for the hip joint. We aim to identify and summarize the existing literature on the musculoskeletal injuries associated with knee and hip PTOA and their risk factors in determining those with a worse prognosis, excluding ACL injuries. Despite the narrative nature of this review, a systematic search for published studies in the last twenty years regarding the most relevant injuries associated with a higher risk of PTOA and associated risk factors for OA was conducted. This review identified the six more relevant injuries associated with knee or hip PTOA. We describe the incidence, risk factors for the injury and risk factors for PTOA of each. Meniscal injury, proximal tibial fracture, patellar dislocation, acetabular, femoral fractures and hip dislocations are all discussed in this review.

Cephalomedullary nailing for reverse oblique intertrochanteric fractures 31A3 (AO/OTA)

INTRODUCTION

Reverse oblique intertrochanteric fractures are classified by the Orthopaedic Trauma Association [OTA]/[AO] as 31A3, and account for up to one-third of all hip fractures, and 2-23% of all trochanteric fractures. The treatment of choice of those fractures is intramedullary nailing as it decreases soft tissue damage and permits early weight bearing.

MATERIAL AND METHODS

A retrospective comparative study was conducted on patients surgically treated for 31A3 fractures from October 2018 to January 2022 in a high-volume regional referral centre. All the patients had been treated with intramedullary nailing.

RESULTS

The selected group included 11 males (16%) and 59 females (84%), with a mean age of 83.6 years (range 61 to 96 years). A Trigen Intertan Nail was the most frequent choice of intramedullary nailing in 33 patients (47%), an Elos Long nail was chosen in 19 cases (27%), while a ZNN nail was used in 18 patients (26%). The mean time between admission and surgery was 2.5 days, with a mean Hb value of 10.5 g/dl reported preoperatively.

CONCLUSION

Patients treated with an Intertan nail reported the lowest TAD, CALTAD, and TALCALTAD mean radiographic values, and the lowest rate of Hb loss and blood transfusions.

Should cannulated screws be removed after a femoral neck fracture has healed, and how? A finite element analysis of the femur before and after cannulated screw removal

PURPOSE

The removal of three inverted triangular parallel cannulated screws after the femoral neck fracture healing is sometimes accompanied by osteonecrosis of the femoral head (ONFH) or its refracture. The purpose of this study was to determine the biomechanical changes of the femur before and after the screw removal using a finite element analysis.

METHODS

The CT data of the femurs were obtained from a 69-year-old healthy female to establish the femur models. The established finite element models consisted of N, C, and R groups: N group, the normal femur; C group (to simulate the femoral neck fracture healing after the internal fixation), the normal femur with three inverted triangular parallel cannulated screws (C1) or with two upper parallel screws (C2). For the R1 or R2 groups, the screws in the model of the C1 or C2 individuals were gradually removed in seven or three types of different screw combinations, respectively. The stresses and displacements of the femur were determined.

RESULTS

(1) Compared with the N group, a uniform stress distribution was stopped by the addition of three screws in the C1 group; in contrast, all screw removals resulted in the stress concentration on the screw holes and the disappearance of stress shielding. Moreover, the average stress of the femoral head in C1 group increased by 37.85%, while that of the femoral neck decreased by 23.03%. (2) Compared with the C1 group, while only the lowest femoral calcar screw was removed, there was a similar stress distribution in the proximal femur, and the average stress of the femoral head increased only by 0.35% although that of the femoral neck increased by 63.62%; however, removal by any other means resulted in a significant stress concentration in the proximal femur and a significant increase in the average stresses of the femoral head and neck (5.96-40.95% and 12.82-75.46%, respectively). (3) Compared with the N or C1 group, there was a significant stress concentration on the screws and its surrounding proximal femur in the C2 group. (4) Compared with the C2 group, the simultaneous removal of two upper screws not only did not cause a significant stress concentration on the proximal femur but also significantly reduced the average stresses of the femoral head and neck by 87.49% and 65.51% respectively. On the contrary, the gradual removal of two screws caused a significant stress concentration on the screw and its surrounding proximal femur although the average stresses of the femoral head and neck decreased by 88.79-89.06% and 67.00-67.22%, respectively. (5) Compared with the N group, the average displacements of the femoral head and neck in the C1 group increased only by 3.12% and 3.37%, respectively. Additionally, compared with the C1 group, while three, two, or one screw was simultaneously removed, the average displacements of the femoral head and neck only fluctuated - 5.51-1.65% and 1.78-9.03%, respectively.

CONCLUSIONS

Residual internal fixation after femoral neck fracture healing may lead to stress concentration on screws and stress shielding around screws. The first removal of the lowest femoral calcar screw and then the second removal of two upper residual screws have a minimum effect on the stress concentration on the proximal femur and the average stress on the femoral head. The incorrect screw removal and resulting femoral load may well be closely related to occurrence in ONFH or its refracture.

Fractures after cephalomedullary nailing of the femur : Systematization of surgical fixation based on the analysis of a single-center retrospective cohort

PURPOSES

Femoral implant related fractures (IRF) are a growing pathology in an increasingly elderly and frail population. A series of IRF after cephalomedullary nail (CMN) fixation of a femoral fracture is analyzed and an algorithm described to guide the management of such fractures.

METHODS

All eligible patients operated on for IRF fixation after CMN were reviewed regarding their demographics, comorbidities, injury pattern, and treatment. Primary outcomes were mortality and local complications. Secondary outcomes were time to consolidation, time to weight-bearing initiation, length of hospitalization, and discharge destination.

RESULTS

The incidence of IRF requiring fixation was 1.3% after 3401 CMN implantation procedures. Elderly women with comorbidities and plate fixation predominated. One-year mortality was 18.6%, being higher for patients presenting with infection and those unable to walk at the end of follow-up. Local complications occurred in 25.6%. Median time to weight-bearing was 9.1 weeks, but longer for patients with plate fixation or complications. Patients presenting with an infection and those discharged to nursing facilities had more comorbidity.

CONCLUSIONS

Following an algorithm presented here, patients were treated either with nail exchange or lateral locking plate fixation, permitting straightforward evaluations and acceptable results in a very high-risk population.

Distal fixation modular stem hemiarthroplasty versus proximal femoral nailing for unstable intertrochanteric fractures: a retrospective cohort study

The treatment of unstable intertrochanteric fractures (UITF) is a controversial issue in the current literature. The aim of this study was to compare the curative effects of distal fixation modular stem (DFMS) hemiarthroplasty with proximal femoral nailing (PFN) on UITFs in the elderly. From February 2017 to November 2019, 98 elderly (≥65 years) patients with UITF were included in this single-center retrospective cohort study. Mean follow-up duration was 24.1±11.9 months. Patients were divided into the DFMS group (52 patients) and the PFN group (46 patients). In the DFMS group, trochanteric fixation was performed using a trochanteric cable plate system. Primary outcome measures included Harris hip score (HHS), mobility score, implant related complications and mortality. Secondary outcome measures included hospitalization duration, surgical time and transfusion rate. Mean age of the patients was 78.7±7.2 years (65-96 years). DFMS group had longer surgical time, higher transfusion rates and longer hospital stays (p<0.05). Mean HHS was 80.7±10.5 and 81.9±12.2 in the DFMS group and PFN group, respectively. There was no statistically significant difference between the two groups in terms of HHS, mobility score and mortality. Implant failure rates were significantly higher in the PFN group (p=0.015). Implant failure, one year mortality and overall mortality rates were 0%, 15.4% and 17.3% in DFMS group and 10.9%, 15.2% and 19.5% in PFN group, respectively. Both surgical methods can be effectively used in the treatment of UITFs with similar satisfactory functional results and similar mortality rates. In addition, the DFMS group exhibited significantly lower implant failure rates and PFN group provided significantly lower surgical time duration, transfusion rate and hospital stay duration.

The efficacy of dynamic compression locking system vs. dynamic hip screw in the treatment of femoral neck fractures: a comparative study

Background

There is still a lack of consensus on which internal fixation method can better maintain the stability of femoral neck fractures (FNF), promote fracture healing, and reduce postoperative complications such as femoral head necrosis and nonunion. Therefore, the purpose of this study was to evaluate the clinical efficacy of the novel dynamic compression locking system (DCLS) versus dynamic hip screw (DHS) in the treatment of FNF.

Methods

Fifty cases of FNF from July 2018 to February 2020 were retrospectively analyzed. According to different treatment methods, they were divided into DCLS group (26 cases) and DHS group (24 cases). Baseline data, intraoperative and postoperative clinical data, reoperation rate, and Harris score were collected to evaluate the clinical efficacy.

Results

All patients were followed up for 24 months. All “fractures” were caused by fall. The baseline data of the two groups were comparable (P > 0.05). There weren’t significant differences in the length of hospital stay and mobility after two years postoperatively between the two groups (P > 0.05). The operation time, blood loss, incision length, fluoroscopy times and the degree of femoral neck shortening after two years postoperatively in the DCLS group were significantly less than those in the DHS group (all P < 0.05). Harris score after two years postoperatively in the DCLS group was significantly higher than that in the DHS group (P < 0.05). Although the reoperation rate in the DHS group was slightly higher than that in the DCLS group, it wasn’t statistical significance (P > 0.05).

Conclusions

Compared with DHS, DCLS in the treatment of FNF had less surgical trauma, shorter incision length, shorter operation time, lower radiation dose and higher Harris scores. Although the reoperation rate in the DHS group was slightly higher than that in the DCLS group, it wasn’t statistical difference. Further research is needed.

Low geriatric nutritional risk index is a risk factor for death within 1 year following hip fracture

PURPOSE

Hip fracture is common in older patients and is associated with high mortality and functional impairment. The Geriatric Nutritional Risk Index (GNRI) evaluates the risk of malnutrition-related complications, and the Barthel Index (BI) evaluates older patients' functional status. The study aim was to determine the risk factors for both death and decreased BI within 1 year after hip fracture.

METHODS

We retrospectively reviewed the records of 108 patients who were treated for hip fractures in 10 public or private hospitals from February to July 2007. Participating facilities comprised eight public or private hospitals with 200-499 beds, and two private or orthopedic hospitals with 20-199 beds. We evaluated several risk factors for death and lower BI within 1 year after hip fracture.

RESULTS

The mortality rate within 1 year postoperatively for patients who survived inpatient stay was 6.5% (7/108). The proportion of patients with decreased postoperative BI was 43.6% (44/101). Binomial logistic regression analysis showed that several factors, including low GNRI (odds ratio [OR]: 0.80; 95% confidence interval [CI: 0.68-0.93]), were risk factors for death within 1 year. Postoperative delirium (OR: 8.84 [1.52-51.6]), postinjury dementia (OR: 34.8 [3.01-402]), preinjury BI (OR: 1.05 [1.02-1.08]), and preinjury dementia (OR: 6.22 [1.73-22.4]) were risk factors for decreased postoperative BI.

CONCLUSIONS

Our findings indicated that lower GNRI was a risk factor for death within 1 year of hip surgery and that delirium and dementia were among the risk factors for decreased BI 1 year after hip fracture.

A Comparative Study of Hip Arthroplasty and Closed Reduction Proximal Femur Nail in the Treatment of Elderly Patients with Hip Fractures

Objective

To compare the clinical effect of hip arthroplasty and closed reduction intramedullary nailing of proximal femur in the treatment of elderly hip fracture patients.

Methods

There are 90 elderly hip fracture patients being recruited in the present study. Fifty patients in Group A received closed reduction intramedullary nailing of proximal femur, and 40 patients in Group B received hip arthroplasty. All patients were followed up for 12 months after surgery, clinical outcomes included surgical indicators, visual analog scale (VAS) score, Harris score, quality of life, mental status, and complications.

Results

The surgery time, bleeding volume, infusion volume of patients in Group A are all significantly lower than those in Group B (p < 0.05), while the weight-bearing activity time and first workout time of Group A are all significantly higher than those in Group B (p < 0.05). The VAS score in patients of Group A at 1 week postoperative is significantly lower than that in patients of Group B (p < 0.05). The Harris score in patients of Group A at 3, 6, and 12 months postoperative are all significantly higher than those in patients of Group B (p < 0.05), and the excellent and good rate of hip function recovery at 12 months postoperative in patient of Group A is significantly lower than that in patients of Group B (80% vs. 95%, p < 0.05). Furthermore, The score of SF-36 standardized physical component, SF-36 standardized mental component and Barthel in patients of Group A at 6 months postoperative are significantly lower than those in patients of Group B (p < 0.05), and the score of mini-mental state examination is significantly higher (p < 0.05), while there are not significantly different at 12 months postoperative (p > 0.05). The incidence of postoperative complications in Group A was significantly lower than that in Group B (10% vs. 27.5%, p < 0.05).

Conclusion

Elderly hip fracture patients treated with closed reduction intramedullary nailing of proximal femur has less surgical trauma and lower complication rates, but slower postoperative recovery compared with hip arthroplasty.

Tips and tricks to avoid implant failure in proximal femur fractures treated with cephalomedullary nails: a review of the literature

Objective:

To describe the surgical aspects potentially contributing to hardware failure of cephalomedullary nails.

Data Sources:

A search of the Embase, PubMed (MEDLINE), Web of Science, and the Cochrane library for reports of hardware failures after intramedullary fixation of proximal femur fractures. Issues of cut out and cut through phenomena related to technique were excluded. Expert opinion of 3 surgeons, each trained on several fixation systems at Level | trauma centers is reported.

Data Extraction:

Three authors extracted data using a predesigned form. Implant type, reported failure mechanism, and associated factors with implant failure were recorded as well as potential bias.

Results:

Of 2182 search results screened, 64 articles were deemed relevant for our research question and were included. The authors identified factors associated with implant failure: preoperative patient and fracture characteristics, intraoperative reduction, implant handling, and postoperative nonunion. Issues were identified as independent modifiable intraoperative risk factors: inadequate fracture reduction, varus position of femoral neck, direct damage of the cephalomedullary nail aperture by eccentric drilling related to guide sleeve handling, and implant design mechanism failures.

Conclusions:

Multiple factors associated with intraoperative handling can influence the healing of proximal femur fractures. Although many of these have been well described and are taught in fracture courses, surgeons should be aware of subtle intraoperative complications reported in the literature that can weaken implants and add to the likelihood of early failure.

Level of Evidence: IV

Patient-specific risk factors for adverse outcomes following geriatric proximal femur fractures

BACKGROUND

Proximal femur fractures (PFFs) occur frequently among geriatric patients due to diverse risk factors, such as a lower bone mineral density and the increased risk of falls.

METHODS

In this review, we focus on recent literature of patient-specific risk factors and their impact on common complications and outcome parameters in patients with PFF.

RESULTS

Patient- and treatment related factors have a significant impact on outcome and are associated with an increased risk of mortality, impairments in functional rehabilitation and complicative courses.

CONCLUSION

Geriatric patients at high risk for complications are nursing home inhabitants suffering from severe osteoporosis, dementia and sarcopenia. The early and ongoing assessment for these individual risk factors is crucial. Strategies including interdisciplinary approaches, addressing comorbidities and facilitating an optimal risk factor evaluation result in a beneficial outcome. The ongoing ambulant assessment and therapy of complicating factors (e.g., malnutrition, sarcopenia, frailty or osteoporosis) have to be improved.

Comparing Perioperative Outcome Measures of the Dynamic Hip Screw and the Femoral Neck System

Background and Objective: Various fixation devices and surgical techniques are available for the management of proximal femur fractures. Recently, the femoral neck system (FNS) was introduced, and was promoted on the basis of less invasiveness, shorter operating time, and less fluoroscopy time compared to previous systems. The aim of this study was to compare two systems for the internal fixation of femoral neck fractures (FNF), namely the dynamic hip screw (DHS) with an anti-rotation screw (ARS) and an FNS. The outcome measures included operating room time (ORT), dose−area product (DAP), length of stay (LOS), perioperative changes in haemoglobin concentrations, and transfusion rate. Materials and Methods: A retrospective single-centre study was conducted. Patients treated for FNF between 1 January 2020 and 30 September 2021 were included, provided that they had undergone closed reduction and internal fixation. We measured the centrum-collum-diaphyseal (CCD) and the Pauwels angle preoperatively and one week postoperatively. Results: In total, 31 patients (16 females), with a mean age of 62.81 ± 15.05 years, were included. Fracture complexity assessed by the Pauwels and Garden classification did not differ between groups preoperatively. Nonetheless, the ORT (54 ± 26.1 min vs. 91.68 ± 23.96 min, p < 0.01) and DAP (721 ± 270.6 cGycm² vs. 1604 ± 1178 cGycm², p = 0.03) were significantly lower in the FNS group. The pre- and postoperative CCD and Pauwels angles did not differ statistically between groups. Perioperative haemoglobin concentration changes (−1.77 ± 1.19 g/dl vs. −1.74 ± 1.37 g/dl) and LOS (8 ± 5.27 days vs. 7.35 ± 3.43 days) were not statistically different. Conclusions: In this cohort, the ORT and DAP were almost halved in the patient group treated with FNS. This may confer a reduction in secondary risks related to surgery.

Clinical implications of anticoagulant oral therapy in elderly patients with hip fracture

BACKGROUND AND AIM

Proximal femur fractures (PFFs) are among the most common fractures, especially in the elderly population. A PFF often represents a life-changing event. Their dramatic effects are attributable not only to the massive hemorrhages caused by the fracture, but also to the high risk of dramatic complications. These risks are supposed to be even higher for patients under oral anticoagulant treatment. In this study we evaluated how oral anticoagulant therapy effected patient's prognosis.   Methods:Ours was a case-control review of over-65 patients treated surgically for proximal femur fractures between 2013 and 2019. Cases were divided in 2 groups depending if they were (Group A) or were not (Group B) under oral anticoagulant therapy at the moment of hospitalization.   Results:200 cases were included in our study: 100 in Group A and 100 in Group B. Surgical delay was significantly higher for cases under oral anticoagulant treatment compared to the other cases. Group A cases were transfused with a significantly higher frequency and with more blood units compared to Group B (p=0.0300; p=0.013). Combined cardiological and vascular complications occurred in 21 cases (10.5%), being significantly more common in Group A (16) than Group B (5), as testified by a chi-square test (P=0.011).   Conclusions:Cases under oral anticoagulant therapy are frail patients with a higher risk to develop massive hemorrhages after an hip fracture. For this reason, it is mandatory to achieve an early stabilization of patient's clinical conditions and then perform surgery as soon as possible.