Nationwide Analysis of Femoral Neck Fractures in Elderly Patients: A Receding Tide

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.

Does Orthopaedic Subspecialty Training Affect Treatment Decision-Making and Outcomes for Displaced Femoral Neck Fractures?

BACKGROUND

Approximately 1.3 to 2.2 million femoral neck fractures occur annually globally, with up to 80% being displaced, requiring hemiarthroplasty or total hip arthroplasty (THA). As the population ages, femoral neck fractures may surpass six million by 2050. Optimal treatment for displaced femoral neck fractures is debated with literature supporting both hemiarthroplasty and THA. Our objective was to determine if subspecialty training plays a role in the decision-making and outcomes of displaced femoral neck fractures.

METHODS

A retrospective analysis was performed for 386 patients who underwent hemiarthroplasty or THA for displaced femoral neck fracture at an academic health system from 2017 to 2023. To assess subspecialty training impact, patients were stratified based on training: adult reconstruction (AR) fellowship or other orthopaedic training (non-AR). Procedure duration, 90-day postoperative complications, length of stay, and discharge disposition were compared between cohorts. A subanalysis was performed to compare the procedures.

RESULTS

The AR surgeons performed THA 31.8% for femoral neck fractures compared to 10.5% for non-AR-trained surgeons (P < 0.001). Patients treated by AR-trained surgeons were on average younger (79 versus 82 years; P = 0.01). Procedure duration was shorter for hemiarthroplasty (80.4 versus 90.1 minutes; P = 0.01) and THA (94.9 versus 132.6 minutes; P = 0.01) when performed by AR surgeons (overall P = 0.01). The THA patients were more likely discharged home when treated by AR surgeons (55.3 versus 28%; P = 0.03). The AR-trained surgeons used cemented prostheses less compared to non-AR surgeons (16.9 versus 33.2%; P < 0.001).

CONCLUSIONS

Subspecialty training plays a role in decision-making, procedure duration, and discharge disposition for femoral neck fractures. The AR-trained surgeons more often perform THA for femoral neck fractures compared to non-AR-trained surgeons. The AR-trained surgeons completed hemiarthroplasty and THA in significantly shorter time compared with non-AR-trained surgeons and more frequently discharged patients home.

Characteristics and Factors Associated With Nonoperative Management and Hospital Outcomes After Hip Fractures Among Community-Dwelling Older Adults: Retrospective Analysis

Nonoperative treatment is used at varying rates among older adults with hip fractures despite the high mortality. This retrospective analysis of 7803 patients 65 and older admitted with hip fractures is to estimate the odds of nonoperative treatment and in-hospital mortality after hip fractures among community-dwelling older adults. 13.6% underwent nonoperative treatment. Compared to the group with operative treatment, the nonoperative group had a higher in-hospital mortality rate (6.51% vs. 1.32%, p < .0001). Male sex, nondisplaced fracture, and comorbidities of acute myocardial infarction, congestive heart failure, cerebrovascular disorder, dementia, and liver disease were associated with an increased likelihood of nonoperative treatment. Nonoperative treatment, advanced age, use of osteoporosis pharmacotherapy, multiple medical comorbidities, and hospital-acquired complications were associated with increased in-hospital mortality. Specific characteristics were associated with nonoperative management and in-hospital mortality among older adults with hip fractures. Additional research is necessary to improve the care of this vulnerable population.

Femoral Head Pathology in Subcapital Hip Fractures: Clinical Value and Cost-Effectiveness in a 230-Patient Case Series

Background/Objectives: Osteoporotic fractures, particularly subcapital hip fractures (SCF), pose a significant healthcare and economic burden. The routine pathological examination of resected femoral heads in such cases is common practice, aimed at identifying malignancies that may have contributed to bone fragility. This study evaluated the cost-effectiveness and clinical utility of routine femoral head pathology in patients undergoing surgical treatment for SCF. Methods: A retrospective cohort study was conducted at a university-affiliated, tertiary care hospital. Patients undergoing surgical treatment for SCF between 2015 and 2018, with available femoral head pathology reports, were included. Data on demographics, prior or active malignancies, surgical procedures, and pathology results were analyzed. Results: The study included 230 patients with a mean age of 82.4 ± 14.1 years, of whom 57% were female. A total of 72 (31%) patients had a history of malignancy at the time of surgery. Pathological examination identified malignancies in eight patients (3.4%), all of whom had active malignancies at the time of admission. The most common malignancies detected were breast cancer and multiple myeloma (three cases each). None of the findings led to changes in patient management. Conclusions: The routine pathological examination of femoral heads following SCF provided a limited diagnostic yield and did not alter clinical management in this cohort. These findings suggest that routine pathology may not be cost-effective and support the adoption of selective screening approaches based on clinical risk factors such as a history of malignancy or atypical fracture presentations.

Low-Demand Cemented Femoral Stem Designs and Revision Risk Following the Hemiarthroplasty Treatment of Geriatric Hip Fracture

BACKGROUND

Cemented fixation is recommended in the hemiarthroplasty treatment of geriatric femoral neck fractures. Certain cemented stems have similarly designed "low-demand" counterparts, but it is unclear whether they yield comparable clinical outcomes. The purpose of this study was to evaluate the revision risk associated with two low-demand stems, Summit Basic (DePuy Synthes) and Versys LD/Fx (Zimmer Biomet), in comparison to their standard counterparts, Summit (DePuy Synthes) and Versys Advocate (Zimmer Biomet).

METHODS

Using our U.S. integrated healthcare system's Hip Fracture Registry, we identified patients aged ≥60 years who were treated with one of these four cemented hemiarthroplasty devices (2009-2022). Low-demand stems were compared with standard stems on the basis of aseptic revision rates (primary outcome measure) as well as periprosthetic fracture and 90-day complications (secondary outcome measures). Multivariable Cox proportional hazards regression was used to adjust for potential confounders.

RESULTS

Overall, there were 9,828 cemented hemiarthroplasties (69.0% female, 78.9% White), including 3,713 low-demand stems and 6,115 standard stems. In the adjusted analysis, low-demand stems were associated with a higher risk of aseptic revision compared with standard designs (hazard ratio [HR] 1.53, 95%CI 1.06-2.22, P = 0.024). This difference was driven primarily by a higher risk of periprosthetic fracture in the low-demand stems (HR 3.40, 95%CI 1.54-7.51, P = 0.003). Similar findings were observed when separately comparing Summit Basic with Summit and Versys LD/Fx to Versys Advocate, and when restricting to procedures performed by experienced total hip arthroplasty surgeons.

CONCLUSIONS

In this study of 9,828 hip fracture patients treated with cemented hemiarthroplasty, low-demand stems were associated with a higher risk of aseptic revision as compared with their standard counterparts. Further research is required to determine the features of the low-demand stems which could be contributing to this finding, as well as the circumstances under which usage of low-demand stems could still be justified based on cost.

Outcomes of internal fixation with Femoral Neck System (FNS) for intracapsular femoral neck fractures

Background

Internal fixation of hip fractures is associated with high reoperation rates. This study investigated the reoperation rates after internal fixation with the femoral neck system (FNS).

Materials and Methods

A single-institution cohort study was conducted on patients aged 18 years or older who sustained intracapsular femoral neck fractures and underwent internal fixation with a fixed-angle implant. Surgeons, patients, and investigators were not blinded. The primary outcome was any hip reoperation at the final follow-up. Secondary outcomes were to characterize a cohort of patients regarding demographics, fracture classification, intraoperative findings, postoperative fracture complications and union rates, and postoperative pain.

Results

This study found that internal fixation with FNS for intracapsular femoral neck fractures was associated with a 23% rate of revision surgery. Of the initial 94 patients who received FNS internal fixation, 44 patients were included for analysis; of those, 10 patients underwent revision surgery. Patients had a 22% rate of in-hospital medical adverse events with a 30-day readmission rate of 9%. Increasing body mass index was associated with increased revision rates (P = 0.037). Patients who sustained displaced femoral neck fractures had a significant decrease in SF-12 Mental Health Composite, SF-12 Physical Health Composite, and quality-of-life subscale scores.

Conclusions

The FNS is a viable alternative for internal fixation of intracapsular femoral neck fractures. The observed rate of revision after internal fixation was comparable with previously published outcomes following fixation with cannulated screws and sliding hip screws.

Level of Evidence

Level IV, Therapeutic Study.

Efficacy and Safety of Dual vs Single Antibiotic-Loaded Cement in Bone Fracture Management: A Systematic Review and Meta-Analysis

Bone fractures often require arthroplasty, which carries the risk of surgical site infections (SSIs) and prosthetic joint infections (PJIs). Antibiotic-loaded bone cement (ALBC) is commonly used to reduce these risks. Dual antibiotic-loaded cement (DALC) has been proposed as a more effective option compared to single antibiotic-loaded cement (SALC). This systematic review and meta-analysis aimed to compare the efficacy and safety of DALC and SALC in preventing infections and related outcomes in arthroplasty. We conducted a systematic review and meta-analysis comparing DALC and SALC in patients undergoing hip or knee arthroplasty for fractures. The primary outcome was infection rate (SSI and PJI), with secondary outcomes including re-revision rates and mortality. Databases searched included PubMed, Cochrane Library, Scopus, and Google Scholar. Data synthesis was performed using Review Manager Software (RevMan 5.4, Cochrane Methods, London, UK), and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Nine studies comprising 55,672 patients were included. Eight studies focused on hip arthroplasty, and four included knee surgeries. In hip arthroplasty, DALC significantly reduced infection rates compared to SALC (OR, 0.64; 95% CI, 0.49 to 0.83; P = 0.001), with moderate heterogeneity (I² = 52%). However, no significant difference was found in knee arthroplasty (OR, 1.21; 95% CI, 0.87 to 1.70; P = 0.26). Overall, DALC showed a significant reduction in infection rates (OR, 0.81; 95% CI, 0.66 to 1.00; P = 0.05). DALC also significantly reduced deep surgical site infections in hip surgeries (OR, 0.46; 95% CI, 0.33 to 0.66; P < 0.001). No significant differences were observed in re-revision rates for either hip or knee arthroplasty. Mortality rates were also not significantly different between DALC and SALC. DALC appears to reduce infection rates, particularly in hip arthroplasty, compared to SALC. However, no significant differences were found in re-revision or mortality rates. These findings suggest that DALC may offer better prophylaxis in hip surgeries, but further research is needed to explore its broader benefits and cost-effectiveness.

Higher Comorbidities are Correlated With Readmission Following Arthroplasty for Femoral Neck Fracture

Background

A desire to control cost and improve patient outcomes following arthroplasty led to the introduction of the Center for Medicare and Medicaid Service Comprehensive Care for Joint Replacement Program. Hemi and total hip arthroplasty for femoral neck fracture has been shown to have worse outcomes than those for osteoarthritis. However, little has been studied about the effect of comorbidities on costs associated with arthroplasty for femoral neck fracture. This study investigates how the number of comorbidities influence 90-day outcomes and cost following hemi or total hip arthroplasty for displaced femoral neck fracture in patients covered by the Comprehensive Care for Joint Replacement bundle.

Methods

We reviewed all Medicare hip fracture patients undergoing hemi or total hip arthroplasty at our institution between April 2016 and November 2020. Basic demographic and perioperative information was collected. The primary outcome was hospital readmission within 90 days. The data set captured 90-day readmission to any institution, not just within our system. Secondary outcomes included 90-day reoperation and outpatient complications. Multiple logistic regression was used to examine the influence of number of comorbidities on the primary and secondary outcomes while controlling for other variables.

Results

The cohort comprised 378 patients (72% female), mean age 82 (±9) years, mean body mass index 23.4 (±4.7) kg/m2. For every additional comorbidity, the odds of related readmission without reoperation increased by 1.261 (95% confidence interval [1.055-1.507], P = .011). Odds of reoperation and odds of outpatient complication did not show statistical significance with the available numbers.

Conclusions

Increasing preoperative comorbidities results in a higher odd of readmission within 90 days following arthroplasty for femoral neck fracture in this Medicare population.

The epidemiology of geriatric fractures: A nationwide analysis of 1 million fractures

OBJECTIVE

Fractures among the geriatric population impose a substantial burden on healthcare systems. This study aims to investigate the incidence and distribution of fractures among geriatric individuals over seven years, analyzing changes by age and sex. The findings will inform national healthcare strategies for addressing the growing impact of geriatric fractures.

MATERIALS AND METHODS

Electronic health records from a nationwide personal health records system were analyzed, focusing on ICD-10 codes for fractures. Recurrent codes for the same patients within three months were excluded. Patients were categorized into three age groups (65-74, 75-84, and 85+ years), and fractures were grouped anatomically. Incidence rates for specific fracture locations were calculated based on the actual population at risk annually. Incidence rates were further stratified by sex and age groups using Turkey's age- and sex-specific populations.

RESULTS

A total of 1,004,663 geriatric fractures (66.9 % female, 33.1 % male) were identified over seven years. The overall fracture incidence among the geriatric population was 1.9 % (1910/100,000). Hip fractures were the most common (25.2 %), followed by wrist (15 %) and lumbar-pelvic fractures (11.9 %). Femur fractures were predominant in the 75-84 and 85+ age groups, while wrist fractures were more common in the 65-74 age group. Fracture incidences generally increased with age, except for ankle, foot, and toe fractures, which decreased with age for both sexes (p < 0.05). The male/female ratio was lowest for wrist, elbow, and humeral shaft fractures (1:3.2, 1:2.7, and 1:2.7, respectively). The lowest overall fracture incidence was observed in 2020 (1568/100,000), while the highest was in 2017 (2523/100,000).

CONCLUSION

With Turkey's aging population, the socioeconomic impact of geriatric fractures is anticipated to rise. Fracture patterns and incidence vary by age and sex among geriatric individuals. These findings provide valuable insights for healthcare planning and the development of community-based preventive measures tailored to specific fracture locations and demographics.

Risk factors for nonunion in femoral neck fracture patients with internal fixation: A multicenter (TRON group) retrospective study

INTRODUCTION

Femoral neck fractures (FNFs) are common in elderly individuals. When minimally displaced, they are typically treated with internal fixation. Nonunion is a complication of internal fixation of FNF, that sometimes necessitates reoperation. Radiographic parameters, including the Pauwels angle and posterior tilt angle, are risk factors for nonunion. However, these parameters are assessed solely in a two-dimensional context. We developed a novel radiographic parameter named the "Kindex." This multicenter investigation aimed to identify risk factors for nonunion following FNF fixation and evaluate the validity of this index.

METHODS

This retrospective multicenter study collected data from 939 FNF patients who underwent internal fixation between 2016 and 2020 at 11 facilities (TRON group). The following exclusion criteria were applied: age <65, insufficient data, and Garden Stage III or IV fracture. Patient data, including age, sex, BMI, ASA classification, alcohol and smoking history, and comorbidities, were recorded. Radiographic measurements of the Pauwels angle and posterior tilt angle at the time of injury were used to calculate the Kindex. Correlations between the Pauwels angle, posterior tilt angle, Kindex, and nonunion were evaluated. A multivariate logistic regression analysis was performed to investigate independent risk factors for nonunion. A receiver operating characteristic (ROC) analysis was performed to determine the cutoff value of the Kindex, and the area under the curve (AUC) was calculated.

RESULTS

The study included 594 patients (males, n = 151; females, n = 443; average age, 80.9 years). Nonunion was observed in 13 cases (2.2 %). While the Pauwels angle and posterior tilt angle did not show significant correlations, the Kindex exhibited strong correlations with both parameters. In the multivariate analysis, the Kindex and renal impairment were independent risk factors for nonunion (Kindex: OR 1.06, p = 0.015; renal impairment: OR 1.48, p = 0.021). In the ROC analysis, a Kindex of 50 was identified as the optimal cutoff value (AUC 0.72).

CONCLUSION

The nonunion rate after internal fixation of FNF was 2.2 %. Renal impairment and the Kindex were identified as independent risk factors. The Kindex at the time of injury may serve as a novel radiographic parameter to consider when evaluating the need for internal fixation in FNF cases.

Effect of cemented vs uncemented on outcomes for hemiarthroplasty in the elderly: A meta-analysis of randomized clinical trials

PURPOSE

In patients undergoing hemiarthroplasty in the elderly, the choice of the cemented method remains controversial. This meta-analysis was undertaken to compare the impact of cemented vs uncemented on outcomes for hemiarthroplasty in the elderly.

METHODS

This study included randomized controlled trials comparing the postoperative effects of cemented vs uncemented in patients with hemiarthroplasty. With no language restrictions, we searched Medline (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Cochrane Collaboration), Clinical Trials.gov, the ISRCTN registry, as well as gray literature with no language restrictions from January 1966 to April 2023. Data were quantitatively summarized using a random-effects model. The primary outcome was 1-year mortality.

RESULTS

This study included 13 randomized controlled trials with 3485 patients. The primary outcomes of the meta-analysis showed that cemented fixation in elderly patients undergoing hemiarthroplasty was superior to noncemented in 1-year mortality (risk ratio [RR] = 0.87, 95% confidence interval [CI]: 0.77, 0.97). Moreover, cemented was associated with a reduced risk of intraoperative periprosthetic fracture (RR = 0.19, 95% CI: 0.07, 0.50), postoperative periprosthetic fracture (RR = 0.34, 95% CI: 0.16,0.72), and loosening (RR = 0.33, 95% CI: 0.11, 0.97).

CONCLUSIONS

Cemented hemiarthroplasty is superior to noncemented in terms of survival. Moreover, cementation reduces the incidence of some implant-related complications. More extensive trials are needed to provide adequate guidance for choosing the proper cemented method.

Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Femoral Neck Fracture in Patients Aged 65 and Older

BACKGROUND

Femoral neck fractures are common in individuals over 65, necessitating quick mobilization for the best outcomes. There's ongoing debate about the optimal femoral component fixation method in total hip arthroplasty (THA) for these fractures. Recent U.S. data shows a preference for cementless techniques in over 93% of primary THAs. Nonetheless, cemented fixation might offer advantages like fewer revisions, reduced periprosthetic fractures, lesser thigh pain, and enhanced long-term implant survival for those above 65. This study compares cementless and cemented fixation methods in THA, focusing on postoperative complications in patients aged 65 and older.

METHODS

We analyzed a national database to identify patients aged 65+ who underwent primary THA for femoral neck fractures between 2016 and 2021, using either cementless (n = 2,842) or cemented (n = 1,124) techniques. A 1:1 propensity-matched analysis was conducted to balance variables such as age, sex, and comorbidities, resulting in two equally sized groups (n = 1,124 each). We evaluated outcomes like infection, venous thromboembolism (VTE), wound issues, dislocation, periprosthetic fracture, etc., at 90 days, 1 year, and 2 years post-surgery. A P-value < 05 indicated statistical significance.

RESULTS

The cemented group initially consisted of older individuals, more females, and higher comorbidity rates. Both groups had similar infection and wound complication rates, and aseptic loosening. The cemented group, however, had lower periprosthetic fracture rates (2.5 versus 4.4%, P = .02) and higher VTE rates (2.9 versus 1.2%, P = .01) at 90 days. After 1 and 2 years, the cementless group experienced more aseptic revision surgeries.

CONCLUSIONS

This study, using a large, national database and propensity-matched cohorts, indicates that cemented femoral component fixation in THA leads to fewer periprosthetic fractures and aseptic revisions, but a higher VTE risk. Fixation type choice should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise. This data can inform surgeons in their decision-making process.

Periprosthetic fracture following arthroplasty for femoral neck fracture: is a cemented stem protective?

BACKGROUND

Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF.

METHODS

Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF.

RESULTS

There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010).

CONCLUSIONS

In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

Proximal hip fractures in 71,920 elderly patients: incidence, epidemiology, mortality and costs from a retrospective observational study

BACKGROUND

The risk of proximal femoral fractures increases with aging, causing significant morbidity, disability, mortality and socioeconomic pressure. The aims of the present work are (1) to investigate the epidemiology and incidence of these fractures among the elderly in the Region of Lombardy; (2) to identify the factors influencing survival; (3) to identify the factors influencing hospitalization and post-operative costs.

METHODS

The Region of Lombardy provided anonymized datasets on hospitalized patients with a femoral neck fracture between 2011 and 2016, and anonymized datasets on extra-hospital treatments to track the patient history between 2008 and 2019. Statistical evaluations included descriptive statistics, survival analysis, Cox regression and multiple linear models.

RESULTS

71,920 older adults suffered a femoral fracture in Lombardy between 2011 and 2016. 76.3% of patients were females and the median age was 84. The raw incidence of fractures was stable from year 2011 to year 2016, while the age-adjusted incidence diminished. Pertrochanteric fractures were more spread than transcervical fractures. In patients treated with surgery, receiving treatment within 48 h reduced the hazard of death within the next 24 months. Combined surgical procedures led to increased hazard in comparison with arthroplasty alone, while no differences were observed between different arthroplasties and reduction or fixation. In patients treated conservatively, age and male gender were associated with higher hazard of death. All patients considered, the type of surgery was the main factor determining primary hospitalization costs. A higher number of surgeries performed by the index hospital in the previous year was associated with financial savings. The early intervention significantly correlated with minor costs.

CONCLUSIONS

The number of proximal femoral fractures is increasing even if the age-adjusted incidence is decreasing. This is possibly due to prevention policies focused on the oldest cohort of the population. Two policies proved to be significantly beneficial in clinical and financial terms: the centralization of patients in high-volume hospitals and a time limit of 48 h from fracture to surgery.

TRIAL REGISTRATION

Non applicable.

Effect of ultrasound-guided pericapsular nerve group (PENG) block on pain during patient positioning for central nervous blockade in hip surgery: a randomized controlled trial

BACKGROUND

Most patients with hip fractures are elderly patients with comorbidities, and well-managed pain management is associated with positive postoperative outcomes. In recent years, new indications for regional anesthesia techniques have been defined, and they have found more place in clinical practice. Herein we investigate the effect of US-guided PENG block on positioning pain and compare that effect to intravenous opioid in patients undergoing surgery under spinal anesthesia for hip fractures. Additionally, we sought to investigate the effect of PENG block on pain scores, opioid intake, time to first analgesic requirement, and quality of recovery within the first 24 h following surgery.

METHODS

In this study, patients were divided into the PENG (n = 42) and control group (n = 42) one hour prior to surgery. A team who was blinded to the assigned groups, collected and evaluated all data such as spinal anesthesia positioning pain, postoperative pain, opioid requirement.

RESULTS

Patients that underwent PENG had statistically significantly lower NRS scores after interventions, immediately before positioning, at positioning and at end of spinal anesthesia. Pain scores during positioning for spinal anesthesia were statistically significantly lower in the PENG group than in the control group (p < 0.001). Total morphine use over the first 24 h was extremely statistically significantly lower in the PENG group (p < 0.001).

CONCLUSIONS

Positive outcomes of PENG block in patient positioning pain before spinal anesthesia, postoperative pain scores, and morphine consumption are consistent with similar studies. High patient satisfaction in patients who underwent PENG block contributes to the literature.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04871061.

Robotic-assisted systems for the safe and reliable treatment of femoral neck fractures: retrospective cohort study

BACKGROUND

Robots are being used in a wide range of surgical procedures. However, in clinical practice, the efficacy of orthopedic robotic-assisted treatment of femoral neck fractures is still poorly reported, particularly in terms of screw placement accuracy, femoral neck fracture healing rates and postoperative functional recovery. Moreover, there is a lack of comparative analysis between robot-assisted surgery and traditional surgical approaches.

PURPOSE

The purpose of this study was to compare the clinical outcomes of patients with femoral neck fractures treated with TiRobot-assisted hollow screw fixation with those of patients with femoral neck fractures treated with traditional surgical approaches.

METHODS

This study included 112 patients with femoral neck fracture who were treated from March 2017 to October 2021 with percutaneous hollow screw internal fixation. These included 56 cases in the TiRobot-assisted surgery group and 56 cases in the standard surgery group. After at least 1 year of follow-up, the treatment outcomes of the two groups were compared, including the amount of intraoperative bleeding, the duration of intraoperative fluoroscopy, the number of guide pin positioning adjustments, the length of hospital stay, the accuracy rate of screw placement, the final Harris Hip Score, the fracture healing rate, and the rate of femoral head necrosis. Statistical analysis software was used to process and analyze the result.

RESULTS

The TiRobot-assisted group had a statistically significant improvement over the control group in terms of intraoperative bleeding, the duration of intraoperative fluoroscopy, the number of guide pin positioning adjustments, length of hospital stay, accuracy of screw placement and incidence of femoral head necrosis (P < 0.05). There was no statistically significant difference in time to surgery, final Harris hip score and fracture healing rate (P > 0.05).

CONCLUSION

This study shows that TiRobot-assisted surgery has the advantages of short hospital stay, high safety, minimally invasive, high success rate of nail placement, and can reduce the amount of intraoperative radiation and the incidence of femoral head necrosis, thus achieving satisfactory clinical outcomes, and is worthy of clinical promotion.

Cold Welding of the Synthes Femoral Neck System Encountered at Conversion to Arthroplasty: A Case Report

CASE

The Synthes Femoral Neck System (FNS) is a relatively new device available to the market in 2019 designed to reduce complication and revision rates after femoral neck fracture stabilization. We present a 77-year-old man with Parkinson disease and avascular necrosis after femoral neck fracture initially managed with the FNS. Subsequent challenges in device removal occurred because of its propensity for bony integration, plate and locking screw welding, and screw head recess destruction.

CONCLUSION

Surgeons must recognize the need for additional available equipment (e.g., burr or broken screw removal set) for successful extraction when FNS removal is required.

Infection after intracapsular femoral neck fracture - does antibiotic-loaded bone cement reduce infection risk after hemiarthroplasty and total hip arthroplasty?

Aims

The aim of this investigation was to compare risk of infection in both cemented and uncemented hemiarthroplasty (HA) as well as in total hip arthroplasty (THA) following femoral neck fracture.

Methods

Data collection was performed using the German Arthroplasty Registry (EPRD). In HA and THA following femoral neck fracture, fixation method was divided into cemented and uncemented prostheses and paired according to age, sex, BMI, and the Elixhauser Comorbidity Index using Mahalanobis distance matching.

Results

Overall in 13,612 cases of intracapsular femoral neck fracture, 9,110 (66.9%) HAs and 4,502 (33.1%) THAs were analyzed. Infection rate in HA was significantly reduced in cases with use of antibiotic-loaded cement compared with uncemented fixated prosthesis (p = 0.013). In patients with THA no statistical difference between cemented and uncemented prosthesis was registered, however after one year 2.4% of infections were detected in uncemented and 2.1% in cemented THA. In the subpopulation of HA after one year, 1.9% of infections were registered in cemented and 2.8% in uncemented HA. BMI (p = 0.001) and Elixhauser Comorbidity Index (p < 0.003) were identified as risk factors of periprosthetic joint infection (PJI), while in THA cemented prosthesis also demonstrated an increased risk within the first 30 days (hazard ratio (HR) = 2.73; p = 0.010).

Conclusion

The rate of infection after intracapsular femoral neck fracture was statistically significantly reduced in patients treated by antibiotic-loaded cemented HA. Particularly for patients with multiple risk factors for the development of a PJI, the usage of antibiotic-loaded bone cement seems to be a reasonable procedure for prevention of infection.

The Prophylactic Effect of Single vs. Dual Antibiotic-Loaded Bone Cement against Periprosthetic Joint Infection Following Hip Arthroplasty for Femoral Neck Fracture: An Analysis of the German Arthroplasty Registry

BACKGROUND

Antibiotic-loaded bone cement in arthroplasties is currently experiencing increased usage. Therefore, single and double antibiotic-loaded bone cements are commercially available and used in orthopedic surgery. The aim of this investigation was to compare the clinical use of single compared to dual antibiotic-loaded bone cement for implant fixation after femoral neck fracture. Further infection rates were to be compared in (partial) arthroplasty for the treatment of femoral neck fracture for both treatment options.

METHODS

On the basis of the German Arthroplasty Registry (EPRD), all cases of femoral neck fracture treated with hemiarthroplasty (HA), or total hip arthroplasty (THA) with single and dual antibiotic-loaded bone cement, were included into the data analysis. The infection risk was compared using Kaplan-Meier estimates.

RESULTS

In total, 26,845 cases (HA 76.3%-THA: 23.7%) with femoral neck fracture were included. Within recent years, an increasing usage of dual antibiotic-loaded cement in Germany, with a current proportion of 7.30% in arthroplasty procedures for femoral neck fracture treatment, has been observed. In patients treated with HA, the proportion of dual antibiotic-loaded cement was 7.86%, while in those treated with THA, 5.46% of all prostheses were fixated with a two antibiotic component cement. For all arthroplasty procedures using single antibiotic-loaded bone cement after six months 1.8%, after one year 1.9%, and after five years 2.3%, of the cases failed due to periprosthetic joint infection (PJI), while in the same time period, in cases with dual antibiotic-loaded bone cement 1.5%, 1.5% and 1.5% suffered from infection (p = 0.34). A infection rate of 1.1% after HA with dual antibiotic-loaded bone cement was reported, compared to a 2.1% infection rate whilst using single antibiotic-loaded bone cement after five years (p = 0.098). The number required for treatment when using HA was 91.

CONCLUSIONS

The use of dual antibiotic-loaded bone cement is increasingly used in arthroplasty procedures after femoral neck fractures. It demonstrates a reduction of PJI after HA and seems, therefore, to be a useful method for the prevention of infection, especially in patients with increased risk factors for PJI.

Risk of Aseptic Revision and Periprosthetic Fracture Following Bipolar Versus Unipolar Hemiarthroplasty

Hemiarthroplasty is currently the most common treatment for displaced femoral neck fractures in the elderly. While bipolar hemiarthroplasty was developed to reduce the risk of acetabular erosion that is associated with traditional unipolar hemiarthroplasty, meta-analyses have reported similar outcomes for bipolar and unipolar hemiarthroplasty devices. The primary objective of this study was to evaluate the risks of aseptic revision and periprosthetic fracture following bipolar versus unipolar hemiarthroplasty in a large integrated health-care system in the United States.

Methods

We conducted a retrospective cohort study using data from the hip fracture registry of an integrated health-care system. Patients aged ≥60 years who underwent hemiarthroplasty for hip fracture between 2009 and 2019 were included. The primary outcome measure was aseptic revision, and the secondary outcome measure was revision for periprosthetic fracture. Cause-specific Cox proportional hazards regression was performed, with mortality considered as a competing event. In the multivariable analysis, estimates were adjusted for potential confounders such as age, sex, race/ethnicity, body mass index, American Society of Anesthesiologists classification, femoral fixation, surgeon volume, type of anesthesia, and discharge disposition.

Results

The study sample included 13,939 patients who had been treated with hemiarthroplasty by 498 surgeons at 35 hospitals. The mean follow-up time was 3.7 ± 2.9 years. The overall incidence of aseptic revision at 5 years following hemiarthroplasty was 2.8% (386). In the multivariable analysis controlling for potential confounders, bipolar hemiarthroplasty was associated with a lower risk of aseptic revision than unipolar hemiarthroplasty (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.59 to 0.94; p = 0.012). Rates of revision for periprosthetic fracture were similar between the bipolar and unipolar devices (HR, 0.79; 95% CI, 0.58 to 1.10; p = 0.16).

Conclusions

In this study of hemiarthroplasty for hip fracture in elderly patients, bipolar designs were associated with a lower risk of aseptic revision than unipolar designs. In contrast to prior research, we did not find any difference in the risk of periprosthetic fracture between the 2 designs.

Level of Evidence

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

Hip hemiarthroplasty for the treatment of femoral neck fractures in dialysis patients

OBJECTIVES

This study sought to delineate the postoperative outcomes in dialysis patients undergoing hip hemiarthroplasty (HHA) for the treatment of femoral neck fractures (FNF) in order to better optimise pre- and postoperative management and minimise short-term morbidity and mortality rates.

METHODS

16,955 patients who had undergone HHA for femoral neck fractures from 2005 to 2018 were isolated from a multi-institutional surgical registry, of which 343 (2.0%) were on dialysis and 16,612 (98.0%) were not. The cohorts were identified/analysed for differences in their comorbidities, demographic factors, and 30-day postoperative complications using Fischer's exact tests and Mann-Whitney U-tests. Coarsened exact matching (CEM) was implemented in order to control for baseline difference in demographics and comorbidities. Multivariate logistic regression analyses were used to assess the impact of dialysis as an independent risk factor for various complications, including reoperations, readmissions, and mortality.

RESULTS

Upon CEM-matching (L1-statistic <0.001), weighted multivariate logistic regression analyses demonstrated dialysis to be an independent risk factor for minor complications (OR 3.051, p < 0.001), pneumonia (OR 3.943, p < 0.001), urinary tract infections (UTIs) (OR 2.684, p < 0.001), major complications (OR 1.892, p < 0.001), unplanned intubation (OR 2.555, p = 0.047), cardiac arrest (OR 11.897, p < 0.001), deep vein thrombosis (DVT), (OR 2.610, p = 0.049), and mortality (OR 2.960, p < 0.001).

CONCLUSIONS

Dialysis independently increased the risk for unplanned intubation, cardiac arrest, blood transfusions, pneumonia, DVT, and mortality. In communicating postoperative expectations, surgeons should aim to clarify the patients' preferences and potential resuscitation designations prior to surgical intervention due to the increased risk of serious complications. A lower threshold of suspicion for DVT in this population is reasonable. Identifying high-risk patient populations that may experience increased rates of complications, with the ensuing financial expenditures, due to medical complexity rather than subpar management may help providers avoid penalties in caring for these patients.

Concomitant fractures in patients with proximal femoral fractures lead to a prolonged hospital stay but not to increased complication rates or in-house mortality if treated surgically: a matched pair analysis

BACKGROUND

Impact of concomitant fractures on patients sustaining a proximal femur fracture remains unclear. Rising numbers and patient need for rehab is an important issue. The objective of our study was to investigate the impact of concomitant fractures, including all types of fractures, when treated operatively, for proximal femur fractures on the length of hospital stay, in-house mortality and complication rate.

METHODS

Observational retrospective cohort single-center study including 85 of 1933 patients (4.4%) with a mean age of 80.5 years, who were operatively treated for a proximal femoral and a concomitant fracture between January 2016 and June 2020. A matched pair analysis based on age, sex, fracture type and anticoagulants was performed. Patient data, length of hospital stay, complications and mortality were evaluated.

RESULTS

The most common fractures were osteoporosis-associated fractures of the distal forearm (n = 34) and the proximal humerus (n = 36). The group of concomitant fractures showed a higher CCI than the control group (5.87 vs. 5.7 points; p < 0.67). Patients with a concurrent fracture had a longer hospital stay than patients with an isolated hip fracture (15.68 vs. 13.72 days; p < 0.056). Complications occurred more often in the group treated only for the hip fracture (11.8%, N = 20), whilst only 7.1% of complications were recorded for concomitant fractures (p < 0.084). The in-house mortality rate was 2.4% and there was no difference between patients with or without a concomitant fracture.

CONCLUSIONS

A concomitant fracture to a hip fracture increases the length of hospital stay significantly but does not increase the complication rate or the in-house mortality. This might be due to the early mobilization, which is possible after early operative treatment of both fractures.

The role of microscopic properties on cortical bone strength of femoral neck

BACKGROUND

Femoral neck fractures are serious consequence of osteoporosis (OP), numbers of people are working on the micro-mechanisms of femoral neck fractures. This study aims to investigate the role and weight of microscopic properties on femoral neck maximum load (L_max), funding the indicator which effects L_max most.

METHODS

A total of 115 patients were recruited from January 2018 to December 2020. Femoral neck samples were collected during the total hip replacement surgery. Femoral neck Lmax, micro-structure, micro-mechanical properties, micro-chemical composition were all measured and analyzed. Multiple linear regression analyses were performed to identify significant factors that affected the femoral neck L_max.

RESULTS

The L_max, cortical bone mineral density (cBMD), cortical bone thickness (Ct. Th), elastic modulus, hardness and collagen cross-linking ratio were all significantly decreased, whereas other parameters were significantly increased during the progression of OP (P < 0.05). In micro-mechanical properties, elastic modulus has the strongest correlation with L_max (P < 0.05). The cBMD has the strongest association with L_max in micro-structure (P < 0.05). In micro-chemical composition, crystal size has the strongest correlation with L_max (P < 0.05). Multiple linear regression analysis showed that elastic modulus was most strongly related to L_max (β = 0.920, P = 0.000).

CONCLUSIONS

Compared with other parameters, elastic modulus has the greatest influence on L_max. Evaluation of microscopic parameters on femoral neck cortical bone can clarify the effects of microscopic properties on L_max, providing a theoretical basis for the femoral neck OP and fragility fractures.

Albumin is an Independent Predictor of up to 9-Year Mortality for Intracapsular Femoral Neck Fractures Aiding in Decision-Making for Total Hip Arthroplasty or Hemiarthroplasty

BACKGROUND

Intracapsular femoral neck fractures in the geriatric population are usually treated with hemiarthroplasty or total hip arthroplasty. The patients' medium-term to long-term mortality is a consideration to help decide which procedure to perform. The aim of this study is to examine whether easily identifiable serum investigations and patient identifiable factors on admission are associated with medium-term and long-term mortality.

METHODS

A consecutive series of 331 patients who sustained intracapsular femoral neck fractures and were over the age of 55 years were identified and retrospectively reviewed. American Society of Anesthesiologists (ASA) grade, cognitive function, gender, age, mobility status, and admission serum investigations were considered.

RESULTS

Low albumin levels, advanced age, men, and a combination of high ASA with lower mobility status were independent predictors of mean 5-year mortality. Similarly, low albumin levels and a combination of high ASA with lower mobility status were found to be independent predictors of longer term mortality (7-9 years). The optimal albumin cut-off to identify patient survival was >42 g/L with an area under the curve of 0.71.

CONCLUSION

We suggest that serum albumin on admission can be utilized as a factor to identify patients who are likely to survive at up to 9-year mean follow-up, to guide decision for total hip arthroplasty over hemiarthroplasty.

How does sleep apnea impact outcomes following primary total hip arthroplasty for femoral neck fractures: a matched-control analysis

BACKGROUND

Cross-sectional studies have demonstrated that the prevalence of sleep apnea (SA) to be increasing within the United States. While studies have shown the association of SA and its association on complications following elective orthopedic procedures, well-powered studies investigating its impact in a traumatic setting are limited. The purpose of this study was to determine whether SA patients undergoing primary total hip arthroplasty (THA) for femoral neck fractures have higher rates of: (1) hospital lengths of stay (LOS); (2) readmissions; (3) complications; and (4) healthcare expenditures.

METHODS

The 100% Medicare Standard Analytical Files was queried from 2005 to 2014 for patients who sustained femoral neck fractures and were treated with primary THA. The study group consisted of patients with concomitant diagnoses of SA, whereas patients without SA served as controls. Study group patients were matched to controls in a 1:5 ratio by age, sex, and various comorbid conditions. Demographics of the cohorts were compared using Pearson's chi-squared analyses, and multivariate logistic regression analyses were used to calculate the odds (OR) of the effects of SA on postoperative outcomes. A p value less than 0.006 was considered to be statistically significant.

RESULTS

The final query yielded 24,936 patients within the study (n = 4166) and control (n = 20,770) cohorts. SA patients had significantly longer in-hospital LOS (6 vs. 5 days, p < 0.0001) but similar readmission rates (24.12 vs. 20.50%; OR: 1.03, p = 0.476). SA patients had significantly higher frequency and odds of developing medical complications (72.66 vs. 43.85%; OR: 1.57, p < 0.0001), and higher healthcare costs ($22,743.79 vs. $21,572.89, p < 0.0001).

CONCLUSION

SA is associated with longer in-hospital LOS, higher rates of complications and healthcare expenditures. This study is vital as it can allow orthopaedists to educate patients with SA on the potential complications which may occur following their procedure.

LEVEL OF EVIDENCE

III.

Epidemiology and Management of Proximal Femoral Fractures in Italy between 2001 and 2016 in Older Adults: Analysis of the National Discharge Registry

This study aims to determine the annual incidence of proximal femoral fractures in Italy in the period between 2001 and 2016 among older adults, and to describe the trends in the clinical management of these cases. Data were retrieved from the National Hospital Discharge records issued by the Italian Ministry of Health and from the Italian Institute for Statistics. The number of hospitalizations increased between 2001 and 2016, while the age-adjusted yearly incidence decreased from 832.2 per 100,000 individuals to 706.2. The median age was 83 years (IQR 78-88) with a large majority of females (76.6%). The type of fracture varied with age in female subjects, with older women more frequently reporting pertrochanteric fractures. Therapeutic strategies for the different types of fracture depended on patients' age. During the study years, improvements in fracture classification and management strategies were observed, with a clear decreasing trend for non-operative solutions. In conclusion, the number of proximal femur fractures in older adults is growing, even if at a lower rate compared to population aging. The Italian surgical practice changed during the study period towards the implementation of the most recent guidelines.

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.

Comparison study of patient demographics and risk factors for infections following primary total hip arthroplasty for femoral neck fractures

INTRODUCTION

While studies have shown favorable outcomes in the treatment of femoral neck fractures with the utilization of total hip arthroplasty (THA), adverse events, such as infections, can still occur. Therefore, the aims of this study were to 1) compare baseline demographics and 2) identify risk factors associated with developing either surgical site infections (SSIs) or peri-prosthetic joint infections (PJIs).

MATERIALS AND METHODS

A retrospective analysis of patients who underwent primary THA for femoral neck fractures were queried from the Medicare database. The inclusion criteria consisted of patients developing SSIs within 90 days or PJIs within 3 years following the index procedure. The query yielded 2502 patients who developed infections in the form of either SSIs (n = 987) or PJIs (n = 1515) out of 57,191 patients treated for femoral neck fractures with primary THA. Primary endpoints were to compare baseline demographic profiles and determine risk factors associated with developing infections. Multivariate binomial logistic regression analyses were performed to determine the odds (OR) of developing infections. A p value less than 0.001 was considered to be statistically significant.

RESULTS

Patients who developed either infections were found to be significantly different when compared to patients who did not develop infections. SSI (10 vs. 8, p < 0.0001) and PJI (9 vs. 5, p < 0.0001) patients both had significantly higher mean Elixhauser Comorbidity Index (ECI) scores compared to their counterparts. The regression model found the greatest risks for developing SSIs included hypertension (OR 1.63, p = 0.001), pathologic weight loss (OR 1.58, p < 0.0001), and iron deficiency anemia (IDA) (OR 1.48, p < 0.0001), whereas IDA (OR 2.14, p < 0.0001), pathologic weight loss (OR 1.75, p < 0.0001), and rheumatoid arthritis (OR 1.57, p < 0.0001) increased the odds for PJIs.

CONCLUSION

This study can be utilized by orthopedic surgeons and other healthcare professionals to adequately educate these patients of the complications which may occur following their surgery.

Comparing Outcomes in Cemented and Press-Fit Hemiarthroplasty

INTRODUCTION

Arthroplasty has become the standard of care for displaced femoral neck fractures in the geriatric cohort. However, details regarding optimal implant design and fixation strategy continue to be debated. We sought to determine whether cemented or press-fit hemiarthroplasties were more advantageous in terms of revision surgery, contralateral hip fractures, hospital length of stay, mortality rates, and survival.

METHODS

All geriatric fragility hip fractures at a level 1 trauma center (2014 to 2019) were retrospectively reviewed for the fracture pattern, fixation methodology, and outcome, yielding 707 femoral neck fractures treated with hemiarthroplasty (309 cemented and 398 press fit). The final follow-up was either date of death or final encounter. Major end points were revision surgery, contralateral fracture, and death. A Z-score test of two proportions was used for dichotomous variables, and a two-tailed t -test was used for continuous variables. Cox proportional hazard was used for revision surgery-free survival between groups, adjusting for age, sex, and American Society of Anesthesiologists status.

RESULTS

Patients who underwent press-fit hemiarthroplasty had a significantly higher rate of revision surgery (7.8% vs 3.9%; P = 0.006). Press-fit cases had a trend toward a decreased risk of contralateral fracture (13% vs 9.8%; P = 0.12), although this did not reach significance. Both groups had similar length of stay ( P = 0.08) and death rates ( P = 0.39). Of those who died, there was a trend toward longer survival in patients who received a press-fit hemiarthroplasty (413 vs 615 days; P < 0.001). There was a trend toward longer survival without repeat surgery in the cemented group without reaching significance (hazard ratio, 0.66 [0.34 to 1.23]; P = 0.201).

CONCLUSION

In this study, we found a markedly longer survival time after press-fit hemiarthroplasty, which we believe reflects surgeons' tendencies to cement the femoral prosthesis in patients with more comorbidities. However, press-fit hemiarthroplasties were more likely to result in repeat procedures on the same hip. Displaced geriatric femoral neck fractures may benefit from a cemented rather than press-fit hemiarthroplasty.

Clinical Outcomes of Total Hip Arthroplasty With the Anterolateral Modified Watson-Jones Approach for Displaced Femoral Neck Fractures

Objective

In recent years, many studies have reported good results with total hip arthroplasty (THA) for displaced femoral neck fractures (FNFs). However, no study has reported the clinical outcomes of the anterolateral modified Watson–Jones THA (MWJ-THA) for displaced FNFs. This study aimed to investigate the clinical results of THA for displaced FNFs at our hospital and to discuss the advantages of MWJ-THA over THA with other approaches for displaced FNFs.

Methods

Forty-three patients who underwent MWJ-THA for displaced FNFs were included in this study. Patient characteristics, preinjury walking ability, activities of daily living, implants used, walking ability (at 1, 3, and 6 months after surgery), cup placement angle, clinical hip score, surgical complications, revision surgery, and death within 1 year after surgery were investigated.

Results

The mean age of the 43 patients was 63.3 years, and the mean body mass index (kg/m²) was 21.1. Regarding the heads used, 28-mm heads were used in 4 patients, 32-mm heads were used in 32 patients, and 36-mm heads were used in 7 patients. The cups were placed in the Lewinnek safety zone (93.0%). Four patients had stem sinkage of a few millimeters. 6 months postoperatively, 38 patients walked unaided, and 4 patients walked with a cane. The Harris Hip Score averaged over 90 points at all time points. No postoperative dislocation was observed. Two patients died within 1 year postoperatively.

Conclusion

In this study, MWJ-THA was performed for displaced FNFs and resulted in no postoperative dislocations. Furthermore, more than 90% of the patients regained their preinjury walking ability at 6 months postoperatively. MWJ-THA has great dislocation control and is effective in treating displaced FNFs.

The Combined Relationship of Vitamin D and Weight-Bearing Sports Participation on Areal Bone Density and Geometry Among Adolescents: ABCD - Growth Study

Osteoporosis is a public health problem, which negatively impacts society and national health services worldwide. Altered mineralization of the skeleton can be caused by persistent vitamin D deficiency. However, the combined impact of both on bone health is still under investigation. In fact, although there is compelling evidence in the literature about the positive effect of weight-bearing sports participation on bone mineral density, its impact on bone geometry gains more attention in pediatric population. The sports modalities that we evaluated were artistic gymnastics and track and field. Nonsports group was composed of 43 adolescents. Bone density was assessed using dual-energy X-ray absorptiometry. Vitamin D concentration was assessed by blood analysis. In the crude comparison of bone outcomes, the sport group presented higher aBMD only in the trochanter (p-value = 0.040). Considering the combination of the engagement in sports and vitamin D, adolescents in the sports group presented significantly higher values of aBMD in lower limbs, whole body, trochanter, shaft, and femur whole body (p-value = 0.024, 0.035, 0.001, 0.019 and 0.003 respectly). In contrast, only the sport group with high vitamin D presented a higher CSA (p-value = 0.015) and femur neck aBMD compared to the non-sport/low vitamin D group. Only adolescents with a combination of sports participation and higher serum concentrations of vitamin D presented better bone geometry, denoting the relevance of the combination of both factors to bone health.

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.

[Short-term effectiveness of orthopedic robot-assisted femoral neck system fixation for fresh femoral neck fractures]

OBJECTIVE

To investigate the short-term effectiveness and advantages of the orthopedic robot-assisted femoral neck system (FNS) fixation in the treatment of fresh femoral neck fractures compared with the traditional manual operation.

METHODS

A clinical data of 74 patients with fresh femoral neck fractures, who had undergone internal fixation with FNS between April 2020 and September 2021, was retrospectively analyzed. Among them, there were 31 cases of TiRobot-assisted operation (trial group) and 43 cases of traditional manual operation (control group). There was no significant difference between groups ( P>0.05) in terms of gender, age, cause of injury, time from injury to operation, fracture side and type. The fracture fixation time (intraoperative fracture reduction to the end of suture), invasive fixation time (incision of internal fixation to the end of suture), the number of placing key-guide needle, incision length, intraoperative blood loss, fracture healing, and Harris score of hip function were recorded and compared.

RESULTS

All operations were performed with no neurovascular injury or incision complications. The invasive fixation time, intraoperative blood loss, the number of placing key-guide needle, and the incision length in the trial group were superior to the control group ( P<0.05), and there was no significant difference in fracture fixation time between groups ( P>0.05). All patients were followed up 4-16 months (mean, 7 months). The fracture did not heal in 1 patient of trial group, and the other fractures healed in 2 groups; the fracture healing time was (17.6±1.9) weeks in trial group and (18.2±1.9) weeks in control group, and there was no significant difference between groups ( t=0.957, P=0.345). At last follow-up, the Harris score of the trial group was 82.4±5.8, which was higher than that of the control group (79.0±7.7), but the difference was not significant ( t=-1.483, P=0.147).

CONCLUSION

Orthopedic robot-assisted FNS fixation in the treatment of fresh femoral neck fractures has the similar short-term effectiveness as the traditional method, but the former has advantages in terms of operation time, intraoperative blood loss, and the number of placing key-guide needle, making the operation more minimally invasive and quicker, and more suitable for older patients.

Association of bone-related biomarkers with femoral neck bone strength

BACKGROUND

Femoral neck fractures are the worst consequence of osteoporosis (OP), and its early prevention and treatment have become a public health problem. This study aims to investigate the relationship of bone-related biomarkers, femoral neck bone mineral density (BMD) and maximum load (L_max), selecting the indicator which can reflect femoral neck bone loss and reduced bone strength.

METHODS

A total of 108 patients were recruited from January 2017 to December 2019. Venous blood samples were collected from patients before total hip replacement, and femoral neck samples were collected during the surgery. Femoral neck BMD, femoral neck L_max, bone-related markers (serum levels of bone turnover markers, protein expression of type I collagen (COL-I) and osteopontin (OPN) in femoral neck) were all measured and analyzed.

RESULTS

The expression of COL-I in femoral neck were significantly decreased, whereas other markers were all significantly increased with the decreasing of femoral neck BMD and L_max (P < 0.05). Among them, serum C-terminal telopeptide of type I collagen (CTX) levels and OPN expression of femoral neck were increased in osteopenia. In multiple linear regression analysis, CTX and OPN were both negatively correlated with femoral neck BMD and L_max, and they were independent factors of femoral neck BMD and L_max, whereas COL-I was independent factor affecting L_max (P < 0.05). Besides, CTX was negatively correlated with COL-I (β = -0.275, P = 0.012) and positively correlated with OPN (β = 0.295, P = 0.003).

CONCLUSIONS

Compared with other indicators, serum CTX was more sensitive to differences in bone mass and bone strength of femoral neck, and could be considered as surrogate marker for OPN and COL-I.Early measurement of CTX could facilitate the diagnosis of osteopenia and provide a theoretical basis for delaying the occurrence of femoral neck OP and fragility fractures.

Acute kidney injury after hip fracture in organ transplant recipients

BACKGROUND

This study aimed to investigate the incidence and risk factors of acute kidney injury (AKI) after hip fracture in organ transplant recipients.

METHODS

In this single-center retrospective cohort study, 795 elderly patients who underwent hip fracture surgery were enrolled. AKI was defined according to Acute Kidney Injury Network criteria. Among the 795 patients, 23 underwent kidney transplantation (KT) and 20 underwent liver transplantation (LT). The incidence of AKI, dialysis requirement, and renal recovery rate were investigated.

RESULTS

AKI occurred in 83 patients (10.5%), of whom 9 (39.1%), 3 (15%), and 71 (9.5%) were in the KT, LT, and non-transplantation groups, respectively. The incidence rates of AKI and severe AKI (17.4% vs. 1.4%) were significantly higher in the KT group than in the non-transplantation group (p = 0.001 for both). The renal recovery rate was significantly lower in the KT group than in the non-transplantation group (p = 0.033). The multivariate analysis revealed that male; body mass index; CKD; alkaline phosphatase; intraoperative hypotension; and history of KT were independent predictors of AKI development.

CONCLUSIONS

AKI and severe AKI after hip fracture occurred more frequently in the KT recipients with lower renal recovery rates. Transplanted kidneys are more vulnerable to AKI after hip fracture. This article is protected by copyright. All rights reserved.

Prediction Models for Prognosis of Femoral Neck–Fracture Patients 6 Months after Total Hip Arthroplasty

Purpose

To establish prediction models for 6-month prognosis in femoral neck–fracture patients receiving total hip arthroplasty (THA).

Patients and Methods

In total, 182 computed tomography image pairs from 85 patients were collected and divided into a training set (n=127) and testing set (n=55). Least absolute shrinkage–selection operator regression was used for selecting optimal predictors. A random-forest algorithm was used to establish the prediction models, which were evaluated for accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC).

Results

The best model in this study was constructed based on demographic data, preoperative laboratory indicators, and three preoperative radiomic features. In the random-forest model, activated partial thromboplastin time, a preoperative radiomic feature (maximum diameter), and fibrinogen were important variables correlating with patient outcomes. The AUC, sensitivity, specificity, PPV, NPV, and accuracy in the training set were 0.986 (95% CI 0.971–1), 0.925 (95% CI 0.862–0.988), 0.983 (95% CI 0.951–1.016), 0.984 (95% CI 0.953–1.014), 0.922 (95% CI 0.856–0.988), and 0.953 (95% CI 0.916–0.990), respectively. The AUC, sensitivity, specificity, PPV, NPV, and accuracy in the testing set were 0.949 (95% CI 0.885–1), 0.767 (95% CI 0.615–0.918), 1 (95% CI 1–1), 1 (95% CI 1–1), 0.781 (95% CI 0.638–0.924), and 0.873 (95% CI 0.785–0.961), respectively.

Conclusion

The model based on demographic, preoperative clinical, and preoperative radiomic data showed the best predictive ability for 6-month prognosis in the femoral neck–fracture patients receiving THA.

Association Between the Femoral Stem Design Type and the Risk of Aseptic Revision After Hemiarthroplasty

INTRODUCTION

Although noncemented hemiarthroplasty has been associated with a higher risk of revision surgery as compared with cemented fixation, it remains uncertain whether this increased risk applies to all noncemented stem design types or only a subset. The purpose of this study was to assess the risk of aseptic revision associated with three common types of noncemented stem designs as compared with cemented fixation in the hemiarthroplasty treatment of femoral neck fractures in the elderly patients.

METHODS

This was a retrospective cohort study of patients aged 60 years and older who sustained a hip fracture and underwent hemiarthroplasty between 2009 and 2018 at one of 35 hospitals owned by a large US health maintenance organization. Hemiarthroplasty fixation was categorized as cemented or noncemented, with the noncemented stems further classified as single wedge without collar, fit and fill without collar, or fit and fill with collar. The primary outcome was aseptic revision, and the median follow-up time was 4.8 years.

RESULTS

Of 12,071 patients who underwent hemiarthroplasty during the study period (average age 82.0 ± 8.4 years, 67.9% women), 807 (6.7%) received a single-wedge stem without collar, 2,124 (17.6%) received a fit-and-fill stem without collar, 2,453 (20.3%) received a fit-and-fill stem with collar, and 6,687 (55.4%) received a cemented stem. Compared with cemented fixation, all the noncemented stem design types were associated with a markedly higher risk of aseptic revision in the multivariable analysis, including single wedge without collar (hazard ratio [HR] 2.00, 95% confidence interval [CI], 1.38 to 2.89, P < 0.001), fit and fill without collar (HR 1.52, 95% CI, 1.14 to 2.04, P = 0.005), and fit and fill with collar (HR 2.11, 95% CI, 1.63 to 2.72, P < 0.001).

CONCLUSION

In the hemiarthroplasty treatment of elderly patients with hip fracture, all routinely used noncemented stem design types were associated with a higher risk of aseptic revision as compared with cemented fixation.

Chronic liver disease and cirrhosis increase morbidity in geriatric patients treated surgically for hip fractures: analysis of the US Nationwide Inpatient Sample

Background

This study aimed to evaluate the impact of chronic liver disease and cirrhosis on inpatient outcomes of geriatric hip fracture surgery.

Materials and methods

Using population-based retrospective study design, this study extracted data from the US Nationwide Inpatient Sample (NIS) database 2005–2014, identifying patients aged ≥ 65 years undergoing hip fracture repair. Main outcomes were in-hospital mortality, any/specific complications, non-routine discharge, extended length of stay (LOS) and hospital costs. Associations between cirrhosis, non-cirrhotic chronic liver disease and outcomes were determined using regression analysis.

Results

Data of 347,363 hip fracture patients included 344,035 without liver disease, 1257 with non-cirrhotic chronic liver disease and 2,071 with cirrhosis. After adjustments, non-cirrhotic chronic liver disease was significantly associated with non-routine discharge (OR: 1.247, 95% CI: 1.038–1.498), acute kidney injury (OR: 1.266, 95% CI: 1.039–1.541), extended LOS (OR: 1.285, 95% CI: 1.122–1.473) and hospital costs (beta: 9173.42, 95% CI: 6925.9–11,420.95) compared to no liver disease; while cirrhosis was significantly associated with higher risk of in-hospital mortality (OR: 2.325, 95% CI: 1.849–2.922), any complication (OR: 1.295, 95% CI: 1.143–1.467), acute kidney injury (OR: 1.242, 95% CI: 1.177–1.433), non-routine discharge (OR: 1.650, 95% CI: 1.412–1.928), extended LOS (OR: 1.405, 95% CI: 1.263–1.562) and hospital costs (beta: 6680.24, 95% CI: 4921.53–8438.95) compared to no liver disease.

Conclusion

In geriatric hip fracture patients undergoing surgical repair, non-cirrhotic chronic liver disease and cirrhosis independently predict non-routine discharge, acute kidney injury, prolonged LOS and greater hospital costs, and cirrhosis is also significantly associated with greater risk of any complication and in-hospital mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02832-y.

Racial and Ethnic Disparities in Hip Fracture Surgery Care in the United States From 2006 to 2015: A Nationwide Trends Study

BACKGROUND

Racial and ethnic disparities in the surgical treatment of hip fractures have been previously reported, demonstrating delayed time to surgery and worse perioperative outcomes for minority patients. However, data are lacking on how these disparities have trended over time and whether national efforts have succeeded in reducing them. The aim of this study was to investigate temporal trends in racial and ethnic disparities in perioperative metrics for patients undergoing hip fracture surgery in the United States from 2006 to 2015.

METHODS

The National Inpatient Sample was queried for White, Black, Hispanic, and Asian patients who underwent hip fracture surgery between 2006 and 2015. Perioperative metrics, including delayed time to surgery (≥2 calendar days from admission to surgical intervention), length of stay (LOS), total inpatient complications, and mortality, were trended over time. Changes in racial and ethnic disparities were assessed using linear and logistic regression models.

RESULTS

During the study period, there were persistent disparities in delayed time to surgery for White versus Black, Hispanic, and Asian patients (eg, White versus Black: 30.1% versus 39.7% in 2006 and 22% versus 28.8% in 2015, Ptrend> 0.05 for all). Although disparities in total LOS remained consistent for White versus Black patients (Ptrend= 0.97), these disparities improved for White versus Hispanic and Asian patients (eg, White versus Hispanic: 4.8 days versus 5.3 in 2006 and 4.1 days versus 4.4 in 2015, Ptrend < 0.05 for both).

DISCUSSION

Racial and ethnic disparities were persistent in time to surgery and discharge disposition for hip fracture surgery between White and minority patients from 2006 to 2015 in the United States. These disparities particularly affected Black patients. Although there were encouraging signs of improving disparities in the LOS, these findings highlight the need for renewed orthopaedic initiatives and healthcare reform policies aimed at reducing perioperative disparities in orthopaedic trauma care.

Revisiting Pauwels' classification of femoral neck fractures

Pauwels' femoral neck fracture classification is based on the biomechanical principle that shear stress and varus force increase along more vertically oriented fractures, resulting in higher risk of fracture displacement and ultimately nonunion. This principle continues to guide construct selection for femoral neck fracture internal fixation and is the foundation for treating non-union with valgus osteotomy. However, with poor inter- and intra-rater reliability, dated treatment recommendations, and unreliable prognostic value, the Pauwels classification cannot be directly applied in its entirety to the management of femoral neck fractures in modern practice.

Established Trauma Triage Score Predicts Risk of Falling After Femoral Neck Fracture Arthroplasty Surgery

INTRODUCTION

The purpose of this study is to determine whether the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) patients is able to predict fall, fracture, periprosthetic fracture, or dislocation risk after femoral neck fracture arthroplasty surgery.

METHODS

Four hundred one patients who underwent hip arthroplasty surgery after a femoral neck fracture at one urban academic medical center were stratified into groups based on their risk scores assigned at femoral neck fracture presentation. The cohort was reviewed for the occurrence of postdischarge falls, secondary fractures, and prosthetic dislocations that resulted in a presentation to the emergency department (ED) after discharge from their hip fracture surgery. The incidence and timing of these complications after discharge were compared between the low-risk and high-risk groups.

RESULTS

The low-risk group included 201 patients, and the high-risk group included 200 patients. The high-risk group had significantly more postdischarge falls resulting in ED presentation (49 vs. 32, p = .035) that occurred significantly sooner (12.6 vs. 18.3 months, p = .034) after discharge.

CONCLUSIONS

The STTGMA model was able to successfully stratify patients who are at a higher risk of sustaining a fall after an arthroplasty procedure for a femoral neck fracture.

A Comparison of Risks and Benefits Regarding Hip Arthroplasty Fixation

Since the field-changing invention of noncemented hip arthroplasty fixation in the 1980s, noncemented fixation has been progressively replacing cemented fixation. However, analyses of fixation frequencies reveal new patterns in cement versus noncemented preferences. Although cementation is again gaining ground in the United States, noncemented models remain the dominant fixation mode, seen in more than 90% of all hip arthroplasties. This stark preference is likely driven by concerns regarding implant durability and patient safety. Although advances in surgical techniques, intensive perioperative care, and improved instrument have evolved in both methods, data from large arthroplasty registries reveal shifting risks in contemporary hip arthroplasty, calling the use of noncemented fixation into question. Varying risk profiles regarding sex, age, or health comorbidities and morphological and functional differences necessitate personalized risk assessments. Furthermore, certain patient populations, based on the literature and data from large registries, have superior outcomes from cemented hip arthroplasty techniques. Therefore, we wanted to critically evaluate the method of arthroplasty fixation in primary hip arthroplasties for unique patient populations.

Treatment of Pauwels type III femoral neck fracture with medial femoral neck support screw: a biomechanical and clinical study

A femoral neck fracture is currently one of the most common types of fracture in clinical practice. The incidence continues to increase due to traffic accidents, trauma, and osteoporosis. This research includes a biomechanical study and a clinical retrospective study. In the biomechanical studies, three groups' effects (Control Group: 3CCS, DHS group, and study Group: 3CCS + mFNSS group) were compared by vertical compression tests, torsion tests, and fatigue tests. All the data were collected and analyzed. We subsequently performed a retrospective analysis of 131 patients with femoral neck fractures. The operative time, intraoperative blood loss, quality of postoperative fracture reduction, and follow-up observation of fracture healing, screw retreatment rates and fixation failure rates, as well as femoral head necrosis rates and hip function in two groups with 3CCS and 3CCS + mFNSS were compared. By the biomechanical study, we found that 3CCS + Mfnss group were biomechanically superior to 3CCS group and superior to the DHS group in terms of resistance to torsion. However, it was less effective than the DHS group in compressive strength and fatigue resistance. In terms of clinical application, 3CCS + mFNSS group was found to have lower screw retreatment rates and femoral head necrosis rates, and to have better fracture healing rates than group with 3CCS, indicating that medial support screws can effectively resist the vertical shear forces of fracture ends and promote the stability and healing of fracture ends, as well as to reduce the incidence of postoperative complications.

Fractures around the hip: inducing life-like fractures as a basis for enhanced surgical training

INTRODUCTION

In this study we investigated if realistic fracture patterns around the hip can be produced on human cadaveric specimens with intact soft tissue envelope. Possible applications of such fractured specimens would be in surgical training.

MATERIALS AND METHODS

7 cadaveric specimens (2 male, 5 female, 2 formalin-fixed, 5 fresh-frozen) were fractured. 2 specimens were fractured on both femurs, 5 only on one side, resulting in 9 fractures total. 5 fractures were set in our custom-made drop-test bench, 2 fractures by inducing axial force using a hammer, and the remaining 2 fractures by a direct dorsal approach and a chisel. AO/OTA and Pauwels classification were used to classify the fractures on the specimens by two independent trauma surgeons.

RESULTS

In our drop-test bench, axial load with the femur adducted by 10° resulted in an intertrochanteric fracture (AO type A1.3), adducted by 20° resulted in a femoral neck fracture (Pauwels type III). Fracture induction using a hammer resulted in two intertrochanteric fractures (AO type A2.2 right, A3.3 left). The use of a chisel resulted in both cases in a femoral neck fracture. The acetabulum could be fractured multifragmentarily through use of a hemiprosthesis as a stamp.

CONCLUSION

A high energetic impulse induced by a custom-made drop-test bench can successfully simulate realistic proximal femur and acetabular fractures in cadaveric specimens with intact soft tissue. Furthermore, axial load using a hammer as well as using a chisel through a direct dorsal approach represent additional methods for fracture induction. These pre-fractured specimens can be utilized in surgical education to provide a realistic teaching experience for specialized trauma education courses.

Association between hospital surgical volume and complications after total hip arthroplasty in femoral neck fracture: A propensity score-matched cohort study

BACKGROUND

For displaced femoral neck fractures (FNF), total hip arthroplasty (THA) or hemiarthroplasty (HA) is preferred rather than fracture fixation. THA for patients with FNF requires skilled operators since patient with FNF likely to have osteoporosis and a higher risk of complications. Several reports suggest that higher hospital surgical volume was associated with a lower risk of complications after THA for osteoarthritis. However, little is known concerning this association with THA for FNF. Herein, we investigated the association between THA and complication and the recovery of physical function after THA to optimize the quality of FNF.

METHODS

A nationwide retrospective cohort study of elderly undergoing THA between April 1, 2011, to March 31, 2018 was performed. The association between hospital surgical volume and complication after THA for FNF was visually described with the restricted cubic spline regression analysis. Then the risk of complications was quantified with propensity score matching analysis based on the cutoff point identified by the restricted cubic spline curve. Primary outcome was secondary revision surgery, and the secondary outcomes included surgical and systemic complications, and the recovery of physical function at hospital discharge.

RESULTS

By visualization of the spline curve, we identified 20 cases per year as cutoff point of low hospital surgical volume. Following 1,396 patients' propensity score-match analysis (mean age 75.2 [SD] 8.8, female 80.4%), the risk of secondary revision surgery was significantly higher among the low hospital surgical volume group (absolute risk difference (RD), 2.44%; p = 0.011). Also, the incidence of blood transfusion was higher in the low hospital surgical volume group (RD, 4.01%; p = 0.049). However, there was no significant difference in the recovery of the transferring and walking ability at discharge between high and low hospital surgical volume groups (63.5% vs 62.6%, 58.5% vs 57.5%; p = 0.74, 0.71, respectively).

CONCLUSION

Our research demonstrated that an increase in hospital surgical volume significantly reduced the incidence of secondary revision surgery after a certain inflection point, but not significantly improved short-term physical functions.

Are functional outcomes and reoperation rates really better than those of cementless stems in displaced femoral neck fractures? An updated systematic review and meta-analysis of randomized controlled trials in current-generation stem designs

BACKGROUND

The aim of the study was to conduct a systematic review and meta-analysis to compare the functional outcomes and reoperation rates of cemented and cementless hip arthroplasty for treating displaced femoral neck fractures in elderly patients.

METHODS

Systematic searches were conducted of literature up to December 2018 on PubMed, Embase, Cochrane, and Web of Science for randomized controlled trials (RCTs) concerning current-generation stem designs only. Two reviewers independently determined eligibility, extracted the outcome data and assessed the risk of bias of eligible studies. The follow-up data and complication rates were pooled by using random-effects models and fixed-effects models, with mean differences and risk ratios for continuous and dichotomous variables, respectively.

RESULTS

Eight RCTs involving 1361 patients (1361 hips) were included in the meta-analysis. Cemented stems were associated with fewer implant-related complications (odds ratio [OR] = 0.303; 95% confidence interval [CI], 0.185%-0.496%; p < 0.001) and reoperations (OR = 0.492; 95% CI, 0.247%-0.977%; p = 0.043). There were no statistically significant differences between groups in functional outcomes, including those assessed by the EuroQol(EQ)-5D and Harris Hip Score, mortality rates, major systemic complications, minor local complications, operation times, intraoperative blood losses, and lengths of hospital stays.

CONCLUSION

In treating displaced femoral neck fracture in elderly patients with hip arthroplasty with current-generation stems, cemented stems were found to have fewer implant-related complications and reoperations than those of cementless stems. Functional outcomes and mortality rates were similar between the groups.

Longitudinal study of risk factors for decreased cross-sectional area of psoas major and paraspinal muscle in 1849 individuals

This 10-year retrospective observational study investigated longitudinal losses in psoas major and paraspinal muscle area in 1849 healthy individuals (1690 male, 159 female) screened using computed tomography. Logistic regression analysis revealed significant decreases in psoas major and paraspinal muscle area at 10 years relative to the baseline area regardless of age or sex, starting at 30 years of age. Only aging [≥ 50 s (odds ratio [OR]: 1.72; 95% confidence interval [CI] 1.05–2.84; p = 0.03) and ≥ 60 s (OR: 2.67; 95% CI 1.55–4.60; p < 0.001)] was a risk factor for decreases in psoas major area. Age ≥ 60 years (OR: 2.05; 95% CI 1.24–3.39; p = 0.005), body mass index ≥ 25 kg/m² (OR: 1.32; 95% CI 1.01–1.73; p = 0.04), and visceral fat ≥ 100 cm² (OR: 1.61; 95% CI 1.20–2.15; p = 0.001) were risk factors for decreases in paraspinal muscle area. Physical activity ≥ 900 kcal/week (OR: 0.68; 95% CI 0.50–0.94; p = 0.02) attenuated paraspinal muscle area loss in male. Our study demonstrated that walking > 45 min daily (Calories = METs (walking: 3.0) × duration of time (h) × weight (60 kg) × 1.05) can reduce paraspinal muscle loss, which may in turn decrease the risk of falls, low-back pain, and sarcopenia.

Rapid preoperative predicting tools for 1-year mortality and walking ability of Asian elderly femoral neck fracture patients who planned for hip arthroplasty

BACKGROUND

Femoral neck fractures in elderly patients typically warrant operative treatment and are related to high risks of mortality and morbidity. As early hip arthroplasties for elderly femoral neck fractures are widely accepted, rapid predicting models that allowed quantitative and individualized prognosis assessments are strongly needed as references for orthopedic surgeons during preoperative conversations.

METHODS

Data of patients aged ≥ 65 years old who underwent primary unilateral hemiarthroplasty or total hip arthroplasty due to femoral neck fracture between January 1st, 2012 and June 30th, 2019 in our center were collected. Candidate variables included demographic data, comorbidities, and routine preoperative screening tests. The main outcomes included 1-year mortality and free walking rate after hip arthroplasty. Patients were randomly divided into derivation and validation groups in the ratio of three to one. Nomograms were developed based on multivariable logistic regressions of derivation group via R language. One thousand bootstraps were used for internal validation. Those models were further tested in the validation group for external validation.

RESULTS

The final analysis was performed on 702 patients after exclusion and follow-up. All-cause 1-year mortality of the entire data set was 23.4%, while the free walking rate was 57.3%. Preoperative walking ability showed the biggest impact on predicting 1-year mortality and walking ability. Static nomograms were created from the final multivariable models, which allowed simplified graphical computations for the risks of 1-year mortality and walking ability in a certain patient. The bias-corrected C index of those nomograms for predicting 1-year mortality in the derivation group and the validation group were 0.789 and 0.768, while they were 0.807 and 0.759 for predicting postoperative walking ability. The AUC of the mortality and walking ability predicting models were 0.791 and 0.818, respectively.

CONCLUSIONS

Our models enabled rapid preoperative 1-year mortality and walking ability predictions in Asian elderly femoral neck fracture patients who planned for hip arthroplasty, with adequate predictive discrimination and calibration. Those rapid assessment models could help surgeons in making more reasonable clinical decisions and subsequently reducing the risk of potential medical dispute via quantitative and individualized prognosis assessments.

2021 John Charnley Award: A protocol-based strategy when using hemiarthroplasty or total hip arthroplasty for femoral neck fractures decreases mortality, length of stay, and complications

AIMS

While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty.

METHODS

In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol.

RESULTS

A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024).

CONCLUSION

The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article: Bone Joint J 2021;103-B(7 Supple B):3-8.

The utility of head CT scans in geriatric patients with hip fractures following a low energy injury mechanism: A retrospective review

OBJECTIVES

Hip fractures are common low-energy orthopaedic injuries in the geriatric population. The purpose of this study is to determine the frequency of CT head exams and the incidence of clinically significant intracranial bleed in patients with low energy hip fractures.

DESIGN

A retrospective cross-sectional review was completed to identify hip fractures presenting to an academic health centre between 2006 and 2015. Our inclusion criteria were those patients with low energy hip fractures and medical records were reviewed to determine whether a CT head scan was utilized as part of their workup.

RESULTS

A total of 2114 patients were reviewed with an average age of 83.2 years. Hip fractures were treated with a hemiarthroplasty in 59.1% of the patients and with a dynamic hip screw in 40.9% of the patients. 26.9% (n = 502) of the patients received a CT head scan as part of their workup. Sixty-two patients (12.3% of patients who received a CT scan or 2.9% of the study population) were found to have had an acute intracranial bleed. None of these patients required neurosurgical intervention and only 9 (14.5% of patients with a positive CT head) had a modification to their thromboprophylaxis post-op. Of the 15 (26.4%) patient on home anticoagulation for a pre-existing medical condition, 10 (67%) had a delay in reinitiating their anticoagulation greater than 24 h post-operatively.

CONCLUSION

During the study period, 26.7% of patients received a CT scan, with only 2.9% of patients suffering from a concurrent intracranial bleed. None of the patients with a positive scan required neurosurgical intervention, and scan results did not routinely alter DVT prophylaxis. Resuming home anticoagulation was delayed greater than 24 h post-operatively in ten (67%) of cases. With the challenges of resource allocation, potential delays to surgery and costs associated with CT scans, these investigations should be reserved for patients who have a history or physical exam findings of head trauma or are on anticoagulation pre-injury in the low energy hip fracture population.

LEVEL OF EVIDENCE

Level III.