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Wolf O, Ghukasyan Lakic T, Ljungdahl J, Sundkvist J, Möller M, Rogmark C, Mukka S, Hailer NP. Reoperation-free survival after hip screws or hip arthroplasty for undisplaced femoral neck fractures in the elderly. Bone Jt Open 2024; 5:87-93. [PMID: 38301730 PMCID: PMC10834084 DOI: 10.1302/2633-1462.52.bjo-2023-0143.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Aims Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately. Methods We retrieved data on all patients aged ≥ 75 years with an uFNF registered in the Swedish Fracture Register from 2011 to 2018. The database was linked to the Swedish Arthroplasty Register and the National Patient Register to obtain information on comorbidity, mortality, and reoperations. Our primary outcome, reoperation, or death at one year was analyzed using restricted mean survival time, which gives the mean time to either event for each group separately. Results Overall, 3,909 patients presenting with uFNFs were included. Of these patients, 3,604 were treated with IF and 305 with primary arthroplasty. There were no relevant differences in age, sex, or comorbidities between groups. In the IF group 58% received cannulated screws and 39% hook pins. In the arthroplasty group 81% were treated with hemiarthroplasty and 19% with total hip arthroplasty. At one year, 32% were dead or had been reoperated in both groups. The reoperation-free survival time over one year of follow-up was 288 days (95% confidence interval (CI) 284 to 292) in the IF group and 279 days (95% CI 264 to 295) in the arthroplasty group, with p = 0.305 for the difference. Mortality was 26% in the IF group and 31% in the arthroplasty group at one year. Reoperation rates were 7.1% in the IF group and 2.3% in the arthroplasty group. Conclusion In older patients with a uFNF, reoperation-free survival at one year seems similar, regardless of whether IF or arthroplasty is the primary surgery. However, this comparison depends on the choice of follow-up time in that reoperations were more common after IF. In contrast, we found more early deaths after arthroplasty. Our study calls for a randomized trial comparing these two methods.
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Affiliation(s)
- Olof Wolf
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | | | - Johan Ljungdahl
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Jonas Sundkvist
- Department of Diagnostics and Intervention (Orthopaedics), Umeå University, Umeå, Sweden
| | - Michael Möller
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Cecilia Rogmark
- Department of Orthopaedics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Sebastian Mukka
- Department of Diagnostics and Intervention (Orthopaedics), Umeå University, Umeå, Sweden
| | - Nils P. Hailer
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
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Lagergren J, Mukka S, Wolf O, Nauclér E, Möller M, Rogmark C. Conversion to Arthroplasty After Internal Fixation of Nondisplaced Femoral Neck Fractures: Results from a Swedish Register Cohort of 5,428 Individuals 60 Years of Age or Older. J Bone Joint Surg Am 2023; 105:389-396. [PMID: 36729034 DOI: 10.2106/jbjs.22.01035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Although most nondisplaced or minimally displaced femoral neck fractures are routinely treated with internal fixation, high rates of secondary surgical procedures are common, especially in the elderly population. Primary arthroplasty in elderly patients has been proposed as an alternative treatment to reduce the need for a secondary surgical procedure. The objective of this study was to describe the rate of conversion to arthroplasty within 5 years after internal fixation of nondisplaced femoral neck fractures in patients ≥60 years of age. METHODS In this observational cohort study of prospectively collected data from the Swedish Fracture Register (SFR) between 2012 and 2018, cross-matched with the Swedish Arthroplasty Register (SAR), 5,428 nondisplaced femoral neck fractures in patients ≥60 years of age were included. Competing risk analysis was used to estimate conversion rates to arthroplasty and mortality in various age groups at 1, 2, and 5 years. RESULTS The cumulative incidence function (CIF) for conversion to arthroplasty was 6.3% at 1 year, 8.1% at 2 years, and 10.1% at 5 years. The conversion rates within 2 years were 6.5% in 60 to 69-year-olds, 9.6% in 70 to 79-year-olds, and 7.8% in ≥80-year-olds. Women had a higher risk of conversion; the hazard ratio (HR) was 1.49 (95% confidence interval [CI], 1.19 to 1.87). The cumulative mortality was 21.3% (95% CI, 20.3% to 22.5%) at 1 year, 31.3% (95% CI, 30.0% to 32.6%) at 2 years, and 54.9% (95% CI, 53.1% to 56.7%) at 5 years. Mortality was higher in men at all time points, and the adjusted 1-year HR was 1.79 (95% CI, 1.61 to 2.00). CONCLUSIONS One in 10 patients ≥60 years of age treated with internal fixation for a nondisplaced femoral neck fracture underwent conversion to arthroplasty within 5 years, and more than one-half of the conversions occurred within the first year. The risk of conversion was highest in women and in patients 70 to 79 years of age. These data warrant further studies in this frail patient group to identify subgroups of patients who would benefit from primary arthroplasty for nondisplaced femoral neck fractures. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Johan Lagergren
- Department of Orthopaedics, Western Hospital Group, Alingsås, Sweden.,Faculty of Medicine, Lund University, Lund, Sweden
| | - Sebastian Mukka
- Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden
| | - Olof Wolf
- Department of Surgical Sciences (Orthopaedics), Uppsala University, Uppsala, Sweden.,Swedish Fracture Register, Gothenburg, Sweden
| | - Emma Nauclér
- Swedish Arthroplasty Register, Gothenburg, Sweden
| | - Michael Möller
- Swedish Fracture Register, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital Gothenburg/Mölndal, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Rogmark
- Swedish Arthroplasty Register, Gothenburg, Sweden.,Department of Orthopaedics, Faculty of Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
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Tohidi M, Mann SM, McIsaac MA, Groome PA. Comparative Effectiveness of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fracture: A Propensity-Score-Matched Cohort Study. J Bone Joint Surg Am 2023; 105:591-599. [PMID: 36758068 DOI: 10.2106/jbjs.22.01193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND The optimal treatment of older patients with a displaced femoral neck fracture remains a controversial topic. This study aimed to compare clinical outcomes across a matched group of patients with a femoral neck fracture treated with either hemiarthroplasty or total hip arthroplasty (THA). METHODS Routinely collected health-care databases were linked to create a population-based cohort of 49,597 patients ≥60 years old from Ontario, Canada, who underwent hemiarthroplasty or THA for a femoral neck fracture between 2002 and 2017. A propensity-score-matched cohort was created using relevant and available predictors of treatment assignment and outcomes of interest. Clinical outcomes consisting of hip dislocation, revision surgery, hospital readmission, and death were compared in the matched cohort using survival analysis. RESULTS Over 99% of THA patients (4,612) were adequately matched 1:1 to hemiarthroplasty patients (total matched cohort = 9,224). Patients treated with THA were at higher risk for hip dislocation at 30 days and 1 and 2 years postoperatively (2-year risk, 1.8% for THA versus 0.8% for hemiarthroplasty; p < 0.001). There was no difference in the short-term (30-day) or long-term (up to 10-year) risk of revision surgery between treatment groups. There was no significant difference in the risk of 30-day hospital readmission between groups. The risk of death at 1 year and 2 years postoperatively was lower for patients treated with THA. CONCLUSIONS For patients with a hip fracture, shared decision-making should involve discussion of the potential higher risk of short-term hip dislocation after THA compared with hemiarthroplasty. The risk of revision surgery was similar between treatment groups at up to 10 years of follow-up. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mina Tohidi
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Stephen M Mann
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Michael A McIsaac
- School of Mathematical and Computational Sciences, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, Kingston, Ontario, Canada
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MUKKA S, HAILER NP, MÖLLER M, GORDON M, LAZARINIS S, ROGMARK C, ÖSTLUND O, SKÖLDENBERG O, WOLF O. Study protocol: The DAICY trial-dual versus single-antibiotic impregnated cement in primary hemiarthroplasty for femoral neck fracture-a register-based cluster-randomized crossover-controlled trial. Acta Orthop 2022; 93:794-800. [PMID: 36200646 PMCID: PMC9535850 DOI: 10.2340/17453674.2022.4819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Older patients with a displaced femoral neck fracture (FNF) are often treated with a cemented primary hemiarthroplasty (HA). The DAICY trial investigates whether high-dose dual-impregnated antibioticloaded cement (DIAC) including gentamicin and clindamycin can reduce the risk of periprosthetic joint infection (PJI) in comparison with low-dose single-impregnated gentamicin antibiotic-loaded cement (SIAC), in patients ≥ 60 years treated with a cemented HA for a displaced FNF. STUDY DESIGN The trial is a national, multicenter, register-based, cluster-randomized, crossover trial. Patients ≥ 60 years with a non-pathological, displaced FNF (Type Garden 3-4/AO 31-B2 or B3) suitable for HA according to local guidelines are eligible for inclusion. Participating orthopedic departments will be randomized to start with either SIAC (control group) or DIAC treatment (intervention group) for 2 years. After 2 years, the study departments will then change to the other treatment arm for the remaining 2 years of the study. Approximately 7,000 patients will be included. The study is pragmatic in that the choice of implant brands, surgical approach and peri- and postoperative protocols follow the local routines of each participating department. All outcome variables will be retrieved after linkage of the study cohort to the following Swedish registers: the Fracture Register, the Arthroplasty Register, the National Patient Register and the Prescribed Drug Registry Outcome: The primary outcome will be periprosthetic joint infection of the index joint within 1 year after surgery. Secondary outcomes will be any reoperation on the index joint, mortality within 90 days and 1 year, resistance patterns of causative bacteria in cases of PJI, and health economics. Potential added value: This trial is designed to support or refute the efficacy of DIAC used in patients with a displaced FNF, potentially reducing PJI and resource allocation. Start of the trial and estimated duration - The DAICY trial started recruiting patients in January 2022 and will continue recruiting for approximately 4 years. Complete follow-up expected in 5 years.
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Affiliation(s)
- Sebastian MUKKA
- Department of Surgical and Perioperative Science (Orthopaedics), Umeå University, Umeå
| | - Nils P HAILER
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala
| | - Michael MÖLLER
- Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg,Swedish Fracture Register, Registercentrum Västra Götaland, Gothenburg
| | - Max GORDON
- Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Karolinska Institutet, Stockholm
| | - Stergios LAZARINIS
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala
| | - Cecilia ROGMARK
- Department of Orthopedics, Lund University, Skåne University Hospital, Malmö,Swedish Arthroplasty Register, Registercentrum Västra Götaland, Gothenburg
| | | | - Olof SKÖLDENBERG
- Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Karolinska Institutet, Stockholm
| | - Olof WOLF
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala,Swedish Fracture Register, Registercentrum Västra Götaland, Gothenburg
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Li Q, Long X, Wang Y, Jiang X, Cai L. Letter to the Editor regarding "Hemiarthroplasty compared to total hip arthroplasty for the treatment of femoral neck fractures: a systematic review and meta-analysis". J Orthop Surg Res 2021; 16:328. [PMID: 34016151 PMCID: PMC8136180 DOI: 10.1186/s13018-021-02490-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/17/2021] [Indexed: 02/08/2023] Open
Affiliation(s)
- Qiujiang Li
- Graduate School of Ningxia Medical University, Yinchuan, Ningxia, China.,Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, No. 56, Zhengyuan Street, Yinchuan, 750002, Ningxia, China
| | - Xingxia Long
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yinbin Wang
- Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, No. 56, Zhengyuan Street, Yinchuan, 750002, Ningxia, China
| | - Xiaocheng Jiang
- Graduate School of Ningxia Medical University, Yinchuan, Ningxia, China.,Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, No. 56, Zhengyuan Street, Yinchuan, 750002, Ningxia, China
| | - Lijun Cai
- Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, No. 56, Zhengyuan Street, Yinchuan, 750002, Ningxia, China.
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6
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Li X, Luo J. Hemiarthroplasty compared to total hip arthroplasty for the treatment of femoral neck fractures: a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:172. [PMID: 33658055 PMCID: PMC7931515 DOI: 10.1186/s13018-020-02186-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/25/2020] [Indexed: 01/11/2023] Open
Abstract
Background Hip replacement is divided into total hip arthroplasty (THA) and hemiarthroplasty (HA); it is still controversial whether to choose THA or HA for femoral neck fractures (FNF). The goal of this study was to review relevant studies in order to determine the HA compared to THA for the treatment of FNF. Patients and methods Using appropriate keywords, we identified relevant studies using PubMed, Cochrane, and Embase. Key pertinent sources in the literature were also reviewed, and all articles published through August 2019 were considered for inclusion. For each study, we assessed odds ratios (ORs), mean difference (MD), and 95% confidence interval (95% CI) to assess and synthesize outcomes. Results We included 19 studies with a total of 413,140 patients in the HA group and 44973 in the THA group. The blood loss, surgery time, and dislocation were all significantly decreased in the HA group than the THA group. The length of hospital, pneumonia, and renal failure were significant increased in the HA group than THA group. There has no significant difference of complication, mortality, reoperation, infection, pulmonary embolism, and myocardial infarct between the two groups. Conclusion HA has favor in decrease blood loss and surgery time. THA has favor in decrease the length of hospital, the incidence of pneumonia and renal failure. For the selection of surgical methods for femoral neck fracture in the elderly, we should consider several aspects, such as the age of the patient, whether there is osteoporosis, the type of femoral neck fracture, the preoperative reduction situation, and the needs of the patient and his family for the postoperative situation. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-020-02186-4.
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Affiliation(s)
- Xinbo Li
- Trauma Orthopedics Ward 1, Ningbo No. 6 Hospital, No. 1059, Zhongshan East Road, Dongliu Street, Yinzhou District, Ningbo City, 315040, Zhejiang Province, China
| | - Jianning Luo
- Trauma Orthopedics Ward 2, Ningbo No. 6 Hospital, No. 1059, Zhongshan East Road, Dongliu Street, Yinzhou District, Ningbo City, 315040, Zhejiang Province, China.
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7
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Kruse M, Mohammed J, Sayed-Noor A, Wolf O, Holmgren G, Nordström R, Crnalic S, Sköldenberg O, Mukka S. Peri-implant femoral fractures in hip fracture patients treated with osteosynthesis: a retrospective cohort study of 1965 patients. Eur J Trauma Emerg Surg 2021; 48:293-298. [PMID: 33484277 DOI: 10.1007/s00068-020-01596-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE There are few studies on incidence rates, treatment and outcomes for peri-implant femoral fractures (PIFF) in the proximity of osteosynthesis. The purpose of this study was to investigate the incidence of PIFF following osteosynthesis of proximal femoral fractures. PATIENTS AND METHODS This retrospective cohort study comprised a consecutive series of hip fracture patients aged 50 years or older and operated with osteosynthesis between 2003 and 2015. Patients were followed-up until 2018, removal of implants or death, for a mean of 4 years (range 0-15). Data on age, sex, housing, hip complications, and reoperations were recorded. The risk of PIFFs was assessed using Cox proportional hazards regression analysis. In patients with two fractures during the study period, only the first fracture was included. RESULTS A total of 1965 osteosynthesis procedures were performed, of which 382 were cephalomedullary nails (CMN), 933 sliding hip devices (SHD) and 650 pins. Mean age was 80 years (range 50-104), 65% of patients were women. A total of 41 PIFFs occurred during the study period. The cumulative incidence of peri-implant fractures was 0.8% for CMN, 2.7% (HR 2.995% CI, 0.87-9.6, p = 0.08) for SHD and 2.0% (HR 2.3 95% CI, 0.6-8.1, p = 0.2) for pins. PIFFs occurred after a mean of 27 months (range 0-143). The 1-year mortality was 34% following PIFF. The majority was treated surgically (66%, 27/41) and the reoperation rate was 15% (4/27). CONCLUSION In this retrospective cohort study, in contrast to previous reports, we found a tendency to a higher cumulative incidence of PIFFs for SHD compared to modern CMN. Our results show cumulative incidences of PIFFs comparable to those described for periprosthetic femur fractures after hip arthroplasty for femoral neck fracture.
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Affiliation(s)
- Mark Kruse
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.
| | - Jabbar Mohammed
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Arkan Sayed-Noor
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Solna, Sweden
| | - Olof Wolf
- Department of Surgical Sciences, Orthopedics, Uppsala University, Uppsala, Sweden
| | - Gunnar Holmgren
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Robin Nordström
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Sead Crnalic
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Olof Sköldenberg
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Solna, Sweden
| | - Sebastian Mukka
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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Haynes MS, Ondeck NT, Ottesen TD, Malpani R, Rubin LE, Grauer JN. Perioperative Outcomes of Hemiarthroplasty Versus Total Hip Arthroplasty for Geriatric Hip Fracture: The Importance of Studying Matched Populations. J Arthroplasty 2020; 35:3188-3194. [PMID: 32654940 DOI: 10.1016/j.arth.2020.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/28/2020] [Accepted: 06/08/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Geriatric femoral neck fracture is a common injury for which hemiarthroplasty (HA) or total hip arthroplasty (THA) may be considered in select patients. As prior database studies comparing these have not used propensity matching, which is a robust statistical method of controlling for potentially confounding variables, unmatched and matched methodologies are contrasted in the present study. METHODS Patients aged ≥70 years who underwent HA or THA for hip fractures were identified from the 2012-2015 National Surgical Quality Improvement database. Propensity score 1:1 matching was performed. Differences in rates of 30-day postoperative adverse outcomes were compared using multivariate logistic regression for unmatched and matched cohorts. RESULTS In total, 15,558 patients (14,403 HA and 1155 THA) were evaluated. Although multivariate outcomes for the unmatched populations were different for blood transfusion, mortality, minor adverse events, major adverse events, and reoperation, multivariate outcomes for matched populations only differed for blood transfusion (odds ratio 0.6 for HA vs THA, P < .001). Of note, although readmissions were similar for the two groups, patients undergoing THA had a 5.4% greater rate of perioperative readmission due to dislocation. CONCLUSION Geriatric patients undergoing HA and THA for hip fracture were compared with and without propensity matching. Once matching was performed, the only differences in outcomes between the two groups were a lower transfusion rate among the HA group and a greater readmission rate due to dislocation among the THA group. This suggests that either procedure can be safely considered if found to be advantageous from a longer-term outcome perspective. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Monique S Haynes
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Nathaniel T Ondeck
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Rohil Malpani
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Lee E Rubin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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Mukka S, Sjöholm P, Aziz A, Eisler T, Kadum B, Krupic F, Morberg P, Sayed-Noor A. A cohort study comparing internal fixation for undisplaced versus hip arthroplasty for displaced femoral neck fracture in the elderly: a pilot study for a clinical trial. Pilot Feasibility Stud 2020; 6:98. [PMID: 32670600 PMCID: PMC7353692 DOI: 10.1186/s40814-020-00642-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 07/06/2020] [Indexed: 12/26/2022] Open
Abstract
Introduction The literature regarding undisplaced femoral neck fractures (FNF) is sparse. The aim of this prospective feasibility study is to compare the clinical outcome after undisplaced FNF treated with internal fixation (IF) and displaced FNF treated with hip arthroplasty. We hypothesized that hip arthroplasty would give a lower incidence of reoperations. Methods A total of 235 patients were included with a median age of 84 years (range 65–99). A consecutive series of 65 patients with undisplaced FNF were treated with IF, and 170 patients with displaced FNF were treated with either a total hip arthroplasty or a hemiarthroplasty. Follow-up interviews were conducted at 1 year using the Harris Hip Score (HHS), WOMAC, and pain numeric rating scale (PNRS). The minimum follow-up time was 22 months. There was no difference in baseline data between the groups. Results Nineteen (8%) hips required reoperation at least once at a mean of 6 months (range 0–35). The rate of reoperation was higher in the IF group compared to the hip arthroplasty group (13.8% vs. 5.9%, 95% CI 0.9–6.4). The overall 1-year and 2-year mortality was 28% and 40%, respectively, with no difference between the groups. The most common reasons for reoperations in the IF group were non-union and avascular necrosis, and 6 patients were treated with hip or excision arthroplasty. In the arthroplasty group, the most common indications were deep infection and dislocation. We did not find any differences between the groups in terms of HHS, WOMAC, and PNRS. Conclusions In this feasibility study, we found no differences in patient-reported outcomes between the groups although IF required a higher rate of reoperations. Further randomized trials are needed to establish the optimal treatment of undisplaced FNF in the elderly. Trial registration ClinicalTrial.org, NCT03392285. Retrospectively registered on 5 February 2018.
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Affiliation(s)
- Sebastian Mukka
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Pontus Sjöholm
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Athir Aziz
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Thomas Eisler
- Department of clinical sciences at Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bakir Kadum
- Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Ferid Krupic
- Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Morberg
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Arkan Sayed-Noor
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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10
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Wolf O, Sjöholm P, Hailer NP, Möller M, Mukka S. Study protocol: HipSTHeR - a register-based randomised controlled trial - hip screws or (total) hip replacement for undisplaced femoral neck fractures in older patients. BMC Geriatr 2020; 20:19. [PMID: 31964340 PMCID: PMC6975074 DOI: 10.1186/s12877-020-1418-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 01/08/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Femoral neck fractures (FNFs), which are common in the older population, are associated with high mortality and morbidity. Some 20% of FNFs are undisplaced (uFNFs). The routine surgical procedure for uFNFs is internal fixation (IF) with 2-3 screws/pins with a reported reoperation rate in older patients (age ≥ 75 years) of up to 21%. The reoperation rate for hemiarthroplasties for displaced fractures is lower than for undisplaced fractures operated with IF. This study will aim to determine whether the outcome for older patients with an uFNF can be improved by replacing the hip instead of preserving it. METHODS A national multicentre, register-based, randomised controlled trial (rRCT) will be conducted. For this trial, 1440 patients, ≥75 years with an acute uFNF, will be allocated. Eligible patients will be identified by the Swedish Fracture Register (SFR) platform, which will notify the admitting orthopaedic surgeon of eligibility. After informed consent has been given and documented, patients will be randomised to either IF (control group) or arthroplasty (intervention group) within the SFR platform. Injury mechanism, fracture classification, date of injury, and type of treatment are registered in the SFR. Type and brand of arthroplasty, surgical approach, and fixation are obtained from the Swedish Hip Arthroplasty Register (SHAR). The study cohort from the SFR will be cross-checked with the National Patient Register and the SHAR for outcome variables at 2, 5, and 10 years. The primary outcome will be a composite variable comprising reoperation rate and mortality at 2 years postoperatively. Secondary endpoints will include reoperation rate and mortality as stand-alone variables. In addition, secondary endpoints will be patient-reported outcomes as measured by the Short Musculoskeletal Functional Assessment questionnaire at 1 year postoperatively as routinely collected within the SFR. Further secondary endpoints will include the occurrence of adverse events such as pneumonia, stroke or myocardial infarction and evaluation of the external validity of the study. DISCUSSION This large, multicentre, register-based randomised controlled trial could potentially shift the treatment of uFNFs in older patients towards primary hip arthroplasty in order to improve the outcome. TRIAL REGISTRATION The trial is registered at www.clinicaltrials.gov (NCT03966716); May 29, 2019.
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Affiliation(s)
- Olof Wolf
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden.
| | - Pontus Sjöholm
- Department of Surgical and Perioperative Sciences (Orthopaedics), Umeå University, Umeå, Sweden
| | - Nils P Hailer
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Michael Möller
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sebastian Mukka
- Department of Surgical and Perioperative Sciences (Orthopaedics), Umeå University, Umeå, Sweden
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Increased risk for postoperative periprosthetic fracture in hip fracture patients with the Exeter stem than the anatomic SP2 Lubinus stem. Eur J Trauma Emerg Surg 2019; 47:803-809. [PMID: 31740996 PMCID: PMC8187181 DOI: 10.1007/s00068-019-01263-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/11/2019] [Indexed: 11/08/2022]
Abstract
Background The purpose of this study was to compare the cumulative incidence of postoperative periprosthetic fracture (PPF) in a cohort of femoral neck fracture (FNF) patients treated with two commonly used cemented stems: either a collarless, polished, tapered Exeter stem or the anatomic Lubinus SP2 stem. Methods In this retrospective multicenter cohort study of a consecutive series of patients, we included 2528 patients of age 60 years and above with an FNF who were treated with either hemiarthroplasty or total hip arthroplasty using either a polished tapered Exeter stem or an anatomic Lubinus SP2 stem. The incidence of PPF was assessed at a minimum of 2 years postoperatively. Results The incidence of PPF was assessed at a median follow-up of 47 months postoperatively. Thirty nine patients (1.5%) sustained a PPF at a median of 27 months (range 0–96 months) postoperatively. Two of the operatively treated fractures were Vancouver A (5%), 7 were Vancouver B1 (18%), 10 were Vancouver B2 (26%), 7 were Vancouver B3 (18%), and 13 were Vancouver C (32%). The cumulative incidence of PPF was 2.3% in the Exeter group compared with 0.7% in the SP2 group (p < 0.001). The HR was 5.4 (95% CI 2.4–12.5, p < 0.001), using the SP2 group as the denominator. Conclusions The Exeter stem was associated with a higher risk for PPF than the Lubinus SP2 stem. We suggest that the tapered Exeter stem should be used with caution in the treatment of FNF. Trial registration The study was registered at clinicaltrials.gov (identifier: NCT03326271).
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