The Comparison of Compression Hip Screw and Bipolar Hemiarthroplasty for the Treatment of AO Type A2 Intertrochanteric Fractures

Failure after intramedullary nailing for geriatric trochanteric fracture: does quality of fracture reduction on the AP and lateral planes show the same results?

PURPOSE

This study aimed to investigate the failure of trochanteric fracture fixation according to the quality of fracture reduction on the anteroposterior (AP) and lateral views.

METHODS

Data from 340 female and 152 male patients ≥ 60 years of age who underwent intramedullary nailing for a trochanteric fracture between 2016 and 2020 were analysed retrospectively. The quality of fracture reduction was classified as type A, type E, and type I on the AP view and type N, type A, and type P on the lateral view according to the relative position of the proximal and distal fragments. The failure rate was evaluated and compared according to the quality of fracture reduction. The risk factors of the fixation failure were investigated by comparison of variables between patients with and without failure and by regression analysis.

RESULTS

Patients with poor reduction, type I and type P had higher failure rates. However, a statistically significant difference was found only for patients with poor reduction (type P) on the lateral view (p < 0.001). Patients with failure showed significantly higher rates of poor reduction on the lateral view and AO/OTA type A3 fractures. The regression analysis also showed that poor reduction on the lateral view (odds ratio [OR] 12.70; 95% confidence interval [CI] 4.0-40.6; p < 0.001) and AO/OTA type A3 fractures (OR 5.40; 95% CI 1.24-23.49, p = 0.025) were risk factors for failure.

CONCLUSION

Poor reduction such as type P reduction was associated with failure after intramedullary nailing for trochanteric fractures. Surgeons should check the quality of fracture reduction carefully with the proper fluoroscopic view to prevent failure in geriatric patients with trochanteric fractures.

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

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

A comparison of hemiarthroplasty versus dynamic hip screw fixation for intertrochanteric femoral fractures: a systematic review

INTRODUCTION

Intertrochanteric fractures are predominantly treated by dynamic hip screw (DHS) fixation. However, recent evidence has found acceptable clinical results following hemiarthroplasty for these fractures. Thus, a systematic review was conducted to compare hemiarthroplasty with DHS fixation for intertrochanteric fractures.

METHODS

A computerised search was performed, using the databases Medline, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials, with supplementation from Google Scholar and appropriate reference lists. Studies with comparative data comparing clinical outcomes of hemiarthroplasty versus DHS fixation were included. Data were extracted and quality assessment of the papers performed by 2 reviewers.

RESULTS

320 articles were independently reviewed by the investigators. A total of 10 studies met the inclusion criteria, comprising 2 randomised controlled trials and 8 cohort designs. 7 of the studies assessed unstable fracture patterns. There was no difference in operating time (SMD -1.169 min; 95% CI, -0.657 to 0.689) or blood transfusion volume (SMD-0.110 units; 95% CI, -0.520 to 0.891) between modalities. There was also no difference in length of stay (SMD -0.778 days; 95% CI, -0.606 to 0.336), mortality (RR 0.942; 95% CI, 0.749-1.183) or major complications. Hemiarthroplasty conferred significantly better Harris Hip Scores at 12 months (SMD 12.3; 95% CI, 0.0135-2.789) and allowed earlier weight-bearing than DHS fixation.

DISCUSSION

Qualitative and quantitative compilation of the included studies demonstrates hemiarthroplasty to result in better functional scores and a quicker time to weight-bearing than DHS fixation for intertrochanteric fractures. Results are comparable for other major parameters, including operative time, length of stay and mortality. Thus, hemiarthroplasty is a suitable alternative to DHS fixation for unstable intertrochanteric fractures in elderly patients.

Internal Fixation versus Hemiarthroplasty in the Treatment of Unstable Intertrochanteric Fractures in the Elderly: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the clinical efficacy of internal fixation versus hemiarthroplasty in the treatment of unstable intertrochanteric fractures in the elderly.

METHODS

A search was conducted in PubMed, Web of Science, Embase, and Cochrane Library databases up to April 2020. The present study compared internal fixation and hemiarthroplasty in the treatment of unstable intertrochanteric fractures in the elderly. RevMan5.3 software provided by the International Cochrane Group was used for the meta-analysis. To compare the differences in the operation time, intraoperative bleeding, length of hospital stay, superficial infection, Harris hip score, mortality within 1 year, mortality within 2 years, reoperation, incidence of deep venous thrombosis (DVT), partial weight-bearing time, non-union, and implant-related complications between an internal fixation group and an hemiarthroplasty group.

RESULTS

A total of 1300 patients were included in nine studies. The results showed that the operation time (MD = -18.09, 95% CI: -27.85--8.34, P = 0.0003), intraoperative bleeding (MD = -195.31, 95% CI: -244.8--147.74, P < 0.0001), implant-related complications (MD = 3.83, 95% CI: 1.74-8.45, P = 0.0008), and partial weight-bearing time (MD = 17.21, 95% CI: 1.63-32.79, P = 0.03) have statistical significance. However, there is not statistical significance for the Harris hip joint function scale (HHS) (MD = 5.60, 95% CI: -1.13-12.33, P = 0.10), DVT (MD = 1.02, 95% CI: 0.45-2.27, P = 0.97), length of hospital stay (MD = -1.08, 95% CI: -2.82-0.66, P = 0.22), superficial Infection (OR = 0.92, 95% CI: 0.43-1.98, P = 0.89), mortality within 1 year (OR = 0.95, 95% CI: 0.61-1.48, P = 0.81), mortality within 2 years (OR = 0.93, 95% CI: 0.61-1.43, P = 0.75), reoperation (MD = 1.80, 95% CI: 0.64-5.04, P = 0.26), and non-union (OR = 1.20, 95% CI: 0.48-3.03, P = 0.70). The result of the subgroup analysis showed no significant differences between the less than 2 years follow-up and the 2 years or more follow-up group. The only difference was for the Harris hip score: the internal fixation group was superior to the hemiarthroplasty group in the less than 2 years subgroup analysis, while there was no difference between the internal fixation group hemiarthroplasty group in the 2 years or more subgroup analysis.

CONCLUSION

Compared with the internal fixation group, those in the hemiarthroplasty group could carry out weight-bearing training early and implant-related complications were reduced, but it requires longer operation time and there is greater intraoperative blood loss. There is no difference in mortality, the incidence of DVT, non-union, HHS, reoperation, length of hospital stay, and superficial infection. Hemiarthroplasty may be a better choice for unstable intertrochanteric fractures in the elderly.

Outcomes of Combined Neck and Trochanter Fractures of the Femur Treated with Cephallomedullary Nail in Elderly

Purpose

Proximal femur fractures are classified into intracapsular neck fractures and extracapsular trochanteric fractures, and several related treatment recommendations in elderly patients have already been introduced. Importantly, we have observed cases of combined intra and extracapsular fractures (i.e., ipsilateral neck and trochanter fractures). The purpose of this study is to report the outcomes of combined neck and trochanter fractures of the femur treated with cephalomedullary nail (CMN) in elderly patients.

Materials and Methods

From January 2010 to December 2014, 410 patients with proximal femoral fractures were fixed using CMN; among this group, 37 patients with combined neck and trochanter fractures were identified. Two of these patients died fewer than three months after injury and another two did not return for follow-up. Thirty-three patients were included and reviewed retrospectively in this study.

Results

All patients were injured by simple fall. Bone union was obtained in 28 of 33 patients. Of the five patients who failed treatment, three experienced implant penetration through head (cut-through and cut-out), one had breakage of CMN and the last one had a loosening of internal fixation device with persistent non-union at final follow-up. The former four patients underwent hip replacement surgery and the latter refused surgery because he had low demand in daily life and many medical problems.

Conclusion

Eighty-five percent of elderly patients with combined neck and trochanter fractures of the femur treated with CMN achieved bone union; these complex fractures require more accurate reduction than usual extra-articular intertrochanteric fractures.

Different impacts of dementia on two-year mortality after osteosynthesis and hemiarthroplasty in treating geriatric hip fractures

BACKGROUND

Geriatric hip fractures are mostly managed by internal fixation (IF) or hemiarthroplasty (HA). Survivorship of dementia patients following these surgeries has not been extensively compared in literature. By analysis of nationwide database, this study aimed to investigate the impact of dementia on two-year mortality after IF and HA in treating geriatric hip fractures.

METHOD

From retrospective review of Taiwan's National Health Insurance Research Database, we enrolled 153,623 subjects aged 65 years and older with hospitalization for first hip fracture operated by IF (93,029 cases) or HA (60,594 cases) between 2000 and 2011. Postoperative mortality was compared between subjects with and without dementia after adjustments of age, gender, Charlson comorbidity index and hospital level.

RESULTS

The prevalence of dementia was 5.24% in the IF and 5.29% in the HA group. In the IF group, dementia increased adjusted hazard ratio of one-year (1.06, 95%CI:1.00-1.13) and two-year mortality (1.10, 95%CI:1.05-1.16). However, short and long-term mortality following HA was not significantly impacted by dementia (in-hospital OR:0.79, 95%CI:0.60-1.03; three-month HR:0.99, 95%CI:0.87-1.12; one-year HR:1.01, 95%CI:0.93-1.10; two-year HR:1.03, 95%CI:0.96-1.09). In a subgroup of dementia patients, mortality following IF was 15% higher than HA in one (p = 0.004) and two years (p < 0.001). The negative prognostic factors included female (HR:1.10; 95%CI:1.03-1.18) and aging 65-84 years (HR:1.15; 95%CI:1.00-1.32).

CONCLUSION

Dementia increased one and two-year mortality following geriatric hip fracture treated by IF, rather than HA. Dementia patients undergoing HA, especially female or 65-84 years old, sustained better one and two-year survival than those receiving IF.

Early Rehabilitation in Elderly after Arthroplasty versus Internal Fixation for Unstable Intertrochanteric Fractures of Femur: Systematic Review and Meta-Analysis

The purpose of this study was to compare the outcomes focusing on the functional outcome and clinical results of replacement arthroplasty (AP) vs. internal fixation (IF) for the treatment of unstable intertrochanteric femoral fracture in elderly. Systematic review and meta-analysis were performed on 10 available clinical studies (2 randomized controlled trials and 8 comparative studies). Subgroup analysis was performed by type of methodological quality. Partial weight bearing time in AP group was earlier than that in IF group (SMD = -0.86; 95% CI = -0.42, 1.29; P = 0.050). The overall outcomes such as mortality, reoperation rate, and complication showed no significant diffrence between the 2 groups (AP vs. IF). Therefore, this systematic review demonstrates that AP provides superior functional outcomes especially earlier mobilization, as compared to IF in elderly patients with an unstable intertrochanteric femoral fracture.