Trend and Economic Implications of Implant Selection in the Treatment of Intertrochanteric Hip Fractures: A Review of the American Board of Orthopaedic Surgery Database From 2007 to 2017

Trends and Complications of Hip Fracture Fixation Among Early Career Orthopaedic Surgeons: An Analysis of the American Board of Orthopaedic Surgery Part II Oral Examination Database

Background

Hip fractures are a major public health concern with a high mortality rate. Numerous risk factors for hip fracture have been identified, and efforts made to reduce complications and improve outcomes. This study aimed to assess recent trends in postoperative complications amongst early-career orthopaedic surgeons.

Methods

This retrospective study analyzed surgical cases submitted to the American Board of Orthopaedic Surgery (ABOS) for the Part II Oral Examination from 2013 to 2022. The database includes patient demographics and medical and surgical complications. Current Procedural Terminology codes reflecting operative fixation for hip fracture were selected. Data was split into two cohorts: 2013-2016 and 2017-2020. Univariate and multivariable logistic regression analyses were used to identify significant differences between cohorts.

Results

49,418 cases were analyzed. Compared to 2013-2016, 2017-2020 had a reduction in the overall medical complication rate (-1.49%, P = 0.0005), saw slight increases in congestive heart failure (+0.18%, P = 0.049), renal failure (+0.37%, P = 0.004), hypotension (+0.41%, P = 0.0007), and hypoxia (+0.41%, P = 0.0016). Minor decreases in myocardial infarction (-0.18%, P = 0.047) and pneumonia (-0.34%, P = 0.021) were noted. No differences occurred in confusion/delirium, deep vein thrombosis/pulmonary embolism, and mortality. There were no significant differences in overall surgical complications. The 90-day readmission rate increased with time (+1.17%, P < 0.0001). Multivariable logistic regression identified a decrease in the likelihood of overall medical complications (Odds Ratio (OR): 0.92 [0.89, 0.96]; P < 0.0001). Decreases were noted for the likelihood of myocardial infarction (OR: 0.81 [0.68, 0.98]; P = 0.031), pneumonia (OR: 0.87 [0.78, 0.97]; P = 0.013), fracture (OR: 0.80 [0.69, 0.92]; P = 0.002), and recurrent/persistent/uncontrolled pain (OR: 0.72 [0.56, 0.92]; P = 0.008). The likelihood of renal failure (OR: 1.18 [1.04, 1.34]; P = 0.009) and readmission increased (OR: 1.14 [1.07, 1.20]; P < 0.0001).

Conclusion

This study found little change in postoperative complication patterns over the past decade. These findings suggest that more efforts are needed to improve hip fracture care and outcomes.

Trends in Medicare Utilization and Reimbursement for Intertrochanteric Femur Fractures: A 21-Year Review

PURPOSE

Sliding hip screw (SHS) and intramedullary (IMN) constructs are commonly utilized treatments for intertrochanteric (IT) femur fractures. The aim of this study was to assess the economic and utilization trends in the management of IT fractures among the Medicare population over the last 21 years.

METHODS

A review of the publicly available Medicare Part B National Summary Data File for years 2000-2021 was performed. Collected data included true physician reimbursement and utilization numbers for all CPT codes pertaining to fixation of IT fractures with either SHS or IMN.

RESULTS

A total of 1,361,112 IMN implants and 739,032 SHS implants were billed to Medicare for intertrochanteric femur fractures during the studied timeline. In this 21-year span, utilization of IMN increased 695% (9648-76,667), while utilization of SHS decreased by 96% (94,223-4224). After adjusting for inflation, the average physician reimbursement for SHS decreased by 34%, while IMN decreased by 41%. Absolute physician reimbursement was found to be $943.36 for SHS and $999.88 for IMN constructs.

CONCLUSION

Intramedullary implants are being increasingly utilized while sliding hip screw, and intramedullary construct reimbursement continues to decrease for intertrochanteric femur fracture fixation. These trends suggest that opting for a sliding hip screw may be more cost-effective when the fracture pattern allows for either construct.

Current surgical status of hip fracture among elderly in China

OBJECTIVE

Hip fracture patients are recommended to undergo surgery within 24-36 h. The present study aimed to analyze the current status of hip fracture surgery among the elderly in China.

METHODS

The baseline information, such as the patient's age, gender, place of residence, place of treatment, fracture type, admission, and operation time, of hip fracture patients >65-years-old were retrieved from the hospital quality monitoring system (HQMS) database from 2013 to 2017 and analyzed.

RESULTS

A total of 304,279 patients >65-years-old with hip fractures were included in this study. The average length of hospital stay was 15 days, and the average waiting time for surgery after admission was 96 h. The average surgery rate of elderly hip fractures in China was 59.6 %, of which the lowest was recorded in the Northwest China (46.4 %).

CONCLUSIONS

The major issues in diagnosing and treating elderly patients with hip fractures in China are the long waiting time for surgery and the low surgery rate.

Comparison of Cephalomedullary Nails with Sliding Hip Screws in Surgical Treatment of Intertrochanteric Fractures: A Cumulative Meta-Analysis of Randomized Controlled Trials

Background

The primary objective of the present study was to compare surgical failures of intertrochanteric fractures of the femur through a meta-analysis of randomized controlled trials and to assess the change in surgical outcomes over time in a cumulative meta-analysis.

Methods

To identify studies evaluating the surgical outcomes of internal fixation using sliding hip screws (SHS) or cephalomedullary (CM) nails for the treatment of intertrochanteric fractures of the femur, all records until August 2021 in the PubMed, Embase, and Cochrane Library databases were searched. Studies with the following characteristics were considered eligible: patients who had an intertrochanteric fracture of the femur (population); patients who received surgical treatment using a CM nail (intervention); patients who received surgical treatment using SHS (comparator); surgical failures that required reoperation, including cut-out or cut-through of lag screws, varus collapse or posterior angulation of proximal fragments, loosening of lag screws or helical blades, and fracture nonunion (outcomes); and two reviewers independently reviewed the titles and abstracts of the randomized controlled trials and selected relevant studies for a full-text review (study design).

Results

Twenty-one studies were included in the final analysis consisting of 1,777 cases in the SHS group and 1,804 cases in the CM nail group. The cumulative standard mean difference was 0.87, indicating that CM nails had no significant effect in improving the surgical outcomes. There was no significant difference in surgical failure between SHS and CM nails for all intertrochanteric fractures (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.76-1.49). Pooled data showed no significant difference between the two groups in terms of surgical failure in unstable intertrochanteric fractures (OR, 0.80; 95% CI, 0.42-1.54).

Conclusions

Although the use of CM nails has become a current trend in the treatment of intertrochanteric fractures, there is no literature supporting their clinical superiority when compared with SHS.

A combined fracture and mortality risk index useful for treatment stratification in hip fragility fractures

Objectives

In this study, we aimed to assess the stratification ability of the Fracture and Mortality Risk Evaluation (FAME) index for reoperation, new fragility fracture, and mortality during one-year follow-up.

Patients and methods

Between November 2018 and July 2019, a total of 94 consecutive hip fragility fracture patients from two centers (20 males, 74 females; mean age: 79.3±8.9 years; range, 57 to 100 years) were retrospectively analyzed. The patients were classified into high, intermediate, and low fracture and mortality risk groups according to the Fracture Risk Assessment Tool (FRAX) score and Sernbo score, respectively, as well as nine combined categories according to the FAME index. Hospital records were reviewed to identify re-fractures (reoperations, implant failure, new fragility fractures on any site) and mortality at one year following the FAME index classification.

Results

Overall re-fracture and mortality rates were 20.2% and 33%, respectively. High fracture risk category (FRAX-H) was significantly associated with higher re-fracture (odds ratio [OR]: 2.9, 95% confidence interval [CI]: 1-8.2, p=0.037) and mortality rates compared to others (OR: 3.7, 95% CI: 1.5-9.3, p=0.003). The patients classified within the FRAX-H category (n=35) had different mortality rates according to their Sernbo classification; i.e., patients classified as low mortality risk (Sernbo-L) (n=17) had lower mortality rates compared to others in this group (n=18) (35.3% and 66.7%, respectively), indicating a low statistical significance (OR: 0.3, 95% CI: 0.1-1.1, p=0.063). Similarly, within patients classified in Sernbo-L category (n=64), those classified as high fracture risk (FRAX-H) (n=17) had significantly higher re-fracture rates compared to others in this group (n=47) (35.3% and 8.5%, respectively), (OR: 5.9; 95% CI: 1.4-24.5), (p=0.017). Multivariate logistic regression analyses adjusting for covariates (age, sex, length of hospital stay and BMI) yielded similar results.

Conclusion

The FAME index appears to be a useful stratification tool for allocating patients in a randomized-controlled trial for augmentation of hip fragility fractures.