[Proximal fracture of the femur in elderly patients. The influence of surgical care and patient characteristics on post-operative mortality]

Intertrochanteric fractures treated by diaphyseal support arthroplasty with hook plate vs cerclage wires only: A retrospective cohort study

Background

The treatment of unstable fractures of the intertrochanteric region of the hip in the elderly is controversial. Conventionally, internal fixation with intramedullary nail or a dynamic hip screw is the treatment of choice in intertrochanteric fractures. Nowadays, some authors encouraged the use hip arthroplasty for management of these fractures with good outcome. The aim of this study is to compare total hip arthroplasty with hook plate against total hip arthroplasty with cerclage cables in the management of unstable intertrochanteric fractures.

Materials and methods

Out of 100 admitted patients to a central university hospital in Beirut between 2013 and 2019 with a diagnosis of unstable intertrochanteric fracture of the hip, only 64 (36 hook plate vs 28 cerclage) patients were selected. This is a retrospective study, patients were excluded if lost to follow up, or if follow up less than one year is available. The data were retrieved from inpatient and outpatient hospital files. Functional outcomes were assessed according to ambulatory capacity. The main clinical measures were early postoperative full weight bearing, postoperative complications, functional outcome and radiologic assessment done by a radiologist in addition to measuring the dysfunction via the Harris Hip Score.

Results

The time to full weight bearing, the rate of postoperative complications, radiologic outcome and the functional outcomes were more satisfactory in the hook - plate group than in the cerclage - cable group.

Conclusion

According to the results, total hip arthroplasty with hook plate is considered the preferred modality of treatment in mobile elderly patients above sixty-five years of age with an unstable intertrochanteric femoral fracture, despite being a bulky foreign material that can lead to trochanteric bursitis.

Hip Fractures: Therapy, Timing, and Complication Spectrum

Objective

Investigation of the treatment of femur fractures and the type of femur fracture‐associated complications regarding timing of surgery and length of hospital stay.

Methods

In this retrospective cohort study, a total of 358 hip fractures were evaluated retrospectively from 1 January 2008 until 31 December 2010 at a level I trauma center in Germany. Inclusion criteria was age >18 years and a proximal femur fracture. Both sexes were evaluated. Mean age was 75.5 years, most patients were female (63.7%). Intervention was the operative treatment of proximal femur fracture. Outcome parameters were time until surgery, complications, reoperations, mortality, and length of hospital stay.

Results

Among the proximal femur fractures (n = 358), 46.6% were pertrochanteric, 11.2% subtrochanteric, and 42.2% femoral neck fractures. Operation upon hip fractures was managed regularly within 24 hours of injury (73%; mean for femoral neck: 28.3 hrs.; mean for pertrochanteric fractures: 21.4 hrs.; mean for subtrochanteric fractures: 19.5 hrs.). Delayed treatment, as well as implantation of hip total endoprosthesis (TEP), increased the overall length of hospital stay (15.4 vs 17.6 days; 18.1 vs 15.8 days). Accordingly, surgical procedures performed within 24 hours of injury resulted in a shorter hospital residence. Longest delay of operation was measured for hip fractures (28.3 hrs.).

In 351 patients, secondary injuries were detected in 94 individuals (26%), with fractures being the most common secondary injury (n = 40). We recorded postoperative complications of nonsurgical and surgical origin, and 33.6% of our patient cohort displayed complications. Complications were distributed among 118 patients. There was no significant difference in complications regarding the time of operation, with most nonsurgical and surgical complications appearing within 24 hours after operation (n = 110 vs n = 31). Nonsurgical complications, such as anemia (n = 49) and electrolyte imbalances (n = 30), were observed more frequently than surgical complications (n = 107 vs n = 34); however, these complications were reduced by delay in surgery (82.0% in 6–24 hrs. vs 74.2% in ≥24 hrs.). Anticoagulant therapy and age did not affect postoperative complications. The hospital mortality of patients was 6.2%. Follow‐up was restrained to ambulatory visits in the clinic.

Conclusions

Surgical management of hip fractures performed within 24 hours of injury minimizes hospital stay. We did not detect significant differences in the spectrum or number of complications regarding delay of surgery. Surgical complications mainly occur with rapid primary care, and medical complications can be reduced by more intensive preparation of patient and operation procedures.

Surgical treatment and management of hip fracture patients

INTRODUCTION

Osteoporosis-related hip fractures are associated with high mortality and costs. The optimum type of treatment for such fractures is controversial. To shed some light on this issue, the surgical treatment and management of osteoporotic hip fractures were discussed during a hip fracture surgical working group at the 2009 International Society For Fracture Repair Annual Meeting comprising leading experts in the field.

MATERIALS AND METHODS

The working group consisted of eight orthopaedic surgeons, six industry representatives and one research scientist. Eleven participants were from Europe and four were from the USA and Canada. Two chairmen posed 12 questions relating to the surgical treatment and management of osteoporotic hip fractures. Each question was discussed and key points were noted.

RESULTS

Surgery should commence within 24-48 h but the patient should be optimized if presenting with ≥3 comorbidities. Specialized centres integrating orthopaedics, geriatricians and rheumatologists could be a solution for the lack of specialist care post-surgery. Surgical technique is important in fracture fixation, as is the implant, but there has been no improvement in implant design in the past 50 years. As a consequence, malunion has become unjustifiably accepted. Fracture healing can be accelerated using pharmaceuticals which are also important in secondary prophylaxis. All displaced femoral neck fractures in geriatric patients should be treated with hip replacement, the choice between using cemented or uncemented fixation being at the surgeon's discretion.

DISCUSSION AND CONCLUSION

This working group discussion highlighted several important issues which could be of interest to the orthopaedic community.

Bipolar hemiarthroplasty compared with internal fixation for unstable intertrochanteric fractures in elderly patients

BACKGROUND

The optimal treatment for unstable intertrochanteric fractures in elderly patients remains controversial. We aimed to compare internal fixation and bipolar hemiarthroplasty for the treatment of unstable intertrochanteric fractures in elderly patients.

METHODS

124 patients aged over 70 years were enrolled into this study (64 internal fixations, 60 bipolar hemiarthroplasties). Patients were followed for two years, and had a clinical, radiological, and functional review at three, six, and twelve months as well as two years.

RESULTS

In the internal fixation group, the fracture reduction and internal fixation were regarded as satisfactory in 44 cases and unsatisfactory in 20 cases. Five patients in the internal fixation group (two with satisfactory results and three with unsatisfactory results) and three patients in the arthroplasty group died before the final two-year follow-up. Five patients in the internal fixation group who had unsatisfactory results suffered complications. At 24 months post-operation, patients who were treated satisfactorily with internal fixation had higher Harris scores, less pain, and better walking ability than those treated with hemiarthroplasty and unsatisfactory internal fixation.

CONCLUSIONS

Internal fixation with good reduction and fixation quality should be the preferred therapeutic method for elderly unstable intertrochanteric fractures, even when severe osteoporosis is present.

Unstable trochanteric fractures in elderly osteoporotic patients: role of primary hemiarthroplasty

OBJECTIVE

Unstable intertrochanteric fractures in osteoporotic patients are difficult to treat. Fixation failure often leads to prolonged morbidity and poor functional outcomes. The objective of the present study was to investigate primary replacement as a suitable option that could minimize complications in selected patients.

METHODS

From January 2004 to March 2007, 28 elderly osteoporotic patients with unstable intertrochanteric fractures were included in this study. Their fractures were classified according to the AO/OTA classification (8 patients, 31A2.2; 17 patients, 31A2.3 and 3 patients, 31A3.3) and their osteoporosis was confirmed by bone densitometry. Hemiarthroplasty was performed in all patients and the outcomes analyzed using the Harris hip score system.

RESULTS

Of the 28 patients, 19 were women and the mean age was 79 years (range, 52-95 years). At a mean follow up of 4.2 years (range, 3-6 years), there were 17 excellent, 7 good, 2 fair and 2 poor results according to the Harris hip score system.

CONCLUSION

In elderly osteoporotic patients with unstable intertrochanteric fractures, hemiarthroplasty is a reliable alternative to internal fixation. The functional outcome has been encouraging and we suggest it as a method of treatment in this group of patients.

[Complications after pertrochanteric fractures]

Fractures at the coxal end of the femur have an incidence of almost 100.000 p.a. in Germany. Pertrochanteric femur fractures make up almost half of this collective. The highest incidence of 1.32% is seen in patients over the age of 85. Osteosynthesis is the treatment of choice. The options include extramedullary nail/screw systems or intramedullary nail systems. Study findings to date do not show a clear advantage of one procedure over another. The published complication rates remain high. The main complication is secondary reduction loss with cutout of the hip screw. Other complications include femoral neck shortening and lateralization of the hip screw with local irritation at the iliotibial tract. Functional outcomes after osteosynthesis are still less than satisfactory. Surgery only frees one third of patients from pain. In addition, a majority of patients also suffer loss of independence and social contacts. An alternative approach to treatment is total joint replacement. This is indicated in extreme cases of osteoporosis in combination with osteoarthritis. However, initial high stability must be weighed against an increased risk of dislocation and a higher rate of 1-year mortality.

[Earlier postoperative mobilization with minimally invasive hip hemiarthroplasty]

Treatment of medial femoral fractures in elderly patients with cemented hip hemiarthroplasty (HEP) is a widely established procedure. The main problems with this procedure are complications associated with soft tissue damage and prolonged immobilization. The aim of this study was to compare the clinical and radiological results after HEP implantation using either an anterior minimally invasive (MIS) approach or a regular transgluteal (TG) approach. In this retrospective study the results of 55 consecutive MIS and 54 consecutive TG approaches for implanted HEP after medial femoral fracture were compared. The time of successful mobilization, duration of the i.v. analgesia as well as the occurrence of any perioperative complications were recorded. The femoral offset, leg length and the femoral alignment were analyzed radiologically. The MIS group could be mobilized earlier (MIS 2. pod vs. TG 4. pod, p <0.01) but the need for i.v. applied analgesia was prolonged (MIS 4.4 pod vs. TG 3.5 pod, p=0.04). In the MIS group the number of perioperative complications was less than in the TG group (MIS 7% vs. TG 17%, p <0.05). The early functional advantages of MIS after HEP implantation for medial femoral fractures are evident also within an elderly group of patients.

Trochanteric fractures in the elderly: the influence of primary hip arthroplasty on 1-year mortality

INTRODUCTION

The aim of the study was to compare the mortality risk and complication rate after operative treatment of pertrochanteric fractures with primary arthroplasty, dynamic hip screw (DHS) or proximal femoral nail (PFN).

PATIENTS AND METHODS

Clinical records including X-rays of all patients with trochanteric femoral fractures, except pathologic fractures and a minimum age of 60 years, which were treated between 1992 and 2005 were entered in this retrospective study. Of these 283 patients, 132 were treated by primary arthroplasty, 109 with a DHS and 42 with a PFN. Survival after 1 year and complications, which had to be treated within this period were our main outcome measurement. Influencing cofactors such as age, gender and comorbidities were reduced by multivariate logistic regression analysis.

RESULTS

Mortality was significantly influenced by age, gender and amount of comorbidities but not by fracture classification. Primary hip arthroplasty did not bear a higher 1-year mortality risk than osteosynthesis in a multiple regression analysis. The main complication with DHS and PFN were cutting out of the hip screw and non-union with a revision rate of 12.8%. With the introduction of hemiarthroplasty, the postoperative dislocation rate decreased from 12 to 0%.

CONCLUSION

For stable fractures a dynamic hip screw (DHS) and for unstable fractures a short proximal femoral nail (PFN) can be recommended. The mortality risk of primary cemented arthroplasty did not differ significantly from the other treatment groups and because of its low complication rate it is a viable treatment option for trochanteric fractures if osteoporosis prevents from full weight bearing or if osteoarthritis makes further operations likely. Primary total hip replacement should be handled with care due to its significantly higher dislocation rate compared with hemiarthroplasty especially in unstable fractures.