Therapeutic advantage of teriparatide in very elderly patients with proximal femoral fractures: a functional and BMD analysis

BACKGROUND

Teriparatide, a recombinant parathyroid hormone, is pivotal in osteoporosis treatment, particularly in post-surgical recovery for hip fractures. This study investigates its efficacy in functional recovery post-hip fracture surgery in elderly patients, a demographic particularly susceptible to osteoporotic fractures.

METHODS

In this retrospective cohort study, 150 elderly patients with proximal femoral fractures undergoing open reduction and internal fixation were enrolled. They were categorized into two groups: receiving 20 µg of daily teriparatide injections for 18 months and receiving standard antiresorptive medications during a 24-month follow-up. Detailed records of patient demographics, Fracture Risk Assessment Tool scores, and comorbidities were kept. Key outcomes, including bone mineral density (BMD) and functional scores (Barthel Index and Visual Analog Scale for hip pain), were evaluated at 3 and 24 months post-surgery.

RESULTS

Out of the original cohort, 126 patients (20 men and 106 women with an average age of 85.5 ± 9.3 years) completed the study. The teriparatide group exhibited significant enhancements in both functional scores and BMD when compared to the control group. Notably, functional improvements were less pronounced in male patients compared to female patients. Additionally, the incidence of new fractures was markedly lower in the teriparatide group.

CONCLUSION

Administering teriparatide daily for 18 months post-surgery for proximal femoral fractures significantly benefits very elderly patients by improving functionality and bone density, with observed differences in recovery between genders. These results reinforce the efficacy of teriparatide as a potent option for treating osteoporosis-related fractures in the elderly and highlight the importance of considering gender-specific treatment and rehabilitation strategies.

[Long-term anticoagulation treatment in proximal femoral fractures as obstacle to surgery in the 24h time window? : Results of an analysis of Quality Assurance data on 32,252 treatment courses with osteosynthesis]

BACKGROUND

Both in Germany and internationally there is a vehement controversy about the appropriate time for care of proximal femoral fractures in older patients. The effort to achieve high quality and uniform standards of care culminated in the German healthcare system in the strict requirement of delay-free surgery within 24 h. Until now, in view of their high vulnerability patients who were severely injured were too often operated on late with the reference to a general medical condition that could be improved preoperatively. In particular, the fear of complications due to a pre-existing long-term anticoagulation treatment was repeatedly emphasized.

OBJECTIVE

The present study is dedicated to the question of whether a delay in surgery of anticoagulated patients with proximal femoral fractures already during the inpatient course has a detrimental effect on the complication statistics and the mortality of the patients. The extent to which external quality assurance data are suitable for rebutting any objections to an operation as soon as possible are examined.

MATERIAL AND METHODS

The study is based on treatment data from the external inpatient quality assurance procedure of the federal state of North Rhine-Westphalia from the years 2018-2020. Patients with a proximal femoral fracture were considered. This includes femoral neck fractures and fractures in the area of the pertrochanteric to subtrochanteric region. Only cases with joint-preserving fracture care were selected. The data sets were analyzed using suitable statistical software.

RESULTS

More general complications and deaths have been observed in anticoagulated patients. The trend of delayed fracture treatment under anticoagulant medication continues to be clearly visible. A positive association between longer preoperative waiting time and undesirable courses can be confirmed.

CONCLUSION

With respect to fracture care when taking anticoagulants, it must be critically examined to what extent a rapid normalization of the coagulation situation is necessary and this actually improves the chances of low complication courses. Should the elimination of the anticoagulant effect by substitution or antidote appear necessary, this should not prevent early care.

Secondary fracture and mortality risk with very high fracture risk osteoporosis and proximal femoral fracture

INTRODUCTION

We aimed to investigate secondary fracture and mortality rates, and risk factors in patients with proximal femoral fractures.

MATERIALS AND METHODS

We conducted a multicenter prospective cohort study on female patients with proximal femoral fractures who underwent surgical treatment between April 2020 and March 2021. Postoperative follow-ups were performed at 6-, 12-, 18-, and 24-month intervals to determine the secondary fracture and mortality rates, and the risk factors and its influence were examined.

RESULTS

Of the 279 registered patients, 144 patients (51.6%) were diagnosed with very high fracture risk osteoporosis. The postoperative osteoporosis rate exceeded 96%; however, osteoanabolic agents were used sparingly. The risk factor of both secondary fracture and mortality was very high fracture risk osteoporosis, and secondary fractures within 12 months were markedly occurred. Secondary fracture rates increased as the number of matched very high fracture risk osteoporosis criteria increased. Notably, secondary fractures and mortality were recorded in 21.4% and 23.5% of the patients who met all criteria, respectively.

CONCLUSION

Over half of the female patients with proximal femoral fractures had very high fracture risk osteoporosis. Although, very high fracture risk osteoporosis demonstrated a notably increased risk of secondary fractures, particularly at 12 months post-surgery, the use of osteoanabolic agents was substantially low. Collectively, our findings highlight the need to consider the risk of very high fracture risk osteoporosis, expand the use of medications to include osteoanabolic agents, and reconsider the current healthcare approach for proximal femoral fractures.

Mortality analyses of elderly patients with proximal femoral fracture during the pandemic: vaccination affects or not

PURPOSE

To evaluate the mortality rate, intensive care unit (ICU) referral, and Charlson comorbidity index (CCI) between different types of vaccinated and non-vaccinated patients operated on due to intertrochanteric femoral fracture (IFF) during the pandemic.

METHODS

Ninety-six patients (43 males, 53 females) who had proximal femur nails (PFN) for the IFF during the pandemic were included in the study. The patients were divided into four subgroups; non-vaccinated, and different types of vaccinated. Mortality rates, ICU referrals, and CCI relations were evaluated.

RESULTS

No significant difference was observed in terms of demographic data such as age, gender, side, CCI, and ICU referrals between the subgroups (p = 0.164, p = 0.546, p = 0.703, p = 0.771, p = 0.627 respectively). The mortality rate was significantly lower in the Sinovac + BioNTech subgroup (p = 0.044).

CONCLUSION

No relationship was found between mortality rate, ICU referral, and CCI in different types of vaccinated and non-vaccinated patient subgroups.

Dynamic hip screw in proximal femoral fractures followed by "single-stage" hip arthroplasty-retrospective analysis

The aim of this study is to present the results of single-stage total hip arthroplasty (THA) after Dynamic Hip Screw (DHS) failure, or secondary posttraumatic osteoarthrosis. From 2003 to 2020, 15 THAs were performed in group of 15 patients for the treatment of DHS failure, or for late complications following femoral neck and pertrochanteric fractures. The mean follow-up period after arthroplasty was 46.9 months (range 7-139). The patients were evaluated retrospectively-both clinically and radiographically, focussing on the demography, infection rate and other complications (revision surgery), during the year 2023. 9 males and 6 females were included in the study, with a mean age of 56.5 years (range 29-93) at the time of primary osteosynthesis. Each of them had proximal femoral fracture treated primarily with a DHS and then late one-stage revision surgery, with hardware removal and THA implantation. The median time between DHS osteosynthesis and THA was 41.2 months (range 4-114). Four patients (26.6%) had complications after THA, with the need for revision in two cases (13.3%). Dislocation rate was 6.6% (one case), with the need for repeated-revision of THA. The infection rate was 6.6% (one patient) with the need for revision of THA. Peroperative periprosthetic femoral fracture was observed in 13.3% (two patients) without any other problems. Six patients (40%) died during the follow-up period. Single-stage total hip arthroplasty with concomitant hardware removal bears a high- mortality rate, with a higher incidence of postoperative complications compared to elective THA.

Outcomes of total hip arthroplasty using dual mobility cups following failed internal fixation of proximal femoral fractures at a mean follow-up of 6 years

INTRODUCTION

Performing total hip arthroplasty (THA) after failed internal fixation of proximal femoral fractures (PFF) is known to be associated with high rates of complications. Dual mobility cups (DMC) are known to lower dislocation events in high-risk patients. Very few reports investigated the outcomes of THA using DMC following failure of internal fixation for PFF.

METHODS

This is a retrospective monocentric continuous study of 31 patients who underwent THA with DMC after failed internal fixation of PFF. The clinical assessment was based on the modified Harris hip score (mHHS) at the last follow-up. The complication rates and radiological analyses were recorded.

RESULTS

The mean follow-up period was 5.96 ± 4.2 years. At the last follow-up, the mean mHHS was 92.9 ± 9.1 with 71% of the patients describing their operated hip as a forgotten hip. No dislocation or aseptic loosening events were noted. One patient developed a septic loosening of the implant. No significant radiological changes were recorded. Sixteen stems (51.6%) were placed in a neutral position, 13 (42%) in valgus (2.74 ± 1.72°), and 2 (6.4%) in varus (6.94 ± 2.02°).

CONCLUSION

This study emphasizes the advantage of using DMC following failed internal fixation of PFF in reducing dislocation and complication events in this high-risk population.

[Regional CT value in prediction of proximal femoral fracture]

OBJECTIVE

To investigate CT values of cancellous bone in femoral neck in adults over 60 years with proximal femoral fractures.

METHODS

From January 2020 to December 2020, a retrospective analysis was performed on 280 subjects aged 60 years or older who underwent bilateral hip CT examination, including 85 males and 195 females, 120 on the left side and 160 on the right side, aged 75 (66, 82) years old. One hundred thirty-six patients with proximal femoral fractures were included in study group and 144 patients without fractures were included in control group. GEOptima CT was used to scan and reconstruct horizontal, coronal and sagittal layers of proximal femur. CT values of cancellous bone in femoral neck were measured and compared between two groups. The relationship between CT values of cancellous bone of femoral neck and proximal femoral fracture was analyzed statistically.

RESULTS

In terms of age, fracture group aged 79(73.3, 85.0) years old, non-fracture group aged 69.5 (64.0, 78.8) years old, and had significant difference in age between two groups (P<0.05). In terms of CT value, regional CT value in fracture group was 8.62(-3.62, 27.15) HU, which was lower than that in non-fracture group 34.31(-5.93, 71.74) HU(P<0.05). CT value on coronal view in fracture group was -8.48(-30.96, 17.46) HU, which was lower than that in non-fracture group 40.49(5.55, 80.71) HU (P<0.05). CT value on sagittal view in fracture group was -31.28(-54.91, -5.11) HU, which was lower than that in non-fracture group 7.74(-20.12, 44.54) HU (P<0.05). CT values on horizontal view in fracture group was 0.17(-23.13, 24.60) HU, which was lower than that in non-fracture group 46.40(10.42, 85.18) HU(P<0.05). The mean regional CT values among three planes in the fracture group were lower than those in the non-fracture group. Logistic regression analysis showed coronal CT value was influencing factors of proximal femoral fracture, and it could be written into regression equations that predict probability of fracture.

CONCLUSION

In adults aged over 60 years old, CT values of cancellous bone of femoral neck decreased with increasing age. The smaller CT value of cancellous bone of femoral neck, the greater risk of proximal femoral fracture.

Idiopathic normal pressure hydrocephalus possibly affects the occurrence of proximal femoral fracture

AIMS

The clinical triad of idiopathic normal pressure hydrocephalus (iNPH) includes gait disturbance, dementia, and urinary incontinence. These symptoms are also frequently observed in patients with proximal femoral fracture (PFF). The aim of this study was to investigate the relationship between PFF and iNPH retrospectively.

PATIENTS AND METHODS

Of the130 patients over 80-years-old with PFF included in this study, 48 were assigned to the PFF group. Forty-eight patients with peripheral vertigo matched with the PFF group for age and sex were included in the control group. We compared the Evans' index (EI), which is a head computed tomography finding of iNPH, and the percentages of patients with EI>0.3 between the two groups. The PFF group was further divided into two subgroups depending on whether EI was higher or lower than 0.3 (the higher or lower subgroup, respectively). We compared the patient's gait abilities before PFF, causes of PFF, cognitive functions, and occurrence of urinary incontinence between both groups.

RESULTS

The mean value of EI in the PFF group was significantly higher than that in the control group (PFF group, 0.301; control group, 0.284; p=0.008). The percentages of patients with EI>0.3 in the PFF and control groups were 62.5% and 35.4%, respectively (p=0.014). In subgroup analyses, the gait ability before injury was worse in the higher subgroup than that in the lower subgroup and was prominent among individuals who could walk only with human assistance (p=0.018). There were no significant differences in other parameters.

CONCLUSION

Elderly patients with PFF may have underlying idiopathic normal pressure hydrocephalus.

LEVEL OF EVIDENCE

III; case-control comparative study.

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.

Relationship between site-specific bone mineral density in the proximal femur and instability of proximal femoral fractures: A retrospective study

BACKGROUND

Proximal femoral fractures can occur in patients with osteoporosis. However, the relationship between bone mineral density (BMD) of the proximal femur and fracture type and instability remains unclear. This study aimed to determine whether there is a relationship between the site-specific BMD of the proximal femur and the instability of proximal femoral fracture.

HYPOTHESIS

The instability of proximal femoral fractures is related to the site-specific BMD of the proximal femur.

PATIENTS AND METHODS

Using dual-energy X-ray absorptiometry (DEXA), the BMD on the non-fractured side was retrospectively examined in 252 women who underwent surgery for proximal femoral fracture at our hospital. The BMD was measured at three sites: the femoral neck (neck), trochanter (trochanter), and intertrochanteric region (inter). The BMD at several sites was compared between the femoral neck and trochanteric fractures. Femoral neck fractures were classified into the displaced and non-displaced types, and trochanteric fractures were classified into stable and unstable types. A comparative analysis was conducted for each proximal femur site and fracture type.

RESULTS

Both total and site-specific BMDs were lower in trochanteric fractures than in femoral neck fractures. No difference was observed between BMD and displaced or non-displaced femoral neck fractures. However, the BMD of the intertrochanteric region was lower in unstable trochanteric fractures (0.57±0.12g/cm2) than in stable trochanteric fractures (0.61±0.11g/cm2) [p<0.05].

DISCUSSION

Several factors, including the patient's age and the bone component of each region, may influence the lower BMD in trochanteric fractures. In trochanteric fractures, the site-specific BMD of the proximal femur may predict the type of fracture and the degree of instability, especially in those with low BMD at the intertrochanteric site. The study findings suggest that a decrease in the BMD of the intertrochanteric region of femoral trochanteric fractures, which is thought to be involved in instability, is associated with fracture type instability.

LEVEL OF EVIDENCE

III, retrospective study.

Efficacy and safety of using aminocaproic acid and tranexamic acid during the perioperative period for treating trochanteric fractures in elderly femurs

BACKGROUND

Tranexamic acid (TXA) has long been the antifibrinolytic hemostatic drug of choice for orthopedic surgery. In recent years, the hemostatic effect of epsilon aminocaproic acid (EACA) has gradually been recognized by orthopedic surgeons and has begun to be used in hip and knee arthroplasty with little mention of the comparison of these two drugs; Therefore, this study compared the efficacy and safety of EACA and TXA in the perioperative period of elderly patients with trochanteric fractures to verify whether EAC could be a "qualified alternative" to TXA and to provide theoretical support for the clinical application of TXA.

METHODS

Two hundred and forty-three patients who received proximal femoral nail antirotation (PFNA) for trochanteric fractures from January 2021 to March 2022 at our institution were included and divided into the EACA group (n = 146) and the TXA group. (n = 97) determined by the drugs used in the perioperative period The main observations were blood loss and blood transfusion.The second second outcome was blood routine, coagulation, Hospital complications and complications after discharge.

RESULTS

The perioperative EACA patients had significantly lower significant blood loss (DBL) than the TXA group (p < 0.0001) and statistically significant lower C-reactive protein in the EACA group than in the TXA group on postoperative day 1 (p = 0.022). Patients on perioperative TXA had better postoperative day one (p = 0.002) and postoperative day five erythrocyte width than the EACA group (p = 0.004). However, there was no statistically significant difference between the two groups in the remaining indicators in both drugs: blood items, coagulation indicators, blood loss, blood transfusion, length of hospital(LOH), total hospital expense, and postoperative complications (p > 0.05).

CONCLUSION

The hemostatic effects and safety of EACA and TXA in the perioperative application of trochanteric fractures in the elderly are essentially similar, and EACA can be considered for use as an alternative to TXA, increasing the flexibility of physicians to use it in the clinical setting. However, the limited sample size included necessitated a high-quality, large sample of clinical studies and long-term follow-up.

Trends in incidence, health care consumption, and costs for proximal femoral fractures in the Netherlands between 2000 and 2019: a nationwide study

This study evaluated the incidence rates and societal burden of hip fractures in The Netherlands. Although incidence in the elderly population is decreasing and hospital stay is at an all-time low, the burden of medical costs and crude numbers of proximal femoral fractures are still rising in our aging population.

PURPOSE

The aim of this nationwide study was to provide an overview of the incidence rate and economic burden of acute femoral neck and trochanteric fractures in The Netherlands.

METHODS

Data of patients who sustained acute proximal femoral fractures in the period January 1, 2000, to December 31, 2019, were extracted from the National Medical Registration of the Dutch Hospital Database. The incidence rate, hospital length of stay (HLOS), health care and lost productivity costs, and years lived with disability (YLD) were calculated for age- and sex-specific groups.

RESULTS

A total of 357,073 patients were included. The overall incidence rate increased by 22% over the 20-year study period from 16.4 to 27.1/100,000 person-years (py). The age-specific incidence rate in elderly > 65 years decreased by 16% (from 649.1 to 547.6/100,000 py). The incidence rate in men aged > 90 has surpassed the incidence rate in women. HLOS decreased in all age groups, hip fracture subtypes, and sexes from a mean of 18.5 to 7.2 days. The mean health care costs, over the 2015-2019 period, were lower for men (€17,723) than for women (€23,351) and increased with age to €26,639 in women aged > 80. Annual cumulative costs reached €425M, of which 73% was spent on women.

CONCLUSION

The total incidence of hip fractures in The Netherlands has increased by 22%. Although incidence in the elderly population is decreasing and HLOS is at an all-time low, the burden of medical costs and crude numbers of proximal femoral fractures are still rising in our aging population.

Clockwise torque results in higher reoperation rates in left-sided femur fractures

PURPOSE

Effects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left- versus right-sided proximal femur fractures using cephalomedullary nailing (CMN).

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis.

RESULTS

In total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00-1.50), odds ratio [OR] 1.23 (95%CI 1.00-1.51), power 49.2% (α=0.05).

CONCLUSION

This study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (postoperative) weightbearing may lead to higher reoperation rates.

LEVEL OF EVIDENCE

Therapeutic level II.

Secondary fracture rates and risk factors 1 year after a proximal femoral fracture under FLS

INTRODUCTION

We aimed to investigate the secondary fracture rates and risk factors in patients with proximal femoral fractures using fracture liaison service (FLS) during the coronavirus disease (COVID)-19 pandemic.

MATERIALS AND METHODS

In this multi-center prospective cohort study, patients with proximal femoral fractures who were treated surgically at three hospitals from April 2020 to March 2021 were included. Follow-up examinations at 6 and 12 months postoperatively were conducted to investigate the clinical data and ascertain whether osteoporosis treatment could be continued.

RESULTS

A total of 316 patients with proximal femoral fractures were registered. During the follow-up period, 17 patients died and 67 patients could not visit the hospitals owing to the COVID-19 pandemic. In total, 172 patients who could be followed-up 12 months postoperatively were examined using dual-energy X-ray absorptiometry during hospitalization; underwent postoperative osteoporosis treatment, mainly with bisphosphonates (89.5%); and were administered medications continuously. Secondary fractures occurred within 1 year in 14 patients (8.1%). Multivariate analysis showed that patients who used sleeping pills and had a lower functional independence measure had an increased risk for developing secondary fractures.

CONCLUSION

During the COVID-19 pandemic, secondary fractures can be prevented if the patients can be followed and osteoporosis treatment can be continued. Conversely, despite adequate osteoporosis drug examination and treatment, a certain number of secondary fractures still occurred. The finding that postoperative osteoporosis therapy using routine medications and rehabilitation is associated with secondary fractures may support the importance of establishing clinical standards consisting of a multidisciplinary collaboration for FLS.

Late deep femoral artery injury after intertrochanteric hip fracture treatment: A case report

INTRODUCTION AND IMPORTANCE

Arterial injury is a rare complication following hip fracture surgery. If not diagnosed appropriately, can lead to life- or limb-threatening situations. This report describes a case of late iatrogenic arterial injury, four weeks following surgery for intertrochanteric fracture.

CASE PRESENTATION

An 89-year-old woman suffered an intertrochanteric fracture. The deep femoral artery was injured four weeks after fracture treatment by dynamic hip screw, following increase of range of motion during the rehabilitation exercises. Pain and swelling increased markedly at the thigh. Slight fever with no tachycardia and the deceptive laboratory tests directed us to late-appearing sepsis. A color Doppler ultrasonography examination did not identify the arterial bleeding. Treatment was carried out to evacuate the presumed pus, but big clots were seen instead, and an active arterial bleeding was discovered. The arterial lesion was sutured and hemodynamic stability was restored.

CLINICAL DISCUSSION

The appearance of injury may be either acute or delayed. Unexplained laboratory results, use of beta-blockers and non-classical symptoms may be obstacles to early diagnosis of arterial injury.

CONCLUSION

A high index of clinical suspicion of arterial injury, even after long period after surgery, should be kept in mind. More precise investigations may be needed, as angiography, for making the diagnosis of arterial injury.

Imaging of the Acutely Injured Hip

Acute hip pain following injury more commonly originates locally in and around the hip joint rather than being referred from the lumbar spine, sacroiliac joints, groin, or pelvis. Clinical assessment can usually localize the pain source to the hip region. Thereafter, imaging helps define the precise cause of acute hip pain. This review discusses the imaging of common causes of acute hip pain following injury in adults, addressing injuries in and around the hip joint. Pediatric and postsurgical causes of hip pain following injury are not discussed.

Clinical and radiological outcome of the Chimaera short nailing system in inter- and subtrochanteric fractures

BACKGROUND

cephalomedullary devices are popular treatment for femoral intertrochanteric or subtrochanteric fractures. Various complications include post-surgical lateral thigh pain and cut-out. To prevent those complications, a new concept cephalomedullary device system was designed (Chimaera, Orthofix®). This study aimed to evaluate the clinical and radiological outcomes in patients with femoral intertrochanteric or subtrochanteric fractures treated with the proximal femoral cephalomedullary device system.

METHODS

A prospective cohort study involved consecutive patients with Arbeitsgemeinschaft für Osteosynthesefragen/ Orthopaedic Trauma Association type 31-A1, 2, 3 fractures treated with the Chimaera short cephalomedullary device system from October 2016 to September 2017 at our level 1 trauma center. The Parker and Palmer mobility score and Jensen social function scores and post-surgical lateral thigh pain were assessed at 3 months post-operatively and compared to before surgery. Radiologic assessment consisted of controlling the position of the cephalic screw by using the tip-apex distance (TAD) and Cleveland zone as well as union and cut-out rates.

RESULTS

We included 99 patients (79 women; 100 hips; one bilateral fracture 3 months after a first trochanteric fracture) with a mean follow-up of 2 years. The Parker and Palmer mobility score decreased by 22% at 3 months post-operatively as compared with the pre-fracture score (42/99 patients showed a return to their pre-injury level). The Jensen social function score increased by 16.5% at 3 months post-operatively as compared with the pre-fracture score (68/99 patients showed a return to their pre-injury level). No major intra-operative complication was recorded. Nine TAD scores were > 25 mm. The mean TAD was 16.5 mm (range 5-36), and the lag screw position was well positioned in most (95%) hips according to Cleveland zones. Three patients required revision surgery (one for cut-out of the lag screw, one for hip osteoarthritis and one for gluteus medius insufficiency). All patients but the one with the cut-out showed fracture union.

CONCLUSION

The Chimaera short cephalomedullary device exhibited good mid-term functional and radiological outcomes.

Characteristics of subsequent contralateral proximal femoral fracture: more convenient access is needed to treat osteoporosis

BACKGROUND

Patients with proximal femoral fracture (PFF) have high mortality and many complications. Osteoporosis increases the risk of subsequent fractures, leading to subsequent contralateral PFF. This study was performed to analyze the features of individuals with subsequent PFF following surgical therapy of first PFF and to ascertain whether such patients received an examination or treatment of osteoporosis. The reasons for lack of examination or treatment were also analyzed.

METHODS

This retrospective study involved 181 patients with subsequent contralateral PFF who underwent surgical treatment in Xi'an Honghui hospital from September 2012 to October 2021. The patients' sex, age, hospital day, mechanism of injury, surgical procedure, fracture interval, fracture type, fracture classification, and Singh index of the contralateral hip at the time of the initial and subsequent fractures were recorded. Whether the patients took calcium and vitamin D supplements, used anti-osteoporosis medication, or underwent a dual X-ray absorptiometry (DXA) scan was recorded, as was the start time of each. Patients who had never undergone a DXA scan or received anti-osteoporosis medication took part in a questionnaire.

RESULTS

The 181 patients in this study comprised 60 (33.1%) men and 121 (66.9%) women. Patients with initial PFF and subsequent contralateral PFF had a median age of 80 years (range 49-96 years) and 82 years (range 52-96 years), respectively. The median fracture interval was 24 (7-36) months. Contralateral fractures occurred at the highest incidence between 3 months and 1 year (28.7%). The Singh index was not significantly different between the two fractures. In 130 (71.8%) patients, the fracture type was the same. No significant difference was found in the fracture type or fracture stability classification. A total of 144 (79.6%) patients had never received a DXA scan or anti-osteoporosis medication. The main reason for not treating osteoporosis further was concern about the safety of drug interactions (67.4%).

CONCLUSIONS

Patients with subsequent contralateral PFF were of advanced age, had a higher proportion of intertrochanteric femoral fractures, had more severe osteoporosis, and had longer hospital stays. The difficulty managing such patients requires multidisciplinary involvement. Most of these patients were not screened or formally treated for osteoporosis. Advanced-age patients with osteoporosis need reasonable treatment and management.

Effect of screw tunnels on proximal femur strength after screw removal: A finite element analysis

BACKGROUND

The presence of screw tunnels in the femoral neck is a problem for patients with proximal femoral fractures after removal of internal fixation. The question of how much does the existence of the screw tunnels affect the strength of the femur and whether the patient needs to be protected with an adjunctive device has been controversial. The objective of this finite element analysis was to determine (1) whether the screw tunnels affects normal weight bearing after removal of internal fixation of a proximal femur fracture, (2) which screw tunnels parameters affect the weight bearing capacity of the entire femur.

HYPOTHESIS

The presence of the screw tunnels reduces the load-bearing capacity of the femur, and the arrangement, diameter and wall thickness of the screw tunnels affect the load-bearing capacity of the femur.

MATERIALS AND METHODS

Twenty patients who underwent surgical treatment for proximal femur fracture at our hospital were included in the study. Computed tomography (CT) values of the screw tunnel wall in the femur after removal of internal fixations were analysed. Mimics v16.0 and Hypermesh v13.0 software programs were used to generate 3-dimensional (3D) tetrahedral finite element models of the proximal femur with different screw tunnel numbers, diameters, thicknesses, and arrangements. An acetabulum exerting a vertical pressure load of 600N on the femoral head was simulated and the force on various parts of the femur in each model was calculated.

RESULTS

There was no difference in the Hounsfield Units of the tunnel walls and cortical bone of the proximal femur (893.48±61.28 vs. 926.34±58.43; p=0.091). In each of the 3D models, the cancellous bone was the first structure to reach maximal stress. The compressive strength of the femur decreased with increasing thickness of the screw tunnel wall and decreased with increasing tunnel diameter. The femoral neck model with the inverted triangle screw tunnel arrangement had the highest compressive strength.

DISCUSSION

The femoral neck with screw tunnels can withstand day-to-day stress without special intervention. For femoral neck fractures fixed with cannulated screws, inverted triangle screws are recommended; For a single screw tunnel in the femoral neck, the larger the diameter of the femoral neck internal screw channel, the weaker the load-bearing capacity of the femur.

LEVEL OF EVIDENCE

III; well-designed computational non-experimental study.

Tranexamic acid in pertrochanteric fractures: a retrospective analysis of perioperative outcomes after fixation with a proximal femoral nail

Background

Treatment of pertrochanteric femoral fractures is often associated with significant blood loss. It has already been demonstrated that the administration of tranexamic acid (TXA) for endoprosthetic procedures reduces blood losses and leads to a decreased frequency of postoperative complications. The aim of this study is to demonstrate whether the administration of TXA as part of osteosynthesis treatment for pertrochanteric fractures using a proximal femoral nail reduces perioperative blood losses and haemorrhage-related complications.

Methods

In a two-centre retrospective cohort study, 1 g TXA i.v. was administered preoperatively to 294 patients who had suffered from pertrochanteric femoral fractures. The subjects were compared clinically to a historical control group who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, transfusion requirement, and occurrence of complications.

Results

The TXA group showed evidence of a reduction in blood loss (TXA = 0.97 ± 0.47 l; nonTXA = 1.06 ± 0.47 l; p = 0.004) and a lower frequency of transfusion (TXA = 20%; nonTXA = 31%; p = 0.032) as compared to the nonTXA group. However, evidence of this therapeutic effect could only be demonstrated at one of the centres on subgroup comparison between the two centres. At the second centre, the data did not show a significant difference. A trend could be seen towards a reduction in postoperative renal failure. No complications occurred resulting from the administration of tranexamic acid.

Conclusion

Preoperative administration of TXA does not lead to an increased rate of thromboembolic complications when applied for treatment of pertrochanteric femoral fractures. Evidence of a positive effect could be seen in principle in relation to the reduction in perioperative blood loss and the frequency of transfusion. The difference in effect between the two centres remains to be clarified: for this reason, it is possible to assume that further factors influencing the efficacy of TXA administration are at play which were not taken into account in this study.

Mortality and functional consequences after revision osteosynthesis for peritrochanteric fractures treated by intramedullary nail: A retrospective study of 312 patients

INTRODUCTION

Osteosynthesis of peritrochanteric fractures by intramedullary nail is associated with a 3 to 15% rate of complications requiring revision surgery. The objective of our study was to compare mortality and autonomy between patients who required revision surgery after osteosynthesis, and patients without revision surgery.

HYPOTHESES

Patients who underwent revision surgery after osteosynthesis of a peritrochanteric fracture by intramedullary nail did not exhibit excess mortality or loss of autonomy compared to those who did not undergo revision surgery.

METHODS

Between January 2017 and October 2019, 312 consecutive patients were operated on for a peritrochanteric fracture by intramedullary nail. Among them, 23 patients (7.4%) required revision surgery (change, nail removal, total hip arthroplasty). Mortality at 90 days and at one year was evaluated and compared between the group of "revision" patients and "no revision" patients. The level of autonomy was assessed by the Parker and Palmer score, one year postoperatively and compared between the 2 groups.

RESULTS

The patients requiring revision surgery were younger: 73 years old vs. 86 years old (p<0.011). The overall mortality was 7.25% at 90 days after surgery and 15% at one year. Mortality was zero at 90 days, and at 1 year, postoperatively for patients requiring revision surgery. There was no significant difference for the mortality at 90 days (p=0.39) between the 2 groups, however at 1 year, it was significantly less for the revision patients (0% vs. 17%, p=0.032). There was no significant difference for the Parker score between the "revision" group; 5 (4-9) and the "no revision" group; 4 (3-7), at one year postoperatively (p=0.24).

CONCLUSION

This study did not show any excess mortality, nor loss of autonomy at 1 year postoperatively, for patients who required osteosynthesis for a trochanteric fracture, and who presented with a complication requiring revision surgery.

LEVEL OF EVIDENCE

III, comparative retrospective study.

Effects of SARS-CoV‑2 infections on inpatient mortality of geriatric patients after proximal femoral fracture surgery

BACKGROUND

The medical challenges caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV‑2) pose a tremendous burden on the healthcare system. This study aimed to analyze the effects of a SARS-CoV‑2 infections or disease progression on inpatient mortality of geriatric patients after proximal femoral fracture surgery.

METHODS

A retrospective analysis was conducted in all patients with a proximal femoral fracture surgically treated in an urban regional trauma center from 01/01/2020 to 01/31/2021. According to PCR test results detecting SARS-CoV‑2, the patients were divided into two groups (SARS-CoV‑2 positive vs. SARS-CoV‑2 negative). Patient data, disease progression data, and treatment-related information were evaluated for all patients. Statistical data analysis was performed using unpaired Student's t test or non-parametric Mann-Whitney U test.

RESULTS

A total of 311 patients (women: 70.4%, age: 82.0 ± 11.0 years) were included in this study. Of these 3.9% (12/311) had a positive test result for SARS-CoV‑2. Significantly more deceased patients were found in the group tested positive for SARS-CoV‑2 (SARS-CoV‑2 positive: 41.7%, SARS-CoV‑2 negative: 5.4%, p < 0.001). In addition, the number of proximal femoral fracture associated deaths correlated with the number of positive test results performed in the Clinic. The length of stay of SARS-CoV‑2 COVID-19 survivors tended to be greater than in those who were tested negative (SARS-CoV‑2 COVID-19 positive: 15.6 ± 13.1 days, SARS-CoV‑2 COVID-19 negative: 11.5 ± 6.5 days, p = 0.683). Furthermore, a significant difference in age was found in SARS-CoV‑2 survivors and SARS-CoV‑2 decedents (deceased: 95.5 ± 7.5 years, alive: 83.5 ± 7.3 years, p = 0.020).

CONCLUSION

The study was conducted before the introduction of SARS-CoV‑2 vaccination. The results therefore refer to immune naive (unvaccinated) patients. In our study, more than 40% of all patients with proximal femoral fractures who tested positive for SARS-CoV‑2 died during hospitalization. An additional, critical factor in this respect was the age of the infected patients. Nonetheless, a positive correlation was demonstrated between the mortality rate and the number of positive SARS-CoV‑2 detections. Regarding the greater length of stay of patients tested positive for SARS-CoV‑2, the limited transfer options (further rehabilitation, skilled nursing facility) of the infected ones can be considered as causal. Particularly the vulnerable older patients are increasingly endangered by a combination of proximal femoral fracture and SARS-CoV‑2.

Prognosis and institutionalization of frail community-dwelling older patients following a proximal femoral fracture: a multicenter retrospective cohort study

Hip fractures are a serious public health issue with major consequences, especially for frail community dwellers. This study found a poor prognosis at 6 months post-trauma with regard to life expectancy and rehabilitation to pre-fracture independency levels. It should be realized that recovery to pre-trauma functioning is not a certainty for frail community-dwelling patients.

INTRODUCTION

Proximal femoral fractures are a serious public health issue in the older patient. Although a significant rise in frail community-dwelling elderly is expected because of progressive aging, a clear overview of the outcomes in these patients sustaining a proximal femoral fracture is lacking. This study assessed the prognosis of frail community-dwelling patients who sustained a proximal femoral fracture.

METHODS

A multicenter retrospective cohort study was performed on frail community-dwelling patients with a proximal femoral fracture who aged over 70 years. Patients were considered frail if they were classified as American Society of Anesthesiologists score ≥ 4 and/or a BMI < 18.5 kg/m² and/or Functional Ambulation Category ≤ 2 pre-trauma. The primary outcome was 6-month mortality. Secondary outcomes were adverse events, health care consumption, rate of institutionalization, and functional recovery.

RESULTS

A total of 140 out of 2045 patients matched the inclusion criteria with a median age of 85 (P₂₅-P₇₅ 80-89) years. The 6-month mortality was 58 out of 140 patients (41%). A total of 102 (73%) patients experienced adverse events. At 6 months post-trauma, 29 out of 120 (24%) were readmitted to the hospital. Out of the 82 surviving patients after 6 months, 41 (50%) were unable the return to their home, and only 32 (39%) were able to achieve outdoor ambulation.

CONCLUSION

Frail community-dwelling older patients with a proximal femoral fracture have a high risk of death, adverse events, and institutionalization and often do not reobtain their pre-trauma level of independence. Foremost, the results can be used for realistic expectation management.

Conversion hip arthroplasty via the direct anterior approach: pearls, pitfalls and personal experience

OBJECTIVE

Conversion total hip arthroplasty (CTHA) through a direct anterior approach (DAA) in supine position.

INDICATIONS

Failed osteosynthesis of proximal femoral fractures or failed conservative hip surgery, with hardware in situ.

CONTRAINDICATIONS

Decayed general conditions, infection (peri-implant or systemic infection), need for greater trochanter reconstruction, severe proximal femur deformity.

SURGICAL TECHNIQUE

Supine position. Mark DAA and expected limited incisions for hardware removal (HR) with the help of a C-arm. Use guidewire and extraction devices for HR. Perform a DAA with particular attention to a wide release of the femur.

POSTOPERATIVE MANAGEMENT

Full progressive weight-bearing starting on day 1, depending on bone quality. Discharge with crutches following patient walking capability. Precautions for 6 weeks.

RESULTS

In all, 27 conversion THAs through a DAA. Mean age at the time of surgery 59.8 (range 18-81) years. Mean body mass index was 23.5 (range 17-31.6). Reasons of previous surgery failures were avascular necrosis of the femoral head, posttraumatic arthritis and nonunion with or without hardware migration. Mean surgical time was 125.8 min (range 58-190 min, standard deviation [SD] 38.2 min). Mean follow-up time was 6.9 years (range 2-15, SD 5.03 years). Mean pre-Harris Hip Score (mHHs) was 24.4 (range 19-36, SD 5.4), while the mean post-mHHS was 90.3 (range 89-91, SD 0.95). Two patients required postoperative osteosynthesis for periprosthetic fractures due to falls. Overall complication rate was 10%.

The effect of cerclage wiring with intramedullary nail surgery in proximal femoral fracture: a systematic review and meta-analysis

PURPOSE

The aim of this study was to evaluate the utility of cerclage wiring with intramedullary nail surgery in the treatment of proximal femoral fractures.

METHODS

MEDLINE, Embase, and Cochrane Library were systematically searched for studies that evaluated the impact of cerclage wiring on proximal femoral fractures published up to September 20, 2021. Pooled analysis identified differences in the (1) fracture healing profile, (2) perioperative variables, (3) complications, and (4) clinical outcome score between cerclage wiring and non-cerclage wiring.

RESULTS

Fourteen studies involving 1,718 patients with proximal femoral fractures who underwent cephalomedullary nailing surgeries were included. The pooled analysis revealed a longer fracture union time in the non-cerclage wiring group than in the cerclage wiring group (mean difference [MD] = - 1.03 months; 95% confidence interval [CI]: - 1.47 to - 0.59; P < 0.001), and there was no difference in the nonunion rate. The operation time was longer in the cerclage wiring group (MD = 14.32 min; 95% CI: 6.42-22.22; P < 0.001), but there were no differences in blood loss and the rate of poor quality of reduction. Superficial and deep infection rates showed no difference between the groups, and the readmission rate also showed no difference. The cerclage wiring group had a higher Harris hip score than the non-cerclage wiring group (MD = 2.13; 95% CI: 0.77-3.49; P = 0.002).

CONCLUSIONS

Intramedullary nailing with cerclage wiring is considered a useful treatment method for proximal femoral fractures. It enables anatomic reduction and stable fixation, thereby reducing union time and facilitating rapid functional recovery.

Expandable Proximal Femoral Nail versus Gamma Proximal Femoral Nail for the treatment of hip reverse oblique fractures

BACKGROUND

Reverse oblique intertrochanteric fractures are classified by the AO/OTA as 31A3 and account for 2-23% of all trochanteric fractures. The Gamma 3-Proximal Femoral Nail (GPFN) and the Expendable Proximal Femoral Nail (EPFN) are among the various devises used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31A1-3 fractures, treated by either a GPFN or an EPFN.

PATIENTS AND METHODS

A total of 67 patients (40 in the GPFN group and 27 in the EPFN group, average age 78.8 years) were treated in our institution between July 2008 and February 2016. Data on postoperative radiological variables, including peg location and tip-apex distance (TAD), as well as orthopedic complications, such as union rate, surgical wound infection and cut-outs rates were also recorded, along with the incidence of non-orthopedic complications and more surgical data. Functional results were evaluated and quantified using the Modified Harris Hip Score (MHHS) and by the Short Form 12 Mental Health Composite questionnaire (SF-12 MHC) in order to assess the quality of life.

RESULTS

The total prevalence of postoperative orthopedic complications including postoperative infection showed a significant difference with a p-value of 0.016 in favor of the EPFN group. Nonetheless, the frequency of revision did not differ between the two groups, being 0.134. The main orthopedic complication in both groups was head cut-out of the GPFN lag screw and the EPFN expendable peg, which was 20% and 7.4%, respectively, and required a revision surgery using a long nail or total hip replacement (THR). However, the average TAD did not significantly differ between groups which might be due to a relatively low cohort to reach a significant difference. Nonunion rate of 5% occurred solely in the GPFN group, with similar results of intraoperative open reduction between both groups. The EPFN group achieved better scores in both questionnaires (p = 0.027 and p = 0.046, respectively). Both the MHHS and SF-12 MCS values significantly differed between groups, with the EPFN group achieving better scores than the GPFN group in both questionnaires (p = 0.027 and p < 0.05, respectively).

CONCLUSIONS

According to this study, the EPFN yields better results in comparison with the GPFN, with relatively less complications rate, for the treatment of unstable reverse oblique pertrochanteric fracture. In light of this results, we conclude that the EPFN might be as good as GPFN for the treatment of reverse oblique intertrochanteric fractures.

LEVEL OF EVIDENCE

Level III retrospective study. The local institutional review board of the Tel Aviv Medical Center approved this study and all the surgeries were done exclusively in this institution.

Patients With Un-Displaced Or Displaced Intra Capsular Proximal Femur Fractures Do Not Represent A Different Patient Group And Have Similar Short And Long Term Mortality

BACKGROUND

Proximal femur fractures in geriatric patients are associated with substantial mortality. Management of intracapsular proximal femur fractures has been based on age, displacement, cognition, and pre-injury mobility. However, over the last decade, there has been a tendency to offer arthroplasty rather than internal fixation for these patients irrespective of displacement, to allow early mobilisation and negate the higher rate of reoperation due to failed internal fixation. There are no previous investigations analysing whether the severity of fracture displacement is related to different patient characteristics.

AIM

This study examines whether patients sustaining undisplaced or displaced intracapsular proximal femur fractures represent different patient groups with different pre-injury characteristics and post-operative mortality, irrespective of treatment modality.

METHODS

A retrospective series of 329 consecutive patients over the age of 55 years who sustained intracapsular proximal femur fractures, who underwent surgical management at a district general hospital over a period of 2 years (2012-2013) were identified using the national hip fracture database. Demographics, American Society of Anaesthesiologist (ASA) grade, pre-injury outdoor mobility status, cognitive status, and admission serum investigations, fracture displacement, type of surgery, and mortality rates at short term (2 years) & long-term (7-9 years) were reviewed.

RESULTS

There were 109 male and 220 female patients with a minimum follow-up of 7 years. The mean age at surgery was 81.6 years (range 55-103 years). There were 63 (19.1%) undisplaced fractures (Garden 1 &2) and, 265 (80.5%) displaced fractures (Garden 3 & 4). The median survival in this cohort was 2.95 years (95% CI 2.3-3.6). Mortality rates were 77.4% (n=257) at long-term (7-9 years) follow-up. Admission patient characteristics showed no statistically significant difference between displaced and undisplaced fracture groups. This included ASA, pre-operative cognition, and mobility status. Fracture displacement was not an independent predictor of mortality at short or long term.

CONCLUSION

In patients sustaining intracapsular proximal femur fractures, the degree of displacement is not a caveat for a different patient group. Fracture displacement is not predicted by the pre-injury level of function and does not predict short or long-term mortality.

Fixation of intraoperative proximal femoral fractures during THA using two versus three cerclage wires - a biomechanical study

Background

Intraoperative proximal femoral fractures (IPFF) are relevant complications during total hip arthroplasty. Fixation using cerclage wires (CW) represents a minimally-invasive technique to address these fractures through the same surgical approach. The goal of treatment is to mobilise the patient as early as possible, which requires high primary stability. This study aimed to compare different cerclage wire configurations fixing IPFF with regard to biomechanical primary stability.

Methods

Standardised IPFF (type II, Modified Mallory Classification) were created in human fresh frozen femora and were fixed either by two or three CW (1.6 mm, stainless steel). All cadaveric specimens (n = 42) were randomised to different groups (quasi-static, dynamic) or subgroups (2 CW, 3 CW) stratified by bone mineral density determined by Dual Energy X-ray Absorptiometry. Using a biomechanical testing setup, quasi-static and dynamic cyclic failure tests were carried out. Cyclic loading started from 200 N to 500 N at 1 Hz with increasing peak load by 250 N every 100 cycles until failure occurred or maximum load (5250 N) reached. The change of fracture gap size was optically captured.

Results

No significant differences in failure load after quasi-static (p = 0.701) or dynamic cyclic loading (p = 0.132) were found between the experimental groups. In the quasi-static load testing, all constructs resisted 250% of the body weight (BW) of their corresponding body donor. In the dynamic cyclic load testing, all but one construct (treated by 3 CW) resisted 250% BW.

Conclusions

Based on this in vitro data, both two and three CW provided sufficient primary stability according to the predefined minimum failure load (250% BW) to resist. The authors recommend the treatment using two CW because it reduces the risk of vascular injury and shortens procedure time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04956-5.

A carbon fiber-reinforced polyetheretherketone intramedullary nail improves fracture site visibility on postoperative radiographic images

INTRODUCTION

To evaluate the advantages of a carbon fiber-reinforced polyetheretherketone (CFR/PEEK) intramedullary nail on the diagnosis of fracture healing because of its radiolucency, we retrospectively reviewed radiographs and computed tomography (CT) images of trochanteric femoral fractures that underwent internal fixation with the CFR/PEEK intramedullary nail or a traditional metallic intramedullary nail.

METHODS

Radiographs and CT images from 20 patients with intertrochanteric femoral fractures treated with a CFR/PEEK intramedullary nail and 20 similar patients treated with a metallic intramedullary nail were reviewed. After division of the intertrochanteric region into three zones on anteroposterior and lateral views of the radiographs, the visibilities of the fracture site, fracture line, and bone formation were evaluated in each zone. A three-grade assessment for existence of scattering and effect of scattering on diagnosis of the surrounding bone was performed on three axial slices of the CT images.

RESULTS

In the CFR/PEEK group, the fracture site was visible in all zones for all cases except for the posterior zone on the lateral view in one case. In the cranial and middle zones on anteroposterior views and the middle zone on lateral views of the radiographs, the visible fracture site rates in the CFR/PEEK group were significantly higher than those in the metal group. The grades for existence of scattering and effect of scattering on diagnosis of surrounding bone on the CT images were significantly lower in the CFR/PEEK group compared with the metal group.

CONCLUSION

Superior fracture site visibility on radiographs was demonstrated in cases treated with the CFR/PEEK intramedullary nail compared with cases treated with the traditional metallic intramedullary nail, thereby confirming the advantages of the CFR/PEEK intramedullary nail for evaluation of fracture reduction and bone formation. The CFR/PEEK nail evoked little scattering on CT images, leading to higher diagnostic values for the peri-prosthetic cancellous and cortical bone compared with the metallic nail.

Total hip arthroplasty for failed acetabular fracture: a double-center comparative study on failed proximal femur fracture

PURPOSE

This study aimed to compare the clinical and radiological outcomes of patients who underwent total hip arthroplasty (THA) after failed osteosynthesis of acetabular fractures vs. fractures of the proximal femur.

METHODS

This is a retrospective comparative study in two centers. A total of 110 patients who underwent THA after osteosynthesis of acetabular or proximal femur fractures were categorized into groups: group 1 (53 patients with acetabular fracture) and group 2 (57 patients with proximal femur fracture). The mean follow-up period was 6.3 (range 2-16.5) years. The Harris hip scores (HHSs), complications, radiological results, and Kaplan-Meier survival curves were evaluated.

RESULTS

The mean preoperative HHSs of 39.4 (group 1) and 41.2 (group 2) were improved to 83.6 and 84.7 at the final follow-up (p < 0.001 and p < 0.001, respectively). There were two cases of aseptic cup loosening, two cases of septic cup loosening, two cases of deep infection, two cases of dislocation, two cases of sciatic nerve palsy, and one case of periprosthetic fracture in group 1, and one case of dislocation and two cases of infection in group 2, which showed a statistical difference in complication rate (p = 0.021). Total cup migration was significantly higher in group 1 (p = 0.015). After a mean follow-up period of 6.3 years, the survival rate was significantly lower in group 1 (69.4% vs. 97.1%, p = 0.015).

CONCLUSION

THA following osteosynthesis of acetabular fracture showed poorer survival, higher complication rate, and higher migration of the acetabular cup than THA following osteosynthesis of proximal femur fracture.

Contralateral non-simultaneous proximal femoral fractures in patients over 65 years old

Purpose

Epidemiological and clinical parameters according to the Parker-Palmer Index (PPI) have not been specifically studied as predictors of re-fracture time in patients over 65 years old with contralateral hip fracture. The main purpose of this study was to assess whether these parameters could represent a prognostic factor in this population.

Methods

This retrospective study included all consecutive patients older than 65 years that suffered from a proximal femoral fracture, 31 according to Association for Osteosynthesis/Orthopaedic Trauma Association classification, treated at our unit between Feb 1st 2019 and Feb 1st 2020.

Results

This study enrolled 387 patients. Thirty-seven of them had already incurred a contralateral hip fracture: seven males and 30 females. The median time between the first and second hip fractures was 3.5 years. This study revealed that increasing age (p = 0.003), male sex (p = 0.029) and a PPI value ≥ 5 between the first and second hip fracture (p = 0.015) are risk factors associated with a contralateral hip fracture in the first three years after the first episode. There were no statistically significant differences regarding anti-osteoporotic therapy and the anatomic site of the first hip fracture episode.

Conclusion

The results of the present study suggest that several risk factors have a crucial role in hip re-fracture time in patients over 65 years old.

A qualitative study exploring content validity and feasibility of frequently used generic health-related quality of life measures in older people with hip fracture: The patients' perspective

OBJECTIVE

To evaluate hip fracture patients´ views on content validity and feasibility of four commonly used generic measures of health-related quality of life (HRQOL).

METHODS

We interviewed 32 elderly hip fracture patients without relevant cognitive impairment (mean age=81 years). Using think-aloud and verbal probing techniques, patients completed the EQ-5D descriptive system, Nottingham Health Profile (NHP), Short-Form 12 Health Questionnaire (SF-12) and WHO Quality of Life-BREF (WHOQOL-BREF).

RESULTS

Patients were mostly not able to self-complete the questionnaires. Content validity was most constrained by problems in comprehensibility (e.g. vaguely phrased). Some items, for instance, were considered irrelevant if the example was inappropriate. Patients named e.g. problems with vision as important for their HRQOL, but none of the instruments included related items.

CONCLUSION

Although patients reported problems with all instruments, we suggest the EQ-5D or SF-12, as these appear to have the fewest limitations in content validity and feasibility from the patient´s perspective.

[Endoprosthetic treatment of pertrochanteric femoral fractures with concomitant coxarthrosis : A consecutive observational study with a control group]

INTRODUCTION

Hip replacement for pertrochanteric femoral fractures (PF) is challenging due to its complexity. Studies regarding this procedures are limited, therefore this monocentric study was conducted. The null hypothesis was no effect between replacement and internal fixation according to revision and mortality.

MATERIAL AND METHODS

Using an electronic database, patients who had received a hip replacement between 2007 and 2016 for a PF with a concomitant coxarthrosis were included in the study. The comparison group consisted of 1000 osteosyntheses for the treatment of PF. With the exception of coxarthrosis, the same inclusion and exclusion criteria were defined. Surgical revision and mortality with endpoint 2 years after the operation were the primary outcomes. At least 2 years postoperatively, a telephone follow-up was done with living patients who underwent replacement.

RESULTS

Records of 90 hip replacements and 15 baseline characteristics were reviewed (e.g., age, sex, body mass index, preoperative blood values, ASA classification, dementia, fracture classification). Replacement was significantly associated with a delay to operation (p < 0.001), a longer duration of operation (p < 0.001), an increased blood loss (p < 0.001), more blood transfusions (p < 0.001), and a longer inpatient stay (p = 0.026). According to the primary outcome, the mortality rate (p = 0.002) and the rate of infection in a subgroup analysis (p = 0.031) were also significantly increased. Using Cox regression, replacement was associated with a significantly higher probability of a shorter survival rate (odds ratio: 1.438, confidence interval: 1.054-1.962). Therefore, the null hypothesis was rejected. At the follow-up 6.1 years postoperatively (3.2-8.6 years), only 17 patients with replacement (20%) were still alive. The mean Parker mobility score was 5.0 points (range 3-9 points).

CONCLUSION

In this study, a significantly higher rate of infection and mortality was observed in patients with hip replacement for a PF and with a concomitant coxarthrosis; compared to osteosynthesis of PF without coxarthrosis. Further studies are mandatory to provide the appropriate treatment for patients with this fracture pattern.

Epidemiology of proximal femoral fractures

INTRODUCTION

With increasing age, the incidence of proximal femoral fractures increases steadily. Although the different treatments are investigated frequently, little is known about the seasonal variation and predisposing factors. The purpose of this study is to investigate the epidemiology, the impact of femoroacetabular impingement, as well as the presence of osteoarthritis.

METHODS

We performed a retrospective review of all patients with pertrochanteric, lateral and medial femoral neck fractures between 2012 and 2019. Inclusion criteria consisted of patients older than 18 years old who presented with isolated proximal femoral fractures without any congenital or hereditary deformity. For analysis, we assessed the demographics, season at time of accident, Kellgren-Lawrence score and corner edge (CE) angle.

RESULTS

In total, 187 patients were identified at a mean age of 75.1 ± 12.9 years old. Females consisted of 54.5% of this cohort. Most commonly, patients tend to present in winter with pertrochanteric fractures whereas no seasonal variation was found for medial femoral neck fractures. Significant correlations between season and age (regression coefficient -0.050 ± 0.021; p < 0.05) were identified. In medial neck fractures, the Gardner score was lower and Kellgren-Lawrence score higher for both female than males (p < 0.05). Patients with lateral neck fractures were significantly younger at 68.6 ± 12.5 years old (p < 0.05). In pertrochanteric fractures, the Kellgren-Lawrence score was significantly higher at 2.1 ± 0.8 (p < 0.05) with higher CE angle at 43.0 ± 7.6° (p = 0.14).

CONCLUSION

With increasing incidences of proximal femoral fractures, it is essential to recognize potential risk factors. This allows for development of new guidelines and algorithm that can aid in diagnosis, prevention, and education for patients.

Management of Traumatology Patients During the Coronavirus (COVID-19) Pandemic: Experience in a Hub Trauma Hospital in Northern Italy

BACKGROUND

As a result of the uncontrolled spread of the COVID-19 virus infection, a health reorganization according to the "hub and spoke" model was necessary. The purpose of the article was to document the adopted corporate protocol and describe the management of the traumatized patient in a Hub center.

METHODS

Our hospital has been identified as one of the three regional Hubs for polytrauma and major traumas, requiring suitable pathways to receive confirmed or suspected COVID-19-positive patients, from the emergency room entrance to the operating room, and finally to the inpatient ward or ICU. From February 23th to April 30th 2020 we analyzed the total number of trauma patients hospitalized and the number of femoral neck fractures surgically treated within 48 h; the data were then compared with the corresponding period of the previous year.

RESULTS

There has been a reduction in the overall number of traumas as a result of government restraint measures. Total occupancy time in the operating theater has increased, but not drastically considering dressing procedures and anesthesia (carried out inside the operating room). The number of patients with femoral neck fractures surgically treated within 48 h (none of the COVID-19-positive patients) decreased from 83.33 to 58.70%, but only slightly lower than the Italian pre-COVID average of 64.70%.

CONCLUSIONS

The correct management of the hospital and the meticulous organization of the traumatized patient have made it possible to contain the potential negative effects on the medical care quality during this unexpected and severe health emergency.

Independent factors associated with long-term functional outcomes in patients with a proximal femoral fracture: A systematic review

INTRODUCTION

The current understanding of prognostic factors of functional recovery after a proximal femoral fracture is limited, and enhancements could improve the prognostic accuracy and target subgroups for additional care strategies. This systematic review aims to identify all studied factors with an independent prognostic value for the long-term functional recovery of patients with a proximal femoral fracture.

MATERIALS AND METHODS

Observational studies with multivariate analyses on prognostic factors of long-term functional outcome after proximal femoral fractures were obtained through an electronic search performed on November 9, 2018.

RESULTS

In the 31 included articles, thirteen prognostic factors were studied by at least two independent studies and an additional ten by only one study. Age, comorbidity, functionality and cognition were factors for which the majority of studies indicated a significant effect. The majority of studies which included sex as a factor found no significant effect. The level of evidence for the remaining factors was deemed too low to be conclusive on their relevance for long-term functional outcome.

CONCLUSION

The identified factors showed overlap with prognostic factors of short-term functional outcomes and mortality. The validity and applicability of prognostic models based on these factors may be of interest for future research.

Modified Candy-Package technique vs Cerclage technique for refixation of the lesser trochanteric fragment in pertrochanteric femoral fractures. A biomechanical comparison of 10 specimens

OBJECTIVES

Separation of the lesser trochanteric fragment in pertrochanteric 3-part fractures leads to a significant weakening of the medial cortical wall. Because of the attachment of the Iliopsoas muscle to this structure, the lesser trochanteric fragment tends to cranial dislocation along this muscle's action direction. Refixation of these fractures using an intramedullary nail and an additional wiring osteosynthesis can be considered an operative standard. Based on an intramedullary osteosynthesis procedure, the question was raised whether a 2-point fixation method was favourable over a 1-point method regarding the pull-out resistance of the lesser trochanteric fragment against the Iliopsoas muscle's force.

METHODS

Based on an intramedullary osteosynthesis (PFNA, DePuy/Synthes/SUI), two groups á five human femora were defined depending on the refixation technique of the lesser trochanteric fragment (1-point supertrochanteric "Cable" vs 2-point super/subtrochanteric fixation "Candy-Package" performed with a 1.25-mm steel cerclage). The specimens were tested using a novel traction setup, simulating the activity pattern of the Iliopsoas muscle. The target value was the resistance of the refixated lesser trochanteric fragment against a defined pull-out force produced by the Iliopsoas muscle. The main parameters considered were the peak traction force (Fmax) and the maximum summative work (WFmax) at construct failure.

RESULTS

The Fmax and WFmax displayed a significant difference in favour of the Candy-Package (2-point super/subtrochanteric fixation) group (822 N vs. 476 N, 13.8 k Nmm vs 4.4 k Nmm, respectively; P = 0.01).

CONCLUSIONS

The Candy-Package technique is a method that displays significantly more resistance than a single cerclage osteosynthesis regarding fragment loosening under the application of a simulated Iliopsoas muscle force in the course of a biomechanical proximal femoral 3-part fracture model.

Can two additions make a big difference?

BACKGROUND

Proximal femoral fractures are a major socioeconomic burden and they occur mainly in geriatric patients. High mortality and complication rates are reported. To reduce the mortality and morbidity of these patients, co-management with geriatricians has been recommended. Most previous studies have focused on relatively comprehensive care models. Models with only a few additions to the usual care have not been extensively evaluated.

METHODS

This retrospective observational study included all patients aged ≥70 years (mean age: 84.5 ± 7.1 years, 70% women) with an isolated proximal femoral fracture treated surgically in our institution from May 2018 to October 2019. In the first 9 months, patients were treated with the usual care (control group, n = 103). In the second 9 months, patients were treated with our multidisciplinary care model (intervention group, n = 104), which included the usual care, plus: (1) one multidisciplinary ward round per week and (2) one "elective" operation slot per day reserved for proximal femoral fractures. Baseline characteristics and outcome measures of the hospital stay were extracted from electronic health records. A 3-month follow-up was conducted by phone.

RESULTS

Baseline characteristics were comparable between groups (p > 0.05). The hospital stay was shorter in the intervention group than in the control group (7.8 ± 4.3 vs. 9.1 ± 4.5; p = 0.022). The intervention reduced the waiting time for surgery by more than 10 h (intervention: 25.4 ± 24.5 vs. control: 35.8 ± 34.1 h; p = 0.013). A structured phone interview was not performed in 30.9% of the cases. The model reduced the overall dissatisfaction rate by more than half (12.9% vs. 32.4%; p = 0.008). On the other hand, the groups had similar perioperative complication rates (25% vs. 24.3%; p > 0.9999) and mortality (4.8% vs. 3.9%; p > 0.9999) and they remained similar at the 3-month follow-up (complications: 20.3% vs. 17.6% p = 0.831, mortality: 18.2% vs. 15.0% p = 0.573).

CONCLUSION

We found that two additions to the usual proximal femoral fracture regimen could significantly improve the overall satisfaction rate, reduce the length of hospital stay and shorten the waiting time for surgery. In contrast to previous studies, we observed no significant improvements in complication or mortality rates. Further changes in the standard care might be needed for this purpose.

Clinical pathways for geriatric patients with proximal femoral fracture improve process and outcome

OBJECTIVE

The objective of the current study was to evaluate the implementation of clinical pathways (CPs) in hip fracture management.

METHODS

Six hundred and five proximal femoral fractures were prospectively included into a hospital data-base. The effects of CPs were evaluated using a pre-during-post design. Different procedural (time to surgery, length of stay, discharge, etc.) and patient outcome parameters (mortality, complications, etc.) were evaluated.

RESULTS

In both categories significant changes could be detected during the three-year period. E.g. significant reduction of time to surgery, improvement of discharge management, reduction of internal complications. However, no significant changes could be demonstrated for mortality or revision rate.

CONCLUSION

We could show a relevant improvement with the implementation of clinical pathways for the treatment of proximal femoral fractures in elderly patients.

LEVEL OF EVIDENCE

III, prospective non-randomised cohort study.

The value of nonoperative versus operative treatment of frail institutionalized elderly patients with a proximal femoral fracture in the shade of life (FRAIL-HIP); protocol for a multicenter observational cohort study

Background

Proximal femoral fractures are strongly associated with morbidity and mortality in elderly patients. Mortality is highest among frail institutionalized elderly with both physical and cognitive comorbidities who consequently have a limited life expectancy. Evidence based guidelines on whether or not to operate on these patients in the case of a proximal femoral fracture are lacking. Practice variation occurs, and it remains unknown if nonoperative treatment would result in at least the same quality of life as operative treatment. This study aims to determine the effect of nonoperative management versus operative management of proximal femoral fractures in a selected group of frail institutionalized elderly on the quality of life, level of pain, rate of complications, time to death, satisfaction of the patient (or proxy) and the caregiver with the management strategy, and health care consumption.

Methods

This is a multicenter, observational cohort study. Frail institutionalized elderly (70 years or older with a body mass index < 18.5, a Functional Ambulation Category of 2 or lower pre-trauma, or an American Society of Anesthesiologists score of 4 or 5), who sustained a proximal femoral fracture are eligible to participate. Patients with a pathological or periprosthetic fractures and known metastatic oncological disease will be excluded. Treatment decision will be reached following a structured shared decision process. The primary outcome is quality of life (Euro-QoL; EQ-5D-5 L). Secondary outcome measures are quality of life measured with the QUALIDEM, pain level (PACSLAC), pain medication use, treatment satisfaction of patient (or proxy) and caregivers, quality of dying (QODD), time to death, and direct medical costs. A cost-utility and cost-effectiveness analysis will be done, using the EQ-5D utility score and QUALIDEM score, respectively. Non-inferiority of nonoperative treatment is assumed with a limit of 0.15 on the EQ-5D score. Data will be acquired at 7, 14, and 30 days and at 3 and 6 months after trauma.

Discussion

The results of this study will provide insight into the true value of nonoperative treatment of proximal femoral fractures in frail elderly with a limited life expectancy. The results may be used for updating (inter)national treatment guidelines.

Trial registration

The study is registered at the Netherlands Trial Register (NTR7245; date 10-06-2018).

[Management of pre-existing anticoagulation for timely treatment of proximal femoral fractures]

Proximal femoral fractures are urgent indications for surgery. In cases of delayed surgical treatment more than 48 h after hospital admittance, increased rates of general complications, local complications and mortality have been proven. Since 2015, the quality target for the external quality assurance by order of the Federal Joint Committee (G-BA) is surgical treatment within 24 h after hospital admittance for osteosynthesis and within 48 h for joint replacement. The foundations for these time intervals are the S2e guidelines for the treatment of femoral neck fractures of adults from the German Society of Trauma Surgery (DGU) and the Austrian Society of Trauma Surgery (ÖGU) and several other international guidelines. The distinction of the temporal specifications between osteosynthesis and joint replacement in Germany is unusual in comparison with other countries. For 15% of each group of patients a prolonged preoperative preparation is accepted. In the structured dialog within the external quality management anticoagulants are quoted as the most frequent reason for delayed surgery. The present review provides a way to achieve compliance with statutory provisions, to minimize the risks of both bleeding and thromboembolism and to achieve surgical treatment of proximal femoral fractures within the agreed time limit.

The trend of radiological severity of hip fractures over a 30 years period: a cohort study

BACKGROUND

Despite advances in operative techniques and preoperative care, proximal femur fractures (PFF) still represent a great public health problem. Displacement and fracture stability have been assumed as important determinants of treatment modality and outcome in such fractures. Purpose of this study was to determine whether the radiological severity of PFF fractures has increased over time.

METHODS

In a cohort study, the plain radiographs of all patients with PFF aged over 50 years who were admitted to Umeå University Hospital in 1981/82, 2002 and 2012 were recruited to examine the types of fractures.

RESULTS

The ratio of undisplaced to displaced femoral neck (FN) fractures was 30 to 70% in 1981/82, 28 to 72% in 2002 and 25 to 75% in 2012. The ratio of stable to unstable intertrochanteric (IT) fractures was 64 to 36% in 1981/82, 68 to 32% in 2002 and 75 to 25% in 2012. The ratio of simple to comminute subtrochanteric fractures was 35 to 65% in 1981/82, 16 to 84% in 2002 and 12 to 88% in 2012. In both FN and IT fractures we found no statistical difference among these 3 study periods, p = 0.67 and p = 0.40. In subtrochanteric fractures we saw a tendency towards more comminute subtrochanteric fractures (1981/82 to 2012), p = 0.09.

CONCLUSIONS

We found no significant increment in the radiological severity of FN and IT over a 30 years' period. However, there was tendency towards an increase in comminute subtrochanteric fractures.

Choice of three different intramedullary nails in the treatment of trochanteric fractures: Outcome, analysis and consideration in midterm

The purpose of this study is to compare the results obtained using three different systems of osteosynthesis, developed for the surgical treatment of fractures of the trochanteric region of the femur, based on the principle intramedullary nailing: the Gamma nail, the Affixus nail and the ZNN nail. This is a retrospective study: 72 trochanteric fractures treated with the Gamma nail, 68 treated with the Affixus nail and 69 treated with the ZNN nail, between the years 2012 and 2014, with the prerequisite of a minimum follow-up of 18 months. The fractures were classified according to the AO system; the most commonly reported subtype was the A2 fracture. Clinical and radiographic examinations were performed, both at hospital admission and post-operatively, at 1, 3, 6, 12 and 18 months. Of the 209 patients, 171 were women and 38 were men. The average age was 83.12 years old. All three systems guaranteed an early mobilization and ambulation in most of the patients. There were no significant differences in the use of the three nails in terms of recovery of previous functional capacity, or in terms of the time required for the fracture to heal. There were no advantages encountered with the use of one intramedullary nail over another and, in particular, when observing the complications and patient outcome, there were no statistically significant differences detected.

Continuous improvement process: ortho-geriatric co-management of proximal femoral fractures

OBJECTIVE

The objective of the current study was to evaluate the effect of a quality management system on treatment and care delivery of proximal femoral fractures. Specifically, our hypothesis was that the "plan-do-check-act (PDCA)" philosophy of the ISO 9001 quality management system results in a continuous improvement process.

METHODS

1015 proximal femoral fractures were prospectively included into a hip fracture database over a 5-year period, after a restructuring process with implementation of clinical pathways and standard operation procedures. A close and structured ortho-geriatric co-management (certified ortho-geriatric center) was the basis for treatment. ISO 9001 certification was granted for the first time in 2012. Procedural and patient outcome parameters were analyzed by year and evaluated statistically using SPSS 25.0.

RESULTS

In both categories (procedural and outcome) significant changes could be detected during the 5-year period, e.g., significant reduction of time to surgery for the first 2 years, improvement in discharge management, and reduction of surgical complications. However, no significant changes could be demonstrated for mortality or internal complications such as pneumonia, urinary tract infections, or postoperative delirium. However, the incidence of the latter was already on a very low level at the onset of the quality improvement process.

CONCLUSION

We could show a relevant and continuous improvement of several quality indicators during a 5-year period after implementation of a quality management system based on the PDCA philosophy for the treatment of proximal femoral fractures in elderly patients. However, other parameters (internal complications, cost-effectiveness, etc.) need our close attention in the future.

Mismatch of long Gamma intramedullary nail with bow of the femur: Does radius of curvature of the nail increase risk of distal femoral complications?

INTRODUCTION

Anterior cortical penetration of the distal nail tip is a recognized complication of intra-medullary nailing of the femur particularly in the geriatric population. This has been attributed to a mismatch between the femoral bow and the radius of curvature (ROC) of the femoral nail. We wanted to see if there was a reduction of this risk comparing cephalomedullary nails with ROC of 200 cm and 150 cm.

METHODS

52 patients were split into 2 groups similar with respect to age, sex and comorbidities. Group A with 25 patients used a nail with a ROC of 200 cm and Group B with 27 patients used a 150 cm ROC nail. Lateral radiographs of the distal femur were evaluated to note the position of the nail tip in relation to the femoral canal. The diameter of the femur at the tip of the nail was divided into 3 equal zones. The anterior one-third was designated as Zone1, the middle one-third as Zone 2 and the posterior one-third as Zone 3.

RESULTS

80% of the cases with a 200 cm ROC nail had the tip of the nail in the anterior one-third of the canal (zone 1). Fracture of the anterior femoral cortex distally by the nail tip was seen in 2 patients.Only 18.5% of cases with a 150 cm ROC nail had the tip of the nail in anterior one-third of the canal (zone 1). There were no incidences of complications such as fractures and anterior cortical perforation.

CONCLUSIONS

A cephalomedullary nail with a ROC of 150 cm had its distal tip more towards the center of the femoral canal when compared to a nail with ROC of 200 cm. No case of anterior femoral penetration was seen when using a nail with an ROC of 150 cm.

Screening for malnutrition in patients admitted to the hospital with a proximal femoral fracture

INTRODUCTION

The prevalence of malnutrition in patients admitted with a proximal femoral fracture is considered high and the negative effects on health are well-studied. The SNAQ and the MNA-SF are two screening tools routinely used during admission of acute medical patients. The aim of this study is to compare the screening capacity of the SNAQ score and the MNA-SF, and to evaluate their predictive values for malnutrition using the ESPEN criteria.

MATERIALS AND METHODS

A single-centre study with data routinely collected prospectively from the original patient records was performed in the Haaglanden Medical Centre Bronovo in the Netherlands. All patients with a proximal femoral fracture consecutively admitted between December 19th 2016 and December 21st 2017 were included. The Intraclass Correlation Coefficient was used to assess the agreement between the malnutrition screening tools and the predictive values were calculated to compare the SNAQ with the MNA-SF using the ESPEN diagnostic criteria as the reference standard.

RESULTS

Data was available from 437 patients. Of all patients admitted with a proximal femoral fracture 16.9% was diagnosed as malnourished by the ESPEN criteria. When screened, 20.1% (SNAQ score) to 47.8% (MNA-SF) of all patients were classified as either at risk for malnutrition or as malnourished. A moderate agreement was found between the MNA-SF and the SNAQ (κ = 0.68). The sensitivity, specificity, PPV and NPV of the SNAQ score were 71.6%, 90.4%, 60% and 94% respectively, compared to 100%, 62.8%, 35.4% and 100% for the MNA-SF.

DISCUSSION

The SNAQ has been proven to be a very specific screening tool and the positive predictive value tends to be higher than that of the MNA-SF. However, 28.4% of all malnourished patients with a proximal femoral fracture had a negative screening test when using the SNAQ score.

CONCLUSIONS

No benefits were observed for the SNAQ over the MNA-SF as a screening tool for malnutrition in admitted patients with a proximal femoral fracture. Missing a significant portion of malnourished patients or those at risk and consequent under treatment of fragile older patients should be avoided. The well-validated MNA-SF seems more preferable as a screening tool for this patient population.

Timing of physiotherapy following fragility hip fracture: delays cost lives

INTRODUCTION

Post-operative physiotherapy (PT) following fragility hip fractures is intended to improve balance, gait, and muscle strength for enhanced functional outcomes. This study aims to assess whether postponing initiation of PT effects patients' outcomes during hospitalization and in the first 3 months following discharge.

MATERIALS AND METHODS

A retrospective study comparing consecutive patients, 65 years and older, who were operated for fragility hip fractures between 2011 and 2016, within 48 h from admission, and started PT treatment either in the first post-operative day (POD1) or later (POD2-5). Patients were operated upon as soon as medically possible and in accordance with theater availability. All surgeries were performed outside of workday hours (either in the afternoon or during the weekend). Group allocation was established corresponding with the surgical day, as PT services are unavailable during weekends and holidays, and surgeries were performed daily. Primary outcomes were mortality either within hospital or in the post-operative year. Secondary outcomes were in-hospital complications, recurrent hospitalizations, and orthopedic complications within 3 months.

RESULTS

747 patients were included in the study; 525 patients started PT at POD1 and 222 had delayed PT. Patients' demographics, living arrangements, age-adjusted Charlsons' co-morbidity index, mobility, hemoglobin levels, and implant type were comparable. In-hospital mortality was significantly higher for the delayed PT group, 6.8 vs. 3.2% (OR 2.2, 95% CI 1.06-4.42, p value 0.034). One-year mortality, in-hospital complications, and the average number of 3 months' recurrent hospitalizations did not differ between groups. A trend for more orthopedic complications was noted in the delayed PT group (p = 0.099), and patients from this group were readmitted more often due to orthopedic surgery-related reasons (p = 0.031).

CONCLUSIONS

Post-operative delay in PT following fragility hip fracture surgery was related to increased risk for in-hospital mortality.

Comparative analysis of non-simultaneous bilateral fractures of the proximal femur

PURPOSE

We performed a monocenter cohort study to determine surgical revision and mortality after sustaining an initial and a non-simultaneous contralateral proximal femoral fracture.

METHODS

We identified all patients surgically treated for a contralateral femoral fracture between 2006 and 2015. Patient demographic characteristics and follow-up were identified by our electronic database; failed information regarding revision and mortality were obtained by telephone, as well as the evaluation of the mobility for all alive patients. The endpoint of the study was set for every patient at least 2 years postoperatively.

RESULTS

Within a total of 2296 patients, we identified 250 patients (10.8%) treated for a contralateral fracture. The mean interval between the two occurrences was 5.2 years and the mean age at the time of contralateral fracture was 84.4 years. Almost every third fracture occurred later than 5 years after the initial fracture, and even every tenth fracture later than 10 years. More than 50% of the patients also had dementia at this time. The total surgical revision rate was 17.2% after initial, and 20.4% after contralateral fracture, but this difference was statistically not significant (p = 0.31). However, revisions for infection or hematoma were more than twice after contralateral fracture (p = 0.006). The 1-year mortality rate was 36%, and dementia (log rank p < 0.001) and male gender (log rank p < 0.001) were significant negative predictors for the survival rate. After a mean of 42 months, the follow-up of the 67 alive patients recorded a mean Parker Score of 5.2 items.

CONCLUSION

Contralateral femoral fracture was accompanied by a higher revision and mortality rate-but patients were also 5 years older. Dementia and male gender were significant negative variables for the survival time. In the future, the highest priority will be the prophylaxis of falling to avoid or at least to decline the number of these fractures in geriatric patients.

Hip fracture in the elderly multidisciplinary rehabilitation (FEMuR) feasibility study: testing the use of routinely collected data for future health economic evaluations

Background

Health economic evaluations rely on the accurate measurement of health service resource use in order to calculate costs. These are usually measured with patient completed questionnaires using instruments such as the Client Service Receipt Inventory (CSRI). These rely on participants' recall and can be burdensome to complete. Health service activity data are routinely captured by electronic databases.The aim was to test methods for obtaining these data and compare with those data collected using the CSRI, within a feasibility study of an enhanced rehabilitation intervention following hip fracture (Fracture in the Elderly Multidisciplinary Rehabilitation: FEMuR).

Methods

Primary care activity including prescribing data was obtained from the Secure Anonymised Information Linkage (SAIL) Databank and secondary care activity (Emergency Department attendances, out-patient visits and in-patient days) directly from Betsi Cadwaladr University Health Board (BCUHB), North Wales, UK. These data were compared with patient responses from the CSRI using descriptive statistics and the intraclass correlation coefficient (ICC).

Results

It was possible to compare health service resource use data for 49 out of 61 participants in the FEMuR study. For emergency department (ED) attendances, records matched in 23 (47%) cases, 21 (43%) over-reported on electronic records compared with CSRI and five participants (10%) under-reported, with an overall ICC of 0.42. For out-patient episodes, records matched in only six cases, 28 participants over-reported on electronic records compared with CSRI and 15 (12%) under-reported, with an overall ICC of only 0.27. For in-patient days, records matched exactly in only five cases (10%), but if an error margin of 7 days was allowed, then agreement rose to 39 (66%) cases, and the overall ICC for all data was 0.88.It was only possible to compare prescribing data for 12 participants. For prescribing data, the SAIL data reported 117 out of 118 items (99%) and the CSRI only 89 (79%) items.

Conclusions

The use of routinely collected data has the potential to improve the efficiency of trials and other studies. Although the methodology to make the data available has been demonstrated, the data obtained was incomplete and the validity of using this method remains to be demonstrated.

Trial registration

Trial registration: ISRCTN22464643 Registered 21 July 2014.