Management of long bone fractures and traumatic hip dislocations in paediatric patients: study protocol for a prospective global multicentre observational cohort registry

INTRODUCTION

Management controversy and clinical equipoise exist in treatments of long bone fractures and traumatic hip dislocation in paediatric patients due to the lack of high-quality clinical evidence. This protocol describes the effort of a large prospective global multicentre cohort study (registry) aiming at providing quality data to assist evidence-based treatment decision-making.

METHODS AND ANALYSIS

Eligible paediatric patients (N=750-1000) with open physes suffering from proximal humerus fractures, distal humerus fractures, proximal radius fractures, forearm shaft fractures, traumatic hip dislocations, femoral neck fractures or tibial shaft fractures will be recruited over a period of 24-36 months. Hospitalisation and treatment details (including materials and implants) will be captured in a cloud-based, searchable database. Outcome measures include radiographic assessments, clinical outcomes (such as range of motion, limb length discrepancies and implant removal), patient-reported outcomes (Patient Reported Outcomes Of Fracture, Patient-Reported Outcomes Measurement Information System (PROMIS) and EuroQol-5D (EQ-5D-Y)) and adverse events.Aside from descriptive statistics on patient demographics, baseline characteristics, types of fractures and adverse event rates, research questions will be formulated based on data availability and quality. A statistical analysis plan will be prepared before the statistical analysis.

ETHICS AND DISSEMINATION

Ethics approval will be obtained before patients are enrolled at each participating site. Patient enrolment will follow an informed consent process approved by the responsible ethics committee. Peer-reviewed publication is planned to disseminate the study results.

TRIAL REGISTRATION NUMBER

NCT04207892.

Monobloc dual-mobility acetabular component versus a standard single-mobility acetabular component

Aims

The benefit of a dual-mobility acetabular component (DMC) for primary total hip arthroplasties (THAs) is controversial. This study aimed to compare the dislocation and complication rates when using a DMC compared to single-mobility (SM) acetabular component in primary elective THA using data collected at a single centre, and compare the revision rates and survival outcomes in these two groups.

Methods

Between 2010 and 2019, 2,075 primary THAs using either a cementless DM or SM acetabular component were included. Indications for DMC were patients aged older than 70 years or with high risk of dislocation. All other patients received a SM acetabular component. Exclusion criteria were cemented implants, patients treated for femoral neck fracture, and follow-up of less than one year. In total, 1,940 THAs were analyzed: 1,149 DMC (59.2%) and 791 SM (40.8%). The mean age was 73 years (SD 9.2) in the DMC group and 57 years (SD 12) in the SM group. Complications and revisions have been analyzed retrospectively.

Results

The mean follow-up was 41.9 months (SD 14; 12 to 134). There were significantly fewer dislocations in the DMC group (n = 2; 0.17%) compared to the SM group (n = 8; 1%) (p = 0.019). The femoral head size did not influence the dislocation rate in the SM group (p = 0.702). The overall complication rate in the DMC group was 5.1% (n = 59) and in the SM group was 6.7% (n = 53); these were not statistically different (p = 0.214). No specific complications were attributed to the use of DMCs. In the DMC group, 18 THAs (1.6%) were revised versus 15 THAs in the SM group (1.9%) (p = 0.709). There was no statistical difference for any cause of revisions in both groups. The acetabular component aseptic revision-free survival rates at five years were 98% in the DMC group and 97.3% in the SM group (p = 0.780).

Conclusion

The use of a monobloc DMC had a lower risk of dislocation in a high-risk population than SM component in a low-risk population at the mid-term follow-up. There was no significant risk of component-specific complications or revisions with DMCs in this large cohort.

Histomorphometric analysis of patients with femoral neck fracture and 25-hydroxyvitamin D deficiency: a cross-sectional study

INTRODUCTION

Vitamin D deficiency causes osteoporosis, bone mineralization disorders, and osteomalacia. Osteomalacia is diagnosed using blood biochemical tests, clinical symptoms, and imaging; however, accurate detection of mineralization disorders requires tissue observation. We investigated the prevalence of bone mineralization disorders and their relationship with serum 25-hydroxyvitamin D (25OHD) levels in patients with untreated osteoporosis with femoral neck fractures.

MATERIALS AND METHODS

A non-demineralized specimen was prepared from the femoral head removed during surgery in 65 patients. Bone histomorphometry of cancerous bone in the femoral head center was conducted. Osteoid volume per bone volume (OV/BV) and osteoid thickness (O.Th) were measured as indicators of mineralization disorder.

RESULTS

The mean serum 25OHD level (11.9 ± 5.7 ng/mL) was in the deficiency range (< 12 ng/mL). There were no clinically diagnosed cases of osteomalacia (OV/BV > 10% and O.Th > 12.5 µm); however, one case of mineralization disorder, considered histologically pre-osteomalacia (OV/BV > 5% and O.Th < 12.5 µm), was observed (OB/BV, 17.6%; O.Th, 12.3 µm). Excluding this case, those with severe (25OHD < 12 ng/mL, at risk of osteomalacia; n = 39) and non-severe deficiency (25OHD ≥ 12 ng/mL; n = 25) did not significantly differ in OV/BV (%; 0.77 ± 0.54 vs. 0.69 ± 0.38, p = 0.484) or O.Th (µm; 5.32 ± 1.04 vs. 5.13 ± 0.78, p = 0.410). Further, 25OHD and OV/BV were not significantly correlated (R = - 0.124, p = 0.327).

CONCLUSION

This is the first study in the twenty-first century to examine serum 25OHD concentrations and bone mineralization disorders in Japanese patients with osteoporosis. The results indicate that vitamin D deficiency does not necessarily cause bone mineralization disorders and rarely leads to osteomalacia.

Comparison of antegrade and retrograde cross pin fixation in the surgical treatment of pediatric supracondylar femur fractures: A biomechanical study

PURPOSE

The aim of this study is to compare biomechanical stability of Kirschner wires (K-wires) sent with antegrade and retrograde technique in the fixation of pediatric supracondylar femur fractures.

MATERIALS AND METHODS

A transverse fracture model was created two centimeters above the physis in 24 synthetic bone models suitable for the pediatric femur bone structure. The models were randomly divided into two groups as 12 bones each. In the first group (Group 1), 12 bone fracture models were retrogradely fixed with two cross K-wires. In the second group (Group 2), the fracture was fixed antegradely. In Group 2, both wire ends were allowed to protrude three millimeters from the femoral condyles. The stability of the groups was tested biomechanically by exposing them to varus and extension forces. The forces corresponding to 1 mm, 2 mm, 3 mm and 4 mm displacement and failure loads were calculated in two groups.

RESULTS

According to the test results regarding displacements and failure loads, the retrograde group was found to be significantly stronger than the antegrade group against varus loads (p < 0.05). When the groups were compared in terms of extension strength, the results of the two groups were similar and there was no statistical difference between them (p > 0.05).

CONCLUSION

Retrograde cross K-wires fixation provides a more stable fixation against varus forces. This is important to prevent varus deformity, which is a clinically less tolerable deformity. However, considering that full-weight mobilization of patients is not allowed after surgery in pediatric supracondylar femur fractures, the surgeon should consider that K-wires can also be sent antegrade to decrease the risk of septic arthritis.

Treatment of pediatric femur supracondylar fractures: comparison of K-wire fixation versus plate-screw fixation

This study aims to compare the clinical and radiological results of patients who underwent plate-screw fixation and K-wire fixation in supracondylar femur fractures in the pediatric population. Patients aged 5-14 years suffering from supracondylar femoral fractures who underwent K-wire and plate-screw fixation were included in the study. Of all patients, follow-up period, age, fracture union time, gender, leg length discrepancy, and Knee Society Score (KSS) data were analyzed. The patients were divided into two groups; fixation with plate (Group A) and fixation with K-wires (Group B). Forty-two patients participated in the study. There was no significant difference between the two groups in terms of age, gender, and follow-up time ( P  > 0.05). When comparing the KSS results, no statistically significant difference was found between the two groups ( P  = 0.612). A statistically significant difference was detected between the two groups regarding union time ( P  = 0.01). When both groups were analyzed, no significant difference was found between the two groups in terms of functional results. Good results can be obtained in both plate-screw and K-wires in pediatric supracondylar femur fractures.

[Risk factors and prognosis of preoperative herat failure after hip fracture]

OBJECTIVE

To explore incidence, risk factors and the relationship between preoperative heart failure and prognosis in elderly patients with hip fracture.

METHODS

A retrospective analysis was performed on 1 569 elderly patients with hip fracture treated from January 2012 to December 2019, including 522 males and 1 047 females, aged 81.00 (75.00, 90.00) years old;896 intertrochanteric fractures and 673 femoral neck fractures. Patients were divided into heart failure and non-heart failure groups according to whether they developed heart failure before surgery, and heart failure was set as the dependent variable, with independent variables including age, gender, fracture type, comorbidities and hematological indicators, etc. Univariate analysis was performed at first, and independent variables with statistical differences were included in multivariate Logistic regression analysis. Independent risk factors for preoperative heart failure were obtained. The length of hospital stay, perioperative complications, mortality at 30 days and 1 year after surgery were compared between heart failure and non-heart failure groups.

RESULTS

There were 91 patients in heart failure group, including 40 males and 51 females, aged 82.00 (79.00, 87.00) years old;55 patients with intertrochanteric fracture and 36 patients with femoral neck fracture. There were 1 478 patients in non-heart failure groups, including 482 males and 996 females, aged 81.00(75.00, 86.00) years old;841 patients with intertrochanteric fracture and 637 patients with femoral neck fracture. There were significant differences in age, sex, coronary heart disease, arrhythmia and dementia between two groups(P<0.05). Multivariate Logistic analysis of statistically significant factors showed that males(OR=1.609, P=0.032), age(OR=1.032, P=0.031), arrhythmia(OR=2.045, P=0.006), dementia (OR=2.106, P=0.014) were independent risk factor for preoperative heart failure. The 30-day and 1-year mortality rates were 9.9% and 26.4% in heart failure group and 3.6% and 13.8% in non-heart failure group, respectively;and had statistical significance between two groups (P<0.05). There were significant differences in pulmonary infection, cerebrovascular complications and cardiovascular complications between two groups (P<0.05). The duration of hospitalization in heart failure group was (16.21±10.64) d compared with that in non-heart failure group (13.26±8.00) d, and the difference was statistically significant (t=2.513, P=0.012).

CONCLUSION

Male, old age, arrhythmia and dementia are independent risk factors for heart failure after hip fracture in elderly patients. Patients with preoperative heart failure have a higher incidence of postoperative pulmonary infection, cerebrovascular and cardiovascular complications, higher mortality at 30 d and 1 year after surgery, and longer hospital stay.

Distinctive Geometrical Traits of Proximal Femur Fractures-Original Article and Review of Literature

Background and Objectives: The incidence of proximal femoral fractures is escalating rapidly, generating a significant challenge for healthcare systems globally and, carrying serious social and economic implications. The primarily object of this study was to discover potential distinguishing factors between fractures occurring in the femoral neck and trochanteric region. Materials and Methods: We performed a prospective cohort study of the radiographic images of 70 people over 65 years of age who were admitted to the orthopedic department with hip fracture and who fulfilled our eligibility criteria. Neck Length (NL), Offset Lenth (OL), Hip Axis Length (HAL), Neck Shaft Angle (NSA), Wiberg Angle (WA), Acetabular Angle (AA), Femoral Neck Diameter (FND), Femoral Head Diameter (FHD), Femoral Shaft Diameter (FSD), Femoral Canal Diameter (FCD) and Tonnis classification were recorded. For the comparison of the categorical variables, Pearson's χ2 criterion was used, while Student's t-test was applied for the comparison of means of quantitative variables across fracture types. Results: There were no statistically significant variances observed while comparing the selected geometric parameters of the proximal femur with the type of fracture. This finding was reaffirmed in relation to age, gender, and Tonnis classification. However, a moderate correlation was noted, revealing comparatively reduced values of HAL, FHD, and FND in women as opposed to men. Conclusions: The inability of our research to establish the differentiative geometric factors between femoral neck and trochanteric fractures underscores the need for further investigations, which would take into consideration the intrinsic characteristics of the proximal femur.

Pertrochanteric hip fracture is associated with mobility decline and poorer physical performance 4 to 6 months post-hip fracture

BACKGROUND

To study the effect of hip fracture type on physical performance, functional ability and change in mobility four to six months after the injury.

METHODS

A total of 1331 patients out of consecutive 2052 patients aged ≥ 65 years who underwent hip fracture surgery were included in the study. Patient information was collected on admission, during hospitalization, by phone interview and at the geriatric outpatient clinic 4 to 6 months after the fracture. Of the 1331 eligible patients, Grip strength, Timed Up and Go -test (TUG), Elderly Mobility Scale (EMS), mobility change compared to pre-fracture mobility level, Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) were used to determine physical performance and functional ability. Logistic regression was used for the analyses which was adjusted for gender, age, American Society of Anesthesiologists score, diagnosis of cognitive disorder, pre-fracture living arrangements, mobility and need of mobility aid.

RESULTS

Patients with pertrochanteric hip fracture had an EMS lower than 14 (Odds Ratio (OR) 1.38, 95% confidence intervals (CI) 1.00-1.90), TUG time ≥ 20 s (OR 1.69, 95% CI 1.22-2.33) and they had declined in mobility (OR 1.58, 95% CI 1.20-2.09) compared to femoral neck fracture patients 4 to 6 months post-hip fracture in multivariable-adjusted logistic regression analyses. Grip strength and functional ability (IADL, BADL) 4 to 6 months after hip fracture did not differ between fracture types. There were no statistically significant differences in physical performance in patients with a subtrochanteric fracture compared to patients with a femoral neck fracture.

CONCLUSIONS

Pertrochanteric hip fracture independently associated with poorer physical performance 4 to 6 months post hip fracture compared to other hip fracture types. Pertrochanteric hip fracture patients should be given special attention in terms of regaining their previous level of mobility.

Osteoid osteomas of the hip: a well-recognized entity with a proclivity for misdiagnosis

OBJECTIVES

The diagnosis of osteoid osteomas (OO) about the hip can be challenging as presenting symptoms can mimic other, more common, periarticular pathologies. Our aims were to identify the most common misdiagnoses and treatments, mean delay in diagnosis, characteristic imaging features and provide tips for avoiding diagnostic imaging pitfalls for patients with OO of the hip.

METHODS

We identified 33 patients (34 tumors) with OO about the hip who were referred for radiofrequency ablation between 1998 and 2020. Imaging studies reviewed included radiographs (n = 29), CT (n = 34), and MRI (n = 26).

RESULTS

The most common initial diagnoses were femoral neck stress fracture (n = 8), femoroacetabular impingement (FAI) (n = 7), and malignant tumor or infection (n = 4). The mean time from symptom onset to diagnosis of OO was 15 months (range, 0.4-84). The mean time from initial incorrect diagnosis to OO diagnosis was 9 months (range, 0-46).

CONCLUSIONS

The diagnosis of OO of the hip is challenging, with up to 70% of cases initially misdiagnosed as a femoral neck stress fracture, FAI, bone tumor, or other joint pathology in our series. Consideration of OO in the differential diagnosis of hip pain in adolescent patients and awareness of the characteristic imaging findings are critical for making an accurate diagnosis.

KEY POINTS

• The diagnosis of osteoid osteoma of the hip can be challenging, as demonstrated by long delays in time to initial diagnosis and high rates of misdiagnoses which can lead to inappropriate interventions. • Familiarity with the spectrum of imaging features of OO, especially on MRI, is imperative given the increase in the utilization of this modality for the evaluation of young patients with hip pain and FAI. • Consideration of OO in the differential diagnosis of hip pain in adolescent patients and awareness of the characteristic imaging findings, including bone marrow edema and the utility of CT, are critical for making a timely and accurate diagnosis.

What is the stable internal fixation for the unstable and osteoporotic supracondylar femoral fractures: a finite element analysis

BACKGROUND

Osteoporotic supracondylar femoral fractures (OSFF) have historically been managed by the lateral anatomical locking plate with reasonable success. However, for some kinds of unstable and osteoporotic supracondylar femoral fractures (UOSFF), especially with bone defects, unilateral locking plate (ULLP) fixation failed or resulted in implant breakage. This paper is going to explore what is the stable internal fixation for UOSFF by adding the bilateral locking plate (BLLP) fixation.

METHODS

OSFF models were divided into two groups according to the fracture line type, which would be further subdivided according to their angle of fracture line, presence of bone defect, location, and degree of bone defect. Thereafter, kinds of locking plate fixation were constructed. A 2010-N load was applied to the femoral head, and a 1086-N load was applied to the greater trochanter. In this condition, the maximum von Mises stress distribution of models were investigated.

RESULTS

Firstly, it was obviously found that the stress concentration in the BLLP group was more dispersed than that in the ULLP group. Secondly, according to the fracture line analysis, the stress value of fracture line type in "\" model group was higher than that of "/" model group. Moreover, with the increase in fracture line angle, the stress value of the model increased. Thirdly, from the bone defect analysis, the stress value of the medial bone defect (MBD) model group was higher than that of the lateral bone defect (LBD) model group. And as the degree of bone defect increased, the stress value increased gradually in the model group.

CONCLUSION

In the following four cases, lateral unilateral locking plate fixation cannot effectively stabilize the fracture end, and double locking plate internal fixation is a necessary choice. First, when the angle of the fracture line is large (30, 45). Second, when the fracture line type is "/." Third, when the bone defect is large. Fourth, when the bone defect is medial.

[Development of the new guidelines on osteoporosis : Methodological and content development]

Since 2018, the present S3 guideline Prophylaxis, Diagnosis and Therapy of Osteoporosis (AWMF 183-001) has been updated following a previous update of the underlying PICO questions (Population-Intervention-Comparison-Outcome questions) for a systematic literature search. The focus of the guideline update, in addition to updating the evidence supporting literature along with recommendations, was the development of a risk calculator for vertebral fractures and femoral neck fractures. This is essential for managing risk assessment because of the multitude of risk factors that contribute to fracture risk. This article considers the development of the guideline update methodologically and substantively, the latter by reflecting on the core themes of the guideline update.

Application of distal femoral 90° locking plate in children with supracondylar femoral fractures

OBJECTIVE

This study aimed to assess the application value of distal femur 90° locking plate fixation for supracondylar femoral fractures (SFF) in children.

PATIENTS AND METHODS

A total of 100 SFF children with or without diabetes who were enrolled in our hospital from January 2018 to January 2020 were randomized into a control group and a study group by the random number table method. The study group received distal femur locking plate fixation, and the control group adopted Kirschner wire (K wire) internal fixation. The primary outcomes of the two groups of children and the secondary outcomes of the diabetic patients were compared.

RESULTS

The fracture union rate of the study group was significantly higher than that of the control group at 12 weeks, 16 weeks, 20 weeks and 24 weeks after the operation (p<0.05), while the rate showed no significant difference between the two groups at 28 weeks after the operation (p>0.05). The two groups showed similar operation time, intraoperative blood loss, intraoperative fluoroscopy time, and hospital stay (p>0.05). The study group yielded a more favorable outcome with regard to the Harris-Hip-Score (HHS) scores, HHS excellent-and-good rate, and Flynn scores satisfaction rate than the control group (p<0.001 or 0.05). The intracavitary pressure of the knee joint of the two groups presented a gradual decline with time, with remarkably lower results in the study group compared with the control group at 8 weeks and 16 weeks after the surgery (p<0.05), and differences at 24 weeks after the surgery did not come up to the statistical standard (p>0.05). Patients experienced fewer postoperative complications after locking plate fixation, as compared to those who received K wire treatment (p<0.05). Compared with the control group, the fracture union rate of diabetic children in the study group was significantly higher at 12 weeks, 16 weeks, and 20 weeks after surgery, respectively (p<0.05), while there was no significant difference between the two groups at 24 weeks and 28 weeks (p>0.05).

CONCLUSIONS

The distal femur 90° locking plate fixation for diabetic children with SFF obviates the need for plate shaping and ensures firm fixation, with biomechanical design, promising efficacy, and few complications. The distal femur 90° locking plate fixation has better efficacy for children with diabetes. It shows great potential as the treatment of choice for diabetic children with SFF.

Effect of psoas and gluteus medius muscles attenuation on hip fracture type

INTRODUCTION

Sarcopenia is defined as a progressive loss of muscle mass and function with increased age. The measurement of muscle mass and attenuation on the axial computed tomography (CT) scan has been reported to be a good indicator for sarcopenia in previous literature. This study aimed to compare muscle mass between the intertrochanteric fracture and femoral neck fracture groups by accurately measuring muscle mass around the hip joint using a CT scan.

METHODS

The cases were matched according to age and gender on a 1-to-1 basis. As a result, a total of 400 patients, 200 patients in each group with the same age and gender characteristics, were included in the study. At the disc of L4-L5 level, the cross-sectional area (CSA) of the psoas muscle was evaluated, and at the disc of L5-S1 level, the CSA of the psoas, iliacus and gluteus medius muscles were evaluated. In addition, attenuation was evaluated using the average Hounsfield Unit (HU) for the specific area.

RESULTS

The mean age of 400 patients (262 females, 138 male) included in the study was 78.49 ± 7.67 years. It was observed that the mean HU values of the patients in the femoral neck fracture group were significantly higher than the intertrochanteric fracture group (p < 0.001, p = 0.008; respectively). At the same time, the mean HU values of the gluteus medius muscle were higher in the femoral neck fracture group (p < 0.001), but in contrast with the psoas muscle, the CSA values of gluteus medius muscle were significantly higher in the intertrochanteric fracture group (p = 0.017).

CONCLUSIONS

Fatty degeneration of the psoas muscle among the muscles around the hip may affect the type of hip fracture. Elderly patients with strong psoas muscles may experience femoral neck fracture due to contraction and torsion during falling.

Comparing two different orthogeriatric models of care for hip fracture patients: an observational prospective cross-sectional study

INTRODUCTION

Patients with hip fractures are almost always operated with quite extensive surgery and are often frail with a high risk of complications, increased dependency, and death. Orthogeriatric interdisciplinary care has shown better results compared with orthopaedic care alone. The best way of delivering orthogeriatric care, however, is still largely unknown. It is believed that a high degree of integration and shared care is better than on-demand consultative services. We aimed to evaluate two different orthogeriatric models for patients with hip fracture.

METHODS

A prospective hip fracture quality database was used to evaluate two coexisting models of care from 2019 to 2021 in our hospital. An 'integrated care model' (ICM) was compared with a 'geriatric consult service' (GCS).

RESULTS

516 patients were available for analysis, 360 from ICM and 156 from GCS. Mean age was 84 years. There were 370 (72%) women. American Society of Anesthesiologists class and prefracture cognitive impairment was similar between the groups. There were more patients with femoral neck fractures in the ICM group, and more patients were living independently prefracture. A logistic regression adjusting for the variables above showed that more patients in the ICM group were given a nerve block preoperatively (OR 2.0 (95% CI 1.31 to 2.97); p<0.01), had their urinary catheter removed the first day after surgery (OR 1.9 (95% CI 1.27 to 2.89); p<0.01), were mobilised to standing or seated in a chair beside the bed the first day after surgery (OR 1.5 (95% CI 1.03 to 2.30); p=0.033) and more ICM patients were considered for treatment against osteoporosis (OR 8.58 (95% CI 4.03 to 18.28); p<0.001). There were no significant differences in time to surgery, length of stay, discharge destination or mortality.

CONCLUSION

The ICM group performed equally good or better on all quality indicators than the GCS.

The direct anterior approach is safe and shortens hospital length of stay following hemiarthroplasty for neck of femur fracture

OBJECTIVE

To investigate the safety of using the anterior approach (AA), compared to the lateral approach (LA), in hemiarthroplasty for the treatment of displaced neck of femur fractures.

DESIGN

Retrospective case-control match cohort study.

SETTING

Level 1 trauma center.

PATIENTS

Retrospective review of prospectively collected data for 39 consecutive intracapsular hip fractures treated with hemiarthroplasty using an AA between 2017 and 2021. Patients operated with the AA were matched in 1:2 ratio with patients that had hemiarthroplasty via a LA.

MAIN OUTCOME MEASURES

Discharge destination, 90-day emergency room (ER) visit or readmission rate, inpatient and 90-day mortality rate, inpatient medical complications, 90-day mechanical complications, 90-day reoperation, and length of hospital stay (LOS).

RESULTS

Discharge destination (p = 0.695), 90-day ER visit or readmission rate (p = 0.315), inpatient (p = 0.719) and 90-day mortality rate (p = 0.815), medical complications (p = 0.524), mechanical complications (p = 0.150) were similar between cohorts. Five patients, all in the LA-group, required re-operations within 90-days (p = 0.106). Patients in AA-group had shorter LOS (9.3 days, 95% CI [7.6-11.1] vs. 14.7 days [95% CI 12.2-17.3], p = 0.002).

CONCLUSIONS

The AA can be safely introduced for the treatment of hip fractures. Similar short-term outcomes relative to the LA were identified. The shorter LOS may reflect the improved early functional recovery offered from the muscle-sparing AA technique. Future, level-1 data should include early- and longer term functional outcome along with cost-effectiveness.

Management for A Depressive Patient with Femoral Neck Fracture by Electroconvulsive Therapy during COVID-19 Pandemic: A Case Report and Literature Review

Electroconvulsive therapy (ECT) is an effective treatment for refractory major depressive disorder with suicidal ideation. The most common adverse medical events are transient retrograde amnesia, falls and pneumonia. Hip fractures, associated with high-energy trauma by convulsions, were occasionally reported in western countries, in the period before the COVID-19 pandemic. Strict COVID-19 regulations influenced the course and further investigation of the treatment of post-ECT complications. A 33-year-old man, previously diagnosed with major depressive disorder, had a history of nine successful sessions of ECT treatment for depression five years ago. He was hospitalized again for 12 sessions of ECT for recurrent depression. Unfortunately, an ECT-induced right hip-neck fracture was noted after the ninth session of ECT, in March 2021. After receiving close reduction and internal fixation of the right femoral neck fracture, with three screws, his original daily function was restored. His treatment was regularly followed up at the outpatient clinic for 20 months; he achieved partial remission with three combined antidepressants. This case of ECT-induced right hip-neck fracture informed psychiatric staff to be aware of this rare adverse complication and ensure its appropriate management, especially during the COVID-19 pandemic.

Neutrophil-lymphocyte ratio as a risk factor for osteoporotic vertebrae fractures and femoral neck fractures

Fracture is associated with osteopenia after osteoporosis. Neutrophil-lymphocyte ratio (NLR) is common in inflammatory diseases. NLR can be used as an effective clinical tool to assess postmenopausal osteoporosis. The aim of this study is to further explore the relationship between elevated NLR and the severity of osteoporotic vertebrae fractures and femoral neck fracture based on magnetic resonance imaging (MRI). A total of 80 patients with osteoporotic vertebrae fractures, osteoporotic femoral neck fracture in Baoding Second Central Hospital from 2017 to 2020 were selected as the research objects. This study included a series of pretreatment factors, mainly including white blood cell count, red blood cell count, hemoglobin, and the general condition of the patients. Statistical methods included Pearson chi-square test, Spearman correlation test, logistic regression analysis and receiver operator characteristic (ROC) curve. According to Pearson chi-square test, Spearman correlation test, univariate/multivariate logistic regression analysis, the severity of osteoporotic vertebrae fractures, osteoporotic femoral neck fracture was significantly correlated with NLR (P < .001). NLR (odds ratio [OR] = 13.229, 95% CI: 4.167-41.998, P < .001) was a significant independent risk factor for osteoporotic vertebrae fractures, osteoporotic femoral neck fracture. receiver operator characteristic (ROC) curve was used to detect the specificity and sensitivity. The level of NLR has an important influence on the severity of osteoporotic vertebrae fractures and femoral neck fracture. The higher the level of NLR, the more serious the osteoporotic vertebrae fractures and femoral neck fracture.

Red Cell Distribution Width-to-High-Density Lipoprotein Cholesterol Ratio (RHR): A Promising Novel Predictor for Preoperative Deep Vein Thrombosis in Geriatric Patients with Hip Fracture

Background

Deep vein thrombosis (DVT) is a devastating complication in geriatric patients before hip fracture surgery, and the predictive value of red cell distribution width (RDW) and high-density lipoprotein cholesterol (HDL-C) for DVTs after hip fracture remains to be established. This study aimed to assess the predictive value of RDW, HDL-C, and RDW-to-HDL-C ratio (RHR) in preoperative DVTs screening.

Methods

We retrospectively analyzed the data of geriatric patients (≥65 years old) admitted for hip fracture surgery between 2015 and 2020. The receiver operating characteristic (ROC) curve and related parameters were used to evaluate the predictive value of the biomarkers. Patients were divided into two groups according to the cutoff value of RHR, and propensity score matching (PSM) and subgroup analyses were performed to assess the true correlations between RHR and DVT.

Results

Among 2566 eligible patients included, we identified RDW with the area under ROC curve (AUC) of 0.532, cut-off value of 15.89, specificity of 88.2%, sensitivity of 18.2%, HDL-C with AUC of 0.574, cut-off value of 1.20, specificity of 55.6%, sensitivity of 59.3%, and RHR with AUC of 0.578, cut-off value of 13.45, specificity of 71.3%, sensitivity of 43.4%. RHR (>13.45) was independently associated with 1.54-fold risk (95% CI: 1.11–2.14, P=0.011) of DVTs among the post-PSM cohort. And compared with the counterparts, the relative risk of RHR associated with DVT was higher in the subgroups of aged 65–79 years (1.61 vs 1.45), non-hypoproteinemia (2.70 vs 1.29), non-diabetic (1.58 vs 1.41), non-hypertension (2.40 vs 1.06), ASA score I-II (2.38 vs 1.04), and femoral neck fracture (1.70 vs 1.50).

Conclusion

RDW, HDL-C and RHR were valuable biomarkers in predicting preoperative DVTs in geriatric patients with hip fracture, and RHR would be more efficient in the subgroups of younger age, better medical condition or femoral neck fracture.

Comparative Interrupted Time Series Analysis of Long-term Direct Medical Costs in Patients With Hip Fractures and a Matched Cohort: A Large-database Study

BACKGROUND

Previous studies on medical costs in patients with hip fractures have focused on medical costs incurred for a short period after the injury. However, patients often had comorbidities before their hip fractures that would have affected medical costs even had they not sustained a fracture. Consequently, these studies may have overestimated the costs associated with hip fractures and did not characterize the duration of increased medical costs adequately. Without knowing this crucial information, it is difficult to craft thoughtful health policy to support these patients' needs.

QUESTIONS/PURPOSES

(1) To compare the direct medical costs for 5 years before fracture and up to 5 years after injury in a group of patients who underwent hip fracture surgery with a matched group of patients who did not experience a hip fracture, (2) to analyze the duration over which the increased direct medical costs associated with a hip fracture continues, and (3) to analyze whether there is a difference in direct medical costs according to age group using a nationwide claims database in South Korea.

METHODS

The National Health Insurance Service Sample cohort in South Korea consisted of 1 million patients who were selected using a systematic, stratified, random sampling method from 48,222,537 individuals on December 31, 2006. Under a compulsory social insurance system established by the National Health Insurance Act, all patients were followed until 2015. Patients with hip fractures and matched controls were selected from the National Health Insurance Service sample of South Korea. Patients with hip fractures were defined as those who were hospitalized with a diagnosis of femoral neck fracture or intertrochanteric fracture and who underwent surgical treatment. We excluded patients with hip fractures before January 1, 2007 to ensure a minimum 5-year period that was free of hip fractures. Patients with hip fractures were matched with patients of the same age and gender at the date of admission to an acute care hospital for surgery (time zero). If patients with hip fractures died during the follow-up period, we performed matching among patients whose difference from the time of death was within 1 month. This method of risk-set matching was repeated sequentially for the next patient until the last patient with a hip fracture was matched. We then sequentially performed 1:5 random sampling for each risk set. A total of 3583 patients in the hip fracture cohort (patients with hip fractures) and 17,915 patients in the matched cohort (those without hip fractures) were included in this study. The mean age was 76 ± 9 years, and 70% were women in both groups. Based on the Charlson comorbidity index score, medication, and medical history, the patients with hip fractures had more comorbidities. Person-level direct medical costs per quarter were calculated for 5 years before time zero and up to 5 years after time zero. Direct medical costs were defined as the sum of that insurer's payments (that is, the National Health Insurance Service's payments), and that patient's copayments, excluding uncovered payments. We compared direct medical costs between patients with hip fractures and the patients in the matched cohort using a comparative interrupted time series analysis. The difference-in-difference estimate is the ratio of the differences in direct medical costs before and after time zero in the hip fracture cohort to the difference in direct medical costs before and after time zero in the matched cohort; the difference in difference estimates were calculated each year after injury. To identify changes in direct medical cost trends in patients with hip fractures and all subgroups, joinpoint regression was estimated using statistical software.

RESULTS

The direct medical costs for the patients with hip fractures were higher than those for patients in the matched cohort at every year during the observation period. The difference in direct medical costs between the groups before time zero has increased every year. The direct medical costs in patients with hip fractures was the highest in the first quarter after time zero. Considering the differential changes in direct medical costs before and after time zero, hip fractures incurred additional direct medical costs of USD 2514 (95% CI 2423 to 2606; p < 0.01) per patient and USD 264 (95% CI 166 to 361; p < 0.01) per patient in the first and second years, respectively. The increase in direct medical costs attributable to hip fracture was observed for 1.5 to 2 years (difference-in-difference estimate at 1 year 3.0 [95% CI 2.8 to 3.2]; p < 0.01) (difference-in-difference estimate at 2 years 1.2 [95% CI 1.1 to 1.3]; p < 0.01; joinpoint 1.5 year). In the subgroups of patients younger than 65, patients between 65 and 85, and patients older than 85 years of age, the increase in direct medical costs attributable to hip fracture continued up to 1 year (difference-in-difference estimate ratio at 1 year 2.7 [95% CI 2.1 to 3.4]; p < 0.01; joinpoint 1 year), 1.5 to 2 years (difference-in-difference estimate ratio at 1 year 2.8 [95% CI 2.6 to 3.1]; p < 0.01; difference-in-difference estimate ratio at 2 years 1.2 [95% CI 1.1 to 1.3]; p < 0.01; joinpoint 1.5 years), and 39 months to 5 years (difference-in-difference estimate ratio at 1 year 5.2 [95% CI 4.4 to 6.2]; p < 0.01; difference-in-difference estimate ratio at 5 years 2.1 [95% CI 1.4 to 3.1]; p < 0.01; joinpoint 39 months) from time zero, respectively.

CONCLUSION

The direct medical costs in patients with hip fractures were higher than those in the matched cohort every year during the 5 years before and after hip fracture. The increase in direct medical costs because of hip fractures was maintained for 1.5 to 2 years and was greater in older patients. Based on this, we suggest that health policies should focus on patients' financial and social needs, with particular emphasis on the first 2 years after hip fracture with stratification based on patients' ages.

LEVEL OF EVIDENCE

Level II, economic analysis.

Analysis of risk factors affecting mortality in elderly patients operated on for hip fractures: A retrospective comparative study

OBJECTIVE

The aims of this study were (1) to investigate the effects of different demographic and perioperative modalities on mortality rates and (2) to compare mortality rates between different implants in elderly patients operated on for hip fractures.

METHODS

In this retrospective study, a total of 314 patients who were operated on for hip fractures were included study. Patients were then divided into four groups based in their implant types: long-stem cementless bipolar hemiarthroplasty (n = 124; 102 female, 22 male; mean age = 84.2 ± 6.4 years), standard-stem cementless bipolar hemiarthroplasty (n = 74; 48 female, 26 male; mean age = 83.5 ± 6.9 years), antegrade intertrochanteric nail (n = 61; 35 female, 26 male; mean age = 78.5 ± 6.8 years), and total hip arthroplasty (n = 55; 34 female, 21 male; mean age = 72.5 ± 4.3 years). Data including gender, age, duration from injury to surgery, American Society of Anesthesiologists (ASA) score, comorbidities, use of antiplatelet agents, Barthel Index of Activities of Daily Living, type of anesthesia, operation time, preoperative hemoglobin values, blood transfusions given, duration of hospital stay, complications, and type of fracture were recorded.

RESULTS

Overall, the mean follow-up was 36.5 (range = 0 - 107) months. The overall mortality rate was 53.2%. The median survival duration was 44.2 ± 5 months (range = 34.3 - 54). Survival rates were found significantly different among the groups (P = 0.001). In the first three years postoperatively, the mortality rate was higher in the standard-stem bipolar hemiarthroplasty group, but in the long-term follow-up, the long-stem bipolar hemiarthroplasty group exhibited the higher mortality rates. It was observed that some parameters had statistically significant effects on the mortality rates. Male gender, higher age, lower hemoglobin values, increased number of blood transfusions, ASA scores ≥3, the existence of ≥ 3 comorbidities were found as main predictors of increased mortality rates.

CONCLUSION

The results of this study have shown that age, gender, preoperative hemoglobin levels, ASA scores, and comorbidities are significant factors affecting mortality in elderly patients operated on for hip fractures. Long-stem cementless bipolar hemiarthroplasty appears to show similar rates of mortality with standard-stem cementless bipolar hemiarthroplasty.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Comparison between femoral block and PENG block in femoral neck fractures: A cohort study

BACKGROUND

Regional analgesia is worth performing in the multimodal postoperative management of hip fracture (HF) because it reduces hospital morbidity and mortality. The aim of this study is to compare the efficacy and side effects of the recently described "Pericapsular Nerve Group (PENG) Block" with those of the femoral block, which is considered the standard of care for postoperative pain control after femoral neck fracture.

MATERIALS AND METHODS

We conducted a comparative observational study at a university hospital (Saint Antoine Hospital, Sorbonne University, Paris, France), where the PENG block was introduced in August 2019. We include all patients from June to October 2019, who were coming for femoral neck fractures and who had an analgesic femoral block or PENG block before their surgery. The primary outcome was the comparison of cumulative postoperative morphine consumption 48 hours after surgery.

RESULTS

Demographics, medical charts, and perioperative data of 42 patients were reviewed: 21 patients before (Femoral group) and 21 patients after the introduction of PENG block (PENG group) in clinical practice. Thirteen total hip arthroplasties (THA) and eight hemi arthroplasties (HA) were included in each group. Demographics were also comparable. The median, postoperative, morphine equivalent consumption at 48 hours was 10 [0-20] mg and 20 [0-50] mg in Femoral and PENG groups respectively (p = 0.458). No statistically significant differences were found in postoperative pain intensity, time to ambulation, incidence of morphine-related side effects, or length of hospital stay. The postoperative muscle strength of the quadriceps was greater in the PENG group than in the Femoral group (5/5 vs. 2/5, p = 0.001).

CONCLUSION

In the management of hip fractures, PENG block is not associated in our study with a significant change in postoperative morphine consumption, compared to femoral block. However, it does significantly improve the immediate mobility of the operated limb, making it appropriate for inclusion in enhanced recovery programs after surgery.

[Risk of micro-fracture in femoral head after removal of cannulated screws for femoral neck fracture]

OBJECTIVE

To explore the changes of bone and risk of micro-fracture in femoral head after removal of cannulated screws following femoral neck fracture healing under the impact force of daily stress.

METHODS

A total of 42 specimens of normal hip joint were collected from 21 adult fresh cadaveric pelvic specimens. Wiberg central-edge (CE) angle, bone mineral density, diameter of femoral head, neck-shaft angle, and anteversion angle of femoral neck were measured. Then, the 3 cannulated screws were implanted according to the AO recommended method and removed to simulate the complete anatomical union of femoral neck fracture. The morphology of screw canal in the femoral head was observed by CT. Finally, the specimens were immobilized vertically within the impact device in an upside-down manner, and the femoral heads were impacted vertically. Every specimen was impacted at 200, 600, and 1 980 N for 20 times with the impacting device. After impact, every specimen was scanned by CT to observe the morphology changes of screw canal in the femoral head. Micro-fractures in the femoral head could be confirmed when there was change in the morphology of screw canal, and statistical software was used to analyze the risk factors associated with micro-fractures.

RESULTS

After impact at 200 and 600 N, CT showed that the morphology of screw canal of all specimens did not change significantly compared with the original. After impact at 1 980 N, there were protrusion and narrowing in the screw canal of the 22 femoral head specimens (11 pelvic specimens), showing obvious changes compared with the original screw canal, indicating that there were micro-fractures in the femoral head. The incidence of micro-fracture was 52.38% (11/21). logistic regression results showed that there was correlation between micro-fracture and bone mineral density ( P= 0.039), but no correlation was found with CE angle, diameter of femoral head, neck-shaft angle, and anteversion angle ( P>0.05).

CONCLUSION

The micro-fractures in the femoral head may occur when the femoral head is impacted by daily activities after removal of cannulated screws for femoral neck fractures, and such micro-fractures are associated with decreased bone density of the femoral head.

Biomechanical analysis for five fixation techniques of Pauwels-III fracture by finite element modeling

BACKGROUND AND OBJECTIVES

There are many fixation methods for Pauwels- III fracture, the most common implants are Locking Plate (LP), Dynamic Hip Screw (DHS), Multiple Lag Screw (MLS), and mixed fixture (DHS+MLS) implants, the common procedure is HemiArthroplasty (HA). However, how these fixtures biomechanically function is not clear. The aims of this study are to compare the mechanical behaviors of these five implants by finite element modeling and determinate the most suitable procedure for individuals with Pauwels- III fractures.

METHODS

We gathered 20 sets of femur images from CT scans in the *.dicom format first, and then processed them by using reverse engineering software programs, such as Mimics, Geomagic Studio, UG-8, Pro-Engineer and HyperMesh. Finally, we assembled and analyzed the five types of fixture models, the LP, DHS, MLS, DHS+LS and HA models, by AnSys.

RESULTS

These numerical models of Pauwels III fractures, including fixators and a simulative HA, were validated by a previous study and a cadaver test. Our analytical findings include the following: the displacements of all fixtures were between 0.3801 and 1.0834 mm, and the differences were not statistically significantly different; the resulting average peaks in stress were e(Ha) = 43.859 ≤ d(LP) = 60.435 ≤ b(MLS) = 68.678 < c(LS+DHS) = 98.478 < a(DHS) = 248.595 in Mpa, indicating that the stress of DHS and DHS+LS are greater than those of LP, HA and MLS, while the last 3 models were not significantly different.

CONCLUSIONS

To optimize the treatment for Pauwels III factures clinically, HA and LP should be proposed.

Influence of coronavirus disease 2019 pandemic state of emergency in orthopaedic fracture surgical treatment

Purpose

After the appearance of first COVID-19 cases in Serbia, state of emergency was declared on 15 March 2020 and lasted for 54 days. The aim of this report is to compare orthopaedic fracture frequencies in this period, when the walk was limited at the home mostly, with those during the same part in the previous year with regular state, thus to examine staying at home as a factor influencing the frequency of different fracture types.

Methods

There were 86 patients during the state of emergency in year 2020 and 106 patients during the same part of year 2019 with a regular state, having orthopaedic trauma surgery. Number of fractures, gender distribution, and age of patients have been compared between these periods.

Results

Total number of fractures decreased for about 19% during the state of emergency. There was nonsignificant difference in fracture frequency for all skeletal areas (p > 0.05), except for distal femoral fractures which occurred more often during the state of emergency (p < 0.05). Female ratio was higher during state of emergency than in regular state for femoral neck fractures.

Conclusion

Restricted going outside the home for 54 days has the influence in total number of fractures and gender distribution in femoral neck fractures. The method of external fixation used could be assumed as a reducing factor of intraoperative virus pandemic propagation among medical staff.

[Analysis of risk factors for necrosis of femoral head after internal fixation surgery in young and mid-aged patients with femoral neck fracture]

OBJECTIVE

To retrospectively analyze the risk factors of avascular necrosis of femoral head (ANFH) after internal fixation in young and mid-aged adults.

METHODS

From January 2007 to December 2017, femoral neck fracture patients (18-60 years old) treated by reduction and internal fixation were retrospectively studied in Peking University Third Hospital. We recorded their gender, age, body mass index (BMI), American Society of Anesthesiology (ASA) grade, reason of injury, fracture side, interval between injury and surgery, location of fracture line, Garden classification, Pauwels classification, reduction method (open or closed), internal fixation and reduction quality. The diagnosis of ANFH was confirmed based on X-ray and MRI images during the follow-up. The internal fixation method included cannulated compression screw (CCS) or dynamic hip screw (DHS, with or without anti-rotation screw). χ² test and Logistic regression analysis were used to analyze the relationship between the various factors and postoperative ANFH.

RESULTS

A total of 113 patients were included in this study, including 63 males and 50 females with an average age of (43.17 ± 12.34) years. They were followed up by (25.08 ± 16.17) months. ASA grade included grade I (21 cases), grade II (55 cases) and grade III (37 cases). The reasons of injury included low-energy trauma (76 cases) and high-energy (37 cases). The fracture line included subcapital type (37 cases), transverse type (74 cases) and basal type (2 cases). Garden classification included type I (3 cases), type II (46 cases), type III (39 cases) and type IV (25 cases). Pauwels classification included type I (21 cases), type II (55 cases) and type III (37 cases). Interval between injury and surgery was (3.88 ± 3.66) days, 108 patients and 5 patients performed closed and open reduction respectively. 63 patients performed CCS, and 50 patients performed DHS. The reduction quality included grade A (91 cases), grade B (18 cases) and grade C (4 cases). 18 patients developed ANFH after surgery, the incidence rate was 15.93% (18/113). The result of χ² test showed the reason of injury (OR=0.19, P < 0.01), Garden classification (OR=0.13, P < 0.01), Pauwels classification (OR=0.12, P = 0.02), internal fixation method (OR=3.29, P = 0.04) and reduction quality (OR=0.33, P < 0.01) were significantly associated with ANFH. These five factors were further included into the Logistic regression analysis, and its results showed that the reason of injury (OR=4.11, P = 0.03) and Garden classification (OR=4.85, P = 0.04) were statistically significant.

CONCLUSION

The reason of injury, Garden classification, Pauwels classification, internal fixation and reduction quality may increase the risk of ANFH after surgery, and the reason of injury and Garden classification were much more significant.

Gluteus Medius Insertion Damage: A Comparison of Reconstruction and Hip Fracture Nails

This study assessed damage to the gluteus medius tendon insertion when performing trochanteric nailing with either a reconstruction nail or a cephalomedullary nail. Ten cadavers were randomized to receive proximal reaming for either a reconstruction nail or cephalomedullary nail; the contralateral hip served as an internal control. One specimen was found to have a displaced femoral neck fracture and was excluded from data analysis. Reconstruction nailing led to tendon damage in 4 of 9 hips, compared to 8 of 9 with hip fracture nailing (p = 0.29). In the reconstruction nail group, the average amount of tendon damaged was 3% (range 0-10%), while in the hip fracture nail group, the average was 15% (range 0-20.3%) (p = 0.0003). Open reaming for placement of a reconstruction nail caused less gluteus medius tendon damage when compared to open reaming for placement of a hip fracture nail. (Journal of Surgical Orthopaedic Advances 29(2):77-80, 2020).

[Preoperative C-reactive protein level has a dose-response relationship with postoperative complications in elderly patients with femoral neck fracture]

OBJECTIVE

To analyze the association of preoperative C-reactive protein (CRP) level with postoperative complications in elderly patients undergoing surgeries for femoral neck fracture.

METHODS

We retrospectively analyzed the data of 147 elderly patients (median age 80 years; 73.5% of the patients were female) undergoing surgeries for femoral neck fracture. According to preoperative CRP level, the patients were divided into normal CRP (< 10 mg/L) group (31 patients), mild elevation group (CRP level of 10-40 mg/L; 51 patients), and severe elevation group (CRP ≥40 mg/L; 65 patients). The association of preoperative CRP levels with postoperative complications was analyzed.

RESULTS

Preoperative CRP level was significantly correlated with the occurrence of postoperative complications (P=0.003). Compared with that in normal CRP group, the unadjusted ORs in mild and severe elevation groups were 0.97 (95%CI: 0.29-3.27) and 3.04 (95%CI: 1.03-8.98) with the adjusted ORs of 1.13 (95%CI: 0.33-3.90) and 4.89 (95%CI: 1.47-16.26), respectively.

CONCLUSIONS

Preoperative CRP level has a dose-response relationship with complications in elderly patients following arthroplasty for femoral neck fracture, and the patients with a preoperative CRP level ≥40 mg/L are exposed to a significantly increased risk for postoperative complications by 3.89 folds compared with the patients with a normal CRP level.

[Epidemiological characteristics of geriatric hip fractures in Hebei Province between 2010 and 2011]

OBJECTIVE

To investigate epidemiological characteristics of geriatric hip fractures between 2010 and 2011 in Hebei province.

METHODS

The digital radiography image data and basic information of patients above 60 years old with hip fractures (femoral neck fracture, femoral intertrochanteric fracture, and femoral head fracture) in 5 hospitals of Hebei province between January 2010 and December 2011 were analyzed retrospectively. All the data including patients' gender, age, and AO types were abstracted and analyzed to investigate the epidemiologic characteristics of geriatric hip fractures in Hebei province.

RESULTS

A total of 4 207 hip fracture patients above 60 years old were included, accounting for 59.61% of all patients with hip fractures and 26.24% of all fractures patients over 60 years old in the same period. There were 1 703 (40.48%) males and 2 504 (59.52%) females (M∶F=1∶1.47). The patients ranged in age from 61 to 99 years, with an average of 75.4 years; the majority of patients aged 70-79 years (43.97%) and the minority of the patients aged 90-99 years (2.02%); women of all ages were more than men, but the difference was not significant ( P>0.05). According to AO classification, there were 2 118 cases (50.34%) of type 31-A, 2 004 case (47.63%) of type 31-B, and 85 cases (2.02%) of type 31-C. Except for the type 31-A1, 31-A3, and 31-C1 of 60-69 age group, and the type 31-A3 of 80-89 age groups, women were significantly more than men.

CONCLUSION

There are more women than men in hip fractures in Hebei province, and 70-79 age group is the high-risk age group of geriatric hip fractures. Among them, intertrochanteric comminuted fractures are common types.

[Application of multidisciplinary doctor-nurse collaboration team on the perioperation management of geriatric hip fractures]

OBJECTIVE

To investigate the effectiveness of multidisciplinary doctor-nurse collaboration team on the perioperation management of geriatric patients with hip fractures.

METHODS

The clinical data of 489 geriatric patients with hip fractures (femoral neck fracture and intertrochanteric fracture) between January 1st 2016 and January 1st 2018 was retrospectively analyzed. Among them, 279 patients were treated with the multidisciplinary doctor-nurse collaboration care (observation group) and 210 patients were treated with the conventional therapeutics and nursing care (control group). There was no significant difference in gender, age, cause of injury, type and classification of fracture, the interval between injury and admission, and Charlson index between the two groups ( P>0.05). The surgery rates, time from hospitalization to operation, length of stay, and the incidences of perioperative complications were compared between the two groups.

RESULTS

The surgery rate was 90.32% (252/279) in observation group and 80.48% (169/210) in control group, showing significant difference between the two groups ( χ 2=9.703, P=0.002). The time from hospitalization to operation and length of stay in observation group [(5.39±2.47), (10.56±3.76) days] were significant shorter than those in control group [(6.13±2.79), (12.27±3.11) days] ( t=-3.075, P=0.002; t=-5.330, P=0.000). The incidence of respiratory complications was 46.15% in control group and 30.56% in observation group; the incidence of cardiovascular system complications was 69.23% in control group and 51.19% in observation group; the incidence of cerebrovascular system complications was 20.12% in control group and 11.11% in observation group; the incidence of deep venous thrombosis was 40.24% in control group and 25.40% in observation group. The incidences of perioperative complications were significantly lower in observation group than in control group ( P<0.05).

CONCLUSION

Multidisciplinary doctor-nurse collaboration team is conducive not only to improve the surgery rates, but also to reduce perioperative complications as well as shorten the length of stay and preoperative waiting time.

[Clinical application of multidisciplinary team co-management in geriatric hip fractures]

OBJECTIVE

To observe the clinical application of multidisciplinary team (MDT) treatment in the management of geriatric hip fractures and evaluate its effectiveness.

METHODS

The clinical data of 76 elderly patients with hip fracture managed by MDT approach between August 2016 and February 2018 (MDT group) were retrospectively analyzed and compared with 102 patients managed by traditional orthopedics approach between January 2014 and December 2015 (conventional group). There was no significant difference in gender, age, fracture type, surgical procedure, and other general data between the two groups ( P>0.05). However, the number of comorbidities in the MDT group was significantly higher than that in the conventional group ( t=6.295, P=0.000), and the proportion of the number of comorbidities between the two groups was also significantly different ( χ 2=28.442, P=0.000). The consultation rate and transfer rate, time to surgery, rate of surgery within 2 or 3 days, operation time, postoperative hospitalization stay, length of hospitalization stay, hospitalization expense, rate of loss to follow-up, and mortality during hospitalization, 30-day mortality, 90-day mortality, and 1-year mortality after operation were compared between the two groups.

RESULTS

The rates of total consultations of the conventional group and the MDT group were 56.86% (58/102) and 56.58% (43/76), respectively, and the rates of total transferred patients were 15.69% (16/102) and 15.79% (12/76), respectively, with no significant differences ( P>0.05). Among them, the proportion of patients who transferred into intensive care unit (ICU) in conventional group was significantly higher than that in MDT group and the rates of patients who received geriatric consultation or transferred into geriatric department in MDT group were both significantly higher than those in conventional group ( P<0.05). There was no significant difference in rates of other department consultation or transfer between the two groups ( P>0.05). The time to surgery, operation time, postoperative hospitalization stay, and length of hospitalization stay in MDT group were significantly less than those in conventional group, but the proportion of patients who received surgery within 3 days in MDT group was significantly higher than that in conventional group ( P<0.05). There was no significant difference in the proportion of patients who received surgery within 2 days ( χ 2=2.027, P=0.155). The hospitalization expenses of total patients, femoral neck fracture, and intertrochanteric fracture subgroups in MDT group were all significantly higher than those in conventional group ( P<0.05). However, there was no significant difference in hospitalization expense of subtrochanteric fracture subgroup between the two groups ( Z=-1.715, P=0.086). The rate of loss to follow-up in conventional group and MDT group was 6.86% (7/102) and 3.95% (3/76), respectively, with no significant difference ( χ 2=0.698, P=0.403). The mortalities at hospitalization, 1 month, 3 months, and 1 year after operation in conventional group were 0, 1.05% (1/95), 3.16% (3/95), and 7.37% (7/95), respectively, and in MDT group were 0, 0, 2.74% (2/73), 6.85% (5/73), respectively, showing no significant differences in mortalities between the two groups ( P>0.05).

CONCLUSION

MDT model in the management of geriatric hip fractures has been shown to reduce time to surgery, postoperative hospitalization stay, length of hospitalization stay, operation time, and the proportion of patients who received ICU consultation or transferred into ICU. Furthermore, MDT can improve the capacity for developing operations for patients with complex medical conditions and make medical resources used more rationally.

[Functional results of bipolar hemiarthroplasty in patients over 65 years of age with intracapsular hip fractures]

INTRODUCTION

Bipolar hemiarthroplasty is an alternative for the treatment of displaced femoral neck fractures in elderly patients with low functional demand and associated comorbidities. The goal was to describe functionality in patients over 65 years of age with intracapsular fractures of the hip.

MATERIAL AND METHODS

Retrospective review of patients over 65 years of age between January 2012 and May 2017. It was evaluated with the Harris Hip Score (HHS) and Oxford scale at six months and the year after surgery. Complications and mortality were documented during the first post-surgical year.

RESULTS

48 cases (12 men; 36 women), average age of 80.8 ± 7.7 years. Most common diseases: high blood pressure (77.1%), osteoporosis (37.5%), diabetes (33.3%) hypothyroidism (29.2%). The percentage of associated postoperative complications was 8.3% (four cases). The median HHS at six and 12 months was: 90.5 (DE: 77.5-96.0) and 96 (DE: 92-98), respectively. The Oxford scale was 45.5 (DE: 38.5-48.0) at six months and 47.0 (DE: 43.5-48.0) per postoperative year. 4.2% (two cases) died during the first post-surgical year and none were associated with the procedure.

DISCUSSION

HA provides good functional outcomes in patients over 65 years of age, with a low rate of complications. No mortality associated with the surgical procedure was observed in our series and in the short term.

[Closed reduction combined with Taylor three-dimensional space stent fixation for supracondylar femoral fracture in children]

OBJECTIVE

To explore the effectiveness and safety of closed reduction combined with Taylor three-dimensional space stent fixation in treatment of supracondylar femoral fractures in children.

METHODS

Between July 2008 and July 2016, 20 patients with supracondylar femoral fractures were treated with closed reduction combined with Taylor three-dimensional space stent fixation. There were 14 males and 6 females, with an average age of 10.3 years (range, 6-14 years). The cause of injury was traffic accident in 5 cases, falling from high place in 6 cases, and falling in 9 cases. All fractures were closed fractures. Among them, 12 cases were flexion type and 8 cases were straight type. According to AO classification, 12 cases were rated as type A1 and 8 cases as type A2. The fractures were over 0.5-5.0 cm (mean, 2.5 cm) of the epiphysis line. The time from injury to surgery was 2-8 days (mean, 3.5 days). Postoperative knee joint function was evaluated based on the Kolment evaluation criteria.

RESULTS

All children were followed up 6-24 months (mean, 18.1 months). There was no complication such as nail infection, vascular nerve injury, external fixation looseing, fracture displacement, or re-fracture. All fractures healed and the fracture healing time was 4-6 weeks with an average of 4.5 weeks. The stent removal time was 8-12 weeks (mean, 9.5 weeks). The gait and knee function recovered, and there was no abnormality of the epiphysis. At last follow-up, the knee joint function were excellent in 18 cases and good in 2 cases according to the Kolment evaluation criteria, and the excellent and good rate was 100%.

CONCLUSION

Closed reduction combined with Taylor three-dimensional space stent fixation is an effective treatment for the children with supracondylar femoral fractures, with small trauma and rapid recovery. It can avoid damaging the tarsal plate, be high fracture healing rate, and promote the recovery of limb function.

Ageing Effects on 3-Dimensional Femoral Neck Cross-Sectional Asymmetry: Implications for Age-Related Bone Fragility in Falling

This paper explores the effects of aging on femoral neck (FN) anatomy in a study of women aged 20-90years in relation to implications for FN fracture propensity in buckling. Five hundred and four participants were scanned by Quantitative Computed Tomography and analyzed using Quantitative Computed Tomography Pro BIT (Mindways). FN cross-section was split through geometric center into superior and inferior sectors. Bone mass, structural measurements, and bone mineral density were analyzed. Buckling ratio was calculated as ratio of buckling radius to cortical thickness. Between 2nd decade and 8th decade, age-related integral bone mass reduction in superior sector was substantially larger than in inferior sector (33% compared to 21%), especially in cortical bone superiorly compared to inferiorly (53% vs 21%; p < 0.001), principally due to reduction in cortical thickness, averaged cortical thickness (56%) with little difference in density. Superior and inferior sector trabecular bone mineral density reduction was similar at 41% and 43% respectively. Differential cortical bone loss in superior sector resulted in a 59% inferior displacement (δ) of center-of-mass from geometric center. Differences in δ and averaged cortical thickness with age accounted for a 151% increase in mean superior buckling ratio from 9 to 23. Analysis confirms significant progressive age-related superior cortical bone loss as the major age effect on FN structure with relative preservation of inferior cortex probably related to maintenance of inferior sector by regular loading as a result of standing and walking. Computation of buckling ratio may allow prediction of fracture propensity in a sideways fall.

It's All About the Timing: When Do I Take This Injury to the Operating Room?

Over time, what was considered urgent or emergent in orthopaedic trauma has been revisited, and as awareness of factors associated with outcomes has increased, priorities have changed. There are multiple procedures performed urgently in the belief that early intervention allowed for better outcomes for the injury and the patient. Classic examples of conditions for which urgent intervention has been implemented include open fractures, femoral neck fractures in the young adult, talus fractures, and compartment syndrome. All of these conditions are considered nonurgent except for compartment syndrome, which requires urgent and timely intervention. Studies have demonstrated that these injuries need to be managed in a timely fashion but not necessarily in the middle of the night. Outcomes can be improved by measures such as early antibiotic administration for open fractures, closed reduction of talus fracture-dislocations, and anatomic reduction of femoral neck fractures. These measures are more important and useful than an emergent trip to the operating room by inexperienced surgeons with staff who may be unprepared. Orthopaedic surgeons should be familiar with open fractures and the timing of irrigation and débridement, the relative urgency of managing talus fractures, and the need for immediate reduction and fixation of femoral neck fractures. For each of these injuries, factors other than timing that affect outcomes will be described. Finally, the emergent nature of diagnosis and management of compartment syndrome must also be understood.

Displaced Radial Neck Fractures: What Are My Options?

Pediatric radial head and neck fractures are uncommon injuries. Fractures are classified using the Judet system based on fracture angulation and displacement. Judet type I and II fractures can be managed nonsurgically with a short course of immobilization in a cast or splint without closed reduction. Most of these patients have an excellent prognosis and functional outcomes. Judet type III and IV injuries, as well as injuries that demonstrate a mechanical block to motion, should be closed reduced with the patient under conscious sedation or general anesthesia. Patients who undergo an unsuccessful closed reduction require closed or open reduction in the operating room. Closed reduction methods include the push and lever techniques with the use of Kirschner wires or Steinmann pins or intramedullary nails. Percutaneous fixation with wires or pins is needed only if the fracture fragment is determined to be unstable, whereas nails are left in place and require a second surgery for removal. Both methods have similar outcomes and an overall positive prognosis for patients. Open reduction and internal fixation should be avoided if at all possible given the higher incidence of wide-ranging complications.

Proximal Femur Fractures in Children: Enigmatic Injuries

Proximal femoral fractures in the skeletally immature patient can be challenging for the orthopaedic surgeon to manage. This type of injury includes the femoral head/neck, intertrochanteric, and subtrochanteric fractures. The Delbet classification system historically describes all injuries in the pediatric proximal femur, except subtrochanteric fractures. Understanding the possible complications (coxa vara, osteonecrosis, premature physeal closure, nonunion) when managing these injuries can help with preoperative and intraoperative decision making. Although the understanding of proximal femur fractures has improved, many of the risk factors for poor outcomes in these injuries are not modifiable. Familiarity with the history, classification, complications, factors influencing the outcome, and management options available in 2018 will help improve the outcomes of pediatric proximal femur fractures.

Association of incident hip fracture with the estimated femoral strength by finite element analysis of DXA scans in the Osteoporotic Fractures in Men (MrOS) study

Finite element model can estimate bone strength better than BMD. This study used such a model to determine its association with hip fracture risk and found that the strength estimate provided limited improvement over the hip BMDs in predicting femoral neck (FN) fracture risk only.

INTRODUCTION

Bone fractures occur only when it is loaded beyond its ultimate strength. The goal of this study was to determine the association of femoral strength, as estimated by finite element (FE) analysis of DXA scans, with incident hip fracture as a single condition or with femoral neck (FN) and trochanter (TR) fractures separately in older men.

METHODS

This prospective case-cohort study included 91 FN and 64 TR fracture cases and a random sample of 500 men (14 had a hip fracture) from the Osteoporotic Fractures in Men study during a mean ± SD follow-up of 7.7 ± 2.2 years. We analysed the baseline DXA scans of the hip using a validated plane-stress, linear-elastic FE model of the proximal femur and estimated the femoral strength during a sideways fall.

RESULTS

The estimated strength was significantly (P < 0.05) associated with hip fracture independent of the TR and total hip (TH) BMDs but not FN BMD, and combining the strength with BMD did not improve the hip fracture prediction. The strength estimate was associated with FN fractures independent of the FN, TR and TH BMDs; the age-BMI-BMD adjusted hazard ratio (95% CI) per SD decrease of the strength was 1.68 (1.07-2.64), 2.38 (1.57, 3.61) and 2.04 (1.34, 3.11), respectively. This association with FN fracture was as strong as FN BMD (Harrell's C index for the strength 0.81 vs. FN BMD 0.81) and stronger than TR and TH BMDs (0.8 vs. 0.78 and 0.81 vs. 0.79). The strength's association with TR fracture was not independent of hip BMD.

CONCLUSIONS

Although the strength estimate provided additional information over the hip BMDs, its improvement in predictive ability over the hip BMDs was confined to FN fracture only and limited.

Randomised trial comparing the transversus abdominis plane block posterior approach or quadratus lumborum block type I with femoral block for postoperative analgesia in femoral neck fracture, both ultrasound-guided

INTRODUCTION

A double-blind randomised controlled trial was conducted to compare the analgesic effect of the transversus abdominis plane block posterior approach or the quadratus lumborum block I versus femoral block, both ultrasound-guided.

MATERIAL AND METHODS

Prospective study with parallel groups with 104 patients with neck of femur fracture undergoing hemiarthroplasty (although 7 participants did not finish the study). The inclusion criteria were patients older than 65 years old, ASA I-III status, who required and gave their consent for hemiarthroplasty. The exclusion criteria were patients with known allergy to local anaesthetics, mental disability, peripheral neuropathy, a coagulopathy disorder, and those patients who received morphine, or a block was performed previous to the surgery. Each patient received one block followed by a spinal anaesthetic technique, performed by the anaesthetist. Pain was measured using a visual analogue score, sensory blockade using cold spray, and motor blockade, evaluating the leg movement. These were compared on arrival in recovery and at 6, 12, 18, and 24h later. Total opioid amount administered in 24 hours, duration of stay in post-anaesthesia care unit, patient satisfaction, and adverse effects were also recorded.

RESULTS

A lower visual analogue score was observed in the quadratus lumborum block group at 6, 12, 18 and 24h (3.7, 1.4, 0.8, 0.7 versus 5.2, 4.6, 3.4, 2.6 in the femoral group, P<.01). Opioid use in 24h was lower in this group (9.7 versus 16.9mg in the femoral group, P<.01). The sensory and motor blockade, satisfaction, and adverse effects, were similar in both groups.

CONCLUSIONS

Quadratus lumborum block is an effective analgesic option to be used in patients with neck of femur fracture. More clinical trials are required to validate this.

[OBSERVATION OF EFFECTIVENESS OF HIP RESURFACING ARTHROPLASTY IN TREATMENT OF OSTEONECROSIS OF FEMORAL HEAD IN YOUNG AND MIDDLE-AGED PATIENTS]

OBJECTIVE

To evaluate the clinical and radiographic outcomes of hip resurfacing arthroplasty (HRA) for treating osteonecrosis of the femoral head (ONFH) in young and middle-aged patients.

METHODS

Between January 2008 and April 2009, 34 patients with ONFH underwent HRA. There were 19 males and 15 females with an average age of 54 years (range, 33-59 years). Of 34 cases, 16 left hips and 18 right hips were involved, including 9 cases of alcohol-induced ONFH, 8 cases of steroid-induced ONFH, 7 cases of traumatic ONFH, and 10 cases of unexplained ONFH. According to modified Ficat classification system, 26 hips were rated as stage III, and 8 hips as stage IV. The Harris hip score (HHS) and modified University of California, Los Angeles (UCLA) activity score were used to evaluate the clinical results. Migration of prosthesis was assessed on the anteroposterior radiographs. The abduction angle was measured on the acetabular side. On the femoral side, varus-valgus shift was determined by measurement of stem-shaft angle. The axial collapse of femoral component was assessed with the component-lateral cortex ratio.

RESULTS

Healing of incision by first intention was achieved in all patients without complications of infection and thrombosis of deep vein of lower extremities. Thirty-two patients were followed up 78 months on average (range, 70-84 months). No implant loosening, infection, femoral neck fracture, dislocation, and inflammatory pseudotumor were observed. At last follow-up, the HHS score was significantly increased to 95.22 +/- 1.47 from preoperative 50.10 +/- 2.27 (t=1.510, P=0.008). Modified UCLA activity score was significantly increased to 7.70 +/- 1.13 from preoperative 3.90 +/- 0.90 (t=0.830, P=0.003). The abduction angle, stem-shaft angle, and compotent-lateral cortex ratio showed no significant difference between at 3 days after operation and last follow-up (P>0.05).

CONCLUSION

If the indication of operation is mastered strictly, HRA may be effective in treatment for ONFH at Ficat stage III or IV in young and middle-aged patients.

[Preliminary analysis of total cost and life quality for elder patients with femoral neck fracture]

OBJECTIVE

To analyze the total cost and life quality of the femoral neck fracture patients who received different surgery and supplement comprehensive data of osteoporotic fracture.

METHODS

One hundred and five patients above 60-year old who were diagnosed femoral neck fracture and received operation in Department of Orthopedics ＆ Traumatology, Beijing Jishuitan Hospital were admitted into our study from August 2013 to December. According to the type of surgery there were 52 and 53 cases in internal fixation (IF) group and hemiarthroplasty (HA) group respectively. At first we collected the medical expense of the patients before and during hospitalization. And then the 1-year medical and non-medical expenses were collected by the cost diary ever 3 months after discharge. At the last follow-up we evaluated the life quality by the EuroQol-5 Dimensions (EQ-5D) and calculated the total cost. Outcome All the patients completed the operation successfully. No nonunion or delayed union cases in IF group, and no cases received revision surgery in both groups. The total average cost was 59 584.9 yuan including 79.1% medical cost and 20.9% non-medical cost. The primary treatment cost accounts for 84.1% of the medical cost. The cost for home care accounts for 90.7% of the non-medical care. The total and medical cost of IF group just account for 40.3% and 38.5% of the HA group and the non-medical showed no significant difference between the 2 groups (P>0.05). In addition the data of life quality and walking capability also showed no significant difference.

CONCLUSION

The main cost for the femoral neck fracture is medical expense in 1-year follow-up. Both surgeries can provide satisfactory outcome, however IF may be more cost-effective compared to the HA because of the less total cost.

[MID- AND LONG-TERM EFFECTIVENESS OF THIRD-GENERATION CERAMIC-ON-CERAMIC TOTAL HIP ARTHROPLASTY IN YOUNGER PATIENTS]

OBJECTIVE

To analyze the mid- and long-term effectiveness of the 3rd-generation ceramic-on-ceramic (CoC) total hip arthroplasty (THA) in the younger patients.

METHODS

A retrospective analysis was made on the clinical data of 68 younger patients (73 hips) who accepted the 3rd-generation CoC THA between March 2001 and May 2009. Of 68 cases, 39 was male and 29 was female with the average age of 38.6 years (range, 18-50 years); there were 15 cases (15 hips) of osteonecrosis of the femoral head, 9 cases (9 hips) congenital dysplasia of the hip, 5 cases (8 hips) of ankylosing spondylitis, 10 cases (10 hips) of osteoarthritis of the hip joint, 12 cases (12 hips) of traumatic hip arthritis, 12 cases (12 hips) of femoral neck fracture, 4 cases (6 hips) of rheumatoid hip arthritis, and 1 case (1 hip) of tumor of the femoral neck. The Harris score and University of California Los Angeles (UCLA) score were used to evaluate the hip joint function and activity level respectively. The visual analogue scale (VAS) was used to assess postoperative thigh pain. Radiological signs of osteolysis, loosening, and alumina ceramic related complications were evaluated continuously. And the Kaplan-Meier survival analysis was used to assess the prosthesis survival.

RESULTS

The average duration of follow-up was 9.7 years (range, 6-14 years). Sandwich ceramic liners fracture was observed in 3 cases (3 hips), and revision was performed; 1 case had "squeaking" hip because of physical activity. At last follow-up, Harris score and UCLA score were significantly improved when compared with preoperative scores (P<0.05). Bony healing was obtained in all patients, without osteolysis, loosening, and thigh pain. The VAS score was 0. The 5-year and 10-year cumulative survival rates for ceramic fracture revision were 98.6% and 95.9%, and the 5-year and 10-year cumulative survival rates for osteolysis and loosening revision both were 100%.

CONCLUSION

The 3rd-generation CoC prosthesis offer an excellent option for younger patients in THA and the mid- and long-term effectiveness are satisfactory.

[Clinical features and proportion analysis of adult hip fractures at 11 hospitals in Southwest China from 2010 to 2011]

OBJECTIVE

To analyze the clinical feature and constituent ratio of adult hip fractures in Southwest China.

METHODS

The data of adult inpatients and outpatients with hip fractures treated between January 2010 and December 2011 in 11 hospitals of the Southwest China were collected and analyzed. The data includes gender, age, age distribution and fracture pattern according to AO classification.

RESULTS

There were a total of 2,833 adult hip fractures, including 1,340 (47.30%) males and 1,493 (52.70%) females, with a male-to-female incidence ratio of 1: 1.11 and a mean age of (66±18) years. The highest frequency of hip fractures was seen in the 71 to 85 years age group (42.18%, 1,195/2,833). There were 844 fractures (29.79%) in the young and middle-aged group (16-<60 years) and 1 898 fractures (70.21%) in the geriatric group (≥60 years). Men had a higher rate than women (men: 577 fractures, 68.4%) in the young and middle-aged group, while women had a higher rate than men (women: 1,226 fractures, 61.64%) in the geriatric group, with a significant difference in the sex distribution between the two groups (χ2=214.001, P<0.01). The proportion of intertrochanteric fracture (type 31-A), femoral neck (type 31-B) and femoral head fracture (type 31-C) was 46.59%, 49.74% and 3.67% respectively. The highest frequency of the sub-type in each fracture type was type 31-A2, type 31-B2 and type 31-C2.

CONCLUSIONS

Women have a higher rate than men in Southwest China. Geriatric patients are more than the young and middle-aged patients. The femoral neck fractures, intertrochanteric fractures and femoral head fractures are in descending orders according to the proportion of the three different hip fractures.

[Characteristics and perioperative management of hemophilia patients with fractures]

OBJECTIVE

To investigate the characteristics and perioperative management of hemophilia patients with fracture.

METHODS

Retrospectively, we analyzed 8 patients with hemophilia combined with fracture, who were admittted to our department from 2005 to 2013. Six patients were with hemophilia A and two with hemophilia B; Based on the severity of hemophilia, 2 cases were light, 3 moderate and 3 severe; Based on the location of fracture, 4 cases were femoral neck fractures, 1 femoral intertrochanteric fracture, 1 bilateral distal femur fractures, 1 tibiofibula fracture, and 1 humerus intercondylar fracture. Blood coagulation factor replacement therapy was conducted preoperatively, intraoperatively and postoperatively, All the patients underwent closed or open reduction and internal fixation or joint replacement. Also, we analyzed the perioperative complications and observed whether the fracture healed.

RESULTS

The average age was 33.5 years (14 to 47 years); In 6 cases, fractures occurred at femur, accounting for 75% of all the fractures; Femoral neck fracture was treated by closed reduction and hollow screws fixation; Femoral intertrochanteric fracture, distal femur fracture, and tibiofibula fracture were treated by open reduction and internal fixation with plate; Humerus intercondylar fracture was treated by elbow joint replacement. Intraoperative bleeding was from 50 to 600 mL, an average of 262 mL; Perioperatively, the average use of FVIII/activated prothrombin complex concentrates (APCC) was 358 U/kg (125 to 554 U/kg). Postoperatively, poor wound healing was observed in 2 patients, and the condition improved after symptomatic treatment; In patients with internal fixation, all the fractures united, and the average healing time was 14 weeks. No complications such as fixation loosening or rupture occurred after internal fixation.

CONCLUSION

Hemophilia combined with fracture mainly occurred in the young, and the site of fracture was given priority to femur. With perfect preoperative preparation, on the basis of the replacement therapy, hemophilia combined with fractures was safe for surgical treatment, and postoperative fractures healing wasgood. But the risk of poor wound healing was high.