Quality of fracture reduction is associated with patient survival at one year, but not 30 days, following trochanteric hip fracture fixation. A retrospective cohort study

INTRODUCTION

Few studies have been performed to evaluate the association between technical surgical factors and patient outcomes following hip fracture surgery. We performed a retrospective cohort study of elderly patients who had undergone fixation of trochanteric hip fractures using a sliding hip screw (SHS), with the aim of establishing whether there was a correlation between quality of fracture reduction and mortality at 30 days and one year.

PATIENTS AND METHODS

A retrospective cohort study was designed. Inclusion criteria were trochanteric (AO 31A1 or 31A2) fractures in patients aged ≥ 65 years, presenting <3 days after injury and fixed using an SHS. Fracture reduction was classified using the Baumgaertner Reduction Quality Criteria (BRQC). A validated predictor of mortality following hip fracture was used to stratify for confounding variables that might affect mortality. Multivariate logistic regression was used to explore the association between fracture reduction and mortality.

RESULTS

329 patients were identified (mean age 86, 27% male). 57% had a good reduction, 39% had a fair reduction and 4% had a poor reduction. As reduction grade deteriorated, predicted mortality increased (good reduction: 7.3%; fair reduction: 8.4%; poor reduction: 15.5%). Without adjustment for predicted mortality, there was a significant correlation between decreasing reduction grade and mortality at both time points (30-day: odds ratio 1.95, p = 0.049; one year: odds ratio 1.86, p = 0.003). When adjusted for predicted mortality, only one year mortality remained significant (30 day: odds ratio 1.61, p = 0.173; one year: odds ratio 1.62, p = 0.037).

CONCLUSION

Some, but not all, of the association between fracture reduction and mortality can be explained by predetermined predictors of a poor outcome. There remains, however, a correlation between poor fracture reduction and mortality at one year. Every effort must be made to achieve an anatomical reduction for these injuries, and trainees must be instructed in methods to achieve this.

Topical administration of tranexamic acid in elderly patients undergoing short femoral nailing for intertrochanteric fracture: A randomised controlled trial

INTRODUCTION

Topical application of tranexamic acid (TXA) has been proposed as an alternative to intravenous administration to reduce perioperative bleeding in orthopaedic surgery. The purpose of this randomised controlled trial was to evaluate the efficacy and safety of 1 g topically applied TXA in patients undergoing fixation of intertrochanteric hip fractures by short femoral nailing.

METHODS

A total of 121 patients were enrolled between May 2018 and January 2020. Patients were randomly allocated (1:1) to receive either 10 mL (1 g) of TXA or 10 mL of normal saline (NS) injected through the subfascial drain following wound closure. Total blood loss, total drain output and blood transfusion requirements up to postoperative day 3 were recorded. Rates of thromboembolic complications and mortality up to 90 days postoperatively were also compared.

RESULTS

There was no statistically significant difference in total blood loss, total drain output or proportion of patients requiring transfusions. Median total blood loss was 1.088 L (IQR: 0.760-1.795) in the TXA group and 1.078 L (IQR: 0.797-1.722) in the NS group (P = .703). Median total drain output was 60 mL (IQR: 40-140) in the TXA group and 70 mL (IQR: 30-168) in the NS group (P = .696). Blood transfusions were administered in 29 patients (47.5%) in the TXA group and 27 patients (45.0%) in the NS group (P = .782). There was also no difference in frequency of thrombotic complications or mortality within 90 days. There were five thrombotic events in the TXA group and four in the NS group (P = .751). The 90-day mortality rate was 6.6% (4 patients) in the TXA group and 3.3% (2 patients) in the NS group (P = .680).

CONCLUSION

A 1 g dose of topically administered TXA did not produce any difference in blood loss, transfusion requirements, thromboembolic complications, or 90-day mortality. Future trials may consider the effect of larger doses in patients undergoing hip fracture fixation surgery.

Intraoperative fractures in cephalomedullary nailing for trochanteric fractures

INTRODUCTION

Cephalomedullary nailing (CMN) is the standard treatment for internal fixation of trochanteric fractures. Complications related to CMN include intraoperative fracture (IF), which is difficult to detect using only plain radiographs. However, analyses of IFs using plain radiographs and computed tomography (CT) with a large sample size of clinical cases are lacking. Therefore, this study aimed to report the incidence of IFs diagnosed by CT, the risk factors for IFs, and a comparison of clinical outcomes between patients with and without IFs.

METHODS

This multicenter retrospective cohort study included 638 patients who underwent CMN fixation for trochanteric fractures. We evaluated IF using pre-and postoperative plain radiographs and CT. The primary outcome was reoperation and the secondary outcome was the proportion of patients who regained independent mobility at 3 months postoperatively. Furthermore, we conducted multivariable logistic regression analyses to examine the association between risk factors and IFs.

RESULTS

Seventy-five (11.8%) patients had IFs, including 53 patients with occult IFs (8.3%). The most common location of IF was at the interference with the lag screw entry (45.3%). The nail insertion procedure (17.3%) was the most common reason for IF. In the assessment of clinical outcomes, patients with IFs had no reoperations and independent mobility at postoperative 3 months was lower (69.6% vs. 79.1%). Regarding regaining independent walking in the IF group, IF distal to lag screw entry and obvious IF diagnosed with plain radiographs were poor factors. The multivariable analysis showed that only inadequate reduction on the anteroposterior view based on the plain radiograph was significantly associated with the incidence of IFs (odds ratio 3.91; 95% CI, 1.28-11.94; p = 0.017).

CONCLUSIONS

This multicenter study indicated that the incidence of IFs detected by CT in CMN treatment for trochanteric fractures was 11.8%. An inadequate reduction in the anteroposterior view based on plain radiographs was the only independent risk factor of IFs. In the assessment of clinical outcomes, patients with IF had no incidences of reoperation. However, patients with IFs tended not to regain independent mobility compared with those without IFs.

Use of a Trochanteric Fixation Nail-Advanced (TFNA) with cement augmentation for treatment of trochanteric fractures in patients greater than sixty five years of age

PURPOSE

Intramedullary nailing is the standard treatment of trochanteric fractures. Mechanical failure such as cut-out and cut-through are associated with high rates of revision surgery, functional impairment, and mortality. The aim of the study was to evaluate the rate of mechanical failure of the cement augmented screws of Trochanteric Fixation Nail-Advanced (TFNA) nails.

PATIENTS AND METHODS

A descriptive, retrospective, multi-operator, single-centre study was performed at our level 1 trauma centre between June 2019 and June 2020. Patients were included if they were > 65 years of age, presented with a trochanteric fracture treated with an augmented TFNA nail with 6 months of follow-up. The primary outcome was fixation failure rate (cut-out or cut-through) at three and six post-operative months. Secondary endpoints were intra-operative data, clinical scores, and radiographic analysis.

RESULTS

Forty-five patients (38 women and 7 men) were analysed. The mean age was 82.84 years (65-102, 9.50). There were no instances of mechanical failure in our series, after either three or six months of follow-up. No patient exhibited cut-out or cut-through. The mean amount of cement injected was 4.72 mL (3-6; 1.05). The mean length of surgery was 37.59 min (25-55; 6.48), and the mean intra-operative radiation exposure was 91.47 cGycm² (25.04-201.81; 51.40) for a mean duration of 43.11 s (17-86; 16.81). The mean duration of hospitalisation was 6.38 days (2-11; 2.27).

CONCLUSIONS

Our clinical results suggest that cement-augmented TFNA screws can be successfully used in the management of trochanteric fractures in patients > 65 years of age.

Low filling ratio of the distal nail segment to the medullary canal is a risk factor for loss of anteromedial cortical support: a case control study

Background

Anteromedial cortical support apposition (positive and/or neutral cortical relations) is crucial for surgical stability reconstruction in the treatment of trochanteric femur fractures. However, the loss of fracture reduction is frequent in follow-ups after cephalomedullary nail fixation. This paper aimed to investigate the possible predictive risk factors for postoperative loss of anteromedial cortex buttress after nail fixation.

Methods

A retrospective analysis of 122 patients with AO/OTA 31A1 and A2 trochanteric femur fractures treated with cephalomedullary nails between January 2017 and December 2019 was performed. The patients were classified into two groups according to the postoperative status of the anteromedial cortical apposition in 3D CT images: Group 1 with contact “yes” (positive or anatomic) and Group 2 with contact “No” (negative, loss of contact). The fracture reduction quality score, tip-apex distance (TAD), calcar-referenced TAD (Cal-TAD), Parker ratio, neck-shaft angle (NSA), and the filling ratio of the distal nail segment to medullary canal diameter in anteroposterior (AP) and lateral fluoroscopies (taken immediately after the operation) were examined in univariate and multivariate analyses. Mechanical complications were measured and compared in follow-up radiographs.

Results

According to the postoperative 3D CT, 84 individuals (69%) were categorized into Group 1, and 38 individuals (31%) were classified as Group 2. The multivariate logistic regression analysis showed that the poor fracture reduction quality score (P < 0.001) and decreasing filling ratio in the lateral view (P < 0.001) were significant risk factors for the loss of anteromedial cortical contact. The threshold value for the distal nail filling ratio in lateral fluoroscopy predicting fracture reduction re-displacement was found to be 53%, with 89.3% sensitivity and 78.9% specificity. The mechanical complication (varus and over lateral sliding) rate was higher in Group 2.

Conclusions

The fracture reduction quality score and the decreasing filling ratio of the distal nail to the medullary canal in the lateral view (a novel parameter causing pendulum-like movement of the nail) were possible risk factors for postoperative loss of anteromedial cortical support.

Intramedullary Fixation of Trochanteric Fractures Can Be Safely Performed by Senior Residents Without Immediate Consultant Supervision

OBJECTIVE

To assess the safety of senior residents performing trochanteric hip fracture surgery without immediate consultant supervision DESIGN: A retrospective chart review of trochanteric hip fractures (AO-OTA 31-A) operated in a single center between years 2011 and 2016 (inclusive). Operations were divided into three groups: Group 1 - surgeon was a senior resident without any immediate supervision; Group 2 - surgeon was a consultant and Group 3 - surgeon was a senior resident supervised by a consultant. The follow-up period was a minimum of 2 years or until death. All re-operations and surgical related mortality were assessed.

SETTING

Helsinki University Hospital, Finland. A tertiary level trauma center.

PARTICIPANTS

987 consecutive trochanteric fractures on 966 patients treated by operative fixation of an intertrochanteric fracture with an intramedullary nail between 2011and 2016 (inclusive).

RESULTS

The total number of reoperations was smaller in Group 1 where the surgeon was a senior resident without any immediate supervision compared to Group 2 where the surgeon was a consultant (5.5 % vs 8.8 %, p < 0.05). There were no significant differences in mortality or length of surgery. The total rate of mechanical complications was 2.0 %, with no significant differences between groups. The observed blade cut-out rate was low: 1.3 %, suggesting a good overall quality of surgery.

CONCLUSIONS

Senior residents can safely perform intramedullary nailing of trochanteric fractures without immediate supervision.

Vibration therapy as an intervention for enhancing trochanteric hip fracture healing in elderly patients: a randomized double-blinded, placebo-controlled clinical trial

BACKGROUND

There are more than 300,000 hip fractures yearly in the USA with mortality rates of 20% within 1 year. The treatment of osteoporotic fractures is a major challenge as bone quality is poor, and healing is expected to delay due to the impaired healing properties with respect to bone formation, angiogenesis, and mineralization. Enhancement of osteoporotic fracture healing and function is therefore critical as a major goal in modern fracture management. Previous pre-clinical studies have shown that low-magnitude high-frequency vibration (LMHFV) accelerates osteoporotic fracture healing. The objective of this study is to investigate the effect of LMHFV on accelerating trochanteric hip fracture healing and functional recovery.

METHODS

This is a randomized, double-blinded, placebo-controlled clinical trial to evaluate the effect of LMHFV in accelerating trochanteric hip fracture healing. All fractures undergo cephalomedullary nail fixation. The primary outcome of this study is time to fracture healing by X-ray. Computed tomography (CT) and dual-energy X-ray absorptiometry (DXA) will also be performed. Blood circulation at the fracture site will be assessed by dynamic perfusion magnetic resonance (MR). Clinical results include functional recovery by muscle strength, timed up and go test (TUG), quality of life questionnaire (SF-36), balancing, falls, and mortality.

DISCUSSION

Previous animal studies have demonstrated LMHFV to improve both normal and osteoporotic fracture healing by accelerating callus formation and mineralization. The mechanical stimulation stimulates angiogenesis by significantly enhancing vascular volume and blood flow velocity. This is the first study to translate LMHFV to enhancing hip fracture healing clinically. Positive results would provide a huge impact in the recovery of hip fracture patients and save healthcare costs.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04063891. Registered on August 21, 2019.

Risk factors for excessive postoperative sliding of femoral trochanteric fracture in elderly patients: A retrospective multicenter study

INTRODUCTION

The application of a load on the internal fixation of a trochanteric fracture exerts a moment along the lag screw, causing the proximal bone fragment to slide along the lag screw, allowing contact between the proximal and distal bone fragments, which promotes healing. However, excessive sliding is related to poor postoperative outcomes. We aimed to identify the risk factors for excessive sliding.

MATERIALS AND METHODS

We conducted a multicenter retrospective study including 115 trochanteric fractures sustained through low-energy trauma in 19 male and 96 female patients aged 60 years or older (mean age: 82.9 years) between September 2013 and December 2014. We measured the postoperative sliding distance after osteosynthesis using a sliding hip screw or intramedullary nailing, and classified participants with ≥8 mm of sliding into the excessive sliding group (ESG) and with <8 mm into non-ESG. Finally, we investigated the risk factors of excessive postoperative sliding.

RESULTS

Fifty participants were classified into the ESG and 65 participants into the non-ESG. Female sex (p = 0.0264), an A3 fracture type (p = 0.0003), greater tip-apex distance (p = 0.0250), and poor reduction in either the anteroposterior or lateral radiographic views (p = 0.0156) were identified as risk factors for excessive sliding by multivariate regression analysis.

CONCLUSIONS

Female sex, an unstable fracture type, a greater tip-apex distance, and a poor reduction, in either the anteroposterior or lateral views, are associated with excessive postoperative sliding. Therefore, surgery should aim to achieve good reduction and stabilization from both radiographic views.

Urban versus rural differences of hip fractures among the elderly in Kyoto, Japan: a 10-year study

Secular changes in the incidence rate of hip fractures were estimated to vary by fracture type, i.e., femoral neck or trochanteric fractures, age, and sex, in urban or rural areas in Kyoto Prefecture, Japan from 2008 to 2017.

PURPOSE

Our survey in Kyoto Prefecture from 2008 to 2017 showed that the incidence rate of femoral neck fractures is generally increasing. We investigated the differences between urban and rural areas in the changes of the incidence rate over time of femoral neck and trochanteric fractures during the same period.

METHODS

Patients aged 65 years and above who sustained hip fractures between 2008 and 2017 and were treated at one of the participating 11 hospitals were included. The ratio of sick beds for acute-term care at the investigated hospitals to total number of beds in the urban area was 16.5% (1863/11,158) and 30.6% (1863/5623) in the rural area. The change in incidence rate was estimated utilizing the population according to the national census conducted in 2010 and 2015.

RESULTS

There were 3559 and 6474 hip fractures in the urban and rural areas, respectively. Femoral neck fractures were 1936 (54.4%) and 2813 (43.5%) in each area. The increase of the population-adjusted numbers was marked by neck fractures in males, in both areas. In women, there was a significant increase in femoral neck fractures in the urban area in those aged 85 years and over. For trochanteric fractures, a significant increase was only found in women aged 65 to 74 years in the rural area.

CONCLUSION

A regional difference in the secular changes in incidence rate of hip fractures was found in women, not in men, mostly because neck fractures in women increased in the over 85 group in the urban area.

Reduction of trochanteric fractures in lateral view is significant predictor for radiological and functional result after six months

OBJECTIVES

The goal of our retrospective study was to determine which radiological parameter after fixation of trochanteric fractures type AO 31 A2 is most important for the position of the fracture after six months. The additional goal was to find how the end position influences mechanical failure and the mobility of the patients.

PATIENTS AND METHODS

We analysed 92 patients operated in one-year period for A 2 type trochanteric fractures with sliding hip screw or proximal femur intramedullary nail. They were divided in two groups according to the radiological position of the proximal fragment six months after the surgery. In group A we had 46 patients with satisfactory and in group B 46 patients with unsatisfactory position. In anteroposterior view we evaluated neck-shaft angle (NSA) and medial cortical support (MCS) and in lateral view anterior cortical support (ACS). Unsatisfactory position was recognized if NSA was in varus or ACS or MCS were negative. We compared the groups regarding basic patients characteristics (age, gender, ASA score, preinjury mobility, and degree of osteoporosis), type and quality of fixation, the position of the fracture (postoperatively and after 6 months), mechanical failure and mobility after 6 months. Statistical significance level was set to p ≤ 0.05.

RESULTS

Basic patients' characteristics as well as type and quality of fixation did not significantly differ between the groups. After the injury the difference between the groups in reduction quality was significant in lateral view (ACS; p=0.001), while after half a year there were significant differences in both views: NSA (p=0.003), ACS and MCS (both p<0.001). Proximal fragment position after six months statistically significant correlated with postoperative ACS in B group (r = 0.386, p = 0.008), but not with NCA nor with MCS. There were also significantly more fixation failures in group B (p<0.001) and less patients regain preinjury mobility (p=0.029).

CONCLUSIONS

In trochanteric fractures reduction in lateral view is the most important prognostic factor for favourable radiological result after half a year. Unsatisfactory position of the proximal fragment after six months influences mechanical failures and walking ability.

Early postoperative Barthel index score and long-term walking ability in patients with trochanteric fractures walking independently before injury: a retrospective cohort study

INTRODUCTION

Trochanteric fractures are one of the most common fragility fractures, and the number of the patients is increasing worldwide. Identifying prognostic factors is important to manage and minimize the social losses caused by postoperative walking impairment. The purpose of this retrospective study is to clarify the association between early postoperative Barthel index score and postoperative long-term walking ability among patients with trochanteric fractures who could walk independently before injury.

MATERIALS AND METHODS

Consecutive patients with trochanteric fractures aged ≥ 65 years who were walking independently before injury were included. Patients were divided into two groups according to the Barthel index score measured within 1 week after surgery; the cut-off value was set at 20 points. The prevalence of walking impairment after 1 year was compared between these two groups after adjusting for confounding factors in a complete case analysis and using the data introduced by the multiple imputation method.

RESULTS

Among the 758 eligible patients, 254 patients (34%) had their walking ability evaluated after 1 year from injury. The patients in the lower Barthel index group showed a significantly impaired walking ability in both analyses (adjusted odds ratio 5.5 and 2.4, 95% confidence intervals 2.4-13 and 1.5-3.8, respectively).

CONCLUSIONS

The present results suggested that the Barthel index score measured in the early postoperative period after trochanteric fractures was associated with the level of long-term walking impairment in patients who could walk independently before injury.

Cement augmentation of internal fixation for trochanteric fracture: a systematic review and meta-analysis

PURPOSE

This study aimed to determine the efficacy and safety of cement augmentation for internally fixed trochanteric fractures through a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched the MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov databases to identify RCTs, published until July 2020 that examined the effects of cement augmentation of internal fixation of trochanteric fractures. The primary outcomes were reoperation and Parker Mobility Score, whereas the secondary outcomes were 1-year mortality rate, EuroQol 5 Dimension, fixation failures, and adverse events. We conducted meta-analyses of the outcome measures using the random-effects models. We evaluated the certainty of evidence based on the Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

We included three RCTs (326 participants). No significant effect was observed in favor of cement augmentation on all these outcomes. The certainty of evidence for fixation failures was very low and that for the other outcomes was low. The overall risk of bias for each outcome was high or of some concern in all included studies.

CONCLUSIONS

The effect of cement augmentation of internal fixation of trochanteric fractures was uncertain for the clinical outcomes due to the low certainty of evidence. Further RCTs with a low risk of selection bias may present convincing conclusions on the efficacy and safety of cement augmentation.

LEVEL OF EVIDENCE

Level 1.

Reduction quality and nail fixation ratio as bone-implant stability factors associated with reoperation for trochanteric fractures

INTRODUCTION

Geriatric trochanteric fractures are a major global issue, and their incidence is steadily rising. Bone quality, fracture type, fracture reduction quality, implant selection, and implant placement affect bone-implant stability in osteoporotic fractures. Our aim in this study was to evaluate the association between bone-implant stability factors, including nail construct, and the rate of reoperation in a more extensive case series with comprehensive variables.

METHODS

This was a retrospective cohort study of 390 patients with trochanteric fractures aged ≥60 years and treated with intramedullary nailing. The primary outcome was the rate of reoperation due to any cause. Univariate and multivariable logistic regression analyses were used to identify factors associated with reoperation.

RESULTS

In this study, 15 patients (3.8%) required reoperation. Univariate analysis showed that the following variables were significantly different between patients who required reoperation and those who did not: T-score at the total hip and lumbar spine, cortical thickness index, fracture type, and reduction quality. Multivariable logistic regression analysis showed that the odds ratio (OR) for A3 fracture type was 2.76 (95% confidence interval [CI], 0.77-9.76; p=0.116) and that for inadequate reduction, assessed by computed tomography, was 2.94 (95% CI, 0.89-9.69; p=0.076). These were independent predictors of reoperation. There was only one case (6.7%) of reoperation among patients with a distal femoral fragment fixation ratio (FR) >0.8. Considering the intraoperative decision-making process, the combination of inadequate reduction and an FR ≤0.8 were associated with the highest reoperation at a rate of 9.3% (OR, 3.327; 95% CI, 1.091-10.142; p=0.043).

CONCLUSIONS

Risk factors on bone-implant stability for reoperation were the reduction quality and fracture type. Regarding the intraoperative decision-making process, the selection of a nail length with an FR >0.8 is a better option when the intramedullary reduction has been maintained intraoperatively.

Factors associated with one year mortality in ill patients with proximal femoral fractures treated non operatively

INTRODUCTION

Non-operative treatment is an exceptional indication for the treatment of proximal femur fracture. The aim of the study was to analyze the mortality rate in one year and associated factors in severely ill patients submitted to non-operative treatment.

METHODS

It was included 28 patients treated from August 2014 to September 2019. Eighteen (64.3%) patients were female and 10 (35.7%) were male. The mean age was 78.7 ± 11.9 years old. The main outcome evaluated was the mortality rate in one year. It was also evaluated the correlation with gender, age, personal habits, number of comorbidities and Charlson Comorbidity Index (CCI).

RESULTS

The functional result was assessed with WOMAC score via telephone call. The mortality rate in one year was 42.8% without statistical positive correlation with any of the studied parameters. Patients with three or more comorbidities didn't have a higher mortality rate comparing to survived patients (83.3% vs 81.3%). The CCI also didn't show any correlation with high mortality (6.9 vs 7.1). The functional result of the survived patients was poor (78.2 points WOMAC).

CONCLUSION

The conclusion is that the mortality rate in one year of ill patients with hip fractures treated non-operatively is 42.8% without correlation with age, gender of number of comorbidities, and the functional result of the survived patients is poor.

Clinical prediction model for postoperative ambulatory ability outcomes in patients with trochanteric fractures

INTRODUCTION

Regaining independent ambulatory ability is one of the primary goals of treatment in patients with trochanteric fractures. This study aimed to develop and evaluate the discriminative accuracy of a clinical prediction model for ambulatory ability outcomes 3 months after surgery for trochanteric fractures.

METHODS

This retrospective cohort study included 346 patients treated with intramedullary nailing for trochanteric fractures who had independent ambulatory ability before their injury. Multiple regression models with preoperative and postoperative factors were used to predict ambulatory ability outcomes at 3 months. A clinical prediction model (CPM) was created based on a decision tree developed using a chi-square automatic interaction detector technique.

RESULTS

Three months after surgery, 263 (76.0%) and 83 (24.0%) patients regained and lost independent ambulatory ability, respectively. Univariate analysis showed that the Barthel index (BI) total score at 2 weeks predicted the ambulatory ability outcome at 3 months with good discriminative accuracy (area under the receiver operating characteristic curve [AUROC]: 0.819; 95% confidence interval [CI]: [0.769, 0.868], cut-off value: 22.5; sensitivity: 69.5%; specificity: 82.3%). Multiple logistic regression analysis showed that preoperative factors (residence before injury, diagnosis of dementia, and serum albumin at admission) and postoperative factors (BI total score at 2 weeks) predicted ambulatory ability outcomes at 3 months (AUROC: 0.710; 95%CI: [0.636, 0.783]; sensitivity: 91.3%; specificity: 41.8%). The CPM with the BI total score at 2 weeks (≤10; 10<, ≤50; >50 points) and dementia status (present; absent) had a moderate discriminative accuracy (AUROC: 0.676; 95%CI: [0.600, 0.752]; sensitivity: 94.7%; specificity: 40.5%).

CONCLUSIONS

We developed a CPM with moderate accuracy to predict ambulatory ability outcomes in patients 3 months after surgery for trochanteric fractures. Our results demonstrate the importance of the BI score measured soon after surgery and dementia status for the prediction of postoperative ambulation.

Infections after intramedullary fixation of trochanteric fractures are uncommon and implant removal is not usually needed

BACKGROUND AND PURPOSE

Infections after intramedullary fixation of trochanteric femoral fractures are rare, but potentially life-threatening complications. There are limited data available to support decision making in these cases.

PATIENTS AND METHODS

A retrospective study of 995 consecutive operatively treated trochanteric fractures was made to find out different risk factors for infection and to describe the results of treatment.

RESULTS

28 patients developed a surgical site infection (2.8%) after intramedullary fixation of trochanteric fracture. 15 patients (1.5%) had a deep and 13 patients (1.3%) a superficial surgical site infection. Cigarette smoking (p<0.05) and prolonged operative time (p<0.05) were significant risk factors for an infection. 15 of 28 patients needed revision surgeries. Implant removal or exchange was needed only for 4 of 28 patients: 1 exchange of the blade, 1 removal of additional cable used to assist reduction and 2 removals of distal locking screws. None of the patients needed additional surgeries for problems with fracture healing. Mortality was not increased among patients with an infection.

INTERPRETATION

Infection after intramedullary fixation of trochanteric fractures can be successfully treated without removal or exchange of the fixation material.

The safety and accuracy of the fluoroscopic imaging during proximal femoral fixation: A computerized 3D reappraisal of the joint penetration risk

BACKGROUND

To assess the success of proximal cephalomedullary nailing operations for treating trochanteric fractures, surgeons utilize 2D fluoroscopy to observe the relative positions of the femoral head and the implant. One distance-based risk parameter, observed from the AP and Lateral projections, is the Tip-Surface Distance(TSD) that dictates how close to the outer cortex should the implant tip be residing to avoid post-surgical complications such as cut-out or joint penetration. In this study, the safety and the accuracy of the orthogonal fluoroscopic imaging were evaluated.

METHODS

A femoral head model was created and the risk zone was defined as a hemispherical shell of 5 mm thickness beneath the subchondral cortex, which should not be violated during screw insertion. The remaining hemisphere beneath the risk zone was designated as the safe zone. To assess the effect of head size, each simulation was conducted for 34, 47, and 60 mm diameter(D_femur) femoral heads. The rate of safe zone violation was calculated for all possible screw endpoints with a TSD of at least 5 mm on fluoroscopic orthogonal views (TSD_AP and TSD_Lat).

RESULTS

The minimum risk of joint penetration was achieved when the TSD_AP/TSD_Lat ratio was 1. For D_femur of 34 mm there was a risk of 91.7% of the safe zone violation when each TSD_AP and TSD_Lat were 5 mm and 0% for 9 mm. For D_femur of 47 mm, the risk was 92.2% for 5 mm and 0% for 11 mm. For D_femur of 60 mm, the risk was 92.3% for 5 mm and 0% for 13 mm. Safety maps were constructed for all possible TSD combinations for 34, 47, and 60 mm femoral heads.

CONCLUSIONS

Depending solely on the orthogonal fluoroscopic images is not a safe and accurate technique for assessing joint penetration risk during proximal femoral fixation due to the spherical geometry of the femoral head. The screw tip can lie completely outside of the femoral head even when it appears inside, in both orthogonal fluoroscopic views. Evidently, when using TSD, more stringent distance limits should be chosen, contrary to the recommended 5 mm limit. Our safety maps for TSD combinations may be used to check the security of the implantation.

Postoperative computed tomography assessment of anteromedial cortex reduction is a predictor for reoperation after intramedullary nail fixation for pertrochanteric fractures

PURPOSE

Postoperative radiographs are routinely used to assess fracture reduction following intramedullary nail fixation for pertrochanteric fractures, even though computed tomography (CT) is a superior modality. We aimed to determine the association between reduction quality assessed by CT and rates of reoperation and to evaluate the association of reoperation and reduction quality according to the assessment modality (plain radiographs vs. CT).

METHODS

A retrospective analysis of 299 consecutive patients treated with intramedullary nail fixation for pertrochanteric fractures was conducted. Fracture reduction measured by postoperative radiographs and CT was categorized as anatomical type, extramedullary type, or intramedullary type. Postoperative data for analysis included reduction status, tip-apex distance (TAD), screw position in the femoral head, sliding distance, and conditions associated with reoperation.

RESULTS

Of the 299 patients included with a mean age of 83.1 ± 8.2 years, there were six patients who required reoperation (2.0%). According to the CT assessments, there were 42 intramedullary reductions (14.0%). Patients with a non-intramedullary reduction based on postoperative CT images were significantly more likely to have proper placement of the screw, a reduced TAD, a reduced sliding distance, and a lower reoperation rate than those with an intramedullary reduction (P < 0.05). The reduction quality assessed by postoperative CT was significantly associated with reoperation (95% CI, 1.45-29.31).

CONCLUSIONS

Intramedullary reduction assessed by CT was associated with reoperation. The reduction quality based on CT findings was more predictive for reoperation than that from plain radiographs.

Reverse wedge effect following intramedullary nail fixation of trochanteric fracture, what does it imply?

Lag screw cut-out is the most common cause of fixation failure of trochanteric fractures. Intraoperative assessment of fracture reduction and fixation quality is vital to avoid fracture reduction and achieve good functional outcomes. In a recent study, Zhang et al. reported the occurrence of a reverse wedge effect after intraoperative nail insertion based on a new computed tomography(CT)-guided fracture classification system, which specifically happened to the basicervical facture type and resulted in valgus deformity with gapping at the medial inferior fracture line. Impingement between the reamer/nail and superolateral cortex of the femoral neck has been regarded as the main cause. Based on these findings, together with an extensive literature review, the practicality of the new fracture classification system, the definition of basicervical trochanteric fracture, and the mechanisms underlying the reverse wedge effect have been deeply discussed. More studies should be carried out in the future to analyse pre- and intraoperative related factors that could affect the intraoperative fragment migration effects and determine highly specific measures to address them.

Benefit of lag screw placement by a single- or two-screw nailing system in elderly patients with AO/OTA 31-A2 trochanteric fractures

Objective

To retrospectively analyze the clinical outcomes of two intramedullary fixation devices, the INTERTAN nail and Gamma3 nail, for treatment of AO/OTA 31-A2 trochanteric fractures in elderly patients.

Methods

In total, 165 elderly patients underwent treatment for AO/OTA 31-A2 trochanteric fractures in our hospital from June 2017 to June 2018 (INTERTAN group, n = 79; Gamma3 group, n = 86). All patients underwent radiological and clinical investigations and were followed up for an average of 12 months. Age, sex, fracture type, surgical time, intraoperative blood loss, fracture healing time, and complications were compared between the two groups.

Results

The surgical time was significantly shorter and the intraoperative blood loss volume was significantly lower in the Gamma3 than INTERTAN group (58.2 ± 2.5 vs. 81.7 ± 14.2 minutes and 170 ± 29 vs. 220 ± 16 mL, respectively). However, there were no significant differences in the reduction quality, hospital stay, fracture healing time, Harris hip score, postoperative complications, or 1-year postoperative mortality.

Conclusion

Both INTERTAN and Gamma3 nails may be effective for surgical treatment of AO/OTA 31-A2 trochanteric fractures in elderly patients. However, the Gamma3 nail was superior to the INTERTAN nail in terms of surgical time and intraoperative blood loss.

Results of revision intramedullary nailing with and without auxillary plate in aseptic trochanteric and subtrochanteric nonunion

PURPOSE

Aim of this study was to investigate whether limited open auxiliary angle stable plate fixation has an effect on functional and radiologic outcomes one year after revision intramedullary nailing in aseptic trochanteric and subtrochanteric fracture nonunion.

METHODS

In a retrospective analysis, surgically revised aseptic trochanteric and subtrochanteric nonunion was evaluated in a total of 190 consecutive patients ranging from 18 to 94 years between 12/2005 and 10/2018.

RESULTS

One year after revision intramedullary nailing, nonunion healing was assessed in 129 out of 136 patients (95%) in group 1 without auxiliary plate fixation and in 51 out of 54 patients (94%) in group 2 with auxiliary plating (p = 0.23). In group 1, range of motion (ROM) was unrestricted in 88 patients and still restricted in 48 patients. In group 2, ROM was free in 34 patients and restricted in 20 patients (p = 0.25). The mean Lower Extremity Functional Scale (LEFS) was 56 points in group 1 and 55 points in group 2 (p = 0.55).

CONCLUSION

This study did not demonstrate significant differences in functional and radiologic outcomes following revision intramedullary nailing of aseptic trochanteric and subtrochanteric fracture nonunion. Limited open auxiliary plate fixation might be a reasonable option especially in cases of relevant varus axis deviation and comminuted or atypical fracture configurations, regardless of patients' age. Retrospectively registered with the German Clinical Trials Register (01/25/2021; ID: DRKS00024112).

Application of the reversed LISS-DF technique in an elderly patient to salvage infection-related failure of trochanteric fracture fixation

Failure of cephalomedullary fixation in geriatric trochanteric fractures is a potential complication. Attempts have been made to optimize the implant fixation (e. g. cement augmentation) and several factors (e. g. malreduction, tip apex distance) have been identified as risk factors for failure. Nevertheless, if intramedullary fixation fails, it is often associated with bone defects in mostly preexisting poor bone-stock. Accordingly, conversion to total hip arthroplasty (THA) is recommended by some authors as the only valid treatment option. However, in specific situations (e. g. implant associated infection) conversion to THA might be less reasonable than an attempt to re-osteosynthesis. This article reports on the successful use of a reversed contralateral LISS-DF (LISS for the distal femur, DePuy Synthes, Zuchwil, Switzerland) application after failed cephalomedullary fixation and failed re-osteosynthesis using a blade plate in a trochanteric fracture in an elderly patient with additional implant associated infection.

Hip fractures among the elderly in Kyoto, Japan: a 10-year study

In Kyoto Prefecture, Japan, the number of hip fractures increased during 2013-2017 compared to 2008-2012. However, the estimated overall incidence rate increased only in femoral neck fractures in men aged ≥75 and women aged ≥85.

PURPOSE

The incidence rate of hip fractures in Japan has plateaued or decreased. We investigated the annual hip fracture occurrences in Kyoto Prefecture, Japan, from 2008 to 2017.

METHODS

Patients aged 65 years and above who sustained hip fractures between 2008 and 2017 and were treated at one of the participating 11 hospitals were included. The total number of beds in these institutions was 3701, accounting for 21.5% of the 17,242 acute-care beds in Kyoto Prefecture. The change in incidence rate was estimated utilizing the population according to the national census conducted in 2010 and 2015.

RESULTS

The total number of hip fractures was 10,060, with 47.5% femoral neck fractures and 52.5% trochanteric fractures. A decrease in number was seen only in trochanteric fractures in the group of 75- to 84-year-old women. The population-adjusted numbers of femoral neck fractures showed a significant increase in all age groups in men, whereas in women, there was an increase in femoral neck fractures in the ≥85 group and trochanteric fractures in the age group 65-74, and a decrease in trochanteric fractures in the age group 75-84. The estimated change in incidence rate showed an increase in femoral neck fractures in men aged ≥75 and women aged ≥85.

CONCLUSION

In Kyoto Prefecture, the number of hip fractures increased in the second half of the study period (2013-2017) compared to the first half (2008-2012). However, the incidence rate had not increased, except in femoral neck fractures in men aged ≥75 and women aged ≥85.

The functional effect of lesser trochanter involvement in hip fractures: A prospective cohort study

INTRODUCTION

Hip fractures are the most common fractures amongst frail older patients. Earlier studies have indicated an impaired hip flexion strength in patients with fractures that include detachment of the lesser trochanter. These patients may experience protracted functional impairment and longer recovery time, causing prolonged rehabilitation journeys. This study aimed to evaluate the effects of a detached lesser trochanter in trochanteric fractures on the recovery of hip function.

METHOD

A prospective observational cohort study was performed between 2016 and 2019. Community dwelling patients aged 70 years or older with AO 31A1-A3 trochanteric fractures were included. Patients followed routine care and were treated with a DHS or PFNA. The groups with and without involvement of the lesser trochanter were analysed. The primary outcome was hip function assessed at 6 weeks, 3 months and 1 year after surgery with the Harris Hip Score. Secondary outcomes included the Ludloff's test, complications, rehabilitation time, and pain-, independence-, and quality of life scores. A propensity score was used to adjust for any baseline differences between the two groups.

RESULTS

A total of 114 patients were included, 51 (44.7%) with involvement of the lesser trochanter and 63 (55.3%) without. Minor differences were observed in the baseline characteristics. No significant difference was observed for the Harris Hip Score (coefficient estimate: 3.31; 95% CI, -5.09-11.72; P = 0.43). The flexion function of the iliopsoas muscle was more often normal with the Ludloff's test in patients without involvement of the lesser trochanter (OR, 2.33; 95% CI, 1.241-4.387; P = 0.009). However, no differences were observed for any of the other secondary outcomes.

CONCLUSION

Although no differences in overall hip function were found, more hip fracture patients with involvement of the lesser trochanter showed prolonged impaired flexion of the hip. The absence of long-term, clinically relevant disadvantages however, proves fixing the lesser trochanter to be redundant.

Does auxiliary cerclage wiring provide intrinsic stability in cephalomedullary nailing of trochanteric and subtrochanteric fractures?

Purpose

The aim of this study was to assess functional and radiological results following cephalomedullary nailing with and without use of auxiliary cable cerclages in a large series of trochanteric and subtrochanteric femoral fractures.

Methods

In a retrospective study of prospectively collected data between January 2014 and March 2019, a total of 260 consecutive patients (155 women and 105 men) with the diagnosis of AO/OTA A1 to A3 fractures were included. The mean age of patients was 76.4 ± 15.6 years. According to the AO/OTA classification, 72 A1 fractures, 124 A2 fractures, and 64 A3 fractures were found. In 72 patients with auxiliary cerclage wiring three A1 fractures, 27 A2 fractures and 42 A3 fractures were assessed. In the patient group with auxiliary cerclages, fracture healing according to the Radiographic Union Score for Hip (RUSH) within one year after surgery was assessed in 68 out of 72 patients (healing rate 94%). The mean RUSH in the group with cerclages was 28.7 ± 2.2 points and was 28.5 ± 2.2 points in the group without cerclages (p = 0.72). In 91 patients available for a complete follow-up, mean functional outcome according to the Lower Extremity Functional Scale (LEFS) was 65.3 ± 17.2 points in the group with cerclages versus 58.4 ± 21 points in the group without cerclages (p = 0.04).

Conclusion

The additional use of cerclages provides intrinsic stability and enables axial alignment and medial cortical support during anatomical fracture reduction and cephalomedullary nail insertion. In the current study, this technique resulted in significantly better functional long-term outcomes than without cerclages. Therefore, it can be recommended as a useful supportive tool especially in comminuted trochanteric and subtrochanteric fractures. Trial registration number DRKS00020550, 01/30/2020, retrospectively registered.