Die dislozierte Schenkelhalsfraktur des geriatrischen Patienten: Einjahresergebnisse

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Fracture arthroplasty of femoral neck fractures]

A paradigm shift in the treatment of elderly patients has recently taken place leading to an increase in joint replacement surgery. The aim of this article is to highlight new developments and to present a treatment algorithm for femoral neck fractures. The age limit must be individually determined considering the comorbidities and perioperative risk profile. Pertrochanteric femoral fractures are nearly exclusively treated by osteosynthesis regardless of age. The situation for femoral neck fractures is more complex. Patients younger than 65 years should generally be treated by osteosynthesis but patients older than 65 years benefit from hemiarthroplasty or total hip arthroplasty. In patients aged between 65 and 75 years with high functional demands and a justifiable perioperative risk, total joint replacement is the treatment of choice. In physically less active patients older than 75 years and poor general condition, preference should be given to hemiarthroplasty.

The fate of proximal femoral fractures in the 10th decade of life: an analysis of 117 consecutive patients

INTRODUCTION

To date, there is a lack of valid data with larger populations of patients in their 10th decade of life in the analyses of proximal femoral fractures.

MATERIAL AND METHODS

The inclusion criteria focused on all proximal femoral fractures in patients 90-99 years of age who underwent surgical treatment between 2009 and 2012. After a period of at least 2 years post-surgery, a retrospective collection of empiric data, including the survival time and surgical revision rate, was performed. Missing data were collected per telephone interview.

RESULTS

A total of 121 proximal femoral fractures in 117 patients in their 10th decade of life were treated. The mean age was 92.3 years. 61 fractures of the femoral neck received hemi- or total hip arthroplasty, while 60 pertrochanteric or subtrochanteric fractures were treated by osteosynthesis using proximal femoral nail (PFN) or dynamic hip screw (DHS). At the time of follow-up, 83/117 patients (71%) were already deceased. The mortality after 30 days, 6 months, 1 year and 2 years was 16%, 37%, and 43%, and 55%, respectively. A total of 22 surgical revisions (19%) were performed: 10 due to early infections, 8 due to haematomas, and 4 due to implant failures with a "cut out" of the femoral neck screw exclusively in DHS. The duration of surgery (with regard to surgical revision) and ASA classification (with regard to survival rate) were significant influence factors. Contralateral proximal femoral fractures were identified in 24/117 patients (20%), irrespective of study period.

CONCLUSIONS

The proximal femoral fractures in the 10th decade of life are associated with high postoperative mortality within the first 6 months. Surgical revision due to complications did not result in a statistically significant reduction of the survival time. From the osteosynthetic perspective, the DHS was associated with a significantly higher "cut-out" rate compared to PFN procedure. With regard to the alloarthoplasty, there were no significant differences observed between hemi- and total hip arthroplasty. A contralateral femoral fractures was observed in 20% of the total study population, but peri-implant or periprosthetic femoral fractures have not been observed in any of the cases thus far.