Sliding hip screw versus intramedullary nail for trochanteric hip fractures; a randomised trial of 1000 patients with presentation of results related to fracture stability

High Rate of Undetected Infections in Failed Osteosynthesis of Pertrochanteric Fractures

OBJECTIVE

The objective of this study was to assess the incidence of infection in patients with cutout after proximal femur fracture (PFF) osteosynthesis.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Third-level trauma center.

PATIENT SELECTION CRITERIA

Patients presenting with a cutout following PFF (OTA/AO 31A) osteosynthesis, between January 2007 and December 2020.

OUTCOME MEASUREMENTS AND COMPARISONS

The primary outcome was infection according to the European Bone and Joint Infection Society criteria.

RESULTS

Sixty-seven patients presenting with a cutout were included, with mean age of 83.3 years (range 63-96), and 51 (76.1%) were women. Of all cases, 16 (24.7%) presented a concomitant infection. The presence of concomitant infection was suspected preoperatively in only 3 of the cases. A subgroup analysis was performed between the cases with infection and those without infection, the groups being comparable in terms of demographic data and postoperative radiological criteria. Patients with underlying infection had a higher rate of surgical wound complication (56.3% vs. 22%, P = 0.014) and higher rates of leukocytosis (11.560 vs. 7.890, P = 0.023).

CONCLUSION

Faced with a cutout after osteosynthesis of a PFF, underlying infection should be considered as a possible etiological factor.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Proximal Femur Fractures - How Decisive are Reduction and the Chosen Implant?

Proximal femoral fractures are frequent and complex injuries requiring prompt and targeted care. Numerous treatment strategies have been described, some of which have been assessed and clinically implemented clinically. The aim of surgical is always the restoration of a pain-free and stable extremity. Mostly elderly patients are affected and treatment is associated with high postoperative complications and mortality rates. With increasing numbers of patients, the topic is of great medical and economic relevance. In this work, the choice of implants for the osteosynthesis of proximal femoral fractures - as depending on the fracture type - will be examined, as based on a review of current literature. Standard care includes cannulated screws, sliding hips screws and cephalomedullary nails. In addition, the influence of implant positioning, fracture reduction and additional measures such as cement augmentation are evaluated and discussed. Careful fracture reduction and the quality of implant positioning are paramount in order to avoid complications.

Early mobilisation after hip fracture surgery is associated with improved patient outcomes: A systematic review and meta-analysis

INTRODUCTION

The aims of this systematic review and meta-analysis were to determine if after hip fracture surgery (1) early mobilisation is associated with improved clinical outcomes, and if so (2) are benefits directly proportional to how soon after surgery the patient mobilises.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review was conducted using four databases to identify all studies that compared postoperative early mobilisation with delayed mobilisation, in patients after hip fracture surgery. The Critical Appraisal Skills Programme checklist was employed for critical appraisal and evaluation of all studies that met the inclusion criteria.

RESULTS

A total of 13 studies, including 297,435 patients were identified, of which 235,275 patients were mobilised early and 62,160 were mobilised late. Six studies assessed 30-day mortality, of which two also investigated 30-day complication rates. Pooled meta-analysis demonstrated that there were significantly lower 30-day mortality rates (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.31-0.41, p < 0.001) and complication rates (OR 0.43, 95% CI 0.36-0.51, p < 0.001) in patients mobilising early after hip fracture surgery. Five studies investigated length of stay (LOS) and meta-analysis revealed no difference between groups (mean difference -0.57 days, 95% CI -1.89-0.74, p = 0.39).

CONCLUSION

Early mobilisation in hip fracture patients is associated with a reduction in 30-day mortality and complication rates compared to delayed mobilisation, but no difference in LOS. These findings illustrate that early mobilisation is associated with superior post operative outcomes. However, a direct casual effect remains to be demonstrated, and further work on the factors underlying delayed mobilisation is required.

The increasing complexity of femoral fragility fractures: incidence, fracture patterns and management over a 10-year period

INTRODUCTION

The purpose of this study was to determine whether there have been changes in the numbers and complexity of femoral fragility fractures presenting to our department over a period of 10 years.

METHODS

Patients >60 years presenting with femoral fragility fractures to our institution in 2018-2019 (397 fractures) were compared with respect to demographic data, incidence rates, fracture classification and surgical management with a historical cohort from 2009-2010 (335 fractures). Pathological and high velocity fractures were excluded.

RESULTS

The gender proportion and average age (83.1 vs. 82.7 years) was unchanged. The number of femoral fractures increased by 19% but the overall incidence in people >60 years fell by 6% (p = 0.41). The proportion of unstable trochanteric fractures (31A2 and A3) increased from 22% to 55% (p < 0.001). The proportion of displaced intracapsular fractures increased from 53% to 72% (p < 0.001). The incidence of stable trochanteric fractures fell from 12.4 to 7.3/10,000 patients>60 years (p = 0.0006) while the incidence of unstable trochanteric fractures (31A2 and 31A3) increased from 3.5 to 8.9/10,000 patients >60 years (p < 0.0001). The proportion of trochanteric fractures treated with an intramedullary (IM) nail increased from 9% to 35% (p = 0.0001). The number of shaft and distal femoral fractures increased by 41% although the incidence did not change significantly. Periprosthetic fractures comprised 70% of femoral shaft fractures in both cohorts.

CONCLUSIONS

The increasing number and complexity of femoral fragility fractures, especially unstable trochanteric fractures and periprosthetic fractures, is likely to have an impact on implant use, theatre time and cost.

Extramedullary versus intramedullary fixation of unstable trochanteric femoral fractures (AO type 31-A2): a systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review was to compare extramedullary fixation and intramedullary fixation for AO type 31-A2 trochanteric fractures in the elderly, with regard to functional outcomes, complications, surgical outcomes, and costs.

METHODS

Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results are presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI).

RESULTS

Fourteen RCTs (2039 patients) and 13 observational studies (22,123 patients) were included. Statistically superior results in favor of intramedullary fixation were found for Harris Hip Score (MD 4.09, 95% CI 0.91-7.26, p = 0.04), Parker mobility score (MD - 0.67 95% CI - 1.2 to - 0.17, p = 0.009), lower extremity measure (MD - 4.07 95% CI - 7.4 to - 0.8, p = 0.02), time to full weight bearing (MD 1.14 weeks CI 0.92-1.35, p < 0.001), superficial infection (RR 2.06, 95% CI 1.18-3.58, p = 0.01), nonunion (RR 3.67, 95% CI 1.03-13.10, p = 0.05), fixation failure (RR 2.26, 95% CI 1.16-4.44, p = 0.02), leg shortening (MD 2.23 mm, 95% CI 0.81-3.65, p = 0.002), time to radiological bone healing (MD 2.19 months, 95% CI 0.56-3.83, p = 0.009), surgery duration (MD 11.63 min, 95% CI 2.63-20.62, p = 0.01), operative blood loss (MD 134.5 mL, 95% CI 51-218, p = 0.002), and tip-apex distance > 25 mm (RR 1.73, 95% CI 1.10-2.74, p = 0.02). No comparable cost/costs-effectiveness data were available.

CONCLUSION

Current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed in a detailed cost-effectiveness analysis.

Evolving trends in hip fracture patterns among the elderly from 2001 to 2022

INTRODUCTION

Hip fractures among the elderly exhibit diverse patterns. Differences regarding treatment and prognosis of displaced versus undisplaced intracapsular fractures are well established. Unstable extracapsular fractures are associated with considerably higher rates of complications than stable fractures, including cutout failures, non-unions, wound complications and hardware related problems. The purpose of this study was to identify trends in the distribution of various types of hip fractures and their complexity between 2001 and 2022.

METHODS

This retrospective study compared hip fractures treated in the years 2001, 2006, 2010, 2014, 2018, and 2022, excluding patients under 60 years old and those with pathological or peri‑prosthetic fractures. Radiographs were reviewed and fracture patterns were categorized as stable extracapsular, unstable extracapsular, subtrochanteric or intracapsular.

RESULTS

Out of 2646 patients admitted with proximal femoral fractures during these years, 2277 patients (69.5 % women) were available for analysis. Over the initial decade, the mean patient age gradually increased from 80 to 82, subsequently stabilizing. Gender distribution remained consistent, and the proportion of intracapsular fractures showed minimal variation (36-38 %). The most significant finding was the marked decrease in the proportion of stable-to-unstable extracapsular fractures during the first decade from 51 % to 31 %, followed by stabilization after 2010. Subgroup analysis by age revealed that while the proportion change between stable and unstable fractures remained insignificant in younger age groups (p = 0.41 for sexagenarians and 0.12 for septuagenarians), a significant change was observed in older patients (p = 0.002 for octogenarians and 0.04 for nonagenarians and older patients).

DISCUSSION

This study reveals a surge in unstable peritrochanteric fractures between 2001 and 2010, particularly pronounced in patients over 80. This trend plateaued in the following decade, aligning with the stabilization of the cohort's mean age at 82. Numerous factors, from bone morphology to systemic markers, influence hip fracture types. Evolutions in osteoporosis screening and treatment over the last three decades may have contributed to the observed shifts in fracture pattern distribution.

CONCLUSION

Understanding these trends enriches treatment strategies and underscores the need for further exploration of the interplay between demographic and anatomical factors in the etiology of specific fracture patterns.

Is the increased use of intramedullary nailing over DHS for intertrochanteric hip fractures justified? - A review of the Irish hip fracture database 2016 -2020

PURPOSE

Intertrochanteric hip fractures are significant and costly injuries and there remains controversy within the orthopaedic literature over the best method of fixation. The Irish Hip Fracture Database (IHFD) was established in 2012 to drive improvements in clinical outcomes and the quality of hip fracture care. This paper will review the outcomes of dynamic hip screw (DHS) versus intra-medullary nailing (IMN) in the treatment of intertrochanteric hip fractures in Ireland.

METHODS

Eligible cases for this study include patients >60 years of age with trochanteric hip fractures treated by DHS or IMN between January 2016 and December 2020. Outcomes recorded and compared include length of stay, inpatient mortality, mobilisation on post-operative day 1 (POD 1), and discharge destination.

RESULTS

5668 hip fractures treated with DHS or IMN were identified. There was no significant difference between inpatient mortality, re-operation rate or length of stay between the two groups. Females and patients with a high ASA grade (IV and V) were more likely to receive IMN. Patients receiving DHS were more likely to be mobilised day 1 post-operatively and be discharged directly home. It was noted that the use of IMN increased from 42% of cases in 2016 to 70% in 2020.

CONCLUSION

IMN use for intertrochanteric fractures continues to increase. However, patients treated with DHS were more likely to mobilise early post-operatively and to go directly home. Notwithstanding the limitations of national registry data research, the dramatic rise in the use of IMN for these fractures appears unsupported by the evidence.

Does intramedullary nail have advantages over dynamic hip screw for the treatment of AO/OTA31A1-A3? A meta-analysis

BACKGROUND

Hip fractures are still unsolved problems nowadays. We evaluated the functional outcomes and complications in the treatment of hip fractures (AO/OTA31A1-A3) to find potential difference and risk between intramedullary nail (IMN) and dynamic hip screw (DHS).

METHOD

We searched PubMed, Embase, Cochrane library up to 19 June 2023 and retrieved any studies comparing IMN and DHS in treatment of Hip fractures. The main outcomes and complications were extracted from the included studies. The fixed-effect model was selected to pool the data for homogeneous studies (I² < 50%). Otherwise, the random effects model was selected (heterogeneity, I² > 50%). The analysis of sensitivity and subgroup was performed to explore the homogeneous studies among studies. The p-value of less than 0.05 was considered statistically significant.

RESULTS

30 RCT studies were included in this meta-analysis. There were significant difference of in the items of blood loss, screening time, femoral neck shortening, non-union, and femoral fractures (p < 0.05). Significant difference was found in the parameter of open reduction of fracture after sensitive analysis (p < 0.05). No significant difference was found in the parameter of Mobility Score at the last follow-up after sensitive analysis (p ≥ 0.05). There was no significant difference in the parameters of open reduction of fracture, required blood transfusion, mean surgical time, hospital stays, time to healing, mean Harris Hip Score, infection, cut out, poor reduction, breakage of implant, failure of fixation, reoperation, and systemic complications of chest infection, decubital ulcer, urinary tract infection and persistent pain in the hip (p ≥ 0.05).

CONCLUSIONS

Our meta-analysis revealed that hip fractures treated with IMN have merits with lower rate of blood loss, femoral neck shortening and non-union; shortcoming of increased risk of femoral fractures. It is suggested that special attention should be paid to the risk of femoral fracture when intramedullary nail was inserted in the intraoperative.

The impact of fixation type for intertrochanteric femoral fracture on patient survival

BACKGROUND

Intramedullary (IM) nail fixation for intertrochanteric fractures is potentially associated with improved postoperative function but may have an increased mortality risk compared to sliding hip screw (SHS) fixation. This study investigated postoperative mortality risk between surgical fixation type for intertrochanteric fracture in patients aged 50 years and older using linked data from the Australian Hip Fracture Registry and National Death Index.

METHODS

Descriptive analysis and Kaplan-Meier survival curves performed unadjusted analysis of mortality and fixation type (short IM nail, long IM nail and SHS). Multilevel logistic regression (AMLR) and Cox modelling (CM) performed adjusted analysis of fixation type and mortality following surgery. Instrumental variable analysis (IVA) was conducted to minimize the effect of unknown confounders.

RESULTS

The 30-day mortality was 7.1% for short IM, 7.8% for long IM and 7.8% for SHS fixation (P = 0.2). The AMLR demonstrated significant increase in 30-day mortality risk for long IM nail compared to short IM nail (OR = 1.2, 95% CI = 1.0-1.4, P < 0.05) but no significant difference for SHS fixation (OR = 1.1, 95% CI = 0.9-1.3, P = 0.5). No significant difference between groups and postoperative mortality was demonstrated by the CM at 30-days nor 1-year nor by the IVA at 30-days.

CONCLUSION

Despite a significant increase in 30-day mortality risk for long IM nail compared to short IM nail fixation in the adjusted analysis, this was not demonstrated in the CM nor IVA indicating the role of confounders influencing the regression findings. There was no significant association in 1-year mortality between long IM nail and SHS compared to short IM nail fixation.

Extramedullary versus intramedullary fixation of stable trochanteric femoral fractures: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis compared extramedullary fixation and intramedullary fixation for stable two-part trochanteric femoral fractures (AO type 31-A1) with regards to functional outcomes, complications, and surgical outcomes.

METHODS

Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results were presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI).

RESULTS

Five RCTs (397 patients) and 14 observational studies (21,396 patients) were included. No significant differences in functional outcomes, complications, or surgical outcomes were found between extramedullary and intramedullary fixation devices, except for a difference in duration of surgery (MD 14.1 min, CI 5.76-22.33, p < 0.001) and intra-operative blood loss (MD 92.30 mL, CI 13.49-171.12, p = 0.02), favoring intramedullary fixation.

CONCLUSION

Current literature shows no meaningful differences in complications, surgical, or functional outcomes between extramedullary and intramedullary fixation of stable two-part trochanteric femoral fractures. Both treatment options result in good outcomes. This study implicates that, costs should be taken into account when considering implants or comparing fixation methods in future research.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapeutic level II.

New Versus Old-How Reliable Is the New OTA/AO Classification for Trochanteric Hip Fractures?

OBJECTIVE

To evaluate the intraobserver and interobserver reliability of the 2018 OTA/AO trochanteric hip fracture (THF) classification compared with the 1983 OTA/AO Muller classification system. To further delineate the reliability of classifying stable and unstable THF using the 2 classification systems.

DESIGN

Radiographic observational study.

SETTING

Multicenter, one Level 1 and one Level 2 trauma centers.

PARTICIPANTS/PATIENTS

Seventy-three radiographic series of patients treated operatively for THF were evaluated by 6 orthopaedic surgeons.

INTERVENTION

The OTA/AO THF classification system was applied by each surgeon to 73 cases in 2 independent assessments performed 4 weeks apart: once by the old classification followed by the new 2018 OTA/AO classification. Each radiographic series included lateral hip and anteroposterior initial radiographs. Eight random cases were duplicated in each of the surveys to evaluate the intraobserver reliability.

MAIN OUTCOME MEASUREMENTS

Intraobserver and interobserver of the group, subgroup and fracture stability classification determined by the interclass coefficient (ICC) and Cohen kappa values.

RESULTS

The interobserver reliability for the group classification (31A1/A2/A3) was moderate using the new classification, whereas substantial agreement was shown using the old classification (0.49 and 0.69, respectively). The reliability of the fracture stability classification was higher using the old classification (0.70 vs. 0.52). Subgroup classifications interobserver agreement was fair for both classification systems, although lower reliability was shown in the old classification (0.34 vs. 0.31).

CONCLUSIONS

The new OTA/AO classification has a lower interobserver reliability for THF classification when compared with the old one.

Association of Hip Fracture With the Use of Walking Assistance Devices Post-surgery: A Retrospective Study Comparing Intertrochanteric and Subtrochanteric Hip Fractures

Background Hip fractures, including intertrochanteric and subtrochanteric fractures, are among the most common types of fractures. The dynamic hip screw (DHS) and the cephalomedullary hip nail (CHN) are the two main techniques used for the fixation of these types of fractures. This study aims to explore the association of the fracture type with the use of walking assistance devices post-surgery, regardless of the fixation technique. Methodology This study is a retrospective study based on the review of de-identified patient data from the American College of Surgeons National Surgical Quality Improvement Program database. Patients aged 65 years old or above who underwent fixation procedures for intertrochanteric or subtrochanteric fractures using CHN or DHS techniques were included in this study. Results A total of 8,881 patients were included and divided into the following two groups: 876 (9.9%) patients treated for subtrochanteric fracture, and 8,005 (90.1%) patients treated for intertrochanteric fracture. No statistical significance was detected in the use of mobility aid postoperatively between the two groups. When compared to CHN, DHS was noted to be the most employed fixation technique among patients with intertrochanteric fractures. One main finding was that patients who underwent surgery using DHS for intertrochanteric fractures were more likely to use walking assistance devices postoperatively compared to those with subtrochanteric fractures treated with the same fixation technique. Conclusions Findings suggest that the use of walking assistance devices post-surgery is independent of the type of fracture and potentially dependent on the fixation technique employed. Future studies focused on the difference in the use of walking assistance devices based on fixation techniques for patients with distinctive sub-types of trochanteric fractures are highly encouraged.

Proximal femoral fracture and female gender are risk factors for recurrent fracture: Cohort study of 292 patients over 75 years-old with iterative osteoporotic fractures

PURPOSE

The purpose of this study was to: 1/ describe the characteristics of a cohort of patients over 75 years of age hospitalized in perioperative geriatric units (UPOG) for iterative fractures; 2/ investigate the risks of institutionalization related to the first fracture; and 3/ search for potential risk factors for iterative fracture.

METHODS

This is a retrospective single-center study analyzing patients over 75 years old, hospitalized in UPOG.

RESULTS

Of the 3207 patients hospitalized, 292 patients had a refracture (9.1%), with a mean age of 85.4+/-5.8 years. Initial fractures were mainly intertrochanteric (43.2%) and the femoral neck (32.9%). Refractures occurred mainly in the first year (55.5%), with a median delay of 9.6 months. Refractures were mainly intertrochanteric (29.5%), peri‑implant (prosthesis, osteosynthesis) (28.8%), and femoral neck (26.7%). Dementia was the only factor for institutionalization after the first fracture episode (p = 0.0002). Proximal femoral fracture (PFF) and female gender were risk factors for iterative fracture (10.2% vs. 6.8%, p = 0.003; 10.7% vs. 6.8%, p = 0.005 respectively), but not age (85.4 vs. 85.8 years, p = 0.24). PFF were more likely to result in the same fracture type in the second episode (58.1% vs 7.1%, p<0.0001). The time to refracture was shorter in case of peri‑implant fracture (p = 0.0002), or discharge directly to home (p = 0.04).

CONCLUSION

PFF and female gender are risk factors for recurrent fracture, which is even more likely to occur early in case of home discharge or peri‑implant fracture.

Mechanical Complications After Intramedullary Fixation of Extracapsular Hip Fractures

Extracapsular hip fractures occur frequently in the elderly as a result of low-energy trauma. Achieving stable fixation in osteoporotic bone to allow early weight bearing is a key objective in the treatment of these injuries. Many of the intraoperative decisions facing surgeons are directed by first determining fracture stability. Unstable fracture patterns should be fixated with intramedullary nails, aiming to control motion around the implant and at the fracture site. Torsion control devices provide additional stability and control, although their exact indications are not precisely defined. Complications that arise as a result of the early loading can be avoided with a good surgical reduction, meticulous technique, and proper implant selection. Mechanical complications include cutout, inordinate proximal femoral shortening, delayed union, early implant fracture, nail toggle, and cut through/medial migration.

No Difference in Conversion Rate to Hip Arthroplasty After Intramedullary Nail or Sliding Hip Screw for Extracapsular Hip Fractures: An Observational Cohort Study of 19,604 Individuals

BACKGROUND

The widespread use of intramedullary nails (IMNs) compared with sliding hip screws (SHSs) in extracapsular hip fractures (AO/OTA 31-A1, 31-A2, 31-A3) has been questioned because of a higher complication rate, although the outcome might have improved through more recent implant designs and the learning curve. This study aimed to investigate if there is a difference with regard to the cumulative incidence of conversion to arthroplasty or any reoperation during the first 5 years after IMN or SHS fixation of extracapsular hip fractures.

METHODS

In this nationwide, observational cohort study, individuals who were ≥60 years of age and were registered in the Swedish Fracture Register (SFR) from 2012 to 2018 due to extracapsular fracture and were primarily treated with an IMN or SHS were followed in the SFR and the Swedish Arthroplasty Register (SAR) for a minimum of 1 year. The primary outcome was the cumulative incidence of conversion to arthroplasty (conversion rate). The secondary outcome was the cumulative incidence of all reoperations (reoperation rate). Both were calculated in a competing risk analysis during the first 5 years.

RESULTS

We included 19,604 individuals (70% women), with a median age of 85 years (range, 60 to 107 years). The 31-A2 fracture was most prevalent (52%), followed by the 31-A1 fracture (28%). No significant differences were seen in the 1-year conversion rate after IMN or SHS use (1.0% compared with 0.9% in the 31-A1 fractures, 1.7% compared with 1.3% in the 31-A2 fractures, and 1.3% compared with 1.5% in the 31-A3 fractures) or in the 1-year reoperation rate (1.9% compared with 1.9% in the type-A1 fractures, 3.4% compared with 2.5% in the type-A2 fractures, and 4.0% compared with 5.2% in the type-A3 fractures). Only in 31-A2 fractures were more reoperations seen after IMN use at 2 and 5 years (p < 0.05). The crude 1-year-mortality was 26.4% (5,178 of 19,604), without significant differences between implants.

CONCLUSIONS

Considering conversion arthroplasty, IMNs and SHSs performed equally well in general. IMN use was associated with more reoperations than SHS use in 31-A2 fractures at 2 years. However, from a clinical perspective, the differences between the implants were small, in particular when considering the competing risk of dying.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Variation of implant use in A1 and A2 trochanteric hip fractures : a study from the National Hip Fracture Database of England and Wales

AIMS

Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines.

METHODS

We used the NHFD to identify all operations for fixation of trochanteric fractures in England and Wales between 1 January 2021 and 31 December 2021. A uniform price band from each of three hip fracture implant manufacturers was used to set cost implications alongside variation in implant use.

RESULTS

We identified 18,156 A1 and A2 trochanteric hip fractures in 162 centres. Of these, 13,483 (74.3%) underwent SHS fixation, 2,352 (13.0%) were managed with short IMN, and 2,321 (12.8%) were managed with long IMN. Total cost of IMN added up to £1.89 million in 2021, and the clinical justification for this is unclear since rates of IMN use varied from 0% to 97% in different centres.

CONCLUSION

Most trochanteric hip fractures are managed with SHS, in keeping with national guidelines. There is considerable variance between hospitals for implant choice, despite the lack of evidence for clinical benefit and cost-effectiveness of more expensive nailing systems. This suggests either a lack of awareness of national guidelines or a choice not to follow them. We encourage provider units to reassess their practice if outwith the national norm. Funding bodies should examine implant use closely in this population to prevent resource waste at a time of considerable health austerity.Cite this article: Bone Jt Open 2022;3(10):741-745.

Comparing the rates and modes of failure of two third generation cephalomedullary nail systems in the treatment of intertrochanteric hip fractures

INTRODUCTION

Cephalomedullary (CMN) implants are commonly used to address elderly intertrochanteric hip fractures. Multiple CMN implant systems exist with subtle variation between manufacturers. Multiple modes of CMN failure have been described in the literature. The present study assessed the local modes and rates of construct failure (nail fracture, cut-out and non-union) of two such implants, after a change in implant supply provided the opportunity for retrospective comparison. Additional investigation was undertaken to assess whether any predictors of failure could be identified based on common radiographic measurement parameters.

METHODS

Based on local implant records, all consecutive patients who suffered an intertrochanteric fracture, treated at a tertiary care hospital with a cephalomedullary nail from January 2014 to January 2018 were included. Patients were excluded if they received a CMN for pathologic fracture. Within the collection period all patients received either a Synthes Trochanteric Fixation Nail (TFN) or Zimmer Natural Nail (ZNN). Patients were retrospectively assessed for fracture reduction and implant technique parameters at the time of initial surgery. Radiographic data were assessed at minimum two years post-operatively to assess for union. Patient demographic data was followed to assess rate and mode of failure.

RESULTS

Six hundred and sixty-two patients were included in the study, from which a propensity matched cohort was derived. Comparing across equivalent cohorts, no differences in the rate or mode of construct failure were identified between the TFN and ZNN. When assessing the entire cohort we observed 39 construct failures (5.9%), which included 31 instances of nail cutout (4.7%), 4 episodes of nail fracture (0.6%) and 4 failures related to non-union (0.6%). Tip to apex distance, sagittal malalignment and Cleveland zone were identified as significant predictors of nail failure.

CONCLUSION

No difference in rates or modes of failure were identified between the TFN and ZNN constructs. Similar to previous reports we again identified the impact of tip to apex distance on construct failure and further identified Cleveland zone and sagittal malalignment as significant risks for failure.

A five-year review comparing 30-day mortality following intramedullary nailing versus sliding hip screw for trochanteric hip fractures

INTRODUCTION

Recent literature suggests that fixation of trochanteric hip fractures with intramedullary nailing carries a higher 30-day mortality than with sliding hip screw. The present study aims to verify whether this statement is reflected in our practice.

PATIENTS AND METHODS

Sliding hip screw and intramedullary nail fixation of trochanteric hip fractures were analysed over a 5-year period, between April 2011 and March 2016. Three investigators independently analysed 919 patients. Data collected included 30-day mortality, OTA classification of hip fracture and ASA grading. Inclusion and exclusion criteria were applied.

RESULTS

493 patients (66%) underwent sliding hip screw while 252 patients (34%) underwent intramedullary femoral nailing. AO/OTA classification was strongly associated with treatment group. It was found that 30-day mortality rate was 4.8% following intramedullary nailing compared to 6.1% with sliding hip screw. Multivariate logistic regression analysis found ASA grade, male gender and age to be associated with increased 30-day mortality with statistical significance. There was no statistically significant association between treatment group and 30-day mortality, nor between ASA grade and treatment group.

CONCLUSIONS

Both the lower 30-day mortality rate of 4.8% with intramedullary nailing and the higher rate of 6.1% with sliding hip screw fixation compare favourably with the mean 7.9% National 30-day mortality rate following hip fractures. The lower 30-day mortality in the intramedullary nailing group was not attributable to lower ASA grading nor due to simpler fracture configuration. ASA grade, male gender and age were shown to be statistically associated with increased 30-day mortality.

IMPLICATIONS

Previous studies may have deterred surgeons from choosing an intramedullary device. However, we hope this study assists surgeons to make an informed decision on the choice of implant particularly when an intramedullary device is required to provide a more stable construct.

Subsequent ipsi- and contralateral femoral fractures after intramedullary nailing of a trochanteric or subtrochanteric fracture: a cohort study on 2012 patients

BACKGROUND

The literature is inconclusive as to whether an intramedullary nail changes the distribution of a subsequent ipsi- or contralateral fracture of the femur. We have compared the incidence, localisation, and fracture pattern of subsequent femoral fractures after intramedullary nailing of trochanteric or subtrochanteric fractures in patients without previous implants in either femur at the time of surgery.

METHODS

Retrospective analysis was performed of a two-centre cohort of 2012 patients treated with a short or long intramedullary nail for the management of trochanteric or subtrochanteric fracture between January 2005 and December 2018. Subsequent presentations with ipsi- and contralateral femoral fractures were documented. Only patients with no previous femoral surgery performed, other than the index nailing were followed. Odds ratios (ORs) for subsequent femoral fracture were calculated using robust variance estimates in logistic regression.

RESULTS

The mean age of the cohort was 82.4 years and 72.1% were female. The total number of patients presenting with subsequent femoral fractures was 299 (14.9%). The number of patients presenting with subsequent ipsilateral and contralateral femoral fractures was 51 (2.5%) and 248 (12.3%) respectively (OR 5.0; CI 3.7-6.9). Twenty-six (8.7%) of all subsequent femoral fractures occured in the ipsilateral shaft, 14 (4.7%) in the ipsilateral metaphyseal area, one (0.33%) in the contralateral shaft, and three (1.0%) in the contralateral metaphysis (OR 10; CI 3.6-29).

CONCLUSION

An intramedullary nail significantly changes the fracture pattern in the event of a second low-energy trauma, reducing the risk of subsequent proximal ipsilateral femoral fractures and increasing the risk of subsequent ipsilateral femoral fractures in the shaft and distal metaphyseal area compared with the native contralateral femur.

Are Intertrochanteric Fractures Evolving? Trends in the Elderly Population over a 10-Year Period

BACKGROUND

Intramedullary devices for the fixation of intertrochanteric fractures are increasing in usage and popularity. This reflects either a shift in adoption of new technology or intertrochanteric fractures becoming more complex or unstable. This trend was observed in our institution, hence we set out to investigate if this was concordant with an associated change in the demographics of the patients or in the morphology of the intertrochanteric fracture pattern over a 10-year period.

METHODS

This is a retrospective cross-sectional comparison undertaken for the first 100 consecutive elderly patients with intertrochanteric fractures admitted to our tertiary institution over 3 yearly intervals, in each of the years 2004, 2007, 2010, and 2013. Fractures were radiologically classified via the Evans and AO classifications. Patient demographics such as age, ethnicity, and comorbidities and surgical data including time, type of fixation, time to surgery, and length of stay were collected via case note reviews to identify possible trends.

RESULTS

The overall mean age was 80.5 years, with no statistically significant trend among age, sex, ethnicity, and comorbidities over the 10-year period. The main finding was a rise in the proportion of unstable intertrochanteric fractures. The proportion of such fractures was 30% in 2004, 42% in 2007, 47% in 2010, and 62% in 2013 (p < 0.001). Patients admitted for intertrochanteric fractures also experienced a shorter hospital length of stay and an increasing trend towards early fracture fixation (p < 0.001), with a greater usage of intramedullary nails in the treatment of such fractures (p < 0.001).

CONCLUSIONS

Intertrochanteric fractures in elderly patients have evolved into more complex fractures over the past ten years, despite there being no change in the age of the patients over the same duration. This increasing proportion of unstable intertrochanteric fractures has brought about a greater tendency to fix these fractures with intramedullary implants.

Sliding hip screw vs intramedullary nail for AO/OTA31A1-A3: a systematic review and meta-analysis

OBJECTIVE

to conduct a systematic review with consequent meta-analysis evaluating the best treatment for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31A1-A3 trochanteric fractures when comparing the sliding hip screw (SHS) to the intramedullary nail (IMN). The outcomes used for comparison are major complications (in total, as well as nonunion and infection specifically), mortality rates, functional outcomes and patient-reported outcome measures (PROM).

MATERIALS AND METHODS

Search strings for the Cochrane Library, CINAHL, Medline and Embase databases were developed with the help of a scientific librarian. Two authors screened the studies from the search string independently using Covidence.org and data extraction was performed similarly. Quality assessment was performed using the Cochrane Risk of Bias tool for randomised trials (ROB2) for RCT studies, and Cochrane Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) for non-RCT studies. Meta-analyses were performed using Log Risk Ratio as the primary effect estimate.

RESULTS

Of the 2,051 studies screened by the two authors, six RCTs and six non-RCTs were included in this meta-analysis, with a total of 10,402 patients. The results indicated no significant differences in total major complications, nonunion, infection or mortality between SHS and IMN treatments for AO/OTA 31A1, 31A2 and 31A3 trochanteric fractures. Due to a lack of compatible data, we were unable to perform a meta-analysis on function scores and PROM. However, there are trends that favour IMN for 31A1 and 31A2 fractures.

CONCLUSION

No significant difference between SHS and IMN was found in the meta-analysis in any of the examined AO/OTA fracture subtypes in terms of primary and secondary outcomes. When assessing function scores and PROM, we found trends favouring IMN for 31A1 and 31A2 fractures that should be explored further.

Surgical interventions for treating extracapsular hip fractures in older adults: a network meta-analysis

BACKGROUND

Hip fractures are a major healthcare problem, presenting a challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising. The majority of extracapsular hip fractures are treated surgically.

OBJECTIVES

To assess the relative effects (benefits and harms) of all surgical treatments used in the management of extracapsular hip fractures in older adults, using a network meta-analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science and five other databases in July 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different treatments for fragility extracapsular hip fractures in older adults. We included internal and external fixation, arthroplasties and non-operative treatment. We excluded studies of hip fractures with specific pathologies other than osteoporosis or resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health-related quality of life (HRQoL) - both reported within 4 months, at 12 months and after 24 months of surgery, and unplanned return to theatre (at end of study follow-up). We performed a network meta-analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes.

MAIN RESULTS

We included 184 studies (160 RCTs and 24 quasi-RCTs) with 26,073 participants with 26,086 extracapsular hip fractures in the review. The mean age in most studies ranged from 60 to 93 years, and 69% were women. After discussion with clinical experts, we selected nine nodes that represented the best balance between clinical plausibility and efficiency of the networks: fixed angle plate (dynamic and static), cephalomedullary nail (short and long), condylocephalic nail, external fixation, hemiarthroplasty, total hip arthroplasty (THA) and non-operative treatment. Seventy-three studies (with 11,126 participants) with data for at least two of these treatments contributed to the NMA. We selected the dynamic fixed angle plate as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison.  We downgraded the certainty of the evidence for serious and very serious risks of bias, and because some of the estimates included the possibility of transitivity owing to the proportion of stable and unstable fractures between treatment comparisons. We also downgraded if we noted evidence of inconsistency in direct or indirect estimates from which the network estimate was derived. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision.  Overall, 20.2% of participants who received the reference treatment had died by 12 months after surgery. We noted no evidence of any differences in mortality at this time point between the treatments compared. Effect estimates of all treatments included plausible benefits as well as harms. Short cephalomedullary nails had the narrowest confidence interval (CI), with 7 fewer deaths (26 fewer to 15 more) per 1000 participants, compared to the reference treatment (risk ratio (RR) 0.97, 95% CI 0.87 to 1.07). THA had the widest CI, with 62 fewer deaths (177 fewer to 610 more) per 1000 participants, compared to the reference treatment (RR 0.69, 95% CI 0.12 to 4.03). The certainty of the evidence for all treatments was low to very low. Although we ranked the treatments, this ranking should be interpreted cautiously because of the imprecision in all the network estimates for these treatments. Overall, 4.3% of participants who received the reference treatment had unplanned return to theatre. Compared to this treatment, we found very low-certainty evidence that 58 more participants (14 to 137 more) per 1000 participants returned to theatre if they were treated with a static fixed angle plate (RR 2.48, 95% CI 1.36 to 4.50), and 91 more participants (37 to 182 more) per 1000 participants returned to theatre if treated with a condylocephalic nail (RR 3.33, 95% CI 1.95 to 5.68). We also found that these treatments were ranked as having the highest probability of unplanned return to theatre. In the remaining treatments, we noted no evidence of any differences in unplanned return to theatre, with effect estimates including benefits as well as harms. The certainty of the evidence for these other treatments ranged from low to very low. We did not use GRADE to assess the certainty of the evidence for early mortality, but our findings were similar to those for 12-month mortality, with no evidence of any differences in treatments when compared to dynamic fixed angle plate. Very few studies reported HRQoL and we were unable to build networks from these studies and perform network meta-analysis.  AUTHORS' CONCLUSIONS: Across the networks, we found that there was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, static implants such as condylocephalic nails and static fixed angle plates did yield a higher risk of unplanned return to theatre. We had insufficient evidence to determine the effects of any treatments on HRQoL, and this review includes data for only two outcomes. More detailed pairwise comparisons of some of the included treatments are reported in other Cochrane Reviews in this series. Short cephalomedullary nails versus dynamic fixed angle plates contributed the most evidence to each network, and our findings indicate that there may be no difference between these treatments. These data included people with both stable and unstable extracapsular fractures. At this time, there are too few studies to draw any conclusions regarding the benefits or harms of arthroplasty or external fixation for extracapsular fracture in older adults. Future research could focus on the benefits and harms of arthroplasty interventions compared with internal fixation using a dynamic implant.

Cephalomedullary nails versus extramedullary implants for extracapsular hip fractures in older adults

BACKGROUND

Hip fractures are a major healthcare problem, presenting a substantial challenge and burden to patients, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. Most hip fractures are treated surgically. This Cochrane Review evaluates evidence for implants used to treat extracapsular hip fractures.

OBJECTIVES

To assess the relative effects of cephalomedullary nails versus extramedullary fixation implants for treating extracapsular hip fractures in older adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, the Cochrane Database of Systematic Reviews, Epistemonikos, ProQuest Dissertations & Theses, and the National Technical Information Service in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles, and conducted backward-citation searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing cephalomedullary nails with extramedullary implants for treating fragility extracapsular hip fractures in older adults. We excluded studies in which all or most fractures were caused by a high-energy trauma or specific pathologies other than osteoporosis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for seven critical outcomes: performance of activities of daily living (ADL), delirium, functional status, health-related quality of life, mobility, mortality (reported within four months of surgery as 'early mortality'; and reported from four months onwards, with priority given to data at 12 months, as '12 months since surgery'), and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure (such as deep infection or non-union). We assessed the certainty of the evidence for these outcomes using GRADE.  MAIN RESULTS: We included 76 studies (66 RCTs, 10 quasi-RCTs) with a total of 10,979 participants with 10,988 extracapsular hip fractures. The mean ages of participants in the studies ranged from 54 to 85 years; 72% were women. Seventeen studies included unstable trochanteric fractures; three included stable trochanteric fractures only; one included only subtrochanteric fractures; and other studies included a mix of fracture types. More than half of the studies were conducted before 2010. Owing to limitations in the quality of reporting, we could not easily judge whether care pathways in these older studies were comparable to current standards of care. We downgraded the certainty of the outcomes because of high or unclear risk of bias; imprecision (when data were available from insufficient numbers of participants or the confidence interval (CI) was wide); and inconsistency (when we noted substantial levels of statistical heterogeneity or differences between findings when outcomes were reported using other measurement tools). There is probably little or no difference between cephalomedullary nails and extramedullary implants in terms of mortality within four months of surgery (risk ratio (RR) 0.96, 95% CI 0.79 to 1.18; 30 studies, 4603 participants) and at 12 months (RR 0.99, 95% CI 0.90 to 1.08; 47 studies, 7618 participants); this evidence was assessed to be of moderate certainty. We found low-certainty evidence for differences in unplanned return to theatre but this was imprecise and included clinically relevant benefits and harms (RR 1.15, 95% CI 0.89 to 1.50; 50 studies, 8398 participants). The effect estimate for functional status at four months also included clinically relevant benefits and harms; this evidence was derived from only two small studies and was imprecise (standardised mean difference (SMD) 0.02, 95% CI -0.27 to 0.30; 188 participants; low-certainty evidence). Similarly, the estimate for delirium was imprecise (RR 1.22, 95% CI 0.67 to 2.22; 5 studies, 1310 participants; low-certainty evidence). Mobility at four months was reported using different measures (such as the number of people with independent mobility or scores on a mobility scale); findings were not consistent between these measures and we could not be certain of the evidence for this outcome. We were also uncertain of the findings for performance in ADL at four months; we did not pool the data from four studies because of substantial heterogeneity. We found no data for health-related quality of life at four months. Using a cephalomedullary nail in preference to an extramedullary device saves one superficial infection per 303 patients (RR 0.71, 95% CI 0.53 to 0.96; 35 studies, 5087 participants; moderate-certainty evidence) and leads to fewer non-unions (RR 0.55, 95% CI 0.32 to 0.96; 40 studies, 4959 participants; moderate-certainty evidence). However, the risk of intraoperative implant-related fractures was greater with cephalomedullary nails (RR 2.94, 95% CI 1.65 to 5.24; 35 studies, 4872 participants; moderate-certainty evidence), as was the risk of later fractures (RR 3.62, 95% CI 2.07 to 6.33; 46 studies, 7021 participants; moderate-certainty evidence). Cephalomedullary nails caused one additional implant-related fracture per 67 participants. We noted no evidence of a difference in other adverse events related or unrelated to the implant, fracture or both. Subgroup analyses provided no evidence of differences between the length of cephalomedullary nail used, the stability of the fracture, or between newer and older designs of cephalomedullary nail.

AUTHORS' CONCLUSIONS

Extramedullary devices, most commonly the sliding hip screw, yield very similar functional outcomes to cephalomedullary devices in the management of extracapsular fragility hip fractures. There is a reduced risk of infection and non-union with cephalomedullary nails, however there is an increased risk of implant-related fracture that is not attenuated with newer designs. Few studies considered patient-relevant outcomes such as performance of activities of daily living, health-related quality of life, mobility, or delirium. This emphasises the need to include the core outcome set for hip fracture in future RCTs.

Unsupervised Data Mining and Effect of Fast Rehabilitation Nursing Intervention in Fracture Surgery

At present, the most commonly used surgical treatment for fractures caused by external force injury is clinical, and unsupervised data mining is more advantageous in the face of the unknown format of perioperative network data. Therefore, this research aims to explore the application effect of unsupervised data mining in the concept of rapid rehabilitation nursing intervention after fracture surgery. 80 patients who underwent fracture surgery in the Department of Orthopedics of XXX Hospital were determined as the subjects, who were rolled into a research group (group R, 40 cases) and a control group (group C, 40 cases) by drawing lots. An unsupervised data mining algorithm based on unsupervised data mining for support vector machines (VDMSVMs) was proposed and applied to two groups of patients undergoing perioperative fracture surgery with the rapid rehabilitation nursing intervention and basic routine nursing. The results showed that the number of important features selected by the VDMSVM algorithm (5) was obviously more than that of the compressed edge fragment sampling (CEFS) algorithm (1) and the multicorrelation forward searching (MCFS) algorithm (2) (P < 0.05). The number of noise features screened by the VDMSVM algorithm (3) was much less in contrast to that of the CEFS algorithm and the MCFS algorithm, which was 8 and 10, respectively (P < 0.05). The Visual Analogue Scale (VAS) scores of the fracture site at the 4th, 8th, 12th, and 16th hour after surgery in group R were all lower than the scores in group C (P < 0.05). The length of hospital stay (LoHS) in group R was greatly shorter than that in group C (P < 0.05). After different nursing methods, the World Health Organization Quality of Life (WHOQOL-BREF) score of patients in group R (89.64 points) was greatly higher than the score in group C (61.45 points) (P < 0.05). The nursing satisfaction score of group R was 92.35 ± 3.65 points, and that in group C was 2.14 ± 1.25 points, respectively (P < 0.05). The test results verified the effectiveness of the feature selection of the VDMSVM algorithm. The rapid rehabilitation nursing intervention was conductive to reducing the postoperative pain of fracture patients, shortening the LoHS of patients, improving the quality of life (QOL) of fracture surgery patients, and increasing the patient's satisfaction with nursing.

Increased mortality after intramedullary nailing of trochanteric fractures: a comparison of sliding hip screws with nails in 19,935 patients

Background and purpose - Intramedullary nails (IMN) have become increasingly common as treatment for trochanteric hip fractures (THF) although they are costlier, and without proven superiority compared with sliding hip screws (SHS). We investigated whether the 2 methods differ in terms of short-term mortality when used in fractures where both methods are suitable. Patients and methods - We extracted data from the Swedish Fracture Register (SFR) on 19,935 patients ≥ 60 years with trochanteric fractures AO type 31-A1 or -A2 who had been treated with either SHS or IMN. We assessed absolute mortality rates and the relative risks (RR) of death after 7, 30, 90, and 365 days using generalized linear models, adjusting for age, sex, and fracture type. We performed a sensitivity analysis on a subgroup of 3,673 patients with information on comorbidity to address this potential confounder. Results - 69% of the patients were women and mean age was 84 years (60-107). IMN was used in 35% of A1 and in 71% of A2 fractures. The use of IMN was associated with a slightly increased adjusted risk of death within 30 days compared with SHS (RR = 1.1, 95% CI 1.0-1.2) with no difference at any other time point. Interpretation - The slightly increased risk of death up to 30 days postoperatively does not support the use of IMN instead of SHS in stable THF.

Trochanteric stabilizing plate in the treatment of trochanteric fractures: a scoping review

Background and purpose - The trochanteric stabilizing plate (TSP) may be used as an adjunct to a sliding hip screw (SHS) in the treatment of trochanteric fractures to increase construct stability. We performed a scoping review of the literature to clarify when and how the TSP may be useful.Methods - A systematic search was performed in 5 databases and followed by a backwards-and-forwards citation search of the identified papers. 24 studies were included.Results - 6 biomechanical studies and 18 clinical studies were included in the review. The studies presented mainly low-level evidence. All studies were on unstable trochanteric fractures or fracture models. Due to the heterogeneity of methods and reporting, we were not able to perform a meta-analysis. In the biomechanical trials, the TSP appeared to increase stability compared with SHS alone, up to a level comparable with intramedullary nails (IMNs). We identified 1,091 clinical cases in the literature where a TSP had been used. There were 82 (8%) reoperations. The rate of complications and reoperations for SHS plus TSP was similar to previous reports on SHS alone and IMN. It was not possible to conclude whether the TSP gave better clinical results, when compared with either SHS alone or with IMN.Interpretation - The heterogeneity of methods and reporting precluded any clear recommendations on when to use the TSP, or if it should be used at all.

Comparison of outcomes after different methods of fixation for extracapsular hip fractures: An observational study

OBJECTIVE

Optimal management of intertrochanteric fractures using either sliding hip screws (SHS) or Intramedullary nail (IMN) fixation has long been disputed and the optimal length of a 'short nail' has yet to be clarified. Our aim was to investigate functional outcomes in patients who have undergone either sliding hip screw fixation or intramedullary fixation using varied lengths of nails to assess potential superiority.

DESIGN

We retrospectively reviewed data from consecutive patients with trochanteric hip fractures between January 2010 - July 2019. Fracture fixation was performed with four different devices; SHS, 220mm and 175mm Targon PFT nails or 180mm Short Affixus Hip Fracture Nails. There was no significant difference in the patient demographics in each treatment group.

MAIN OUTCOME MEASURES

Patients were followed up for 1 year post operatively to determine if there were differences in mobility and pain with the different fixation methods.

RESULTS

There was no significant difference in the overall complication rate between methods of fixation. Overall Intramedullary nail fixation resulted in an improved mean pain score compared to SHS (mean difference 0.25, 95% CI 0.11 - 0.39, p=0.0005). On sub-analysis this was only statistically significant in 220mm Targon nails (mean difference 0.35, CI 0.19-0.57, p=0.0010) and not for the other two nails. In addition, there was a significant difference in mobility score (mean difference 0.38, CI 0.12-0.63, p=0.0036). On sub-analysis this was only statistically significant favouring the for 220 mm Targon nail (mean difference 0.57, CI 0.27-0.87, p=0.0002).

CONCLUSION

We advise caution in interpreting the results of studies between different nails and SHS, as not all nails appear to be the same. Design features of modern nails such as length, proximal diameter, the use of a compression screw, lag screw interface within the nail and valgus inclination may all play a role in functional outcomes.

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.

Treatment of intertrochanteric nonunion after sliding hip screw fixation with a short cephalomedullary nail

Intertrochanteric femur fracture nonunions are a rare complication that can be difficult to treat with limited evidence regarding treatment options. Revision fixation is typically reserved for well-aligned nonunions with sufficient femoral head bone stock. The most common implant used for revision fixation is a sliding hip screw implant. The use of a short cephalomedullary nail (CMN) for revision fixation has not been previously reported. This article presents a technique for reamed short CMN revision fixation of well-aligned nonunions with sufficient bone stock that is a simpler and potentially less morbid treatment option compared to open procedures with fixed-angle devices. For nonunions with poor femoral head bone stock and/or malaligned fractures, a fixed-angle implant, with or without a valgus osteotomy, may be necessary, while arthroplasty is reserved for nonunions with poor proximal femur bone stock that are not amenable to fixed-angle implant fixation.

CT scans better assess lateral wall morphology of "stable appearing" intertrochanteric (IT) femur fractures and predict early failure of sliding hip screw (SHS) fixation

To compare the efficacy of plain x-ray images and computed tomography (CT) to assess the morphology of the lateral wall (LW) component of intertrochanteric (IT) femur fractures and determine predictors of early fixation failure.

DESIGN

Retrospective cohort study.

SETTING

Level-one trauma center.

PATIENTS/PARTICIPANTS

One hundred forty-two adult patients with IT fractures treated with either a sliding hip screw (SHS) or a cephalomedullary nail (CMN) who had both pre-op plain x-ray images and CT scans with at least 6 weeks of follow-up were reviewed.

INTERVENTION

Preoperative CT scan and plain radiographs of the affected hip.

MAIN OUTCOME MEASUREMENTS

Lateral wall assessment based on plain x-rays versus CT imaging in relation to implant failure.

RESULTS

One hundred forty-two patients met inclusion criteria, 105 patients treated with a CMN, and 37 with a SHS. There was a poor correlation between the assessment of the LW on plain x-ray images and CT scans. Failures in the SHS group were significantly associated with all CT measurements (P < .05) but not with plain film LW assessment (P = .66). Fifteen patients had an early implant failure (6 CMN, 9 SHS). There were no statistically significant associations between any radiographic measurement (plain images and CT) and CMN failures.

CONCLUSIONS

Plain film images are not accurate for assessing lateral wall morphology/integrity and are not predictive of SHS implant failures. Our novel CT measurements were effective at detecting lateral wall patterns at risk for treatment failure with SHS implants.Level of Evidence: Level III.

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.

Inter- and intra-observer reliability of the new AO/OTA classification of proximal femur fractures

INTRODUCTION

Hip fractures are a global health burden, with an incidence that is projected to increase from 66,000/year currently in the United Kingdom to 100,000/year by 2033. The classification of intertrochanteric fractures is key to the treatment algorithms advising on their surgical management. The AO/OTA classification is the most commonly used system, initially published in 1990 and subsequently shown to have poor inter- and intra-observer reliability, it was revised in 2018 with the main aim of re-classifying and further defining the 31-A2 group.

METHODS

150 plain film anteroposterior and lateral plain film radiographs of intertrochanteric fractures from three hospitals were classified using the 2018 AO/OTA classification of intertrochanteric fractures by six Orthopaedic Surgeons (2 Consultants, 4 Trainees), all were blinded to the definitive surgical treatment for patients. Radiographs were re-classified after a minimum of 3-months, Cohen's Kappa for inter-observer reliability was calculated from first round classifications and intra-observer reliability from first and second classifications.

RESULTS

Mean Kappa for inter-observer reliability for AO group classification (e.g. 31-A1) was 0.479 (0.220 - 0.771, for sub-group classification (e.g. 31-A1.1) reliability reduced to 0.376 (0.276 - 0.613). Intra-observer reliability was comparable for both group and sub-group classifications, 0.661 and 0.587 respectively.

CONCLUSIONS

The revised 2018 AO/OTA classification aimed to simply the classification of intertrochanteric fractures, however it remains unreliable with only a "moderate" inter-observer reliability at group level with this falling to "fair" when sub-group classifications are made. Identification of stable and unstable injuries using the new AO/OTA system remains fraught with difficulties and appears difficult to apply with consistent accuracy.

Intramedullary nailing versus sliding hip screw for A1 and A2 trochanteric hip fractures

AIMS

This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)).

METHODS

A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant.

RESULTS

The overall agreement between surgeons on implant choice was fair (kappa = 0.27 (95% confidence interval (CI) 0.25 to 0.28)). Factors associated with preference for IMN included USA compared to Europe or the UK (Europe odds ratio (OR) 0.56 (95% CI 0.47 to 0.67); UK OR 0.16 (95% CI 0.12 to 0.22); p < 0.001); exposure to IMN only during training compared to surgeons that were exposed to both (only IMN during training OR 2.6 (95% CI 2.0 to 3.4); p < 0.001); and A2 compared to A1 fractures (Type A2 OR 10 (95% CI 8.4 to 12); p < 0.001).

CONCLUSION

In an international cohort of orthopaedic surgeons, there was a large variation in implant preference for patients with A1 and A2 trochanteric fractures. This is due to surgeon bias (country of practice and aspects of training). The observation that surgeons favoured the more expensive implant (IMN) in the absence of convincing evidence of its superiority suggests that surgeon de-biasing strategies may be a useful focus for optimizing patient outcomes and promoting value-based healthcare. Cite this article: Bone Joint J 2021;103-B(4):775-781.

Fractures around Trochanteric Nails: The "Vergilius Classification System"

INTRODUCTION

The fractures that occurred around trochanteric nails (perinail fractures, PNFs) are becoming a huge challenge for the orthopaedic surgeon. Although presenting some specific critical issues (i.e., patients' outcomes and treatment strategies), these fractures are commonly described within peri-implant ones and their treatment was based on periprosthetic fracture recommendations. The knowledge gap about PNFs leads us to convene a research group with the aim to propose a specific classification system to guide the orthopaedic surgeon in the management of these fractures.

MATERIALS AND METHODS

A steering committee, identified by two Italian associations of orthopaedic surgeons, conducted a comprehensive literature review on PNFs to identify the unmet needs about this topic. Subsequently, a panel of experts was involved in a consensus meeting proposing a specific classification system and formulated treatment statements for PNFs. Results and Discussion. The research group considered four PNF main characteristics for the classification proposal: (1) fracture localization, (2) fracture morphology, (3) fracture fragmentation, and (3) healing status of the previous fracture. An alphanumeric code was included to identify each characteristic, allowing to describe up to 54 categories of PNFs, using a 3- to 4-digit code. The proposal of the consensus-based classification reporting the most relevant aspects for PNF treatment might be a useful tool to guide the orthopaedic surgeon in the appropriate management of these fractures.

Clockwise Torque of Sliding Hip Screws: Is There a Right Side?

OBJECTIVES

This study evaluated whether patients with a left-sided femoral neck fracture (FNF) treated with a sliding hip screw (SHS) had a higher implant failure rate than patients treated for a right-sided FNF. This was performed to determine the clinical relevance of the clockwise rotational torque of the femoral neck lag screw in a SHS, in relation to the rotational stability of left and right-sided FNFs after fixation.

METHODS

Data were derived from the FAITH trial and Dutch Hip Fracture Audit (DHFA). Patients with a FNF, aged ≥50, treated with a SHS, with at least 3-month follow-up data available, were included. Implant failure was analyzed in a multivariable logistic regression model adjusted for age, sex, fracture displacement, prefracture living setting and functional mobility, and American Society for Anesthesiologists Class.

RESULTS

One thousand seven hundred fifty patients were included, of which 944 (53.9%) had a left-sided and 806 (46.1%) a right-sided FNF. Implant failure occurred in 60 cases (3.4%), of which 31 were left-sided and 29 right-sided. No association between fracture side and implant failure was found [odds ratio (OR) for left vs. right 0.89, 95% confidence interval (CI) 0.52-1.52]. Female sex (OR 3.02, CI: 1.62-6.10), using a mobility aid (OR 2.02, CI 1.01-3.96) and a displaced fracture (OR 2.51, CI: 1.44-4.42), were associated with implant failure.

CONCLUSIONS

This study could not substantiate the hypothesis that the biomechanics of the clockwise screw rotation of the SHS contributes to an increased risk of implant failure in left-sided FNFs compared with right-sided fractures.

LEVEL OF EVIDENCE

Therapeutic Level II.See Instructions for Authors for a complete description of levels of evidence.

Fluoroscopic Marker-Based Guidance System Improves Gamma Lag Screw Placement During Nailing of Intertrochanteric Fractures: A Randomized Controlled Trial

OBJECTIVES

To determine whether a fluoroscopy-based navigation system would improve tip-apex distance (TAD) compared with the conventional technique.

DESIGN

Randomized controlled trial.

SETTING

Level 1 trauma center.

PATIENTS

A total of 161 patients were screened for inclusion in the study. After meeting inclusion and exclusion criteria, 31 patients were randomized (n = 18 navigated vs. n = 13 control group), with the patient blinded to the result.

INTERVENTION

Fluoroscopy-based navigated guidance of lag screw length and position.

MAIN OUTCOME MEASURES

Average TAD and the proportion of TAD over 25 mm.

RESULTS

TAD was lower in the navigated group compared with the control group (mean = 17.5 vs. 24.2 mm; P = 0.0018). No navigated cases exceeded the 25 mm TAD threshold, compared with 39% of conventional cases (P = 0.0076). Navigation resulted in fewer drilling attempts compared with the conventional technique (median = 1 vs. 4 attempts; P < 0.0001). We detected no significant differences in operation time or total number of fluoroscopic images (P > 0.05).

CONCLUSIONS

Fluoroscopy-based computer navigated Gamma nailing for intertrochanteric fractures improved TAD and reduced the number of drilling attempts without increasing operation time compared with the conventional fluoroscopy-guided technique in a teaching hospital setting.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Early mechanical complications following fixation of proximal femur fractures: From prevention to treatment

Proximal femur fractures have significant functional repercussions in both older adults (sometimes life-threatening) and younger adults (socioeconomic). This study will review the early mechanical complications (EMC) associated with the fixation of femoral neck (FNF) and trochanteric (TF) fractures. What is the nature of these complications? They consist of incorrect fracture fixation, secondary displacement and/or fixation failure (FNF: 3-10%; TF: 5-7%), and more rarely, secondary fractures distal to the implant. What are the risk factors and how can they be controlled? They are related to the patient (osteoporosis), to the type of fracture (FNF: posterior comminution, magnitude of displacement, vertical fracture line, fracture of calcar/TF: comminution of calcar, lesser trochanter fracture, metaphyseal comminution, lateral cortex fracture, greater trochanter comminution), to the chosen treatment (FNF: triple screw fixation or screw-plate are preferable/TF: all implants suitable for simple fractures, cervicomedullary implants for complex fractures), and to the surgical technique (quality of reduction, implant positioning). How should they be treated? Early revision of internal fixation can be difficult and increases the infection risk. Inter- or subtrochanteric valgus osteotomy leads to satisfactory results but is difficult to carry out. Secondary arthroplasty, which is the preferred option in older adults, leads to good outcomes but is technically more difficult, and has a higher complication rate in EMC of trochanteric fractures. LEVEL OF EVIDENCE: V.

Mobility after intertrochanteric hip fracture fixation with either a sliding hip screw or a cephalomedullary nail: Sub group analysis of a randomised trial of 1000 patients

AIMS

The aim of this study was to determine if different patient groups have superior mobility regain following intertrochanteric hip fracture fixation with a cephomedullary nail compared to a sliding hip screw (SHS).

PATIENTS AND METHODS

The present study is a subgroup analysis of patients which were enrolled into a randomized controlled trial which randomized 1000 patients with an intertrochanteric hip fracture to fixation with either a short cephomedullary nail (Targon® PF or PFT) or a SHS. In the present study the two treatment groups were dicotomised on the basis of six variables determined at the time of admission; age (<80; ≥80 years), sex, residence (admitted from own home; institutional care), mobility (mobility score ≥7 [good]; <7 [poor]), mental status (AMTS < 7 [cognitively impaired]; ≥7) and health status (ASA < 3; ≥3). The primary outcome measure was the difference between mobility score pre-fracture and mobility score during the year after hip fracture fixation.

RESULTS

Patients less than 80 years of age, those admitted from their own home, cognitively intact patients and patients who mobilised without assistance pre-fracture, recovered superior mobility when fracture fixation was performed with a nail compared to a SHS. Those patients admitted from institutional care, those with significant cognitive or mobility impairment at the time of the injury did not have any significantly improved benefit in mobility regain with a nail compared to a SHS.

CONCLUSION

Fixation of an intertrochanteric hip fracture with a cephomedullary nail results in superior recovery of mobility for younger patients who prior to the injury were more mobile, cognitively intact and living at home.

Cephalomedullary nailing versus sliding hip screws for Intertrochanteric and basicervical hip fractures: a propensity-matched study of short-term outcomes in over 17,000 patients

BACKGROUND

Hip fractures are associated with poor mortality and morbidity outcomes. Controversy exists over what the preferred treatment is between sliding hips screws (SHSs) and cephalomedullary nails (CMNs) for stable intertrochanteric (IT) and basicervical (BC) hip fractures. The purpose of this study was to compare early postoperative outcomes and complications in patients treated with SHS to those treated with CMN in IT and BC hip fractures.

METHODS

We used the National Surgical Quality Improvement Program database to identify IT and BC hip fractures, excluding subtrochanteric hip fractures treated with a SHS and CMN for 2008 to 2016. After propensity score matching, there were 8505 patients in the SHS cohort and 8505 in the CMN cohort. Propensity score-adjusted multivariate regression models assed SHS as an independent risk factor for the following 30-day outcomes: mortality, postoperative major and minor complications, discharge disposition, readmission and reoperation, length of hospital stay (LOS), and operative time.

RESULTS

No difference in mortality was encountered between SHS and CMN (p = 0.440). Compared to CMN, the SHS cohort had an 11.6% decreased likelihood of a minor complication (p < 0.001); however, no difference was found between CMN and SHS for major complications (p = 0.117). SHS patients were less likely to have transfusion (p < 0.001), DVT (p = 0.007), and MI (0.024). SHS patients were 12.5% more likely to go home (p = 0.002). No association was discovered between being treated with a SHS and reoperation (p = 0.449) and readmission (p = 0.588). SHS patients had almost a quarter of a day longer LOS (p = 0.041). Patients treated with SHS had a statistically significant (p < 0.001), but clinically irrelevant 2-min longer procedure.

LEVEL OF EVIDENCE

III.

Fractures in older adults. A view of the future?

INTRODUCTION

It is accepted that the incidence of fractures in patients aged ≥ 65 years is increasing but little is known about which fractures are becoming more common in this group of patients. Virtually all research has concentrated on the classic fragility fractures of the proximal femur, proximal humerus, pelvis, spine and distal radius but it is likely that other fractures are becoming more common.

METHODS

We have examined two prospectively collected databases 10 years apart to see which fractures are becoming more common in ≥ 65 year old patients. We compared the fractures to look for epidemiological differences over the 10-year period and we compared the epidemiology of the fractures that had increased in incidence with equivalent fractures in the < 65 year old population.

RESULTS

Analysis shows that in older female patients fractures of the clavicle, finger phalanges, ankle and metatarsus are increasing in incidence. In males there is an increasing incidence of fractures of the proximal humerus, distal humerus, metacarpus, pelvis, femoral diaphysis, distal tibia and ankle. In females the basic epidemiology of fractures in the ≥ 65 year old population was very similar to the fractures seen in younger females and we believe that the increasing incidence of fractures in the future will mainly be low velocity fractures following falls. In older males however, it is apparent that there is a much wider variation in the causes of fracture.

DISCUSSION

We believe that the changes in fracture epidemiology in older patients relate to improved health and longevity and analysis of our population during the study period shows significant social changes which are associated with increased longevity and improved health. It is probable that fractures in older patients will continue to increase in incidence and that other fractures that are now commonly seen in middle-aged patients will be seen in older patients. Surgeons will have to treat more complex fractures in older males than in older females and it is likely that there will be a higher incidence of open and multiple fractures. Appropriate management techniques will need to be established.

Femoral neck fractures after internal fixation of trochanteric fractures with implants in situ in adults: A systematic review

INTRODUCTION

Femoral neck fractures (FNF) after internal fixation of trochanteric fractures (AIFTF) with the implant in situ (WIIS) are uncommon. Publications of FNFAIFTFWIIS are rare. The purpose of this systematic review of the literature is to report on the frequency, risk factors, mechanisms, clinical presentation, diagnostic and therapeutic modalities, outcomes and the eventual prevention of this complication.

MATERIALS AND METHODS

A comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of FNFAIFTFWIIS and series of trochanteric fractures (TF) with this complication in adults published between inception of journals to May 2018 were eligible for inclusion. Cases with fractures in pathological bone, undergoing treatment with hip replacement, or after partial or total implant removal were excluded. Relevant information was divided in two parts. Part I included the analysis of cases of FNFAIFTFWIIS, with the objective of establishing the eventual risk factors, mechanisms, diagnostic, treatment modalities, and outcomes. Part II analyzed series of TFs with implants in situ which included cases of FNFs for assessing the incidence of FNFs in this condition.

RESULTS

Overall 77 publications with 104 cases of FNFAIFTFWIIS met the inclusion criteria. The median incidence of this complication was 0,43%. The mean age was 80 years (range, 42-96).The prevalent factors for FNFAIFTFWIIS were osteoporosis, and the presence of the implant in the femoral neck and head. A short nail or screw with the tip far from the subchondral bone was of influence as a stress riser factor, but not prevalent because in two thirds of the cases the FNF occurred when the implant was introduced up to the subchondral bone. Other risk factors analysed included varus reduction or nonunion of the TF, and the breakage of the hip screw, which modify the forces exerted over the femoral neck, and may contribute to the FNF. The FNFs were spontaneous, i.e. not related to trauma or fall, in more than two thirds of the cases.

CONCLUSION

The etiology of FNFAIFTFWII should be considered multifactorial. The frequency seems low. Although a subchondral positioning of the hip screw might diminish the incidence of FNFS, a correct surgical technique does not preclude a FNFAIFTFWIIS, and in fact the incidence of this complication was higher in these correctly treated patients. FNFAIFTFWIIS is a fragility fracture and adequate management of systemic osteoporosis should be targeted as a main factor of prevention.

Stability of extracapsular hip fracture: Does it affect rehabilitation outcome of post-acute patients?

BACKGROUND

Various factors have been shown to affect rehabilitation outcome of hip fractured patients. The degree of extracapsular fracture stability may also affect functional recovery. The aim of our study was to assess the relationship between extracapsular hip fracture stability and rehabilitation outcome in a post-acute setting.

METHODS

A retrospective cohort study of 144 hip fractured patients was carried out in a post-acute geriatric rehabilitation center from 1/2014 to 6/2015. The main outcome measures were the Functional Independence Measure (FIM) instrument, motor FIM (mFIM), Montebello Rehabilitation Factor Score (MRFS) on the mFIM and length of stay (LOS). The associations between patients with stable vs. unstable and clinical, demographic and comorbidity variables, were assessed by the Mann-Whitney U and chi-square tests. A multiple linear regression model was used to estimate the association between fracture stability and LOS score after controlling for sociodemographic characteristics and chronic diseases.

RESULTS

Rehabilitation outcomes (FIM and mFIM score changes, mFIM MRFS) were found independent of extracapsular hip fracture stability. Patients with an unstable fracture presented with a significantly longer LOS compared with a stable fracture (p = .008). Multiple linear regression analysis showed that fracture stability was significantly associated with LOS after adjustment for confounding demographic, clinical and functional variables (p = .009).

CONCLUSION

Patients with unstable extracapsular hip fractures may require a prolonged rehabilitation period in order to achieve the same functional gain as patients with stable fractures.