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Gounot A, Charlot A, Guillon P, Schaefer A, Moslemi A, Boutroux P, Sautet A. The use of uncemented stems in femoral neck fractures in elderly patients: A comparative study of 671 cases. Orthop Traumatol Surg Res 2024; 110:103878. [PMID: 38582221 DOI: 10.1016/j.otsr.2024.103878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 10/07/2023] [Accepted: 02/14/2024] [Indexed: 04/08/2024]
Abstract
INTRODUCTION The use of cemented stems in elderly patients is associated with the risk of intraoperative embolic complications. Uncemented stems eliminate this risk, but their use is controversial because of the risk of mechanical complications, with estimated subsidence between 3.6 and 30% and periprosthetic fractures between 2.1 and 11% at 6 weeks. A retrospective multicenter comparative study was conducted using a propensity score analysis to evaluate mechanical performances of uncemented stems in femoral neck fractures in elderly patients to (1) compare the risk of mechanical complications and (2) assess the use of metaphyseal-anchored stems for this indication. HYPOTHESIS There is no difference in the risk of mechanical complications, intraoperatively or postoperatively, between these stems. MATERIALS AND METHODS We conducted a multicenter retrospective comparative study including 358 uncemented and 313 cemented stems. The mean age was 84.5 years [83.9-85.1]. The inclusion criteria were patients 70 years and older and a follow-up of at least 6 weeks. The primary endpoint was a composite endpoint comprised of stem subsidence≥2mm or periprosthetic fracture (up to 3 months postoperatively). The secondary endpoints were infection, stem subsidence≥2mm, and operative time. These endpoints were analyzed using a propensity score to control confounding factors. A secondary analysis used the same endpoints to compare metaphyseal-anchored (short stems) versus Corail-like stems. RESULTS After adjusting for the propensity score, we found 11.17% mechanical complications in the uncemented group (n=40, 5.59% subsidence, and 5.59% fractures) versus 13.42% for the cemented group (n=42, 7.99% subsidence, and 5.43% fractures). There was no statistically significant difference between the 2 values (Odds Ratio [OR]=0.64 [95% Confidence Interval [CI]: 0.14-2.85] [p=0.7]). The mortality rate due to cement embolism was 1%. There was no difference in the rate of subsidence (OR=0.55 [95% CI: 0.02-12.5] [p=0.7]), periprosthetic fracture (OR=0.65 [95% CI: 0.13-3.12] [p=0.7]) or infection (OR=0.71 [95% CI: 0.32-1.55] [p=0.4]). However, the operative times were longer in the cemented group (p=0.03 for hemiarthroplasties [mean additional time 16minutes] and p=0.02 for total hip arthroplasties [mean additional time 22minutes]). No difference was observed between the metaphyseal-anchored (short stems) and Corail-like stems regarding operative time, rate of infection, and rate of stem subsidence or periprosthetic fractures. DISCUSSION This is one of the first studies to highlight cemented stem subsidence when used for femoral neck fractures in elderly patients. Using uncemented stems in this indication is still warranted, especially since they do not bring about more mechanical complications in the first few months. Metaphyseal-anchored short stems seem to give the same results as "standard" stems. However, these findings need to be assessed in the longer term. LEVEL OF EVIDENCE III; retrospective comparative study.
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Affiliation(s)
- Alexandre Gounot
- Département de chirurgie orthopédique et traumatologique, GHI Le Raincy Montfermeil, 10, rue du Général-Leclerc, 93370 Montfermeil, France.
| | - Anahita Charlot
- Département de chirurgie orthopédique et traumatologique, GHI Le Raincy Montfermeil, 10, rue du Général-Leclerc, 93370 Montfermeil, France
| | - Pascal Guillon
- Département de chirurgie orthopédique et traumatologique, GHI Le Raincy Montfermeil, 10, rue du Général-Leclerc, 93370 Montfermeil, France
| | - Augustin Schaefer
- Département d'anesthésie, hôpital Ambroise-Paré, Assistance publique-Hôpitaux de Paris (AP-HP), 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Aymane Moslemi
- Département de chirurgie orthopédique et traumatologique, hôpital Saint-Antoine, Assistance publique-Hôpitaux de Paris (AP-HP), 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Pierre Boutroux
- Département de chirurgie orthopédique et traumatologique, hôpital Saint-Antoine, Assistance publique-Hôpitaux de Paris (AP-HP), 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Alain Sautet
- Département de chirurgie orthopédique et traumatologique, hôpital Saint-Antoine, Assistance publique-Hôpitaux de Paris (AP-HP), 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
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Boukebous B, Biau D, Gao F. AtoG: A simple score to predict complications and death after hip fractures, in line with the comprehensive geriatric assessment. Orthop Traumatol Surg Res 2024; 110:103827. [PMID: 38280714 DOI: 10.1016/j.otsr.2024.103827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/07/2023] [Accepted: 01/22/2024] [Indexed: 01/29/2024]
Abstract
INTRODUCTION Proximal Femur Fractures (PFFs) are a significant public health issue and occur in the context of global frailty and aging. Recent literature identifies new patient-related prognostic factors that focus on socioeconomic environment, patient well-being, or nutrition status. Specific scores have been developed, but in most cases, they fail to be in line with the comprehensive geriatric assessment, or do not assess the newly identified prognostic factors, contain multitude collinearities, or are too complex to be used in the daily practice. Hypothesis A comprehensive score with equal representation of the patient's dimensions does at least as good as the Charlson score (CCI), to predict complications and mortality. OBJECTIVE To develop a new comprehensive prognostic score, predicting inpatient complications and mortality up to 5-year after PFF. MATERIAL AND METHODS The patients treated surgically for PFF on a native hip, between 2005 and 2017 were selected from a French national database. The variables were the gender, age, the type of treatment (osteosynthesis or arthroplasty), and the CCI. The outcomes were the medical and surgical complications as inpatient and the mortality (up to 5-year). Variables were grouped into dimensions with similar clinical significance, using a Principal Component Analysis, for instance, bedsores and malnutrition. The dimensions were tested for 90-day mortality and complications, in regressions models. Two scores were derived from the coefficients: SCOREpond (strict ponderation), and SCORE (with loose ponderation: 1 point/risk factors, -1 point/protective factors). Calibration, discrimination (ROC curves with Area Under Curves AUC), and cross-validation were assessed for SCOREpond, SCORE, and CCI. RESULTS Analyses were performed on 7756 fractures. The factorial analysis identified seven dimensions: age; brain-related conditions (including dementia): 1738/7756; severe chronic conditions (for instance, organ failures) 914/7756; undernutrition: 764/7756; environment, including social issues or housing difficulties: 659/7756; associated trauma: 814/7756; and gender. The seven dimensions were selected for the prognostic score named AtoG (ABCDEFG, standing for Age, Brain, Comorbidities, unDernutrition, Environment, other Fractures, Gender). The median survival rate was 50.8 months 95% CI [49-53]. Anaemia and urologic complications were the most prevalent medical complications (1674/7756, 21%, and 1109/7756, 14.2%). A total of 149/7756 patients (1.9%) developed a mechanical inpatient complication (fractures or dislocations), with a slightly higher risk for arthroplasties. The AUCs were 0.69, 0.68, and 0.67 for AtoGpond, AtoG, and CCI, respectively, for 90-day mortality, and 0.64, 0.63, and 0.56 for complications. Compared to patients with AtoG=0, Hazard Ratios for 90-day mortality were 2.3 95% CI [1.7-2.9], 4.2 95% CI [3.1-5.4], 6 95% CI [4.5-8.1], 8.3 95% CI [6.5-12.9], and 13.7 95% CI [8-24], from AtoG=1 to AtoG≥5, respectively (p<10-4); the 90-day survival decreased by 5%/point, roughly. The sur-risk of mortality associated with AtoG was up to 5-year: HR=1.51 (95% CI [1.46-1.55], p<10-4). Compared to AtoG=0, from AtoG=1 to AtoG≥5, the pooled Odd Ratios were 1.14 95% CI [1.06-1.2], 1.53 95% CI [1.4-1.7], 2.17 95% CI [1.9-2.4], 2.9 95% CI [2.4-3.4], and 4.9 95% CI [3.3-7.4] for any complication (p<10-4). CONCLUSION AtoG is a multidimensional score in line with the concept of comprehensive geriatric assessment. It had good discrimination and performance in predicting 90-day mortality and complications. Performances were as good as CCI for 90-day mortality, and better than it for the complications. LEVEL OF PROOF IV; retrospective cohort study.
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Affiliation(s)
- Baptiste Boukebous
- Université Paris Cité, équipe ECAMO, Centre of Research in Epidemiology and Statistics (CRESS), Inserm, UMR 1153, Paris, France; Service de chirurgie orthopédique et traumatologique, Beaujon/Bichat, université Paris Cité, AP-HP, Paris, France.
| | - David Biau
- Université Paris Cité, équipe ECAMO, Centre of Research in Epidemiology and Statistics (CRESS), Inserm, UMR 1153, Paris, France; Service de chirurgie orthopédique et traumatologique, Cochin, université Paris Cité, AP-HP, Paris, France
| | - Fei Gao
- Recherche sur les Services et management en santé (RSMS) - U1309, université de Rennes, EHESP, CNRS, Inserm, Arènes - UMR 6051, 35000 Rennes, France
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Pala E, Ruggieri P. The role of dual mobility hip prosthesis in the management of intracapsular neck of femur fractures. Injury 2024; 55:111324. [PMID: 38280755 DOI: 10.1016/j.injury.2024.111324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Affiliation(s)
- Elisa Pala
- Department of Orthopedics and Orthopedic Oncology, University of Padova, Padova, Italy
| | - Pietro Ruggieri
- Department of Orthopedics and Orthopedic Oncology, University of Padova, Padova, Italy.
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Erivan R, Bourzat N, Mulliez A, Mougues C, Descamps S, Boisgard S, Villatte G. Single-use versus reusable ancillaries for dual mobility cup in total hip replacement. A prospective randomized short-term safety and feasibility comparison. Orthop Traumatol Surg Res 2023; 109:103658. [PMID: 37451339 DOI: 10.1016/j.otsr.2023.103658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/07/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Single-use (SU) ancillaries for cup preparation in total hip arthroplasty (THR) aim to reduce the costs of hip replacement surgery. These devices have been recently introduced, but their safety and feasibility have not been studied. Therefore, we performed a prospective randomized study aiming to assess the impact in our department of using these SU ancillaries versus standard reusable ancillaries for dual mobility THR regarding 1) the cost, 2) operative time, 3) quality of primary fixation. HYPOTHESIS We hypothesized that the use of SU ancillaries for acetabular preparation would reduce maintenance costs, and so optimise the operating procedure, reduce the overall cost of surgery, save time, while maintaining the same quality of prosthesis fitting. METHOD We conducted a randomised, controlled, open-label, two-arm, single-centre, prospective therapeutic trial with a medico-economic objective. Inclusions were made prospectively from patients hospitalised and surgically managed in our department for arthrosis over 18 years old treated with dual mobility THR. RESULTS In the current study, 18/20 (90%) of the cases required the use of one SU reamer when using SU ancillaries. Only two cases (10%) required a second SU reamer (without SU failure regarding the acetabular implant) because there was too much subchondral bone left and not enough cancellous bone allowing correct cup fitting. We also found that the test implant supplied in the SU kit had a less secure press-fit than the reusable metal test implants. There was one of primary press-fit failure in the SU group requiring a different cup with additional screws. The estimated cost to the supplier per procedure was 20,105 euros using single-use reamers versus 26,666 euros using conventional ancillary kits, a saving of 6561 euros (p<0.001). For the healthcare institution, the median price per intervention on the differentiating points was 2648 euros versus 2580 euros, with no significant difference (p=0.297). The results show an average societal cost of 52,199 euros using single-use and 53,572 euros using reusable ancillary equipment, with a significant difference between the two groups (p<0.003). The average cost of Healthcare Risk Waste (HCRW) disposal in the SU group was 5.2 euros per intervention against 5.1 euros in the RU group, without significant difference (p=0.910). We found a similar result for the cost of disposal of non-HCRW waste per procedure: 0.37 euros in the SU group versus 0.34 in the RU group, without significant difference (p=0.345). CONCLUSION SU ancillaries significantly reduce the table set up time and have the potential to facilitate time and cost savings but further research is needed in this direction. Our study shows that the daily workload, operating times, and the number of boxes of instruments to be sterilised are decreased. The associated environmental gain is significant. Nevertheless, the economic promise of these SU ancillaries is only partially supported in this trial owing to the small number of patients. Further work will be needed to obtain a more powerful medico-economic assessment of this promising ancillary product. LEVEL OF EVIDENCE II; prospective randomized study.
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Affiliation(s)
- Roger Erivan
- Université de Clermont Auvergne, CHU de Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, 63000 Clermont-Ferrand, France.
| | | | - Aurélien Mulliez
- Délégation à la recherche clinique et aux innovations (DRCI), CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Chalin Mougues
- Délégation à la recherche clinique et aux innovations (DRCI), CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Stéphane Descamps
- Université de Clermont Auvergne, CHU de Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, 63000 Clermont-Ferrand, France
| | - Stéphane Boisgard
- Université de Clermont Auvergne, CHU de Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, 63000 Clermont-Ferrand, France
| | - Guillaume Villatte
- Université de Clermont Auvergne, CHU de Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, 63000 Clermont-Ferrand, France
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Boukebous B, Gao F, Biau D. Hip fractures after 60 years of age in France in 2005-2017: Nationwide sample of statutory-health-insurance beneficiaries. Orthop Traumatol Surg Res 2023; 109:103677. [PMID: 37678611 DOI: 10.1016/j.otsr.2023.103677] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/02/2023] [Accepted: 05/16/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Proximal femoral factures (PFFs) constitute a heavy medical, social, and economic burden. Overall, orthopaedic conditions vary widely in France regarding the patients involved and treatments applied. For PFFs specifically, data are limited. Moreover, the ongoing expansion of geriatric orthopaedics holds promise for improving overall postoperative survival. The objectives of this retrospective study of a nationwide French database were: 1) to describe the pathway of patients with PFFs regarding access to care, healthcare institutions involved, and times to management; 2) to look for associations linking these parameters to post-operative mortality. HYPOTHESIS Across France, variations exist in healthcare service availability and time to management for patients with PFFs. MATERIAL AND METHODS A retrospective analysis of data in a de-identified representative sample of statutory-health-insurance beneficiaries in France (Échantillon généraliste des bénéficiaires, EGB, containing data for 1/97 beneficiaries) was conducted. All patients older than 60 years of age who were managed for PFFs between 2005 and 2017 were included. The following data were collected for each patient: age, management method, Charlson's Comorbidity Index (CCI), home-to-hospital distance by road, and type of hospital (public, non-profit private, or for-profit private), and time to surgery were collected. The study outcomes were the incidence of PFF, mortality during the first postoperative year, changes in mortality between 2005 and 2017, and prognostic factors. RESULTS In total 8026 fractures were included. The 7561 patients had a median age of 83.8 years and a mean CCI of 4.6; both parameters increased steadily over time, by 0.18 years and 0.06 points per year, respectively (p<10-4 for both comparisons). Management was by total hip replacement in 3299 cases and internal fixation in 4262 cases; this information was not available for 465 fractures. The overall incidence increased from 90/100,000 in 2008 to 116/100,000 in 2017 (p=0.03). Of the 8026 fractures, 5865 (73.1%) were managed in public hospitals (and this proportion increased significantly over time), 1629 (20.3%) in non-profit private hospitals (decrease over time), and 264 (3.3%) in for-profit private hospitals. The home-to-hospital distance ranged from 7.5 to 38.5km and increased over time by 0.26km/year (95% confidence interval [95%CI]: 0.15-0.38) (p<10-4). Median time to surgery was 1 day [1-3 days], with no significant difference across hospital types. Mortality rates at 90 days and 1 year were 10.5% (843/8026) and 20.8% (1673/8026), respectively. Two factors were significantly associated with day-90 mortality: the CCI (hazard ratio [HR], 1.087 [95%CI: 1.07-1.10] [p<10-4]) and time to surgery>1 day (HR 1.35 [95%CI: 1.15-1.50] [p<0.0001]). Day-90 mortality decreased significantly from 2005 to 2017 (HR 0.95 [95%CI: 0.92-0.97] [p<10-4]), with no centre effect. CONCLUSION The management of PFF in patients older than 60 varied widely across France. Time to surgery longer than 1 day was a major adverse prognostic factor whose effects persisted throughout the first year. This factor was present in over half the patients. Day-90 mortality decreased significantly from 2005 to 2017 despite increases in age and comorbidities. LEVEL OF EVIDENCE IV Retrospective cohort study.
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Affiliation(s)
- Baptiste Boukebous
- Équipe Ecamo, CRESS (Centre of Research in Epidemiology, Statistics), Inserm, UMR 1153, université Paris-Cité, Paris, France; Service de chirurgie orthopédique et traumatologique, Beaujon-Bichat, University Hospital, Assistance publique-Hôpitaux de Paris, université Paris-Cité, Paris, France.
| | - Fei Gao
- Université de Rennes, EHESP, CNRS, Inserm, Arènes-UMR 6051, RSMS (Research on Services, Management in Health), U 1309, Rennes, France
| | - David Biau
- Équipe Ecamo, CRESS (Centre of Research in Epidemiology, Statistics), Inserm, UMR 1153, université Paris-Cité, Paris, France; Service de chirurgie orthopédique et traumatologique, Cochin University Hospital, Assistance publique-Hôpitaux de Paris, université Paris-Cité, Paris, France
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Pangaud C, Pioger C, Pauly V, Orleans V, Boyer L, Argenson JN, Ollivier M. Total hip arthroplasty reduces the risk of dislocation after femoral neck fracture. Orthop Traumatol Surg Res 2023; 109:103575. [PMID: 36754167 DOI: 10.1016/j.otsr.2023.103575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/28/2022] [Accepted: 01/24/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Femoral neck fracture in the elderly patient can either be managed using hemi-arthroplasty (HA) or total hip arthroplasty (THA). The aim of this study was to explore the rate of three selected complications in each procedure: is the dislocation rate higher with HA compared to THA? Is the blood transfusion rate higher with THA compared to HA? Do the patients who underwent THA require more ICU transfer than the patients who underwent HA? Is the ICU transfer correlated to the use of cement for stem fixation? METHOD Based on a national health-care database, a comparative and retrospective study was conducted. 96,184 patients were included after having a surgery for femoral neck fracture between 2014 and 2017. The mean follow up was 3.5 years (Min. 2 years-Max. 5 years). The population was divided into two groups: hemiarthroplasty (HA) and total hip arthroplasty (THA). The primary outcome was the dislocation rate and the secondary outcomes were the blood transfusion rate and the need for ICU after surgery. RESULTS At two years of follow up in the Hemiarthroplasty group, 3647 patients had a dislocation episode over 64,106 patients: 5.69%. In the Total Hip Arthroplasty group: 1904 patients had a dislocation episode over 32,078 patients: 5.94% (p=0.26711). The percentage of deceased patient without dislocation was 17.76% in the HA group and 11.56% in the THA group (p<0.001). The univariate hazard ratio for dislocation was higher in the THA group: HR 1.063 IC 95% (0.993-1.138) p=0.077. The multivariate analysis calculating competitive risk with death and dislocation found THA to be a protective factor of dislocation HR 0.926 IC 95% (0.866-0.991) p=0.0266. The rate of blood transfusion was 5.59% in the THA group and 7.03% in the HA group (p<0.001), The multivariate analysis found HR=1.062 IC 95% (0.99-1.139) p=0.0955. The need for ICU transfer after the surgery was 7.04% in the HA group and 8.08% in the THA group (p<0.001). The multivariate analysis found HR 0.995 IC 95% (0.921-1.076) p=0.9094. Finally, only cement was found as an independent risk factor of ICU transfer after surgery: HR 1.254 IC 95% (1.164-1.35) p<0.0001. CONCLUSION THA for femoral neck fracture allows to reduce the risk of dislocation compared to hemiarthroplasty. The multivariate analysis failed to prove the superiority of one procedure over the other regarding blood transfusion risk and the need for ICU transfer. The use of cemented stem appears to be a risk factor of ICU transfer after hip arthroplasty. LEVEL OF EVIDENCE III, Retrospective comparative study.
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Affiliation(s)
- Corentin Pangaud
- Institute of Movement Science UMR 7287, Aix-Marseille université et CNRS, Marseille, France; Institute of Movement and Locomotion, Marseille, France.
| | - Charles Pioger
- Public Teaching Hospital of Paris, Ambroise-Paré Hospital, Paris, France
| | - Vanessa Pauly
- CEReSS-Health Services Research and Quality of Life Center, faculté de médecine, secteur Timone, EA 3279, CEReSS - centre d'étude et de recherche sur les services de santé et la qualité de vie, Aix-Marseille University, 27, boulevard Jean-Moulin, 13005 Marseille, France; Department of Epidemiology and Health Economics, AP-HM, Marseille, France; Department of Medical Information, AP-HM, Marseille, France
| | - Veronica Orleans
- CEReSS-Health Services Research and Quality of Life Center, faculté de médecine, secteur Timone, EA 3279, CEReSS - centre d'étude et de recherche sur les services de santé et la qualité de vie, Aix-Marseille University, 27, boulevard Jean-Moulin, 13005 Marseille, France; Department of Epidemiology and Health Economics, AP-HM, Marseille, France; Department of Medical Information, AP-HM, Marseille, France
| | - Laurent Boyer
- CEReSS-Health Services Research and Quality of Life Center, faculté de médecine, secteur Timone, EA 3279, CEReSS - centre d'étude et de recherche sur les services de santé et la qualité de vie, Aix-Marseille University, 27, boulevard Jean-Moulin, 13005 Marseille, France; Department of Epidemiology and Health Economics, AP-HM, Marseille, France; Department of Medical Information, AP-HM, Marseille, France
| | - Jean Noël Argenson
- Institute of Movement Science UMR 7287, Aix-Marseille université et CNRS, Marseille, France; Institute of Movement and Locomotion, Marseille, France
| | - Matthieu Ollivier
- Institute of Movement Science UMR 7287, Aix-Marseille université et CNRS, Marseille, France; Institute of Movement and Locomotion, Marseille, France
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