Les fractures du col du fémur après 50 ans

Unplanned emergency department visits within 90 days of hip hemiarthroplasty for osteoporotic femoral neck fractures: Reasons, risks, and mortalities

Objectives

Bipolar hemiarthroplasty is commonly performed to treat displaced femoral neck fractures in osteoporotic patients. This study aimed to assess the occurrence and outcomes of unplanned return visits to the emergency department (ED) within 90 days following bipolar hemiarthroplasty for displaced femoral neck fractures.

Methods

The clinical data of 1322 consecutive patients who underwent bipolar hemiarthroplasty for osteoporotic femoral neck fractures at a tertiary medical center were analyzed. Data from the patients' electronic medical records, including demographic information, comorbidities, and operative details, were collected. The risk factors and mortality rates were analyzed.

Results

Within 90 days after surgery, 19.9% of patients returned to the ED. Surgery-related reasons accounted for 20.2% of the patient's returns. Older age, a high Charlson comorbidity index score, chronic kidney disease, and a history of cancer were identified as significant risk factors for unplanned ED visits. Patients with uncemented implants had a significantly greater risk of returning to the ED due to periprosthetic fractures than did those with cemented implants (P = 0.04). Patients who returned to the ED within 90 days had an almost fivefold greater 1-year mortality rate (15.2% vs 3.1%, P < 0.001) and a greater overall mortality rate (26.2% vs 10.5%, P < 0.001).

Conclusions

This study highlights the importance of identifying risk factors for unplanned ED visits after bipolar hemiarthroplasty, which may contribute to a better prognosis. Consideration should be given to the use of cemented implants for hemiarthroplasty, as uncemented implants are associated with a greater risk of periprosthetic fractures.

Acetabular erosion after bipolar hip hemiarthroplasty for femoral neck fracture in elderly patients: a retrospective study

BACKGROUND

The choice between total hip arthroplasty (THA) and hemiarthroplasty (HA) to treat displaced femoral neck fractures, particularly among the elderly, is still controversial. Acetabular erosion consists of a late multifactorial process that may happen after hip HA resulting in significant postoperative burden. This study aims to investigate the impact of acetabular erosion progress after hip HA in patients over 70 years old.

MATERIALS AND METHODS

This is a 5-year (2013-2018) retrospective study including consecutive series of patients >70 years who were treated with bipolar hip HA for femoral neck fractures. Patients were categorised into 3 groups for analysis (A = 70-75 years, B = 75-80 years, C = >80 years). The study enrolled a total number of 813 patients who met the inclusion criteria. We assessed acetabular erosion through radiological examinations and measured functional deterioration using the modified Harris Hip Score (mHHS) at 6 and 12 months follow-up. Our comprehensive investigation extended over a maximum period of 5 years. The correlation of patients' characteristics and HA features on erosion progress was assessed.

RESULTS

There were no significant differences in sex distribution, injury side, BMI, ASA score, bipolar head diameter, mHHS and leg-length discrepancy among the groups (p > 0.05). During the follow-up period, acetabular erosion with consequential conversion to THA was observed in 6.13%, 4.22% and 1.96% for Groups A, B and C respectively (p = 0.009). A statistically significant difference of acetabular erosion was observed in Group A compared to patients of Group C.

CONCLUSIONS

Age constitutes a significant factor of acetabular wear after HA in the elderly. The higher rate of acetabular wear in patients <75 years suggests that THA is a more viable option, as HA is for patients >80 years old.

Augmented versus non-augmented Trochanteric Fixation Nail-Advanced (TFNA) nails for treating trochanteric fractures in patients over sixty-five years of age

PURPOSE

Intramedullary nailing is a common treatment for pertrochanteric fractures. However, implant-related mechanical failures, such as cut-out and cut-through, lead to higher rates of revision surgery, loss of autonomy, and mortality. Cemented augmentation enhances the bone-implant interface. This study compared the frequency of mechanical failures between augmented and non-augmented Trochanteric Fixation Nail-Advanced (TFNA) nails.

METHODS

This descriptive, retrospective study at a level 1 trauma centre included patients aged > 65 years with pertrochanteric fractures treated by a short augmented or non-augmented TFNA nail. The primary outcome was the comparison of cut-out or cut-through rates between groups at three and six months postoperatively.

RESULTS

Of the 181 patients analysed, 103 had augmented TFNA nails and 78 had non-augmented TFNA nails. There were no statistically significant differences between groups in terms of demographic characteristics, AO/OTA classification, or quality of reduction. The failure rate was significantly lower in the augmented group than in the non-augmented group: 1 (0.97%) versus 9 (11.54%) (p = 0.005). At six months postoperatively, there was no significant difference between the two groups concerning functional recovery, as measured by the Parker and EuroQoL 5-Dimensions scores.

CONCLUSIONS

For patients aged over 65 years, the use of the augmented TFNA nail may reduce the risk of fixation failures such as cut-out.

Clinical Effectiveness of Total Hip Arthroplasty Compared With Hemiarthroplasty in Adults Undergoing Surgery for Displaced Intracapsular Hip Fracture: A Single-Centre Retrospective Cohort Study

BACKGROUND

The National Institute for Health and Care Excellence (NICE) recommends offering total hip arthroplasty (THA) over hemiarthroplasty (HA) for displaced intracapsular hip fractures, taking the premorbid functionality, present co-morbidities, and functional benefit beyond two years into account. Concerns remain whether the higher surgical burden and incidence of complications in THA would outweigh the potential benefits in the elderly.

METHOD

This retrospective cohort study evaluates the differences in surgical outcomes of THA vs HA in 85 patients with displaced intracapsular fractures, based on the time taken for patients to ambulate to walking frame/crutches and wheelchair post-operatively and the incidence of post-operative complications.

RESULTS

 Patients who received HA were significantly older (p<0.0001, <0.05) and had poorer pre-operative ambulatory function (p=0.032, p<0.05) than those of the THA group. HA patients had a significantly faster recovery to walking frame/crutches (20.2 days) compared to THA patients (47.3 days) (Mann-Whitney U=447.500, n=46, p=0.043, <0.05 two-tailed). While no significant differences were found in deep vein thrombosis (DVT), infected prosthesis, or dislocation incidence, hospital-acquired pneumonia (HAP) was more prevalent in THA patients (p=0.044, <0.05). Time to the walking frame had a significant effect on DVT/PE (p<0.001,

CONCLUSION

HA patients showed favourable outcomes in time to ambulate post-operatively and incidence of HAP among patients with advanced age and those with poorer pre-operative ambulatory function.

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Key Words

• geriatrics and internal medicine
• hemiarthroplasty
• hip fracture
• orthopaedic arthroplasty
• total hip arthroplasty

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MESH Headings Collapse

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Affiliation(s)

Dhanushan Gnanendran Trauma and Orthopaedics, York General Hospital, York, USA
Yanamrigesh Yanaganasar Geriatrics, Lincoln County Hospital, Lincoln, GBR
Jayagautham M Rajan Trauma and Orthopaedics, Bronglais General Hospital, Aberystwyth, GBR
Zulkifli B Hassan Trauma and Orthopaedics, Hospital Sultan Ismail, Johor Bahru, MYS
Neshvinder Balbir Singh Trauma and Orthopaedics, Newcastle University Medicine Malaysia, Johor Bahru, MYS
Lau Min Yi Trauma and Orthopaedics, Hospital Sultan Ismail, Johor Bahru, MYS
Mohamed F Nadzree Trauma and Orthopaedics, Hospital Sultan Ismail, Johor Bahru, MYS

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Complications after Dynamic Hip Screw Osteosynthesis of Proximal Femoral Fractures at Army Instructional Hospital-Libreville

The DHS system is an effective means of open reduction and internal fixation of proximal femur fractures. Postoperative complications are little described and deserve to be studied for better preventive and curative treatment. We report the observations of five (5) patients who presented postoperative complications specific to the DHS system at army instructional Hospital-Libreville. These described complications are related to deterioration of internal fixation leading to callus, nonunion, or infection. Those found are the cut out phenomenon, avascular necrosis of the femoral head, and the fracture of the DHS system. All these complications required surgical revision without functional repercussions at the last follow-up. Complications of internal fixation by the DHS system can be avoided by rigorous asepsis, adequate indications for surgery, and rigorous surgical techniques. Good management can restore hip function.

Dual mobility total hip arthroplasty in the treatment of femoral neck fractures

AIMS

To evaluate the rate of dislocation following dual mobility total hip arthroplasty (DM-THA) in patients with displaced femoral neck fractures, and to compare rates of dislocation, surgical-site infection, reoperation, and one-year mortality between DM-THA and bipolar hemiarthroplasty (BHA).

METHODS

Studies were selected based on the following criteria: 1) study design (retrospective cohort studies, prospective cohort studies, retrospective comparative studies, prospective comparative studies, and randomized controlled studies (RCTs)); 2) study population (patients with femoral neck fracture); 3) intervention (DM-THA or BHA); and 4) outcomes (complications during postoperative follow-up and clinical results). Pooled meta-analysis was carried out to evaluate the dislocation rate after DM-THA and to compare outcomes between DM-THA and BHA.

RESULTS

A total of 17 studies (ten cohort studies on DM-THA and seven comparative studies of DM-THA and BHA) were selected. These studies included 2,793 patients (2,799 hips), made up of 2,263 DM-THA patients (2,269 hips) and 530 BHA patients (530 hips). In all, 16 studies were analyzed to evaluate dislocation rate after DM-THA. The cumulative dislocation rate was 4% (95% confidence interval (CI) 3 to 5). Seven studies were analyzed to compare the rates dislocation and surgical-site infection. The rate of dislocation was significantly lower in the DM-THA group than in the BHA group (risk ratio (RR) 0.3; 95% CI 0.17 to 0.53, p < 0.001, Z -4.11). There was no significant difference in the rate of surgical-site infection between the two groups (p = 0.580). Six studies reported all-cause reoperations. The rate of reoperation was significantly lower in the DM-THA group than in the BHA group (RR 0.5; 95% CI 0.32 to 0.78, p = 0.003, Z -3.01). Five studies reported one-year mortality. The mortality rate was significantly lower in the DM-THA group than in the BHA group (RR 0.58 95% CI 0.45 to 0.75, p < 0.0001, Z -4.2).

CONCLUSION

While the evidence available consisted mainly of non-randomized studies, DM-THA appeared to be a viable option for patients with displaced fractures of the femoral neck, with better reported rates of dislocation, reoperation, and mortality than BHA. Cite this article: Bone Joint J 2020;102-B(11):1457-1466.

Dual mobility total hip arthroplasty in the treatment of femoral neck fractures

Aims

To evaluate the rate of dislocation following dual mobility total hip arthroplasty (DM-THA) in patients with displaced femoral neck fractures, and to compare rates of dislocation, surgical-site infection, reoperation, and one-year mortality between DM-THA and bipolar hemiarthroplasty (BHA).

Methods

Studies were selected based on the following criteria: 1) study design (retrospective cohort studies, prospective cohort studies, retrospective comparative studies, prospective comparative studies, and randomized controlled studies (RCTs)); 2) study population (patients with femoral neck fracture); 3) intervention (DM-THA or BHA); and 4) outcomes (complications during postoperative follow-up and clinical results). Pooled meta-analysis was carried out to evaluate the dislocation rate after DM-THA and to compare outcomes between DM-THA and BHA.

Results

A total of 17 studies (ten cohort studies on DM-THA and seven comparative studies of DM-THA and BHA) were selected. These studies included 2,793 patients (2,799 hips), made up of 2,263 DM-THA patients (2,269 hips) and 530 BHA patients (530 hips). In all, 16 studies were analyzed to evaluate dislocation rate after DM-THA. The cumulative dislocation rate was 4% (95% confidence interval (CI) 3 to 5). Seven studies were analyzed to compare the rates dislocation and surgical-site infection. The rate of dislocation was significantly lower in the DM-THA group than in the BHA group (risk ratio (RR) 0.3; 95% CI 0.17 to 0.53, p < 0.001, Z −4.11). There was no significant difference in the rate of surgical-site infection between the two groups (p = 0.580). Six studies reported all-cause reoperations. The rate of reoperation was significantly lower in the DM-THA group than in the BHA group (RR 0.5; 95% CI 0.32 to 0.78, p = 0.003, Z −3.01). Five studies reported one-year mortality. The mortality rate was significantly lower in the DM-THA group than in the BHA group (RR 0.58 95% CI 0.45 to 0.75, p < 0.0001, Z −4.2).

Conclusion

While the evidence available consisted mainly of non-randomized studies, DM-THA appeared to be a viable option for patients with displaced fractures of the femoral neck, with better reported rates of dislocation, reoperation, and mortality than BHA.

Risk factors associated with osteonecrosis of femoral head after internal fixation of femoral neck fracture:a systematic review and meta-analysis

BACKGROUND

Although the risk factors associated with osteonecrosis of femoral head (ONFH) after internal fixation of femoral neck fracture (IFFNF) have been frequently reported, the results remain controversial. Therefore, its related risk factors were systematically evaluated and meta-classified in this study.

METHODS

Literature on risk factors of ONFH caused by IFFNF was retrieved in PubMed, Embase and Cochrane Library due June 2019. Review Manager 5.3 software was applied to data synthesis, and Stata 13.0 software was adopted for analyses of publication bias and sensitivity.

RESULTS

A total of 17 case-control studies with 2065 patients were included. The risk of ONFH after IF was 0.40-fold higher in patients with Garden III-IV FNF than that in patients with Garden I-II (OR: 0.40, 95%CI: 0.29-0.55). The risk of OFNH with retained IF was uplifted by 0.04 times (OR: 0.04, 95%CI: 0.02-0.07). There was nonsignificant relationship between gender and ONFH after IFFNF (OR: 1.27, 95%CI: 0.84-1.94). Moreover, ONFH after IFFNF presented no association with age (OR:1.66, 95%CI: 0.89-3.11), injury-operation interval (OR:1.29, 95%CI: 0.82-2.04), fracture reduction mode (OR:1.98, 95%CI: 0.92-4.26), preoperative traction (OR:1.69, 95%CI: 0.29-9.98) and mechanism of injury (OR:0.53, 95%CI: 0.06-4.83). Egger's and Begg's tests indicated a publication bias (P = 0.001).

CONCLUSION

It was demonstrated that Garden classification and retained IF were important influencing factors of ONFH after IFFNF. Gender, age, injury-operation interval, fracture reduction mode, preoperative traction and the mechanism of ONFH were irrelevant to the complication.

Is non-operative treatment still relevant for Garden Type I fractures in elderly patients? The femoral neck impaction angle as a new CT parameter for determining the indications of non-operative treatment

BACKGROUND

The indications of non-operative treatment of undisplaced femoral neck fractures are controversial. The objective of this study was to assess whether two computed tomography (CT) parameters, the femoral neck impaction angle (IA) and the femoral neck posterior tilt angle (PTA), were effective in predicting the risk of secondary displacement after non-operative treatment of Garden I femoral neck fractures in patients aged 65 years or over.

HYPOTHESIS

The working hypotheses were that the IA in the coronal plane and PTA in the axial plane predicted secondary displacement after non-operative treatment of Garden I femoral neck fractures, could be reproducibly and reliably measured on CT scans, and could serve to identify Garden I fractures at risk for secondary displacement after non-operative treatment.

METHODS

Forty-nine patients aged 65 years or over with Garden I fractures treated non-operatively were included in a prospective single-centre study. CT images were used to measure the IA as the position of the fracture line relative to the femoral head in the coronal plane and the PTA as the position of the femoral head centre relative to the femoral neck axis in the axial plane.

RESULTS

After non-operative treatment, secondary displacement occurred in 22 (45%) patients. The PTA was not significantly different between the groups with vs. without secondary displacement (p=0.62). IA values≤135° were significantly associated with secondary displacement (odds ratio, 11.73; 95% confidence interval [95%CI], 3.04-45.28; p=0.004). An IA≤135° was 72.73% sensitive and 81.48% specific for predicting secondary displacement. IA measurement was reproducible, with intra-class and inter-class Cohen's kappa values of 0.94 (95%CI, 0.90-0.97) and 0.9011 (95%CI, 0.83-0.94), respectively.

DISCUSSION

The IA measured on CT images may hold promise for identifying Garden I hip fractures at high risk for secondary displacement after non-operative treatment. IA measurement is reproducible and reliable and may help to determine the indications of non-operative treatment.

LEVEL OF EVIDENCE

II, prospective cohort study.

Mortality Rate and Mid-Term Outcomes of Total Hip Arthroplasty Using Dual Mobility Cups for the Treatment of Femoral Neck Fractures in a Middle Eastern Population

BACKGROUND

The dual mobility cups (DMCs) were shown to reduce dislocation rate following total hip arthroplasty for any etiology, including femoral neck fractures. No reported studies evaluating DMC results for femoral neck fracture in a Middle Eastern population were found in the literature.

METHODS

This study aims to look for mortality rate, clinical, and functional outcomes in a population having specific rituals involving extreme hip positions as part of their daily activities.

RESULTS

Of an initial sample of 174 patients (177 operated hips), 18 (10.3%) patients (20 hips) died after a mean of 39.6 ± 13.8 months (ranging from 2 to 49 months) with only 3 (1.7%) during the first post-operative year. Twelve patients (13 hips) were lost to follow-up and 19 patients (19 hips) had their radiological data incomplete. In the final sample of 125 patients (125 hips), no dislocation, aseptic loosening, or infection was encountered. The mean modified Hip Harris Score was of 94.8 ± 8.4. The mean modified Hip Harris Score of 40 patients who used to practice regularly oriental sitting position or prayers was 94.1 ± 3.1. After surgery, 36 of these 40 patients (90%) described their hip as "a forgotten hip." Multivariate analyses found correlation only between mortality and cardiovascular co-morbidities.

CONCLUSION

DMC implants showed excellent clinical and functional results. The majority of patients having rituals and customs involving extreme hip positions were able to resume their daily activities. The observed low mortality rate should incite future research to investigate its correlation with the use of DMCs.

Hemiarthroplasty or total hip arthroplasty in recent femoral neck fractures?

The optimal treatment of recent femoral neck fractures remains debated. The available options are internal fixation, hemiarthroplasty (HA) and total hip arthroplasty (THA). There is a consensus in favour of internal fixation in younger patients. In elderly individuals who are institutionalised and have limited physical activity, HA is usually performed when the joint line is intact. Whether HA or THA deserves preference in patients aged 60 years or over is unclear. In addition, there are two types of HA, unipolar and bipolar, and two types of THA, conventional and dual-mobility. Both HA types provide similar outcomes with satisfactory stability but a risk of acetabular wear that may eventually require conversion to THA. THA is associated with better functional outcomes and a lower risk of revision surgery in self-sufficient, physically active patients. Instability is the leading complication of conventional THA and occurs with a higher incidence compared to HA. With all implant types, preoperative factors associated with mortality and complications include walking ability and level of self-sufficiency, nutritional status, and haematocrit. An evaluation of these factors before surgery is of paramount importance. Factors amenable to treatment should be corrected by working jointly with geriatricians to develop a preoperative management strategy. In patients who are self-sufficient, physically active, and free of risk factors, THA remains the option of choice, as it provides better functional outcomes. A dual-mobility implant deserves preference to prevent instability. HA is indicated in patients whose self-sufficiency and physical activity are limited. A unipolar implant should be used, as no evidence exists that bipolar implants provide additional benefits. When performing HA, the posterior approach should be avoided given the risk of instability. For THA, in contrast, the posterior approach is a reliable option in the hands of an experienced surgeon using a dual-mobility cup. Cement fixation of the stem is recommended to minimise the risk of peri-prosthetic fracture.

New scoring system at admission to predict walking ability at discharge for patients with hip fracture

INTRODUCTION

A reliable scoring system that predicts the walking ability of hip fracture patients would be useful for clinicians. Here we developed a scoring system for hip fracture patients and evaluated its predictive ability.

HYPOTHESIS

We hypothesized that age, sex, presence of dementia, walking ability before the injury, fracture type, serum hemoglobin level, serum albumin level and interval in days between admission and surgery would be the predictive factors of the walking ability at discharge.

MATERIAL AND METHODS

Data from 409 patients who underwent hip fracture surgery were included. We analyzed factors that affected walking ability and developed a scoring system that predicts the probability of walking unaided or with a cane at discharge.

RESULTS

The mean age of the patients was 81.3 years. A total of 164 (40%) patients could walk unaided or with a cane at discharge. Multivariate logistic regression analysis showed that the obstructive factors for the ability to walk unaided or with a cane at discharge were older age (odds ratio [OR]=0.962, p=0.002), dementia (OR=0.126, p<0.001), use of a cane before injury (OR=0.396, p<0.001), trochanteric fracture (OR=0.571, p=0.027) and low serum albumin level (OR=4.15, p<0.001) at admission. The scoring system used the following formula: Score=5-0.04×age+albumin-2(with dementia)- 1(with use of a cane before injury)-1(with trochanteric fracture). The C-statistics for the scoring system was 0.81 (95% confidence interval, 0.77-0.85).

DISCUSSION

This newly developed scoring system of information at admission predicted the discharge mobility of hip fracture patients. In addition to the previously known risk factors, serum albumin level at admission was detected as a new predictor for mobility at discharge.

LEVEL OF PROOF

IV, retrospective study.

Functional outcome and health related quality of life after dual mobility cup total hip replacement for displaced femoral neck fractures in middle aged Egyptian patients

AIM

This study was done to assess the functional and clinical results after one year of cemented THR with dual mobility cup for the treatment of fracture neck femur in active middle-aged patients in Egypt (Middle Eastern population).

PATIENTS AND METHODS

This study included 31 patients (32 hips) with displaced femoral neck fractures that were admitted to El Hadara University Hospital, Alexandria, Egypt. Their mean age was 66.4 ± 5.9 years. Fifteen patients were females. All the patients were treated with total hip replacement using a cemented dual mobility cup (Ecofit^® 2 M, Implantcast GmbH, Germany) total hip replacement through the standard posterior approach. Functional assessment was done using Harris Hip Score (HHS), SF-36 questionnaire for health related quality of life (HRQoL) with assistance of a physiotherapist.

RESULTS

The mean HHS improved over the follow up period from 79.04 ± 7.9 at 12 weeks to an average of 92.8 ± 11.1 at 1 year follow up. HRQoL measures showed a pattern of initial drop at 3 months postoperatively, then a steady rise to be restored at 1 year as compared to the preoperative baseline measures. There were no dislocations encountered in this series over one year follow up. The following complications were encountered; 1 deep infection, 2 deep vein thrombosis, 2 heterotopic ossifications, and 1 patient died within one year after surgery.

CONCLUSIONS

Dual mobility cup total hip replacement is an acceptable method for treatment of displaced femoral neck fracture in active middle aged patients in Egypt as it provides pain relief and good function without compromising the stability.

The evolution of outcomes and indications for the dual-mobility cup: a systematic review

PURPOSE

Instability following total hip arthroplasty remains a common and disabling complication. The dual mobility cup (DMC) allows a reduction in the dislocation rate. An increasing number of studies have been undertaken to better understand DMC long term outcomes and complications. The goal of this systematic review was to clarify its different uses and outcomes according to the indications.

METHODS

A comprehensive literature review was performed using the keywords 'dual mobility' and 'tripolar cup' with no limit regarding the year of publication. One hundred seventy six publications were identified.

RESULTS

Current literature shows that "contemporary" dual mobility cup are a significant indication to manage instability following primary and revision hip arthroplasty. Survivorship at midterm is comparable to other articulations for primary THA, but is more difficult to evaluate in revision. Intra-prosthetic dislocation, wear, and loosening are now uncommon with new generations of DMC.

CONCLUSIONS

Compared to previous generations of DMC, the current "contemporary" DMC presents a significant improvement. Current literature reveals a tendency to increase the indications but further studies with long term follow up remain important to consolidate these findings.

Has a patient type with peri-prosthetic femoral fractures evolved?

PURPOSE

Peri-prosthetic fractures (PPF) have been showing a constant increase. The typical patient described in the SOFCOT symposium in 2005 with PPF was an elderly 77-year-old woman with hip athroplasty (HA). The purpose of this study was to actualize the characteristics of this population. Our hypothesis is that patient type remains a female, but much older, with an equal distribution between HA and knee arthroplasty (KA).

METHODS

All cases of PPF were retrospectively gathered during an 18 month period. Besides regular epidemiologic data, we noted autonomy level (Parker, Devane), residence and dependence (Katz), the type of implant, of fracture, the severity of fracture, the onset and the state of solidity of the prosthesis.

RESULTS

The series consisted of 81 patients (58 F, 23 M) (81 fractures), mean age of 82.2 years; 3.5% of them were admits from the emergency admits; and 69.1% lived at home. Parker's mean score was 4.6, Devane's mean score was 1.8 and Katz's mean score was 4.2. There were totals of 46 HA fractures and 39 total knee arthroplasty (TKA) of which four were inter-prosthetic and three were either KA or proximal osteosynthesis. Onset before fracture for HA was 12.1 years, 7.9 years for KA, and 10.2 years for all series. Patients were younger for HA (80.8 years) than for KA (84.1 years). The fracture was mostly noticed in the third proximal (49.4%), spiral segment (44.5%) and around the implant, while 34.8% of loosening was observed for HA versus 7.7% for KA.

DISCUSSION-CONCLUSION

The patient type has evolved confirming our hypothesis: they are always a female more than 82 years old with a number of fractures on KA similar to that of HA. The patients lived at home, had some autonomy, were somewhat independent in their daily activities but sedentary. Fractures were mostly on the third proximal femur, spiral segment and around the implant. PPF remains rare and a theoretical increase is yet to be confirmed.

LEVEL OF EVIDENCE

prospective study type IV, cohort study.

Total hip arthroplasty with minimal invasive surgery in elderly patients with neck of femur fractures: our institutional experience

The purpose of this study was to investigate whether minimal invasive surgery (MIS) in elderly patients with neck of femur fractures would reduce the peri-operative complications and improve the post-operative ambulation and length of hospital stay in his cohort of patients. Forty elderly patients were treated with either total hip arthroplasty (THA) or bipolar prosthesis using MIS transgluteal approach. A matched reference group treated with a conventional surgical approach formed the control group. All procedures were performed by the same surgeon. Selection of acetabular component included Novae® uncemented press fit dual mobility concept socket or Bipolar Hemi-Arthroplasty (BHA). The femoral implant was Corail® uncemented stem or Fjord® cemented stem when primary instability was encountered. The follow-up was done for all patients and its minimum length was more than thirty-six months. The average length of the skin incision was 7 (6-8) SD 0.7 cm. Eighteen THA, twenty-two BHA, thirty-seven uncemented femoral stems and three cemented stems were implemented. The length of the procedure was the same as those of the reference group. The operative and post-operative blood loss and analgesic use were significantly decreased in the MIS group. Radiographic implants positioning was similar amongst the two groups. No skin complication, no primary infection, no death within ninety days and no dislocations were observed. MIS approach for implanting THA after a femoral neck fracture in the elderly appears to be a reliable procedure.

Prevalence of protein-energy malnutrition in hospital patients over 75 years of age admitted for hip fracture

INTRODUCTION

One percent of falls in over-75 years old cause hip fracture (HF). Protein-energy malnutrition (PEM) is associated with falls and fracture. PEM screening and perioperative nutritional management are recommended by the European Society of Parenteral and Enteral Nutrition, yet data on nutritional status in elderly HF patients are sparse. The Mini Nutritional Assessment (MNA) score is presently the most effective screening tool for PEM in over-75 years old.

OBJECTIVE

The principal objective of the present study was to determine the prevalence on MNA of PEM in patients aged over 75 years admitted for HF. Secondary objectives were to identify factors associated with PEM and its role as a factor of evolution.

MATERIALS AND METHODS

A prospective observational epidemiological study included 50 patients aged over 75 years admitted for HF in an 8-bed orthopedic surgery department with a geriatric follow-up unit. PEM was defined by MNA<17/30. Assessment systematically comprised associated comorbidity (Cumulative Illness Rating Scale-Geriatric [CIRS-G]), cognitive status on the Mini Mental State Examination (MMSE), functional status on activities of daily life (ADL), and mean hospital stay (MHS). Scores were compared on quantitative tests (Student t) with the significance threshold set at P<0.05.

RESULTS

Mean age for the 50 patients was 86.1 years (range, 77-94 years). Prevalence of PEM was 28%; a further 58% of patients were at risk for PEM. PEM was associated with elevated CIRS-G (P<0.006), greater numbers of severe comorbidities (P=0.006), more severe cognitive disorder (P=0.005) and functional dependence (P=0.002), and 8 days' longer MHS (P=0.012).

DISCUSSION

The present study confirmed the high prevalence of PEM in HF patients aged over 75 years, supporting longer hospital stay. MNA is a diagnostic gold standard, not to be replaced by albuminemia or body-mass index in this perioperative clinical situation. Given the present economic stakes relating to geriatric trauma patients' hospital stay, it is essential to prevent, diagnose and treat PEM in elderly subjects.

LEVEL OF EVIDENCE

Level IV; prospective cohort study.

Incidence and risk factors of subsequent hip fractures in Korea: multicenter study

This study analyzes the incidence of subsequent hip fractures and its risk factors in the northwestern region of Korea. We analyzed hip fracture patients who visited any of the 5 teaching hospitals in the Bucheon and Incheon area from January 2000 to December 2010. Medical records were reviewed and presence of subsequent hip fractures, alcohol history, marital status, live in solitude, dementia, dizziness, American society of anesthesiologists score, osteoporosis treatment after fracture, body mass index (BMI) and initial bone mineral density were analyzed. The average follow-up period was 12 months (range 1-130 months). A total of 2,546 patients (women 1,770, men 776) who had experienced hip fractures were included. Of these, subsequent hip fractures were found in 233 patients (9.2%) (women 187, men 46). Mean age at the time of the first fracture was 79.2 yr old (range 50-100 yr). The average interval between the first fracture and the subsequent hip fractures was 30.2 months (range 4 days-154 months). In this large-scale, retrospective, multicenter study, overall incidence of subsequent hip fractures is 9.2%. Independent risk factors of subsequent fracture are women, BMI<22 kg/m(2), and being unmarried.

Can preoperative CRP levels predict infections of bipolar hemiarthroplasty performed for femoral neck fracture? A retrospective, multicenter study

INTRODUCTION

Current recommendations urge us to operate quickly on femoral neck fractures to reduce the risk of comorbidity decompensation. In some cases, this leads us to operate when an underlying infection is present. In this study, we evaluated the infection rate of bipolar hemiarthroplasty after femoral neck fracture and attempted to relate it to preoperative C-reactive protein (CRP) levels.

MATERIALS AND METHODS

The infection rate of bipolar hemiarthroplasty was evaluated in a dual-center, retrospective study of 260 patients over a 2-year period. During the first year, the preoperative CRP levels were not taken into account when scheduling the procedure. During the second year, if preoperative CRP levels were above 50 mg/L, the procedure was delayed to look for and treat any ongoing infections.

RESULTS

The overall periprosthetic infection rate in this study was 4.85 % (range 4.8-4.9), with 33 % of patients passing within 1 year due to the infection. In the group where CRP was not taken into consideration, 59 of the 143 operated away patients (41 %) had their preoperative CRP levels measured. Twenty-nine of these patients had CRP > 50 mg/L when they were operated. Of the seven infections in the group, one patient had CRP > 50 mg/L, two had CRP < 50 mg/L, and four patients did not have preoperative CRP levels measured. In the group where CRP was taken into consideration, 104 of the 117 patients (89 %) had their preoperative CRP assessment. Thirty of these patients had CRP > 50 mg/L upon admission; their procedure was delayed to determine the etiology of this CRP elevation. No cause was found in 16 of these 30 patients, and they were operated despite having CRP > 50 mg/L. There were five infections in this group: four patients had CRP > 50 mg/L and were treated accordingly; one patient had preoperative CRP < 50 mg/L. In patients where the preoperative CRP levels were taken into account, the delay before surgery was twice as long as those where CRP levels were not considered.

DISCUSSION

C-reactive protein (CRP) level alone is not a good preoperative predictive factor for periprosthetic joint infection, although 80 % of the patient with an infected bipolar hemiarthroplasty had CRP > 50 mg/L upon admission. The increased delay due to the CRP analysis is not without consequence for this cohort. Two previous studies have looked into the predictive ability of CRP levels, but these involved scheduled surgical procedures.

CONCLUSION

This study could not validate the use of CRP levels, nor a 50 mg/L threshold, as predictive factors for a preexisting infection during bipolar hemiarthroplasty for femoral neck fracture. As a consequence, new infection screening tools must be developed and validated.

[Preoperative management to reduce morbidity and mortality of hip fracture]

Hip femur is extremely common in the elderly and is one of the most common reasons for admission in trauma care. The main reported causes of death after hip fracture were cardiovascular (29%), neurological (20%) and pulmonary. Large epidemiological studies have shown a relatively small decrease in mortality for 20 years despite an active approach to medical and surgical management. Yet 57% of deaths occurring within 30 days post-surgery are preventable because they are not related to a pre-existing disease. Preoperative management to optimize these patients could help to reduce morbidity and mortality and is thus a crucial issue. The anesthesia consultation is used to evaluate the perioperative risk, treat pain, manage treatment and stabilize the patient. An operative delay of more than 48hours after admission increases mortality. This period should not be prolonged by unnecessary investigations that will not change the perioperative management. The preoperative period is a key moment because it allows to choose the anesthetic technique. Even if this choice is controversial, continuous spinal anesthesia (titrated) do not modify the cardiovascular and neurological physiological balance of these precarious patients.

[Earlier postoperative mobilization with minimally invasive hip hemiarthroplasty]

Treatment of medial femoral fractures in elderly patients with cemented hip hemiarthroplasty (HEP) is a widely established procedure. The main problems with this procedure are complications associated with soft tissue damage and prolonged immobilization. The aim of this study was to compare the clinical and radiological results after HEP implantation using either an anterior minimally invasive (MIS) approach or a regular transgluteal (TG) approach. In this retrospective study the results of 55 consecutive MIS and 54 consecutive TG approaches for implanted HEP after medial femoral fracture were compared. The time of successful mobilization, duration of the i.v. analgesia as well as the occurrence of any perioperative complications were recorded. The femoral offset, leg length and the femoral alignment were analyzed radiologically. The MIS group could be mobilized earlier (MIS 2. pod vs. TG 4. pod, p <0.01) but the need for i.v. applied analgesia was prolonged (MIS 4.4 pod vs. TG 3.5 pod, p=0.04). In the MIS group the number of perioperative complications was less than in the TG group (MIS 7% vs. TG 17%, p <0.05). The early functional advantages of MIS after HEP implantation for medial femoral fractures are evident also within an elderly group of patients.

Unipolar versus bipolar uncemented hemiarthroplasty for elderly patients with displaced intracapsular femoral neck fractures

PURPOSE

To compare outcomes of unipolar versus bipolar uncemented hemiarthroplasty and determine factors affecting outcomes.

METHODS

433 and 274 elderly patients with displaced intracapsular femoral neck fractures underwent uncemented unipolar hemiarthroplasty and uncemented bipolar hydroxyapatite-coated hemiarthroplasty, respectively. Surgical options were based on the patient's general condition and preinjury mobility status. In the respective groups, the mortality of 377 and 242 patients and the mobility of 270 and 217 patients were reviewed at the 4-month follow-up. Patient age, sex, American Society of Anesthesiologists [ASA] score, mobility, and mortality of the 2 groups were compared.

RESULTS

Patients who underwent unipolar hemiarthroplasty were significantly older, less fit, and less mobile (p<0.001). Patients who underwent bipolar hemiarthroplasty achieved better outcomes for mortality and mobility (p<0.001). Among patients who were able to walk unaided before injury, more of those having bipolar hemiarthroplasty were able to do so at month 4 than those having unipolar hemiarthroplasty (13% vs. 33%, p<0.001). Mortality within 4 months was associated with age, male gender, and ASA score. When patients were stratified according to age groups, mortality within 4 months was lower in patients having bipolar hemiarthroplasty.

CONCLUSION

In elderly patients with femoral neck fractures who were fit and physiologically young, uncemented bipolar hemiarthroplasty seemed to achieve better functional outcome.

Treatment of femoral neck fractures in elderly patients over 60 years of age - which is the ideal modality of primary joint replacement?

BACKGROUND

Femoral neck fractures in the elderly are frequent, represent a great health care problem, and have a significant impact on health insurance costs. Reconstruction options using hip arthroplasty include unipolar or bipolar hemiarthroplasty (HA), and total hip arthroplasty (THA). The purpose of this review is to discuss the indications, limitations, and pitfalls of each of these techniques.

METHODS

The Pubmed database was searched for all articles on femoral neck fracture and for the reconstruction options presented in this review using the search terms "femoral neck fracture", "unipolar hemiarthroplasty", "bipolar hemiarthroplasty", and "total hip arthroplasty". In addition, cross-referencing was used to cover articles eventually undetected by the respective search strategies. The resulting articles were then reviewed with regard to the different techniques, outcome and complications of the distinct reconstruction options.

RESULTS

THA yields the best functional results in patients with displaced femoral neck fractures with complication rates comparable to HA. THA is beneficially implanted using an anterior approach exploiting the internervous plane between the tensor fasciae latae and the sartorius muscles allowing for immediate full weight-bearing. Based on our findings, bipolar hemiarthroplasty, similar to unipolar hemiarthroplasty, cannot restorate neither anatomical nor biomechanical features of the hip joint. Therefore, it can only be recommended as a second line of defense-procedure for patients with low functional demands and limited live expectancy.

CONCLUSIONS

THA is the treatment of choice for femoral neck fractures in patients older than 60 years. HA should only be implanted in patients with limited life expectancy.