Die Duokopfprothese zur Therapie der Schenkelhalsfraktur – Einfluss von OP-Dauer, Tageszeit und Erfahrung des Operateurs auf die Komplikationsrate

Is there an optimal timing for surgical treatment of pediatric supracondylar humerus fractures in the first 24 hours?

Background

We aimed to determine the ideal surgical timing in the first 24 hours after admission to the hospital of pediatric supracondylar humerus fractures (SHF) that do not require emergent intervention.

Materials and Methods

Patients who underwent surgery in our institution between January 2011 and January 2019 due to pediatric Gartland type 3 SHFs were evaluated retrospectively. Open fractures, fractures associated with vascular injury and compartment syndrome, flexion type fractures were excluded. A total of 150 Gartland type 3 were included. The effect of early (<12 hours) or late (>12 hours) surgical interventions, daytime or night-time surgeries, working or non-working hour surgeries on operative parameters (operative duration and open reduction rate, reduction quality on postoperative early radiographs) were evaluated in pediatric SHFs.

Results

Early (<12 hours) or late (>12 hours), daytime or nighttime, working or non-working hour surgeries were found to be similar in Gartland type 3 patients regarding early postoperative reduction quality, duration of surgery, open reduction rate (p>0.05). Mean times passed from first admission to hospital until surgery were longer in working hour, late (>12 hours) and daytime surgery groups than non-working hour, early (<12 hours) and night-time surgery groups (p<0.001).

Conclusion

Although delaying the operation to the working hours seems to prolong the time until surgery in pediatric Gartland type 3 SHF patients who do not require emergent intervention such as open fractures, neurovascular impairment and compartment syndrome, there may not be a time interval that makes a difference for the patients if surgery is performed within the first 24 hours, thus the surgery could be scheduled according to the surgeons’ preference.

Level of Evidence: Level 3, Retrospective cohort study

[Influence of timing of surgery on complication rates after cemented hemiarthroplasty for treatment of medial femoral neck fractures]

BACKGROUND

The optimal timing of the implantation of a cemented hemiarthroplasty in the management of displaced medial femoral neck fractures is still the subject of current research. According to the current recommendations, these cases should be surgically treated within 24 h. The aim of this study was to evaluate the impact of the timing of surgery on operation-specific and nonspecific complications, intensive care treatment as well as mortality.

MATERIAL AND METHODS

Overall, 152 cases were retrospectively investigated regarding several parameters (demographic data, comorbidities, surgery time, duration of hospital stay, intensive care treatment, general, bleeding, operation-specific and nonspecific complications). The statistical analysis was performed using the χ²-test and the unpaired Student's t‑test as well as logistic regression analyses.

RESULTS

A total of 152 patients were included and 71.1% of the operations were performed within 24 h and the remaining 28.9% after 24 h. All groups showed a similar profile of comorbidities. The analysis of the intensive care treatment showed no significant differences between the individual groups. The rate of postoperative pneumonia was moderately higher among the patients with a procedure after 24 h; however, with no severe courses. There were no significant differences regarding all other complications and the mortality rate between the individual time points of surgery.

CONCLUSION

The present study demonstrated that patients operated on after 24 h showed no disadvantages regarding other complications, intensive care treatment or mortality, except from an increased postoperative pneumonia rate. These results could be taken into consideration for the next update of the treatment guidelines.

Risk analysis and clinical outcomes of intraoperative periprosthetic fractures: a retrospective study of 481 bipolar hemiarthroplasties

BACKGROUND

Intraoperative periprosthetic fractures (IPF) are a well-described complication following hip hemiarthroplasty. Our aims were to identify risk factors that characterize IPF and to investigate postoperative mobility.

METHODS

We retrospectively reviewed 481 bipolar hemiarthroplasties for displaced femoral neck fractures; of which, 421 (87.5%) were performed without cement, from January 2013 to March 2018. Data on the patients' demographics, comorbidities, femoral canal geometry (Dorr canal type, Canal Flare Index), surgeon's experience (junior vs. senior surgeon), and timing of surgery (daytime vs. on-call duty) were obtained. In patients with intraoperative fractures, further information was obtained. Patient mobility was assessed using matched-pair analysis. Mobility was classified according to the NHFD mobility score. The chi-square test, Fisher's exact test, and Fisher-Freeman-Halton exact test were used for comparison between categorical variables, while the Mann-Whitney U test was used for continuous variables. The data analysis was performed using SPSS.

RESULTS

Of 481 procedures, 34 (7.1%) IPFs were encountered. The Dorr canal type C was identified as a significant risk factor (p = .004). Other risk factors included female sex (OR 2.30, 95% CI .872-6.079), stovepipe femur (OR 1.749, 95% CI .823-3.713), junior surgeon (OR 1.204, 95% CI .596-2.432), and on-call-duty surgery (OR 1.471, 95% CI .711-3.046), although none showed a significant difference. Of 34 IPFs, 25 (73.5%) were classified as Vancouver type A. The treatment of choice was cerclage wiring. Within the 12 matched pairs identified, the postoperative mobility was slightly worse for the IPF group (delta = .41).

CONCLUSIONS

IPF is a serious complication with bipolar hemiarthroplasty. The identification of risk factors preoperatively, in particular femur shape, is crucial and should be incorporated into the decision-making process.

Pinning of supracondylar fractures in children - Strategies to avoid complications

In the pediatric population supracondylar humerus fracture (SHF) is one of the most common injuries. Diagnosis is based on inspection and conventional radiography. SHFs should be classified according to the modified Gartland classification, which guides treatment. Non-displaced or minimally displaced fractures (Gartland type-I) should be treated non-operatively, completely displaced type III fractures require closed reduction and K-wire fixation. In type-II fractures, important landmarks, such as the anterior humeral line (Roger´s line), the shaft-physeal angle (Baumann´s angle) and the shaft condylar angle should be considered to guide treatment. Special attention has to be paid for potential rotational dislocation, which is indicated by a ventral spur. In such cases surgery is necessary. The degree of acceptable extension malpositioning depends on patient´s age. In 10-year-old children fractures with a shaft condylar angle of more than 15° are still suitable for non-operative therapy. Timing for surgery is controversially discussed. Postponing surgery to the next day seems reasonable if absence of pain, intact soft tissue and normal neurovascular status are present. Neurovascular complications are not uncommon, especially in Gartland type-III fractures and in cases with additional forearm injuries. A white hand without palpable pulse needs emergency surgery, the management of the pulseless pink hand is still controversially discussed. Different operative techniques exist for surgical treatment. The golden standard is closed reduction and percutaneous K-wire pinning. Crossed pinning seems to achieve best biomechanical stability. Since ulnar nerve injuries are reported to occur in 6% after medially inserting K-wires, lateral divergent insertion of two K-wires has been compared to crossed pinning fixation in several randomized controlled trials. Meta-analyses demonstrated a higher risk for ulnar nerve injury for the crossed pinning technique while risk for loss of fixation was higher in lateral only pinning. In both cases, K-wires should be removed 3-6 weeks after surgery with consolidation of the fracture. Clinical and radiological follow-up should be carried out at 3 weeks post fracture fixation to rule out loss of reduction. If this should occur, early revision surgery has been demonstrated beneficial.

State of Practice: Endovascular Treatment of Acute Aneurysmal SAH in Germany

BACKGROUND AND PURPOSE

Acute aneurysmal SAH is a severe disease that requires prompt treatment. Endovascular coiling and neurosurgical clipping are established treatment options. Our intention was to determine the state of current practice in acute aneurysmal SAH treatment in Germany, with emphasis on logistic and temporal aspects.

MATERIALS AND METHODS

We interviewed 74 German university and nonuniversity hospitals with an anonymous questionnaire comprising 15 questions concerning the practice of treatment and diagnostics of acute aneurysmal SAH at their respective institutions. The response rate was 74% among all institutions (55/74); among university hospitals, 77%; and among nonuniversity hospitals, 72%.

RESULTS

The majority of all aneurysms were treated endovascularly (66% of acute aneurysmal SAH, 66% of unruptured aneurysms). Treatment on weekends was provided by 100% of endovascular and 96% of neurosurgical facilities. Average patients with acute aneurysmal SAH were not treated during the night (98%). Seventy percent of endovascular and 78% of neurosurgical treatments were not started later than 8:00 pm. Fifty-three percent of hospitals would not start a same-day diagnostic angiography in acute aneurysmal SAH if treatment was scheduled for the following day. Eighty-two percent of all centers performed DSA after clipping to evaluate the treatment results.

CONCLUSIONS

Our survey gives a detailed summary of the current practice of endovascular treatment and related topics in acute aneurysmal SAH in Germany and also reveals considerable changes in practice in comparison with older data.

[Length of hospital stay for patients with proximal femoral fractures : Influencing factors]

BACKGROUND

In departments of orthopedic and trauma surgery patients with proximal femoral fractures constitute the largest proportion of trauma patients. The length of stay (LOS) has economic consequences and prolonged LOS leads to a shortage in bed capacity.

OBJECTIVES

In this study treatment and patient-related factors that influence the LOS of patients with proximal femoral fractures were investigated.

MATERIAL AND METHODS

Treatment and patient-related data of 242 patients (age >64 years) were recorded retrospectively and included residential aspects, legal guardianship, time of admission and surgery, hospital mortality, LOS, diagnosis, comorbidities, medication, surgical treatment, general and surgical complications, intensive care therapy and American Society of Anesthesiologists (ASA) classification.

RESULTS

Of the patients, one fifth came from a nursing home and were under supervised care or a healthcare proxy at the time of admission. Two thirds were admitted to hospital and operated on during on-call service periods. One half of the patients did not return to their previous domestic environment and were usually admitted to a nursing home. Patients who came from or were admitted to nursing homes, who were under healthcare supervision as well as patients who rapidly underwent surgery had a shorter LOS. Hospitalization and surgery during on-call service periods did not extend the LOS and showed a tendency towards reduction. Older age correlated with a longer LOS and surgical complications doubled the LOS.

DISCUSSION

Surgical treatment during on-call service periods, short preoperative waiting times and avoidance of surgical complications shortened LOS and thus had an impact on costs and bed capacity.

Hemiprosthesis for Femoral Neck Fractures in the Elderly: A Retrospective Study of 319 Patients

Background

In geriatric patients with Pauwels types II and III femoral neck fractures, hemiprosthesis is the therapy of choice.

Objectives

This study was conducted to analyze the results after cemented hemiprosthesis placement, the first year after surgery.

Patients and Methods

This retrospective study was conducted on 319 patients over 70 years with displaced femoral neck fractures treated surgically at our hospital from 2007 to 2012. All medical information was available including retrospective posthospital discharge records as well as inpatient course and one-year mortality.

Results

From a total of 319 patients, 78% (n = 249) were female and 22% (n = 70) were male, with the mean age of 83.6 years. Seventeen percent of the patients suffered from heart failure, 23% from diabetes, and 19% from renal insufficiency. Time to surgery averaged one day postinjury. Average operative time skin-to-skin was 50 minutes. Seventy-three percent of the patients could mobilize independently on discharge. Of the remaining patients, 2/3 had already lost independent mobilization prior to the fracture. Hospital mortality averaged 5% (national average in Germany: 8%), and 30-day and 90-day mortality rates were 5% and 15%, respectively. Within one year, 22% of the patients died (national average: 27%). Also, 14 patients were re-admitted, for contralateral prosthetic implantation (n = 7) or revision after the periprosthetic fracture (n = 5). Fifty-three percent of the patients were admitted to hospital during the year for other diseases (national average: 54%).

Conclusions

Hemiprosthesis placement for displaced femoral neck fractures is a common and safe procedure. Despite recent decreases in hospital mortality, the risk of death remains more than twice as high within one year than that for uninjured patients of the same age.

[Factors influencing course of hospitalization in patients with hip fractures: Complications, length of stay and hospital mortality]

BACKGROUND

Time of surgery, age, sex, and co-morbidities influence the complication and mortality rate in patients with hip fractures. Patients with relevant co-morbidities, who were hospitalized at the weekend have a higher mortality rate. Complications prolong length of stay (LOS), which results in higher costs and shortage of bed capacity.

OBJECTIVES

The influence of various factors on hospitalization with emphasis on complications, LOS, and clinical mortality should be observed.

MATERIALS AND METHODS

Retrospectively, 242 patients with hip fractures (>64a) were observed. In addition to age and sex, time of hospitalization and surgery, intensive care therapy, hospital mortality, LOS, comorbidities, ASA, and complications were recorded. Times were assigned to the work week or the weekend or regular or on-call duty service.

RESULTS

29.8 % were hospitalized at the weekend, 66.1% on on-call duty, 24.1% were operated on the weekend, 67.4% on on-call duty. 86.3% were operated <48 h after admission. The mortality rate was 8.3%. Longer time to surgery results in more frequent intensive care therapy, prolongs the LOS, and increases overall complications. Advanced age increases mortality and LOS. A higher value of the ASA classification leads to increased mortality; co-morbidities lead to more frequent intensive care therapy. Surgical complications prolong LOS of 10.8d (86.4%).

CONCLUSION

Hospitalization is influenced by age, ASA and co-morbidities as well as by time to surgery and operation in day or late and nighttime service. Early surgery and prevention of surgical complications reduce LOS.

[Early complication rate of fractures close to the hip joint. Dependence on treatment in on-call services and comorbidities]

BACKGROUND

Guidelines advocate early surgery for proximal femoral fractures so that operations are frequently performed in on-call duty times. Multimorbid patients also suffer more frequently from postoperative complications. Does on-call duty or night shift services correlate with higher postoperative complication rates and what influence do comorbidities have?

PATIENTS AND METHODS

In 300 patients (> 65 years) postoperative surgical and non-surgical complications were documented and correlated with comorbidities, on-call duty and night shift service times.

RESULTS

Postoperative complications were observed in 10.7 % of surgical and 62 % of non-surgical cases. Surgery in on-call duty and night shift times did not increase the postoperative complication rate. Comorbidities, age and ASA classification correlated with postoperative complications which significantly prolonged hospital stay.

CONCLUSION

Surgery of proximal femoral fractures in on-call duty and night shift times is justified because postoperative complications are not increased. Comorbidities and higher age correlated with postoperative complications. Postoperative complications should be avoided because they result in prolonged hospital stay.

[Fractures of the knee joint in the elderly: osteosynthesis versus joint replacement]

BACKGROUND

The aim of open reduction and internal fixation (ORIF) of fractures around the knee joint is the exact anatomic reconstruction of joint surfaces in order to achieve an early and load stable bone situation. Primary endoprosthetics as the initial treatment can represent an alternative treatment option for a closely selected number of geriatric patients.

OBJECTIVES

The chances and risks of primary endoprosthetics in comparison to ORIF as the gold standard for initial treatment of fractures close to the knee joint in the elderly are presented

MATERIAL AND METHODS

A selective search of the literature was carried out in consideration of national recommendations and own experience gained as head of a center for geriatric traumatology.

RESULTS

If the soft tissue coverage is not damaged by the injury, primary endoprosthetics can offer advantages compared to ORIF when a load stable joint is indispensable due to poor compliance, pre-existing arthritis and advanced age.

DISCUSSION

The risk of postoperative loss of correction is minimized by the prosthesis but the revision possibilities are very limited due to voluminous prostheses with a high degree of coupling. The indications for primary prosthesis implantation for acute treatment of fractures close to the knee should therefore be closely controlled because this should be the first and last intervention for fracture treatment in geriatric patients.

The epidemiology of paediatric supracondylar fracture fixation: a population-based study

INTRODUCTION

The epidemiology of paediatric supracondylar fracture (SCF) fixation has not been evaluated at a population level. The purpose of this study was to: (1) determine the incidence density rate (IDR) of SCF fixation and (2) determine the rate of and risk factors for re-operation.

METHODS

Using administrative databases, all patients who underwent SCF fixation (closed reduction percutaneous pinning (CRPP) or open reduction (OR)) in Ontario between April 2002 and March 2010 were identified. Exclusion criteria included age (>12 years), a prior or concurrent non-SCF elbow fracture or previous humeral osteotomy. The overall IDR of SCF fixation and for subgroups of age, sex and season were calculated. A multivariate regression (immediate and short-term re-operation) and a Cox proportional hazards model (long-term re-operation) were used to identify patient, injury and provider factors that influenced re-operation risk and were reported as odds ratios or hazard ratios (HRs) with 95% confidence intervals (CIs), respectively.

RESULTS

A total of 3235 patients with a median age of 6.0 years (interquartile range (IQR): 3.0) underwent SCF fixation. The median follow-up was 6.0 years (IQR: 3.7). The majority underwent a CRPP (78.7%) which were performed after hours (75.6%). The overall IDR was 20.7/100,000 person-years (py), but it varied significantly by season and age. Re-operation was uncommon in the immediate (1.0%), short-term (1.4%) and long-term (0.3%) follow-up period. As compared to CRPP, patients who underwent OR were more likely to undergo early nerve exploration (odds ratio: 7.8 (CI: 3.0-20.6)) and re-operation in the long term (HR: 3.0 (CI: 1.0-8.7)). Increased surgeon volume of SCF fixation was protective against repeat fixation (odds ratio: 0.9 (CI: 0.9-1.0)) and re-operation in the long term (HR: 0.9 (CI: 0.8-1.0)).

CONCLUSIONS

While SCF fixation is common, the rate of re-operation is low. No differences existed between the sexes and a higher volume of fixations occurred during the summer months.

Mortality after proximal femur fracture with a delay of surgery of more than 48 h

PURPOSE

For hip fractures, guidelines require surgery as soon as possible, but not later than 48 h. Some authors observed a positive and some a negative effect of early operation on mortality rate. The aim was to evaluate the mortality rate of patients with a delay of surgery >48 h after admission, as well as influencing factors and reasons for delay.

METHODS

One hundred and thirty-six patients with hip fractures (>65a) from 2007 to 2011 were included. Comorbidities, the American Society of Anaesthesiologists (ASA) classification, time of admission and surgery, and mortality were recorded up to 12 months. Reasons for delay were divided into administrative-related or patient-related. The following time intervals were observed: 48.01-72 h (2-3 days), 72.01-120 h (3-5 days), 120.01-168 h (5-7 days), 168 h (>7 days).

RESULTS

94.9 % of the reasons for delay were patient-related. The mean survival times of the first three intervals were almost the same (9.5-9.9 months) (p = 0.75). The last group had a significantly shorter survival time (7.8 months). Summarizing the first three groups, a significant shorter (p = 0.03) survival time and significantly higher (p = 0.04) 12-month mortality rate in patients with a delay >7 days was observed. The probability of death was primarily dependent on the ASA classification (p < 0.0001) and secondarily on the patient's age at the time of injury (p = 0.005).

CONCLUSIONS

In hip fractures, reasons for a delay >48 h are mainly patient-related. A delay up to 7 days did not influence survival time and mortality negatively. The higher the value of the ASA classification and the older the patient was at the time of injury, the higher the mortality rate and the shorter the survival time.

Mortality and quality of life after proximal femur fracture-effect of time until surgery and reasons for delay

INTRODUCTION

Studies yield conflicting results from the effect of early surgery on mortality. Some observed a positive, others a negative and some did not find any effect of early operation. In this study, mortality and quality of life in relation to time until surgery as well as reasons for delay were observed prospectively.

MATERIAL AND METHODS

Data of 138 patients (>65 years) with proximal femoral fractures and consecutive surgery were observed. Demographic data as well as mortality rate, survival time and Barthel Index up to 1 year in relation to different time frames were observed. Reasons for operative delay were divided into being administrative or patient-related.

RESULTS

Three-month mortality was 10.1% and 1-years was 23.9%. Neither time from injury until hospital admission nor from injury until surgery or from hospital admission until surgery up to 48 hours had any effect on mortality and survival time. The age of patients dying in the follow-up period was significantly higher than the age of patients surviving (86.8 vs. 84.4 years). No influence of any delay in time until surgery on the Barthel Index was observed.

CONCLUSION

In proximal femoral fractures, a delay of surgery up to 48 hours did not influence mortality and Barthel Index negatively, nor did other associating factors. Only the patients age at the time of injury influences mortality rate, survival time, and Barthel Index significantly. The older the patient at the time of injury; the higher the mortality rate, the shorter the survival time and the lower the Barthel Index.

Dorsal versus transgluteal approach for hip hemiarthroplasty: an analysis of early complications in seven hundred and four consecutive cases

PURPOSE

Hemiarthroplasty (HA) is an established treatment for femoral neck fractures of the elderly. Several surgical approaches are currently used including dorsal and transgluteal. It is still unclear whether one approach may be advantageous. We compared early complication rates after dorsal and transgluteal approaches.

METHODS

We retrospectively analysed a cohort including 704 consecutive patients who received HA for femoral neck fracture; 212 male and 492 female patients were included, and the mean age was 80.4 years (SD 9.8 years). In 487 patients a dorsal and in 217 a transgluteal approach was chosen. In all patients an Excia stem with self-centring bipolar head manufactured by Aesculap (Tuttlingen, Germany) was used. We evaluated early postoperative complications including dislocation, infection, haematoma, seroma and perioperative fracture. Complication rates after dorsal and transgluteal approaches were calculated and compared by the chi-square test.

RESULTS

After a dorsal approach 10.5 % [confidence interval (CI) 7.7-13.2 %] of the patients suffered one or more early complications. Following a transgluteal approach this proportion was 9.7 % (CI 5.7-13.6 %), which was not significantly different (p = 0.75). The predominant complication after a dorsal approach was dislocation (3.9 %; CI 2.2-5.6 %). The dislocation rate after a transgluteal approach was significantly lower (0.5 %; CI 0-1.4 %). Postoperative haematoma however was seen after a transgluteal approach in 5.5 % (CI 2.5-8.6 %), which was significantly more frequent than after a dorsal approach (1.2 %; CI 0.2-2.2 %). The frequency of the other types of complications did not significantly differ.

CONCLUSIONS

The rate of early surgical complications after dorsal and transgluteal approaches is not significantly different. However, the dorsal approach predisposed to dislocation, whereas the transgluteal approach predisposed to haematoma.

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.