Hip fractures: current review of treatment and management

Rate of Complications after Hip Fractures Caused by Prolonged Time-to-Surgery Depends on the Patient's Individual Type of Fracture and Its Treatment

INTRODUCTION

Hip fractures are common injuries in the elderly and are usually treated with timely surgery. While severe postoperative complications are reported for up to 10% of patients, many studies identified predictive factors for the occurrence of complications postoperatively. A controversially discussed factor is "time-to-surgery". The aim of the study was to examine if time-to-surgery was associated with the occurrence of complications and if the complication rate differed between the patient individual fracture types of intracapsular on the one hand and extracapsular hip fractures on the other hand. We hypothesized that time-to-surgery had less impact on complications in intracapsular hip fractures compared to extracapsular ones, and therefore, guidelines should pay attention to the patient individual case scenario.

MATERIALS AND METHODS

All patients who were admitted to the Department of Trauma and Orthopaedic Surgery of an academic teaching hospital for hip fracture surgery (n = 650) over a five-year period were included in the study. After the application of the exclusion criteria, such as periprosthetic or pathologic fractures, cases needed immediate surgical treatment, and after outlier adjustment, 629 cases remained in the study. Hip fractures were classified into intracapsular fractures (treated by hip arthroplasty) and extracapsular fractures (treated by intramedullary nailing osteosynthesis). The occurrence of severe complications in patients treated within 24 h was compared with patients treated later than 24 h after injury. For statistical evaluation, a multivariate logistic regression analysis was performed to investigate the impact of time-to-surgery interval on the occurrence of complications.

RESULTS

Patients with an extracapsular fracture, which was treated with intramedullary nailing (44.5%), rarely suffered a serious complication when surgery was performed within 24 h after injury. However, when the interval of the time-to-surgery was longer than 24 h, the complication rate increased significantly (8.63% vs. 25.0%, p = 0.002). In contrast to this finding in patients with intracapsular fractures (55.5%), which were treated with cemented arthroplasty, complication rates did not depend on the 24 h interval (26.17% vs. 20.83%, p = 0.567).

CONCLUSIONS

The occurrence of complications after surgical treatment of hip fractures is associated with the time interval between injury and surgery. A 24 h time interval between injury and surgical procedure seems to play a major role only in extracapsular fractures treated with osteosynthesis but not in intracapsular fractures treated with arthroplasty. Therefore, guidelines should take notice of the patient individual case scenario and, in particular, the individual hip fracture type.

Retrospective evaluation of radiological and clinical outcomes after surgical treatment of proximal femur fractures utilizing TFNA

INTRODUCTION

The aim of this study was to evaluate the clinical and radiological outcomes of patients treated with the TFN-Advanced™ Proximal Femoral Nailing system (TFNA¸ DePuy Synthes, West Chester, PA) including intra- and postoperative complications.

MATERIALS AND METHODS

All patients with an acute proximal femur fracture consequently treated with a TFNA between September 2014 and December 2018 were evaluated. Clinical and radiological data were assessed for intra- and postoperative complications, including treatment failure. In addition, intra- and postoperative X-rays were used to determine the position of the implant, and any migration, via tip-apex-distance (TAD) and the caput-collum-diaphyseal angle (CCD). The accuracy of the fracture reduction was rated by both observers according to Baumgartners criteria.

RESULTS

275 consecutive patients (mean age 77.5 ± 14.1; 70.2% female) were included. The predominant OTA/AO fracture classification was 31A2 (140 cases, 50.7%). The average surgical time was 69 min (± 39.8). The reduction quality was good in 253 cases (92.0%) and acceptable in 22 cases (8.0%). In 18 cases, a pre-defined primary outcome parameter (6.5%) was recorded after a mean of 8.2 ± 8.0 months. During the observational period, 19 patients (6.9%) required a total of 23 additional surgeries. Implant removal was not considered a failure in the absence of pain. Significant group differences were observed with younger age (p = 0.001), lower Charlson Comorbidity Index (CCI)-score (p = 0.041) and lower rate of osteoporosis (p = 0.015) in the failure group. There were no cases of cut-out or cut-through among the patients who underwent augmentation as part of osteosynthesis.

CONCLUSIONS

Proximal femur fractures treated with the TFNA show low complication rates and high levels of radiological healing. Implant-related complications might be more common in patients with younger age, a lower CCI-score and lower frequency of osteoporosis. Usage of cement augmentation could potentially be beneficial to reduce postoperative cut-through and cut-out.

The ensemble artificial intelligence (AI) method: Detection of hip fractures in AP pelvis plain radiographs by majority voting using a multi-center dataset

Introduction

This article was undertaken to explore the potential of AI in enhancing the diagnostic accuracy and efficiency in identifying hip fractures using X-ray radiographs. In the study, we trained three distinct deep learning models, and we utilized majority voting to evaluate their outcomes, aiming to yield the most reliable and precise diagnoses of hip fractures from X-ray radiographs.

Methods

An initial study was conducted of 10,849 AP pelvis X-rays obtained from five hospitals affiliated with Başkent University. Two expert orthopedic surgeons initially labeled 2,291 radiographs as fractures and 8,558 as non-fractures. The algorithm was trained on 6,943 (64%) radiographs, validated on 1,736 (16%) radiographs, and tested on 2,170 (20%) radiographs, ensuring an even distribution of fracture presence, age, and gender. We employed three advanced deep learning architectures, Xception (Model A), EfficientNet (Model B), and NfNet (Model C), with a final decision aggregated through a majority voting technique (Model D).

Results

For each model, we achieved the following metrics:For Model A: F1 Score 0.895, Accuracy 0.956, Specificity 0.973, Sensitivity 0.893.For Model B: F1 Score 0.900, Accuracy 0.960, Specificity 0.991, Sensitivity 0.845.For Model C: F1 Score 0.919, Accuracy 0.966, Specificity 0.984, Sensitivity 0.899.For Model D: F1 Score 0.929, Accuracy 0.971, Specificity 0.991, Sensitivity 0.897.We concluded that Model D (majority voting) achieved the best results in terms of the F1 score, accuracy, and specificity values.

Conclusions

Our study demonstrates that the results obtained by aggregating the decisions of multiple models through voting, rather than relying solely on the decision of a single algorithm, are more consistent. The practical application of these algorithms will be difficult due to ethical, legal, and confidentiality issues, despite the theoretical success achieved. Developing successful algorithms and methodologies should not be viewed as the ultimate goal; it is important to understand how these algorithms will be used in real-life situations. In order to achieve more consistent results, feedback from clinical practice will be helpful.

Functional Status in Older Persons After Hip Fracture Surgery: A Longitudinal Study of Indonesian Patients

BACKGROUND

Hip fractures are one of the most serious injuries affecting older adults. Evidence-based knowledge regarding the functional status of older persons after hip fracture can provide information critical for developing effective continuous-care and rehabilitation programs.

PURPOSE

This study was developed to examine the post-hospital-discharge outcome measures and predictors of functional status in older adults in Indonesia after hip fracture surgery.

METHODS

The functional status of 109 patients discharged from an orthopedic hospital in Indonesia after hip fracture surgery was evaluated in this prospective cohort study. Functional status was evaluated using measures of physical and independent activities of daily living (PADL and IADL, respectively) at 1, 3, and 6 months postdischarge. Predictors of changes in functional status, including age, length of hospital stay, comorbidity, prefracture walking ability, type of surgery, status of depression and nutrition, type of insurance, and residential status (urban vs. rural), were also examined. Data were analyzed using generalized estimating equations.

RESULTS

Significant improvements in PADL were found at 3 and 6 months, and significant improvements in IADL were found at 6 months. Predictors of poor outcomes found in this study included age, a dependent prefracture walking ability, depression, and having public health insurance.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The findings of this study support the effectiveness of using presurgery assessments to identify individuals at a higher postdischarge risk of having poor PADL and IADL outcomes. Home nursing or subacute rehabilitation is recommended to improve and maintain functional status in older persons after hip fracture surgery. In addition, interventions and rehabilitation should take into consideration different recovery periods for PADL and IADL after hospital discharge after hip fracture surgery.

Unstable minimally displaced lateral compression type 1 (LC1) pelvic ring injuries have a similar hospital course as intertrochanteric femur fractures

INTRODUCTION

The purpose of this study was to evaluate how the hospital course of minimally displaced LC1 fractures, with and without occult instability, compares with that of intertrochanteric femur fractures.

PATIENTS AND METHODS

Retrospective comparative cohort analysis at an urban level one trauma center of 40 consecutive patients with an isolated LC1 pelvic ring injury and 40 age/sex matched patients with an isolated intertrochanteric femur fracture was performed. Medical records and radiographs were reviewed for patient and injury characteristics, including demographics, displacement, time to surgery, ambulation, physical therapy (PT) clearance, hospital length of stay (LOS), and inpatient morphine milligram equivalents (MME).

RESULTS

The LC1 pelvic ring injury group included 26 (65%) patients with ≥ 10 mm of displacement on lateral stress radiographs. The unstable LC1 group, compared to the stable LC1 group, had a greater LOS (median difference (MD): 2 days, 95% confidence interval (CI): 1 to 4, p = 0.0004), longer time to ambulate 15 feet (MD: 1 day, CI: 1 to 2, p = 0.0002), longer time to clear PT (MD: 2 days, CI: 1 to 3, p = 0.0003), and more inpatient MMEs (MD: 386 MME, CI: 225.8 to 546.7, p = 0.0002). The unstable LC1 and intertrochanteric fracture groups had no detectable differences in LOS (p = 0.24), days to ambulate 15 feet (p = 0.46), days to clear PT (p = 0.95), and inpatient MMEs (p = 0.06).

CONCLUSION

Patients with minimally displaced unstable LC1 injuries had worse hospital courses than stable LC1 injuries and similar hospital courses as intertrochanteric femur fractures. These findings emphasize the associated morbidity of unstable LC1 injuries.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

No difference between lag screw and helical blade for cephalomedullary nail cut-out a systematic review and meta-analysis

INTRODUCTION

Cephalomedullary nail (CMN) cut-out is a severe complication of treatment of intertrochanteric femur fractures. This study aimed to identify modifiable risk factors predictive of implant cut-out including: CMN proximal fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, screw location, and surgeon fellowship training.

METHODS

A systematic review of the published literature was conducted on Pubmed/MEDLINE and Cochrane Library databases for English language papers (January 1st, 1985-May 10th, 2020), with 21 studies meeting inclusion/exclusion criteria. Studies providing quantitative data comparing factors affecting CMN nail cut-out were included, including fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, and screw location. Twelve studies were included and graded by MINOR and Newcastle-Ottawa Scale to identify potential biases. Meta-analysis and pooled analysis were conducted when possible with forest plots to summarize odds ratios (OR) and associated 95% confidence interval (CI).

RESULTS

There was no difference in implant cut-out rate between lag screws (n = 745) versus helical blade (n = 371) (OR: 1.03; 95% CI: 0.25-4.23). Pooled data analysis revealed TAD > 25 mm (n = 310) was associated with higher odds of increased cut-out rate relative to TAD < 25 mm (n = 730) (OR: 3.72; 95% CI: 2.06-6.72).

CONCLUSION

Our review suggests that cephalomedullary implant type (lag screw vs. helical blade) is not a risk factor for implant cut-out. Consistent with the previous literature, increased tip-apex distance > 25 mm is a reliable predictor of implant cut-out risk. Suboptimal screw location and poor reduction quality are associated with increased risk of screw cut-out.

LEVEL OF EVIDENCE

Level III.