Internal fixation versus arthroplasty for displaced femoral neck fractures: what is the evidence?

Hemiarthroplasty vs. internal fixation for nondisplaced femoral neck fracture in mainland China: a cost-effectiveness analysis

Objective

Nondisplaced femoral neck fractures constitute a substantial portion of these injuries. The optimal treatment strategy between internal fixation (IF) and hemiarthroplasty (HA) remains debated, particularly concerning cost-effectiveness.

Methods

We conducted a cost-effectiveness analysis using a Markov decision model to compare HA and IF in treating nondisplaced femoral neck fractures in elderly patients in China. The analysis was performed from a payer perspective with a 5-year time horizon. Costs were measured in 2020 USD, and effectiveness was measured in quality-adjusted life-years (QALYs). Sensitivity analyses, including one-way and probabilistic analyses, were conducted to assess the robustness of the results. The willingness-to-pay threshold for incremental cost-effectiveness ratio (ICER) was set at $11,083/QALY following the Chinese gross domestic product in 2020.

Results

HA demonstrated higher cumulative QALYs (2.94) compared to IF (2.75) but at a higher total cost ($13,324 vs. $12,167), resulting in an ICER of $6,128.52/QALY. The one-way sensitivity analysis identified the costs of HA and IF as the most influential factors. Probabilistic sensitivity analysis indicated that HA was more effective in 69.3% of simulations, with an ICER below the willingness-to-pay threshold of $11,083 in 58.8% of simulations.

Conclusions

HA is a cost-effective alternative to IF for treating nondisplaced femoral neck fractures in elderly patients in mainland China.

Revision rate following unipolar versus bipolar hemiarthroplasty

INTRODUCTION

There has been much debate on use of bipolar or unipolar femoral heads in hemiarthroplasty for the treatment of femoral neck fractures. The outcome of these implants should be studied in the America Joint Replacement Registry (AJRR).

METHODS

All primary femoral neck fractures treated with hemiarthroplasty between January 2012 and June 2020 were searched in the AJRR. All cause-revision of unipolar and bipolar hemiarthroplasty and reasons for revision were assessed for these patients until June of 2023.

RESULTS

There were no differences in number and reason for all cause revisions between unipolar and bipolar hemiarthroplasty (p = 0.41). Bipolar hemiarthroplasty had more revisons at 6 months postoperatively (p = 0.0281), but unipolar hemiarthroplasty had more revisions between 2 and 3 years (p = 0.0003), and after 3-years (p = 0.0085), as analysed with a Cox model. Patients with older age (HR = 0.999; 95% CI, 0.998-0.999; p = 0.0006) and higher Charlson Comorbidity Index (HR = 0.996; 95% CI, 0.992- 0.999; p = 0.0192) had a significant increase in revision risk.

CONCLUSIONS

We suggest that surgeons should consider using bipolar prosthesis when performing hemiarthroplasty for femoral neck fracture in patients expected to live >2 years post injury.

Cemented Versus Uncemented Hemiarthroplasty for Displaced Intracapsular Neck of Femur Fractures in the Elderly: Outcomes and Costings

Background

Hemiarthroplasty (HA) is a common form of treatment for displaced neck of femur fractures. There is ongoing debate as to whether cemented or uncemented HA is a more superior treatment modality. The aim of this study was to compare the outcomes between patients that underwent cemented HA to uncemented HA. Secondarily, we analysed the costs associated of each treatment option.

Methods

This was a retrospective study conducted at a busy district general hospital. The study included 335 patients that were treated with either a cemented or uncemented HA for a displaced neck of femur fracture between January 2017 and December 2018. Data collected included age, sex, American Society of Anesthesiologist (ASA) score, treatment modality, length of stay (LOS) and general costs.

Results

197 (58.8%) of the cohort underwent cemented HA and 138 (41.2%) underwent uncemented HA. Mean age for the cemented cohort was 84.7 years and 85.9 years in the uncemented group (p = 0.31). There was no significant differences between the groups with regard to mean LOS and discharge disposition (p = 0.44). There were no significant difference in 30-day and 1-year mortality between the two groups (p = 0.2). We did find a statistically significant difference in the costings between the two procedures, with cemented HAs costing £66 more than uncemented HAs (p < 0.001).

Conclusion

We found that both cemented and uncemented HAs produced comparable results. We found a statistically significant reduction in operative time and costs associated with uncemented HA. Uncemented HA implants may be considered where a shorter operation duration is essential.

Calcar-guided short-stem total hip arthroplasty in fractures of the femoral neck: a prospective observational study of 68 hips

INTRODUCTION

The indications for cementless short-stem total hip arthroplasty (THA) have been expanded due to encouraging results. However, no evidence in cases of femoral neck fractures (FNFs) is available. We aimed to prospectively obtain data on the safety and the clinical outcomes of a cementless calcar-guided short stem in patients with FNFs.

MATERIALS AND METHODS

We conducted a prospective observational study of 68 patients diagnosed with FNFs who underwent short-stem THA between 2016 and 2019 with a calcar-guided stem. Complications during follow-up leading to revision were documented, and patient reported outcome measurements recorded. Stem migration was analyzed using the Einzel-Bild-Röntgen-Analysis Femoral Component Analysis software.

RESULTS

The mean follow-up was 33.8 ± 14.8 months. The patient mortality at last follow-up was 10.6%. Two patients required stem revision, due to periprosthetic fracture and late aseptic loosening, respectively, corresponding to 96.2% stem survival. Survivorship for the endpoint of revision for any reason was 91.1% at 6 years. All revisions occurred in females. The mean Harris Hip Score at the last follow-up was 93.0 ± 8.9. The mean axial migration at last follow-up was 1.90 ± 1.81 mm. No significant influence on migration was found regarding gender, age, weight, and body mass index.

CONCLUSIONS

The clinical and radiological findings were satisfying and most patients benefited from the minimally invasive procedure. However, as for conventional THA as well, implant survivorship and mortality were markedly worse compared to results regarding osteoarthritis. Especially in elderly female patients with FNF, cementless short-stem THA is a concern and a cemented THA should be the first choice.

Direct anterior versus antero-lateral approach in hip joint hemiarthroplasty

BACKGROUND

Femoral neck fractures are common injuries in the elderly and represent a major source of morbidity and mortality. Due to the benefits, bipolar hip hemiarthroplasty (BHH) is a popular method to treat. The purpose of this study is to evaluate the functional and radiographic outcomes for BHH comparing the direct anterior approach (DAA) to the anterolateral approach (ALA) to the hip joint.

METHODS

We used a prospective, randomized observational study design, where we enrolled 83 patients at a level-I-trauma center presenting with indication for BHH. We followed up the participants at defined intervals over a period of 1 year. The follow-up examinations were carried out at defined time intervals for a period of 1 year. Calculations were performed with Statistical Package for Social Sciences (SPSS) 21.0.

RESULTS

Concerning postoperative pain sensation, the anterior group had statistically significantly decreased pain levels at one (p = 0.02), seven (p = 0.04) and 14 days (p = 0.02) following the intervention when compared to the ALA sample. The postoperative modified Barthel-Index showed a statistically significant difference on the first postoperative day at the anterior group.

CONCLUSION

Although we compared two minimally invasive approaches, our results shows a statistically significant difference in pain intensity and mobility for the early postoperative period using the direct anterior approach.

What makes fixation of femoral neck fractures fail? A systematic review and meta-analysis of risk factors

INTRODUCTION

This systematic review aims to provide an overview of predictors for failure of treatment of displaced femoral neck fracture (dFNF) with internal fixation and quantify their risk of fixation failure in a meta-analysis.

PATIENTS AND METHODS

PubMed, Embase, Web of Science, Cochrane Library, and EMCare were searched for original studies published from January 2000, including adult patients with an internally fixated dFNF, that reported data on predictors for fixation failure defined as revision surgery due to non-union, avascular femoral head necrosis or cut-out of implant. RevMan version 5 software was used to pool univariable Odds Ratio's (OR) for predictors of fixation failure by means of a random effects model.

RESULTS

This review included 16 articles (15 articles cohort studies and one randomised trial). Twenty-four predictors for fixation failure were identified and analysed, 16 of which were evaluated in just one study. Data of 7 predictors were pooled in a meta-analysis. Female sex (OR 1.78, 95% confidence interval [CI] 1.26-2.52), smoking (OR 3.64, 95% CI 1.68-7.91), age >50 years (OR 3.64, 95% CI 1.68-7.91), inadequate fracture reduction (OR 2.28, 95% CI 1.62-3.22), fixation with cannulated screws (CS) or pins compared to fixed angle devices (OR 2.16, 95% CI 1.03-4.54) were identified as significant predictors for fixation failure.

CONCLUSION

This study can help surgeons to choose the preferred treatment for patients with a dFNF and substantiate future algorithms and guidelines for treatment of FNF.

Fixation vs Arthroplasty for Femoral Neck Fracture in Patients Aged 40-59 Years: A Propensity-Score-Matched Analysis

Background

Methods

Results

Conclusions

Comparison of femoral neck system to multiple cancellous screws and dynamic hip screws in the treatment of femoral neck fractures

OBJECTIVE

To compare the short-term outcomes of the femoral neck system (FNS) with multiple cancellous screws (MCS) and dynamic hip screws (DHS) in the treatment of femoral neck fractures.

METHODS

A retrospective analysis was performed on 157 patients with fresh femoral neck fractures treated with FNS (from September 2019 to October 2020), MCS, and DHS (from January 2018 to October 2020). According to internal fixation methods, all patients were divided into the FNS group (54 cases), MCS group (51 cases), and DHS group (52 cases). Demographic data were also collected, recorded, and compared, including the follow-up time, days of hospitalization, operation time, blood loss, intraoperative fluoroscopy times (IFT), weight-bearing time (WBT), length of femoral neck shortening (LFNS), Harris hip score, and complications (such as internal fixation failure, bone nonunion, and avascular necrosis of the femoral head) between the three groups.

RESULTS

Overall, 157 patients with a mean age of 61.8 (range, 18-89) years were analyzed. In the FNS group, IFT (median 10.5) was significantly lower than that in the MCS group (median 21) and DHS group (median 20.5) (P<0.05), and WBT was significantly earlier than that of the MCS group (P<0.05). In the FNS group, the median hospitalization time, operation time, and blood loss were 2 (2, 4) days, 45 (40-59) min, and 30 (20, 50) ml, respectively. They were all significantly less than 3.5 (3, 6) days, 72 (55-88.75) min, and 50 (30, 50) ml in the DHS group, respectively (P < 0.05). There was no statistical difference in LFNS, quality of reduction, internal fixation failure rate, and Harris hip score at the latest follow-up (P>0.05). No surgical complications such as incision infection, deep infection, pulmonary embolism, or femoral head necrosis were found in any of the three groups.

CONCLUSION

FNS, MCS, and DHS are all effective for femoral neck fractures. However, a lower IFT of FNS shortens the operation time. Compared to MCS, FNS has the advantages of being a simple operation, with early WBT; compared to DHS, a minimally invasive operation is the main advantage of FNS.

Non-sliding Fixation Shows Improved Clinical Outcomes for Displaced Femoral Neck Fractures as Compared to Sliding Fixation

Objective

To compare the clinical outcomes between use of sliding fixation (three cannulated screws, TCS) and non-sliding fixation (four cannulated screws, FCS) in the treatment of femoral neck fractures.

Methods

We retrospectively analyzed 102 patients with fresh femoral neck fractures treated with TCS (60 cases) and FCS (42 cases) between January, 2018 and December, 2019. The demographic data, follow-up time, hospitalization time, operation time, blood loss, length of femoral neck shortening (LFNS), soft tissue irritation of the thigh (STIT), Harris hip score, and complications (such as internal fixation failure, non-union, and avascular necrosis of the femoral head) were also collected, recorded, and compared between the two groups.

Results

A total of 102 patients with an average age of 60.9 (range, 18–86) years were analyzed. The median follow-up time was 25 (22 to 32) months. The LFNS in the FCS group (median 1.2 mm) was significantly lower than that in the TCS group (median 2.8 mm) (P < 0.05). In the Garden classification, the number of displaced fractures in the TCS group was significantly lower than that in the FCS group (P < 0.05). The median hospitalization time, operation time, blood loss, reduction quality, internal fixation failure rate (IFFR), STIT, and Harris hip score were not statistically different between the two groups (P > 0.05). However, in the subgroup analysis of displaced fractures, the LFNS (median 1.2 mm), STIT (2/22, 13.6%), and Harris hip score (median 91.5) of the FCS group at the last follow-up were significantly better than the LFNS (median 5.7 mm), STIT (7/16, 43.8%), and Harris hip score (median 89) of the TCS group (P < 0.05). No complications such as incision infection, deep infection, pulmonary embolism, or femoral head necrosis were found in either group.

Conclusion

TCS and FCS are effective for treating femoral neck fractures. For non-displaced fractures, there was no significant difference in the clinical outcomes between the two groups. However, for displaced fractures, the LFNS of the FCS is significantly lower than that of the TCS, which may reduce the occurrence of STIT and improve the Harris hip score.

Management of femoral neck fractures with the ALMIS approach in elderly patients: Outcomes compared to posterior approach

INTRODUCTION

Over the last 2 decades, several minimally invasive surgical techniques and approaches have been introduced for hip arthroplasty, including anterolateral minimally invasive surgery (ALMIS) introduced by Röttinger in 2004. As described, this muscle sparing approach promises faster recovery and lower dislocation rates. Although there has been a peaked recent interest in minimally invasive surgery (MIS) hip arthroplasty, few studies support the superiority of ALMIS compared to the more traditional posterior approach. The present study examines the safety and early complications of elderly patients undergoing ALMIS compared to a posterior approach for hemiarthroplasty of displaced femoral neck fractures.

METHODS

In a retrograde level III case-control study, 100 consecutive elderly patients with primary hip arthroplasty were divided into two groups. The first group consisted of 50 consecutive cases operated with the ALMIS approach and the second group of 50 consecutive cases operated through a posterior approach. Operative time, postoperative complication rates, length of hospitalization, blood loss, and leg-length discrepancy, were reviewed retrospectively.

RESULTS

No differences were observed in post-operative complications. Overall, the operative time was significantly greater in the ALMIS group compared to the posterior approach group (75 ± 12 vs 67.5 ± 16 min, respectively; p ≤ 0.01). However, the operating time of the second half of the ALMIS cohort (N = 25), did not differ from the posterior approach group (72.7 ± 10.5 vs 67.5 ± 16, respectively; p = 0.19). Leg length discrepancy was significantly less in the ALMIS group compared to the posterior exposure group (1.5 ± 3.2 vs 3.2 ± 3.3, respectively; P≤0.1).

CONCLUSIONS

The results of the retrograde analysis, although limited in sample size, shows no major differences in ALMIS compared to a more traditional posterior approach in terms of immediate post-operative complications. Although the overall operating time was longer in the patients treated with ALMIS, the second cohort of patients treated with this method had an operating time that was similar to that observed with posterior approach. Leg-length discrepancies were significantly less in patients treated with ALMIS.

Cemented Vs Cementless Femoral Fixation for Total Hip Arthroplasty After Displaced Femoral Neck Fracture: A Nationwide Analysis of Short-Term Complications and Readmission Rates

BACKGROUND

Active patients with displaced femoral neck fractures are often treated with total hip arthroplasty (THA). However, optimal femoral fixation in these patients is controversial. The purpose of this study was to compare early complication and readmission rates in patients with hip fracture treated with THA receiving cemented vs cementless femoral fixation.

METHODS

The National Readmissions Database was queried to identify patients undergoing primary THA for femoral neck fracture from 2016 to 2017. Postoperative complications and unplanned readmissions at 30, 90, and 180 days were compared between patients treated with cemented and cementless THA. Univariate and multivariate analyses were performed to compare differences between groups and account for confounding variables.

RESULTS

Of 17,491 patients identified, 4427 (25.3%) received cemented femoral fixation and 13,064 (74.7%) cementless. The cemented group was significantly older (77.2 vs 71.1, P < .001), had more comorbidities (Charlson comorbidity index: 4.44 vs 3.92, P < .001), and had a greater proportion of women (70.5% vs 65.2%, P < .001) compared with the cementless group. On multivariate analysis, cemented fixation was associated with reduced rates of periprosthetic fracture (odds ratio: 0.052, 95% confidence interval: 0.003-0.247, P = .004) at 30 days but similar readmission rates at 30, 90, and 180 days (odds ratio range: 1.012-1.114, P > .05) postoperatively compared with cementless fixation. Cemented fixation was associated with greater odds of medical complications at 180 days postoperatively (odds ratio:: 1.393, 95% confidence interval: 1.042-1.862, P = .025).

CONCLUSION

Cemented femoral fixation was associated with a lower short-term incidence of periprosthetic fractures, higher incidence of medical complications, and equivalent unplanned readmission rates within 180 days postoperatively compared with cementless fixation in patients undergoing THA for femoral neck fracture.

LEVEL OF EVIDENCE

Level III.

Treatment of Traumatic Femoral Neck Fractures with an Intramedullary Nail in Osteoporotic Bones

PURPOSE

Sufficient anchoring of intramedullary osteosynthesis in the femoral head in a femoral neck fracture is a challenge with increasing age of the patients and decreasing bone quality. For older patients with inferior bone quality, it has not been investigated whether the application of an intramedullary force carrier, as a minimally invasive and rapid intervention, can provide a considerable benefit and reduce the postoperative complication and lethality rate. This retrospective study aimed to investigate the stability and functionality after the acute treatment of a femoral neck fracture in osteoporotic bone using an intramedullary force carrier even with higher grade fracture types.

MATERIAL AND METHODS

The retrospective analysis was based on a collective of 82 patients over 60 years of age with a femoral neck fracture treated with a gliding nail in our centre between 1999 and 2006.

RESULTS

The average time to follow-up was 69.05 months (median 71.0; minimum 27.0-maximum 108.0). Female patients made up more than two-thirds of the patient collective at 63 of the 82 patients (76.83%). The average age of the patients was 77.76 years (median 78.00; range 60.00-93.00).In 66 patients (80.49%), the implantation showed good results and no complications or further treatments. 24/82 patients of our collective had died in our re-evaluation. In no case, a pseudarthrosis or severe impaction with neck shortening occurred (loss of offset).11/82 patients had femoral head necrosis which led to total hip replacement in 8 cases, a hemiarthroplasty in 2 cases and in 1 case a remaining Girdlestone situation because of a deep infection. Another five patients also had to undergo a total hip replacement because of a central perforation of the blade in one case, breakout of the blade after another fall in another two cases and a lateral dislocation of the blade in two cases.

CONCLUSION

The use of an intramedullary force carrier in the osteoporotic bone can mean distinct advantages for the selected patient as a minimally invasive and rapid surgical method compared to extensive surgery, even in the case of severe injuries. However, the advantages and disadvantages for the patient should be considered critically.

Development and validation of a predictive nomogram for postoperative osteonecrosis of the femoral head with cannulated screws fixation

Background

Osteonecrosis of the femoral head (ONFH) remains a major complication of femoral neck fractures. Early interventions require preliminary prediction and detection. In this study, we aimed to evaluate the perioperative variables of postoperative ONFH in femoral neck fracture patients with closed reduction and cannulated screw fixation. We also established and validated an individualized nomogram for the prediction of postoperative ONFH.

Methods

We included 470 patients with ONFH from two hospitals [First Affiliated Hospital of University of Science and Technology of China (n=360) and Southern Branch of the First Affiliated Hospital of the University of Science and Technology of China (n=110)]. We evaluated the prognostic value of multiple perioperative variables using a Cox regression model in the training cohort. We developed a nomogram for the prediction of ONFH using a logistic regression model. We assessed the performance of this nomogram in a validation cohort and evaluated its clinical value.

Results

Of the 470 patients who met the inclusion criteria, 141 (30.0%) developed postoperative ONFH. We found alcohol use [odds ratio (OR), 1.743, 95% confidence interval (CI), 1.042-2.901, P=0.033], cerebrovascular disease (OR, 5.357, 95% CI, 2.318-13.13, P<0.001), interval to surgery (OR, 5.273, 95% CI, 2.724-10.43, P<0.001), Garden classification (OR, 23.17, 95% CI, 6.812-145.3, P<0.001), Garden index (OR, 5.935, 95% CI, 2.670-14.184, P<0.001), interval to partial weight-bearing (OR, 0.053, 95% CI, 0.006-0.296, P=0.002), and six-month Harris hip score (OR, 0.856; 95% CI, 0.792-0.919, P<0.001) were independent predictors of postoperative development of ONFH. Based on these variables, we developed a nomogram that showed good discrimination in both the training [area under the curve (AUC) =0.865] and the validation cohort (AUC =0.877). The favorable performance of this nomogram was also confirmed in the validation cohort.

Conclusions

We developed and validated an easy-to-use nomogram for predicting postoperative ONFH. This nomogram can aid decision-making of intraoperative interventions and postoperative rehabilitation plans for patients, surgeons, and osteo-rehabilitative physicians.

Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in the Elderly: A Cost-Effectiveness Analysis

OBJECTIVE

To evaluate the cost-effectiveness of screw fixation versus hemiarthroplasty for nondisplaced femoral neck fractures in low-demand elderly patients.

METHODS

We constructed a Markov decision model using a low-demand, 80-year-old patient as the base case. Costs, health-state utilities, mortality rates, and transition probabilities were obtained from published literature. The simulation model was cycled until all patients were deceased to estimate lifetime costs and quality-adjusted life years (QALYs). The primary outcome was the incremental cost-effectiveness ratio with a willingness-to-pay threshold set at $100,000 per QALY. We performed sensitivity analyses to assess our parameter assumptions.

RESULTS

For the base case, hemiarthroplasty was associated with greater quality of life (2.96 QALYs) compared with screw fixation (2.73 QALYs) with lower cost ($23,467 vs. $25,356). Cost per QALY for hemiarthroplasty was $7925 compared with $9303 in screw fixation. Hemiarthroplasty provided better outcomes at lower cost, indicating dominance over screw fixation.

CONCLUSIONS

Hemiarthroplasty is a cost-effective option compared with screw fixation for the treatment of nondisplaced femoral neck fractures in the low-demand elderly. Medical comorbidities and other factors that impact perioperative mortality should also be considered in the treatment decision.

LEVEL OF EVIDENCE

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

Age matters when comparing hemiarthroplasty and total hip arthroplasty for femoral neck fractures in Medicare patients

INTRODUCTION

The optimal treatment of patients with a displaced intracapsular femoral neck fracture remains controversial. We utilised a national database of Medicare patients to determine if there was any difference in complications and reoperation rate of patients undergoing total hip arthroplasty (THA) or hemiarthroplasty (HA) for femoral neck fractures.

METHODS

This study utilised the PearlDiver Patient Records Database, a national for-fee database of Medicare patient procedure and diagnosis records from 2005 to 2012. Outcome procedures and diagnoses including revision, dislocation, infection, and cardiovascular events that occurred during the study time period were also identified over the entire study period as well as 90 days and 2 years.

RESULTS

We identified 275,439 patients with femoral neck fractures who underwent HA and 26,017 patients who underwent THA, respectively. Patients undergoing HA had significantly lower rates (p < 0.0001) of revision 2.48% versus 3.85% (OR = 0.633; 95% CI, 0.592-0.678), dislocation 1.76% versus 3.39% (0.512; 0.476-0.551), infection 3.44% versus 4.87% (0.694; 0.657-0.737). There was no statistical significant difference in 2-year cardiac morbidity (p = 0.252). However, when controlling for age, patients 65-69 years showed no significant difference in infection or revision over the study period or at 2 years.

CONCLUSIONS

In this study, patients who underwent THA for femoral neck fractures had a higher rate of dislocations, infections and increased rates of repeat surgery than those who underwent HA but this difference was not significant in patients 65-69 years. Hemiarthroplasty may result in fewer complications in older Medicare patients although this difference may not be present in younger Medicare patients.

A case report depicting patient's installation on the fracture table when an ankle spanning external fixator is already in place

BACKGROUND

Fractures of the proximal and diaphyseal femur are frequently internally fixed using a fracture table. Moreover, some femoral neck fractures may be treated with total hip arthroplasty using a direct anterior approach and a traction table. Fracture and traction tables both use a boot tightly fitted to the patient's foot in order to: 1) obtain fracture reduction by traction and adequate rotation exerted on the slightly abducted or adducted extremity; or 2) adequately expose the hip joint using traction, rotation and extension to implant total hip arthroplasty components. In some instances, multiply injured patients may present with both a proximal or diaphyseal femur fracture and a diaphyseal or distal tibia or ankle fracture necessitating an ankle spanning external fixator on the same limb. Frequently, the tibia or ankle fracture has to be treated first, and standard use of the fracture or traction table may be thereafter difficult due to the external fixator construct preventing tight fitting of the boot to the patient's foot.

CASE PRESENTATION

In order to address this situation, the authors describe a simple technique allowing rigid fixation of the limb with an ankle spanning external fixator to the traction or fracture table, providing accurate control of the position of the lower limb in all planes for adequate fracture reduction and fixation or total hip arthroplasty. The technique is exemplified with a clinical case.

CONCLUSIONS

This technique allows an efficient way to: 1) timely stabilize diaphyseal or distal tibia or ankle fractures; and 2) subsequently use all the advantages of a fracture or traction table to adequately reduce and fix proximal or diaphyseal femur fractures, or optimally expose femoral neck fractures for total hip arthroplasty using a direct anterior approach.

Factors Influencing the Outcome of Osteosynthesis in the Fracture of the Femoral Neck in Young Adult Patients

Objectives  To evaluate the factors that influence the outcome of osteosynthesis after closed reduction of the fracture of the femoral neck in young adult patients.

Methods  A retrospective study was conducted, reviewing the data of patients operated in a large orthopedic hospital from 2003 to 2011; a total of 81 patients met the inclusion criteria. The time interval between the fracture and the surgery, the initial fracture deviation, the quality of the reduction, and the placement of the implant were evaluated.

Results  The present study observed a strong relationship between the quality of the reduction and therapeutic success. The degree of the initial deviation and the time elapsed between the initial trauma and the osteosynthesis did not influence the surgical outcome regarding bone consolidation. The correct positioning of the implants was associated with a satisfactory evolution in the postoperative period.

Conclusion  The quality of the reduction and the positioning of the implants are factors that influence the results of osteosynthesis in fractures of the femoral neck in young adult patients.

HOPE-Trial: Hemiarthroplasty Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Octogenarians: A Randomized Controlled Trial

BACKGROUND

The choice of primary hemiarthroplasty or total hip arthroplasty in patients ≥80 years of age with a displaced femoral neck fracture has not been adequately studied. As the number of healthy, elderly patients ≥80 years of age is continually increasing, optimizing treatments for improving outcomes and reducing the need for secondary surgery is an important consideration. The aim of the present study was to compare the results of hemiarthroplasty with those of total hip arthroplasty in patients ≥80 years of age.

METHODS

This prospective, randomized, single-blinded trial included 120 patients with a mean age of 86 years (range, 80 to 94 years) who had sustained an acute displaced femoral neck fracture <36 hours previously. The patients were randomized to treatment with hemiarthroplasty (n = 60) or total hip arthroplasty (n = 60). The primary end points were hip function and health-related quality of life at 2 years. Secondary end points included hip-related complications and reoperations, mortality, pain in the involved hip, activities of daily living, surgical time, blood loss, and general complications. The patients were reviewed at 3 months and 1 and 2 years.

RESULTS

We found no differences between the groups in terms of hip function, health-related quality of life, hip-related complications and reoperations, activities of daily living, or pain in the involved hip. Hip function, activities of daily living, and pain in the involved hip deteriorated in both groups compared with pre-fracture values. The ability to regain previous walking function was similar in both groups.

CONCLUSIONS

We found no difference in outcomes after treatment with either hemiarthroplasty or total hip arthroplasty in active octogenarians and nonagenarians with a displaced femoral neck fracture up to 2 years after surgery. Hemiarthroplasty is a suitable procedure in the short term for this group of patients.

LEVEL OF EVIDENCE

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

Hip hemi-arthroplasty for neck of femur fracture: What is the current evidence?

This editorial reviews and summarises the current evidence (meta-analyses and Cochrane reviews) relating to the use of hip hemi-arthroplasty for neck of femur fractures. Regarding the optimal surgical approach, two recent meta-analyses have found that posterior approaches are associated with: higher rates of dislocation compared to lateral and anterior approaches; and higher rates of re-operation compared to lateral approaches. Posterior approaches should therefore be avoided when performing hip hemi-arthroplasty procedures. Assessing the optimal prosthesis head component, three recent meta-analyses and one Cochrane review have found that while unipolar hemi-arthroplasty can be associated with increased rates of acetabular erosion at short-term follow-up (up to 1 year), there is no significant difference between the unipolar hemi-arthroplasty and bipolar hemi-arthroplasty for surgical outcome, complication profile, functional outcome and acetabular erosion rates at longer-term follow-up (2 to 4 years). With bipolar hemi-arthroplasty being the more expensive prosthesis, unipolar hemi-arthroplasty is the recommended option. With regards to the optimal femoral stem insertion technique, three recent meta-analyses and one Cochrane Review have found that, while cemented hip hemi-arthroplasties are associated with a longer operative time compared to uncemented Hip Hemi-arthroplasties, cemented prostheses have lower rates of implant-related complications (particularly peri-prosthetic femoral fracture) and improved post-operative outcome regarding residual thigh pain and mobility. With no significant difference found between the two techniques for medical complications and mortality, cemented hip hemi-arthroplasty would appear to be the superior technique. On the topic of wound closure, one recent meta-analysis has found that, while staples can result in a quicker closure time, there is no significant difference in post-operative infections rates or wound healing outcomes when comparing staples to sutures. Therefore, either suture or staple wound closure techniques appear equally appropriate for hip hemi-arthroplasty procedures.

Femur neck fracture in young adults, is it really an urgent surgery indication: retrospective clinical study

Introduction

Femur neck fracture comprises a significant part of intracapsular femur fracture in the intracapsular area of proximal femur and it is mostly seen in elder people. However, these kinds of fractures may be seen in young adults. The present study aims to search factors that affect femoral neck fractures in young adults after surgery carried out by internal determination method.

Methods

Files of patients who were applied internal determination through closed reduction and cannulated screw because of intracapsular femur neck fractures between 2010 and 2015 were analyzed retrospectively. Fractures were evaluated by means of Garden classification, which is based on radiological appearance. The cases were examined in terms of timing of surgery in two groups. Cases operated in the first 24 hours after trauma consisted of group 1 and after 24 hours group 2. Radiological staging in femoral head avascular necrosis was evaluated by Ficat-Arlet classification system whereas acetabular fractures and hip functionality was evaluated by Letournel and Judet system, which is based on direct graph of fracture line.

Results

Mean age at the time of surgery for 31 cases included in the study was 40.04 ± 9.63 year. The average duration from injury to surgery was 6.6 (1-20) days. Thirty nine percent of fractures was nondisplaced whereas 61% was displaced. The average follow-up period was 4.9 ± 1.35 years. The rate of nonunion was found 16% and femoral head avascular necrosis 6.4%. According to Judet System, 67.7% of cases showed excellent/good and 32.3% moderate/bad functional results. Six cases had a secondary surgery. Cases who had displaced fractures statistically showed worse functional results and underwent more secondary surgery than patients with nondisplaced fractures (P>0.05). As a result of logistic regression analysis, presence of displacement was a factor negatively affecting the judet score but did not affect the rate of complication. There were no significant differences between the two groups according to the surgical timing in terms of functional outcomes and complications.

Conclusion

Because of surgical treatment of femoral neck fractures in the first 24 hours does not affect functional outcomes and complication rate, surgery is recommended in optimal conditions. In the case of displacement, care must be taken in terms of poor functional results.

Has the risk of dislocation after total hip arthroplasty performed for displaced femoral neck fracture improved with modern implants?

BACKGROUND

Displaced femoral neck fractures (DFNF) in the elderly can be treated with hemiarthroplasty or total hip arthroplasty (THA). One concern with utilizing THA in this setting is post-operative dislocation. The purposes of this study were to determine the incidence of hip dislocation following THA for DFNF and to identify risk factors for dislocation.

METHODS

The charts of 66 posterior-approach THA cases performed for DFNF with mean post-operative follow-up of 4.4 years were retrospectively reviewed. Pre-operative patient demographic data and intra-operative clinical data were recorded including age, race, gender, height, weight, body mass index (BMI), femoral head diameter, acetabular cup diameter, use of an elevated liner, and cementing of femoral component. For patients with available post-operative pelvis radiographs, acetabular cup inclination and version angles were also calculated.

RESULTS

Four dislocation (4/66, 6%) events occurred at an average of 51 days after surgery. No specific risk factors for dislocation were identified but the use of a cemented femoral stem did approach significance (p = 0.06). 47% of the acetabular cups were located outside of the Lewinnek safe zone. Although the dislocation rate of THAs with acetabular cups outside of the safe zone was higher than the dislocation rate for THAs with cups in the safe zone (12.5% vs 0%), placement of acetabular cups outside of the safe zone was not a risk factor for dislocation.

CONCLUSIONS

Posterior THA with proper cup positioning and meticulous soft tissue repair is an effective treatment option for DFNF with low dislocation risk.

Nationwide Analysis of Femoral Neck Fractures in Elderly Patients: A Receding Tide

BACKGROUND

Geriatric femoral neck fractures are associated with substantial morbidity and medical cost. We evaluated the incidence and management trends of femoral neck fractures in recent years in the U.S.

METHODS

Patient data from 2003 through 2013 were obtained from the Nationwide Inpatient Sample database. Femoral neck fractures in patients ≥65 years old were identified and grouped using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for internal fixation, hemiarthroplasty, or total hip arthroplasty (THA). The nationwide incidence of femoral neck fractures was calculated and presented as an age-adjusted population rate. Univariable methods were used for trend analysis and comparisons between groups. Logistic regression modeling was used to analyze complications.

RESULTS

From 2003 to 2013, we identified 808,940 femoral neck fractures in patients ≥65 years old. The national age-adjusted incidence of femoral neck fractures decreased from 242 per 100,000 U.S. adults in 2003 to 146 in 2013. The proportion of fractures managed operatively with THA increased over time (5.9% in 2003 versus 7.4% in 2013; p < 0.001). Concurrently, the use of hemiarthroplasty declined (65.1% versus 63.6%; p < 0.001). In 2013, the median age of the patients treated with THA was significantly younger (77.3 years) compared with that in the hemiarthroplasty and internal fixation groups (83.2 and 82.0 years). The THA group had significantly higher median initial hospital costs ($17,097) compared with the hemiarthroplasty and internal fixation groups ($14,776 and $10,462).

CONCLUSIONS

In the last decade, the total number and population rate of femoral neck fractures in the elderly declined significantly. There was a modest but significant increase in the utilization of THA.

CLINICAL RELEVANCE

This report identifies the changing trends in clinical practice in the treatment of geriatric femoral neck fractures in the U.S. Treating physicians should be aware of these trends, which include a decreasing national incidence of geriatric femoral neck fractures as well as an increase in the use of THA.

A retrospective cohort study of concomitant ipsilateral extra-capsular and intra-capsular fractures of the proximal femur. Are they casual findings or an undervalued reality?

BACKGROUND

Fractures of the proximal femur constitute a major public health problem, with an annual incidence in Spain of 7.6 cases per 1000 inhabitants over 65 years of age. Hip fractures are frequent in elderly patients, related to osteoporosis and with low energy trauma, which means that they can be considered a geriatric syndrome. Simultaneous ipsilateral extra- and intra-articular hip fractures are considered as very rare are, and generally speaking, classified as extra- or intra-capsular fractures. Moreover, there is no consensus with regard to treatment of these concomitant fractures.

AIM

To estimate the incidence of concomitant ipsilateral extra- and intra-capsular fractures of the proximal femur, and to describe the diagnostic process and the clinical characteristics of these concomitant fractures.

PATIENTS AND METHODS

Retrospective cohort study of patients with hip fractures. The incidence of combined extra- and intra-capsular fractures was estimated, a confidence interval of 95% (95%CI) was calculated and a descriptive analysis was drawn up.

RESULTS

Between May 2010 (the date on which the Orthopaedic and Trauma Surgery Department of our new Hospital began the surgical activity) and December 2016, 33 (median age, 86 years-old) of the 2625 hip fractures were classified as simultaneous extra- and intra-capsular ipsilateral fractures. The overall cumulative incidence was of 1.3% (95%CI:0.9-1.8%). In 32 (97%) of the patients, the fracture was a consequence of a low energy trauma (ground level fall), while the remainder was due to a medium energy trauma (skating). In all cases the two fracture lines seem to be independent of each other, which suggests different mechanisms of injury from that of isolated subcapital or intrertrochanteric fracture.

CONCLUSION

The incidence of concomitant ipsilateral extra- and intra-capsular fractures of the proximal femur must be taken into account in patients over 65 years of age. It is clinically relevant to identify these concomitant fractures in order to arrive at a correct diagnosis, which will facilitate preoperative planning and the choice of the best treatment to achieve a better outcome. Misdiagnosis may cause further problems, such as fixation failures, disability and, in a worst case scenario, an increased risk of death. Therefore, a good and complete preoperative study is important, along with both good quality X-ray projections and 2D and 3D Ct-Scans in case of doubt.

Effect of comorbidities on the association between age and hospital mortality after fall-related hip fracture in elderly patients

The relation between age and mortality after hip fracture was analyzed in elderly patients. 5.5% of the 31,884 patients died. Compared to those 65-74 years old, the multivariate OR for mortality for those 75-84 and ≥85 were 2.11 (95% CI: 1.61-2.77) and 4.10 (95% CI: 3.14-5.35).

PURPOSE

To analyze the impact of Elixhauser comorbidities on the relation between age and mortality after hip fracture in elderly patients.

METHODS

Cross-sectional study of the population ≥65 years old hospitalized in Spain in 2013 with a diagnosis of fall-related hip fracture in the Basic Minimum Set Data (BMSD). The impact of Elixhauser comorbidities on the association between mortality and age groups (65-74, 75-84, ≥85) was analyzed by logistic regression models with progressive adjustment for demographic variables and comorbidities introduced individually.

RESULTS

We identified 31,884 patients, 5.5% of which died during hospitalization. Compared with those 65-74 years old, the multivariate OR of mortality for those 75-84 and ≥85 years old decreased from 2.23 (95% CI: 1.71-2.90) and 4.57 (95% CI: 3.54-5.90) to 2.11 (95% CI: 1.61-2.77) and 4.10 (95% CI: 3.14-5.35), respectively after adjustment for comorbidities. The OR of mortality for men was 1.77 (95% CI: 1.58-1.98) compared to women. The comorbidities with higher OR for mortality were congestive heart failure (OR: 3.88; 95% CI: 3.42-4.41), metastasis (OR: 3.44; 95% CI: 2.27-5.20), fluid and electrolyte disorders (OR: 2.95; 95% CI: 2.47-3.52), coagulation deficiencies (OR: 2.87; 95% CI: 2.08-3.96), and liver disease (OR: 2.40; 95% CI: 1.82-3.17).

CONCLUSIONS

The association between age and mortality after hip fracture remains after adjusting for numerous comorbidities. However, some potentially controllable disorders are associated with an increased risk for mortality, thus, improving their management could benefit survival.

The value of modular hemiarthroplasty for unstable femoral neck fractures in elderly patients with coxarthrosis

Background

Displaced femoral neck fractures are common in the elderly patient. The surgical treatment options consist of a hemiarthroplasty (HA) or total hip arthroplasty (THA). However, the best surgical choice is still under debate. Bipolar HAs do not address preexisting arthritic changes of the acetabulum, which may lead to an unfavorable clinical outcome. The purpose of the present study was to conduct a long term follow-up analysis of the bipolar hemiarthroplasty with particular focus on the influence of preoperative acetabular osteoarthritis on the functional outcome.

Methods

In a retrospective observational study, the medical charts of consecutive patients treated with a bipolar hemiarthroplasty at a level one trauma center between 2004 and 2008 were reviewed before a final radiographic and clinical follow-up was performed. The outcome variables consisted of arthritic findings on the pre- and postoperative x-rays with particular focus on double fond osteophyte (DFO) and posterior wall sign (PWS) as well as the revision rate and functional scores.

Results

This study included 102 patients with a mean age of 77.2 years. Most patients (75 %) had a Kellgren-Lawrence grading scale (KLGS) of 2 or 3. While only 30 % of patients had a DFO, most patients (73 %) had a PWS. The DFO correlated significantly with the KLGS, but no correlation was seen with the clinical outcome. Most patients showed a decreased offset by a mean of −7.8 mm. The mean modified Harris Hip Score (HHS) of 90.3 and the mean Merle d'Aubigné score of 10.8 correlated significantly. Despite a significant correlation of the HSS subcategory of pain and the preoperative KLGS, there was no statistical relationship between the arthritic x-ray measurements and the clinical outcome.

Conclusions

In the presented study population, the presence of radiographic acetabular osteoarthritis did not influence the clinical outcome after bipolar hemiarthroplasty for displaced femoral neck fractures.

What is the impact of age on reoperation rates for femoral neck fractures treated with internal fixation and hemiarthroplasty? A comparison of hip fracture outcomes in the very elderly population

METHODS

A retrospective comparative study was performed at a level 1 trauma center at which electronic medical records and digital radiographs were reviewed for 949 femoral neck fractures. For the primary outcome of reoperation based on age, Kaplan-Meier models were built and analysis applied.

RESULTS

A total of 334 fractures were nondisplaced treated with closed reduction and percutaneous pinning (CRPP), and 615 were displaced managed with hemiarthroplasty (HA). Overall, 98 patients (10.33%) required reoperation. Increasing reoperation rates for CRPP was seen with each subsequent age group. The opposite was seen with HA in which increasing age groups showed lower reoperation rates.

Cemented versus uncemented arthroplasty in patients with a displaced fracture of the femoral neck

The aim of this randomised controlled study was to compare functional and radiological outcomes between modern cemented and uncemented hydroxyapatite coated stems after one year in patients treated surgically for a fracture of the femoral neck. A total of 141 patients aged > 65 years were included. Patients were randomised to be treated with a cemented Exeter stem or an uncemented Bimetric stem. The patients were reviewed at four and 12 months.

The cemented group performed better than the uncemented group for the Harris hip score (78 vs 70.7, p = 0.004) at four months and for the Short Musculoskeletal Function Assesment Questionnaire dysfunction score at four (29.8 vs 39.2, p = 0.007) and 12 months (22.3 vs 34.9, p = 0.001). The mean EQ-5D index score was better in the cemented group at four (0.68 vs 0.53, p = 0.001) and 12 months (0.75 vs 0.58, p = < 0.001) follow-up. There were nine intra-operative fractures in the uncemented group and none in the cemented group.

In conclusion, our data do not support the use of an uncemented hydroxyapatite coated stem for the treatment of displaced fractures of the femoral neck in the elderly.

Cite this article: Bone Joint J 2015;97-B:1475–80.

Reduced time to surgery improves mortality and length of stay following hip fracture: results from an intervention study in a Canadian health authority

BACKGROUND

Existing literature demonstrating the negative impact of delayed hip fracture surgery on mortality consists largely of observational studies prone to selection bias and may overestimate the negative effects of delay. We conducted an intervention study to assess initiatives aimed at meeting a 48-hour benchmark for hip fracture surgery to determine if the intervention achieved a reduction in time to surgery, and if a general reduction in time to surgery improved mortality and length of stay.

METHODS

We compared time to surgery, length of stay and mortality between pre- and postintervention patients with a hip fracture using the Kaplan-Meier estimator and Cox proportional hazards model adjusting for age, sex, comorbidities, type of surgery and year.

RESULTS

We included 3525 pre- and 3007 postintervention patients aged 50 years or older. The proportion of patients receiving surgery within the benchmark increased from 66.8% to 84.6%, median length of stay decreased from 13.5 to 9.7 days, and crude in-hospital mortality decreased from 9.6% to 6.8% (all p < 0.001). Adjusted analyses revealed reduced mortality in hospital (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.57-0.81) and at 1 year (HR 0.87, 95%CI 0.79-0.96). Independent of the intervention period, having surgery within 48 hours demonstrated decreased adjusted risk of death in hospital (HR 0.51, 95%CI 0.41-0.63) and at 1 year postsurgery (HR 0.72, 95% CI 0.64-0.80).

CONCLUSION

Coordinated, region-wide efforts to improve timeliness of hip fracture surgery can successfully reduce time to surgery and appears to reduce length of stay and adjusted mortality in hospital and at 1 year.

Intra- and extra-capsular hip fractures in the elderly: Two different pathologies?

OBJECTIVES

To compare intracapsular (IC) and extracapsular (EC) hip fractures (HIF) in elderly patients in order to determine if they are different pathologies.

SUBJECTS AND METHODS

Longitudinal, observational, descriptive, analytical prospective design, using a non-probabilistic sample from a full sample collection with 647 subjects (male and female), of 60 or more years old, admitted with HIF to the Department of Orthopedics and Traumatology of the Hospital, between January 1, 2010 and December 31, 2012. Follow-up was for 1 year post HIF. Socio-demographic, etiological, developmental, therapeutic and prognostic variables are compared.

RESULTS

This is the first study on this subject with Latin American population. EC HIF incidence was superior to IC, contrary to that published in European/American populations. There are significant differences in etiological variables (χ(2)=6.34, p<0.042), with traumatic etiology in EC and non-traumatic in IC. There are also differences in therapeutic interventions performed (osteosynthesis for EC, arthroplasty for IC), with the decision on not to operate being lower in IC (both p<0.0000). The variables associated with the decision on not to perform surgery are age, etiology and postoperative mortality.

DISCUSSION

The results are similar to other studies, adding the IC association with non-traumatic origin, in particular the trend of statistical association between IC and non-primary osteoporotic pathology (neoplasms, renal osteodystrophy, primary hyperparathyroidism). A further analysis was performed on the differences between Latin American and European/American populations in the incidence of either type of HIF. There are important etiological and therapeutic differences between IC and EC HIF; therefore it would be advisable to consider them as distinct disease entities.

Functional outcome after successful internal fixation versus salvage arthroplasty of patients with a femoral neck fracture

OBJECTIVES

To determine patient independency, health-related and disease-specific quality of life (QOL), gait pattern, and muscle strength in patients after salvage arthroplasty for failed internal fixation of a femoral neck fracture.

DESIGN

Secondary cohort study to a randomized controlled trial.

SETTING

Multicenter trial in the Netherlands, including 14 academic and nonacademic hospitals.

PATIENTS

Patients after salvage arthroplasty for failed internal fixation of a femoral neck fracture were studied. A comparison was made with patients who healed uneventfully after internal fixation.

INTERVENTION

None (observatory study).

MAIN OUTCOME MEASUREMENTS

Patient characteristics, SF-12, and Western Ontario McMaster osteoarthritis index scores were collected. Gait parameters were measured using plantar pressure measurement. Maximum isometric forces of the hip muscles were measured using a handheld dynamometer. Differences between the fractured and contralateral leg were calculated. Groups were compared using univariate analysis.

RESULTS

Of 248 internal fixation patients (median age, 72 years), salvage arthroplasty was performed in 68 patients (27%). Salvage arthroplasty patients had a significantly lower Western Ontario McMaster osteoarthritis index score (median, 73 vs. 90; P = 0.016) than patients who healed uneventfully after internal fixation. Health-related QOL (SF-12) and patient independency did not differ significantly between the groups. Gait analysis showed a significantly impaired progression of the center of pressure in the salvage surgery patients (median ratio, -8.9 vs. 0.4, P = 0.013) and a significant greater loss of abduction strength (median, -25.4 vs. -20.4 N, P = 0.025).

CONCLUSIONS

Despite a similar level of dependency and QOL, salvage arthroplasty patients have inferior functional outcome than patients who heal after internal fixation of a femoral neck fracture.

LEVEL OF EVIDENCE

Therapeutic level III.

Surgery for hip fracture yields societal benefits that exceed the direct medical costs

BACKGROUND

A hip fracture is a debilitating condition that consumes significant resources in the United States. Surgical treatment of hip fractures can achieve better survival and functional outcomes than nonoperative treatment, but less is known about its economic benefits.

QUESTIONS/PURPOSES

We asked: (1) Are the societal benefits of hip fracture surgery enough to offset the direct medical costs? (2) Nationally, what are the total lifetime benefits of hip fracture surgery for a cohort of patients and to whom do these benefits accrue?

METHODS

We estimated the effects of surgical treatment for displaced hip fractures through a Markov cohort analysis of patients 65 years and older. Assumptions were obtained from a systematic literature review, analysis of Medicare claims data, and clinical experts. We conducted a series sensitivity analyses to assess the effect of uncertainty in model parameters on our estimates. We compared costs for medical care, home modification, and long-term nursing home use for surgical and nonoperative treatment of hip fractures to estimate total societal savings.

RESULTS

Estimated average lifetime societal benefits per patient exceeded the direct medical costs of hip fracture surgery by USD 65,000 to USD 68,000 for displaced hip fractures. With the exception of the assumption of nursing home use, the sensitivity analyses show that surgery produces positive net societal savings with significant deviations of 50% from the base model assumptions. For an 80-year-old patient, the breakeven point for the assumption on the percent of patients with hip fractures who would require long-term nursing home use with nonoperative treatment is 37% to 39%, compared with 24% for surgical patients. Nationally, we estimate that hip fracture surgery for the cohort of patients in 2009 yields lifetime societal savings of USD 16 billion in our base model, with benefits and direct costs of USD 21 billion and USD 5 billion, respectively. For an 80-year-old, societal benefits ranged from USD 2 billion to USD 32 billion, using our range of estimates for nursing home use among nonoperatively treated patients who are immobile after the fracture.

CONCLUSIONS

Surgical treatment of hip fractures produces societal savings. Although the magnitude of these savings depends on model assumptions, the finding of societal savings is robust to a range of parameter values.

LEVEL OF EVIDENCE

Level III, economic and decision analyses. See the Instructions for Authors for a complete description of levels of evidence.

Treatment of femoral neck fracture with a minimal invasive surgical approach for hemiarthroplasty - clinical and radiological results in 180 geriatric patients

Purpose :

The Direct Anterior Approach (DAA) is well established as a minimal access approach in elective orthopaedic hip surgery. For the growing number of elderly patients with femoral neck fractures treated with Bipolar Hip Hemiarthroplasty (BHH), only a few results do exist. The study shows the clinical and radiological outcome for 180 patients treated by a modified DAA with BHH.

Materials and Methods :

The data of 180 geriatric patients with medial femoral neck fractures were evaluated retrospectively. The general and surgical complications, mobilisation using the Timed Up and Go test (TUG), the social environment pre- and postoperative and the radiological results have been compared with established approaches for geriatric hip surgery.

Results :

After joint replacement, 18 (10%) patients were developed pneumonia, of which 3 (1.7%) died during hospitalisation. In 7 cases (4%), surgical revision had to be carried out: three times (1.7%) because of a seroma, three times (1.7%) because of subcutaneous infection, and one time (0.6%) because the BHH was removed, owing to deep wound infection. One dislocation (0.6%) occurred, as well as one femoral nerve lesion (0.6%) occured. 88.3% of patients were mobilised on walkers or crutches; the Timed Up and Go Test showed a significant improvement during inpatient rehabilitation. 83% were discharged to their usual social environment, 10% were transferred to a short-term care facility and 7% were relocated permanently to a nursing home. 3/4 of patients had a cemented stem alignment in the range between -5° and 5°, while 2/3 of patients had a maximum difference of 1 cm in leg length.

Conclusion :

Using the modified DAA, a high patient satisfaction is achieved after implantation of a BHH. The rate of major complications is just as low as in conventional approaches, and rapid mobilisation is possible.

Role of fracture and repair type on pain and opioid use after hip fracture in the elderly

BACKGROUND AND PURPOSE

Pain after hip fracture repair is related to worse functional outcomes and higher fracture care costs than that for patients with no or less pain. However, to our knowledge, few studies have examined the roles of hip fracture type or surgical procedure as factors influencing postoperative pain or opioid analgesic requirements. Our goal was to determine whether the type of hip fracture or hip fracture repair affects postoperative pain or opioid analgesic requirements in the elderly patient.

METHODS

We conducted a retrospective review of 231 patients ≥65 years old admitted to a hip fracture center for surgical repair. Fracture patterns were classified into femoral neck (FN) versus intertrochanteric (IT), stable versus unstable, and type of surgical repair. Demographic and intraoperative variables, postoperative pain scores, and opioid analgesic use data were collected and analyzed according to the type of hip fracture and type of surgical repair.

RESULTS

There were no differences in postoperative pain when comparing FN versus IT fractures, stable versus unstable fractures, or type of surgical repair. Patients with FN fractures had higher analgesic requirements on postoperative days 1, 2, and 3. There was no difference in postoperative analgesic requirements among patients with stable versus unstable fractures or type of surgical repair. Otherwise, there were no differences in postoperative pain or opioid analgesic use based on the surgical repair or fracture type. Overall, patients with hip fracture experienced low levels of pain.

The societal costs of femoral neck fracture patients treated with internal fixation

SUMMARY

The study rationale was to provide a detailed overview of the costs for femoral neck fracture treatment with internal fixation in the Netherlands. Mean total costs per patient at 2-years follow-up were <euro>19,425. Costs were higher for older, less healthy patients. Results are comparable to internationally published costs.

INTRODUCTION

The aim of this study was to provide a detailed overview of the cost and healthcare consumption of patients treated for a hip fracture with internal fixation. A secondary aim was to compare costs of patients who underwent a revision surgery with patients who did not.

METHODS

The study was performed alongside the Dutch sample of an international randomized controlled trial, concerning femoral neck fracture patients treated with internal fixation. Patient characteristics and healthcare consumption were collected. Total follow-up was 2 years. A societal perspective was adopted. Costs included hospital costs during primary stay and follow-up, and costs related to rehabilitation and changes in living situation. Costs were compared between non-revision surgery patients, implant removal patients, and revision arthroplasty patients.

RESULTS

A total of 248 patients were included (mean age 71 years). Mean total costs per patient at 2-years follow-up were <euro>19,425. In the non-revision surgery patients total costs were <euro>17,405 (N = 137), in the implant removal patients <euro>10,066 (N = 38), and in the revision arthroplasty patients <euro>26,733 (N = 67). The main contributing costs were related to the primary surgery, admission days, physical therapy, and revision surgeries.

CONCLUSIONS

The main determinant was the costs of admission to a rehabilitation center/nursing home. Costs were specifically high in elderly with comorbidity, who were less independent pre-fracture, and have a longer admission to the hospital and/or a nursing home. Costs were also higher in revision surgery patients. The 2-years follow-up costs in our study were comparable to published costs in other Western societies.

Randomized trial of hemiarthroplasty versus internal fixation for femoral neck fractures: no differences at 6 years

BACKGROUND

Hemiarthroplasty has been shown superior to internal fixation for displaced femoral neck fractures (FNF) in the first 2 years. However, there are unanswered questions about the performance of hemiarthroplasty over the longer term compared with internal fixation.

QUESTIONS/PURPOSES

We sought to compare hemiarthroplasty with internal fixation in terms of (1) outcomes scores for pain, hip function, and quality of life at a minimum of 5 years after surgery in a randomized trial. A secondary purpose was to compare (2) patient survival and (3) frequency of reoperation in the two groups.

METHODS

A total of 222 consecutive patients older than 60 years, including those cognitively impaired, with FNF were randomized to either internal fixation with two parallel screws or bipolar hemiarthroplasty. At a minimum followup of 4.9 years (mean, 5.9 years; range, 4.9-7.2 years), 68 of the 70 surviving patients were examined by a study nurse and study physiotherapist blinded to initial treatment. Questionnaires on hip function (Harris hip score), quality of life (Eq5D), and activity of daily living function (Barthel ADL) were administered. The Barthel ADL index score was split into good function (score 95 or 100) and reduced function (score below 95).

RESULTS

The mean survival of the groups was similar with 66.4% (73 of 110) of the patients undergoing hemiarthroplasty and 70.5% (79 of 112) of the patients undergoing internal fixation having died since surgery (p = 0.51). Only 12 of 31 living patients in the internal fixation group had retained their native hips at a mean of 6 years. Between 2 and 6 years, there were two new major reoperations (both in the internal fixation group, for avascular necrosis and deep wound infection). The mean Harris hip score was 66 (SD 19) and 67 (SD 20) in the internal fixation and hemiarthroplasty groups, respectively (p = 0.96). The mean Eq5D index was 0.50 (SD 0.40) in the internal fixation group and 0.34 (SD 0.36) in the hemiarthroplasty group (p = 0.10). Function in terms of ADLs was comparable between the groups; of the patients in the internal fixation group, 42% reported good function on the Barthel ADL index, and the corresponding number in the hemiarthroplasty group was 51% (p = 0.44).

CONCLUSIONS

Hemiarthroplasty has predictable and good long-term results after FNF and is the treatment of choice compared with internal fixation. Further studies will evaluate if total hip arthroplasty has advantages over hemiarthroplasty in patients with fracture with long life expectancy.

Targon Femoral Neck for femoral-neck fracture fixation: lessons learnt from a series of one hundred and thirty five consecutive cases

PURPOSE

Internal fixation versus joint replacement for treating intracapsular hip fractures is still a major debate. The Targon FN fixation concept is innovative; two small case series are promising. We present the first larger series.

METHODS

We conducted prospective documentation of all Targon FN cases since 2006. The implant was used for all undisplaced fractures, and for displaced fractures in patients of a biological age ≤60 years. Besides demographic data and fracture classification, we analysed infection, haematoma, implant perforation, nonunion and operative revision procedures.

RESULTS

In 135 cases (mean age 71 years; average operation time 60 minutes; average hospital stay ten days), we found a surgical complication rate of 16.4%. Conversion to joint replacement was necessary in 9.6%. Complication rate was significantly higher in displaced fractures.

CONCLUSIONS

Our study confirms low general complication rates. However, implant perforation seems to be underestimated. Optimised reduction technique may help to reduce this complication.

Surgical treatment of trochanteric and cervical hip fractures in the United States: 2000-2009

The objective of this study was to evaluate the most common treatments performed for hip fractures over the last decade in the United States. The leading treatment for trochanteric fractures was internal fixation, accounting for 96%-98% of surgical treatments each year. For cervical fractures, hemiarthroplasty (HA), total hip arthroplasty (THA), and internal fixation were performed nearly 61%, 5%, and 33% of the time, respectively, each year without any sign of change during the period assessed. The surgical choice for cervical fractures varied greatly by patient age. In 2009, two-thirds of patients younger than 60 years underwent internal fixation while two-thirds of patients 60 years or older underwent HA. Regardless of patient age, HA was performed more often than THA for cervical hip fractures.

Lower reoperation rate for cemented hemiarthroplasty than for uncemented hemiarthroplasty and internal fixation following femoral neck fracture: 12- to 19-year follow-up of patients aged 75 years or more

BACKGROUND AND PURPOSE

Elderly patients with displaced femoral neck fractures are commonly treated with a hemiarthroplasty (HA), but little is known about the long-term failure of this treatment. We compared reoperation rates for patients aged at least 75 years with displaced femoral neck fractures treated with either internal fixation (IF), cemented HA, or uncemented HA (with or without hydroxyapatite coating), after 12-19 years of follow-up.

METHODS

4 hospitals with clearly defined guidelines for the treatment of 75+ year-old patients with a displaced femoral neck fracture were included. Cohort 1 (1991-1993) with 180 patients had undergone IF; cohort 2 (1991-1995) with 203 patients had received an uncemented bipolar Ultima HA stem (Austin-Moore); cohort 3 (1991-1995) with 209 patients had received a cemented Charnley-Hastings HA; and cohort 4 (1991-1998) with 158 patients had received an uncemented hydroxyapatite-coated Furlong HA. Data were retrieved from patient files, from the region-based patient administrative system, and from the National Registry of Patients at the end of 2010. We performed survival analysis with adjustment for comorbidity, age, and sex.

RESULTS

Cemented HA had a reoperation rate (RR) of 5% and was used as reference in the Cox regression analysis, which showed significantly higher hazard ratios (HRs) for IF (HR = 3.8, 95% CI: 1.9-7.5; RR = 18%), uncemented HA (HR = 2.2, CI: 1.1-4.5; RR = 11%) and uncemented hydroxyapatite-coated HA (HR = 3.6, CI: 1.8-7.4; RR = 16%).

INTERPRETATION

Cemented HA has a superior long-term hip survival rate compared to IF and uncemented HA (with and without hydroxyapatite coating) in patients aged 75 years or more with displaced femoral neck fractures.

Adherence to a femoral neck fracture treatment guideline

PURPOSE

In 2007 the Dutch Surgical Society published a clinical practice guideline for the treatment of hip fracture patients, based on the best available international evidence at that time. We investigated to what extent treatment of femoral neck fracture patients in the Netherlands corresponded with these guidelines, and determined differences in patient characteristics between the treatment groups.

METHODS

All femoral neck fracture patients treated in 14 hospitals between February 2008 and August 2009 were included. Patient characteristics, X-rays, and treatment data were collected retrospectively.

RESULTS

From a total of 1,250 patients 59% had been treated with arthroplasty, 39% with internal fixation, and 2% with a non-operative treatment. While 74% of the treatment choices complied with the guideline, 12% did not. In 14% adherence could not be determined from the available data. Arthroplasty was preferred over internal fixation in elderly patients with severe comorbidity, pre-fracture osteoporosis and a displaced fracture, who were ambulatory with aids pre-fracture (odds ratio, OR 2.2-58.1). Sliding hip screws were preferred over cancellous screws in displaced fractures (OR 1.9).

CONCLUSIONS

Overall guideline adherence was good. Most deviations concerned treatment of elderly patients with a displaced fracture and implant use in internal fixation. Additional data on these issues, preferably at a higher scientific level of evidence, is needed in order to improve the guideline and to reinforce a more uniform treatment of these patients.

Risk factors for acute kidney injury after hip fracture surgery in the elderly individuals

OBJECTIVE

We aimed to evaluate possible risk factors assocıated wıth acute kidney injury (AKI) after hip fracture surgery in the elderly individuals.

DESIGN

Level II diagnostic study, evidence obtained from prospective cohort study from 1 center with level 2, and 3 patients.

PATIENTS

A total of 165 patients (>65 years) with femoral neck fracture were enrolled in this prospective study between 2007 and 2010. Two patients were dropped for inadequate laboratory follow-up data. Patients with kidney failure or renal replacement therapy (RRT) history or AKI at admission were excluded.

INTERVENTION

Nephrology consultation was obtained from all patients at admission. All patients had undergone bipolar cemented hip arthroplasty that was performed by the same surgical team in all patients within 24 hours of fracture and admission under the same protocol.

MAIN OUTCOME MEASUREMENTS

Serum creatinine (SCr), urine output, and complete blood counts were evaluated at baseline and daily basis thereafter. The AKI was defined based on Acute Kidney Injury Network classification. Hospital charges were converted from Turkish Liras to US dollars and rounded.

RESULTS

Among 163 patients, AKI occurred in 25 (15.3%) patients, all within the first 48 postoperative hours. Three (1.8%) patients required RRT. Baseline SCr levels were restored within 4.84 ± 1.34 days on average (3-8 days). No patient required RRT after discharge. The mean hospital stay was 3 days (2-6 days) longer and the hospital charge was 2500 US$ higher for the patients with AKI. After multivariable adjustment, only lower estimated glomerular filtration rate levels (odds ratio 0.945, 95%confidence interval 0.92-0.96) emerged as an independent predictor for AKI.

CONCLUSION

The AKI represents a frequent complication after hip fracture surgery associated with longer hospital stay and higher treatment costs with increased morbidity. Our results show baseline renal function is an independent predictor of AKI.

Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients

BACKGROUND

The treatment options for displaced femoral neck fracture in elderly are screw fixation, hemiarthroplasty and total hip arthroplasty based primarily on age of the patient. The issues in screw fixation are ideal patient selection, optimal number of screws, optimal screw configuration and positioning inside the head and neck of femur. The problems of screw fixation may be loss of fixation, joint penetration, avascular necrosis of femoral head, nonunion, prolonged rehabilitation period and the need for second surgery in failed cases. We hereby present results of a modified screw fixation technique in femoral neck fractures in patients ≥50 years of age.

MATERIALS AND METHODS

Patients ≥50 years of age (range 50-73 years) who sustained displaced femoral neck fracture and fulfilled the inclusion criteria were enrolled in this prospective study. They were treated with closed reduction under image intensifier control and cannulated cancellous screw fixation. Accurate anatomical reduction was not aimed and a cross sectional contact area of >75% without varus was accepted as good reduction. Four screws were positioned in four quadrants of femoral head and neck, as parallel and as peripheral as possible. Radiological and functional results were evaluated periodically. Sixty four patients who could complete a minimum followup of two years were analyzed.

RESULTS

Radiologically, all fractures healed after mean duration of 10 weeks (range 8-12 weeks). There was no avascular necrosis. Nonanatomical healing was observed in 45 cases (70%). All patients except one had excellent functional outcome and could do cross-legged sitting and squatting. Chondrolysis with progressive head resorption was seen in one case, which was converted to total hip arthroplasty.

CONCLUSION

Closed reduction and cannulated cancellous screw fixation gives satisfactory functional results in large group of elderly patients. The four quadrant parallel peripheral (FQPP) screw fixation technique gives good stability, allows controlled collapse, avoids fixation failure and achieves predictable bone healing in displaced femoral neck fracture in patients ≥50 years of age.

Mortality in centenarians with hip fractures

The proximal femur is one of the primary areas of weakness in the skeleton due to osteoporosis. With more than 50,000 Americans aged at least 100 years, an increasing number of these extremely elderly patients will present with hip fractures. A paucity of literature exists on functional outcomes and mortality rates in the centenarian population who sustain hip fractures. This study evaluated the mortality rate in centenarians who sustained hip fractures to determine whether operative intervention is safe and appropriate.The authors retrospectively reviewed 23 patients (22 women and 1 man) aged at least 100 years with hip fractures treated at their institution between 2003 and 2010. Twenty-one patients were treated operatively and 2 were treated nonoperatively. Mean Charlson comorbidity index was 2 (range, 0 to 5). The patients' medical charts or the Social Security Death Index was used to determine their dates of death. Average patient age was 101.9 years at injury and 102.8 years at death. Cumulative in-hospital, 30- and 90-day, 6- and 12-month, and 2-, 3-, and 6-year mortality rates for operatively treated patients were 15%, 20%, 30%, 45%, 60%, 70%, 90%, and 95%, respectively. Both patients treated nonoperatively died within 90 days. One patient is still alive 6 years postoperatively. Postoperative complications occurred in 9 (43%) patients.Although this patient population is a relatively small subset of the elderly population, the number of these patients is rapidly increasing. Operating on patients older than 100 years carries an acceptable mortality rate. Age alone should not preclude centenarians from undergoing operative treatment for hip fractures.

Iatrogenic false aneurysms. A rare complication of hip surgery

The purpose of this study was to determine the incidence of arterial false aneurysms following hip surgery diagnosed and treated in our hospital between January 1995 and January 2010. We conducted a retrospective analysis of all patients undergoing hip surgery (osteosynthesis, hemiarthroplasty, total arthroplasty, or revision arthroplasty) under our care. To determine the incidence of arterial false aneurysm, we identified patients with abnormal bleeding through the surgical wound postoperatively. Out of the 11,839 patients undergoing hip surgery during the study period, 321 had abnormal bleeding that aroused suspicion of an associated vascular lesion. Among these, the presence of a false aneurysm requiring specific treatment was confirmed in eight patients. False aneurysms are a rare and occasionally severe complication of hip surgery that typically manifest with significant haemorrhage during the postoperative period. The management of these lesions by interventional radiology is associated with few complications and permits rapid patient stabilisation and early recovery, avoiding more aggressive and sometimes fruitless surgical exploration.

Total hip replacement versus open reduction and internal fixation of displaced femoral neck fractures: a randomized long-term follow-up study

BACKGROUND

Clinical trials with short and intermediate-term follow-up have demonstrated superior results for total hip replacement as compared with internal fixation with regard to hip function and the need for secondary surgery in elderly patients with a displaced intracapsular femoral neck fracture. The aim of the present study was to compare the results of total hip replacement with those of internal fixation over a long-term follow-up period of seventeen years.

METHODS

We enrolled 100 patients who had sustained a femoral neck fracture in a single-center, randomized controlled trial;all patients had had a healthy hip before the injury. The study group included seventy-nine women and twenty-one men with a mean age of seventy-eight years (range, sixty-five to ninety years). The subjects were randomly assigned to either total hip replacement (the arthroplasty group) (n = 43) or internal fixation (the control group) (n = 57). The primary end point was hip function, evaluated with use of the Harris hip score. Secondary end points included mortality, reoperations, gait speed, and activities of daily life. Follow-up evaluations were performed at three months and at one, two, four, eleven, and seventeen years.

RESULTS

The Harris hip score was higher in the total hip arthroplasty group, with a mean difference of 14.7 points (95%confidence interval, 9.2 to 20.1 points; p < 0.001 [analysis of covariance]) during the study period. We found no difference in mortality between the two groups. Four patients (9%) in the total hip replacement group and twenty-two patients (39%) in the internal fixation group had undergone a major reoperation (relative risk, 0.24; 95% confidence interval, 0.09 to 0.64).The overall reoperation rate was 23% (ten of forty-three) in the total hip replacement group and 53% (thirty of fifty-seven) in the internal fixation group (relative risk, 0.44; 95% confidence interval, 0.24 to 0.80). The results related to gait speed and activities of daily living favored the arthroplasty group during the first year.

CONCLUSIONS

Over a period of seventeen years in a group of healthy, elderly patients with a displaced femoral neck fracture, total hip replacement provided better hip function and significantly fewer reoperations compared with internal fixation without increasing mortality.

LEVEL OF EVIDENCE

Therapeutic Level I.