Resolving controversies in hip fracture care: the need for large collaborative trials in hip fractures

Perioperative geriatrics: A bibliometric analysis of the top 100 cited articles in an emerging specialty

BACKGROUND

The success of modern medicine has led to surgery being performed on an increasingly older, frailer and more comorbid population. As a result, perioperative geriatrics has emerged as an important specialty, relevant to both medical and surgical disciplines. Only a small number of papers have been published on the topic. A bibliometric analysis is used to identify themes and trends in current research and practice.

OBJECTIVES

To identify and describe research topics relating to perioperative geriatrics; to find themes and gaps in the current literature.

METHODS

Thompson Reuters Web of Science indexing database was searched for all manuscripts relating to perioperative geriatrics. Of these, the top 100 were subcategorised into manuscript type, age, theme, specialty, journal and citation rate.

RESULTS

The highest cited article was by Bhandari et al with 294 citations. The highest citation rate was achieved by Partridge et al, with 23.75 citations/year. Across the series, the mean number of citations was 50.41 (range 294-12). The highest number of manuscripts were published between 2010 and 2019 (n = 55), with 70% of manuscripts published in journals with impact factor <5. The specialty with the highest number of publications was orthopaedics (n = 36). Most articles focussed on surgical management of geriatrics patients, followed by anaesthetic management.

CONCLUSION

This is the first bibliometric analysis of the top 100 most cited papers in perioperative geriatrics. Only 395 papers were returned, indicating that this needs to be further researched as a topic. Key themes identified were surgical management of hip fractures and anaesthetic preoperative assessment. Emerging themes from this study highlight the need for perioperative publications in the fields of geriatric vascular, general, plastic and gynaecology.

Is the Timing of Surgery a Sufficient Predictive Factor for Outcomes in Patients with Proximal Femur Fractures? A Systematic Review

(1) Background: Hip fractures are currently recognized as major public health problems, raising many issues in terms of both patients' quality of life and the cost associated with caring for this type of fracture. Many authors debate whether to operate as soon as possible or to postpone surgery until the patient is stable. The purpose of this review was to review the literature and obtain additional information about the moment of surgery, the time to surgery, length of hospital stay, and how all of these factors influence patient mortality and complications. (2) Methods: The systematic search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and PICO guidelines, using the Google Scholar platform, for articles published between 2015 and 2023. Quality assessment was performed. (3) Results: After applying the inclusion criteria, 20 articles were included in the final list. Those who had surgery within 48 h had lower in-hospital and 30-day mortality rates than those who operated within 24 h. The American Society of Anesthesiologists (ASA) score is an important predictive factor for surgical delay, length of hospital stay (LOS), complications, and mortality. (4) Conclusions: Performing surgery in the first 48 h after admission is beneficial to patients after medical stabilization. Avoidance of delayed surgery will improve postoperative complications, LOS, and mortality.

The Impact of Surgical Timing of Hip Fracture on Mortality: Do the Cause and Duration of Delay Matter?

Purpose

Delay in performance of hip fracture surgery can be caused by medical and/or administrative reasons. Although early surgery is recommended, it is unclear what constitutes a delayed surgery and whether the impact of delayed surgery can differ depending on the reason for the delay.

Materials and Methods

A total of 269 consecutive hip fracture patients over 50 years of age who underwent surgery were prospectively enrolled. They were divided into two groups: early and delayed (time from reaching the hospital to surgery less than or more than 48 hours). Patients were also categorized as fit or unfit based on anesthetic fitness. One-year mortality was recorded, and regression analyses were performed to assess the impact of delay on mortality.

Results

A total of 153 patients (56.9%) had delayed surgery with a mean time to surgery of 87±70 hours. A total of 115 patients (42.8%) were considered medically fit to undergo surgery. No difference in one-year mortality was observed between patients with early surgery and those with delayed surgery (P=0.854). However, when assessment of the time to surgery was performed in a continuous manner, mortality increased with prolonged time to surgery, particularly in unfit patients, and higher mortality was observed when the delay exceeded six days (fit: P=0.117; unfit: P=0.035).

Conclusion

The effect of delay on mortality was predominantly observed in patients who were not considered medically fit, suggesting that surgical delays might have a greater impact on patients with medical reasons for delay.

Factors associated with delayed surgery in elderly hip fractures in India

Early hip fracture surgery is recommended to decrease the morbidity and mortality. The extent to which such guidelines are being followed in developing countries like India is unknown. About 20% of the patients presented to hospital after 24 hours of injury, and only one-third had surgery within 48 hours of presentation.

INTRODUCTION

Early hip fracture surgery is recommended to decrease the morbidity and mortality following hip fractures. Understanding the factors responsible for delay in surgery is important to improve the quality of hip fracture care. This study was conducted to study the factors causing delay in elderly hip fracture surgery in India.

METHODS

In this prospective study, 272 consecutive hip fracture surgeries at a single hospital were included. Delayed surgery was defined as when the time to surgery (reaching hospital to start of incision) was more than 48 hours. Additionally, the total time to surgery (including time taken for patients to reach hospital after injury) was studied. Factors associated with delayed surgery were assessed using regression models.

RESULTS

Eighty-seven (32%) patients had a surgery within 48 hours of presentation. Majority of the patients had a delay (82%, N = 151/185) due to one or more medical reasons. Fifty-four (20%) patients presented to hospital after 24 hours of injury. The mean total time to surgery was 112 ± 90 hours with time after reaching hospital contributing to 78% of the total time. Multiple comorbidities (odds ratio, OR = 3.47 [1.42-8.45]), fall as mode of injury (OR = 3.54 [1.61-7.80]), requiring an additional investigation (OR = 10.4 [3.4-31.81]), and requiring arthroplasty (OR = 40.57 [7.01-234.97]) were independently associated with delayed surgery.

CONCLUSION

Only about one-third of the patients received surgery within 48 hours of reaching the hospital, and about 20% of the patients presented to hospital after 24 hours of injury. Delayed surgery was primarily due to medical comorbidities. Hospitals should establish protocols to ensure faster optimization of patients.

Does the fracture of the lateral wall affect the degree of collapse and the degree of sliding of the cephalic plate, in pertrochanteric fractures treated by intramedullary interlocking? Radiological study and review of the literature

BACKGROUND

Lateral wall fracture has been recognized as an important sign of instability of pertrochanteric fractures. The aim of the present study is to assess the relationship between lateral wall fractures, helical blade telescoping and neck shortening in fractures treated with intramedullary nailing.

MATERIAL AND METHOD

A descriptive radiological study was performed at our institution. Patients who suffered a pertrochanteric fracture, treated at Hospital 12 de Octubre by intramedullary nailing were included. All fractures were classified according to Evans and AO systems. Preoperative and postoperative radiological assessment was carried out including a lateral wall fracture classification, helical blade telescoping and femoral neck shortening.

RESULTS

210 patients were included, 48% had a fracture of the femoral lateral wall. Helical blade telescoping was higher in lower lateral wall fractures with respect to higher fractures. Difference was statistically significant (p<0.05). Neck shortening was higher in fractures with femoral lateral wall disruption; despite not have found any significant differences comparing to fractures with intact lateral wall (P=.39). Multivariate analysis showed statistically significant association between helical blade telescoping, neck shortening and lateral wall fracture.

CONCLUSIONS

There is evidence of a higher helical blade telescoping and neck shortening in pertrochanteric fractures with lateral wall fracture treated with intramedullary nails, especially in those with most unstable patterns such us fractures of the lateral wall distal to the vastus ridge.

Hip fracture care and national systems: The United States and Canada

While it is widely understood that management of hip fractures not only represents clinical decision making dilemmas for the individual orthopaedist, these increasingly common injuries present economic burdens to local and national systems as well. This supplement article looks at current clinical trends, as well as systems-based issues in the United States and Canada.

Outcomes of elderly patients with nondisplaced or minimally displaced femoral neck fractures treated with internal fixation: A systematic review and meta-analysis

BACKGROUND

Internal fixation remains the treatment of choice for non-displaced femoral neck fractures in elderly patients. Improved outcomes with arthroplasty following displaced femoral neck fractures may indicate that outcomes of non-displaced patterns should be reexamined. The aim of our study was to conduct a systematic review of the orthopaedic literature to determine the outcomes of internal fixation for the treatment of non-displaced and minimally displaced femoral neck fractures in elderly patients.

METHODS

Relevant articles were identified using PubMed, Embase, and CENTRAL databases. Manuscripts were included if they contained (1) patients 60 years or older with (2) nondisplaced or minimally displaced (Garden I or II) femoral neck fractures (3) treated with internal fixation (4) separately reported outcomes in this patient population. The primary outcome was reoperation. Secondary outcomes included mortality, patient-reported outcomes, length of hospitalization, infection, and transfusions. Fixed and random effects modeling was used to determine pooled estimates of the outcomes.

RESULTS

Twenty-seven studies were identified with a total of 21,155 patients, all of which were treated with internal fixation. The pooled risk of reoperation was 14.1% (95% CI: 10.6-18.2). The risk of one-year mortality was 14.6% (95% CI: 11.5-18.2) based on the reporting in 15 studies.

CONCLUSIONS

The risk of reoperation and mortality following the treatment of nondisplaced femoral neck fractures in the elderly with internal fixation exceeds 14%. This complication profile may be unacceptably high. Arthroplasty may offer improved short-term functional outcomes and a reduced risk of reoperation. However, there is currently little evidence to consider this treatment to be an alternative to internal fixation.

Short Versus Long Cephalomedullary Nails for Pertrochanteric Hip Fractures: A Randomized Prospective Study

OBJECTIVE

To compare functional and clinical outcomes in patients with pertrochanteric hip fractures treated with either a short (SN) or long (LN) cephalomedullary nail.

DESIGN

Prospective, randomized.

SETTING

Clinical investigation was performed at the Mayo Clinic's Level 1 Trauma Center in Rochester, MN.

PATIENTS/PARTICIPANTS

Two hundred twenty patients with intertrochanteric fractures were prospectively randomized to an SN or LN cohort. A total of 168 patients (SN, n = 80; LN, n = 88) had a mean follow-up of 13.9 months. Fifty-two patients did not meet the minimum 3-month follow-up. Demographics were comparable between the cohorts.

MAIN OUTCOME MEASURES

The primary outcome measurement was functional outcome evaluated by Short Form (SF-36) and Harris Hip scores (HHS) at 3 months. Secondary outcomes included implant failure, peri-implant fracture, mortality, operative time, estimated blood loss, and reoperation.

RESULTS

SN and LN cohorts were comparable in all aspects of the SF-36. There was a clinically insignificant difference in the HHS between cohorts. Patients treated in the SN cohort experienced shorter operative times but did not differ in tip-to-apex distance or subtrochanteric fracture extension. There was no difference in implant cutout, deep surgical site infection, or peri-implant fractures.

CONCLUSIONS

Patients treated with SNs or LNs for pertrochanteric femur fractures experienced comparable functional outcomes as measured by SF-36 and HHS. When compared with the LN cohort, SN patients experienced no difference in peri-implant fracture or lag-screw cutout and tolerated up to 3 cm of subtrochanteric fracture line extension.

LEVEL OF EVIDENCE

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

Reduced complication rates for unstable trochanteric fractures managed with third-generation nails: Gamma 3 nail versus PFNA

INTRODUCTION

Third-generation nails for the management of unstable trochanteric fractures were evaluated with regard to outcomes.

PATIENTS AND METHODS

A prospective observational study comparing the Gamma 3 nail and the Proximal Femoral Nail Antirotation (PFNA) in 106 unstable trochanteric fractures confirms the recently reported low intra- and postoperative complication rates from retrospective cohort studies.

RESULTS

Studies of same generations of both intramedullary nail systems did not reveal significant differences in intra- or postoperative complications. Intraoperative dislocation during nail insertion occurred 7 times for the Gamma nail and 9 times for the PFNA. The standard PFNA had to be exchanged intraoperatively for a shorter one on two occasions. Superficial wound healing disorders and hematoma requiring revision were observed in four patients in the Gamma 3 nail group and in three patients in the PFNA group. No deep infections were documented. Mechanical complications required revision in four patients (7.5%) after Gamma nailing and in two patients (3.8%) after PFNA. Postoperative rotation of the head-neck fragment was observed for the Gamma nail in three patients, not in the PFNA group. This was not statistically significant (p = 0.08). There were neither incidences of cut out without renewed trauma nor intraoperative fracture or postoperative femoral fracture. Nonunion affected 1 of 18 patients in late follow-up (p = 0.3) in the Gamma 3 nail group.

DISCUSSION

The Gamma 3 nail and the PFNA yielded comparable clinical results and significantly improved outcomes for unstable trochanteric fractures compared to older nail generations.

Association of Overlapping Surgery With Increased Risk for Complications Following Hip Surgery: A Population-Based, Matched Cohort Study

IMPORTANCE

Overlapping surgery, also known as double-booking, refers to a controversial practice in which a single attending surgeon supervises 2 or more operations, in different operating rooms, at the same time.

OBJECTIVE

To determine if overlapping surgery is associated with greater risk for complications following surgical treatment for hip fracture and arthritis.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective population-based cohort study in Ontario, Canada (population, 13.6 million), for the years 2009 to 2014. There was 1 year of follow-up. This study encompassed 2 large cohorts. The "hip fracture" cohort captured all persons older than 60 years who underwent surgery for a hip fracture during the study period. The "total hip arthroplasty" (THA) cohort captured all primary elective THA recipients for arthritis during the study period. We matched overlapping and nonoverlapping hip fractures by patient age, patient sex, surgical procedure (for the hip fracture cohort), primary surgeon, and hospital.

EXPOSURES

Procedures were identified as overlapping if they overlapped with another surgical procedure performed by the same primary attending surgeon by more than 30 minutes.

MAIN OUTCOMES AND MEASURES

Complication (infection, revision, dislocation) within 1 year.

RESULTS

There were 38 008 hip fractures, and of those, 960 (2.5%) were overlapping (mean age of patients, 66 years [interquartile range, 57-74 years]; 503 [52.4%] were female). There were 52 869 THAs and of those, 1560 (3.0%) overlapping (mean age, 84 years [interquartile range, 77-89 years]; 1293 [82.9%] were female). After matching, overlapping hip fracture procedures had a greater risk for a complication (hazard ratio [HR], 1.85; 95% CI, 1.27-2.71; P = .001), as did overlapping THA procedures (HR, 1.79; 95% CI, 1.02-3.14; P = .04). Among overlapping hip fracture operations, increasing duration of operative overlap was associated with increasing risk for complications (adjusted odds ratio, 1.07 per 10-minute increase in overlap; P = .009).

CONCLUSIONS AND RELEVANCE

Overlapping surgery was relatively rare but was associated with an increased risk for surgical complications. Furthermore, increasing duration of operative overlap was associated with an increasing risk for complications. These findings support the notion that overlapping provision of surgery should be part of the informed consent process.

Sliding hip screw versus intramedullary nail for trochanteric hip fractures; a randomised trial of 1000 patients with presentation of results related to fracture stability

AIMS

To determine the optimum choice of implant for a patient with a the different types of trochanteric hip fracture.

PATIENTS AND METHODS

1000 patients with a trochanteric hip fracture were randomised to internal fixation of the fracture with either a Sliding Hip Screw or an intramedullary nail. Fractures were subdivided into two part fractures, comminuted fractures and fractures at the level of the lesser trochanter (reversed/oblique and transverse). Functional assessment for up to one year from injury was undertaken by a research nurse blinded to the treatment allocation.

RESULTS

The mean age of patients was 82years and 77% were female. There was a significantly improved regain of mobility for those treated with the intramedullary nail. No statistically significant differences between the two types of fixation methods was observed for mortality, fracture healing complications, re-operations, hospital stay, length of surgery, blood transfusion requirements, medical complications, degree of residual pain or regain of independence. These finding were valid for all fracture types.

CONCLUSION

This study is the first adequately powered randomised trial on this topic and demonstrates that there are no notable differences in either process or functional outcomes between these two treatment methods, other than a tendency to better regain of mobility for those fractures fixed with an intramedullary nail.

Prolonged pre-operative hospital stay as a predictive factor for early outcomes and mortality after geriatric hip fracture surgery: a single institution open prospective cohort study

INTRODUCTION

The aim of this open prospective cohort study was to determine if a prolonged pre-operative hospital stay is a true predictor of higher morbidity or mortality in geriatric patients with hip fractures.

MATERIALS AND METHODS

We analysed early outcome parameters, such as functional independence measure (FIM), at discharge and four months post-operatively, peri-operative nonsurgical complications, intra-hospital and one year mortality compared with prolonged pre-operative hospital stay in 308 patients from a continuous cohort of 344.

RESULTS

Average pre-operative stay was 8.39 ± 5.80 days. Delaying surgery for > 72 hours was independently predictive for general complications and lower motor FIM gain at four months. All findings worsen progressively after the fifth day of delay. Pre-operative period was not found to be an independent predictor of mortality.

CONCLUSION

In all observed outcome parameters except mortality, pre-operative delay > 72 hours was shown to be a true predictive factor.

Evidence based management of intracapsular neck of femur fractures

Neck of femur fractures are occurring at an increased incidence. Functionally independent patients without cognitive impairment can expect reasonable life expectancy. This indicates the need for a durable surgical option that optimises the chance to return to pre-injury functional status, with minimal risk of complications and reoperation. Most fractures are displaced. Surgical options include internal fixation, hemiarthroplasty or total hip arthroplasty (THA). Evidence is conclusive that arthroplasty options outperform internal fixation in terms of function, quality of life and reoperation rates. In anyone other than young patients where head preserving surgery is required, arthroplasty is the standard of care. Hemiarthroplasty is the heavily favoured arthroplasty option for surgeons. However, in patients other than the extreme elderly, medically infirm, neurologically impaired, or with little or no ambulatory capacity, the evidence to support hemiarthroplasty is lacking. In functionally independent patients without cognitive impairment, THA should be considered the gold standard, producing better functional and quality of life outcomes, lower reoperation rates and better cost effectiveness, with no difference in complications or mortality. An increased risk of dislocation does exist. This may be reduced with modern surgical technique and implant options. Low amounts of research have been afforded to undisplaced fractures. For this fracture type, surgery is the standard of care. Despite a higher risk of reoperation, internal fixation is the preferred option for all age groups. Further study is required to identify the difference between internal fixation and THA, in particular, for unstable fracture patterns in elderly patients.

Sliding hip screw versus the Targon PFT nail for trochanteric hip fractures

Aims

To compare the outcomes for trochanteric fractures treated with a sliding hip screw (SHS) or a cephalomedullary nail.

Patients and Methods

A total of 400 patients with a trochanteric hip fracture were randomised to receive a SHS or a cephalomedullary nail (Targon PFT). All surviving patients were followed up to one year from injury. Functional outcome was assessed by a research nurse blinded to the implant used.

Results

Recovery of mobility, as assessed by a mobility scale, was superior for those treated with the intramedullary nail compared with the SHS at eight weeks, three and nine months (p-values between 0.01 and 0.04), the difference at six and 12 months was not statistically significant (p = 0.15 and p = 0.18 respectively). The mean difference was around 0.4 points (0.3 to 0.5) on a nine point scale. Surgical time for the nail was four minutes less than that for the SHS (p < 0.001). Fracture healing complications were similar for the two groups. There were no statistically significant differences between implants for any other recorded outcomes including the need for post-operative blood transfusion, wound healing complications, general medical complications, hospital stay or mortality.

Conclusion

This study confirms the findings of a previous study that both methods of treatment produce similar results, although intramedullary fixation does result in marginally improved regain of mobility in comparison with the SHS. Cite this article: Bone Joint J 2017;99-B:1210–15.

Hip fracture registries: utility, description, and comparison

Hip fractures (HF) are prevalent and involve high morbidity and mortality so improving their management is important. HF registries are a good way to improve knowledge about this condition and its quality of care, while at the same time reducing clinical variability, optimizing efficiency, improving outcomes, and reducing costs.

INTRODUCTION

Hip fractures (HF) are a prevalent fragility fracture secondary to osteoporosis that involves high morbidity and mortality. They are low-impact fractures, resulting from a fall from a standing or sitting height. Despite numerous Clinical Practice Guidelines that establish uniform recommendations for their care, great variability persists regarding clinical and healthcare outcomes. Fracture registries can help detect deficits and establish measures to improve care. The objective of this work is to analyze the contents that a HF registry should have and to compare the characteristics of some national HF registries.

METHODS

A literature search was conducted on several national hip fracture registries, and those that contain relevant information on the variables and their outcomes were selected.

RESULTS

The selected HF registries were compared using the parameters they measure as well as the outcomes in the different countries. The variables collected in the majority of the databases and those that give useful information are as follows: sociodemographic variables (age, sex, place of residence), clinical variables (function before and after HF, anesthesia risk as measured by the ASA score, type of fracture, type of surgery and anesthesia, and in-hospital and 1-month mortality), and healthcare variables (pre-operative and overall stay, presence of collaboration with orthogeriatrics or with any clinician in addition to the surgeon, secondary prevention of new fractures by assessing the fall risk, and need for osteoporosis treatment).

CONCLUSION

The recording of HF cases in different countries improves knowledge about handling this condition and its quality of care, while at the same time reducing clinical variability, optimizing efficiency, improving outcomes, and reducing costs. The debate on the variables that should be recorded is timely, such as organizing how to collect each measurement, and even trying to unify the national and international registries or using a current proposal such as the one from the Fragility Fracture Network.

Publication Productivity of Early-Career Orthopedic Trauma Surgeons

The goals of this study were to: (1) define the publication productivity of early-career orthopedic trauma surgeons over time; (2) compare the early-career publication productivity of recent orthopedic trauma fellowship graduates vs their more senior colleagues; and (3) determine the proportion of fellowship graduates who meet the Orthopaedic Trauma Association (OTA) publication criteria for active membership early in their careers. Orthopedic trauma fellowship graduates from 1982 to 2007 were analyzed. A literature search was performed for each fellow's publications for the 6-year period beginning the year of fellowship graduation. Publication productivity was compared between early and recent groups of graduates, 1987 to 1991 and 2003 to 2007, respectively. Fulfillment of OTA publication criteria was determined. Seventy-nine percent of graduates contributed to 1 or more publications. The recent group produced more total publications per graduate (4.06 vs 3.29, P=.01) and more coauthor publications (2.60 vs 2.04, P=.019) than the early group. The number of first-author publications did not differ between groups (1.46 vs 1.25, P=.26). A greater percentage of the recent group met current OTA publication criteria compared with the early group (51% vs 35%, P=.04). The findings showed that recent orthopedic trauma graduates had increased publication productivity compared with their more senior colleagues, although a proportion had not qualified for active OTA membership 6 years into their career. Overall, these data are encouraging and suggest that young orthopedic trauma surgeons remain committed to sustaining a high level of academic excellence.

Predictive variables of open reduction in intertrochanteric fracture nailing: a report of 210 cases

BACKGROUND

Factors that impede closed reduction in intertrochanteric fractures remain unknown. This study was designed with the aim of establishing radiological variables that can predict an open reduction when nailing those type of fractures.

MATERIALS AND METHODS

Observational prospective study carried out between March 2013 and March 2015. Patients of both gender who suffered an intertrochanteric fracture, and who were surgically treated by intramedullary nailing (PFN-A), were included. Patients were evaluated by means of a questionnaire designed in 12 de Octubre Trauma department. Radiological parameters assessed preoperatively, after fracture reduction in the traction table, and after fixation were: calcar, lateral wall and posterior buttress integrity or disruption; lesser trochanter location, varus or valgus deformities, and flexion or extension of the proximal fragment.

RESULTS

Association between open reduction and the following types of fractures was statistically significant (p<0.001): subtypes A2.3, A3.2 and A3.3 of AO classification and subtypes IV and V of Evans classification. There were four radiological parameters associated with the need for open reduction: disruption of lateral wall (p<0.0000), posterior wall fracture (p<0.001), calcar (p<0.004) and malalignment in the axial view (p<0.001).

CONCLUSIONS

Open reduction seems to be necessary for complex fracture patterns such as A2.3, A3.2 and A3.3 types of AO/OTA classification, as well as types IV and V of Evans classification. There are four major radiological parameters that can predict the need of approaching the fracture site: posterior buttress, calcar disruption, lateral wall disruption and proximal fragment flexion. The development of high quality evidence regarding this topic is necessary due to the vast impact that open reduction can have on elderly patients.

Hip fracture surgery: improving the quality of the evidence base

Hip fracture is a common injury associated with high mortality, long-term disability and huge socio-economic burden. Yet there has been relatively little research into best treatment, and evidence that has been generated has often been criticised for its poor quality. Here, we discuss the advances made towards overcoming these criticisms and the future directions for hip fracture research: how co-ordinating existing national infrastructures and use of now established clinical research networks will likely go some way towards overcoming the practical and financial challenges of conducting large trials. We highlight the importance of large collaborative pragmatic trials to inform decision/policy makers and the progress made towards reaching a consensus on a core outcome set to facilitate data pooling for evidence synthesis and meta-analysis. These advances and future directions are a priority in order to establish the high-quality evidence base required for this important group of patients.

Management of hip fracture

INTRODUCTION

Hip fracture poses a significant global challenge both to healthcare systems and to patients themselves. We outline the management of this injury, highlight areas where the evidence is deficient and discuss research efforts towards improving the quality of the evidence base.

SOURCES OF DATA

We searched MEDLINE, PubMed and the Cochrane Library, using the core search terms 'hip fracture' and 'proximal femoral fracture'. In addition we reviewed national treatment guidelines for hip fracture care and references from relevant articles. Only articles published in English from inception to March 2015 were included.

AREAS OF AGREEMENT

Modern hip fracture management should consist of a coordinated multidisciplinary approach with orthogeriatrician input, early surgery, adequate analgesia and liaison with related services to facilitate safe supported discharge.

AREAS OF CONTROVERSY

The optimum thromboprophylaxis to reduce venous thromboembolism remains a topic for debate. The use of bone cement has received much attention recently with concerns about its safety in the frailest of hip fracture patients.

GROWING POINTS

An increasing understanding of the severity and impact of sustaining a hip fracture upon quality of life.

AREAS TIMELY FOR DEVELOPING RESEARCH

Strategies to improve postoperative mobility, postoperative nutrition and the role of home-based rehabilitation. There is a need to identify the optimum analgesic regimes and assessment tools for hip fracture patients with cognitive impairment.

Pseudogout at the knee joint will frequently occur after hip fracture and lead to the knee pain in the early postoperative period

Background

Symptomatic knee joint effusion is frequently observed after hip fracture, which may lead to postoperative knee pain during rehabilitation after hip fracture surgery. However, unfortunately, very little has been reported on this phenomenon in the literature. The purpose of the current study was to investigate the relationship between symptomatic knee effusion and postoperative knee pain and to clarify the reason of the effusion accompanied by hip fracture.

Methods

A total of 100 patients over 65 years of age with an acute hip fracture after fall were prospectively followed up. Knee effusion was assessed on admission and at the operating room before the surgery. If knee effusion was observed at the time of the surgery, synovial fluid was collected into syringes to investigate the cause of the effusion using a compensated polarized light microscope. Furthermore, for each patient, we evaluated age, sex, radiographic knee osteoarthritis (OA), type of the fracture, laterality, severity of the fracture, and postoperative knee pain during rehabilitation. These factors were compared between patients with and without knee effusion at the time of the surgery. As a statistical analysis, we used Mann–Whitney U-test for patients’ age and categorical variables were analyzed by chi-square test or Fisher’s exact test.

Results

A total of 30 patients presented symptomatic knee effusion at the time of the surgery. In patients with knee effusion, numbers of intertrochanteric fracture, radiographic knee OA, and postoperative knee pain were significantly large compared to those without effusion. In terms of synovial fluid analysis, calcium pyrophosphate dihydrate crystals were observed in 80% of patients with knee effusion.

Conclusion

From our study, approximately 63% of patients with knee effusion at the time of the surgery had postoperative knee pain. In addition, this effusion was basically related to pseudogout.

Clinical trial networks in orthopaedic surgery

The aim of this study was to review the role of clinical trial networks in orthopaedic surgery. A total of two electronic databases (MEDLINE and EMBASE) were searched from inception to September 2013 with no language restrictions. Articles related to randomised controlled trials (RCTs), research networks and orthopaedic research, were identified and reviewed. The usefulness of trainee-led research collaborations is reported and our knowledge of current clinical trial infrastructure further supplements the review. Searching yielded 818 titles and abstracts, of which 12 were suitable for this review. Results are summarised and presented narratively under the following headings: 1) identifying clinically relevant research questions; 2) education and training; 3) conduct of multicentre RCTs and 4) dissemination and adoption of trial results. This review confirms growing international awareness of the important role research networks play in supporting trials in orthopaedic surgery. Multidisciplinary collaboration and adequate investment in trial infrastructure are crucial for successful delivery of RCTs.

Cite this article: Bone Joint Res 2014;3:169–74.

How to set up and manage a trainee-led research collaborative

BACKGROUND

Ensuring that doctors in training acquire sufficient knowledge, experience and understanding of medical research is a universal and longstanding issue which has been brought into sharper focus by the growth of evidence based medicine. All healthcare systems preparing doctors in training for practice have to balance the acquisition of specific clinical attitudes, knowledge and skills with the wider need to ensure doctors are equipped to remain professionally competent as medical science advances. Most professional medical bodies acknowledge that this requires trainee doctors to experience some form of research education, not only in order to carry out original research, but to acquire sufficient academic skills to become accomplished research consumers in order to remain informed throughout their professional practice. There are many barriers to accomplishing this ambitious aim.

DISCUSSION

This article briefly explains why research collaboratives are necessary, describes how to establish a collaborative, and recommends how to run one. It is based on the experiences of the pioneering West Midlands Research Collaborative and draws on the wider literature about the organisation and delivery of high quality research projects. Practical examples of collaborative projects are given to illustrate the potential of this form of research organisation.

SUMMARY

The new trainee-led research collaboratives provide a supportive framework for planning, ownership and delivery of high quality multicentre research. This ensures clinical relevance, increases the chances of research findings being translated into changes in practice and should lead to improved patient outcomes. Research collaboratives also enhance the research skills and extend the scientific horizons of doctors in training.

Prospective Non-randomized Studies in Orthopaedics and Traumatology: Systematic Assessment of its Methodological Quality

In surgical interventions, randomization and blinding may be difficult to implement. In this situation, non-randomized prospective studies (EPNR) can generate the best evidence. The objective of this study is to evaluate, by means of the scale proposed by Downs & Black, the quality of EPNR published in our country and to assess the interobserver reproducibility of this scale. EPNR published in Acta Ortopedica Brasileira and Revista Brasileira de Ortopedia until 2011 and prior to 2006 were included. Two of us independently applied the Downs & Black scale. The studies were stratified by period of publication, journal and type of intervention. The scores obtained were considered to assess the reliability of the scale and groups comparison. 59 studies were considered, seven excluded during the assessments. There were no differences between the scores, except for the type of intervention, which showed better methodological quality for studies involving clinical interventions (p < 0.001). The correlation coefficient for the Downs & Black score was 0.79 (95% CI 0.65 to 0.88), demonstrating good reliability. EPNR present methodological quality similar when stratified by the periodic publication and publication period. Studies with clinical interventions have better methodological quality. The Downs & Black scale shows good interobserver reproducibility.

Collaborative multicenter trials in Latin America: challenges and opportunities in orthopedic and trauma surgery

CONTEXT AND OBJECTIVE Orthopedic research agendas should be considered from a worldwide perspective. Efforts should be planned as the means for obtaining evidence that is valid for health promotion with global outreach. DESIGN AND SETTING Exploratory study conducted at Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil, and McMaster University, Hamilton, Canada. METHODS We identified and analyzed collaborative and multicenter research in Latin America, taking into account American and Canadian efforts as the reference points. We explored aspects of the data available from official sources and used data from traffic accidents as a model for discussing collaborative research in these countries. RESULTS The evaluation showed that the proportion of collaborative and multicenter studies in our setting is small. A brief analysis showed that the death rate due to traffic accidents is very high. Thus, it seems clear to us that initiatives involving collaborative studies are important for defining and better understanding the patterns of injuries resulting from orthopedic trauma and the forms of treatment. Orthopedic research may be an important tool for bringing together orthopedic surgeons, researchers and medical societies for joint action. CONCLUSIONS We have indicated some practical guidelines for initiatives in collaborative research and have proposed some solutions with a summarized plan of action for conducting evidence-based research involving orthopedic trauma.

Patient safety in orthopaedics

We summarise and highlight the safety concerns within the field of trauma and orthopaedic surgery with particular emphasis placed on current controversies and reforms within the United Kingdom National Health Service.

Prospective randomized controlled trial comparing dynamic hip screw and screw fixation for undisplaced subcapital hip fractures

BACKGROUND

Neck of femur fractures (NOFFs) are a common cause of morbidity and mortality in our community. Minimally displaced intracapsular fractures are treated with internal fixation by a two-hole dynamic hip screw (DHS) or three partially threaded cancellous screws. Data to support the superiority of one are limited. This prospective randomized controlled trial compares outcomes with these two fixation methods.

METHODS

We prospectively recruited patients over 50 years, with an acute fracture subcapital NOFF, who walked and lived independently, and were cognitively intact. They were randomized into DHS or cancellous screw groups and followed up for 2 years (overall 75.9%). Outcomes of mortality, revision, loss of fixation, avascular necrosis, surgical complications, WOMAC, Harris hip score and SF-12 were measured.

RESULTS

We recruited 62 patients (31 DHS, 29 cancellous screws, 2 failed consent). Six deaths (19.3%) were seen in each group. A total of 3.2% of DHS (1 out of 31) and 10.3% (3 out of 29) of cancellous screw patients required re-operation (P = 0.272). There was no statistical significant difference in patient satisfaction, quality of life (QoL), radiological union or osteonecrosis. There are trends towards better functional scores and QoL in cancellous screws, particularly at 1 year (P = 0.0061), but with a higher re-operation rate. There was a combined mortality and transition to institutional care of 40.0% (24 out of 60) at 2 years.

CONCLUSIONS

This study found no difference in outcomes between DHS and cancellous screws in the treatment of subcapital NOFFs in a fit, independent population, but we found a high level of physical decline in previously fit, independently ambulating patients. A large, multicentre trial will be required to differentiate between these two fixation methods.

Uneven global distribution of randomized trials in hip fracture surgery

BACKGROUND AND PURPOSE

Hip fractures are among the top causes of global disability. Conduction of high-quality studies such as randomized controlled trials to assess the effectiveness of interventions remains crucial. The geographic distribution of hip fracture studies is largely unknown. We wanted to make a global assessment of national contributions of randomized controlled trials on surgical interventions for hip fracture.

METHODS

We performed a systematic search for randomized controlled trials on surgical interventions for hip fracture that were published from May 1970 to May 2011. Study information including sample size and study location was abstracted. The number of trials and cumulative sample size of hip fracture clinical trials were analyzed with respect to geographic region (city, country, and continent).

RESULTS

We identified 199 randomized trials investigating surgical interventions. Sweden ranked highest with 50 trials (8,941 patients). The United Kingdom followed with 40 trials (7,589 patients). Other countries contributed substantially less. The United States and Canada together contributed only a tenth of the total number of trials contributed by European countries.

INTERPRETATION

Global contributions to randomized trials and the total number of patients recruited have been led by Scandinavian countries and the UK. Countries with few trials but a large burden of hip fractures have an opportunity to engage in high-quality research to resolve important surgical questions and improve the generalizability of study results.

Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials

Purpose

Displaced femoral neck fractures in healthy elderly patients have traditionally been managed with hemiarthroplasty (HA). Recent data suggest that total hip arthroplasty (THA) may be a better alternative.

Methods

A systematic review of the English literature was conducted. Randomized controlled trials comparing all forms of THA with HA were included. Three authors independently extracted articles and predefined data. Results were pooled using a random effects model.

Results

Eight trials totalling 986 patients were retrieved. After THA 4 % underwent revision surgery versus 7 % after HA. The one-year mortality was equal in both groups: 13 % (THA) versus 15 % (HA). Dislocation rates were 9 % after THA versus 3 % after HA. Equal rates were found for major (25 % in THA versus 24 % in HA) and minor complications (13 % THA versus 14 % HA). The weighted mean of the Harris hip score was 81 points after THA versus 77 after HA. The subdomain pain of the HHS (weighted mean score after THA was 42 versus 39 points for HA), the rate of patients reporting mild to no pain (75 % after THA versus 56 % after HA) and the score of WOMAC (94 points for THA versus 78 for HA) all favored THA. Quality of life measured with the EQ-5D favored THA (0.69 versus 0.57).

Conclusions

Total hip arthroplasty for displaced femoral neck fractures in the fit elderly may lead to higher patient-based outcomes but has higher dislocation rates compared with hemiarthroplasty. Further high-quality randomized clinical trails are needed to provide robust evidence and to definitively answer this clinical question.

Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip: a randomised trial of 600 fractures

In a randomised trial involving 598 patients with 600 trochanteric fractures of the hip, the fractures were treated with either a sliding hip screw (n = 300) or a Targon PF intramedullary nail (n = 300). The mean age of the patients was 82 years (26 to 104). All surviving patients were reviewed at one year with functional outcome assessed by a research nurse blinded to the treatment used. The intramedullary nail was found to have a slightly increased mean operative time (46 minutes (sd 12.3) versus 49 minutes (sd 12.7), p < 0.001) and an increased mean radiological screening time (0.3 minutes (sd 0.2) versus 0.5 minutes (sd 0.3), p < 0.001). Operative difficulties were more common with the intramedullary nail. There was no statistically significant difference between implants for wound healing complications (p = 1), or need for post-operative blood transfusion (p = 1), and medical complications were similarly distributed in both groups. There was a tendency to fewer revisions of fixation or conversion to an arthroplasty in the nail group, although the difference was not statistically significant (nine versus three cases, p = 0.14). The extent of shortening, loss of hip flexion, mortality and degree of residual pain were similar in both groups. The recovery of mobility was superior for those treated with the intramedullary nails (p = 0.01 at one year from injury). In summary, both implants produced comparable results but there was a tendency to better return of mobility for those treated with the intramedullary nail.

Central coordination as an alternative for local coordination in a multicenter randomized controlled trial: the FAITH trial experience

Background

Surgeons in the Netherlands, Canada and the US participate in the FAITH trial (Fixation using Alternative Implants for the Treatment of Hip fractures). Dutch sites are managed and visited by a financed central trial coordinator, whereas most Canadian and US sites have local study coordinators and receive per patient payment. This study was aimed to assess how these different trial management strategies affected trial performance.

Methods

Details related to obtaining ethics approval, time to trial start-up, inclusion, and percentage completed follow-ups were collected for each trial site and compared. Pre-trial screening data were compared with actual inclusion rates.

Results

Median trial start-up ranged from 41 days (P25-P75 10-139) in the Netherlands to 232 days (P25-P75 98-423) in Canada (p = 0.027). The inclusion rate was highest in the Netherlands; median 1.03 patients (P25-P75 0.43-2.21) per site per month, representing 34.4% of the total eligible population. It was lowest in Canada; 0.14 inclusions (P25-P75 0.00-0.28), representing 3.9% of eligible patients (p < 0.001). The percentage completed follow-ups was 83% for Canadian and Dutch sites and 70% for US sites (p = 0.217).

Conclusions

In this trial, a central financed trial coordinator to manage all trial related tasks in participating sites resulted in better trial progression and a similar follow-up. It is therefore a suitable alternative for appointing these tasks to local research assistants. The central coordinator approach can enable smaller regional hospitals to participate in multicenter randomized controlled trials. Circumstances such as available budget, sample size, and geographical area should however be taken into account when choosing a management strategy.

Trial Registration

ClinicalTrials.gov: NCT00761813

Future perspectives: the need for large clinical trials

Fragility fractures represent a growing problem with large economic and patient burdens that are likely to increase as the population ages. The elderly patient with osteopenic bone presents a unique surgical challenge with appreciable risks associated with each surgical treatment option. As demonstrated in this supplement, the current evidence suggests that the best surgical treatment options for patients with fragility fractures remains largely unknown. Additional evidence, from large clinical trials, is required before definitive treatment recommendations can be made in many cases. In this article, we review the example of the femoral neck fracture to illustrate this point.

Fixation versus primary replacement of displaced femoral neck fractures in the elderly

Hip fractures are among the most common debilitating injuries in the elderly and are a significant cause of morbidity and mortality worldwide. Despite the ever-increasing literature on the topic of hip fractures, optimal treatment remains uncertain. Trials with small sizes, methodological limitations, strict inclusion criteria and wide confidence intervals leave the optimal approach to treating hip fractures unknown and controversial. In 2005, the International Hip Fracture Research Collaborative was officially established with the mandate of resolving controversies in hip fracture management. Presently, two multicenter randomized trials, FAITH and HEALTH, are underway. The FAITH trial (Fixation Using Alternative Implants for the Treatment of Hip Fractures) will compare Sliding Hip Screws and Cancellous Screws; the HEALTH trial (Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty) will compare total hip arthroplasty and hemi-arthroplasty. The present paper reviews current controversies in hip fracture care. Ultimately, only large randomized trials, such as FAITH and HEALTH, will resolve the longstanding controversy of whether primary replacement or fixation is the preferred treatment modality in this common fracture. Subsequent trials need to focus on surgical strategies in the cognitively impaired patient.

Recent aspects on outcomes in geriatric fracture patients

As the population ages, the number of fragility fractures is expected to increase dramatically. These injuries are frequently associated with less than satisfactory outcomes. Many of the patients experience adverse events or death, and few regain their pre-injury functional status. Many also lose their independence as a result of their fracture. This manuscript will explore problems and some potential solutions to evaluate the outcomes of geriatric fracture care. Specific, system-wide, and societal concerns will be discussed. Limited suggestions will be made for future steps to improve outcomes assessments.

A critical appraisal of the SPRINT trial

The Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures (SPRINT) was a randomized controlled trial to evaluate rates of reoperation and complications resulting from reamed versus unreamed intramedullary nailing for the treatment of tibial shaft fractures. The trial found a possible benefit for reamed intramedullary nailing in patients with closed tibial fractures, but no difference was found between the 2 approaches in patients with open fractures. This article is a review and critique of the methodology used in the SPRINT trial. Numerous aspects of the trial's design served to greatly reduce the potential bias, producing sound and reliable results. Overall, the SPRINT trial should provide recommendations for change in clinical practice and also set a benchmark for the conduct of randomized controlled trials in orthopedic surgery.