Hip hemiarthroplasty for femoral neck fractures in end-stage renal disease patients on dialysis compared to patients with late-stage chronic kidney disease

Effect of Chronic Kidney Disease on All-Cause Mortality After Hip Fracture Surgery: A Retrospective Cohort Study

In this retrospective cohort study, we investigated: (1) The impact of comorbid chronic kidney disease (CKD) on postoperative mortality in patients with a hip fracture; (2) mortality variations by dialysis type, potentially indicating CKD stage; (3) the efficacy of different hip fracture surgical methods in reducing mortality for patients with CKD. This study included 25,760 patients from the Korean National Health Insurance Service-Senior cohort (2002-2019) who underwent hip fracture surgery. Participants were categorized as CKD and Non-CKD. Mortality rate was determined using a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) through a Cox proportional-hazard model. During follow-up, we ascertained that 978 patients (3.8%) had CKD preoperatively. Compared to the Non-CKD group, the mortality risk (HR) in the CKD group was 2.17 times higher (95% confidence interval [CI], 1.99-2.37). In sensitivity analysis, the mortality risk of in patients who received peritoneal dialysis and hemodialysis was 6.21 (95% CI, 3.90-9.87) and 3.62 times (95% CI, 3.11-4.20) higher than that of patients who received conservative care. Mortality risk varied by surgical method: hip hemiarthroplasty (HR, 2.11; 95% CI, 1.86-2.40), open reduction and internal fixation (HR, 2.21; 95% CI, 1.94-2.51), total hip replacement (HR, 2.27; 95% CI, 1.60-3.24), and closed reduction and percutaneous fixation (HR, 3.08; 95% CI, 1.88-5.06). Older patients with CKD undergoing hip fracture surgery had elevated mortality risk, necessitating comprehensive pre- and postoperative assessments and management.

Surgical Challenge in the Management of Spontaneous, Bilateral, Nontraumatic, Neglected Femoral Neck Fractures in a Patient With End-Stage Renal Disease: A Case Report and Literature Review

Renal osteodystrophy is a spectrum of diseases that affect several organ systems including the musculoskeletal system by decreasing bone density which increases the risk of fractures. Fractures around the femoral neck are usually traumatic and unilateral and, rarely, bilateral and atraumatic. In this report, we present the case of a 37-year-old female patient with a known history of chronic kidney disease who sustained an atraumatic bilateral neck of femur fracture with late presentation. In addition, we present a review of neglected femoral neck fracture management in a young patient with renal disease and osteoporosis.

Impaired renal function is an independent risk factor for complications after surgery for femoral neck fracture

BACKGROUND

The metabolic abnormalities that occur secondary to chronic kidney disease (CKD) increase the risk of femoral neck fractures compared to the general population. The purpose of this study is to determine whether impaired renal function is an independent risk factor for complications after surgery for femoral neck fracture.

METHODS

The ACS-NSQIP database was reviewed for patients who underwent total hip arthroplasty, hemiarthroplasty and open reduction internal fixation (ORIF) for femoral neck fractures between 2007 and 2018. Patients were split into cohorts based on calculated estimated glomerular filtration rate. Demographic information, comorbidities, and 30-day complications were analysed with univariate and multivariate analyses using chi-square, Fischer's exact and analysis of variance testing.

RESULTS

The total number of patients for the study was 163,717. Patients with CKD stage 4 and 5 had an increased rate of any complication (39.1 and 36.7% respectively) compared with higher eGFRs (p < 0.001). Similarly, 30-day mortality was increased at 6.0% and 6.7% for both stage 4 and 5 (p < 0.001). By multivariate regression, those with CKD Stage 4 and 5 were at increased risk for any complication compared to patients with a normal preoperative eGFR of 90-120 (p < 0.001).

CONCLUSIONS

This study demonstrated that patients with CKD Stage 4 and 5 are at increased risks of all complications, including death, renal, pulmonary and thromboembolic disease. Therefore, these patients should be cared for from a multidisciplinary approach with close attention to postoperative medications and fall prevention to help mitigate the risk of complications in the immediate postoperative period.

Reoperation rate and implant survivorship compared between cementless and cemented bipolar hemiarthroplasty in femoral neck fracture patients with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is commonly associated with aging and disorders of mineral and bone metabolism. Femoral neck fracture (FNF) is one of the most common fractures among older adults with coexisting CKD, and bipolar hemiarthroplasty (BHA) is a preferred treatment. However, the optimal method of stem fixation has not been conclusively determined. Accordingly, this study aimed to investigate the reoperation rate and implant survivorship compared between cementless and cemented BHA in FNF patients with CKD.

METHODS

A total of 183 FNF patients with moderate to severe CKD who underwent BHA during 2003 to 2019 were recruited and divided into either the cemented (CT group, n = 56) or cementless (CL group, 127) groups. Demographic data, preoperative laboratory investigations, preoperative radiographic outcomes, perioperative outcomes, and 90-day morbidity, mortality, and reoperation rates for any reason were recorded and compared between groups. Kaplan-Meier survival analysis was used to compare implant survivorship between the CT and CL groups. Cox proportional hazards regression model was used to identify independent risk factors for implant survivorship.

RESULTS

There were no significant differences in patient characteristics or preoperative data between groups, except for Dorr's classification of proximal femoral geometry. The CT group had a significantly lower proportion of Dorr type A (p = 0.020), and a higher proportion of Dorr type C (p<0.001). The CT group also had significantly more intraoperative blood loss (p<0.01). No significant differences in morbidity or mortality were observed. The median follow-up time in the CT group and CL group was 22.6 months (range: 0-151) and 22.6 months (range 0-154), respectively (p = 0.607). The reoperation rate was 5.4% and 4.7% among CT and CL patients, respectively (p = 1.000). There was no significant difference in the mean survival time between the CT (139.5 ± 6.3 months, 95%CI: 127.1-151.8) and CL (142.5 ± 4.7 months, 95%CI: 133.2-151.7) groups (p = 0.880). Univariate and multivariate analyses revealed no independent risk factors for implant survivorship.

CONCLUSION

The results of this study showed no significant differences in the reoperation rate or implant survivorship between cemented and cementless BHA for treating FNF in moderate to severe CKD patients. A well-designed larger and longer-term study is needed to confirm these results.

Possible effects of hyperparathyroidism in the loss of osseointegration of dental implants: A case report

Background: Hyperparathyroidism (HPT) is a common endocrine disorder with potential complications on the skeletal, renal, neurocognitive and cardiovascular systems. Its association with the lack of osseointegration of dental implants has not been described in the medical literature. Case presentation: This case report aims to discuss two cases of dental implant loss in which a high level of parathormone (PTH) was found in the absence of any other systemic or local comorbidity, suggesting the possible correlation between HPT and implant. Both patients were referred to the clinic complaining about prosthetic complications, gingival inflammation and mobility of the dental prosthesis. After a Cone-Beam computed Tomography evaluation, all implants of both patients were removed for rejection arising from periimplantitis and then four implants were inserted in the patient 1 and five implants in the patient 2. For both patients short implants (Bicon LLC, Boston, Massachusetts, USA), featured by 4 mm in diameter and 5 mm in height, were used and the prosthesis substructure was made of Trinia® (Bicon LLC, Boston, Massachusetts, USA). During the fifth year, the patients reported complications and the implant treatment failure. In order to establish the causes of failure, a thorough investigation was performed. Since no causes were detected, the patients were required to perform a blood test to evaluate bone metabolism and specifically to assess parathyroid-hormone levels (PTH), calcium levels and vitamin D. Results: The results of the blood tests showed normal calcemia, vitamin D deficiency and elevated PTH levels in both patients. After an endocrinologist's consultation, secondary hyperparathyroidism was diagnosed. Conclusion: It is reasonable to assume that the loss of osseointegration of dental implants can be correlated with the effects of HPT.

Correlation between Preoperative Serum Levels of Calcium, Phosphate, and Intact Parathyroid Hormone and Radiological Outcomes in Spinal Interbody Fusion among End-Stage Renal Disease Patients

Spinal fusion surgery for end-stage renal disease (ESRD) patients is a clinical challenge. This study aimed to investigate whether postoperative radiological outcomes are related to preoperative serum calcium, phosphate, or intact parathyroid hormone (iPTH) levels in patients with ESRD who underwent spinal interbody fusion surgery. This study included 62-consecutive patients with ESRD who underwent anterior cervical discectomy and fusion (ACDF) or transforaminal lumbar interbody fusion (TLIF) surgery for symptomatic spinal disorder. The most recent preoperative serum calcium, phosphate, and iPTH levels were recorded, and the postoperative radiographic outcomes were assessed. A significant correlation was found between the occurrence of cage subsidence and higher blood phosphate, calcium–phosphate product (Ca × P), and iPTH levels in the TLIF group. The occurrence of pedicle screw loosening was related to higher blood phosphate and Ca × P product in the TLIF group. However, no correlation was found between the fusion grades and the serum levels in either the TLIF or ACDF groups. These results indicated that higher preoperative serum phosphate and Ca × P product are risk factors for both cage subsidence and screw loosening in patients with ESRD who underwent TLIF surgery. Higher iPTH levels are also a possible risk factor for cage subsidence.

Neck of Femur Fracture in Young Patients With End-Stage Renal Disease and Hyperparathyroidism: A Report of Three Cases and Proposed Treatment Algorithm

Secondary hyperparathyroidism is a complication arising from untreated end-stage renal disease (ESRD). It can invariably lead to osteoporosis and subsequently cause pathological neck of femur (NOF) fracture. Despite being young, osteosynthesis in neck of femur fractures of these patients often leads to nonunion and implant failure due to severely osteoporotic bone. We present our experience in managing three young patients with ESRD and secondary hyperthyroidism who sustained NOF fractures. All three patients were successfully treated and showed no complication at one year post-operation. Based on our experience and literature review, we propose a simple algorithm to guide the management of these patients.

Prognostic performance of clinical assessment tools following hip fracture in patients with chronic kidney disease

Purpose

People living with chronic kidney disease (CKD) are at a higher risk of hip fracture with an associated increased mortality risk compared to individuals without CKD. Our study aimed to evaluate the clinical assessment tools that best predict mortality risk following hip fracture for patients with CKD.

Methods

Patients with CKD G3b-5D admitted to Lancashire Teaching Hospitals NHS Foundation Trust, U.K. between June 2013 and Dec 2019 were included. The association between CKD and post-fracture mortality risk was evaluated. All patients were assessed using tools that evaluated frailty status, co-morbidity, pre-operative risk, functional status and cardiopulmonary fitness. Receiver operating characteristic curve analyses were performed to determine the prognostic accuracy of the assessment tools for 30 day and 1 year mortality following hip fracture in patients with CKD.

Results

397 patients fulfilled inclusion criteria with a mean age of 83.5 ± 9.2 years. Older age, female sex, intracapsular fracture and more severe CKD, co-morbidity and frailty status were all associated with an increased mortality risk. Patients with dialysis-dependent CKD and severe/very severe frailty had a hazard ratio for mortality of 2.55 (95% Cl 2.11–2.98) and 3.11 (95% Cl 2.47–3.93), respectively. The Clinical Frailty Scale demonstrated the best prognostic accuracy for both 30 day [Area Under the Curve (AUC) 0.91, 95% Cl 0.84–0.97] and 1 year mortality (AUC 0.93, 95% Cl 0.87–1.00).

Conclusion

Patients with advanced CKD and severe frailty have a high mortality risk following hip fracture. The Clinical Frailty Scale is an excellent prognostic tool for mortality in this setting and could be easily incorporated into routine clinical practice.

Femoral Neck Fracture in a Hemodialysis Patient after Liver Transplantation: A Case Report

Background

Surgical treatment of femoral neck fractures is usually performed as an urgent procedure so that restoration of the ability to stand and walk can be achieved as quickly as possible. However, orthopedic surgeons need to be aware of undertreated or untreated diseases in their patients. Organ transplant recipients require immunosuppressive agents and steroids postoperatively. Hemodialysis patients also exhibit immunological deterioration and are included among immunocompromised patients. We report a case in which conservative treatment was chosen for a hepatic transplant recipient on hemodialysis who suffered a femoral neck fracture because signs of inflammation of unknown etiology were intermittently seen.

Case

The patient was a 70-year-old man who had undergone liver transplantation from a living donor as treatment for hepatocellular cancer and hepatic failure with cirrhosis. Dialysis for end-stage renal failure was initiated at approximately 1 year postoperatively. Cyclosporine was administered as an immunosuppressive agent. The patient subsequently fell off a bicycle and was unable to walk because of right hip pain. He was brought to our hospital by ambulance, and a right hip radiograph revealed a femoral neck fracture. His white blood cell count and C-reactive protein levels were intermittently elevated with unknown etiology. Conservative treatment was finally adopted, although a bipolar hip arthroplasty was planned. At 5 months after the injury, the patient was able to walk alone in a stable manner using a pair of crutches and was discharged.

Discussion

Conservative treatment for a femoral neck fracture, which generally requires surgery, may be acceptable in organ transplant recipients on hemodialysis.

Bipolar Hemiarthroplasty and Parathyroidectomy at the Same Setting for Fragility Fractures Secondary to Renal Bone Disease

BACKGROUND

From 1980s to the new millennium, the number of patients surviving with end stage renal disease (ESRD) has increased by 3 fold. This is driven by early detection of primordial and primary risk factors, state of the art renal replacement therapy and ease of public access to healthcare. Renal osteodystrophy (RO) is a metabolic bone disease causing significant morbidity in patients with ESRD, in particular fragility fractures. In this case series, we present the surgical management of 3 ESRD patients with pathological fractures of the neck of femur (NOF) and surgical treatment (parathyroidectomy) of tertiary hyperparathyroidism of ESRD patients in the same surgical setting. Up to date there has been no reports on bipolar hemiarthroplasty and total parathyroidectomy implemented in the same operative setting.

METHODS

We present 3 cases, 2 males and a female with an average age of 48 years. All patients presented with no trauma or minimal trauma. With high index of suspicion and after confirming the diagnosis with advanced imaging, the patients underwent cemented modular hemiarthroplasty with posterior approach. Parathyroidectomy was sequentially performed to address the tertiary hyperparathyroidism at the same setting. We followed them for 48 months.

RESULTS

At 48-month follow up, all the patients were at their pre-morbid ambulatory status and there were no major complications. They did not need any revision surgery or re-operation either for the hemiarthroplasty surgery or the parathyroidectomy during the follow up period.

CONCLUSION

To avoid diagnostic pitfalls in this group of patients we recommend MRIs of both hips in patients complaining of unilateral hip pain even when the roentgenograms are clear of fractures. Total parathyroidectomy at the same setting with the bipolar hemi-arthroplasty is a safe combination. This reduces the anaesthesia risk, the recovery time as well as the equilibrium time for calcium homeostasis.