Cortical thickness in the intertrochanteric region may be relevant to hip fracture type

Sagittal support rather than medial cortical support matters in geriatric intertrochanteric fracture: A finite element analysis study

Hip fracture, increasing exponentially with age, is osteoporosis's most severe clinical consequence. Intertrochanteric fracture, one of the main types of hip fracture, is associated with higher mortality and morbidity. The current research hotspots lay in improving the treatment effect and optimizing the secondary stability after intertrochanteric fracture surgery. Cortex buttress reduction is a widely accepted method for treating intertrochanteric fracture by allowing the head-neck fragment to slide and rigidly contact the femoral shaft's cortex. Medial cortical support is considered a more effective option in treating young patients. However, osteo-degenerations features, including bone weakness and cortical thickness thinning, affect the performance of cortex support in geriatric intertrochanteric fracture treatment. Literature focusing on the age-specific difference in cortex performance in the fractured hip is scarce. We hypothesized that this osteo-19 degenerative feature affects the performance of cortex support in treating intertrochanteric fractures between the young and the elderly. We established twenty models for the old and the young with intertrochanteric fractures and performed static and dynamic simulations under one-legged stance and walking cycle conditions. The von Mises stress and displacement on the femur, proximal femoral nail anti-rotation (PFNA) implant, fracture plane, and the cutting volume of cancellous bone of the femur were compared. It was observed that defects in the anterior and posterior cortical bone walls significantly increase the stress on the PFNA implant, the displacement of the fracture surface, and cause a greater volume of cancellous bone to be resected. We concluded that ensuring the integrity and alignment of the anterior and posterior cortical bones is essential for elderly patients, and sagittal support is recommended. This finding suggests that the treatment method for intertrochanteric fracture may differ, considering the patient's age difference.

Different types of hip fragility fractures have different values of 25-hydroxyvitamin D and parathyroid hormone

BACKGROUND

Vitamin D insufficiency/deficiency is related to fragility fracture. In most previous studies, there was no assessment of vitamin D deficiency status separately for hip fracture types. The first aim is to evaluate vitamin D and parathyroid hormone (PTH) status in patients with hip fracture. The second objective is to determine whether there are differences in vitamin D and PTH between the femoral neck fracture and the femoral metaphyseal fracture group.

METHODS

62 men and 248 women with fragility hip fractures were enrolled. 25-hydroxyviamin D [25(OH)D] and intact PTH (iPTH) values were evaluated, and femoral neck bone mineral density (BMD) was measured on the uninjured side. Vertebral fractures (VFs) were assessed using radiographs of the thoracic and lumbar spine. We examined the relationships of 25(OH)D value with the number of prevalent VFs, T-score of femoral neck, and iPTH level. These analyses were also performed, neck fracture and trochanteric fracture separately.

RESULTS

Mean age was 85 years. The mean 25(OH)D was 11.2 (range, 4.0-26.1) ng/ml, whereas the mean iPTH value was 48.9 pg/ml (range, 9-429 pg/ml). The mean number of VFs was 1.5 (range, 0-11), and the mean T-score was -3.3 (range, -5.2 to -0.5). There was a weak correlation between the 25(OH)D value and the number of VFs. There was a weak but significant correlation between 25(OH)D and iPTH values. In the patients with trochanteric fractures, 25(OH)D value was significantly lower and iPTH value was significantly higher than those with neck fractures. There was a significant correlation between the 25(OH)D value and number of the VFs, 25(OH)D, and iPTH values only in trochanteric fractures.

CONCLUSIONS

Vitamin D deficiency was severe and PTH levels were higher in the trochanteric fractures. Both vitamin D deficiency and high PTH levels were suggested to have association with bone fragility.

Relationship between site-specific bone mineral density in the proximal femur and instability of proximal femoral fractures: A retrospective study

BACKGROUND

Proximal femoral fractures can occur in patients with osteoporosis. However, the relationship between bone mineral density (BMD) of the proximal femur and fracture type and instability remains unclear. This study aimed to determine whether there is a relationship between the site-specific BMD of the proximal femur and the instability of proximal femoral fracture.

HYPOTHESIS

The instability of proximal femoral fractures is related to the site-specific BMD of the proximal femur.

PATIENTS AND METHODS

Using dual-energy X-ray absorptiometry (DEXA), the BMD on the non-fractured side was retrospectively examined in 252 women who underwent surgery for proximal femoral fracture at our hospital. The BMD was measured at three sites: the femoral neck (neck), trochanter (trochanter), and intertrochanteric region (inter). The BMD at several sites was compared between the femoral neck and trochanteric fractures. Femoral neck fractures were classified into the displaced and non-displaced types, and trochanteric fractures were classified into stable and unstable types. A comparative analysis was conducted for each proximal femur site and fracture type.

RESULTS

Both total and site-specific BMDs were lower in trochanteric fractures than in femoral neck fractures. No difference was observed between BMD and displaced or non-displaced femoral neck fractures. However, the BMD of the intertrochanteric region was lower in unstable trochanteric fractures (0.57±0.12g/cm2) than in stable trochanteric fractures (0.61±0.11g/cm2) [p<0.05].

DISCUSSION

Several factors, including the patient's age and the bone component of each region, may influence the lower BMD in trochanteric fractures. In trochanteric fractures, the site-specific BMD of the proximal femur may predict the type of fracture and the degree of instability, especially in those with low BMD at the intertrochanteric site. The study findings suggest that a decrease in the BMD of the intertrochanteric region of femoral trochanteric fractures, which is thought to be involved in instability, is associated with fracture type instability.

LEVEL OF EVIDENCE

III, retrospective study.

Incremental Element Deletion-Based Finite Element Analysis of the Effects of Impact Speeds, Fall Postures, and Cortical Thicknesses on Femur Fracture

The proximal femur’s numerical simulation could give an effective method for predicting the risk of femoral fracture. However, the majority of existing numerical simulations is static, which does not correctly capture the dynamic properties of bone fractures. On the basis of femoral fracture analysis, a dynamic simulation using incremental element deletion (IED)-based finite element analysis (FEA) was developed and compared to XFEM in this study. Mechanical tests were also used to assess it. Different impact speeds, fall postures, and cortical thicknesses were also studied for their implications on fracture types and mechanical responses. The time it took for the crack to shatter was shorter when the speed was higher, and the crack line slid down significantly. The fracture load fell by 27.37% when the angle was altered from 15° to 135°, indicating that falling forward was less likely to cause proximal femoral fracture than falling backward. Furthermore, the model with scant cortical bone was susceptible to fracture. This study established a theoretical foundation and mechanism for forecasting the risk of proximal femoral fracture in the elderly.

Effect of neutrophil-to-lymphocyte ratio on short-term prognosis of elderly patients with hip fracture

OBJECTIVE

To investigate the effect of neutrophil-to-lymphocyte ratio (NLR) on short-term prognosis in elderly patients with hip fracture.

METHODS

Altogether, 124 elderly patients with hip fractures who underwent surgery in our hospital were retrospectively studied, and they were divided into survival group (n=98) and death group (n=26) according to their 1-year survival. General data of both groups were collected and compared, and indicators with statistical differences in univariate analysis were further examined by logistic regression analysis. Venous blood samples were drawn from all patients 1 day after the surgery to detect and compare NLR, serum procalcitonin (PCT) and C-reactive protein (CRP) levels between both groups. ROC curve was used to analyze the clinical value of NLR in predicting the prognosis of patients. NLR cutoff value obtained by the ROC curve analysis was adopted to divide the patients into high and low ratio groups, and Kaplan-Meier (K-M) curves were used to assess the survival rate of patients in both groups.

RESULTS

There were significant differences in age, gender, marital status, medical history and American Society of Anesthesiologists (ASA) grades between both groups. Logistic regression analysis showed that advanced age (≥85 years), male gender, and higher ASA grades (III-IV) were risk factors for short-term poor prognosis in elderly patients with hip fracture. Compared with survival group, NLR, PCT and CRP levels were higher in death group. ROC curve showed that the AUC of NLR predicting patients' prognosis was 0.804 at a cutoff value of 6.939%. K-M curves showed that the overall survival was lower in high-ratio group than in low-ratio group.

CONCLUSION

Advanced age (overall survival was lower in high-ratio group than in low-ratio group), male gender, and higher ASA grades (III-IV) were risk factors for short-term poor prognosis in elderly patients with hip rifracture. NLR has some clinical value in predicting and evaluating the prognosis of patients.

Locking retrograde nail, non-locking retrograde nail and plate fixation in the treatment of distal third femoral shaft fractures: radiographic, bone densitometry and clinical outcomes

BACKGROUND

Distal third femoral shaft fractures are characterized by increasing incidence and complexity and are still considered a challenging problem (high morbidity and mortality). No consensus on best surgical option has been achieved. This study aims to investigate radiographic, mineral bone densitometry and clinical outcomes of locking retrograde intramedullary (LRN) nailing, non-locking retrograde intramedullary nailing and anatomical locking plate to surgically treat distal third femoral shaft fractures in young adults. Our hypothesis was that there is no significant statistical difference among the surgical options in terms of results (radiographic, bone densitometry and outcomes assessment).

METHODS

Retrospective study: 90 patients divided into three groups (group 1 LRN, group 2 NLRN, group 3 plating). Average age was respectively 42.67 (± 18.32), 44.27 (± 15.11) and 42.84 (± 18.32) years. Sex ratio F:M was respectively 2.75, 2.33 and 2.00. AO Classification, KOOS, NUSS and RUSH score, VAS, DEXA scans and plain radiographs were used. Evaluation endpoint: 12 months after surgery.

RESULTS

There were no statistical differences in terms of surgery time, transfusions, and wound healing. Results were similar with regard to average time of bone healing, RUSH scores, VAS, KOOS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients outcomes.

CONCLUSIONS

Our results showed no statistical difference in the use of LNR, NLNR and plating for treatment of distal third femur shaft fractures in terms of radiographic, bone densitometry and clinical outcomes. Good subjective and objective results are provided by all three techniques. The choice among the studied techniques must be based on surgeons' experience, indications and subjective patients' aspects. The absence of relevant similar data in the published literature does not allow definitive validation (or rejection) of our hypothesis. A more powered study with a bigger cohort is needed for definitive validation.

Does Femoral Morphology Predict the Risk of Periprosthetic Fracture After Cementless Total Hip Arthroplasty?

BACKGROUND

Periprosthetic femur fracture remains a leading mode of early failure following cementless total hip arthroplasty (THA). The purpose of this study is to determine if a specific femoral morphology is associated with an increased risk of acute, periprosthetic fracture after cementless THA.

METHODS

An institutional arthroplasty registry was used to identify 32 primary, cementless THAs revised for acute, postoperative periprosthetic fracture ("fracture" cohort) within 3 months of the index procedure. Patients were matched 1:2 to 64 THAs without fracture ("control" cohort) for age, body mass index, gender, and stem design. Preoperative radiographic measurements performed on anteroposterior pelvis and femur radiographs included the neck-shaft angle, endosteal width at 4 locations, and external cortical diameter at 2 locations. These measurements were used to calculate the morphological cortical index, canal flare index, canal calcar ratio, and canal bone ratio. Postoperative measurements included canal fill and stem alignment. Statistical analyses included clustered regressions, Fisher's exact test, and Student's t-test.

RESULTS

The mean endosteal width at 10 cm distal to the lesser trochanter was greater in fracture patients, although not statistically significant (P = .1). However, this resulted in differences in the canal flare index (P = .03), canal calcar ratio (P = .03), and canal bone ratio (P = .03) between the 2 cohorts. These ratios indicate decreased meta-diaphyseal taper in fracture patients. Preoperative femoral neck-shaft angle was more varus in fracture patients (P = .04).

CONCLUSION

Patients sustaining an acute, periprosthetic fracture with cementless femoral fixation after THA had thinner distal cortices and a decreased meta-diaphyseal taper.

Risk Factors and Trends Associated With Mortality Among Adults With Hip Fracture in Singapore

IMPORTANCE

Examining trends in mortality following hip fracture and its associated factors is important for population health surveillance and for developing preventive interventions.

OBJECTIVE

To examine temporal trends in, and risk factors associated with, mortality following hip fracture over 18 years in Singapore.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based cohort study included men and women aged 50 years and older admitted to Singapore hospitals for first hip fracture identified and followed up from 2000 to 2017. Demographic information, fracture type, and Charlson Comorbidity Index (CCI) score were retrieved from nationwide claims data, and mortality data were from the National Death Registry. Data were analyzed from August 2018 to December 2019.

MAIN OUTCOMES AND MEASURES

Adjusted hazard ratios (aHRs) and their 95% confidence intervals were estimated using Cox proportional hazards regression. Kaplan-Meier life table methods were used to calculate survival following the hip fracture on a cohort basis. The crude survival over time since fracture was compared by sex, age group, ethnicity, CCI, and fracture type. Standardized mortality ratios (SMRs) were calculated using all-cause mortality obtained from Singapore population life tables.

RESULTS

Among 36 082 first inpatient admissions for hip fractures (mean [SD] patient age, 78.2 [10.1] years; 24 902 [69.0%] female; 30 348 [84.1%] Chinese, 2863 [7.9%] Malay, 1778 [4.9%] Indian, and 1093 [3.0%] other ethnicity), elevated rates of mortality were observed for male sex (aHR, 1.46; 95% CI, 1.41-1.52), Malay ethnicity (aHR, 1.23; 95% CI, 1.15-1.30 vs Chinese ethnicity), older age (aHR, 5.20; 95% CI, 4.27-6.34 for age ≥85 years vs 50-54 years), high CCI score (aHR, 3.62; 95% CI, 3.42-3.84 for CCI ≥6 vs CCI of 0), trochanteric fractures (aHR, 1.11; 95% CI, 1.06-1.16 vs cervical fractures), and earlier cohorts (aHR, 0.59; 95% CI, 0.56-0.62 for 2012-2017 vs 2000-2005). Absolute mortality decreased significantly over time: by 21% in 2006 to 2011 and by 40% in 2012 to 2017, compared with 2000 to 2005. On long-term follow-up, differences in survival associated with sex and ethnicity tended to diminish, whereas differences associated with older age, higher CCI score, and trochanteric fractures increased. In the first year after fracture, reductions in SMR were observed comparing the periods 2013 to 2016 with 2003 to 2007 in women (SMR, 2.05; 95% CI, 1.91-2.20 vs SMR, 2.54; 95% CI, 2.39-2.70, respectively) but not among men (SMR, 3.28; 95% CI, 3.04-3.54 vs SMR, 3.42; 95% CI, 3.18-3.68, respectively).

CONCLUSIONS AND RELEVANCE

Malay ethnicity, older age, male sex, prefracture comorbidity, and trochanteric fractures were independently associated with increased risk of death, identifying population groups that could be targeted for intervention strategies. The improvement in relative mortality for women but not men suggests the need to develop interventions that improve mortality outcomes for men.

Radiographic, Bone Densitometry and Clinic Outcomes Assessments in Femoral Shaft Fractures Fixed by Plating or Locking Retrograde Nail

Introduction:

Distal femoral shaft fractures are characterized by increasing incidence and complexity and are still considered a challenging problem (high morbidity and mortality). No consensus on best surgical option has been achieved.

Aim:

This study aims is to investigate radiographic, mineral bone densitometry and clinical outcomes of locking retrograde intramedullary (LRN) nailing and anatomical locking plate to surgically treat distal femoral shaft fractures in young adults based on the hypothesis that there is no statistical difference among the two surgical options in terms of results (radiographic, bone densitometry and outcomes assessment).

Methods:

Retrospective study: 30 patients divided into 2 groups (Group 1 LRN, Group 2 Nailing). Average age was 42.67±18.32 for Group 1 and 42.84 ±18.32 for Group 2 (range of age 18-65 for both groups). Gender Ratio (male: female) was 2.75 (11:4) for both Group 1 and 2. AO Classification, NUSS and RUSH score, VAS, Dexa scans, plain radiographs were used. Evaluation endpoint: 12 months after surgery (mean follow up 16.24).

Results:

No statistical difference in terms of surgery time, transfusions, wound healing. Similar results with regard to average time of bone healing, RUSH scores, VAS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients outcomes. Only one patient of each group had reduction of mineral bone densitometry values.

Conclusion:

No statistical difference about the use of LNR or Nailing for treatment of distal femur shaft fractures in terms of radiographic, bone densitometry and outcomes has been found accordingly to our results. Good subjective and objective results are provided by both techniques. The choice among the two techniques must be based on surgeons’ experience, indications and subjective patients’ aspects. The absence of relevant similar data in the published literature does not allow definitive validation (or rejection) of our hypothesis. A more powered study with bigger cohort is needed for definitive validation.

Differences in Bone Mineral Density and Hip Geometry in Trochanteric and Cervical Hip Fractures in Elderly Chinese Patients

OBJECTIVE

To assess the differences in bone mineral density (BMD) and hip geometry in trochanteric and cervical hip fractures in elderly Chinese patients.

METHODS

A consecutive series of 196 hip fracture patients aged over 50 years was recruited from November 2013 to October 2015, including 109 cases of cervical fractures (36 males and 73 females) and 87 cases of trochanteric fractures (34 males and 53 females). All patients were evaluated through dual-energy X-ray absorptiometry, and baseline characteristics, BMD and structural parameters were collected and reviewed.

RESULTS

There were statistically significant differences in age, height, and body mass index between patients with each type of fracture, and patients with trochanteric fractures were older than those with cervical fractures, especially in women. The BMD in trochanteric fractures was markedly lower than in cervical fractures in all five sites of the hip by an approximate reduction of 10%, in both men and women. The cross-sectional area, cross-sectional moment of inertia, and the cortical thickness in the cervical fracture group were significantly higher than in the trochanteric fracture group. However, the buckling ratio of both the femoral neck and trochanteric region were significantly lower in the cervical fracture group. Age (/10 years), cross-sectional moment of inertia in femoral neck and buckling ratio in trochanteric region were significant risk factors for trochanteric fractures compared with cervical fractures.

CONCLUSIONS

Compared with cervical hip fractures, patients with trochanteric fractures were older, had a lower BMD, and had less bone mechanical strength, especially in female patients. Age, femoral neck cross-sectional moment of inertia (FNCSMI), and trochanteric region buckling ratio (ITBR) were stronger risk factors for trochanteric hip fractures than for cervical fractures.

Radiofrequency echographic multi-spectrometry for the in-vivo assessment of bone strength: state of the art-outcomes of an expert consensus meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

PURPOSE

The purpose of this paper was to review the available approaches for bone strength assessment, osteoporosis diagnosis and fracture risk prediction, and to provide insights into radiofrequency echographic multi spectrometry (REMS), a non-ionizing axial skeleton technique.

METHODS

A working group convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis met to review the current image-based methods for bone strength assessment and fracture risk estimation, and to discuss the clinical perspectives of REMS.

RESULTS

Areal bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) is the consolidated indicator for osteoporosis diagnosis and fracture risk assessment. A more reliable fracture risk estimation would actually require an improved assessment of bone strength, integrating also bone quality information. Several different approaches have been proposed, including additional DXA-based parameters, quantitative computed tomography, and quantitative ultrasound. Although each of them showed a somewhat improved clinical performance, none satisfied all the requirements for a widespread routine employment, which was typically hindered by unclear clinical usefulness, radiation doses, limited accessibility, or inapplicability to spine and hip, therefore leaving several clinical needs still unmet. REMS is a clinically available technology for osteoporosis diagnosis and fracture risk assessment through the estimation of BMD on the axial skeleton reference sites. Its automatic processing of unfiltered ultrasound signals provides accurate BMD values in view of fracture risk assessment.

CONCLUSIONS

New approaches for improved bone strength and fracture risk estimations are needed for a better management of osteoporotic patients. In this context, REMS represents a valuable approach for osteoporosis diagnosis and fracture risk prediction.