Prospective comparison of the anterior and lateral approach in hemiarthroplasty for hip fractures: a study protocol

Course of fear of falling after hip fracture: findings from a 12-month inception cohort

OBJECTIVES

To examine the course of fear of falling (FoF) up to 1 year after hip fracture, including the effect of prefracture FoF on the course.

DESIGN

Observational cohort study with assessment of FoF at 6, 12 and 52 weeks after hip fracture.

SETTING

Haaglanden Medical Centre, the Netherlands.

PARTICIPANTS

444 community-dwelling adults aged 70 years and older, admitted to hospital with a hip fracture.

MAIN OUTCOME MEASURE

Short Falls Efficacy Scale International (FES-I), with a cut-off score ≥11 to define elevated FoF levels.

RESULTS

Six weeks after hip fracture the study population-based mean FES-I was located around the cut-off value of 11, and levels decreased only marginally over time. One year after fracture almost one-third of the population had FoF (FES-I ≥11). Although the group with prefracture FoF (42.6%) had slightly elevated FES-I levels during the entire follow-up, the effect was not statistically significant. Patients with persistent FoF at 6 and 12 weeks after fracture (26.8%) had the highest FES-I levels, with a mean well above the cut-off value during the entire follow-up. For the majority of patients in this group, FoF is still present 1 year after fracture (84.9%).

CONCLUSIONS

In this study population, representing patients in relative good health condition that are able to attend the outpatient follow-up at 6 and 12 weeks, FoF as defined by an FES-I score ≥11 was common within the first year after hip fracture. Patients with persistent FoF at 12 weeks have the highest FES-I levels in the first year after fracture, and for most of these patients the FoF remains. For timely identification of patients who may benefit from intervention, we recommend structural assessment of FoF in the first 12 weeks after fracture.

Comparison of Anterior and Lateral Approach in Hip Hemiarthroplasty for Femur Neck Fractures in the Elderly: Clinical and Radiographic Outcomes

Introduction

Many surgical approaches have been described for hip hemiarthroplasty (HHA) treating femur neck fractures (FNFs). Direct lateral approach (DLA) is one of the most used. Today, the direct anterior approach (DAA) has become very attractive, but it seems to involve more intra-operative fractures. Our main endpoint was to demonstrate that the DAA may be a valid alternative comparing to the DLA.

Materials and methods

Patients affected by FNFs and treated with HHA between the years 2016 and 2020 were studied. We divided the treatment of the fractures according to the surgical approach. The analysis was focused on perioperative complications and radiological outcomes.

Results

There were a total of 166 patients. The DLA group included patients with an average age of 83.5 years and the DAA group of 83 years. We found similar surgical times (DLA 67 min vs DAA 61 min; p = 0,55), number of transfusions (DLA 3/person vs DAA 4/person; p = 0,91), perioperative complications (fractures: DLA 0 vs DAA 0 - dislocations: DLA 2,50% vs DAA 0) and functional outcomes (HHS: DLA 83 points vs DAA 87 points; p = 0,71). There were no statistical differences comparing diaphyseal filling (Canal Fill Index at the proximal third: DLA 0,79 vs DAA 0,78; p= 0,24), bone loss (Paprosky I: DLA 96,25% vs DAA 91,86%; p = 0,47) and prevalence of heterotopic ossification (Broker low degree: DLA 93,75% vs 95, 34%; p = 0,87).

Conclusion

Analysing perioperative complications and studying post-operative radiographic evolution, our results suggest that the DAA is a valid alternative to the DLA in HHA treating FNFs.

High risks of failure observed for A1 trochanteric femoral fractures treated with a DHS compared to the PFNA in a prospective observational cohort study

INTRODUCTION

Both the DHS and the PFNA are common and well-studied treatment options for stable trochanteric fractures. The aim of the current study was to compare the implant failure rates of these two implants in 31A1 type trochanteric femoral fractures.

MATERIALS AND METHODS

A single-centre observational cohort study was conducted in the Hip Fracture Unit of a multicentre level 1 trauma teaching hospital between December 2016 and October 2018. Patients with an AO/OTA type 31A1 fracture were included. Pathological fractures, bilateral fractures, high-energy traumas and patients younger than 18 years of age were excluded. Surgery was performed using either a DHS or PFNA. Both were used routinely for stable trochanteric fractures, and allocation was decided by the surgeon performing the operation. The primary outcome of this study was the implant failure rate in the first postoperative year. Secondary outcomes included the reoperation rate, functional recovery, pain and morphine use.

RESULTS

Data were available from 126 patients treated with a DHS (n = 32, 25.4%) or PFNA (n = 95, 74.6%). Minor differences were observed in the patient characteristics including the prevalence of cognitive impairment (18.8% vs 40.2%; P = 0.028), prefracture independence in activities of daily living (87.1% vs 67.4%; P = 0.034) and prefracture mobility (independently without aides: 61.3% vs 40.4%; P = 0.033). Fractures treated with a DHS showed 25% implant failures, compared to 1.1% for fractures treated with a PFNA (P = 0.004). No differences were observed in any of the secondary outcomes.

CONCLUSIONS

Significantly more implant failures were observed for the DHS compared the PFNA within 1 year after surgery. Despite the fact that this did not result in differences in revision surgery, we conclude that the PFNA, considering the minimal number of implant-related fractures is a viable implant for A1 type trochanteric fractures.

Direct anterior approach versus direct lateral approach in total hip arthroplasty and bipolar hemiarthroplasty for femoral neck fractures: a retrospective comparative study

BACKGROUND

In the current literature, there is no consensus on the best surgical approach in hip replacement for femoral neck fractures (FNFs).

AIM

The aim of this study is to compare the direct anterior approach (DAA) and the direct lateral approach (DLA) in patients treated with bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) for FNFs.

MATERIALS AND METHODS

Patients with displaced FNFs (Garden type III and IV) treated operatively using BHA and THA were enrolled. The surgical approach techniques DAA and DLA are compared. The analysed variables are: mean surgery time, number of blood units transfused perioperatively, percentage of patients transfused, perioperative complications, pain and functional outcomes at 1 and 6 months and mortality at 1, 3 and 12 months.

RESULTS

Between 2015 and 2017, 37 patients underwent BHA by the DAA and 38 patients underwent BHA by the DLA, 69 patients underwent THA by the DAA and 60 patients underwent THA by the DLA. For THA, the DAA compared to the DLA had a higher mean surgery time (100.8 min vs. 97.7 min), a lower mean number of blood units transfused perioperatively (1.4 U vs. 1.9 U), a significantly lower percentage of patients transfused (53.6% vs. 71.7%), a higher rate of perioperative complications (10.1% vs. 1.6%), a lower pain referred and better functional outcomes in the first 6 postoperative months and a significantly lower mortality rate at 12 months (2.9% vs. 16.7%). For BHA, the advantages of the DAA over DLA are not as significant.

CONCLUSIONS

The direct anterior approach in THA for FNFs provides significant benefits in the early post-operative period compared to the direct lateral approach in terms of functional recovery, residual pain, blood loss and mortality rate in the elderly active population.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Intrathecal Morphine Is Associated with Less Delirium Following Hip Fracture Surgery: A Register Study

Background

Delirium is a common complication after proximal femoral fracture surgery, with pain and opioid consumption as the contributing factors. The administration of intrathecal morphine may decrease these factors postoperatively and potentially reduce delirium.

Objectives

This research aimed to study the association between the use of intrathecal morphine and the occurrence of delirium.

Methods

A retrospective analysis of a prospective register kept in a non-academic hospital in the Netherlands was performed. The register contained data of all patients with proximal femur fractures that were surgically treated with osteosynthesis or prosthesis. Patients receiving spinal anesthesia (SA group) were compared with patients receiving spinal anesthesia with the addition of intrathecal morphine (SIM group). The administration of either SA or SIM was based on the preference of the anesthesiologist. The primary outcome was the incidence of delirium, as defined by the DSM-V classification. The follow-up lasted until hospital discharge. Both univariate and multivariate analyses were performed.

Results

The SA group consisted of 451 patients, and the SIM group included 34 patients. Delirium occurred in 19.7% in the SA group versus 5.9% in the SIM group (P = 0.046). This association remained significant after correction in multivariate analysis (OR of delirium in the SA group, 95% CI: 1.062 - 21.006, P = 0.041). Additionally, multivariate analysis revealed that age, gender, preoperative cognitive impairment, and fracture treatment (osteosynthesis or prosthesis) were independently associated with delirium.

Conclusions

This retrospective study found an independent association between the use of intrathecal morphine and a lower incidence of delirium. This clinically relevant decrease in delirium should be studied in a prospective randomized study.

The functional effect of lesser trochanter involvement in hip fractures: A prospective cohort study

INTRODUCTION

Hip fractures are the most common fractures amongst frail older patients. Earlier studies have indicated an impaired hip flexion strength in patients with fractures that include detachment of the lesser trochanter. These patients may experience protracted functional impairment and longer recovery time, causing prolonged rehabilitation journeys. This study aimed to evaluate the effects of a detached lesser trochanter in trochanteric fractures on the recovery of hip function.

METHOD

A prospective observational cohort study was performed between 2016 and 2019. Community dwelling patients aged 70 years or older with AO 31A1-A3 trochanteric fractures were included. Patients followed routine care and were treated with a DHS or PFNA. The groups with and without involvement of the lesser trochanter were analysed. The primary outcome was hip function assessed at 6 weeks, 3 months and 1 year after surgery with the Harris Hip Score. Secondary outcomes included the Ludloff's test, complications, rehabilitation time, and pain-, independence-, and quality of life scores. A propensity score was used to adjust for any baseline differences between the two groups.

RESULTS

A total of 114 patients were included, 51 (44.7%) with involvement of the lesser trochanter and 63 (55.3%) without. Minor differences were observed in the baseline characteristics. No significant difference was observed for the Harris Hip Score (coefficient estimate: 3.31; 95% CI, -5.09-11.72; P = 0.43). The flexion function of the iliopsoas muscle was more often normal with the Ludloff's test in patients without involvement of the lesser trochanter (OR, 2.33; 95% CI, 1.241-4.387; P = 0.009). However, no differences were observed for any of the other secondary outcomes.

CONCLUSION

Although no differences in overall hip function were found, more hip fracture patients with involvement of the lesser trochanter showed prolonged impaired flexion of the hip. The absence of long-term, clinically relevant disadvantages however, proves fixing the lesser trochanter to be redundant.

Prognostic Factors for Short-term Recovery of Independence in a Multistate Model for Patients With a Hip Fracture

OBJECTIVES

This study investigates the transitions of community-dwelling patients with a proximal femoral fracture towards recovery of independence using multistate modeling. The prognostic value of factors affecting the short-term rate of recovery of independence in activities of daily living was assessed for the resilient portion of the population.

DESIGN

An inception cohort was recruited between 2016 and 2019.

SETTING AND PARTICIPANTS

Only community-dwelling older patients admitted with a proximal femoral fracture were included.

MEASURES

Follow-up was performed at 6 weeks and 3 months, when the patients' living situation and level of independence were recorded. Multistate modeling was used to study the transition rates of the population through prespecified states of the recovery process. Using this model, prognostic factors for the recovery of independence were identified for resilient patients (defined as those patients who managed to return home at any point in the follow-up after discharge).

RESULTS

A total of 558 patients were included, and 218 (40.9%) recovered to prefracture levels of independence. Of the resilient patients, 20.7% were discharged home directly, and 79.3% via a rehabilitation home. In this patient group, a more favorable American Society of Anesthesiologists classification, better prefracture mobility, and the absence of a prefracture fear of falling were statistically significantly associated with a successful recovery. A low level of prefracture independence was inversely associated, meaning that patients with a low level of prefracture independence had a higher chance of successful recovery.

CONCLUSIONS AND IMPLICATIONS

This study identified 4 factors with an independent prognostic value for the recovery of independence in resilient patients after a proximal femoral fracture. These factors could be used to construct clinical profiles that contribute to the assessment of the patient's post-acute care needs and recovery capacity. In addition, multistate modeling has been shown to be an effective and versatile tool in the study of recovery prognostics.

Optimized clinical practice for superaged patients with hip fracture: significance of damage control and enhanced recovery program

With the advent of global aging, the incidence, mortality, and medical costs of hip fracture among aged patients are increasing annually. The number of controlled clinical studies and health economics analyses that conform to evidence-based medicine principles is growing day by day. However, unfortunately, no specific recommendations regarding the procedures for the treatment of hip fracture are available. Meanwhile, the existence of both traditional treatment systems and new treatment theories means that most doctors confront difficult choices in their daily practice. These factors make the therapeutic approach for aged patients, especially among superaged patients with hip fracture, extremely challenging. This study focuses on superaged patients (> 80 years as defined by the World Health Organization) with hip fracture and includes their preoperative pathological condition; therapeutic decision-making in terms of the benefit and risk ratio, damage control theory, and enhanced recovery after surgery were also investigated. These patients were discussed specifically by combining the current treatment strategies from several experts and the results of a meta-analysis published recently. The study presents some new ideas and approaches currently recognized in the field, such as preoperative assessment, surgical planning, safety consideration, complication intervention, and enhanced recovery implementation, and further presents some clear interpretations regarding misunderstandings in clinical practice. Finally, optimized treatment according to damage control principles and enhanced recovery after surgery during the perioperative period among superaged hip fracture patients is defined.