Implants for trochanteric fractures in Norway: the role of the trochanteric stabilizing plate-a study on 20,902 fractures from the Norwegian hip fracture register 2011-2017

No benefit of the trochanteric stabilizing plate on loss of fracture reduction in AO/OTA 31-A2 trochanteric fractures

Aims

Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

Methods

Overall, 31 patients with AO/OTA 31-A2 trochanteric fractures were randomized to either a SHS alone or a SHS with an additional TSP. To compare postoperative fracture motion, radiostereometric analysis (RSA) was performed before and after weightbearing, and then at four, eight, 12, 26, and 52 weeks. With the "after weightbearing" images as baseline, we calculated translations and rotations, including shortening and medialization of the femoral shaft.

Results

Similar migration profiles were observed in all directions during the course of healing. At one year, eight patients in the SHS group and 12 patients in the TSP group were available for analysis, finding a clinically non-relevant, and statistically non-significant, difference in total translation of 1 mm (95% confidence interval -4.7 to 2.9) in favour of the TSP group. In line with the migration data, no significant differences in clinical outcomes were found.

Conclusion

The TSP did not influence the course of healing or postoperative fracture motion compared to SHS alone. Based on our results, routine use of the TSP in AO/OTA 31-A2 trochanteric fractures cannot be recommended. The TSP has been shown, in biomechanical studies, to increase stability in sliding hip screw constructs in both unstable and intermediate stable trochanteric fractures, but the clinical evidence is limited. This study showed no advantage of the TSP in unstable (AO 31-A2) fractures in elderly patients when fracture movement was evaluated with radiostereometric analysis.

Posterior Protrusion Measures (PPM) for Three-Dimensional (3D) CT Classification of Pertrochanteric Fractures

Introduction We introduced a novel numerical index known as posterior protrusion measures (PPM), derived from lateral plain radiograph images, which effectively serves to distinguish stable from unstable pertrochanteric fractures. The present study aims to scrutinize PPM values among two classified fracture patterns, stable and unstable, within the three-dimensional (3D) CT classification system, establishing a numeric threshold for PPM to differentiate between these groups; explore the potential relationship between the PPM index and unclassified categories; investigate how groups divided by the PPM threshold value can predict fracture stability based on 3D CT. Materials and methods In this study, three observers were tasked with measuring PPM on a single occasion. The chi-square test assessed the association between each demographic parameter on a categorical scale and stable/unstable groups. Continuous variables were also subject to examination. Receiver operating characteristic (ROC) analysis was employed to determine optimal cut-off points of PPM for predicting the presence of stable versus unstable groups. Additionally, the chi-square test examined the linear relation between separated groups based on the defined threshold PPM value and the stable/unstable groups. Results A total of 106 pertrochanteric fractures were identified using CT scan images and plain radiographs in the 3D CT classification system, revealing the stable group of 35 patients and the unstable group of 71 patients. The PPM values for stable/unstable fractures were, on average (± standard deviation), 0.34±0.25/0.50±0.29 for observer 1, 0.31±0.23/0.57±0.31 for observer 2, and 0.41±0.29/0.57±0.26 for observer 3, respectively (p<0.01). We established 0.3 as the cut-off value for PPM. The average PPM value among three observers represented each patient to assess fracture stability. The group with PPM <0.3 included 27 patients (16 stable and 11 unstable), and the group with PPM ≥0.3 group comprised 79 patients (19 stable and 60 unstable; p<0.005). Conclusion The present study revealed a significant difference in PPM values among stable and unstable 3D CT classification groups. Additionally, a threshold PPM value of 0.3 suggests a pivotal point for differentiating fracture stability. This innovative methodology makes a substantial contribution to clinical endeavors, potentially circumventing the necessity for 3D CT scanning.

A Demographic Survey of Pertrochanteric Fractures Based on the Revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) Classification Using 3D CT Scan Images

Introduction A demographic survey of femoral pertrochanteric fractures provides several important information for the healthcare system of a country since this fracture is commonly seen in the elderly and has a poor postoperative functional prognosis that is a burden on society. The importance of accurately classifying pertrochanteric fractures as stable or unstable cannot be understated. However, the use of plain radiograph images alone is known to underestimate fracture severity with low inter- or intra-observer agreement. Computed tomography (CT) images offer information for a more accurate classification of pertrochanteric fractures. With this three-dimensional (3D) CT-based study using the revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification, the purpose of this study is to elucidate the epidemiological demography of patients with pertrochanteric fractures. Material and methods We retrospectively collected 808 patients from five hospitals, classified into two groups: stable (A1) or unstable (A2). Age, gender, fracture laterality, and surgery timing were identified as epidemiological variables. Patients with both preoperative plain radiographs and 3D CT scans were included in the study. The exclusion criteria were AO/OTA A3 type fractures, pathological fractures, previous ipsilateral surgery, 60 years old or younger, and conservatively treated patients. The primary outcome involved detailing the total number of fractures based on classification (A1 or A2) and variables. The secondary outcome involved a comparison between the A1 and A2 groups. Results The mean age of patients at the time of surgery was 85 years (range: 61-103 years). There were 637 female and 171 male patients. There were 463 left-sided fractures and 345 right-sided fractures. Of the 808 patients, 371 (45.9%) were classified to have A1 fractures, and 437 (54.1%) had A2 fractures. The age at surgery, gender, fracture laterality, and surgery timing between the A1 and A2 groups were compared. The mean and standard deviation of the age at surgery for patients in the A1 and A2 groups were 84.9±7.7 and 86.9±6.8, respectively. The number of patients for each age distribution of 61-69, 70-74, 75-79, 80-84, 85-89, 90-94, and 95 or older for the A1 and A2 groups was 18 and 7, 18 and 12, 43 and 44, 76 and 82, 107 and 132, 79 and 110, and 30 and 50, respectively, showing that the difference in categorial distribution was statistically significant (p=0.002). Overall, 278 females and 93 males were classified to have A1 fractures compared with 359 females and 78 males with A2 fractures (p=0.01). There were 166 right-sided and 205 left-sided stable A1 fractures and 179 right-sided and 258 left-sided A2 fractures (not significant (NS)). Among the total number of A1 and A2 surgeries by month, the most were in December with 77 surgeries (37 and 40, respectively), and the least was in June with 37 (18 and 19, respectively). The seasonal classification for A1 and A2 surgeries is as follows: spring with 172 (74 and 98, respectively), summer with 150 (70 and 80, respectively), autumn with 193 (90 and 103, respectively), and winter with 208 (97 and 111, respectively) (NS). Conclusion In this demographic study of 808 patients with pertrochanteric fractures classified by 3D CT images, 371 had A1 fractures and 437 had A2 fractures. A2 fractures were significantly more in females with an age peak of 85-89 years.

Posterior Protrusion Measures (PPM) as an Innovative Index in Classifying Plain Lateral Radiograph Images of Pertrochanteric Fracture Using the Revised AO Foundation/Orthopaedic Trauma Association (AO/OTA) Classification

Introduction The absence of a precise fracture classification system that classifies pertrochanteric fractures into either stable or unstable contributes to a burden on healthcare and has several major implications. We propose an innovative graphical index, which we refer to as posterior protrusion measures (PPM), using plain lateral view radiograph images for the revised AO Foundation (Arbeitsgemeinschaft für Osteosynthesesfragen)/Orthopedic Trauma Association (AO/OTA) classification system. This study aims to: (i) introduce the use of PPM for classifying fractures into stable or unstable under the revised AO/OTA classification system and set the threshold numeric value, (ii) elucidate the reproducibility of inter and intra-observer agreement, and investigate the consistency of fracture classification using PPM versus computed tomography (CT) scan images. Materials and methods Out of 146 patients identified from the database, a total of 126 patients were enrolled in the study. Pertrochanteric fractures were classified as either stable or unstable. Three surgeons were assigned for PPM determination. Regarding the demographical data, the chi-square test was used to assess the significance of each parameter on a categorical scale between the two groups. The independent sample t-test or the Mann-Whitney U test was used to compare the two independent groups. Interclass correlation coefficient (ICC) values for continuous variables and kappa values (κ) for categorical variables were calculated to assess inter-observer and intra-observer agreement. Receiver-operating characteristic (ROC) analysis was used to determine optimal cut-off points of PPM to predict consistency between separate fracture classification groups, one using PPM values with a threshold derived from plain radiograph images, and the other using CT scan images. Results Among a total of 126 pertrochanteric fractures, the A1 (stable) group consisted of 39 patients (10 males, 29 females), whereas the A2 (unstable) group consisted of 87 patients (14 males, 73 females) (not significant, NS). Intraclass correlation coefficient (ICC) values of PPM for the inter-observer agreement were 0.796 (0.723-0.852), 0.664 (0.554-0.751), and 0.702 (0.601-0.781) at first examination and 0.729 (0.635-0.801) at the second. The intra-observer agreement was 0.869 (0.819-0.906) and 0.603 (0.480-0.703). We examined for consistency of fracture classification group of PPM values with a threshold of 0.4 (A1<0.4, A2=0.4 or more) and CT-based group. For the first examination, there was mostly "moderate" agreement in fracture classification (stable or unstable) between plain radiograph and CT scan images, κ (95%CI): 0.427 (0.266-0.588), 0.493 (0.335-0.651), and 0.359 (0.176-0.544), and for the second, 0.418 (0.251-0.585), and 0.451 (0.284-0.620), respectively. Conclusion We propose a supplementary tool, namely PPM that allows for possible alternative classification of pertrochanteric fractures into A1 (stable) and A2 (unstable) using plain radiograph images under the revised AO/OTA classification system. In this study, a PPM threshold value of 0.4 demonstrated a moderate inter- and intra-observer agreement. It is noteworthy to mention that there was a satisfactory consistency of fracture classification using PPM derived from plain radiograph images when compared to classification using CT scan images. In addition, the PPM method provides a numerical score.

Evaluation of risk factors and outcomes associated with mortality after hip fracture surgery in eldery patients

Objective: In this retrospective study, it was aimed to compare mortality related risk factors and outcomes in patients who underwent proximal femoral nail and partial hip prosthesis for hip fracture. Material and Method: In our study, a total of 618 patient files who underwent hip fracture operations, including partial hip replacement (n=350) and proximal femoral nail (n=268) were retrospectively analyzed. Age, gender, fracture side, cause, type of fracture, type of operation, blood transfusion, hospital stay, anesthesia type and one-year survival times of the patients were examined. Results: Gender, age, side, mechanism, anesthesia, comorbid diseases, cause of mortality, one-year mortality and survival time differences between patient groups were not statistically significant (p>0.05). However, fracture type, blood transfusion and hospital stay differences between groups were statistically significant (p

Total hip arthroplasty compared to bipolar and unipolar hemiarthroplasty for displaced hip fractures in the elderly: a Bayesian network meta-analysis

Purpose

Displaced femoral neck fractures (FNF) usually require surgical treatment with either a total hip arthroplasty (THA), unipolar hemiarthroplasty (U-HHA), or bipolar hemiarthroplasty (B-HHA). However, there is still controversy regarding the optimal implant. This network meta-analysis compared the outcomes and complication rates of THA versus B-HHA and versus U-HHA in elderly patients with FNF.

Material and methods

This study was conducted according to the PRISMA extension statement for reporting of systematic reviews, and incorporated network meta-analyses of health care interventions. The literature search was performed in September 2020. All randomized clinical trials comparing two or more of the index surgical interventions for displaced FNF in the elderly were eligible for inclusion. For the Bayesian network meta-analysis, the standardized mean difference (SMD) and Log Odd Ratio (LOR) were used.

Results

Data from 24 RCTs (2808 procedures) were analysed. The mean follow-up was 33.8 months. The THA group had the longest surgical time (SMD 85.74) and the greatest Harris Hip Score (SMD − 17.31). THA scored similarly in terms of mortality (LOR 3.89), but had lower rates of revision surgeries (LOR 2.24), higher rates of dislocations (LOR 2.60), and lower rates of acetabular erosion (LOR − 0.02). Cementless implants required a shorter surgical duration (− 18.05 min; P = 0.03). Mortality was positively associated with acetabular erosion (P = 0.006), female gender (P = 0.007), revision (P < 0.0001).

Conclusion

THA led to the highest Harris Hip scores and lowest rate of revision surgery compared to B-HHA and U-HHA. However, B-HHA had the lowest dislocation rate when compared with U-HHA and THA. No significant differences in functional outcomes and complication rates were found between cemented and uncemented implants; however, a tendency for lower mortality, revision and dislocation rates in cemented implants was evidenced.

Level of evidence

I, Bayesian network meta-analysis of RCTs.

Trochanteric stabilizing plate in the treatment of trochanteric fractures: a scoping review

Background and purpose - The trochanteric stabilizing plate (TSP) may be used as an adjunct to a sliding hip screw (SHS) in the treatment of trochanteric fractures to increase construct stability. We performed a scoping review of the literature to clarify when and how the TSP may be useful.Methods - A systematic search was performed in 5 databases and followed by a backwards-and-forwards citation search of the identified papers. 24 studies were included.Results - 6 biomechanical studies and 18 clinical studies were included in the review. The studies presented mainly low-level evidence. All studies were on unstable trochanteric fractures or fracture models. Due to the heterogeneity of methods and reporting, we were not able to perform a meta-analysis. In the biomechanical trials, the TSP appeared to increase stability compared with SHS alone, up to a level comparable with intramedullary nails (IMNs). We identified 1,091 clinical cases in the literature where a TSP had been used. There were 82 (8%) reoperations. The rate of complications and reoperations for SHS plus TSP was similar to previous reports on SHS alone and IMN. It was not possible to conclude whether the TSP gave better clinical results, when compared with either SHS alone or with IMN.Interpretation - The heterogeneity of methods and reporting precluded any clear recommendations on when to use the TSP, or if it should be used at all.