Associations between Early Surgery and Postoperative Outcomes in Elderly Patients with Distal Femur Fracture: A Retrospective Cohort Study

Treatment of supracondylar femoral fractures by minimally invasive techniques vs. exposure of the fracture site: A retrospective cohort study

INTRODUCTION

Fractures of the distal femoral third are an important cause of morbidity and mortality, and their treatment is currently controversial.

OBJECTIVES

To compare the results between minimally invasive techniques versus exposure of the fracture site. Secondly, to evaluate the relationship between demographic factors, mechanism of injury and surgical delay with patient prognosis.

METHOD

Retrospective cohort study carried out between 2015 and 2021 in a tertiary hospital. Data collection was performed by reviewing medical histories, measuring demographic and hospital parameters and definitive treatment strategy. One year of follow-up was completed in all patients, assessing the occurrence of surgical complications and mortality. A stratified analysis of the variables of interest was performed among patients over 65 years of age.

RESULTS

128 fractures were recorded, with definitive osteosynthesis being performed in 117. Patients who underwent minimally invasive techniques required a shorter hospital stay (9 [7-12] vs. 12 [8.75-16] days) (p=0.007), with no differences in mortality or complications during follow-up. In those over 65 years of age, opening the fracture site was associated with an increased risk of infection compared to minimally invasive techniques (33.3% vs. 2%) (p=0.507). All the deceased were patients over 65 years of age (33.7% at one year). Surgical delay longer than 48hours increased mortality by 10% among those older than 65 years (p=0.3). High-energy trauma had a higher proportion of pseudarthrosis (27.6% vs. 6.1%) (p=0.011).

CONCLUSIONS

Minimally invasive techniques decreased hospital stay but not complications or long-term mortality.

LEVEL OF EVIDENCE

IIb.

[Translated article] Treatment of supracondylar femoral fractures by minimally invasive techniques vs. exposure of the fracture site: A retrospective cohort study

INTRODUCTION

Fractures of the distal femoral third are an important cause of morbidity and mortality, and their treatment is currently controversial.

OBJECTIVES

To compare the results between minimally invasive techniques versus exposure of the fracture site. Secondly, to evaluate the relationship between demographic factors, mechanism of injury and surgical delay with patient prognosis.

METHOD

Retrospective cohort study carried out between 2015 and 2021 in a tertiary hospital. Data collection was performed by reviewing medical histories, measuring demographic and hospital parameters and definitive treatment strategy. One year of follow-up was completed in all patients, assessing the occurrence of surgical complications and mortality. A stratified analysis of the variables of interest was performed among patients over 65 years of age.

RESULTS

128 fractures were recorded, with definitive osteosynthesis being performed in 117. Patients who underwent minimally invasive techniques required a shorter hospital stay (9 [7-12] vs. 12 [8.75-16] days) (p=0.007), with no differences in mortality or complications during follow-up. In those over 65 years of age, opening the fracture site was associated with an increased risk of infection compared to minimally invasive techniques (33.3% vs. 2%) (p=0.507). All the deceased were patients over 65 years of age (33.7% at one year). Surgical delay longer than 48h increased mortality by 10% among those older than 65 years (p=0.3). High-energy trauma had a higher proportion of pseudarthrosis (27.6% vs. 6.1%) (p=0.011).

CONCLUSIONS

Minimally invasive techniques decreased hospital stay but not complications or long-term mortality.

LEVEL OF EVIDENCE

IIb.

Intraoperative Fracture during the Insertion of Advanced Locking Screws (T2 Alpha Femur Retrograde Intramedullary Nailing System): Report of Two Cases and Identifying Causes and Prevention

Background: Recently, the T2 alpha nailing system (Stryker, Inc.), which has advanced locking screws that can attach a screw to a rod, has been used worldwide and is expected to improve fracture fixation. We analyzed two cases of supracondylar femoral fractures in older adult patients, in which intraoperative fractures occurred during the insertion of advanced locking screws of the T2 alpha femur retrograde intramedullary nail. Case presentation: A 93-year-old and an 82-year-old woman each underwent T2 alpha femur retrograde nail fixation for supracondylar femur fractures at separate hospitals, and advanced locking screws were used as the proximal transverse locking screws. In both patients, a fracture line was observed at the proximal screw postoperatively, and the fractures were refixed with distal cable wiring and/or femoral distal plates. The patients were subsequently discharged from the same facility with no remarkable pain. Conclusions: When inserting advanced locking screws, it is necessary to enlarge the screw hole in the near-bone cortex with a counterbore drill, which might add torque to the bone cortex that could result in fractures. If the sleeve is distant from the bone, the counterbore drill will not reach the bone, the screw hole will not expand, and the insertion of advanced locking screws will apply a strong torque to the bone cortex and may result in fracture. Moreover, it is important to confirm that the counterbore drill is securely inserted under fluoroscopy and to carefully enlarge the bony foramen manually to prevent fractures during screw insertion.

Early surgery improves survival after femoral fractures in the elderly: A retrospective review of 502 fragility fractures

AIMS

Fragility fractures are a growing global healthcare burden; fragility fractures of the femur have been shown to occur in a highly comorbid patient group, with parallels to hip fracture patients. This study aimed to investigate if early surgery for femoral fractures, distal to the hip, resulted in a reduction in mortality in patients over 65 years of age.

METHODS

A retrospective review of prospectively collected data for all consecutive femoral fractures in patients aged over 65 years who underwent surgical management between January 2000 and December 2018. Data was extracted from the Fracture Outcomes Research Database (FORD) and analysed to assess if early surgery, defined as occurring within 48 h of hospital admission with a fragility femur fracture, had an effect on 30 day and 1 year mortality.

RESULTS

502 eligible patients were included; median follow up time was 57 months. 24 patients (4.7%) died within 30 days of surgery and 105 patients (20.9%) had died within 1 year of surgery. Patients who underwent surgery within 48 h of admission had a significantly reduced chance of mortality within 1 year of surgery compared to patients who had surgery more than 48 h after admission (OR = 0.401, 95% CI 0.25-0.65, p<0.001). Following Multivariate Cox Regression analysis the hazard ratio of 1 year mortality following early surgery remained significantly reduced (HR = 0.57, 95% CI 0.36-0.92, p = 0.020).

CONCLUSIONS

This study demonstrates that fragility femoral fracture patients represent a similar cohort to hip fracture patients, with high mortality rates. We recommend that hip fracture management principles are also employed for fragility femoral fractures in patients over 65 years, with rapid pre-operative optimisation to ensure these patients undergo early surgical intervention.

Predictors of in-hospital surgical site infections in surgically managed acetabular fractures: A nationwide analysis

Background

A surgical site infection (SSI) rate of 4%-8% has been reported in patients who undergo open reduction and internal fixation (ORIF) for acetabular fractures. Studies have identified risk factors for SSI, but none have performed a nationwide analysis of SSI in surgically managed acetabular fracture patients.

Methods

The National Inpatient Sample (NIS) database was queried for patients who underwent ORIF for acetabular fractures from 2016 to 2019. Analysis was performed on all patients who underwent ORIF for acetabular fractures, as well as those who only underwent ORIF for isolated acetabular fractures. Clinical characteristics, hospital course, discharge disposition, and hospitalization costs were compared between groups. Multivariate regression analysis was conducted to assess predictors of SSI.

Results

41,725 patients undergoing acetabular fracture repair were identified, of which 490 (1.2%) developed SSI during hospitalization. Age (45.90 vs 49.90, p < 0.001) and Injury Severity Scale (5.99 vs 8.30, p < 0.001) were increased in patients who developed SSI. History of hypertension (HTN) (OR = 2.343, 95% CI 1.96-2.80, p < 0.001), longer hospital length of stay (30.27 days vs 10.00 days, p < 0.001) and total charges ($469,005 vs $193,032, p < 0.001) were associated with SSI. Lower rates of routine discharge were seen in SSI patients (OR = 0.333, 95% CI 0.260-0.426, p < 0.001). Higher rates of inpatient death were associated with SSI (OR = 2.210, 95% CI 1.172-4.17, p = 0.019). Multiple procedures in addition to acetabular fracture repair, iliac artery embolization, substance abuse, later time to internal fixation and HTN were predictive of SSI (p < 0.001).

Conclusions

Severity of injury, time to fixation, and factors associated with compromised cardiovascular integrity were predictors of SSI. Identifying patients at risk for SSI should lead to clinical maneuvers that may optimize outcome.