Radiological predictive factors in the healing of displaced intracapsular hip fractures. A clinical study of 404 cases

Influence of surgical quality (according to postoperative radiography) on mortality, complications and recovery of walking ability in 1425 hip fracture patients

PURPOSE

To evaluate the influence of surgical quality (as evaluated in the post-surgical radiographic control) on mortality, complications and recovery of walking ability in patients older than 64 years with hip fracture.

PATIENTS AND METHODS

Retrospective observational study of a single-center, consecutive cohort of 1425 patients operated from December/2012 to March/2018. Average age was 85.66±7.13 (65-108) years and 966 (67.86%) were female. Extracapsular fractures (811 cases, 56.91%) were fixed with trochanteric nails (Affixus-DePuy / PFNA-Synthes) (795 cases) or sliding-hip-screw-plates (Biomet) (16 patients). Intracapsular fractures (614, 43.09%) were treated with cannulated screws (Smith-Nephew) (134 cases) or with arthroplasty (472 bipolar and 8 total hip, Furlong-JRI or Exeter-Stryker). Postoperative radiographs were used to determine surgical quality (reduction, compression, screw position, tip-apex, stem position, Voss, intraoperative fracture). Patients were followed clinically and radiographically in outpatient clinic after 1, 3, 6, and 12 months.

STATISTICAL ANALYSIS

Bivariate analysis (Pearson, Fischer, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and Relative Risks (RR) were calculated.

RESULTS

196 patients (13.75%) died along follow-up, and poor reduction was found to be a risk factor for mortality both in trochanteric nail group (p=0.0495) (RR 1.510, 1.01-2.26) and in cannulated screw group (p=0.0023) (RR 6.48, 2.40-17.53); this is a previously non-published risk factor. Surgical complications included 33 infections (2.36%), 12 non-unions (1.27%), 12 cut-outs (1.47%), 7 broken nails (0.86%), 21 hemiarthroplasty dislocations (4.37%), and 8 ischemic necrosis of the femoral head (5.97%). The significant risk factors were: poor reduction for trochanteric nail breakage (p=0.041) (RR 4.47, 1.13-17.67), poor reduction for non-union in cannulated screws (p=0.035) (RR 10.91, 1.70-70.09), as well as "tip-apex distance" over 25mm in trochanteric fractures for "cut-out" type of fixation failure (p=0.0159) (RR 3.84, 1.19-12.40). Previous walking ability was restored in 564 patients (39.58%) and worsened in 581 (40.77%), but statistical relationships were not found, although follow-up data were inadequate in 212 cases (14.88%).

CONCLUSIONS

Appropriate reduction of hip fractures is a significant step to reduce mortality, nail breakage and non-union. Adequate position of sliding screw (avoiding tip-apex distances over 25mm) is important to reduce "cut-out" in trochanteric fractures.

Non-operative predictors for subsequent interventions after intracapsular femoral neck fractures in elderly: A comprehensive analysis of the Hungarian nationwide health insurance database

OBJECTIVES

To investigate the correlation between non-operative prognostic factors and non-prosthetic fracture-related treatments following internal fixation of intracapsular femoral neck fractures in elderly patients.

DESIGN AND SETTING

Retrospective observational cohort study. Comprehensive analysis of the Hungarian nationwide health insurance database.

PARTICIPANTS

Data of in-patient records with S7200 ICD-10 codes were collected from the Hungarian National Health Insurance Fund Administration (HNHIFA) and from the health care provider institutes. The patients with femoral neck fractures in the year of 2000, following reduction and internal fixation aged 60 years or older were evaluated. The secondary, non-prosthetic fracture related treatments during the 8 year follow-up period were registered.

MAIN OUTCOME MEASURES

Of the prognostic factors, age, gender, type of fracture, season and day of the primary surgery, length of waiting time to the operation and the accompanied diseases were evaluated as risk factors for all type of fracture-related further interventions, with the exception of arthroplasties.

RESULTS

A total of 2895 patients with intracapsular femoral neck fractures met the study criteria. The mean age was 77.96 years (SD: 8.54). The cohort of the patients was observed for a total of 10,077.8 person-years. The non-prosthetic fracture related treatment was performed in 265 patients (9,2%); the median of the time elapsed to the secondary definitive treatment was 3.5 months. With Cox regression analysis, significant correlation was revealed between the incidence of non-prosthetic treatment and younger age (year, HR = 0.977, p = 0.002), surgical delay (12-24 h vs 0-6 h, HR = 1.518, p = 0.023; 24h+ vs 0-6 h, HR = 1.372, p = 0.050), season of primary osteosynthesis (fall vs summer, HR = 0.636, p = 0.012), and type of femoral neck fracture (intracapsular displaced vs intracapsular undisplaced, HR = 1.340, p = 0,047). There was no significant effect of the day of primary surgery, the gender and the presence of co-morbidities on the incidence of further surgical interventions.

CONCLUSION

The summertime primary surgical intervention, delay of surgery longer than 12 h and type of femoral neck fracture are independent predictors of non-prosthetic further treatment of femoral neck fractures in elderly patients.

LEVEL OF EVIDENCE

Level IV, evidence from cohort studies.

Assessment of technical skill in hip fracture surgery using the postoperative radiograph: pilot development and validation of a final product analysis core outcome set

Aims

To develop a core outcome set of measurements from postoperative radiographs that can be used to assess technical skill in performing dynamic hip screw (DHS) and hemiarthroplasty, and to validate these against Van der Vleuten’s criteria for effective assessment.

Methods

A Delphi exercise was undertaken at a regional major trauma centre to identify candidate measurement items. The feasibility of taking these measurements was tested by two of the authors (HKJ, GTRP). Validity and reliability were examined using the radiographs of operations performed by orthopaedic resident participants (n = 28) of a multicentre randomized controlled educational trial (ISRCTN20431944). Trainees were divided into novice and intermediate groups, defined as having performed < ten or ≥ ten cases each for DHS and hemiarthroplasty at baseline. The procedure-based assessment (PBA) global rating score was assumed as the gold standard assessment for the purposes of concurrent validity. Intra- and inter-rater reliability testing were performed on a random subset of 25 cases.

Results

In total, 327 DHS and 248 hemiarthroplasty procedures were performed by 28 postgraduate year (PGY) 3 to 5 orthopaedic trainees during the 2014 to 2015 surgical training year at nine NHS hospitals in the West Midlands, UK. Overall, 109 PBAs were completed for DHS and 80 for hemiarthroplasty. Expert consensus identified four ‘final product analysis’ (FPA) radiological parameters of technical success for DHS: tip-apex distance (TAD); lag screw position in the femoral head; flushness of the plate against the lateral femoral cortex; and eight-cortex hold of the plate screws. Three parameters were identified for hemiarthroplasty: leg length discrepancy; femoral stem alignment; and femoral offset. Face validity, content validity, and feasibility were excellent. For all measurements, performance was better in the intermediate compared with the novice group, and this was statistically significant for TAD (p < 0.001) and femoral stem alignment (p = 0.023). Concurrent validity was poor when measured against global PBA score. This may be explained by the fact that they are measuring difference facets of competence. Intra-and inter-rater reliability were excellent for TAD, moderate for lag screw position (DHS), and moderate for leg length discrepancy (hemiarthroplasty). Use of a large multicentre dataset suggests good generalizability of the results to other settings. Assessment using FPA was time- and cost-effective compared with PBA.

Conclusion

Final product analysis using post-implantation radiographs to measure technical skill in hip fracture surgery is feasible, valid, reliable, and cost-effective. It can complement traditional workplace-based assessment for measuring performance in the real-world operating room . It may have particular utility in competency-based training frameworks and for assessing skill transfer from the simulated to live operating theatre.

Cite this article: Bone Joint Open 2020;1-9:594–604.

The role of a trauma review system and development of intra-operative checklists in improving the quality of fracture fixations in a high volume tertiary centre

INTRODUCTION

In high volume centres, audits are essential to ensure good surgical techniques and fracture fixations to avoid complications, revision surgeries and poor outcomes. A method to assess fixations for fractures of different regions employing different implants and surgical demands is a challenge. We present here a simple method of review and follow-up work flow of more than 6000 fixations every year that helped in improving outcomes and also provide training for residents and junior staff.

MATERIALS AND METHODS

The results of 6348 fracture fixations in 2014, led to a trauma review system in January 2015 to classify all fracture fixations by senior consultants into three categories: category A (good fixations); category B (acceptable fixations; need further follow-up); category C (poor/unacceptable fixations needing revision) combined with a teaching program. A strategy was evolved that included the following practices: (1) identifying 'red flag' fractures that led to frequent failures, (2) routine senior surgeons' involvement in such fractures, (3) evolving 'intra-operative checklists', (4) requirement of senior surgeons' intervention if there was a 'fiddle time' of more than 20 min, and (5) approval of post-fixation c-arm image by a senior person before closure. The impact of these rules on the fixations for 2015, 2016 and 2017 were prospectively analysed.

RESULTS

In the years 2015, 2016 and 2017 the number of fracture fixations performed were 6579, 6978 and 7012, respectively. There was a significant increase (p < 0.001) in the number of category A fixations (87.7%, 94.6% and 96.3% in 2015, 2016 and 2017, respectively) and also a decrease in the number of category C fixations (2.23%, 0.7% and 0.2% in 2015, 2016 and 2017, respectively). The quality of fixations of the 'red flag' fractures also improved.

CONCLUSION

We present here a very effective, tested, simple and easily reproducible method of audit and follow-up work flow that can be used in all high turnover trauma centres to improve outcomes and can also serve as a teaching resource for junior staff.

STUDY DESIGN

Prospective study.

LEVEL OF EVIDENCE

Level II.

Radiographic fracture features predicting failure of internal fixation of displaced femoral neck fractures

INTRODUCTION

Fixation-related complications of displaced femoral neck fractures treated by internal fixation are accompanied by high mortality and morbidity. The aim of this study is to investigate the pre- and postoperative radiographic fracture characteristics in relation to patient age and the occurrence of reoperation caused by fixation failure.

METHODS

The preoperative radiographs of all patients presenting with a proximal femur fracture between January 2004 and December 2012 were retrospectively assessed for fracture type and dislocation (AP and lateral view). Patients with a displaced femoral neck fracture treated by closed reduction and internal fixation were included. The postoperative radiographs were assessed on adequate fracture reduction and correct position of the implant. Patient characteristics and outcome in terms of occurrence of fixation failure (implant breakout, non-union) and reoperation rate were recorded.

RESULTS

Hundred and-forty-nine patients were admitted with a displaced femoral neck fracture and treated by internal fixation. Fixation failure was seen in 34 (23%) patients; 9 patients suffered from osteonecrosis. In total, 37 (25%) patients underwent reoperation caused by fixation-related complications. Taking the different age categories into account, 44% of the patients >75 years suffered fixation failure compared with 17% of the patients <65 years. Postoperative incorrect reduction, with persisting dorsoventral dislocation and/or lack of medial support resulted in reoperation in 37% of the patients, compared to 19% reoperations in patients with adequate reduction.

CONCLUSION

The results of this study show that patient age and fracture reduction are important predictors for reoperation. In the preoperative treatment plan, patient age should be taken into account and surgeons should strive for anatomical reduction. Patients over 75 should always undergo arthroplasty. In patients aged 65-75, conversion to arthroplasty should be strongly considered if anatomical reduction is impossible.