Clinical Practice Guidelines in Action: Differences in Femoral Neck Fracture Management by Trauma and Arthroplasty Training

Effect of Fracture Type, Treatment, and Surgeon Training on Reoperation After Vancouver B Periprosthetic Femur Fractures

BACKGROUND

The treatment of Vancouver B periprosthetic proximal femur fractures (PPFFs) is complex due to the overlap between arthroplasty and orthopedic trauma techniques. Our purpose was to assess the effects of fracture type, treatment difference, and surgeon training on the risk of reoperation in Vancouver B PPFF.

METHODS

A collaborative research consortium of 11 centers retrospectively reviewed PPFFs from 2014 to 2019 to determine the effects of variations in surgeon expertise, fracture type, and treatment on surgical reoperation. Surgeons were classified as per fellowship training, fractures using the Vancouver classification, and treatment as open reduction internal fixation (ORIF) or revision total hip arthroplasty with or without ORIF. Regression analyses were performed with reoperation as the primary outcome.

RESULTS

Fracture type (Vancouver B3 versus B1: odds ratio [OR]: 5.70) was an independent risk factor for reoperation. No differences were found in reoperation rates with treatment (ORIF versus revision: OR 0.92, P = .883). Treatment by a nonarthroplasty-trained surgeon versus an arthroplasty specialist led to higher odds of reoperation in all Vancouver B fracture (OR: 2.87, P = .023); however, no significant differences were seen in the Vancouver B2 group alone (OR: 2.61, P = .139). Age was a significant risk factor for reoperation in all Vancouver B fractures (OR: 0.97, P = .004) and in the B2 fractures alone (OR: 0.96, P = .007).

CONCLUSION

Our study suggests that age and fracture type affect reoperation rates. Treatment type did not affect reoperation rates and the effect of surgeon training is unclear.

Total hip arthroplasty for displaced femoral neck fracture: Survey of orthopaedic surgeons in Ontario, Canada

BACKGROUND

Total hip arthroplasty (THA) for displaced femoral neck fractures in older patients remains a controversial topic. This study describes patient and surgeon factors that are associated with surgeons' recommendation of THA for this patient population. Furthermore, this study explores surgeon perceptions on why most patients are treated with hemiarthroplasty over THA.

METHODS

In October 2019, a cross-sectional survey was mailed to practicing orthopaedic surgeons in Ontario, Canada. The questionnaire included paper patient cases to capture surgical practice variation using a full factorial, vignette-based experimental design. Multilevel linear regression and multivariable linear regression were used to determine patient and surgeon factors that are associated with treatment recommendations.

RESULTS

Of a target population of 494 practicing surgeons, 302 (61.1%) responded. Sixty percent of respondents worked in the community, and most respondents (89.4%) had fellowship training. Surgeon-level predictors of treatment with THA included higher volume of THA for fracture in the last 12 months, having an elective THA practice, and increasing years in practice. Pre-existing hip arthritis increased likelihood to recommend THA, while increasing patient age and comorbidity burden decreased likelihood to recommend THA. There are medical, institutional, financial, and historic reasons why most patients are treated with hemiarthroplasty over THA.

INTERPRETATION

This survey identified several patient and surgeon-level factors that were associated with treatment recommendation for THA. Hemiarthroplasty remains the more common treatment for this patient population for multiple reasons. There is potential for differential access to care when the factors driving treatment decisions are unrelated to the patient.

Comparison between Orthopaedic Trauma versus Arthroplasty Fellowship Training on Outcomes of Total Hip Arthroplasty for Femoral Neck Fracture

BACKGROUND

This study aimed to identify differences in patient characteristics, perioperative management methods, and outcomes for total hip arthroplasty (THA) for femoral neck fracture (FNF) when performed by orthopaedic surgeons who have arthroplasty versus orthopaedic trauma training.

METHODS

This study was a multicenter, retrospective review of 636 patients who underwent THA for FNF between 2010 and 2019. There were 373 patients who underwent THA by an arthroplasty surgeon, and 263 who underwent THA by an orthopaedic trauma surgeon. Comorbidities, management methods, and outcomes were compared between patients operated on by orthopaedic surgeons who had arthroplasty versus trauma training.

RESULTS

Arthroplasty-trained surgeons had shorter operative times (102 vs 128 minutes, P<0.0001) and utilized tranexamic acid more frequently than trauma-trained surgeons (48.8 vs 18.6%, P<0.0001). Orthopaedic trauma surgeons more frequently utilized an anterior approach. Patients of arthroplasty-trained surgeons had lower rates of complications including pulmonary embolism (1.6 vs 6.5%, P=0.0019) and myocardial infarction (1.6 vs 11.0%, P<0.0001). Similarly, patients of arthroplasty-trained surgeons were discharged faster (5.3 vs 7.9 days, P<0.0001) with greater ambulation capacity (92.2 vs 57.2 feet, P<0.0001). Dislocation, periprosthetic joint infection, and revision were similar between both groups. When adjusted for covariates, there was no difference in 90-day, 1-year, or 2-year mortality.

CONCLUSION

A THA performed for FNF by arthroplasty surgeons was associated with lower in-hospital morbidities and improved functional statuses at discharge. However, mortalities and complications after discharge were similar between both specialties when adjusted for confounding variables. Optimization of protocols may further improve outcomes for THA for FNF.

Effects of Spinal Anesthesia in Geriatric Hip Fracture: A Propensity-Matched Study

OBJECTIVES

To identify whether anesthesia type is associated with surgical outcomes in geriatric patients undergoing operative treatment for a hip fracture.

DESIGN

Retrospective database review of prospectively collected data.

PATIENTS

Patients included in the American College of Surgeons National Surgical Quality Improvement Program database. All included patients were 65-89 years of age and had a hip fracture treated with internal fixation, arthroplasty, or intramedullary device. Patients were excluded for open, pathologic, stress-related, or periprosthetic hip fractures.

INTERVENTION

Use of spinal anesthesia (SA) or general anesthesia (GA).

MAIN OUTCOME MEASUREMENTS

Complications, mortality, and discharge destination.

RESULTS

A total of 23,649 cases met inclusion and exclusion criteria and were successfully matched using propensity score matching: 15,766 GA and 7883 SA. The odds of sustaining a complication were 21% lower in the SA group compared with those in the GA group (odds ratio SA/GA 0.791; 95% confidence interval, 0.747-0.838). The 30-day mortality rate was not correlated with SA or GA choice. Patients who underwent SA were significantly more likely to be discharged to home (odds ratio SA/GA 1.65; 95% confidence interval, 1.531-1.773).

CONCLUSIONS

No mortality difference exists between patients undergoing SA and those undergoing GA for hip fracture surgery. For patients undergoing hip fracture surgery with SA, there is lower 30-day complication profile and higher discharge to home rate compared with those undergoing GA. Both anesthesia modalities may be acceptable.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Configuration of short- and long-threaded cannulated screws in proximal femoral plating decreases varus collapse of femoral neck fractures: A retrospective cohort study

OBJECTIVES

Proximal femoral plating serves as a good alternative for the fixation of femoral neck fractures, but fixation loss still occurs. This study aimed to evaluate the effect of a hybrid configuration of short- and long-threaded cannulated screws in proximal femoral plating in terms of decreasing varus collapse of femoral neck fractures.

MATERIALS AND METHODS

We retrospectively analyzed 86 patients with femoral neck fractures who were fixed by proximal femoral plating from January 2015 to June 2019. These patients were divided into two groups according to screw configuration: short- and long-threaded cannulated screws (SLTS, n = 38) and short-threaded cannulated screws (STS, n = 48). Radiological and clinical outcomes including screw withdraw, nonunion, avascular necrosis, caput-collum-diaphysis (CCD) angle, amount of femoral neck shortening (FNS), and Harris Hip Score (HHS) were compared between the groups.

RESULTS

Preoperative characteristics including age, gender, Garden type, duration of surgery, and reduction quality were not significantly different between the two groups (p > 0.05). Less decreased CCD angle was observed in the SLTS group (-0.4° (-1.4 - 1.8)) compared with that in the STS group (7.9° (6.3 - 11.0)) (p < 0.001). The SLTS group also presented with fewer amount of FNS (3.2 (2.7 - 3.8) mm vs. 5.1 (4.2 - 5.9) mm, p < 0.001). Bone union was achieved in all patients and no avascular necrosis was observed during the follow-up. The HHS was higher in the SLTS group (86.4 ± 5.1) than that in the STS group (81.5 ± 4.5) (p < 0.001).

CONCLUSION

The hybrid configuration of short- and long-threaded screws in proximal femoral plating offers better resistance against varus collapse and yields better functional outcomes in femoral neck fractures.

Diagnostic Value of Magnetic Resonance (MR) Combined with Computed Tomography (CT) in Patients with Stress Injury of Femoral Neck

BACKGROUND The purpose of this research was to study and analyze the diagnostic value of magnetic resonance (MR) combined with computed tomography (CT) in patients with stress injury of the femoral neck. MATERIAL AND METHODS The 58 patients with stress injury of the femoral neck who were treated in our hospital from July 2017 until July 2019 were selected as subjects on the basis of clinical pathology and surgery, MR and CT examination, and related imaging data retrospectively analyzed. We observed all patients using different diagnostic methods to determine the value of diagnosis and treatment of disease. RESULTS The patients selected for this study were confirmed by clinicopathology and surgery; the positive rate of CT diagnosis was 65.5%, the positive rate of MR diagnosis was 74.1%, and the positive rate of combined diagnosis was 91.4%. Through statistical analysis, CT and MR showed no significant difference in the detection of stress lesions in different femoral necks, indicating no statistical significance (P>0.05). However, the amount of stress lesions detected in the combined diagnosis was higher than that in the two separate detection methods, with statistically significant difference (P<0.05). The grading of stress lesions in all patients examined through MR showed that there was no proportion of grade 0, whereas grades 3-4 were the highest, accounting for 20.7% and 32.8% respectively. In CT scanning of all patients, fracture lines were observed in 35 patients, of which 25 were transparent lines and 10 were strip dense shadows; Periosteal reaction was observed in 34 patients, of whom umbilical concave was observed in 18 patients. Osteoporosis was observed in 30 patients, and the lesion showed a zone of reduced density in the cortical bone, with a stripelike shape and unclear boundary. The density tended to increase in the cavum medullare of 32 patients, with porosis being visible. Compared with CT diagnosis, the accuracy, sensitivity, and specificity of MR detection were not significantly different (P>0.05). The accuracy, sensitivity, and specificity of the combined detection were higher than that of CT and MR detection alone, with statistically significant differences between groups (P<0.05). CONCLUSIONS The application of MR combined with CT in early clinical diagnosis and treatment of femoral neck stress injury will improve the diagnosis rate; the imaging signal is obvious, which is helpful to further evaluate the severity of disease.

Management of Rotator Cuff Injuries

Management of Rotator Cuff Injuries Clinical Practice Guideline is based on a systematic review of current scientific and clinical research. The purpose of this clinical practice guideline is to guide the clinician's ability to diagnose and treat rotator cuff tears in adults by providing evidence-based recommendations for key decisions that affect the management of patients with rotator cuff injuries. This guideline contains 33 recommendations, including both diagnosis and treatment. In addition, the work group highlighted the need for better research in the diagnosis and treatment of rotator cuff injuries.

Does Surgeon Fellowship Training Influence Outcomes in Hemiarthroplasty for Femoral Neck Fracture?

BACKGROUND

The aim of this study is to compare the outcomes (90 days and 1 year) of patients with femoral neck fracture undergoing hemiarthroplasty by surgeons with different fellowship training: trauma, arthroplasty, and general orthopedics.

METHODS

This study is a retrospective review of consecutive patients undergoing hip hemiarthroplasty for femoral neck fracture from 2010 to 2018. Comorbidities, perioperative details, demographics, injury variables, and time-to-surgery were compared between the fellowship training cohorts, in addition to outcomes including dislocation, periprosthetic joint infection, and mortality at 90 days and 1 year.

RESULTS

A total of 298 hips with an average age of 77.8 years underwent hemiarthroplasty for femoral neck fracture. Arthroplasty surgeons had a significantly shorter operative duration (82 minutes, P = .0014) and utilized the anterior approach more frequently (P < .0001). The general orthopedists had a significantly increased total surgical complication risk compared to both the arthroplasty and trauma fellowship-trained cohorts at both 90 days (11.8% vs 1.6% vs 3.9%, P = .015) and 1 year (18.2% vs 4.9% vs 7.1%, P = .008). The overall mortality risk was 11.7% at 90 days and 22.8% at 1 year. When adjusted for covariates, including comorbidities, gender, age, and preoperative walking capacity, both the arthroplasty fellowship-trained cohort (odds ratio 0.381, 95% confidence interval 0.159-0.912, P = .030) and the general orthopedist cohort (odds ratio 0.495; 95% confidence interval 0.258-0.952, P = .035) had reduced risk of 1-year mortality compared to the trauma fellowship-trained cohort.

CONCLUSION

Hemiarthroplasty performed for femoral neck fractures may result in fewer complications when performed by arthroplasty fellowship-trained surgeons. An arthroplasty weekly on-call schedule and adjusted institutional protocols may be utilized to improve outcomes and reduce complications.

LEVEL OF EVIDENCE

Level II, retrospective cohort.