The Quality of Dying in Frail Institutionalized Older Patients After Nonoperative and Operative Management of a Proximal Femoral Fracture: An In-Depth Analysis

Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, little is known about the quality of dying (QoD) while this is an integral part of palliative care and could influence decision making on nonoperative- (NOM) or operative management (OM). To identify the QoD in frail patients with a proximal femoral fracture. Data from the prospective FRAIL-HIP study, that studied the outcomes of NOM and OM in institutionalized older patients ≥70 years with a limited life expectancy who sustained a proximal femoral fracture, was analyzed. This study included patients who died within the 6-month study period and whose proxies evaluated the QoD. The QoD was evaluated with the Quality of Dying and Death (QODD) questionnaire resulting in an overall score and 4 subcategory scores (Symptom control, Preparation, Connectedness, and Transcendence). In total 52 (64% of NOM) and 21 (53% of OM) of the proxies responded to the QODD. The overall QODD score was 6.8 (P25-P75 5.7-7.7) (intermediate), with 34 (47%) of the proxies rating the QODD 'good to almost perfect'. Significant differences in the QODD scores between groups were not noted (NOM; 7.0 (P25-P75 5.7-7.8) vs OM; 6.6 (P25-P75 6.1-7.2), P = .73). Symptom control was the lowest rated subcategory in both groups. The QoD in frail older nursing home patients with a proximal femoral fracture is good and humane. QODD scores after NOM are at least as good as OM. Improving symptom control would further increase the QoD.

[Concept for the treatment of periprosthetic proximal femoral fractures]

Due to demographic changes and increased survival rates of total hip arthroplasties, the incidence of periprosthetic proximal femoral fractures is increasing. The current treatment concept requires accurate preoperative planning. Besides patient-related risk factors, fracture type, prosthesis stability, and bone quality influence whether osteosynthesis or a revision arthroplasty is required.

[Management of the cut-out of various forms of osteosynthesis for proximal femoral fractures]

Proximal femoral fractures are a common type of injury in older people. A cut-out of the femoral neck screw after initial osteosynthetic surgery of proximal femoral fractures is a frequent and feared complication. There could be different causes for cut-outs. Osteoporosis and necrosis of the femoral head could be biological reasons for cut-outs; however, mechanical factors, such as reduction, implant position and morphological characteristics of fractures also have a major influence on the cut-out rate. The treatment of the cut-out is often complex and depends on the destruction of the femoral head and the acetabulum. If the bone quality is still good and the head is not completely destroyed, a reosteosynthesis can be performed. Conversion to an endoprosthetic replacement is often the only possibility. Endoprosthetic treatment is often complex and associated with a high morbidity.

A new hip fracture risk index derived from FEA-computed proximal femur fracture loads and energies-to-failure

Hip fracture risk assessment is an important but challenging task. Quantitative CT-based patient-specific finite element (FE) analysis (FEA) incorporates bone geometry and bone density in the proximal femur. We developed a global FEA-computed fracture risk index to increase the prediction accuracy of hip fracture incidence.

PURPOSE

Quantitative CT-based patient-specific finite element (FE) analysis (FEA) incorporates bone geometry and bone density in the proximal femur to compute the force (fracture load) and energy necessary to break the proximal femur in a particular loading condition. The fracture loads and energies-to-failure are individually associated with incident hip fracture, and provide different structural information about the proximal femur.

METHODS

We used principal component analysis (PCA) to develop a global FEA-computed fracture risk index that incorporates the FEA-computed yield and ultimate failure loads and energies-to-failure in four loading conditions of 110 hip fracture subjects and 235 age- and sex-matched control subjects from the AGES-Reykjavik study. Using a logistic regression model, we compared the prediction performance for hip fracture based on the stratified resampling.

RESULTS

We referred the first principal component (PC1) of the FE parameters as the global FEA-computed fracture risk index, which was the significant predictor of hip fracture (p-value < 0.001). The area under the receiver operating characteristic curve (AUC) using PC1 (0.776) was higher than that using all FE parameters combined (0.737) in the males (p-value < 0.001).

CONCLUSIONS

The global FEA-computed fracture risk index increased hip fracture risk prediction accuracy in males.

[Treatment of proximal femoral fractures : Principles, tips and tricks]

Proximal femoral fractures occur at an annual incidence of approximately 200/100,000 inhabitants and mortality rates range up to 30% especially in geriatric patients where complications are not necessarily associated to surgery. In nearly all cases surgical treatment is required. Procedures to preserve the femoral head have to be performed as early as possible (as specified by the Federal Joint Committee, GBA, within 24 h). For joint-preserving approaches in medial femoral neck fractures a time to surgery within 6 h is considered to be advantageous. Perioperative patient care is of high importance regarding the prevention of pneumonia, renal failure, delirium and further complications. Postoperatively full weight bearing enables for early mobilization and prevention of surgery-related complications. Nonunions, avascular necrosis of the femoral head, cut-out and prosthetic dislocation must be avoided by the selection of the appropriate procedure. Minimally displaced femoral neck fractures are primarily treated by osteosynthesis and conservative management is only considered in isolated cases. For displaced femoral neck fractures, factors such as a young biological age with high activity levels, the absence of arthritis and good bone quality with a successful reduction favor for a femoral head-preserving osteosynthesis. Otherwise, (hybrid) total hip replacement (THR) is the preferred method for unstable and displaced fractures, whereby hemiarthroplasty should only be considered for very old and patients with pre-existing diseases. Fractures in the trochanteric region are treated with a proximal femoral nail and subtrochanteric fractures are managed using a long proximal femoral nail. To avoid secondary complications, the choice of optimal treatment should be based on a good understanding of the injury pattern, biomechanical and technical aspects of each procedure.

Therapeutic advantage of teriparatide in very elderly patients with proximal femoral fractures: a functional and BMD analysis

BACKGROUND

Teriparatide, a recombinant parathyroid hormone, is pivotal in osteoporosis treatment, particularly in post-surgical recovery for hip fractures. This study investigates its efficacy in functional recovery post-hip fracture surgery in elderly patients, a demographic particularly susceptible to osteoporotic fractures.

METHODS

In this retrospective cohort study, 150 elderly patients with proximal femoral fractures undergoing open reduction and internal fixation were enrolled. They were categorized into two groups: receiving 20 µg of daily teriparatide injections for 18 months and receiving standard antiresorptive medications during a 24-month follow-up. Detailed records of patient demographics, Fracture Risk Assessment Tool scores, and comorbidities were kept. Key outcomes, including bone mineral density (BMD) and functional scores (Barthel Index and Visual Analog Scale for hip pain), were evaluated at 3 and 24 months post-surgery.

RESULTS

Out of the original cohort, 126 patients (20 men and 106 women with an average age of 85.5 ± 9.3 years) completed the study. The teriparatide group exhibited significant enhancements in both functional scores and BMD when compared to the control group. Notably, functional improvements were less pronounced in male patients compared to female patients. Additionally, the incidence of new fractures was markedly lower in the teriparatide group.

CONCLUSION

Administering teriparatide daily for 18 months post-surgery for proximal femoral fractures significantly benefits very elderly patients by improving functionality and bone density, with observed differences in recovery between genders. These results reinforce the efficacy of teriparatide as a potent option for treating osteoporosis-related fractures in the elderly and highlight the importance of considering gender-specific treatment and rehabilitation strategies.

Management of patients with proximal femur fractures under DOACs

PURPOSE

In the past, preinjury direct oral anticoagulant (DOAC) intake has led to delays in time to surgery (TTS) in patients with proximal femur fractures and delays in surgery have been associated with impaired outcomes. Although healthcare institutions/federal committees have set rules for treatment within 24 h of injury, comprehensive guidelines for the perioperative management of these patients, in particular when on preinjury DOACs, are still lacking. This contribution aims to summarize the current evidence on the safe time window for surgery in patients with proximal femur fractures on preinjury DOACs and to outline therapeutic options if emergency DOAC reversal becomes necessary.

METHODS

Narrative review based upon selective review of the pertinent literature.

RESULTS

For the majority of patients with proximal femur fractures and on preinjury DOACs, early surgery appears safe as soon as medical clearance has been obtained. There may be an increase in the need for blood products but with data not yet conclusive. Work-up including assessment of remaining anticoagulant activity and potential reversal should be restricted to patients at risk for bleeding complications, in particular in the presence of renal/hepatic impairment. Methodology for rapid assessment of DOACs including quantitative/qualitative concentration levels is work in progress. In the case of bleeding, rapidly acting reversal agents are available.

CONCLUSION

Preinjury DOAC use should not routinely delay surgery in patients with proximal femur fractures.

Safety of urgent surgery for the patients with proximal femur fracture treated with platelet aggregation inhibitors: a propensity-score matching analysis

INTRODUCTION

To compare the various perioperative outcomes in an urgent surgery setting among patients with proximal femur fracture (PFF) who received platelet aggregation inhibitors (PAIs) and those who did not.

METHODS

We retrospectively reviewed the data of 1,838 patients who underwent surgery for PFF between January 2011 and January 2021. We conducted 1:1 propensity-score matching and compared the perioperative outcomes, including operation time, postoperative complications, hospital stay, mortality, and variables related to bleeding risk (e.g., number of transfusion profiles, hemoglobin levels, and laboratory data, including coagulation battery).

RESULTS

Of the 492 patients who were treated with PAIs, 484 were 1:1 matched to the untreated control group. The PAI group showed shorter operation time than the matched control group (72.3 min for PAI vs. 77.7 min for control; P = 0.041), and the control group showed more pulmonary thromboembolism (0.2% for PAI vs 1.7% for control; P = 0.046) than the PAI group. The other complications and length of hospital stay, mortality rate, transfusion profile, and the laboratory test (except preoperative international normalized ratio, INR) showed no significant difference between the groups. Subgroup analyses of the patients treated with only aspirin (aspirin: 306, matched control: 306), only clopidogrel (clopidogrel: 100, matched control: 100), and others who were treated with dual anticoagulation (dual anticoagulation: 78, matched control: 78) showed no significant differences in perioperative outcomes among the groups.

CONCLUSION

The patients who were treated with PAI could undergo PFF surgery safely without delay, which led to no significant difference in operation time, postoperative complication risk, perioperative blood transfusion, and variables related to bleeding risk. Therefore, we believe that it is unnecessary to delay surgery for patients with PFF who receive PAI.

Proximal Femur Fractures - How Decisive are Reduction and the Chosen Implant?

Proximal femoral fractures are frequent and complex injuries requiring prompt and targeted care. Numerous treatment strategies have been described, some of which have been assessed and clinically implemented clinically. The aim of surgical is always the restoration of a pain-free and stable extremity. Mostly elderly patients are affected and treatment is associated with high postoperative complications and mortality rates. With increasing numbers of patients, the topic is of great medical and economic relevance. In this work, the choice of implants for the osteosynthesis of proximal femoral fractures - as depending on the fracture type - will be examined, as based on a review of current literature. Standard care includes cannulated screws, sliding hips screws and cephalomedullary nails. In addition, the influence of implant positioning, fracture reduction and additional measures such as cement augmentation are evaluated and discussed. Careful fracture reduction and the quality of implant positioning are paramount in order to avoid complications.

History of proximal femur fractures in the German literature

INTRODUCTION

German-speaking surgeons have left a deep imprint on the history of diagnostics and treatment of proximal femur fractures. Some of the studies published in German have fell into oblivion, others are cited until today, although sometimes quite inaccurately. The cause of such inaccuracies are citations from secondary sources due to unavailability of the original or inability to read it because of a language barrier. In the current literature, globally predominated by English articles, the "German history" of treatment of proximal femur fractures remains undervalued. The aim of the present article is to point out its contribution.

MATERIALS AND METHODS

Literature search was performed in original publications and historical sources.

RESULTS

The German-speaking surgeons have considerably contributed to the development of the treatment of proximal femur fractures. The analyzed period between 1847 and 1970 may be divided into three basic periods. In the first period (1847-1896), the German-speaking surgeons (Langenbeck, Trendelenburg, König, Heine, Dolinger) were the first worldwide to start treating the fractures of proximal femur operatively. In the second period (1897-1935), mainly in the 1930s, the initiative in Europe was taken over by surgeons publishing studies in France and in Belgium. Overseas, American surgeons were coming to the forefront. In Germany, only Pauwels developed the first biomechanical classification of femoral neck fractures. In the third period (1936-1970), mainly in the 1940s and 1950s, implants were designed (Pohl, Künstcher), based on close collaboration between German engineers and surgeons, that served as a model for a dynamic hip screw and a proximal femoral nail, which are currently the implants of choice in the treatment of trochanteric fractures.

CONCLUSION

The historical contribution of German-speaking surgeons to understanding the issue of proximal femur fractures and their operative treatment is far more significant than presented in the historical studies published in English.

[Long-term anticoagulation treatment in proximal femoral fractures as obstacle to surgery in the 24h time window? : Results of an analysis of Quality Assurance data on 32,252 treatment courses with osteosynthesis]

BACKGROUND

Both in Germany and internationally there is a vehement controversy about the appropriate time for care of proximal femoral fractures in older patients. The effort to achieve high quality and uniform standards of care culminated in the German healthcare system in the strict requirement of delay-free surgery within 24 h. Until now, in view of their high vulnerability patients who were severely injured were too often operated on late with the reference to a general medical condition that could be improved preoperatively. In particular, the fear of complications due to a pre-existing long-term anticoagulation treatment was repeatedly emphasized.

OBJECTIVE

The present study is dedicated to the question of whether a delay in surgery of anticoagulated patients with proximal femoral fractures already during the inpatient course has a detrimental effect on the complication statistics and the mortality of the patients. The extent to which external quality assurance data are suitable for rebutting any objections to an operation as soon as possible are examined.

MATERIAL AND METHODS

The study is based on treatment data from the external inpatient quality assurance procedure of the federal state of North Rhine-Westphalia from the years 2018-2020. Patients with a proximal femoral fracture were considered. This includes femoral neck fractures and fractures in the area of the pertrochanteric to subtrochanteric region. Only cases with joint-preserving fracture care were selected. The data sets were analyzed using suitable statistical software.

RESULTS

More general complications and deaths have been observed in anticoagulated patients. The trend of delayed fracture treatment under anticoagulant medication continues to be clearly visible. A positive association between longer preoperative waiting time and undesirable courses can be confirmed.

CONCLUSION

With respect to fracture care when taking anticoagulants, it must be critically examined to what extent a rapid normalization of the coagulation situation is necessary and this actually improves the chances of low complication courses. Should the elimination of the anticoagulant effect by substitution or antidote appear necessary, this should not prevent early care.

Should recommended laboratory-test cut-offs allowing surgery be followed for proximal femoral fractures in patients on direct oral anticoagulant therapy?

BACKGROUND

Proximal femoral fractures (PFFs) in elderly patients must receive prompt surgical treatment. Optimal PFF-surgery timing in patients on direct oral anticoagulant (DOA) therapy is a specific but common clinical issue. Recommendations exist about the anti-Xa or anti-IIa levels and creatinine clearance values required to allow surgery. The objectives of this study in patients older than 75 years who required PFF surgery were to evaluate bleeding when the recommendations were versus were not applied and to assess concordance between DOA-activity-assay results and creatinine clearance used to help determine the wait to surgery.

HYPOTHESIS

Peri-operative bleeding is more marked when surgery is performed while the DOA is still active.

PATIENTS AND METHODS

This single-centre, retrospective, comparative, observational study included 87 patients older than 75 years who required arthroplasty or intra-medullary nailing for PFF and were taking DOA therapy. Surgery was performed after versus before the laboratory-test results fell below the recommended cut-offs in 68 patients (Rec+ group) versus 19 patients (Rec- group), respectively. The study outcomes were blood loss estimated using the Mercuriali's formula and the proportion of patients requiring post-operative blood transfusions.

RESULTS

Mean blood loss was 287.1mL in the Rec+ group and 411.7mL in the Rec- group (p=0.12). Blood transfusions were required by a post-operative haemoglobin level below 0.8g/dL in 11 (16.2%) Rec+ patients and 6 (31.6%) Rec- patients (p=0.2). Concordance was poor between DOA activity and creatinine clearance (Cohen's κ, 0.16; p=0.146).

DISCUSSION

Peri-operative bleeding was not significantly more severe when PFF surgery was performed while DOA therapy was still active. These data suggest that PFF surgery within 48h may be appropriate in patients older than 75 years on DOA therapy.

LEVEL OF EVIDENCE

IV; retrospective single-centre study.

Risk Factors for 30-Days Mortality After Proximal Femoral Fracture Surgery, a Cohort Study

Purpose

The primary objective of this study was to identify new risk factors and to confirm previously reported risk factors associated with 30-day mortality after hip fracture surgery.

Patients and methods

A prospective hip fracture database was used to obtain data. In total, 3523 patients who underwent hip fracture surgery between 2011 and 2021 were included. Univariable and multivariable logistic regression was used to screen and identify candidate risk factors. Twenty-seven baseline factors and 16 peri-operative factors were included in the univariable analysis and 28 of those factors were included in multivariable analysis.

Results

8.6% of the patients who underwent hip fracture surgery died within 30 days after surgery. Prognostic factors associated with 30-day mortality after hip fracture surgery were as follows: age 90-100 years (OR = 4.7, 95% CI: 1.07-19.98, p = 0.041) and above 100 years (OR = 11.3, 95% CI: 1.28-100.26, p = 0.029), male gender (OR = 2.6, 95% CI: 1.97-3.33, p < 0.001), American Society of Anesthesiologists (ASA) 3 and ASA 4 (OR = 2.1, 95% CI: 1.44-3.14, p < 0.001), medical history of dementia (OR = 1.7, 95% CI: 1.25-2.36, p = 0.001), decreased albumin level (OR = 0.94, 95% CI: 0.92-0.97, p < 0.001), decreased glomerular filtration rate (GFR) (OR = 0.98, 95% CI: 0.98-0.99, p < 0.001), residential status of nursing home (OR = 2.1, 95% CI: 1.44-2.87, p < 0.001), higher Katz Index of Independence in Activities of Daily Living (KATZ-ADL) score (OR = 1.1, 95% CI: 1.01-1.16, p=0.018) and postoperative pneumonia (OR = 2.4, 95% CI: 1.72-3.38, p < 0.001).

Conclusion

A high mortality rate in patients after acute hip fracture surgery is known. Factors that are associated with an increased mortality are age above 90 years, male gender, ASA 3 and ASA 4, medical history of dementia, decreased albumin, decreased GFR, residential status of nursing home, higher KATZ-ADL score and postoperative pneumonia.

Secondary fracture and mortality risk with very high fracture risk osteoporosis and proximal femoral fracture

INTRODUCTION

We aimed to investigate secondary fracture and mortality rates, and risk factors in patients with proximal femoral fractures.

MATERIALS AND METHODS

We conducted a multicenter prospective cohort study on female patients with proximal femoral fractures who underwent surgical treatment between April 2020 and March 2021. Postoperative follow-ups were performed at 6-, 12-, 18-, and 24-month intervals to determine the secondary fracture and mortality rates, and the risk factors and its influence were examined.

RESULTS

Of the 279 registered patients, 144 patients (51.6%) were diagnosed with very high fracture risk osteoporosis. The postoperative osteoporosis rate exceeded 96%; however, osteoanabolic agents were used sparingly. The risk factor of both secondary fracture and mortality was very high fracture risk osteoporosis, and secondary fractures within 12 months were markedly occurred. Secondary fracture rates increased as the number of matched very high fracture risk osteoporosis criteria increased. Notably, secondary fractures and mortality were recorded in 21.4% and 23.5% of the patients who met all criteria, respectively.

CONCLUSION

Over half of the female patients with proximal femoral fractures had very high fracture risk osteoporosis. Although, very high fracture risk osteoporosis demonstrated a notably increased risk of secondary fractures, particularly at 12 months post-surgery, the use of osteoanabolic agents was substantially low. Collectively, our findings highlight the need to consider the risk of very high fracture risk osteoporosis, expand the use of medications to include osteoanabolic agents, and reconsider the current healthcare approach for proximal femoral fractures.

[Disproportionately increased incidence of proximal femoral fractures in a level one trauma center : Epidemiological analysis from 2016 to 2022]

BACKGROUND

Proximal femoral fractures represent the most frequent fracture entity in Germany accounting for more than 20% of all fractures. According to a decision of the Federal Joint Committee from 2019, proximal femoral fractures also have to be surgically treated within 24 h. In order to quantify a subjectively perceived increase in workload in trauma surgery at a supraregional trauma center, a retrospective analysis of the number of surgically treated proximal femoral fractures was performed. Proximal femoral fractures were chosen due to their high incidence and homogeneous treatment.

METHODS

Using ICD-10 codes, all surgically treated proximal femoral fractures from 2016 to 2022, including the patient's zip code, were retrieved from the database of the trauma center.

RESULTS

The number of surgically treated proximal femoral fractures doubled from 2016 to 2022. The highest increase (60%) was recorded from 2020 to 2022. Heat maps show an increase in the catchment area radius as well.

CONCLUSION

When compared (inter)nationally, a disproportionate increase in the amount of surgically treated proximal femoral fractures was recorded at the trauma center studied. The increase of the catchment area radius and the number of patients treated in the urban area show that less and less hospitals participate in emergency treatment. Possible explanations are a lack of resources aggravated by the recent COVID-19 pandemic and a lack of qualified personnel, interface problems between the federal states or the strict requirements of the Federal Joint Committee in the treatment of proximal femoral fractures. It must be assumed that there is a clearly increased workload for all professions involved in the trauma center investigated, although the infrastructure has remained unchanged.

[Effects of the COVID-19 pandemic on the course of geriatric trauma patients with proximal femoral fractures]

BACKGROUND/OBJECTIVE

In 2020 the COVID-19 pandemic posed a major challenge to the healthcare system. The hypothesis is that the COVID-19 pandemic in 2020 had an impact on the care of older adults with proximal femoral fractures due to resource scarcity, regardless of whether or not the patient was infected.

MATERIAL AND METHODS

This study analyzed the data of 87 hospitals which entered 15,289 patients in the Geriatric Trauma Register ("AltersTraumaRegister DGU®", ATR-DGU) in Germany in 2019 and 2020. In this study we analyzed the influence of the COVID-19 pandemic on the inpatient treatment of hip fractures as well as the mid-term follow-up during the first 120 days. For the main analysis, we compared patients documented during the COVID-19 pandemic in 2020 (April-December) with a control group in 2019 (April-December). Additionally, we performed a subgroup analysis of the periods with high COVID-19 incidence rates.

RESULTS

Between 2019 and 2020 a total of 11,669 patients (2020: n = 6002 patients vs. 2019: n = 5667 patients) were included in this study. Only minor differences were found between the patients treated during the pandemic; however, when the COVID-19 incidence in Germany was greater than 50/100,000 residents, significantly fewer patients (p < 0.001) were discharged to a geriatric rehabilitation ward (27.2% vs. 36.3%) and an increased mortality rate during inpatient treatment was determined (8.4% vs. 4.6%) (p < 0.001).

DISCUSSION

The healthcare system was able to respond to the pandemic and patients' clinical courses were not impaired as long as the incidences were low. Nevertheless, the healthcare system reached its limits in times of higher incidence, which was also directly reflected in the patient outcome, mortality and place of discharge.

Les fractures de l’extrémité supérieure du fémur : Estimation du coût médical direct de la prise en charge hospitalière

INTRODUCTION

Proximal femur fractures are one of the most common injuries in older adults representing a serious health condition in developed as well as developing countries.

AIM

This study aimed to assess the hospitalization costs of the proximal femur fracture.

METHODS

We conducted a prospective descriptive study spread over six months about patients hospitalized and operated on for proximal femur fractures. In order to estimate the cost we referred to the nomenclature of professional acts and the prices set by the Ministry of Public Health and the Ministry of Finance.

RESULTS

The study included 100 patients, 55 females and 45 males with an average age of 76 years. The average hospital length of stay was 5 days. The preoperative stay was at a mean of three days. The average total hospitalization cost for these fractures was 2877 Tunisian Dinars depending on the type of fracture and surgical treatment. The main components of the costs were hospital stay costs and human resources costs 40%, cost of the implant 25.9%, cost of consumables 12%, operating cost 10%, cost of additional examinations 9% and cost of medications 2%.

CONCLUSION

Proximal femur fractures represent an important cause of health resource consumption. To reduce the cost of hospital care, we recommend limiting the length of hospital stay as much as possible, investing in total hip and hemi-arthroplasties and adapting economical behavior taking into account the cost of consumables.

Patients risk for mortality at 90 days after proximal femur fracture - a retrospective study in a tertiary care hospital

BACKGROUND

Despite improving the management of proximal femur fractures (PFF) with legal requirements of timing the surgery within 24 h, mortality rates in these patients remain still high. The objective of our study was to analyze potential cofactors which might influence the mortality rate within 90 days after surgery in PFF to avoid adverse events, loss of quality of life and high rates of mortality.

METHODS

In this retrospective, single-center study all patients with PFF aged 65 years and older were included. We recorded gender, age, type of fracture, surgery and anesthesia, time, comorbidities and medication as well as complications and mortality rate at 90 days. Separate logistic regression models were used to assess which parameters were associated with patients' mortality. The mortality rate was neither associated with timing, time and type of surgery nor time and type of anesthesia, but with higher age (OR 1.08 per year; 95% CI 1.034-1.128), lower BMI (OR 0.915 per kg/m2; 95% CI 0.857-0.978), higher CCI (OR 1.170 per point; 95% CI 1.018-1.345), dementia (OR 2.805; 95% CI 1.616-4.869), non-surgical complications (OR 2.276; 95% CI 1.269-4.083) and if mobilization was impossible (OR 10.493; 95% CI 3.612-30.479).

RESULTS

We analyzed a total of 734 patients (age ≥ 65 years) who had a PFF in 2019 and 2020 and received surgery. 129 patients (17.6%) died until 90 days at an median age of 89.7 years (range 65-101 years).

CONCLUSION

The proportion of patients who died until 90 days after surgery is still high. It is less extend influenced by surgical and anaesthesiologic factors than by patient-related factors like age or lower BMI. Physicians should be aware of the importance of avoiding adverse events and the importance of patients' mobilization to reduce mortality and improve patients' outcome.

Mechanical outcomes of the TFNA, InterTAN and IMHS intramedullary nailing systems for the fixation of proximal femur fractures

INTRODUCTION

Hip fractures have become a major public health priority due to their increasing incidence. Intramedullary (IM) nailing has gained popularity as a surgical technique for managing these fractures. However, comparative studies with extramedullary devices indicate potentially increased mechanical complications associated with IM nailing. Specifically, there have been recent reports of early implant fracture associated with the TFNA system. This study compares the rate of mechanical complications between 3 implants. Secondarily, we analysed the factors associated with implant fracture and all other mechanical complications.

METHODS

This retrospective study included 803 IM nails performed between 2008-2021 for the fixation of proximal femur fractures at a level 1 trauma centre. We recorded patient demographics, AO fracture classification, implant specification and intra-operative parameters such as tip-apex distance, Cleveland index, reduction quality, presence of medial calcar integrity, neck-shaft angle. The outcomes analysed included implant fracture, lag screw cut-out, >10 mm backing out, autodynamisation, periprosthetic fracture, non-union at 6 months and time to revision surgery.

RESULTS

The overall implant fracture rate was 3.1 % (25/803), with no statistically significant difference between the three devices (p = 0.51). The TFNA group included 183 patients with a median follow-up of 1.6 years. The TFNA fracture rate was 2.2 % (4/183) which occurred at 207 +/- 16.66 days post-operatively. The rate of all mechanical complications was 4.9 % in the TFNA group, 12.9 % in the InterTAN group and 17 % in the IMHS group. Non-union (p < 0.001) and increasing lag screw length (p < 0.02) were identified as risk factors for implant fracture and other mechanical complications. The reverse oblique fracture pattern (AO 31 A3.1) was associated with mechanical complications only (p < 0.01). The cumulative survival rates without revision for the TFNA, InterTAN, IMHS groups were 97.8 %, 95.5 % and 87.9 % respectively at 2.5 years.

DISCUSSION

The rates of implant fracture were comparable between the three nailing systems. The TFNA provides effective fixation for proximal femur fractures using a traditional screw without cement augmentation. The TFNA was associated with an overall reduction in mechanical complications compared to the InterTAN and IMHS. Previously reported mechanical complications associated with IM Nails may relate to older device designs.

Mortality analyses of elderly patients with proximal femoral fracture during the pandemic: vaccination affects or not

PURPOSE

To evaluate the mortality rate, intensive care unit (ICU) referral, and Charlson comorbidity index (CCI) between different types of vaccinated and non-vaccinated patients operated on due to intertrochanteric femoral fracture (IFF) during the pandemic.

METHODS

Ninety-six patients (43 males, 53 females) who had proximal femur nails (PFN) for the IFF during the pandemic were included in the study. The patients were divided into four subgroups; non-vaccinated, and different types of vaccinated. Mortality rates, ICU referrals, and CCI relations were evaluated.

RESULTS

No significant difference was observed in terms of demographic data such as age, gender, side, CCI, and ICU referrals between the subgroups (p = 0.164, p = 0.546, p = 0.703, p = 0.771, p = 0.627 respectively). The mortality rate was significantly lower in the Sinovac + BioNTech subgroup (p = 0.044).

CONCLUSION

No relationship was found between mortality rate, ICU referral, and CCI in different types of vaccinated and non-vaccinated patient subgroups.

Dynamic hip screw in proximal femoral fractures followed by "single-stage" hip arthroplasty-retrospective analysis

The aim of this study is to present the results of single-stage total hip arthroplasty (THA) after Dynamic Hip Screw (DHS) failure, or secondary posttraumatic osteoarthrosis. From 2003 to 2020, 15 THAs were performed in group of 15 patients for the treatment of DHS failure, or for late complications following femoral neck and pertrochanteric fractures. The mean follow-up period after arthroplasty was 46.9 months (range 7-139). The patients were evaluated retrospectively-both clinically and radiographically, focussing on the demography, infection rate and other complications (revision surgery), during the year 2023. 9 males and 6 females were included in the study, with a mean age of 56.5 years (range 29-93) at the time of primary osteosynthesis. Each of them had proximal femoral fracture treated primarily with a DHS and then late one-stage revision surgery, with hardware removal and THA implantation. The median time between DHS osteosynthesis and THA was 41.2 months (range 4-114). Four patients (26.6%) had complications after THA, with the need for revision in two cases (13.3%). Dislocation rate was 6.6% (one case), with the need for repeated-revision of THA. The infection rate was 6.6% (one patient) with the need for revision of THA. Peroperative periprosthetic femoral fracture was observed in 13.3% (two patients) without any other problems. Six patients (40%) died during the follow-up period. Single-stage total hip arthroplasty with concomitant hardware removal bears a high- mortality rate, with a higher incidence of postoperative complications compared to elective THA.

Risk factors for postoperative delirium in orthopaedic hip surgery patients: a database review

BACKGROUND

Postoperative delirium is a common problem affecting admitted patients that decreases patient satisfaction and increases the cost and complexity of care. The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to compare rates and risk factors of postoperative delirium for total hip arthroplasty (THA) and hemiarthroplasty patients indicated for osteoarthritis or proximal femur fracture.

METHODS

The 2021 NSQIP database was queried for patients using Current Procedural Terminology (CPT) codes for THA and hemiarthroplasty and ICD-10 codes for osteoarthritis or proximal femur fracture. Demographic, past medical history, preoperative labs, and functional status data were recorded. Procedural data were also collected. Finally, postoperative outcomes and complications were reviewed.

RESULTS

Overall, 16% of patients had postoperative delirium. Delirium patients were older on average (82.4 years vs. 80.7 years, p < 0.001), had a lower BMI (19.5 vs. 24.8, p < 0.001), were more likely to have a history of dementia (54.6% vs. 13.6%, p < 0.001), were less likely to have an independent functional status (p < 0.001) or live alone (p < 0.001), and were more likely to have sustained a recent fall (p < 0.001). Delirium patients were more likely to be hyponatremic or hypernatremic (p = 0.002), anemic (p < 0.001), and severely dehydrated (p < 0.001), among other lab abnormalities. Delirium patients were also more likely to experience additional postoperative complications, including pneumonia, pulmonary embolism, urinary tract infection, stroke, cardiac arrest, sepsis, and unplanned reoperation and readmission after discharge (all p < 0.05).

CONCLUSIONS

In this study, factors associated with postoperative delirium in patients undergoing hemiarthroplasty and THA were identified, including older age, lower BMI, certain medical conditions, decreased functional status, certain lab abnormalities, and postoperative complications. These findings can be used by clinicians to better inform care and to determine when orthopaedic joint replacement patients may be at an increased risk for postoperative delirium.

Outcomes in very elderly ICU patients surgically treated for proximal femur fractures

Proximal femur fractures (PFF) are a common injury in elderly patients that significantly impact mobility and daily living activities. Mortality rates in this population are also high, making effective treatment essential. Recent advances in intensive and geriatric care have enabled complex surgical interventions that were previously not feasible. However, there is a lack of studies focusing on outcome parameters in very elderly patients (≥ 90 years) who receive intensive care treatment following PFFs. In this retrospective study, we analyzed multi-layered data of 148 patients who were 90 years or older and received intensive care after trauma and orthopedic surgical treatment for PFFs or periprosthetic fractures between 2009 and 2019. All patients received a 365-day follow-up. To identify potential predictors of mortality, all deceased and surviving patients were subjected to multiple logistic regression analyses. We found that 22% of patients deceased during in-hospital care, and one-year survival was 44%. Independent predictors of one-year all-cause mortality included higher CCI and SOFA scores at ICU admission. Overall, 53% of patients who resided in private dwellings prior to admission were able to return home. Our study highlights the utility of using CCI and SOFA scores at ICU admission as prognostic indicators in critically ill very elderly patients who undergo surgical treatment for PFFs. These scores can provide valuable insight into the severity of illness and potential outcomes, which can inform resource allocation, prioritize endangered patients, and aid in end-of-life discussions and planning with patients and their families. Our findings can help improve the management of PFFs in very elderly patients and contribute to optimized patient care.

Submuscular nonlocking plates: an effective option for pediatric extra-articular proximal femur fractures

The aim of this study is to evaluate the results of submuscular plating using nonlocking plates for extra-articular proximal femur fractures (EPFF) in children. From our hospital records, we retrieved data of 15 children treated with submuscular plating with nonlocking dynamic compression plates (DCP) for EPFF between January 2010 and September 2021. EPFF was defined as a proximal femur fracture within 10% of the femoral length below the lesser trochanter. Patients' demographics, as well as details of the duration of operation, type of DCP used, time to union, complications, and outcomes using Flynn criteria were noted. There were nine males and six females. Mean age of the patients was 10.8 ± 1.9 years (range 7-14 years). All the patients had fracture union and two patients had union with an angulation less than 10°. All fractures healed uneventfully with a mean time to union of 11.8 ± 1.2 weeks (range 10-15 weeks). No patient required surgery for complications or malunion. Using Flynn criteria, excellent outcomes were seen in 13 out of 15 patients. There were no poor outcomes. Our study shows that submuscular plating using nonlocking plates is an effective option for treating pediatric EPFF. Treatment of these tricky fractures with submuscular plating using nonlocking plates shows excellent outcomes with minimal complications.

Epidemiology of proximal femur fractures in the young population of Qatar

PURPOSE

To review the epidemiological characteristics of proximal femur fractures in the young population (< 60 years) of Qatar between 2017 and 2019.

METHODS

All patient treated for proximal femur fractures at Hamad General Hospital (HGH), a level one trauma center, were retrospectively reviewed between Jan 2017 and Dec 2019. All adults (18-60 years) with proximal femur fracture (femur head, femur neck, intertrochanteric and subtrochanteric fractures) were included with no restriction to the AO/OTA classification or fractures subtypes. Excluded cases were pathological fractures, cases with insufficient documentation or no radiographs.

RESULTS

A total of 203 patients with a mean age of 40.07 ± 11.76 years were included, of who 89.9% were males. The incidence of proximal femur fracture was 3.12/100,000/year. Fall from height (48.1%) followed by road traffic accidents (26.9%) were common cause of injury. The most common fracture type was intertrochanteric fracture (36.1%) followed by femur neck fractures (33.7%).

CONCLUSION

This study provides the initial insights into the proximal femur fractures in the young population of Qatar. This is the first study to investigate of the epidemiology of such fractures in this particular patient group. Contrary to the existing literature on older age groups, the majority of the injuries were observed in males. Falls from height followed by road traffic accidents were the primary mechanisms leading to these fractures. Improved understanding of the profile of these injuries can aid in their prevention by implementing more effective safety measures.

[Regional CT value in prediction of proximal femoral fracture]

OBJECTIVE

To investigate CT values of cancellous bone in femoral neck in adults over 60 years with proximal femoral fractures.

METHODS

From January 2020 to December 2020, a retrospective analysis was performed on 280 subjects aged 60 years or older who underwent bilateral hip CT examination, including 85 males and 195 females, 120 on the left side and 160 on the right side, aged 75 (66, 82) years old. One hundred thirty-six patients with proximal femoral fractures were included in study group and 144 patients without fractures were included in control group. GEOptima CT was used to scan and reconstruct horizontal, coronal and sagittal layers of proximal femur. CT values of cancellous bone in femoral neck were measured and compared between two groups. The relationship between CT values of cancellous bone of femoral neck and proximal femoral fracture was analyzed statistically.

RESULTS

In terms of age, fracture group aged 79(73.3, 85.0) years old, non-fracture group aged 69.5 (64.0, 78.8) years old, and had significant difference in age between two groups (P<0.05). In terms of CT value, regional CT value in fracture group was 8.62(-3.62, 27.15) HU, which was lower than that in non-fracture group 34.31(-5.93, 71.74) HU(P<0.05). CT value on coronal view in fracture group was -8.48(-30.96, 17.46) HU, which was lower than that in non-fracture group 40.49(5.55, 80.71) HU (P<0.05). CT value on sagittal view in fracture group was -31.28(-54.91, -5.11) HU, which was lower than that in non-fracture group 7.74(-20.12, 44.54) HU (P<0.05). CT values on horizontal view in fracture group was 0.17(-23.13, 24.60) HU, which was lower than that in non-fracture group 46.40(10.42, 85.18) HU(P<0.05). The mean regional CT values among three planes in the fracture group were lower than those in the non-fracture group. Logistic regression analysis showed coronal CT value was influencing factors of proximal femoral fracture, and it could be written into regression equations that predict probability of fracture.

CONCLUSION

In adults aged over 60 years old, CT values of cancellous bone of femoral neck decreased with increasing age. The smaller CT value of cancellous bone of femoral neck, the greater risk of proximal femoral fracture.

[Palliative treatment of proximal femur fracture: results of intrathecal phenol (SPING block) in frail older patients]

This case series describes the clinical outcomes of intrathecal phenol (SPING block) as palliative, non-operative treatment of proximal femur fracture (PFF) in frail older patients with comorbidities and pre-morbid limited mobility. The goal of treatment is to provide adequate pain relief. Ten patients (mean age 89.9, SD 6.4 years) were treated with SPING block. Mean pain score (using NRS) decreased from 5.7 at admission to 1.0 within 4-8 hours after treatment, and 0.5 at discharge; without additional analgesics and irrespective of the type of fracture. Mean hospital stay was 1.9 (SD 0.9) days. Only 2 patients experienced side effects after treatment, i.e. temporary hypotensia and fever. Based on this case series, SPING block could be a promising palliative pain treatment in frail older patients with PFF. Further research is necessary to determine the effects of this treatment on quality of life and cost-effectiveness in this increasing group of patients.

Long-Term Outcomes of Decompression and Grafting in Acute Pathological Proximal Femur Fractures in Children with Unicameral Bone Cysts: A Retrospective Study Utilizing a 120° Fixed-Angle Low-Contact Locking Pediatric Hip Plate

BACKGROUND Unicameral bone cysts (UBCs) are benign tumor-like lesions that are the most common cause of pathological proximal femur fracture in children. This study aimed to present the outcomes of acute, unstable, pathological proximal femur fractures secondary to UBCs in children. MATERIAL AND METHODS We retrospectively reviewed data on 12 patients with a mean age of 9.3 years (7-12 years) who were initially treated with decompression and grafting, followed by stabilization using a 120° fixed-angle low-contact locking pediatric plate (LCLPP). The Musculoskeletal Tumor Society (MSTS) scores, Capanna classification of cyst repair, time to union, collodiaphyseal angle (CDA), and limb length discrepancy (LLD) were evaluated. RESULTS The mean follow-up was 33.1 months (range, 13-96 months). The mean union time was 9.5 weeks (8-14 weeks). The mean time for reparation of the cyst was 6.9 months (range 3-9 months). Four patients had Dormans type IB, while the remaining had type IIB fractures. According to the Capanna classification, repairs in 10 cases were grade I and in 2 cases grade II. At the last follow-up, the mean 120.8° of preoperative CDA was corrected to 140.9° (P<0.001) and there was no difference compared to the healthy side (P=0.214). The mean postoperative MSTS score was 97.1% (29.1 points). Two patients experienced LLD at the affected extremities, while the other 10 patients healed without any complications. CONCLUSIONS Fixation of acute unstable fractures secondary to UBCs with a 120° fixed-angle LCLPP is a reliable and successful option after decompression and grafting of the lesion.

Distinctive Geometrical Traits of Proximal Femur Fractures-Original Article and Review of Literature

Background and Objectives: The incidence of proximal femoral fractures is escalating rapidly, generating a significant challenge for healthcare systems globally and, carrying serious social and economic implications. The primarily object of this study was to discover potential distinguishing factors between fractures occurring in the femoral neck and trochanteric region. Materials and Methods: We performed a prospective cohort study of the radiographic images of 70 people over 65 years of age who were admitted to the orthopedic department with hip fracture and who fulfilled our eligibility criteria. Neck Length (NL), Offset Lenth (OL), Hip Axis Length (HAL), Neck Shaft Angle (NSA), Wiberg Angle (WA), Acetabular Angle (AA), Femoral Neck Diameter (FND), Femoral Head Diameter (FHD), Femoral Shaft Diameter (FSD), Femoral Canal Diameter (FCD) and Tonnis classification were recorded. For the comparison of the categorical variables, Pearson's χ2 criterion was used, while Student's t-test was applied for the comparison of means of quantitative variables across fracture types. Results: There were no statistically significant variances observed while comparing the selected geometric parameters of the proximal femur with the type of fracture. This finding was reaffirmed in relation to age, gender, and Tonnis classification. However, a moderate correlation was noted, revealing comparatively reduced values of HAL, FHD, and FND in women as opposed to men. Conclusions: The inability of our research to establish the differentiative geometric factors between femoral neck and trochanteric fractures underscores the need for further investigations, which would take into consideration the intrinsic characteristics of the proximal femur.

Comparison of pericapsular nerve group block and femoral nerve block in spinal anesthesia position analgesia for proximal femoral fractures in geriatric patients: a randomized clinical trial

BACKGROUND

This study aimed to compare the analgesic efficacy of the femoral nerve block (FNB) with that of the pericapsular nerve group (PENG) block in the lateral decubitus position for spinal anesthesia in geriatric hip fracture surgery.

METHODS

Patients aged ≥65 years scheduled to undergo hip fracture surgery for proximal femur fractures with an American Society of Anesthesiologists physical status of class I-IV and body mass index of 18-40 kg/m2 were included in the study. The PENG block or FNB was performed 20 min before positioning for spinal anesthesia. Lateral position, hip flexion, and lumbar spine flexion pain were evaluated during spinal anesthesia.

RESULTS

Sixty patients completed the study. The median pain scores for lateral positioning were 2 (0-4) and 2.5 in the PENG and FNB groups, respectively (P=0.001). The median pain scores during hip flexion were 1 (0-4) and 2.5 in the PENG and FNB groups, respectively (P<0.001). The median pain score during lumbar flexion was 1 (0-4) and 2.0 in the PENG and FNB groups, respectively (P=0.001). The two groups did not show a significant difference in the quality of the spinal anesthesia position (P>0.05).

CONCLUSION

Pre-operative PENG block is more effective in reducing the pain associated with spinal anesthesia position than FNB in geriatric hip fractures. Both blocks had a similar effect on posture quality and the number of spinal interventions.

Age-related Changes with the Trabecular Bone of Ward's Triangle and Neck-shaft Angle in the Proximal Femur: A Radiographic Study

OBJECTIVE

The Ward triangle is an important area used clinically to diagnose and assess osteoporosis and its fracture risk in the proximal femur. The main objective of this study was to investigate the rules of development and maturation of the trabeculae of Ward's triangle to provide a basis for the prevention and treatment proximal femur fracture.

METHODS

From January 2018 to December 2019, individuals from 4 months to 19 years old who underwent hip growth and development assessments at the Third Hospital of Hebei Medical University were selected retrospectively. The outpatient electronic medical record system was used to collect information such as age, gender, imaging images, and clinical diagnosis. The development score and maturity characteristics of the trabecular bone were analyzed using hip radiograph data. Correlation analysis was performed to identify the relationship among age, neck-shaft angle and development and maturity score of the trabecular bone.

RESULTS

A total of 941 patients were enrolled in this study, including 539 males and 402 females. Primary compression trabeculae were all present at 1 year of age and matured at 7 years of age and older; primary tension trabeculae were all present at 4 years of age and matured at 18 years of age. Secondary compression trabeculae were present at 4 years of age and matured at 18 years of age. In addition, the neck-shaft angle progressively decreases from 4 months to 14 years of age but barely changes between 15 and 19 years of age.

CONCLUSION

In short, the development and maturation of the trabeculae in the ward' triangle followed a specific temporal pattern that was related to the neck-shaft angle. Therefore, these findings can help us understand structure and mechanical characteristics of proximal femoral trabeculae, and improve our understanding of the mechanism and treatment of proximal femoral fractures.

Multi-view information fusion using multi-view variational autoencoder to predict proximal femoral fracture load

Background

Hip fracture occurs when an applied force exceeds the force that the proximal femur can support (the fracture load or "strength") and can have devastating consequences with poor functional outcomes. Proximal femoral strengths for specific loading conditions can be computed by subject-specific finite element analysis (FEA) using quantitative computerized tomography (QCT) images. However, the radiation and availability of QCT limit its clinical usability. Alternative low-dose and widely available measurements, such as dual energy X-ray absorptiometry (DXA) and genetic factors, would be preferable for bone strength assessment. The aim of this paper is to design a deep learning-based model to predict proximal femoral strength using multi-view information fusion.

Results

We developed new models using multi-view variational autoencoder (MVAE) for feature representation learning and a product of expert (PoE) model for multi-view information fusion. We applied the proposed models to an in-house Louisiana Osteoporosis Study (LOS) cohort with 931 male subjects, including 345 African Americans and 586 Caucasians. We performed genome-wide association studies (GWAS) to select 256 genetic variants with the lowest p-values for each proximal femoral strength and integrated whole genome sequence (WGS) features and DXA-derived imaging features to predict proximal femoral strength. The best prediction model for fall fracture load was acquired by integrating WGS features and DXA-derived imaging features. The designed models achieved the mean absolute percentage error of 18.04%, 6.84% and 7.95% for predicting proximal femoral fracture loads using linear models of fall loading, nonlinear models of fall loading, and nonlinear models of stance loading, respectively.

Conclusion

The proposed models are capable of predicting proximal femoral strength using WGS features and DXA-derived imaging features. Though this tool is not a substitute for predicting FEA using QCT images, it would make improved assessment of hip fracture risk more widely available while avoiding the increased radiation exposure from QCT.

Effect of preoperative sleep disorders on delirium in proximal femoral surgery patients aged 60 or older

OBJECTIVE

To examine the effect of preoperative sleep disorders on delirium in patients older than 60 years of age who underwent surgery for proximal femoral fracture.

METHODS

This is a prospective observational study. We prospectively selected 143 patients with proximal femoral fracture who underwent surgery between April 2021 and April 2022. The primary outcome was postoperative delirium (PD). Multiple logistic regression analyses were performed and a receiver operating characteristic (ROC) curve was generated. The preoperative sleep quality of all eligible participants was assessed through the Pittsburgh Sleep Quality Index (PSQI). The Confusion Assessment Method (CAM) was used to assess PD from the first to the seventh day postoperatively. Patients were divided into two groups according to the PD diagnosis: (1) the no PD (NPD) group and (2) the PD (PD) group.

RESULTS

Of 143 eligible patients, 43 (30.1%) were diagnosed with PD. Multiple logistic regression analysis demonstrated that postoperative ICU admissions (OR = 2.801, p = 0.049) and preoperative sleep disorders (OR = 1.477 p < 0.001) were independently associated with PD. A receiver operating characteristic (ROC) curve demonstrated that the preoperative PSQI score was predictive of PD (AUC 0.808, 95% CI 0.724 ~ 0.892, p < 0.001).

CONCLUSION

Preoperative sleeping disorders may be an independent risk factor leading to PD and an independent predictive factor for the development of delirium in proximal femoral surgery patients aged 60 or older.

Idiopathic normal pressure hydrocephalus possibly affects the occurrence of proximal femoral fracture

AIMS

The clinical triad of idiopathic normal pressure hydrocephalus (iNPH) includes gait disturbance, dementia, and urinary incontinence. These symptoms are also frequently observed in patients with proximal femoral fracture (PFF). The aim of this study was to investigate the relationship between PFF and iNPH retrospectively.

PATIENTS AND METHODS

Of the130 patients over 80-years-old with PFF included in this study, 48 were assigned to the PFF group. Forty-eight patients with peripheral vertigo matched with the PFF group for age and sex were included in the control group. We compared the Evans' index (EI), which is a head computed tomography finding of iNPH, and the percentages of patients with EI>0.3 between the two groups. The PFF group was further divided into two subgroups depending on whether EI was higher or lower than 0.3 (the higher or lower subgroup, respectively). We compared the patient's gait abilities before PFF, causes of PFF, cognitive functions, and occurrence of urinary incontinence between both groups.

RESULTS

The mean value of EI in the PFF group was significantly higher than that in the control group (PFF group, 0.301; control group, 0.284; p=0.008). The percentages of patients with EI>0.3 in the PFF and control groups were 62.5% and 35.4%, respectively (p=0.014). In subgroup analyses, the gait ability before injury was worse in the higher subgroup than that in the lower subgroup and was prominent among individuals who could walk only with human assistance (p=0.018). There were no significant differences in other parameters.

CONCLUSION

Elderly patients with PFF may have underlying idiopathic normal pressure hydrocephalus.

LEVEL OF EVIDENCE

III; case-control comparative study.

Risk scoring models for patients with proximal femur fractures: Qualitative systematic review assessing 30-day mortality and ease of use

BACKGROUND

Hip fractures are a common orthopaedic injury affecting a particularly frail and vulnerable patient cohort. They are at risk of many complications, including prolonged length of stay and mortality. Efforts to identify those at high risk may be beneficial. Over 25 risk prediction models are published for patients with hip fractures.

AIM

The primary aim of this study was to assess the performance of predictor scores in predicting 30-day mortality. The secondary aim was to assess the ease of use of these systems.

METHODS

A qualitative systematic review was performed. A search was conducted on online databases, including PubMed, CINAHL, Clinical Trials.gov, Cochrane, DARE, EMBASE, SCOPUS, and Web of Science.. The terms fragility hip fractures and risk prediction models were utilised while performing the search. These were then expanded using Boolean operators and similar terms. Search results were imported to Covidence. Primary observational studies using one or more hip fracture mortality prediction models and 30-day mortality as an outcome were included. Systematic reviews and studies on specific patient groups defined other medical conditions (e.g. COVID positive or dialysis patients) were excluded.

RESULTS

3,101 studies were screened following duplicate removal. 34 papers were included in the review, in which 23 scoring systems were reported. Six of these were pre-operative and reported in multiple studies. Most demonstrated appropriate fit and fair discrimination. Five of the six pre-operative scoring systems examined, displayed appropriate ease of use, allowing risk calculation at the time of admission.

CONCLUSION

Nottingham Hip Fracture Score remains the most extensive reported scoring system and performs fair overall with AUROCs of 0.64-0.80 and good fit in calibration across all studies. However, new systems utilise many similar predictors. There is a need for the standardisation of publications on scoring systems to allow further systematic review and meta-analyses.

[Proximal femoral fracture with bony ankylosis of the hip joint : Case report of difficult surgical treatment]

A 78-year-old female patient sustained a left-sided proximal femoral fracture due to a fall. Since childhood the patient had suffered from ankylosis of unknown origin in the ipsilateral hip joint. The recommended intramedullary osteosynthesis could restore the original status quo before the fracture. It needs less time in the operating room (OR) and includes a lower risk for intraoperative complications than a hip joint endoprosthesis. Arthroplasty can lead to a significant improvement in mobility of the hip joint but requires more time in the OR for the surgical procedure and anesthesia time and includes a higher risk for intraoperative and postoperative complications. The antetorsion angle of 76° in this patient deviated extremely from the standard and made the intramedullary osteosynthesis for this type of fracture a challenge. Using improvised techniques led to a load-stable fracture treatment that ultimately led to a satisfactory result.

Proximal femur geometry: a major predictor of proximal femur fracture subtypes

INTRODUCTION

Proximal femur geometry (PFG) represents an important risk factor for the occurrence of hip fractures. There are currently few studies regarding the correlation between PFG and the occurrence of a specific fracture subtype, and those that exist have small cohorts and present with different methodologies and contradictory results. Therefore, there is no consensus in the literature regarding this topic. The present study aimed to establish the contribution of the PFG in the occurrence of different subtypes of proximal femur fractures (PFF): intertrochanteric, neck and subtrochanteric.

METHODS

Analysis of 1022 plain anteroposterior pelvic radiographs of patients consecutively admitted to the emergency room of a Level 1 Trauma Centre between 2013 and 2019 after low energy trauma who presented with PFF and underwent surgical treatment. Patients were analysed considering age, gender and subtype of PFF (intertrochanteric, neck or subtrochanteric). Radiological parameters including cervicodiaphyseal angle (CDA), horizontal offset (HO), femoral neck width (FNW), femoral neck length (FNL), great trochanter-pubic symphysis distance (GTPSD), acetabular teardrop distance (ATD) and width of the intertrochanteric region (WIR) were measured and compared between the different subtypes of fractures (7154 measurements). Statistical analysis was conducted recurring to absolute measurements and measurements ratios. The correlation was assessed using t-test.

RESULTS

There were statistically significant differences in proximal femur geometry between the different subtypes of fractures. Patients presenting with femoral neck fractures had greater CDA (132.5 ± 6.9 vs. 130.0 ± 7.3; p < 0.001) and lower HO (45.8 ± 7.4 vs. 49.0 ± 8.0; p < 0.001), HO/ATD (0.34 ± 0.068 vs. 0.37 ± 0.072; p < 0.001) and HO/GTPSD (0.26 ± 0.049 vs. 0.28 ± 0.039; p < 0.001) than patients with intertrochanteric/subtrochanteric fractures.

CONCLUSIONS

PFG represents an important contributor to the occurrence of different fracture subtypes. Femoral neck fractures are associated with greater CDA and lower HO, HO/ATD and HO/GTPSD when compared to intertrochanteric or subtrochanteric fractures.

[Antiagregants, anticoagulants and proximal femur fracture]

Hip fractures are common in the elderly, particularly due to an increased susceptibility to falls and greater bone frailty, especially in women. The consequences of such events are potentially serious. Early management (< 48 hours) significantly reduces the mortality and postoperative complications. Because of their comorbidities, older people are often on antiplatelet therapy, anticoagulant therapy, or both. However, there are no definitive recommendations for the perioperative management of antiplatelet and anticoagulant treatment in the early surgery of hip fractures. The purpose of this article is to review the management of these patients.

Local anesthetic with monitored anesthesia care in cephalomedullary nailing of proximal femur fractures

INTRODUCTION

Proximal femur fractures have high rates of morbidity, mortality, and perioperative complications. Limiting anesthesia, especially in the elderly population, is a priority from a medical perspective. The goal of the current study is to present a technique of using local anesthetic with monitored anesthesia care (MAC) for the fixation of intertrochanteric (IT) femur fractures with cephalomedullary nailing (CMN), provide early clinical results in a small series of patients, and evaluate the safety, efficiency, and anesthetic efficacy of our technique.

HYPOTHESIS

The use of only local anesthetic with MAC for the fixation of IT fractures is safe and leads to decreased operative times when compared to spinal and general anesthesia.

MATERIALS AND METHODS

Patients undergoing cephalomedullary nailing (CMN) with a long nail for IT femur fractures by a single surgeon from January 2020 to June 2021 were identified retrospectively from a prospectively-collected patient registry. Patient demographics, operative time, length of hospital stay, perioperative medication use, and complications were collected. Analysis of variance, Chi2, linear regression, and two-sampled T-tests were performed to analyze potential differences between the local anesthesia group and the general or spinal anesthesia group.

RESULTS

Thirty-seven patients were identified. Eleven patients underwent CMN using local anesthesia with MAC, 11 using spinal anesthesia, and 15 using general anesthesia. The local anesthesia group demonstrated significantly lower operating room times and anesthesia induction to incision time compared to other anesthesia techniques. The local anesthesia group also trended towards less need for vasopressors during surgery and less postoperative delirium. No differences were identified in intraoperative narcotic use, complications, patient mortality, or hospital readmissions.

CONCLUSIONS

Local anesthesia with MAC for the treatment of IT fractures with CMN was associated with decreased operating room times and had similar complication rates including blood transfusions, readmissions, and mortalities, when compared to spinal and general anesthesia.

LEVEL OF EVIDENCE

III, therapeutic.

Outcomes of direct anterior approach for uncemented total hip replacement in medial femoral neck fractures: a retrospective comparative study on the first 100 consecutive patients

BACKGROUND

With the aging of the population, the incidence of medial femoral neck fractures is likely to increase, and along them the need for total hip replacement. The present study aimed to analyze whether the use of the direct anterior hip approach, compared with posterolateral approach in medial proximal femur fracture patients, results in any advantage in terms of complications rate and functional recovery.

METHODS

A total of 162 patients were included in the study, and divided by approach: 100 performed with direct anterior approach (group A) and 62 with posterolateral approach (group B). The two populations were overlapping in age (75 vs 74 years; p = 0.13), sex (58F 42M vs 46F 16M; p = 0.12) and BMI (24 vs 24; p = 0.77).

RESULTS

Group A showed a higher ASA score compared to group B (3 vs 2; p = 0.04). Similar hospital stays (7 vs 7 days; p = 0.55) and complication rates (6% vs 8%; p = 0.61) were observed among groups, the most frequent being periprosthetic fractures, and need for allogeneic blood transfusion (20% vs 13%; p = 0.25). Patients in group A (96 vs 85 min; p = 0.10) showed a slightly, longer surgical time and a faster postoperative functional recovery witnessed by the ability to climb stairs at hospital discharge (37% vs 21%; p = 0.041).

CONCLUSION

The use of the direct anterior hip approach was effective in the management of frail patients with medial femoral neck fractures managed by total hip arthroplasty, allowing faster functional recovery in the elderly population.

How Often Do Complications and Mortality Occur After Operatively Treated Periprosthetic Proximal and Distal Femoral Fractures? A Register-based Study

BACKGROUND

The incidence of periprosthetic femoral fractures is increasing because of an increasing number of primary THAs and TKAs. High rates of complications and mortality are associated with periprosthetic fractures, but few studies have evaluated and compared the population-based incidences of these events after fractures.

QUESTIONS/PURPOSES

(1) What is the annual incidence of periprosthetic fractures treated with surgery in one hospital district in Finland? (2) How are those incidences changing over time? (3) What is the risk of complications, reoperations, and death after those injuries?

METHODS

This register-based study evaluated 2259 patients who underwent revision THA or TKA or any surgery for a femoral fracture between January 2004 and December 2016 at the only hospital in our district where these types of operations are performed. During the study period, the diagnosis and operation codes of the operated-on patients varied greatly, and they were somewhat inaccurate. We thus evaluated radiographs of all 2259 patients one by one, and created inclusion and exclusion criteria based on radiologic findings and medical records. Of those, 12% (279 of 2259) had periprosthetic fractures that met the inclusion criteria, and from these, we formed two study groups (periprosthetic proximal femur fractures, n = 171; periprosthetic distal femur fractures, n = 108). Eighty-eight percent (1980 of 2259) of the patients were excluded because they were treated for a condition other than periprosthetic femoral fracture. The follow-up period ended in December 2019 or at the time the patient died. To evaluate the population-based incidence, we drew the number of individuals with THA or TKA in the hospital district from the Finnish Arthroplasty Register and the Finnish Hospital Discharge Register. The characteristics of patients with operatively treated periprosthetic femoral fractures were evaluated in terms of age, gender, fracture type, implant type, and time from the index operation to periprosthetic fracture. The annual incidences of periprosthetic femoral fractures are summarized per 1000 person-years of individuals living with an implanted THA or TKA and per 100,000 individuals per year living in our hospital district. The risks of death, complications, and reoperations were evaluated for both groups, and comparisons were made in terms of patient characteristics.

RESULTS

The mean annual incidence of operatively treated periprosthetic proximal femur fractures per 1000 people living with THA implants was 2.3 ± 0.9 (95% confidence interval 1.8 to 2.7) per year, and for those with periprosthetic distal femur fractures with TKA implants, it was 1.3 ± 0.6 (95% CI 1.0 to 1.7). There was an increasing trend in the incidence of periprosthetic proximal femur fractures from 1.6 to 3.8 (95% CI 1.8 to 2.8) per 1000 arthroplasties, and it increased from 0.4 to 1.7 (95% CI 2.4 to 4.4) for periprosthetic distal femur fractures between 2004 and 2016. The mean population-based incidence of periprosthetic proximal femur fractures per 100,000 person-years was 5.3 ± 2.2 (95% CI 4.1 to 6.4) per year, and for periprosthetic distal femur fractures, it was 3.4 ± 1.7 (95% CI 2.5 to 4.4). The incidence of periprosthetic proximal femur fractures related to 100,000 person-years increased from 3.2 to 8.9 (95% CI 3.9 to 6.6), while the incidence of periprosthetic distal femur fractures increased from 1.3 to 4.4 (95% CI 2.4 to 4.8) during the study period. The cumulative incidence of major complications after periprosthetic proximal femur fracture was 8.8% at 1 year (95% CI 5.1% to 13.6%) and 12.3% at 10 years (95% CI 7.5% to 18.4%), and after periprosthetic distal femur fracture, it was 7.4% at 1 year (95% CI 3.5% to 13.4%) and 9.3% at 10 years (95% CI 4.7% to 15.7%). The cumulative incidence of reoperation after periprosthetic proximal femur fracture was 10.5% at 1 year (95% CI 6.5% to 15.7%) and 13.5% at 10 years (95% CI 8.9% to 19.1%), and for periprosthetic distal femur fracture, it was 8.3% at 1 year (95% CI 4.1% to 14.5%) and 13.8% at 10% years (95% CI 7.8% to 21.4%). The cumulative incidence of death after periprosthetic proximal femur fracture was 8.2% at 1 year (95% CI 4.7% to 12.9%) and 47.3% at 10 years (95% CI 38.1% to 55.9%), and after periprosthetic distal femur fractures, it was 14.8% at 1 year (95% CI 8.8% to 22.2%) and 67.8% at 10 years (95% CI 56.3% to 76.9%).

CONCLUSION

The increased use of THA and TKA has led to an increase in the incidence of operatively treated periprosthetic fractures, which means there will be more revisions in the future. Older age, frailty of these patients, and often-complicated fracture patterns are related to a high rate of complications, reoperations, and mortality. Healthcare systems must prepare for a large increase in revisions for periprosthetic fracture, which are morbid events for patients and costly ones for healthcare systems.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Admission screening form and osteoporosis educational appointment: a novel fracture liaison service system for identifying osteoporosis patients and facilitating medication initiation

Our FLS team aimed to ensure that patients admitted to the orthopedic department were promptly initiated for medication and identify and initiate medication for patients admitted to other departments. Our innovative FLS system along with admission screening and osteoporosis education have proven effective in identifying patients with osteoporosis and initiating medication.

PURPOSE

The fracture liaison service (FLS) plays a crucial role in the secondary prevention of fragility fractures by involving various medical professionals. Our FLS team had two goals for preventing primary and secondary fractures: ensuring that patients admitted to the orthopedic department were promptly initiated on medication and identifying and initiating medication for patients admitted to other departments.

METHODS

From April 2020 to March 2023, we analyzed the number of dual-energy X-ray absorptiometry (DEXA) scans performed, the DEXA rate among patients with proximal femoral fractures, and the rate of medication initiation each year. Our hospital implemented the FLS system in April 2022. It is a unique system utilizing admission screening form and osteoporosis educational appointments conducted by rehabilitation staff to initiate medication for orthopedic and non-orthopedic patients.

RESULTS

The average monthly number of DEXA scans increased significantly, with 47.7 in 2020, 57.0 in 2021, and 90.8 in 2022. The DEXA rate among proximal femoral fracture patients increased from 23.3% in 2020 to 88.1% in 2021 and 100% in 2022. The rate of treatment initiation also increased remarkably, from 21.7% in 2020, to 68.7% in 2021, reaching 97.8% in 2022. We performed 504 interventions, resulting in 251 patients diagnosed with osteoporosis, of whom 134 (56 from non-orthopedic departments) successfully started medication.

CONCLUSIONS

Our innovative FLS system, incorporating an admission screening form and osteoporosis educational appointments, proved effective in identifying patients with osteoporosis and facilitating medication initiation, which will prevent both primary and secondary fractures.

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.

Relationship between site-specific bone mineral density in the proximal femur and instability of proximal femoral fractures: A retrospective study

BACKGROUND

Proximal femoral fractures can occur in patients with osteoporosis. However, the relationship between bone mineral density (BMD) of the proximal femur and fracture type and instability remains unclear. This study aimed to determine whether there is a relationship between the site-specific BMD of the proximal femur and the instability of proximal femoral fracture.

HYPOTHESIS

The instability of proximal femoral fractures is related to the site-specific BMD of the proximal femur.

PATIENTS AND METHODS

Using dual-energy X-ray absorptiometry (DEXA), the BMD on the non-fractured side was retrospectively examined in 252 women who underwent surgery for proximal femoral fracture at our hospital. The BMD was measured at three sites: the femoral neck (neck), trochanter (trochanter), and intertrochanteric region (inter). The BMD at several sites was compared between the femoral neck and trochanteric fractures. Femoral neck fractures were classified into the displaced and non-displaced types, and trochanteric fractures were classified into stable and unstable types. A comparative analysis was conducted for each proximal femur site and fracture type.

RESULTS

Both total and site-specific BMDs were lower in trochanteric fractures than in femoral neck fractures. No difference was observed between BMD and displaced or non-displaced femoral neck fractures. However, the BMD of the intertrochanteric region was lower in unstable trochanteric fractures (0.57±0.12g/cm2) than in stable trochanteric fractures (0.61±0.11g/cm2) [p<0.05].

DISCUSSION

Several factors, including the patient's age and the bone component of each region, may influence the lower BMD in trochanteric fractures. In trochanteric fractures, the site-specific BMD of the proximal femur may predict the type of fracture and the degree of instability, especially in those with low BMD at the intertrochanteric site. The study findings suggest that a decrease in the BMD of the intertrochanteric region of femoral trochanteric fractures, which is thought to be involved in instability, is associated with fracture type instability.

LEVEL OF EVIDENCE

III, retrospective study.

Mortality following proximal femoral fractures in elderly patients: a large retrospective cohort study of incidence and risk factors

BACKGROUND

Global prevalence of osteoporosis and fragility fractures is increasing due to the aging population. Proximal femoral fractures are among the most common orthopedic conditions in elderly that significantly cause health deterioration and mortality. Here, we aimed to evaluate the mortality rates and risk factors, besides the functional outcomes after these injuries.

METHODS

In a retrospective cohort study, all patients admitted with a femoral neck or intertrochanteric fracture between 2016 and the end of 2018 were enrolled in this study. Medical records were reviewed to include patients over 60 years of age who had a proximal femoral fracture and had a complete medical record and radiographs. Exclusion criteria included patients with pathological fractures, cancer under active treatment, follow-up loss, and patient access loss. Demographic and clinical features of patients alongside the details of fracture and patient management were recorded and analyzed. In-hospital and post-discharge mortalities due to included types of fractures at one and 12 months were the primary outcome. Modified Harris Hip Scores (mHHS) was the measure of functional outcome.

RESULTS

A total of 788 patients including 412 females (52.3%) and 376 males (47.7%) with a mean age of 76.05 ± 10.01 years were included in this study. Among patients, 573 (72.7%) had an intertrochanteric fracture, while 215 (27.3%) had a femoral neck fracture, and 97.1% of all received surgical treatment. With a mean follow-up of 33.31 months, overall mortality rate was 33.1%, and 5.7% one-month and 20.2% 12-months rates. Analysis of 1-month mortality showed a significant mortality difference in patients operated after 48 h of fracture (p = 0.01) and in patients with American Society of Anesthesiologists (ASA) scores of 3-4 compared to ASA scores of 1-2 (p = 0.001). One-year mortality data showed that the mortality rate in femoral neck fractures was lower compared to other types of fracture. Surgical delay of > 48 h, ASA scores of 3-4, and treatment by proximal femoral plate were associated with shorter survival. The overall mean mHHS score was 53.80 ± 20.78.

CONCLUSION

We found several risk factors of mortality, including age ≥ 80 years, a > 48-hour delay to surgery, and pre-operative ASA scores of 3-4 in patients with proximal femoral fracture. Furthermore, the use of a proximal femoral plate was a significant risk factor for mortality and lower mHHS scores.

Holistic pedestrian safety assessment for average males and females

Objective

An integrated assessment framework that enables holistic safety evaluations addressing vulnerable road users (VRU) is introduced and applied in the current study. The developed method enables consideration of both active and passive safety measures and distributions of real-world crash scenario parameters.

Methods

The likelihood of a specific virtual testing scenario occurring in real life has been derived from accident databases scaled to European level. Based on pre-crash simulations, it is determined how likely it is that scenarios could be avoided by a specific Autonomous Emergency Braking (AEB) system. For the unavoidable cases, probabilities for specific collision scenarios are determined, and the injury risk for these is determined, subsequently, from in-crash simulations with the VIVA+ Human Body Models combined with the created metamodel for an average male and female model. The integrated assessment framework was applied for the holistic assessment of car-related pedestrian protection using a generic car model to assess the safety benefits of a generic AEB system combined with current passive safety structures.

Results

In total, 61,914 virtual testing scenarios have been derived from the different car-pedestrian cases based on real-world crash scenario parameters. Considering the occurrence probability of the virtual testing scenarios, by implementing an AEB, a total crash risk reduction of 81.70% was achieved based on pre-crash simulations. It was shown that 50 in-crash simulations per load case are sufficient to create a metamodel for injury prediction. For the in-crash simulations with the generic vehicle, it was also shown that the injury risk can be reduced by implementing an AEB, as compared to the baseline scenarios. Moreover, as seen in the unavoidable cases, the injury risk for the average male and female is the same for brain injuries and femoral shaft fractures. The average male has a higher risk of skull fractures and fractures of more than three ribs compared to the average female. The average female has a higher risk of proximal femoral fractures than the average male.

Conclusions

A novel methodology was developed which allows for movement away from the exclusive use of standard-load case assessments, thus helping to bridge the gap between active and passive safety evaluations.

Risk factors, classification, and operative choices of femur fractures at a Tertiary Hospital: first report from Somalia

A traumatic femur fracture is a significant cause of morbidity, affecting one to three million individuals annually. The present is the first study investigated the epidemiological characteristics, risk factors, classification, mechanisms of injury, and early management of femoral fractures in Somalia. This retrospective epidemiological study included all patients with a femur fracture who were admitted for four years between November 2018 and December 2022 to the orthopedic and trauma surgery department. We reviewed patient demographic characteristics, including age and gender, the mechanism of injury, injury characteristics, and the type of fixation performed. We reviewed the radiographs and classified the fracture using the AO/OTA classification system. During the study period, a total of 402 patients were treated for femur fractures; 256 (64%) were males, and 144 (36%) were females. The mean patient age was 47.7 ± 8.5 years. Regarding the anatomical location of femur fractures, the proximal (31A, 31B) was the most common, accounting for 50% of the patients. Femur neck fracture (31B) was the most common in the proximal femur fractures. Gunshot 82 (59.42%) was the leading cause of femur shaft fractures. Most patients with femur shaft fractures were males; 150 (86.20%) and 152 (64.47%) were young patients between 19 and 40 years old. Almost half of the patients (86) with femur shaft fractures had open fractures. The distribution of the mechanism of injury significantly differed according to age (p < 0.001). Younger patients (< 40 years) were predominantly injured due to gunshot injuries compared to elderly cases (> 60 years), where falls from standing height were the primary mechanism of injuries. There was a statistically significant difference between the mechanism of injury and gender categories (p < 0.001). Male patients were injured mainly by gunshots in about 40%, while 80% of fractures in female patients were due to falls from standing height. Female fractures occurred primarily in the proximal, while the males had an equal fracture rate for proximal and shaft fractures. Femur fracture causes significant morbidity and mortality. The study findings revealed that the most common femur fracture type was femur neck fracture, and low-energy injuries were the most common mode of injury in the elderly. Proximal femur fractures occur in older age and mainly in females. Gunshots were the most common cause of femur shaft fractures in Somalia, a country that has struggled with wars for over 30 years.

population

Proximal femoral fractures are a serious complication, especially for elderly patients. Detailed epidemiological analyzes provide a valuable resource for stakeholders in the health care system in order to foresee future development possibly influenceable by adaption of therapeutic procedures and prevention strategies. This work aimed at answering the following research questions: (1) What are the incidence rates of proximal femoral fractures in the elderly U.S. population? (2) What is the preferred treatment procedure for these fractures? Proximal femoral fractures occurred between January 1, 2009 and December 31, 2019 in patients ≥ 65 years were identified from the Medicare Physician Service Records Data Base. The 5% sample of Medicare beneficiaries, equivalent to the records from approximately 2.5 million enrollees formed the basis of this study. Fractures were grouped into head/neck, intertrochanteric, and subtrochanteric fractures. The overall incidence rate, age and sex specific incidence rates as well as incidence rate ratios were calculated. Common Procedural Terminology (CPT) codes were used to identify procedures and operations. In 2019, a total number of 7982 femoral head/neck fractures was recorded. In comparison to 9588 cases in 2009, the incidence substantially decreased by 26.6% from 666.7/100,000 inhabitants to 489.3/100,000 inhabitants (z =  - 5.197, p < 0.001). Also, in intertrochanteric fractures, a significant decline in the incidence by 17.3% was evident over the years from 367.7/100,000 inhabitants in 2009 to 304.0 cases per 100,000 inhabitants in 2019 (z =  - 2.454, p = 0.014). A similar picture was observable for subtrochanteric fractures, which decreased by 29.6% (51.0 cases per 100,000 to 35.9 cases per 100,000) over the time period (z =  - 1.612, p = 0.107). Head/neck fractures were mainly treated with an arthroplasty (n = 36,301, 40.0%). The majority of intertrochanteric fractures and subtrochanteric fractures received treatment with an intramedullary device (n = 34,630, 65.5% and n = 5870, 77.1%, respectively). The analysis indicated that the incidence of all types of proximal femoral neck fractures decreased for the population of elderly patients in the U.S. within the last decade. Treatment of head and neck fractures was mainly conducted through arthroplasty, while intertrochanteric and subtrochanteric fractures predominantly received an intramedullary nailing.