Femoral Fracture Surgery Research Articles

Does tranexamic acid reliably reduce blood loss in proximal femur fracture surgery?

PurposeThe aim of our study was to investigate the use of tranexamic acid in patients with proximal femoral fractures and compare the total blood loss, transfusion rates, complications, and the application method.MethodsA retrospective single center cohort study (level I trauma center) with 1479 patients treated operatively for a proximal femoral fracture between January 2016 and June 2020 was performed. 1 g of tranexamic acid was applied (systemic, topic or combined application). Patient data, surgical procedure, complications, and mortality were assessed. Hemoglobin levels, blood loss and transfusion rates for patients with and without tranexamic acid and the application methods were compared.Results667 femoral neck fractures, 701 pertrochanteric and 109 subtrochanteric fractures were included. Mean age was 80.8 years. 274 patients received tranexamic acid. At admission average hemoglobin was 12.2 g/l. Hemoglobin drop postoperatively was less after tranexamic acid (9.72 vs. 9.35 g/dl). Transfusion rates were lowered significantly by 17.1% after tranexamic acid. Blood loss was reduced for all patients after tranexamic acid independent of fracture morphology. The combination of 1 g i.v. and 1 g topical-applied tranexamic acid seems to be more effective. Complication rates did not differ.ConclusionTranexamic acid is effective in reducing blood loss and transfusion rates, without increasing the risk of thromboembolic events after proximal femoral fractures. For open reduction and nailing and arthroplasty in fracture setting combined topical and single i.v. application seems most effective and closed reduction with nailing can be treated by single dose i.v. application of 1 g tranexamic acid.

Advantages of a Dedicated Orthopaedic Trauma Operating Room for Diaphyseal Femur Fractures.

To examine the impact of instituting a dedicated orthopaedic trauma operating room (DOTOR) at a Level I trauma center on diaphyseal femur fracture management. Retrospective cohort study. Regional, university-based Level I trauma center. Trauma patients 18-65 years of age who presented between October 2016 and December 2018 (approximately 1 year before and after implementation of the DOTOR) and underwent surgery for diaphyseal femur fractures. One hundred twenty-eight patients met eligibility criteria for inclusion: 60 were treated before and 68 after implementation of the DOTOR. Implementation of a DOTOR in October 2017. Percentage of external fixation versus intramedullary nailing, time from emergency department visit to definitive fixation, duration of surgery, and hospital length of stay. The only significant difference in patient demographics between the before and after groups was mechanism of injury (P = 0.003). Percentage of external fixators as an initial procedure decreased from 15% to 2.9% (P = 0.024). Time to definitive fixation with intramedullary nail decreased from 1083 minutes to 659 minutes (P = 0.002). There was no significant change in median operative time of intramedullary nailing (P = 0.573). Although not statistically significant, hospital length of stay decreased from 7 days to 5.5 days after implementation (P = 0.158). Cost analysis revealed annual cost savings of more than $261,678 for diaphyseal femur fractures alone by implementing a DOTOR. For diaphyseal femur fractures, instituting a DOTOR at a Level I trauma center reduced the percentage of patients requiring a 2-stage fixation, reduced the time to definitive fixation, and yielded cost savings. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

TRANEXAMIC ACID IN REDUCING BLOOD LOSS IN PROXIMAL FEMUR FRACTURE SURGERY: AN OBSERVATIONAL STUDY

Background: Blood transfusion during orthopedic surgery is associated with different types of complications. The goal of this research was to observe if tranexamic acid could help in reducing perioperative blood loss after proximal femur fracture surgery. Methods: At Shree Birendra Hospital, a total of 60 patients with proximal femur fractures participated in this one-year observational study. The study group (n=30) received 1g intravenous tranexamic acid at induction of anesthesia, whereas the control group (n=30) received intravenous normal saline. Using a proximal femoral nailing device, all patients underwent closed reduction and internal fixation. Preoperative and postoperative hematological parameters, as well as intraoperative blood loss were measured. Patients were followed up till the third day for the need of blood transfusion. Statistics Program for Social Sciences version 20.0 was used to analyze the data. Results: The study’s preoperative hemoglobin and hematocrit were 10.5±1.43gm/dl versus 10.9±1.2gm/dl and 31.5±4.19% versus 32.7±3.6%, respectively, compared to the control group. In the study versus control group, the values were 10.1±1.0gm versus 9.9±0.8gm (p=0.01) and 30.3±3% versus 29.7±2.4% (p=0.03) on day one and 10±0.69gm versus 9.68±0.51gm (p=0.049) and 30±2.07% versus 29.04±1.53% (p=0.049) on day three. Total blood loss in the study group was 156.79±43.46ml compared to 392.63±92.32ml in the control group (p=0.00), with both apparent and hidden blood loss being lower in the study group. Conclusions: In patients undergoing minimally invasive surgery of proximal femoral fractures using proximal femoral nailing system, intravenous administration of a single dose of 1g tranexamic acid at the time of induction of anesthesia lowers blood loss by a significant amount.

Comparison of Efficacy and Safety of Transdermal Buprenorphine Patch and Conventional Analgesics in Intra-capsular Femur Neck Fracture Post Hemiarthroplasty.

One of the most common fractures in the elderly population is a fracture of the neck of femur. Effective post-operative analgesia is a major challenge. Age-related co-morbidities restrict the choice of analgesics. The purpose of this study was to compare the efficacy and safety of transdermal buprenorphine [TDB] patch and conventional analgesics following hemiarthroplasty for intra-capsular fracture neck of femur. This was a prospective, randomized control study done in 60 patients undergoing hemiarthroplasty for intra-capsular fracture neck of femur over a period of 2years. Patients were randomized in 2 groups. Group A received a combination of IV paracetamol and tramadol for first 48h followed by oral formulation. In Group B patients, a transdermal buprenorphine patch of 5mcg/h was applied at the beginning of surgery and was continued 2weeks post-operative.Pain score by VAS was observed both at rest and on movement and followed up till 14days post-operative. Primary target was to maintain a VAS ≤ 4. Rescue analgesic was given if the VAS was ≥ 6. Secondary targets were number of rescue analgesics required, adverse reactions and complications if any. Group B had significantly lower pain scores at rest and during movement [p value 0.0012 to ≤ 0.0001], so was rescue analgesia requirement. No significant side effects were seen in TDB group. TDB patch is safe and provides superior analgesia and compliance as compared to conventional analgesics in the post-operative period in proximal femur fracture surgeries.

Effects of SARS-CoV‑2 infections on inpatient mortality of geriatric patients after proximal femoral fracture surgery.

BackgroundThe medical challenges caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV‑2) pose a tremendous burden on the healthcare system. This study aimed to analyze the effects of a SARS-CoV‑2 infections or disease progression on inpatient mortality of geriatric patients after proximal femoral fracture surgery.MethodsA retrospective analysis was conducted in all patients with a proximal femoral fracture surgically treated in an urban regional trauma center from 01/01/2020 to 01/31/2021. According to PCR test results detecting SARS-CoV‑2, the patients were divided into two groups (SARS-CoV‑2 positive vs. SARS-CoV‑2 negative). Patient data, disease progression data, and treatment-related information were evaluated for all patients. Statistical data analysis was performed using unpaired Student’s t test or non-parametric Mann-Whitney U test.ResultsA total of 311 patients (women: 70.4%, age: 82.0 ± 11.0 years) were included in this study. Of these 3.9% (12/311) had a positive test result for SARS-CoV‑2. Significantly more deceased patients were found in the group tested positive for SARS-CoV‑2 (SARS-CoV‑2 positive: 41.7%, SARS-CoV‑2 negative: 5.4%, p < 0.001). In addition, the number of proximal femoral fracture associated deaths correlated with the number of positive test results performed in the Clinic. The length of stay of SARS-CoV‑2 COVID-19 survivors tended to be greater than in those who were tested negative (SARS-CoV‑2 COVID-19 positive: 15.6 ± 13.1 days, SARS-CoV‑2 COVID-19 negative: 11.5 ± 6.5 days, p = 0.683). Furthermore, a significant difference in age was found in SARS-CoV‑2 survivors and SARS-CoV‑2 decedents (deceased: 95.5 ± 7.5 years, alive: 83.5 ± 7.3 years, p = 0.020).ConclusionThe study was conducted before the introduction of SARS-CoV‑2 vaccination. The results therefore refer to immune naive (unvaccinated) patients. In our study, more than 40% of all patients with proximal femoral fractures who tested positive for SARS-CoV‑2 died during hospitalization. An additional, critical factor in this respect was the age of the infected patients. Nonetheless, a positive correlation was demonstrated between the mortality rate and the number of positive SARS-CoV‑2 detections. Regarding the greater length of stay of patients tested positive for SARS-CoV‑2, the limited transfer options (further rehabilitation, skilled nursing facility) of the infected ones can be considered as causal. Particularly the vulnerable older patients are increasingly endangered by a combination of proximal femoral fracture and SARS-CoV‑2.

Association between pre-operative complications, comorbidities, and in-hospital mortality in a hip fracture cohort: a register study in a tertiary hospital in Brazil.

The incidence of hip fractures is increasing exponentially due to an aging Brazilian population. Older people had significant comorbidities which increases the risk of post-operative mortality. Our purpose was to examine the association between pre-operative infections and comorbidities on the risk of post-operative in-hospital mortality after proximal femur fracture surgery's, beyond that, to evaluate the association between comorbidities and time to surgery. This is a population-based cohort retrospective study, using medical records of all sixyear consecutive surgical procedures for correction of hip fracture in a tertiary teaching Hospital in Brazil. The exclusion criteria aimed to exclusively allocate patients who had their first hip fracture secondary to low-energy trauma. Multivariate logistical regression was performed and receiver operating characteristic (ROC) curve with area under curve (AUC) to evaluate the sensitivity and specificity of the model. p-value < 0.05 was considered significant. Final sample was composed by 856 consecutive patients with 81years of median and 164 patients were excluded. The median length of hospital say was fivedays with - l mortality at 3.6%. Significant variables for increased mortality included the presence of pre-operative infection (odds ratio (OR): 3.9(1.12-8.54), chronic obstructive pulmonary disease (COPD) (OR: 3.83(1.36-10.82)), and systemic arterial hypertension (SAH) (OR: 4.1(1.18-14.25)). Development of pre-operative infection was associated with a delay to surgery (OR: 1.1 (1.08-1.13)). In older people with proximal femur fracture, the presence of pre-operative infection, COPD and SAH were the strongest risk factor for post-operative in-hospital mortality. Pre-operative infection was associated with statistically significant delay to surgery.

Distal Femur Kırıkları için Retrograd Intramedüller Çivileme Sonuçlarının Değerlendirilmesi: 3. Basamak Travma Merkezi Retrospektif Çalışması

Aim: Distal femur fractures can be treated with modern anatomic plates and nails. This study aimed to examine the clinical and radiological results of displaced distal femur fractures in adult people who had been treated with a retrograde intramedullary nail (RIN). Material and Methods: The study included all patients who underwent RIN surgery for distal femur fracture between January 2013 and April 2018 in a level 3 trauma center. Patients were divided into two groups based on fracture pattern: open fracture and closed fracture. The preoperative and postoperative clinical, radiological and functional characteristics of patients who had RIN for a distal femur fracture were analyzed. Results: Thirty patients were included in the study. 21 (70%) patients were male. The median age of the patients was 39 (range, 18-58) years. 17 (56.7%) of the affected femur were left-sided. The etiology of the fractures was traffic accident and fall in 19 (63.3%) patients and gunshot injury in 11 (36.7%) patients. Of the patients, 17 (56.7%) were closed fractures and 13 (43.3%) were open fractures. There were no significant differences between two groups related to the surgery time (p=0.086), fluoroscopy time (p=0.805), blood loss (p=0.967), and hospitalization time (p=0.967), clinical pain and function scores (p=0.341, p=0.902), and union time (p=0.385) at the postoperative period. Conclusion: RIN is a minimally invasive method that may prevent excessive blood loss and decrease the duration of surgery time. It is an effective and reliable surgical intervention that should be considered for the treatment of distal femur fractures.

Predictors of post-hip fracture knee pain in hospitalized older adults with intertrochanteric femoral fracture.

Post-hip fracture knee pain (PHFKP) is an important issue that contributes to reduced gait speed and prolonged hospitalization. Femoral morphology has been reported to contribute to the development of PHFKP, but an independent association has not been confirmed and clinically applicable cutoffs for predicting the development of PHFKP remain unclear. To determine whether femoral morphology and knee extension range of motion limitation are independent factors in PHFKP and to determine cutoffs for predicting the development of PHFKP. Retrospective chart review study. Convalescent inpatient rehabilitation hospital. Patients in a convalescent ward after intertrochanteric femoral fracture surgery. PHFKP development, radiographic femoral morphology (leg length discrepancy and neck-shaft angle), and knee extension range of motion limitation. PHFKP developed in 36 (35%) of the 103 patients enrolled. The PHFKP group had a longer hospital stay (p=.029), greater weight (p=.031), greater knee extension range of motion limitation (p=.001), and more varus neck-shaft angle (p < .001) compared to the non-PHFKP group. Varus neck-shaft angle (odds ratio, 0.85; 95% confidence interval [CI], 0.78-0.92; p < .001) and knee extension range of motion limitation (odds ratio, 1.18; 95% CI, 1.07-1.30; p=.001) were significant factors for PHFKP development. Neck-shaft angle discrepancy and knee extension range of motion limitation demonstrated moderate accuracy in discriminating development of PHFKP according to receiver operating characteristic analysis, with cutoffs of 9.6° and 7.5°, respectively. Areas under the receiver operating characteristic curve were 0.77 (95% CI, 0.66-0.88; p < .001) for neck-shaft angle discrepancy and 0.67 (95% CI, 0.56-0.79; p=.004) for knee extension range of motion limitation. Varus neck-shaft angle and knee extension range of motion limitation were identified as independent predictors of PHFKP. The cutoff for neck-shaft angle may be useful for predicting PHFKP development and to define an acceptable angle of fracture reduction to prevent PHFKP.

The Impact of the COVID-19 Pandemic on the Neck of the Femur and Hip Fracture Surgery Volumes in the Lazio Region.

This study compares surgery volumes for fractures of the neck of the femur (FNF) and hip replacements during the COVID-19 pandemic compared with previous years. Historical (2018–2019) and pandemic (2020–2021) surgery rates for FNF and hip replacement in Lazio, adjusted for age and gender, were calculated per period and compared with a Poisson regression model. For hip replacement surgery, a comparison of different types of hospitals was also made. Before COVID-19’s spread, no difference was found in the volume of surgery of both interventions. From the lockdown to the end of 2021, a decrease in surgery volumes for FNF with stabilization between summer 2020 and summer 2021, as well as an additional decline beginning at the start of Omicron’s spread, were found. Hip replacement surgeries showed a greater decline during the lockdown period and increased during summer 2020 and during the Delta wave period. The increment in hip replacements, mainly observed in 2021, is due to private and religious hospitals. These results highlight that the pandemic emergency, caused by SARS-CoV-2, has had an important indirect effect on the population’s health assistance in the field of orthopedics.

The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis: the epidemiology and two-year outcomes from a prospective cohort in Great Britain.

AimsThe aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE).MethodsThis was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants.ResultsA total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define ‘at risk’. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE.ConclusionThe experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials.Cite this article: Bone Joint J 2022;104-B(4):519–528.

Local Infiltrative Analgesia of Murine Femur Fractures In Vivo Does Not Inhibit Fracture Healing.

The opioid epidemic in the United States has forced care providers to seek out alternatives to narcotic analgesics. Physicians involved in trauma care, including orthopaedic trauma surgeons, often have patients requiring significant amounts of these medications, especially in the perioperative period, given the acuity and severity of their injuries. Modalities such as local infiltration of fractures with anesthetic agents during operative treatment may provide some benefit to this population by decreasing postoperative pain and narcotic usage. However, prior data suggest that these agents are chondrotoxic, which may impede secondary fracture healing. The purpose of this study was to investigate the hypothesis that local anesthetics decrease secondary bone healing and callus formation in stabilized murine femur fractures through chondrocyte apoptosis. Male C57BL/6 mice underwent intramedullary stabilization and fracture of bilateral femurs followed by immediate infiltration of the fracture site with local anesthetic agents. Femurs were dissected at 10- and 20-days post-fracture and evaluated by muCT and histological analysis. No significant differences were seen in callus size or mineralization between controls and fractures treated with a local anesthetic. When the callus was analyzed histologically, local anesthetic agents appeared to increase cartilage density. Therefore, infiltration of local anesthetics during operative treatment of fracture as part of a multimodal approach to pain control does not appear to significantly affect callus formation in a preclinical model, although subclinical molecular effects may be present. Local infiltrative analgesia with local anesthetics may be used as an adjunct for perioperative pain control during femur fracture surgery without a significant effect on secondary bone healing.

Surgically Treated Femoral Neck Stress Fractures Are Likely to Result in Military Separation During Basic Combat Training.

Femoral neck stress fractures are a common condition affecting military service members, most noticeably during basic combat training. Previous studies have investigated the risk factors for femoral neck stress fracture development in basic trainees and outcomes associated with treatment; however, few studies have focused on operatively treated femoral neck stress fracture in the military trainee. Doing so would be important not only for the military, but also providers caring for athletes, such as distance runners, who have a heightened risk for femoral neck stress fracture development. (1) What proportion of US Army trainees completing basic combat training at Fort Jackson, SC, USA, who undergo surgery for femoral neck stress fracture during basic training subsequently leave military service because of the injury? (2) What factors are related to the patient or the fracture are associated with a higher likelihood of military separation? (3) What factors on the initial MRI are associated with progression of the stress fracture extent? A retrospective study of a longitudinally maintained database of stress injuries involving basic combat trainees from a single military post was reviewed over a 3-year period. Inclusion criteria included basic trainees undergoing surgery for a femoral neck stress fracture between January 2018 and June 2020 with a minimum of 1-year follow-up. Surgery was indicated for service members with complete and tension-sided femoral neck stress fractures and those with high risk compression-sided stress fractures, generally representing fractures involving more than 50% of the femoral neck width. Over the study period, 57 service members (51% [29 of 57] women with a mean age of 24 years) underwent surgery for a femoral neck stress fracture, and all 57 had a minimum of 1-year follow-up. Identified service members underwent independent data collection including injury and radiographic parameters based on chart and imaging review. Documented fracture line progression on repeat imaging was present in 39% of service members, with a mean fracture line progression of 55% of the femoral neck width. Service members were subdivided based upon the ability to return to military service at 1 year. Univariate analysis was performed using patient and injury variables to identify factors associated with the ability to return to military service. Overall, 58% (33 of 57) of service members who had a femoral neck stress fracture treated surgically underwent military separation. A higher proportion of service members who demonstrated fracture line progression leading to surgical treatment remained in the military (58% [14 of 24] versus 30% [10 of 33]; odds ratio 0.3 [95% confidence interval (CI) 0.1 to 0.9]; p = 0.03). With the numbers available, we found no other patient- or fracture-related variables associated with military separation, although we suspect we may have been underpowered on some of these comparisons, in particular gender (61% [20 of 33] of individuals separated after surgery for this injury were women compared with 38% [9 of 24] who were retained; OR 2.6 [95% CI 0.9 to 7.56]; p = 0.09). The extent of osseous edema on T1-weighted imaging in association with a hip effusion demonstrated a significant positive correlation with final fracture percentage (r = 0.62; p = 0.003). Military service members with a femoral neck stress fracture initially managed nonoperatively but with progression of the fracture line requiring surgical intervention were more likely to return to military duties and complete basic combat training, suggesting that early diagnosis of femoral neck stress fractures may be associated with better functional recovery after surgical treatment. Additionally, the extent of the osseous edema on initial MRI T1-weighted imaging sequences may help predict the final extent of femoral neck stress fractures on repeat imaging. Further investigations should incorporate patient-reported outcomes and further explore factors associated with fracture progression and the inability to return to active duty or sport. Level III, therapeutic study.

Retrospective Comparison of Postoperative Fascia Iliaca Block and Multimodal Drug Injection on Early Function of the Knee in Femoral Fractures Using Retrograde Intramedullary Nailing.

Introduction There is a common concern about the pain and rehabilitation of the knee after femoral retrograde intramedullary nailing. It is essential for early postoperative knee function required for physical self-maintenance in daily life. And a favorable rehabilitation of the knee usually promotes the quality of life. However, early rehabilitation is absent or insufficient for many patients in postoperative management. This retrospective study aims to evaluate the effect of early knee function improvement in comparison to postoperative fascia iliaca blocking (FIB) and multimodal drug injection (MDI). Patients and Methods. A retrospective analysis of 41 patients receiving femoral fracture treatment with retrograde intramedullary nailing, was performed during 2018–2020. 19 patients were treated with MDI as postoperative analgesia, and 22 patients were treated with FIB. Rehabilitation started on the first postoperative day and lasted for 3 months. Visual analog scale (VAS), the range of motion (ROM) of the knee, and single assessment numeric evaluation (SANE) were assessed. Results There was no significant difference shown in any of the demographic, fracture types, and operative time. All patients performed regular and voluntary knee rehabilitation and weight-bearing at home following the instruction from the orthopedic staff. Pain in the FIB group at postoperative 1-day was milder (1.7 ± 1.1), compared with that in the MDI group (2.8 ± 1.3, p=0.038). There was a significant difference in VAS between two groups at postoperative 1-month (p=0.031), with a peak score in the FIB group (3.3 ± 0.9). At postoperative 3-month, both groups had pain relief with similar VAS (p=0.465). The ROM of the knee in both groups was continuously improved during the first three months. The SANE in the MDI group was significantly different compared with FIB at 1-month (p=0.026). However, scores of SANE were similar in both groups at 3 months (p=0.541). All patients were identified as fractures union at 9-month or 12-month follow-up. Conclusion The knee pain was commonly experienced in this series of retrograde femoral nailings. Both MDI and FIB provided immediate and effective pain control after femoral fracture surgery. MDI was more beneficial to continuous pain control and knee rehabilitation in the early follow-up. The extent of pain relief and knee function improvement reached the same level at postoperative 3-month.

Cumulated ambulation score as predictor of postoperative mobility in patients with proximal femur fractures.

The cumulated ambulation score (CAS) has been developed as an index for evaluating mobility in the early postoperative period. This study aimed to estimate the association between CAS and independent ambulation after surgery for proximal femur fractures. This retrospective cohort study included 223 elderly patients who underwent surgery for proximal femur fractures and had independent ambulation before the injury. Multivariable logistic regression analyses with cognitive impairment, pre-injury Barthel index, and CAS as the test variables were used to predict independent ambulation at 2weeks (model 1) and 3months (model 2) postoperatively. We established scoring systems based on the modeling results. The number of patients with independent ambulation at 2weeks and 3months postoperatively was 115 and 169, respectively. Univariate analysis showed that the CAS was significantly associated with independent ambulation at 2weeks and 3months postoperatively. Multivariable analysis showed that models 1 and 2 had good predictive accuracies, with areas under the receiver-operating characteristic curve of 0.855 and 0.868, respectively. Among the explanatory variables, only the CAS in model 2 was not significantly associated with the postoperative ambulatory ability. Scoring systems for both models 1 and 2 also had good predictive accuracies, with cut-off scores of 3.5 for model 1 and 9.5 for model 2. The CAS predicted independent ambulation at 2weeks postoperatively; however, this relationship was limited at 3months postoperatively. Therefore, the CAS may help estimate independent ambulation at discharge from an acute-care hospital.

Broken prosthetic distal inter-locking modular femur stem: a case report of rare implant type failure

A 79-year old female presented with broken REEFTM stem (Depuy) femur prosthesis. She had three hip surgeries for trauma, followed by primary hip replacement (15 years before presenting) and later fifth surgery (seven years before presenting) for periprosthetic subtrochanteric femur fracture with a Depuy REEFTM stem system. The non-union at left femur subtrochanteric region fracture landed in this implant failure. The complex medical comorbidities and multiple hip surgeries made this a high-risk scenario. Patient recuperated satisfactorily but passed away 2 years post-operatively with urosepsis. Conclusion is tha no prosthetic stem can be completely immune to failure.

Evaluation of haemodynamic stability with the fascia iliaca compartment block in the elderly undergoing hip surgeries

Background and Aims:Elderly patients with hip fracture have a high anaesthetic risk. Peri-operative management poses a challenge requiring a multi-disciplinary approach. This study investigated whether the fascia iliaca compartment block (FICB) with general anaesthesia (GA) using a supra-glottic device (SGD) can provide adequate analgesia and peri-operative haemodynamic stability and avoid post-operative complications.Methods:This prospective observational cross-sectional study was conducted after Institutional Review Board clearance and written informed consent of 30 patients of the American Society of Anesthesiologists grade II and III, undergoing elective surgery for fracture neck femur fracture, were obtained. After pre-medicating patients with inj. Glycopyrrolate and Midazolam, ultra-sonography (USG)-guided FICB was given in the supine position with a high-frequency linear probe using 30 ml of 0.25 % bupivacaine with 8 mg dexamethasone. After confirming the effect of the block at 20 min, patients were given GA with inj. Propofol and proper size I-gel was placed, and patients were maintained on oxygen, nitrous oxide, and sevoflurane.Results:FICB with GA using an SGD provides peri-operative haemodynamic stability with minimal changes in mean blood pressure and a heart rate with p value < 0.05. The visual analogue scale (VAS) score before giving the block was 9.5 ± 0.5, which decreased to 2.7 ± 0.49 at 20 min after giving the block, which was statistically significant. The post-operative duration of analgesia was 456 ± 43.438 min.Conclusion:Elderly patients with fracture neck femur often have one or more co-morbidities. In such patients, FICB with GA using an SGD is a useful technique providing peri-operative haemodynamic stability and satisfactory post-operative analgesia.

Abstract No.: ABS1604: A comparative study of bupivacaine versus ropivacaine in preoperative fascia iliaca compartment block in patients posted for proximal femur fracture surgeries under spinal anaesthesia

Background and Aims:Positioning for spinal anaesthesia is challenging in patients with femur/hip fractures as it causes severe pain/distress. Peripheral nerve blocks are safe adjuncts without side-effects of systemic analgesics. This study was conducted to compare the efficacy between bupivacaine and ropivacaine in ultrasound-guided fascia iliaca compartment block (FICB) for positioning of spinal anaesthesia.Methods:70 patients( 35 in each group) of American Society of Anesthesiologists physical class I-III, either sex, aged between 18-70 years, posted for proximal femur surgeries were randomly allocated in two groups. All patients in group B received 30ml of 0.25%bupivacaine and in groupR 30ml of 0.25%ropivacaine was administered for FICB.. Onset of sensory block was noted every two minutes using pinprick method. Fifteen minutes later spinal anaesthesia was performed with 0.5% hyperbaric bupivacaine in sitting position. Analgesia during positioning was assessed. The quality of patient positioning for spinal anaesthesia was recorded. Vitals were monitored before(baseline) and after block for every 5minutes until 15minutes. The time for first rescue analgesic request and 24h opioid consumption was noted.Results:Mean onset of FICB in group B was 6.17±1.403 minutes and group R was 10.51±1.772 minutes which was statistically significant (p value <0.001). There was no significant difference in visual analogue scale(VAS) during positioning and quality of positioning in both groups. Time to first rescue analgesia in group B was 409.71±85.146 minutes and groupR was 445.71±77.736 minutes (p value 0.0069) but the difference was not statistically significant. There was no significant difference in 24hour opioid consumption among the two groups.Conclusion:FICB provides analgesia which helps in positioning of the patient for spinal anaesthesia with bupivacaine having faster onset of action compared to ropivacaine but provides comparable duration of analgesia and 24 hour opioid consumption.

Survival of proximal femoral fractures vs. mean life expectancy of the general population : Retrospective analysis of 1000 geriatric patients minimum 10years after operation

Surgery for geriatric proximal femoral fractures (PF) is associated with high mortality rates within the first year. Studies with follow-up of at least 10years after surgery are lacking. Based on our database, we reviewed patients with PF who underwent surgery and were followed for aminimum of 10years. Only patients aged 65-99years were included. The primary endpoint was survival compared to the mean life expectancy of the general population evaluated by the German Federal Statistical Office. The secondary endpoint was any revision later than 1year after surgery. After aminimum of 10years telephone calls were conducted with living patients or their relatives. From a total of 1203consecutive patients 1000patients with 1000 PF were evaluated after amean of 12.2years (range 10.0-14.0 years). The mean survival was 4.5 ± 1.6years, and the 10-year survival rate was 13.1%. Atotal of 7 periods with arange of 5years were analyzed, starting from 65-69years up to 95-99years. Compared to the mean life expectancy of the general population, the survival rate of the sample was significantly shorter up to 9years. Both genders were equally affected. With increasing age, this gap declined based on shorter life expectancy. Asubgroup analysis revealed that patients with survival > 1year did not demonstrate significantly better results. Revisions later than 1year after the index surgery were infrequent, and only 27(2.7%) were recorded. Geriatric patients with PF have significantly shorter life expectancy than the general population evaluated by the German Federal Statistical Office. This reflects fragility and morbidity of patients with PF.

Effect of general and sub-arachnoid anesthesia on the incidence of postoperative delirium and cognitive impairments in elderly Chinese patients

&#x0D; &#x0D; &#x0D; &#x0D; Purpose: To investigate the effect of general and subarachnoid (spinal) anesthesia on the incidence of postoperative delirium and cognitive impairments in elderly Chinese patients.&#x0D; Methods: Elderly Chinese patients (n = 281) aged 65 – 79 years (mean age = 74.12 ± 4.15 years) who underwent proximal femoral fracture surgery were recruited over a 1-year period for this study. The patients were evaluated using neuropsychological assessment battery (NAB) 24 h before surgery, and on the first day 1 month after surgery. Data on activity of daily living (ADL) (in this case toileting at the time of discharge) were recorded and analyzed.&#x0D; Results: There was no significant difference in the number of patients that developed postoperative delirium between the two anesthesia groups (p &gt; 0.05). Although the trail making test (TMT) scores (parts A and B) were increased on the first day 1 month after surgery, there were no significant differences in NAB results between the two groups (p &gt; 0.05). Patients who received subarachnoid (spinal) anesthesia had significantly higher dependency for toileting at the time of discharge than those who received general anesthesia (p &lt; 0.05).&#x0D; Conclusion: These results show that general and subarachnoid (spinal) anesthesia do not cause postoperative delirium and cognitive dysfunction in elderly Chinese patients who underwent proximal femoral fracture surgery.&#x0D; &#x0D; &#x0D; &#x0D;

Evaluation of Ultrasound-guided Pre-emptive Fascia Iliaca Compartment Block for Postoperative Analgesia in Femur and Hip Fracture Surgeries: A Randomised Controlled Trial

Introduction: Spinal anaesthesia is the preferred anaesthetic technique for fractures of the hip and femur. Ultrasound-guided Fascia Iliaca Compartment Block (FICB) provides more intense analgesia which can prolong the duration of postoperative analgesia and also mitigate the pain encountered while positioning for spinal anaesthesia. Aim: To evaluate the efficacy of ultrasound-guided pre-emptive FICB in hip and femur fracture surgeries. Materials and Methods: This randomized, double-blinded, clinical study was conducted between May 2019 and December 2019, at SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India. Total 66 patients scheduled for hip and femur fracture surgeries under spinal anaesthesia were randomly divided into two groups i.e, group A received Ultrasound-Guided (UG) FICB preoperatively and group B received no block. All the patients received fentanyl 1 mcg/kg intravenous (i.v.) 15 min before spinal anaesthesia. The anaesthesiologist performing spinal anaesthesia graded the score of positioning as 0 as not satisfactory, 1 as satisfactory, 2 as good, 3 as optimal. The time for the first request for analgesia, consumption of analgesics and Visual Analog Scale (VAS) scores for 24 hours postoperatively and any adverse effects were compared between the two groups. Student’s t-test was used to compare continuous data and unpaired t-test for categorical data. Results: The time for the first request for analgesia was 671.52±66.73 min in group A and 480.3±57.65 min in group B and was statistically significant (p-value &lt;0.0001). In group A, the quality of positioning for spinal anaesthesia was optimal in 13 and good in 14 patients. In group B, it was unsatisfactory in 12 and just satisfactory in four patients (p-value=0.0009). Majority of the patients (24) in group A required three doses of paracetamol, while 26 patients required two doses for group B. The total number of doses for tramadol was 4 in group A, and 17 in group B. The VAS scores were reduced at the 8th and 10th hours following surgery in group A. No adverse effects were encountered in the study. Conclusion: The FICB prolongs the time to first request for analgesia postoperatively, improves patient positioning for spinal anaesthesia, reduces the consumption of analgesics, and improves VAS scores postoperatively without any adverse effects.