Intertrochanteric Fracture Patients Research Articles

A New Postoperative Stability Score to Predict Loss of Reduction in Intertrochanteric Fractures in Elderly Patients

The study aimed to validate a newly developed postoperative stability score for evaluating clinical follow-up in elderly patients with low-energy hip fractures. From 1 January 2020 to 31 December 2021, we enrolled patients aged over 65 who underwent cephalomedullary nail fixation using proximal femoral nail antirotation II (PFNAII) and had at least 6 months of follow-up; excluding multiple fractures, pathological fractures, and periprosthetic fractures. We collected general patient data. Parameters such as TAD, Parker’s ratio (AP and lateral), and the new postoperative stability score were recorded. A loss of reduction was defined using the decline in the Chang reduction quality criteria (CRQC) score within one month. Among the 108 enrolled patients, 23 (21.3%) experienced a loss of reduction, with a mean age of 82.1 years and a mean follow-up time of 7.4 months. Univariate analysis showed no significant association between loss of reduction and general data. However, the new postoperative stability score correlated significantly with loss of reduction (mean scores: 6.68 vs. 4.83, p = 0.045). Multivariate analysis confirmed this association (odds ratio: 0.076, 95% confidence interval: 0.022–0.263, p < 0.05). The newly developed postoperative stability score, incorporating surgical technique assessment, improves prediction accuracy for loss of reduction in elderly intertrochanteric fracture (ITF) patients.

Extending the intermedullary nail will not reduce the potential risk of femoral head varus in PFNA patients biomechanically: a clinical review and corresponding numerical simulation

Femoral head varus is an important complication in intertrochanteric fracture patients treated with proximal femoral nail anti-rotation (PFNA) fixation. Theoretically, extending the length of the intramedullary nail could optimize fixation stability by lengthening the force arm. However, whether extending the nail length can optimize patient prognosis is unclear. In this study, a review of imaging data from intertrochanteric fracture patients with PFNA fixation was performed, and the length of the intramedullary nail in the femoral trunk and the distance between the lesser trochanter and the distal locking screw were measured. The femoral neck varus status was judged at the 6-month follow-up. The correlation coefficients between nail length and femoral neck varus angle were computed, and linear regression analysis was used to determine whether a change in nail length was an independent risk factor for femoral neck varus. Moreover, the biomechanical effects of different nail lengths on PFNA fixation stability and local stress distribution have also been verified by numerical mechanical simulations. Clinical review revealed that changes in nail length were not significantly correlated with femoral head varus and were also not an independent risk factor for this complication. In addition, only slight biomechanical changes can be observed in the numerical simulation results. Therefore, commonly used intramedullary nails should be able to meet the needs of PFNA-fixed patients, and additional procedures for longer nail insertion may be unnecessary.

Association between increased systemic immune-inflammation index and postoperative delirium in older intertrochanteric fracture patients

Background and purposeThe systemic immune-inflammation index (SII), a novel inflammation index derived from the counts of circulating platelets, neutrophils and lymphocytes, has been studied in the treatment of acute cancer and ischemic stroke (AIS). However, the clinical value of the SII in postoperative delirium patients has not been further investigated. The purpose of our research was to study the incidence and preoperative risk factors for postoperative delirium (POD) and verify whether the SII could serve as a potential marker for POD in older intertrochanteric fracture patients. Finally, we created a novel nomogram for predicting POD in older patients with intertrochanteric fractures.MethodsWe enrolled elderly patients with intertrochanteric fractures who underwent proximal femoral nail antirotation (PFNA) between February 2021 and April 2023. Univariate and multivariate logistic analyses were subsequently performed to confirm the risk factors and construct a nomogram model.Calibration curve and clinical decision curve analysis (DCA) were used to assess the model’s fitting performance. The performance of the nomogram was evaluated for discrimination, calibration, and clinical utility.ResultsA total of 293 patients were eligible for inclusion in the study, 25.6% (75/293) of whom had POD. The POD patients had higher SII values than the non-POD patients. The SII was strongly correlated with POD in older intertrochanteric fracture patients, and the optimal cutoff value was 752.6 × 109. Multivariate analysis revealed that age, diabetes, total albumin, SII > 752.6 × 109 and a CRP > 20.25 mg/L were independent risk factors for POD patients. By incorporating these 5 factors, the model achieved a concordance index of 0.745 (95% CI, 0.683–0.808) and had a well-fitted calibration curve and good clinical application value.ConclusionThe SII is a simple and valuable biomarker for POD, and the new nomogram model can be used to accurately predict the occurrence of POD. They can be utilized in clinical practice to identify those at high risk of POD in older intertrochanteric fracture patients.

Lateral wall thickness is not associated with revision risk of medially stable intertrochanteric fractures fixed with a sliding hip screw.

This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality. This retrospective study included ITF patients aged 50 years and over treated with SHS fixation between 2019 and 2021 at a major trauma centre. Demographic information, fracture type, delirium status, American Society of Anesthesiologists grade, and length of stay were collected. LWT and tip apex distance were measured. Revision surgery and mortality were recorded at a mean follow-up of 19.5 months (1.6 to 48). Cox regression was performed to evaluate independent risk factors associated with revision surgery and mortality. The cohort consisted of 890 patients with a mean age of 82 years (SD 10.2). Mean LWT was 27.0 mm (SD 8.6), and there were 213 patients (23.9%) with LWT < 20.5 mm. Overall, 20 patients (2.2%) underwent a revision surgery following SHS fixation. Adjusting for covariates, LWT < 20.5 mm was not independently associated with an increased revision or mortality risk. However, factors that were significantly more prevalent in LWT < 20.5 mm group, which included residence in care home (hazard ratio (HR) 1.84; p < 0.001) or hospital (HR 1.65; p = 0.005), and delirium (HR 1.32; p = 0.026), were independently associated with an increased mortality risk. The only independent factor associated with increased risk of revision was older age (HR 1.07; p = 0.030). LWT was not associated with risk of revision surgery in patients with an ITF fixed with a SHS when the calcar was intact, after adjusting for the independent effect of age. Although LWT < 20.5 mm was not an independent risk factor for mortality, patients with LWT < 20.5 mm were more likely to be from care home or hospital and have delirium on admission, which were associated with a higher mortality rate.

Factors associated with postoperative quality of life in patients with intertrochanteric fracture

Introduction: Intertrochanteric fractures, which make up the majority of hip fractures, are a common and serious injury that can greatly impact quality of life. Treatment of such fractures comprises nearly half of the costs contributed to hip fractures. Identifying the factors affecting the functional outcomes of patients after intertrochanteric fracture can help to reduce burden of disease for the patient and healthcare system. The present study investigated the factors underlying the worsening of short form-36 score (SF-36) scores for intertrochanteric fracture patients. Materials and methods: This retrospective cohort study was designed based on data from our clinic. All consecutive patients with intertrochanteric fractures from November 2016 to September 2020 were reviewed. The exclusion criteria included patients having a second injury or having had previous surgery related to the hip and those with incomplete data. Baseline characteristics of patients were extracted from annotated records. The lab data were acquired from the electronic hospital system. The outcomes were SF-36 scores obtained by phone contact with patients or their families. Statistical analysis was conducted in SPSS. Results: A total of 310 patients were included in the current study. The female gender, advanced age, history of diabetes, thyroid malfunction, cancer, osteoporosis, anticoagulant use and blood transfusion were identified as risk factors for lower SF-36 scores. Low levels of haemoglobin before surgery, blood urea nitrogen (BUN), BUN/Creatinine, and white blood count values correlated with lower SF-36 scores. Conclusion: Numerous contextual variables affected the functional outcomes of the patients. Consideration of these factors could be helpful in reducing costs and improving the quality of life for intertrochanteric fracture patients.

Reliability of lateral wall-thickness measurement in trochanteric fractures and parameters associated with lateral wall integrity.

The AO Foundation/Orthopaedic Trauma Association (AO/OTA) introduced a new trochanteric fracture classification in January 2018, concerning the lateral wall integrity. It suggested the intramedullary nail fixation in patients with an incompetent lateral wall fracture. To determine the reliability of lateral wall-thickness measurement and the fracture parameters associated with lateral wall integrity. This retrospective study evaluated patients with an intertrochanteric fracture who had had surgery in King Chulalongkorn Memorial Hospital between January 2014 and January 2019. The lateral wall was measured by anteroposterior plain radiography by four raters, two times each. The demographic data and fracture parameters were assessed and compared with respect to lateral wall integrity. In a total of 236 femurs and 232 patients having the 2018 AO/OTA-specified 31A1 and 31A2 intertrochanteric fractures, the lateral wall-thickness measurement showed excellent inter-rater reliability at 0.944 (0.927-0.957) and good-to-excellent intra-rater reliability ranging from 0.835 to 0.972. The parameters associated with lateral wall incompetence as per the multivariate logistic regression analysis were fracture angle (odds ratio [OR] = 0.95), distal greater trochanter involvement (OR = 9.47), and fragments at the intertrochanter area (OR = 4.49) and at the lesser trochanter (OR = 2.6). Some of the parameters related to trochanteric fractures are associated with lateral wall incompetence. Lateral wall-thickness measurement is a reproducible method, which has been suggested for use by the AO/OTA 2018 classification. It is easy to use and can help select the appropriate treatment for intertrochanteric fracture patients.

Comparative study to measure femoral malrotation in inter-trochanteric femur fracture done by conventional and fluoroscopic method

: Rotational malalignment following intramedullary nailing in intertrochanteric femur fractures is an under recognized complication. The incidence is varied from 17 to 35% as per literature. In this study we used intraoperative fluoroscopic method to assess anteversion angle, incidence of malalignment and to check whether intraoperative fluoroscopy is useful to reduce incidence of rotational malalignment or not. Twenty patients of intertrochanteric femur fracture who presented to hospital between 1 October 2019 to 30 September 2020 were divided in two groups of 10 patients each. Group 1 was operated with intraoperative fluoroscopic method and group 2 operated by conventional method of intramedullary nailing. Alignment measured as angle of anteversion by post-operative CT scan and comparison between two groups was done.: The incidence of rotational malalignment was 15%. Three patients had significant difference of 15° in anteversion angle compared to opposite normal femur. All these three malalignments were seen in the fluoroscopic group 1 and had unstable fracture patterns. Unstable fracture patterns are at increased risk of rotational malalignment. In intra operative fluoroscopic method distal femur posterior condylar axis is taken in to consideration. Most of the elderly people have some degree of fixed flexion deformity of the knee due to arthritic changes. This requires more internal rotation to achieve straight posterior condylar axis. This may be the reason for internal rotation malalignment in the fluoroscopic method.

Excess Mortality for Femoral Intertrochanteric Fracture Patients Aged 50 Years and Older Treated Surgically and Conservatively in Tianjin, China: A Cohort Study.

Intertrochanteric fracture is one type of hip fracture, which is the most serious consequence of osteoporosis. Along with the growing elderly population, intertrochanteric fracture is expected to rise increasingly. The aim of this study was to assess excess mortality after intertrochanteric fractures and to identify the predictors of long-term mortality by therapy among patients aged 50 years and older in Tianjin. This is a retrospective cohort study on mortality for 3029 patients aged 50 years and older in Tianjin experiencing an intertrochanteric fracture between December 26, 2014 and December 31, 2018. Data were from Tianjin Hospital Hip Fracture (THHF) cohort. Follow-up period was until March 31, 2022. Mortality, excess mortality, and comorbidities were analyzed and stratified by therapy and gender. Time dependent Cox models were performed to estimate the effects of the variables. Absolute mortality for all the patients was 5.90% at 3 months, 12.55% at 12 months, 19.92% at 24 months and 27.28% at 36 months. Absolute mortality for surgical group was 1.57% at 3 months, 4.77% at 12 months, 8.49% at 24 months and 12.07% at 36 months, significantly lower than conservative group: 10.50% at 3 months, 20.73% at 12 months, 31.96% at 24 months and 43.04% at 36 months. We found a substantially lower mortality (hazard ratio [HR] 0.34, 95% confidence internal, [CI]: 0.23-0.52, p = 0.000) among patients undergoing surgical therapy than those undergoing conservative therapy, even when controlled for gender, age, the length of hospital stay, and all the comorbidities. Female patients (HR 0.68, 95% CI: 0.58-0.79, p = 0.000) were less likely to die than male patients after an intertrochanteric fracture. Patients treated by the two methods were both found to have excess mortality rates compared to the general population, although in different levels. The excess mortality rates for patients in the conservative therapy group were 14.46% in males and 17.93% in females, while in the surgical therapy group, 2.78% in females and 4.37% in males. The comorbidities moderate or severe renal disease (HR 2.19, 95% CI: 1.61-2.98, p = 0.000), metastatic solid tumor (HR 6.35, 95% CI: 1.56-25.85, p = 0.010), hypoproteinemia (HR 1.22, 95% CI: 1.01-1.47, p = 0.034), and older age (HR 1.89, 95% CI: 1.73-2.08, p = 0.000) were also risk factors on mortality. A worse-case analysis for the primary outcome were performed as sensitivity analysis and it was consistent with the original conclusion. Intertrochanteric factures for people aged 50 years older were found to have excess mortality compared to the general population in Tianjin city, and preventing the fractures in the hip for elderly people was imperative. After controlling tfor comorbidities and age, female gender and surgical therapy were protective factors for the death after fractures, which could provide strong evidence for patients and surgeons to make decisions.

Measurement of Harris Hip Scoring During Early post-operative Period in Intertrochanteric Fractures FemurTreated with Dynamic Hip Screw

Objectives: Intertrochanteric fractures of femur are difficult fractures to reconstruct because of strong biomechanical forces leading to failure of many an implant designs in the past. After failure of many designs Dynamic Hip Screw (DHS) has stood the test of time. We have prospectively studied the functional recovery of these fractures in 60 patients for 24weeks using Harris Hip scores. Harris hip score was used to measure the outcome. Material and Methods: It was a descriptive case series done between 15th March 2022 to 14 January2023 in Department of Orthopedics Surgery, Avicenna Hospital, Lahore. Sixty patients of intertrochanteric fractures within 2weeks ofinjury of age≥50 yearswere inducted in a descriptive study and Harris Hip Score was used to study the rehabilitation during 6 months after surgery. Patients with other fractures of same limb or multiple fractures, BMI &gt;35.0kg/m2, or diabetic (BSR &gt;200 mg/dl), patients with pre-existing symptomatic acetabular diseases, patient with previous stroke, hemiparesis or other neuromuscular disorder likely to interfere with uneventful rehabilitation were excluded. Patients were were followed-up in OPD after 12, 20 and 24 weeks of surgery. On each visit biplane X-rays were made, patient was interviewed and Harris hip score was calculated. In the end according to Harris hip score, functional outcome was categorized as excellent, good, fair and poor outcomes. Results: Out of these 60 patients, 20 (33.33%) were male and 40 (66.67%) were female. Mean age was 61.40 ± 5.97 years. Mean duration of fracture was 8.05 ± 2.51 months. In ourstudy, functional outcome was excellent in 63.33%, good in 26.67%, fair in 5.0% and poor in 5.0% cases. Mean Harris hip score was 88.40 ± 7.91. Conclusion: Harris hip score can be used to assess rehabilitation of patients treated with DHS for intertrochanteric fractures in early post operative period.

How much of the superolateral femoral neck should be removed in intramedullary nail fixation for intertrochanteric fracture?

The objective of this study was to measure how much of the superolateral femoral neck should be removed to reduce the incidence of wedge effect. Simulating surgery: Computed Tomography images of 131 intertrochanteric fracture patients were included, three-dimensionally reconstructed, virtually reduced and implanted with Proximal Femoral Nail Antirotation blade-Ⅱ(PFNA-Ⅱ) nail. The antero-posterior length and media-lateral width of the intersection between superolateral femoral neck and PFNA-Ⅱ nail were measured. Retrospective study: The pre- and postoperative CT of 30 patients were collected. The average varus angle of the neck-shaft angle and the correlation between the angles and the difference in the actual and estimated width of the fragments removed were measured. Models of 108 patient were selected for analysis. The average antero-posterior length and media-lateral width were 14.46 mm (14.00-14.93 mm) and 9.33 mm (8.79-9.87 mm), respectively. The AO/OTA classification was not significantly associated with the outcome, but the gender was. In the retrospective study, the mean value of the varus angles was -4.58° (SE = 6.85°), and the difference of width was strongly positively correlated with the varus angle with a correlation coefficient of 0.698. Results obtained in this study can improve the understanding of this region and help surgeons to make appropriate preoperative planning to reduce the incidence of wedge effect. Retrospective study provided effective proof of the reliability of this study.

EFFECTIVENESS OF SKIN TRACTION ON PREOPERATIVE PAIN SCALE IN INTERTROCHANTERFRACTURE PATIENTS

Fracture is a condition where the continuity of bone tissue is broken. Intertrochanter fractures are fractures that occur in the pelvic bones with a transverse line from the greater trochanter to the lesser trochanter. Broken bones are a potential or real threat to a person's integrity, so they experience physiological and psychological disorders that can cause reactions in the form of pain. Traumatic pain due to bone fractures that damage healthy tissue. The first treatment is to observe whether there are other accompanying injuries, after that skin traction is applied which is considered effective before performing surgery to reduce pain. Objective: to determine the reduction in pain scale in intertrochanteric fracture patients after skin traction was applied. The method in this research uses a pre-experimental design with a one group pretest-posttest design. Data collection techniques used questionnaire sheets and the Numeric Rating Scale (NRS) pain scale. Data analysis used paired T test. The results showed that the intensity of pain before and after being given skin traction had decreased. The conclusion in the study was that the installation of skin traction before surgery could reduce the pain scale in intertrochanter fracture patients.

A Good Tip-Apex Distance Does Not Make Up For a Poor Reduction in Intertrochanteric Hip Fractures Treated with an Cephalomedullary Nail: The Utility of the Neck-Shaft Angle in Preventing Fixation Failure.

Determine if any fracture characteristics or radiographic parameters were predictive of fixation failure [FF] within 1 year following cephalomedullary nailing for intertrochanteric fractures. A consecutive series of intertrochanteric hip fracture patients (AO/OTA 31A) treated with a cephalomedullary nail were reviewed. Pre-fixation (neck-shaft angle [NSA], distance from ischial tuberosities to greater and lesser trochanters, integrity of lesser trochanter, and fracture angulation) and post-fixation (post-fixation NSA, posteromedial cortex continuity, lag screw position, tip to apex distance [TAD], and post-fixation angulation and translation) radiographic parameters were measured by blinded independent reviewers. The FF and non-FF groups were statistically compared. Logistic regression was performed to determine radiographic parameter correlates of FF. Of 1249 patients, 23 (1.8%) developed FF within 1 year. The FF patients were younger than their non-FF counterparts (77.2 years vs 81.0 years, p=0.048), however there were no other demographic differences. The FF cohort did not differ in frequency of TAD over 25 mm (4.3% vs 9.6%, p=0.624) and had decreased mean TAD (13.6mm vs 16.3mm, p=0.021) relative to the non-FF cohort. The FF cohort had a higher rate of a post-fixation coronal plane NSA more than 10° different from the contralateral side (delta NSA>10°, 34.8% vs 13.7%, p=0.011) with the majority fixed in relative varus. For every 1° increase in varus compared to the contralateral side the odds of FF increased 7% (OR=1.065, 95%CI[1.005-1.130], p=0.034) on univariate analysis. On univariate logistic regression, patients with an absolute post-fixation NSA of 10° or more of varus compared to contralateral were significantly more likely to have a FF (OR=3.139, 95%CI[1.067-8.332], p=0.026). Despite an acceptable TAD, post-fixation NSA in relative varus as compared to the contralateral side was significantly associated with failure in intertrochanteric hip fractures fixed with a cephalomedullary nail. Prognostic Level III.

Early Posttraumatic Antifibrinolysis Reduces Perioperative Hidden Blood Loss in Elderly Patients with an Intertrochanteric Fracture: A Randomized Controlled Trial.

This study aimed to determine the efficacy and safety of posttraumatic antifibrinolysis with multidose tranexamic acid (TXA) in reducing perioperative hidden blood loss (HBL) in elderly intertrochanteric fracture patients. Ninety-six elderly intertrochanteric fracture patients admitted to our department from June 2021 to September 2022 were randomized into two groups. The control group (Group A) received 100 mL of normal saline, while the experimental group (Group B) received 1.5 g of TXA intravenously q12 h from postadmission Day 1 (PAD1) to the day before surgery, and both groups received 1.5 g of TXA q12 h from postoperative Day 1 (POD1) to POD3. Haemoglobin (Hb), haematocrit (Hct), coagulation parameters, fibrinogen degradation product (FDP), and D-dimer (D-D) were recorded from PAD1 to POD3. HBL was calculated using the gross formula and recorded as the primary outcome. In all-over analyses, the patients in Group B had lower perioperative HBL (on PAD3, POD1, and POD3), preoperative HBL (HBLpre), decline of haemoglobin (ΔHb-on PAD3), allogeneic blood transfusion (ABT) rate, FDP (on PAD3), and D-D (on PAD3) compared with Group A. No significant differences were exhibited in postoperative HBL (HBLpost) between the 2 groups. In subgroup analyses, for patients who received intervention within 24 h, the result is consistent with the whole. For patients who received intervention over 72 h of injury, there were no significant differences in perioperative HBL, ΔHb, ABT rate, FDP, and D-D between the 2 groups. There were no significant differences in APTT, PT, the rate of venous thromboembolism, wound complications, or 90-day mortality between the 2 groups. For elderly intertrochanteric fracture patients, early posttraumatic antifibrinolysis with multidose TXA is effective in reducing perioperative HBL, which mainly manifests as the reduction of preoperative HBL, especially for patients injured within 24 h. Application of TXA beyond 72 h of injury was ineffective.

Study protocol: biomechanical testing, finite element analysis and prospective, randomized, clinical study of single screw cephalomedullary nailing versus integrated dual interlocking screw fixation for unstable (31A21–3) intertrochanteric fractures in patients > 70 years old

BackgroundHip fractures are an increasingly common consequence of falls in older people that are associated with a high risk of death and reduced function. The vast majority of intertrochanteric fractures require surgical treatment to withstand early mobilization and weight bearing, which prevents complications due to prolonged bed rest and aids in fracture healing.MethodsThis study is compromised by two parts, the experimental study and the clinical part. In the first part, a standard 130° nail will be used with the appropriate lag screw(s) and dynamic distal locking in synthetic osteoporotic femurs and the transmission of forces in the proximal femur, measured by a cortical surface-strain distribution, will be evaluated using digital image correlation. Finite element parametric models of the bone, the nails and their interface will be also developed. Finite element computations of surface strains in implanted femurs, after being validated against biomechanical testing measurements, will be used to assist the comparison of the nails by deriving important data on the developed stress and strain fields, which cannot be measured through biomechanical testing. In the other part, will set up a prospective, randomized, comparative clinical study among the Gamma3 and IT cephalomedullary nailing, in order to investigate if there are any statistical important differences in the main radiological measurements and functional status in closed unstable intertrochanteric fractures (A21-3) in patients aged over 70 years old at the 24-week follow-up evaluation using patient reported disease-specific outcomes.DiscussionThis study will be the first to compare clinical, radiological and biomechanical measurements of the two different cephalomedullary nails. Our main hypothesis is that the IT nail would provide better radiological outcome and probably better clinical results than the Gama3 nail.Clinical trial registration International Standard Randomized Controlled Trial Number (ISRCTN): https://doi.org/10.1186/ISRCTN15588442, registered on 19/4/2022.

The impact of preoperative single low-dose dexamethasone on in-hospital prognosis in geriatric intertrochanteric fracture patients: Analysis of secondary outcomes in a randomized controlled trial

BackgroundIntertrochanteric fracture in the geriatric population is associated with poor prognosis, which may be attributed to consistent stress and the systemic inflammatory response. Dexamethasone is an exogenous glucocorticoid commonly used in clinical practice for broad anti-inflammatory action. The purpose is to investigate whether a single preoperative low-dose dexamethasone can improve the in-hospital prognosis in geriatric intertrochanteric fracture patients undergoing internal fixation surgery. MethodsBetween June 2020 and October 2022, 219 eligible patients with intertrochanteric fractures were in this study. After meeting the inclusion and exclusion criteria, 160 patients were randomly allocated to the dexamethasone or placebo groups (80 patients who are geriatric with an intertrochanteric fracture in each group). The patients in the dexamethasone group received 10 mg (2 mL) of dexamethasone intravenously, whereas the patients in the placebo group received 2 mL of saline intravenously within 30 minutes before being sent to the operating room. The efficacy-related outcomes (the first bed-chair transfer ability, in-hospital mortality, and length of stay) and safety-related outcomes (infection events and hyperglycemia) were collected for analysis. ResultsThere were no significant differences in the baseline characteristics between the 2 groups. The dexamethasone group had a significantly higher rate of the first bed-chair transfer than the placebo group (65.0% [52/80] vs 48.8% [39/80], relative risk = 1.46, 95% confidence interval = 1.02 to 2.11; P = .038). One patient in the dexamethasone group and 7 patients in the placebo group died during hospitalization (1.3% [1/80] vs 8.8% [7/80], relative risk = 0.92, 95% confidence interval = 0.86 to 0.99; P = .07). No differences were found in the length of stay, infections, and hyperglycemia between the 2 groups. ConclusionA single preoperative low-dose of dexamethasone can improve the in-hospital prognosis (increase the ability of the first bed-chair transfer and potentially decrease the in-hospital mortality) in geriatric intertrochanteric fracture patients after internal fixation surgery.

Changes in Lipid biomarker related to trauma severity in intertrochanteric fracture patients.

This study aimed to identify whether there are elevations or declines in specific plasma lipids in intertrochanteric fracture (ITF) patients which might serve as potential biomarkers for assessing the severity of trauma, or therapeutic targets for controlling post-traumatic responses. Ten metal work removal patients were enrolled. Their preoperative blood samples served as the control group (C group). Their 24-hour postoperative blood samples served as the moderate trauma group (M group). The ITF group was composed of 12 intertrochanteric fracture patients. A total of 707 lipid species were identified from 32 plasma samples (10 controls, 10 moderate trauma and 12 ITF samples). We first identified 31 lipids that were elevated and 6 lipids that were decreased in the more severe trauma group in aged patients, with an especially strong relationship among 14 lipids that are candidates as markers for trauma severity evaluation. Fourteen lipids were identified as potential markers of bone trauma. The definition of important lipids in trauma may not only provide guidance for the formulation of optimum ITF operation time, but may also have importance in other traumatic models, and in further understanding the components of the systemic inflammatory response for new drug targets.

A single preoperative low-dose dexamethasone may reduce the incidence and severity of postoperative delirium in the geriatric intertrochanteric fracture patients with internal fixation surgery: an exploratory analysis of a randomized, placebo-controlled trial

ObjectivePostoperative delirium (POD) is a common complication along with poor prognosis in geriatric intertrochanteric fracture (ITF) patients. However, the prevention and treatment of POD remain unclear. Previous studies have confirmed that POD is essentially a consequence of neuro-inflammatory responses. Dexamethasone is a glucocorticoid with comprehensive anti-inflammatory effects, while a high dose of dexamethasone correlates with many side effects or even adverse consequences. Thus, this prospective study aims to discuss whether a single preoperative low-dose dexamethasone can reduce the impact of POD on geriatric ITF patients with internal fixation surgery.MethodsBetween June 2020 and October 2022, there were 219 consecutive ITF patients assessed in our department. Of the 219 ITF patients, 160 cases who met the inclusion and exclusion criteria were finally enrolled and randomly allocated to the dexamethasone group and the placebo group (80 geriatric ITF patients in each group) in this prospective study. The patients in the dexamethasone group received intravenous 10 mg (2 ml) dexamethasone while the patients in the placebo group received intravenous 2 ml saline in 30 min before being sent to the operating room, respectively. The baseline characteristics, surgical information, incidence and severity of POD as the efficacy-related outcomes, and infection events and hyperglycemia as safety-related outcomes (adverse events), were collected and analyzed between the two groups. The severity of POD was evaluated by Memorial Delirium Assessment Scale (MDAS) score.ResultsThere were no differences in baseline characteristics and surgical information between the dexamethasone group and the placebo group. The dexamethasone group had a lower incidence of POD than the placebo group within the first 5 days after surgery [(9/80, 11.3% vs. 21/80, 26.3%, RR = 0.83, 95% CI 0.71–0.97, P = 0.015]. The dexamethasone group had lower MDAS scores (Mean ± SD) than the placebo group [13.2 ± 1.0 (range 11 to 15) vs. 15.48 ± 2.9 (range 9 to 20), P = 0.011, effect size = 0.514]. There were no differences in infection events and hyperglycemia between the two groups.ConclusionsA single preoperative low-dose dexamethasone may reduce the incidence and severity of POD in geriatric ITF patients with internal fixation surgery.Trial registration: ChiCTR2200055281.

The impact of fixation type for intertrochanteric femoral fracture on patient survival.

Intramedullary (IM) nail fixation for intertrochanteric fractures is potentially associated with improved postoperative function but may have an increased mortality risk compared to sliding hip screw (SHS) fixation. This study investigated postoperative mortality risk between surgical fixation type for intertrochanteric fracture in patients aged 50 years and older using linked data from the Australian Hip Fracture Registry and National Death Index. Descriptive analysis and Kaplan-Meier survival curves performed unadjusted analysis of mortality and fixation type (short IM nail, long IM nail and SHS). Multilevel logistic regression (AMLR) and Cox modelling (CM) performed adjusted analysis of fixation type and mortality following surgery. Instrumental variable analysis (IVA) was conducted to minimize the effect of unknown confounders. The 30-day mortality was 7.1% for short IM, 7.8% for long IM and 7.8% for SHS fixation (P = 0.2). The AMLR demonstrated significant increase in 30-day mortality risk for long IM nail compared to short IM nail (OR = 1.2, 95% CI = 1.0-1.4, P < 0.05) but no significant difference for SHS fixation (OR = 1.1, 95% CI = 0.9-1.3, P = 0.5). No significant difference between groups and postoperative mortality was demonstrated by the CM at 30-days nor 1-year nor by the IVA at 30-days. Despite a significant increase in 30-day mortality risk for long IM nail compared to short IM nail fixation in the adjusted analysis, this was not demonstrated in the CM nor IVA indicating the role of confounders influencing the regression findings. There was no significant association in 1-year mortality between long IM nail and SHS compared to short IM nail fixation.

Effectiveness validation of a novel comprehensive classification for intertrochanteric fractures

To validate the effectiveness of a novel comprehensive classification for intertrochanteric fracture (ITF). The study included 616 patients with ITF, including 279 males (45.29%) and 337 females (54.71%); the age ranged from 23 to 100 years, with an average of 72.5 years. Two orthopaedic residents (observers Ⅰ and Ⅱ) and two senior orthopaedic surgeons (observers Ⅲ and Ⅳ) were selected to classify the CT imaging data of 616 patients in a random order by using the AO/Orthopaedic Trauma Association (AO/OTA) classification of 1996/2007 edition, the AO/OTA classification of 2018 edition, and the novel comprehensive classification method at an interval of 1 month. Kappa consistency test was used to evaluate the intra-observer and inter-observer consistency of the three ITF classification systems. The inter-observer consistency of the three classification systems evaluated by 4 observers twice showed that the 3 classification systems had strong inter-observer consistency. Among them, the κ value of the novel comprehensive classification was higher than that of the AO/OTA classification of 1996/2007 edition and 2018 edition, and the experience of observers had a certain impact on the classification results, and the inter-observer consistency of orthopaedic residents was slightly better than that of senior orthopaedic surgeons. The intra-observer consistency of two evaluations of three classification systems by 4 observers showed that the consistency of the novel comprehensive classification was better for the other 3 observers, except that the consistency of observer Ⅳ in the AO/OTA classification of 2018 version was slightly higher than that of the novel comprehensive classification. The results showed that the novel comprehensive classification has higher repeatability, and the intra-observer consistency of senior orthopaedic surgeons was better than that of orthopaedic residents. The novel comprehensive classification system has good intra- and inter-observer consistency, and has high validity in the classification of CT images of ITF patients; the experience of observers has a certain impact on the results of the three classification systems, and those with more experiences have higher intra-observer consistency.

Whether Assisted Intramedullary Nail Implantation Without Traction Table is as Safe and Effective as Using Traction Table of Older Intertrochanteric Fracture Patients?

Despite promising clinical outcome proposals, there has been relatively little published regarding the use of traction table-assisted intramedullary nail implantation for intertrochanteric fractures. The purpose of this study is to further summarize and evaluate published clinical studies comparing the clinical outcomes of using traction table and without traction table in the management of intertrochanteric fracture. A comprehensive literature search using PubMed, Cochrane Library, and Embase was systematically performed to evaluate all studies included in the literature up to May 2022. The search terms included "intertrochanteric fractures", "hip fractures", and "traction table" with Boolean operators "AND" and "OR". The following information was extracted and summarized: demographic information, setup time, surgical time, amount of bleeding, fluoroscopy exposure time, reduction quality, and Harris Hip Score (HHS). A total of eight clinical controlled studies involving 620 patients were eligible for the review. The mean age at the time of injury was 75.3 years (traction table group 75.7 years, non-traction table group 74.9 years). The most common assisted intramedullary nail implantation method of non-traction table group included lateral decubitus position (4 studies), traction repositor, (3 studies) and manual traction (1 studies). Included studies results all support that there was no difference between the two groups in terms of reduction quality and Harris Hip Score, and the non-traction table group had an advantage in terms of setup time. However, there were still disputes in terms of surgical time, amount of bleeding and fluoroscopy exposure time. For patients with intertrochanteric fractures, assisting intramedullary nail implantation without traction table is as safe and effective as using traction table and doing so without a traction table may be more advantageous in terms of setup time.