Intertrochanteric Hip Fractures Research Articles

Treatment and presentation of intertrochanteric hip fractures during the COVID-19 pandemic in a third-level care hospital

Treatment and presentation of intertrochanteric hip fractures during the COVID-19 pandemic in a third-level care hospital

Development and Validation of Two-Step Prediction Models for Postoperative Bedridden Status in Geriatric Intertrochanteric Hip Fractures.

Patients with intertrochanteric hip fractures are at an elevated risk of becoming bedridden compared with those with intraarticular hip fractures. Accurate risk assessments can help clinicians select postoperative rehabilitation strategies to mitigate the risk of bedridden status. This study aimed to develop a two-step prediction model to predict bedridden status at 3 months postoperatively: one model (first step) for prediction at the time of admission to help dictate postoperative rehabilitation plans; and another (second step) for prediction at the time before discharge to determine appropriate discharge destinations and home rehabilitation programs. Three-hundred and eighty-four patients were retrospectively reviewed and divided into a development group (n = 291) and external validation group (n = 93). We developed a two-step prediction model to predict the three-month bedridden status of patients with intertrochanteric fractures from the development group. The first (preoperative) model incorporated four simple predictors: age, dementia, American Society of Anesthesiologists physical status classification (ASA), and pre-fracture ambulatory status. The second (predischarge) model used an additional predictor, ambulation status before discharge. Model performances were evaluated using the external validation group. The preoperative model performances were area under ROC curve (AUC) = 0.72 (95%CI 0.61-0.83) and calibration slope = 1.22 (0.40-2.23). The predischarge model performances were AUC = 0.83 (0.74-0.92) and calibration slope = 0.89 (0.51-1.35). A decision curve analysis (DCA) showed a positive net benefit across a threshold probability between 10% and 35%, with a higher positive net benefit for the predischarge model. Our prediction models demonstrated good discrimination, calibration, and net benefit gains. Using readily available predictors for prognostic prediction can assist clinicians in planning individualized postoperative rehabilitation programs, home-based rehabilitation programs, and determining appropriate discharge destinations, especially in environments with limited resources.

No Difference in Clinical and Hospital Quality Outcomes in Treatment of Reverse Obliquity Intertrochanteric Hip Fractures (AO/OTA 31.A3) Based on Cephalomedullary Nail Length

IntroductionThe purpose of this study was to evaluate outcomes following reverse obliquity (RO) intertrochanteric hip fractures based on the use of short cephalomedullary nails (CMNs) compared to long CMNs for fixation. MethodsAn IRB-approved prospectively collected hip fracture registry at an urban academic medical center was queried for all AO/OTA 31A3.1-3 reverse obliquity intertrochanteric (RO) fractures. One hundred and seventy patients with age > 55 years old and minimum 6-month follow-up were identified for analysis. Data was collected for patient demographics, injury details, intraoperative radiographic parameters, perioperative physiologic parameters, hospital quality measures, and outcomes including radiographic time to healing, need for reoperation, nonunion, and mortality. Comparative analyses were conducted between cohorts. Additional multivariable binary logistic and linear regression analyses were performed to evaluate for factors independently associated with short and long nail usage. ResultsThe mean age of the entire cohort was 80.91±10.09 years: 103 patients had a long CMN implanted, and 67 patients had a short CMN implanted. There were no demographic differences or differences in radiographic time to healing, rates of mortality, readmission, nonunion, and need for reoperation. Univariable analysis revealed that short CMN had lower intraoperative blood loss (111.19±83.97mL vs 176.72±161.45mL, p=0.002), decreased need for transfusion (37% vs. 55%, p=0.022), and shorter procedures (118.67±57.87min vs. 148.95±77.83min, p=0.002. Multivariable analysis revealed that short nail usage was associated with decreased intraoperative blood loss, decreased need for transfusion, and shorter operative times. ConclusionNail length does not affect healing or hospital quality outcomes in the treatment of RO hip fractures. The use of short CMNs for these fractures did correlate with lower intraoperative blood loss, operative time, and need for blood transfusion, with non-inferior outcomes and similar hospital quality measures when compared to long CMNs.

Accuracy of detecting burst of the lateral wall in intertrochanteric hip fractures with plain radiographs: Is postoperative CT necessary?

BackgroundPostoperative burst of the lateral femoral wall is thought to be the main predictor of reoperation for intertrochanteric fractures, which is routinely evaluated using plain radiographs. We retrospectively compared computed tomography (CT) scans and radiographs regarding the ability to detect burst of the lateral wall. We also investigated whether intramedullary nails may cause iatrogenic burst of the lateral wall. MethodsFrom January 2010 to December 2021, patients aged 65 years and older who undergone intertrochanteric fractures treated with the proximal femoral nail antirotation 2 (PFNA-Ⅱ) were included. The incidence of burst of the lateral wall was evaluated with two different imaging modalities by two observers. Two rounds of evaluation were performed: (1) with plain radiographs alone; and (2) with CT scans combined with radiographs. Interobserver and intraobserver agreement (κ value) for evaluation of the lateral wall burst was assessed. ResultsA total of 1507 patients were included (362 males and 1145 females). Compared with radiographs alone (12.0 %, 181/1507 patients), a higher rate of lateral wall burst was found by CT scans combined with radiographs (72.9 %, 1098/1507 patients) for observer 1 at first reading (P < 0.001). Similar results were seen in other evaluations. Interobserver and intraobserver agreement was substantial for radiographs alone (κ, 0.659–0.727) and almost perfect for CT scans combined with radiographs (κ, 0.847–0.926). ConclusionsComputed tomography combined with radiographs is superior to radiographs alone for detecting burst of the lateral wall after intertrochanteric fracture fixation. Additionally, PFNA-Ⅱ could cause iatrogenic burst of the lateral wall for intertrochanteric fractures in the elderly.

Hip Fracture Repair by the Post-Call Surgeon: A Multicenter Retrospective Review.

The purpose of this study was to evaluate surgeons' ability to perform or supervise a standard operation with agreed-upon radiologic parameters after being on call. We reviewed a consecutive series of patients with intertrochanteric hip fractures treated with a fixed angle device at 9 centers and compared corrected tip-apex distance and reduction quality for post-call surgeons versus those who were not. Subgroup analyses included surgeons who operated the night before versus not and attending-only versus resident involved cases. Secondary outcomes included union and perioperative complications. One thousand seven hundred fourteen patients were of average age 77 years. Post-call surgeons treated 823 patients and control surgeons treated 891. Surgical corrected tip-apex distance did not differ between groups: on-call 18 mm versus control 18 mm (P = 0.59). The Garden indices were 160° on the AP and 179° on the lateral in both groups. In 66 cases performed by surgeons who operated the night before, the TAD was 17 mm. No difference was noted in corrected tip-apex distance with and without resident involvement (P = 0.101). No difference was observed in pooled fracture-related complications (P = 0.23). Post-call surgeons demonstrated no difference in quality and no increase in complications when performing hip fracture repair the next day compared with surgeons who were not on call.

Optimizing the Entry Point for Medullary Hip Screws.

Medullary hip screws (MHSs) are the most common treatment of intertrochanteric hip fractures because they can be used for varied fracture patterns and resist shortening. Identifying the appropriate MHS entry point can be intellectually and technically challenging. We aimed to quantify the variability in the ideal entry point (IEP) for MHSs. Standing alignment radiographs of 50 patients were evaluated using TraumaCad (Brainlab). The femoral neck shaft angle and the offset from the tip of the greater trochanter (GT) to the femur's longitudinal axis ('greater trochanter offset') were measured. Five MHS system templates were superimposed on the femur's longitudinal axis, and the distance from the GT tip to MHS's top center was measured. Five independent reviewers each templated 20 images such that all images were measured at least twice. A random sample of five images was selected for all five raters to measure and to calculate an intraclass coefficient Mean IEPs were compared with an independent sample Student t -test. The mean GT offset was 13.5 ± 5.6 mm (range 12.9 to 26.7 mm). The mean neck shaft angle was 129.5 ± 4.0 (range 120 to 139). The mean IEP for nail systems ranged from 5.7 to 7.1 mm medial to the GT tip; there was no notable difference in pairwise comparison of nail systems or in aggregate. Intraclass coefficient for all ratings, measurements, and nail types ranged from moderate to good. Both intra-rater and inter-rater reliability were excellent. In a sample with broad variation in femoral anatomy, there is a specific, roughly 1.5 mm wide interval that is 6.4 mm medial to the GT tip that serves as the IEP for the most common MHS systems. No notable difference seems to exist in the IEP among these MHS systems.

A systematic review and meta-analysis on the impact of nail length in treating intertrochanteric fractures

The management of intertrochanteric hip fractures remains a subject of ongoing debate, particularly regarding the ideal nail length for treatment. To address this, a systematic review and meta-analysis, based on randomized controlled trials (RCTs), were conducted to assess the outcomes associated with using short and long nails to fix intertrochanteric femur fractures. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for comprehensive reporting, a thorough search was conducted across four databases (Cochrane, Google Scholar, Web of Science, and PubMed) from inception until March 07, 2022. The study encompassed all RCTs comparing the outcomes of short and long nail fixation for intertrochanteric hip fractures. A total of 620 patients with intertrochanteric fractures from six RCTs were included in this analysis. Short nails were used in 50.3% of the patients (312 out of 620). The utilization of short nails was significantly associated with a reduction in operative time (weighted mean difference [WMD] = −20.33; 95% confidence interval [CI]: −29.90–−10.76) and decreased blood loss (WMD = −106.31; 95% CI: −155.43–−57.19). However, no substantial differences were observed between the two types of implants in terms of length of hospital stay, Harris hip score, reoperation rate, complication rate, and 1-year mortality rate. The length of nails used to treat intertrochanteric hip fractures does not have a notable impact on factors such as functional recovery, blood transfusion frequency, reoperation likelihood, complications, or 1-year mortality rates. Nonetheless, when comparing the fixation of intertrochanteric fractures, it is worth noting that short nails result in shorter surgery duration and reduced blood loss compared to long nails.

Is the increased use of intramedullary nailing over DHS for intertrochanteric hip fractures justified? – A review of the Irish hip fracture database 2016 –2020

PurposeIntertrochanteric hip fractures are significant and costly injuries and there remains controversy within the orthopaedic literature over the best method of fixation. The Irish Hip Fracture Database (IHFD) was established in 2012 to drive improvements in clinical outcomes and the quality of hip fracture care. This paper will review the outcomes of dynamic hip screw (DHS) versus intra-medullary nailing (IMN) in the treatment of intertrochanteric hip fractures in Ireland. MethodsEligible cases for this study include patients >60 years of age with trochanteric hip fractures treated by DHS or IMN between January 2016 and December 2020. Outcomes recorded and compared include length of stay, inpatient mortality, mobilisation on post-operative day 1 (POD 1), and discharge destination. Results5668 hip fractures treated with DHS or IMN were identified. There was no significant difference between inpatient mortality, re-operation rate or length of stay between the two groups. Females and patients with a high ASA grade (IV and V) were more likely to receive IMN. Patients receiving DHS were more likely to be mobilised day 1 post-operatively and be discharged directly home. It was noted that the use of IMN increased from 42% of cases in 2016 to 70% in 2020. ConclusionIMN use for intertrochanteric fractures continues to increase. However, patients treated with DHS were more likely to mobilise early post-operatively and to go directly home. Notwithstanding the limitations of national registry data research, the dramatic rise in the use of IMN for these fractures appears unsupported by the evidence.

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.

Efficacy of preoperative Tranexamic Acid in patients undergoing intertrochanteric hip fracture surgery: A randomized placebo controlled trial.

To determine the efficacy of preoperative Tranexamic Acid (TXA) in reducing perioperative allogenic blood transfusion frequency in patients with intertrochanteric fractures treated with Dynamic Hip Screw (DHS). We conducted this placebo controlled double-blinded randomized trial in Orthopaedics & Traumatolgy Division Lady Reading Hospital, Peshawar from 1st January 2020 to 25th December 2022. All patients with intertrochanteric hip fractures fulfilling the inclusion criteria were treated with Dynamic Hip Screw (DHS) and were randomly divided into two equal groups. One group was administered single dose IV Tranexamic Acid (TXA) in a dose of 15mg/kg body weight in 100ml of saline while the other group (Placebo) was given 100 ml normal saline preoperatively. Post-operative Hemoglobin was measured on first, second and third day. The frequency of allogenic blood transfusions in the perioperative period was determined in both groups based upon the transfusion trigger (Hemoglobin 9g/dl). Categorical variables were compared with Chi-square test and mean with Independent sample t-test. P value of <0.05 was considered significant. The total number of patients in our trial were 200 which were equally but randomly allocated into TXA group and Placebo group each containing 100 patients. The mean age of the patients in TXA group was 48.16±1.75 years and the age of patients in the Placebo group was 48.35±1.60. The baseline demographic and clinical variables of both groups were identical (p< 0.05). The average preoperative hemoglobin was 11.5±4.2 g/dl in TXA group and 11.3±2.4g/dl in the Placebo group (p>0.05). The frequency of allogenic blood transfusion was significantly lower (p<0.05) in TXA group (13%, n=13) than in the Placebo group (41%, n=41). Tranexamic acid (TXA) significantly reduces the frequency of peri operative allogenic blood transfusion in patients undergoing Dynamic Hip Screw (DHS) for intertrochanteric fractures.

Assessing the Necessity of Extra Reduction Aides in Intramedullary Nailing of Intertrochanteric Hip Fractures.

This study aims to determine which intertrochanteric (IT) hip fracture and patient characteristics predict the necessity for adjunct reduction aides prior to prep and drape aiming for a more efficient surgery. Institutional fracture registries from two academic medical centers from 2017-2022 were analyzed. Data on patient demographics, comorbidities, fracture patterns identified on radiographs including displacement of the lesser trochanter (LT), thin lateral wall (LW), reverse obliquity (RO), subtrochanteric extension (STE), and number of fracture parts were collected, and the need for additional aides following traction on fracture table were collected. Fractures were classified using the AO/OTA classification. Regression analyses identified significant risk factors for needing extra reduction aides. Of the 166 patients included, the average age was 80.84±12.7 years and BMI was 24.37±5.3 kg/m2. Univariate regression revealed increased irreducibility risk associated with RO (odds ratio [OR] 27.917, P≤0.001), LW (OR 24.882, P<0.001), and STE (OR 5.255, P=0.005). Multivariate analysis significantly correlated RO (OR 120.74, P<0.001) and thin LW (OR 131.14, P<0.001) with increased risk. However, STE (P=0.36) and LT displacement (P=0.77) weren't significant. Fracture types 2.2, 3.2, and 3.3 displayed elevated risk (P<0.001), while no other factors increased risk. Elderly patients with IT fractures with RO and/or thin LW are at higher risk of irreducibility, necessitating adjunct reduction aides. Other parameters showed no significant association, suggesting most fracture patterns can be achieved with traction manipulation alone.

Cut-Through versus Cut-Out: No Easy Way to Predict How Single Lag Screw Design Cephalomedullary Nails Used for Intertrochanteric Hip Fractures Will Fail?

This study aims to compare patients in whom fixation failure occurred via cut-out (CO) or cut-through (CT) in order to determine patient factors and radiographic parameters that may be predictive of each mechanism. This retrospective cohort study includes 18 patients with intertrochanteric (IT) hip fractures (AO/OTA classification 31A1.3) who underwent treatment using a single lag screw design intramedullary nail in whom fixation failure occurred within one year. All patients were reviewed for demographics and radiographic parameters including tip-to-apex distance (TAD), posteromedial calcar continuity, neck-shaft angle, lateral wall thickness, and others. Patients were grouped into cohorts based on the mechanism of failure, either lag screw CO or CT, and a comparison was performed. No differences in demographics, injury details, fracture classifications, or radiographic parameters were observed between CO/CT cohorts. Of note, a similar rate of post-reduction TAD>25 mm (P=0.936) was observed between groups. A higher rate of DEXA (dual energy X-ray absorptiometry) confirmed osteoporosis (25.0% vs. 60.0%) was observed in the CT group, but without significance. The mechanism of CT failure during intramedullary nail fixation of an IT fracture did not show an association with clinical data including patient demographics, reduction accuracy, or radiographic parameters. As reported in previous biomechanical studies, the main predictive factor for patients in whom early failure might occur via the CT effect mechanism may be related to bone quality; however, conduct of larger studies will be required in order to determine whether there is a difference in bone quality.

The Effect of Bone Quality on Treatment of Intertrochanteric Fractures with Helical Blade Versus Lag Screw Fixation in Cephalomedulary Nails.

The specific aim of this retrospective study was to determine whether bone quality has any effect on the complication rates or overall survivorship between helical blades and lag screws in cephalomedullary nails used for intertrochanteric hip fractures. The authors reviewed clinical charts and radiographic studies of patients between January 2012 and August 2019. We reviewed radiographic images (pre-, intra-, and post-operative) to evaluate fracture fixation type, fracture reduction grade, and post-operative complications. We collected dual energy x-ray absorptiometry scan results (T-score) and serum alkaline phosphatase (ALP) isoenzyme activity values to evaluate patient bone quality. We included 303 cases (helical: 197, screw: 106) in the study. Complications were found in 31 (16%) helical blade cases and 23 (22%) lag screw cases. No statistically significant difference was detected when comparing complication rates with patient bone quality between the two groups. These two groups had similar one-year implant survivorship with respect to T-score, the low ALP level group, and normal ALP level group. The helical blade had higher implant survivorship compared to lag screw in five-year survival rate with respect to osteoporotic group, high ALP level group, and normal ALP level group (osteoporotic: 77% vs 69%, high ALP: 73% vs 67%, normal ALP: 70% vs 64%). Similar complication rates were observed between helical blade and lag screw constructs in cephalomedullary femoral nails when accounting for patient bone quality. However, the helical blade design had a higher five-year survival rate.

Prospective Associations Between Fear of Falling, Anxiety, Depression, and Pain and Functional Outcomes Following Surgery for Intertrochanteric Hip Fracture.

Fear of falling, anxiety, depression, and pain levels are important risk factors for poor functional outcomes that may potentially be modifiable. We aimed to examine prospective associations between those factors following surgery for intertrochanteric hip fracture. This study is a prospective observational cohort study of patients aged over 65 diagnosed with isolated intertrochanteric hip fracture. Three hundred and seventy patients who underwent intramedullary fixation surgery were screened; 188 cases were included in our final evaluation. Patients with any concomitant fracture, major psychiatric/neurocognitive and neurological disorders and those with any other major disease were excluded from the study. Age, Charlson Comorbidity Index (CCI), Geriatric Depression Scale (GDS), State-Trait Anxiety Inventory (STAI), Falls Efficacy Scale International (FES-I), and Visual Analog Scale (VAS) scores on the day of surgery (baseline) were evaluated as predictors of poor/good outcome at 90 days after surgery, by Harris Hip Score (HHS) with a cut-off score of 70. HHS score was significantly predicted at baseline by the full model [χ2 (7) = 18.18, P = .01]. However, only STAI-state scores were significantly added to the model [Exp (B) 95% CI: .92 (.86-.99)]. In this prospective cohort study, we found that higher levels of anxiety state on the day of surgery predicts a poor outcome at 90 days following surgery. We did not find significant associations between other variables, including age, GDS, STAI-trait, FES-I, VAS, and CCI. This potentially modifiable psychological factor may inform surgeons and could be a potential mediator. Future prospective studies are needed to replicate these findings. Prognostic level I.

Comparison of calcareous replacement hemiarthroplasty and proximal femoral nail in elderly ıntertrochanteric femur fractures

Background: In this study, a retrospective evaluation was made of patients aged 70 years and over who were applied with proximal-femoral nail (PFN) or calcareous replacement cemented hemiarthroplasty in respect of early and late-stage morbidity and mortality and functional personal independence. Methods: The study included a total of 77 patients aged over 70 years with an AO type 31-A1 or 31-A2 fracture. The patients were separated into two groups as those applied with proximal femoral nailing and those applied with calcar replacement hemiarthroplasty. Statistical comparison was made of the groups in respect of preoperative age, comorbidities, type of anaesthesia, ASA score, and fracture type, and postoperative amount of blood loss, albumin decrease, wound complications, other complications, Harris hip functional scores, Barthel daily living activity index, mortality rates. Results: The two groups were found to be similar in respect of age, gender, comorbidities, AO fracture type and type of anaesthesia. The operating time was shorter in the proximal femoral nailing group. The Harris hip scores and the Barthel daily living activity ındex values were similar in both groups. Rates of wound infection were higher in the hemiarthroplasty group. Mortality rates at one month, six months and one year were similar in both groups. Conclusions: Proximal femoral nailing can be one of the primary treatment options for intertrochanteric hip fractures in the elderly. Furthermore, although functional results and mortality rates are similar, as cemented calcar replacement hemiarthroplasty has serious life-threatening complications, it should not be the first choice of treatment method.

FELLOWSHIP-TRAINED ORTHOPAEDIC TRAUMATOLOGISTS ACHIEVE BETTER POSTOPERATIVE RADIOLOGICAL PARAMETERS AFTER CEPHALOMEDULLARY NAILING OF INTERTROCHANTERIC FRACTURES COMPARED WITH COMMUNITY SURGEONS

Intertrochanteric fractures are common, accounting for nearly 30% of all fracture related admissions. Some have suggested that these fractures should be treated in community hospitals so as not to tax the resources of Level One trauma centers. Since many factors predictive of fixation failure are related to technical aspects of the surgery, the purpose of this study was to compare radiographic parameters after fixation comparing trauma fellowship trained surgeons to non-fellowship trained community surgeons to see if these fractures can be treated successfully in either setting.Using our hospital system's trauma database, we identified 100 consecutive patients treated with cephalomedullary nails by traumatologists, and 100 consecutive patients treated by community surgeons. Quality of reduction, neck shaft angle (NSA), tip-to apex distance (TAD) were compared.The mean TAD for the trauma group was 10mm compared to 21mm for the community group (p&lt;0.001). The mean postoperative NSA for the trauma group was 133 degrees compared to 127 degrees for the community group (p&lt;0.001). The mean difference in the NSA of the fractured side compared to the normal hip was 2.5 degrees of valgus in the trauma group compared to 5 degrees of varus for the community group (p&lt;0.001). There were 93 good reductions in the trauma group compared to 19 in the community group (p&lt;0.001). There were no poor reductions in the trauma group and 49 poor reductions in the community group (p&lt;0.001).Fellowship trained traumatologists achieved significantly more accurate reductions and implant placement during cephalomedullary nailing of intertrochanteric hip fractures.

Morbidity and Mortality Analysis in the Treatment of Intertrochanteric Hip Fracture with Two Fixation Systems: Dynamic Hip Screw (DHS) or Trochanteric Fixation Nail Advance (TFNA).

The aim of this study was to compare the clinical outcomes, complications, and mortality of patients with intertrochanteric hip fracture treated with dynamic hip screw (DHS) vs. trochanteric fixation nail advance (TFNA). We evaluated 152 patients with intertrochanteric fractures concerning age, sex, comorbidity, Charlson Index, preoperative gait, OTA/AO classification, time from fracture to surgery, blood loss, amount of blood replacement, changes in gait, full weight-bearing at hospital discharge, complications, and mortality. The final indicators encompassed the adverse effects linked to implants, postoperative complications, clinical healing or bone healing duration, and functional score. The study included a total of 152 patients, out of which 78 (51%) received DHS treatment and 74 (49%) received TFNA treatment. The results of this study show that the TFNA group demonstrated superiority (p < 0.001). However, it should be noted that the TFNA group had a higher frequency of the most unstable fractures (AO 31 A3, p < 0.005). Full weight-bearing at discharge also decreased in patients with more unstable fractures (p = 0.005) and severe dementia (p = 0.027). Mortality was higher in the DHS group; however, a longer time from diagnosis to surgery was also observed in this group (p < 0.005). The TFNA group has shown a higher success rate in achieving full weight-bearing at hospital discharge when treating trochanteric hip fractures. This makes it the preferred choice for treating unstable fractures in this region of the hip. Additionally, it is important to note that a longer time to surgery is associated with increased mortality in patients with hip fractures.

Primary Cementless Femoral Stems in Conversion Hip Arthroplasty After Failed Fixation of Intertrochanteric Fractures.

Salvage conversion hip arthroplasty is a viable solution to restore function and reduce pain after failed intertrochanteric hip fracture fixation. Our primary objective was to assess early outcomes achieved with primary cementless metaphyseal-engaging femoral stems for conversion hip arthroplasty compared with revision diaphyseal-engaging stems. This was a retrospective review of 70 patients with failed intertrochanteric hip fractures subsequently managed with conversion total hip arthroplasty or hemiarthroplasty. Thirty-five patients who underwent conversion using a primary cementless stem were compared with 35 patients who underwent conversion using a revision stem. The groups were similar regarding sex, body mass index, American Society of Anesthesiologists classification, preoperative diagnosis, and implants removed. Clinical and radiographic outcomes and complications were compared over a mean follow-up of 6 years. The primary stem cohort had a shorter mean hospital stay (3.03 vs 4.34 days, P=.028). There were no significant differences between the primary and revision cohorts regarding mean time to conversion (2.26 vs 1.75 years, P=.671), operative time (127 vs 131 minutes, P=.611), incidence of discharge to home (54.3% vs 37.1%, P=.23), postoperative complications (5.71% vs 5.71%, P=1.0), reoperations (5.71% vs 11.4%, P=.669), leg length discrepancy (5.33 vs 7.38 mm, P=.210), subsidence (20.0% vs 23.3%, P=.981), and Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (78.6 vs 81.9, P=.723). We report comparable outcomes of conversion hip arthroplasty with the use of primary cementless and revision stems. Current primary cementless femoral stems may be considered for conversion hip arthroplasty for failed intertrochanteric fracture fixation. [Orthopedics. 2024;47(1):e6-e12.].

Is there a time when we should treat a fresh hip fracture in a physiologically elder patient with palliative care?

HISTORY - A 92-year-old female patient presents to the Emergency Room with a displaced intertrochanteric hip fracture after a fall from bed. She lives in a full care nursing home with severe dementia and wears an adult diaper. She does not walk anymore (for 3 months) and the family decision makers (they have power of attorney) have decided that she is not a surgical candidate except under extreme circumstance. Medically, she has moderate aortic regurgitation and a long history of chronic pulmonary fibrosis that has required occasional oxygen supplementation. She has Type 2 diabetes and takes oral meds for this. She has swallowing difficulties and eats mostly pureed food. She only communicates when she has pain and does not recognize her family when they visit. Her hemoglobin and electrolytes are within normal limits. Her vitals are stable, and she is mildly hypertensive.

Outcomes of cement augmentation in fragility trochanteric hip fractures – A multicenter randomized controlled trial follow-up

PurposeCement augmentation is considered to improve the bone-implant construct stability in hip fragility fractures, additionally biomechanical studies show that cement augmentation improves the pull-out strength and increases resistance to failure. Thus far, the advantage of these technique used in a clinical scenario is yet to be determined Methodsa randomized, multicenter, single-blinded clinical trial was conducted in patients aged 65 years or older who were admitted to two level I trauma centers with a fragility intertrochanteric hip fracture during September 2015 and December 2017. Patients were stratified into 2 groups: patients between 65 and 85 years and older than 85 years. A balanced block randomization was performed using blocks of 6 patients: 3 patients assigned to the control group (no augmentation) and 3 patients to the intervention group. Follow-up visits were done at 1, 3, 6 and 12 postoperative months documenting the tip-apex distance (TAD) as well as followed up after 5 to 7 years of surgical procedure documenting EQ5D, Parker Mobility Score and mortality rates at these different time points. ResultsA total of 90 patients were included but only 53 patients completed a one-year follow up. The mean immediate postoperative and one-year follow up TAD measurement from the whole cohort (20.99 mm vs 21.3 mm, respectively) showed no statistical significance (P = 0.18). For patients in the control group, the difference of TAD measurements from the immediate postoperative and one-year follow-up was –0.25 mm (P = 0.441). For patients included in the intervention group, the difference of TAD measurement from the immediate postoperative and 1-year follow up was -0.48 mm (P = 0.383). No statistical difference was found when stratified by age (p = 0.78). One patient from the control group had an implant failure after 1-month postoperative. Readmission after 30 days showed no statistical difference between both groups (7 vs. 7 patients, p = 0.754). Augmentation did not show a difference in most of the functional outcomes nor quality of life after 5 to 7 years of surgical procedure. ConclusionsThe use of augmentation can be considered a safe procedure for the fixation of fragility hip fractures.