Intracapsular Hip Fractures Research Articles

Commentary: Dynamic hip screw fixation versus multiple screw fixation for intracapsular hip fracture.

of fragility hip fracture also increases. By 2050, the incidence is predicted to be around 4.5 million.1 Treatment of intracapsular hip fractures depends on many factors including patient age, fracture pattern, degree of fracture displacement and comorbidities. For younger patients (<65 years of age), the femoral head should be preserved using an internal fixation method, either multiple screw fixation or dynamic hip screw (DHS), to avoid any long-term complication of arthroplasty.2 For elderly patients, both internal fixation methods are suitable for nondisplaced intracapsular hip fractures. Nonetheless, arthroplasty is preferable for displaced intracapsular hip fractures because of a lower reoperation rate and better functional outcome.3 In this issue, Jettoo et al.4 compared DHS fixation with multiple screw fixation for intracapsular hip Commentary: Dynamic hip screw fixation versus multiple screw fixation for intracapsular hip fracture

Ambulatory Ability and Personal Independence After Hemiarthroplasty and Total Arthroplasty for Intracapsular Hip Fracture: A Prospective Comparative Study

BackgroundTotal hip arthroplasty (THA) has not only been associated with best functional outcomes but also with higher dislocation risk when compared with bipolar hemiarthroplasty (HA). The functionality and activities of daily living (ADL) of patients treated with THA or HA for intracapsular hip fracture (IHF) have been scarcely investigated in comparison with the preoperative status. MethodsTwo comparable groups of 60 patients with an IHF who had undergone either THA or bipolar HA were created matching several preoperative characteristics. Matched variables included age, gender, body mass index, surgical delay, American Society of Anesthesiologists class, comorbidity, cognitive status, educational status, prefracture functional status, and radiographic fracture classification. Patients were prospectively followed up for 1 year using telephone interviews. ResultsThe ambulatory ability (5-item scale) and ADL Index significantly decreased in both the groups in comparison with the prefracture status at the 4-month and 1-year follow-up. The need for walking aids (5-item scale) at 4 months was significantly higher among patients who had undergone HA. Lower scores on the ADL Index were recorded among patients with HA in comparison with those with THA at 4 months and 1 year. No significant differences in ambulatory ability, complication rate, and mortality were detected between the 2 groups although HA and THA were associated with a tendency to a higher prevalence of general and local complications, respectively. ConclusionTHA provides better short-term results in terms of ADLs and allows early discontinuation in the use of walking aids as compared with bipolar HA in elderly cognitively intact patients with IHF.

Radiographic templating of total hip arthroplasty for femoral neck fractures.

The purpose of this study was to evaluate the use of pre-operative digital templating to minimize complications including limb length discrepancy (LLD), intraoperative fractures and early dislocations in patients with intracapsular femoral neck fractures. We retrospectively compared 23 patients undergoing total hip arthroplasty (THA) for intracapsular femoral fractures with pre-operative digital templating and 48 patients without templating. The mean post-operative LLD was significantly lower in patients who had pre-operative templating than in the control group (6.7 vs. 11.5mm, p = 0.023). Only three patients (13%) with templating had LLD greater than 1.5cm, compared to the 15 patients (31%) without templating (p = 0.17). In eight cases the final femoral stem size matched the templated size, while 19 patients were within two size increments. Complications included one dislocation and one intra-operative fracture in the control group. The present study demonstrated that careful pre-operative planning may reduce LLD in patients undergoing THA due to intracapsular hip fractures.

On-table decision-making in intracapsular hip fracture surgery: mid-term results of a pilot study.

At the present time, it is generally recommended to use hip replacement in dislocated fractures to avoid failure after internal fixation. A problem is that previous research has demonstrated that observers have problems in discriminating between dislocated and undislocated fractures. A possible solution to this problem would be to use arthroplasty in the majority of the cases. However, this also means that many fractures with the potential for uneventful healing would be replaced. In the current investigation, the mid-term outcome was recorded for patients with intracapsular hip fractures who were treated with either internal fixation or arthroplasty. A novel treatment algorithm was employed. After careful exclusion of cases with known risk factors for failure after internal fixation, a technique called on-table decision was used to identify suitable patients for internal fixation. A total of 72 patients with intracapsular hip fractures were studied with a median follow-up time of 12months (IQR 8-15.25months). Nineteen (19) patients (26%) were excluded in the selection process, leaving 53 (74%) for on-table decision-making. Thirty patients (42%) were identified as suitable for internal fixation and gave anatomically stable closed reductions. Two of these patients (7%) exhibited non-unions and one (3%) avascular necrosis. The mid-term outcome after internal fixation is promising. The careful selection process may be helpful in identifying fracture patterns for which internal fixation may be considered as a safe and less invasive alternative to hip arthroplasty.

Inequalities in use of total hip arthroplasty for hip fracture: population based study

Objectives To determine whether the use of total hip arthroplasty (THA) among individuals with a displaced intracapsular fracture of the femoral neck is based on national guidelines or if there...

Adherence to guidelines regarding total hip replacement for fractured neck of femur.

Introduction In 2011 the National Institute for Health and Care Excellence (NICE) published guidelines suggesting that clinicians offer total hip replacement (THR) to patients with displaced intracapsular hip fractures who could walk independently outside with no aids or one stick, who are not cognitively impaired and are ASA (American Society of Anesthesiologists) grade ≤2. They also stated that best practice is operating within 36 hours of presentation. This audit aimed to determine whether Scarborough Hospital was following these guidelines and compared the results with the national average. Methods Two years of data (January 2012 - December 2013) were collected retrospectively from Scarborough Hospital's hip fracture database on all patients presenting with an intracapsular hip fracture. Data were analysed to determine whether patients who had a THR fulfilled NICE criteria. Furthermore, patients with hemiarthroplasties who were eligible for THRs were identified. Finally, the time to surgery was calculated to examine whether patients receiving THRs waited longer than patients receiving hemiarthroplasties. Results In 2012, 48.6% of all eligible patients received a THR while in 2013 the figure was 55.9%. These percentages are much higher than the national average. However, 36 (53.7%) of the 67 patients who received a THR did not fulfil all the NICE criteria, mainly owing to high ASA grade. The mean time from presentation to theatre for THR was 8 hours and 37 minutes longer for THR patients than for hemiarthroplasty in 2012. This difference was reduced to 2 hours and 12 minutes in 2013. Conclusions Small general hospitals can meet and even exceed the standards regarding treatment strategies for hip factures. However, there is still room for improvement. Departmental training may be useful in achieving this aim. The anaesthetic team should be involved at the earliest opportunity, to help optimise patients preoperatively and determine whether patients listed for THR with higher ASA grades are suitable for this surgery.

Total hip replacement for elderly neck of femur fracture patients

In keeping with recently published national guidelines, the use of total hip replacement for treating displaced intracapsular hip fractures in elderly patients has significantly increased. This is based on the principle that it provides improved functional outcomes when compared to hemiarthroplasty. Whilst recent published evidence supports this hypothesis, there are concerns regarding higher dislocation rates, cost-effectiveness and difficulties with service provision. The aim of this review is to discuss the benefits of total hip replacement surgery over hemiarthroplasty and to explore patient selection criteria. A review of surgical techniques and difficulties specific to this patient cohort will also be presented. We hope to provide the reader with an up-to-date summary of total hip replacement surgery for hip fractures in elderly patients in order to help decision making, minimize complications and guide further research.

Provision of Total HIP Replacement for Displaced Intracapsular HIP Fracture and the Outcomes: Audit of Local Practice Based on NICE Guidelines

Hip fractures are becoming an increasing public health issue due to an ageing population (1). Total hip replacements (THR) produce better outcomes in certain patients who were functioning independently before the injury (2). We aimed to assess whether the management of intracapsular hip fracture is carried out in accordance with the National Institute for Health and Care Excellence (NICE) hip fracture guidance (1) and the outcomes with regards to performing THRs on those patients who fulfil the described criteria. Data was collected retrospectively from the 1st April 2012 to 31st March 2013 from all fractured neck of femur patients admitted to our hospital. Of the 382 patients fit for an operation, 78 (20.4%) met with the NICE hip fracture guidance for a total hip replacement. Of those eligible, 32 (41.0%) did receive a THR and 4 (2.8%) patients of the 142 not eligible for a total hip replacement also received a THR. Of those eligible for a THR, the patients who underwent that procedure had a significantly lower mortality rate compared to those who underwent a hemiarthroplasty (0% versus 19.6% at 1 year, p = 0.007). However, those who did not meet the NICE criteria but underwent a THR had the worst mortality rate (50% at 30 days and 1 year). The provision rate of THR in displaced intracapsular hip fracture is low at 41.0% for those who met the NICE criteria. The results suggest that the decision process when determining if a patient should undergo THR for a fractured neck of femur is multifactorial.

Both Intracapsular and Extracapsular Hip Fractures Likely to Benefit from Femoral Nerve Blocks

Ultrasound-guided femoral nerve block is increasingly used for analgesia in emergency department patients with hip fracture. Given the anatomy of innervation, a logical question is whether intracapsular fractures might be less amenable to this technique than …

Assessing the impact of fracture pattern on transfusion requirements in hip fractures.

Hip fractures in the elderly represent a major source of morbidity and mortality, with allogeneic blood transfusions (ABTs) associated with increased mortality. This study assesses the ABT requirements between the most common patterns of hip fracture; intertrochanteric (IT) and intracapsular (IC). The impact of operation type on transfusion rates was also assessed. A retrospective study was performed for all patients entered on the national hip fracture database over 1year in a teaching hospital. Records of 559 patients were reviewed and, following exclusion criteria, 474 were evaluated (198 IT, 276 IC). Baseline haematological parameters and ABTs were identified using hospital systems. Analysis was performed in SPSS, using independent samples t tests, one-way ANOVAs and Chi square tests. Patient groups were matched on gender, anaesthetic type, American Society of Anesthesiologist (ASA) grade, cognitive score and coagulation parameters. A significantly greater proportion of IT patients required an ABT during admission (39.4 vs. 22.5%, p<0.001). For IT fractures a greater proportion of patients required an ABT when undergoing an intramedullary nail operation compared with those requiring a dynamic hip screw (67.4 vs. 32.0%, p<0.001). Similarly, for IC fractures transfusion rates in patients undergoing an internal fixation were significantly lower than those undergoing hemiarthroplasty or arthroplasty (9.4 vs. 26.4 vs. 20.8%, p=0.033). Patients with IT hip fractures are significantly more likely to require an ABT than those with IC hip fractures. Patients undergoing an intramedullary nail for IT fractures have significantly higher transfusion rates than for other types of operation.

Inequalities in access to total hip arthroplasty for hip fracture: a population-based study

BackgroundIn June, 2011, the National Institute for Health and Care Excellence (NICE) recommended that total hip arthoplasty (THA) should be offered to a defined group of patients with displaced intracapsular hip fractures. We sought to determine whether national practice was consistent with national recommendations, or whether systematic inequalities exist in accessing THA for hip fracture. MethodsData for this observational study came from the UK National Hip Fracture Database (NHFD), which records data from all hospitals that treat adults with hip fractures in England, Wales, and Northern Ireland. Included were all patients within the NHFD who were aged over 60 and received operative treatment for a non-pathological displaced intracapsular hip fracture between July 1, 2011, and April 30, 2015. Provision of THA to patients eligible under criteria published by NICE were analysed with recursive partitioning and logistic regression. Findings114 119 patients with hip fracture were included, of whom 11 683 (10%) underwent THA. Recursive partitioning showed that NICE eligibility criteria did not optimally explain THA. Among patients satisfying NICE criteria, logistic regression demonstrated that access to THA was restricted by higher age (odds ratio 0·88, 95% CI 0·87–0.88), lower Abbreviated Mental Test Score (1·44, 1·34–1·54), higher American Society of Anesthesiologists score (0·74, 0·66–0·84), male sex (0·85, 0·77–0·93), walking with a stick (0·32, 0·28–0·35), and quintiles of increasing socioeconomic deprivation (1·0 [referent]; lowest vs highest quintile 1·30, 1·13–1·51). Patients treated during the week were more likely to receive THA than those treated at the weekend (1·12, 1·04–1·21). InterpretationThere are wide disparities in access to THA among individuals with hip fractures, and compliance with NICE guidance is poor. Patients with higher levels of socioeconomic deprivation and those requiring surgery at the weekend are less likely to receive THA. Inconsistent compliance with NICE recommendations means that the optimum treatment for older adults with hip fractures can depend on where and when they present to hospital. FundingNational Institute for Health Research.

The provision of total hip replacement for displaced intracapsular hip fractures.

The National Institute for Health and Care Excellence (NICE) currently recommends the use of total hip replacement (THR) for displaced intracapsular hip fractures in patients who meet certain mobility, cognitive and health criteria. A multicentre prospective audit was conducted within a defined geographic region to assess current practice and variation in provision of THR for displaced intracapsular hip fractures. A total of 879 patients with hip fractures, admitted to 8 acute trauma units, were included in this study. Of 462 patients with displaced intracapsular hip fractures, 169 fulfilled the NICE criteria for THR. THR was performed for only 49 of (29%) the eligible patients. There was significant variation in THR provision between the eight units (0% to 50% THR usage, p<0.001). There were statistically significant differences in age, ASA (American Society of Anesthesiologists) grade, abbreviated mental test score and walking ability prior to the injury between patients who underwent fixation, THR or hemiarthroplasty (all p≤0.05). There was a significantly increased chance of not undergoing THR if a patient was older than 77 years (median age for the THR eligible cohort; relative risk [RR]: 7.9, 95% confidence interval [CI]: 2.8-22.0, p<0.001). There was also a trend for this with patients who were ASA grade 3 compared with ASA grade 1 or 2 (RR: 2.7, 95% CI: 1.0-7.3, p=0.06). The surgeons gave multifactorial reasons for not performing THR in eligible patients. There is significant variation in the provision of THR for eligible hip fracture patients, which is influenced by both patient demographics and the unit to which a patient is admitted.

Ultrasound-guided nerve blocks for intracapsular and extracapsular hip fractures

ObjectivesTo compare pain relief between patients with intracapsular and extracapsular hip fractures who received an ultrasound-guided femoral nerve block (USFNB). DesignA multicenter, prospective, randomized, clinical trial. SettingThe study was conducted in the emergency departments of 3 academic hospitals located in New York City. SubjectsPatients aged ≥60 years presenting to the emergency department with hip fracture. MethodsA subgroup analysis from a larger data set was conducted of patients with intracapsular and extracapsular hip fractures who received an USFNB. We compared pain scores at baseline and then at 2 and 3 hours after the nerve block was performed, and also assessed pain relief at 2 and 3 hours. ResultsSeventy-seven patients were randomized to receive USFNB, of which 68 had follow-up data at 2 and 3 hours and were included in the data analysis. Thirty-one were diagnosed with intracapsular and 37 with extracapsular hip fractures. In both groups, reductions in pain scores were clinically and statistically significant. In the intracapsular group, mean pain scores decreased from 6.23 to 3.81 (P < .0001) at 2 hours and from 6.23 to 3.87 (P < .0001) at 3 hours. In the extracapsular group, mean pain scores decreased from 6.62 to 3.89 (P < .0001) at 2 hours and from 6.62 to 3.46 (P < .0001) at 3 hours. These differences were similar between the extracapsular and intracapsular groups at 2 hours (P = .92) and at 3 hours (P = .58), thus demonstrating similar reductions in pain in the 2 groups. The differences in pain relief between the intracapsular and extracapsular groups were also similar: 1.61 (confidence interval [CI], 1.14-2.08) vs 1.35 (CI, 0.96-1.75) at 2 hours (P = .39) and 1.68 (CI, 1.21-2.15) vs 1.38 (CI, 0.89-1.87) at 3 hours (P = .38). ConclusionUltrasound-guided femoral nerve block was equally effective in reducing pain for patients with both intracapsular and extracapsular hip fractures.

VITAMIN D AND ITS RELATION WITH THE ANATOMICAL LOCATION OF HIP FRACTURE IN CHILEAN OLDER ADULTS HOSPITALIZED

in older adults, deficit of Vitamin D and hip fractures are common. There exists relationships between both conditions, and it have been shown that supplementation of Vitamin D improve prognosis of hip fractures. In the case of Chile, information about relationship between Vitamin D and hip fractures is scarce. quantify plasma levels of vitamin D and relate them to the anatomical location of hip fracture. cross-sectional study. 222 Chilean adults ≥60 years, hospitalized for hip fracture between June, 2014 and June, 2015. We use data of medical records about gender, age, seasonality and anatomical location of hip fracture (intra and extracapsular). We measure plasmatic levels of Vitamin D (PLVD) and glomerular filtration rate (GFR) (MDRD-6). Kolmogorov-Smirnov test and non-parametric test were used. For determine relations between PLVD and anatomical location we use linear regression. there was a predominance of women (80.6%). The average age was 80.7 years (SD=7.8). Intracapsular hip fractures were 43.2%. 80% of the sample presents Vitamin D in deficitary levels (n = 180). PLVD average was 13.3 ng/cc (SD=6.7), in subjects with intracapsular fractures were significantly lower (p<0.001). PLVD in subjects with hip fracture should be monitored, as there are differences according to anatomical location of the fracture. This precedent could favor the treatment and recovery of subjects presenting for the first time hip fracture.

Dynamic locking plate vs. simple cannulated screws for nondisplaced intracapsular hip fracture: A comparative study

IntroductionIntracapsular hip fractures (ICHF) are a common cause of morbidity and mortality and pose a great economic burden on the health care systems. Appropriate surgical treatment requires balancing optimal outcomes with the cost of treatment to the health care system. While in elderly patients with displaced ICHF arthroplasty became the standard of care, the internal fixation method for conserving the femoral head in younger patients or in nondisplaced ICHF is still in debate. We compared a dynamic locking plate with the standard cancellous cannulated screws (CCS) for treatment of nondisplaced ICHF. MethodsAll patients treated with internal fixation for nondisplaced ICHF between July 2009 and December 2012 at our level one trauma center were included in this study. Patients treated with Targon FN (Aesculap) implants and CCS (Synthes) were compared. Charts were reviewed for demographics, intraoperative data and peri/post operative complications retrospectively. Radiographical analysis, pain (VAS), quality of life (SF12) and function (MHHS) data were prospectively gathered. ResultsOne hundred and fifteen non-displaced ICHFs were treated with internal fixation, 81 with CCS and 34 with Targon FN implant; the mean follow-up was 19 and 28 months, respectively. Group fracture characteristics (Garden/Powel classification), and demographics, excluding age, were not significantly different. Post-operative revision rates of the Targon FN and CCS groups, perioperative complications were not statistically different (p>0.05). Quality of life (SF-12), function (Modified Harris Hip Score) and Visual Analogue Scale (VAS) pain scores were not statistical different. ConclusionsComplication rates and clinical outcomes for the treatment of nondisplaced ICHF with Targon FN and SCC showed no significant differences. Based on this evidence in consideration of the substantial cost differential between the Targon FN and SCC we suggest SCC for treatment of nondisplaced ICHF. Level of EvidenceIII

Uncemented fully hydroxyapatite-coated hip stem for intracapsular femoral neck fractures in osteoporotic elderly patients: a multicenter study.

There is still debate over the limits of age and bone stock quality of patients on whom to use an un-cemented straight stem coated with hydroxyapatite (HA). We studied a group of 244 patients with a displaced intracapsular fracture of the femoral neck who underwent cementless hemiarthroplasty or total hip arthroplasty. 143 patients were reviewed at the two-year follow up. A fully HA-coated stem for intracapsular hip fracture results in a satisfactory return to pre-injury mobility and a low complications rate. The advantage reported in the literature of a low mortality rate with use of an un-cemented implant in elderly patients was shown to be greater still on finding an immediate primary stability and rapid osteointegration of the implant.

Intra- and extracapsular hip fractures in the elderly: Two different pathologies?

ObjectivesTo compare intracapsular (IC) and extracapsular (EC) hip fractures (HIF) in elderly patients in order to determine if they are different pathologies. Subjects and methodsLongitudinal, observational, descriptive, analytical prospective design, using a non-probabilistic sample from a full sample collection with 647 subjects (male and female), of 60 or more years old, admitted with HIF to the Department of Orthopedics and Traumatology of the Hospital, between January 1, 2010 and December 31, 2012. Follow-up was for 1 year post HIF. Socio-demographic, etiological, developmental, therapeutic and prognostic variables are compared. ResultsThis is the first study on this subject with Latin American population. EC HIF incidence was superior to IC, contrary to that published in European/American populations. There are significant differences in etiological variables (χ2=6.34, P<0.042), with traumatic etiology in EC and non-traumatic in IC. There are also differences in therapeutic interventions performed (osteosynthesis for EC, arthroplasty for IC), with the decision on not to operate being lower in IC (both P<0.0000). The variables associated with the decision on not to perform surgery are age, etiology and postoperative mortality. DiscussionThe results are similar to other studies, adding the IC association with non-traumatic origin, in particular the trend of statistical association between IC and non-primary osteoporotic pathology (neoplasms, renal osteodystrophy, primary hyperparathyroidism). A further analysis was performed on the differences between Latin American and European/American populations in the incidence of either type of HIF. There are important etiological and therapeutic differences between IC and EC HIF; therefore it would be advisable to consider them as distinct disease entities.

Pre-operative nutritional serum parameters as predictors of failure after internal fixation in undisplaced intracapsular proximal femur fractures

IntroductionCurrent management of undisplaced hip fractures is based on internal fixation. Reported revision rates of 12–17% for this procedure negatively impact on patient morbidity and mortality. The aim of this novel study is to examine if the nutritional status of these patients is associated with failure of internal fixation. Patients and methodsA consecutive series of 111 undisplaced intracapsular hip fractures treated with cannulated screw was identified. These were retrospectively reviewed including routine admission serum investigations (lymphocyte count and albumin levels). Radiological investigations were used to assess fracture classification, posterior-tilt angle, fixation adequacy, screw configuration and failure (avascular-necrosis, non-union and screw cut-out). Results16% of fixations failed (18 patients). Patients with fixation-failure had a significantly lower albumin (35g/l vs. 40g/l, p=0.02) and lymphocyte count (0.7×109l vs. 1.4×109l, p≤0.001) than non-failure patients. Lymphocyte count, albumin level and posterior-tilt angle were independent predicators of failure on binary logistic regression analysis. We suggest that routine laboratory tests can be used to identify patients at greatest risk of failure of internal fixation.

Anatomy, classification and treatment of intracapsular hip fractures.

Hip fractures are increasingly common, given the increasing ageing, osteoporotic population with significant medical comorbidities. This review summarizes the anatomy of the proximal femur, reviews classification systems and gives recommendations for use of each treatment modality.

Lateral versus posterior approach for insertion of hemiarthroplasties for hip fractures: A randomised trial of 216 patients

Continued debate exists about the merits of the different surgical approaches for arthroplasty of the hip. For hemiarthroplasty to the hip the two most commonly used approaches are lateral and posterior. 216 patients with an intracapsular hip fracture being treated with a cemented hemiarthroplasty were randomised to surgery using either a lateral or posterior approach. Surviving patients were followed up for one year with pain and functional outcomes assessed by an assessor blinded to the treatment allocation. No statistically significant differences were observed for any of the outcome measures including mortality, degree of residual pain and regain of walking ability. A subjective assessment of the ease of surgery favoured the lateral approach. In conclusion both surgical approaches appear to produce comparable function outcomes.