Intracapsular Hip Fractures Research Articles

Economic evaluation plan of a RCT of hydroxyapatite-coated uncemented hemiarthroplasty versus cemented hemiarthroplasty for the treatment of displaced intracapsular hip fractures

AimThis paper describes the methods applied to assess the cost-effectiveness of cemented versus uncemented hemiarthroplasty among hip fracture patients in the World Hip Trauma Evaluation Five (WHiTE5) trial.MethodsA within-trial cost-utility analysis (CUA) will be conducted at four months postinjury from a health system (National Health Service and personal social services) perspective. Resource use pertaining to healthcare utilization (i.e. inpatient care, physiotherapy, social care, and home adaptations), and utility measures (quality-adjusted life years) will be collected at one and four months (primary outcome endpoint) postinjury; only treatment of complications will be captured at 12 months. Sensitivity analysis will be conducted to assess the robustness of the results.ConclusionThe planned analysis strategy described here records our intent to conduct a within-trial CUA alongside the WHiTE5 trial.

The Feasibility of the Ultrasound-Guided Femoral Nerve Block Procedure with Low-Dose Local Anesthetic in Intracapsular and Extracapsular Hip Fractures.

The local anesthetic dosages used in the current literature in regional applications of local anesthetics are frequently high for surgical purposes, and there are no sufficient dosage studies for emergency department (ED) management. The aim of this study was to determine the success of lower local anesthetic dosages capable of reducing costs and excessive exposure to drugs in pain control in patients with femoral neck fractures (FNFs) in the ED. Patients ≥65years of age with FNFs and reporting Wong-Baker Pain Rating Scales scores ≥8 were included in this prospective, interventional study. Patients underwent ultrasound-guided regional femoral block with 5mL 2% prilocaine. Pain scores before the procedure and at 30min and 2h postprocedure were compared with the Friedman test and Wilcoxon test with Bonferroni correction. Forty patients, 20 with intracapsular and 20 with extracapsular FNFs, were enrolled. The initial pain scores of patients with both intra- and extracapsular fractures were 8 (range 8-10). A statistically significant 50% decrease in pain scores was observed in both groups 30min after the regional block procedure (p<0.001). A statistically significant 75% decrease in pain scores was observed in both groups 2h after the regional block procedure (p<0.001). No statistically significant difference was determined in the change in 30-min and 2-h pain scores between the groups. The administration of 5mL 2% prilocaine for pain control in FNFs in elderly patients in the ED can reduce systemic analgesic requirements by establishing effective analgesia in both intracapsular and extracapsular fractures.

Age related changes in the bone microstructure in patients with femoral neck fractures

BackgroundThe risk of femoral neck fracture progressively increases with age. However, the reasons behind this consistent increase in the fracture risk can't be completely justified by the decrease in the bone mineral density. The objective of this study was to analyze the correlation between various bone structural features and age. Study Design & MethodsA total of 29 consecutive patients who suffered an intracapsular hip fracture and underwent joint replacement surgery between May 2012 and March 2013 were included in this study. A 2 cm × 1 cm Ø cylindrical trabecular bone sample was collected from the femoral heads and preserved in formaldehyde. Bone mineral density (BMD), microarchitecture, organic content and crystallography were analyzed using a Dual-energy X-ray absorptiometry scan, micro-CT scan, and high resolution magic-angle-spinning-nuclear magnetic resonance (MAS-NMR), respectively. Statistical correlations were made using Spearman´s or Pearson´s correlation tests depending on the distribution of the continuous variables. ResultsThe mean patient age was 79.83 ± 9.31 years. A moderate negative correlation was observed between age and the hydrogen content in bone (1H), which is an indirect estimate to quantify the organic matrix (r = −0.512, p = 0.005). No correlations were observed between BMD, trabecular number, trabecular thickness, phosphorous content, apatite crystal size, and age (r = 0.06, p = 0.755; r = −0.008, p = 0.967; r = −0.046, p = 0.812; r = −0.152, p = 0.430, respectively). A weak positive correlation was observed between Charlson´s comorbidity index (CCI) and c-axis of the hydroxiapatite (HA) crystals (r = −0.400, p = 0.035). ConclusionThe femoral head relative protein content progressively decreases with age. BMD was not correlated with other structural bone parameters and age. Patients with higher comorbidity scores had larger HA crystals. The present results suggest that the progressive increase in the hip fracture risk in elderly patients could be partially explained by the lower bone protein content in this age group.

Fat distribution may predict intra- or extra-capsular hip fracture in geriatric patients after falling

IntroductionHip fractures can be divided into intra-capsular and extra-capsular fracture based on fracture location; these two types of fracture have different pathogeneses, treatments and prognoses. Many factors influence the patterns of hip fractures, including the injury mechanism, areal bone mineral density and the geometry of the hip. However, the relationship between body composition and hip fracture pattern has not yet been discussed.In this investigation, an analysis of the body compositions of geriatric patients with hip fractures were conducted to identify differences between fat and muscle distributions between patients with intra- and extra-capsular hip fractures. Material and methodsFrom December 2017 to February 2019, 139 patients with a hip fracture were prospectively enrolled in this study. The groups of patients that were diagnosed as having intra- and extra-capsular hip fractures were compared in terms of patient demographics, pre-operative laboratory data, bone mineral density (BMD) and body composition including muscle and fat distributions obtained using dual-energy X-ray absorptiometry (DXA) . ResultsEighty-six and 53 patients were diagnosed with intra-capsular and extra-capsular hip fractures, respectively. A significantly higher serum glucose level, a lower hemoglobin level, a lower T-score level in the proximal femur region, a lower T-score of all parts of interest, and a lower percentage fat content on the region of bilateral proximal hips (gynoid region) and in the lower limb region, were observed in patients with an extra-capsular hip fracture than in those with an intra-capsular hip fracture. However, with all confounding factors controlled for, only the T-score at the proximal femur, percentage fat content in the region of bilateral proximal hips and the ratio of android fat content to gynoid fat content (A/G ratio) are the most relevant factors in predicting the patterns of hip fracture in geriatric patients after falling. ConclusionThis work demonstrates that lower fat content in the region of bilateral proximal hips and a lower BMD on the proximal femur may predict greater vulnerability of geriatric patients to extra-capsular rather than intra-capsular hip fracture after a falling accident.

CORRELATION BETWEEN HARRIS HIP SCORE (HHS) AND BODY MASS INDEX (BMI) IN PATIENTS WITH FEMORAL NECK FRACTURE AFTER HEMIARTHROPLASTY

Femoral neck fracture is an intracapsular hip fracture. Hemiarthroplasty is one of the treatment options that replaces femoral aspect of hip joint with a prosthesis, while leaving the acetabulum intact. The treatment’s goal is to return the patient to premorbid capacity. Harris Hip Score (HHS) is an assessment for the outcome of hip surgery which contains: pain, functional capacity, deformity and range of motion (ROM). The purpose of study is to determine relation of BMI and Harris Hip Score (HHS) in patients with femoral neck fracture after hemiarthroplasty. This study is analytic-observational study with cross-sectional design conducted in June-September 2014 in Orthopedic’s Polyclinic of General Hospital dr. Zainoel Abidin Banda Aceh. Respondents in this study is 26. Comparative assessment of outcome was analysed by Kruskal-Wallis test with Mann-Whitney test as Post-hoc analysis and correlative assessment was analysed by Spearman test. Comparative assessment present significant relation of BMI (p = 0,006; r=0.458) with Harris Hip Score (HHS) in patients with femoral neck fracture after hemiarthroplasty.

Randomised controlled trial comparing hydroxyapatite coated uncemented hemiarthroplasty with cemented hemiarthroplasty for the treatment of displaced intracapsular hip fractures: a protocol for the WHITE 5 study

IntroductionHip fracture is a serious injury in adults, especially those aged over 60 years. The most common type of hip fracture (displaced intracapsular) is treated for the majority of patients...

The Effect of Surgical Approach on Outcomes Following Total Hip Arthroplasty Performed for Displaced Intracapsular Hip Fractures: An Analysis from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man.

Studies have suggested that the anterolateral approach is preferable to the posterior approach when performing total hip arthroplasty (THA) for a displaced intracapsular hip fracture, because of a perceived reduced risk of reoperations and dislocations. However, this suggestion comes from small studies with short follow-up. We determined whether surgical approach in THAs performed for hip fracture affects revision-free hip survival, patient survival, and intraoperative complications. We retrospectively analyzed all stemmed primary THAs for hip fracture that were recorded in the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man that were performed between 2003 and 2015. The 2 surgical approach groups, posterior and anterolateral, were matched for patient and surgical confounding factors using propensity scores, with outcomes compared using regression modeling (with regression model ratios of <1 representing a reduced risk of the specified outcome in the posterior group). Outcomes were 5-year hip survival free from revision (all-cause revision, revision for dislocation and/or subluxation, and revision for periprosthetic fracture), patient survival (30 days, 1 year, and 5 years postoperatively), and intraoperative complications. After matching, 14,536 THAs (7,268 per group) were studied. Five-year cumulative revision-free survival rates were similar (posterior group, 97.3%, and anterolateral group, 97.4%; subhazard ratio [SHR], 1.15 [95% confidence interval (CI), 0.93 to 1.42]). Five-year survival rates free from revision for dislocation (SHR, 1.28 [95% CI, 0.89 to 1.84]) and for periprosthetic fracture (SHR, 1.03 [95% CI, 0.68 to 1.56]) were also comparable between the 2 approach groups. Thirty-day patient survival was significantly higher following a posterior approach (99.5% compared with 98.8%; hazard ratio [HR], 0.44 [95% CI, 0.30 to 0.64]), which persisted at 1 year (HR, 0.73 [95% CI, 0.64 to 0.84]) and 5 years (HR, 0.87 [95% CI, 0.81 to 0.94]) postoperatively. The posterior approach was associated with a lower risk of intraoperative complications (odds ratio [OR], 0.59 [95% CI, 0.45 to 0.78]). In THA for hip fracture, the posterior approach was associated with a similar risk of revision and a lower risk of both patient mortality and intraoperative complications compared with the anterolateral approach. We propose that the posterior approach is as safe as the anterolateral approach when performing THA for hip fracture and that either approach may be used according to surgeon preference. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

High Incidence of Intraoperative Fractures With a Specific Cemented Stem Following Intracapsular Displaced Hip Fracture

BackgroundTo reduce costs of orthopedic implants, the government decided to standardize implants used across different specialties in a group of hospitals located in the same geographic area. The usual cemented stem used in the context of intracapsular displaced geriatric hip fractures was replaced by another stem. Abnormal intraoperative calcar and trochanteric fractures were noted. The purpose of this study is to determine the incidence of intraoperative periprosthetic fractures following an intracapsular displaced hip fracture treated with this specific cemented stem compared to the previous implant. MethodsThis is a retrospective cohort study comparing an historic cohort of hip fractures treated with the OmniFit EON (Stryker, Kalamazoo, MI) cemented stem with a new cohort of patients who received the Corail (DePuy Synthes, Warsaw, IN) cemented stem. Four orthopedic surgeons reviewed operative reports and postoperative radiographs. ResultsThe treatment group included 348 patients who received the Corail stem. The control group included 77 patients. The 2 groups had similar baseline characteristics (P > .05) except for the presence of dementia. Incidence of intraoperative calcar or greater trochanteric fracture was 15.5% for the Corail group and 2.7% for the control group (P < .05). No patient-related factors or surgeon-related factors were related to a higher number of fractures in the treatment group (P > .05). ConclusionThe Corail cemented stem presents an abnormal number of iatrogenic intraoperative fractures following displaced femoral neck fracture in our geriatric population. No external factor seems to explain this high number of fractures. Implant design should be questioned. Level of EvidenceIII.

Treatment of the displaced intracapsular fracture for the ‘fitter’ elderly patients: A randomised trial of total hip arthroplasty versus hemiarthroplasty for 105 patients

Controversy exists for the optimum method of surgical treatment for the ‘fitter’ elderly patient with a displaced intracapsular fracture. 105 patients were randomised to treatment with either a cemented polished tapered stem hemiarthroplasty or a cemented total hip arthroplasty (THR) with a cemented acetabular cup. All patients were followed up for a minimum of one year using a blinded assessment of functional outcome.Those patients treated with a THR had a tendency to a longer hospital stay and increased medical (12 versus 62) and surgical complications (4 versus 2) in comparison to those treated by hemiarthroplasty. Mean operative times (842 versus 52 min) and operative blood loss (335mls versus 244mls) were increased for THR. Final outcome measures of residual pain and regain of function were similar for both methods of treatment.We recommend that caution should be exercised regarding the increased promotion of THR for intracapsular hip fractures until further studies are completed.

Internal fixation implants for intracapsular hip fractures in adults

Internal fixation implants for intracapsular hip fractures in adults

Surgical interventions for treating intracapsular hip fractures in adults: a network meta-analysis

Surgical interventions for treating intracapsular hip fractures in adults: a network meta-analysis

Preoperative sizing of hip hemiarthroplasties to accurately estimate head size from non- standardised pelvic radiographs: Can it be done?

BackgroundPreoperative sizing of implants for hip fracture patients requiring a hemiarthroplasty is difficult due to non-standardised radiographs, absence of sizing marker, variable patient position and body habitus. We investigated whether a simple tool could help predict femoral head size, allowing surgeons to safely proceed with surgery when implant stocks are limited, and to potentially improve theatre efficiency. MethodsThree independent reviewers measured the maximum width of the contralateral (intact) femoral head using PACS software in 50 cases of intracapsular hip fracture. This was linearly regressed on actual implant size to calculate the average magnification coefficient. Inter- and intra-rater reliability were evaluated using intraclass correlation coefficients (ICC). ResultsThe best fitting magnification constant was 118% (95% confidence interval 16.0–19.7%), which achieved a mean error of 1.7 mm. Prediction accuracy was significantly improved by allowing a constant (intercept) as a second parameter in the regression model (p = 0.01), which achieved a mean error of just 1.4 mm from the implant used. The inclusion of the constant reduces errors at the upper and lower extremes of head sizes. ICCs for inter- and intra-rather agreement were 0.94 and 0.98 respectively. Conclusion(s)We have shown that hip hemiarthroplasty head sizes can be reliably and accurately predicted from non-standardised pre-operative radiographs. We have devised a method which can easily be adopted by other centres and tailored to the characteristics of their radiology department.

Total hip arthroplasty versus hemiarthroplasty for independently mobile older adults with intracapsular hip fractures

BackgroundDisplaced intracapsular hip fractures are typically treated with hemiarthroplasty (HA) or total hip arthroplasty (THA). A number of professional bodies recommend considering THA for patients that were independently mobile and cognitively intact before injury. The aim of this study was to compare the outcomes between HA and THA for independently mobile older adults with hip fractures.MethodsA systematic review and meta-analysis of RCTs was undertaken alongside analysis of a propensity score matched national cohort of older adults (aged > 60) with hip fractures. Participants were identified for the propensity score matched cohort from the National Hip Fracture Database (NHFD), which was linked to Hospital Episode Statistics (HES) and civil death registration data. The primary outcomes were 12-month dislocation, revision, and mortality. The secondary outcomes were length of stay, discharge home, unplanned re-admission, functional outcomes, and health-related quality of life.ResultsFive RCTs reported higher THA dislocation but this was not statistically significant (THA risk ratio [RR] 2.77, 95% CI 0.81 to 9.48). However, THA dislocation was significantly higher in the national observational dataset (sub-distribution hazard ratio [SHR] 1.73, 95% CI 1.24 to 2.41). Meta-analysis of data from four RCTs did not identify a significant difference in terms of revision (RR 1.52, 95% CI 0.56 to 4.14). However, THA revision was significantly lower in the national dataset (SHR 0.66, 95% CI 0.48 to 0.90). Meta-analysis of data from 5 RCTs suggested higher mortality amongst patients undergoing HA (RR 0.63, 95% CI 0.38 to 1.04), which was also observed within the national registry dataset (hazard ratio 0.45, 95% CI 0.37 to 0.54).ConclusionsNational clinical registries can provide important context when interpreting RCT data, which may alone be inadequate for comparing the safety profile of surgical interventions. These data suggest that THA is at significantly higher risk of dislocation but lower risk of revision within 12 months. The finding from both RCT and clinical registry data that THA is associated with lower 12-month mortality amongst the fittest patients with hip fractures requires urgent further study to determine whether or not this can be replicated in other balanced populations.

Le score de Nottingham pour les fractures de hanche (NHFS) est-il un élément prédictif de la mortalité à 30 jours après fracture cervicale vraie ?

BackgroundThe Nottingham hip fracture score (NHFS) was developed to predict 30-day mortality following a fracture of the hip. While the NHFS has been validated in three hip fracture populations within Great Britain, these studies make no distinction between the type of fracture and surgery. Literature “however” shows an increased risk for mortality after a hemi-arthroplasty following an intra-capsular hip fracture. To verify whether the mortality after an intra-capsular hip fracture is higher compared to the predicted mortality score according to the NHFS, a validation of the NHFS in patients with a hemi-arthroplasty after an intra-capsular hip fracture was performed. MethodsThe NHFS was calculated for consecutive patients presenting with an intra-capsular fracture of the hip in two level II trauma teaching hospitals between 1 January 2011 and 1 May 2016. The observed 30-day mortality was compared with that predicted by the NHFS using several validation statistics. ResultsA total of 901 patients were included in the present study. Mean age in the patients was 83 years (SD 8) and 623 (68 %) of the patients were female. Almost 60 % of the patients had an ASA-score (ASA, American Society of Anaesthesiologists;) of≥3 and overall 30-day mortality was 9.5 % (n=86). The median NHFS was 5, and there was no significant change in median NHFS over the past 5 years. The mortality rate in the studied population of hemi-arthroplasty patients was significantly higher than mortality rates predicted by the NHFS. (p=0.022, Pearson's Chi2 test) ConclusionsFindings suggest that for a patient with a hemi-arthroplasty following an intra-capsular hip fracture, there could be an underestimation for the 30-day mortality rate following the NHFS prediction model. Level of EvidencePrognostic Level III, retrospective cohort study.

Hypermineralization in the femoral neck of the elderly

Hip fragility depends on the decline in bone mass as well as changes in bone microstructure and the properties of bone mineral and organic matrix. Although it is well-established that low bone mass or osteoporosis is a key factor in hip fracture risk, it is striking to observe that 92% of 24 patients who have sustained an intracapsular hip fracture showed hypermineralization at the superior-anterior quadrant, a critical region associated with increased hip fracture risk. In-depth material studies on a total of 12 human cadaver femurs revealed increased degree of mineralization in the hypermineralized tissue: calcium weight percentage as measured by quantitative backscattered electron imaging increased by approximately 15% compared with lamellar bone; mineral-to-matrix ratio obtained by Raman microspectroscopy imaging also increased. Immunohistochemistry revealed localized type II collagen in the hypermineralized region, implying its cartilaginous nature. At the ultrastructural level, X-ray scattering revealed significantly smaller (on average 2.3 nm thick and 15.6 nm long) and less ordered bone minerals in the hypermineralized tissue. Finally, the hypermineralized tissue was more brittle than lamellar bone under hydrated state – cracks propagated easily in the hypermineralized region but stopped at the lamellar boundary. This study demonstrates that hypermineralization of femoral neck cortical bone is a source of bone fragility which is worth considering in future fracture risk assessment when the origin of hip fracture is unclear based on current evaluation standards. Statement of SignificanceHypermineralization of femoral cortical bone in older adults might occur in many more hip fracture cases than presently known. Yet, this tissue remains largely unknown to the orthopedic community possibly due to coarse resolution of clinical imaging. The current study showed the hypermineralized tissue had reduced fracture resistance which could be attributed to the material changes in mineral content, organic matrix, and mineral platelets properties. It thus could be a source for fracture initiation. Consequently, we believe hypermineralization of femoral neck cortical bone should be considered in hip fragility assessment, especially when low bone mass cannot be identified as a primary contributor to hip fracture.

Validation of the Nottingham Hip Fracture Score (NHFS) to predict 30-day mortality in patients with an intracapsular hip fracture

BackgroundThe Nottingham Hip Fracture Score (NHFS) was developed to predict 30-day mortality following a fracture of the hip. While the NHFS has been validated in three hip fracture populations within Great Britain, these studies make no distinction between the type of fracture and surgery. Literature ‘however’ shows an increased risk for mortality after a hemi-arthroplasty following an intra-capsular hip fracture. To verify whether the mortality after an intra-capsular hip fracture is higher compared to the predicted mortality score according to the NHFS, a validation of the NHFS in patients with a hemi-arthroplasty after an intra-capsular hip fracture was performed. MethodsThe NHFS was calculated for consecutive patients presenting with an intra-capsular fracture of the hip in two level II trauma teaching hospitals between 1 January 2011 and 1 May 2016. The observed 30-day mortality was compared with that predicted by the NHFS using several validation statistics. ResultsA total of 901 patients were included in the present study. Mean age in the patients was 83 years (SD 8) and 623 (68%) of the patients were female. Almost 60% of the patients had an ASA-score (American Society of Anaesthesiologists [ASA]) of≥3 and overall 30-day mortality was 9.5% (n=86). The median NHFS was 5, and there was no significant change in median NHFS over the past 5 years. The mortality rate in the studied population of hemi-arthroplasty patients was significantly higher than mortality rates predicted by the NHFS (p=0.022, Pearson's Chi-squared test). ConclusionsFindings suggest that for a patient with a hemi-arthroplasty following an intra-capsular hip fracture, there could be an underestimation for the 30-day mortality rate following the NHFS prediction model. Level of evidencePrognostic Level III, retrospective cohort study.

The long-term outcomes following internal fixation for intracapsular hip fractures in an Irish tertiary referral centre.

The burden associated with hip fractures is increasing worldwide. Arthroplasty procedures are more commonly performed for intracapsular fractures due to increased risk of compromise to the femoral head blood supply. However, we know from the Irish Hip Fracture Database that a significant proportion of these fractures undergo internal fixation. We sought to investigate the long-term outcomes for these patients including revision rates, functional outcome and mortality rates. All intracapsular fractures treated by internal fixation (IF) from 2005 to 2009 were identified. Pre-operative anatomical fracture location and level of fracture displacement was established. Hospital records were used to record mortality and revision rates. The modified Harris hip score was our primary functional outcome measure. One hundred twelve intracapsular fractures underwent IF over a 5-year period. The mean age was 68.6 (range 14-95years). A mean follow-up time of 8.15years (range 6.7-10.1years) was achieved. There was a 5-year mortality rate of 36.6%. There was a significantly higher revision rate in displaced fractures (24.4%) than in undisplaced fractures (11.1%) (p = 0.01). We found no difference in functional outcome between displaced fractures [85.9 (± 16.9)] and undisplaced fractures [86.01 (± 18.8)]. Those aged younger than 65 at the time of surgery had a significantly better MHHS (p = 0.02) at long-term follow-up; however, there was a revision rate of 43.8% in this group. Whilst a good functional outcome can be achieved with internal fixation, particularly in younger patients, the risk of requiring revision surgery approaches 50% for these patients.

Peri-operative outcomes for ORIF of acetabular fracture in the elderly: Comparison with displaced intracapsular hip fractures in a national pelvic and acetabular referral centre over 5 years

IntroductionThe increasing incidence of acetabular fractures in the elderly and the fracture complexity seen in this cohort represents one of the greatest challenges faced by trauma orthopaedic surgeons today. There are no formal guidelines of best practice in the treatment of these patients. Management options vary from non-operative, acute ORIF, and/or total joint replacement. Although surgical intervention allows for earlier mobilization and avoidance of the complications of prolonged bedrest, the patients ability to tolerate what is often major surgery is always of concern. This is in stark contrast to intracapsular hip fractures, (a fracture within the same joint), where acute surgery is recommended in virtually all cases. ObjectivesThis study was undertaken to evaluate the peri-operative outcomes for geriatric patients undergoing acetabular ORIF and hemiarthroplasty to assess if there is a significant difference in early outcome parameters. DesignThis is a retrospective case–control study. SettingThis study was performed in the National Centre for Pelvic and Acetabular surgery. Patients42 age- and sex-matched patients with comparable ASA grades were included in each arm of the study. Patient selection in the acetabular ORIF group was consecutive patients managed operatively in the centre during the period 2010–2015. The selection for the hemiarthroplasty group was by random selection of age- and sex-matched patients undergoing hemiarthroplasty during the same period. Main outcome measurementsThe primary outcomes that were proposed prior to the study being performed was perioperative mortality and post-op complications. Secondary outcomes were operating times, blood loss and need for ICU admission. ResultsA significant difference between the two cohorts was observed with operative times, blood loss, need for transfusion, and need for ICU admission, all higher in the acetabular ORIF group. There was no significant difference in mortality or post-op infection. ConclusionsOur paper supports the concept that acute ORIF of acetabular fractures, with appropriate peri-operative support, can be undertaken safely. There is no difference in the major peri-operative outcomes of mortality or infection when compared with hip fracture patients requiring hemiarthroplasty.

The reliability of a Garden, AO and simple II stage classifications for intracapsular hip fractures

IntroductionSuccessful treatment starts by accurate classification of pathology, but there is no conclusive, reliable and universally accepted method for classification of intracapsular femoral neck fractures. As a perfect classification should have high intra- and interobserver agreement, this study aims to access reliability of three classification systems: Garden, AO and simple II stage classification. Materials and methodsFour orthopaedic trauma surgeons (two of them professors) and two senior orthopaedic trauma residents were invited to evaluated 136 blinded anterior-posterior and lateral X-rays of patients with femoral neck fractures. Observers classified fractures according to IV stage Garden, AO and simple II stage classifications. The exercise was repeated after one month on same but randomised X-rays. Cohen kappa was used to measure inter- and intraobserver agreement. Fleiss kappa was used to access multi-rater agreement. ResultsAO classification showed an overall agreement of 0.22 (fair agreement). Garden classification had overall reliability slightly higher than AO, but matching same fair agreement group (0.33). II stage classification provided the highest estimates: from 0.35 (fair agreement) to 0.83 (almost perfect agreement) and multi-rater agreement of 0.50 (moderate agreement). There was seen no difference in intra- and interobserver agreement between observer groups (professors, trauma surgeons and trauma residents) DiscussionAll three classification systems showed equal adoption among differently experienced observer groups. Despite this finding, IV stage Garden and AO classifications should be avoided in clinical use because of poor reproducibility. Only simple II stage classification showed sufficient intra- and interobserver reliability. Level of evidenceIV, Retrospective study.

Total Hip Arthroplasty for Hip Fractures: Time to Surgery With Respect to Surgical Revision, Failure, and Mortality.

Introduction:There are increasing demands to perform surgery of hip fractures without delay. However, few studies have assessed the time to surgery in relation to outcome measurements.Methods:A total of 643 consecutive patients with a minimum age of 60 years underwent total hip arthroplasty (THA) for an intracapsular hip fracture. For this retrospective case series, demographic data and the outcome measurements—(1) any surgical revision, (2) implant failure, and (3) mortality—were documented from a prospective clinical database. The time from admission to surgery was also documented prospectively and then data were divided into 4 groups according to the time of surgery: (1) within 12 hours, (2) >12 to 24 hours, (3) >24 to 48 hours, and (4) later than >48 hours. The study end point was 2 years after surgery. Final evaluation was conducted for any missing data through a telephone interview.Results:The patients comprised 456 women (70.9%) and 187 men (29.1%) with a mean age of 80.2 years (range 60-104 years; standard deviation ±7.4). Descriptive data were without effect in all 4 groups. Time to surgery did not significantly influence revision for any reason (P = .323), implant failure (P = .521), and mortality (P = .643). Cox regression analysis identified male sex (P < .001; 95% confidence interval (CI), 1.27-2.44), American Society of Anesthesiologists score ≥3 (P < .001; 95% CI, 2.12-21.59), C-reactive protein level >21 mg/L (P < .018; 95% CI, 1.09-2.60), hemoglobin level <12.0 g/dL (P = .033; 95% CI, 1.04-2.68), and dementia (P < .000; 95% CI, 1.50-2.86) as independent significant risk factors for mortality.Conclusion:Time to surgery had no effect on revision for any reason, implant failure, and mortality in patients undergoing THA for an intracapsular hip fracture.