Surgical Management Of Hip Fractures Research Articles

Clinical outcomes of post-surgery osteoporosis treatment in elderly intertrochanteric fracture patients: a prospective study

Background: This study aims to evaluate the clinical and functional outcomes of administering zoledronic acid in elderly patients undergoing surgical management of hip fractures. The goal is to assess the impact on mortality, postoperative complications, and functional recovery as measured by the modified Harris hip score. Methods: A prospective study was conducted over 18 months at a tertiary care center in New Delhi, India, involving 42 patients aged 60 and above with intertrochanteric femur fractures. Patients received surgical fixation and standard postoperative care. Zoledronic acid (5 mg) was administered intravenously three months post-surgery. Data on demographics, injury-to-surgery interval, fracture type, DEXA score, and functional outcomes were collected at follow-ups of 6 weeks, 3 months, 6 months, and 12 months. Results: The mean age of participants was 72.67 years. Zoledronic acid administration was associated with a 9.5% mortality rate. Functional outcomes, measured by the modified Harris hip score, significantly improved from a mean of 42.14 at 6 weeks to 77.68 at 12 months (p<0.001). Younger patients (<70 years) had significantly better scores at 3 months compared to older patients (>80 years). However, no significant differences were observed at 6 and 12 months. The mean modified Harris hip scores did not differ significantly between patients with osteopenia and osteoporosis at any time point. Additionally, the type of surgical fixation (intramedullary versus extramedullary) showed no significant impact on functional outcomes. Conclusions: Zoledronic acid administration in elderly hip fracture patients may reduce mortality and enhance functional recovery. The study supports its use in postoperative care to improve outcomes, although larger, randomized controlled studies are needed to confirm these findings. The results suggest that zoledronic acid can be an effective adjunct therapy in managing osteoporosis-related hip fractures in the geriatric population.

Perioperative geriatrics: A bibliometric analysis of the top 100 cited articles in an emerging specialty.

The success of modern medicine has led to surgery being performed on an increasingly older, frailer and more comorbid population. As a result, perioperative geriatrics has emerged as an important specialty, relevant to both medical and surgical disciplines. Only a small number of papers have been published on the topic. A bibliometric analysis is used to identify themes and trends in current research and practice. To identify and describe research topics relating to perioperative geriatrics; to find themes and gaps in the current literature. Thompson Reuters Web of Science indexing database was searched for all manuscripts relating to perioperative geriatrics. Of these, the top 100 were subcategorised into manuscript type, age, theme, specialty, journal and citation rate. The highest cited article was by Bhandari et al with 294 citations. The highest citation rate was achieved by Partridge et al, with 23.75 citations/year. Across the series, the mean number of citations was 50.41 (range 294-12). The highest number of manuscripts were published between 2010 and 2019 (n = 55), with 70% of manuscripts published in journals with impact factor <5. The specialty with the highest number of publications was orthopaedics (n = 36). Most articles focussed on surgical management of geriatrics patients, followed by anaesthetic management. This is the first bibliometric analysis of the top 100 most cited papers in perioperative geriatrics. Only 395 papers were returned, indicating that this needs to be further researched as a topic. Key themes identified were surgical management of hip fractures and anaesthetic preoperative assessment. Emerging themes from this study highlight the need for perioperative publications in the fields of geriatric vascular, general, plastic and gynaecology.

SLIDING HIP SCREW CONSTRUCTS ARE ASSOCIATED WITH EARLY MOBILIZATION, RETURN TO DOMICILE, AND SHORTER LENGTH OF STAY WHEN COMPARED TO AN INTRAMEDULLARY NAIL: RESULTS FROM THE SCOTTISH HIP FRACTURE AUDIT

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies.A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p&lt;0.05 denoted significance.13638 records were included (72% female). 9867 received a SHS (72%).No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's.There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p&lt;0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p&lt;0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p&lt;0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations.Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS.Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted.

The Lateral Femoral Cutaneous and Over the Hip (LOH) Block for the Surgical Management of Hip Fractures: A Safe and Effective Anesthetic Strategy.

To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip (LOH) block. Retrospective. Orthopedic specialty hospital. 40 patients who presented between November 2021 and February 2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used. Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve, and accessory obturator nerve. Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates. A total of 120 patients (40 each: general, spinal, and LOH block) were compared. The cohorts were similar in age, race, body mass index, sex, Charlson comorbidity index, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block cohort ( P < 0.05). Total OR time and anesthesia time were the shortest for the LOH block cohort ( P < 0.05). Patients in the LOH block cohort also had lower postoperative pain scores ( P < 0.05). Length of hospital stay was the shortest for patients in the LOH block cohort ( P < 0.05), and during discharge, patients in the LOH block cohort ambulated the furthest ( P < 0.05). No differences were found for anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates. The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly patients requiring surgery. In addition, this block may decrease postoperative pain and length of hospital stay, and allow for greater ambulation in the early postoperative period for patients with hip fracture. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Racial Disparities in Early Adverse Events and Unplanned Readmission after Open Fixation of Below- Knee Fractures

Category: Trauma; Ankle; Hindfoot; Other Introduction/Purpose: Race-based differences in the surgical management of hip fractures are well-established. Studies assessing these disparities for below-knee fractures have yet to be conducted despite their high volume. Our purpose was to determine whether 1) early postoperative complications and 2) time to surgery for operative fixation of below-knee fractures differ for black versus white patients, and to assess whether disparities exist between fracture subtypes. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients (&gt;=18 years) undergoing open fixation of below-knee fractures between 2010-2019. This yielded 9,172 patients; 1,120 (12%) were black. We collected patient demographics and preoperative risk factors. Primary outcomes were 30-day postoperative complications and time to surgical fixation. Fractures were further subclassified as tibia and/or fibula shaft, isolated malleolar, bi/trimalleolar, and pilon fractures. Nearest-neighbor propensity score matching in a 1:1 ratio was applied to compare outcomes by race. Alpha = 0.05. Results: After matching, we identified 1,120 white patients with equal propensity scores as our black patients. Black patients had 1.5 times higher odds (95% confidence interval [CI]: 1.0-2.0) of experiencing any early adverse event when compared with matched white counterparts. Blacks also had 1.9 times higher odds (95% CI: 1.2-3.0) of requiring unplanned readmission within 30 days of operative fixation. Fifty-eight black patients (5.3%) required short-term readmission, compared with 351 white patients (4.5%) - 32 (2.9%) in the matched cohort. The most common reasons for readmission were wound, gastrointestinal, thromboembolic, and recurrent musculoskeletal complications for both races. There were no significant differences by race in time to surgery. Fracture subtype was not associated with postoperative complications or time to surgery in the multivariable analysis. Conclusion: Racial disparities in the early postoperative course after open fixation of below-knee fractures exist, with significantly higher rates of early adverse events and unplanned readmission for black versus white patients that persist after propensity matching. These trends may be secondary to a host of community- and hospital-level factors, illustrating the importance of interventions that consider the differences between hip and non-hip fractures and increase resources to vulnerable areas.

The association between perioperative blood transfusions and venous thromboembolism risk following surgical management of hip fractures

IntroductionDespite high rates of transfusion reported among hip fracture patients in the perioperative period, the relationship between perioperative transfusions and VTE has not been thoroughly explored. Therefore, we used a national database to evaluate how perioperative transfusions among patients undergoing surgical management of hip fractures impacted 1) deep vein thrombosis (DVT) and 2) pulmonary embolism (PE) risk. MethodsThe Targeted Hip Fracture Database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients undergoing surgical management of hip fractures from 2016 to 2019. A multivariate logistic regression was conducted using various patient-specific variables to identify risk factors for DVT and PE. A nearest-neighbor propensity score matched (PSM) comparison between patients receiving and not receiving perioperative blood transfusions (1:1) was additionally conducted. ResultsPrior to our PSM, preoperative transfusions were not associated with DVT incidence (OR: 1.48, 95% CI: 0.80–2.50; p = 0.2). However, intra-operative/post-operative transfusions (OR: 1.26, 95% CI: 1.02–1.56; p = 0.00.30) as well as the receipt of both transfusion types (OR: 1.81, 95% CI: 1.10–2.81; p = 0.012) were associated with an increased risk of DVT. The latter of these findings remained significant following PSM (OR: 1.73, 95% CI: 1.04–2.73; p = 0.025). No relationship was demonstrated between PE risk and perioperative transfusion receipt. ConclusionOur findings emphasize the importance of perioperative blood management strategies among patients undergoing surgical repair of hip fracture. Specifically, orthopaedic surgeons should aim to optimize hip fracture patients prior to surgical intervention as well as intra-operatively to reduce transfusion incidence.

The effect of zoledronic acid and high-dose vitamin D on function after hip fractures. A prospective cohort study.

Hip fractures are associated with functional decline and increased mortality. The aim of this study was to investigate the effect of zoledronic acid and high-dose vitamin D on function and mortality after hip fractures. Forty-five patients received zoledronic acid and high dose of vitamin D during hospitalization after fracture management. These patients were compared with a control group of 46 patients. Pre- and postoperative prospectively collected data including ASA score, Charlson comorbidity score, presence of dementia, Vitamin D, and the Barthel index were available. Final follow-up was performed after one year. Primary outcome was patients' function at final follow-up as measured with Barthel index score. Secondary outcomes included mortality, assessment of pain, and complications. Barthel index score at final follow-up was decreased in both groups. There was no significant difference in Barthel index between the two groups (15.5 ± 5.0 vs 15.8 ± 5.8, p = 0.850). However, the Barthel index in the control group decreased beyond the smallest detectable change (3 points). Mortality was statistically different between groups (8.8% vs 28.2%, p = 0.047). Complications and pain at final follow-up were not different between groups. Multivariate analysis revealed that preoperative Barthel index and Charlson comorbidity score independently affected function at final follow-up. Logistic regression analysis disclosed that not receiving active treatment and complications were associated with increased mortality. Medical treatment after surgical management of hip fractures results in reduced mortality and lessens the functional decline associated with these fractures.

Pre-injury use of antiplatelet and anticoagulations therapy are associated with increased mortality in a cohort of 1038 hip fracture patients.

Hip fractures are a large burden on the health care systems of developed nations. Patients usually have multiple co-morbidities and the pre-injury use of anticoagulants and anti-platelet medication is common. This study used a single hospital hip fracture database to facilitate a retrospective analysis of the impact of anti-coagulation and anti-platelet therapy on mortality and complications after surgical management of hip fractures. There were 92 patients on warfarin, 69 on DOAC, 260 antiplatelet patients and 617 control patients. Mortality rates at 30 days were 4.8% for the control group, 12.6% for the antiplatelet group, warfarin 7.0%, 9.5% for Direct Oral Anticoagulant (DOAC) group, p=0.004. Mortality rates at 1 year were 22.4% for the control group, 32.3% for the antiplatelet group, 29.3% for the warfarin group and 29.0% for DOAC group (p=0.007). Amongst complications, significant differences were found in transfusion (DOAC) and wound ooze (warfarin) rates, but the study did not detect significant clinical consequences arising from these differences. A matched analysis for age, sex, and ASA was undertaken to look in more detail at mortality data. Some mortality differences remained between groups with anti-platelet medication associated with increased mortality, but the differences no longer appeared to be significant. Our data suggests that this is a non-causal association, which could be incorporated into predictive mortality risk scores such as the Nottingham hip fracture score. We believe that pre-injury antiplatelet therapy is a strong indicator for high risk patients with higher expected mortality after hip fracture surgery. We saw no evidence to support delayed surgery in patients taking DOACs.

Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study.

PurposeThirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients.MethodsA multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019.ResultsActual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57–5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification.ConclusionCOVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.

Overview of classification and surgical management of hip fractures

Hip fractures represent one of the biggest healthcare problems and an epidemic is expected to arise due to the ageing population. Various classifications have been proposed over the years which failed to achieve high reliability in defining the whole spectrum of proximal femoral fracture deformity. Nevertheless, orthopaedic surgeons commonly communicate using the most popular differentiation which divides hip fractures to intracapsular or extracapsular, with further subclassification to displaced or undisplaced. Based on this broad categorization, sliding screw devices or cephalomedullary systems dominate the fixation of extracapsular fractures, whereas intracapsular fractures are treated with screw/plate fixation or arthroplasty. Early surgical treatment facilitates best outcomes and return to pre-injury level of activity. Hip fracture pathology covers a huge part of routine orthopaedic practice and orthopaedic surgeons at every level should be well versed on them. In this review we will summarize all the basic and current evidence regarding the classification and treatment of hip fractures.

The Effect of Pre-Operative Medical Co-Morbidities on Rehabilitation Outcomes Following Surgery for Hip Fracture Management in Geriatric Populations.

Introduction:As a result of increasing longevity, we are seeing more elderly patients with complex medical co-morbidities who sustain hip fractures requiring surgical management. The aim of this study is to understand and analyze the effect of preoperative medical comorbidities and associated low physiological reserve status on functional rehabilitation outcomes following surgical management of hip fractures.Materials and methods:This study conducted a retrospective analysis of 73 patients who fulfilled the inclusion criteria .We utilized the de Morton Mobility Index (DEMMI) scores pre surgery and at the time of discharge from hospital following a period of rehabilitation as a measure of their pre and post-surgery functional status. The Physiological and Operative Score (POSSUM) was used as our tool to objectively quantify medical co-morbidities including but not limited to cardiovascular and pulmonary conditions.Results:The median age of our study population was 83 years of which 55(75%) were female. Time to surgery was a median of 21.0 hours, IQR (15.0-29.0), with a median physiological score of 21.0, IQR (19.0-26.0), the median pre surgery DEMMI was 85.0, IQR (55.5- 100.0) and the median DEMMI at discharge was 33.0, IQR (30.0-41.0).There is a moderate correlation between DEMMI pre and DEMMI at 3 months, 0.38 that is statistically significant, p = 0.001.Discussion:The effect of medical co- morbidities which causes the patient to have a poor physiological reserve even when coupled with the effect of the operative stress have no significant negative impact on the 90-day functional outcome of these patients.Conclusion:This study demonstrated that the presence of medical comorbidities in patients who require surgical management of hip fractures would not adversely affect their rehabilitation outcomes. The preinjury functional status of a patient is a significant factor in predicting functional rehabilitation outcomes.

Upper gastrointestinal bleeding in neck of femur fracture patients: a single tertiary centre experience.

This study aimed to identify the incidence of perioperative acute upper gastrointestinal bleeding (UGIB) in our hip fracture patients; to evaluate the characteristics, management and clinical outcomes of these patients; and to explore risk factors and protective factors. Of the 1691 consecutive patients admitted for surgical management of hip fractures, 11 (0.65%) had UGIB and a further four patients for each case were selected as controls for evaluation of risk factors and protective factors. Pre-existing peptic ulcer disease was identified as a risk factor for acute UGIB (odds ratio 7.9; 95% confidence interval: 1.1-54.9). This study reported a very low incidence of UGIB in hip fracture patients. Despite being a high-risk population, timely endoscopic evaluation can be safely undertaken to optimise patient outcome. When risk factors such as history of peptic ulcer disease are present, additional precaution including gastro-protective agent and nutritional support should be undertaken.

Resident Participation in Fixation of Intertrochanteric Hip Fractures: Analysis of the NSQIP Database.

Future generations of orthopaedic surgeons must continue to be trained in the surgical management of hip fractures. This study assesses the effect of resident participation on outcomes for the treatment of intertrochanteric hip fractures. The National Surgical Quality Improvement Program (NSQIP) database (2010 to 2013) was queried for intertrochanteric hip fractures (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 820.21) treated with either extramedullary (Current Procedural Terminology [CPT] code 27244) or intramedullary (CPT code 27245) fixation. Demographic variables, including resident participation, as well as primary (death and serious morbidity) and secondary outcome variables were extracted for analysis. Univariate, propensity score-matched, and multivariate logistic regression analyses were performed to evaluate outcome variables. Data on resident participation were available for 1,764 cases (21.0%). Univariate analyses for all intertrochanteric hip fractures demonstrated no significant difference in 30-day mortality (6.3% versus 7.8%; p = 0.264) or serious morbidity (44.9% versus 43.2%; p = 0.506) between the groups with and without resident participation. Multivariate and propensity score-matched analyses gave similar results. Resident involvement was associated with prolonged operating-room time, length of stay, and time to discharge when a prolonged case was defined as one above the 90th percentile for time parameters. Resident participation was not associated with an increase in morbidity or mortality but was associated with an increase in time-related secondary outcome measures. While attending surgeon supervision is necessary, residents can and should be involved in the care of these patients without concern that resident involvement negatively impacts perioperative morbidity and mortality. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hip Fractures: Appropriate Timing to Operative Intervention

BackgroundThe purpose of this study is to (1) identify the incidence of surgical delay in hip fractures, (2) evaluate the time point surgical delay puts patients at increased risk for complications, and (3) identify risk factors for surgical delay in the setting of surgical management of hip fractures. MethodsA multi-center database was queried for patients of 60 years of age or older undergoing surgical treatment of a hip fracture. Surgical delay was defined by days from admission until surgical intervention. Univariate analyses and multivariate analyses were performed on all groups. ResultsA total of 4215 patients underwent surgery for their hip fracture. Of those experiencing surgical delay, 3304 (78%) patients experienced surgical delay of ≥1 day, 1314 (31%) had delay of ≥2 days, and 480 (11%) experienced delay of ≥3 days. There was a significant difference in complications if patients experienced surgical delay of ≥2 days (P ≤ .01). Multivariate analyses identified multiple risk factors for delay of ≥2 days including congestive heart failure (odds ratio 3.09, 95% confidence interval 2.04-4.66) and body mass index ≥40 (odds ratio 2.31, 95% confidence interval 1.31-4.08). Subgroup analysis identified that patients undergoing total hip arthroplasty were not at risk for complications with surgical delay of ≥2 days. ConclusionSurgical delay of ≥2 days in the setting of hip fractures is common and confers an increased risk of complications in those undergoing non-total hip arthroplasty procedures. We recommend surgical intervention prior to 48 hours from hospital admission when possible. Healthcare systems can utilize our non-modifiable risk factors when performing quality assessment and cost accounting.

Initial Preoperative Management of Geriatric Hip Fractures.

Hip fractures are a common emergency among the geriatric population and often requires immediate hospitalization for proper assessment. More than 90% of the time, hip fractures are suffered by individuals older than 65 and are usually precipitated predominantly by falls. Current studies show that the average individual over 65 years falls at least once a year, and roughly 1 out of every 4 of these individuals succumb to their injuries just 12 months following surgical treatment. Moreover, timely treatment and management of these hip fractures have shown to decrease mortality by reducing cardiopulmonary and venous thromboembolic complications that often accompany hip surgeries. As a result, an emphasis on initial preoperative assessment is important to help identify the presence of ancillary factors such as preexisting comorbidities, which can impact the course of treatment. Delaying surgical management of hip fractures has been linked to decreased functional outcomes and increased mortality rates. Time, rather than technique, appears to be a recurring factor that can impact the long-term survival of these patients. The initial preoperative assessment, therefore, presents a window of opportunity where possible interventions can be made in an effort to reduce the delay of surgery, minimize postsurgical complications, and ultimately improve mortality rate among patients with hip fracture.

The management of intracapsular hip fractures

Hip fractures are the most common, serious musculo-skeletal injury to affect the elderly population. Approximately 80 000 hip fractures occur each year in the UK with an estimated annual associated cost of £2 billion. The annual burden of hip fractures is expected to increase over the coming years as a result of demographic changes to the UK population. There is significant mortality and morbidity associated with these injuries. It is therefore essential that a multidisciplinary approach is employed to maximize potential recovery after this injury. The surgical management of hip fractures varies depending upon the anatomical location of the fracture. Approximately one half of all hip fractures are intracapsular in nature. In this article we explore the current controversies in treatment of these fractures and factors which may affect management decisions.

Complications of the surgical management of hip fractures

Hip fracture surgery in the elderly can be a very challenging field with the potential complications being devastating. These complications often result in reoperation and revision surgery associated with significant morbidity and mortality. This article presents common surgical complications associated with intracapsular, extra-capsular, and subtrochanteric fractures. We discuss the risk factors of complications, aetiology, tips to avoid them, and also the management options based on current evidence. We believe that this can be a valuable resource for a trainee orthopaedic surgeon as well as refreshing the current knowledge base for practising orthopaedic surgeons.

Common complications in hip fracture surgery: Tips/tricks and solutions to avoid them.

Surgical management of hip fractures in elderly people is challenging and complications relating to surgery could be devastating. They often lead to reoperation and revision surgery and can be associated with significantly increased morbidity and mortality. The most common surgical complications after internal fixation of hip fractures include cut-out, nonunion, Z-effect/medial migration, periimplant failure and avascular necrosis. High quality surgical fixation is of outmost importance to avoid surgical complications. This article presents the aetiology, risk factors and incidence of perioperative and post-fracture fixation complications. Technical tips and tricks for a successful fixation as well as the contemporary evidence surrounding the augmentation of osteoporotic bone fixation in internal fixation of hip fractures are discussed.

The impact of preoperative medical clearance procedures on the time to definitive surgical management of hip fractures

The impact of preoperative medical clearance procedures on the time to definitive surgical management of hip fractures

Clinical and functional outcomes of the PCCP study: a multi-center prospective study in Italy.

The standard surgical management of hip fractures is associated with tissue trauma and bleeding which are added to the fracture injury. The percutaneous compression plate (PCCP) is a minimally invasive device that has been demonstrated in previous studies to reduce postoperative complications and blood loss. This prospective, multi-center, observational study assessed clinical and functional outcomes with PCCP as treatment for trochanteric fractures. Patients with a stable or unstable proximal femoral fracture of type AO 31.A1 or 31.A2 were enrolled in eight hospitals in Italy. The primary outcome of interest was the recovery of the pre-fracture functional status at 1-year follow-up; secondary outcomes of interest included blood transfusions, surgical time, complications, and mortality. A total of 273 patients were enrolled. The ASA score was 3 or 4 in 72.5 % of patients. The mean surgical time was 44.1 min; the mean post-surgery blood transfusions was 0.9 units. At 1 year, 48 patients (17.6 %) died, 28 (10.2 %) were lost to follow-up, 4 patients (1.5 %) were excluded, hence 193 patients (70.3 %) were available for final evaluation. At the 1-year follow-up visit, 51.9 % of patients recovered or improved their pre-fracture modified Harris Hip Score, 49.1 % of patients improved or maintained their walking abilities, and 66.6 % of patients residing at home pre-surgery maintained their domicile. The overall mortality rate was 17.6 %. Major complications included two fracture collapses, one excessive sliding of the cephalic screw leading to a partial fracture collapse and one back-out of the diaphyseal screw. This study demonstrates that treatment of trochanteric fractures with PCCP gives good outcomes and significant advantages such as low blood loss, short surgical time, low risk of complications, and good functional recovery in the majority of the patients.