Nonunion of fractures of the femoral neck in children

The authors present the prospective clinical outcome of nine pseudoarthroses resulting from surgical treatment carried out in nine children, whose ages varied from 6 years and 2 months to 14 years and 2 months (mean 10 years and 2 months), who had fractures of the femoral neck. Five were classified as type II, according to the Delbet classification modified by Colonna, and four were type III. The initial fractures were caused by high-energy traumas, such as trampling, bicycle falls, and car accidents. Treatment of choice was valgus osteotomy of the femoral neck associated or not with insertion of bony graft. The mean time of follow-up was 38 months, ranging from 23 to 71 months, and the mean time of pseudoarthrosis consolidation after osteotomy was 76.6 days, varying from 45 to 240 days. In this study, all the pseudoarthroses consolidated. For final analysis of clinical and radiographic results, the Ratliff’s classification was used. We obtained three cases as good results, five as fair and one as poor. The authors concluded that valgus osteotomy is a good option for treatment of pseudoarthrosis in the femoral neck fractures in children.     

Segmental neck of femur fractures: A unique case report of an ipsilateral subcapital,greater trochanteric and intertrochanteric fracture and proposed management algorithm

INTRODUCTION

Neck of femur fractures are now increasingly common in an ageing population. The management is well known and has been described in great detail. Concomitant ipsilateral segmental fractures of the neck of femur (SFNOF) however are rare and their investigation and management is poorly described.

PRESENTATION OF CASE

We present the surgical management of a unique and complex case of an ipsilateral subcapital, greater trochanteric and intertrochanteric fracture sustained in an 87-year-old female following a low trauma injury. This fracture configuration has not been described in the literature to date, neither has our method of reconstruction for this fracture, namely hemiarthorplasty, trochanteric stabilising plate and cerclage wires.

DISCUSSION

15 cases from 1989 to 2011 managed by 8 different fixation devices and followed up for an average of 17 months (2–58 months). There was an initial mortality rate of 13% (n = 2). All associated with low energy trauma occurred in female (n = 8), and most with high energy trauma occurred in males (83%; n = 5). The diagnosis was delayed or missed in 20% of cases, and the most common pattern was a concomitant undisplaced subcapital and intertrochanteric fracture (37.5%, n = 6). The overall risk of avascular necrosis was 20%, with a greater risk in patients greater than 65 years of age (33%).

CONCLUSION

Ipsilateral SFNOF are rare injuries with a bimodal distribution, and carry a greater risk of AVN. We advise that all SFNOF should have pre-operative CT planning and propose an algorithm to treat these patients with a standardised surgical approach.     

Delayed union of an operated fracture of the femoral neck

Fracture of the femoral neck continues to be a vexing clinical and therapeutic challenge for the orthopedic surgeon. The fracture has a propensity for non-union and avascular necrosis. It is a challenge for the orthopedic surgeon to decide when to intervene in a case with non-union where the implant continues to be in place. We present a case with persistent clinical and radiological non-union signs where the fracture eventually united after 32 months. The case bolsters the view that a continued conservative regime might entail good results in such situations.     

CRP monitoring in fractured neck of femur. A waste of resource?

AimWe aim to assess post-operative CRP serum values in a cohort of patients who underwent surgical treatment for neck of femur fracture (NOF#), and whether CRP is a valid tool for the assessment of these patients post-operatively.Study Design and MethodsRetrospective analysis was carried out on all NOF#'s admitted for surgical fixation between August 2015 and July 2016 in a district general hospital. Primary analysis included serum CRP levels until day 7 post-operatively, with secondary analysis of any documented evidence of post-operative complications (medical and surgical) within 30 days post-operatively.ResultsA total of 365 patients were surgically treated for NOF#’s over the study period. CRP serum levels peaked over the first two days post-operatively to median (IQ range) of 226 mg/L (158–299 mg/L), decreasing to 67 mg/L (45.5–104 mg/L) by day 7 post-operatively. 116 patients had documented post-operative complications within 30 daysof operation. CRP levels in patients with and without complications showed no statistical significance in day-1, day-2 and day-3 post-operatively. However, a significant difference was demonstrated on day-4 (p = 0.017), day-5 (p = 0.003), day-6 (p = 0.02) and day-7 (p = 0.031).ConclusionsDuring the first three days of the postoperative period we cannot recommend routine CRP serum blood test monitoring in NOF# patients, as it is not diagnostic in the acute inflammatory phase for medical or surgical complications.     

Hip fracture care during the 2020 COVID-19 first-wave: a review of the outcomes of hip fracture patients at a Scottish Major Trauma Centre

Background and Purpose of the StudyThis study reviewed whether the response to the Coronavirus (COVID-19) pandemic affected the care for hip fracture patients at a major trauma centre in Scotland during the first-wave lock-down period.MethodsAll patients referred to Orthopaedics with a hip fracture in a major trauma centre in Scotland were captured between 14 th March and 28 th May (11 weeks) in 2020 and 2019. Patients were identified using electronic patient records. The primary outcomes are time to theatre, length of admission and 30-day mortality. Secondary outcomes are COVID-19 prevalence, duration of surgery, proportion of patients to theatre within 36 hours and COVID-19 positive 30-day mortality from time of surgery. 225 patients were included: 108 from 2019 and 117 from 2020.The main findings30-day mortality was 3.7% (n=4) in 2019 and 8.5% (n=10) in 2020 (p=0.142). There was no statistical difference with time to theatre (p=0.150) nor duration of theatre (p=0.450). Duration of admission was reduced from 12 days to 6.5 days (p=<0.005). 4 patients tested positive for COVID-19 during admission, one 5 days after discharge, all underwent surgical management. 30-day mortality for COVID-19 positive patients during admission was 40%. COVID-19 prevalence of patients that were tested (n=89) was 5.62%.ConclusionsThis study has shown the care of hip fracture patients has been maintained during the COVID-19 pandemic. There is no statistically significant change in mortality, time to theatre, and duration of surgery, however, the patient’s admission duration was significantly less than the 2019 cohort.     

Preferential low bone mineral density of the femoral neck in patients with a recent fracture of the proximal femur

Bone mass is an important determinant of resistance to fractures. Whether bone mineral density (BMD) in subjects with a fracture of the proximal femur (hip fracture) is different from that of age-matched controls is still debated. We measured BMD of the femoral neck (FN) on the opposite side to the fracture, as well as femoral shaft (FS) and lumbar spine (LS) BMD by dual-photon absorptiometry in 68 patients (57 women and 11 men, mean age 78.8±1.0) 12.4±0.8 days after hip fracture following a moderate trauma. These values were compared with BMD of 93 non-fractured elderly control subjects (82 women and 11 men), measured during the same period. As compared with the controls, FN BMD was significantly lower in fractured women (0.592±0.013 v. 0.728±0.014 g/cm²,P<0.001) and in fractured men (0.697±0.029 v. 0.840±0.052,P<0.05). Expressed as standard deviations above or below the mean BMD of age and sex-matched normal subjects (Z-score), the difference in FN BMD between fractured women and controls was highly significant (–0.6±0.1 v. +0.1±0.1,P<0.001). As compared with mean BMD of young normal subjects, BMD was decreased by 36.9±1.4 and 22.4±1.5% (P<0.001) in fractured and control women, respectively. There was no significant difference between FN BMD of 33 women with cervical and 24 with trochanteric hip fractures (0.603±0.017 v. 0.577±0.020). FN BMD was lower than 0.705 g/cm² in 90% of fractured women. The prevalence of fracture increased with decreasing FN BMD, reaching 100% with values below 0.500 g/cm². FS and LS BMD were significantly lower in women with hip fracture than in controls (1.388±0.036 v. 1.580±0.030,P<0.001, for FS, and 0.886±0.027 v. 0.985±0.023,P<0.01, for LS), but these differences were not significant when expressed as a Z-score. In men with a recent hip fracture, FS BMD was significantly lower than in controls (1.729±0.096 v. 2.069±0.062,P<0.01), but the difference at the LS level did not reach statistical significance. These results indicate that both women and men with a recent hip fracture had decreased bone mineral density of the femoral neck, femoral shaft and lumbar spine. However, the difference appeared to be of higher magnitude for the femoral neck suggesting a preferential bone loss at this site.     

Methodological issues in the identification of hip fractures using routine hospital data: a database study

The proportion of the population over the age of retirement has risen in many countries, and this means there is a corresponding rise in the incidence of hip fractures. However, in order to reliably investigate the ability of interventions to prevent fracture, there needs to be a reliable measure of the incidence of hip fracture. The purpose of this study was to examine the inclusion and exclusion criteria used to identify hip fracture from hospital admission data and to examine the impact that these criteria have on estimated incidence of hip fracture. We examine the influence of: individual compared to consultant episode data; primary data compared to any diagnosis of hip fracture; emergency compared to elective admissions; and the influence of type and rate of surgery on incidence estimates. The results showed that classifying hip fractures by use of consultant episodes overestimated the rate of hip fracture by 6–31%, and this overestimation has increased in recent years. The use of primary diagnosis as opposed to any diagnosis underestimates hip fracture by 5%. Two percent (2%) of the people studied had an operation for a hip fracture but did not have a hip fracture diagnosis (many had a multiple fracture diagnosis), and 5.5% of the people studied had an elective admission for the hip fracture (perhaps falling in hospital during an elective admission). We conclude that the selection criteria can have a great influence on the number of hip fractures identified using routine data. There should be a standardized selection procedure for the identification of hip fracture, as this would enable interventions and preventive measures to be evaluated over time and facilitate comparisons of rates in different regions and countries, in order to examine factors associated with hip fracture.     

Pathological femoral neck fracture in a male patient due to non-simultaneous bilateral transient hip osteoporosis: A case report: Statements and Declarations

We report a case of a 31-year-old man who developed a non-simultaneous bilateral transient hip osteoporosis (THO) complicated with an atraumatic undisplaced pathological femoral neck fracture (FNF) of his left hip. He was successfully treated with internal fixation on the left hip, and a follow-up Magnetic Resonance Imaging evidenced satisfactory resolution on the right side. Diagnosis and management of THO are usually challenging as symptoms before pathological FNFs might be misdiagnosed. This case highlights the importance of suspecting pathological FNFs when pain persists despite conservative treatment. Finally, surgical treatment is strongly recommended if a pathological FNF is confirmed.Level of evidenceLevel IV.     

Re-Admissions Following Hip Fracture Surgery

INTRODUCTION

Hip fractures in the elderly are a growing problem with a predicted incidence of 117,000 cases per year by 2016. Re-admission following a healthcare episode is an important outcome measure, which reflects non-fatal adverse events and indicates the natural history of disease. The purpose of this observational, multicentre audit was to examine rates and reasons for re-admission following hip fracture, to identify areas in the index admission and rehabilitation care that could be improved to prevent re-admission.

PATIENTS AND METHODS

A total of 535 patients (> 65 years old) in two district general hospitals in the UK who underwent hip fracture surgery were recruited into the study.

RESULTS

Of the study cohort, 72 patients (13.5%) died during their index admission and 88 (19.0%) of 463 patients were re-admitted once within 3 months. Causes of re-admission were attributed to medical (54.8%), failure to rehabilitate (23.8%), orthopaedic (19.0%) and surgical (2.4%) reasons. Infection was the most common (31.0%) reason for re-admission and arguably the most treatable. During the 3-month postoperative period, the mortality rate was 21.3%, increasing in those re-admitted to 35.1% representing the frailty of this group of patients.

CONCLUSIONS

High rates of re-admission are seen following discharge in elderly patients with hip fractures. Re-admitted patients have high mortality rates. Understanding causes of re-admission may help to reduce this burden.     

股骨头毁损三联征:股骨头骨折-脱位合并股骨颈骨折

股骨头合并同侧股骨颈骨折是一种严重而复杂的创伤,保髋手术大多会失败。其治疗的难点及预后的关键在股骨颈骨折上。鉴于股骨颈骨折的发生与股骨头骨折-脱位之间存在明显的、前后关联的贯序特点,笔者认为以股骨头毁损三联征（disastrous triad of femoral head,DTFH）来概括这种类型的损伤,更能反映其损伤机制和预后特点。结合临床观察和文献资料,DTFH可分为3个类型：Ⅰ型,普通型DTFH,股骨颈骨折的发生紧随于股骨头骨折-脱位之后,是同一暴力造成的损伤;Ⅱ型,医源型DTFH,是在股骨头骨折-脱位的诊疗过程中发生了医源性股骨颈骨折;Ⅲ型,应力型DTFH,发生于股骨头骨折-脱位的治疗之后,在股骨头骨折面的远侧缘发生应力性股骨颈骨折。本文对各型DTFH的临床特点进行了初步的讨论。     

Co-existing ipsilateral subcapital and subtrochanteric fracture of the proximal femur

Background  Co-existing subcapital and subtrochanteric fracture on the same side of the hip is rare. We are not aware of a similar case reported in the literature. Case study  We present a rare case of co-existing ipsilateral subcapital and subtrochanteric fracture in a 67-year-old woman. The mechanism of injury was low energy. Therapeutic implication  The outcome of internal fixation using a Proximal Femoral Nail was satisfactory. This work was carried out in the Department of Trauma and Orthopaedics, Southend University Hospital NHS Foundation Trust, Essex, UK.     

Displaced intracapsular neck of femur fractures: Outcome of 810 hydroxyapetite coated (HAC) uncemented hemiarthroplasties

A Cochrane review influenced new NICE guidelines, which recommended surgeons: Offer cemented implants to patients undergoing surgery with arthroplasty. However our trust routinely uses HAC uncemented stem (Taperloc^®, Biomet) hemiarthroplasties. A review of a consecutive series of uncemented HAC stem hemiarthroplasties including measures such as intro-operative complications, mortality and revision surgery.Prospectively collected data between January 2008 and June 2014 was used, with medical record and radiographic reviews performed.810 consecutive Taperloc uncemented hemiarthroplasty with monopolar heads were performed in 763 patients, with a minimum 12 month follow-up (12–90) follow-up. Mean age 83 yrs; 71% female. Meantime to operation was 28.5 h. 30 day mortality: 4.4% (33/763). One year mortality was 11.2% (89/763). 2.5% (20/810) were admitted on a separate admission with the periprosthetic fracture. 0.6% (5/810) were revised to total hip replacement for subsidence and associated pain. Only 1% (8/810) had intraoperative calcar fractures, all of which were treated with intraoperative cabling with no evidence of clinically relevant subsidence or medium term complications requiring revision surgery within a year.To the author’s knowledge this is largest outcome series for modern design uncemented hemiarthroplasty. Our study shows comparable data to cemented hemiarthroplasty but no deaths in the first 2 days post-op. Our series also demonstrates a well below average mortality figures which are clearly multifactorial but believe uncemented prosthesis play a role. We believe that uncemented proven stem design hemiarthroplasty remains a safe and good surgical option for displaced intracapsular fractures.     

Factors influencing discharge location following hip fracture

INTRODUCTION: Outcome measures following hip fracture usually consider morbidity and mortality following injury.(5) Few studies have looked at post injury discharge location as an outcome measure following hip fracture. Discharging patients to a different location frequently delays discharge whilst the necessary social arrangements are made. Early identification of these patients could reduce these delays. The aim of this study was to determine factors influencing discharge location following hip fracture. METHODS: Three thousand two hundred and forty consecutive patients were admitted to our centre with a fractured neck of femur. Data was prospectively collected by independent audit clerks on a standardised proforma. Our outcome measure was whether the patient was discharged from hospital either to their place of normal residence or to an alternative location. Factors influencing discharge location were identified using multivariate logistic regression analysis. RESULTS: Increasing age was associated with increasing risk of requiring discharge to an alternative location (DAL) (p<0.001). This risk rose from 13% in the sixth decade by approximately 10% every additional decade. Males were 2.5 times more likely than females to require DAL. Patients who were more independent prior to injury were less likely to require DAL. Patients who sustained their injury whilst in hospital were 2.3 times more likely to require DAL compared to those who fell in their own homes. CONCLUSION: The following risk factors are associated with increased risk of requiring discharge to an alternative location: (1) pre-injury dependence, (2) increasing age, (3) male sex, (4) injury sustained whilst in hospital. Early identification of patients requiring DAL could reduce inpatient delays.     

The male neck of femur

Fractured neck of femur in elderly is associated with mortality which is reported in literature to vary between 20 and 40%. One of the factors which is suggested to be a risk factor is male sex. We reviewed 83 male necks of femur patients admitted over a period of a year to assess the patient’s physical status, influence of co-morbidities, postoperative course and mortality. The in-hospital mortality was 26.5% and 1-year mortality was 44.6%. The in-hospital mortality for female neck of femur patients during the same period was 18%. Increasing age, high ASA category and post-operative chest infections were associated with high peri-operative mortality, and fall sustained in an acute hospital ward was associated with high 1-year mortality in addition to ASA grade and chest infection. Patients who had a chest infection in the post-operative period had in-hospital mortality of 46.2% (P value 0.006) and a 1-year mortality of 73.1% (P value 0.001). Patients who fell in the ward as inpatients under geriatric care had 60% mortality.     

Blood transfusions and hip fracture mortality - A retrospective cohort study

BackgroundHip fractures are associated with serious morbidity and mortality. Low haemoglobin at presentation has been shown to be associated with increased mortality in hip fracture patients. This comorbid patient group commonly receives packed red cell blood transfusions during their hospital admission, the impact of which is less clear.Aims and objectivesWe aim to assess the rate, appropriateness and impact of blood transfusions on one-year mortality in hip fracture patients. We also aim to assess the impact of patients taking anticoagulant medications at presentation on the rates of blood transfusions in this patient group.MethodsA retrospective cohort study of 324 consecutive hip fracture patients. Data was collected from the national hip fracture database, electronic patient records and PACS.Results75 patients received a blood transfusion. Receiving a blood transfusion increased absolute risk of one-year mortality by 2.466 (p < 0.05). Adjusted for age, sex, comorbidities, residence prior to admission and time from presentation to surgery increased the risk of one-year mortality was 2.790 (p < 0.05).28% of patients who went on to receive a transfusion had a haemoglobin of less than 100 g/L at presentation. 94.6% of transfused patients had a pre-transfusion haemoglobin of less than 90 g/L. There was no increased risk of requiring a blood transfusion if anticoagulant medication was being taken at presentation.ConclusionReceiving a blood transfusion during an admission for hip fracture carried an increased risk of one-year mortality of almost two and a half times. With appropriate preoperative optimisation, taking an anticoagulant medication at presentation did not increase the risk of requiring a transfusion. Most blood transfusions were administered appropriately using thresholds. Just over a quarter of patients who received a transfusion had an admission haemoglobin of less than 100 g/L, showing it as a poor predictor of blood transfusion requirement during admission.     

There is no weekend effect in hip fracture surgery – A comprehensive analysis of outcomes

Background

Previous studies have shown that some patient groups suffer adverse outcomes if they are acutely admitted to hospital over a weekend. We aimed to investigate this ‘weekend effect’ at our centre in patients presenting with a hip fracture.

Direct oral anticoagulants (DOACs) and neck of femur fractures: Standardising the perioperative management and time to surgery

Demographic projections for hip fragility fractures indicate a rising annual incidence by virtue of a multimorbid, ageing population with more noncommunicable diseases (NCDs). NCDs are characterised by slow progression and long duration ranging from ischaemic cardiovascular disease, cerebrovascular disease, diabetes, chronic obstructive pulmonary disease to various cancers. Management of this disease burden often involves commencing patients on oral anticoagulants to reduce the risk of thromboembolic events. The use of direct oral anticoagulants (DOACs) in clinical practice has increased due to their rapid onset of action, short half-life and predictable anticoagulant effects, without the need for routine monitoring. Safe and timely surgical intervention relies on reversal of anticoagulants. However, the lack of specific evidence-based guidelines for the perioperative management of patients on DOACs with hip fractures has proved challenging; in particular, the accessibility of DOAC-specific assays, justification of the cost-benefit ratio of targeted reversal agents and indications for neuraxial anaesthesia. This has led to potentially avoidable delays in surgical intervention. Following a literature review of the pharmacokinetic and pharmacodynamics of commonly used DOACs in our region including the role of surrogate markers, we propose a systematic, evidence-based guideline to the perioperative management of hip fractures DOACs. We believe this standardised protocol can be easily replicated between hospitals. We recommend that if patients are deemed suitable for a general anaesthesia, with satisfactory renal function, optimal surgical time should be 24 h following the last ingested dose of DOAC.     

A comparative biomechanical study of proximal femoral nail (InterTAN) and proximal femoral nail antirotation for intertrochanteric fractures

Purpose

The purpose of this study was to compare the biomechanical strength of the cephalomedullary nail InterTAN in cases of intertrochanteric fractures with the commonly used PFNA.

Methods

Sixteen fresh specimens of the proximal femur were used as intertrochanteric fracture models and were fixed using two fixation devices: the new proximal femoral nail (InterTAN) and proximal femoral nail antirotation (PFNA). An intertrochanteric fracture was created in composite bone models. Each specimen was loaded to simulate single leg stance while stiffness, migration (cut out), compressive force across the fracture site, and distal fragment rotation were monitored. The different internal fixation methods were tested by an experimental press analysis.

Results

Results of tests for femoral strength, stiffness, stability, and bearing capacity demonstrated that the biomechanical function of InterTAN was better than that of PFNA (P < 0.05). Compared with the PFNA nail, InterTAN showed increased strength, stiffness, and resistance torque of 30 %, 15 %, and 27 %, respectively.

Conclusion

Comparison of the treatment of intertrochanteric fractures with InterTAN and PFNA internal fixation showed that the InterTAN yielded improvement relative to the PFNA. InterTAN has a firmer and biomechanically superior performance and is therefore an ideal internal fixation method for treating intertrochanteric fractures. Additional research in osteopenic bone is necessary to comprehensively characterize the effects of the design enhancements of these two implants.     

Hip fracture risk assessment using composite indices of femoral neck strength: the Rancho Bernardo study

The objective of this work was to examine the prediction of incident hip fracture risk by composite indices of femoral neck strength, constructed from dual X-ray absorptiometry (DXA) scans of the hip. These indices integrate femoral neck size and body size with bone density, and reflect the structures ability to withstand axial compressive forces and bending forces, and the ability to absorb energy in an impact. We studied a prospective cohort of community-dwelling women, 55 years or older at baseline, average age 72 years, that was established in 1988, with follow-up until 1998. Higher baseline values of each composite strength index were associated with lower risk of incident hip fracture in this cohort. After adjusting for age and body mass index, relative risks associated with each standard deviation increment in the composite indices were 0.39 for compression strength (95% confidence interval 0.25–0.60), 0.43 for bending strength (95% confidence interval 0.27–0.70), and 0.34 for impact strength (95% confidence interval 0.20–0.58). Larger bone size relative to body size was associated with lower risk of incident hip fracture. After adjusting for age, body mass index, and bone density, each standard deviation increment in femoral neck width normalized by body weight was associated with incident hip fracture relative risk of 0.38 (95% confidence interval 0.20–0.70). Our results suggest that composite indices of femoral neck strength, constructed from DXA measurements, have the potential to improve hip fracture risk assessment. This needs further exploration in larger cohorts and in different population sub-groups.     

创伤和关节外科医师行初次全髋关节置换术治疗股骨颈骨折的早期临床疗效对比研究

背景:因股骨颈骨折行初次全髋关节置换术(THA)的患者逐年增多,而不同亚专业医师的治疗结果是否存在差异尚不可知.目的:探讨创伤与关节外科医师行初次THA治疗股骨颈骨折患者的早期临床疗效.方法:回顾性分析2014年1月至2018年6月因股骨颈骨折行初次THA患者103例,根据所收入的亚专业组分为创伤医师组43例,关节医师...