Trochanteric fragility fractures

Objective

Use of standardized cement augmentation of the proximal femur nail antirotation (PFNA) for the treatment of trochanteric fragility fractures, which are associated with high morbidity and mortality, to achieve safer conditions for immediate full weight-bearing and mobilization, thus, improving preservation of function and independency of orthogeriatric patients.

Indications

Trochanteric fragility fractures (type 31-A1–3).

Contraindications

Ipsilateral arthritis of the hip, leakage of contrast agent into the hip joint, femoral neck fractures.

Surgical technique

Reduction of the fracture on a fracture table if possible, or minimally invasive open reduction of the proximal femur, i.?e., using collinear forceps if necessary. Positioning of guidewires for adjustment of the PFNA and the spiral blade, respectively. Exclusion of leakage of contrast agent and subsequent injection of TRAUMACEM? V⁺ into the femoral head–neck fragment via a trauma needle kit introduced into the spiral blade. Dynamic or static locking of the PFNA at the diaphyseal level.

Postoperative management

Immediate mobilization of the patients with full weight-bearing and secondary prevention, such as osteoporosis management is necessary to avoid further fractures in the treatment of these patients.

Results

A total of 110 patients older than 65 years underwent the procedure. Of the 72 patients available for follow-up (average age 85.3 years), all fractures healed after an average of 15.3 months. No complications related with cement augmentation were observed. Approximately 60?% of patients achieved the mobility level prior to trauma.

     

Low failure rate by means of DLBP fixation of undisplaced femoral neck fractures

Background

This study evaluated the clinical results of a new implant in the internal fixation of undisplaced femoral neck fractures.

Method

Irrespective of their age, 149 patients with undisplaced (Garden I and II) femoral neck fractures were included in a prospective multicentre clinical cohort study and were treated by internal fixation by means of the Dynamic Locking Blade Plate (DLBP). The mean age was 69 years and the follow-up at least one year.

Results

The DLBP fixation resulted in 6 out of 149 failures caused by AVN (2x), non-union (2x), loss of fixation (3x) or combination of these.

Conclusion

The fixation of undisplaced femoral neck fractures by the DLBP resulted in a low failure rate of 4 %.

     

Hip hemiarthroplasty for femur neck fractures: minimally invasive direct anterior approach versus postero-lateral approach

Background

The minimally invasive direct anterior approach (MDAA) has been reported to be useful in total hip arthroplasty. The benefits of this approach may be useful for the treatment of femoral neck fractures. Aim of this study is to compare MDAA and postero-lateral approach (PLA) in patients treated with hip hemiarthroplasty for femoral neck fractures.

Materials and methods

Between 2013 and 2014, 109 patients underwent bipolar hip hemiarthroplasty for femoral neck fracture: 88 female and 21 male with a mean age of 88 years old. PLA was performed in 54 cases and MDAA in 55 cases.

Results

The mean surgery time was significantly lower in MDAA group (P = 0.001). The hemoglobin loss was significantly lower in MDAA group (P = 0.02). The mean postoperative pain was significantly lower in the MDAA group (P = 0.001). The mean hospitalization period was 2 days lower in the MDAA group but with no significant difference between the two groups (P = 0.09). Hip dislocation was higher in PLA cases (7.4 %) than in MDAA cases (1.8 %). Periprosthetic fracture occurred only in one case of PLA. Great trochanter fracture occurred in 1 MDAA cases, while no cases were observed in the PLA group.

Conclusions

Minimally invasive direct anterior approach for hip hemiarthroplasty in elderly people with femoral neck fracture provided significant benefit in the early postoperative period when compared to the postero-lateral approach in terms of surgery time, hemoglobin loss, postoperative pain, time of recovery and dislocation rate.

Level of evidence

Therapeutic study, level IV (case series).

     

Treatment of the displaced femoral neck fractures: indications and limits of osteosynthesis

Purpose

Opinions about the optimal treatment of displaced femoral neck fractures in the elderly are still divided. The two main options are internal fixation and arthroplasty. The aim of our study was to determine the most adequate surgical procedure for displaced, Garden type III–IV femoral neck fractures: which patients should undergo an osteosynthesis or primary arthroplasty, with the least prospect of complications?

Methods

We analyzed 489 femoral neck fractures treated by percutaneous osteosynthesis. We also compared the results of displaced fractures treated with primary arthroplasty versus secondary arthroplasty performed due to the failure of primary osteosynthesis.

Results

The rate of redisplacement in the Garden type III group was 7.6%, and in the Garden type IV group, it was 25.5%, mainly in the case of subcapital fractures. Also, walking ability was examined 4 months after injury. In the ASA score II–III group, most of the patients were able to walk with or without walking aids, but in the case of ASA score IV, most of them were immobile or died during the hospital or posthospital phase. Our research also proved that, in cases of femoral neck fractures treated with primary arthroplasty, the complication rate is lower than after secondary arthroplasty due to failure of the primary osteosynthesis.

Conclusions

Based on our results, we recommend osteosynthesis in the case of Garden type III femoral neck fractures and, in turn, arthroplasty with respect to the high rate of early redisplacement in the case of Garden type IV fractures, especially in the case of subcapital fractures. For patients confined to a bed and in poor general condition (ASA score IV), the first choice treatment option is the minimally invasive percutaneous osteosynthesis.

     

Total medical costs of treating femoral neck fracture patients with hemi- or total hip arthroplasty: a cost analysis of a multicenter prospective study

Summary

The aim of this study was to determine the total medical costs for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients. The mean total costs per patient at 2 years of follow-up were €26,399. These results contribute to cost awareness.

Introduction

The absolute number of hip fractures is rising and increases the already significant burden on society. The aim of this study was to determine the mean total medical costs per patient for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients.

Methods

The population was the Dutch sample of an international randomized controlled trial consisting of femoral neck fracture patients treated with hemi- or total hip arthroplasty. Patient data and health care utilization were prospectively collected during a total follow-up period of 2 years. Costs were separated into costs for hospital care during primary stay, hospital costs for clinical follow-up, and costs generated outside the hospital during rehabilitation. Multiple imputations were used to account for missing data.

Results

Data of 141 participants (mean age 81 years) were included in the analysis. The 2-year mortality rate was 19 %. The mean total cost per patient after 10 weeks of follow-up was €15,216. After 1 and 2 years of follow-up the mean total costs were €23,869 and €26,399, respectively. Rehabilitation was the main cost determinant, and accounted for 46 % of total costs. Primary hospital admission days accounted for 22 % of the total costs, index surgery for 11 %, and physical therapy for 7 %.

Conclusions

The main cost determinants for hemi- or total hip arthroplasty after treatment of displaced femoral neck fractures (€26,399 per patient until 2 years) were rehabilitation and nursing homes. Most of the costs were made in the first year. Reducing costs after hip fracture surgery should focus on improving the duration and efficiency of the rehabilitation phase.

     

Clinical results of treatment of garden type 1 and 2 femoral neck fractures in patients over 70-year old

Introduction

We retrospectively analyzed the clinical results of treatment of impacted or undisplaced femoral neck fractures (Garden types 1 and 2) by osteosynthesis in elderly patients >70-year old.

Materials and methods

We retrospectively reviewed the radiological results of 52 patients who were followed up for at least 6 months from April 2002 to December 2008. The average age of the patients was 77.6 years (range 70–97 years), and 38 patients were females. The mean follow-up period was 11.7 months (range 6–19 months). Thirteen cases were Garden type 1 fractures, and 39 were Garden type 2 fractures. We assessed the relationships between the occurrence of complications and age, sex, Garden stage, bone mineral density (BMD), history of contralateral hip fracture, and any additional hip injury.

Results

Major complications occurred in 18 cases (34.6 %), including nonunion (8 cases), osteonecrosis (6 cases), stress fracture of the subtrochanter (2 cases), excessive pull-out of a screw (1 case), and deep infection (1 case). The development of complications was associated with Garden stage 2, BMD, and additional hip injury. However, other factors were not associated with complications. Reoperations were performed in 16 cases (30.1 %), and 2 of the patients died during follow-up.

Conclusion

A relatively high rate of complications or reoperations developed after treatment of Garden 2 femoral neck fractures in senile patients >70 years of age with osteoporosis. Although internal fixation has been recommended in the literature for undisplaced femoral neck fractures, primary arthroplasty may be a better option for treatment of Garden type 2 fractures in elderly patients.

     

Femoral malrotation after surgical treatment of femoral shaft fractures in children: a retrospective CT-based analysis

Background

Rotational malalignment is an important and not always avoidable complication after surgical treatment of femoral shaft fractures. The purpose of this study was to determine the incidence of rotational malalignment in children after surgical treatment of femoral shaft fractures and to identify potential patient- and treatment-related risk factors based on data obtained from CT scans.

Methods

We conducted a retrospective analysis of all patients aged less than 15 years with femoral shaft fractures admitted to our level 1 trauma centre between January 2004 and July 2014. Patients having obtained postoperative CT scans were included for the determination of rotational malalignment. A difference of greater than 15° in femoral torsion between both legs was considered as clinically relevant. Additionally, demographic data and clinical information such as fracture type, treatment method, fluoroscopy time and operating time were reviewed.

Results

A total of 24 patients were enrolled in this study. Clinically relevant femoral malrotation was identified in 10 patients (41.6%). Surgical revision was performed in 7 patients (29.2%). There was no association between the type of surgical procedure, age and the incidence and/or amount of femoral malrotation.

Conclusions

The data suggest that relevant femoral malrotation is an evident problem after surgical treatment of femoral shaft fractures in children that requires critical postoperative assessment.

Level of evidence

Level III, retrospective study.

     

Efficacy of osteoporosis pharmacotherapies in preventing fracture among oral glucocorticoid users: a network meta-analysis

Summary

Efficacy of osteoporosis medication is not well-established among patients taking oral glucocorticoids. We assessed the efficacy of approved osteoporosis pharmacotherapies in preventing fracture by combining data from randomized controlled trials. Teriparatide, risedronate, and etidronate were associated with decreased vertebral fracture risk.

Introduction

Several osteoporosis drugs are approved for the prevention and treatment of glucocorticoid (GC)-induced osteoporosis. However, the efficacy of these treatments among oral GC users is still limited. We aimed to examine the comparative efficacy of osteoporosis treatments among oral GC users.

Methods

We updated a systematic review through to March 2015 to identify all double-blinded randomized controlled trials (RCTs) that examined osteoporosis treatment among oral GC users. We used a network meta-analysis with informative priors to derive comparative risk ratios (RRs) and 95 % credible intervals (95 % CrI) for vertebral and non-vertebral fracture and mean differences in lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD). Treatment ranking was estimated using the surface under the cumulative ranking curve (SUCRA) statistic. A meta-regression was completed to assess a subgroup effect between patients with prior GC exposures and GC initiators.

Results

We identified 27 eligible RCTs examining nine active comparators. Etidronate (RR, 0.41; 95%CrI?=?0.17–0.90), risedronate (RR?=?0.30, 95%CrI?=?0.14–0.61), and teriparatide (RR?=?0.07, 95%CrI?=?0.001–0.48) showed greater efficacy than placebo in preventing vertebral fractures; yet, no treatment effects were statistically significant in reducing non-vertebral fractures. Alendronate, risedronate, and etidronate increased LS BMD while alendronate and raloxifene increased FN BMD. In preventing vertebral fractures, teriparatide was ranked as the best treatment (SUCRA: 77 %), followed by risedronate (77 %) and zoledronic acid (76 %). For non-vertebral fractures, teriparatide also had the highest SUCRA (69 %), followed by risedronate (64 %). No subgroup effect was identified with regards to prior GC exposure.

Conclusions

Despite weak trial evidence available for fracture prevention among GC users, we identified several drugs that are likely to prevent osteoporotic fracture. Teriparatide, risedronate, and etidronate were associated with decreased vertebral fracture risk.

     

Treatment of periprosthetic acetabular fractures after previous hemi- or total hip arthroplasty

Objective

Treatment of displaced periprosthetic acetabular fractures in elderly patients. The goal is to stabilize an acetabular fracture independent of the fracture pattern, by inserting the custom-made roof-reinforcement plate and starting early postoperative full weight-bearing mobilization.

Indications

Acetabular fracture with or without previous hemi- or total hip arthroplasty.

Contraindications

Non-displaced acetabular fractures.

Surgical technique

Watson-Jones approach to provide accessibility to the anterior and supraacetabular part of the iliac bone. Angle-stable positioning of the roof-reinforcement plate without any fracture reduction. Cementing a polyethylene cup into the metal plate and restoring prosthetic femoral components.

Postoperative management

Full weight-bearing mobilization within the first 10 days after surgery. In cases of two column fractures, partial weight-bearing is recommended.

Results

Of 7 patients with periprosthetic acetabular fracture, 5 were available for follow-up at 3, 6, 6, 15, and 24 months postoperatively. No complications were recognized and all fractures showed bony consolidation. Early postoperative mobilization was started within the first 10 days. All patients except one reached their preinjury mobility level. This individual and novel implant is custom made for displaced acetabular and periprosthetic fractures in patients with osteopenic bone. It provides a hopeful benefit due to early full weight-bearing mobilization within the first 10 days after surgery.

Limitations

In case of largely destroyed supraacetabular bone or two-column fractures according to Letournel additional synthesis via an anterior approach might be necessary. In these cases partial weight bearing is recommended.

     

Rekonstruktion des medialen patellofemoralen Ligaments mit autologer Grazilissehne in patellarseitig implantatfreier Technik

Objective

Anatomic reconstruction of the medial patellofemoral ligament using autologous gracilis tendon in an implant-free technique on the patellar side to regain patellofemoral stability.

Indications

Recurrent dislocations, primary dislocation with high risk of recurrence, and dislocations with (osteo-)chondral flake fractures. As combined approach together with other procedures (trochleoplasty, tibial tubercle osteotomy). Revisions.

Contraindications

As an isolated procedure in patients with high degrees of trochlear dysplasia, chronic dislocation of the patella, and patellofemoral maltracking without instability.

Surgical technique

Harvesting of the gracilis tendon. Drilling of a V-shaped tunnel with a special aiming device in anatomic position on the medial side of the patella. Drilling of a femoral tunnel in anatomic position under fluoroscopic control. Passage of the graft, arthroscopic-guided tensioning, and femoral fixation with a biodegradable interference screw.

Postoperative management

Partial weight bearing (20 kg) for 1–2 weeks. No limitation in range of motion. No orthosis. Specific sports allowed after approximately 3 months.

Results

Perioperative complications associated specifically with the technique were observed in 1.0?% (7 of 729 cases). In a series of 72 consecutive cases from May 2010 to October 2010, the following were recorded after 4.0 ± 0.1 years: recurrent dislocations in 3.2?%, a Tegner activity score of 5.1 ± 1.8, and subjective satisfaction in 92?% (follow-up rate 87.5?%). No fracture of the patella was seen in any of our patients.

     

Reducing intraoperative duration and ionising radiation exposure during the insertion of distal locking screws of intramedullary nails: a small-scale study comparing the current fluoroscopic method against radiation-free,electromagnetic navigation

Background

Intramedullary nailing is the standard surgical treatment for mid-diaphyseal fractures of long bones; however, it is also a high radiation dose procedure. Distal locking is regularly cited as a demanding element of the procedure, and there remains a reliance on X-ray fluoroscopy to locate the distal holes. A recently developed electromagnetic navigation (EMN) system allows radiation-free distal locking, with a virtual on-screen image.

Objective

To compare operative duration, fluoroscopy time and radiation dose when using EMN over fluoroscopy, for the distal locking of intramedullary nails.

Method

Consecutive patients with mid-diaphyseal fractures of the tibia and femur, treatable with intramedullary nails, were prospectively enrolled during a 9-month period. The sample consisted of 29 individuals, 19 under fluoroscopic guidance and 10 utilising EMN. Participants were allocated depending on the type of intramedullary nail used and surgeon’s preference. These were further divided into tibial and femoral subcategories, relative to the fracture site.

Results

EMN reduced fluoroscopy time by 49 (p = 0.038) and 28 s during tibial and femoral nailings, respectively. Radiation dose was reduced by 18 cGy/cm² (p = 0.046) during tibial and 181 cGy/cm² during femoral nailings when utilising EMN. Operative duration was 11 min slower during tibial nailings using EMN, but 38 min faster in respect of femoral nailings.

Conclusions

This study has evidenced statistically significant reductions in both fluoroscopy time and radiation dose when using EMN for the distal locking of intramedullary nails. It is expected that overall operative duration would also decrease in line with similar studies, with increased usage and a larger sample.

     

Measuring femoral neck torsion angle using femoral neck oblique axial computed tomography reconstruction

Purpose

To propose a novel method for measuring the femoral neck torsion angle (FNTA) with femoral neck oblique axial computed tomography (CT) reconstruction.

Methods

Fifty-five patients (24 females, 31 males; mean age 48.8 years [range, 20–91 years]) were included in the study. CT scans were performed on the left femurs of 27 patients and the right femurs of the remaining 28 patients. The images were analyzed independently by two observers using oblique axial femoral neck CT reconstruction. Intra-observer and inter-observer agreement was calculated as intraclass correlation coefficient (ICC).

Results

FNTA can be measured with high intra-observer (ICC?=?0.961) and high inter-observer (ICC?=?0.982) agreement. Mean FNTA was slightly larger in women than in men, and the mean left FNTA was slightly larger than the right, but neither difference was statistically significant.

Conclusions

Femoral neck oblique axial CT reconstruction can be used to obtain accurate measurement of FNTA with good reproducibility. No significant differences were found in FNTA between sexes or sides.

     

Die palmare winkelstabile Plattenosteosynthese bei Extensionsfrakturen des distalen Radius

Objective

Bony healing of dislocated distal radius fractures after open reduction and internal stabilization by locking screws/pins using palmar approach.

Indications

Extraarticular distal radius fractures type A2/A3, simple extra- and intraarticular fractures type C1 according to the AO classification, provided a palmar approach is possible.

Contraindications

Forearm soft tissue lesions/infections. As a single procedure if a volar approach not possible.

Surgical technique

Palmar approach to the distal radius and fracture. Open reduction. Palmar fixation of the plate to radial shaft with single screw. After fluoroscopy, distal fragments fixed using locking screws.

Postoperative management

Below-the-elbow cast for 2 weeks. Early exercise of thumb and fingers, wrist mobilization after cast removal. Complete healing after 6–8 weeks.

Results

Ten patients averaged 100?% range of motion of the unaffected side after 43±21 months. No complications observed. DASH score averaged 12±16 points; Krimmer wrist score was excellent in 7, good in 2, and fair in one.

     

Outcome of periprosthetic femoral fractures following total hip replacement treated with polyaxial locking plate

Background

The number of patients with total hip replacement (THR) is likely to grow. Periprosthetic femoral fractures occur in 0.1–4.5 % of patients with THR. Treatment of periprosthetic fractures in the vicinity of well-fixed implants has focused on lateral plating. The purpose of this study was to evaluate polyaxial locking plate treatment of periprosthetic fractures with THR in regard to fracture type, surgical procedure, complications, and outcome.

Methods

Between 2007 and 2013, 109 patients underwent surgical treatment for periprosthetic femur fractures with 66 fractures in the vicinity to a THR. Fifteen patients were excluded. Therefore, 51 patients with a mean age of 78.7 years were identified. There were 76.5 % females. Average BMI was 27.1 kg/m². Follow-up averaged 25 months. Total hip stems were uncemented in 63 %. Low-energy mechanism predominated. Fractures were classified according to AO/OTA and Vancouver classifications with the majority (70.6 %) classified as AO/OTA type A fractures. Surgeries were performed utilizing a polyaxial locking plate. Complications were recorded concerning infection, union, fixation failure, and revision surgery.

Results

After the index procedure, 90.2 % healed. Non-union formation was diagnosed in 5.9 % with 2.0 % leading to hardware failure. All patients with non-union formation had interprosthetic fractures (χ ² = 0.016). Additionally, these fractures were classified as AO/OTA type B fractures (χ ² = 0.003).

Conclusions

Surgical management despite polyaxial locked plate fixation continues to be challenging and may still result in non-union formation. Non-union formation is increased in AO/OTA type B fractures and related to interprosthetic fractures.

Level of evidence

Level IV.

     

Incidence of hip fracture and prevalence of osteoporosis in Turkey: the FRACTURK study

Summary

The incidence of hip fractures in Turkey increased markedly from that reported in 1988/1989 so that FRAX® models for Turkey should be revised.

Introduction

The MEDOS study in 1988/1989 reported that men and women from Turkey had exceptionally low rates of hip fracture. The aim of the FRACTURK study was to estimate current and future hip fracture risks and the prevalence of osteoporosis in Turkey.

Methods

Hip fracture cases in 2009 were identified from interviews of a population-based sample of 26,424 residents aged 50 years or more in 12 different regions of Turkey and in two hospital surveys. Bone mineral density was evaluated by DXA in an age-stratified sample of 1,965 men and women.

Results

Hip fracture incidence in the community-based survey was similar to that in the hospital survey. The age-specific incidence in men and women was substantially higher than that reported for 1988/1989. At the age of 50 years, the remaining lifetime probability of a hip fracture was 3.5% in men and 14.6% in women. In 2009, there were approximately 24,000 hip fractures estimated in Turkey, 73% of which were found in women. Assuming no change in the age- and sex-specific incidence, the number of hip fractures was expected to increase to nearly 64,000 in 2035. The prevalence of osteoporosis at the femoral neck was 7.5% and 33.3% in men and women, respectively, aged 50 years or more.

Conclusion

Although Turkey is still among the countries with low hip fracture rates in Europe, the incidence has increased markedly in the last 20 years. This finding can be used to recalibrate fracture risk assessment models for Turkey.

     

Treatment responses with once-weekly teriparatide therapy for osteoporosis

Summary

Monitoring bone mineral density is useful to assess treatment response for osteoporosis, but it does not always reflect fracture prevention. Two types of bone mineral density thresholds were used to analyze data from a once-weekly teriparatide trial, and they appear to be useful indicators of treatment success for osteoporosis.

Introduction

This study aimed to clarify whether the criteria of treatment response could be used to evaluate treatment success with once-weekly teriparatide.

Methods

The data of subjects whose lumbar or femoral neck bone mineral density (BMD) was measured in the TOWER study were included. The least significant change (LSC) and the absolute change were used as the criteria for judgment of treatment success. The correlation between the incidence of fractures and the treatment response was also assessed.

Results

There was no significant difference in baseline characteristics between the placebo and teriparatide groups. Once-weekly teriparatide therapy for 72 weeks showed treatment success in 79.2 % of the subjects for lumbar BMD and 44.1 % for femoral neck BMD by LSC and in 50.5 and 39.6 % by absolute change, respectively. A lower incidence of vertebral fracture was observed in patients who achieved treatment success for lumbar BMD. With the LSC, some treatment success was observed in the early phase of treatment, and it increased with treatment duration.

Conclusions

It appears that the LSC could be used as a surrogate efficacy indicator at an earlier stage of treatment, and the absolute criterion of ?2.5SD was confirmed as a useful marker of long-term treatment success.

     

Epiphyseal Arterial Network and Inferior Retinacular Artery Seem Critical to Femoral Head Perfusion in Adults With Femoral Neck Fractures

Background

A better understanding of the blood supply of the femoral head is essential to guide therapeutic strategies for patients with femoral neck fractures. However, because of the limitations of conventional techniques, the precise distribution and characteristics of intraosseous arteries of the femoral head are not well displayed.

Questions/purposes

To explore the characteristics and interconnections of the intraosseous vessel system between different areas of the femoral head and the possible blood supply compensatory mechanism after femoral neck fracture.

Methods

The three-dimensional (3-D) structures of the intraosseous blood supply in 30 uninjured normal human femoral heads were reconstructed using angiography methods and microCT scans. The data were imported in the AMIRA^® and MIMICS^® software programs to reconstruct and quantify the extra- and intraosseous arteries (diameter, length). In a separate experiment, we evaluated the residual blood supply of femoral heads in 27 patients with femoral neck fractures before surgery by analyzing digital subtraction angiography data; during the study period, this was performed on all patients in whom hip-preserving surgery was planned, rather than arthroplasty. The number of affected and unaffected subjects included in the three groups (superior, inferior, and anterior retinacular arteries) with different types of fractures (Garden Types I–IV) were recorded and analyzed (Fisher’s exact test) to reflect the affected degrees of these three groups of retinacular arteries in patients after femoral neck fractures.

Results

The main results of our cadaver study were: (1) the main blood supply sources of the femoral head were connected by three main network structures as a whole, and the epiphyseal arterial network is the most widely distributed and the primary network structure in the femoral head; (2) the main stems of the epiphyseal arteries which were located on the periphery of the intraosseous vascular system have fewer anastomoses than the network located in the central region; (3) compared with the round ligament artery and anterior retinacular artery, the inferior retinacular artery has a relatively large caliber. Digital subtraction angiography of the 27 patients with hip fractures indicated that the inferior retinacular arterial system had a high likelihood of being unaffected after femoral neck fracture (100% [14 of 14] in nondisplaced fractures and 60% [six of 10] in Garden Type III fractures).

Conclusions

The epiphyseal arterial network and inferior retinacular arterial system appear to be two important structures for maintaining the femoral head blood supply after femoral neck fracture. Increased efforts to protect these key structures during surgery, such as drilling and placing internal implants closer to the central region of the femoral head, might be helpful to reduce the effect of iatrogenic injury of the intraosseous vascular system.

Clinical Relevance

3-D anatomic evidence of intraosseous arterial distribution of the femoral head and the high frequency with which the inferior retinacular arteries remained patent after femoral neck fracture lead us to consider the necessity of drilling and placing internal implants closer to the central region of the femoral head during surgery. Future controlled studies might evaluate this proposition.

     

Thoracic kyphosis and rate of incident vertebral fractures: the Fracture Intervention Trial

Summary

Biomechanical analyses support the theory that thoracic spine hyperkyphosis may increase risk of new vertebral fractures. While greater kyphosis was associated with an increased rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture.

Introduction

Biomechanical analyses suggest hyperkyphosis may increase risk of incident vertebral fracture by increasing the load on vertebral bodies during daily activities. We propose to assess the association of kyphosis with incident radiographic vertebral fracture.

Methods

We used data from the Fracture Intervention Trial among 3038 women 55–81 years of age with low bone mineral density (BMD). Baseline kyphosis angle was measured using a Debrunner kyphometer. Vertebral fractures were assessed at baseline and follow-up from lateral radiographs of the thoracic and lumbar spine. We used Poisson models to estimate the independent association of kyphosis with incident fracture, controlling for age and femoral neck BMD.

Results

Mean baseline kyphosis was 48° (SD?=?12) (range 7–83). At baseline, 962 (32 %) participants had a prevalent fracture. There were 221 incident fractures over a median of 4 years. At baseline, prevalent fracture was associated with 3.7° greater average kyphosis (95 % CI 2.8–4.6, p?<?0.0005), adjusting for age and femoral neck BMD. Before adjusting for prevalent fracture, each 10° greater kyphosis was associated with 22 % increase (95 % CI 8–38 %, p?=?0.001) in annualized rate of new radiographic vertebral fracture, adjusting for age and femoral neck BMD. After additional adjustment for prevalent fracture, estimated increased annualized rate was attenuated and no longer significant, 8 % per 10° kyphosis (95 % CI ?4 to 22 %, p?=?0.18).

Conclusions

While greater kyphosis increased the rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture.

     

The Frank Stinchfield Award

Background

Hip fractures are a major public health concern. For displaced femoral neck fractures, the needs for medical services during hospitalization and extending beyond hospital discharge after total hip arthroplasty (THA) may be different than the needs after THA performed for osteoarthritis (OA), yet these differences are largely uncharacterized, and the Medicare Severity Diagnosis-Related Groups system does not distinguish between THA performed for fracture and OA.

Questions/purposes

(1) What are the differences in in-hospital and 30-day postoperative clinical outcomes for THA performed for femoral neck fracture versus OA? (2) Is a patient’s fracture status, that is whether or not a patient has a femoral neck fracture, associated with differences in in-hospital and 30-day postoperative clinical outcomes after THA?

Methods

The National Surgical Quality Improvement Program (NSQIP) database, which contains outcomes for surgical patients up to 30 days after discharge, was used to identify patients undergoing THA for OA and femoral neck fracture. OA and fracture cohorts were matched one-to-one using propensity scores based on age, gender, American Society of Anesthesiologists grade, and medical comorbidities. Propensity scores represented the conditional probabilities for each patient having a femoral neck fracture based on their individual characteristics, excluding their actual fracture status. Outcomes of interest included operative time, length of stay (LOS), complications, transfusion, discharge destination, and readmission. There were 42,692 patients identified (41,739 OA; 953 femoral neck fractures) with 953 patients in each group for the matched analysis.

Results

For patients with fracture, operative times were slightly longer (98 versus 92 minutes, p = 0.015), they experienced longer LOS (6 versus 4 days, p < 0.001), and the overall frequency of complications was greater compared with patients with OA (16% versus 6%, p < 0.001). Although the frequency of preoperative transfusions was higher in the fracture group (2.0% versus 0.2%, p = 0.002), the frequency of postoperative transfusion was not different between groups (27% versus 24%, p = 0.157). Having a femoral neck fracture versus OA was strongly associated with any postoperative complication (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.1–3.8]; p < 0.001), unplanned readmission (OR, 1.8; 95% CI, 1.0–3.2; p = 0.049), and discharge to an inpatient facility (OR, 1.7; 95% CI, 1.4–2.0; p < 0.001).

Conclusions

Compared with THA for OA, THA for femoral neck fracture is associated with greater rates of complications, longer LOS, more likely discharge to continued inpatient care, and higher rates of unplanned readmission. This implies higher resource utilization for patients with a fracture. These differences exist despite matching of other preoperative risk factors. As healthcare reimbursement moves toward bundled payment models, it would seem important to differentiate patients and procedures based on the resource utilization they represent to healthcare systems. These results show different expected resource utilization in these two fundamentally different groups of patients undergoing hip arthroplasty, suggesting a need to modify healthcare policy to maintain access to THA for all patients.

Level of Evidence

Level III, therapeutic study.

     

The circulating sphingosine-1-phosphate level predicts incident fracture in postmenopausal women: a 3.5-year follow-up observation study

Summary

A high level of circulating sphingosine-1-phosphate (S1P) is associated with a high incidence of osteoporotic fracture and a high rate of an insufficient response to bisphosphonate therapy.

Introduction

Sphingosine-1-phosphate (S1P) is a significant regulator of bone metabolism. Recently, we found that a high plasma S1P level is associated with low bone mineral density (BMD), high levels of bone resorption markers (BRMs), and a high risk of prevalent vertebral fracture in postmenopausal women. We investigated the possibility that S1P is a predictor of incident fracture.

Methods

A total of 248 postmenopausal women participated in this longitudinal study and were followed up for a mean duration of 3.5 years (untreated [n?=?76] or treated with bisphosphonate or hormone replacement therapy [n?=?172]). The baseline plasma S1P level and prevalent and incident fracture occurrence were assessed.

Results

A high S1P level was significantly associated with a higher rate of prevalent fracture after adjusting for femoral neck (FN) BMD, BRM, and potential confounders (odds ratio?=?2.05; 95 % confidence interval [CI]?=?1.03–4.00). Incident fractures occurred more frequently in the highest S1P tertile (T3) than in the lower two tertiles (T1–2) after adjusting for confounders, including baseline FN BMD, prevalent fracture, antiosteoporotic medication, annualized changes in FN BMD, BRM, and potential confounders (hazard ratio?=?5.52; 95 % CI?=?1.04–56.54). Insufficient response to bisphosphonate therapy occurred more frequently in T3 than T1–2 (odds ratio?=?4.43; 95 % CI?=?1.02–21.25).

Conclusions

The plasma S1P level may be a potential predictor of fracture occurrence and an insufficient response to bisphosphonate therapy in postmenopausal women.