No difference in flexion power despite iliopsoas fatty degeneration in healed hip fractures with large lesser trochanter displacement

Objective

To evaluate iliopsoas atrophy and loss of function after displaced lesser trochanter fracture of the hip.

Design

Cohort study.

Setting

District hospital.

Patients

Twenty consecutive patients with pertrochanteric fracture and displacement of the lesser trochanter of?>?20 mm.

Intervention

Fracture fixation with either an intramedullary nail or a plate.

Outcome measurements

Clinical scores (Harris hip, WOMAC), hip flexion strength measurements, and magnetic resonance imaging findings.

Results

Compared with the contralateral non-operated side, the affected side showed no difference in hip flexion force in the supine upright neutral position and at 30° of flexion (205.4 N vs 221.7 N and 178.9 N vs. 192.1 N at 0° and 30° flexion, respectively). However, the affected side showed a significantly greater degree of fatty infiltration compared with the contralateral side (global fatty degeneration index 1.085 vs 0.784), predominantly within the psoas and iliacus muscles.

Conclusion

Severe displacement of the lesser trochanter (>?20 mm) in pertrochanteric fractures did not reduce hip flexion strength compared with the contralateral side. Displacement of the lesser trochanter in such cases can lead to fatty infiltration of the iliopsoas muscle unit. The amount of displacement of the lesser trochanter did not affect the degree of fatty infiltration.

Level of evidence

II.

     

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).

     

In-hospital mortality risk of intertrochanteric hip fractures: a comprehensive review of the US Medicare database from 2005 to 2010

Purpose

Intertrochanteric hip fracture is a common injury in the Medicare population. Very little is known about the in-hospital mortality risk of intertrochanteric hip fractures and associated demographics for the US Medicare population. The purpose of this study is to determine the in-hospital mortality rate of closed intertrochanteric hip fractures and to evaluate demographic factors influencing an increased mortality risk.

Methods

The PearlDiver Medicare database from 2005 to 2010 was queried for closed intertrochanteric hip fractures. Stratified sampling was conducted by creating subset for individuals with a death discharge from inpatient facilities. Statistical analysis was performed where appropriate.

Results

Throughout 2005–2010 there were a total of 1,138,142 intertrochanteric hip fractures. There were 19,385 deaths during the initial hospital stay, yielding a mortality rate of 1.70%. There was a 1.83% mortality rate for patients 75 and older and patients over the age of 84 comprised the majority of deaths at 58%. The mortality rate was lower for females (1.39%) than for males (2.56%) (p < 0.0002).

Conclusion

We found in the Medicare database that there is a relatively low rate of in-hospitality mortality associated with intertrochanteric hip fractures; this rate is lower than previously reported. We report a 1.70% in-hospital mortality using a complete Medicare dataset. Based on previous reporting for short term and one-year mortality risk, the present study suggests that mortality risk is greatest after patients have been released from the hospital. More attention should be paid to understanding and attenuating the mortality associated with intertrochanteric hip fractures after the acute hospital phase.

     

Greater trochanter chip fractures in the direct anterior approach for total hip arthroplasty

Background

The direct anterior approach (DAA) for the treatment of total hip arthroplasty (THA) has gained popularity in recent years. Chip fractures of the greater trochanter are frequently seen, but the risk factors for such fractures are unknown. The study aimed to identify the risk factors for chip fractures in patients undergoing primary THA by the DAA during the surgeons’ learning curve.

Materials and methods

From November 2011 to April 2015, the first experiences of three surgeons who performed 120 THAs by the DAA (120 hips; 40 cases per beginner surgeon) were included. The incidence of chip fracture of the greater trochanter, the size of the greater trochanter as measured by computed tomography, and the patients’ characteristics were retrospectively investigated.

Results

After exclusion of 11 hips, the remaining 109 hips were investigated. Chip fracture of the greater trochanter was identified in 32 hips (29.4 %). Univariate analysis with and without fractures showed that the width and depth of the greater trochanter were statistically significant risk factors (p = 0.02 and p < 0.001, respectively). Multivariate analysis using a logistic regression model demonstrated that the depth of the greater trochanter was an independent risk factor for chip fracture of the greater trochanter (OR 1.725; 95 % CI 1.367–2.177; p < 0.001).

Conclusion

The size of the greater trochanter was identified as a risk factor for chip fracture of the greater trochanter. Novice surgeons should pay attention to the size of the greater trochanter when performing THA by the DAA.

     

The use of a dual mobility cup in the management of recurrent dislocations of hip hemiarthroplasty

Background

Dislocation is one of the most frequent causes of failure of hemiarthroplasties of the hip, which is the most common treatment for femoral neck fractures in elderly patients. A revision with conversion to total hip arthroplasty is the gold standard in case of failure of closed reduction: however, the use of standard or modular components shows variable outcomes. The use of a dual mobility cup has been evaluated in patients with unstable implants, given the good outcomes obtained in primary and revision surgery. The aim of this study was to assess the results of revisions by dual mobility cups in unstable hemiarthroplasties.

Materials and methods

Thirty-one patients (mean age 75.4 years) were retrospectively evaluated between 2006 and 2010 after conversion to total hip arthroplasty with dual mobility cups for recurrent dislocations. The mean number of dislocations was 2.6 (range 2–5). The evaluation was performed by the American Society of Anesthesiologists physical function score (ASA) and the Harris hip score, and several radiologic criteria.

Results

The mean follow-up was 3.8 years. No recurrence of dislocation was recorded. The ASA score remained unchanged, and the mean Harris hip score improved from 62.2 before dislocation to 76.0 points postoperatively.

Conclusions

Dual mobility cups may be a useful option in the treatment of a hemiarthroplasty dislocation. No risk of a new revision due to instability after insertion of dual mobility cups resulted in our experience, and this option may be strongly considered in cases of revisions of unstable hemiarthroplasties. Level of evidence IV.

     

The Fascia Iliaca Block as the Primary Intraoperative Anesthesia for Hip Fracture Surgery: A Preliminary Study

Background

Early surgical intervention for hip fractures in the elderly has proven efficacious. However, surgical delays commonly occur in this patient population due to comorbid conditions that put these patients at a high risk for hypotension-related complications of general or neuraxial anesthesia or anticoagulants that delay the safe use of neuraxial anesthesia.

Questions/Purposes

The questions/purposes of this study are (1) to investigate if a fascia iliaca block in conjunction with light to moderate sedation could provide adequate analgesia throughout open surgery for intertrochanteric hip fractures (AO/OTA 31-1) without requiring conversion to general anesthesia with airway support and (2) to assess its perioperative complication profile.

Methods

A retrospective chart review was conducted to identify patients with intertrochanteric hip fractures who underwent anesthesia with a fascia iliaca block over a 1.5-year period.

Results

In the six patients identified, there were no intraoperative conversions to general anesthesia requiring airway support. Additionally, there were no intraoperative complications, no mortalities within 30 days, 2 patients on anticoagulation who required a blood transfusion, and a single patient who developed a postoperative hospital-acquired pneumonia that resolved with an antibiotic course.

Conclusions

In this series of patients, we demonstrate that a fascia iliaca block can reliably be utilized as the primary anesthetic for patients undergoing surgical fixation of intertrochanteric hip fractures, with an acceptable perioperative complication profile. Although concomitant sedation was provided with the block, this anesthesia strategy has the potential to reduce preoperative delays and minimize the overall burden of sedative and anesthetic medications in a geriatric population. These initial findings may serve as a basis for future, higher-quality prospective and comparative studies.

     

Second fractures among older adults in the year following hip,shoulder, or wrist fracture

Summary

We report on second fracture occurrence in the year following a hip, shoulder or wrist fracture using insurance claims. Among 273,330 people, 4.3 % had a second fracture; risk did not differ by first fracture type. Estimated adjusted second fracture probabilities may facilitate population-based evaluation of secondary fracture prevention strategies.

Introduction

The purpose of this study was estimate second fracture risk for the older US population in the year following a hip, shoulder, or wrist fracture.

Methods

Observational cohort study of Medicare fee-for-service beneficiaries with an index hip, shoulder, or wrist fragility fracture in 2009. Time-to-event analyses using Cox proportional hazards models to characterize the relationship between index fracture type (hip, shoulder, wrist) and patient factors (age, gender, and comorbidity) on second fracture risk in the year following the index fracture.

Results

Among 273,330 individuals with fracture, 11,885 (4.3 %) sustained a second hip, shoulder or wrist fracture within one year. Hip fracture was most common, regardless of the index fracture type. Comparing adjusted second fracture risks across index fracture types reveals that the magnitude of second fracture risk within each age-comorbidity group is similar regardless of the index fracture. Men and women face similar risks with frequently overlapping confidence intervals, except among women aged 85 years or older who are at greater risk.

Conclusions

Regardless of index fracture type, second fractures are common in the year following hip, shoulder or wrist fracture. Secondary fracture prevention strategies that take a population perspective should be informed by these estimates which take competing mortality risks into account.

     

Hip fractures in users of first- vs. second-generation bisphosphonates

Summary

This study compared population hip fracture rates for women with a prior fragility fracture who were treated with first-generation versus second-generation bisphosphonate therapies. The observational study found that, relative to women treated with etidronate, a first-generation bisphosphonate, women treated with the second-generation therapies ‘alendronate’ or ‘risedronate’ were equally likely to be admitted to hospital for hip fracture. Our findings must be confirmed in large randomized head-to-head controlled trials.

Introduction

Few studies have examined hip fracture outcomes among users of first- versus second-generation bisphosphonates. We compared hip fracture rates among elderly women with a history of fracture dispensed first- and second-generation bisphosphonates, hypothesizing that hip fracture rates would be higher among users of first- versus second-generation bisphosphonates after adjusting for confounders.

Methods

Administrative data from Ontario, Canada from 01 April 1998 to 31 March 2002 was used to identify population-based bisphosphonate-naïve cohorts of subjects age 66 years and older initiated on first- (etidronate plus calcium; e; n?=?1,460) bisphosphonates. Multivariate Cox proportional hazard models were used for analysis.

Results

During over 23,000 person-years of follow-up, we observed 293 hospital admissions for first hip fracture. The unadjusted event rates yielded approximately 12.5 hospital admissions for hip fracture per 1,000 person-years of follow-up in each study group. Relative to the etidronate plus calcium group, females in the alendronate or risedronate group were equally likely to be admitted for hip fracture (adjusted rate ratio [aRR]?=?1.0; 95% CI 0.6–1.6).

Conclusions

The findings of this study suggest similar rates of hip fracture between the first- and second-generation bisphosphonates when used continuously among elderly females with a prior history of fracture.

     

Extended trochanteric osteotomy (ETO) fixation for femoral stem revision in periprosthetic fractures: Dall–Miles plate versus cables

Background

Extended trochanteric osteotomy (ETO) is a well-established surgical technique used for femoral stem retrieval in revision hip arthroplasty procedures. Fixation of ETO is commonly achieved through wire, cable or cable–plate fixation. No evidence exists to date to suggest which method is superior when used in an acute traumatic setting.

Methods

Thirty cases of acute periprosthetic fracture requiring femoral stem revision with an ETO were identified over a 10-year period. Each case had a loose femoral prosthesis which was revised using an ETO approach. Nineteen of these were fixed using cables only, and 11 were fixed using a cable–plate construct. Radiographic outcomes measured included greater trochanter migration, osteolysis, union, time to union and overall success using the Beals and Tower classification. Clinical outcomes were assessed using the modified Harris Hip Score.

Results

Twenty-three Vancouver B/C-type fractures were identified. The remaining seven consisted of other fracture types with a loose femoral stem requiring revision through ETO. Mean follow-up was 32 months in the cable group and 12 months in the cable–plate group. The cable–plate construct performed better than cables alone. Mean migration rates were 1.7 mm lower in the cable–plate group (p < 0.05). Beals and Tower classification of radiographic outcomes was significantly better in the cable–plate group (p < 0.01). Modified Harris Hip Scores were better in this group also (p < 0.05).

Conclusion

When utilising an ETO approach for femoral stem revision in acute periprosthetic fractures, superior clinical and radiographic outcomes can be achieved if fixation involves a cable–plate system instead of cables only.

     

Visit-to-visit variation of fasting plasma glucose is a predictor of hip fracture in older persons with type 2 diabetes: the Taiwan Diabetes Study

Summary

We investigated the association between fasting plasma glucose variability (FPG-CV) and the risk of hip fracture in elderly diabetic patients. Our finding showed a temporal association between FPG-CV and hip fracture as patients categorized as FPG-CV greater than 25.4 % showed an increased risk in hip fractures.

Introduction

Hip fracture is a major health burden in the population and is associated with high rates of mortality and morbidity especially in elderly. It is evident that diabetes mellitus is a risk factor of osteoporosis which is a significant risk factor of hip fracture. However, epidemiological studies exploring the risks of hip fracture among type 2 diabetic patients are limited.

Methods

A retrospective study of 26,501 ethnic Chinese older persons enrolled in the National Diabetes Care Management program in Taiwan was conducted; related factors were analyzed with extended Cox proportional hazards regression models to competing risk data on hip fracture incidence.

Results

The results show a temporal association between FPG-CV and hip fracture as patients categorized as FPG-CV greater than 25.4 % showed an increased risk in hip fractures, confirming a linear relationship between the two. After multivariate adjustment, the risk of hip fracture increased among patients with FPG-CV of 25.4–42.3 % and >42.3 % compared with patients with FPG-CV of ≦ 14.3 % (hazard ratio, 1.35; 95 % confidence interval 1.14–1.60 and 1.27; 1.07–1.52, respectively). Significant linear trends among various FPG-CV were observed.

Conclusions

Thus, the present study demonstrated the importance of glucose stability for fracture prevention in older persons with type 2 diabetes. Future studies should be conducted to explore whether reduction in glucose oscillation in older adults with diabetes mellitus can reduce the risk of hip fracture.

     

A systematic review and meta-analysis of the direct anterior approach for hemiarthroplasty for femoral neck fracture

Background

We performed a systematic review and meta-analysis to assess whether the direct anterior approach (DAA) is associated with improved functional and clinical outcomes compared to other surgical approaches for hemiarthroplasty for displaced femoral neck fractures.

Materials and methods

Randomized trials and cohort studies of hemiarthroplasty performed via DAA versus another surgical approach (anterolateral, lateral, posterolateral, posterior) were included. Our primary outcome was postoperative functional mobility. Secondary outcomes included overall complication rate, dislocation rate, perioperative fracture, infection rate, re-operation rate, overall mortality, operative time, pain, intra-operative blood loss, and length of stay.

Results

Nine studies met inclusion criteria, comprising a total of 698 hips (330 direct anterior, 57 anterolateral, 89 lateral, 114 posterolateral, 108 posterior approach). With regard to functional mobility, DAA was favored in 4 studies, and no study favored another approach over DAA. DAA had a significantly lower dislocation rate compared to posterior capsular approaches. Analysis of other secondary outcomes did not identify statistically significant differences.

Conclusion

This is the first systematic review and meta-analysis of the DAA for hemiarthroplasty. Available evidence suggests superior early functional mobility with the DAA. The DAA is associated with a significantly lower dislocation rate compared to posterior capsular approaches for hemiarthroplasty.

     

Surgical treatment of periprosthetic femoral fractures: a retrospective study with functional and radiological outcomes from 2010 to 2016

Background

The treatment of periprosthetic femoral fractures is a great challenge for the orthopedic surgeon and requires a knowledge of bone fracture fixation as well as skills and experience in revision surgery. The aim of this retrospective study was to evaluate the functional and radiological outcomes of periprosthetic femoral fractures surgically treated in our department from 2010 to 2016.

Materials and methods

This study involved 73 patients with a periprosthetic femoral fracture after total hip arthroplasty or hemiarthroplasty. Periprosthetic femoral fractures were classified using the Vancouver system. Functional outcomes were assessed using Harris hip score, Palmer Parker score, SF-36 score and ambulatory status. Radiological findings were classified using Beals and Tower’s criteria.

Results

The mean age of patients was 79.6 years old. Local risks factors were identified in 67% of the patients, principally osteoporosis (63.0%), followed by osteolysis (26.0%) and loosening of the stem (8.2%). According to the Vancouver classification, there were 10 type A, 49 type B and 14 type C fractures. Of the type B fractures, 26 were B1, 17 were B2 and 6 were B3. Applying Beals and Tower’s criteria, radiological results were excellent in 24 patients (32.9%), good in 35 (47.9%) and poor in 14 (19.2%). The mean Harris hip score post-operatively was 72.5.

Conclusions

These kinds of fractures should be assessed individually and the optimal treatment plan should be made in accordance with the bone stock quality, stem stability, location of the fracture and patient expectations.

     

Mid-Term Survivals After Cementless Bipolar Hemiarthroplasty for Unstable Intertrochanteric Fractures in Elderly Patients

Background

Treatment of unstable intertrochanteric fracture in elderly patients remains challenging. The purpose of this prospective study is to determine clinical and radiological results of cementless bipolar hemiarthroplasty using a fully porous-coated stem in osteoporotic elderly patients with unstable intertrochanteric fractures with follow-up over 5 years.

Quality of life,resource use,and costs related to hip fracture in Estonia

Summary

We assessed the impact of hip fracture on health-related quality of life (HRQoL) and costs in Estonia. The mean 18-month HRQoL loss in quality adjusted life years (QALY) was estimated at 0.31, and the average cumulative cost from a societal perspective was 8146 euros per hip fracture patient.

Introduction

The aim of this study is to estimate the impact of hip fracture on HRQoL, resource consumption, and cost over 18 months after the fracture among individuals aged over 50 in Estonia.

Methods

A cohort of 205 hip fracture patients ≥50 years was followed up for 18 months. HRQoL was estimated before fracture (recall), after fracture, and at 4, 12, and 18 months using the EQ-5D instrument. Health care utilization and costs were obtained from a public health insurance fund database; social, informal, and indirect costs were estimated using patient-reported data.

Results

Hip fracture resulted in the mean 18-month HRQoL loss of 0.31 QALYs. The mean 18-months cumulative cost of hip fracture from a societal perspective was estimated at 8146 (95 % CI 6236–10717) euros per patient. Most of the cost was related to health care (56 %) and informal care (33 %), while social care contributed only 5 %. Utilization of outpatient rehabilitation and nursing care was low (8 % of patients).

Conclusions

The impact of hip fracture on HRQoL and cost was substantial. Despite appropriate inpatient care, utilization of rehabilitation, nursing care, and social care were low and potentially insufficient to meet the needs of patients with low HRQoL. The shortfall may partially explain a remarkably high use of informal care.

     

Clinical results of hemiarthroplasty using new bipolar cups for stage 3 or lower osteonecrosis of the femoral head: a retrospective study

Purpose

The aim of this study was to evaluate clinical and radiographic findings of stage 3 or lower osteonecrosis of the femoral head (ONFH) with intact acetabular cartilage in patients treated with bipolar hemiarthroplasty (BHA).

Methods

A total of 79 hips that underwent BHA for ONFH were included in this study. The average observation period was 7.6 years. Clinical results were evaluated using the Harris hip score. We performed radiographic analysis to assess the migration of the outer cup, the permanent image around the outer cup, and loosening of the stem.

Results

The total Harris hip score improved from 50 points before surgery to 92 points at final follow-up, while pain improved from 14 points to 36 points. Flexion improved from 94° to 120° and abduction from 27° to 37°. One patient on dialysis showed progress in terms of inward migration, and revision surgery was performed on the patient 14 years after the original surgery.

Conclusions

Midterm performance of BHA for stage 3 or lower ONFH at our hospital was good.

     

Osteosynthese und Pfannenwechsel bei periprothetischer Azetabulumfraktur über einen Kocher-Langenbeck-Zugang

Objective

Reconstruction/stable fixation of the acetabular columns to create an adequate periacetabular requirement for the implantation of a revision cup.

Indications

Displaced/nondisplaced fractures with involvement of the posterior column. Resulting instability of the cup in an adequate bone stock situation.

Contraindications

Periprosthetic acetabulum fractures with inadequate bone stock. Extended periacetabular defects with loss of anchorage options. Isolated periprosthetic fractures of the anterior column. Septic loosening.

Surgical technique

Dorsal approach. Dislocation of hip. Mechanical testing of inlaying acetabular cup. With unstable cup situation explantation of the cup, fracture fixation of acetabulum with dorsal double plate osteosynthesis along the posterior column. Cup revision. Hip joint reposition.

Postoperative management

Early mobilization; partial weight bearing for 12 weeks. Thrombosis prophylaxis. Clinical and radiological follow-ups.

Results

Periprosthetic acetabular fracture in 17 patients with 9 fractures after primary total hip replacement (THR), 8 after revision THR. Fractures: 12 due to trauma, 5 spontaneously; 7 anterior column fractures, 5 transverse fractures, 4 posterior column fractures, 1 two column fracture after hemiendoprosthesis. 5 type 1 fractures and 12 type 2 fractures. Operatively treated cases (10/17) received 3 reinforcement ring, 2 pedestal cup, 1 standard revision cup, cup-1 cage construct, 1 ventral plate osteosynthesis, 1 dorsal plate osteosynthesis, and 1 dorsal plate osteosynthesis plus cup revision (10-month Harris Hip Score 78 points). Radiological follow-up for 10 patients: consolidation of fractures without dislocation and a fixed acetabular cup. No revision surgeries during follow-up; 2 hip dislocations, 1 transient sciatic nerve palsy.

     

Wrist hemiarthroplasty for irreparable DRF in the elderly

Introduction

The authors update their results of wrist hemiarthroplasty for irreparable distal radius fracture in the elderly, at a minimum of 2-year follow-up.

Materials and methods

Between 2011 and 2018, 25 consecutive independent elderly patients (24 female, 27 wrists) were treated with wrist hemiarthroplasty for distal radius fracture at a single institution. The average age was 77 years (range 65–88). They all were independent at home. A total of 19 wrists were treated at the acute stage, and 8 secondary procedures. The average follow-up was 32 months (range 24–44).

Results

There was no dislocation, loosening, infection nor removal of the implants. We observed 3 CRPS. At final follow-up, the average VAS pain was 1/10, mean forearm pronation/supination arc was 150°, and mean active flexion–extension arc was 60°. Average wrist extension was 36°. Mean grip strength was 68% of contralateral side. Mean Lyon wrist score was 74%. Mean Quick DASH score was 26%, and mean PRWE score was 25%.

Discussion

Our data suggest that treatment of acute irreparable distal radius fracture in the independent elderly patient with a bone-preserving primary wrist hemiarthroplasty may be a viable option. Longer-term follow-up are needed to confirm these preliminary data.

     

Clinical Management of Osteoporotic Fractures

Purpose of Review

This review examines recent literature regarding the clinical management of fragility fractures, provides insight into new practice patterns, and discusses controversies in current management.

Recent Findings

There are declining rates of osteoporosis management following initial fragility fracture. Management of osteoporotic fractures via a multidisciplinary team reduces secondary fracture incidence and improves overall osteoporotic care. Anabolic agents (abaloparatide and teriparatide) are effective adjuvants to fracture repair, and have shown positive results in cases of re-fracture in spite of medical management (i.e., bisphosphonates). For AO 31-A1 and A2 intertrochanteric hip fractures (non-reverse obliquity), no clinical advantage of intramedullary fixation over the sliding hip screw (SHS) has been proven; SHS is more cost-effective.

Summary

As fragility fracture incidence continues to rise, orthopedic surgeons must play a more central role in the care of osteoporotic patients. Initiation of pharmacologic intervention is key to preventing subsequent fragility fractures, and may play a supportive role in initial fracture healing. While the media bombards patients with complications of medical therapy (atypical femur fractures, osteonecrosis of jaw, myocardial infarction), providers need to understand and communicate the low incidence of these complications compared with consequences of not initiating medical therapy.

     

The Baba classification focused on implant designs is useful in setting the therapeutic strategy for interprosthetic femoral fracture

Purpose

The purpose of this study was to investigate the clinical outcomes of femoral fracture with implants on the proximal and distal sides to verify whether actual fracture morphologies follow the fracture types of Baba classification focusing on implant designs useful for periprosthetic femoral fracture.

Methods

Prosthesis was present in 85 with periprosthetic femoral fractures. Excluding 73 patients with fracture around the femoral stem or fracture of the TKA femoral component alone, 12 patients with 14 legs with both implants were investigated. All patients were radiographically assessed for implant stability according to the Baba classification. For clinical evaluation, intra- and postoperative complications, the operation time, and intra-operative blood loss were investigated.

Results

The Baba classification fracture type showed the implant as unstable and stable types in 3 and 11 legs, respectively. The consistency rate between the Baba classification-based judgment of plain radiograms acquired at the time of injury and actual surgical findings was 100%. As a result of treatment according to the Baba classification, bone union was achieved in all patients. There were no intra- or postoperative complications.

Conclusions

Applying the Baba classification, implant stability could be sufficiently evaluated in not only periprosthetic femoral fractures following hip arthroplasty, but also interprosthetic femoral fractures, thereby verifying its usefulness in setting the treatment strategy.

     

What are the risk factors for post-operative infection after hip hemiarthroplasty? Systematic review of literature

Background

Femoral neck fractures are frequent in the elderly population and lead to high morbidity and mortality. Hemiarthroplasty is an established surgical procedure for displaced intracapsular femoral neck fractures. Post-operative infection is frequent and is potentially devastating for the patient and the healthcare services. The goal of this study was to identify the risk factors of infection after hemiarthroplasty and help adapt our surgical practice.

Methods

A systematic review of the literature was performed in July 2015 by two authors using the MedLine, PubMed and Cochrane databases. We used the MeSH keywords “hip hemiarthroplasty” AND “infection” to identify risk factors and methods of prevention for surgical site infection after hemiarthroplasty. Following the search, two authors independently performed the first stage based on titles and abstracts.

Results

Thirty-seven articles were selected. Review and analysis of the references was performed to find other articles of interest. Thirteen articles were selected to analyse. According to literature, the surgical site infection (SSI) rate after hip hemiarthroplasty (HHA) is between 1.7 and 7.3 %. Pre-operative comorbidities (obesity, liver disease, advanced age), operative conditions (junior surgeon, uncemented stems, time of surgery) and post-operative management (length of hospitalisation, haematoma, prolonged wound drainage and two urinary catheterisations) were identified as risk factors of surgical site infection. Authors describe conditions to decrease the incidence of these complications and underline the importance of “a specialised hip team” that provides fast care and helps decrease the duration of hospitalisation.

Conclusions

Careful patient management for hemiarthroplasty is vital and may decrease the incidence of surgical site infection, which is associated with high morbidity and high procedure cost. Our review suggests that there are specific correctable risk factors for SSIs after HHA. Being able to identify these risk factors leads to better care because of SSI prevention in patients undergoing HHAs after femoral neck fractures. To improve the outcomes, some methods of prevention of surgical site infection are available: before, during and after the operation.

Study design

Review of literature. Level of evidence: IV