Posterior approach compared to direct lateral approach resulted in better patient-reported outcome after hemiarthroplasty for femoral neck fracture.

Background and purpose - Hemiarthroplasty (HA) is the most common treatment for displaced femoral neck fractures in many countries. In Norway, there has been a tradition of using the direct lateral surgical approach, but worldwide a posterior approach is more often used. Based on data from the Norwegian Hip Fracture Register, we compared the results of HA operated through the posterior and direct lateral approaches regarding patient-reported outcome measures (PROMs) and reoperation rate. Patients and methods - HAs due to femoral neck fracture in patients aged 60 years and older were included from the Norwegian Hip Fracture Register (2005-2014). 18,918 procedures were reported with direct lateral approach and 1,990 with posterior approach. PROM data (satisfaction, pain, quality of life (EQ-5D), and walking ability) were reported 4, 12, and 36 months postoperatively. The Cox regression model was used to calculate relative risk (RR) of reoperation. Results - There were statistically significant differences in PROM data with less pain, better satisfaction, and better quality of life after surgery using the posterior approach than using the direct lateral approach. The risk of reoperation was similar between the approaches. Interpretation - Hemiarthroplasty for hip fracture performed through a posterior approach rather than a direct lateral approach results in less pain, with better patient satisfaction and better quality of life. The risk of reoperation was similar with both approaches.

Perioperative mortality in hip fracture patients treated with cemented and uncemented hemiprosthesis: a register study of 11,210 patients.

PURPOSE: Adverse events associated with the use of bone cement for fixation of prostheses is a known complication. Due to inconclusive results in studies of hip fracture patients treated with cemented and uncemented hemiprostheses, this study was initiated. METHODS: Our study is based on data reported to the Norwegian Hip Fracture Register on 11,210 cervical hip fractures treated with hemiprostheses (8,674 cemented and 2,536 uncemented). RESULTS: Significantly increased mortality within the first day of surgery was found in the cemented group (relative risk 2.9, 95 % confidence interval 1.6-5.1, p=0.001). The finding was robust giving the same results after adjusting for independent risk factors such as age, sex, cognitive impairment and comorbidity [American Society of Anesthesiologists (ASA) score]. For the first post-operative day the number needed to harm was 116 (one death for every 116 cemented prosthesis). However, in the most comorbid group (ASA worse than 3), the number needed to harm was only 33. CONCLUSIONS: We found increased mortality for the cemented hemiprosthesis the first post-operative day compared to uncemented procedures. This increased risk is closely related to patient comorbidity estimated by the patient's ASA score.

Clinical outcome after undisplaced femoral neck fractures.

BACKGROUND AND PURPOSE: Little attention has been paid to undisplaced femoral neck fractures. By using data from the Norwegian Hip Fracture Register, we investigated the risk of reoperation and the clinical outcome after treatment of these fractures in patients over 60 years of age. METHODS: Data on 4,468 patients with undisplaced femoral neck fractures who were operated with screw osteosynthesis were compared to those from 10,289 patients with displaced femoral neck fractures treated with screw osteosynthesis (n = 3,389) or bipolar hemiarthroplasty (n = 6,900). The evaluation was based on number of reoperations and patient assessment at 4 and 12 months of follow-up. RESULTS: The 1-year implant survival was 89% after screw fixation for undisplaced fractures, 79% after screw fixation for displaced fractures, and 97% after hemiarthroplasty for displaced fractures. Patients with displaced fractures who were operated with internal fixation had a higher risk of reoperation (RR = 1.9, CI: 1.7-2.2), reported more pain, were less satisfied, and had lower quality of life than patients with undisplaced fractures treated with internal fixation (p < 0.05). Patients with displaced fractures who were operated with hemiarthroplasty had a lower risk of reoperation than patients with undisplaced fractures who were operated with internal fixation (RR = 0.32, CI: 0.27-0.38). Furthermore, they had the lowest degree of pain, were most satisfied, and reported the highest quality of life. INTERPRETATION: The differences in clinical outcome found were less than what is considered to be of clinical importance. The results support the use of screw osteosynthesis for undisplaced femoral neck fractures in elderly patients, although even better results were obtained in the hemiarthroplasty group in patients with displaced fractures.

Patient satisfaction, pain, and quality of life 4 months after displaced femoral neck fractures: a comparison of 663 fractures treated with internal fixation and 906 with bipolar hemiarthroplasty reported to the Norwegian Hip Fracture Register.

BACKGROUND: Primary arthroplasty and internal fixation are the two main options for treatment of displaced femoral neck fractures. Despite the fact that there have been several randomized studies, the optimal treatment in the elderly is still controversial. In the present study, based on data from the Norwegian Hip Fracture Register, we compared satisfaction, pain, and quality of life 4 months after surgery in patients over 70 years of age with a displaced femoral neck fracture operated with internal fixation or with a bipolar hemiarthroplasty. PATIENTS AND METHODS: Data on 1,569 fractures in patients over 70 years of age operated with internal fixation (n = 663) or hemiarthroplasty (n = 906) were registered in the hip fracture register. The register also included data on patient satisfaction, pain, and quality of life (EQ-5D) assessed 4 months after surgery using VAS scales and EQ-5D health questionnaires. RESULTS: Patients operated with hemiarthroplasty had less pain (VAS 27 vs. 41), were more satisfied with the result of the operation (VAS 33 vs. 48), and had better EQ-5D index score 4 months postoperatively (0.51 vs. 0.42) than patients who were operated with internal fixation. INTERPRETATION: Our findings suggest that elderly patients with displaced femoral neck fracture should be treated with arthroplasty.

The Norwegian Hip Fracture Register: experiences after the first 2 years and 15,576 reported operations.

BACKGROUND AND PURPOSE: The Norwegian Hip Fracture Register was established in January 2005 to collect nationwide information as a basis for improved management of patients with hip fractures. We now report our experience after the first 2 years. METHODS: After both primary operations and reoperations, the surgeons fill in a standardized 1-page form with information about the patient, the fracture, and the operation. Fractures treated with a total hip arthroplasty are reported to the national arthroplasty register, but are added to the hip fracture register before analyses are performed. 4, 12, and 36 months postoperatively, a standardized questionnaire including health-related quality of life (EQ-5D), visual analog scales concerning pain and patient satisfaction, and Charnley class for functional assessment is sent directly from the register to the patients. To evaluate the completeness of registration, our data were compared with data from the Norwegian Patient Registry (NPR). RESULTS: During the first year of registration, all 55 hospitals treating hip fractures in Norway started to report their hip fracture operations. During 2005, the monthly reporting increased and it stabilized in 2006. 13,251 primary-operated hips (mean age of patients: 80 years; 72% females) and 2,325 reoperations were reported during 2005 and 2006. Compared to the NPR, the completeness of registration was 64% in 2005 and 79% in 2006. 58% of the patients who were alive answered the 4-month questionnaire. The non-responders were older, were more often cognitively impaired, and had a higher degree of comorbidity than the responders. Undisplaced femoral neck fractures (19% of all fractures) were almost exclusively operated with screw osteosynthesis (95%). Dislocated femoral neck fractures (38% of all fractures) were operated with a hemiarthroplasty in 52% of the cases. Osteosynthesis with a hip compression screw was the predominant operation method for trochanteric fractures (81%). INTERPRETATION: After only 2 years, our nationwide system for surveillance of demographics, treatment, and outcome of hip fractures is functioning well. As expected, the response rate for the 4-month questionnaires was relatively low due to the old population with high comorbidity and cognitive impairment. The different treatment methods used for patients in the same groups of fracture types show that there is still no consensus in Norway regarding the treatment of hip fractures.

Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register.

BACKGROUND: Intramedullary nailing is commonly recommended as the treatment of choice for transverse/reverse oblique trochanteric (AO/OTA type A3=intertrochanteric) and subtrochanteric fractures. However, only to a limited extent is this approach supported by superior results in well designed clinical trials, and the sliding hip screw (SHS) is still a frequently used implant for these fractures. The aim of the present study was to compare IM nails and SHS in the treatment of transverse/reverse oblique trochanteric and subtrochanteric fractures using data from the Norwegian Hip Fracture Register (NHFR). METHODS: Data on 2716 operations for acute transverse/reverse oblique trochanteric or subtrochanteric fractures were collected from the NHFR from 2005 to 2010. Surgeons reported patient characteristics and details from initial surgery and reoperations, and patients answered questionnaires about pain, satisfaction, and quality of life (EQ-5D) 4, 12, and 36 months postoperatively. Reoperation rates were calculated using Kaplan-Meier analyses. Primary outcome measures were pain (Visual Analogue Scale (VAS)), satisfaction (VAS), quality of life (EQ-5D), and reoperation rates at one year. RESULTS: The treatment groups were similar regarding age, gender, ASA-class, cognitive impairment, and preoperative EQ-5Dindex score. At one year reoperation rates were 6.4% and 3.8% for SHS and IM nails, respectively (p=0.011). Patients treated with SHS also had slightly more pain (VAS 30 vs. 27, p=0.037) and were less satisfied (VAS 31 vs. 36, p=0.003) compared to patients treated with IM nail. There was no statistically significant difference in the EQ-5Dindex score, but the mobility was significantly better for the IM nail group. CONCLUSION: 12 months postoperatively patients with transverse/reverse oblique trochanteric and subtrochanteric fractures operated with a SHS had a higher reoperation rate compared to those operated with an IM nail. Small differences regarding pain, satisfaction, quality of life, and mobility were also in favour of IM nailing. Consequently, a change in our treatment strategy for these fractures could be considered.

TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up.

BACKGROUND: Both intramedullary nails and sliding hip screws are used with good results in the treatment of intertrochanteric and subtrochanteric fractures. The aim of our study was to assess whether use of the TRIGEN INTERTAN nail, as compared with a sliding hip screw, resulted in less postoperative pain, improved functional mobility, and reduced surgical complication rates for patients with an intertrochanteric or subtrochanteric fracture. METHODS: In a prospective, randomized multicenter study, 684 elderly patients were treated with the INTERTAN nail or with a sliding hip screw with or without a trochanteric stabilizing plate. The patients were assessed during their hospital stay and at three and twelve months postoperatively. A visual analogue scale (VAS) pain score was recorded at all time points, and functional mobility was assessed with use of the timed Up & Go test. The Harris hip score (HHS) was used to assess hip function more specifically. Quality of life was measured with the EuroQol-5D (EQ-5D). Radiographic findings as well as intraoperative and postoperative complications were recorded and analyzed. RESULTS: Patients treated with an INTERTAN nail had slightly less pain at the time of early postoperative mobilization (VAS score, 48 versus 52; p = 0.042), although this did not influence the length of the hospital stay and there was no difference at three or twelve months. Regardless of the fracture and implant type, functional mobility, hip function, patient satisfaction, and quality-of-life assessments were comparable between the groups at three and twelve months. The numbers of patients with surgical complications were similar for the two groups (twenty-nine in the sliding-hip-screw group and thirty-two in the INTERTAN group, p = 0.67). CONCLUSIONS: INTERTAN nails and sliding hip screws are similar in terms of pain, function, and reoperation rates twelve months after treatment of intertrochanteric and subtrochanteric fractures.

Total hip replacement after femoral neck fractures in elderly patients : results of 8,577 fractures reported to the Norwegian Arthroplasty Register.

BACKGROUND: A total hip arthroplasty (THA) is often used as treatment for failed osteosynthesis of femoral neck fractures and is now also used for acute femoral neck fractures. To investigate the results of THA after femoral neck fractures, we used data from the Norwegian Arthroplasty Register (NAR). PATIENTS AND METHODS: The results of primary total hip replacements in patients with acute femoral neck fractures (n = 487) and sequelae after femoral neck fractures (n = 8,090) were compared to those of total hip replacements in patients with osteoarthrosis (OA) (n = 55,109). The hips were followed for 0-18 years. The Cox multiple regression model was used to construct adjusted survival curves and to adjust for differences in sex, age, and type of cement among the diagnostic groups. Separate analyses were done on the subgroups of patients who were operated with Charnley prostheses. RESULTS: The survival rate of the implants after 5 years was 95% for the patients with acute fractures, 96% for the patients with sequelae after fracture, and 97% for the OA patients. With adjustment for age, sex, and type of cement, the patients with acute fractures had an increased risk of revision compared to the OA patients (RR 1.6, 95% CI: 1.0-2.6; p = 0.05) and the sequelae patients had an increased risk of revision (RR 1.3, 95% CI: 1.2-1.5; p < 0.001). Sequelae hips had higher risk of revision due to dislocation (RR 2.0, 95% CI: 1.6-2.4; p < 0.001) and periprosthetic fracture (RR 2.2, 95% CI: 1.5-3.3; p < 0.001), and lower risk of revision due to loosening of the acetabular component (RR 0.72, 95% CI; 0.57-0.93; p = 0.01) compared to the OA patients. The increased risk of revision was most apparent for the first 6 months after primary operation. INTERPRETATION: THA in fracture patients showed good results, but there was an increased risk of early dislocations and periprosthetic fractures compared to OA patients.