Hip Fractures in Centenarians: Functional Outcomes, Mortality, and Risk Factors from a Multicenter Cohort Study.

Background: Increasing longevity has caused the very old population to become the fastest-growing segment. The number of centenarians (over 100 years old) is increasing rapidly. Fractures in the elderly lead to excessive medical costs and decreased quality of life with socioeconomic burdens. However, little research has thoroughly examined the functional outcomes and mortality of hip fractures in centenarians. Methods: This is a retrospective observational study. Sixty-eight centenarian hip fracture patients were admitted to the 10 institutions from February 2004 to December 2019. Fifty-six patients with 1-year follow-up were finally included. The following data were obtained: sex, age, body mass index, Charlson comorbidity index value on the operation day, Koval's classification for ambulatory ability, type of fracture, the time interval from trauma to surgery, American Society of Anesthesiologists grade, surgery-related complications, and duration of hospital stay. Postoperative Koval's classification (at 1 year after surgery) and information about death were also collected. Multivariate analysis was performed to analyze the risk factors affecting mortality 1 year after surgery. Results: Mortality rates were 26.8% at 6 months and 39.3% at 1 year. The 90-day mortality was 19.6%, and one of them (2.1%) died in the hospital. The 1-year mortality rates for the community ambulatory and non-community ambulatory groups were 29% and 52%, respectively. Only 9 (16.1%) were able to walk outdoors 1 year after surgery. The remaining 47 patients (83.9%) had to stay indoors after surgery. Multivariate analysis demonstrated that the pre-injury ambulatory level (adjusted hazard ratio, 2.884; p = 0.034) was associated with the risk of mortality. Conclusions: We report a 1-year mortality rate of 39.3% in centenarian patients with hip fractures. The risk factor for mortality was the pre-injury ambulatory status. This could be an important consideration in the planning of treatment for centenarian hip fracture patients.

Relationship between pressure ulcer risk and sarcopenia in patients with hip fractures.

OBJECTIVE: Pressure ulcer (PU) is a frequent complication of hip fractures. PUs can develop at any time after a hip fracture but most appear within 2-4 days after surgery. The purpose of this study was to investigate the association between hip fractures due to sarcopenia and the risk of PUs in patients with hip fracture. METHOD: Between March 2017 and March 2019, patients aged ≥65 years of age with hip fractures were included in this retrospective cohort study. PU risk assessment according to the Braden Scale was performed within the first few hours after arrival at hospital. Skeletal muscle mass index (SMI) and hand grip strength were evaluated for a diagnosis of sarcopenia. RESULTS: Of the 289 patients admitted to the study institution, 180 patients were finally enrolled in the study (129 females; 51 males). In male patients, as SMI increased, so too did the Braden Scale score, which was statistically significant (p=0.02). However, there was no statistically significant difference between SMIs and Braden Scale scores in female patients (p=0.304). In male patients, there was no statistically significant difference between hand grip strength and Braden Scale score (p=0.251). However, in female patients, as hand grip strength increased, so too did the Braden Scale score; this was also statistically significant (p=0.041). CONCLUSION: In this study, decreased muscle mass and muscle weakness in patients with hip fractures were associated with increased PU risk as measured by Braden Scale scores in both males and females.

Touchless Control of Picture Archiving and Communication System in Operating Room Environment: A Comparative Study of Input Methods.

BACKGROUND: The advancement of computer information technology would maximize its potential in operating rooms with touchless input devices. A picture archiving and communication system (PACS) was compared with a touchless input device (LMC-GW), relaying to another person to control a mouse through verbal guidance, and directly controlling a mouse. METHODS: Participants (n = 34; mean age, 29.6 years) were prospectively enrolled and given nine scenarios to compare the three methods. Each scenario consisted of eight tasks, which required 6 essential functions of PACS. Time elapsed and measurement values were recorded for objective evaluation, while subjective evaluation was conducted with a questionnaire. RESULTS: In all 8 tasks, manipulation using the mouse took significantly less time than the other methods (all p < 0.05). Study selection, panning, zooming, scrolling, distance measuring, and leg length measurement took significantly less time when LMC-GW was used compared to relaying to another person (all p < 0.01), whereas there were no significant differences in time required for measuring the angles and windowing. Although the touchless input device provided higher accessibility and lower contamination risk, it was more difficult to handle than the other input methods (all p < 0.01). CONCLUSIONS: The touchless input device provided superior or equal performance to the method of verbal instruction in the environment of operating room. Surgeons agreed that the device would be helpful for manipulating PACS in operating rooms with less contamination risk and disturbance of workflow. The touchless input device can be an alternative option for direct manipulation of a mouse in operation rooms in the future.

A prospective randomized controlled trial to evaluate effect of chewing gum on postoperative ileus in elderly patient after hip fracture.

ABSTRACT: Factors related to developing postoperative ileus (POI) vary from pharmacologic, inflammatory, hormonal, metabolic, gastrointestinal physiology, neurologic, to psychological factors. Although orthopedic-related incidence of postoperative ileus is about 10%, these studies are limited to spine surgery and pelvic surgery. The purpose of this study was to investigate prevalence of POI and to analyze effect of chewing gum on POI and bowel function in elderly patients after hip fracture surgery.A prospective randomized controlled trial was conducted at the Gyeongsang National University Hospital. Elderly patients with hip fracture who underwent surgery from March 2017 to June 2018 were eligible to participate. Patients were excluded if they had a mastication disability, impaired cognitive function, previous history of gastrointestinal disease, respiratory disease and low oxygen saturation, hip arthroplasty with causes other than hip fractures, acetabular fractures, periprosthetic fractures, or pathological fractures. Patients with consciousness problem by excessive anesthesia were also excluded. Patients were classified into 2 groups by randomization. Group I received sugar-free gum and were encouraged to chew 6 hours following surgery until the first intestinal gas is released. Group II was given the same postoperative procedure and encouraged to consume water after 6 hours.After applying exclusion criteria, 74 patients were finally included. Thirty-one patients were classified to Group I and 43 patients were classified to the Group II. Prevalence of POI in all patients with hip fracture was 63.5% (47/74). Prevalence of POI in Group I was statistically significant lower than that in Group II (Group I: 41%, Group II: 79.1%, P = .01)The prevalence of POI in elderly patients with hip fracture was 63.5%. Chewing gum had a significant effect on reduction of POI in elderly patients with hip fractures.

Dual mobility total hip arthroplasty in the treatment of femoral neck fractures.

AIMS: To evaluate the rate of dislocation following dual mobility total hip arthroplasty (DM-THA) in patients with displaced femoral neck fractures, and to compare rates of dislocation, surgical-site infection, reoperation, and one-year mortality between DM-THA and bipolar hemiarthroplasty (BHA). METHODS: Studies were selected based on the following criteria: 1) study design (retrospective cohort studies, prospective cohort studies, retrospective comparative studies, prospective comparative studies, and randomized controlled studies (RCTs)); 2) study population (patients with femoral neck fracture); 3) intervention (DM-THA or BHA); and 4) outcomes (complications during postoperative follow-up and clinical results). Pooled meta-analysis was carried out to evaluate the dislocation rate after DM-THA and to compare outcomes between DM-THA and BHA. RESULTS: A total of 17 studies (ten cohort studies on DM-THA and seven comparative studies of DM-THA and BHA) were selected. These studies included 2,793 patients (2,799 hips), made up of 2,263 DM-THA patients (2,269 hips) and 530 BHA patients (530 hips). In all, 16 studies were analyzed to evaluate dislocation rate after DM-THA. The cumulative dislocation rate was 4% (95% confidence interval (CI) 3 to 5). Seven studies were analyzed to compare the rates dislocation and surgical-site infection. The rate of dislocation was significantly lower in the DM-THA group than in the BHA group (risk ratio (RR) 0.3; 95% CI 0.17 to 0.53, p < 0.001, Z -4.11). There was no significant difference in the rate of surgical-site infection between the two groups (p = 0.580). Six studies reported all-cause reoperations. The rate of reoperation was significantly lower in the DM-THA group than in the BHA group (RR 0.5; 95% CI 0.32 to 0.78, p = 0.003, Z -3.01). Five studies reported one-year mortality. The mortality rate was significantly lower in the DM-THA group than in the BHA group (RR 0.58 95% CI 0.45 to 0.75, p < 0.0001, Z -4.2). CONCLUSION: While the evidence available consisted mainly of non-randomized studies, DM-THA appeared to be a viable option for patients with displaced fractures of the femoral neck, with better reported rates of dislocation, reoperation, and mortality than BHA. Cite this article: Bone Joint J 2020;102-B(11):1457-1466.

Clinical and Radiological Outcomes after Various Treatments of Midshaft Clavicle Fractures in Adolescents.

BACKGROUD: Controversy exists about the optimal treatment of midshaft clavicle fractures in the presence of significant displacement, comminution, or shortening of the fracture in adolescents. The purpose of this study was to compare the clinical and radiological outcomes of 4 different treatments for midshaft clavicle fractures in adolescents: conservative treatment with a figure-of-8 (FO8) brace, open reduction and internal fixation with a plate (OPL), minimally invasive plate osteosynthesis (MIPO), and intramedullary nail fixation with a threaded Steinmann pin (TSP). METHODS: A total of 94 teenagers with midshaft clavicle fractures were divided into the FO8, OPL, MIPO, and TSP groups (n = 24, 33, 16, and 21, respectively). We analyzed clinical and radiological outcomes and complications in each group and compared the results among the groups. RESULTS: All groups showed satisfactory clinical and radiological outcomes, but each group showed different results for the assessment items. The Constant-Murley scores were higher in the operated groups than in the FO8 group. Recovery of joint motion was faster in the operated groups. The TSP group had the highest cosmetic satisfaction with respect to the satisfaction score and measured scar length. Fracture union was achieved in all patients. At the final follow-up, the bone length was closer to normal in the OPL and TSP groups than in the FO8 and MIPO groups, and angulation was less in the OPL and TSP groups than in the MIPO and FO8 groups. The TSP and MIPO groups obtained faster bone healing than the OPL and FO8 groups. In the operated groups, 9 patients had metal-induced irritating symptoms; 1, supraclavicular nerve injury symptoms; and 4, refractures after plate removal. CONCLUSIONS: The nonoperatively treated group had no iatrogenic complications. The operated groups complained of various disadvantages induced by surgery; however, these groups achieved faster functional recovery and slightly better radiological and functional results than the nonoperative group.

Changes in Gait and Radiographic and Clinical Results of Calcaneal Lengthening Osteotomy in Children with Idiopathic Flexible Flatfoot.

BACKGROUD: In this study, we aimed to analyze kinematic and kinetic changes in gait and to assess radiographic and clinical improvement after calcaneal lengthening osteotomy (CLO) in children with idiopathic symptomatic flexible flatfoot deformities. METHODS: The study group consisted of 22 children (28 feet) with idiopathic symptomatic flexible flatfoot, which was treated by CLO as an index operation. We excluded patients with flatfoot that developed secondary to neuromuscular diseases. There were 18 boys (22 feet) and 4 girls (6 feet). The average age of the patients was 10.8 ± 1.51 years. Surgical results were assessed by radiologic imaging, clinical evaluation, and gait analysis, which were performed before surgery and 1 year after surgery. Medical records were reviewed to check postoperative complications. RESULTS: Talonavicular coverage was recovered to 16.7° from 32.7° (p < 0.01). Lateral talo-first metatarsal angle and calcaneal pitch angle increased by 20.1° and 9.9°, respectively (p < 0.01). Weight-bearing radiographs demonstrated a decrease in the anteroposterior angle and lateral talocalcaneal angle by 6.9° and 10°, respectively (p < 0.01). Hindfoot valgus was corrected to near neutral position after CLO. Kinematic results showed that the ankle valgus angle in the coronal plane was reduced from 35.48° preoperatively to 16.64° postoperatively during gait (p < 0.05). The preoperative out-toeing gait (preoperative foot progression angle, 20.31°) was also normalized to 14.21° postoperatively. The kinetics results showed that the push-off moment (maximum ankle plantar flexion) on the sagittal plane increased from 0.66 Nm/kg preoperatively to 0.83 Nm/kg postoperatively (p < 0.01). The mean Yoo score was 9.2 ± 1.05 postoperatively: satisfactory in 24 cases (86%) and unsatisfactory in 4 cases. Of the 4 unsatisfactory cases, 2 cases were overcorrection and 2 cases were undercorrection, and 3 of them were well managed by wedge foot insoles. CONCLUSIONS: The 3-dimensional deformities of the flexible flatfoot were effectively corrected by CLO, based on the morphological assessment using radiologic imaging. The correction was well maintained during gait at 1 year after the operation.

Blood Transfusion for Elderly Patients with Hip Fracture: a Nationwide Cohort Study.

BACKGROUND: This nationwide study aimed to investigate the blood transfusion status of elderly hip fracture patients and to examine the effect of packed red blood cell transfusion on all-cause mortality. METHODS: From the Korean National Health Insurance Service-Senior cohort consisting of 588,147 participants aged over 60 years in 2002, a total of 14,744 new-onset hip fracture patients aged 65-99 years were followed up for 11 years. The adjusted hazard ratios (aHRs), risk ratios, and their 95% confidence intervals were estimated by the Cox proportional hazard model and Poisson regression model. RESULTS: There were 10,973 patients (74.42%) in the transfusion group and 3,771 (25.58%) patients in the non-transfusion group. The mean volume of blood transfusion was 1,164.51 mL (± 865.25; median, 800 mL; interquartile range, 640-1,440). In the multivariable-adjusted Cox proportional hazard model, the transfusion group had 1.34-fold more risk of all-cause mortality than the non-transfusion group (aHR, 1.34; 95% confidence interval [CI], 1.26-1.42). In the multivariate-adjusted Poisson regression model, hip fracture patients in the transfusion group were 1.43 (adjusted risk ratio [aRR], 1.43; 95% CI, 1.09-1.87; P = 0.009) folds more likely to die within 30 days than those in the non-transfusion group. The mortality risk was highest at 90 days (aRR, 1.64; 95% CI, 1.40-1.93; P < 0.001) and slightly decreased at 180 days (aRR, 1.58; 95% CI, 1.40-1.79; P < 0.001) and 1 year (aRR, 1.43; 95% CI, 1.31-1.58; P < 0.001). CONCLUSION: In this nationwide representative cohort study, blood transfusion was performed in 75% of hip fracture patients. Even after adjusting for comorbidity and anticoagulant use, the postoperative results (hospitalization, mortality) of the transfusion group did not show significantly worse results than the non-transfusion group. Therefore, adequate patient blood management can only improve the patient's outcome after hip fracture surgery.

Suicide in Elderly Patients with Hip Fracture: A South Korean Nationwide Cohort Study.

BACKGROUND: The purpose of the present study was to evaluate the incidence rate (IR) of suicide in elderly patients with hip fracture on the basis of a nationwide cohort and to analyze the change in the hazard ratio for suicide after hip fracture over time in comparison with a control group. METHODS: Patients with hip fracture and their matched controls were selected from the National Health Insurance Service-Senior cohort (NHIS-Senior) of the Republic of Korea. The NHIS-Senior consists of 558,147 people selected by a 10% simple random-sampling method from a total of 5.5 million subjects ≥60 years of age in 2002. Risk-set matching (1:2) on the propensity score was performed with use of a nearest neighbor matching algorithm with a maximum caliper of 0.1 for the hazard components. The IR of suicide and 95% confidence interval (CI) were calculated on the basis of a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) with use of the Cox proportional-hazard model with a robust variance estimator that accounts for clustering within matched pairs. RESULTS: A total of 11,477 patients with hip fracture and 22,954 matched controls were included. The mean duration of follow-up was 4.59 years, generating 158,139 person-years. During follow-up, a total of 170 suicides were identified. Comparisons at up to 180 days and 365 days showed that patients with hip fracture were at higher risk for suicide than matched controls (p = 0.009 and 0.004, respectively; stratified log-rank test). During the first 180 days of follow-up, 14 suicides were identified in patients with hip fracture during 11,152 person-years (IR, 266.1 per 100,000 person-years; 95% CI, 157.6 to 449.4). Patients with hip fracture were 2.97 times more likely to kill themselves than their matched controls during the same period (HR = 2.97; 95% CI, 1.32 to 6.69). CONCLUSIONS: Hip fracture in elderly patients increased suicide risk within a year. A new approach to psychiatric evaluation and management is needed in elderly patients with hip fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Urinary retention after total joint arthroplasty of hip and knee: Systematic review.

PURPOSE: Postoperative urinary retention (POUR) is a common complication after total joint arthroplasties (TJAs). The POUR is managed with urinary catheterization, which is associated with a risk of urinary tract infection and subsequent periprosthetic joint infection. The purpose of this review was to afford a comprehensive understanding of POUR and its management. METHODS: We identified 15 original articles concerning POUR after TJA, which were published from January 2010 to February 2019. The diagnostic method, incidence, risk factors, and management of POUR of the 15 studies were reviewed. RESULTS: The incidence of POUR was ranged from 4.1% to 46.3%. Ultrasound was used for the detection of POUR among the total of the 15 studies. The following factors of old age, male gender, benign prostatic hypertrophy, history of urinary retention, spinal/epidural anesthesia, excessive fluid administration, patient-controlled analgesia, the use of opiates, underlying comorbidities, and poor American Society of Anesthesiologists (ASA) grade were risk factors for POUR. Most of the studies did not use indwelling catheterization during surgery. The POUR patients were managed with intermittent catheterization. The most common volume criterion for bladder catheterization was 400 mL. In inevitable use of an indwelling catheter, it should be removed within 48 h. CONCLUSIONS: This review provided an up-to-date guide for the detection and management of POUR. LEVEL OF EVIDENCE: Level III.

Machine learning-based identification of hip arthroplasty designs.

BACKGROUND: The purposes of this study were to develop a machine learning-based implant recognition program and to verify its accuracy. METHODS: Postoperative anteroposterior (AP) X-rays (≥300 dpi) were collected of patients who underwent total hip arthroplasty. X-rays with a wire or plate added and those without a true anteroposterior view were excluded. A total of 170 X-ray images of hip implants from 29 brands were collected from five hospitals and a Google image search. These collected images were manually reorganised to ensure appropriate labelling. Collected images were preprocessed to have grey-scaled pixels with histogram equalisation for efficient training. Images varied by +10/-10°, and 3606 unique images derived from the original 170 images were created for training. Discussion of the validation set being derived 25% of training set. The recognition model structure consisted of two steps: object detection and clustering. Model training was performed with Keras deep learning platform. RESULTS: The 170 X-ray images of hip implants were used to build a stem detection model using YOLOv3. Manually labelled images were successfully trained into the stem detection model. Evaluation of 58 newly labelled X-ray images showed highly accurate stem detection (mean average precision > 0.99). Fully connected layers generated 29 class outputs. After training, a receiver operating characteristic curve was generated with a test set containing 25% of all stem-cropped images, yielding an area under the curve of 0.99. CONCLUSION: Femoral stem identification in patients with total hip arthroplasty was very accurate. This technology could be used to collect large-scale implant information. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: This program has the following clinical relevance. First, we can prepare the implants needed for revision surgery by identifying the old types of implants. Second, it can be used to diagnose peripheral osteolysis or periprosthetic fracture by further developing the ability to sensitise implant detection. Third, an automated implant detection system will help organise imaging data systematically and easily for arthroplasty registry construction.

Effect of heart failure on postoperative short and long-term mortality in elderly patients with hip fracture.

INTRODUCTION: We designed a comparative study using elderly hip fracture patients with and without heart failure (HF). The purpose of this study was to assess 1) prevalence of HF, compare 2) early and late mortality after elderly hip fracture between HF and non-HF patients and to assess 3) risk factors of mortality after hip fractures in elderly patients with HF. In addition, we also investigated 4) whether there is a difference in mortality according to the severity of left ventricular (LV) systolic dysfunction classified by LV ejection fraction (EF) in HF patients through subgroup analysis. METHODS: This study included 1992 patients (1992 hips) who were diagnosed as having unilateral femoral neck or intertrochanteric fractures and who underwent surgery at two hospitals between January 2004 and June 2018. The patients were categorized into a non-HF group (1782 patients) and a HF group (210 patients; mild [119 patients] and moderate-to- severe HF subgroups [91 patients]). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the non-HF and HF. Logistic regression analysis was conducted to identify independent factors associated with mortality. RESULTS: Of 1992 patients, 210 (10.5%) patients were diagnosed with HF. The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were respectively 1.6%, 3.6%, 5.1%, 8.4%, and 12.9% in the non-HF group, and 5.7%, 9.5%, 12.4%, 17.1%, and 25.2% in the HF group (p ≤ 0.001). The factors that affected 1-year mortality were sex (OR, 2.10; 95% CI, 1.62-2.72; p < 0.001) and age (OR, 1.04; 95% CI, 1.02-1.06; p < 0.001) and presence of HF (OR, 1.62; 95% CI, 1.45-1.86; p = 0.005). In subgroup analysis, the factors that affected 30-day mortality were only moderate-to-severe HF (OR, 4.01; 95% CI, 1.10-8.78; p = 0.009). CONCLUSIONS: In elderly patients with hip fracture, the comparison between the HF and non-HF patients revealed that HF was an independent factor of mortality at a minimum of 1-year follow-up, and severity of LV systolic dysfunction classified by LVEF in patients with hip fracture was also a risk factor of 30-day mortality.

The effect of surgery type on mortality in elderly patients with pertrochanteric femoral fracture: A Korean nationwide cohort study.

BACKGROUND/OBJECTIVE: The purpose of this study is to analyze the effect of surgical methods on mortality and the relative risk of patients who underwent internal fixation (IF) or hemiarthroplasty (HA) after being diagnosed as a pertrochanteric fracture over 65 years old in a Korean nationwide cohort with a single insurance medical system. METHODS: The Korean National Health Insurance Service-Senior cohort (NHIS-Senior, NHIS-2018-2-111) was used in this study. The eligibility criteria for incident hip fracture patients were the following: (1) first-time admission to acute care hospitals (index admission) with pertrochanteric fracture (ICD-10 S721), (2) three years of hip fracture-free period, (3) recipients of typical surgeries including IF, HA, (4) age between 65 and 99. RESULTS: a total of 7223 patients were enrolled in the cohort. There were 1662 patients (23%) in the HA group and 5561 patients (77%) in the IF group. Mortality rates of the IF group and HA group were 13.46 and 17.94 cases per 100 person-years, respectively. In the multivariable-adjusted Cox proportional hazard model, the HA group had 1.22 times more hazard of all-cause mortality than IF group (aHR 1.22, 95% CI 1.13-1.32). In subgroup analysis, aged 65-79 and female patients showed a prominent association between surgery type and mortality (aHR 1.52, 95% CI 1.29-1.79). CONCLUSIONS: In patients with pertrochanter fracture over 65 years, 1.22-fold mortality rate was observed when HA was performed compared to that of IF, and the difference in mortality was particularly prominent within 1-year after surgery.

Comparison of intraoperative radiation exposure with and without use of distal targeting device: a randomized control study.

INTRODUCTION: When locking intramedullary nails, inserting the distal interlocking screw accurately and quickly with less radiation exposure is very important. The purpose of this randomized control study was to compare radiation exposure and accuracy of distal locking screws between free-hand fluoroscopic guidance and the use of a distal targeting system (DTS). MATERIALS AND METHODS: Inclusion criteria of this study were patients older than 60 years who need an intramedullary nailing due to unstable intertrochanteric and subtrochanteric fracture. The primary outcome was the attempt numbers of image intensifier during the insertion of distal locking screws. Secondary outcomes were operative time and angles between distal locking screws and nail. RESULTS: A total of 36 patients participated in the study. Eighteen patients using free-hand fluoroscopic guidance were assigned to Group I while 18 patients using DTS were assigned to Group II. The number of attempts of image intensifier during distal screw insertion (57.3 ± 31.42 vs. 11.5 ± 7.41, p < 0.001), ratio of attempt number for distal screws to the total attempts (0.33 ± 0.21 vs. 0.12 ± 0.08, p = 0.001), the number of hand exposure to image intensifier directly (75.0 ± 29.55 vs. 13.5 ± 19.07, p < 0.001), and the time of radiation exposure during distal screws insertion (42.57 ± 2.42 s vs. 12.72 ± 8.10 s, p < 0.001) were significantly lower in Group II compared to those in Group I. And, operation time (96.3 min ± 18.94 vs. 76.1 min ± 14.10, p < 0.001) was also statistically significantly lower in Group II. Both distal locking screws were significantly closer to perpendicular direction to the nail in Group II. CONCLUSION: The attempt number of image intensifier during the insertion of two distal locking screws was significantly reduced with DTS compared with that with free hand fluoroscopic guidance. Angle between distal locking screws and nail was also more accurate using DTS.

Relationship of chronic obstructive pulmonary disease severity with early and late mortality in elderly patients with hip fracture.

INTRODUCTION: We conducted a comparative study to compare patients with and without chronic obstructive pulmonary disease (COPD) and to analyze the effect of COPD severity on mortality in elderly patients with hip fractures who were diagnosed by pulmonologists. The purposes of this study were to compare early and late mortality after hip fracture between COPD and non-COPD patients and to assess risk factors of mortality after hip fractures in elderly patients with COPD. METHODS: This study included 1294 patients (1294 hips) who were diagnosed as having unilateral femoral neck or intertrochanteric fractures and who underwent surgery at two hospitals between 2004 and 2017. The patients were categorized into a non-COPD group (853 patients) and a COPD group (441 patients; mild-to-moderate [354 patients] and severe-to-very severe COPD subgroups [87 patients]). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the non-COPD and COPD groups. Logistic regression analysis was conducted to identify independent factors associated with mortality. RESULTS: The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.3%, 2.5%, 3.5%, 6.6%, and 10.7%, respectively, in the non-COPD group, and 2.9%, 5.7%, 7.7%, 11.8%, and 16.6%, respectively, in the COPD group (p = 0.049, p = 0.004, p = 0.002, p = 0.002, and p = 0.004, respectively). The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates in the severe-to-very severe COPD group were 4.6%, 6.9%, 11.5%, 20.7%, and 26.4%, respectively. In elderly patients with hip fracture, COPD increased the risk of mortality for 1.6 times and 1.7 times at 3 months and 1 year postoperative, respectively. In subgroup analysis, severe-to-very severe COPD was associated with 1.55-fold and 1.65-fold increased postoperative mortality risk at 6 months and 1 year respectively, as compared with mild-moderate COPD. CONCLUSIONS: In elderly patients with hip fracture, the comparison between the COPD and non-COPD patients revealed that COPD was an independent factor of mortality at a minimum of 1-year follow-up, and COPD severity in patients with hip fracture was also a risk factor of 6-month and 1-year mortality.

Biomechanical Evaluation of Internal Fixation of Pauwels Type III Femoral Neck Fractures: A Systematic Review of Various Fixation Methods.

BACKGROUND: The purpose of this systematic review was to investigate various fixation methods or implants used in the treatment of Pauwels type III femoral neck fractures. METHODS: PubMed Central, OVID Medline, Cochrane Collaboration Library, Web of Science, Embase, and AHRQ databases were searched to identify relevant studies published until August 2017 with English language restriction. Studies were selected on the basis of the following inclusion criteria: biomechanical study of Pauwels type III femoral neck fractures and the use of dynamic hip screw (DHS) or multiple screw fixation or other devices for fixation of the fracture. RESULTS: A total of 15 studies were included in the systematic review. Eight studies were conducted using cadavers, six studies using sawbones, and one using a finite element model. During the mechanical testing, each study measured mechanical stiffness, failure to cyclic loading, failure to vertical loading of each fixation device. DHS was included in 11 studies, multiple screw fixation in 10 studies, and other devices in six studies. Baitner et al. and Samsami et al. reported that the mechanical stiffness of DHS was superior to three inverted triangular screw fixation. Hawks et al. and Gumustas et al. reported that using a transverse calcar screw can withstand vertical loading better than three inverted triangular screw fixation. In addition, there were some studies where instruments such as Intertan nail, locking plate or other devices showed excellent biomechanical properties. CONCLUSIONS: There are a variety of methods and instruments for fixation of the Pauwels type III fractures. However, it is difficult to conclude that any method is more desirable because there are advantages and disadvantages to each method. Therefore, we should pay attention to the implant choice and consider adequate weight bearing affecting the stiffness of the implant.

Difference in Mortality Rate by Type of Anticoagulant in Elderly Patients with Cardiovascular Disease after Hip Fractures.

BACKGROUND: The purpose of this study was to investigate the difference in mortalilty rate between cardiovascular disease (CVD) patients and non-CVD patients after hip fracture surgery performed in elderly patients. In addition, we compared the effect of CVD medication on mortality after hip fracture surgery. METHODS: Patients who underwent surgery for femoral intertrochanteric or neck fracture from January 2003 to December 2013 were enrolled in this study. After applying exclusion criteria, we categorized patients into group I (833 patients, non-CVD group) and group II (811 patients, CVD group). The CVD group was subcategorized as group IIa (332 patients, no medication), group IIb (381 patients, antiplatelet agents), and group IIc (98 patients, anticoagulation agents). Cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year were compared between the groups. RESULTS: In the 1,644 patients, the cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year was 0.1%, 0.5%, 0.7%, and 8.2%, respectively, in group I and 1.0%, 1.6%, 2.5%, and 8.8%, respectively, in group II (p = 0.02, p = 0.03. p = 0.01, and p = 0.72, respectively). In the 811 group II patients, the cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year was 0.3%, 0.6%, 1.2%, and 6.6%, respectively, in group IIa; 0.8%, 1.6%, 2.1%, and 9.4%, respectively, in group IIb; and 4.1%, 5.1%, 8.2%, and 13.3%, respectively, in group IIc (p = 0.003, p = 0.01, p = 0.004, and p = 0.10, respectively). CONCLUSIONS: CVD increases short-term mortality within 30 days, 60 days, and 3 months in elderly hip fracture patients. The use of anticoagulants in CVD patients increases the rate of surgical delay and short-term mortality within 30 days, 60 days, and 3 months.

Acute Cholecystitis in Elderly Patients after Hip Fracture: a Nationwide Cohort Study.

BACKGROUND: Because acute cholecystitis in elderly hip fracture is not easily distinguishable from other gastrointestinal symptoms and involves atypical clinical behaviors, it may not be diagnosed in the early stage. However, the exact incidences could not be reported. We utilized data from a nationwide claims database and attempted to assess the incidence of acute cholecystitis in elderly hip fracture patients and how cholecystitis affects mortality rates after hip fracture. METHODS: Study subjects were from the Korean National Health Insurance Service-Senior cohort. From a population of approximately 5.5 million Korean enrollees > 60 years of age in 2002, a total of 588,147 participants were randomly selected using 10% simple random sampling. The subjects included in this study were those who were over 65 years old and underwent surgery for hip fractures. RESULTS: A total of 15,210 patients were enrolled in the cohort as hip fracture patients. There were 7,888 cases (51.9%) of femoral neck fracture and 7,443 (48.9%) cases of hemiarthroplasty. Thirty-six patients developed acute cholecystitis within 30 days after the index date (30-day cumulative incidence, 0.24%). Four of the 36 acute cholecystitis patients (11.1%) died within 30 days versus 2.92% of patients without acute cholecystitis. In the multivariate-adjusted Poisson regression model, hip fracture patients with incident acute cholecystitis were 4.35 (adjusted risk ratio 4.35; 95% confidence interval, 1.66-11.37; P = 0.003) times more likely to die within 30 days than those without acute cholecystitis. CONCLUSION: Incidence of acute cholecystitis in elderly patients after hip fracture within 30 days after the index date was 0.24%. Acute cholecystitis in elderly hip fracture patients dramatically increases the 30-day mortality rate by 4.35-fold. Therefore, early disease detection and management are crucial for patients.

Gait analysis after total hip arthroplasty using direct anterior approach versus anterolateral approach: a systematic review and meta-analysis.

BACKGROUND: Comparative studies of total hip arthroplasty using the direct anterior approach (DAA) compared with the anterolateral approach (ALA) by gait analysis compared the results of the two groups, the damage to the abductor muscle, with objective and detailed kinematic as well as kinetic data of actual gait. The purpose of this systematic review was to analyze the differences in gait such as time-dependent parameters, kinetics, and kinematics after THA using the DAA compared with ALA. METHODS: PubMed Central, OVID Medline, Cochrane Collaboration Library, Web of Science, EMBASE and AHRQ carried out a comprehensive search for all relevant randomized controlled trials and comparative studies, up to December 2018. Based on the following criteria, studies were selected: 1) study design: randomized controlled trials or non-randomized comparative studies; 2) study population: patients with primary osteoarthritis or avascular necrosis; 3) intervention: total hip arthroplasty by DAA or ALA; 4) Kinetic and kinematic data after gait analysis in the plains during postoperative follow-up. RESULTS: Of the 148 studies, 7 randomized controlled trials and 5 comparative studies were finally included in this systematic review. The peak hip flexion within 3 months after surgery was described in two studies and was significantly higher in the DAA group. (OR = 1.90; 95% CI [1.67,2.13]; P < 0.01, Z = 16.18). The gait speed within 3 months after surgery was reported in 3 studies and was significantly higher in the DAA group than in the ALA group. (SMD = 0.17; 95% CI [0.12,0.22]; P < 0.01, Z = 6.62) There was no difference between the two groups in stride length, step length, and hip range of motion in sagittal plane. CONCLUSIONS: In this meta-analysis, gait speed and peak hip flexion within 3 months after surgery were significantly higher in the DAA group than in the ALA group. Despite a few significant differences between two approaches, determining whether the reported differences in terms of postoperative gait values are clinically meaningful remains a substantial challenge.

Mechanical effect of different implant caput-collum-diaphyseal angles on the fracture surface after fixation of an unstable intertrochanteric fracture: A finite element analysis.

BACKGROUND/OBJECTIVE: The choice of implant is one of the most easily controllable factors affecting the outcome of intertrochanteric fractures. While most of the caput-collum-diaphysis (CCD) angles of the femur are within the range of 125° and 130°, there is a shortage of data on whether 125° or 130° implants are preferable. Thus, the present finite element analysis (FEA) aimed to compare the biomechanical effects on the fracture surface when using implants with different CCD angles where the anatomical CCD angle of the femur was between 125° and 130°. METHODS: After establishing a finite element model of an unstable intertrochanteric fracture from the femur with a native CCD angle of 127.3°, proximal femoral nail antirotation (PFNA) models with CCD angles of 125° and 130° were virtually implanted to have the same position of screw tip, respectively. RESULTS: In the one-leg stance during walking, when the implant with 130º CCD angle was used, the magnitude of compressive stress (1.61 and 2.12 MPa in the 130° and 125° model, respectively) was lower and the area of the fracture surface under tensile stress (55% and 5% in 130° and 125° model, respectively), the interfragmentary movements (40.9% more movement in 130° model), and the magnitude of bone deformation (23.5% more deformation in 130° model) were more than those of the 125° model. CONCLUSION: The intertrochanteric fracture fixed with PFNA with a 125º CCD angle revealed less interfragmentary movement on the fracture surface when the native CCD was an in-between angle in the FEA.