Predictors of outcomes after internal fixation of periprosthetic femoral hip fractures Subgroup analysis of the peri-implant and peri-prosthetic fractures Spanish registry (PIPPAS).

PURPOSE: To identify risk factors predisposing patients to poor outcomes after fixation of periprosthetic hip fractures around femoral stems. METHODS: Prospective multicentre cohort study of fractures around a hip replacement stem managed by internal fixation. The primary outcome was one-year mortality, while secondary outcomes were local complications and healthcare burden-related outcomes (nursing facility utilization and hospital length of stay). RESULTS: One-year mortality was 16.2%. Age-adjusted Charlson Comorbidity Index score (OR=1.17; 95%CI=1.03-1.33)), Pfeiffer Short Portable Mental Status Questionnaire (SPMSQ) score (OR=1.16; 1.06-1.28), prosthetic dysfunction (OR=1.90; 1.00-3.61), and postoperative medical complications (OR=1.97; 1.06-3.68) were predictors of mortality. Patients with prior prosthetic dysfunction, lower Pfeiffer SPMSQ scores, Vancouver A fractures, and fractures fixed only using cerclages were at higher risk of local complications, which occurred in 9.3% of cases. Medical (OR=1.81; 1.05-3.13) and local complications (OR=5.56; 2.42-3.13) emerged as consistent risk factors for new institutionalization. Average hospitalization time was 13.9±9.2 days. Each day of fixation delay led to an average 1.4-day increase in total hospitalization. CONCLUSION: Frail periprosthetic hip-fracture patients with poorer functional status, dysfunctional replacements, and postoperative complications are at increased risk of mortality. Postoperative complications are more common in patients with dysfunctional arthroplasties, Vancouver A fractures, and fixation using cerclages alone. Postoperative complications were the most consistent predictor of higher healthcare resource utilization.

Complications of standard versus long cephalomedullary nails in the treatment of unstable extracapsular proximal femoral fractures: A randomized controlled trial.

AIMS: To compare in a prospective randomized trial the mechanical complications in patients with unstable extracapsular proximal femur fractures without subtrochanteric extension (AO/OTA 31-A2 and 31-A3) METHODS: We prospectively studied 182 patients with unstable extracapsular proximal femur fractures without fractures lines extending more than 3 cm below the lesser trochanter, randomized to receive either a 'standard' (240 mm) nail or a long nail and followed them up for 1 year. RESULTS: We found no difference in the incidence of mechanical or general complications between the two groups, no cut-outs, no fractures of the tip the implant, 1 cut-through and 2 malrotations in the LN group, 2 non-unions that were reoperated, one on each group. The commonest complication was blade lateral migration, 13 (14%) patients in SN and 6 (9%) in the LN. The operating time was shorter in the SN group 51 minutes compared to 67 minutes in the LN group (p=0.000075). The mortality at 1,3 and 12 months in the SN group was of 2%, 6%, 12% while in the LN group was 12%, 18% and 22%. These differences where significative at 1 (p=0.007) and 3 months (p=0.013), but not at 12 months (p=0.075). CONCLUSIONS: We recommend the use of standard nails (240 mm) for this group of fractures, since it does not produce more mechanical complications, and it is faster, cheaper and easier to interlock distally.

Risk of Mortality for Proximal Femoral Fracture in Patients With and Without COVID-19. A Retrospective Cohort Study.

Background: SARS-CoV-2 (COVID-19) has resulted in a widespread loss of lives, morbidity, and major disruptions to the healthcare system. Hip fractures are an emergent condition which require early intervention to reduce increased risk of mortality and morbidity. Infection of SARS-CoV-2 may contribute to increased mortality due to the role of infection and immune response. This study investigated the impact of COVID-19 infection (defined by clinical symptoms) on mortality following proximal femoral fracture (PFF) repair procedures. Methods: This study was a retrospective cohort study. Data from the Premier Healthcare Database® was extracted for patients presenting for PFF during 2019 for control, and February 2020-September 2020 to represent a COVID time-period. Results: A total of N = 73 953 subjects were enrolled for the 2019 period, and a total of N = 34 842 subjects were enrolled for the COVID period. For the 2019 period, subjects who had a PFF procedure and who had flu/COVID-like illness had 2.47 (CI:2.11, 2.88) times the odds of mortality compared to those who did not have flu/COVID-like illness. Subjects who had a PFF procedure and who had flu/COVID-like illness during the COVID period had 2.85 times (CI:2.36, 3.42) the odds of mortality compared to those who did not have flu/COVID-like illness. For the COVID period, within subjects who did not have a PFF procedure, those with flu/COVID-like illness had increased odds of mortality compared to those who did not have flu/COVID-like illness (OR:2.26, CI:1.57, 3.21). Conclusions: Hip fractures present high risk for mortality and morbidity, where timely intervention is critical to improved outcomes. Presence of infection such as flu/COVID-like illness may influence mortality in patients undergoing hip fracture repair procedures. Consideration of infection status as a comorbidity is important to proper management and achieving optimal outcomes.

Mortality Rates of Patients with Proximal Femoral Fracture in a Worldwide Pandemic: Preliminary Results of the Spanish HIP-COVID Observational Study.

BACKGROUND: The outbreak of coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), in December 2019 in Wuhan, People's Republic of China, has developed into an unprecedented pandemic with enormous pressure on health-care providers around the world. A higher mortality rate has been described in older infected individuals. Patients with hip fracture are a particularly vulnerable population during this pandemic because older age is associated with a higher mortality rate. Our aim was to describe the early mortality rate and demographic variables in a hip fracture sample population in Spain during the coronavirus pandemic. METHODS: This is a multicenter, observational, retrospective, descriptive study. We collected data from 13 major hospitals in Spain from the beginning of the national state of alarm (declared on March 14, 2020, by the Spanish government) until the end of our study period on April 4, 2020. All patients who were ≥65 years of age, presented to the Emergency Department of the participating hospitals during this period with a diagnosis of proximal femoral fracture, and had a minimum follow-up of 10 days were included in the cohort. In addition to mortality, demographic and other potential prognostic variables were also collected. RESULTS: In this study, 136 patients with a hip fracture were included. Of these patients, 124 underwent a surgical procedure and 12 were managed nonoperatively. The total mortality rate was 9.6%. Sixty-two patients were tested for COVID-19, with 23 patients being positive. The mortality rate for these 23 patients was 30.4% (7 of 23 patients) at a mean follow-up of 14 days. The mortality rate was 10.3% (4 of 39) for patients who had been tested and had a negative result and 2.7% (2 of 74) for patients who had not been tested. Of the 12 patients who were managed nonoperatively, 8 (67%) died, whereas, of the 124 patients who were surgically treated, 5 (4%) died. Results differed among centers. CONCLUSIONS: There is a higher mortality rate in patients with a hip fracture and an associated positive test for COVID-19. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The floating knee: a review on ipsilateral femoral and tibial fractures.

In 1975, Blake and McBryde established the concept of 'floating knee' to describe ipsilateral fractures of the femur and tibia.1 This combination is much more than a bone lesion; the mechanism is usually a high-energy trauma in a patient with multiple injuries and a myriad of other lesions.After initial evaluation patients should be categorised, and only stable patients should undergo immediate reduction and internal fixation with the rest receiving external fixation.Definitive internal fixation of both bones yields the best results in almost all series.Nailing of both bones is the optimal fixation when both fractures (femoral and tibial) are extra-articular.Plates are the 'standard of care' in cases with articular fractures.A combination of implants are required by 40% of floating knees.Associated ligamentous and meniscal lesions are common, but may be irrelevant in the case of an intra-articular fracture which gives the worst prognosis for this type of lesion. Cite this article: Muñoz Vives K, Bel J-C, Capel Agundez A, Chana Rodríguez F, Palomo Traver J, Schultz-Larsen M, Tosounidis, T. The floating knee. EFORT Open Rev 2016;1:375-382. DOI: 10.1302/2058-5241.1.000042.

Exon array analysis reveals genetic heterogeneity in atypical femoral fractures. A pilot study.

Atraumatic subtrochanteric and diaphyseal (atypical) femoral fractures are a rare, but important adverse event in patients treated with potent anti-resortive agents. The mechanisms involved are unknown and particularly the association with genetic variants has not been explored. The aim of the study was to identify rare genetic variants that could be associated with the occurrence of these fractures. We performed a genome-wide analysis of up to 300,000 variants, mainly distributed in gene coding regions, in 13 patients with atypical femoral fractures and 268 control women, either healthy or with osteoporosis. Twenty one loci were more frequent in the fracture group, with a nominal p value between 1 × 10(-6) and 2.5 × 10(-3). Most patients accumulated two or more allelic variants, and consequently the number of risk variants was markedly different between patients and controls (p = 2.6 × 10(-22)). The results of this pilot study suggest that these fractures are polygenic and are associated with the accumulation of changes in the coding regions of several genes.

[Study on the improvement of trauma patient care: TRAUMACAT project]. / Estudio para la mejoría de la atención hospitalaria inicial del paciente politraumatizado: proyecto TRAUMACAT.

UNLABELLED: Multiple injuries are a major source of morbidity and mortality in young people. The aim of this study was to evaluate the effect of a collaborative strategy to improve the implementation of six clinical indicators, recognized internationally, for the treatment of trauma patient. Prospective, multicentre, pre-and post-intervention study, in ten referral hospitals, offering polytrauma care in Catalonia. 378 patients were recruited for the pre-intervention study and 501 for the post-intervention study. All patients had a history of high-energy trauma requiring admission to critical or semi-critical care unit. INTERVENTION: collaborative strategy aimed at participating professionals, involving the creation of a panel of experts, appointment of monitors to encourage improvements at each centre, training, distribution of information, material and meetings, to exchange impressions. MAIN OUTCOME MEASURES: frequency and characteristics of trauma and percentage of compliance with clinical indicators. Study of 879 trauma patients. The injury mechanism was overall blunt trauma, in both pre and post intervention phases. The medium ISS (injury severity score) was 21 ± 12,8 and the medium TRISS (trauma and injury severity score) was 26,4 ± 11,4. We didn't find differences between both study phases, in relation to the severity of injury. The mortality rate was 11.5%. We observed significant improvement in the performance of chest X-rays (45% vs. 62%) and pelvis X-rays (27% vs. 62%) in the trauma box and in the fixation of the pelvis in patients with a fracture at this site (24% vs. 49%). The use of diagnostic radiology in hemodynamically unstable patients remained low (33%). The collaborative strategy was effective in improving certain indicators of clinical management.

Estudio para la mejoría de la atención hospitalaria inicial del paciente politraumatizado: proyecto TRAUMACAT / Study on the improvement of trauma patient care: TRAUMACAT project

Los politraumatismos constituyen una importante causa de morbimortalidad en la población joven. El objetivo del estudio fue recoger y analizar el efecto de una estrategia de carácter colaborativo para mejorar la aplicación de 6 indicadores clínicos reconocidos a nivel internacional como imprescindibles en el correcto tratamiento de los pacientes politraumatizados. Estudio prospectivo multicéntrico pre y postintervención en 10 hospitales de referencia en la atención de pacientes politraumatizados de Catalunya. Se reclutaron respectivamente 378 y 501 pacientes en el período pre y postintervención. Para ser incluidos debían tener antecedentes de un traumatismo de alta energía, siendo preciso su ingreso en una unidad de críticos o semicríticos. Intervención: estrategia colaborativa dirigida a profesionales de los hospitales participantes, que incluyó la constitución de un grupo de expertos, asignación de responsables para incentivar mejoras en cada centro, formación, distribución de material informativo y reuniones para intercambio de experiencias. Principales medidas de resultado: frecuencia y características del politraumatismo y porcentaje en el cumplimiento de indicadores clínicos. Análisis de 879 pacientes politraumatizados. Los mecanismos de lesión fueron mayoritariamente causados por trauma cerrado en ambas fases del estudio. El ISS (injury severity score) medio global de toda la muestra fue de 21 ± 12,8 y el TRISS (trauma and injury severity score) medio global de la serie del 26,4 ± 11,4. No hubo diferencias en cuanto a la gravedad entre los 2 períodos del estudio. La mortalidad global de la muestra fue del 11,5%. En cuanto a los indicadores clínicos, se identificaron mejoras significativas en los períodos pre y postintervención en la realización de radiografías de tórax (el 45 frente al 62%) y de pelvis (el 27 frente al 62%) en cubículo de trauma y en la fijación de la pelvis en pacientes con fractura a este nivel (el 24 frente al 49%). En el traslado de pacientes hemodinámicamente inestables a radiología diagnóstica no se observaron cambios, manteniéndose valores de cumplimiento bajos (33%). La estrategia colaborativa ha sido efectiva para mejorar algunos indicadores de manejo clínico (AU)

Multiple injuries are a major source of morbidity and mortality in young people. The aim of this study was to evaluate the effect of a collaborative strategy to improve the implementation of six clinical indicators, recognized internationally, for the treatment of trauma patient. Prospective, multicentre, pre-and post-intervention study, in ten referral hospitals, offering polytrauma care in Catalonia. 378 patients were recruited for the pre-intervention study and 501 for the post-intervention study. All patients had a history of high-energy trauma requiring admission to critical or semi-critical care unit. Intervention: collaborative strategy aimed at participating professionals, involving the creation of a panel of experts, appointment of monitors to encourage improvements at each centre, training, distribution of information, material and meetings, to exchange impressions. Main outcome measures: frequency and characteristics of trauma and percentage of compliance with clinical indicators. Study of 879 trauma patients. The injury mechanism was overall blunt trauma, in both pre and post intervention phases. The medium ISS (injury severity score) was 21 ± 12,8 and the medium TRISS (trauma and injury severity score) was 26,4 ± 11,4. We didn't find differences between both study phases, in relation to the severity of injury. The mortality rate was 11.5%. We observed significant improvement in the performance of chest X-rays (45% vs. 62%) and pelvis X-rays (27% vs. 62%) in the trauma box and in the fixation of the pelvis in patients with a fracture at this site (24% vs. 49%). The use of diagnostic radiology in hemodynamically unstable patients remained low (33%). The collaborative strategy was effective in improving certain indicators of clinical management (AU)