Results of Subtrochanteric Femoral Fractures Fixation by Proximal Femoral Locking Compression Plate.

The treatments of subtrochanteric femoral fractures are a challenge. It accounts about 10.0% to 34.0% of all hip fractures with a high complication rate. This area consists of mostly cortical bone with high stress generation thus heal slowly. The fracture is too proximal to adequately control with implants for femoral shaft and too distal to control with implants for intertrochanteric fractures. The intrinsic insecurity of this fracture and forces of the muscles with comminuted medial calcar is giving the fracture a tendency to varus crumple. Extramedullary implants are associated with higher rate of implant failure while intramedullary nails are not suitable for short proximal segment and wide medullary canal. Recently proximal femoral locking compression plate (PF-LCP) has been applied in treatment of proximal femur including subtrochanteric fractures. It has an excellent result in respect of union, fewer complications and early rehabilitation. The aim of this study was to assess the rate and time taken for union of fractures by PF-LCP and determine perioperative parameters. This prospective study was conducted from March 2019 to September 2020 at Mymensingh Medical College Hospital through non randomized purposive sampling. Total 25 patients aged above 18 years irrespective of sex with closed subtrochanteric fracture were included but pathological fractures, multiple injuries were excluded from the study. Union status evaluated by Radiographic Union Score for Tibial (RUST) fracture of Whelan; where antero-posterior and lateral radiographs (X-ray) based assessment of healing of the four cortices done. The entity cortical scores were added to give an entire score; 4 being the least amount demonstrating fracture are positively not healed and 12 being the highest score representing that the fracture is positively healed. The mean age of the patients was 42.04±14.97 years with range 22-70 years. Majority of patients were male (60.0%) and most of injury (64.0%) due to road traffic accident with most fractures was Seinsheimer type III (48.0%). Average operative time was 121.92 minutes, follow up period was 41.12 weeks (24-48 weeks) and time taken for union was 14.16 weeks (11-28 weeks). According to RUST scores; fracture union rate 88.0% with delayed union 12.0% and no nonunion. There were two patients with superficial wound infection and no implant failure. This study concludes that PF-LCP is a safe and reliable implant for the treatment of subtrochanteric femoral fractures.

Posterior Hip Pericapsular Block (PHPB) with pericapsular nerve group (PENG) block for hip fracture: a case series.

BACKGROUND: Pain after total hip arthroplasty (THA) for femoral neck fracture (FNF) can be severe, potentially leading to serious complications. PENG block has become an optional local analgesic strategy in hip fracture surgery, but it cannot provide effective pain relief for the posterior capsule of the hip joint. Therefore, we modified the traditional sacral plexus nerve block and named it Posterior Hip Pericapsule Block (PHPB) to complement the blockade of the relevant nerves innervating the posterior hip capsule region. Thereby, we detail the analgesic effect of PHPB combined with PENG block on five hip fracture patients and the effect on their hip motor function. METHODS: This case series was conducted from December 2023 to February 2024. We performed ultrasound-guided PHPB combined with PENG block on five patients with hip fractures. Numerical Rating Scale (NRS) pain scores at rest and maximum NRS pain scores during limb movement of the five patients were recorded within 48 h after surgery. Their hip flexion, abduction, adduction, keen flexion and quadriceps muscle strength were also recorded. Serious postoperative complications, including wound infection, hematoma formation, or nerve injury, were recorded. RESULTS: They experienced effective pain control within 48 h postoperatively, with NRS pain scores at rest decreasing from 3.0 (3.0, 4.5) to 0.0 (0.0, 1.0) and maximum NRS pain scores during limb movement from 8.0 (7.5, 8.5) to 1.0 (0.5, 2.0). They can autonomously perform hip flexion, abduction, adduction, and knee flexion within 48 h postoperatively without any signs of movement disorders or quadriceps muscle weakness. No severe postoperative complications, such as wound infections, hematoma formation or nerve damage, were observed in any of the patients. CONCLUSIONS: Ultrasound-guided PENG block combined with PHPB provided effective analgesia for hip fracture patients in the perioperative period. It maintained hip joint motor function and quadriceps muscle strength within 24 h after THA.

Sleep and risk of hip fracture and falls among middle-aged and older Chinese.

The study aimed to assess the prospective associations between sleep duration, sleep restfulness, midday napping and hip fracture (HF) and falls in a nationally representative Chinese population. Data were from the China Health and Retirement Longitudinal Study which was conducted from 2013 to 2018. In total, 10,508 individuals without a history of HF in 2013 were included. Nighttime sleep duration, sleep restfulness and midday napping were self-reported. Logistic regression analyses were performed to examine the relationships between sleep problems and HF as well as falls, adjusting for covariates. A total of 313 (3.0%) participants reported HF, and 3899 (37.1%) experienced at least one fall event over the following 5-year period. Participants who had a short sleep duration (≤ 6) were more likely to report HF (OR = 1.27, 95% CI = 1.00-1.62) and falls (OR = 1.18, 95% CI = 1.07-1.30) than those who had a normal sleep duration (6-9 h) in the fully adjusted model. Participants having unrestful sleep were also more likely to report falls (OR = 1.23, 95% CI = 1.11-1.36) than those who had restful sleep. However, there was no significant association between midday napping and HF and falls. In conclusion, short sleep duration and sleep restfulness were independently associated with an increased risk of HF and falls, which may have important clinical and public health implications. Interventions to improve sleep quality may reduce the risk of HF and fall accidents among middle-aged and older people.

Impact of operative position on rotational alignment after intramedullary nailing of trochanteric fractures: a comparative analysis of lateral decubitus versus supine position.

BACKGROUND: Fixation of trochanteric fractures with an intramedullary nail in a non-physiological position can cause poor functional outcomes. The aim of this study is to evaluate the effect of intraoperative patient position on rotational alignment in intramedullary nail fixation of trochanteric fractures. METHODS: The femoral rotational alignment of 84 trochanteric fracture patients who underwent intramedullary nailing was measured by computed tomography (CT) images. Patients were divided into two groups: the supine position on the fracture table (FT) (Group 1, n = 42) and the lateral decubitus (LD) position (Group 2, n = 42). Femoral malrotation angles were measured and divided into three subgroups: insignificant, significant, and excessive. The number of intraoperative fluoroscopy images, preparation time, surgery time, and anesthesia time in both groups were compared. RESULTS: The malrotation degrees of patients in Group 1 ranged from 17° external rotation (ER) to 57° internal rotation (IR), with a mean of 10° IR. Of the patients in Group 1, 27 were insignificant, 5 were significant, and 10 were in the excessive subgroup. The malrotation degrees of patients in Group 2 ranged from 33° ER to 47° IR, with a mean of 11° IR. Of the patients in Group 2, 21 were insignificant, 12 were significant, and 9 were in the excessive subgroup. There was no statistically significant relationship between patient position and malrotation angle. The number of intraoperative fluoroscopy images, preparation time, and anesthesia time were statistically lower in Group 2. There was no statistically significant difference between Group 1 and Group 2 in terms of surgery time. CONCLUSION: Intramedullary nailing in the LD position is a reliable and practical surgical method in the treatment of femoral trochanteric fractures since there is no need for the use of a FT, the surgeon is exposed to less radiation, there is no risk of complications related to the traction of the FT, and there is a shorter operation time.

Inpatient zoledronic acid in older hip fracture patients is well tolerated and safe.

Administering zoledronic acid (ZA) to older hip fracture patients during the hospital stay has faced safety concerns. However, in this study of 161 patients, no ZA-related side effects or readmissions were observed, demonstrating that ZA administration during hospitalization is safe and effective for secondary fracture prevention. PURPOSE: According to the 2022 Dutch 'Osteoporosis and fracture prevention' guideline, zoledronic acid (ZA) is the preferred osteoporosis treatment for hip fracture patients. Less than 25% of hip fracture patients visit the outpatient fracture liaison service, therefore inpatient administration of ZA during the hip fracture hospitalization is now recommended in patients > 75 years. In the OLVG Hospital, inpatient administration of ZA during hospitalization for hip fracture in older patients has been standard of care since 2020. METHODS: This single center retrospective observational follow-up study included hip fracture patients > 75 years admitted to the orthogeriatric ward of the OLVG Hospital, and treated with 5 mg of ZA intravenously on the day of hospital discharge between June 2020 and December 2022. Life expectancy estimated < 12 months, creatinine clearance < 35 ml/min, hypocalcemia, and high risk of osteonecrosis of the jaw were contra-indications. During three months of follow-up (FU) adverse events, emergency room visits, hospital readmissions, and death were recorded. RESULTS: In 161 consecutive hospitalized hip fracture patients (mean age 86 ± 6 years, 65% female, 18% nursing home) ZA was administered and no adverse events were recorded. During 3 months of FU, 8 patients (5%) visited the emergency room, 19 patients (12%) were re-admitted to the hospital, 3 with a new fracture (2 contralateral hip, 1 radius), and 17 patients (11%) died of reasons unrelated to ZA. CONCLUSION: This study shows that inpatient administration of zoledronic acid during hip fracture hospitalization is safe and feasible to prevent future fragility fractures in older hip fracture patients.

Improving agreement in assessing subtrochanteric fracture healing among orthopedic surgeons using the Radiographic Union Score for Hip (RUSH).

BACKGROUND: Prompt identification of fracture healing is crucial for medical decision-making and clinical research. This study aims to assess the effectiveness of the Radiographic Union Score for Hip (RUSH) in subtrochanteric fractures and determine the optimal scoring threshold for fracture healing. METHODS: We obtained 94 sets of X-ray films from the postoperative follow-up of 35 patients who underwent intramedullary nail fixation for subtrochanteric fractures. Six orthopedic trauma surgeons evaluated the imaging data and determined fracture healing based on subjective judgment. They then scored the X-ray images using the RUSH form. After four weeks, the same observers re-evaluated 47 randomly selected sets of radiographs. Subsequently, the observers and study designer conducted a consensus meeting where they agreed on whether the fractures had healed. We used Fleiss kappa to evaluate agreement among observers based on subjective impressions, and the intraclass correlation coefficient assessed RUSH score consistency. Regression analysis examined the relationship between scores and fracture healing consensus using a receiver operator characteristic (ROC) curve. RESULTS: Based on overall impressions, the agreement level among orthopedic trauma surgeons for determining the healing status of subtrochanteric fractures was moderate (Kappa = 0.564, 95% CI: 0.511-0.616). However, utilizing the RUSH scoring system can improve the consistency to a substantial level of agreement (ICC = 0.748, 95% CI: 0.663-0.817). Regarding intraobserver reliability, there were significant differences among orthopedic trauma surgeons in judging fracture healing based on overall impressions. However, using the RUSH scoring form, the attending group achieved better intraobserver consistency than the resident group. Regression analysis and ROC curve analysis revealed a strong correlation between the RUSH total score, cortical bone score, cancellous bone score, and consensus on fracture healing. The AUC values are 0.769 (95% CI: 0.670-0.868), 0.779 (95% CI: 0.681-0.876), and 0.771 (95% CI: 0.674-0.867), respectively. CONCLUSIONS: Our study highlights the effectiveness of the RUSH scoring system in enhancing interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing in orthopedic trauma surgeons. We propose setting 21 points as the threshold for the simplified RUSH scoring system to determine fracture healing. This system includes only eight items related to cortical bone, with a total score of 24 points.

90-Day Complication and Readmission Rates for Geriatric Patients With Hip Fracture at Different Time Points From COVID-19 Positivity: A Database Study.

INTRODUCTION: Geriatric patients with hip fracture are at risk of having COVID-19 while needing fracture treatment. Understanding the associated risks of variable timing of COVID-19 before surgery may help direct care algorithms. METHODS: Geriatric patients with documented hip fracture surgery were identified within the PearlDiver M157 database. Patients with a preoperative COVID-19 diagnosis were classified based on time from diagnosis to surgery: ≤ 1 week, > 1 to ≤ 4 weeks, > 4 to ≤ 7 weeks, > 7 to ≤ 10 weeks, and > 10 to ≤ 13 weeks. The association of COVID-19 diagnoses with 90-day complications was evaluated. RESULTS: Overall, 263,771 patients with hip fracture were identified, of which COVID-19 within 13 weeks of surgery was documented for 976. On multivariable analysis, patients with COVID-19 infection within ≤ 1 week preoperatively demonstrated increased rates of minor adverse events (odds ratio (OR) = 1.50), all adverse events (OR = 1.59), sepsis (OR = 1.70), and pneumonia (OR = 2.35) (P ≤ 0.0007 for each). For time points greater than 1 week, there were no differences in complication rates. DISCUSSION: Patients with COVID-19 within 1 week of hip fracture surgery demonstrated greater odds of 90-day complications. Reassuringly, patients with COVID-19 diagnoses more than 1 week preoperatively were not associated with increased odds of any assessed complication.

The Patient with Hip Fracture.

Hip fractures are a frequent cause of hospitalization in the elderly population and can lead to significant morbidity and mortality. As the population continues to age, the incidence of hip fractures is expected to increase. The internist/hospitalist plays a critical role in the care of this population as many patients have multiple medical comorbidities. Management of the fragility hip fracture patient requires knowledge of several perioperative topics including preoperative risk assessment, risk reduction strategies, the optimal timing of surgical repair, venous thromboembolism prevention, and postoperative care considerations such as early mobilization with physical therapy, and osteoporosis treatment.

Effects of adjunctive esketamine on depression in elderly patients undergoing hip fracture surgery: a randomized controlled trial.

BACKGROUND: Depression is a prevalent perioperative psychiatric complication among elderly hip fracture patients. Esketamine has rapid and robust antidepressant effects. However, it is unknown whether it can alleviate depressive symptoms in elderly patients who undergo hip fracture surgery. This study aimed to explore whether the adjunctive esketamine in patient-controlled intravenous analgesia (PCIA) could improve depressive symptoms in elderly patients undergoing hip fracture surgery. METHODS: A single-center, prospective, double-blind and randomized controlled clinical trial was carried out from July 2022 to August 2023 at the Wenzhou People's Hospital among 90 patients, aged ≥ 65 years with hip fracture undergoing elective surgery. Participants were randomly allocated to either the esketamine group (group S) or the control group (group C). In Group S, patients were administered 0.5 mg/kg of esketamine as a PCIA adjuvant for 48 h, while the control group received saline. The primary outcome was the assessment of depressive symptoms using the Geriatric Depression Scale-15 (GDS-15) on postoperative day 2. The secondary outcomes were assessments of depressive symptoms on postoperative day 7 and postoperative day 30, serum levels of brain-derived neurotrophic factor (BDNF) and 5-hydroxytryptamine (5-HT), postoperative pain intensity, the number of effective PCIA presses, sufentanil consumption, and adverse events. RESULTS: The prevalence and GDS-15 scores of depression were significantly lower in group S on postoperative day 2 (28.6% vs. 53.5%; 3.5 ± 1.8 vs. 4.3 ± 1.7, P < 0.05). In group S, the number of effective PCIA presses was significantly lower on postoperative day 2 than that in group C [2(1-4) vs. 1(0-2), P<0.05]. Higher levels of BDNF (23.8 ± 1.7 ng/mL vs. 25.3 ± 2.0 ng/mL, P < 0.05) and 5-HT (219.5 ± 19.5 ng/mL vs. 217.0 ± 22.2 ng/mL, P < 0.05) in the blood were observed on postoperative day 2 in group S. CONCLUSION: In elderly patients aged ≥ 65 years undergoing hip fracture surgery, the administration of adjunctive esketamine in PCIA could improve depressive symptoms and increase levels of BDNF and 5-HT in the blood. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2200061956 (Date: 13/07/2022).

Comparison of liberal versus restrictive transfusion strategies after hip surgery in patients with coronary artery disease: a post hoc analysis of the FOCUS trial.

BACKGROUND: There are no clear recommendations for optimal transfusion thresholds for patients with coronary artery disease who undergo noncardiac surgery. By comparing restrictive and liberal transfusion strategies for coronary artery disease combined with hip surgery, this study hopes to provide recommendations for transfusion strategies in this special population. METHODS: A total of 805 patients from the FOCUS trial (Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) with coronary artery disease combined with hip surgery were divided into two groups based on transfusion thresholds: restricted transfusion (a hemoglobin level of 8 g/deciliter) and liberal transfusion (a hemoglobin threshold of 10 g/deciliter). The primary outcome of this study was a composite endpoint including in-hospital death, myocardial infarction, unstable angina, and acute heart failure. The secondary endpoints included other in-hospital adverse events and 30- and 60-day follow-up events. Analyses were performed by intention to treat. RESULTS: Except for the proportion of congestive heart failure patients, the baseline levels of the two groups were comparable. The median number of transfusion units in the liberal transfusion group was 2 units, and the median transfusion volume in the restricted transfusion group was 0 units. The primary outcome was not significantly different between the two groups (9.2% vs. 9.4%, p = 0.91). The incidence of in-hospital myocardial infarction events was lower in the liberal transfusion group than in the restricted transfusion group (3.2% vs. 6.2%) (OR = 0.51, P = 0.048). The remaining in-hospital endpoint events, except for myocardial infarction, were not significantly different between the two groups. The 30-day and 60-day endpoints of death and inability to walk independently were not significantly different between the two groups, with ORs (95% CI) of 1.00 (0.75-1.31) and 1.06 (0.80-1.41), respectively. We also found no interaction between transfusion strategies and factors such as age, sex, or multiple underlying comorbidities at the 60-day follow-up. CONCLUSIONS: There was no significant difference in the in-hospital, 30-day or 60-day outcome endpoints between the two groups. However, this study demonstrated that a liberal transfusion strategy tends to reduce the incidence of in-hospital myocardial infarction events in patients with coronary artery disease combined with hip surgery compared to a restrictive transfusion strategy. More high-quality studies should be designed to investigate the optimal transfusion threshold in patients with coronary artery disease treated without cardiac surgery.

Disparities in Dual-energy X-ray Absorptiometry Scan Utilization Across Race/Ethnic Groups Before and After Hip Fractures.

BACKGROUND: Geriatric hip fractures are common and important sentinel events regarding bone health. Although dual x-ray absorptiometry (DEXA) scans are a standard method for determining bone density, differences in use among various race/ethnic groups around the time of hip fracture may reveal disparities within the healthcare system. METHODS: The 2014 to 2016 Medicare Standard Analytic Files PearlDiver data set was used to identify geriatric patients sustaining hip fracture. From that cohort, those who had a DEXA scan before or after their fracture were defined. For the defined cohorts, patient age, sex, Elixhauser Comorbidity Index, race/ethnicity, and income (based on zip code) were defined and compared with univariate and multivariate analyses. RESULTS: Of 58,099 hip fracture patients, only 19.8% had had a DEXA scan before fracture and 3.9% of the remaining group had the DEXA scan after fracture. Of the hip fracture population, 91.0% identified as White and 9.0% as non-White (Native American, Black, Hispanic, Asian, or Other). Before hip fracture, controlling for other variables and compared with White patients, all non-White categories were at lesser odds of having had the DEXA scan. After hip fracture, Black, Hispanic, and other patients were also at lesser odds of having the DEXA scan. DISCUSSION: Using a large Medicare data set, controlling for patient age, sex, Elixhauser Comorbidity Index, and income marker, this study revealed disparities in DEXA scan utilization across race/ethnic groups before and after presenting with a hip fragility fracture. Identification of such disparities highlights the needs for improved medical access and care for this at-risk hip fracture population.

Fracture-related infections after osteosynthesis for hip fracture are associated with higher mortality: A retrospective single-center cohort study.

BACKGROUND AND PURPOSE:  Fracture-related infections (FRIs) after osteosynthesis for hip fractures have not been thoroughly investigated. Our primary aim was to assess the association between FRIs and mortality after osteosynthesis for hip fracture. Secondary aims were to investigate the incidence, microbiology, and general epidemiological aspects of these FRIs. METHODS:  This retrospective single-center study included 1,455 patients > 18 years old with non-pathological hip fractures treated with osteosynthesis between 2015 and 2019. Medical records were reviewed and FRIs were diagnosed based on current consensus criteria. The follow-up period was 2 years. Mortality was estimated using Kaplan-Meier survival analysis. Cox regression analyses were performed to investigate the potential association between FRIs, as a time-dependent variable, and increased mortality. RESULTS: The median age for the entire cohort was 83 (interquartile range 75-89) years and 69% were females. At the 2-year follow-up mark, the crude mortality rate was 33% in the non-FRI group and 69% (11 of 16 patients) in the FRI group. Cox regression analysis assessing mortality risk revealed a hazard ratio of 3.5 (95% confidence interval [CI] 1.9-6.4) when adjusted for confounders. The incidence of FRI was 1.1% (16 of 1,455 patients). Staphylococcus aureus was the most common pathogen. Most FRI patients (94%) required at least 1 revision and 56% underwent ≥ 2 revision. CONCLUSION:  We found an association between FRIs after hip fracture osteosynthesis and increased mortality, underscoring the critical need for FRI prevention measures in this frail patient group. The incidence and microbiological findings were consistent with previous studies.

Pathoanatomy and pathomechanics of pertrochanteric fractures - an MRI study.

BACKGROUND AND STUDY AIMS: Magnetic resonance imaging (MRI) has been used for more than 20 years in the region of the proximal femur to diagnose occult, or incomplete, fractures of the femoral neck and the trochanteric segment. MRI has also potential to contribute to the understanding of the pathogenesis and pathoanatomy of trochanteric fractures. METHODS: The group including 13 patients was examined by MRI for a suspected, or incomplete, fracture of the trochanteric segment within 24 hours post-injury. In all cases, this was the first injury to the hip joint, with the other hip joint remaining intact. RESULTS: The coronal scans showed a marked fracture line which, in the region of the intertrochanteric line, extended from the base of the greater trochanter (GT) medially and distally and involved the medial cortex. This inclination, however, was gradually changing posteriorwards and close before the posterior cortex. The fracture line was passing vertically along the lateral trochanteric wall as far as the level of the lesser trochanter (LT). Then the fracture line changed its course and ran horizontally to the cortex of the LT. Sagittal scans showed clearly the primary fracture line originating in the greater trochanter, extending medially and starting to separate the posterior cortex. CONCLUSION: Analysis of MRI findings has documented that the primary fracture line in pertrochanteric fractures originates in the GT and extends distally, medially and anteriorly towards the anterior cortex, the intertrochanteric line and the LT. Thus, the GT presents a rather vulnerable site and is always broken into more fragments than shown by a radiograph.

The impact of ethnicity on care and outcome after hip fracture in England and Wales.

Aims: To determine if patient ethnicity among patients with a hip fracture influences the type of fracture, surgical care, and outcome. Methods: This was an observational cohort study using a linked dataset combining data from the National Hip Fracture Database and Hospital Episode Statistics in England and Wales. Patients' odds of dying at one year were modelled using logistic regression with adjustment for ethnicity and clinically relevant covariates. Results: A total of 563,640 patients were included between 1 April 2011 and 1 October 2020. Of these, 476,469 (85%) had a coded ethnicity for analysis. Non-white patients tended to be younger (mean 81.2 vs 83.0 years), and were more commonly male (34.9% vs 28.5%; p < 0.001). They were less likely to be admitted from institutional care (12.9% vs 21.8%; p < 0.001), to have normal cognition (53.3% vs 62.0%; p < 0.001), and to be free of comorbidities (22.0% vs 26.8%; p < 0.001), but were more likely to be from the most deprived areas (29.4% vs 17.3%; p < 0.001). Non-white patients were more likely to experience delay to surgery for medical reasons (14.8% vs 12.7%; p < 0.001), more likely to be treated with an intramedullary nail or a sliding hip screw (52.5% vs 45.1%; p < 0.001), and less likely to be mobilized by the day after surgery (74.3% vs 79.0%; p < 0.001). Mortality was higher among non-white inpatients (9.2% vs 8.4% for white), but was lower at one year after hip fracture (26.6% vs 30.3%). Conclusion: Our study identified serious problems with the quality of NHS ethnicity data. Despite this, we have shown that there is complex variation in case-mix and hip fracture morphology between ethnic groups. We have also identified variations in care received between ethnic groups, and that disparities in healthcare may contribute to poorer outcome. Inpatient mortality is higher in non-white patients, although this finding reverses after discharge, and one-year mortality is lower. Patients from ethnic minority backgrounds experience disparities in healthcare, however at one year postoperatively non-white patients have a statistically significant lower mortality after controlling for relevant clinical covariates.

Incidence of Rotational Malalignment after Intertrochanteric Fracture Intramedullary Nailing: A CT-Based Prospective Study.

Background and Objectives: Rotational malformation after intramedullary nailing of intertrochanteric fractures is a relatively common, possibly severe, and difficult-to-detect complication, since intraoperative radiographic imaging allows for the assessment of the quality of reduction in the frontal and sagittal planes, but not in the transverse plane. The purpose of this study is to evaluate the rotational malalignment after intramedullary nailing of intertrochanteric fractures and to investigate a possible connection with specific patients' or fractures' characteristics. Materials and Methods: 74 patients treated with intramedullary nailing due to an intertrochanteric fracture underwent a postoperative CT of the pelvis-hips and knees. The value of the anteversion was measured both in the operated-on (angle 1) and in the healthy hip (angle 2) based on the technique described by Jeanmart et al. and the difference in anteversion (D angle = angle 1 minus angle 2) was calculated. A positive D angle indicated the presence of excessive internal overcorrection of the distal fragment during fracture reduction, while a negative D angle indicated the presence of excessive external overcorrection. The absolute value of the D angle represents the postoperative difference in anteversion between the two hips. The patients were divided into three groups according to this value: group A, with D < 5° (physiological difference); group B, with 5° < D < 15° (acceptable rotational alignment); and group C, with D ≥ 15° (rotational deformity). Results: Group A constitutes 56.8%, group B 12.2%, and group C 31.1% of the study population. Overall, 79.7% of the patients presented a positive angle D, while, for group C, the percentage was even higher at 91.3%. According to the AO/OTA classification system, 37.8% of the cases were stable fractures, 47.3% were unstable fractures, and 14.9% were reverse oblique fractures. Based on our analysis, the type of fracture has a serious impact on the rotational alignment, since the statistical significance of the mean angle D for the three types of fracture is reliable (p = 0.029). Stable fractures present the lowest anteversion difference values, while reverse oblique fractures present the highest difference. Conclusions: Our study reveals that the percentage of rotational malalignment after the intramedullary nailing of intertrochanteric fractures remains high (31.1%), despite the proper use of radiographic imaging during the intraoperative fracture reduction. In most cases (91.3%), this malalignment appears to be a matter of internal overcorrection. A clear correlation between hip's rotational deformity and patients' functional outcome has yet to be proven, and constitutes our objective in the near future.

Sex differences in mobility recovery after hip fracture: a time series analysis.

Introduction: Sex differences are commonly reported for hip fracture incidence rates and recovery. Current knowledge about mobility recovery after hip fracture involves clinical assessments of physical capacity or patient-reported outcomes. Information on mobility performance during daily life is missing but relevant to evaluate patients' recovery. Hence, it remains unclear whether sex differences exist in the longitudinal progression of mobility performance in hip fracture patients. To investigate this, we pooled data from four studies in Germany and Norway. Methods: In all studies, real-world mobility was assessed continuously over 1 to 7 days using a sensor fixed to the unaffected frontal thigh. All studies assessed mobility at different time points that were allocated to three distinct phases: Acute and post-acute phase (week 1-6), extended recovery (7-26), and long-term recovery (27-52). Sex-specific continuous trajectories of the median (50th percentile) as well as the 1st (25th percentile) and 3rd quartile (75th percentile) were estimated using quantile regression models with splines for daily walking and standing duration; number of sit-to-stand-to-walk transfers and walking bouts; mean walking bout duration; maximum number of steps per walking bout. Results: There were 5,900 valid observation days from n = 717 participants (mean age = 83.4 years, SD 6.1). The majority was female (75.3%), with similar sex distribution across all studies. Demographics of both sexes were comparable, but a higher percentage of women was living alone (69.0% compared to 40.9% in men) and had experienced an indoor fall leading to the fracture (74.3% compared to 67.4% in men). There were clear sex differences in mobility recovery. Women improved their mobility faster than men, but men showed larger increases later in the year after surgery. At the end of the first year, both sexes reached comparable levels in almost all mobility parameters. Conclusion: We identified varying aspects of mobility recovery between men and women, i.e., timely development of mobility recovery shows different patterns. Our findings support the consideration of sex differences in planning and implementing rehabilitation measures for hip fracture patients and highlight the need to provide adapted support at different time points. The underlying mechanisms of these sex differences need further investigation.

Implementation status of postoperative rehabilitation for older patients with hip fracture in Kyoto City, Japan: A population-based study using medical and long-term care insurance claims data.

Continuing rehabilitation after hip fractures is recommended to improve physical function and quality of life. However, the long-term implementation status of postoperative rehabilitation is unclear. This study aims to investigate the implementation status of postoperative rehabilitation for older patients with hip fractures and the factors associated with continuing rehabilitation. A retrospective cohort study evaluated medical and long-term care insurance claims data of patients aged 75 years or older in Kyoto City, Japan, who underwent hip fracture surgeries from April 2013 to October 2018. We used logistic regression analysis to examine factors associated with six-month rehabilitation continuation. Of the 8,108 participants, 8,037 (99%) underwent rehabilitation the first month after surgery, but only 1,755 (22%) continued for six months. The following variables were positively associated with continuing rehabilitation for six months: males (adjusted odds ratio: 1.41 [95% confidence interval: 1.23-1.62]), an intermediate frailty risk (1.50 [1.24-1.82]), high frailty risk (2.09 [1.69-2.58]) estimated using the hospital frailty risk scores, and preoperative care dependency levels: support level 1 (1.69 [1.28-2.23]), support level 2 (2.34 [1.88-2.90]), care-need level 1 (2.04 [1.68-2.49]), care-need level 2 (2.42 [2.04-2.89]), care-need level 3 (1.45 [1.19-1.76]), care-need level 4 (1.40 [1.12-1.75]), and care-need level 5 (1.31 [0.93-1.85]). In contrast, dementia was cited as a disincentive (0.53 [0.45-0.59]). Less than 30% of older patients continued rehabilitation for six months after surgery. Factors associated with continuing rehabilitation were male sex, higher frailty risk, care dependency before hip fracture surgeries, and non-dementia.

Mobile assessment of visual function helps to prevent Re-Injury in elderly patients with recent hip fractures.

INTRODUCTION: Patients undergoing surgery due to hip fracture face an elevated risk of a subsequent fall during rehabilitation. An important contributing factor to this risk is deteriorated visual function, often responsive to intervention. This study aims to explore differences in visual acuity (VA) and stereovision (SV) between individuals with a history of fall-related hip injuries (study group) and age-matched controls, utilizing a mobile application (EuvisionTab, ET) to distinguish age-related visual decline from pathological vision. MATERIALS & METHODS: A total of 32 and 71 participants were enrolled in the study and control groups, respectively (mean age: 74.9 years, range: 60-96). Monocular logMAR VA was measured using a tablet by means of an adaptive threshold-search algorithm. SV was assessed using low-dot density static and dynamic random dot stereograms. An age-dependent reference limit for VA was established. For ET stereotests, the number of correctly identified optotypes out of 10 random presentations served as the measure for further comparisons. Visually impaired status in the study group was determined if patients failed either the VA threshold or the SV criteria. RESULTS: In the control group, an apparent but statistically nonsignificant decline in VA was observed, while stereovision remained stable and did not exhibit significant age-related variations based on ET stereotests. Conversely, the study group demonstrated significantly worse results in monocular VA (p = 0.0032) and for both stereotests (p = 0.018 for static, p = 0.036 for dynamic) according to paired samples t-test and chi-square test, respectively. Hip injuries were significantly associated with visual impairment (OR = 4.88, p = 0.0012). DISCUSSION: This study focuses on one possible risk factor of elderly falls, namely, vision impairment. Patients with visual decay present a higher incidence of hip injuries compared to age-matched controls. This data suggest that vision screening and, when feasible, restoration of visual function may contribute to the prevention of secondary falls, refractures, or contralateral fractures. A mobile-based screening protocol, executable as part of a postoperative bedside examination and independent of specialized eye care, can be proposed.

Developing a prediction model for preoperative acute heart failure in elderly hip fracture patients: a retrospective analysis.

BACKGROUND: Hip fractures in the elderly are a common traumatic injury. Due to factors such as age and underlying diseases, these patients exhibit a high incidence of acute heart failure prior to surgery, severely impacting surgical outcomes and prognosis. OBJECTIVE: This study aims to explore the potential risk factors for acute heart failure before surgery in elderly patients with hip fractures and to establish an effective clinical prediction model. METHODS: This study employed a retrospective cohort study design and collected baseline and preoperative variables of elderly patients with hip fractures. Strict inclusion and exclusion criteria were adopted to ensure sample consistency. Statistical analyses were carried out using SPSS 24.0 and R software. A prediction model was developed using least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression. The accuracy of the model was evaluated by analyzing the area under the receiver operating characteristic (ROC) curve (AUC) and a calibration curve was plotted to assess the model's calibration. RESULTS: Between 2018 and 2019, 1962 elderly fracture patients were included in the study. After filtering, 1273 were analyzed. Approximately 25.7% of the patients experienced acute heart failure preoperatively. Through LASSO and logistic regression analyses, predictors for preoperative acute heart failure in elderly patients with hip fractures were identified as Gender was male (OR = 0.529, 95% CI: 0.381-0.734, P < 0.001), Age (OR = 1.760, 95% CI: 1.251-2.479, P = 0.001), Coronary Heart Disease (OR = 1.977, 95% CI: 1.454-2.687, P < 0.001), Chronic Obstructive Pulmonary Disease (COPD) (OR = 2.484, 95% CI: 1.154-5.346, P = 0.020), Complications (OR = 1.516, 95% CI: 1.033-2.226, P = 0.033), Anemia (OR = 2.668, 95% CI: 1.850-3.847, P < 0.001), and Hypoalbuminemia (OR 2.442, 95% CI: 1.682-3.544, P < 0.001). The linear prediction model of acute heart failure was Logit(P) = -2.167-0.637×partial regression coefficient for Gender was male + 0.566×partial regression coefficient for Age + 0.682×partial regression coefficient for Coronary heart disease + 0.910×partial regression coefficient for COPD + 0.416×partial regression coefficient for Complications + 0.981×partial regression coefficient for Anemia + 0.893×partial regression coefficient for Hypoalbuminemia, and the nomogram prediction model was established. The AUC of the predictive model was 0.763, indicating good predictive performance. Decision curve analysis revealed that the prediction model offers the greatest net benefit when the threshold probability ranges from 4 to 62%. CONCLUSION: The prediction model we developed exhibits excellent accuracy in predicting the onset of acute heart failure preoperatively in elderly patients with hip fractures. It could potentially serve as an effective and useful clinical tool for physicians in conducting clinical assessments and individualized treatments.