Internal fixation of intra-capsular proximal femoral fractures in patients older than 80 years: Still relevant? Multivariate analysis of a prospective multicentre cohort.

BACKGROUND: Arthroplasty is now widely used to treat intra-capsular proximal femoral fractures (PFFs) in older patients, even when there is little or no displacement. However, whether arthroplasty is associated with lower mortality and complication rates in non-displaced or mildly displaced PFFs is unknown. The objectives of this prospective study were: (1) to evaluate early mortality rates with the two treatment methods, (2) to identify risk factors for complications, (3) and to identify predictors of functional decline. HYPOTHESIS: Arthroplasty and internal fixation produce similar outcomes in non-displaced fractures of patients older than 80 years with PFFs. MATERIAL AND METHODS: This multicentre prospective study included consecutive patients older than 80 years who were managed for intra-capsular PFFs at eight centres in 2014. Biometric data and geriatric assessment scores (Parker Mobility Score, Katz Index of Independence, and Mini-Nutritional Assessment [MNA] score) were collected before and 6 months after surgery. Independent risk factors were sought by multivariate analysis. We included 418 females and 124 males with a mean age of 87±4years. The distribution of Garden stages was stage I, n=56; stage II, n=33; stage III, n=130; and stage IV, n=323. Arthroplasty was performed in 494 patients and internal fixation in 48 patients with non-displaced intra-capsular PFFs. RESULTS: Mortality after 6 months was 16.4% overall, with no significant difference between the two groups. By multivariate analysis, two factors were significantly associated with higher mortality, namely, male gender (odds ratio [OR], 3.24; 95% confidence interval [95% CI], 2.0-5.84; P<0.0001) and high ASA score (OR, 1.56; 95% CI, 1.07-2.26; P=0.019). Two factors were independently associated with lower mortality, with 75% predictive value, namely, high haematocrit (OR, 0.8; 95% CI, 0.7-0.9; P=0.001) and better Parker score (OR, 0.5; 95% CI, 0.3-0.8; P=0.01). The cut-off values associated with a significant risk increase were 2 for the Parker score (OR, 1.8; 95% CI, 1.1-2.3; P=0.001) and 37% for the haematocrit (OR, 3.3; 95% CI, 1.9-5.5; P=0.02). Complications occurred in 5.5% of patients. Surgical site infections were seen in 1.4% of patients, all of whom had had arthroplasty. Blood loss was significantly greater with arthroplasty (311±197mL versus 201±165mL, P<0.0002). Dependency worsened in 39% of patients, and 31% of patients lost self-sufficiency. A higher preoperative Parker score was associated with a lower risk of high postoperative dependency (OR, 0.86; 95% CI, 0.76-0.97; P=0.014). DISCUSSION: Neither treatment method was associated with decreased mortality or better function after intra-capsular PFFs in patients older than 80 years. Early mortality rates were consistent with previous reports. Among the risk factors identified in this study, age, preoperative self-sufficiency, and gender are not amenable to modification, in contrast to haematocrit and blood loss. CONCLUSION: Internal fixation remains warranted in patients older than 80 years with non-displaced intra-capsular PFFs. LEVEL OF EVIDENCE: III, prospective case-control study.

Is arthroplasty preferable to internal fixation for the treatment of extracapsular fracture of the upper femur in the elderly?

INTRODUCTION: Although internal fixation is the reference treatment for extracapsular fracture of the upper femur, indications for arthroplasty are broadening, especially in unstable comminutive fracture in fragile bone. The present study hypothesis was that arthroplasty reduces early mortality and morbidity and provides better recovery of autonomy in over-80 year-old patients than does internal fixation. MATERIAL AND METHODS: A prospective multicenter study was conducted on 8 sites. Internal fixation was systematically used in 5 centers; arthroplasty was used systematically in 1 center, and reserved for unstable fracture in 2 centers. A total of 697 patients aged over 80 years (mean age, 85±5 years), presenting with extracapsular fracture, were included; 521 were treated by internal fixation and 176 by arthroplasty. Results were studied on multivariate analysis of ASA score, blood loss, transfusion, and also of treatment modality as an independent factor for early (first 6 months) mortality and morbidity (mechanical, general and nutritional complications) and functional outcome (autonomy and dependence). RESULTS: Overall mortality was 19.2%. Autonomy deteriorated in 56% of patients alive at 6 months and dependence worsened in 44%. Two percent of those managed by internal fixation underwent revision for disassembly (n=8) or infection (n=1). Eight percent of those managed by arthroplasty underwent revision for dislocation (n=4), implant loosening (n=3) or infection (n=7). On univariate analysis, mortality was higher in the arthroplasty group (25%) than with internal fixation (17%; P=0.002), as were blood loss (425±286mL versus 333±223mL; P<0.0001), transfusion rate (61% versus 32%; P<0.0001) and infection (4% versus 0.2%; P<0.001). On multivariate analysis, however, treatment modality no longer showed impact on mortality or on morbidity and autonomy at 6 months. Nutritional status was better conserved at 6 months following arthroplasty, but dependence worsened. Poor preoperative autonomy, ASA score, and nutritional status and time to treatment were independent factors for mortality. Transfusion, associated with onset of mechanical complications, significantly increased dependence. CONCLUSION: Type of treatment had little impact on mortality, morbidity or functional outcome. Differences seemed more related to preoperative functional and nutritional status. LEVEL OF EVIDENCE: III, prospective case-control study.

[Non-traumatic myositis ossificans circumscripta]. / Myosite ossifiante circonscrite non traumatique.

BACKGROUND: Myositis ossificans circumscripta is a benign lesion with an acute course and may simulate a malignant tumor. It usually follows trauma to soft tissue. CASE REPORTS: Case n. 1. A 13 year-old girl was admitted because of a painful inflammatory tumour in the left thigh. Initial X-rays were normal. Ultrasound imaging showed a heterogeneous echogenic mass with several extending shadow cones in the distal part of the vastus medialis muscle resembling a calcifying hematoma. Twenty days later, X-rays showed a vague calcified peripheral rim in the medial distal part of the thigh. White blood count was normal, and blood sedimentation rate was 46 millimeters in the first hour. CT scan showed a transparent zone between the lesion and the adjacent bone and a lucent central area, surrounded by a dense outer area consistent with myositis ossificans. Histological examination of the excised mass confirmed myositis ossificans. Two years later, the patient was asymptomatic and X-rays showed no ossification. Case n. 2. A 14 year-old girl suffered from pain in the right anterior hip area since 10 days. She denied any trauma. A firm mass was palpable in the anterior superior iliac spine area and X-rays revealed a calcific density. CT scan showed a dense bony mass in the right gluteus medius muscle clearly separated from the adjacent bony pelvis by a soft tissue plane. Histological examination of the excised mass confirmed myositis ossificans. One year later, the patient was asymptomatic and X-rays of the pelvis showed no ossification. CONCLUSION: Myositis ossificans circumscripta is rare in children. CT scan suggests the benign nature of the lesion by demonstrating integrity of bony cortex and characteristic disposition of calcifications. The biopsy is not necessary if the diagnosis is certain. Surgery permits to reduce the evolution.

Vertebral hemangioma. Spontaneous spinal canal remodeling after fracture.

STUDY DESIGN: The patient in this report had a fracture of a hemangiomatous vertebra with a fragment protruded into the canal and without neurological signs. There was a 12 month follow-up. RESULTS: After conservative treatment, there were no neurologic signs, a good fusion, and natural remodeling of the spinal canal. CONCLUSIONS: The risk of a hemangiomatous vertebra fracture with a fragment retropulsed into the spinal canal and without neurologic signs is low. Also, a remodeling of the spinal canal can occur, as after a burst fracture.

[Osteosarcoma of the sacrum. Apropos of a case in a 14 year-old girl]. / Ostéosarcome du sacrum. A propos d'une observation chez une adolescente de 14 ans.

The authors report a case of sacral osteosarcoma, which is a rare and dreaded tumor. Sciatica was the first manifestation. Patients with refractory sciatica and normal plain films and computed tomography studies of the lumbar spine should undergo magnetic resonance imaging to look for a sacral lesion.

[Metastases in the cauda equina in visceral cancers. Apropos of 2 cases]. / Les métastases de la queue de cheval des cancers viscéraux. A propos de deux cas.

Two new cases of cauda equina metastases from visceral cancers are reported. This diagnosis is only infrequently considered in patients with intra-dural lesions visualized by magnetic resonance imaging or saccoradiculography. The diagnosis is especially difficult in patients with no known primary cancer. Diagnosis rests on surgery during which only a biopsy is performed. Treatment is symptomatic and focuses on relieving pain. Prognosis is bleak.

[Congenital cutaneous aplasia of the scalp. Apropos of 4 cases]. / Les aplasies cutanées congénitales du scalp. A propos de 4 observations.

Report of four cases of congenital defects of the scalp. In two of these cases, the skin defect was associated with a skull defect and in one, there were other cranial deformities. In each case, the lesion seemed isolated in otherwise normal children. This study contains a review of congenital scalp defects. The different aspects of this rare disease are presented and the treatment is discussed with reference to natural evolution. The authors differentiate between cases with isolated lesion and cases with associated malformations or abnormalities, malformation syndromes, as has been previously defined. In the case of skull defects, it is thought that immediate reparatory surgery must be performed, to prevent infection and hemorrhage of sagittal venous sinus, as it was the case in one of the four children. The covering of the defect can be realized with rotated skin flaps, which seem preferable to any form of plastic surgery, for cosmetic reasons, and for the secondary treatment of the skull defect, if this is necessary. When spontaneous closure of the bone defect, is not noted, which occurs generally in the case of large defects, it seems reasonable to close the latter by cranio-plasty, to protect the brain. In one of the four cases reported, this technical approach of the lesion was used, with a good result being reported, four years later.