High risks of failure observed for A1 trochanteric femoral fractures treated with a DHS compared to the PFNA in a prospective observational cohort study.

INTRODUCTION: Both the DHS and the PFNA are common and well-studied treatment options for stable trochanteric fractures. The aim of the current study was to compare the implant failure rates of these two implants in 31A1 type trochanteric femoral fractures. MATERIALS AND METHODS: A single-centre observational cohort study was conducted in the Hip Fracture Unit of a multicentre level 1 trauma teaching hospital between December 2016 and October 2018. Patients with an AO/OTA type 31A1 fracture were included. Pathological fractures, bilateral fractures, high-energy traumas and patients younger than 18 years of age were excluded. Surgery was performed using either a DHS or PFNA. Both were used routinely for stable trochanteric fractures, and allocation was decided by the surgeon performing the operation. The primary outcome of this study was the implant failure rate in the first postoperative year. Secondary outcomes included the reoperation rate, functional recovery, pain and morphine use. RESULTS: Data were available from 126 patients treated with a DHS (n = 32, 25.4%) or PFNA (n = 95, 74.6%). Minor differences were observed in the patient characteristics including the prevalence of cognitive impairment (18.8% vs 40.2%; P = 0.028), prefracture independence in activities of daily living (87.1% vs 67.4%; P = 0.034) and prefracture mobility (independently without aides: 61.3% vs 40.4%; P = 0.033). Fractures treated with a DHS showed 25% implant failures, compared to 1.1% for fractures treated with a PFNA (P = 0.004). No differences were observed in any of the secondary outcomes. CONCLUSIONS: Significantly more implant failures were observed for the DHS compared the PFNA within 1 year after surgery. Despite the fact that this did not result in differences in revision surgery, we conclude that the PFNA, considering the minimal number of implant-related fractures is a viable implant for A1 type trochanteric fractures.

Prognostic Factors for Short-term Recovery of Independence in a Multistate Model for Patients With a Hip Fracture.

OBJECTIVES: This study investigates the transitions of community-dwelling patients with a proximal femoral fracture towards recovery of independence using multistate modeling. The prognostic value of factors affecting the short-term rate of recovery of independence in activities of daily living was assessed for the resilient portion of the population. DESIGN: An inception cohort was recruited between 2016 and 2019. SETTING AND PARTICIPANTS: Only community-dwelling older patients admitted with a proximal femoral fracture were included. MEASURES: Follow-up was performed at 6 weeks and 3 months, when the patients' living situation and level of independence were recorded. Multistate modeling was used to study the transition rates of the population through prespecified states of the recovery process. Using this model, prognostic factors for the recovery of independence were identified for resilient patients (defined as those patients who managed to return home at any point in the follow-up after discharge). RESULTS: A total of 558 patients were included, and 218 (40.9%) recovered to prefracture levels of independence. Of the resilient patients, 20.7% were discharged home directly, and 79.3% via a rehabilitation home. In this patient group, a more favorable American Society of Anesthesiologists classification, better prefracture mobility, and the absence of a prefracture fear of falling were statistically significantly associated with a successful recovery. A low level of prefracture independence was inversely associated, meaning that patients with a low level of prefracture independence had a higher chance of successful recovery. CONCLUSIONS AND IMPLICATIONS: This study identified 4 factors with an independent prognostic value for the recovery of independence in resilient patients after a proximal femoral fracture. These factors could be used to construct clinical profiles that contribute to the assessment of the patient's post-acute care needs and recovery capacity. In addition, multistate modeling has been shown to be an effective and versatile tool in the study of recovery prognostics.

The Prognostic Value of Metabolic Profiling in Older Patients With a Proximal Femoral Fracture.

INTRODUCTION: High mortality rates of approximately 20% within 1 year after treatment are observed for patients with proximal femoral fractures. This preliminary study explores the prognostic value of a previously constructed mortality risk score based on a set of 14 metabolites for the survival and functional recovery in patients with proximal femoral fractures. MATERIALS AND METHODS: A prospective observational cohort study was conducted including patients admitted with a proximal femoral fracture. The primary outcome was patient survival, and the recovery of independence in activities of daily living was included as a secondary outcome. The mortality risk score was constructed for each patient and its prognostic value was tested for the whole population. RESULTS: Data was available form 136 patients. The mean age of all patients was 82.1 years, with a median follow-up of 6 months. Within this period, 19.0% of all patients died and 51.1% recovered to their prefracture level of independence. The mortality score was significantly associated with mortality (HR, 2.74; 95% CI, 1.61-4.66; P < 0.001), but showed only a fair prediction accuracy (AUC = 0.68) and a borderline significant comparison of the mortality score tertile groups in survival analyses (P = 0.049). No decisive associations were found in any of the analyses for the functional recovery of patients. DISCUSSION: These findings support the previously determined prognostic value of the mortality risk score. However, the independent prognostic value when adjusted for potential confounding factors is yet to be assessed. Also, a risk score constructed for this specific patient population might achieve higher accuracies for the prediction of survival and functional recovery. CONCLUSIONS: A modest prediction accuracy was observed for the mortality risk score in this population. More elaborate studies are needed to validate these findings and develop a tailored model for clinical purposes in this patient population.

The functional effect of lesser trochanter involvement in hip fractures: A prospective cohort study.

INTRODUCTION: Hip fractures are the most common fractures amongst frail older patients. Earlier studies have indicated an impaired hip flexion strength in patients with fractures that include detachment of the lesser trochanter. These patients may experience protracted functional impairment and longer recovery time, causing prolonged rehabilitation journeys. This study aimed to evaluate the effects of a detached lesser trochanter in trochanteric fractures on the recovery of hip function. METHOD: A prospective observational cohort study was performed between 2016 and 2019. Community dwelling patients aged 70 years or older with AO 31A1-A3 trochanteric fractures were included. Patients followed routine care and were treated with a DHS or PFNA. The groups with and without involvement of the lesser trochanter were analysed. The primary outcome was hip function assessed at 6 weeks, 3 months and 1 year after surgery with the Harris Hip Score. Secondary outcomes included the Ludloff's test, complications, rehabilitation time, and pain-, independence-, and quality of life scores. A propensity score was used to adjust for any baseline differences between the two groups. RESULTS: A total of 114 patients were included, 51 (44.7%) with involvement of the lesser trochanter and 63 (55.3%) without. Minor differences were observed in the baseline characteristics. No significant difference was observed for the Harris Hip Score (coefficient estimate: 3.31; 95% CI, -5.09-11.72; P = 0.43). The flexion function of the iliopsoas muscle was more often normal with the Ludloff's test in patients without involvement of the lesser trochanter (OR, 2.33; 95% CI, 1.241-4.387; P = 0.009). However, no differences were observed for any of the other secondary outcomes. CONCLUSION: Although no differences in overall hip function were found, more hip fracture patients with involvement of the lesser trochanter showed prolonged impaired flexion of the hip. The absence of long-term, clinically relevant disadvantages however, proves fixing the lesser trochanter to be redundant.

Independent factors associated with long-term functional outcomes in patients with a proximal femoral fracture: A systematic review.

INTRODUCTION: The current understanding of prognostic factors of functional recovery after a proximal femoral fracture is limited, and enhancements could improve the prognostic accuracy and target subgroups for additional care strategies. This systematic review aims to identify all studied factors with an independent prognostic value for the long-term functional recovery of patients with a proximal femoral fracture. MATERIALS AND METHODS: Observational studies with multivariate analyses on prognostic factors of long-term functional outcome after proximal femoral fractures were obtained through an electronic search performed on November 9, 2018. RESULTS: In the 31 included articles, thirteen prognostic factors were studied by at least two independent studies and an additional ten by only one study. Age, comorbidity, functionality and cognition were factors for which the majority of studies indicated a significant effect. The majority of studies which included sex as a factor found no significant effect. The level of evidence for the remaining factors was deemed too low to be conclusive on their relevance for long-term functional outcome. CONCLUSION: The identified factors showed overlap with prognostic factors of short-term functional outcomes and mortality. The validity and applicability of prognostic models based on these factors may be of interest for future research.

Screening for malnutrition in patients admitted to the hospital with a proximal femoral fracture.

INTRODUCTION: The prevalence of malnutrition in patients admitted with a proximal femoral fracture is considered high and the negative effects on health are well-studied. The SNAQ and the MNA-SF are two screening tools routinely used during admission of acute medical patients. The aim of this study is to compare the screening capacity of the SNAQ score and the MNA-SF, and to evaluate their predictive values for malnutrition using the ESPEN criteria. MATERIALS AND METHODS: A single-centre study with data routinely collected prospectively from the original patient records was performed in the Haaglanden Medical Centre Bronovo in the Netherlands. All patients with a proximal femoral fracture consecutively admitted between December 19th 2016 and December 21st 2017 were included. The Intraclass Correlation Coefficient was used to assess the agreement between the malnutrition screening tools and the predictive values were calculated to compare the SNAQ with the MNA-SF using the ESPEN diagnostic criteria as the reference standard. RESULTS: Data was available from 437 patients. Of all patients admitted with a proximal femoral fracture 16.9% was diagnosed as malnourished by the ESPEN criteria. When screened, 20.1% (SNAQ score) to 47.8% (MNA-SF) of all patients were classified as either at risk for malnutrition or as malnourished. A moderate agreement was found between the MNA-SF and the SNAQ (κ = 0.68). The sensitivity, specificity, PPV and NPV of the SNAQ score were 71.6%, 90.4%, 60% and 94% respectively, compared to 100%, 62.8%, 35.4% and 100% for the MNA-SF. DISCUSSION: The SNAQ has been proven to be a very specific screening tool and the positive predictive value tends to be higher than that of the MNA-SF. However, 28.4% of all malnourished patients with a proximal femoral fracture had a negative screening test when using the SNAQ score. CONCLUSIONS: No benefits were observed for the SNAQ over the MNA-SF as a screening tool for malnutrition in admitted patients with a proximal femoral fracture. Missing a significant portion of malnourished patients or those at risk and consequent under treatment of fragile older patients should be avoided. The well-validated MNA-SF seems more preferable as a screening tool for this patient population.

Surgical Approaches and Hemiarthroplasty Outcomes for Femoral Neck Fractures: A Meta-Analysis.

BACKGROUND: The lateral approach (LA), posterior approach (PA), and anterior approach (AA) are conventional surgical access routes for hemiarthroplasty in proximal femoral fractures. This meta-analysis assesses and compares the outcomes and attempts to identify the best approach for hemiarthroplasty in the treatment of proximal femoral fractures. METHODS: An electronic search was performed from inception to October 25, 2017, for comparative studies including at least 2 of the conventional approaches. Outcomes including operation time, surgical blood loss, perioperative fractures, wound infections, dislocations, and hospital length of stay were plotted in forest plots. RESULTS: Twenty-one eligible studies were selected including 3 randomized, controlled trials, 7 prospective and 11 retrospective cohort studies. The odds ratio (OR) for dislocations was significantly higher for the PA compared with the AA (OR, 2.61; 95% confidence interval [CI], 1.26 to 5.43; P = .01) and the LA (OR, 2.90; 95% CI, 1.63 to 5.14; P = .0003). The PA had a higher risk of reoperation compared to the AA (OR, 1.25; 95% CI, 1.12 to 1.41; P < .0001). No significant differences were found concerning perioperative fractures, wound infections, and hospital length of stay. Some studies suggest a better short-term functional outcome using the AA compared to the PA. CONCLUSION: The PA for hemiarthroplasty in proximal femoral fractures poses an increased risk of dislocation and reoperation compared to the LA and AA. There are no evident advantages of the PA and its routine use for fracture-related hemiarthroplasty should be questioned.

Prospective comparison of the anterior and lateral approach in hemiarthroplasty for hip fractures: a study protocol.

BACKGROUND: The Direct Anterior Approach (DAA) is an alternative approach to the currently most used Lateral Approach (LA) for hip replacement in femoral neck fracture patients. Compared to the LA, the DAA minimizes soft tissue damage. Sparing muscle tissue may facilitate early and improved postoperative mobility. It may also be associated with fewer complications, increased quality of life and lower 1-year mortality. The aim of this study is to compare postoperative complications, hip function and patient mobility after hemiarthroplasty via the anterior or lateral approach following a displaced femoral neck fracture. METHODS: 138 elderly patients with displaced femoral neck fractures will be operated using either the direct anterior approach or the lateral approach for a hemiarthroplasty in a single centre, prospective, comparative cohort study. The choice of surgical approach will depend on the expertise of the trauma surgeon on call. The primary outcome of this study will be the functionality of the hip after surgery measured using the Harris Hip Score during routine outpatient check-ups. Secondary outcomes include surgical and non-surgical complication rates, admission time, postoperative pain, rehabilitation time, performance in activities of daily living, health-related quality of life measured, cognitive function and balance. DISCUSSION: Many approaches are known for hip replacement arthroplasty in trauma patients with little consensus on the preferred method. Identifying the best approach facilitating an adequate and fast recovery could optimize patient independence and quality of life and minimize rehabilitation costs, morbidity and mortality rates. The study design will reflect daily clinical practice and aims to present an accurate depiction of clinical outcomes. TRIAL REGISTRATION: This trial entered the Dutch Trial Registry with registration number (NTR)6238 on the 24th of April 2017. http://www.trialregister.nl/trialreg/index.asp . Protocol version 2.0 16-03-2017.

Do clinical characteristics and outcome in nonagenarians with a hip fracture differ from younger patients?

AIM: To compare clinical characteristics and outcome of nonagenarian hip fracture patients with younger patients aged 65-89 years. METHODS: This was a cohort follow-up study of admissions for a hip fracture between 2005-2010 (mean follow up of 3.5 years) in two teaching hospitals in The Netherlands; 230 nonagenarians and 1014 patients aged 65-89 years were included. Clinical characteristics, adverse events, mobility and mortality were compared. RESULTS: Nonagenarians were more likely to be female and anemic (both P<0.001), and had more trochanteric fractures (P=0.005). The number of American Society of Anesthesiologists III/VI classified patients did not differ between the two groups. During the hospital stay, adverse events were more frequently observed in nonagenarians compared with younger patients (P<0.001). The length of stay was significantly longer in nonagenarians (P<0.001), and the 90-day readmission rate was similar. Absolute mortality was higher in nonagenarians (P<0.001), excess mortality, however, was comparable. Before admission, 40.0% of the nonagenarians lived in their own home, and 40.9% had returned 3 months postfracture. The rate of returning to their own home was lower compared with younger patients (P<0.001). Prefracture mobility was worse in nonagenarians compared with the younger group, but 3 months after discharge, the number of patients that regained prefracture mobility was comparable in both age groups. CONCLUSIONS: Nonagenarian hip fracture patients differ significantly from younger patients aged 65-89 years with respect to clinical characteristics and long-term outcome. However, almost half of the nonagenarians returned to their own home and more than half regained their prefracture level of mobility. Given these findings, prevention strategies for hip fracture and adverse events during hospital stay that focus particularly on frail nonagenarians are highly recommended.

Contralateral hip fractures and other osteoporosis-related fractures in hip fracture patients: incidence and risk factors. An observational cohort study of 1,229 patients.

PURPOSE: To report risk factors, 1-year and overall risk for a contralateral hip and other osteoporosis-related fractures in a hip fracture population. METHODS: An observational study on 1,229 consecutive patients of 50 years and older, who sustained a hip fracture between January 2005 and June 2009. Fractures were scored retrospectively for 2005-2008 and prospectively for 2008-2009. Rates of a contralateral hip and other osteoporosis-related fractures were compared between patients with and without a history of a fracture. Previous fractures, gender, age and ASA classification were analysed as possible risk factors. RESULTS: The absolute risk for a contralateral hip fracture was 13.8 %, for one or more osteoporosis-related fracture(s) 28.6 %. First-, second- and third-year risk for a second hip fracture was 2, 1 and 0 %. Median (IQR) interval between both hip fractures was 18.5 (26.6) months. One-year incidence of other fractures was 6 %. Only age was a risk factor for a contralateral hip fracture, hazard ratio (HR) 1.02 (1.006-1.042, p = 0.008). Patients with a history of a fracture (33.1 %) did not have a higher incidence of fractures during follow-up (16.7 %) than patients without fractures in their history (14 %). HR for a contralateral hip fracture for the fracture versus the non-fracture group was 1.29 (0.75-2.23, p = 0.360). CONCLUSION: The absolute risk of a contralateral hip fracture after a hip fracture is 13.8 %, the 1-year risk was 2 %, with a short interval between the 2 hip fractures. Age was a risk factor for sustaining a contralateral hip fracture; a fracture in history was not.

Outcome in hip fracture patients related to anemia at admission and allogeneic blood transfusion: an analysis of 1262 surgically treated patients.

BACKGROUND: Anemia is more often seen in older patients. As the mean age of hip fracture patients is rising, anemia is common in this population. Allogeneic blood transfusion (ABT) and anemia have been pointed out as possible risk factors for poorer outcome in hip fracture patients. METHODS: In the timeframe 2005-2010, 1262 admissions for surgical treatment of a hip fracture in patients aged 65 years and older were recorded. Registration was prospective from 2008 on. Anemic and non-anemic patients (based on hemoglobin level at admission) were compared regarding clinical characteristics, mortality, delirium incidence, LOS, discharge to a nursing home and the 90-day readmission rate. Receiving an ABT, age, gender, ASA classification, type of fracture and anesthesia were used as possible confounders in multivariable regression analysis. RESULTS: The prevalence of anemia and the rate of ABT both were 42.5%. Anemic patients were more likely to be older and men and had more often a trochanteric fracture, a higher ASA score and received more often an ABT. In univariate analysis, the 3- and 12-month mortality rate, delirium incidence and discharge to a nursing home rate were significantly worse in preoperatively anemic patients.In multivariable regression analysis, anemia at admission was a significant risk factor for discharge to a nursing home and readmission < 90 days, but not for mortality. Indication for ABT, age and ASA classification were independent risk factors for mortality at all moments, only the mortality rate for the 3-12 month interval was not influenced by ABT. An indication for an ABT was the largest negative contributor to a longer LOS (OR 2.26, 95% CI 1.73-2.94) and the second largest for delirium (OR 1.67, 95% CI 1.28-2.20). CONCLUSIONS: This study has demonstrated that anemia at admission and postoperative anemia needing an ABT (PANT) were independent risk factors for worse outcome in hip fracture patients. In multivariable regression analysis, anemia as such had no effect on mortality, due to a rescue effect of PANT. In-hospital, 3- and 12-month mortality was negatively affected by PANT, with the main effect in the first 3 months postoperatively.