A 10- to 12-year follow-up study of delta ceramic-on-ceramic total hip arthroplasty.

BACKGROUND: We previously reported five-to-seven-year results of total hip arthroplasty (THA) with the use of delta ceramic-on-ceramic (CoC) bearing. We conducted an extension study with a CT scan at a minimum of 10 years after surgery. METHODS: From March 2009 to March 2011, 273 patients (310 hips) received cementless THA with delta CoC bearing, porous-coated cup and hydroxyapatite-coated stem. In this extended study, 252 patients (144 men and 108 women) (288 hips) with a mean age of 49.7 years (16-83) at surgery were followed for a mean of 10.4 years (10-12) with CT scans in 133 hips (46.2%, 133/288). Clinical and radiographic evaluations were made at each follow-up and Kaplan-Meier survival analysis was performed with revision and reoperation as endpoints. RESULTS: There were no more ceramic fractures. Compared to mid-term results, the incidence of squeaking and RLLs increased to 3.1% (9/288) and 19.4% (56/288), respectively. The RLL progressed to focal osteolysis in 3 hips (5.4%, 3/56). No hip had detectable wear or prosthetic loosening. Two hips were reoperated due to periprosthetic joint infection and periprosthetic femoral fracture in each. The survivorship decreased to 98.3% (96.7-99.9%) at 12 years. CONCLUSION: During the extended follow-up, no additional ceramic fracture occurred, and the incidence of squeak increased by 0.7%. The long-term survivorship of Delta CoC THA was encouraging. However, focal osteolysis occurred around the hydroxyapatite-coated stem in 1% (3/288). LEVEL OF EVIDENCE: II (Prospective cohort study).

No differences in the efficacy among various core decompression modalities and non-operative treatment: a network meta-analysis.

BACKGROUND: Core decompression (CD) has been used to treat early-stage (pre-collapse) osteonecrosis of the femoral head (ONFH) in an attempt to prevent collapse. Recently, other adjunctive treatments including bone grafting (BG) and bone marrow mononuclear cells (BMMC) were combined to traditional CD to improve the results. We assessed the efficacy of various CD modalities and non-operative treatment through a network meta-analysis (NMA). METHODS: Nine randomized controlled trials with a minimum two year follow-up were retrieved from PubMed, Embase, and Cochrane Library search. Treatment modalities categorized into five; (1) traditional CD alone, (2) CD combining BG, (3) CD combining BMMC, (4) CD combining BG and BMMC, and (5) non-operative treatment. The rate of conversion to total hip arthroplasty (THA) and the radiologic progression were compared among the five treatments. RESULTS: A total of 453 hips were included in our NMA; 151 hips in CD, 70 hips in CD combining BG, 116 hips in CD combining BMMC, 25 hips in CD combining BG and BMMC, and 91 hips in non-operative treatment. There were no differences in the rate of THA conversion across all five treatment modalities. The pooled risk ratio compared with non-operative treatment for THA conversion was 0.92 (95% CI, 0.19-4.43; p = 0.915) in traditional CD; 4.10 (95% CI, 0.37-45.42; p = 0.250) in CD combining BG; 0.30 (95% CI, 0.04-2.49; p = 0.267) in CD combining BMMC; and 1.78 (95% CI, 0.05-63.34; p = 0.750) in CD combining BG and BMMC. No significant differences were found in terms of the radiologic progression across all treatments. CONCLUSIONS: In the current NMA, we did not find any differences in the rates of THA conversion and radiologic progression across all CD modalities and non-operative treatment. These results question the assumption that CD changes the natural course of ONFH. Considering that size of necrotic portion is the major determinant of future collapse of the necrotic femoral head and the collapse does not occur in small lesions even without any treatment, a large-scale randomized controlled trial is necessary to confirm the effectiveness of CD. LEVEL OF EVIDENCE: Level I, meta-analysis.

Conservative Treatment for Minimally Displaced Type B Periprosthetic Femoral Fractures.

BACKGROUND: Surgical treatment has been invariably indicated for Vancouver type B periprosthetic femoral fractures (PFFs), which involve femoral diaphysis around stem. We evaluated the outcomes of nonoperative management in patients with minimally displaced type B PFFs around cementless stem. METHODS: From October 2009 to March 2016, 60 type B PFFs were treated at 1 institution. Among them, 19 minimally (<5 mm) displaced PFFs (31.7%, 19/60), which occurred around cementless stems, were treated nonsurgically with use of teriparatide. There were 6 men and 13 women. The mean age was 77.9 years (range, 51-98 years) at the time of PFF. The femoral stem was stable (type B1) in 11 patients and unstable (type B2) in 8. Teriparatide was injected from 1 to 4 months (mean, 3.2 months). We evaluated time to radiologic union and union rate. RESULTS: A successful union was obtained in 16 patients (89.5%, 17/19) at 2 to 6 months (mean, 3.5 months). The union rate was 100% (11/11) in type B1 fractures and 75% (6/8) in type B2 fractures. CONCLUSION: Our study showed that conservative treatment is feasible for the cases of type B1 minimally displaced periprosthetic fractures, and it may also be considered as an alternative option for type B2 minimally displaced periprosthetic fractures.

Conversion Hip Arthroplasty in Failed Fixation of Intertrochanteric Fracture: A Propensity Score Matching Study.

BACKGROUND: Conversion hip arthroplasty is a salvage procedure for failed internal fixation of intertrochanteric fractures. However, the technical difficulties and perioperative morbidity of conversion arthroplasty are uncertain. METHODS: We compared the type of arthroplasty (total hip arthroplasty or hemiarthroplasty), operative parameters, perioperative morbidity, 1-year mortality, implant stability, and clinical results of 33 conversion hip arthroplasties due to a failed internal fixation of intertrochanteric fracture with those of a matched control group of 33 primary hip arthroplasties due to the same fracture. Propensity score was used for the control matching of gender, age, and body mass index. RESULTS: Total hip arthroplasty was more frequently performed in the conversion group (10/33) compared to the primary group (3/33) (P = .016). The operation time, perioperative blood loss, amount of transfusion, and risk of femoral fracture during the operation were increased in the conversion group. The overall 1-year mortality was 3% (1 patient) in the conversion group and 9% (3 patients) in the primary group (P = .307). At a mean of 3-year follow-up, there was no significant difference in clinical results and none of the implants were loose in both groups. CONCLUSION: In patients with failed internal fixation of intertrochanteric fracture, conversion hip arthroplasty should be planned and executed, bearing in mind the increased operative morbidities corresponding to operation time, perioperative blood loss, requirement of transfusion, and intraoperative femoral fracture.

Combined Anterior and Posterior Approach in Total Hip Arthroplasty for Crowe IV Dysplasia or Ankylosed Hips.

We evaluated 70 patients (71 hips) who underwent complex total hip arthroplasty (THA) through the combined anterior and posterior approach. Sixty-five patients (32 dislocated hips and 34 ankylosed hips) were followed-up at a minimum of 3 years (median, 6 years; range, 3-10 years). Seven patients (10.6%), who had transient paresthesia on the anterior thigh, recovered within 3 months. All patients had a good clinical outcome in terms of range of motion, pain and recovery of walking. At the latest follow-up, all prostheses had bone-ingrown stability without any detectable wear or osteolysis. The combined approach allows an excellent exposure of the acetabulum for accurate cup alignment, leg lengthening and mobilization of joint in complex THA without trochanteric osteotomy, excessive abductor release and femoral shortening osteotomy.

Posterior Approach and Inferior Capsulotomy in Bipolar Hemiarthroplasty for Femoral Neck Fractures: Comparison with Superior Capsulotomy.

Background: Hemiarthroplasty is frequently used to treat displaced femoral neck fractures in elderly patients, but it has a higher risk of postoperative dislocation. We introduced the posterior approach and inferior capsulotomy (PAICO) to enhance joint stability after bipolar hemiarthroplasty for femoral neck fracture. We evaluated whether the PAICO would have a lower dislocation rate than the conventional posterior approach with superior capsulotomy. Methods: From January 2021 to December 2021, we prospectively recruited 25 patients (25 hips) aged 50 years or older who underwent bipolar hemiarthroplasty for femoral neck fractures due to low-energy trauma as the PAICO group. We compared the PAICO group with a historical control group who had undergone hemiarthroplasty in 7 institutes between 2010 and 2020. The primary endpoint was dislocation within 1 year after the surgery. We compared data from the PAICO group with the data from the historical control group from the Korean Hip Fracture Registry which was carried out in South Korea. Results: A total of 25 patients (25 hips) were enrolled in the present study; 3,477 patients (3,571 hips) who underwent bipolar hemiarthroplasty were reviewed as the historical control group. In the PAICO group, we observed no dislocation, whereas the dislocation rate in the control group was 1.3%. Conclusions: In patients with displaced femoral neck fractures, the PAICO approach demonstrated comparable results in operation time and complication rates when compared to bipolar hemiarthroplasty using superior capsulotomy. Notably, there were no observed cases of dislocation among patients who underwent the PAICO approach. We recommend this PAICO approach to surgeons using the posterior approach, hoping to prevent dislocation in bipolar hemiarthroplasty.

National trends of surgical treatment for intertrochanteric fractures in Korea.

Intramedullary nailing has been reported to have better outcome compared with traditional plate fixation in surgical treatment of intertrochanteric fractures. We evaluated the trends of surgical treatment of intertrochanteric fracture in Korea. Data of patients with intertrochanteric fractures, who were operated between the years of 2006 and 2011, was obtained from the Health Insurance Review and Assessment Service. The ratio of intramedullary nailing increased from 27.9% in 2006 to 64.3% in 2011 (P < 0.001), while the ratio of plate fixation decreased. During recent 5 yr, the utilization of intramedullary nailing doubled in clinical practice of intertrochanteric fractures in Korea.

The Effect of Denosumab in Elderly Patients Regarding Bone Density and Fracture Risk.

BACKGROUND: With an aging population, the importance of treating and diagnosing osteoporosis is increasing. Osteoporosis, previously known as a resorptive change primarily related to endocrinological mechanisms, is also being approached as a phenomenon of senile change. Denosumab is gaining popularity among osteoporosis medications due to its ability to increase bone mineral density (BMD) and the economic benefit arising from the 6-month cycle. In line with previous literature, this study aimed to examine the BMD-augmenting effect of denosumab through which it reduces fracture risk in individuals aged over 80 years. METHODS: We reviewed patients who received denosumab between 2018 and 2022 with a minimum clinical observation period of 12 months. BMD was measured every 12 months, and patients were classified per their period of denosumab use. Fracture risk was evaluated using the fracture risk assessment tool (FRAX) and fracture incidence during the observation period were assessed. RESULTS: Among 155 patients, a significant increase in BMD was observed at 3 sites: the lumbar spine, femoral neck, and total hip (p<0.001, p<0.001, and p=0.001, respectively). The patients were divided according to the length of clinical follow-up they received, and similar results were found in all subgroups. Fracture risk assessment was performed using FRAX and the incidence of fracture events during follow-up. FRAX significantly decreased in all subgroups except those who received 24 months of follow-up (p=0.003, p=0.41, p=0.001 in the 12, 24, and ≥36 months groups, respectively). CONCLUSIONS: Denosumab use resulted in long-term BMD increase and reduced fracture risk in individuals aged 80 and above.

Change of Symptoms after Total Hip Arthroplasty in Patients with Hip-Spine Syndrome.

Purpose: Elderly patients with degenerative diseases undergo treatment for the hip and spine; these patients present with various symptoms. This study focused on patients with residual symptoms, predominantly pain, even after receiving treatment for their spinal lesions. Materials and Methods: Patients who underwent total hip arthroplasty (THA) between 2016 and 2022 at a single tertiary hospital were included in the study. Of the 417 patients who underwent primary THA, a retrospective review of 40 patients with previous lesions of the spine was conducted. Patients were stratified to two cohorts: Patients with symptoms related to the spine (Group A), and those with hip-related symptoms (Group B). Pre- and postoperative comparisons of groups A and B were performed. Results: Improvements in patients' symptoms were observed in groups A and B after THA. In Group A, the mean preoperative visual analog scale (VAS) score was 5.10±0.876, which showed a postoperative decrease to 2.70±1.767. In Group B, the mean preoperative VAS score was 5.10±1.539, which showed a postoperative decrease to 2.67±1.493. Conclusion: According to the findings, promising results were achieved with THA in treatment of debilitating diseases of the hip for both the prognosis of the disease, as well as the patients' symptoms. In addition, in some cases elderly patients with dual pathologies underwent treatment for spinal lesions without performance of any evaluation related to the hip. Thus, evaluation of a patient's hip must be performed and performance of THA in patients with symptoms even after treatment of spinal lesions is recommended.

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.

Dislocation after total hip arthroplasty: a randomized clinical trial of a posterior approach and a modified lateral approach.

We compared the dislocation rate of total hip arthroplasty between posterior approach and lateral approach in a prospective randomized trial. One hundred ninety-six hips were randomly chosen for a posterior approach with a posterior soft tissue repair (99 hips) or a lateral approach (97 hips). The average duration of follow-up was 37.9 months. Three hips (3%) dislocated in the lateral group, whereas none from the posterior group dislocated. At the final follow-up, the Harris hip score and limping were similar in the 2 groups. The joint stability obtained by the posterior soft tissue repair in the posterior approach group seemed to produce more favorable result when compared to the stability obtained from the lateral approach group.

Use of cementless acetabular component with a hook and iliac flanges in revision arthroplasty for massive acetabular defect.

BACKGROUND: Revision hip arthroplasty of massive acetabular defect, severe combined defect, or pelvic discontinuity is challenging. The purpose of this study was to determine the midterm outcome and survivorship of a new revision technique using cementless acetabular cup supplemented with a hook and three iliac flanges in massive acetabular defects. MATERIALS: From January 2000 to June 2004, we revised 17 severe acetabular defects, 14 combined defects and three pelvic discontinuities according to the American Academy of Orthopaedic Surgeons (AAOS) classifications, in which bone stock at the dome was not available to provide support for the cup. These revisions were performed using a cementless porous-coated hemispherical cup with a hook and flanges. RESULTS: One patient (one hip) underwent resection arthroplasty due to infection 1 year after the revision. The remaining 16 hips were evaluated at a mean of 6.8 (range 5-9) years postoperatively. Thirteen acetabular components (81%) showed no migration and were stable with bone ingrowth. Three hips showed progressive medial and upward migration during the 18-24 months after the index revision, after which migration was not progressive. The Merle d'Aubigné hip score was 14.5 (range 12-18) points at the latest follow-up evaluation. Survival rate was 94.4% when revision for any reason was considered as the end point [95% confidence interval (CI) 83.9-100%] and 82.0% (95% CI 62.8-100%) when loosening of the cup was considered as the end point. CONCLUSION: Results of this type of revision were superior to previously reported results of acetabular revisions with the use of various techniques and devices.

The Efficacy of Selective Estrogen Receptor Modulators Monotherapies in Postmenopausal Women with Osteopenia.

BACKGROUND: The impact of osteopenia as a risk factor for fractures is underrecognized. Moreover, the efficacy of selective estrogen receptor modulators (SERMs) in postmenopausal women with osteopenia is limited. This study aimed to evaluate the efficacy of SERMs in postmenopausal women with osteopenia. METHODS: Thirty-two postmenopausal women with osteopenia were treated with 3 types of SERMs medication: raloxifene (group I, N=15), bazedoxifene (group II, N=8), and raloxifene with cholecalciferol (group III, N=9). Bone mineral density (BMD) was measured using dual energy X-ray absorptiometry scans before treatment to after 3 years of treatment once a year. RESULTS: Patients in group I showed significant increases in hip BMD, -1.93 to -1.73 and spine BMD, -1.85 to -1.67. In addition, patients in groups II and III showed significant increases in hip BMD, -1.93 to -1.69 and -2.22 to -1.86, respectively and spine BMD, -2.1 to -1.3 and -2.22 to -1.37, respectively. The BMD increased in the hip and spine by 9.7% and 10.3%, respectively in group I, 38.0% and 12.4%, respectively in group II, and 38.2% and 16.2%, respectively in group III. CONCLUSIONS: In this study, we found that SERMs could improve spine and hip BMD. In conclusion, preemptive treatment using SERMs is necessary for postmenopausal women with osteopenia. None of the patients experienced fractures during the follow-up period.

Little impact of antiplatelet agents on venous thromboembolism after hip fracture surgery.

Since the late 1980s, low dose aspirin has been used to prevent stroke and ischemic heart disease. However, prophylactic effect of antiplatelets against venous thromboembolism (VTE), in patients who undergo hip fracture surgery (HFS) is controversial. Our purpose was to determine the incidence of symptomatic VTE after HFS and to evaluate whether antiplatelets reduce the development of symptomatic VTE following HFS. We retrospectively reviewed 858 HFS in 824 consecutive patients which were performed from May 2003 to April 2010 at an East Asian institute. We compared the incidence of symptomatic VTE in antiplatelet users and non-users using multivariate logistic regression analyses. Overall incidences of symptomatic pulmonary embolism including fatal pulmonary embolism, and symptomatic deep vein thrombosis in this study were 2.4% (21/858), and 3.5% (30/858), respectively. The incidence of symptomatic VTE was 4.8% (12/250) in antiplatelet users and 4.3% (26/608) in non-users (P = 0.718). It is suggested that antiplatelet agents are not effective in prevention of symptomatic VTE after HFS.

Cementless bipolar hemiarthroplasty using a hydroxyapatite-coated long stem for osteoporotic unstable intertrochanteric fractures.

Treating senile osteoporotic patients with unstable hip fractures remains a challenge. We evaluated the results of 87 cementless bipolar hemiarthroplasties using an extensively hydroxyapatite-coated long stem for unstable intertrochanteric fractures in senile patients. Sixty-one hips were followed for a minimum of 2 years (mean, 36 months) postoperatively. The mean Merle d'Aubigne and Postel hip score was 14.7 points (12-18). Two hips were reoperated because of infection. Of the remaining 59 hips, 48 were included in the radiographic analysis. Although cortical porosis around the stem was seen in 18 hips, there was no loosening or osteolysis. Cementless bipolar hemiarthroplasty using an extensively hydroxyapatite-coated long stem is a useful option for the treatment of unstable intertrochanteric fracture in senile patients with severe osteoporosis.

Septic arthritis of the hip in patients with femoral head osteonecrosis.

Septic hip is rare in patients with femoral head osteonecrosis (FHON) and has been known to occur in those who are immune compromised. Thus, surgeons do not concern about the superimposed septic hip in immunocompetent patients. We report five patients who had FHON and concomitant septic arthritis of the hip. No patients were immune compromised. All patients had an elevation of ESR and CRP. Two patients had an otherwise unexplained fever preoperatively. Two patients had had a remote septic focus. When a patient with FHON has an unexplained elevation of ESR and CRP, concomitant septic arthritis of the hip should be suspected even though the patient is not immune compromised.

The Efficacy of Suture Fixation of the Greater Trochanter in Unstable Intertrochanteric Fractures.

BACKGROUD: Intertrochanteric fractures are one of the most common fractures in the elderly, especially those having osteoporosis. Stable intertrochanteric fractures may be fixed with implants including the dynamic hip screw and proximal femoral nail antirotation; however, this method is difficult to apply to unstable fractures. Bipolar hemiarthroplasty can be applied to unstable fractures and it prevents complications by facilitating early ambulation in the elderly. Many studies reported on how to fix the greater trochanter in unstable fractures during arthroplasty. We suggest that suture fixation alone can be a useful, effective, and affordable method. METHODS: We retrospectively enrolled 294 patients who underwent hemiarthroplasty for an unstable intertrochanteric fracture, and 225 patients were included in this study after excluding 69 patients who had not been available for follow-up until 1 year after surgery or died. The patients were divided into suture fixation and wiring fixation groups. Relationships of operation time, estimated blood loss, tip-to-stem distance, union rate, and physical performance in the groups of suture fixation and wiring were analyzed respectively. RESULTS: Changes in the tip-to-stem distance between the initial assessment at 1 year after surgery were statistically significantly different between the suture fixation group and wiring group (p < 0.001). There was no significant difference in change of the Koval score between the suture fixation and wiring groups (p = 0.362). The operation time and estimated intraoperative blood loss were statistically significantly lower in the suture group than in the wiring group (p < 0.001). There was no significant difference in the union rate between the groups (p = 0.470). CONCLUSIONS: Compared to tension-band wiring, the suture fixation technique demonstrated an effective fixing force. In addition to the clinical results, it had an advantage of preventing complications due to shortening of the operation time and estimated intraoperative blood loss. Suture fixation of the greater trochanter is recommended for elderly patients with unstable intertrochanteric fractures.

Cementless total hip arthroplasty with delta-on-delta ceramic bearing in patients younger than 30 years.

BACKGROUND: Despite improvements in the mechanical properties of alumina ceramics, the outcome of total hip arthroplasty (THA) with contemporary ceramic bearings in young patients remains a matter of concern. We evaluated the results of cementless THA with the use of the delta ceramic bearing, and determined the prevalence of osteolysis, squeaking, and ceramic fracture in patients aged < 30 years at mid-term. METHODS: From March 2008 to January 2012, 76 consecutive patients (91 hips), younger than 30 years, underwent cementless THA with Delta ceramic bearings. In each follow-up, the clinical evaluation including noise and radiological evaluations were recorded. RESULTS: Among them, 72 patients (86 THAs) were followed-up for a minimum of 5 years (mean 70.8; 60-95.9 months). There were 44 men (47 hips) and 28 women (39 hips). The mean age at the time of the index arthroplasty was 25.9 (16-30) years and the mean preoperative Harris Hip Score (HHS) was 59.4 (23-79) points. HHS improved to 96.3 (64-100) points at the final follow-up evaluation. 8 hips (9.3%) exhibited grinding or squeaking. No hip had aseptic loosening and no hip was revised. No osteolysis was detected around any acetabular or femoral components. CONCLUSIONS: Our results suggest that cementless THA with the use of Delta ceramic bearing provides satisfactory results without osteolysis or ceramic fracture in patients aged <30 years at a mid-term follow-up.Clinical Trials.gov Protocol Registration System (trial no. NCT01838096).

Initially missed occult fractures of the proximal femur in elderly patients: implications for need of operation and their morbidity.

INTRODUCTION: Occult fractures of the proximal femur are not evident on radiographs and the diagnoses are often missed or delayed. We tried to determine whether the delay of diagnosis in elderly patients lead to increased morbidity and increased need for operation. MATERIALS AND METHODS: We identified 26 elderly patients (> or =65 years of age) who were diagnosed as having an occult fracture of the proximal femur over a 3-year period. In 17 patients (17 hips, non-delayed group), the occult fracture was suspected at the first visit and the diagnosis was made on CT and/or MR images (MRI). In the remaining nine patients (9 hips, 34.6% delayed group), the diagnosis was delayed by a mean of 8.4 days (range 4-25 days). We compared the occurrence of fracture displacement, need for operation, change in activity level, and mortality between the non-delayed and delayed groups. RESULT: Displacement of fracture occurred in 4 of 9 delayed patients and none of 17 non-delayed patients. Ten non-delayed patients needed operative treatment, whereas eight delayed patients needed operative treatment (p = 0.190). The activity level decreased in 6 of 7 surviving patients of the delayed group, whereas it decreased in 4 of 15 surviving patients of the non-delayed group (p = 0.020). CONCLUSION: A delayed diagnosis of occult fracture in elderly patients resulted in increased rate of secondary displacement of the fracture and increased morbidity. In patients suspected of having occult hip fractures, additional studies, such as MRI and/or CT scans should be recommended to confirm the presence of hip fracture.

Assessing Low Skeletal Mass in Patients Undergoing Hip Surgery: The Role of Sonoelastography.

PURPOSE: To analyze the utility of sonoelastography-a radiation-free procedure to characterize muscle properties-as an instrument to qualitatively and quantitatively assess the rectus femoris muscle. MATERIALS AND METHODS: Fifty-one consecutive patients who underwent a pelvic computed tomography (CT) exam were enrolled prospectively. The final analysis was conducted using data from 39 patients after 12 were removed due to exclusion criteria (muscle strength could not be measured due to poor cognition [n=11]; too young [n=1]). The potential correlation between average Hounsfield unit (HFU) at the rectus femoris muscle (measured by CT) and muscle quality grade (determined by sonoelastography) was assessed along with a retrospective analysis of the relationship between hand grip strength, knee extensor power, history of intensive care unit stay, length of hospital day and sonoelastographic grade. RESULTS: There was a significant correlation between sonoelastographic grade and the average HFU (P<0.001). Furthermore, hand grip strength (P<0.001) and knee extensor power (P<0.001) decreased significantly as the sonoelastographic grade increased. The likelihood of an intensive care unit stay and prevalence of low skeletal mass increased significantly with an increase in sonoelastography grade (P=0.037, P<0.001, respectively). The sensitivity, specificity, and accuracy of sonoelastographic images for predicting low skeletal mass were 77.3%, 100%, and 87.5%, respectively. CONCLUSION: Sonoelastography advantages, including the lack of radiation and greater accessibility, may make it a valuable alternative to qualitatively and quantitatively identify sarcopenia and low skeletal mass.