Fixation of intraoperative proximal femoral fractures during THA using two versus three cerclage wires - a biomechanical study

Background Intraoperative proximal femoral fractures (IPFF) are relevant complications during total hip arthroplasty. Fixation using cerclage wires (CW) represents a minimally-invasive technique to address these fractures through the same surgical approach. The goal of treatment is to mobilise the patient as early as possible, which requires high primary stability. This study aimed to compare different cerclage wire configurations fixing IPFF with regard to biomechanical primary stability. Methods Standardised IPFF (type II, Modified Mallory Classification) were created in human fresh frozen femora and were fixed either by two or three CW (1.6 mm, stainless steel). All cadaveric specimens (n = 42) were randomised to different groups (quasi-static, dynamic) or subgroups (2 CW, 3 CW) stratified by bone mineral density determined by Dual Energy X-ray Absorptiometry. Using a biomechanical testing setup, quasi-static and dynamic cyclic failure tests were carried out. Cyclic loading started from 200 N to 500 N at 1 Hz with increasing peak load by 250 N every 100 cycles until failure occurred or maximum load (5250 N) reached. The change of fracture gap size was optically captured. Results No significant differences in failure load after quasi-static (p = 0.701) or dynamic cyclic loading (p = 0.132) were found between the experimental groups. In the quasi-static load testing, all constructs resisted 250% of the body weight (BW) of their corresponding body donor. In the dynamic cyclic load testing, all but one construct (treated by 3 CW) resisted 250% BW. Conclusions Based on this in vitro data, both two and three CW provided sufficient primary stability according to the predefined minimum failure load (250% BW) to resist. The authors recommend the treatment using two CW because it reduces the risk of vascular injury and shortens procedure time.

Outcomes after perioperative SARS-CoV-2 infection in patients with proximal femoral fractures: an international cohort study

ObjectivesStudies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with perioperative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multivariate analysis.SettingProspective, international, multicentre, observational cohort study.ParticipantsPatients undergoing any operation for a proximal femoral fracture from 1 February to 30 April 2020 and with perioperative SARS-CoV-2 infection (either 7 days prior or 30-day postoperative).Primary outcome30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality.ResultsThis study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68 to 3.13, p<0.001), age >80 years (OR 1.60, 95% CI 1.1 to 2.31, p=0.013), preoperative diagnosis of dementia (OR 1.57, 95% CI 1.15 to 2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18 to 2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06 to 2.48, p=0.025). Mortality at 30 days was lower in patients with a preoperative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42 to 0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220) or type of anaesthetic given (p=0.787).ConclusionsPatients undergoing surgery for a proximal femoral fracture with a perioperative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with individualised medical and anaesthetic care, including medical optimisation before theatre. Careful preoperative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups.Trial registration numberNCT04323644

Complications after Dynamic Hip Screw Osteosynthesis of Proximal Femoral Fractures at Army Instructional Hospital-Libreville

The DHS system is an effective means of open reduction and internal fixation of proximal femur fractures. Postoperative complications are little described and deserve to be studied for better preventive and curative treatment. We report the observations of five (5) patients who presented postoperative complications specific to the DHS system at army instructional Hospital-Libreville. These described complications are related to deterioration of internal fixation leading to callus, nonunion, or infection. Those found are the cut out phenomenon, avascular necrosis of the femoral head, and the fracture of the DHS system. All these complications required surgical revision without functional repercussions at the last follow-up. Complications of internal fixation by the DHS system can be avoided by rigorous asepsis, adequate indications for surgery, and rigorous surgical techniques. Good management can restore hip function.

Impact of concomitant injuries in geriatric patients with proximal femur fracture

Aims The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures. Methods A retrospective, multicentre registry-based study was undertaken. Between 1 January 2016 and 31 December 2019, data for 24,919 patients from 100 hospitals were collected in the Registry for Geriatric Trauma. This information was queried and patient groups with and without concomitant injury were compared using linear and logistic regression models. In addition, we analyzed the influence of the different types of additional injuries. Results A total of 22,602 patients met the inclusion criteria. The overall prevalence of a concomitant injury was 8.2% with a predominance of female patients (8.7% vs 6.9%; p < 0.001). Most common were fractures of the ipsilateral upper limb. Concomitant injuries resulted in prolonged time-to-surgery (by 3.4 hours (95 confidence interval (CI) 2.14 to 4.69)) and extended length of stay in hospital by 2.2 days (95% CI 1.74 to 2.61). Mortality during the admission was significantly higher in the concomitant injury group (7.4% vs 5.3%; p < 0.001). Additionally, walking ability and quality of life were reduced in these patients at discharge. More patients were discharged to a nursing home instead of their own home compared to patients without additional injuries (25.8% vs 30.3%; p < 0.001). Conclusion With a prevalence of 8.2%, the appearance of a concomitant injury is common in elderly patients with hip fracture. These patients are at a greater risk for death during the admission, longer hospital stays, and delayed surgery. This knowledge is clinically important for all who are involved in the treatment of proximal femur fractures. Cite this article: Bone Joint J 2021;103-B(9):1526–1533.

Comparison of Forces Applied During Inserting A Cementless Femoral Stem Versus A Test To Failure: A Pilot Trial

Background The increasing number of total hip arthroplasties (THA) and the more common use of uncemented stems are leading to an increasing incidence of intraoperative proximal femoral fractures (IPFF), making them a clinically relevant complication. When inserting the stem, the surgeon has to find a compromise between sufficient anchorage and the risk of fracture. Only a few biomechanical studies investigated forces that are necessary, or already risky, when inserting a femoral stem. Therefore, the aim of the study was to determine the forces occurring during the insertion of the stem and the forces that lead to IPFF. Methods Two female chemically untreated fresh-frozen human cadavers, aged 71 and 83 years and weighed 54 kg and 65 kg respectively, underwent left and right implantation of a THA stem by an experienced orthopaedic surgeon. The insertion of the stem was followed by a failure test, in which the surgeon hit the stem so hard that a fracture occurred. The forces, occurred while insertion and test to failure, were measured using an impulse hammer. Results The observed forces varied greatly. Over the four performed implantations, the forces ranged from 1317.7 N to 4347.5 N during insertion, and from 526.5 N to 7383.9 N during the failure test. The comparison between insertion versus failure test showed significantly higher peak forces (P < 0.001, P < 0.001, P = 0.002) in the failure test for implantations 1, 3 and 4. The comparison was not possible for implantation 2 because of a sensor error. Conclusions The biomechanical experiments presented in this study have shown that even with the small number of implantations, significantly higher hammering forces were required to cause a visually or acoustically perceptible IPFF than were necessary for adequate seating of the femoral stem. However, as fractures often cannot be perceived intraoperatively, it is important to advance the development of supporting systems for intraoperative use.