Perioperative mortality and morbidity of hip fractures among COVID-19 infected and non-infected patients: A systematic review and meta-analysis / 中华创伤杂志(英文版)

PURPOSE@#Hip fractures among elderly patients are surgical emergencies. During COVID-19 pandemic time, many such patients could not be operated at early time because of the limitation of the medical resources, the risk of infection and redirection of medical attention to a severe infective health problem.@*METHODS@#A search of electronic databases (PubMed, Medline, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials) with the keywords "COVID", "COVID-19″, "SARS-COV-2", "Corona", "pandemic", "hip fracture", "trochanteric fracture" and "neck femur fracture" revealed 64 studies evaluating treatment of hip fracture in elderly patients during COVID-19 pandemic time. The 30-day mortality rate, inpatient mortality rate, critical care/special care need, readmission rate and complications rate in both groups were evaluated. Data were analyzed using Review Manager (RevMan) V.5.3.@*RESULTS@#After screening, 7 studies were identified that described the mortality and morbidity in hip fractures in both COVID-19 infected (COVID-19 +) and non-infected (COVID-19 -) patients. There were significantly increased risks of 30-day mortality (32.23% COVID-19 + death vs. 8.85% COVID-19 - death) and inpatient mortality (29.33% vs. 2.62%) among COVID-19 + patients with odds ratio (OR) of 4.84 (95% CI: 3.13 - 7.47, p < 0.001) and 15.12 (95% CI: 6.12 - 37.37, p < 0.001), respectively. The COVID-19 + patients needed more critical care admission (OR = 5.08, 95% CI: 1.49 - 17.30, p < 0.009) and they remain admitted for a longer time in hospital (mean difference = 3.6, 95% CI: 1.74 - 5.45, p < 0.001); but there was no difference in readmission rate between these 2 groups. The risks of overall complications (OR = 17.22), development of pneumonia (OR = 22.25), and acute respiratory distress syndrome/acute respiratory failure (OR = 32.96) were significantly high among COVID-19 + patients compared to COVID-19 - patients.@*CONCLUSIONS@#There are increased risks of the 30-day mortality, inpatient mortality and critical care admission among hip fracture patients who are COVID-19 +. The chances of developing pneumonia and acute respiratory failure are more in COVID-19 + patients than in COVID-19 ‒ patients.

Prediction of early postoperative desaturation in extreme older patients after spinal anesthesia for femur fracture surgery: a retrospective analysis / 대한마취과학회지

BACKGROUND: Postoperative desaturation in older individuals is rarely addressed in the literature. The objective of this retrospective study was to investigate whether a preoperative spirometric test and arterial blood gas analysis (ABGA) might predict postoperative desaturation after spinal anesthesia in extreme older patients.METHODS: The medical records of 399 patients (age ≥ 80 yrs) who were administered spinal anesthesia for a femur neck fracture surgery were retrospectively reviewed. Early postoperative desaturation was defined as a reduction of oxygen saturation (SpO₂) below 90% within 3 days of surgery, despite O₂ supply via a nasal prong. Binary logistic regression analysis was used to identify predictors of early postoperative desaturation.RESULTS: The incidence of postoperative desaturation was 12.5%. Major morbidity rate was significantly higher in the desaturation group (n = 50) than that in the non-desaturation group (n = 349) (14% vs. 3.2%, P = 0.001) with more frequent postoperative stays in the intensive care unit (22% vs. 12%, P = 0.004). In a binary logistic regression analysis, preoperative ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO₂/FiO₂ ratio) (OR, 0.972; 95% CI 0.952–0.993; P = 0.010) and history of cardiovascular disease (OR, 2.127; 95% CI 1.004–4.507; P = 0.049) predicted postoperative desaturation.CONCLUSIONS: Preoperative PaO₂/FiO₂ ratio, but not preoperative spirometry, was predictive of the postoperative desaturation in older patients after being administered spinal anesthesia for femur fracture surgery. Based on our results, preoperative ABGA may be helpful in predicting early postoperative desaturation in these patients.

A Study Of Femoral Neck Anteversion Angle In Central Indian Population: A Guide For Orthopaedic Surgeries Including Hip Arthroplasty

Background: Femoral neck anteversion angle is the angle which measures the anterior rotation of the neck of thefemur around the shaft. Its variation in the various population groups is attributed to various factors such asheredity, diet, climatic factors and lifestyle. This angle is clinically significant for orthopedicians while doinghip arthroplasties and osteotomies where it is pertinent to restore the anatomy of proximal femur for stability ofthe hip joint.Context and purpose of the study: There is no baseline data of Femoral Neck Anteversion angle for Central Indianpopulation. The present study was aimed to fill this lacuna and to give the normal values of femoral neckanteversion angle for above specified population.Materials and methods: 152 dried femora were procured from department of anatomy consisting of 77 femora ofright side and 75 femora of left side. Anteversion angle is recorded using goniometer. Means were calculated andstatistically correlated for laterality using independent student‘t’ test. p value was thus obtained.Results: Mean anteversion angle of right side was found to be 19.03º ± 12.11º and that of the left side came outto be 18.62º ± 10.8º. Among 152 femora taken, 7 retroverted and 7 neutral verted femora were also found in thestudy.Conclusion: So much variation in the angle of anteversion along with the presence of retroversion (4.6%) andneutral version (4.6%) is a challenge for both implant designer companies as well as orthopedicians. Thus,present study acts as a guide for normal values and range of this clinically significant angle.

Predictors of Intraoperative Fractures during Hemiarthroplasty for the Treatment of Fragility Hip Fractures

BACKGROUND: The aim of our study was to determine the rate and preoperative predictors of intraoperative fracture (IOF) during hip hemiarthroplasty (HA) in patients who have sustained a fragility hip fracture injury. METHODS: We reviewed 626 patients who underwent HA at our institution using the National Hip Fracture Database. Various patient- and surgery-related data including demographic information, cement usage, surgeon grade, time to surgery, and operative duration were collected. The metaphyseal diaphyseal index and modified canal bone ratio were measured on preoperative radiographs. We compared patients with and without IOF with respect to all variables collected. Multivariate regression modeling was used to identify significant preoperative risk factors for IOF. RESULTS: There was a 7% incidence of IOF in our cohort exclusively comprising of Vancouver A fractures. The majority of these complications were treated nonoperatively (52%). There was no statistically significant difference with respect to cement usage, surgeon grade, operative duration, time to surgery, and radiographic parameters collected. Increasing age was found to be the most significant preoperative risk factor for predicting IOF (p = 0.024, overall relative risk = 1.06). CONCLUSIONS: Our identified predictor of increasing age is nonmodifiable and illustrates the importance of meticulous surgical technique in older patients. Furthermore, its independence from fixation methods or prosthesis design as a predictor of IOF may support using an uncemented prosthesis in patients at risk from cement implantation.

Prediction of Type of Proximal Femur Fracture by Analysis of Serum Makers / 대한골다공증학회지

PURPOSE: To analyze serum markers in proximal femur fracture patients, which are known to be accompanied with osteophorosis or metabolic diseases, and consider it as predictive factor and to study how it affects on the fracture form. MATERIALS AND METHODS: Vit. D3 known as serum marker of Vit. D, 25(OH)D, and 1,25(OH)2D of 152 patients from April, 2013 to March, 2014 who visited our hospital and diagnosed as proximal femur fracture(Femur neck fracture 73, Intertrochanteric fracture 79) were analyzed. Also, serum calcium level corrected by serum protein, phosphate, creatinine, alkaline phosphatase, estradiol, IGF-1, and PTH were compared and analyzed. RESULTS: Femur neck fracture group showed significantly low value of D3, 25(OH)D, and 1,25(OH)2D (P-value<0.05) as the values were 37.72+/-7.21 pg/mL, 27.05+/-8.43 ng/mL, 25.05+/-6.78 pg/mL in femur neck fracture group, and 40.36+/-6.97 pg/mL, 29.54+/-9.12 ng/mL, 28.87+/-7.43 pg/mL in intertrochanteric fracture group respectively. The number of patients who were diagnosed as hypovitaminosis D. due to serum 25(OH)D value lower than 30ng/ml were significantly high in femur neck fracture group as the numbers were 56 in femur neck fracture, and 44 in intertrochanteric fracture. Serum calcium level corrected by serum protein, phosphate, creatinine, alkaline phosphatase, estradiol, IGF-1 and PTH level showed no significant difference between two groups. CONCLUSION: Serum 25(OH)D level was decreased in proximal femur fracture patiens, and was lower as the patient was older and BMD was lower. Therefore it is thought that proximal femur fracture is affected by vitamin D metabolism.

Association between BMI (Body Mass Index) and Proximal Femur Fractures Type in Korean People / 대한골다공증학회지

OBJECTIVES: The purpose of this analysis is to study whether the factors including bone mineral density (BMD) and age which influence fracture occurrence is involved in proximal femur fracture type. Any correlation of body mass index (BMI) and obesity to fractures of the proximal femur was investigated in particular. METHODS: Two hundred fifty two patients hospitalized for femur neck fracture and intertrochanteric fracture over 60 under 90 years old were examined. Only simple fall down trauma for excluding pathologic fractures was included. About 225 patients, past medical, drug and social history were investigated and BMD and BMI (body mass index) were measured. Patients were classified into two groups (femoral neck fracture and intertrochanteric fracture). Significant differences in BMD and BMI between these two groups were investigated. RESULTS: There was no statistically significant difference between two proximal femur fracture type with regard to age, sex and BMD. But two groups seem to have statistically significant different with BMI. Most patients had normal weight, thus no significant differences were found in degree of obesity between two groups. CONCLUSIONS: This study shows that the higher the patients have BMI, the more frequently intertrochanteric fracture is occurred. But, owing to normal obesity levels seen in most patients in this study, any definitive correlation between obesity and each type of proximal femur fracture could not be found.

Pediatric Femoral Neck Fractures: Our 10 Years of Experience

BACKGROUND: Femoral neck fractures are rare injuries in children, but the high incidence of long term complications make it an important clinical entity. The aim of this retrospective study was to analyze the clinical outcomes of pediatric femur neck fractures that we managed over a 10 year period. METHODS: The study included 36 children (20 boys and 16 girls) who sustained femoral neck fractures and completed a minimum follow-up of one year. The children were treated either conservatively, or by open reduction and internal fixation (ORIF), or closed reduction and internal fixation (CRIF). The outcomes were analyzed using Ratliff criteria and a detailed record of complications was kept for all patients. RESULTS: The mean age of included patients was 10 years (range, 3 to 16 years) and the average follow-up was 3.2 years (range, 1.1 to 8.5 years). Based on Delbet's classification system, there were 0 type I (transepiphyseal), 16 type II, 11 type III, and 9 type IV fractures. There were 8 undisplaced fractures, 4 of which later displaced after being managed initially in a hip spica. A satisfactory outcome was obtained in 27 (75%) children. Avascular necrosis (AVN) was the most common complication. It was seen in 7 of our patients, all of whom had an unsatisfactory outcome. Other complications included three cases each of coxa vara, non-union, and arthritic changes; and one case each of infection, primary screw perforation of head, and premature epiphyseal closure. Complications were lowest in the group treated by ORIF. Only 2 patients managed exclusively by conservative treatment ultimately achieved a satisfactory outcome. CONCLUSIONS: We believe that internal fixation of pediatric femoral neck fractures is preferred whenever feasible because conservative treatment carries a high risk of failure of reduction. Aggressive operative treatments aimed at anatomical reduction should be the goal and there should be no hesitation in choosing ORIF over CRIF. Outcome of patients is influenced primarily by development of AVN which occurs as an independent entity without much relation to the mode of treatment carried out.

Hemiarthroplasty Using a Modular Hip Segment in a Patient with a Long Stem Total Knee Prosthesis

Femoral neck fractures frequently occur in elderly patients and the treatment strategies for this are well documented. Revision knee arthroplasty using a long intra-medullary stem has recently been increasingly used for treating complications such as infection, aseptic loosening or instability. The current case had a femoral neck fracture with a well-fixed, long stem knee prosthesis, which reached to near the lesser trochanter of the femur. The authors performed the surgery using impaction of the modular hip segment; its inner diameter was fit to the outer diameter of the femoral stem of the knee prosthesis. At two years postoperative follow-up, the result was excellent without loosening or osteolysis.

Orthopaedic Surgical Treatment of Hip Fractures

Hip fracture is much more common after the age of 65 year old, and this malady has increased because to the longer average life span with the advances of medical care. Despite the development of the treatments and rehabilitation techniques, hip fracture is well known for having high rates of complications and mortality. The risk factors, mechanisms of injury and the underline disease of hip fracture are also well known, and this has helped these patients to recover as soon as possible and to walk and move earlier after appropriate surgical operations. Most fractures must be treated by an open operation and performing rigid internal fixation or arthroplasty. We report here on the major operational treatments for femur neck fracture and intertrochanter fracture.

A case of renal osteodystrophy with bilateral femoral neck fractures before renal replacement therapy / 대한내과학회지

Renal osteodystrophy (ROD) is an early complication in chronic kidney disease (CKD). Irreversible skeletal complications and deformities in children are already present before CKD progresses to end stage renal disease; therefore, the early detection of coexisting ROD is important in children with CKD. In the present work, we present a case of ROD in a 14-year-old female patient with chronic renal failure. The patient had already suffered bilateral femoral neck fractures before starting extracorporeal dialysis. On the 21st day after dialysis, external fixations of the femoral neck were performed.

Hip Arthroplasty Using Cementless Modular Femoral Stem for Displaced Femoral Neck Fracture in Patients More than 70 Years Old

Purpose: To evaluate the clinical and radiological results of hip arthroplasty using a cementless modular femoral stem in patients older than 70 years with a femoral neck fracture. Materials and Methods: From January 2002 to May 2005, 67 hip arthroplasty procedures (66 patients) using a cementless modular femoral stem for displaced femoral neck fractures in patients older than 70 years of age were evaluated. All the patients were followed up for more than 2 years. The mean age at surgery was 77 (70~92) years. There were 22 men and 44 women. The mean follow up period was 31 months (24~41). The clinical evaluation was performed by examining the perioperative Activities of Daily Living (ADL) and postoperative complications. The radiological evaluation for femoral stem loosening and osteolysis was performed using the serial postoperative radiographs. The radiological evaluation for leg length discrepancies was performed using the immediate postoperative radiograph. Results: In preoperative ADL, 31 cases (46%) were in grade 1, 21 (31.5%) in grade 2, 14 (21%) in grade 3, 1 (1.5%) in grade 4 and none in grade 5. A review of the postoperative ADL revealed 25 cases (37.5%) in grade 1, 18 (27%) in grade 2, 21 (31%) in grade 3, 3(4.5%) in grade 4 and none in grade 5. Postoperative restoration of the ADL was observed in 48 cases (71.5%). There were no significant complications. Radiographically, all cases showed stable bony fixation of the femoral stem with the exception of 1 case, who showed subsidence and a pedestal reaction. Postoperative leg length discrepancy was observed in 5 cases (7.5%) but was <1 cm in all cases. Conclusion: In elderly patients older than 70 years of age with a displaced femoral neck fracture, cementless hip arthroplasty using a modular femoral stem provides good initial stability and subsequent secure bony fixation with minimal complications.

A Case of Atypical Bone Growth after Femur Neck Fracture in the Paraplegic Patient with Trochanteric Sore

PURPOSE: Heterotopic ossification in pressure sore patients is reported to rarely develop, but once it occurs, it frequently causes joint stiffness and mobilization restriction. The aim of this article is to report our experience of atypical bone growing at femur neck fracture site with chronic, extensive pressure sore in patient with paraplegia secondary to spinal injury. METHODS: A 28-year-old male patient presented with atypical bone growth at femur neck fracture site with pressure sore. He had undergone atypical growth bone removal and separation of united iliac bone and femur, and then pressure sore was covered by advanced rotation flap. RESULTS: The patient mobilized hip joint and rode in a wheelchair. Complications such as dehiscence, infection, hematoma and flap necrosis did not occur. CONCLUSION: We experienced successful correction of atypical bone growth removal and recovery of pressure sore. We report our experience of atypical bone growth of fracture site and the related literature was reviewed.

Migration of Multiple Cannulated Screws in the Treatment of Femur Neck Fractures

PURPOSE: We wanted to assess the characteristics and clinical significance of screw migration after surgical treatment of femoral neck fractures. MATERIALS AND METHODS: We reviewed 44 hips (22 males, 22 females) that were treated with closed reduction and multiple cannulated screws between February 1998 and May 2005. The medical records and radiographs were analyzed retrospectively at a minimum of 18 months after surgery. 3 mm migration was arbitrarily chosen as the differentiating measure between the migration (27cases) and the nonmigration (17 cases) groups. The anatomical location of the fracture, Garden's classification, comminution, the screw position in the femoral head and the complications were statistically compared between the migration and nonmigration groups. The time sequence of events after surgery and the distance of migration were evaluated in the migration group. RESULTS: No significant differences between the two groups were noted in regard to complications, the screw position in the femoral head, the degree of displacement of fractures with using Garden's classification and the anatomic location of the fracture. There was a statistically significant difference between the two groups with regard to comminution (p=.001). In the migration group, the screws started migrating from 1 month after the operation and this was remarkable at 3~6 months. The average migration was 6.51 mm with 4.23 mm migration occurring in the first 3 months. CONCLUSION: For comminuted femur neck fractures that are treated with multiple cannulated screws, screw migration and shortening of the femoral neck can be anticipated to happen at 3 months after surgery.

Rupture of Thoracic Empyema for Femur Neck Fracture Surgery under Combined Spinal-Epidural Anesthesia: A case report / 대한마취과학회지

Thoracic empyema can result from the pleural accumulation of infected fluid or the infection of accumulated pleural fluid. The causes of empyema are pneumonia, surgery of lung, mediastinum, diaphragm, trauma, and so on. The impact of anesthetic technique (regional versus general versus combination of both) on the respiratory complication rate has not been established. A 86-yr-old male patient, who had COPD about 15 years and chronic empyema for several months, scheduled to operation for a femur neck fracture. We report a case that this patient with COPD and empyema operated under combined spinal-epidural anesthesia and converted to general anesthesia because of the rupture of the chronic empyema.

Bilateral Femoral Neck Fractures in a Young Adult: A Case Report

Ipsilateral femur shaft and neck fractures are occurred by high energy trauma, usually in motor vehicle accidents or fall from a height. Simultaneous Ipsilateral femur shaft and neck fractures and contralateral femur neck fracture are not yet reported in Korea. Authors report a case of simultaneous bilateral femoral neck fractures combined with a ipsilateral femoral shaft fracture in a young adult treated with anatomical reduction, internal fixation and vascularized bone graft with a review of the literature.

Pulmonary Embolism after Spinal Anesthesia Induction for the Surgical Reduction of a Femur Neck Fracture: A case report / 대한마취과학회지

This case involved a pulmonary thromboembolism, which originated from the lower extremity. A 68-year-old female, with a femur neck fracture, underwent spinal anesthesia with 0.5% heavy bupivacaine 11 mg for total hip arthroplasty. Ten minutes after the induction of spinal anesthesia, dyspnea, tachycardia and hypotension appeared. Under the impression of a pulmonary embolism, intubation was done and dopamine and epinephrine were infused. The operation stopped and she was sent to the intensive care unit. On the spiral CT chest angiogram, a pulmonary embolism was found. Deep venous thrombosis was detected in the left lower extremity on the venogram. Heparin therapy was started at a rate of 800 U/hour with a bolus of 5000 U. A consultative operation for the removal of deep vein thrombosis was performed by a chest surgeon, and total hip arthroplasty was performed successfully under spinal anesthesia.

Fracture of Femur Neck with Heterotopic Ossification in Spinal Cord Injured Patient

Heterotopic ossification(H.O.) is a common complication in spinal cord injured patients. The majority of heterotopic ossification in spinal cord injury occurs around hip joints. Fracture of femur is also a quite common complication in spinal cord injured patient, however H.O. associated with femur fracture at the hip was rarely reported. The author experienced femur neck fracture in a spinal cord injured patient with preexisting H.O. The proper management of femur neck fracture and the prevention of H.O. were reviewed and discussed.

Unipolar Versub Bipolar Hip Hemiarthroplasty for Fractures of Femoral Neck in the Dlderly / 대한정형외과학회잡지

Among the 85 cases of prosthetic replacement of femoral neck fracture which had been operated at Department of Orthopaedic Surgery, Korea Veterans Hospital from January, 1982 to May, 1990, 32 cases (15 unipolar hemiarthroplasty and 17 bipolar hemiarthroplasty) were examined clinically and radiologically at an average 7.7 years postoperatively. And the results were as follows; 1. The group I (Unipolar hip hemiarthroplasty without cement) had Harris hip score - average 79.4. The group II (Unipolar hip hemiarthroplasty with cement) had Harris hip score average 87.3. The group III (Bipolar hip hemiarthroplasty without cement) had Harris hip score average 80.5. The group IV (Bipolar hip hemiarthroplasty with cement) had Harris hip score average 86. 2. There were 2 cases of stem loosening (13%) among 15 cases in unipolar hip hemiarthroplasty and 1 case (6%) among 17 cases in bipolar hip hemiarthroplasty. 3. The movement of two components in bipolar hip hemiarthroplasty was noted in all cases and the movement of the outer bearing joint was more active than that of the inner. And the movement of the two components was not correlated with the use of cement. But Harris hip score was superior cement stem group to noncement stem group. 4. Unipolar hip hemiarthroplasty showed the similar clinical and radiological results with bipolar hip hemiarthroplasty of femoral neck fracture in the elderly. As a result, unipolar and bipolar hip hemiarthroplasty were considered the proper treatment method of the femoral neck fracture in the elderly.

Cementless Bipolar Hemiarthroplasty for the Management of Fracture of the Femoral Neck / 대한정형외과학회잡지

Various methods for the treatment of fracture of the femur neck including total hip arthroplasty have been developed and performed, but it is still called the ""unsolved fracture"" in certain situations. The role of bipolar hemiarthroplasty as primary treatment of fracture of the femur neck, however, continues to be controversial. The authors reviewed and analysed 38 cases of cementless bipolar hemiarthroplasty in patients between the ages of 51 and 69 at the Department of Orthopaedic Surgery, Chosun University, during the period from January, 1989 to December, 1994. The purposes of the study were to analyse the clinical and radiological results and to detect the motions of bipolar cup. At the average 38 months follow up, 31 (81.6%) of the patients were satisfied by Lunceford methods. But, 24 (63.2%) of the patients suffered from inguinal area pain and discomfort while they resumed their normal Korean life-styles. As time elapsed, the amount of the outer bearing motion was more than that of the inner bearing motion. the acetabular erosion were present in 2 patients.

Treatment of Fractures of the Femur Neck in Children / 대한정형외과학회잡지

We have treated total 37 cases of femoral neck fracture in children who were under the 16 years old in age at the Catholic University Medical College since 1985, followed them for average 21 months to analyse their types of fracture and treatment, complications and prevention of complications, and obtained the following results. 1. According to the Delbet's classification, type I was 1 case, II were 18(49%), most common, III were 10 and IV were 8 cases. Their ages were average 8.2 years and boys were predominant in 27 cases. 2. Thirty-six cases were treated with open reduction and internal fixation within 1-13 days after fracture, but only one type IV was treated with closed reduction, followed by hip spica cast for 6 to 9 weeks in all. 3. The fixation devises were removed at average 8.7 months after operatio. 4. fifteen complications were observed in 11 cases(37%), that were AVN(3 cases), early physeal closure(8 cases), coxa vara(3 cases), coxa valga and limb shortening(each 1 case), and their causes were severe fracture displacement(2 cases), penetration of fixation devices to physis(8 cases), incomplete reduction and loss of initial reductio (1 case) etc, but were not correlated with their method of fracture treatment. Conclusively, the femur neck fracture in children could favorably be treated with open reduction and internal fixation to reduce their complications. Physeal early closures due to penetration of screws and pin were most common cause of complications, and their long-term follow-up should be necessary.