Timing of surgery for internal fixation of intracapsular hip fractures and complications at 1 year; a 32 year clinical study of 2,366 patients at a single center.

BACKGROUND: Timing of hip fracture surgery for the internal fixation of an intracapsular fracture remains controversial and few studies to date have been able to determine the optimum time to surgery in minimizing osteonecrosis and non-union with intracapsular fractures after fixation. METHODS: Using a local hip fracture database managed by the senior author over a 32 year period, those who underwent osteosynthesis following intracapsular fractures were assessed for risk of development of non-union and osteonecrosis. Multivariate regression analysis was performed focusing on factors that were predictive of complications. Patient demographics, time from injury to surgery, fixation method, fracture pattern and complications at one year were reported. The primary outcome was whether delay to surgery contributed to risk of complications, defined as non-union or osteonecrosis. Secondary outcomes assessed the contribution of other factors to these complications. RESULTS: 2,366 patients were identified with an average age of 74.7 years and 66.5% were female. 1189 (50.3%) of fractures were displaced. 481 (20.3%) had a complication at one year following fixation. 78 (3.3%) were fixed by DHS, 6 (0.3%) by cephalomedullary nail, (1257) 53.1% by cannulated screws and 1025 (43.3%) by Targon® screw. Multivariate regression revealed no significant correlation between delay to surgery and complication rates (OR 0.99, 95% CI 0.99, 1.01, p = 0.55). Significant variables include female sex (OR 2.03, 95% CI 1.58, 2.62, p<0.0001), fracture displacement (OR 4.8, 95% CI 3.79, 6.14, p<0.0001), independent mobility (OR 0.64, 95% CI 0.47, 0.87, p = 0.004) and use of Targon® screws compared to parallel screws (OR 0.61, 95% CI 0.48, 0.76, p<0.0001). CONCLUSIONS: Our study demonstrates no relationship between timing of surgery for fixation of intracapsular fracture and complication rates. Female sex and fracture displacement increased risk of complications whereas independent mobility and use of Targon® screw device in comparison to parallel screws were protective against non-union but not avascular necrosis.

The efficacy of intravenous tranexamic acid administration at induction in definitive hip fracture surgery: Is there a role?

Tranexamic acid (TXA) is a cheap and powerful drug that has several uses in surgery and is well established in elective orthopaedic surgery. At present, limited small studies have looked into its role in the acute hip fracture. Transfusion in the geriatric population presents risks and increased costs to healthcare systems around the world. Our retrospective study looks at the role of TXA administration at induction for both intracapsular fracture requiring hemiarthroplasty and our preferred method of fixation of extracapsular fracture by intramedullary nail (IM nail). We show a statistically significant reduction in the number of patients requiring transfusion as well as mean haemoglobin (Hb) drop in those undergoing hemiarthroplasty. This was not replicated in those undergoing IM nail fixation. Both groups showed no increase in 1-year mortality or thromboembolic events following TXA administration. These results support the use of TXA for hemiarthroplasty for intracapsular hip fractures over the age of 60. OBJECTIVES: The aim of this pre and post interventional study looks at the effects of intravenous administration of tranexamic acid on induction for elderly patients undergoing hemiarthroplasty or intramedullary nail fixation for hip fractures. DESIGN: Pre and post interventional, randomised observational study SETTING: Large hip fracture unit, Level 2 Trauma Centre, single centre PATIENTS: Two arms of the study looking at those aged above the age of 60 undergoing hemiarthroplasty and intramedullary nail fixation without and with tranexamic acid on induction. RESULTS: 12.1% of hemiarthroplasties required post-operative transfusion without tranexamic acid compared to 2.6% of those with tranexamic acid (n=15 vs n=3 respectively, p=0.006). Equally, the mean Hb drop in g/L is reduced in those with tranexamic acid compared to those without (mean Hb = 14.6 vs 17.7 respectively, p=0.034). This was not replicated in the IM nail group between those without and those with tranexamic acid (n=31 vs n=20 respectively, p= 0.16). The mean Hb drop in g/L was not statistically significant in the tranexamic acid arm compared to without (mean Hb = 19.2 vs mean Hb = 21.9, p=0.11). Gross reporting of thromboembolic events did not demonstrate an increase in the number of those with DVT, PE, MI or stroke. 1-year mortality was not statistically significant in either hemiarthroplasty or IM nail fixation following tranexamic acid administration. CONCLUSIONS: Tranexamic acid both statistically significantly reduces the number of patients requiring transfusion post hemiarthroplasty and also the value of mean Hb drop without appearing to increase in thromboembolic events or 1 year mortality rates. This does not appear to be emulated in the IM nail fixation although both thrombotic events and 1-year mortality rates are also not affected by administration of TXA. We propose that TXA has a role in hemiarthroplasty surgery in reducing post-operative transfusions. LEVEL OF EVIDENCE: Level 3 - retrospective cohort study.