Management of Trochanteric Fractures: Are We NICE Compliant?

INTRODUCTION: The National Institute for Health and Care Excellence (NICE) updated the 2011 hip fracture management guidelines on January 6, 2023, suggesting that clinicians offer sliding hip screws in preference to intramedullary nails for trochanteric fractures above and including the lesser trochanter except reverse oblique fractures. This study aims to assess the compliance of our hospital with the updated guidelines while comparing the results with our performance prior to the update together with the national average. MATERIALS AND METHODS: A retrospective observational study was done to analyse if trochanteric fractures managed surgically were compliant with NICE guidelines. Pathological fractures secondary to tumours and AO/OTA 31A1.1 fractures were excluded. Fractures were classified using the 2018 AO/OTA classification system independently by two authors, with a review from a senior consultant if there was interobserver variation. Group A (n=60) included trochanteric fractures managed surgically three months prior to the update, while Group B (n=46) included patients managed operatively three months following the update. RESULTS: The compliance rates for Group A and Group B were similar at 88.33% and 89.13%, respectively, while the national average was about 67% over the course of six months. DISCUSSION: 31A2 fractures showed higher rates of non-compliance in both groups. Non-compliance was thought to be multifactorial: surgeon bias, inaccurate classification of fractures and a lack of awareness of guidelines. CONCLUSIONS: While there is scope for improvement, district general hospitals can achieve high rates of compliance. Educating and training doctors could help improve compliance.

No effect of hydroxyapatite-coated sliding hip screw threads on screw migration in the femoral head/neck of pertrochanteric fractures: a randomized controlled trial using radiostereometric analysis.

INTRODUCTION: Cut-out is the most frequently reported mechanical failure of internal fixation of pertrochanteric fractures. The purpose of this study was to examine if hydroxyapatite-coated screw thread on a sliding hip screw (SHS) could reduce screw migration within the femoral head in patients with stable pertrochanteric fractures. MATERIALS AND METHODS: In a double-blinded randomized controlled study, 37 patients at mean age 78 (range 56-96), with pertrochanteric fracture (Evans I, II, IV) received surgery with a SHS with a hydroxyapatite-coated or a non-coated lag screw thread. Radiostereometry and standard radiographs were obtained 1 day, 6 weeks, 3- and 6 months post-operatively to evaluate screw and fracture migration and fracture reposition. The two groups were combined to describe fracture migration. RESULTS: There was similar and small screw migration in the femoral head between the two groups at 6 weeks, 3- and 6 months (p > 0.12). Fracture migration occurred predominantly in the first 6 weeks, where fracture impaction was 5.95 mm (CI 95% 2.87 to 9.04) and anterior rotation of the femoral head was -2.94° (CI 95% - 5.22 to - 0.66). Migration of the fracture (total translation) correlated to the post-operative fracture reposition (p = 0.002), but not significantly to screw migration (p = 0.09). Neither screw total translation (rho 0.06, p = 0.79) nor fracture total translation (rho 0.04, p = 0.77) correlated with bone mineral density. CONCLUSION: There was no clinical benefit of hydroxyapatite coating on lag screw migration in this patient cohort. Migration of the pertrochanteric fractures was higher with poor fracture reposition but fractures generally stabilized after 6 weeks follow-up. The study was registered at ClinicalTrials.gov (NCT05677061). LEVEL OF EVIDENCE II: Patient-blinded prospective randomized study. Trial registration number The study was registered at ClinicalTrials.gov (NCT05677061).

The effects of two fixation methods on blood loss in patients with trochanteric fracture: dynamic hip screw vs. proximal femoral nail anti-rotation.

Aim The two most commonly used implants for treatment of trochanteric fractures are the dynamic hip screw (DHS) and proximal femoral nail antirotation (PFNA). The aim of this study was to evaluate blood loss in patients with trochanteric fracture treated with DHS or PFNA. Methods This retrospective comparative study included 61 patients with trochanteric fracture, who were divided according to a surgical method into DHS and PFNA groups. In the PFNA group, a short third generation gamma-nail was used for osteosynthesis (Supernail GT, Lima Corporate, Italy), and in the DHS group a dynamic hip screw was used (Synthes, Oberdorf, Switzerland). Complete blood count with haemoglobin and haematocrit values was taken preoperatively and on the first day postoperatively and a number of red blood cell transfusions (RBC) were evaluated. Electronic medical records from 2022 were used to collect patient data. Results There were no significant differences in terms of gender and age between the groups (p=0.510 and p=0.087, respectively), as well as in the fracture type distribution (p=0.886). The duration of postoperative hospitalisation was similar between the groups (p=0.643). There was no statistically significant association between the number of RBC transfusions and fixation method (p=0.091), as well as in postoperative haemoglobin and haematocrit levels between the groups (p=0.180 and p=0.225, respectively). Conclusion Both DHS and PFNA implants are safe surgical techniques for the treatment of trochanteric fractures, with similar blood loss, number of blood transfusions and hospital stay.

The impact of fixation type for intertrochanteric femoral fracture on patient survival.

BACKGROUND: Intramedullary (IM) nail fixation for intertrochanteric fractures is potentially associated with improved postoperative function but may have an increased mortality risk compared to sliding hip screw (SHS) fixation. This study investigated postoperative mortality risk between surgical fixation type for intertrochanteric fracture in patients aged 50 years and older using linked data from the Australian Hip Fracture Registry and National Death Index. METHODS: Descriptive analysis and Kaplan-Meier survival curves performed unadjusted analysis of mortality and fixation type (short IM nail, long IM nail and SHS). Multilevel logistic regression (AMLR) and Cox modelling (CM) performed adjusted analysis of fixation type and mortality following surgery. Instrumental variable analysis (IVA) was conducted to minimize the effect of unknown confounders. RESULTS: The 30-day mortality was 7.1% for short IM, 7.8% for long IM and 7.8% for SHS fixation (P = 0.2). The AMLR demonstrated significant increase in 30-day mortality risk for long IM nail compared to short IM nail (OR = 1.2, 95% CI = 1.0-1.4, P < 0.05) but no significant difference for SHS fixation (OR = 1.1, 95% CI = 0.9-1.3, P = 0.5). No significant difference between groups and postoperative mortality was demonstrated by the CM at 30-days nor 1-year nor by the IVA at 30-days. CONCLUSION: Despite a significant increase in 30-day mortality risk for long IM nail compared to short IM nail fixation in the adjusted analysis, this was not demonstrated in the CM nor IVA indicating the role of confounders influencing the regression findings. There was no significant association in 1-year mortality between long IM nail and SHS compared to short IM nail fixation.

Comparison of Cephalomedullary Nails with Sliding Hip Screws in Surgical Treatment of Intertrochanteric Fractures: A Cumulative Meta-Analysis of Randomized Controlled Trials.

Background: The primary objective of the present study was to compare surgical failures of intertrochanteric fractures of the femur through a meta-analysis of randomized controlled trials and to assess the change in surgical outcomes over time in a cumulative meta-analysis. Methods: To identify studies evaluating the surgical outcomes of internal fixation using sliding hip screws (SHS) or cephalomedullary (CM) nails for the treatment of intertrochanteric fractures of the femur, all records until August 2021 in the PubMed, Embase, and Cochrane Library databases were searched. Studies with the following characteristics were considered eligible: patients who had an intertrochanteric fracture of the femur (population); patients who received surgical treatment using a CM nail (intervention); patients who received surgical treatment using SHS (comparator); surgical failures that required reoperation, including cut-out or cut-through of lag screws, varus collapse or posterior angulation of proximal fragments, loosening of lag screws or helical blades, and fracture nonunion (outcomes); and two reviewers independently reviewed the titles and abstracts of the randomized controlled trials and selected relevant studies for a full-text review (study design). Results: Twenty-one studies were included in the final analysis consisting of 1,777 cases in the SHS group and 1,804 cases in the CM nail group. The cumulative standard mean difference was 0.87, indicating that CM nails had no significant effect in improving the surgical outcomes. There was no significant difference in surgical failure between SHS and CM nails for all intertrochanteric fractures (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.76-1.49). Pooled data showed no significant difference between the two groups in terms of surgical failure in unstable intertrochanteric fractures (OR, 0.80; 95% CI, 0.42-1.54). Conclusions: Although the use of CM nails has become a current trend in the treatment of intertrochanteric fractures, there is no literature supporting their clinical superiority when compared with SHS.

Mortality in patients with trochanteric hip fractures (AO/OTA 31-A) treated with sliding hip screw versus intramedullary nail: A retrospective national registry study of 9547 patients from the Danish Fracture Database.

BACKGROUND: Whether trochanteric hip fractures (AO/OTA 31-A) should be treated with an intramedullary nail (IMN) or sliding hip screw (SHS) is debated. Recent studies suggest an association between IMN and excess mortality rates compared to SHS, but higher quality studies fail to show this association. Furthermore, there is an increased usage of IMN with sparse evidence supporting this rise. Our aim was to compare mortality rates between IMN and SHS in patients with AO/OTA 31-A fractures. Secondarily, to investigate choice of implant in relation to fracture subtype. METHODS: This national registry study is based on data from the Danish Fracture Database (DFDB). Data were retrieved on patients aged ≥65 years treated for a non-pathological AO/OTA type 31-A fracture with IMN or SHS from January 1, 2012 to December 31, 2018. Data from DFDB were merged with data from the Danish Civil Registration System (CRS) for time of death. Mortality rates were recorded at 30 days, 90 days, and 1 year and presented as crude mortality and adjusted for age, gender, ASA-class, and AO/OTA-subtype. RESULTS: A total of 9,547 patients were included. The mean age was 83 years, 69% were female, and 55% were ASA-class 3-5. We found higher mortality rates for IMN-patients at 30 days, 90 days, and 1 year. The crude relative mortality risk for IMN was also significantly higher at both 30 days (1.20) and 90 days (1.11). Adjusted relative mortality risk for IMN was 1.12 [0.96; 1.31] at 30-days, 1.03 [0.91; 1.17] at 90-days, and 1.01 [0.92; 1.11] at 1 year. Most patients suffered a 31-A2 fracture (56%) and, overall, 74% of patients were treated with IMN. CONCLUSION: We found significantly increased crude relative mortality risk at 30 days and 90 days in patients treated with IMN. However, when adjusting for confounders the two groups had similar mortality risks. In total, 74% of all patients in this cohort were treated with IMN. LEVEL OF EVIDENCE: This study has level of evidence: III.

Finite element analysis of necessity of reduction and selection of internal fixation for valgus-impacted femoral neck fracture.

This study compared the biomechanical characteristics of different treatment strategies based on finite element analysis. Posterior tilt and valgus angle were measured on X-ray from ten valgus-impacted femoral neck fractures, and 7 finite element models that were generated to compare the stress and displacement. The results showed that in the intact femur, von Mises stress was concentrated at the medial and inferior sides of the femoral neck. In valgus-impacted femoral neck fractures, von Mises stress was at the same locations but was 5.66 times higher than that in the intact femur. When 3 cannulated screws were used for internal fixation, anatomic reduction diminished the stress at the fracture end from 140.6 to 59.14 MPa, although displacement increased from 0.228 to 0.450 mm. When the fracture was fixed with a sliding hip screw (SHS) + cannulated screw, there was less stress at the fracture end and greater displacement with anatomic reduction than that without reduction (stress: 15.9 vs 37.9 MPa; displacement: 0.329 vs 0.168 mm). Therefore, the SHS + cannulated screw has superior biomechanical stability than 3 cannulated screws, and is recommended following anatomic reduction to treat valgus-compacted femoral neck fractures.

Internal Fixation of Garden Type III Femoral Neck Fractures with Sliding Hip Screw and Anti-Rotation Screw: Does Increased Valgus Improve Healing?

Background and Objectives: The aim of this study was to compare the effect of valgus versus anatomic reduction on internal fixation of Garden type III femoral neck fractures using the sliding hip screw (SHS) and anti-rotation screw (ARS) regarding the radiographic and therapeutic outcome. Patients and Methods: A retrospective case-controlled study was performed in a level I trauma center. All patients between 2006 and 2020 aged younger than 70 years with a Garden type III femoral neck fracture and a Kellgren-Lawrence score under grade III stabilized using SHS and ARS were identified. One-hundred and nine patients were included, with a group distribution of sixty-eight patients in group A (anatomic reduction) and forty-one patients in group B (valgus reduction). Results: Mean age was 55 years, and the mean Kellgren-Lawrence score was 1 in both groups. Mean femoral neck angle was 130.5 ± 3.8° in group A and 142.8 ± 4.3° in group B (p = 0.001), with an over-correction of 12° in group B. Tip-apex distance was 10.0 ± 2.8 mm in group A versus 9.3 ± 2.8 mm in group B (p = 0.89). Healing time was 9 weeks in group A compared to 12 weeks in group B (p = 0.001). Failure rate was 4.4% in group A and 17.1% in group B (p = 0.027). Conclusions: Anatomic reduction of Garden type III femoral neck fractures in patients younger than 70 years treated using SHS and ARS resulted in significantly lower failure rates and shorter healing times than after valgus reduction. Therefore, it can be recommended to achieve anatomic reduction.

A nationwide study of blood transfusion in hip fracture patients : linked analysis from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service.

AIMS: The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients. METHODS: A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes. RESULTS: A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001), intramedullary fixation (OR 7.15 (95% CI 6.50 to 7.86); p < 0.001), and sliding hip screw constructs (OR 2.34 (95% CI 2.19 to 2.50); p < 0.001). Blood transfusion during admission was significantly associated with higher rates of 30-day mortality (OR 1.35 (95% CI 1.19 to 1.53); p < 0.001) and 60-day mortality (OR 1.54 (95% CI 1.43 to 1.67); p < 0.001), as well as delays to postoperative mobilization, higher likelihood of not returning to their home, and longer length of stay. CONCLUSION: Blood transfusion after hip fracture was common, although practice varied nationally. RBCT is associated with adverse outcomes, which is most likely a reflection of perioperative anaemia, rather than any causal effect. Use of RBCT does not appear to reverse this effect, highlighting the importance of perioperative blood loss reduction.Cite this article: Bone Joint J 2022;104-B(11):1266-1272.

Variation of implant use in A1 and A2 trochanteric hip fractures : a study from the National Hip Fracture Database of England and Wales.

AIMS: Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines. METHODS: We used the NHFD to identify all operations for fixation of trochanteric fractures in England and Wales between 1 January 2021 and 31 December 2021. A uniform price band from each of three hip fracture implant manufacturers was used to set cost implications alongside variation in implant use. RESULTS: We identified 18,156 A1 and A2 trochanteric hip fractures in 162 centres. Of these, 13,483 (74.3%) underwent SHS fixation, 2,352 (13.0%) were managed with short IMN, and 2,321 (12.8%) were managed with long IMN. Total cost of IMN added up to £1.89 million in 2021, and the clinical justification for this is unclear since rates of IMN use varied from 0% to 97% in different centres. CONCLUSION: Most trochanteric hip fractures are managed with SHS, in keeping with national guidelines. There is considerable variance between hospitals for implant choice, despite the lack of evidence for clinical benefit and cost-effectiveness of more expensive nailing systems. This suggests either a lack of awareness of national guidelines or a choice not to follow them. We encourage provider units to reassess their practice if outwith the national norm. Funding bodies should examine implant use closely in this population to prevent resource waste at a time of considerable health austerity.Cite this article: Bone Jt Open 2022;3(10):741-745.

Reoperation for sliding hip screws vs cannulated cancellous screws in femoral neck fractures: A study from the Danish Fracture Database Collaborators.

INTRODUCTION: It is still debated whether to use cannulated cancellous screw (CCS) or sliding hip screw (SHS) implants for femoral neck fracture (FNF) patients but there are no studies large enough to evaluate on smaller differences. The aim were to compare the reoperation and mortality rates of a large cohort of FNF patients above 60 years of age with internal fixation using CCS and SHS implants, with stratification by fracture classification. METHODS: This register study employed prospectively collected data from 2014 to 2018 from the Danish Fracture Database, including 2-year follow-up and data on age, sex, surgery, comorbidity and fracture classification. Reoperation data was retrieved from the Danish National Patient Register. The primary outcome was major reoperation, defined as re-osteosynthesis, conversion to arthroplasty, non-union surgery, Girdlestone procedure or deep infection 1-year post-surgery. Relative risk (RR) for the CCS group compared with the SHS group was estimated using Cox proportional hazards modelling, adjusted for age, sex and comorbidity (including 95% confidence intervals). RESULTS: A total of 2,598 FNFs were included, 1,731 with CCS (67%) and 867 with SHS (33%). The overall 1-year major reoperation rate was 15% with CCS and 13% with SHS, yielding an adjusted RR of 1.10 (0.88; 1.37) for CCS compared to SHS. The adjusted RR was 1.15 (0.77; 1.69) for undisplaced FNF, 1.09 (0.68; 1.75) for displaced FNF and 1.35 (0.94; 1.94) for transcervical FNF, which increased to 1.42 (1.01; 2.00) after 2 years. The minor reoperation rate was higher for CCS (3%) than SHS (1%), yielding an adjusted RR of 2.28 (1.14; 4.51). The adjusted RR for CCS compared to SHS was 0.83 (0.62; 1.12) for 30-day mortality and 0.96 (0.82; 1.14) for 1-year mortality. CONCLUSIONS: We found no difference between CCS and SHS in major reoperation rates; however, for transcervical FNF, CCS was associated with higher reoperation rates. Furthermore, CCS was associated with a higher risk of minor reoperation than SHS. There were no differences in mortality rates.

Primary Hemiarthroplasty for the Treatment of Basicervical Femoral Neck Fractures.

Purpose Basicervical femoral neck fractures are uncommon injuries that occur at the extracapsular base of the femoral neck at its transition with the intertrochanteric line. Controversy remains in the orthopedic literature as to the optimal method of treatment for this fracture type given the inherent instability and greater rate of implant failure with traditional fixation constructs. The purpose of this study is to quantify the incidence and preferred treatment methods of basicervical hip fractures at a single, regional, Level 1 trauma center and to identify differences in postoperative complications between treatment options. Methods The present study is a retrospective case series from a single regional health network, including 316 patients with hip fractures. Basicervical femoral neck fractures were identified. Reoperation rates within 90 days, implant failures or nonunions, postoperative ambulation distances and range of motion, and discharge dispositions were compared across patients grouped by surgical treatment with either cephalomedullary nail, sliding hip screw, or hemiarthroplasty (HA). Results Basicervical femoral neck fractures represented 6.6% of this study population. The cephalomedullary nail group demonstrated rates of implant failure and return to the operating room within 90 days of 40% (4/10) and 20% (2/10), respectively. No patients who underwent hemiarthroplasty experienced a failure of fixation or return to the operating room. Conclusions This study suggests a much lower rate of fixation failure or need for reoperation with hemiarthroplasty treatment compared to cephalomedullary nail construct for basicervical femoral neck fractures and may be an underutilized treatment method for this fracture type. The promising results seen with this case series should encourage further investigation into HA as a primary treatment for these uncommon, yet challenging, fractures.

A five-year review comparing 30-day mortality following intramedullary nailing versus sliding hip screw for trochanteric hip fractures.

INTRODUCTION: Recent literature suggests that fixation of trochanteric hip fractures with intramedullary nailing carries a higher 30-day mortality than with sliding hip screw. The present study aims to verify whether this statement is reflected in our practice. PATIENTS AND METHODS: Sliding hip screw and intramedullary nail fixation of trochanteric hip fractures were analysed over a 5-year period, between April 2011 and March 2016. Three investigators independently analysed 919 patients. Data collected included 30-day mortality, OTA classification of hip fracture and ASA grading. Inclusion and exclusion criteria were applied. RESULTS: 493 patients (66%) underwent sliding hip screw while 252 patients (34%) underwent intramedullary femoral nailing. AO/OTA classification was strongly associated with treatment group. It was found that 30-day mortality rate was 4.8% following intramedullary nailing compared to 6.1% with sliding hip screw. Multivariate logistic regression analysis found ASA grade, male gender and age to be associated with increased 30-day mortality with statistical significance. There was no statistically significant association between treatment group and 30-day mortality, nor between ASA grade and treatment group. CONCLUSIONS: Both the lower 30-day mortality rate of 4.8% with intramedullary nailing and the higher rate of 6.1% with sliding hip screw fixation compare favourably with the mean 7.9% National 30-day mortality rate following hip fractures. The lower 30-day mortality in the intramedullary nailing group was not attributable to lower ASA grading nor due to simpler fracture configuration. ASA grade, male gender and age were shown to be statistically associated with increased 30-day mortality. IMPLICATIONS: Previous studies may have deterred surgeons from choosing an intramedullary device. However, we hope this study assists surgeons to make an informed decision on the choice of implant particularly when an intramedullary device is required to provide a more stable construct.

Surgical treatment options for femoral neck fractures in the elderly.

This review paper on femoral neck fractures in the elderly provides updated information from the most recent literature and examines the advantages and disadvantages of different surgical treatment options. Femoral neck fractures are a common injury that many orthopaedic surgeons will encounter within their practice. These injuries are associated with significant morbidity, and the economic impact of surgically fixing these fractures is notable. Contemporary treatment options include internal fixation, hemiarthroplasty, and total hip arthroplasty. For non-displaced fractures, both internal fixation and hemiarthroplasty remain feasible options. Hemiarthroplasty decreases re-operation rate, while internal fixation decreases operative time, blood loss, and infection risk. Newly designed fixation constructs require further investigation. For displaced fractures, the literature strongly supports arthroplasty. Most elderly patients with displaced femoral neck fractures should be managed with a hemiarthroplasty. In select active elderly patients, total hip arthroplasty may achieve favourable early functional outcomes as compared to a hemiarthroplasty. Finally, cemented arthroplasty decreases periprosthetic fracture risk as compared to cementless arthroplasty. However, experienced arthroplasty surgeons with significant expertise in press-fitting techniques may achieve similar outcomes with cementless arthroplasty.

Intramedullary nail versus sliding hip screw for stable and unstable trochanteric and subtrochanteric fractures : 17,341 patients from the Norwegian Hip Fracture Register.

AIMS: The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability. METHODS: We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. RESULTS: Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). CONCLUSION: This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN. Cite this article: Bone Joint J 2022;104-B(2):274-282.

Sliding hip screw vs intramedullary nail for AO/OTA31A1-A3: a systematic review and meta-analysis.

OBJECTIVE: to conduct a systematic review with consequent meta-analysis evaluating the best treatment for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31A1-A3 trochanteric fractures when comparing the sliding hip screw (SHS) to the intramedullary nail (IMN). The outcomes used for comparison are major complications (in total, as well as nonunion and infection specifically), mortality rates, functional outcomes and patient-reported outcome measures (PROM). MATERIALS AND METHODS: Search strings for the Cochrane Library, CINAHL, Medline and Embase databases were developed with the help of a scientific librarian. Two authors screened the studies from the search string independently using Covidence.org and data extraction was performed similarly. Quality assessment was performed using the Cochrane Risk of Bias tool for randomised trials (ROB2) for RCT studies, and Cochrane Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) for non-RCT studies. Meta-analyses were performed using Log Risk Ratio as the primary effect estimate. RESULTS: Of the 2,051 studies screened by the two authors, six RCTs and six non-RCTs were included in this meta-analysis, with a total of 10,402 patients. The results indicated no significant differences in total major complications, nonunion, infection or mortality between SHS and IMN treatments for AO/OTA 31A1, 31A2 and 31A3 trochanteric fractures. Due to a lack of compatible data, we were unable to perform a meta-analysis on function scores and PROM. However, there are trends that favour IMN for 31A1 and 31A2 fractures. CONCLUSION: No significant difference between SHS and IMN was found in the meta-analysis in any of the examined AO/OTA fracture subtypes in terms of primary and secondary outcomes. When assessing function scores and PROM, we found trends favouring IMN for 31A1 and 31A2 fractures that should be explored further.

Quality of fracture reduction is associated with patient survival at one year, but not 30 days, following trochanteric hip fracture fixation. A retrospective cohort study.

INTRODUCTION: Few studies have been performed to evaluate the association between technical surgical factors and patient outcomes following hip fracture surgery. We performed a retrospective cohort study of elderly patients who had undergone fixation of trochanteric hip fractures using a sliding hip screw (SHS), with the aim of establishing whether there was a correlation between quality of fracture reduction and mortality at 30 days and one year. PATIENTS AND METHODS: A retrospective cohort study was designed. Inclusion criteria were trochanteric (AO 31A1 or 31A2) fractures in patients aged ≥ 65 years, presenting <3 days after injury and fixed using an SHS. Fracture reduction was classified using the Baumgaertner Reduction Quality Criteria (BRQC). A validated predictor of mortality following hip fracture was used to stratify for confounding variables that might affect mortality. Multivariate logistic regression was used to explore the association between fracture reduction and mortality. RESULTS: 329 patients were identified (mean age 86, 27% male). 57% had a good reduction, 39% had a fair reduction and 4% had a poor reduction. As reduction grade deteriorated, predicted mortality increased (good reduction: 7.3%; fair reduction: 8.4%; poor reduction: 15.5%). Without adjustment for predicted mortality, there was a significant correlation between decreasing reduction grade and mortality at both time points (30-day: odds ratio 1.95, p = 0.049; one year: odds ratio 1.86, p = 0.003). When adjusted for predicted mortality, only one year mortality remained significant (30 day: odds ratio 1.61, p = 0.173; one year: odds ratio 1.62, p = 0.037). CONCLUSION: Some, but not all, of the association between fracture reduction and mortality can be explained by predetermined predictors of a poor outcome. There remains, however, a correlation between poor fracture reduction and mortality at one year. Every effort must be made to achieve an anatomical reduction for these injuries, and trainees must be instructed in methods to achieve this.

Treatment of intertrochanteric nonunion after sliding hip screw fixation with a short cephalomedullary nail.

Intertrochanteric femur fracture nonunions are a rare complication that can be difficult to treat with limited evidence regarding treatment options. Revision fixation is typically reserved for well-aligned nonunions with sufficient femoral head bone stock. The most common implant used for revision fixation is a sliding hip screw implant. The use of a short cephalomedullary nail (CMN) for revision fixation has not been previously reported. This article presents a technique for reamed short CMN revision fixation of well-aligned nonunions with sufficient bone stock that is a simpler and potentially less morbid treatment option compared to open procedures with fixed-angle devices. For nonunions with poor femoral head bone stock and/or malaligned fractures, a fixed-angle implant, with or without a valgus osteotomy, may be necessary, while arthroplasty is reserved for nonunions with poor proximal femur bone stock that are not amenable to fixed-angle implant fixation.

CT scans better assess lateral wall morphology of "stable appearing" intertrochanteric (IT) femur fractures and predict early failure of sliding hip screw (SHS) fixation.

To compare the efficacy of plain x-ray images and computed tomography (CT) to assess the morphology of the lateral wall (LW) component of intertrochanteric (IT) femur fractures and determine predictors of early fixation failure. DESIGN: Retrospective cohort study. SETTING: Level-one trauma center. PATIENTS/PARTICIPANTS: One hundred forty-two adult patients with IT fractures treated with either a sliding hip screw (SHS) or a cephalomedullary nail (CMN) who had both pre-op plain x-ray images and CT scans with at least 6 weeks of follow-up were reviewed. INTERVENTION: Preoperative CT scan and plain radiographs of the affected hip. MAIN OUTCOME MEASUREMENTS: Lateral wall assessment based on plain x-rays versus CT imaging in relation to implant failure. RESULTS: One hundred forty-two patients met inclusion criteria, 105 patients treated with a CMN, and 37 with a SHS. There was a poor correlation between the assessment of the LW on plain x-ray images and CT scans. Failures in the SHS group were significantly associated with all CT measurements (P < .05) but not with plain film LW assessment (P = .66). Fifteen patients had an early implant failure (6 CMN, 9 SHS). There were no statistically significant associations between any radiographic measurement (plain images and CT) and CMN failures. CONCLUSIONS: Plain film images are not accurate for assessing lateral wall morphology/integrity and are not predictive of SHS implant failures. Our novel CT measurements were effective at detecting lateral wall patterns at risk for treatment failure with SHS implants.Level of Evidence: Level III.

Treatment of Pathologic Peritrochanteric Fractures Using Sliding Hip Screws Augmented with Cerclage Reconstruction Plates.

We proposed a new method to augment the traditional sliding hip screw (SHS) with cerclage reconstruction plates to treat pathologically impending and actual peritrochanteric fractures as well as to revise open reductions and internal fixations to increase the construct strength against the shearing force, thus reducing the implant failure rate. In this retrospective study, patients with peritrochanteric pathology with at least two years of follow-up who underwent augmentation with cerclage reconstruction plates (modified SHS) and conventional SHS between 1 May 2015 and 31 May 2017 were divided into groups A (n = 12) and B (n = 28), respectively. Demographic data, surgery duration, blood loss, complications, and local radiotherapy were analyzed. The average surgery duration was significantly longer in group A (p = 0.013). The estimated intraoperative and perioperative blood losses were not significantly different between the groups. The implant survival rates were not significantly different under competing risk analysis. The success rate of a revision surgery with modified SHS was excellent, and implant survival time was >2 years, as observed with the previous SHS constructs. Subtrochanteric region involvement and a postoperative visual analog scale ≥4 could be risk factors of implant failure and revision surgery. This technique can be an alternative treatment for difficult pathologic peritrochanteric fractures, especially those with previous plating failure.