Postoperative pneumonia after femoral fracture surgery: an in-depth retrospective analysis.

BACKGROUND: Femoral fractures significantly contribute to disability, predominantly in the elderly. Despite this, data on postoperative pneumonia following femoral fracture surgeries remains sparse. Our study sought to explore the incidence and impact of postoperative pneumonia on outcomes following such surgeries. METHODS: A retrospective study analyzed femoral fracture patients hospitalized from 2016 to 2022. We scrutinized postoperative outcomes, including pneumonia, hospital stay duration, intensive care unit (ICU) admissions, and in-hospital mortality. We established stringent diagnostic criteria for postoperative pneumonia, incorporating both clinical signs and radiological evidence, excluding patients with prior infections or those discharged within 24 h post-surgery. Statistical analyses involved Chi-square and t-tests, linear regression, and logestic regression using SPSS. RESULTS: Out of 636 patients, 10.8% were diagnosed with postoperative pneumonia. The average age was 79.55 ± 8.57 years, with a male prevalence of 47.8%. Common comorbidities were hypertension (78.3%), diabetes (60.9%), and cardiovascular diseases (40.6%). Surgical interventions were categorized as intramedullary nailing (40.6%), partial hip replacement (37.7%), and dynamic hip screw (21.7%). Postoperative pneumonia was associated with older age (AOR = 1.053, 95% CI 1.020 to 1.087, p = 0.002), ICU admission (AOR = 2.283, 95% CI 1.256 to 4.148, p = 0.007), and longer length of hospital stay (AOR = 1.079, 95% CI 1.030 to 1.130, p = 0.001). The presence of pneumonia was associated with a 2.621-day increase in hospitalization after adjusting for other variables (p < 0.001, 95% CI: 1.454 to 3.789). CONCLUSION: This study accentuates the clinical significance of postoperative pneumonia in femoral fracture patients, with a noted incidence of 10.8%. A notable association with older age, prolonged hospital stays, and ICU admissions was observed, underscoring the necessity of addressing this complication to improve patient outcomes and healthcare resource allocation.

Risk factors for femoral stem fracture following total hip arthroplasty: a systematic review and meta analysis.

BACKGROUND: Femoral stem fracture following total hip arthroplasty (THA) is an infrequent but nevertheless devastating complication, with an increasing worldwide prevalence as demand for primary THA continues to increase. The aim of this study was to perform a systematic review and meta-analysis of risk factors for femoral stem fracture to help identify at risk patients. METHODS: A systematic search was conducted on EMBASE, MEDLINE and AMED to identify relevant studies. Data regarding study design, source, population, intervention, and outcomes was collated. Data extraction was performed on a custom form generated using Cochrane recommended methodology and analysis of risk factors performed including odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: A total of 15 studies reporting a total of 402 stem fractures in 49 723 THAs were identified. The median time from index procedure to stem fracture was 68 months (IQR 42.5-118) whilst mean age at index surgery was 61.8 years (SD 6.9). Male gender (OR = 3.27, 95% CI = 2.59-4.13, p < 0.001), patient weight above 80 kg (OR = 3.55, 95% CI = 2.88-4.37, p < 0.001), age under 63 years (OR = 1.22, 95% CI = 1.01-1.49, p < 0.001), varus stem alignment (OR = 5.77, 95% CI = 3.83-8.7, p < 0.001), use of modular implants (OR = 1.95, 95% CI = 1.56-2.44, p < 0.01) and undergoing revision arthroplasty (OR = 3.33, 95% CI = 2.70-4.1, p < 0.001) were significant risk factors for prosthetic stem fracture. A risk window of 15 years post-surgery was identified. CONCLUSIONS: This review concludes that patient weight, younger age, male sex, varus stem alignment, revision arthroplasty and use of modular stems are significant risk factors for femoral stem fracture. Modifying these risk factors where possible may help reduce incidence of femoral stem fracture in at risk patients.

Differences in femoral fracture localizations in men and women in Switzerland between 1998 and 2021-reversal of the secular trend?

Number and age-standardized incidences of femoral fractures by sex and localization were determined annually between 1998 and 2021 in subjects aged 45 years or older living in Switzerland. The number and incidences of femoral neck, pertrochanteric, subtrochanteric, and femoral shaft fractures followed distinct unexpected trend patterns. INTRODUCTION: Long-term incidence trends for femoral fractures by individual localizations are unknown. METHODS: Annual absolute number of hospitalizations and median age at hospital admission between 1998 and 2021 were extracted from the medical database of the Swiss Federal Office of Statistics by sex and 10-year age groups for the following 10th International Classification of Diseases (ICD-10) codes: femoral neck (ICD-10 S72.0), pertrochanteric (S72.1), subtrochanteric (S72.2), and femoral shaft fractures (S72.3). Age-standardized incidence rates (ASI) and corresponding trends were calculated. RESULTS: Over 24 years, the number of femoral neck fractures increased in men (+ 45%) but decreased in women (- 7%) with ASI significantly decreasing by 20% and 37% (p < 0.001 for trend for both), respectively. By contrast, the number of pertrochanteric fractures increased by 67% and 45% in men and women, respectively, corresponding to a horizontal ASI-trend in men (n.s.) and a modest significant decreasing ASI-trend in women (p < 0.001). The number of subtrochanteric fractures increased in both sexes with corresponding modest significant reductions in ASI-trends (p = 0.015 and 0.002, respectively). Femoral shaft fractures almost doubled in men (+ 71%) and doubled in women (+ 100%) with corresponding significant increases in ASI-trends (p = 0.001 and p < 0.001, respectively). Age at admission increased for all fracture localizations, more so in men than in women and more so for subtrochanteric and shaft fractures than for "typical" hip fractures. CONCLUSION: Incidence changes of pertrochanteric fractures and femoral shaft fractures deserve increased attention, especially in men. Pooling diagnostic codes for defining hip fractures may hide differing patterns by localization and sex.

Surgical treatment of osteogenesis imperfecta: a summary of the incidence of femoral implant-related complications in children with Sillence type I, III and IV.

PURPOSE: This study explored the incidence of IRCs used in the procedures of the femur in children with osteogenesis imperfecta (OI) and investigated the independent risk factors of IRCs. METHODS: Three hundred eight-eight cases of surgical data about children with OI were included, who were treated with plate, elastic nail, Kirschner wire and telescopic rod. The choice of different procedures depended on the age of children, the status of femur and the availability of devices. Patient demographics and major IRCs were recorded to compare the outcomes of the four procedures. Then, Cox proportional hazard regression was used to analyse the independent risk factors of IRC, and subgroup analysis was applied to further verify the above results. RESULTS: The total incidence of IRC in the four groups was 90.1% (191/212) for plate, 96.8% (30/31) for Kirschner wire, 87.7% (57/65) for elastic nail and 30.0% (24/80) for telescopic rod. The incidence of IRC in the telescopic rod was lower than that in plate, elastic nail and Kirschner wire (P < 0.001). Cox proportional hazard regression analysis confirmed that procedure was the independent risk factor of IRC (HR, 0.191; 95% CI, 0.126-0.288; P < 0.001), fracture (HR, 0.193; 95% CI, 0.109-0.344; P < 0.001) and deformity (HR, 0.086; 95% CI, 0.027-0.272; P < 0.001). In addition, age of surgery was the independent risk factor of fracture (HR, 0.916; 95% CI, 0.882-0.952; P < 0.001) and deformity (HR, 1.052; 95% CI, 1.008-1.098; P = 0.019). Subgroup analysis confirmed that age of surgery, gender, classification, preoperative state and angle did not affect the effect of telescopic rod on reducing the risk of IRCs. CONCLUSIONS: In our cohort, lower incidence of IRCs was observed in telescopic rod group compared with plate, Kirschner wire and elastic nail. Procedure and age of surgery were independent risk factors of fracture. Likewise, procedure and age of surgery were independent risk factors of deformity, and procedure was independent risk factors of IRC.

Low rate of periprosthetic femoral fracture with the Hueter anterior approach using stems cemented according to the 'French paradox'.

Aims: The aim of this retrospective study was to assess the incidence of early periprosthetic femoral fracture (PFF) associated with Charnley-Kerboull (CK) femoral components cemented according to the 'French paradox' principles through the Hueter anterior approach (HAA) in patients older than 70 years. Methods: From a prospectively collected database, all short CK femoral components implanted consecutively from January 2018 to May 2022 through the HAA in patients older than 70 years were included. Exclusion criteria were age below 70 years, use of cementless femoral component, and approaches other than the HAA. A total of 416 short CK prostheses used by 25 surgeons with various levels of experience were included. All patients had a minimum of one-year follow-up, with a mean of 2.6 years (SD 1.1). The mean age was 77.4 years (70 to 95) and the mean BMI was 25.3 kg/m2 (18.4 to 43). Femoral anatomy was classified according to Dorr. The measured parameters included canal flare index, morphological cortical index, canal-calcar ratio, ilium-ischial ratio, and anterior superior iliac spine to greater trochanter (GT) distance. Results: Among the 416 THAs, two PFFs (0.48% (95% confidence interval 0.13 to 1.74)) were observed, including one Vancouver type B2 fracture 24 days postoperatively and one intraoperative Vancouver type B1 fracture. Valgus malalignment and higher canal bone ratio were found to be associated with PFF. Conclusion: This study demonstrated that short CK femoral components cemented according to the French paradox were associated with a low rate of early PFF (0.48%) in patients aged over 70 years. Longer follow-up is warranted to further evaluate the rate of fracture that may occur during the bone remodelling process and with time.

[Disproportionately increased incidence of proximal femoral fractures in a level one trauma center : Epidemiological analysis from 2016 to 2022]. / Überproportional angestiegene Inzidenz proximaler Femurfrakturen in einem Level-One-Traumazentrum : Epidemiologische Analyse von 2016 bis 2022.

BACKGROUND: Proximal femoral fractures represent the most frequent fracture entity in Germany accounting for more than 20% of all fractures. According to a decision of the Federal Joint Committee from 2019, proximal femoral fractures also have to be surgically treated within 24 h. In order to quantify a subjectively perceived increase in workload in trauma surgery at a supraregional trauma center, a retrospective analysis of the number of surgically treated proximal femoral fractures was performed. Proximal femoral fractures were chosen due to their high incidence and homogeneous treatment. METHODS: Using ICD-10 codes, all surgically treated proximal femoral fractures from 2016 to 2022, including the patient's zip code, were retrieved from the database of the trauma center. RESULTS: The number of surgically treated proximal femoral fractures doubled from 2016 to 2022. The highest increase (60%) was recorded from 2020 to 2022. Heat maps show an increase in the catchment area radius as well. CONCLUSION: When compared (inter)nationally, a disproportionate increase in the amount of surgically treated proximal femoral fractures was recorded at the trauma center studied. The increase of the catchment area radius and the number of patients treated in the urban area show that less and less hospitals participate in emergency treatment. Possible explanations are a lack of resources aggravated by the recent COVID-19 pandemic and a lack of qualified personnel, interface problems between the federal states or the strict requirements of the Federal Joint Committee in the treatment of proximal femoral fractures. It must be assumed that there is a clearly increased workload for all professions involved in the trauma center investigated, although the infrastructure has remained unchanged.

Incidences and Outcomes of Operatively Treated Interprosthetic Femoral Fractures Compared to Vancouver Type C and Rorabeck Type II Fractures.

BACKGROUND: This case-control study evaluated the incidences and outcomes of interprosthetic femoral fracture (IPFF) (Group I) and performed comparisons with Vancouver type C (Group II) and Rorabeck type II (Group III) periprosthetic femoral fractures (PPFF) occurring at similar anatomic sites. METHODS: A retrospective analysis was performed for all patients who had a previously implanted total hip arthroplasty (THA) and total knee arthroplasty (TKA), who lived in the hospital district and had undergone surgery due to PPFF. A total of 153 PPFFs [Group I (n = 31), Group II (n = 21), and Group III (n = 108)] were included. The annual incidences of PPFFs were summarized per 100,000 individuals. The risks of complications, reoperations, and mortalities were evaluated for all groups. RESULTS: The mean population-based annual incidence was 0.9 per 100,000 person years for Group I, 0.7 per 100,000 person years for Group II, and 3.1 per 100,000 person years for Group III. A total of 25 of 153 (16%) major complications were found and 23 of 153 (13%) cases resulted in a revision surgery. The cumulative incidence of death in Group I was 50.4% at 10 years, in Group II it was 63.8% at 10 years, and in Group III it was 74.9% at 10 years. CONCLUSION: The annual incidence of the IPFF almost doubled while the incidence of Vancouver type C stayed stable and Rorabeck type II incidence increased 5-fold. Most of the major complications occurred in IPFF group, while Rorabeck type II patients had the worst survival.

What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States?

BACKGROUND: Periprosthetic femoral fractures are a serious complication that put a high burden on patients. However, comprehensive analyses of their incidence, mortality, and complication rates based on large-registry data are scarce. QUESTIONS/PURPOSES: In this large-database study, we asked: (1) What is the incidence of periprosthetic femoral fractures in patients 65 years and older in the United States? (2) What are the rates of mortality, infection, and nonunion, and what factors are associated with these outcomes? METHODS: In this retrospective, comparative, large-database study, periprosthetic femoral fractures occurring between January 1, 2010, and December 31, 2019, were identified from Medicare physician service records encompassing services rendered in medical offices, clinics, hospitals, emergency departments, skilled nursing facilities, and other healthcare institutions from approximately 2.5 million enrollees. These were grouped into proximal, distal, and shaft fractures after TKA and THA. We calculated the incidence of periprosthetic femur fractures by year. Incidence rate ratios (IRR) were calculated by dividing the incidence in 2019 by the incidence in 2010. The Kaplan-Meier method with Fine and Gray subdistribution adaptation was used to calculate the cumulative incidence rates of mortality, infection, and nonunion. Semiparametric Cox regression was applied with 23 measures as covariates to determine factors associated with these outcomes. RESULTS: From 2010 to 2019, the incidence of periprosthetic femoral fractures increased steeply (TKA for distal fractures: IRR 3.3 [95% CI 1 to 9]; p = 0.02; THA for proximal fractures: IRR 2.3 [95% CI 1 to 4]; p = 0.01). One-year mortality rates were 23% (95% CI 18% to 28%) for distal fractures treated with THA, 21% (95% CI 19% to 24%) for proximal fractures treated with THA, 22% (95% CI 19% to 26%) for shaft fractures treated with THA, 21% (95% CI 18% to 25%) for distal fractures treated with TKA , 22% (95% CI 17% to 28%) for proximal fractures treated with TKA, and 24% (95% CI 19% to 29%) for shaft fractures treated with TKA. The 5-year mortality rate was 63% (95% CI 54% to 70%) for distal fractures treated with THA, 57% (95% CI 54% to 62%) for proximal fractures treated with THA, 58% (95% CI 52% to 63%) for shaft fractures treated with THA, 57% (95% CI 52% to 62%) for distal fractures treated with TKA , 57% (95% CI 49% to 65%) for proximal fractures treated with TKA, and 57% (95% CI 49% to 64%) for shaft fractures treated with TKA. Age older than 75 years, male sex, chronic obstructive pulmonary disease (HR 1.48 [95% CI 1.32 to 1.67] after THA and HR 1.45 [95% CI 1.20 to 1.74] after TKA), cerebrovascular disease after THA, chronic kidney disease (HR 1.28 [95% CI 1.12 to 1.46] after THA and HR 1.50 [95% CI 1.24 to 1.82] after TKA), diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis were clinical risk factors for an increased risk of mortality. Within the first 2 years, fracture-related infections occurred in 5% (95% CI 4% to 7%) of patients who had distal fractures treated with THA, 5% [95% CI 5% to 6%]) of patients who had proximal fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had shaft fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had distal fractures treated with TKA , 7% (95% CI 5% to 9%) of patients who had proximal fractures treated with TKA, and 6% (95% CI 4% to 8%) of patients who had shaft fractures treated with TKA. Nonunion or malunion occurred in 3% (95% CI 2% to 4%) of patients with distal fractures treated with THA, 1% (95% CI 1% to 2%) of patients who had proximal fractures treated with THA, 2% (95% CI 1% to 3%) of patients who had shaft fractures treated with THA, 4% (95% CI 3% to 5%) of those who had distal fractures treated with TKA, , 2% (95% CI 1% to 4%) of those who had proximal fractures treated with TKA, and 3% (95% CI 2% to 4%) of those who had shaft fractures treated with TKA. CONCLUSION: An increasing number of periprosthetic fractures were observed during the investigated period. At 1 and 5 years after periprosthetic femur fracture, there was a substantial death rate in patients with Medicare. Conditions including cerebrovascular illness, chronic kidney disease, diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis are among the risk factors for increased mortality. After the surgical care of periprosthetic femur fractures, the rates of fracture-related infection and nonunion were high, resulting in a serious risk to affected patients. Patient well-being can be enhanced by an interdisciplinary team in geriatric traumatology and should be improved to lower the risk of postoperative death. Additionally, it is important to ensure that surgical measures to prevent fracture-related infections are followed diligently. Furthermore, there is a need to continue improving implants and surgical techniques to avoid often-fatal complications such as fracture-associated infections and nonunion, which should be addressed in further studies. LEVEL OF EVIDENCE: Level III, therapeutic study.

The increasing complexity of femoral fragility fractures: incidence, fracture patterns and management over a 10-year period.

INTRODUCTION: The purpose of this study was to determine whether there have been changes in the numbers and complexity of femoral fragility fractures presenting to our department over a period of 10 years. METHODS: Patients >60 years presenting with femoral fragility fractures to our institution in 2018-2019 (397 fractures) were compared with respect to demographic data, incidence rates, fracture classification and surgical management with a historical cohort from 2009-2010 (335 fractures). Pathological and high velocity fractures were excluded. RESULTS: The gender proportion and average age (83.1 vs. 82.7 years) was unchanged. The number of femoral fractures increased by 19% but the overall incidence in people >60 years fell by 6% (p = 0.41). The proportion of unstable trochanteric fractures (31A2 and A3) increased from 22% to 55% (p < 0.001). The proportion of displaced intracapsular fractures increased from 53% to 72% (p < 0.001). The incidence of stable trochanteric fractures fell from 12.4 to 7.3/10,000 patients>60 years (p = 0.0006) while the incidence of unstable trochanteric fractures (31A2 and 31A3) increased from 3.5 to 8.9/10,000 patients >60 years (p < 0.0001). The proportion of trochanteric fractures treated with an intramedullary (IM) nail increased from 9% to 35% (p = 0.0001). The number of shaft and distal femoral fractures increased by 41% although the incidence did not change significantly. Periprosthetic fractures comprised 70% of femoral shaft fractures in both cohorts. CONCLUSIONS: The increasing number and complexity of femoral fragility fractures, especially unstable trochanteric fractures and periprosthetic fractures, is likely to have an impact on implant use, theatre time and cost.

Early Periprosthetic Femur Fractures After Primary Cementless Total Hip Arthroplasty: High Risk of Periprosthetic Joint Infection and Subsequent Reoperation.

BACKGROUND: Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late. METHODS: We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation. RESULTS: Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union). CONCLUSIONS: There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.

Fewer native and periprosthetic femoral fracture patients receive an orthogeriatric review and expedited surgery compared to hip fracture patients.

INTRODUCTION: Disproportionate emphasis has been attributed to hip fracture over other femoral fractures through implementation of Best Practice Tariff (BPT).This retrospective comparative observational cohort study aimed to evaluate the epidemiology of native and periprosthetic femoral fractures and establish any disparities in their management relative to hip fractures. METHODS: All patients ⩾60 years admitted with a native or periprosthetic femoral fracture during July 2016-June 2018 were identified using our hospital database. Results were compared to National Hip Fracture Database data over the same period. RESULTS: 58 native femoral, 87 periprosthetic and 1032 hip fractures were identified. (46/58) 79% and 76/87 (89%) of native and periprosthetic femoral fractures were managed operatively. Surgery was performed <36 hours for 34/46 (74%) of native femoral and 33/76 (43%) of periprosthetic fractures compared to 826/1032 (80%) for hips. Median time to surgery was longer in periprosthetic femoral than hip fracture patients (44.7 vs. 21.6 hours; p < 0.0001). Orthogeriatrician review occurred in 24/58 (41%) and 48/87 (55%) of native and periprosthetic fractures compared to 1017/1032 (99%) for hips (p < 0.0001). One year mortality was 35%, 20% and 26% for native femoral, periprosthetic and hip fracture patients. Cox proportional hazard ratio was higher for native femoral than hip fracture patients (1.75; 95% CI, 1.12-2.73). CONCLUSIONS: This study demonstrates large disparities in management of other femoral and periprosthetic fractures compared to hip fractures, specifically time to surgery and orthogeriatrician review. This may have resulted in the comparatively higher mortality rate of native femoral fracture patients. Expansion of the BPT to include the whole femur is likely to improve outcomes.

Management of Isolated Greater Trochanter Fractures Associated With Total Hip Arthroplasty.

Periprosthetic hip fractures are recognized complications associated with total hip arthroplasty. Over the past decade, there has been a 2.5-fold increase in the incidence of periprosthetic fractures which is expected to grow exponentially in the future. Most of these fractures require surgical fixation or revision arthroplasty. Fractures of the greater trochanter represent a subset of periprosthetic fractures for which there is currently no consensus in the literature regarding the optimal management. The purpose of this review was to outline the management strategies available to address these fractures, with formulation of recommendations for fractures sustained intraoperatively, postoperatively, and in the setting of primary and revision total hip arthroplasty.

Trends in incidence, health care consumption, and medical and productivity costs of femoral shaft fractures in the Netherlands between 2005 and 2019.

INTRODUCTION: Population-based knowledge on the occurrence of femoral shaft fractures is necessary for allocation of health care services, optimization of preventive measures, and research purposes. This nationwide study aimed to provide an overview on the incidence of femoral shaft fractures over a 15-year period and to gain insight into health care consumption and work absence with associated costs in the Dutch population. METHODS: Data of patients who sustained an acute femoral shaft fracture in the years 2005-2019 were extracted from the National Medical Registration of the Dutch Hospital Database. The incidence rate, hospital length of stay (HLOS), direct medical costs, productivity costs, and years lived with disability were calculated for age- and gender specific groups. RESULTS: A total of 15,847 patients with a femoral shaft fracture were included. The incidence rate increased with 13 % over this 15-year period (5.71/100,000 persons per year in 2005 and 6.47/100,000 in 2019). The mean HLOS per patient was 13.8 days in 2005-2009 versus 8.4 days in 2015-2019 for the entire group. Mean HLOS per patient increased with age (10.0 days for age group 0-9 and 12.7 days for age group >80), but declined over time from 13.6 days in 2005-2009 to 8.8 days in 2015-2019 in males, and from 13.7 days and to 8.2 days, respectively, in females. The costs due to work absence was higher in males. Cumulative health care costs were highest in females >80 years (8.4 million euros versus 1.6 million in males). CONCLUSION: The incidence rate of femoral shaft fractures increased over the past 15 years in the Netherlands. Mean HLOS per patient has decreased in all age groups and in both sexes. Health care costs were highest for female octogenarians.

Proximal hip fractures in 71,920 elderly patients: incidence, epidemiology, mortality and costs from a retrospective observational study.

BACKGROUND: The risk of proximal femoral fractures increases with aging, causing significant morbidity, disability, mortality and socioeconomic pressure. The aims of the present work are (1) to investigate the epidemiology and incidence of these fractures among the elderly in the Region of Lombardy; (2) to identify the factors influencing survival; (3) to identify the factors influencing hospitalization and post-operative costs. METHODS: The Region of Lombardy provided anonymized datasets on hospitalized patients with a femoral neck fracture between 2011 and 2016, and anonymized datasets on extra-hospital treatments to track the patient history between 2008 and 2019. Statistical evaluations included descriptive statistics, survival analysis, Cox regression and multiple linear models. RESULTS: 71,920 older adults suffered a femoral fracture in Lombardy between 2011 and 2016. 76.3% of patients were females and the median age was 84. The raw incidence of fractures was stable from year 2011 to year 2016, while the age-adjusted incidence diminished. Pertrochanteric fractures were more spread than transcervical fractures. In patients treated with surgery, receiving treatment within 48 h reduced the hazard of death within the next 24 months. Combined surgical procedures led to increased hazard in comparison with arthroplasty alone, while no differences were observed between different arthroplasties and reduction or fixation. In patients treated conservatively, age and male gender were associated with higher hazard of death. All patients considered, the type of surgery was the main factor determining primary hospitalization costs. A higher number of surgeries performed by the index hospital in the previous year was associated with financial savings. The early intervention significantly correlated with minor costs. CONCLUSIONS: The number of proximal femoral fractures is increasing even if the age-adjusted incidence is decreasing. This is possibly due to prevention policies focused on the oldest cohort of the population. Two policies proved to be significantly beneficial in clinical and financial terms: the centralization of patients in high-volume hospitals and a time limit of 48 h from fracture to surgery. TRIAL REGISTRATION: Non applicable.

Risk factors, classification, and operative choices of femur fractures at a Tertiary Hospital: first report from Somalia.

A traumatic femur fracture is a significant cause of morbidity, affecting one to three million individuals annually. The present is the first study investigated the epidemiological characteristics, risk factors, classification, mechanisms of injury, and early management of femoral fractures in Somalia. This retrospective epidemiological study included all patients with a femur fracture who were admitted for four years between November 2018 and December 2022 to the orthopedic and trauma surgery department. We reviewed patient demographic characteristics, including age and gender, the mechanism of injury, injury characteristics, and the type of fixation performed. We reviewed the radiographs and classified the fracture using the AO/OTA classification system. During the study period, a total of 402 patients were treated for femur fractures; 256 (64%) were males, and 144 (36%) were females. The mean patient age was 47.7 ± 8.5 years. Regarding the anatomical location of femur fractures, the proximal (31A, 31B) was the most common, accounting for 50% of the patients. Femur neck fracture (31B) was the most common in the proximal femur fractures. Gunshot 82 (59.42%) was the leading cause of femur shaft fractures. Most patients with femur shaft fractures were males; 150 (86.20%) and 152 (64.47%) were young patients between 19 and 40 years old. Almost half of the patients (86) with femur shaft fractures had open fractures. The distribution of the mechanism of injury significantly differed according to age (p < 0.001). Younger patients (< 40 years) were predominantly injured due to gunshot injuries compared to elderly cases (> 60 years), where falls from standing height were the primary mechanism of injuries. There was a statistically significant difference between the mechanism of injury and gender categories (p < 0.001). Male patients were injured mainly by gunshots in about 40%, while 80% of fractures in female patients were due to falls from standing height. Female fractures occurred primarily in the proximal, while the males had an equal fracture rate for proximal and shaft fractures. Femur fracture causes significant morbidity and mortality. The study findings revealed that the most common femur fracture type was femur neck fracture, and low-energy injuries were the most common mode of injury in the elderly. Proximal femur fractures occur in older age and mainly in females. Gunshots were the most common cause of femur shaft fractures in Somalia, a country that has struggled with wars for over 30 years.

Epidemiology and risk factors for premature physeal closure in distal femur fractures.

BACKGROUND AND PURPOSE: Premature physeal closure (PPC) is a common and concerning complication to distal femoral fractures as the distal growth plate accounts for 70% of the growth of the femur. The literature is not unanimous in determining the risk factors of PPC, and the epidemiological characterization of these fractures is limited. Our aim was to calculate the population-based incidence and investigate risk factors for PPC in these fractures. PATIENTS AND METHODS: In this register-based study, between 2014 and 2021, 70 children with distal femoral physeal fractures presented to our hospital. Demographic data, and fracture- and treatment-related details were collected using the Kids' Fracture Tool. A directed acyclic graph (DAG) was constructed to determine confounding factors used in the risk analysis. RESULTS: Physeal fractures of the distal femur occurred with an annual incidence of 6/105 children, and a resulting PPC occurred in 16/70 (23%) with an annual incidence of 1.3/105 children. In multivariable analysis, dislocation exceeding 10 mm was a risk factor for PPC (OR 6.3, CI 1.4-22). CONCLUSION: One-fourth of distal femoral physeal fractures developed PPC. Greater dislocation and higher injury energy were significant risk factors, whereas choice of fracture treatment was not an independent risk factor. All patients with PPC belonged in the age group 11-16 years.

Current standard of care for distal femur fractures in Germany and Switzerland.

BACKGROUND: Distal femur fractures occur with an incidence of 4.5/100,000 and show a prevalence of 0.4%. Causes include low-impact trauma in older patients and high-impact trauma in younger patients without pre-existing medical conditions. The aim of this study was to perform a comprehensive evaluation of trauma mechanisms, trauma-promoting factors, comorbidities, medication history and type of surgical care to provide an overview of the causes of injury and the most appropriate therapeutic approach. METHODS: In this multicenter cohort study a retrospective analysis of 229 patients who sustained a distal femur fracture between January 2011 and December 2020 was performed. Individual fracture patterns, fracture predisposing factors, concomitant disease profiles, medication history, treatment strategy and associated complications were analyzed. RESULTS: 229 patients were included in the retrospective analysis. A total of 113-type 33 A, 50-type 33 B and 66-type 33 C fractures were diagnosed, of whom 92% received a lateral locking plate osteosynthesis. There was a complication in 14.4% of all cases, of which 6.1% were attributable to infection. Significant risk factors for developing a complication were an increased BMI (29.9 ± 8.5 kg/m2; p = 0.04), fracture displacement of over half a shaft width (p < 0.001) and AOC fractures (p < 0,016), specifically C2 fractures (p < 0,008). CONCLUSION: In this multicenter retrospective cohort study, lateral locking plate osteosynthesis was the method of choice and was selected in over 90% of cases, regardless of the fracture classification and risk factors. A complication rate of 14.4% emphasizes the necessary analysis of patient- and care-specific risk factors and a resulting adjustment of the therapy strategy. An increased BMI (29.9 ± 8.5 kg/m2; p = 0.04), fracture displacement of over half a shaft width (p < 0.001) and AOC fractures (p < 0,016), specifically C2 fractures (p < 0,008) increase the risk of developing a complication and should prompt an early switch to a treatment strategy that provides more stability.

Rectangular Taper Stem Designs Are Associated With a Higher Risk for Periprosthstic Femoral Fractures After Cementless Total Hip Arthroplasty.

BACKGROUND: Periprosthetic femoral fractures (PFFs) remain a major concern following cementless total hip arthroplasty (THA). This study aimed to evaluate the association between different types of cementless tapered stems and the risk of postoperative PFF. METHODS: A retrospective review of primary THAs performed at a single center from January 2011 to December 2018 included 3,315 hips (2,326 patients). Cementless stems were classified according to their design. The incidence of PFF was compared between flat taper porous-coated stems (type A), rectangular taper grit-blasted stems (type B1), and quadrangular taper hydroxyapatite-coated stems (type B2). Multivariate regression analyses were performed to identify independent factors related to PFF. The mean follow-up duration was 61 months (range, 12 to 139). Overall, 45 (1.4%) postoperative PFFs occurred. RESULTS: The incidence of PFF was significantly higher in type B1 stems than in type A and type B2 stems (1.8 versus 0.7 versus 0.7%; P = .022). Additionally, more surgical treatments (1.7 versus 0.5 versus 0.7%; P = .013) and femoral revisions (1.2 versus 0.2 versus 0%; P = .004) were required for PFF in type B1 stems. After controlling for confounding variables, older age, diagnosis of hip fracture, and use of type B1 stems were significant factors associated with PFF. CONCLUSION: Type B1 rectangular taper stems were found to have higher risks for postoperative PFF and PFF requiring surgical management than type A and type B2 stems in THA. Femoral stem geometry should be considered when planning for cementless THA in elderly patients who have compromised bone quality.

Perioperative allogenic blood transfusions are associated with increased fracture related infection rates, but not nonunion in operatively treated distal femur fractures.

INTRODUCTION: Distal femur fractures are common injuries that remain difficult for orthopedic surgeons to treat. High complication rates, including nonunion rates as high as 24% and infection rates of 8%, can lead to increased morbidity for these patients. Allogenic blood transfusions have previously been identified as risk factors for infection in total joint arthroplasty and spinal fusion surgeries. No studies have explored the relationship between blood transfusions and fracture related infection (FRI) or nonunion in distal femur fractures. METHODS: 418 patients with operatively treated distal femur fractures at two level I trauma centers were retrospectively reviewed. Patient demographics were collected including age, gender, BMI, medical comorbidities, and smoking. Injury and treatment information was also collected including open fracture, polytrauma status, implant, perioperative transfusions, FRI, and nonunion. Patients with less than three months of follow up were excluded. RESULTS: 366 patients were included in final analysis. One hundred thirty-nine (38%) patients received a perioperative blood transfusion. Forty-seven (13%) nonunions and 30 (8%) FRI were identified. Allogenic blood transfusion was not associated with nonunion (13% vs 12%, P = 0.87), but was associated with FRI (15% vs 4%, P<0.001). Binary logistic regression analysis identified a dose dependent relationship between number of perioperative blood transfusions and FRI: total transfusion ≥2 U PRBC RR= 3.47(1.29, 8.10, P = 0.02), ≥3 RR= 6.99 (3.01, 12.40, P<0.001), and ≥4 RR= 8.94 (4.03, 14.42, P<0.001). DISCUSSION: In patients undergoing operative treatment of distal femur fractures, perioperative blood transfusions are associated with increased risk of fracture related infection, but not the development of a nonunion. This risk association increases in a dose-dependent relationship with increasing total blood transfusions received.

Femoral fractures in the immature skeleton: Characterization, risk factors, and treatment options in a developing country.

INTRODUCTION: Femur fracture is one of the most frequent reasons for admission to paediatric trauma units and has a bimodal incidence. The trauma mechanism varies according to the patient's age. Non-operative treatment continues to be performed, although surgical treatment has gained popularity in recent years. Paediatric orthopaedic traumatologists should always bear in mind the already known general principles of treatment. In this study, we aimed to provide a general characterization of femoral fractures, risk factors, and current definitive treatment methods in a developing Latin American country. MATERIALS AND METHODS: This is an observational, analytical, retrospective study with a non-probabilistic sample of consecutive cases of skeletally immature patients with femoral fractures treated at a trauma hospital in Asunción, Paraguay, from January to December 2022. Patients with diseases fragile bones and femoral fractures were excluded. Demographic and clinical characteristics of the study population were analysed. RESULTS: Traffic accidents were the most frequent cause of femoral fractures in our population. Femur fractures were more common in males. The femoral shaft was the most frequent fracture site. Age was one of the most important criteria for defining the treatment approach, considering non-operative management in children younger than 4 years. CONCLUSIONS: Fracture of the femoral shaft in male patients is the most frequent presentation at our Institution. Summer vacations and traffic accidents are the main risk factors identified in Paraguayan children who suffer a femoral fracture. Non-operative treatment is preferred in children under 4 years of age, while surgical treatment is preferred in children aged 5 years and above. Paediatric orthopaedic traumatologists should be involved in parent education to promote children's safety, especially by increasing care and vigilance during school vacations and dangers related to traffic accidents.