Bipolar hemiarthroplasty for the treatment of femoral neck fractures with minimally invasive anterior approach in elderly.

OBJECTIVES: The purpose of the study was to evaluate the efficacy of hemiarthroplasty with minimally invasive direct anterior approach (DAA) for the treatment of femoral neck fracture in elderly patients. We aimed to compare the DAA and the standard anterolateral approach (ALA), assessing multiple peri­ and post-operative parameters. DESIGN AND SETTING: Between December of 2015 and May of 2017, patients operated with medial femoral neck fractures using bipolar hemiarthroplasty with DAA or ALA were evaluated. The volume of bleeding and transfusion, postoperative level of pain, mobilisation and functional outcome were assessed retrospectively. PARTICIPANTS: Patients between the age of 75 and 85, suffering Garden Type III Pauwels Type III and Garden Type IV medial femoral neck fractures were entered to the study. Patients had no history of anticoagulant therapy; the operation was performed in the first 48 h. All patients received similar postoperative pain management and physiotherapy. The type of implants was determined by the patients' bone morphology and quality. MAIN OUTCOME MEASURES: The outcomes of interest were the level of postoperative pain, blood loss, rate of recovery and physiotherapy, altered gait pattern and accuracy of leg length, related to DAA and ALA techniques. RESULTS: The 51 patients operated with DAA showed significantly less pain, based on VAS (visual analogue scale), starting of the first postoperative day. Those patients who were subjected to DAA met with the criteria of hospital discharge 1.68 days earlier, compared to ALA patients. The length of leg was accurately set in 21% of ALA vs 54.9% of DAA patients. On the 12th week follow-up, limping was detected only 5.9% of DAA vs 46% of ALA groups. On the postoperative 2nd and 6th weeks, the HHS (Harris Hip Score) was significantly better in patients with DAA, compared to ALA (77 vs 65 and 91 vs 77, p < .05). CONCLUSION: The bipolar hemiarthroplasty with DAA allows earlier mobilisation, reduced postoperative pain and need for rehabilitation with an overall better functional outcome, compared to ALA. DAA is proven a reliable choice for femoral neck fractures, offering good outcome and faster recovery, similarly to total hip arthroplasties with degenerative arthritis.

Efficacy of microbiological culturing in the diagnostics of joint and periprosthetic infections.

OBJECTIVES: To evaluate the efficacy of conventional microbiological examinations in the diagnostics of septic joint and periprosthetic inflammations. DESIGN AND SETTING: Evidence Level IV, retrospective clinical study of case series. Patients treated with small and large joint septic inflammations or with periprosthetic joint infections (PJI) were entered into the study. Demographics, microbiological cultures and inflammatory mediators were evaluated. PARTICIPANTS: Between 2012 and 2016, total of 1116 hip and 241 knee surgeries were performed at our Department in relation to prostheses; including primary and revision arthroplasties and further surgeries due to PJI. During this period, 72 patients were operated with large joints infections or PJI and another 65 patients were treated due to small joint infections. MAIN OUTCOME MEASURES: The main outcome of interest was to evaluate the sensitivity of conventional microbiological cultures in the primary diagnostics of joint and periprosthetic infections. RESULTS: The most frequent bacteria strains were the Staphylococci: in 43 cases (22.16%) Staphylococcus aureus, in 22 cases (11.34%) coagulase-negative Staphylococcus, in 3 cases (1.54%) Staphylococcus epidermidis and in 4 cases (2.06%) methicillin-resistant S. aureus (MRSA) were detected. In 30 cases (21.88%), the primary microbiological investigation could not reveal the presence of bacteria. CONCLUSION: Based on our data, the efficacy of conventional microbiological testing in the diagnostics of different type of joint infections is questionable. Therefore, further studies are warranted to evaluate the efficacy of novel diagnostic testing tools in prospective randomized controlled trials.

Non-operative predictors for subsequent interventions after intracapsular femoral neck fractures in elderly: A comprehensive analysis of the Hungarian nationwide health insurance database.

OBJECTIVES: To investigate the correlation between non-operative prognostic factors and non-prosthetic fracture-related treatments following internal fixation of intracapsular femoral neck fractures in elderly patients. DESIGN AND SETTING: Retrospective observational cohort study. Comprehensive analysis of the Hungarian nationwide health insurance database. PARTICIPANTS: Data of in-patient records with S7200 ICD-10 codes were collected from the Hungarian National Health Insurance Fund Administration (HNHIFA) and from the health care provider institutes. The patients with femoral neck fractures in the year of 2000, following reduction and internal fixation aged 60 years or older were evaluated. The secondary, non-prosthetic fracture related treatments during the 8 year follow-up period were registered. MAIN OUTCOME MEASURES: Of the prognostic factors, age, gender, type of fracture, season and day of the primary surgery, length of waiting time to the operation and the accompanied diseases were evaluated as risk factors for all type of fracture-related further interventions, with the exception of arthroplasties. RESULTS: A total of 2895 patients with intracapsular femoral neck fractures met the study criteria. The mean age was 77.96 years (SD: 8.54). The cohort of the patients was observed for a total of 10,077.8 person-years. The non-prosthetic fracture related treatment was performed in 265 patients (9,2%); the median of the time elapsed to the secondary definitive treatment was 3.5 months. With Cox regression analysis, significant correlation was revealed between the incidence of non-prosthetic treatment and younger age (year, HR = 0.977, p = 0.002), surgical delay (12-24 h vs 0-6 h, HR = 1.518, p = 0.023; 24h+ vs 0-6 h, HR = 1.372, p = 0.050), season of primary osteosynthesis (fall vs summer, HR = 0.636, p = 0.012), and type of femoral neck fracture (intracapsular displaced vs intracapsular undisplaced, HR = 1.340, p = 0,047). There was no significant effect of the day of primary surgery, the gender and the presence of co-morbidities on the incidence of further surgical interventions. CONCLUSION: The summertime primary surgical intervention, delay of surgery longer than 12 h and type of femoral neck fracture are independent predictors of non-prosthetic further treatment of femoral neck fractures in elderly patients. LEVEL OF EVIDENCE: Level IV, evidence from cohort studies.