Patients aged ninety years and older are exposed to increased risk of one-year mortality after hip fractures.

BACKGROUND: The increase in the population over 90 years old suggests an expected surge in the number of extreme elderly patients sustaining hip fractures. OBJECTIVE: The aim of this study is to identify factors associated with 1-year mortality and determine the conditions that are associated with an unfavorable survival outcome in nonagenarians. DESIGN: Cross-sectional study SUBJECTS: Nonagenarian patients presenting with hip fractures between 2013 and 2018. METHODS: Bivariate and multivariate analyses were performed to identify variables associated with mortality, and a survival analysis was conducted to determine whether the Charlson Comorbidity Index (CCI) is associated with mortality. RESULTS: A total of 127 patients, with a mean age of 92.84 years was assessed, identifying 1-year mortality rate in 53.5% of patients. According to the bivariate analysis, requirement of postoperative vasopressor support, transfusion, decompensated heart failure and general anesthesia were associated with a higher probability of 1-year mortality after surgery. Body mass index, health status, dementia or CCI ≥ 3 were not associated with mortality. Similarly, the Kaplan-Meier survival analysis showed no difference in mortality rate of patients with CCI ≥ 3 (p = 0.282). CONCLUSION: Patients older than 90 years with hip fractures have higher mortality rates per year than younger patients. Some associations were found, but more studies are needed to reach final conclusions, which could help identify higher-risk patients and be able to implement additional measures.

Diagnostic imaging concordance study: Are traction radiographs necessary in a hip fracture?

INTRODUCTION: Hip fractures are a pathology that have emerged as a major subject over the years, due to increased prevalence and the multiple surgical treatments involved. The characterization and classification of the lesion is essential for proper surgical planning, with anteroposterior (AP), lateral and traction radiograph of the hip, paramount for decision-making. PATIENTS AND METHODS: This is a retrospective concordance study of 64 patients with hip fracture who consulted the hospital between January and July 2017. Four radiographs were taken of each: AP, AP with traction, lateral and lateral with traction. This set of images was evaluated by 9 observers, with different levels of experience, to answer questions regarding the classification, emphasize in potential instability and requirement of other images. A statistical analysis of concordance between and within observers was performed using Cohen's kappa coefficient. RESULTS: Of the 64 patients, 70.6% were women; the average age was 69.5 years. 82.8% presented a secondary fracture from falling from their own height. As the observer's experience increases, the need for traction radiograph decreases; interobserver kappa goes from 0.98 in experts to 0.01 in students. Traction radiograph is important in the diagnosis of potentially unstable fractures. Of the 1,503 radiographs with traction, 636 (42.38%) were classified as potentially unstable. And of the 708 without traction, 560 (79.1%) were classified as potentially unstable. CONCLUSIONS: Traction hip radiograph continues to be a useful tool in training environments to adequately classify an intertrochanteric fracture, considering it is a low-cost, minimal morbidity intervention, and is easily accessible. In similar studies, we found similar findings regarding the usefulness of traction to perform an adequate classification in people in training or in young orthopedists. It also influences to determine the potential instability, and this would modify the choice of the implant.

Adaptación transcultural al Español y Validación de la Escala de Lysholm para evaluar la funcionalidad de la rodilla / Cross-cultural adaptation to Spanish and Validation of Lysholm knee Score

Introducción La escala de Lysholm fue desarrollada en 1982 y modificada en 1985 con el fin de evaluar la funcionalidad de los pacientes con lesiones ligamentarias; desde entonces ha sido ampliamente utilizada para evaluar subjetivamente a los pacientes en relación con su capacidad funcional. El propósito de este estudio fue realizar su traducción y adaptación transcultural al español colombiano y desarrollar la validación psicométrica a través de la evaluación de la consistencia interna y fiabilidad test-retest. Materiales y métodos Previa identificación de la escala original de interés, se realizó traducción (inglés-español), adaptación cultural y re-traducción (español-inglés) por expertos lingüistas nativos, quienes valoraron la similitud del contenido de ambos productos (original y retraducido). Asimismo, dicha última versión fue valorada por 40 pacientes con enfermedad de rodilla (lesión meniscal, ruptura de ligamento cruzado anterior, condromalacia y gonartrosis), quienes confirmaron comprender el texto. Posteriormente fue evaluada la consistencia interna mediante la prueba de alfa de Cronbach para todos los ítems, y el coeficiente correlación intraclase­puntaje total del sub-constructo a través de una muestra aleatoria (n=93), la cual validó la estructura factorial de la escala. Resultados El alfa de Cronbach fue de 0,737 y el coeficiente de correlación interclase fue de 0,844, asociado a una concordancia inter-observador alta (Gamma=0,752). El gráfico de Bland-Altman no demostró diferencias sistemáticas entre las mediciones Discusión La presente versión al español (colombiano) de la escala Lysholm es una herramienta válida para medir la funcionalidad en pacientes con lesiones meniscales del ligamento cruzado anterior, condromalacia patelofemoral y gonartrosis en países de habla hispana (preferentemente en Colombia).

Background The Lysholm scale was developed in 1982 and modified in 1985 in order to assess the functionality of patients with knee ligament injuries; since then it has been widely used to subjectively evaluate patients in relation to their functional capacity. The purpose of the study was to carry out its translation and cross-cultural adaptation to Colombian Spanish and to develop psychometric validation through the evaluation of internal consistency and test-retest reliability. Methods After identifying the original scale of interest, translation (English-Spanish), cultural adaptation and re-translation (Spanish-English) were carried out by native linguist experts, who assessed the similarity of the content of both products (original and retranslated). Likewise, this latest version was evaluated by 40 patients with knee disease (meniscal injury, anterior cruciate ligament rupture, chondromalacia and gonarthrosis), who confirmed that they understood the text. Subsequently, the internal consistency was evaluated using Cronbach's alpha test for all items, and the intraclass correlation coefficient ­ ??total score of the sub-construct through a random sample (n=93), which validated the factorial structure of the scale. Results Cronbach's alpha was 0.737 and the interclass correlation coefficient was 0.844, associated with a high inter-observer agreement (Gamma=0.752). The Bland-Altman plot did not show systematic differences between the measurements Discussion This Spanish (Colombian) version of the Lysholm scale is a valid tool to measure functionality in patients with meniscal lesions of the anterior cruciate ligament, patellofemoral chondromalacia and gonarthrosis in Spanish-speaking countries (preferably in Colombia).

Rodilla Flotante: modificación de la clasificación de Fraser y factores asociados con los resultados funcionales / Floating knee: modification on the Fraser classification and factors associated with functional results

Introducción Los casos de rodilla flotante son secundarios a traumas de alta energía, lo que conlleva altas tasas de complicaciones y múltiples patrones de fractura. Este estudio introduce una modificación de la Clasificación de Fraser e identifica factores relacionados con los resultados funcionales. Métodos Se realizó un estudio de cohorte ambidireccional con pacientes diagnosticados con rodilla flotante manejados entre los años 2008 al 2012 en un hospital de referencia. Se recolectaron variables demográficas, presencia de lesión vascular, infección y fracturas abiertas. Se utilizó una modificación de la Clasificación de Fraser para clasificar las fracturas óseas. La Clasificación de Fraser Modificada (CFM) abarcó la siguiente distribución: Tipo I, Tipo II A, Tipo II B y Tipo II C, además de adicionar los Tipos III A, III B y III C. Se evaluó la correlación entre la funcionalidad y la CFM. Se utilizaron los criterios de Karlstrom y Olerud para evaluar la funcionalidad. Resultados Se incluyeron 34 pacientes en el estudio, 30 (88%) hombres y 4 (12%) mujeres con un promedio de edad de 32 años±10,3. Según la CFM las fracturas Tipo II A con 15 (44%) casos y la Tipo I con 13 (38%) casos fueron las fracturas más comunes. 17 (50%) pacientes presentaron un resultado excelente, 3 (9%) bueno, 5 (15%) aceptable y 9 (26%) pobre. Se encontró una correlación moderada entre un resultado pobre y la Clasificación de Fraser Modificada (rho=0.42, p=0.046). La edad ≥ 40 años (OR 6.7 IC 95% 1.1 ­ 41, p=0.03) y la infección en la extremidad inferior afectada (OR 7.2 IC 95% 1.5 ­ 33, p=0.01), se asociaron con un resultado funcional aceptable/pobre. Discusión La Clasificación de Fraser Modificada incluye más patrones de fractura en comparación con la clasificación de Fraser original, permitiendo una mejor caracterización radiológica de las fracturas, con una correlación moderada con los resultados funcionales. La edad ≥ 40 años y la infección en la extremidad comprometida, se asociaron con un resultado funcional aceptable/pobre.

Background Floating Knee is due to high energy trauma, with high rates of complications and multiple patterns of fractures. A modification of the Fraser Classification is introduced, and identifies factors associated with functional outcomes. Methods An ambidirectional cohort study was conducted in a referral teaching hospital during 2008 and 2012. Demographic variables, vascular lesion, infection, and open fractures were recorded. A modification of the Fraser Classification was used to classify the fractures. The Modified Fraser Classification (MFC) encompasses the following distribution: Type I, Type II A, Type II B, and Type II C, and Type III A, Type III B, and Type III C, was added. The correlation between functionality and the MFC was assessed. The Karlstrom and Olerud criteria were used to determine the functional outcome. Results A total of 34 patients were included, of whom 30 (80%) were males and 4 (12%) females. The mean age was 32 years±10.3. According to the MFC, the Type II A (n=15 - 44%) and Type I (n=13 - 38%) were the most common. The functionality outcomes of the patients were Excellent in 50% (17), Good in 9% (3), Acceptable in 15% (5), and Poor in 26% (9). There was a moderate correlation between poor outcomes and the Modified Fraser Classification (rho=0.42, P=0.046). Age ≥ 40 years (OR 6.7, 95% CI; 1.1 ­ 41, P=0.03) and infection (OR 7.2, 95% CI; 1.5 ­ 33, P=0.01) were associated with acceptable/poor results. Discussion The Modified Fraser Classification includes more patterns of fractures in comparison with the original Fraser Classification, allowing for a better characterisation of the patients, with moderate correlation with functional outcomes. Age ≥ 40 years and infection were associated with an acceptable/poor result.

Clinical implications of impingement of the anterior femoral cortex after cephalomedullary nailing.

BACKGROUND: Cortical impingement is a common complication after cephalomedullary nailing, but the evidence about its consequences is very limited. The aim of this study was to assess the clinical implications of cortical impingement on patients treated with cephalomedullary nails. METHODS: A cohort study was carried out at a Level I academic Institution with consecutive patients treated with cephalomedullary nails during 2010 and 2013. Demographic and nail variables were recorded as well as cortical impingement was determined on the radiographs. Clinical outcomes such as pain, femoral fractures, and delayed or nonunion of the fracture were detected during the follow-up. The follow-up was divided into short- (6-12 months), medium- (12.1-36 months), and long-term follow-up (≥36.1months). Descriptive statistics were used, and Chi-square or Fisher's exact tests measured the association between categorical variables. The Mann-Whitney U test was performed to evaluate differences between cortical impingement in terms of pain, and pain and the follow-up categories. RESULTS: A total of 119 patients were analyzed with a mean age of 74.8 years±17.1, and a mean follow-up of 23.5 months±12.1. Overall the pain was present in 61 (51.2%) cases, and it was observed in 28/59 (47.4%) and 33/60 (55%) of the patients with presence or absence of cortical impingement respectively. There was not a statistically significant association between cortical impingement and pain (p=0.20), neither differences were detected between pain and the follow-up groups (p=0.48). Out of 59 cases with cortical impingement, femoral fractures were observed in two patients (3.3%), and delayed union of the fractures was seen in two patients who did not present impingement. Since patients with delayed union received treatment as soon as it was diagnosed, no cases of nonunion of fractures were identified. CONCLUSIONS: Cortical impingement of the anterior cortex of the femur was not associated with the presence of pain, so that other causes should be assessed to explain the pain after 6 months of being treated with a cephalomedullary nail. Femoral fractures, and delayed union or nonunion of the fracture may occur theoretically in patients with cortical impingement.

Cephalomedullary nails: factors associated with impingement of the anterior cortex of the femur in a Hispanic population.

INTRODUCTION: Impingement and penetration of the anterior cortex of the femur have been reported as complications after cephalomedullary nailing. The purpose of this study was to determine factors related to nail impingement in our population of Hispanic patients. MATERIALS AND METHODS: A non-matched case-control study was carried out and 156 patients who underwent cephalomedullary nailing from 2010 and 2013 were included; 78 cases with anterior cortical impingement and 78 control cases without impingement were documented. Demographic variables and specifications of the nails such as manufacture and radius of curvature were recorded. The presence of impingement, angle of incidence on radiographs--indirect measurement of the femoral bow on the sagittal plane--and nail entry site were determined. Bivariate and multivariate logistic regression analyses were performed to identify the factors associated with cortical impingement. RESULTS: The distribution by sex corresponded to 87 females (56%) and 69 males (44%) with a mean age of 75 years [SD 18.2]. Cortical impingement was presented in 78 cases (50%) and 6 (3.8%) patients evidenced penetration of the anterior cortex of the femur. On the bivariate analysis the posterior nail start site is highlighted, which showed a positive association with impingement (OR 4.3; 95% CI 1.1-36 and p = 0.04). After the multivariate analysis, the factors associated with anterior cortical impingement included female gender (OR 2.2; 95 % CI 1.1-4.6 and p ≤ 0.038), straight nails-short nails-(OR 4.9; 95% CI 2.2-10 and p ≤ 0.001) and angle of incidence ≥7° (OR 4.9; 95% CI 2.2-10 and p ≤ 0.001), the latter showing a likelihood of 57 % for impingement, increasing to 90% with an angle of incidence of 11°. CONCLUSIONS: Posterior entry site should be avoided and an anterior site should be used. Female gender, straight nails and greater angle of incidence of the femur were associated with cortical impingement. A specific intramedullary nail design is needed for the Hispanic population due to high impingement and anterior cortical penetration rates seen with conventional nails. Short curved nails and long nails with a lower radius of curvature are required.