Does Inpatient Mobilization Predict 1-Year Mortality After Femoral Neck Fracture Treated With Hemiarthroplasty?

OBJECTIVE: To determine whether inpatient mobilization (defined as ambulation before hospital discharge) is associated with 1-year mortality and 90-day hospital readmission in patients treated with a hip hemiarthroplasty for a femoral neck fracture. DESIGN: Retrospective case-control. SETTING: Academic Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred twelve consecutive femoral neck fractures were treated with hip hemiarthroplasties with a minimum of 1 year of follow-up. INTERVENTION: All study patients were treated with a hip hemiarthroplasty and weight-bearing as tolerated postoperative day 1. Patients were prescribed daily physical therapy with the goal of mobilization before discharge from hospital. MAIN OUTCOME MEASURES: Mortality at 1 year; hospital readmission within 90 days. RESULTS: Two hundred twelve patients were included in the study. One-year mortality was 29%. One hundred thirty-two (62%) patients were able to ambulate before hospital discharge. Ambulation with physical therapy before discharge from hospital was a significant predictor of 1-year mortality when compared with patients who were unable to ambulate (hazard ratio 0.57; 95% confidence interval, 0.34-0.94; P = 0.03), which equates to 43% reduction in risk of mortality. There was no difference in the 90-day readmission rates for ambulatory versus nonambulatory patients. CONCLUSIONS: Ambulation with physical therapy before discharge reduced the risk of 1-year mortality by 43%, without an effect on 90-day readmission. Sixty-two percentage of our cohort was able to ambulate before discharge. Future investigations are warranted to further identify those patients at heightened risk of mortality and readmission and the role of early rehabilitation in recovery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

New Developments in Hip Fracture Treatment to Reduce Morbidity and Mortality.

There have been major changes in the treatment of various hip fracture patterns in the proximal femur. The orthopaedic surgeon should be up to date on device management, current guidelines, and techniques in the care of hip fracture patterns.

Practical Surgical Techniques for Revision Total Hip Arthroplasty.

Although total hip arthroplasty is an extremely successful procedure, the continual increase in the number of total hip arthroplasties that are performed is associated with the substantial burden of revision total hip arthroplasty. Modes of total hip arthroplasty failure include instability, aseptic loosening, infection, periprosthetic fracture, hardware failure, and component wear, all of which are indications for revision total hip arthroplasty. Surgeons must have a sound preoperative revision total hip arthroplasty plan and must be familiar with a variety of component removal and exposure techniques, such as the extended trochanteric osteotomy. Alternative surgical plan(s) and extra implants for reconstruction on both the acetabular and femoral sides should be available in anticipation of unexpected findings. Component removal and exposure techniques can be refined to avoid complications and achieve a successful outcome in patients who undergo revision total hip arthroplasty.

Arthroplasty for Unreconstructable Acute Fractures and Failed Fracture Fixation About the Hip and Knee in the Active Elderly: A New Paradigm.

The techniques, materials, and designs for total joint arthroplasty underwent major improvements in the past 30 years. During this time, trauma surgeons classified the severity of fractures as well as identified certain articular fractures that do not have good outcomes and have a high rate of failure after internal fixation. Advanced improvements in arthroplasty have increased its reliability and longevity. Total joint arthroplasty is becoming a standard of care for some acute articular fractures, particularly displaced femoral neck fractures in the active elderly. Total joint arthroplasty also has become the standard of care after failed internal fixation in patients who have very complicated fractures about the knee, hip, and shoulder. As the population ages, fractures worldwide continue to rapidly increase. Elderly patients have a high risk for fractures that result from falls because of their poor bone quality. The current active elderly population participates in higher risk activities than previous elderly populations, which places them at risk for more injuries. This has become both a worldwide healthcare problem and an economic problem. Surgeons need to manage fractures in the active elderly with the latest advancements in technology and patient selection to ensure rapid recovery and the reduction of complications.

Complete Wear-Through of a Polyethylene Liner and Metal-Backed Acetabular Cup Resulting in a Unique Form of Catastrophic Total Hip Arthroplasty Failure: A Case Report.

CASE: We describe a case of total hip arthroplasty failure where a cobalt-chrome femoral head completely wore through the polyethylene liner and the titanium acetabular cup. The patient subsequently underwent revision total hip arthroplasty with acetabular revision and femoral head exchange. CONCLUSION: This case illustrates the natural history of catastrophic failure in a metal-on-polyethylene total hip arthroplasty design. If recognized earlier, this patient may have been a candidate for isolated liner and head exchange. Additionally, this case represents a unique complication in using mixed metals in total hip arthroplasty, where the harder cobalt-chrome femoral head wore completely through the much softer titanium component.

Subcapital fractures: in the bucket or on top of the neck?

Femoral neck fractures have a 30% reoperation rate when internally fixed. To reduce the reoperation rate, the surgeon must accurately decide which fractures are best fixed and which fractures require a prosthesis. The literature supports the fact that nondisplaced fractures should be internally fixed. Fractures in patients physiologically younger than 65 years should also be fixed if they have no comorbidities. The most important factors in reducing failure rate of fixation are patient selection and anatomic reduction. A femoral neck fracture left in varus is doomed to failure and reoperation. Femoral neck fractures that are displaced in patients older than 65 years require a decision-making algorithm to decide how they should be treated. In the physiologically active patient older than 65 years, internal fixation may be considered. In most patients older than 65 years, prosthetic replacement should be considered. Nursing home patients and patients with comorbidities who are not expected to live longer than 6 to 7 years should receive a hemiarthroplasty. Studies show a high reoperation rate if the patient with hemiarthroplasty survives more than 6 or 7 years. In the active elderly with little or no comorbidities, a total hip replacement should be considered. This is not only cost effective but provides the best pain relief of any of the treatment options for displaced femoral neck fractures. Treatment of femoral neck fractures remains a challenge, but the surgeon must develop an algorithm to select proper treatment options for the patient. The decision-making process is always shared with the patient.

Effect of nicotine and tobacco administration method on the mechanical properties of healing bone following closed fracture.

We previously showed different effects of tobacco and nicotine on fracture healing, but due to pump reservoir limits, maximum exposure period was 4 weeks. To allow flexibility in pre- and post-fracture exposure periods, the objective of this study was to compare a new oral administration route for nicotine to the established pump method. Four groups were studied: (1) pump saline, (2) pump saline + oral tobacco, (3) pump saline/nicotine + oral tobacco, and (4) pump saline + oral nicotine/tobacco. Sprague-Dawley rats (n = 84) received a transverse femoral fracture stabilized with an intramedullary pin 1 week after initiating dosing. After 3 weeks, no difference was found in torsional strength or stiffness between oral nicotine/tobacco or pump nicotine + tobacco, while energy absorption with oral nicotine/tobacco was greater than pump nicotine + tobacco (p < 0.05). Compared to saline control, strength for oral nicotine/tobacco was higher than control (p < 0.05), and stiffnesses for pump nicotine + tobacco and oral nicotine/tobacco were higher than control (p < 0.05). No differences in energy were found for either nicotine-tobacco group compared to saline control. Mean serum cotinine (stable nicotine metabolite) was different between pump and oral nicotine at 1 and 4 weeks, but all groups were in the range of 1-2 pack/day smokers. In summary, relevant serum cotinine levels can be reached in rats with oral nicotine, and, in the presence of tobacco, nicotine can influence mechanical aspects of fracture healing, dependent on administration method. Caution should be exercised when comparing results of fracture healing studies using different methods of nicotine administration.

Locking plates for extremity fractures.

Thirty-three peer-reviewed studies met the inclusion criteria for the Overview. Criteria were framed by three key questions regarding indications for the use of locking plates, their effectiveness in comparison with traditional nonlocking plates, and their cost-effectiveness. The studies were divided into seven applications: distal radius, proximal humerus, distal femur, periprosthetic femur, tibial plateau (AO/OTA type C), proximal tibia (AO/OTA type A or C), and distal tibia. Patient enrollment criteria were recorded to determine indications for use of locking plates, but the published studies do not consistently report the same enrollment criteria. Regarding effectiveness, there were no statistically significant differences between locking plates and nonlocking plates for patient-oriented outcomes, adverse events, or complications. The literature search did not identify any peer-reviewed studies that address the cost-effectiveness or cost-utility of locking plates.

Fractures of the femoral neck.

Fractures of the femoral neck are increasing at an exponential rate as a result of the longevity of the general population. The Garden and Pauwels classifications both are routinely used to describe displacement and stability of femoral neck fractures. Osteonecrosis and nonunion remain problematic because of the compromised blood supply to the femoral head in displaced fractures. Nondisplaced fractures and displaced fractures in patients physiologically younger than 65 years are treated with closed or open reduction and internal fixation. Anatomic reduction is the single most important step in the treatment and fixation of these difficult fractures. Because of the higher complication rate in patients physiologically older than 65 years, a prosthetic replacement may be considered for the treatment of displaced fractures. In patients who are low-level community ambulators or nursing home ambulators with comorbidities and who are not expected to live more than 5 years after injury, a hemiprosthesis is indicated. In active, elderly patients physiologically older than 65 years who are expected to live longer than 5 years after injury, a total hip replacement is the treatment of choice. Total hip replacement relieves pain and allows faster rehabilitation than other forms of treatment in this age group. Patients with preexisting hip disease also are treated with total hip replacement. An algorithm that considers physiologic age and activity level of the patient is helpful when deciding whether to fix or replace the hip in a patient with a displaced femoral neck fracture. It is also useful in deciding what type of prosthesis to use. The treatment of femoral neck fractures remains complex and difficult. Because of the enormous burden of this injury, orthopaedists must improve results in the care of femoral neck fractures.

Biomechanical comparison of extended trochanteric osteotomy and slot osteotomy for femoral component revision in total hip arthroplasty.

BACKGROUND: Depending upon the clinical presentation and need for exposure in revision hip arthroplasty, an extended trochanteric osteotomy or slot osteotomy could be used for removal of an inaccessible distal cement mantle, infected material, or distal fragment of a broken stem. This study is a biomechanical comparison of these two osteotomy techniques. METHODS: A press-fit femoral component with a 20-cm straight stem was implanted in each of ten synthetic femurs. The stiffness of these components implanted in the femurs was measured for a compressive load condition simulating the stance phase of level walking. Half of the femurs then received an extended trochanteric osteotomy, and the other half a slot osteotomy. Stiffness testing was repeated both after the osteotomized bone was removed, and after it was fixed back in place by cerclage wiring. FINDINGS: The stiffness of the femoral component/synthetic femur constructs in the slot osteotomy group was significantly greater than in the extended trochanteric osteotomy group. INTERPRETATION: This study demonstrated that in the laboratory setting, the slot osteotomy was significantly stiffer than the more traditional extended trochanteric osteotomy. However, the clinical implications of this increased stiffness are unknown. The ultimate choice of the type of osteotomy depends upon the exposure requirements for a given clinical situation.

Activity level in young patients with primary total hip arthroplasty: a 5-year minimum follow-up.

Increased activity level after total hip arthroplasty (THA) is considered a risk factor for early prosthetic failure in young patients. Forty-one primary total hip arthroplasties in 34 patients were evaluated. Walking activity was measured using a pedometer to record gait cycles. Patients completed a University of California, Los Angeles (UCLA) activity questionnaire. Linear wear rates were measured. Mean ages at surgery and final follow-up were 42 and 50.3 years, respectively (mean gait cycles per year, 1.2 million; mean UCLA score, 6; mean linear wear, 0.16 mm/y). Increased body mass index and age correlated with decreased gait cycles per year. Patients with systemic disease were less active than patients with localized hip conditions. Femoral head diameter was a predictor of linear wear. The average gait cycles per year and wear rate for this population do not appear accelerated relative to average values reported in older populations.

Factors influencing the initial micromotion between polyethylene acetabular cups and titanium alloy shells.

Mechanical test factors affecting short-term rotational stability under combined torsional and compressive loading was assessed in modular press-fit acetabular components with 4 different locking mechanism designs, by measuring the micromotion of the liner-shell interface at either room (20 degrees C) or body temperature (37 degrees C) and with either a high (2,943 N) or low (490 N) compressive load. Liner-shell constructs whose short-term stability was statistically significantly affected by temperature exhibited more rotational stability at body temperature than at room temperature. Liner-shell constructs whose short-term stability was statistically significantly affected by the level of compressive load exhibited more rotational stability with high compressive loads than with low loads. Liner-shell constructs with different locking mechanism designs were influenced by temperature and compressive loads differently. It is recommended to consider including these factors in tests of acetabular component locking mechanisms.

Precooling an acetabular liner makes its insertion into a metal shell easier.

Temporary shrinkage of an acetabular polyethylene liner due to precooling could reduce the force required to snap the liner into its metal shell. This study documented cooling and heating rates of liners with a particular locking mechanism design, determined forces required to seat liners in their shells as a function of temperature, and quantified the force surgeons can exert with their thumbs when seating a liner. It took up to 8 minutes to cool 58- and 70-mm liners in an ice-water bath from room temperature to near 0 degrees C, and up to 24 minutes to subsequently warm these liners to near body temperature. Forces required to seat liners were greater at room and body temperatures than at 0 degrees C. Liners precooled to 0 degrees C required insertion forces that could be generated manually by surgeons.