Femoral neck fractures are a commonly encountered injury in orthopaedic practice and result in significant morbidity and mortality. It is essential that surgeons are able to recognize specific fracture patterns and patient characteristics that indicate the use of particular implants and methods to effectively manage these injuries. Use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help dictate appropriate treatment. Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty. Recent reports demonstrate diversity among orthopaedic surgeons in regard to the optimal treatment of femoral neck fractures and changing trends in management. The present discussion focuses on the current indications and methods for femoral neck fracture management to provide direction with respect to appropriate and effective care of these injuries.

Femoral neck fractures: current management.

STUDY DESIGN Retrospective cohort analysis. OBJECTIVE To compare 30-day perioperative clinical outcomes of surgical odontoid stabilization by an anterior or posterior operative approach in elderly patients. SUMMARY OF BACKGROUND DATA Surgical stabilization of odontoid fractures is superior to nonoperative management in geriatric patients. How elderly patients with odontoid fractures fare after anterior and posterior approaches, however, is not well defined. MATERIALS AND METHODS Retrospective review of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database (2005-2013). Elderly patients (≥65 y) with odontoid fractures who underwent odontoid stabilization through anterior or posterior approaches were identified by International Classification of Diseases 9th Revision/Common Procedure Terminology codes. Exclusion criteria included concomitant subaxial spine surgery, instrumentation noncontiguous with the atlantoaxial interval, and combined approaches. Baseline demographics and perioperative details were compared. Adverse events, mortality, reoperation, discharge, and readmission rates within 30 days of operation were compared using bivariate and multivariate generalized linear regressions. RESULTS One hundred forty-one patients (male-81; female-60; average age: 77.8±6.5 y; anterior approach-48; posterior approach-93) were analyzed. Patients scheduled to have a posterior approach had significantly more nonunions preoperatively and higher body mass indices. Operative times for posterior surgeries were significantly longer. Age, comorbidities, functional dependence, time to surgery, and length of hospital stay were similar between groups. There were no significant differences in the relative risk (RR) of the composite outcome of "any adverse event" after adjusting for differences in baseline characteristics. Patients who underwent an anterior approach were more likely to have an unplanned hospital readmission (RR=8.95; 95% confidence interval, 2.21-36.29; P=0.002) and have significantly more revision operations (RR=19.51; 95% confidence interval, 2.49-152.62; P=0.005) than patients who had a posterior operation. CONCLUSIONS An anterior approach for odontoid fracture stabilization in patients ≥65 years old were associated with shorter operative times and greater RRs of unplanned readmissions and revision operations within 30 days of surgery relative to a posterior approach.

Anterior Versus Posterior Approaches for Odontoid Fracture Stabilization in Patients Older Than 65 Years: 30-day Morbidity and Mortality in a National Database.

Preoperative pneumonia, reported in 0.3% to 3.2% of hip fracture patients, may be a risk factor for adverse outcomes of hip fracture repair. No studies have reported on baseline differences or adverse outcomes in surgically managed geriatric hip fracture patients with and without preoperative pneumonia, and no data argue for or against delaying surgery in these patients. A retrospective cohort of geriatric patients with operatively treated hip fractures from 2005 to 2012 was identified in the National Surgical Quality Improvement Program database. Preoperative pneumonia was present in 82 (1.2%) of 7128 geriatric hip fracture patients identified and was associated with male sex, transfer status, functional status, preoperative anemia, confusion, dyspnea at rest, and chronic obstructive pulmonary disease. Multivariate analysis of 30-day outcomes of hip fracture repair revealed that preoperative pneumonia was associated with a higher risk for any adverse event (relative risk [RR] = 1.44), serious adverse event (RR = 1.79), and death (RR = 2.08) after hip fracture repair. Underweight body mass index at time of surgery (<18.5 kg/m²) was predictive of 30-day mortality (RR = 4.67). Surgical delay of 1 to 4 days was not associated with adverse events. Geriatric hip fracture patients with preoperative pneumonia, especially the underweight, are at increased risk for complications and death after hip fracture repair. We cannot recommend against early hip fracture surgery in this population.

Does Preoperative Pneumonia Affect Complications of Geriatric Hip Fracture Surgery

Introduction Current literature suggests that total hip replacement (THR) is superior to hemiarthroplasty (HA) for neck of femur fracture in selected group of patients. The outcomes of THR undertaken for trauma setting remain unclear when comparing with elective THR. We compared the outcomes of THR trauma cohort with best-matched elective cohort. Methods We retrospectively reviewed 102 patients that underwent THR due to trauma from 2011 to 2013. We had access to 90 cases with complete records. Another 90 matched elective cases were obtained from local arthroplasty database. The elective cases were matched for gender, surgical approaches, surgeon’s grade, types of implant, patient’s age at operation date of ±5 years and operation date of ±60 days. Subsequently, the selection criteria were relaxed to patient’s age at operation date of ±10 years and operation date of ±60 days. Unmatched cases were excluded. Complications and death rate were compared. Results The average age for both cohorts was 70 years. The trauma cohort had statistically significant lower BMI and longer hospital stay (p = 0.001). The Functional Comorbidity Index (FCI) and Charlson Age Comorbidity Index (CACI) were the same for both cohorts, reflecting an active patient selection for THR in our centre. The trauma cohort had higher surgical complication rate (9% vs 4%), particularly higher dislocation rate (7% vs 1%); and higher medical complication rate (32% vs 6%). These were consistent with the literature. Contrary to literature, the trauma cohort had six dislocations that five of them were done via anterolateral approach. Among the eight trauma cases with surgical complications, six cases were performed by trainees. The cause of surgical complications remains unclear due to the nature of retrospective study. The trauma cohort had higher death rate than the elective cohort (14% vs 4%), with one post-operative cardiac arrest in the trauma cohort. The rest were non-orthopaedic related deaths, ranging between four months to four years. Conclusion A more robust way of selecting trauma patients for THR is warranted to reduce morbidity and mortality. Follow-up for the trauma cohort is warranted, as the patients are likely to outlive the implants.

/pdf/total-hip-replacement-for-neck-of-femur-fracture-comparing-1619ypm5xr.pdf

Total hip replacement for neck of femur fracture: Comparing outcomes with matched elective cohort

This meta-analysis compared clinical outcomes of arthroplasty vs. osteosynthesis for displaced femoral neck fractures. Meta-analysis was performed on the difference in revision rate and overall mortality between participants undergoing osteosynthesis vs. total hip arthroplasty (THA), osteosynthesis vs. hemiarthroplasty (HA), or THA vs. HA. Pooled direct and indirect results indicated no significant difference in mortality between THA and HA (pooled OR = 0.87, 95% CI 0.55 to 1.38; P = 0.556), between THA and osteosynthesis (pooled OR = 1.17, 95% CI 0.69 to 1.99; P = 0.553), and between HA and osteosynthesis (pooled OR = 1.21, 95% CI 0.84 to 1.74; P = 0.304). Pooled direct and indirect results indicated no significant difference in revision rates between THA and HA (pooled OR = 0.90, 95% CI 0.26 to 3.19; P = 0.874). But, fewer revisions (OR = 0.19, 95% CI 0.10 to 0.34; P = 0.000) were seen in patients treated with THA than osteosynthesis and also in those treated with HA than osteosynthesis (OR = 0.12, 95% CI 0.07 to 0.20; P = 0.000). After excluding studies without showing normal cognition in inclusion criteria, pooled direct and indirect results also indicated no significant difference in mortality between THA, HA, and osteosynthesis. Similarly, there was no significant difference in revision rates between THA and HA, but HA and THA had significantly lower revision rates compared with osteosynthesis. There was no significant difference in overall mortality among osteosynthesis, HA, and THA. However, HA and THA had significantly lower revision rates compared with osteosynthesis. Results of the present study provide support for the use of hip arthroplasty to treat displaced fractures of the femoral neck.

/pdf/comparison-of-arthroplasty-vs-osteosynthesis-for-displaced-1zte73aj2l.pdf

Comparison of arthroplasty vs. osteosynthesis for displaced femoral neck fractures: a meta-analysis.

Open reduction internal fixation versus hemiarthroplasty versus total hip arthroplasty in the elderly: a review of the National Surgical Quality Improvement Program database.

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Open reduction internal fixation versus hemiarthroplasty versus total hip arthroplasty in the elderly: a review of the National Surgical Quality Improvement Program database.