Aims

We chose unstable extra-capsular hip fractures as our study group because these types of fractures suffer the largest blood loss. We hypothesised that tranexamic acid (TXA) would reduce total blood loss (TBL) in extra-capsular fractures of the hip.

Introduction

We implemented an exhaustive operative and supervision algorithm for surgical treatment of hip fractures primarily based on own previously published literature. The purpose was to improve supervision and reduce the rate of reoperations.

Introduction: The use of intramedullary nailing (IMHS) has increased at the expense of the dynamic hip screw (DHS), although the outcome is not different in the studies of pertrochanteric fractures (PTF), known as AO/OTA type 31A1-2 fractures with a preoperative intact lateral femoral wall. We therefore investigated the two implants in the subgroup of PTF with a fractured greater trochanter.

Materials and Methods: Six hundred thirty-five consecutive patients with PTF fixated by a short IMHS or by a DHS mounted on a four hole lateral plate were prospectively included between 2002 and 2008. The fractures were preoperatively classified according to AO/OTA classification system, including status of the greater and lesser trochanter. The integrity of the lateral femoral wall, fracture reduction and implant positioning were assessed postoperatively. Reoperations due to technical failures were recorded for one year.

Results: Among the 311 patients sustaining a PTF with a fractured greater trochanter, 4% (6/158) operated with an IMHS were reoperated compared to 14% (22/153) with a DHS (p=0.001). Multivariate logistic regression analysis combining demographic and biomechanical parameters showed the IMHS to have a lower rate of reoperation (p=0.002).

During the operative procedure, the lateral femoral wall was fractured in 6% (9/158) of patients, in which an IMHS was performed versus 28% (42/153) operated with a DHS (p< 0.001). Among the DHS, a fractured lateral femoral wall was confirmed to be a predictor of a reoperation (31% (13/42) of patients with a fractured lateral femoral wall versus 8% (9/111) with an intact lateral femoral wall, p< 0.001).

As in other studies, the different reoperation rate would have been overseen in the main group of AO/ OTA type 31A1-2 PTF fractures (4% (6/164) IMHS versus 6% (30/471) DHS, p=0.196).

Conclusion: The IMHS seems to have a lower reoperation rate than the DHS in the subgroup of PTF with a fractured greater trochanter. In contrast to the DHS, the IMHS presumably keeps the integrity of the lateral femoral wall. In future studies, PTF should be divided into subgroups.

Introduction: We derived an exhaustive operative and supervision guideline for the treatment of hip fractures from the current international and own published literature, and implemented the guidelines in our department.

Methods: 1274 unselected consecutive patients admitted with a hip fracture were included, 336 of these prospectively after implementation of the new guideline. Demographic parameters, hospital treatment and re-operations were assessed from patient journals. Re-operations were recorded after six months.

Results: 95% (320/336) of operative procedures were found to have followed the new guideline treatment compared to 78% (733/938) prior to its introduction (p< 0.001 X2). Retrospectively we found that only 12% (121/1053) of operative procedures performed as the new guideline prescribes were re-operated compared to 24% (53/221) of operative procedures performed with other methods (p< 0.001 X2). In logistic regression analysis combining sex, age, ASA score, cognitive function, new mobility score, time from admission to operation and level of surgeon’s experience, not following the guideline was the only significant predictor for re-operation (p< 0.001 log. reg.)

After implementing the guideline, the rate of unsupervised junior registrars performing operations declined from 20% (188/938) to 6% (21/336, p< 0.001 X2). The rate of reoperations declined from 15% (139/938) to 10% (35/336, p=0.044 X2, p=0.043 log.reg.), with a 20% (85/436) to 13% (23/174) decline for intracapsulary and an 11% (54/502) to 7% (12/162) decline for extracapsulary fractures.

Conclusion: An exhaustive operative guideline for hip fracture treatment can be implemented. In our case, the guideline both raised the rate of supervision and reduced the rate of reoperations.

Introduction: Cam-type femoroacetabular impingement (FAI) is a pre-osteoarthritic condition causing premature joint degeneration. Cam-deformities are characterised by decreased cranial offset of the femoral head/neck junction and aspherity of the femoral head causing delamination of the acetabular cartilage and detachment of the acetabular labrum. To asses the epidemiological aspects of cam-type FAI we evaluated Nötzlis alpha angle and our own Triangular Index (TI) for use on plain AP pelvic radiographs.

Materials and Methods: Cam malformation was assessed in 2.803 pelvic radiographs by the alpha (α) angle and the TI to define pathological cut off values. The α-angle and TI were assessed in AP and lateral hip radiographs of 164 patients scheduled for THR and the influence of varying rotation on the α-angle and TI was assessed in femoral specimens. The distribution of Cam-deformities was assessed in 3.712 standardized AP pelvic radiographs using the α-angle and TI.

Results: Mean AP α-angle male/female was 55°/45°. The α-angle and TI was highly interrelated, OR 8.6–35 (p< 0.001). Almost all cam-malformations were identifiable in AP projections, sensitivity 88–94% compared to axial view. The TI proved robust for cam identification during rotation (± 20°) compared to the α-angle (−10° to +20°). The distribution of pathologic TI and α-angle (Right/Left) were 11.6/12.5% and 6.1/7.4% in males and 2.2/3.2% and 2.1/3.8% in females. We found a pronounced sexrelated difference in cam-deformity distribution, OR 2.0–6.3 (p< 0.001).

Conclusion: The triangular index and the α-angle were found reliable for epidemiological purpose. Overall prevalence of definite cam-deformity was app. 10% in men and 2,5% in women.

Introduction: Re-operations after intertrochanteric fractures (ITF) are often caused by fracture displacement following postoperative mobilisation. The biomechanical complexity of the fracture, implant position, and the patient’s characteristics are known to influence postoperative outcome significantly. We investigated the importance of an intact lateral femoral wall (LFW) for the postoperative displacement after fixation by a sliding compression hip screw (SHS).

Methods: Two hundred and fourteen consecutive patients with ITF fixated by 135° SHS mounted on four hole lateral plates were included between 2002 and 2004. The fractures were preoperatively classified according to the AO/OTA classification system. The status of the greater and lesser trochanter, the integrity of the LFW and implant positioning were assessed postoperatively. Re-operations due to technical failure were recorded for six months.

Results: Only three percent of patients (5/168) with postoperatively intact LFW’s were re-operated within six months, while twenty-two percent (10/46) of patients with fractured LFW’s had been re-operated (p < 0.001). In multivariate logistic regression analyses combining demographic and biomechanical parameters, a compromised LFW was a significant predictor for reoperation (p = 0.010). Seventy-four percent (34/46) of the LFW fractures occurred during the operative procedure itself. Peri-operative LFW fractures only occurred in three percent (3/103) of the AO/OTA type 31A1–A2.1 ITF fractures, compared to thirty-one percent (31/99) of the AO/OTA type 31A2.2–A2.3 fractures (p < 0.001).

Conclusions: A postoperative fractured LFW was found to be the main predictor for reoperation after ITF. Consequently we conclude that patients with pre- or potential postoperative LFW fractures are not treated adequately by SHS. ITF should therefore be classified according to the integrity of the LFW, especially in regard to randomized trials comparing fracture implants.

Introduction: Rehabilitation of hip fracture patients is often lengthy with bed day consumption accounting for up to 85 % of the total hospitalization cost. Data suggests that patients who suffer surgical complications requiring re-operation have an excessive length of hospitalization, but the overall impact of surgical complications including those not requiring re-operations have not been examined in detail.

Methods: Six hundred consecutive, unselected patients with a primary hip fracture were included between 2002 and 2004. All patients received surgery and a multimodal rehabilitation program. Surgical complications were stratified into those requiring re-operation (< six months) and those not allowed mobilization postoperatively due to instability of the fracture. Surgical complications were audited and classified as being due to a patient fall, infection or due to a suboptimal surgical procedure, specified as suboptimal operation method, fracture reduction or implant position.

Results: 19.3 % (116/600) of the admitted patients were re-operated or immobilized. Assuming that the patients with complications otherwise would have had the same length of stay as the remaining patients, 27.2 % (3814/14038) of total bed day consumption was due to surgical complications. The audit of complications showed that 64 complications (55 %) were due to a suboptimal primary surgical procedure, 18 (16 %) to infections, 6 (5 %) to falls and 28 (24 %) could not be ascribed to an apparent course.

Conclusions: Surgical complications secondary to primary hip fracture surgery accounts for 27.2 % of the total bed consumption if secondary admissions due to re-operations are taken into account. Our audit suggests that as much as half the complications potentially could be spared through optimization of surgical procedures.

Femoroacetabular cam impingement is thought to be a cause of premature osteoarthritis of the hip.

The presence of cam malformation was determined in 2803 standardised anteroposterior (AP) pelvic radiographs from the Copenhagen Osteoarthritis Study by measuring the alpha (α) angle and the triangular index, a new measure of asphericity of the femoral head. In addition, the α-angle and the triangular index were assessed on the AP and lateral hip radiographs of 82 men and 82 women randomly selected from patients scheduled for total hip replacement (THR). The influence of varying femoral rotation on the α angle and the triangular index was also determined in femoral specimens under experimental conditions.

From the 2803 radiographs the mean AP α-angle was 55° (30° to 100°) in men and 45° (34° to 108°) in women. Approximately 6% of men and 2% of women had cam malformation. The α-angle and triangular index were highly inter-related. Of those patients scheduled for THR, 36 men (44%) and 28 women (35%) had cam malformation identifiable on the AP radiographs. The triangular index proved to be more reliable in detecting cam malformation when the hip was held in varying degrees of rotation.

The combination of the α-angle and the triangular index will allow examination of historical radiographs for epidemiological purposes in following the natural history of the cam deformity.