Aims. We aimed to characterise the effect of expeditious hip fracture surgery in elderly patients within 24 hours of admission on short-term post-operative outcomes. Patients and Methods. Patients age 65 or older that underwent surgery for closed femoral neck and intertrochanteric hip fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program between 2011 and 2014. Multivariable propensity-adjusted logistic regressions were performed to determine associations between early surgery within 24 hours and post-operative complications, controlling for selection bias in patients undergoing early surgery based on observable characteristics. Results. A total of 26 051 patients were included in the study; 5921 (22.7%) had surgery within 24 hours of admission, while 20 130 (77.3%) patients had surgery after 24 hours. Propensity-adjusted multivariable logistic regressions demonstrated that surgery within 24 hours was independently associated with lower odds of respiratory complications including pneumonia, failure to extubate, or reintubation (odds ratio (OR) 0.78, 95% confidence interval (CI) 0.67 to 0.90), and extended length of stay (LOS) defined as ≥ 6 days (OR 0.84, 95% CI 0.78 to 0.90). Conclusion. In elderly patients with hip fractures, early surgery within 24 hours of admission is independently associated with less pulmonary complications including pneumonia, failure to extubate, and reintubation, as well as shorter LOS. Cite this article: Bone Joint J 2017;99-B:1216–22

Introduction. Unstable intertrochanteric hip fractures (AO 31A2) continue to be a challenge, as non-locking implants have shown a considerable rate of loss of reduction. Intramedullary fixation has been recommended, although screw cut-out has been identified as problematic. This study was performed to ascertain whether treatments with the established proximal femoral nail (PFN) and the newer PFNA with blade design (proximal femoral nail antirotation) have advantages over the use of the Percutaneous Compression Plate (PCCP, developed by Gotfried). Methods. Cohort study. Between March 2003 and March 2008, 134 patients with unstable fractures were treated with a PCCP, (n=44, 78.3 yrs, ASA 2.8), a PFN (n=50, 77.2 yrs, ASA 2.8), or a PFNA (n=40, 75.8 yrs, ASA 2.6). The patients (31 PCCP, 33 PFN, 30 PFNA) were then reexamined clinically and radiologically after approximately 21 months. Results. The PCCP was found to require less implantation time than the PFN and the PFNA (60 vs. 80 vs. 84 min, p<0.001) and less radiation exposition time (PCCP 139 vs. PFN 283 vs. PFNA 188 seconds, p<0.001). The rate of reoperations due to wound infections and hematomas amounted to 2% for the PCCP, 4% for the PFN, and 5% for the PFNA (p=0.799). Due to mechanical complications, 9% of patients implanted with a PCCP, 13% of those implanted with a PFN, and 5% of those implanted with a PFNA had to be reoperated (p=0.353). The cut-out rate was 2% after implantation of the PCCP, 4% after the PFN, and 5% after implantation of the PFNA (p=0.799). In one case, the shaft was fractured intraoperatively (PFNA). The tip-apex distance for the lower femoral neck screw (PCCP 22mm vs. PFN 30mm vs. PFNA 30mm, p<0.001), stress-related varisation of the collodiaphyseal (CCD) angle (4° for all implants), impaction (PCCP 5mm vs. PFN 5mm vs. PFNA 6mm, p=0.662) and femoral shortening (PCCP 3mm vs. PFN 3mm vs. PFNA 4mm, p=0.876) were not determinants of the postoperative function. On the basis of their scores according to Merle d'Aubigné and Harris, there was no variation in the results of the follow-up examinations. Conclusions. The use of the PCCP for the treatment of unstable trochanteric fractures presents a minimally invasive method of implantation, as well as a promising therapy option with regards to operation time, radiologic examination time, and rate of complications. Processes of impaction due to stress are seldom observed. No benefits could be established in an intramedullary treatment with the PFN or the PFNA; thus, it appears that the higher cost of these implants is avoidable

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study.

Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality.

We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year.

We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip.

Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function. The percutaneous compression plate (PCCP) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure. It has several potential mechanical advantages over the conventional compression hip screw (CHS). Our aim in this prospective, randomised, controlled study was to compare the outcome of patients operated on using these two devices.

We randomised 104 patients with intertrochanteric fractures (AO/OTA 31.A1–A2) to surgical treatment with either the PCCP or CHS and followed them for one year postoperatively.

The mean operating blood loss was 161.0 ml (8 to 450) in the PCCP group and 374.0 ml (11 to 980) in the CHS group (Student’s t-test, p < 0.0001). The pain score and ability to bear weight were significantly better in the PCCP group at six weeks post-operatively. Analysis of the radiographs in a proportion of the patients revealed a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients, 18.9%); Fisher’s exact test, p < 0.02.

The PCCP device was associated with reduced intra-operative blood loss, less postoperative pain and a reduced incidence of collapse of the fracture.