Aims

This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days.

Aims

The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability.

We welcome letters to the Editor concerning articles that have recently been published. Such letters will be subject to the usual stages of selection and editing; where appropriate the authors of the original article will be offered the opportunity to reply.

Background

Systematic reviews disagree, but some recent studies have shown better function and less pain after operation with bipolar hemiarthroplasty compared to fixation by two screws in elderly patients operated for displaced femoral neck fractures. There is still uncertainty regarding the mortality associated with both procedures.

Background

A well conducted randomised study found similar functional results for patients with displaced femoral neck fracture comparing operation with a modern uncemented bipolar hemiarthroplasty with a cemented bipolar hemiarthroplasty. The mortality associated with the two procedures has not been sufficiently investigated.

Introduction

Undisplaced femoral neck fractures have been given little attention in the literature. By using data from the Norwegian Hip Fracture Register, this study investigates risk for reoperation and the clinical results, including pain, patient satisfaction, and quality of life, after undisplaced femoral neck fractures in elderly patients.

Introduction

The treatment of trochanteric and subtrochanteric fractures remains controversial, and new implants are constantly being developed trying to improve outcome and minimize the number of complications in these fractures.

In Norway the Sliding Hip Screw(SHS), with or without a Trochanteric Stabilizing Plate (TSP), is still the most commonly used implant, but worldwide nailing of these fractures is increasing. This trend, however, has not been supported by documentation of better clinical results compared to the SHS in well designed studies. Therefore, in the present study we compared the recently launched Trigen Intertan nail (Smith and Nephew) with the SHS in the treatment of trochanteric and subtrochanteric fractures.

Using data from the Norwegian Hip Fracture Register, 8639 cemented and 2477 uncemented primary hemiarthroplasties for displaced fractures of the femoral neck in patients aged > 70 years were included in a prospective observational study. A total of 218 re-operations were performed after cemented and 128 after uncemented procedures. Survival of the hemiarthroplasties was calculated using the Kaplan-Meier method and hazard rate ratios (HRR) for revision were calculated using Cox regression analyses. At five years the implant survival was 97% (95% confidence interval (CI) 97 to 97) for cemented and 91% (95% CI 87 to 94) for uncemented hemiarthroplasties. Uncemented hemiarthroplasties had a 2.1 times increased risk of revision compared with cemented prostheses (95% confidence interval 1.7 to 2.6, p < 0.001). The increased risk was mainly caused by revisions for peri-prosthetic fracture (HRR = 17), aseptic loosening (HRR = 17), haematoma formation (HRR = 5.3), superficial infection (HRR = 4.6) and dislocation (HRR = 1.8). More intra-operative complications, including intra-operative death, were reported for the cemented hemiarthroplasties. However, in a time-dependent analysis, the HRR for re-operation in both groups increased as follow-up increased.

This study showed that the risk for revision was higher for uncemented than for cemented hemiarthroplasties.

Background: The treatment of trochanteric and subtrochanteric fractures is still controversial. In Norway the most commonly used implant for these fractures is the Sliding Hip Screw (SHS), with or without a trochanteric support plate. The Intertan nail (Smith & Nephew) has been launched as a nail with improved biomechanical properties for the treatment of these fractures, but so far it has not been shown that the clinical results are superior to the traditional Sliding Hip Screw.

We wanted to investigate any differences in pain and function between the new Intertan nail and the Sliding Hip Screw in the early postoperative phase.

Materials and Methods: 665 patients older than 60 years with a trochanteric or subtrochanteric fracture were randomized to either a SHS (CHS/DHS) or an Intertan nail in 5 hospitals. For practical reasons only 315 patients (47%) were evaluated at day 5 postoperatively (163 Intertan and 152 SHS), and these patients were used for our analysis. Pain was measured using a Visual Analog Scale (VAS), and early functional mobility by the “Timed Up and Go”- test (TUG-test). T-tests and chi-square tests were used to examine differences between the groups.

Results: The average pain at rest was similar for the 2 groups (VAS 21). Pain at mobilization, however, differed, where patients operated with the Intertan nail had less pain than those operated with the SHS (VAS 47 vs. 53, p = 0.02). The difference between the implants was most pronounced for the simple two-part fractures (AO Type A1). More patients treated with the nail than with the SHS performed the TUG-test at day 5 (85/163 vs. 63/152, p = 0.06), but there was no statistically significant difference regarding the average speed the TUG-test was performed with (71 vs. 66sec, p = 0.36). The implant type did not influence the length of hospital stay.

Discussion/Conclusion: Regarding early postoperative pain and function, there seems to be similar or better results for trochanteric and subtrochanteric fractures treated with the Intertan nail compared to the SHS. The difference in measured pain level was statistically significant, but may not be clinically significant (a difference of VAS 6). We could not detect any significant differences in terms of early functional mobility between the two implants.

In our opinion it still remains to show good long-term results and acceptable complication rates before the new Intertan nail is widely taken into use. Due to the additional costs for the Intertan nail also economic aspects should be considered when choosing the implant and operative method for these fractures.

Aims: To calculate one-year survival after dislocated intracapsular femoral neck fractures and to assess factors associated with increased risk of death.

Patients: 2045 patients treated for dislocated intracapsular femoral neck fractures during 2005 were registered in The Norwegian Hip Fracture Registry and were included in the present study.

Methods: Almost all hospitals in Norway reported proximal femoral fractures to the Registry using standard forms filled in by the operating surgeons. Survival was calculated using Kaplan Meier survival analyses, and the impact of factors possibly influencing the survival was estimated using Cox regression analysis. Mortality data for all patients were obtained from Statistics Norway.

Results: 2045 patients having dislocated intracapsular femoral neck fractures operated with 2 pins/screws (1071) and bipolar hemiprosthesis (974) were enrolled in the Registry during 2005. Among these, 333 patients died within the first year after the operation; 2 pins/screws (170) and bipolar hemiprosthesis (163). Factors adversely associated with survival included high age, male gender, dementia and with an increase in preoperative ASA classification. No statistically significant difference was found regarding preoperativ delay or for the two different treatment methods.

Conclusion: After one year there is no difference in risk of death between operation methods; 2 pins/screws and hemiprosthesis, for dislocated femoral neck fractures.