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Pronóstico, epidemiología. Aspectos generales. Experiencia
Abstract
Describe 289 hip fractures that were admitted at Hospital Universitario del Valle between November 1, 2003 and June 30, 2004. The patients had the first appointment at 2.7 days after the fallen, 60% the patients were women, at he age average were 75 years. In the hospital 228 patients were operated (79%). The surgery was realized in average at the twelve days after that they were admitted at the hospital. The days in the hospital were in average 17.5 days. The index of Katz at the admission was 3.96 and the Parker index was 6.56. The mortality in the hospital was of 30 patients (11%). The following during six months was in 114 patients of the people that were operated; we found loss of initial reduction the hip fracture in 10% and infection in 4%.
... [5][6][7][8] Sin embargo, los estudios sobre mortalidad intrahospitalaria (MIH) asociada a FC son escasos, generalmente retrospectivos y, habitualmente, tratan a la MIH como una variable más dentro del contexto de caracterizaciones epidemiológicas generales de muestras de pacientes con FC, refiriéndose a ella con relación a su incidencia. [9][10][11] Por diversos motivos, MIH por FC es analizada como parte de la llamada mortalidad temprana a 30 días, 12 aunque en diversos países es considerada desde hace tiempo indicador de calidad del manejo hospitalario, 13,14 Como la estancia hospitalaria de los pacientes con FC en Chile es alta, 4 formando parte importante de los primeros 30 días posteriores a la fractura, MIH debiera considerarse como indicador de la calidad del manejo general de las FC. Entre otras razones, pues es verificable, confiable, sencilla de medir y útil: Generalmente, puede limitarse conociendo las variables que la determinan e implementando acciones para minimizar o anular su efecto. ...
... La incidencia de MIH se asemeja a publicaciones estadounidenses, europeas y japonesas. [9][10][11][19][20][21][22] La mortalidad temprana a 30 días reportada varía entre 2,5 y 13,3%, con promedios de 8%. 12,23 Considerando otras publicaciones, y que MIH es una fracción de esta mortalidad a 30 días, parece razonable que permanezca bajo 5%. ...
Introducción Las fracturas de cadera (FC) presentan alta mortalidad. Existen escasos estudios que profundizan en la mortalidad intrahospitalaria (MIH) asociada.
Objetivo Describir MIH en pacientes ≥ 60 años con FC.
Materiales y Métodos Corte transversal, descriptivo y analítico, monocéntrico, de colección completa. Fueron evaluados 647 sujetos, de ambos géneros, ingresados con FC entre 01.01.2010 y 31.12.2012, agrupándolos en fallecidos y egresados vivos. Se registró fallecimientos, género, edad, ubicación anatómica, tipo de traumatismo, lugar de ocurrencia de FC, tiempo fractura-fallecimiento, tiempo de estancia hospitalaria, porcentaje de operados, diagnósticos asociados a FC, diagnóstico de fallecimiento, comorbilidad asociada al diagnóstico de fallecimiento y lugar de fallecimiento. Datos en planilla ortogeriátrica, análisis descriptivo.
Resultados MIH = 3,09%. Edad promedio 84 años. Los diagnósticos de fallecimiento más importantes fueron infecciones (40%) y enfermedad tromboembólica (15%). El 80% presentó comorbilidad crónica relacionada con la causa de fallecimiento. Sin diferencias significativas según edad, género, ubicación anatómica de la FC, lugar de ocurrencia de la FC, tiempo de estancia hospitalaria. Hubo diferencias significativas en cantidad de no operados, mayor en el grupo con MIH (p < 0.000), esperable por sesgo de selección. Es deseable identificar precozmente los sujetos con FC que presentan alto riesgo de MIH. Esto, para definir manejo conservador, optimizar calidad de vida y recursos hospitalarios.
... Martínez concuerda con algunos factores que aumentan la mortalidad y morbilidad, observando que la consulta tardía en un 60% de sus pacientes, la falta de recursos del 50% de los pacientes en estudio que llevó a un retraso mayor de 6 días y un 21% no recibieron el trata- 26 miento quirúrgico propuesto, generan resultados no satisfactorios. ...
Objetivo: Determinar si existe diferencia significativa en la efectividad entre el abordaje posterior (AP) y lateral(AL) tras hemiartroplastía de cadera (H) en ancianos con fractura de cuello femoral en el Servicio de Traumatología del Hospital Víctor Lazarte Echegaray de Trujillo (HVLE) durante el período 2010-2016.
Material y métodos. Estudio observacional, retrospectivo, analítico, comparativo,transversal y de cohortes en el Servicio de Ortopedia y Traumatología del Hospital Víctor Lazarte Echegaray en el periodo enero 2010 a diciembre 2015. Se incluyeron 52 pacientes ancianos con fractura de cuello femoral manejados quirúrgicamente, donde el grupo I de cohorte (26 pacientes) fue tratado con hemiartroplastía de cadera con abordaje posterior (HAP) y el grupo II de cohorte (26 pacientes) con hemiartroplastía de cadera con abordaje lateral (HAL). Se midió la efectividad usando la funcionalidad con el Score de Harris, la morbilidad tardía, que comprende si presenta rigidez articular, luxación, dismetría de miembros inferiores, infección, inicio de bipedestación, lesión del nervio ciático y la calidad de vida con el Short Form - 12 (SF-12). Nivel de evidencia: 2+ B.
Resultados. Respecto a los pacientes sometidos a H, la población masculina y femenina fue de 31% y 27%, y 69% y 73% en el grupo I y II, respectivamente. Los rangos fueron de 80 a 90 años (65%) y 65 a 79 años (81%), en quienes se realizaron mayor número de intervención en el grupo I y II, respectivamente. El sangrado presentó un promedio de 284,2 ml y 347,7 ml en el grupo I y II, respectivamente(p= 0,043). La transfusión sanguínea presentó un promedio de1,1 y 2,5 paquetes globulares en el grupo I y II (p= 0,040). El tiempo operatorio presentó un promedio de 75 min y 96 min, en el grupo I y II (p= 0,102). La funcionalidad pobre en un 42% y 27% en el grupo I y II, aceptable en 38% y 58% en el grupo I y II, bueno en un 8% y 8% en el grupo I y II y excelente en un 12% y 8% en el grupo I y II, respectivamente (p= 0,554). Morbilidad tardía, luxación 2% de pacientes en el grupo II (p= 0,313), rigidez articular 58% y 54% en el grupo I y II, respectivamente, (p= 0,50), dismetría de miembros inferiores, 54% y 77% en el grupo I y II (p= 0,080), inicio de la bipedestación dentro de 30– 44 días, 23% y 27% en el grupo I y II, dentro de 45 – 60 días, 77% y 73% en elgrupo I y II (p= 0,749). Calidad de vida, salud física mejor y peor en un 28% y32%, y 72% y 68% en el grupo I y II, respectivamente (p= 0,456); asimismo,salud mental mejor y peor en un 42% y 46% y 58% y 54% en grupo I y II, respectivamente(p= 0,780).
Conclusiones. La HAP es más efectiva que la HAL.
Palabras clave: Hemiartroplastía (H), Abordaje posterior(AP), Abordaje lateral(AL), Score de Harris, SF-12, Morbilidad tardía.
... Su prevalencia aumenta y las tendencias apuntan a que en las próximas décadas se acentúe este fenómeno como consecuencia del aumento de edad en la población nacional y mundial. [1][2][3][4] En este contexto, emergen como un importante problema de salud, situándose entre las afecciones ortopédicas de mayor morbilidad y mortalidad, pues ocurre generalmente en pacientes ancianos, que padecen enfermedades crónicas con deterioro en su estado de salud. 5 Su tratamiento esencialmente quirúrgico, es un reto a afrontar por los especialistas en Anestesiología y Reanimación. ...
Introduction: Hip fracture is a common cause of hospitalization, occupies a leading place in morbidity and mortality due to orthopedic disease. Objective: To identify the perioperative variables that influence the morbidity and mortality of the patients who undergo hip fracture surgery at the Central Military Hospital "Dr. Carlos J. Finlay". Methods: a retrospective, analytical study was conducted in 135 patients surgically intervened between January and December 2014. They were divided into two groups for statistical analysis, deceased and alive. The variables studied were: cause of death, postoperative mortality rates, clinical and surgical prognostic factors of death and main complications. Results: The mortality rate at 30 days after surgery was 2.2% and 17.8% a year later. The main causes of death were acute myocardial infarction (45.8%) and pulmonary thrombus embolism (16.7%). The probability of dying due to ischemic heart disease or physical state ASA 4 was eight times higher, five times more if they had anemia, four times higher if they received general anesthesia, intraoperative blood transfusion or postoperative complication, three times higher in those patients ASA 3 and blood loss greater than 500 mL, and it increases if the hospitalization exceeds seven days. The most frequent complications were anemia (33.3%) and hypotension (16.7%). Conclusions: A history of ischemic heart disease, preoperative anemia, high physical status classification, use of general anesthesia, blood loss greater than 500 mL, use of blood transfusions, stay of more than seven days and appearance of postoperative complications.
... En Europa y Estados Unidos de Norteamérica las más frecuentes son las FIC 16,17,39 . En nuestra serie predominan las FEC, lo mismo en otras series chilenas 10 y latinoamericanas 40 . Esto permite plantearse la existencia de variables genéticas involucradas. ...
Background:
Hip fractures (HFx) are an important geriatric syndrome, with a high incidence in developing countries.
Aim:
To describe characteristics of a group of Chilean patients with HFx.
Patients and methods:
In a cross-sectional study we included patients aged 60 years or more with a HF admitted to an orthopedic service along three years. Age, incidence, location, seasonality, hospital stay, time between HFx and surgery, mortality, prior treatment for osteoporosis, anatomical location, etiology and type of surgery were evaluated.
Results:
We reviewed 647 patients with a median age of 81 years (76% women). The calculated incidence of hip fracture for people aged ≥ 65 years was 177/100,000. Sixty six percent of fractures were extracapsular. Mean hospital stay was 17 days and the mean lapse between the fracture and surgery was 19 days. Eighty four percent of patients had osteoporosis and only 5% were receiving treatment. Eighty three percent of patients were operated. Osteosynthesis was mainly used for extracapsular fractures and arthroplasty for intracapsular lesions. Intracapsular HFx tended to occur more commonly during warm seasons (Odds ratio = 1.534). Mortality at one year was 24%. It was higher among non-operated patients in whom the proportion of males and number of comorbidities were significantly higher.
Conclusions:
A high proportion of patients with HFx have osteoporosis albeit a reduced number is receiving treatment. Non-operated patients had a higher risk profile and higher mortality.
Objetivo. Establecer los factores asociados, la incidencia acumulada y un modelo de predicción para infección de sitio operatorio (ISO) en artroplastia total de cadera (ATC), en el Hospital Víctor Lazarte Echegaray (HVLE) EsSalud, en el período 2005-2014. Material y método. Estudio observacional, retrospectivo y transversal. Se estudiaron los expedientes de los 301 pacientes intervenidos de ATC; solo 208 cumplieron con los criterios de inclusión. Se almacenó la información en Excel y se pasó a los programas estadísticos R y SPSS 23.0, procediendo a realizar análisis de frecuencias, correlación y análisis multivariado de regresión logística. Realizamos un modelo predictor a través de la curva ROC. Resultados. Se halló 17 casos de ISO (8,2%). En las características generales, el IMC fue la única variable con significancia estadística media de 28,88 ± 4,03 kg/m² en pacientes que presentaron ISO, a diferencia de una media de 26,53 ± 3,24 kg/m² en los pacientes sin ISO; p<0,01. En los antecedentes mórbidos, los factores asociados fueron: diabetes mellitus (DM), infección concomitante (IC) y corticoterapia (CT). La DM tuvo un OR de 8,67 (IC 95% de 1,53 - 49,30), la IC tuvo un OR de 27,43 (IC 95% de 2,62 - 287,04), básicamente a foco urinario, y la CT un OR de 24,70 (IC 95% de 5,34 - 114, 33). De los factores perioperatorios, la transfusión sanguínea (TS) presentó significancia estadística, con un OR de 7,45 (IC 95% de 1,62 - 34,18). La Curva ROC presentó un área bajo la curva de 0,877. Conclusiones. La incidencia de ISO es 8,2%. El IMC, DM, IC, CT y TS son factores asociados a ISO en ATC. Estas 5 variables tienen una potencia de predicción de 87,7 % para ISO en ATC. Evidencia. 2B. Palabras clave: Infección de sitio operatorio, Artroplastia total de cadera, Factores asociados, Incidencia acumulada.
Objetivo. Determinar el nivel de correlación diagnóstica entre la Resonancia Magnética y la Artroscopía en Lesiones Meniscales. Materiales y métodos. El diseño de investigación es observacional, prospectivo, de pruebas diagnósticas, de corte transversal. Se pide el ingreso a Sala de Operaciones del HVLE y clínicas particulares para recolectar datos e información necesaria acerca de la Resonancia Magnética (RM) ya realizada y la intervención quirúrgica por realizar. Posteriormente, distribuimos ambas resultados en las tablas de 2x2.
Resultados. La edad promedio fue 38,6 años (12-65 años), con 51 pacientes de sexo masculino y 12 del femenino, las lesiones meniscales de mayor incidencia fueron las verticales, a predominio de longitudinales con el 39 %, con ligera mayoría en el menisco medial, la razón de momios diagnóstica resultó 16 para menisco lateral, 14 para el medial y 13 para ambos. Conclusión: No existe alta correlación diagnóstica entre la Resonancia magnética y la Artroscopía de rodilla en lesiones meniscales, en nuestro medio, por lo cual no es recomendable condicionar los procedimientos en la artroscopía de rodilla por los resultados de un estudio de RM. Nivel de evidencia: II. Palabras clave: Resonancia magnética, Artroscopía de rodilla, Lesiones meniscales, Nivel de correlación diagnóstica.
Objetivo. Determinar la calidad de vida tras artroplastia parcial y osteotomía valguizante en adulto mayor con fractura intertrocantérica. Materiales y métodos. Estudio observacional, analítico, retrospectivo, transversal y de casos y controles en el servicio de Ortopedia y Traumatología del Hospital Essalud IV “Víctor Lazarte Echegaray”, periodo enero 2009 a diciembre 2011. Se incluyeron a 52 pacientes mayores de 65 años con fractura intertrocantérica manejados quirúrgicamente, donde el grupo casos (22 pacientes) fueron tratados con artroplastia parcial y el grupo control (30 pacientes) con osteotomía valguizante con placa angulada 1300. Se midió la calidad de vida usando el Short Form – 12 (SF-12). Resultados. La población femenina fue de 39 (61,5 %), la población masculina fueron 13 (38,5 %). La edad promedio fue 81,69 (±7,97) años, siendo el rango 76 a 85 años (55,8 %) donde se realizaron mayor número de intervención. Los pacientes sometidos a APC se determinó que 12 pacientes (54,5 %) tuvieron mejor calidad de vida y 10 (45,5 %) tuvieron peor calidad de vida. En el grupo de OVC se determinó que 8 pacientes (26,7 %) tuvieron mejor calidad de vida y 22 (73,3 %) presentaron peor calidad de vida. Conclusiones. Los pacientes sometidos a artroplastia parcial obtienen mejor calidad de vida comparado con la osteotomía valguizante con placa angulada 130°. Palabras clave: Artroplastia parcial, Osteotomía valguizante, Fractura intertrocantérica.
Resumen
Introducción
La tendencia mundial es realizar cirugía temprana en el manejo de las fracturas intertrocantéricas de cadera con el objetivo de disminuir mortalidad y complicaciones postoperatorias, pero los resultados no son concluyentes y el consenso mundial está basado en evidencia de moderada y baja calidad. El objetivo del estudio es evaluar si existen diferencias en mortalidad y tiempo de estancia hospitalaria postoperatoria en pacientes intervenidos quirúrgicamente antes y después de las 48 horas del ingreso hospitalario.
Materiales y métodos
Estudio retrospectivo de los pacientes operados por fracturas intertrocantéricas entre 2007 y 2013 con datos extraídos de historias clínicas y encuestas telefónicas. Se realizó un análisis de supervivencia a los 6 y 12 meses con el método estadístico Kaplan Meier y Log-Rank-test. Para comparar las proporciones de mortalidad y las medias entre grupos se utilizó X2 y t student respectivamente.
Resultados
La mortalidad a los 6 meses en el grupo de cirugía temprana alcanzó el 2,9% y en cirugía tardía, el 15,1% (p = 0,02). La estancia hospitalaria disminuyó 5 días en los pacientes operados antes de 48 horas (p = 0,008). No se puso de manifiesto diferencia estadísticamente significativa en la mortalidad al año en los grupos comparados.
Discusión
En el estudio se evidenció menor porcentaje de mortalidad a los 6 meses de la intervención quirúrgica y disminución en la estancia hospitalaria postoperatoria en el grupo de cirugía temprana. Respecto a la bibliografía mundial, la cirugía temprana tiene mayor repercusión en mortalidad en el primer semestre.
Nivel de evidencia clínica. Nivel III.
Objective: to demonstrate the influence of preoperative and postoperative factors in the final result of rehabilitation treatment of hip fractures in patients admitted in the "Gustavo Aldereguía Lima" University Hospital of Cienfuegos municipality. Methods: a prospective, longitudinal, descriptive and observational study was conducted in 68 cases admitted due to hip fracture from January to June, 2010, operated on or not residents of this municipality. The main variables assessed from the moment of fracture up to one year after were: age, sex, validity, comorbid disease, preoperative and postoperative complications, final result. All were collected in the study period and were registered in a data form created to that end, in addition to the anesthetic checkup sheets, the geriatric assessment and the clinical records. Results: in the group of results is highlighted the age group of 80 to 89 years with predominance in the 50 % of study patients, as well as the female sex with the 72 %: the extracapsular fractures were the more frequent in the 63 % of total. The orthopedic complications were present in the 23 % of cases, preoperative rehabilitation in the 76 %, postoperative over 1 to 7 days in the 96 and the 86 % of patients assessed in hip specialized consultation, the 89 % of patients achieved to walk freely with some type of help. Conclusions: results demonstrate the experience obtained by specialists in the use of new technologies during the surgical act. The preoperative assessments by Geriatric or Anesthesia and the performing of an early rehabilitation, from the health and psychological measures with an strict outpatient follow-up and controlling the fulfillment of family training in the care of these patients.
Resumen
Introducción
La incidencia de luxación en reemplazos de cadera es mayor en pacientes con alto riesgo de inestabilidad. El uso de copas de doble movilidad (CDM) tiene menor incidencia de luxación que el de las prótesis convencionales.
Materiales y métodos
Estudio de cohorte retrospectiva. Pacientes llevados a reemplazo total de cadera (RTC) entre 2011 y 2014, con copas de doble movilidad, operados por abordaje posterolateral por el mismo grupo de cirujanos. Se evaluó la incidencia de luxación y la razón de utilizar CDM. Las diferencias entre grupos se calcularon mediante la prueba exacta de Fisher para las variables cualitativas y el test de Wilcoxon para las variables continuas.
Resultados
Se incluyó a 103 pacientes con una media de edad de 79,5 años, el 73,7% de los cuales eran mujeres. Las principales razones para usar CDM fueron: fractura de cadera (65%) y revisión (31%). La incidencia de luxación protésica alcanzó el 7,7% y se presentó principalmente en mujeres (87,5%; p = 0,677). De los pacientes que presentaron luxación, el 87,5% tenía fractura y el 63%, enfermedad de la esfera mental.
Discusión
La luxación protésica continúa siendo un problema, incluso con el uso de CDM, en pacientes de alto riesgo. La incidencia de luxación en fracturas y cirugía de revisión en nuestra institución es similar a la reportada en la bibliografía. Observamos que en nuestro estudio las luxaciones se presentaron principalmente en pacientes que tenían como factor de riesgo fractura y alteración de la esfera mental, lo que puso de manifiesto que este segundo factor tenía gran importancia.
Nivel de evidencia clínica
Nivel IV. Estudio observacional.
Background:
Lower limb fractures are more frequent among older patients with osteopenia after a low energy fall and/or among young patients who sustain a high energy trauma. The prevalence of hip, femur and knee fractures at the High Specialty Medical Unit, Hospital de Traumatología y Ortopedia "Lomas Verdes" is unknown.
Material and methods:
Cross-sectional study, descriptive and retrospective design. Cases with low extremity fractures treated from January 1st, 2012 to December 31st, 2013 at the Hip, Femur and Knee Service, High Specialty Medical Unit, Hospital de Traumatología y Ortopedia "Lomas Verdes", were reviewed.
Results:
Most patients (52.2%) were females; 64.1% of patients were over 60 years of age. Fracture distribution according to the segment involved was as follows: 73.4% (n = 1,327) were femur fractures, 13.5% (n = 244) tibial plateau fractures, and 13.2% (n = 238) patellar fractures. 66.8% (n = 1,209) of patients had a long hospital stay (more than 10 days). According to the anatomical location of fractures, transtrochanteric fractures (49.1%) were the most frequent ones, followed by patellar fractures (13.2%), and femur shaft fractures (12.7%).
Conclusions:
The prevalence of lower limb fractures at our hospital corresponds to what has been reported internationally.
We have studied the incidence of fractures of the proximal femur in one English county from 1968 to 1991. Numbers have increased steadily, but the age-specific incidence has remained relatively unchanged since 1981. The increase is due to the rise in the population most at risk; this is likely to continue causing a 20% increase in demand for treatment by the year 2000. Suitable allocation of resources must be planned.
We report a prospective study of 232 consecutive patients with hip fractures. All were over 64 years of age and living independently before admission to a geriatric orthopaedic ward. We assessed the value, at admission, of predicting factors for independent living at one year after injury.
The most important factors were: (1) preinjury function in activities of daily living (grade A or B on the Katz et al (1963) scale); (2) absence of other medical conditions which would impair rehabilitation; and (3) cognitive function better than 7 on the Pfeiffer (1975) mental questionnaire. The odds ratios (95% CI) for these three predictors were 3.5 (1.3 to 9.1), 2.9 (1.3 to 6.1) and 2.4 (1.9 to 4.9), respectively. When all predictors were positive at admission, 92% were living independently at one year; with one, two or three negative predictors, the percentages living independently were 76, 61 and 27, respectively.
The median values of the total number of days in hospital, irrespective of diagnosis, during the first year were 12, 24, 29 and 149 days for the four groups. The mortality at one year was predictable on admission only by the number of medical conditions: with no other diagnosis than the fracture the mortality was 0%; with one or two additional conditions the mortality was 14%; and with three or more additional diagnoses it was 24%.
These simple and robust predictors can be used to optimise resources for rehabilitation.
At an average follow-up of 2.1 years, we reviewed the records of 241 patients who had had a fracture of the hip. The average age of the patients was 75.4 years. The rate of mortality one year after the fracture was 21.6 per cent for the total group, 8.0 per cent for the low-risk group, and 49.4 per cent for the high-risk group. The standard mortality ratio was six times higher for the high-risk group than for the general population (individuals who did not have a fracture), matched for age. It was highest for patients who were less than seventy years old and lowest for those who were older than eighty. However, in the second year after the fracture, the standard mortality ratio approached unity--that is, the rate of mortality approached that of the general population. The results suggest that there is an inverse relationship between mortality and advanced age and that the impact of a fracture of the hip on mortality is seen primarily in the first year after injury.
We studied the Medicare data from 1984 through 1987 for 687,850 fractures of the hip that had occurred in the United States. Our purpose was to determine the geographic, sex-specific, and age-interval variations in the relative risk of fracture of the hip in elderly white individuals. The rates of cervical, trochanteric, and subtrochanteric fracture, and the over-all rate of fracture at any of the three levels, increased with age, were greater for women than for men, and were higher in the Southern part of the country. However, there were regional, sex, and age variations. The ratio of cervical to trochanteric fractures was significantly higher in the East South Central region and lower in the Middle Atlantic and New England regions (p < 0.05). These were the same areas with the highest and lowest over-all rates, respectively, of fracture of the hip. The ratio of cervical to trochanteric fractures decreased from 1.52 in women who were sixty-five to sixty-nine years old to 0.81 in women who were at least eighty-five years old, but it stayed at approximately 1.00 for the corresponding age-groups of men. The ratio of fracture of the hip in women to fracture of the hip in men varied depending on the level of the fracture.
Methods of meta-analysis, a technique for the combination of data from multiple sources, were applied to analyze 106 reports of the treatment of displaced fractures of the femoral neck. Two years or less after primary internal fixation of a displaced fracture of the femoral neck, a non-union had developed in 33 per cent of the patients and avascular necrosis, in 16 per cent. The rate of performance of a second operation within two years ranged from 20 to 36 per cent after internal fixation and from 6 to 18 per cent after hemiarthroplasty (relative risk, 2.6; 95 per cent confidence interval, 1.4 to 4.6). Conversion to an arthroplasty was the most common reoperation after internal fixation and accounted for about two-thirds of these procedures. The remaining one-third of the reoperations were for removal of the implant or revision of the internal fixation. For the patients who had had a hemiarthroplasty, the most common reoperations were conversion to a total hip replacement, removal or revision of the prosthesis, and débridement of the wound. Although we observed an increase in the rate of mortality at thirty days after primary hemiarthroplasty compared with that after primary internal fixation, the difference was not significant (p = 0.22) and did not persist beyond three months. The absolute difference in perioperative mortality between the two groups was small. An anterior operative approach for arthroplasty consistently was associated with a lower rate of mortality at two months than was a posterior approach. Some reports showed promising results after total hip replacement for displaced fractures of the femoral neck; however, randomized clinical trials are still needed to establish the value of this treatment.
We assessed 882 patients presenting with a proximal femoral fracture by a new mobility score and by a mental test score, to determine which was of the most value in forecasting mortality at one year. Both scores gave a highly significant prediction, but the mobility score had a greater predictive value and is easier to perform.
Current knowledge regarding the basic epidemiology of fractures is largely limited to a few fracture sites, notably those of the hip and distal forearm. To clarify the patterns of incidence of limb fractures in the elderly, we used data from a 5% sample of the U.S. Medicare population over age 65 years during the years 1986-1990. We identified incident fractures of the proximal humerus, other parts of the humerus, proximal radius/ ulna, shaft of the radius/ulna, distal radius/ulna, pelvis, hip, other parts of the femur, patella, ankle, and other parts of the tibia/fibula from diagnoses and procedures coded on claims for inpatient services, outpatient facility use, and physician services. We used Poisson regression to investigate the relation between demographic factors and fracture risk at these sites. Fractures at the hip were the most common, accounting for 38% of the fractures identified. The proximal humerus, distal radius/ulna, and ankle also were common fracture sites. A pattern of rapidly rising rates with age was seen for fractures of the pelvis, hip, and other parts of the femur among women. Fractures distal to the elbow or knee, however, had, at most, modest increases in incidence with age over 65 years. For each of the fractures studied, women had higher rates than men of the same race, and whites generally had higher rates than blacks of the same gender. Gender-related differences in risk were larger among whites than among blacks, and racial differences in risk were more marked among women than among men.
One hundred elderly patients who had an intertrochanteric femoral fracture were randomized to treatment with a compression hip-screw with a plate (fifty patients) or a new intramedullary device, the intramedullary hip-screw (fifty patients). All patients were followed prospectively for one year or until death. A detailed assessment of the functional status and the plain radiographs of the hip was performed one, three, six, and twelve months postoperatively. The two treatment groups were strictly comparable. The operative time needed to insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw with the plate (p = 0.02), but use of the intramedullary hip-screw was associated with less estimated intraoperative blood loss (p = 0.011). The prevalence of perioperative complications, such as bronchopneumonia, cardiac failure, and urinary tract infection, was comparable in the two treatment groups. There were one intraoperative fracture of the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the intramedullary hip-screw. One patient had pulling-out of the compression hip-screw on the seventh postoperative day. Four patients had a trochanteric wound hematoma, without infection, after insertion of an intramedullary hip-screw. All but one of the fractures healed. The one non-union, which was in a patient who had a compression hip-screw, was treated with a hemiarthroplasty. The mortality rate was similar in the two treatment groups. The patients who had an intramedullary hip-screw had, on the average, significantly better mobility at one (p < 0.0001) and three months (p = 0.0013) postoperatively. This difference was no longer seen at six and twelve months, although the patients who had an intramedullary hip-screw still had significantly better walking ability outside the home at those time-periods (p = 0.05). The compression hip-screw was removed from two patients because of pain in the mid-portion of the thigh, which had begun after consolidation of the fracture. Fourteen patients who had an intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at twelve months postoperatively. Cortical hypertrophy was significantly related to the use of two interlocking screws (p = 0.02). Six of these patients also had pain in the mid-portion of the thigh, and the nail had been locked with two screws in five of them. Three of the six patients had the hardware removed because of the pain, and the symptoms resolved. A seventh patient had pain without cortical hypertrophy. The intramedullary hip-screw device was associated with significantly less sliding of the lag-screw and subsequent shortening of the limb in the region of the thigh (p = 0.012 and 0.019, respectively); these differences were more pronounced when the unstable fractures in the two treatment groups were compared (p < 0.001).
In postmenopausal women, a history of any fracture is an important risk factor for a future hip fracture. Whether similar findings apply to aging men remains to be established. We conducted a systematic review and meta-analysis of the literature to compare men and women with respect to the relative risk of hip fracture after a wrist or spine fracture.
Studies published in full from January 1982 through September 2002 in English, French, or German were identified from the PubMed database and from reference lists of retrieved articles. We included cohort studies that reported fractures associated with minimal trauma of the wrist or spine as a risk factor for a subsequent hip fracture among (white) women and men who were fifty years old or older. Data were extracted by two independent reviewers and were checked for accuracy in a second review. Differences in assessments were resolved by consensus of the two reviewers.
Nine cohort studies were included in this meta-analysis: five studies were conducted in the United States and four, in Europe. After homogeneity of association was demonstrated across all studies, a fixed-effects meta-analysis was used to calculate pooled relative risks with 95% confidence intervals. Among postmenopausal women, the relative risks for a future fracture of the hip after a fracture of the wrist or spine were 1.53 (95% confidence interval, 1.34 to 1.74; p < 0.001) and 2.20 (95% confidence interval, 1.92 to 2.51; p < 0.001), respectively. In older men, these relative risks were 3.26 (95% confidence interval, 2.08 to 5.11; p < 0.001) and 3.54 (95% confidence interval, 2.01 to 6.23; p < 0.001), respectively. Fractures of the distal part of the radius increased the relative risk of hip fracture significantly more in men than in women (p = 0.002). The impact of a spine fracture, conversely, did not differ between genders (p = 0.11). Sensitivity analyses with use of random-effects methodology confirmed these findings to be robust.
This meta-analysis suggests that a previous spine fracture has an equally important impact on the risk of a subsequent hip fracture in both genders. The prospective association between a Colles fracture and a subsequent hip fracture, however, is significantly stronger among men than among postmenopausal women. Men with a Colles fracture are at high risk for a future hip fracture and should be evaluated as candidates for preventive measures.
The treatment of intertrochanteric hip fractures has evolved over the past 80 years because of a better understanding of fracture anatomy, application of biomechanical principles, and novel technologic advances. Surgical treatment of intertrochanteric hip fractures is the current standard of care, with short-term goals of fracture stabilization and early patient mobilization and the long-term objective of restoring patients to their previous level of independence and function. Treatment for stable intertrochanteric hip fractures includes use of percutaneous intramedullary devices and open reduction and internal fixation using a sliding hip screw. To date, none of these devices has shown any clear clinical advantage over the dynamic hip screw. Intramedullary fixation has multiple theoretical advantages for the treatment of unstable fracture patterns; however, it remains unclear if ultimate functional outcome warrants the added expense of such treatment. For patients with a reverse obliquity fracture pattern, the advantage of the intramedullary construct has been shown.
Presentation de la serie du symposium de les fractures des sujets ages de plus de 80 ans
- F Jacquot
- Jm Feron
- Bonnevialle
Jacquot F, Feron JM, Bonnevialle P. Presentation de la serie du symposium de les fractures des sujets ages de plus de 80 ans. Revue Chirurgie Orthopedique. 89 : 2S138-2S142. 2003.
Fractures diaphysaires fe-morales au-dela de 70 ans. Interets de l’enclouage centro-medullaire par clou de Grosse et Kempf ou Gamma long
- P Bonnevialle
- D Laques
- G Fabre
Bonnevialle P, Laques D, Fabre G, et al. Fractures diaphysaires fe-morales au-dela de 70 ans. Interets de l’enclouage centro-medullaire par clou de Grosse et Kempf ou Gamma long. Revue Chirurgie Orthopedique. 88: 41-50. 2002.
Pronostic vital des frac-tures de l’extremite superieure du femurEtude de 506 patients de 60 ans et plus
- P Czernichow
- Jm Thomine
- N Biga
Czernichow P, Thomine JM, Biga N, et al. Pronostic vital des frac-tures de l’extremite superieure du femur.Etude de 506 patients de 60 ans et plus. Revue Chirurgie Orthopedique. 76 : 161-169. 1990.
Suivi a un an de 100 patients ages victims d’une fracture de hanche
- Fx Raoux
- Ch Lafont
- Vellas
Raoux FX, Lafont CH, Vellas B, Suivi a un an de 100 patients ages victims d’une fracture de hanche. Ann Gerontol. 7 : 267-278. 1993.