Search Results (118)

Background/Objectives: Femoral neck and proximal femur fractures in the elderly can result from low-energy trauma due to osteoporotic changes and contribute significantly to increased morbidity and mortality. Despite various treatment options, closed reduction and internal fixation (CRIF) with intramedullary nails has become the predominant approach. While a minimally invasive approach reduces complications and speeds recovery, this outcome is not always feasible in practice. The primary surgical goal remains achieving a stable and precise fracture reduction, favoring CRIF when possible. Our study aims to evaluate the clinical, radiological, and functional outcomes of patients operated on using the Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique. Methods: Patients who underwent surgery for intertrochanteric femur fractures between June 2019 and June 2021 were analyzed. Patients who were between 75 and 90 years old and had undergone surgery with a proximal femoral nail (PFN) were included in the study. Patients were excluded if they required general anesthesia, if an acceptable reduction could not be achieved with the PFN, if they did not attend the last follow-up examination, or if the follow-up period was <4 years. Patients were functionally assessed using the Harris hip score at the 6th month and at the last follow-up and using the visual analog scale at the surgery, at the 4th hour after surgery, and at the time of discharge. For radiological assessment, the classification of reduction quality and the measurement of the tip–apex distance were used. Results: Forty patients (22F/18M) were included in the study. Their mean age was 83.0 ± 2.9 years. The mean time from trauma to surgery was 6.8 ± 2.3 h. Patients were mobilized on average 1.53 ± 0.8 h after surgery, and the mean hospitalization time was 27.4 ± 8.1 h. No statistically significant decrease in hemoglobin value was observed before or after surgery (p = 0.476). The Harris hip score was 73.3 ± 3.2 at the 6th month postoperatively and 74.9 ± 2.5 at the last follow-up (p = 0.296). The reduction quality was found to be poor in only two patients. Conclusions: The WALANT technique’s promising results in terms of pain management, blood loss control, and early mobilization show that it is a viable alternative to conventional anesthesia methods in geriatric hip fractures. Full article

Background: Benign bone tumors and tumor-like lesions in the proximal femur increase the risk of pathological fractures, often requiring surgical intervention. However, no consensus exists on the optimal treatment strategy. We developed a structured approach to guide the selection of implant types (compression hip screw [CHS] or intramedullary nail [IMN]) with or without bone grafting. This study aims to validate our treatment strategy through a retrospective analysis and a review of previous surgical outcomes. Methods: We sought to validate this strategy through a retrospective analysis of 16 patients (6 males and 10 females, mean age at surgery 37.4 years [range, 16–64 years]) with primary benign bone tumors or tumor-like conditions of the proximal femur, including the femoral head and neck. Curettage and synthetic or autologous bone graft was performed according to our treatment flowchart, utilizing either CHS or IMN for internal fixation. We compared the blood loss, operative time, time to full weight bearing, and perioperative complications between the CHS and IMN groups. Results: Blood loss did not significantly differ between the CHS and IMN groups (p = 0.11), but the operative time was significantly longer in the CHS group (p < 0.01). Two CHS cases experienced local recurrence, while no postoperative fractures were observed in either group. The median time to full weight bearing was 5 weeks, consistent with previous reports. No perioperative complications were noted. Conclusions: Our strategy achieved favorable clinical outcomes. IMN was selectively used in patients with non-aggressive benign tumors not involving the femoral head and neck, yielding good results with reduced surgical invasiveness, while in those patients with aggressive disease involving the head and neck, CHS was more appropriate. This approach may serve as a practical guide for surgical decision-making in benign proximal femoral bone tumors. Full article

Fragility fractures of the pelvis (FFPs) are common in elderly patients, particularly those with osteoporosis. FFPs can be associated with high mortality, morbidity, and functional decline. Known risk factors include being over 80 years old and delays in surgical intervention when this is required. While the role of surgery in FFPs remains less defined than in proximal femoral fractures in the elderly, studies indicate that surgical fixation offers improved survival and functional outcomes. Similarly, the choice of fixation method, whether posterior or anterior, and their combinations, vary between clinicians. It depends on the fracture type and patient-specific factors, such as bone quality and comorbidities, as well as the surgeon’s experience and the availability of resources. Additionally, orthobiologic adjuncts such as cement augmentation and sacroplasty can enhance the stability of an osteoporotic fracture during surgical intervention. Furthermore, medical treatments for osteoporosis, especially the use of teriparatide, have demonstrated beneficial effects in reducing fractures and promoting healing of the FFPs. Return to pre-injury activities is often limited, with independence rates remaining low at mid-term follow-up. Factors that influence clinical outcomes include fracture type, with Type III and IV fractures generally leading to poorer outcomes, and patient age, functional reserve, and comorbidities. The present tutorial aims to summarise the relevant evidence on all aspects of FFPs, inform an updated management strategy, and provide a template of the reconstruction ladder referring to the most available surgical techniques and treatment methods. Further research, based on large-scale studies, is needed to address the open questions described in this manuscript and refine surgical techniques, as well as determine optimal treatment pathways for this vulnerable patient population. Full article

Background: The global number of operatively treated proximal femoral fractures is steadily growing, driven by the demographic shift toward an increasingly elderly, frail, and comorbid population. This clinical condition profoundly impacts not only patient health but also the finances of healthcare systems. The aim of this economic analysis was to investigate the impact on direct costs of orthogeriatric co-management (OGCM) compared to standard of care (SOC). Methods: A retrospective analysis was conducted investigating two comparable cohorts of patients aged 75 and above, originating from the exact same geographic area, who underwent surgical treatment for proximal femoral fractures in 2023. The two cohorts differed in their perioperative care protocols: one followed an OGCM (n = 143) protocol, while the other adhered to a SOC protocol (n = 141). Economic data were retrieved from the centralised finance department managing the two hospital sites under investigation. Results: The findings revealed that the OGCM protocol was associated with direct costs that were not higher (CHF 16,019 vs. CHF 16,713, p = 0.78) compared to SOC, despite higher daily costs in the OGCM cohort (CHF 2504 vs. CHF 2202, p < 0.0001). This difference was largely driven by a significantly shorter length of stay in the OGCM group (6 days vs. 7 days, p = 0.002). Conclusions: Optimising resource allocation through tailored geriatric care protocols suggests not only an improvement in clinical outcomes but also a reduction in economic burden, thereby alleviating pressure on the healthcare system. Full article

Background: Toggling of the short cephalomedullary nail is an understudied phenomenon characterized by a change in the longitudinal axis of the nail in relation to the longitudinal axis of the femoral medullary canal, with subsequent potential loss of reduction. This retrospective study aims to examine the incidence and impact of toggling of short cephalomedullary nails in cases with wide femoral canals. Methods: One thousand two hundred fifty-six (1256) cases that received short proximal femoral nails for intertrochanteric fractures were reviewed. Of them, 101 cases that had wide femoral canals (≥15 mm) and a minimum radiographic follow-up of 6 weeks were included in this study. Outcome measures included nail toggling, varus malunion and revision surgery. Results: After a mean radiographic follow-up of 53.5 weeks, sixteen cases (15.8%) showed significant nail toggling of more than 4 degrees and had subsequent varus displacement of the fracture. In all 16 cases, there was deficient proximal nail fixation, in the form of either a lag device not engaging the lateral wall (2 cases), lateral proximal femoral wall fracture/incompetency (7 cases), or a combination of the two factors (7 cases). Despite this, all sixteen cases achieved fracture union. Five additional cases had complications related to poor initial reduction (four cases) or femoral head avascular necrosis (one case). The other 80 cases had minimal (0–4 degrees) nail toggling and healed without varus malunion, and none of them required revision surgery. Conclusions: Short cephalomedullary nails may toggle in patients with wide femoral canals. The effect of femoral canal width on nail movement and subsequent varus malunion may be abolished when the lag device engages the lateral proximal femoral cortex, and the lateral cortical bone is intact. In patients with wide femoral medullary canals or cases with proximal lateral femoral cortical fracture, the utilization of long or intermediate length cephalomedullary nails may be a more viable option. Full article

Background and Objectives: Our study aimed to retrospectively examine the routine radiographs on the first postoperative day of osteosynthesis applications performed in the supine position with the help of a traction table, in the lateral decubitus position, and in the supine position in patients with intertrochanteric fractures of the femur who had a proximal femoral nail applied. It also aimed to compare them in terms of radiology. This study investigated the effects of three different patient positions on fracture reduction, a topic rarely encountered in the literature. Materials and Methods: Patients who underwent proximal femoral nailing in three different positions—the supine, traction table, and lateral decubitus positions—due to femoral intertrochanteric fractures in two different centers were analyzed. A total of 157 patients with complete early radiographs were included in this study to evaluate the quality of postoperative reduction and fixation. Results: There was a significant difference between the traction table-assisted supine position group (mean: 25.31 mm) and both the lateral decubitus position (mean: 31.91 mm) and supine position (mean: 31.79 mm) groups in terms of the TAD (p = 0.000). Regarding the collodiaphyseal angle, the traction table-assisted supine position (mean: 130.720°) and lateral decubitus position (mean: 130.290°) groups showed significantly higher values than the supine position group (mean: 124.190°) (p = 0.000). The average lengths of the lag and compression screws were lower in the lateral decubitus position group compared with the other groups (p = 0.000). Patients in the supine position group had smaller nail diameters and lengths (p = 0.000). When examining the Cleveland–Bosworth lag screw placements, the most frequent position was center–center, including 22 patients (31%) in the traction table-assisted supine position group, 15 patients (30.6%) in the lateral decubitus position group, and 9 patients (24.3%) in the supine position group, though the difference was not statistically significant (p = 0.203). Among the reduction criteria we investigated, the TAD on the traction table was statistically significantly closer to the targeted measurement, with an average of 25.31 mm, compared with the other two positions (p = 0.000). The collodiaphyseal angle was significantly within the target range in the traction table-assisted supine group, averaging 130.720°, compared with the supine position (p = 0.000). In the traction table group, according to the modified Baumgaertner classification, 59.2% achieved a good reduction; according to the Ikuta classification, subtype N accounted for 69.4%; and according to the Cleveland–Bosworth classification, a center–center placement was present in 31% of patients. Conclusions: All three types of operation can be preferred according to the habits of the surgeon operating and the variables during the operation (the fracture type, history of orthopedic surgery, and the material components of the application phase). Accompanied by these data, we recommend the traction table operation as a priority and the lateral decubitus position operation as a second preference in compliance with the technical requirements. Full article

Background: Pertrochanteric fractures of the proximal femur present a common challenge for traumatologists, with intramedullary nailing emerging as the preferred treatment. Complication rates are around 20%, including screw jamming, refractures, implant breakage, or medial migration, with cut-out being the most common. A tip–apex distance (TAD) of >25 mm and incorrect cephalic screw position are predictive factors for cut-out. This study assesses outcomes using the Elos intramedullary nail, based on the experience of the Department of Orthopedics and Traumatology at Ospedale Maggiore in Bologna. Methods: We conducted a retrospective cohort study of 344 patients treated with the Elos intramedullary nail for pertrochanteric femoral fractures from 1 January 2017 to 31 December 2022. The Elos^®-Intrauma nail was implanted using the standard technique. Initial X-rays classified fractures according to the AO-OTA classification, and postoperative X-rays confirmed the cephalic screw’s placement per Cleveland’s regions. Patients were divided into two groups: optimal cephalic screw position (positions 5-8-9) and other positions. We evaluated TAD, calcar-referred TAD (CalTAD), and postoperative reduction quality using Chang’s criteria. The incidence of cut-out and other complications were assessed in connection with these measurements. Results: Among the 344 patients, 227 (65.9%) had the screw in positions 5-8-9, while 117 (34.1%) had it in other positions. The median TAD was 19.47 ± 6.26 mm (range 3.96–46.6), with TAD ≤ 25 mm in 265 patients (77%). The median CalTAD was 22.37 ± 5.65 mm (range 8.75–45.3), with CalTAD ≤ 25 mm in 231 patients (67.1%). According to Chang’s criteria, 8 cases (2.3%) had poor reduction, 139 cases (40.4%) had acceptable reduction, and 197 cases (57.3%) had excellent reduction. Cut-out occurred in four cases (1.19%). Multivariate analysis revealed only poor reduction and TAD > 25 mm as independent predictors of cut-out (p < 0.05), while cephalic screw position, CalTAD, and fracture type did not impact cut-out incidence. Conclusions: This study indicates that optimal TAD and quality of reduction are crucial for minimizing cut-out risks. The Elos intramedullary nail shows favorable outcomes with a low cut-out incidence when these parameters are met. Emphasis should be placed on achieving a TAD ≤ 25 mm and excellent reduction quality to reduce complications. Full article

This paper presents the process of preparing and conducting a uniaxial compression test, developing the results, and determining the compressive strength of a femur made using 3D printing technology. The study considers the variable thickness of the outer layer—imitating cortical bone tissue—and the varying density of the inner layer—imitating trabecular bone tissue—which, with further analysis, may aim to replicate different states of osteoporosis. The compressive strength of the bones varied depending on the thickness of the outer layer and the filling degree. Failure patterns were observed, corresponding to different variants of the produced bones. The predominant failure pattern was the fracture of the femoral head or neck at the proximal end of the femur. The results were compared with previous studies on commercial femur bones, as well as those created using 3D printing technology by other authors. The highest compressive strength was found in the bone with an outer layer thickness of 3.0 mm and 30% infill, with a value of 4778 N. A very similar compressive strength was recorded for the bone with an outer thickness of 2.1 mm and 30% infill, reaching 4519 N. The lowest compressive strength, 2116 N, was observed in the bone with an outer thickness of 1.2 mm and 20% infill. Full article

Background: Stress shielding (SS) after total hip arthroplasty (THA) leads to proximal femoral bone loss and increases the risk of complications such as implant loosening and periprosthetic fracture. While various low-stiffness stems have been developed to prevent SS, they often compromise mechanical stability. A novel femoral stem composed of Ti-33.6Nb-4Sn (TNS) alloy offers a gradually decreasing Young’s modulus from proximal to distal regions, potentially improving load distribution and reducing SS. This study aimed to evaluate the mid-term clinical and radiographic outcomes of the TNS stem, with a particular focus on its effectiveness in suppressing SS. Methods: A prospective clinical study was conducted involving 35 patients who underwent THA using the TNS stem, with a minimum follow-up of 7 years. Twenty-one patients with Ti6Al4V metaphyseal-filling stems served as controls. Clinical outcomes were assessed using Japanese Orthopaedic Association (JOA) scores, and radiographic SS was graded using Engh’s classification and analyzed in Gruen zones. Inter-examiner reliability and statistical comparisons between groups were performed using appropriate tests. Results: The TNS group showed significantly higher preoperative JOA scores than the control group, but no significant difference in final scores. Both groups demonstrated significant improvement postoperatively. Third-degree SS occurred in the TNS group, although the overall SS grade distribution was significantly lower than in the control group (p = 0.03). SS frequency was significantly reduced in Gruen Zones 2, 3, and 6 in the TNS group. Conclusions: The TNS stem demonstrated a significant reduction in SS progression compared to conventional titanium stems over a 7-year period, with comparable clinical outcomes. However, the occurrence of third-degree SS indicates that material optimization alone may be insufficient, highlighting the need for further design improvements. Full article

Despite advancements in surgical techniques, including the utilization of intra-operative fluoroscopy and custom surgical guides, intra-articular implant placement during the pinning of capital physeal fractures can occur and may result in catastrophic complications. Our objective in this study was to compare the epiphyseal purchase afforded by a linear and triangular pattern of Kirschner wires for stabilizing femoral capital physeal fractures. Archived pelvic limb computed tomography scans of 16 skeletally immature dogs were obtained, from which virtual femoral models were created. Separate linear and triangular arrangements of three virtual 1.6 mm Kirschner wires were centered on the thickest region of the proximal epiphysis. The length of each Kirschner wire implanted within the proximal femoral epiphysis was measured. Kirschner wire placement in triangular and linear patterns resulted in a mean epiphyseal purchase for each wire of 8.4 mm and 8.0 mm, respectively. The cumulative Kirschner wire purchase was greater with the triangular pattern (p = 0.004). The mean difference in the cumulative wire purchase was 1.3 mm. The use of a triangular Kirschner wire pattern resulted in greater implant purchase within the epiphysis compared to the linear pattern. The triangular Kirschner wire pattern may reduce the risk of intra-articular implant placement by more closely centering the wires within the thickest region of the epiphysis. Full article

Proximal femoral fractures (PFFs) are the most frequent type of bone injury among the elderly. In Italy alone, 906,111 hospital admissions for hip fractures were recorded between 2007 and 2017. Globally, due to the aging population, the number of cases is expected to rise to 21.3 million by 2050. In older individuals, fractures of the femoral neck are commonly managed with prosthetic implants. While hemiarthroplasty has long been the standard treatment, total hip arthroplasty (THA) is increasingly favored for more active or functionally demanding patients. Among the surgical options, dual mobility THA (DM-THA) stands out for its potential to significantly reduce postoperative complications, particularly dislocations, when compared to both conventional THA and hemiarthroplasty. This study aimed to determine the most effective surgical strategy—dual mobility THA versus hemiarthroplasty—for managing femoral neck fractures in elderly patients. A thorough literature review was conducted using PubMed, Web of Science, and Scopus, focusing on the most recent and relevant publications. The findings highlight a consistent trend: patients treated with DM-THA generally experience better outcomes than those receiving hemiarthroplasty. Based on current evidence, DM-THA should be regarded as the preferred intervention for elderly individuals with femoral neck fractures, except in cases where severe comorbidities or anesthesia-related risks require a more conservative approach. Full article

Wearable and lightweight devices facilitate real-world physical activity (PA) assessments. MX metrics, as a cut-point-free parameter, evaluate acceleration above which the most active X minutes are accumulated. It provides insights into the intensity of PA over specific durations. This study evaluated the association of MX metrics and clinical tests in older adults recovering from proximal femoral fracture (PFF). Analyses were conducted on the PFF cohort from the baseline assessment of the Mobilise-D project using an accelerometer-based device. Participants (N = 396) were categorized into four recovery groups: acute, post-acute, extended recovery, and long-term recovery. Mobility capacity was assessed through the 6 min walking test (6MinWT), Short Physical Performance Battery (SPPB), 4-m walking test (4MWT), and hand grip (HG) strength. Mobility perception was evaluated using the Late-Life Function and Disability Instrument (LLFDI). Eight MX metrics (M1–M90) were calculated using the GGIR package in R. Results showed a moderate to strong positive correlation between M1 and M30 and lower limb mobility capacity tests and mobility perception (Lower Extremity domains) particularly in the extended and long-term recovery groups. MX metrics can be used for measuring PA intensity among older adults recovering from PFF. Hence, MX metrics have a high potential for clinical use as personalized PA targets in PFF rehabilitation. Full article

Background/Objectives: Proximal femur fractures are common in the older population and are related to bone quality. Our work evaluates bone parameters from pelvic anteroposterior (AP) radiographs in patients with trochanteric and sub-capital fractures to determine if there are predictive morphology parameters for each fracture type. Methods: Data from 237 medical records were extracted from patients who arrived at our hospital with trochanteric and sub-capital femoral fractures. Descriptive data and radiological evaluation of the calcar-to-canal ratio (CCR), cortical thickness index (CTI), and Dorr classification were measured by two observers and statistically evaluated. Results: A total of 202 patients were found to be eligible for the study. The mean patient age was 81.41 ± 7.27 years old. The mean age of the trochanteric group was significantly higher than that of the sub-capital group (p = 0.005). There were no statistically significant differences in gender and comorbidities. The CCR showed significance, but the CTI and Dorr classification did not show a significant difference (p = 0.001, p = 0.78, and p = 0.98). A high degree of reliability was shown for all measurements. The ICC for CTI and CCR was p = 0.791 and p = 0.770 (p < 0.001), and Cronbach’s alpha was 0.815 and 0.796, respectively. Logistic regression was found to be significant in predicting 60.4% of correct forecasts with an odds ratio of 0.011 and 95% confidence interval (p = 0.001). For CTI, the correct forecasting rate was 48%, with an odds ratio of 0.615 (p = 0.78). Conclusions: We found that, out of the measured parameters, the CCR stood out as important, showing that higher CCR levels are linked to an increased likelihood of trochanteric fractures. Full article

Background/Objectives: Bone mineral density (BMD) loss leads to osteoporosis, significantly increasing fracture risk in both the axial and peripheral skeleton. The extent to which it is possible to estimate the degree of osteoporosis in the hip by determining the density in Hounsfield Unit (HU) measurements derived from computed tomography (CT) scans and to calculate quantitative BMD and T values from the HU values should be examined. Methods: A total of 240 patients (mean age: 64.9 ± 13.1 years, BMI: 26.8 ± 6.8 kg/m²) underwent CT-based BMD assessments using CTXA-Hip. Subregions of the proximal femur, including the femoral head, femoral neck, and intertrochanteric region, were analyzed for cancellous density in HUs using circular and irregular region-of-interest (ROI) measurements. Correlations between HU values and DEXA-equivalent BMD (mg/cm²) and T values were computed. Predictive power for osteoporosis was evaluated using ROC curve analysis. Results: Cancellous bone density in the proximal femur showed a significant decline with increasing age and decreasing BMI (p < 0.05). The median BMD for the entire hip was 0.684 mg/cm², and the median HU value for the proximal femur was 123.15. Strong correlations were observed between HU values and BMD (R² = 0.904, p < 0.001) and T values (R² = 0.911, p < 0.001). A T value of −2.5 corresponded to an HU value of 95.79 in the entire femur. ROC analysis demonstrated high sensitivity (0.92) and specificity (0.93) for HU-based osteoporosis prediction. Conclusions: HU measurements provide a reliable method for estimating BMD and T values in the proximal femur, offering a valuable diagnostic tool for osteoporosis. The highest predictive accuracy was achieved when using an irregular ROI from the entire proximal femoral region. Full article

Background/Objectives: Osteoporosis is prevalent in the elderly and increases fracture risk. Bone density is commonly assessed using dual-energy X-ray absorptiometry (DEXA). The femoral cortical thickness index (CTI) also provides indirect information for osteoporosis. It remains unclear whether there are intra-individual differences and if a correlation to fracture risk of the CTI in fractured femora results due to fracture related malrotation during X-rays. The aim of this study was to investigate the individual bilateral CTI in patients with proximal femoral fractures. Methods: A retrospective analysis of 200 surgically treated patients (100 trochanteric, 100 femoral neck fractures) was performed. Measurements included the bilateral CTI at 10 and 15 cm below the lesser trochanter. Analysis of the correlation of those examinations, in comparison to the contralateral CTI at 15 cm, and correlation of the CTI with the body mass index (BMI) and age was performed. Results: Results showed significant differences (p < 0.001) in bilateral CTIs for both fracture types at 15 cm with a strong inter-rater reliability (ICC > 0.9). There was no significant correlation between age and CTI, as well as BMI and CTI in both cohorts (p > 0.1). Sex-specific subgroup analyses revealed that females exhibited significant differences in CTI between fractured and non-fractured sides (p < 0.001). Conclusions: In conclusion, CTI, and the modified CTI at 15 cm below the lesser trochanter in fractured proximal femora, is lower compared to the non-fractured side. The femoral CTI could help in daily clinical routines and circumstances, where more detailed risk prediction tools are lacking. Full article