Intramedullary nails in the treatment of trochanteric and subtrochanteric fractures

Et hoftebrudd er en alvorlig og potensielt dødelig hendelse for et eldre, skrøpelig individer. Et slikt brudd fører svært ofte til økt hjelpebehov, varig nedsatt funksjon og ovedødelighet. Valg av implantat i behandlingen av trokantære og subtrokantære brudd har vært diskutert over flere tiår. Målet med dette prosjektet var å beskrive hvordan en intramedullær nagle påvirker lokalisasjon og morfologi ved et nytt hoftebrudd, å gjennomføre en oppdatert sammenlikning av glideskrue og intramedullær nagle i behandlingen av henholdsvis stabile og ustabile trokantære og subtrokantære brudd i Norge, samt sammenlikne de ulike intramedullære naglene i utstrakt bruk i Norge. Resultatene i dette prosjektet støtter de gjeldende internasjonale og nasjonale retningslinjer, der en intramedullær nagle anbefales i behandlingen av trokantære og subtrokantære brudd. Implantatnære brudd er fremdeles en utfordring, og vi har funnet at en intramedullær nagle påvirker fordelingen av et påfølgende lårbensbrudd i betydelig grad. Vi har identifisert signifikante forskjeller i reoperasjonsrate ved bruk av ulike typer lange intramedullære nagler, noe som understreker verdien av registre for å overvåke implantater i bruk ved behandling av trokantære og subtrokantære bruddA hip fracture is a serious event in the geriatric patient, causing considerable morbidity and increased mortality. Choice of implant in the surgical treatment of trochanteric and subtrochanteric fractures has been debated for decades. The aim of this research project was to describe the impact of an intramedullary nail (IMN) in the event of a subsequent femoral fracture (Sffx), conduct an updated comparison of the sliding hip screw (SHS) and the IMN in stable versus unstable trochanteric and subtrochanteric fractures in Norway and compare the outcomes of different IMN designs. The results of this thesis support the current international and national guidelines recommending the use of an IMN in the treatment of unstable trochanteric and subtrochanteric fractures. Peri-implant fractures are however, still a challenge, and the presence of an IMN significantly changes the distribution of a subsequent fracture. We have identified significant differences in reoperation rate between different brands of long IMNs, emphasizing the value of registers in the surveillance of performance and outcomes of implants used in the treatment of trochanteric and subtrochanteric fractures.Doktorgradsavhandlin

Intramedullary nail versus sliding hip screw for stable and unstable trochanteric and subtrochanteric fractures: 17,341 patients from the Norwegian Hip Fracture Register

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. Methods We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. Results Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). Conclusion This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN.acceptedVersio

Subsequent ipsi- and contralateral femoral fractures after intramedullary nailing of a trochanteric or subtrochanteric fracture: a cohort study on 2012 patients

Background: The literature is inconclusive as to whether an intramedullary nail changes the distribution of a subsequent ipsi- or contralateral fracture of the femur. We have compared the incidence, localisation, and fracture pattern of subsequent femoral fractures after intramedullary nailing of trochanteric or subtrochanteric fractures in patients without previous implants in either femur at the time of surgery. Methods: Retrospective analysis was performed of a two-centre cohort of 2012 patients treated with a short or long intramedullary nail for the management of trochanteric or subtrochanteric fracture between January 2005 and December 2018. Subsequent presentations with ipsi- and contralateral femoral fractures were documented. Only patients with no previous femoral surgery performed, other than the index nailing were followed. Odds ratios (ORs) for subsequent femoral fracture were calculated using robust variance estimates in logistic regression. Results: The mean age of the cohort was 82.4 years and 72.1% were female. The total number of patients presenting with subsequent femoral fractures was 299 (14.9%). The number of patients presenting with subsequent ipsilateral and contralateral femoral fractures was 51 (2.5%) and 248 (12.3%) respectively (OR 5.0; CI 3.7–6.9). Twenty-six (8.7%) of all subsequent femoral fractures occured in the ipsilateral shaft, 14 (4.7%) in the ipsilateral metaphyseal area, one (0.33%) in the contralateral shaft, and three (1.0%) in the contralateral metaphysis (OR 10; CI 3.6–29). Conclusion: An intramedullary nail significantly changes the fracture pattern in the event of a second low-energy trauma, reducing the risk of subsequent proximal ipsilateral femoral fractures and increasing the risk of subsequent ipsilateral femoral fractures in the shaft and distal metaphyseal area compared with the native contralateral femur.publishedVersio

Subsequent ipsi- and contralateral femoral fractures after intramedullary nailing of a trochanteric or subtrochanteric fracture: a cohort study on 2012 patients

Background: The literature is inconclusive as to whether an intramedullary nail changes the distribution of a subsequent ipsi- or contralateral fracture of the femur. We have compared the incidence, localisation, and fracture pattern of subsequent femoral fractures after intramedullary nailing of trochanteric or subtrochanteric fractures in patients without previous implants in either femur at the time of surgery. Methods: Retrospective analysis was performed of a two-centre cohort of 2012 patients treated with a short or long intramedullary nail for the management of trochanteric or subtrochanteric fracture between January 2005 and December 2018. Subsequent presentations with ipsi- and contralateral femoral fractures were documented. Only patients with no previous femoral surgery performed, other than the index nailing were followed. Odds ratios (ORs) for subsequent femoral fracture were calculated using robust variance estimates in logistic regression. Results: The mean age of the cohort was 82.4 years and 72.1% were female. The total number of patients presenting with subsequent femoral fractures was 299 (14.9%). The number of patients presenting with subsequent ipsilateral and contralateral femoral fractures was 51 (2.5%) and 248 (12.3%) respectively (OR 5.0; CI 3.7–6.9). Twenty-six (8.7%) of all subsequent femoral fractures occured in the ipsilateral shaft, 14 (4.7%) in the ipsilateral metaphyseal area, one (0.33%) in the contralateral shaft, and three (1.0%) in the contralateral metaphysis (OR 10; CI 3.6–29). Conclusion: An intramedullary nail significantly changes the fracture pattern in the event of a second low-energy trauma, reducing the risk of subsequent proximal ipsilateral femoral fractures and increasing the risk of subsequent ipsilateral femoral fractures in the shaft and distal metaphyseal area compared with the native contralateral femur

Timing of hip hemiarthroplasty and the influence on prosthetic joint infection

Introduction Previous research suggested that patients have increased risk of infection with increased time from presentation with a femoral neck fracture to treatment with a hip hemiarthroplasty (HHA). The purpose of this study was to determine if rates of prosthetic joint infections within 3 months of surgery was affected by the time from patient presentation with a femoral neck fracture to the time of treatment with HHA. Materials and methods Acute hip fractures treated with HHA between 2005 and 2017 at three centres in Norway were enrolled in the study. Multi-trauma patients were excluded. Univariable analysis was performed to determine any significant effect of pre-operative waiting time on infection rate. Two pre-planned analyses dichotomizing pre-operative waiting time cut-offs were performed. Results There were 2300 patients with an average age of 82 (range, 48–100) years included of which 3.4% experienced a prosthetic joint infection within 3 months. The primary analysis found no significant difference in infection rate depending on time to surgery (OR = 1.06 (95% CI 0.94–1.20, p = 0.33)). The secondary analyses showed no significant differences in infection rates when comparing pre-operative waiting time of <24 hours vs �24 hours (OR = 0.92 (95% CI 0.58–1.46, p = 0.73)) and <48 hours vs �48 hours (OR = 1.39 (95% CI 0.81– 2.38, p = 0.23)). Conclusion Based off of a large retrospective Norwegian database of hip fractures there did not appear to be a significant difference in infection rate based on pre-operative wait time to surgery