Dislocation of total hip replacement in patients with fractures of the femoral neck: A prospective cohort study of 713 consecutive hips

Background Total hip replacement is increasingly used in active, relatively healthy elderly patients with fractures of the femoral neck. Dislocation of the prosthesis is a severe complication, and there is still controversy regarding the optimal surgical approach and its influence on stability. We analyzed factors influencing the stability of the total hip replacement, paying special attention to the surgical approach

Quality of life and femoral neck fractures

The worldwide increase of hip fractures is a major challenge for the health care system and society. The treatment of femoral neck fractures in the elderly is still controversial, and even more so from an international perspective. Optimising the treatment for improved outcome and a reduced need for secondary surgery is mandatory for humanitarian and economical reasons. The importance of incorporating the patients's perspective of outcome in clinical trials is acknowledged and there are now numerous instruments for assessing the quality of life. We evaluated two quality of life instruments, the EQ-5D and the SF-36, in patients with femoral neck fractures and also measured the quality of life two years after different interventions. In two prospective studies the EQ-5D was validated and it appeared to be an appropriate quality of life instrument in elderly patients with femoral neck fractures. There was a good correlation between the quality of life (EQ-5D index scores) and other outcome measures such as pain, mobility and independence in activities of daily living (ADL). The results also showed high responsiveness, i.e. ability to capture clinically important changes, for both the EQ-5D and the SF-36. The questionnaire response rate for both instruments was high. The rated prefracture EQ-5D index scores showed good correspondence with the scores of an age- matched Swedish reference population. The quality of life in patients with femoral neck fractures treated with internal fixation (IF) decreased, particulary in patients with fracture healing complications. The fracture healing complications rate at two years in patients with displaced femoral neck fractures treated with IF was 36% compared to 7% in patients with undisplaced fractures. The quality of life of patients with uneventfully healed fractures at two year was significantly lower in patients with primarily displaced fractures compared with patients with undisplaced fractures. In a prospective randomised trial patients with displaced femoral neck fractures were randomised to IF or a total hip replacement (THR). The failure rate after two years was higher in the IF group compared with the THR group with regard to hip complications, 36% and 4%, and the number of reoperated patients, 42% and 4%. Hip function and quality of life (EQ-5D) were generally better in the THR group. In summary, THR provided a better outcome than IF for an elderly, relatively healthy, lucid patient with a displaced femoral neck fracture. In a study of elderly women with femoral neck fractures almost half of the patients displayed signs of protein-energy malnutrition. Underweight was associated with muscle fatigue, cognitive dysfunction and low quality of life (Nottingham Health Profile, NHP). In a prospective randomised trial protein rich liquid supplementation in combination with an anabolic steroid given during 6 months to lean elderly women after a femoral neck fracture was shown to positively affect lean body mass, ADL and quality of life (EQ-5D). Fracture healing complications had a negative impact on body weight, lean body mass and quality of life

Extramedullary fixation of 569 unstable intertrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus three other screw-plate systems

We compared the efficacy of the Medoff sliding plate (MSP) with 3 other screw-plate systems for fixation of unstable intertrochanteric fractures in a randomized multicenter trial of 569 elderly patients. The MSP has biaxial dynamic capacity along both the neck and the shaft of the femur unlike the other systems, which lack dynamic capacity along the shaft. 268 fractures were operated on with the MSP, and 301 with the dynamic hip screw (DHS), with or without a trochanteric stabilizing plate (DHS/TSP) or with the dynamic condylar screw (DCS). The MSP had recently been shown to the surgeons.The patients in the groups were similar as regards age, domestic situation, preinjury walking ability and type of fracture. We followed the patients clinically and radiographically for at least 1 year. There was no significant difference in walking ability at follow-up or rate of return to home. Fixation failure occurred in 18/268 fractures operated on with the MSP, in 8/238 with the DHS, in 3/49 with the DHS/TSP and in 1/14 with the DCS. The difference in the rate of fixation failure was not statistically significant when the MSP group was compared to the 3 other groups. In 14 of the 18 fixation failures in the MSP group, the biaxial dynamic capacity of the MSP had not been used due to technical errors by surgeons, unfamiliar with the new method. No selection bias was found regarding fracture types in the 2 subgroups of patients with correct or inadequate biaxial dynamization. Extramedullary fixation of unstable intertrochanteric fractures with these implants showed a low failure rate. When using the MSP, biaxial dynamization must be correctly performed