|Abstract / Summary
Background – Proximal femoral fractures are the most common fractures treated in Denmark. In recent years several improvements have been made, including the establishment of guidelines, but many questions are still unanswered.
Purpose - This thesis investigates the influence of surgical delay on mortality in low-energy femoral fractures, the data available for long term survival of the cephalomedullary nails and the sliding hip screws, and the surgery-related factors influencing the risk of reoperation following osteosynthesis of the femoral neck fractures.
Methods - Study I was a retrospective registry-based study of the association between surgical delay and early mortality following low-energy proximal femoral fractures. Study II was identical to study I, but performed on distal femoral fractures. Study III was a systematic review of the currently available literature on the 1-year performance of the implants used in pertrochanteric fractures. Study IV was a retrospective study based on both registry data and x-ray evaluation of several surgical details to evaluate their association to the subsequent risk of reoperation.
Results - In study I mortality was 10.8% at day 30 and 17.4% at day 90. For the 30-day mortality risk surgical delay > 12h compared to ≤ 12h, of > 24h compared to ≤ 24 h and of > 48 h compared to ≤ 48 h increased the risk of death. For the 90-days mortality risk only the estimate for surgical delay > 24 h compared to ≤ 24 h was significant. When the surgery was performed by a surgeon with experience level below “attending”, the risk of both 30 day and 90 day mortality increased significantly by approximately 25 %. In study II mortality was 7.1% at day 30 and 12.5% at day 90. The logistical regression analysis did not demonstrate any association between surgical delay or the educational level of the surgeon, and mortality following surgery for a distal femoral fracture. Study III identified 30 publications for SHS and 54 for IMN. All studies identified were evidence level II (prospective observational studies and small randomized clinical trials) or III (retrospective observational studies). None of the studies, in which patients were operated after the latest update of the implant was introduced, specify whether the older or the updated version was used. In study IV 13% of patients underwent reoperation within 1 year. Of the variables investigating the osteosynthesis only an insufficient reduction of the fracture, placing the implants with an angle to the shaft of ≤125°, and perforating the caput with an implant were significantly associated with an increase in risk of reoperation in the multivariable analysis. We found no association between reoperation and the number of implants used, posterior distance, calcar distance, tip-caput distance or whether the implants were parallel or not.
Conclusion – A short surgical delay in hip fractures may reduce the early mortality. This effect was not demonstrated for distal femoral fractures. The evidence available for performance of the implants used for trochanteric fractures is scarce and better post-marked evaluation may be advised. And for osteosynthesis of a femoral neck fracture, proper patient selection and sufficient reduction seem to be more important for risk of reoperation than the specific details of the implant position.