Complications in trochanteric and subtrochanteric femoral fractures

The hip fracture is a major public health problem. The majority of hip fracture patients are elderly with comorbidities and there is a strong association with osteoporosis, especially for the extracapsular (trochanteric and subtrochanteric) types of fractures. The management of these patients is associated with a huge risk for medical and surgical complications. One of the most important risks is significant blood-loss and a subsequent need for blood transfusion. The treatment of choice for patients with extracapsular hip fracture is acute surgery with internal fixation, such as intramedullary nailing or plating with sliding hip screw. A hip arthroplasty is a salvage procedure and an option for the treatment of failures after internal fixation. In this doctoral project we study the complications, the epidemiology and the influence of early surgery in the management of this subgroup of hip fracture patients.

In Study I, a retrospective cohort study with a 5–11 years follow-up, 88 patients reoperated 1999 – 2006 at SÖS with a secondary hip arthroplasty due to healing complications after internal fixation of a trochanteric or a subtrochanteric fracture were analysed. The total reoperation rate was 16% (14/88). The most common reason for a reoperation was a periprosthetic fracture (n = 6). Multivariable Cox regression analysis of reoperations using femoral stems with standard length, compared with long stems, showed a trend for increased risk with a hazard ratio (HR) of 4 (p = 0.06). A recommendation for using long femoral stems may be one way to reduce the risk for reoperations.

In Study II, a retrospective cohort study, 987 patients operated with an intramedullary nail due to an unstable trochanteric or subtrochanteric hip fracture at SÖS, between January 1, 2011 and December 31, 2013 were analysed. Using the red blood cell transfusion rate and mortality as the main outcome measures, logistic regression analysis was used to adjust for anticoagulants, ASA class, fracture type, preoperative haemoglobin (Hb) value and time to surgery. It was found that anticoagulants (relative risk (RR) 2.0) and surgery delayed for more than 24 hours (RR 3.9) were significantly associated with an increased rate of preoperative transfusions.

In Study III, a retrospective case-control study of 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant were analysed. All patients were operated at SÖS within 24 hours with an intramedullary nail due to a trochanteric or subtrochanteric hip fracture after a low-energy trauma between January 1, 2011 and December 31, 2014. All patients on warfarin were reversed if necessary to INR ≤1.5 before surgery using vitamin K and/or four-factor prothrombin complex concentrate (PCC). There were no significant differences in the calculated blood-loss, in-house adverse events, mortality or pre- or perioperative transfusion rates between the groups. There was an increased rate of postoperative transfusions in the control group. The study demonstrated the safety of using vitamin K and/or PCC to be able to operate within 24 hours.

In Study IV, a descriptive epidemiological register study, a total of 10548 patients registered in the national Swedish Fracture Register from January 2014 to December 2016 were analysed. Individual patient data (age, gender, injury location, injury cause, fracture type, treatment and timing of surgery) were retrieved from the register database. Mortality data was obtained from the Swedish Death Register. The majority of the patients were elderly females (69%) who had sustained their fracture from a fall at the same level (83%) at the patients’ residence (75%). The most commonly used implant was a short antegrade intramedullary nail (42%). With increasing fracture complexity, the proportion of intramedullary nails was increasing, and also the use of long versus short nails. Most of the patients were operated within 36 hours (90%). There was an increased mortality for males, and for all those who were delayed to surgery >36 hours.

The major conclusions of this thesis were the epidemiological aspects, analyses showing the medical and surgical complexity of these fractures and the importance of optimising patients promptly before the surgery within 24 hours.

List of scientific papers

I. Hip arthroplasty after failed fixation of trochanteric and subtrochanteric fractures. Anders Enocson, Leif Mattisson, Carin Ottosson, Lasse J Lapidus. Acta Orthopaedica. 2012; 83:5, 493-498.
https://doi.org/10.3109/17453674.2012.688724

II. What is the influence of a delay to surgery >24 hours on the rate of red blood cell transfusion in elderly patients with intertrochanteric or subtrochanteric hip fractures treated with cephalomedullary nails? Leif Mattisson, Lasse J. Lapidus, Anders Enocson. Journal of Orthopaedic Trauma. Aug 2018; 32(8):403–407.
https://doi.org/10.1097/BOT.0000000000001183

III. Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study. Leif Mattisson, Lasse J. Lapidus, Anders Enocson. BMC Musculoskeletal Disorders. June 2018; 19:203.
https://doi.org/10.1186/s12891-018-2126-3

IV. Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish Fracture Register. Leif Mattisson, Alicja Bojan, Anders Enocson. BMC Musculoskeletal Disorders. October 2018; 19:369.
https://doi.org/10.1186/s12891-018-2276-3