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Purpose: The patients with femoral metastasis in the inter- or subtrochanteric area could be treated with intramedullary nailing or prosthetic reconstruction, however, it is controversial which surgical treatment could offer less complications and implant failure. Our purpose was to define the risk of complications and implant survival in patients treated with intramedullary nailing or prosthetic reconstruction. Methods: We analyzed studies reporting the risk of complications, reoperations and removal of the implant in patients treated with intramedullary nailing, hemiarthroplasty, arthroplasty or megaprosthesis. Results: We analyzed 27 studies (1346 patients) reporting patients treated with intramedullary nail (51%), hemiarthroplasty (15%), arthroplasty (2%), megaprosthesis with (25%) or without (7%) acetabular component. No difference was found in the overall risk of complications between patients treated with intramedullary nailing 6%, hemiarthroplasty or total hip arthroplasty 7% and megaprosthesis 11% (p = 0.23). However, patients treated with megaprosthesis had increased risk of reoperation due to infection (70%), compared to the patients treated with intramedullary nail (13%), and patients treated with hemiarthroplasty or total hip arthroplasty (23%) (p = 0.02). Revision due to disease progression was required in 61% of the patients treated with intramedullary nail, but not in patients treated with hemiarthroplasty, total arthroplasty, and megaprosthesis (p = 0.03). Conclusion: Patients treated with megaprosthesis had higher risk of reoperation due to infection, while patients treated with intramedullary nailing had higher risk of revision due to disease progression. Regarding patients treated with megaprosthesis, the risk of reoperation due to dislocation was higher in those treated with acetabular component. [ABSTRACT FROM AUTHOR]

Purpose: Although there are concerns about nonunion of the greater tuberosity or shoulder weakness, hemishoulder arthroplasty (HSA) is a viable treatment option for irreducible four-part proximal humerus fractures-dislocation without rotator cuff tear arthropathy. This study aims to analyze the long-term radiological and functional outcomes of HSA. Methods: This study enrolled 36 patients who underwent HSA due to irreducible four-part proximal humerus fracture-dislocation without rotator cuff tear arthropathy between March 2005 and May 2020. The exclusion group included 10 reverse total shoulder arthroplasty patients. The mean age and mean follow-up period were 68.6 years old and 48.6 months, respectively. Radiological assessments, such as vertical and horizontal greater tuberosity position, greater tuberosity healing, and implant position, were evaluated. Clinically, American Shoulder and Elbow Surgeons Score (ASES), Constant-Murley Score (CMS), and range of motion were evaluated. Results: The greater tuberosity union rate was 55.6% (n = 20), with 44.4% (n = 16) experiencing nonunion, malunion, and bone resorption. The mean vertical and horizontal greater tuberosity positions showed significant difference at last follow-up compared to immediate postoperation. The retroversion of the implant was 23.8 ± 4.61°, and the acromio-humeral interval was 7.6 ± 1.34 mm. The mean last follow-up ASES and CMS were 39.5 ± 4.03 and 55.4 ± 10.41, respectively. The mean active forward flexion, abduction, internal rotation, and external rotation were 100.9 ± 15.04°, 92.5 ± 14.47°, 44.2 ± 12.83°, and 42.5 ± 15.32°, respectively. Conclusion: In long-term follow-up, the greater tuberosity was superiorly migrated and externally rotated. Active forward flexion and abduction in the last follow-up were significantly limited. However, in terms of pain relief, a satisfactory result was seen. [ABSTRACT FROM AUTHOR]

Purpose: Clostridium difficile colitis is a serious complication in elderly patients undergoing surgery. The objectives of this study were: (1) to use a nationwide sample of patients to report the incidence and timing of C. difficile colitis in geriatric patients who underwent surgery for hip fractures, (2) to identify preoperative factors associated with developing C. difficile colitis and mortality. Methods: This was a retrospective evaluation of the 2016–2019 ACS Targeted Hip Fracture database merged with the ACS-NSQIP database. Patients undergoing surgery for hip fracture were included. Outcomes studied were incidence, preoperative, and postoperative risk factors for occurrence of C. difficile infection and mortality. Chi-squared tests were used to compare demographics between the patients infected (study) and not infected (control). Logistic regression models were utilized to compute the odds ratios (OR) testing for the association of independent factors on developing C. difficile infection postoperatively and mortality. A statistical threshold was set at p < 0.008. Results: The incidence of C. difficile infection within 30 days of hip fracture surgery was 0.81%. Fifty percent of infections were diagnosed within 9 days postoperatively. Preoperative and hospital-associated factors associated with development of C. difficile infection were ≥ 2 days until operation (OR 1.88 [95% CI 1.39–2.55], p < 0.001) and dependent functional status (OR 1.43 [95% CI 1.14–1.79], p = 0.002). After adjusting for multiple comorbidities, increased age, male sex, COPD, CHF, dependent functional status, and C. difficile infection were associated with increased mortality within 30 days of surgery (all p < 0.001). Conclusion: Clostridium difficile colitis is a serious infection after hip fracture surgery in geriatric patients with an incidence of about 1%. Patients at increased risk should be targeted with preventative measures to prevent the morbidity from this complication. [ABSTRACT FROM AUTHOR]

Purpose: Following proximal humeral fractures hemiarthroplasty (HA) or reversed total shoulder arthroplasty (rTSA) are performed if osteosynthesis or conservative treatment is not possible. HA has been reported to result in decreased functional outcomes compared with rTSA. Secondary shoulder arthroplasty, performed after a different initial treatment, has also been associated with inferior outcomes. Methods: Patients recieving a shoulder arthroplasty related to a proximal humeral fracture from 2010 to 2019 were included. A retrospective analysis of functional outcomes was performed using QuickDASH and subjective shoulder value (SSV). Results: The mean [standard deviation (SD)] follow-up time among the 82 included patients was 48 (28) months. The mean age was 70 (10) years. The mean age for HA was significantly different from rTSA [57 (9) and 72 (21) years; p <.001]. The mean QuickDASH score for primary arthroplasty was 11 (2) versus 12 (16) for secondary arthroplasty (p =.313). The mean SSV for primary arthroplasty was 84 (22) versus 82 (17) for secondary arthroplasty (p =.578). The mean QuickDASH score for HA was 24 (36) versus 9 (15) for rTSA (p =.346). The mean SSV for HA was 70 (34) versus 86 (17) for rTSA (p =.578). Conclusion: Functional outcomes after fracture-related shoulder arthroplasty were excellent in an older population, even when performed secondarily after failed primary osteosynthesis or conservative treatment. No significant differences in shoulder function were identified between rTSA and HA, likely due to restrictive indications for HA. [ABSTRACT FROM AUTHOR]

Purpose: Proximal humeral fracture-dislocations (PHFD) are challenging to treat. In older patients, usually arthroplasty is performed. In younger patients, osteosynthesis is chosen. This study presents functional outcomes of these different treatment modalities. Methods: All patients operated for PHFD from 2010 until 2017 were included. Osteosynthesis was performed in younger patients and if reconstruction was possible. Either an open deltopectoral approach or a minimal invasive plate osteosynthesis (MIPO) was performed. Hemiarthroplasty (HA) was done if reconstruction of the tubercles was possible, age was below 63 years and no signs of osteoarthritis were present. In all other cases, a reverse total shoulder arthroplasty (rTSA) was done. The primary endpoint was functional outcome assessed with the QuickDASH Score (QDS). Secondary outcomes were subjective shoulder value (SSV), complications, revisions, and conversion into arthroplasty. Results: The mean follow-up of 40 patients was 56 ± 24 months. The mean QDS was 4.5 (0.6–9.1) and the mean SSV was 90 (80–98.6). Of these, 33 patients (mean age: 50) had an osteosynthesis, 25 were treated with MIPO. Only 18% were converted into an arthroplasty after a mean of 22 months. Among them, 7 patients received a primary arthroplasty (mean age: 68), no revisions were recorded. Subgroup analysis showed functional outcome deficits in avascular necrosis (AVN) compared to no AVN (p = 0.021), revision surgery compared to no revision (p = 0.040) and in HA compared to rTSA (p = 0.007). Conclusion: Both osteosynthesis and primary arthroplasty after PHFD can lead to good or even excellent functional outcome. Revision rates in osteosynthesis are high. Revision procedures or secondary conversion into arthroplasty after failed osteosynthesis decrease outcome scores significantly. [ABSTRACT FROM AUTHOR]

Distal humeral fractures represent approximately 2% of fractures in adults and are often treated operatively to restore stable humeral columns and allow early elbow motion. Diagnosis is made with orthogonal radiographs. The traction view radiograph and computed tomography with three-dimensional reconstruction can be helpful in preoperative planning. Treatment options include: (1) nonoperative management, which is reserved for lower-demand, medically unwell, elderly patients, (2) surgical osteosynthesis, which remains the treatment of choice for most fractures, and (3) prosthetic replacement with either hemiarthroplasty or total elbow arthroplasty, which is indicated for distal complex comminuted fracture patterns in elderly, low-demand patients with poor bone quality. A thorough understanding of the anatomy around the elbow is critical when planning surgical approach and reduction. Controversies exist in the following areas: (1) surgical approach, (2) management of the ulnar nerve, (3) plating technique—parallel versus orthogonal, and (4) whether osteosynthesis or prosthetic elbow replacement is superior in the elderly population. [ABSTRACT FROM AUTHOR]

Shoulder hemiarthroplasty has historically been the gold standard treatment for proximal humeral fractures not suitable to open reduction and internal fixation. In the last decades, reverse shoulder arthroplasty has gained more and more importance. Aim of this study is to retrospectively analyze subjective and objective outcomes of a group of consecutive patients. Fifty-one patients were evaluated with a mean follow-up of 18 months (range 12-60). For all the cases, the same surgical technique was performed in all cases. Range of motion, Constant-Murley score, ponderate Constant-Murley score, visual analog score and a patients' self-assessment scale were calculated. Anatomic tuberosities healing, stem positioning or mobilization were evaluated on postoperative X-rays and follow-up CT-scans. Statistical analysis was performed to calculate a correlation between subjective and objective results. Thirty-five patients (75%) declared to be satisfied of the operated shoulder. The mean CMS was 50 (17-91), the mean pCMS 72 (16-111). The mean forward flexion measured was 98° (40°-170°), the mean external rotation with adducted arm 22° (0°-60°), the mean internal rotation at sacrum (gluteus-T12). Four implants needed revision. Forty-seven stems were correctly positioned; 84.3% of tuberosities was anatomic or low positioned and consolidated in 74.5% of cases. Statistical analysis revealed significant correlation between CMS, pCMS, VAS and subjective satisfaction and between anatomic tuberosities healing and 3-part fractures. HA implant is a valid and reliable technique for the treatment of proximal humeral fracture. From our data, patients' satisfaction depends upon pain relief more than upon restore of function. [ABSTRACT FROM AUTHOR]

The article reviews in detail various fixation methods for intertrochanteric fractures. These include the dynamic hip screw (DHS) as the most commonly used implant and extensively studied implant for extra-capsular hip fractures, the cephalomedullary nails which are the most commonly used fracture fixation device for intertrochanteric fractures and the proposed hemiarthroplasty as an alternative to internal fixation for unstable intertrochanteric fracture in elderly patients.

Background: Proximal humeral fracture constitutes a medical emergency on most occasions in which the decision to perform either open reduction and internal fixation (ORIF) or hemiarthroplasty is determined by the operating surgeon. Hemiarthroplasty is a more expensive and technically challenging procedure that requires compliance with rigorous and prolonged rehabilitation postsurgically. We assessed whether racial differences exist in utilization of hemiarthroplasty versus ORIF in patients with proximal humeral fracture. Methods: Patients with primary diagnosis of closed proximal humeral fracture undergoing either hemiarthroplasty or ORIF were selected from Nationwide Inpatient Sample databases for 1990-2000 ( n = 10,306). Results: Among white patients with proximal humeral fracture, 35.3% underwent hemiarthroplasty when compared with 17.2% of black and 26.9% of Hispanic patients ( P < 0.001). Results of multivariate analysis adjusted for age, sex, hospital volume, year, and site of fracture on proximal humerus confirmed that black patients were less likely to undergo hemiarthroplasty when compared with white patients (OR = 0.76; 95% CI = 0.54, 1.08). Conclusions: Our findings are consistent with studies documenting racial differences in utilization of elective orthopedic procedures. Given that humeral fracture is an emergency on most occasions, and our data suggest that differences in utilization more likely reflect surgeons' operative decisions than patient preferences. We cannot ascertain whether differential procedure utilization is clinically justified. Further studies are needed to confirm whether surgeons' operative decisions are a factor in the differential utilization of arthroplasty procedures by race and to understand outcomes and indications for ORIF and hemiarthroplasty, especially in black patients. [ABSTRACT FROM AUTHOR]