Christian Fang

The Effectiveness of a Geriatric Hip Fracture Clinical Pathway in Reducing Hospital and Rehabilitation Length of Stay and Improving Short-Term Mortality Rates

Background: A geriatric hip fracture clinical pathway, led by an orthopedic surgeon, was developed in 2007. This clinical pathway team is multidisciplinary and consists of surgeons, physicians, anesthetists, nurses, physiotherapists, occupational therapists, medical social workers, dieticians as well as voluntary support groups. Methods: From early 2007 onward, all patients older than 65 years with acute isolated hip fractures were included. During the whole inpatient treatment, all relevant data were captured prospectively. The data in 2006, before the implementation of the clinical pathway, were collected retrospectively through computer record system. A study of the length of stay in acute and rehabilitation hospital and also the short-term mortality rate was carried out to compare the difference before and after the implementation of the pathway. Results: From 2007 onward, more than 1300 hip fractures were treated. After the implementation of the pathway, the preoperative length of stay was markedly shortened by 4 days, from an average of 6.1 days in 2006 to 1.5 days in 2011 (P < .05). The postoperative length of stay and the overall acute hospital length of stay also improved significantly. The length of stay in rehabilitation hospital was also significantly shorter in the 4-year period. Although the number of hip fractures increased annually with increased age and number of comorbidities each year, the inpatient mortality rate showed a gradual decrease from 2.7% in 2006 to 1.25% in 2010. The 30 days mortality rate also showed a decrease from 3.65% in 2006 to 2.75% in 2010. Conclusion: Geriatric hip fracture clinical pathway is an excellent approach to the geriatric hip fracture service. The most significant improvement is the dramatic shortening of the length of hospital stay. Our success in the past 5 years has proven its value and sustainability.

Masquelet Technique for Treatment of Posttraumatic Bone Defects

Masquelet technique, which is the use of a temporary cement spacer followed by staged bone grafting, is a recent treatment strategy to manage a posttraumatic bone defect. This paper describes a series of 9 patients treated with this technique of staged bone grafting following placement of an antibiotic spacer to successfully manage osseous long bone defects. The injured limbs were stabilized and aligned at the time of initial spacer placement. In our series, osseous consolidation was successfully achieved in all cases. This technique gives promising result in the management of posttraumatic bone defects.

Dynamic hip screw blade fixation for intertrochanteric hip fractures

Purpose. To assess the one-year outcome of a dynamic hip screw (DHS) blade in the treatment of AO/OTA 31-A1 and 31-A2 intertrochanteric hip fractures. Methods. 35 men and 65 women aged 47 to 100 (mean, 83) years underwent fixation with a DHS blade for A1 (n=47) and A2 (n=53) intertrochanteric hip fractures after a low-energy injury. Patients were operated on within 48 hours of admission. Anteroposterior and lateral radiographs were examined for the tip-apex distance and femoral shortening. Potential complications were looked for, including implant migration, cut-out, loosening, or breakage. Functional outcome was based on the Parker mobility score. Results. The 30-day and one-year mortality rates were 5% and 20%, respectively. At the one-year followup, 81 patients were available, and all fractures had healed without varus deformity. The mean tip-apex distance was 14.1 (range, 5.7–31.1; SD, 4.3) mm. The mean femoral shortening was 4.9 (range, 0–20.2; SD, 4.8) mm. The mean Parker score decreased to 3.8 at one-year follow-up from 5.9 before injury (p<0.001). There was one loss of fixation secondary to a nontraumatic subcapital fracture at 3 months, for which a bipolar hemiarthroplasty was performed. Conclusion. The DHS blade system is effective in treating AO/OTA 31-A1 and 31-A2 intertrochanteric hip fractures and results in a low complication rate.

Cementless Total Hip Arthroplasty Specifically Designed for Asians: Clinical and Radiologic Results at a Mean of 10 Years

It is known that the proximal femoral osteometry is different between Asians and whites. An uncemented femoral stem was therefore designed by us specifically for Asians, and we now report the medium-term clinical results. Results of a proximally porous-coated femoral component anatomically matched for Asians were analyzed in a consecutive cohort of 48 hips. The mean follow-up was 10.3 years. The mean Harris hip score was 39.4 preoperatively and 94.2 at last follow-up (P < .001). All stems had bone ingrowth. Stem survival was 100% up to 14 years using revision as the end point. Eight acetabular component revisions were performed for bearing surface failures and osteolysis. This femoral stem, specifically designed for better fit in an Asian population, had excellent clinical and radiologic outcome.

Assessment of postoperative short-term and long-term mortality risk in Chinese geriatric patients for hip fracture using the Charlson comorbidity score.

INTRODUCTION The clinical outcome of geriatric patients with hip fracture depends on surgical management as well as other medical factors. This study aimed to evaluate the relationship between Charlson comorbidity score and in-patient, 30-day, and 1-year mortality in Chinese geriatric patients who underwent surgery for hip fracture. METHODS This was a historical cohort study conducted in a tertiary trauma referral centre in Hong Kong. From 1 January 2009 to 31 December 2010, 759 operated hip fracture patients who were over 65 years were recruited. The Charlson Comorbidity Index of each patient was retrieved from their medical records. The total Charlson comorbidity score, the highest Charlson comorbidity score, and the Charlson comorbidity score were calculated. The associations between these scores and in-patient, 30-day, and 1-year mortality were examined using Mann-Whitney U test and Cox regression model. RESULTS The mean in-patient, 30-day, and 1-year mortality rate was 0.8%, 2.5%, and 16.3%, respectively. The total Charlson comorbidity score was significantly associated with in-patient mortality (P=0.031). The total Charlson comorbidity score (P<0.001) and Charlson comorbidity score (P=0.010) were significantly associated with 30-day mortality. All three scores were also significantly related to 1-year mortality (P<0.001). A Cox regression model demonstrated the relationship between total Charlson comorbidity score and 30-day and 1-year mortality. This can help predict 30-day and 1-year mortality risk in geriatric patients admitted for hip fracture surgery. CONCLUSION The Charlson comorbidity score provides a good preoperative indicator of 30-day and 1-year mortality in geriatric patients with hip fracture.

Propagation of Bisphosphonate-Related Femoral Stress Fractures Despite Femoral Nailing: A Cautionary Tale From 2 Cases

We report 2 cases of atypical femoral fracture displacement despite treatment with intramedullary (IM) nailing. Both patients had received more than 3 years of bisphosphonates. One patient had prophylactic fixation of an atypical femur fracture due to intractable pain. The other had undergone nailing previously for a traumatic shaft fracture. The patient then received bisphosphonate later and sustained an atypical fracture with the nail in place. Both femoral nails were slotted, cannulated stainless steel piriformis entry designs. These 2 cases are among the first reported failures of IM fixation in preventing displacement of a bisphosphonate stress fracture. We advice caution when using slotted nails in prophylaxis of atypical femur fractures because of its significantly reduced torsional stiffness compared to modern nonopen sectioned nails.

Increased Fracture Collapse after Intertrochanteric Fractures Treated by the Dynamic Hip Screw Adversely Affects Walking Ability but Not Survival

In osteoporotic hip fractures, fracture collapse is deliberately allowed by commonly used implants to improve dynamic contact and healing. The muscle lever arm is, however, compromised by shortening. We evaluated a cohort of 361 patients with AO/OTA 31.A1 or 31.A2 intertrochanteric fracture treated by the dynamic hip screw (DHS) who had a minimal follow-up of 3 months and an average follow-up of 14.6 months and long term survival data. The amount of fracture collapse and shortening due to sliding of the DHS was determined at the latest follow-up and graded as minimal (<1 cm), moderate (1-2 cm), or severe (>2 cm). With increased severity of collapse, more patients were unable to maintain their premorbid walking function (minimal collapse = 34.2%, moderate = 33.3%, severe = 62.8%, and p = 0.028). Based on ordinal regression of risk factors, increased fracture collapse was significantly and independently related to increasing age (p = 0.037), female sex (p = 0.024), A2 fracture class (p = 0.010), increased operative duration (p = 0.011), poor reduction quality (p = 0.000), and suboptimal tip-apex distance of >25 mm (p = 0.050). Patients who had better outcome in terms of walking function were independently predicted by younger age (p = 0.036), higher MMSE marks (p = 0.000), higher MBI marks (p = 0.010), better premorbid walking status (p = 0.000), less fracture collapse (p = 0.011), and optimal lag screw position in centre-centre or centre-inferior position (p = 0.020). According to Kaplan-Meier analysis, fracture collapse had no association with mortality from 2.4 to 7.6 years after surgery. In conclusion, increased fracture collapse after fixation of geriatric intertrochanteric fractures adversely affected walking but not survival.

Minimally invasive plate osteosynthesis for proximal humeral fractures

Purpose. To report the outcome after minimally invasive plate osteosynthesis (MIPO) through the deltoid-splitting approach for proximal humeral fractures. Methods. 10 men and 30 women aged 37 to 88 years underwent MIPO through the deltoid-splitting approach using the Proximal Humerus Internal Locking System or the Locking Proximal Humerus Plate for 2-part (n=18), 3-part (n=20), and 4-part (n=2) proximal humeral fractures. The rehabilitation protocol was standardised. Results. All 40 patients were followed up at 3 months, 34 (85%) at 6 months, 30 (75%) at one year, and 13 (33%) at 2 years. Two patients had malunion. No patient had avascular necrosis, infection, nerve palsy, or nonunion. The mean Constant score at one year and 2 years was 75 and 87.5, respectively. The Constant score at 6 months correlated to that at one year (r=0.926, p<0.0001) and at 2 years (r=0.874, p=0.0001). In younger patients, improvement in the range of motion was faster. The early plateau group (those with no further improvement after 6 months) and the late plateau group (those with no further improvement after one year) did not differ significantly in age, fracture grade, or hand dominance. Conclusion. MIPO for fixation of proximal humeral fractures using a locking plate is safe and effective in enabling an early return of shoulder function.

Sliding hip screw versus sliding helical blade for intertrochanteric fractures: a propensity score-matched case control study.

The spiral blade modification of the Dynamic Hip Screw (DHS) was designed for superior biomechanical fixation in the osteoporotic femoral head. Our objective was to compare clinical outcomes and in particular the incidence of loss of fixation. In a series of 197 consecutive patients over the age of 50 years treated with DHS-blades (blades) and 242 patients treated with conventional DHS (screw) for AO/OTA 31.A1 or A2 intertrochanteric fractures were identified from a prospectively compiled database in a level 1 trauma centre. Using propensity score matching, two groups comprising 177 matched patients were compiled and radiological and clinical outcomes compared. In each group there were 66 males and 111 females. Mean age was 83.6 (54 to 100) for the conventional DHS group and 83.8 (52 to 101) for the blade group. Loss of fixation occurred in two blades and 13 DHSs. None of the blades had observable migration while nine DHSs had gross migration within the femoral head before the fracture healed. There were two versus four implant cut-outs respectively and one side plate pull-out in the DHS group. There was no significant difference in mortality and eventual walking ability between the groups. Multiple logistic regression suggested that poor reduction (odds ratio (OR) 11.49, 95% confidence intervals (CI) 1.45 to 90.9, p = 0.021) and fixation by DHS (OR 15.85, 95%CI 2.50 to 100.3, p = 0.003) were independent predictors of loss of fixation. The spiral blade design may decrease the risk of implant migration in the femoral head but does not reduce the incidence of cut-out and reoperation. Reduction of the fracture is of paramount importance since poor reduction was an independent predictor for loss of fixation regardless of the implant being used. Cite this article: Bone Joint J 2015;97-B:398–404.The spiral blade modification of the Dynamic Hip Screw (DHS) was designed for superior biomechanical fixation in the osteoporotic femoral head. Our objective was to compare clinical outcomes and in particular the incidence of loss of fixation. In a series of 197 consecutive patients over the age of 50 years treated with DHS-blades (blades) and 242 patients treated with conventional DHS (screw) for AO/OTA 31.A1 or A2 intertrochanteric fractures were identified from a prospectively compiled database in a level 1 trauma centre. Using propensity score matching, two groups comprising 177 matched patients were compiled and radiological and clinical outcomes compared. In each group there were 66 males and 111 females. Mean age was 83.6 (54 to 100) for the conventional DHS group and 83.8 (52 to 101) for the blade group. Loss of fixation occurred in two blades and 13 DHSs. None of the blades had observable migration while nine DHSs had gross migration within the femoral head before the fracture healed. There were two versus four implant cut-outs respectively and one side plate pull-out in the DHS group. There was no significant difference in mortality and eventual walking ability between the groups. Multiple logistic regression suggested that poor reduction (odds ratio (OR) 11.49, 95% confidence intervals (CI) 1.45 to 90.9, p = 0.021) and fixation by DHS (OR 15.85, 95%CI 2.50 to 100.3, p = 0.003) were independent predictors of loss of fixation. The spiral blade design may decrease the risk of implant migration in the femoral head but does not reduce the incidence of cut-out and reoperation. Reduction of the fracture is of paramount importance since poor reduction was an independent predictor for loss of fixation regardless of the implant being used. Cite this article: Bone Joint J 2015;97-B:398-404.

The use of three-dimensional printing technology in orthopaedic surgery: A review

Three-dimensional (3-D) printing or additive manufacturing, an advanced technology that 3-D physical models are created, has been wildly applied in medical industries, including cardiothoracic surgery, cranio-maxillo-facial surgery and orthopaedic surgery. The physical models made by 3-D printing technology give surgeons a realistic impression of complex structures, allowing surgical planning and simulation before operations. In orthopaedic surgery, this technique is mainly applied in surgical planning especially revision and reconstructive surgeries, making patient-specific instruments or implants, and bone tissue engineering. This article reviews this technology and its application in orthopaedic surgery.