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Evidence-based guidelines, new implants may help determine best proximal hip fracture fixation method
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VIENNA — Techniques orthopaedic trauma surgeons use to treat proximal femoral fractures vary by country, which leads to the inconsistent use of internal fixation, hemiarthroplasty and total hip arthroplasty (THA), said Cecilia Rogmark, MD, PhD, who moderated a symposium 1 June at the 18th EFORT Annual Congress.
Surgeons worldwide particularly need better guidance regarding how to best treat subgroups of these patients, such as patients who are younger than 60-years-old or who have comorbidities, she said.
More evidence-based medicine (EBM) will also help surgeons make good treatment decisions for their patients regarding displaced and non-displaced femoral neck fractures. But, in terms of implementing EBM, “there are a lot of barriers,” Bjarke Viberg, PhD, said.
Viberg noted international EBM guidelines for these fractures differ in Holland, Denmark, Scotland, England, Australia, the United States and Germany/Austria. In addition, there are obstacles to not implementing EBM for proximal femoral fractures, which include inadequate access to implants, a lack of resources or financing to acquire equipment, for example used to perform cemented arthroplasty, and a lack of training.
Furthermore, surgeons who have performed these treatments for a long time may not be willing to change or feel limited by the guidelines, he said.
These obstacles must be overcome, Viberg said.
The Hansson Pinloc System (Swemac), an angled internal implant with a plate that connects three pins, may prove to be effective for these fractures based on initial results of a multicenter randomized, controlled trial Torsten Johansson, MD, presented.
Results of the timed-up-and-go test were similar between the new device and standard pins at the 3-month and 12-month follow-up in patients at least 50-years-old who were treated between May 2014 and January 2017.
Among patients with displaced fractures, 15% who received the Pinloc device and 33% of patients who received standard pins required a reoperation with THA or hemi-arthroplasty, Johansson said.
“This Pinloc device is technically more demanding,” Johansson said, adding it can be more complicated to work with compared with two screws and two pins. There is also the possibility the three drill holes made to implant the device can weaken the femoral bone cortex vs. two standard drill holes with pinning, he said.
“So far, no major differences. No recommendation, so far. Pinloc may not be the savior,” Johansson said.
However, he said, “This is probably the first prospective study including undisplaced femoral neck fractures, as far as I know.”
Johansson added, “I also feel it is ethical to give some sort of guidelines, what we should do today.” – by Susan M. Rapp
Reference:
Rogmark C, et al. Symposium: Treatment of the proximal femoral neck fracture: Internal fixation or arthroplasty. Presented at the 18th EFORT Annual Congress: 31 May - 2 June 2017, Vienna.
Disclosures: Johansson, Rogmark and Viberg report no relevant financial disclosures.