Eur Orthop Traumatol DOI 10.1007/s12570-014-0259-x
ORIGINAL ARTICLE
Current concepts for treating proximal femur fractures in Europe A. Scola & N. Haas & U. Stöckle & P. Giannoudis & J. C. Bel & M. S. Larsen & C. Candrian & J. M. Munoz-Vives & F. Gebhard
Received: 23 April 2014 / Accepted: 13 June 2014 # EFORT 2014
Abstract Introduction Proximal femur fractures (PFFs) are frequent injuries in the elderly patient population of every trauma centre. This type of facture represents the most important socio-economic impact of osteoporosis. A European standard of care has not been established yet. Material and methods The aim of the study is to evaluate the standards in treatment of this fracture within the EFORT (European Federation of National Associations of Orthopaedics and Traumatology). Within the annual congress 2013 and online EFORT home page, 581 surgeons were asked by a questionnaire. The PFF treatment Europe survey focused on training of the A. Scola (*) : F. Gebhard Department of Orthopaedic and Trauma, University Clinic Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany e-mail:
[email protected] N. Haas Charité, Campus Virchow, Berlin, Germany U. Stöckle BG Trauma Hospital Tübingen, Tübingen, Germany P. Giannoudis Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, UK J. C. Bel Orthopaedic and Trauma Department, Pavilion T, E. Herriot Hospital, CHU Lyon, Lyon, France M. S. Larsen Department of Orthopaedics, Odense University Hospital, Odense, Denmark
surgeons as well as the number of proximal femur fractures treated in their hospitals and by themselves. Furthermore, the survey consisted of five different cases of a PFF. Each fracture had to be classified by the AO (Arbeitsgemeinschaft für Osteosynthese) classification. After that, the decision for operative or non-operative treatment had to be made. The implant for this type of fracture had to be chosen. At the end of each case, a postoperative X-ray with an osteosynthesis according to AO/ ASIF (Association for the Study of Internal Fixation) was shown and the surgeons had to decide whether they agree to the treatment. Results In a case of AO/ASIF-type B3 fracture, 73.72 % of the surgeons classified it correctly, 82.78 % in a case of AO/ASIFtype B1 fracture, 26.86 % in a case of A1 fracture (due to the missing second plane), 63.70 % in a case of A3 fracture and 95.18 % in a case of A1 fracture, respectively. The treatment was agreed with in the following: 74.14 % in a case of B3, 89.33 % in a case of B1, 63.72 % in a case of B2, 86.73 % in a case of A3 and 93.09 % in a case of A1 fracture. Conclusion In conclusion, the current European system of education and training in combination with the increasing cooperation between the countries has improved the overall understanding of PFF fracture patterns. Although there are still regional differences in the treatment of PFF, the major principles in addressing PFF throughout Europe are meanwhile more congruent than those two decades ago. The study proves a successful implementation of the topic “trauma” within the European education course concepts. Keywords Proximal femur fracture . EFORT . Osteoporosis . AO classification
C. Candrian Department of Surgery and Orthopaedics, Lugano, Switzerland
Introduction
J. M. Munoz-Vives Centre Hospitalari Andorrà, Escaldes-Engordany, Principality of Andorra
Proximal femur fractures (PFFs) are frequent injuries in the elderly patient population of every trauma centre. Especially in
Eur Orthop Traumatol Fig. 1 Case number 1. A 31B3 fracture according to AO classification
that group, the rising incidence of this type of fractures represents the most important socio-economic impact of osteoporosis [1, 2]. In the year 2000, there were approximately 424,000 hip fractures worldwide in men and 1,098,000 in women. This number, based upon altering demographics and the increase in life expectancy, is expected to increase dramatically. Furthermore, it is known worldwide that PFFs are linked with high rates of mortality (up to 40 % in the first year [3, 4]) and morbidity [5–8]. Ten years ago, the “Standardised Audit of Hip Fractures in Europe (SAHFE)” developed a data set based on the Swedish Multicenter Hip Fracture study data collection forms [9–11]. It showed very divergent ways to address a PFF. The treatment decision ranged from conservative treatment up to total hip replacement with a high variation in between. Given the impact of this kind of , the aim of this study is to evaluate the current concepts for treating proximal femur fractures in Europe. The study group hypothesized that years of improving education in trauma surgery in Europe by various organisations, i.e. EFORT (European Federation of National Associations of Orthopaedics and Traumatology) or AO (Arbeitsgemeinschaft für Osteosynthese) Trauma, would lead to a more standardised approach to PFF today.
Material and methods Within the EFORT congress 2013 and online EFORT home page, a questionnaire has been set up. The proximal femur Fig. 2 Case number 2. A 31B1 fracture according to AO classification
fracture treatment Europe (PFFTE) survey included questions to the training of the surgeons and the number of proximal femur fractures treated in their hospitals and by themselves. Furthermore, the survey consisted of five different cases (Figs. 1, 2, 3, 4 and 5) of a proximal femur fracture. Each fracture had to be classified by the AO classification. After that, the decision for operative or non-operative treatment had to be made. Then, the implant for this type of fracture had to be chosen. At the end of each case, a postoperative X-ray with an osteosynthesis according to AO/ASIF (Association for the Study of Internal Fixation) recommendations [12] was shown and the surgeons had to decide whether they agree to the treatment. The five cases with the AO classification are shown in Figs. 1, 2, 3, 4 and 5.
Results Within 6 months, 581 surgeons throughout EFORT European countries did the full survey. The training of the surgeons was as follows: 65 % were orthopaedic surgeons, 29 % trauma surgeons, 3 % general surgeons and 3 % other surgeons. In 34 %, more than 200 PFFs are treated annually at designated departments, 150 to 200 cases in 14 %, 100 to 150 cases in 17 %, 50 to 100 cases in 20 % and less than 50 cases in 15 %. The majority of the surgeons, 38 %, treat 20 to 50 cases personally each year. The further distribution is as follows:
Eur Orthop Traumatol Fig. 3 Case number 3. A31B2 fracture according to AO classification
11 % less than 10 cases, 22 % 10 to 20 cases, 18 % 50 to 70 cases and 11 % more than 70 cases a year. Case 1 (Fig. 1) shows, according to the AO classification, a 31B3 fracture. It was classified as follows: 8.55 % A1, 3.42 % B1, 14.32 % B2 and 73.72 % B3. Of the surgeons, 99.36 % chose an operative treatment. The majority of surgeons, 85.89 %, chose an arthroplasty (46.79 % bipolar prosthesis and 39.10 % total hip prosthesis). The overall results are shown in Table 1. The postoperative X-ray showed a bipolar non-cemented prosthesis (Fig. 1). Of the surgeons, 74.14 % agreed with the treatment and 25.86 % disagreed. Case 2 (Fig. 2) shows a 31B1 fracture. It was classified within the survey as follows: 82.78 % B1, 4.64 % A1, 2.43 % B2 and 10.18 % B3. The choice of treatment was 91.39 % operative and 8.61 % conservative. The primary choice by 71.96 % was screws/ pins. The further division is shown in Table 2. The postoperative X-ray showed a treatment (Fig. 2) with three parallel screws. Of the surgeons, 89.33 % agreed with the treatment. Case 3 (Fig. 3) shows a 31B2 fracture (unfortunately, no secondary plane was provided). The specification of the surgeons was as follows: 68.17 % B3, 26.86 % B2, 2.26 % B1 and 2.71 % A2.
Fig. 4 Case number 4. A 31A3 fracture according to AO classification
Of the surgeons, 99.10 % decided for an operative treatment and 49.89 % chose a total hip replacement as their primary treatment. Table 3 shows the overall decisions. The postoperative X-ray showed an osteosynthesis (Fig. 3) with a principle of a dynamic hip screw device (Targon FN). Of the surgeons, 63.72 % agreed with the treatment and 36.28 % disagreed. Case 4 (Fig. 4) shows a 31A3 fracture. The classification of the surgeons was as follows: 63.70 % A3, 28.77 % A1, 0.23 % B1, 5.48 % B2 and 1.83 % B3. Of the surgeons, 98.17 % chose an operative treatment. The first choice of treatment in 79.91 % was a proximal femur nail. The others were distributed as shown in Table 4. The postoperative X-ray (Fig. 4) showed a treatment with a proximal femur nail; 86.73 % agreed to the treatment. Case 5 (Fig. 5) shows a 31A1 fracture. Of the surgeons, 95.18 % classified it as A1, 1.38 % B1, 2.98 % B2 and 0.46 % B3. The choice of treatment in 97.20 % was operative. The primary type of implant in 77.29 % was a dynamic hip screw (DHS). The further distribution is shown in Table 5. The postoperative X-ray (Fig. 5) showed a treatment with DHS; 93.09 % agreed to the treatment.
Eur Orthop Traumatol Table 2 Choice of treatment for case 2
Fig. 5 Case number 5. A 31A1 fracture according to AO classification
Discussion The number of PFF treated at various departments through Europe shows a high impact of this type of fractures to the health-care systems. Regarding to epidemiological studies especially in the elderly population with its major risk factor of osteoporosis, the numbers of PFF are increasing [13–15]. In a study by Mann over the period of 10 years, the frequency of PFF in Germany was rising steadily [16]. In 2003, for example, 7.8 million people were affected by osteoporosis in Germany [17]. The annual costs for the treatment are around 5.4 billion euros [17]. Thus, the treatment of this type of fracture is in the focus at all times, especially since the costs rise exponentially if a revision of the primary treatment is necessary [18]. This is one of the reasons why the treatment is performed almost exclusively by orthopaedic and trauma surgeons. In some countries, e.g. Germany, those two groups of surgeons already have the same professional training. In our study, 94 % of the participants defined themselves as orthopaedic or trauma surgeons. In all cases, the majority of these orthopaedic trauma surgeons classified the fracture correctly. One exception is case number 3. The reason for this could be the lack of the second plane of the X-ray showing the fracture plane more clearly. In comparison to the SAHFE study where multiple classification systems were used, this study showed that the understanding of the fracture patterns based on the AO/ASIF Table 1 Choice of treatment for case 1
Answer
Responses (%)
Screws/pins Dynamic hip screw Proximal femur nail Bipolar prosthesis Total hip replacement Other
1.92 3.63 4.06 46.79 39.10 4.49
Answer
Responses (%)
Screws/pins Dynamic hip screw Proximal femur nail Bipolar prosthesis Total hip replacement
71.96 10.60 3.09 5.30 5.52
Other
3.53
classification has dramatically improved [19]. The high interobserver reliability of classification is the result of the high activity of education throughout Europe, e.g. in EFORT congresses or AO Trauma courses. Regarding the decision for an operative or conservative treatment, the surgeons decided according to the literature and AO/ASIF recommendations. The early possibility of mobilization and the high risk of secondary displacements are the indications for stabilization even for non-displaced fractures [20]. The differentiation in stable and unstable pertrochanteric fractures and the impact on the implant are meanwhile well known and included in the decision-making. Thus, in case 4 (unstable fracture AO 31A3), the proximal femur nail is by far the most chosen option. In case 5 with a stable fracture (AO 31A1), the DHS is the choice of treatment. Both treatment options in these two cases are according to the actual literature [21]. In this survey, there was a common agreement to treat displaced femoral neck fractures in the elderly with
Table 3 Choice of treatment for case 3
Table 4 Choice of treatment for case 4
Answer
Responses (%)
Screws/pins Dynamic hip screw Proximal femur nail Bipolar prosthesis Total hip replacement Other
15.80 14.00 4.29 14.22 49.89 1.81
Answer
Responses (%)
Screws/pins Dynamic hip screw Proximal femur nail Bipolar prosthesis Total hip replacement Other
0.23 11.42 79.91 2.28 1.14 5.02
Eur Orthop Traumatol Table 5 Choice of treatment for case 5
Answer
Responses (%)
Screws/pins Dynamic hip screw Proximal femur nail Bipolar prosthesis Total hip replacement
3.21 77.29 16.51 0.69 0.92
Other
1.38
arthroplasty (case 1). The discussion in the literature whether total or hemi hip replacement should be performed is also displayed in this survey [22–24]. However, with the lack of detailed knowledge about the patient, there is no further evaluation possibility of this topic. In conclusion, the European system of education and training in combination with the increasing cooperation between the countries has improved the overall understanding of PFF fracture patterns. Although there are still little regional differences how to address PFF, the overall agreement of treatment throughout Europe is meanwhile very high. The study clearly proves the successful implementation of the topic “trauma” within the European course concepts. Today, the strategy to treat a PFF is more homogenous/congruent within Europe as it has been two decades ago. The study proves the hypothesis that educational efforts in teaching the standards of fragility fracture treatment examplewise by the PFF improve patient care even in a large surgical population as Europe. Conflict of interest The authors are members of the EFORT Trauma Task Force. The authors express their thanks to the EFORT head office for the support in the conduct of the survey.
References 1. Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7(5):407–413 2. Smith DP, Enderson BL, Maull KI (1990) Trauma in the elderly: determinants of outcome. South Med J 83(2):171–177 3. Diaz Curiel M, Garcia JJ, Carrasco JL, Honorato J, Perez Cano R, Rapado A, Alvarez Sanz C (2001) Prevalence of osteoporosis assessed by densitometry in the Spanish female population. Med Clin (Barc) 116(3):86–88 4. Kanis JA, Oden A, McCloskey EV, Johansson H, Wahl DA, Cooper C (2012) A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporos Int 23(9):2239–2256 5. Becker C, Gebhard F, Fleischer S, Hack A, Kinzl L, Nikolaus T, Muche R (2003) Prediction of mortality, mobility and admission to long-term care after hip fractures. Unfallchirurg 106(1):32–38 6. Magaziner J, Lydick E, Hawkes W, Fox KM, Zimmerman SI, Epstein RS, Hebel JR (1997) Excess mortality attributable to hip fracture in white women aged 70 years and older. Am J Public Health 87(10): 1630–1636
7. Marottoli RA, Berkman LF, Cooney LM Jr (1992) Decline in physical function following hip fracture. J Am Geriatr Soc 40(9):861–866 8. Thorngren KG, Norrman PO, Hommel A, Cedervall M, Thorngren J, Wingstrand H (2005) Influence of age, sex, fracture type and prefracture living on rehabilitation pattern after hip fracture in the elderly. Disabil Rehabil 27(18–19):1091–1097 9. Scheerlinck T, Opdeweegh L, Vaes P, Opdecam P (2003) Hip fracture treatment: outcome and socio-economic aspects. A one-year survey in a Belgian University Hospital. Acta Orthop Belg 69(2):145–156 10. Raaymakers EL, Marti RK, Concerning Tero Heikkinen et al (2003) Hemiarthroplasty or osteosynthesis in cervical hip fractures: matched-pair analysis in 892 patients. Arch Orthop Trauma Surg 123(2-3):134, author reply 5 11. Heikkinen T, Parker M, Jalovaara P (2001) Hip fractures in Finland and Great Britain—a comparison of patient characteristics and outcomes. Int Orthop 25(6):349–354 12. Rüedi T, Buckley RE, Moran CG (2007) AO principles of fracture management vol. 2: specific fractures. Georg Thieme, New York 13. Cummings SR, Kelsey JL, Nevitt MC, O’Dowd KJ (1985) Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev 7:178–208 14. Hillier TA, Cauley JA, Rizzo JH, Pedula KL, Ensrud KE, Bauer DC, Lui LY, Vesco KK, Black DM, Donaldson MG, Leblanc ES, Cummings SR (2011) WHO absolute fracture risk models (FRAX): do clinical risk factors improve fracture prediction in older women without osteoporosis? J Bone Miner Res 26(8):1774–1782 15. Hadji P, Klein S, Haussler B, Kless T, Linder R, Rowinski-Jablokow M, Verheyen F, Gothe H (2013) The bone evaluation study (BEST): patient care and persistence to treatment of osteoporosis in Germany. Int J Clin Pharmacol Ther 51(11):868–872 16. Mann E, Meyer G, Haastert B, Icks A (2010) Comparison of hip fracture incidence and trends between Germany and Austria 1995-2004: an epidemiological study. BMC Public Health 10:46 17. Haussler B, Gothe H, Gol D, Glaeske G, Pientka L, Felsenberg D (2007) Epidemiology, treatment and costs of osteoporosis in Germany—the BoneEVA Study. Osteoporos Int 18(1):77–84 18. Thakar C, Alsousou J, Hamilton TW, Willett K (2010) The cost and consequences of proximal femoral fractures which require further surgery following initial fixation. J Bone Joint Surg (Br) 92(12): 1669–1677 19. Heikkinen T, Partanen J, Ristiniemi J, Jalovaara P (2005) Evaluation of 238 consecutive patients with the extended data set of the Standardised Audit for Hip Fractures in Europe (SAHFE). Disabil Rehabil 27(18–19):1107–1115 20. Handoll HH, Parker MJ (2008) Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev 3, CD000337 21. Stern R, Lubbeke A, Suva D, Miozzari H, Hoffmeyer P (2011) Prospective randomised study comparing screw versus helical blade in the treatment of low-energy trochanteric fractures. Int Orthop 35(12):1855–1861 22. Ossendorf C, Scheyerer MJ, Wanner GA, Simmen HP, Werner CM (2010) Treatment of femoral neck fractures in elderly patients over 60 years of age—which is the ideal modality of primary joint replacement? Patient Saf Surg 4(1):16 23. Kendrick BJ, Wilson HA, Lippett JE, McAndrew AR, Andrade AJ (2013) Corail uncemented hemiarthroplasty with a Cathcart head for intracapsular hip fractures. Bone Joint J 95-B(11):1538–1543 24. Hartel M, Arndt M, Eulenburg CZ, Petersen JP, Rueger JM, Hoffmann M (2014) Restoration of hip architecture with bipolar hemiarthroplasty in the elderly: does it affect early functional outcome? Arch Orthop Trauma Surg 134(1):31–38
