The Incidence of Fractures Among the Adult Population of Germany–an Analysis From 2009 through 2019

Age-related traumatic anatomy and personalized medial incision design for calcaneal fractures in older adults using three-dimensional mapping

BACKGROUND

Calcaneal fractures usually arise from high-energy trauma and predominantly impact young individuals. In older adults (aged ≥ 50 years), declining bone density and muscle strength increase fracture risk from low-energy trauma, leading to a bimodal epidemiological distribution. The intricacies of calcaneal fractures in older adults, alongside osteoporosis and soft tissue fragility, complicate surgical intervention. This study aims to analyze age-related differences in calcaneal fracture characteristics using three-dimensional(3D) mapping and assess their impact on medial incision design.

METHOD

A total of 95 patients with closed calcaneal fractures were categorized into two groups: Younger (< 50 years, n = 61) and Older (≥ 50 years, n = 34). The process of 3D fracture mapping was executed utilizing Mimics and 3-matic software, alongside the reconstruction of soft tissue, which encompassed the posterior tibial neurovascular bundle. Differences in fracture distribution and incision parameters (length, α angle, D1, and D2) were statistically analyzed, with p < 0.05 considered statistically significant.

RESULTS

Fracture lines in both groups were predominantly located around the lateral Gissane's angle and critical weight-bearing areas of the calcaneus. In the Younger Group, fracture lines were long, continuous, and involved fewer fragments, correlating with high-energy trauma. The Older Group showed more comminuted lines, characteristic of osteoporotic fractures. The α angle and D1 distance were significantly smaller in the Older Group (p < 0.05), indicating closer proximity to the medial malleolus. D2 values were also smaller (p < 0.05), with 48.65% intersecting the neurovascular bundle compared to 31.34% in the Younger Group.

CONCLUSION

Age significantly influences medial wall fracture patterns and complexity in calcaneal injuries. A personalized medial incision based on fracture morphology provides better exposure and reduction compared to traditional methods. Although the incision is closer to the neurovascular bundle in older patients, meticulous surgical technique guarantees safety. The integration of a medial incision with sinus-tarsi (ST) approach minimizes the necessity for extensive lateral exposure, thereby diminishing soft tissue complications and improving surgical outcomes for the elderly population.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Extracorporeal Shock Wave Therapy (ESWT) as Part of the Treatment of Delayed Healing of Bone Fracture

The following paper provides an overview of the procedure of extracorporeal shockwave therapy and a classification of the current literature. The PubMed, Lvivo and WebOfScience databases were searched for "Extracorporeal Shockwave Therapy" and "Fracture nonunion". A total of 45 studies were identified, 12 of which were included in the analysis after narrowing them down. Fracture healing rates after the application of extracorporeal shockwave therapy (ESWT) averaged 69.25% (52-86%). Overall, it can be seen that the studies are based on small samples (average 154 patients) with a high variance in sample sizes (17-924 patients).

[Old and young-Differences in the treatment of proximal humeral fractures?]

The rising incidence of proximal humeral fractures has made this an important topic in the treatment reality of trauma surgery. Given the variety of treatment options available, the question arises as to what extent patient age influences the choice of treatment and, consequently, the functional outcome. In our approach the morphological features of the fracture and individual patient characteristics form the foundation for determining whether surgical or conservative treatment should be pursued. Whenever possible, joint-preserving reconstruction should be the goal in younger patients. In older patients, the implantation of reverse shoulder arthroplasty is the treatment of choice. Joint replacement enables early mobilization of older patients, facilitating a swift return to daily life. Looking ahead, a further increase in the fracture incidence and a corresponding rise in the rate of necessary surgical interventions are anticipated.

Comparing mortality in the elderly after proximal femur fractures and coxarthrosis: the effect of individual health characteristics and day of surgery

PURPOSE

This study investigates mortality variations between elective and urgent hip surgeries, focusing surgery timing and its impact on post-operative mortality. By comparing cases of femoral neck fractures, pertrochanteric fractures, and coxarthrosis across different follow-up durations, it aims to identify factors contributing to increased mortality.

METHODS

We used a random sample of German longitudinal health claims data (N = 250,000, 2004-2019) and identified 10,310 patients aged 50 years and older who underwent surgery for femoral neck fracture, pertrochanteric fracture, or coxarthrosis between 2004 and 2014. We tracked mortality at 30 days, 1 year, and 5 years. Cox proportional models were used, adjusted for the following covariates at the time of surgery: sex, age, comorbidities, nursing home dependency, discharge diagnosis, and weekday of surgery.

RESULTS

Mortality probabilities were 5% at 30 days, 15.6% at 1 year, and 38.9% at 5 years, with significantly higher risks for fractures than coxarthrosis. Key factors influencing mortality included age, comorbidities (e.g., heart failure, stroke, myocardial infarction, dementia), and care dependency levels. Women had lower risks than men across all periods. Short-term mortality was most affected by comorbidities, while long-term mortality correlated with chronic health conditions such as nicotine abuse and diabetes mellitus, and care needs. Surgery timing showed no consistent weekday effects.

CONCLUSION

Mortality differences reflect the impact of acute trauma from emergency surgery rather than the surgical procedure itself, emphasizing the need for optimized planning, preparation, early treatment and adaptable care structures in an aging population.

[Decision-making process between plate osteosynthesis vs. endoprosthesis in proximal humerus fractures of the rheumatoid arthritis shoulder]

The shoulder joint is involved in a high percentage of rheumatoid arthritis (RA) cases. At the same time, patients with RA develop osteoporosis at an early stage, which significantly increases the risk of fracture. In recent years, joint-preserving procedures with stable-angle implants have become available for individuals with low disease activity and good medication control. However, this approach is dependent on the fracture morphology and, if not adequately addressed, is associated with a high rate of revision surgery. In rotator cuff reconstruction, recent data show encouraging results regarding regenerative capacity, which does not necessarily indicate immediate reverse shoulder arthroplasty. Follow-up treatment must consider delayed osseous healing.

[Excess mortality of patients who negative for COVID-19 with proximal femoral fractures during the pandemic : What can we learn for future pandemics?]

BACKGROUND

The global COVID-19 pandemic led to excess mortality, especially for vulnerable older patients with simultaneous comorbidities. Patients with proximal femoral fractures already have a high mortality risk of up to 30% during the first postoperative year. The purpose of this study was not only to investigate the impact of COVID-19 on the mortality of patients tested positive but also of negatively tested patients with proximal femoral fractures.

METHODS

A single center cohort study of 2186 patients (mean age 79.8 years) who were surgically treated for a proximal femoral fracture at a level I trauma center was retrospectively carried out. The mortality and complication rates before the COVID-19 pandemic (January 2016-February 2020) and during the pandemic (March 2020-October 2021) were compared. A standardized treatment protocol was carried out during the total observational period. Orthogeriatric co-management was negatively impaired by the pandemic. Patient data, COVID-19 infections, surgical procedure, time from admission to surgery, postoperative complications and mortality were analyzed.

RESULTS

The pandemic group included 596 patients with an average age of 79.7 years. During the pandemic 26 patients were tested positive for COVID-19 (18 women, 8 men, average age 81.4 years, minimum 63 years, maximum 99 years, SD 9 years). Patients who tested positive for COVID-19 had more comorbidities than COVID-19 negative patients during the same period (Charlson comorbidity index, CCI 6.26 vs.5.25 points p < 0.037). The prepandemic control group consisted of 1590 patients with an average age of 79.9 years and a mean CCI of 5.86 points. Patients tested positive had a much longer hospitalization and a longer duration on the intensive care unit (p < 0.001) and a complication rate of 62.5%, especially due to the occurrence of pneumonia (p < 0.001). The mortality rate during the pandemic did not differ between patients tested positive or patients tested negative but was significantly higher for both groups in comparison to the period before the pandemic (pandemic 14% vs. 15.4%, before the pandemic 3.1%).

CONCLUSION

Patients suffering from COVID-19 infection and proximal femoral fractures have a high risk of complications and a high mortality. The total increase in mortality for all patients with critical injuries, such as hip fractures during the pandemic emphasizes the importance of early mobilization and orthogeriatric co-management, which was discontinued during the pandemic and the lockdown.

Mortality After Iliosacral Screw Fixation for Osteoporotic Pelvic Ring Fractures

Background

Fragility fractures of the posterior pelvic ring are associated with osteoporosis and are becoming more common with demographic change. Known limitations of conservative therapy include a significant loss of autonomy and high mortality. Surgical stabilisation using percutaneous sacroiliac (SI) or trans-iliac trans-sacral (TITS) screws, has been established to increase mobility, but long-term results have not yet been studied.

Materials and Methods

138 patients with percutaneous SI and TITS screw fixation of the posterior pelvic ring in osteoporotic fragility fractures were followed up for more than a year postoperatively in this retrospective study. Thereby, all patients were operated in the conventional supine position in a hybrid operating room consisting of a fixed, robot-assisted 3D flat-panel detector and a navigation system.

Results

34 patients were male and 104 female. The mean age was 77.6 ± 9 years. 26 patients were ASA 1 + 2, 93 patients ASA 3 and 19 patients ASA 4. 80 fractures were classified as FFP 2, 23 FFP 3 and 35 FFP 4. Time to surgery was 127.5 ± 113.2 hours. Hospitalisation lasted an average of 15.7 ± 8.5 days. At the time of discharge, 68.8% of the patients had regained their original mobility, while 31.2% remained limited. The home situation remained unchanged in 73.9% of the patients, worsened in 26.1% and improved in 2.8%. 90.6% of the screw fixations showed no signs of loosening. In 9.4%, loosening could not be ruled out radiologically, but a surgical revision was not necessary. The 1-year mortality rate was 10.1%.

Conclusion

Percutaneous navigated screw fixation of the posterior pelvic ring in fragility fractures is a simple, safe, minimally invasive and precise method with good clinical results in terms of rapid recovery with early mobilization of patients to maintain autonomy and reduce mortality. Further clinical studies with controlled cohorts and a large number of patients with long follow-up periods should be carried out to compare the procedure with other methods. In particular, the question of an additional standardized treatment of the anterior pelvic ring in unstable dislocated fragility fractures should be investigated.

[How does the preoperative waiting time affect hospital mortality and complication rates in geriatric patients with medial femoral neck fractures?]

BACKGROUND

The current guidelines of the German Federal Joint Committee on the treatment of proximal femoral fractures require that patients with a proximal femoral fracture receive surgical treatment as soon as possible and within 24 h of admission. This is intended to reduce perioperative complication rate and mortality.

OBJECTIVE

The aim of this study was to analyze the hospital mortality as well as complication rates and types in relation to the preoperative waiting time.

METHODOLOGY

From 2010 to 2020, a total of 575 patients with femoral neck fractures treated with a bipolar prosthesis were retrospectively analyzed with respect to hospital mortality and the occurrence of complications. Patients with pathological fractures, femoral neck fractures more than 4 weeks old and those treated with osteosynthesis were excluded. Patient-specific data, hospital mortality and complication rates and types were recorded.

RESULTS

During the study period, the implementation of the given guidelines resulted in a reduction in the preoperative waiting time from a median of 38 h in 2010 to 19 h in 2020. Surgical treatment was performed on average after 14.2 h in patients who had surgery within 24 h after admission and on average after 40.2 h for those who had surgery after 24 h. The average American Society of Anesthesiologists (ASA) score for all 575 patients was 2.76. The group of patients who had surgery after more than 24 h had a significantly higher ASA classification (p = 0.024). A total of 12 (4.2%) patients in the group surgically treated within 24 h died, compared to 24 (8.5%) deaths in the group surgically treated after 24 h (p = 0.035). The complication rate for the entire cohort was 15% (88 patients). There was no difference in the occurrence of complications and the overall complication rate with respect to the timing of surgery.

CONCLUSION

During the study period the preoperative waiting time was halved from 39h to 19 h. Patients who were surgically treated within 24 h had a significantly lower hospital mortality than those surgically treated after 24 h; however, the group surgically treated after 24 h simultaneously showed higher baseline comorbidities and in the adjusted analysis for age and ASA score, the 24‑h threshold no longer emerged as an independent risk factor for hospital mortality. Regarding complication rates, no significant differences were found between the groups based on the timing of surgery.

Proximal humerus fractures: Treatment controversies

The treatment of proximal humerus fractures is challenging, and significant controversy exists even regarding which patients are indicated for surgical treatment. When surgery is indicated, open reduction and internal fixation is the most common type of treatment. Arthroplasty is reserved for unreconstructible fractures. Hemiarthroplasty may not provide good, reliable function but may be the best option in younger or middle-aged patients when fracture fixation is not feasible. While several studies reported no benefit of surgical treatment in elderly patients, more recent literature showed better outcomes with reverse total shoulder arthroplasty.

Epidemiology of osteoporotic ankle fractures in South Korea: a nationwide retrospective cohort study (2006-2022)

PURPOSE

Ankle fractures, ranking as one of the very common osteoporotic fractures, pose a substantial socioeconomic burden. We aimed to investigate the incidence of elderly ankle fractures, refracture risks, and mortality rates in South Korea.

METHODS

Utilizing the Korean National Health Insurance Service (NHIS) registry from January 2006 to December 2022, individuals over 50 years with ankle fractures were identified. Osteoporotic ankle fractures were defined using admission diagnoses, procedural codes, and cast-related codes. Incidence rates, refracture rates, and one-year mortality rates were analyzed with standardization adjusted for gender and age distribution.

RESULTS

From 2006 to 2022, annual ankle fracture incidence rose from 193.90 to 278.83 per 100,000 person-years. Women exhibited 1.93 times higher incidence than men, with a notable increase in women. Most common in ages 60 to 69, ankle fracture rates increased until 2019 and after 2020 but decreased between 2019 and 2020. The one-year ankle refracture rates and osteoporotic refracture rates increased from 3.55% and 4.56% in 2007 to 9.32% and 10.37% in 2021, respectively. The one-year mortality rate after ankle fractures decreased from 2.10% in 2007 to 1.49% in 2021.

CONCLUSION

This study offers insights into the epidemiology of osteoporotic ankle fractures in South Korea, revealing increasing incidence, gender differences, age-related patterns, and trends in refracture and mortality rates over the study period. This study examines the incidence, refracture risk, and mortality of osteoporotic ankle fractures in South Korea using a nationwide dataset (2006-2022). The incidence of ankle fractures increased significantly, especially in women, and refracture rates also rose, highlighting an unmet need for better osteoporosis management.

[Patient specific implants and instruments in orthopaedic trauma: 3D prints and implants in perlvic and hip fractures]

Modern pelvic surgery is essentially influenced by technological innovations. One of the most impressive advances in this field is the integration of 3D printing and the associated possibility for the production of 1:1 models of the pelvic skeleton. Using these models, conventional pelvic implants can preoperatively be more exactly and patient-specifically contoured. The use of this technology has the potential to substantially improve the quality of care and simultaneously to optimize the surgical results. By the use of 3D-printed implants, which are individually adapted to the anatomical conditions of the patient, operations can not only be carried out more quickly and efficiently but also with a greater accuracy and potentially fewer complications. This article presents two instructive cases. Case 1 demonstrates how a proximal femoral fracture with a pre-existing deformity of the femur can be treated with a patient-specific implant. Treatment with conventional intramedullary or extramedullary implants was not possible. Case 2 illustrates the treatment of a pelvic ring fracture and the advantage of 3D printing for the preoperative patient-specific contouring of conventional plate systems.

Plate osteosynthesis versus non-surgical treatment in displaced proximal humerus fractures-long term functional outcome and quality of life

PURPOSE

This study aimed to assess the long-term outcomes of patients treated with plate osteosynthesis versus non-operative treatment for proximal humerus fractures (PHF) after a mean follow-up period of 10 years.

METHODS

A retrospective cohort study was conducted, including patients with PHF treated between 2004 and 2014. Patients were divided into two groups: those who underwent plate osteosynthesis (PO) and those managed non-surgically (NO). Functional outcomes, including range of motion, strength, and patient-reported quality of life were evaluated using standardized assessments such as the Constant-Murley score and Short-Form-36 (SF-36) questionnaire.

RESULTS

A total of 241 patients (161 in the Surgical Group and 80 in the Non-Operative Group) were included in the study. With a mean follow-up of 10.4 ± 3.1 years, both groups demonstrated comparable functional outcomes. The Constant-Murley score in the Surgical Group was 53.5 ± 21.8 compared to 60.1 ± 24.2 in the Non-Operative Group (p = 0.225). Complication rates were significantly higher in the PO group. The revision rate for patients treated with plate osteosynthesis was 37.9%. Patient-reported Quality of Life, assessed using the SF-12 questionnaire, revealed no significant differences between the Surgical and Non-Operative Groups.

CONCLUSION

This long-term follow-up study demonstrates that after a minimum of 5 years, there were no significant differences in functional outcomes or quality of life between patients treated with plate osteosynthesis and those who were managed non-operatively for displaced proximal humerus fractures. Both treatment approaches can offer favorable results, and the choice of treatment should consider individual patient characteristics and preferences.

[Endoprosthesis in proximal humerus fractures -What is important?]

In cases of complex proximal humeral fractures a fracture prosthesis is an established treatment option. In the geriatric patient population, the use of reverse total shoulder arthroplasty is gaining in relevance. This article focuses on the specific requirements and challenges associated with the application of reverse total shoulder arthroplasty. Decisive for the success are a structured perioperative management, meticulous preoperative planning, thorough patient education and standardized protocols for infection and bleeding prophylaxis. Intraoperatively, emphasis is placed on precise implantation techniques and stable tuberosity fixation, of which the latter is essential for postoperative function. A humeral inclination of 135° has been shown to be associated with better tuberosity healing. Complications, such as scapular notching or instability can be minimized through an accurate surgical technique and optimized implant management. Postoperative care is tailored to the individual, employing either a shoulder abduction brace or an early functional rehabilitation approach. Overall, reverse shoulder arthroplasty provides an effective fracture treatment for geriatric patients, ensuring long-term functional and clinical benefits.

Influencing factors for fragility fractures of the pelvis on length of stay and complication rate

PURPOSE

Increasing incidence of fragility pelvic ring fractures (FFP) is driven by demographic. An analysis of the patient population, along with the factors influencing total length of stay (LoS), and endpoints such as complications is essential for a better understanding and treatment of FFP injuries.

METHODS

This retrospective data analysis includes all inpatients treated from January 2018 to December 2022, with an FFP. Excluded were patients < 65 years, high-energy trauma, acetabular fractures, or pathological fractures. Collected data included demographics as well as information about comorbidities, diagnostics, therapy, LoS and complications.

RESULTS

A total of 363 patients were included, of which 14% (n = 52) were male and 86% (n = 311) female. The average age was 84.4 ± 6.6 years. While 31.1% (n = 113) were mobile without aid before onset of symptoms there was a significant (p < 0.01) decrease to 5.2% (n = 19) at discharge. Only 43.8% (n = 159) remained self-dependent at discharge, compared to 62.3% (n = 226) before injury (p < 0.01). Significantly longer LoS was found with higher FFP types (p < 0.01), higher number of complications (p < 0.01) as well as operative treatment (p < 0.01) and MRI diagnostics (p < 0.01). A significant increase on the number of complications was found with FFP IV (p = 0.02) and operative treatment (p < 0.01).

CONCLUSION

Higher FFP types, higher number of complications, as well as operative treatment and MRI diagnostics prolonged the total LoS. FFP IV and operative treatment were associated with higher number of complications. By identifying specific factors influencing the inpatient stay, further prospective studies may show improved complication/ mortality rates by optimizing those factors.

Fracture analysis of working-age adults in Turkey: a 7-year national registry study

BACKGROUND

The primary objective of this study was to examine the incidence of fractures among individuals aged 20-64 years over a 7-year timeframe by utilising an electronic recording system that is integrated with a substantial portion of the Turkish population.

METHODS

De-identified health records were acquired from the nationwide personal health recording system. Four age groups were established: 20-34, 35-44, 45-54, and 55-64 years. Incidence rates were further analysed according to sex and age group.

RESULTS

A total of 3,286,991 fractures were recorded in the 7-year time period, with male patients accounting for 62.1% of those cases. The overall fracture incidence rate in the Turkish adult population was 1029/100,000. The incidence rate was 727.44/100,000 for women and 1158.86/100,000 for men (p < 0.001). The age group with the highest number of fractures was 20-34 years with 1337.012 (37.3%) fractures. Wrist fractures (17.46%), finger fractures (14.4%), and foot fractures (11.85%) accounted for 43.7% of all fractures. In women, the incidence of fractures, excluding those of the hand and wrist, increased significantly as the age groups increased (p < 0.05).

CONCLUSION

Wrist, finger, and foot fractures were found to be the most common fractures among individuals aged 20-64 years. Fracture incidence was highest in men and in the age group of 20-34 years, encompassing individuals who are more active in work and sports.

Developing a core outcome set for acetabular fractures: a systematic review (part I)

BACKGROUND

There are indications that clinical studies investigating the surgical treatment of acetabular fractures assess different outcomes. This heterogeneity reduces the comparability of study results and, thus, limits the knowledge generated from research. Core outcome sets (COS) contain a minimum set of outcomes that should be measured in studies investigating a specific disease or injury. A COS for surgically treated acetabular fractures does not yet exist. Therefore, the aim of this study is to identify the reported outcomes in studies investigating the surgical treatment of acetabular fractures.

METHODS

Studies including skeletally mature individuals (≥ 16 years) with isolated acetabular fractures treated surgically were included. Studies with polytrauma patients, pathological fractures, additional pelvic fractures, exclusively non-surgical treatment, or juvenile individuals were excluded. Three databases and two clinical trial registries were searched on 15 November 2022. The identified outcomes were grouped and subsequently categorized according to the Core Outcome Measures in Effectiveness Trials Guidelines.

RESULTS

A total of 193 studies were included, which reported a cumulative total of 2581 outcomes. After grouping, 266 unique outcomes were identified. No outcome was examined in all studies. Pain, ability to walk independently, range of motion, quality of reduction, and heterotopic ossification were the most reported unique outcomes and assessed in at least 60% of included studies. A total of 105 outcomes were only assessed in one of the included studies. Outcomes of all five core areas and 25 outcome domains of the Core Outcome Measures in Effectiveness Trials taxonomy were examined. Furthermore, outcomes were named and defined differently, measured at different time points, and assessed using a variety of measurement instruments.

CONCLUSION

Overall, this systematic review shows that a wide range of outcomes are measured in studies examining surgical treatment of acetabular fractures. The results of this systematic review will be used in a subsequent study to develop the COS for surgically treated acetabular fractures by using the Delphi method.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022357644; COMET: 2123.

Direct and indirect costs of long bone fracture nonunions of the lower limb : the economic burden on the German healthcare system

Aims

Fracture nonunion represents a major complication in orthopaedic surgery, occurring in 5% to 10% of fracture patients. Fracture nonunions are associated with pain and loss of function, and lead to a substantial socioeconomic burden. The present retrospective cohort study analyzed direct and indirect costs and length of hospital stay, number of surgical procedures, and hospital (re-)admissions of nonunion patients.

Methods

Data from 18- to 65-year-old patients surgically treated for lower limb fractures and nonunions in a German level I trauma centre between 2012 and 2018 were analyzed. A total of 193 patients with nonunion were included, and 2,511 patients with fractures served as the control group. Direct costs were calculated using reimbursement according to the diagnosis-related group (DRG). Indirect costs were calculated including daily sickness allowance and productivity loss.

Results

The median healing time of nonunion patients was 45 weeks. Treatment expenses showed a 2.6-fold increase in direct costs, a 3.3-fold increase in indirect costs, and a 3.3-fold increase in total costs for nonunion patients compared to the control group. As every patient with a nonunion suffered from a fracture prior to nonunion treatment, costs were calculated by adding the median direct costs of €10,487 (IQR 9,173 to 15,262), median daily sickness allowance of €23,046 (IQR 14,892 to 36,264), median productivity loss of €85,714 (IQR 60,949 to 126,650), and median total socioeconomic burden of €123,334 (IQR 88,630 to 176,329).

Conclusion

Nonunions not only pose a significant burden on the injured individual and on healthcare systems, but also have a substantial socioeconomic impact. High direct and indirect costs illustrate that healing complications need to be detected and addressed as early as possible.

Hospitalisation from fractures in New Zealand octogenarians: LiLACS NZ

Longitudinal data quantifying fracture rates beyond 80 years are lacking. Over 5 years, hospitalised fracture incidences increased by 85% in Māori and 73% in non-Māori octogenarians. However, while fracture-related hospital nights increased by 107% in non-Māori, they remained stable for Māori. Hospitalised fracture risk increases markedly with 5 years of advanced ageing.

PURPOSE

Fractures become increasingly common in people beyond 80 years, the most serious resulting in hospitalisation. This study examines longitudinal changes in hospitalised fractures in octogenarians.

METHODS

Hospital discharge records from a cohort study of Māori aged 80-90 years and non-Māori turning 85 years (LiLACS NZ) were used to determine the incidence of hospitalised fractures for 5 years before and 5 years after enrolment.

RESULTS

Records were available for 378 Māori (aged 82.6 ± 2.8 years; mean ± SD) and 498 non-Māori (84.6 ± 0.5 years). In the 5 years prior to enrolment, 22 (5.8%) Māori and 43 (8.6%) non-Māori were hospitalised at least once for fracture, and 29 (7.7%) Māori and 62 (12.4%) non-Māori sustained hospitalised fractures in the 5 years following enrolment. Hospitalised fracture incidences were 1270/100,000 person-years in Māori and 2048/100,000 person-years in non-Māori before enrolment, increasing to 2345 (P = 0.02) and 3541 (P = 0.002) /100,000 person-years in the subsequent 5 years, respectively. Pelvis/femoral fractures accounted for almost half (47%) of fractures. Fracture-related hospital nights increased 107% in non-Māori (P < 0.0001), but remained stable for Māori, from before to after enrolment. Following enrolment, 21% of hospital nights spent by non-Māori women were fracture-related.

CONCLUSION

In octogenarians, hospitalised fracture risk increased markedly with 5 years of ageing, almost doubling fracture-related hospitalisation time in non-Māori but having little effect on time spent in hospital for Māori. Projections of fracture burden in advanced age need to consider rapidly changing risk with small increases in age and differences between demographic groups.

Fracture-Related Infection of the Proximal Femur - Diagnostics and Treatment

PURPOSE

With the aging population and rising life expectancy the incidence of trauma-related injuries, particularly proximal femur fractures, is expected to increase. Complications such as fracture-related infections (FRI) significantly impede the healing process and pose substantial risks to patients. Despite advancements in understanding, diagnosing, and treating FRI, challenges persist in achieving optimal outcomes. This review addresses the significance of FRI following proximal femur fractures, emphasizing diagnostic methodologies and therapeutic modalities to enhance clinical care.

FINDINGS

Notably, a consensus definition for FRI has been established, providing clarity for accurate diagnosis. Diagnostic criteria encompass confirmatory and suggestive elements, facilitating precise identification of FRI. Therapeutic strategies for FRI in proximal femur fractures include a spectrum of surgical and antimicrobial approaches. Surgical interventions, ranging from debridement with implant retention over implant removal/exchange to staged conversions to arthroplasty, are tailored based on fracture stability, individual patient factors, and infection characteristics. The intricate decision-making process is elucidated, highlighting the importance of individualized treatment plans and multidisciplinary collaboration. Antimicrobial therapy plays a pivotal role in FRI management, with empirical regiments targeting common pathogens and local delivery systems offering sustained antibiotic release. Microbiological analysis and collaboration with infectious disease specialists should guide antimicrobial treatment and ensure optimal therapy efficacy.

CONCLUSION

Managing FRI following proximal femur fractures requires a tailored, multidisciplinary approach. Treatment strategies should be guided by diagnostic precision, patient-specific considerations, and collaboration among surgical, infectious disease, and clinical teams. Implementing comprehensive therapeutic approaches is essential for mitigating the impact of FRI and improving patient outcomes.

Survival and risk factor analysis in patients with septic arthritis: a retrospective study of 192 cases

BACKGROUND

Septic arthritis (SA) presents a complex clinical challenge, often resulting in significant morbidity and mortality. This study aimed to (1) assess overall mortality rates and (2) identify potential factors contributing to increased mortality risk in patients with SA.

METHODS

This retrospective study on SA patients treated at a German university hospital between January 1, 2011, and December 31, 2021. Patients were identified using International Classification of Diseases (ICD)-10 codes for septic arthritis, specifically "M00.-". The study evaluated mortality rates and analyzed comorbidities, pathogens, and other potential risk factors. Kaplan-Meier survival curves and odds ratios (OR) were calculated to assess mortality risk.

RESULTS

In a cohort of 192 patients diagnosed with SA, 64 patients (33.3%) died during a mean follow-up period of 54.4 ± 42 months. The overall mortality rate was 17.5% at one year, 19.9% at two years, and 28.3% at five years. Patients aged 65 years or older, as well as those with arterial hypertension, congestive heart failure, chronic renal disease, chronic liver disease, malignancy, steroid use and immunosuppression showed significantly higher mortality rates (p < 0.05). Chronic renal disease (OR = 2.80), malignancy (OR = 3.40), and chronic heart failure (OR = 2.62) were identified as significant notably risk factors for mortality.

CONCLUSION

This study highlights a notably high mortality rate among vulnerable patients with SA, particularly those with pre-existing comorbidities. Recognizing and addressing these risk factors early could improve patient outcomes. These results unterscore the need for close monitoring of SA patients, particularly those with chronic organ conditions, and timely intervention for sepsis to reduce mortality risk.

Which Factors Influence the Need for Inpatient Aftercare of Elderly Patients After Hospital Treatment for Proximal Humerus Fractures?

Introduction

While epidemiology and treatment strategies of proximal humerus fractures have been well studied, post-hospital care is poorly analysed. Corresponding data is available in the context of hip fractures, but the evidence regarding proximal humerus fractures is weak. Aim of this study is to identify risk factors for institutionalisation required after discharge into inpatient aftercare for elderly patients treated for proximal humerus fractures.

Materials and Methods

For this retrospective single-centre investigation, n = 295 patients (age 70 (58,79) years, 63.7% female) admitted to hospital from home due to proximal humerus fractures were included and divided into two study groups: Patients being discharged home ('Home') vs being discharged into aftercare ('Aftercare'). Differences regarding demographic and clinical data were analysed. Odds ratios (OR) of influencing factors (adjusted for age) were calculated by logistic regression analysis.

Results

Increased age notably increased the likelihood for discharge of patients into 'Aftercare' (OR 1.09 [1.06;1.12] per year of life). Age-independent indicators for 'Aftercare' were higher ASA score (OR 2.16 per ASA point [1.37;3.49]; P < .001), anterior surgical approach (OR 6.05 [1.93,27.1]; P < .006), duration of surgery (OR 1.01 per min [1.00,1.02]; P < .012), non-surgical complications (OR 3.82 [1.60,9.49]; P < .003), length of stay (OR 1.12 per day [1.04,1.22]; P < .005), ICU stay (OR 3.15 [1.71,6.00]; P < .001) and reversely surgery (OR 0.39 [0.19,0.80]; P < .010).

Conclusion

Increased Age and higher ASA score notably increase the likelihood for post-hospital discharge to an inpatient aftercare facility. Available literature in the context of hip fractures is confirmed. The results of this study may assist in identifying patients at risk and may serve as a stepstone in establishing a scoring system for elderly patients with proximal humerus fractures.

Safety and complications of antimicrobial coated compared to conventional intramedullary femoral nails in proximal femoral fractures

PURPOSE

The aim of this study was to compare one-year mortality and the incidence of complications, particularly fracture-related infections, between patients with proximal femur fractures treated with novel noble metal-coated implants and those treated with uncoated implants, to detect possible effects of the coating on these endpoints.

METHODS

Design: Retrospective cohort observational study.

SETTING

Level 1 trauma centre. Patient Selection Criteria: All patients ≥ 18 years old with proximal femur fracture, who were treated with an intramedullary femur nail between 01.09.2020 and 01.10.2022 were included. The coated group (COATED) included patients who were treated with a coated implant. The control group (CONTROL) was treated with uncoated implants. Pathological fractures were excluded.

RESULTS

188 patients who matched the criteria were included (COATED: 93, CONTROL: 95). There was no significant difference in the one-year mortality or complication rate between the two groups. The fracture-related infection rate did not differ (p = 0.31) between both groups. Complications were observed in 59% of all cases and the overall one-year mortality rate was 42%. There was a significant correlation between complication occurrence and hospital stay (p < 0.01).

CONCLUSION

The coated intramedullary nail was similar to the uncoated nail in terms of perioperative complications and 1-year mortality rate. This suggests that the novel coated implant is safe for common clinical use. Further prospective multicentre studies with larger sample sizes are needed to detect a potential impact of coated implants on the incidence of fracture-related infections.

Fractures in Hereditary Neuromuscular Disorders: Frequency, Risk Factors, and Implications

BACKGROUND

Hereditary neuromuscular disorders (NMD) are associated with compromised bone health and elevated fracture risk, though data are largely lacking.

OBJECTIVE

This study aimed to assess the prevalence and risk factors of fractures in hereditary NMD.

METHODS

We conducted a retrospective study in a cohort of adult patients with diverse hereditary NMD, using data from electronic medical records.

RESULTS

Among 469 patients, 505 fractures were recorded, with 5.5% of patients experiencing a fracture within the past year. In the 10 years preceding study inclusion, 31.1% of all patients sustained at least one fracture. The fracture rate was 47.3/1000 patient-years. Fracture incidence was highest in the second decade of life and the first five years after symptom onset. Fracture recurrence occurred in 25.6% over the next two years. Fractures were most prevalent in patients with Duchenne muscular dystrophy, myotonic dystrophy type 1/2, and spinal muscular atrophy. Patients with Vignos scale 5-6 had the highest fracture risk. Major osteoporotic fractures accounted for 28.6%, and 71.3% were caused by low-energy trauma. Long-term complications of a fracture were present in 44.2%, with 9.0% losing ambulation. Osteoporosis was confirmed in 47.5% of DXA scans. In patients with a normal DXA scan, 66.7% experienced a subsequent fracture. Hip T-scores declined with increasing Vignos scale (r = -0.27, p = 0.001). Fracture risk factors included glucocorticoid use, alcohol abuse, recent falls, and previous emergency visits for falls (all p < 0.05).

CONCLUSION

This cohort exhibited a high prevalence of fractures and osteoporosis, emphasizing the need for regular bone health assessment and fracture prevention in hereditary NMD patients.

[Indications for surgical treatment of traumatic fractures of the thoracic spine and lumbar spine]

Fractures of the thoracic (Th) and lumbar (L) vertebrae are among the most frequent fracture entities in Germany and particularly affect the thoracolumbar junction (TLJ; Th11-L2). Based on expert recommendations and consensus meetings, the thoracolumbar AOSpine injury score was established for patients with healthy bone and the osteoporotic fracture (OF) score for geriatric patients with the respective classifications for treatment decisions. In both cohorts, the treatment decision is based on the fracture morphology, neurological status and patient-specific contextual factors. In terms of fracture morphology, surgical treatment is generally indicated for distraction and rotation/translation injuries. The treatment decision for compression fractures is more complex as additional factors must be taken into consideration. The decision in patients with healthy bone is primarily influenced by imaging morphological criteria (deformity and destruction) whereas in osteoporotic patients the decision is influenced by individual criteria, such as the general condition, the possibility of low pain mobilization and concomitant diseases. Overall, the treatment decision for fractures of the TLJ is not dogmatic as individual factors must be considered and high-quality studies are lacking.

Triangular Screw Placement to Treat Dysmorphic Sacral Fragility Fractures in Osteoporotic Bone Results in an Equivalent Stability to Cement-Augmented Sacroiliac Screws-A Biomechanical Cadaver Study

Background: Sacroiliac screw fixation in elderly patients with pelvic fractures remains a challenging procedure for stabilization due to impaired bone quality. To improve it, we investigated the biomechanical properties of combined oblique sacroiliac and transiliosacral screw stabilization versus the additional cement augmentation of this construct in a cadaver model of osteoporotic bone, specifically with respect to the maximal force stability and fracture-site motion in the displacement and rotation of fragments. Methods: Standardized complete sacral fractures with intact posterior ligaments were created in osteoporotic cadaver pelvises and stabilized with a triangle of two oblique sacroiliac screws from each side with an additional transiliosacral screw in S1 (n = 5) and using the same pelvises with additional cement augmentation (n = 5). A short cyclic loading protocol was applied, increasing the axial force up to 125 N. Sacral fracture-site motion in displacement and rotation of the fragments was measured by optical motion tracking. Results: A maximum force of 65N +/- 12.2 N was achieved using the triangular screw stabilization of the sacrum. Cement augmentation did not provide any significant gain in maximum force (70 N +/- 29.2 N). Only low fragment displacement was observed (2.6 +/- 1.5 mm) and fragment rotation (1.3 +/- 1.2°) without increased stability (3.0 +/- 1.5 mm; p = 0.799; 1.7 +/- 0.4°; p = 0.919) following the cement augmentation. Conclusions: Triangular stabilization using two obliques and an additional transiliosacral screw provides sufficient primary stability of the sacrum. Still, the stability achieved seems very low, considering the forces acting in this area. However, additional cement augmentation did not increase the stability of the sacrum. Given its lack of beneficial abilities, it should be used carefully, due to related complications such as cement leakage or nerve irritation. Improving the surgical methods used to stabilize the posterior pelvic ring will be a topic for future research.

The distribution of lateral rib fractures: a validation and further development of the AO/OTA classification system in patients with fractures at the rib shaft

INTRODUCTION

Rib fractures are prevalent and clinically significant injuries, often associated with thoracic trauma. Despite their frequency, the precise distribution and characteristics of rib shaft fractures remain underexplored. This study investigates the distribution, location, and classification of lateral rib fractures using the AO/OTA classification, focusing on fracture patterns and the relationship to neighbored ribs.

METHODS

The study retrospectively analyzed 116 patients with 617 isolated rib fractures treated at a Level 1 trauma center over seven years. Using CT scans, fractures between the tubercle and osteochondral junction of the rib shaft were examined. Fracture type, dislocation, and location were categorized according to AO standards. The 116 patients underwent detailed statistical analysis to identify distribution patterns and correlations between fracture characteristics.

RESULTS

The fractures predominantly occurred between the fifth and seventh ribs, with a focus in the anterolateral to lateral region (40°-69°). Type A fractures were more anteriorly located, while type B fractures and dislocations shifted posteriorly. A regression analysis confirmed the significance of fracture type and dislocation in determining fracture position. Moreover, fractures showed clustering patterns, with adjacent ribs more likely to be injured. A caudal shift in fracture density and localization from the cranial to the caudal thorax was also observed.

DISCUSSION AND CONCLUSION

The findings validate the AO/OTA classification for rib fractures, highlighting the need for refined subsegmental divisions within the rib shaft for more precise clinical application. The study underscores the relationship between fracture location, type, and associated injuries, advocating for multicenter studies and a comprehensive classification system for thoracic trauma. This could enhance our understanding of injury patterns and inform treatment strategies.

Mental health implications of fracture-related infections : a longitudinal quality of life study

Aims

Fracture-related infections (FRIs) are a major concern for patients and healthcare systems, yet their impact on mental health has been largely overlooked. This study aimed to assess the longitudinal impact of FRI on patients' quality of life.

Methods

A prospective study was conducted at a level 1 trauma centre between January 2020 and December 2022. In total, 56 patients participated, with quality of life assessed at five timepoints: one week preoperatively, and one, three, six, and 12 months postoperatively. Statistical analysis was performed using repeated measures analysis of variance (ANOVA) with adjusted post-hoc analysis.

Results

The preoperative Physical Component Summary score on the 36-Item Short-Form Health Survey questionnaire (SF-36) was 26.71, increasing to 30.40 at one month, remaining stable at three months. A modest increase was observed at six months (32.45, p = 0.003), but it decreased to 29.72 at 12 months. The preoperative Mental Component Summary score (SF-36) was 46.48, decreasing to 39.89 at one month (p = 0.027) and to 36.03 at three months (p ≤ 0.001). However, it improved at six (42.74) and 12 months (44.05). Positive changes were seen in EuroQol five-dimension questionnaire (EQ-5D) subdimensions, such as mobility, self-care, usual activities, and pain/discomfort, while anxiety/depression scores decreased over time. The EQ-5D visual analogue scale (VAS) score increased to 62.79 at six months (p ≤ 0.001) and decreased to 58.2 at 12 months (p = 0.011).

Conclusion

FRIs substantially affect mental health and quality of life, particularly during the initial three months of treatment. This study emphasizes the importance of addressing psychological aspects early in FRI management, advocating for holistic care encompassing both physical and psychological aspects of treatment.

The vulnerability of hip fracture patients with cognitive impairment: an analysis of health conditions, hospital care, and outcomes

BACKGROUND

Cognitive impairment, including dementia, and hip fracture are both common among older patients. Both conditions are associated with increased morbidity and mortality. Cognitive impairment is often underdiagnosed and may remain undetected in hip fracture patients. Little is known about the prevalence, specific characteristics, and outcomes of hip fracture patients with cognitive impairment. This analysis aimed to compare hip fracture patients with and without cognitive impairments regarding their health conditions, hospital care, and the risk of complications and mortality.

METHODS

This study used data derived from the EMAAge project, a prospective multi-center cohort study conducted in Berlin, Germany. Patients aged 40 years and older with hip fracture were stratified into three cognitive status groups: no cognitive impairment (NCI), moderate cognitive impairment (MCI), and severe cognitive impairment (SCI). Categorization was based on patients' ability to engage in interviews and their performance on the 6-item Cognitive Impairment Test (6-CIT). Standardized mean differences were used to compare various health-related parameters and health care utilization measures. Regression models, both adjusted and unadjusted, were calculated for the number of complications and the mortality rate.

RESULTS

Cognitive impairment was present in 37% of the 310 hip fracture patients in the study cohort. Patients with cognitive impairment had a worse baseline health profile, delayed admission to the emergency department, a longer time to surgery, and were less likely to be referred to a rehabilitation program. In the adjusted regression model for the number of complications, the incidence rate ratio was 1.237 (p = 0.292) for MCI patients and 2.065 (p < 0.001) for SCI patients compared with NCI patients. The adjusted odds ratio for mortality was 1.046 (p = 0.942) for MCI patients and 2.875 (p = 0.060) for SCI patients.

CONCLUSIONS

Hip fracture patients with cognitive impairment, particularly severe impairment, arrive at the ED in a considerably poorer state of health and are at a higher risk of adverse outcomes, including complications and mortality. Timely identification of this at-risk group upon arrival appears to be essential to providing adequate care. This study highlights the need for interventions and research aimed at improving prevention, emergency care and outcomes for this vulnerable group, addressing their specific risk factors, and promoting the quality of care in hospital and after discharge.

External validation and revision of the Lafontaine criteria for unstable distal radius fractures: a retrospective study

BACKGROUND

The Lafontaine criteria are the most commonly cited criteria for predicting unstable distal radius fractures. However, formal validation of the performance of these criteria remains limited. Therefore, we aimed to evaluate the Lafontaine criteria as a diagnostic prediction rule for distal radius fractures, assess the inter-rater reliability and predictive ability of various parameters for distal radius instability, and develop new criteria for fracture instability using reliable and highly predictive factors.

METHODS

This retrospective study included 274 adult patients with acute distal radius fractures treated with closed reduction and immobilisation between January 2019 and December 2022. Patients who underwent immediate surgery, were lost to follow-up before 4 weeks, or had unacceptable alignment after reduction were excluded. The Lafontaine criteria were validated using the area under the receiver operating characteristic curve (AUROC). Criteria with an AUROC > 0.7 were considered acceptable. The criteria were updated using risk factors with stronger associations in the multivariable logistic regression analysis, and the inter-rater reliability of potential predictors was evaluated.

RESULTS

The median age of the patients was 63 years; 78% were female. Redisplacement occurred in 39% of the cases. The AUROC for the Lafontaine criteria was 0.65 (95% confidence interval [CI] 0.57-0.74). Multivariable logistic regression showed that age 56-74 years (odds ratio [OR] 3.92, 95% CI 1.82-9.16, p < 0.001) age > 74 years (OR 6.34, 95% CI 2.66-16.2, p < 0.001), associated ulna fracture (OR 1.61, 95% CI 0.92-2.84, p = 0.10), and initial radial shortening > 3 mm (OR 5.78, 95% CI 3.11-11.2, p < 0.001) were the strongest predictive factors of fracture instability. These predictors demonstrated substantial inter-rater reliability, making them suitable for clinical use. Updating the model with these risk factors resulted in an AUROC of 0.74 (95% CI 0.66-0.82).

CONCLUSIONS

The performance of the Lafontaine criteria in discriminating unstable distal radius fractures was unacceptable in our study cohort. The updated criteria using age group (< 56 years, 56-74 years, and > 74 years), associated ulnar fractures, and initial radial shortening > 3 mm was found to have moderate discrimination; however, further research is warranted to improve the prediction and measurement reliability of fracture instability.

[Palmar Displacement in Distal Radius Fractures following Extension Injuries of the Wrist]

BACKGROUND

Fractures of the distal radius have been traditionally classified based on the suspected mechanism of injury. Among clinicians, the terms "Colles" and "Smith" fractures are commonly used to refer to a distal radius fracture that is either displaced to the dorsal (Colles) or palmar (Smith) side of the radius. When analysing x-rays, it is not uncommon for a Smith fracture to be detected in cases where patients describe a fall on the wrist in an extended position. Thus, the question arises how a flexion-type fracture can occur after an extension injury. So far, only little research has been conducted into this subject.

MATERIAL AND METHODS

The aim of this study was to analyse the mechanisms of injury that lead to various types of distal radius fractures. Particular emphasis was placed on "Smith" fractures and on the biomechanical, physiological and anatomical characteristics that contribute to their occurrence. To assess these relationships, data of fractures were collected following a life-like fracture simulation using a "drop-bench" in non-formalin fixated human specimens. These fractures were produced between January 2016 and December 2021. Biographic data of all specimens used were available. Additionally, all biomechanical and physical characteristics of the fracture simulation were fully documented.

RESULTS

Of the 122 specimens with a full data set, 17 (13.9%) fractures were determined to be Smith fractures based on their radiological appearance. In 10 of these flexion fractures, the wrist was set in dorsal extension. The mean angle of extension was 86.3 degrees for flexion fractures compared to 90.5 degrees for extension fractures. Six out of 10 Smith-type fractures that were set in dorsal extension were also exposed to pronation, whereas only one was exposed to supination. The mean potential energy for fracture creation was 168.0 joules for Smith fractures in dorsal extension, whereas all other fractures showed a mean of 185.2 joules.

CONCLUSIONS

It can be concluded that a Smith fracture is not limited to being the result of a fall on the wrist in a flexed position. The same fracture may also be the result of a fall with the wrist in an extended position if certain physical factors are applicable.

[Radial Head Arthroplasty: Pearls and Pitfalls]

Fractures of the radial head are among the more common injuries of the upper extremity. Their incidence is increasing, and these fractures are often associated with ligamentous injuries or occur as part of complex injury patterns, such as the terrible triad, Monteggia-like lesions, or Essex-Lopresti injuries. Radial head fractures are classified according to the Mason/Johnston system. In cases where the fracture is not reconstructable, or when osteosynthesis fails, radial head arthroplasty may be indicated.Several prosthetic designs are available, each offering unique features. These include differences in polarity, modularity, and shaft fixation techniques, such as cemented, cementless, or "intentionally loose" fixation. This article, supported by case reports, highlights the indications, surgical approach, and implantation techniques for radial head arthroplasty. Additionally, common pitfalls are discussed, along with strategies to prevent or manage them. These pitfalls include postoperative elbow stiffness, elbow joint instability, and prosthetic overstuffing.

Which screw corridors can be used for bilateral fragility fractures of the pelvis with a transverse fracture component (FFP IVb)?

BACKGROUND

Fragility fractures of the pelvis are becoming increasingly important in an ageing society. However, they are under-represented in the current research literature. In particular, unstable bilateral fragility fractures of the sacrum (FFP IVb) benefit from surgical treatment, but individual fracture patterns need to be considered in the surgical decision. This study describes the sacral anatomy in patients with FFP IVb pelvic fractures, with particular emphasis on the identification and evaluation of possible trans-sacral screw corridors, with particular emphasis on the transverse fracture components.

METHODS

Design: Retrospective clinical study.

SETTING

Level 1 trauma center. Patient Selection Criteria: The study reviewed 100 patients admitted for bilateral FFP with a transverse fracture between 01 / 2013 and 11 / 2023 that had a preoperative computed tomography (CT) of the pelvis including the fifth vertebra, treated with FFP IVb using preoperative multiplanar CT scans to analyze sacral anatomy. Outcome Measures and Comparisons: Sacral types and transitional abnormalities were classified, and corridor dimensions for S1 and S2 were measured, including estimated bone density using Hounsfield units. Bone corridors ≥ 8 mm were considered adequate. In addition, possible trans-sacral screw corridors were evaluated, taking into account the transverse fracture component.

RESULTS

While large trans-sacral screw corridors (≥ 8 mm) for S1 and S2 were identifiable in most cases, the actual feasibility for screw placement was limited due to the transverse fracture component's location, resulting in meaningful corridors in only 80 % for S1 and 47 % for S2. Additionally, in 4 % of patients without an S1 corridor, trans-sacral screw fixation was deemed inadequate due to the fracture line passing through S2.

CONCLUSIONS

These results indicate that not all FFP IVb fractures can be effectively stabilized using trans-sacral screw or bar fixation, necessitating alternative techniques for some cases. Furthermore, precise preoperative planning is essential for the management of these fractures due to complexity of anatomy. To identify the most suitable treatment approaches, further clinical studies are required.

LEVEL OF EVIDENCE

III.

Tranexamic acid: single topical application for femoral neck fractures treated with arthroplasty results in lowest blood loss

PURPOSE

Tranexamic acid is widely accepted for hip fractures but there is no agreement about dose or application method and the use is still off label for hip fractures. The aim of our study was to find the best application method of tranexamic acid in patients with femoral neck fractures comparing total blood loss, hemoglobin and transfusion rate.

METHODS

A retrospective single centre cohort study (level I trauma centre) with 2008 patients treated operatively for a proximal femur fracture between January 2016 and January 2022 was performed. 1 g of tranexamic acid was applied in 314 cases (systemic, topic or combined application) if patients consented. Patient data, surgical procedure, complications, and mortality were assessed. Haemoglobin levels, blood loss and transfusion rates were compared amongst application methods.

RESULTS

For 884 femoral neck fractures treated with arthroplasty blood loss was significantly reduced by tranexamic acid which 314 had received in total (1151.0 ml vs 738.28 ml; p < 0.001). 151 patients received 1 g of tranexamic acid systemically which reduced blood loss from 1151 to 943.25 ml. Combined application of 1 g i.v. and 1 g topically reduced blood loss even further to 869.79 ml and topical application achieved the lowest total blood loss at 391.59 ml (average reduction of 759.41 ml compared to without tranexamic acid), p < 0.001. Transfusion rate and amount of RBC units transfused were the lowest for topical use and showed the highest hemoglobin levels postoperatively. Complication rates did not differ for adverse vascular events.

CONCLUSION

Tranexamic acid effectively reduces blood loss and transfusion rates and shows higher hemoglobin levels postoperatively, without increasing the risk of thromboembolic events after proximal femoral fractures. Single topic application of 1 g for arthroplasty treatment of femoral neck fractures has better results for blood loss reduction than single i.v. or combined application.

Early Mobilization in Post-Orthopedic Surgery Patients: A Scoping Review

Post-orthopedic surgery patients need to undergo a recovery process with immobilization to minimize pain or swelling. Maximum care through early mobilization intervention can accelerate the return of body function and minimize medical complications. This literature review aims to determine early mobilization-based interventions that can be applied to post-orthopedic surgery patients. The method used in reviewing this article is a scoping review of secondary data in online databases including EBSCOhost, PubMed, Sage, and ScienceDirect. There are 8 articles analyzed and the early mobilization interventions found include motion interventions (increasing range of motion), Progressive Muscle Relaxation interventions (reducing pain, increasing muscle strength effects and short-term kinesiophobia), weight bearing interventions (reducing stiffness and pain), positioning interventions (reducing post-operative blood loss and increasing range of motion), and Neuromuscular Electrical Stimulation interventions (increasing muscle strengthening). These five types of early mobilization can reduce the length of stay in the hospital. Early mobilization based on motion and PMR showed significantly better results because the range of motion recovery time was faster, which was six weeks after surgery. This literature review can provide additional information for nurses as nursing care providers or other health workers regarding the importance of multidisciplinary collaboration in providing early mobilization interventions in post-orthopedic surgery patients. For further research, it is hoped that it can increase the research sample of post-orthopedic surgery patients in determining the effectiveness of various other early mobilization interventions in post-orthopedic surgery patients so that the review article can cover a wider range.

Treatment of Proximal Humeral Fractures in Older Patients During COVID-19 Pandemic in Germany

Purpose

The COVID-19 pandemic had a severe influence on the entire health sector. Until today, the effect of a SARS-CoV-2 infection on older patients with a proximal humeral fracture (PHF) is unknown. This study examined the following questions: Did the incidence of PHF of older people in Germany vary during the pandemic? Did the treatment change between the lockdown and non-lockdown periods? Was a SARS-CoV-2 infection associated with a worse outcome?

Methods

Retrospective claims data of the BARMER health insurance were analysed. All in- and outpatient cases of insurance holders ≥65 years from 01/2010 to 09/2022, with coded diagnosis of PHF were analysed. Primary endpoints were the 1-month incidence of PHF per 100,000 insurance holders, number of operative therapies, in-hospital death and in-hospital major adverse events (MAEs).

Results

174,898 inpatient PHF cases were included. During the lockdown periods, the total incidence fell, while the outpatient incidence partially increased during the pandemic-period. Regarding the therapy allocation, there were no relevant persisting changes. In a detailed analysis of 23,979 PHF cases from 01/2020 to 09/2022, 4.1% patients suffered from a SARS-CoV-2 infection and showed a notably higher in-hospital mortality (8.1% vs 2.5%; risk adjusted OR 2.79, 95% CI 2.11-3.70, p < 0.001) and more MAEs (17.0% vs 7.8%; risk adjusted OR 1.43, 95% CI 1.15-1.77, p < 0.001).

Conclusion

During the COVID-19 pandemic, the overall incidence of PHF in older patients was reduced. The treatment allocation did not change between the pre- and intra-pandemic period. An infection with SARS-CoV-2 was associated with higher mortality and more MAEs.

[Potential consequences of the German hospital reform and the resolution of the Federal Joint Committee on the treatment of proximal femoral fractures for the Federal State of Saxony : Improvement or hazard for the quality of care?]

BACKGROUND

The German hospital landscape is undergoing comprehensive changes due to the increasing aging population and staff shortages in the healthcare sector. These changes are driven by the current hospital reform and the guidelines of the Federal Joint Committee (G-BA) for the treatment of proximal femoral fractures.

OBJECTIVE

To investigate the effects of the hospital reform and the implementation of the G‑BA guidelines for the treatment of proximal femoral fractures in Saxony.

METHODS

Based on the number of proximal femoral fracture surgeries performed in all certified trauma centers in Saxony (East Saxony/West Saxony Trauma Network) in 2019 and 2022, a simulation was conducted to visualize the implementation of the G‑BA guidelines and the hospital reform.

RESULTS

Applying the criteria of the G‑BA resolution results in a reduction of hospitals treating proximal femoral fractures in Saxony from 42 to 28 (-33%). The implementation of the planned hospital reform further reduces the number of such hospitals to 15 (-64%). This reduction leads to a significant increase in case numbers in the remaining hospitals (twofold to threefold) and up to a fourfold increase by 2030. This comes with an increased need for operating capacities (1.2 operating rooms per week) and about 7400 secondary transfers per year. In the districts of North Saxony, Bautzen, Central Saxony, and the Erzgebirge District, no hospital would be available to treat geriatric proximal femoral fractures.

CONCLUSION

The planned reform and the current implementation of the G‑BA resolution pose a high risk to create gaps in care in Saxony with a markedly reduced number of hospitals involved in treatment of proximal femoral fractures. The necessary operating resources and inpatient capacities in the remaining hospitals are insufficient to care for the expected number of patients given the personnel and capacity shortages.

Comparison of two surgical treatment strategies for fragility fractures of the pelvis based on early postoperative mobility outcomes using insole force sensors

INTRODUCTION

Increasing incidences for fragility fractures of the pelvis (FFP) have been reported and surgical treatment remains demanding. While conventional screw osteosynthesis is a common method, complications may arise due to altered bone morphology in the osteoporotic pelvic bone. The iFuse implant system is a novel implant, first introduced for treatment of degenerative sacroiliac joint dysfunction, which offers promising biomechanical characteristics with potential benefits for treatment of FFP. Yet data on the use for FFP is limited. The objective of this study is to compare early postoperative mobility of patients treated with screw osteosynthesis only versus patients treated with additional iFuse stabilization based on insole force sensor gait analysis. We hypothesized that additional iFuse implantation leads to superior postoperative mobility.

MATERIALS AND METHODS

In the prospective observational study, 37 orthogeriatric patients with FFP types II-IV were included. Postoperative mobility of patients treated with conventional screw osteosynthesis only (group 1) and patients with additional iFuse implantation (group 2) was compared. Mobility was examined using insole force sensors (Loadsol®, Novel GmbH).

RESULTS

Postoperative comparison of gait analysis showed no significant difference in average (APF) and maximum peak force (MPF) between group 1 (n = 19, APF 64.9% ± 13.3, MPF 76.0% ± 14.1) and group 2 (n = 18, APF 67.6% ± 9.9, MPF 78.2% ± 10.1). Gait symmetry measured by FTI (force-time integral) ratio was significantly higher in group 2 (48.5% ± 3.3) than in group 1 (44.9% ± 5.4; p = 0.023). Median Barthel Index was higher in group 2 (55) compared to group 1 (45), yet not significantly (p = 0.058). Postoperative pain levels showed no significant differences between both groups.

CONCLUSION

Comparison of early postoperative mobility showed similar mobility outcomes in both groups. Patients with additional iFuse implantation had a more balanced gait pattern, whereas no significance was found in peak force parameters. Additional iFuse implantation showed promising results regarding patient mobility, therefore our hypothesis was partly confirmed. In future long-term examinations with larger patient cohorts should be aimed for.

[Geriatric traumatological management of osteoporosis : "Let the first fracture be the last"]

In Germany more than 800,000 osteoporotic fractures occur every year, with severe medical, social and health economic consequences. Nevertheless, as in many other countries there is a large gap in care. Fractures frequently occur in older geriatric patients, who are increasingly being (or should be) treated in geriatric trauma centers. This multidisciplinary approach offers the opportunity not only to restore the patient's mobility and independence but also to set the course for preventing further fractures. Diagnosing osteoporosis and initiating treatment early after a fracture is particularly important as there is an imminently high risk of further fractures in the months and years following a fracture. This review article describes a pragmatic, guideline-based approach to osteoporosis management for geriatric trauma patients. It discusses fracture risk assessment, current treatment thresholds and treatment strategies as well as the individual osteoporosis drugs, the indications and contraindications. This review aims to show that the treatment of osteoporosis within the framework of a geriatric traumatology team is feasible in the majority of cases. It is suggested that a treatment decision can be systematically made based on a few questions or a flow chart.

Compressive effect and collapse behavior of three different transsacral implants in sacral fragility fractures - a retrospective analysis of 106 cases

PURPOSE

The aim of this study were the retrospective evaluation of the compressive effect and complication rates of transsacral stabilization of osteoporosis-associated sacral fragility fractures in 106 patients using three different implants (6.0 mm sacral bar, n = 32; 7.3 mm screw, n = 26; 7.5 mm ISG-Rod System, n = 48) with regard to the image morphological and clinical-perioperative outcome.

METHODS

For this purpose, the sacral width was determined preoperatively and postoperatively using multiplanar CT reconstructions and correlated with the measured bone density (HU). The results were compared with each other on an implant-specific basis.

RESULTS

A significant compressive effect was found for all implants (6.0 mm sacral bar 7.1 ± 3.4 mm, 7.3 mm screw 6.9 ± 1.8 mm, 7.5 mm ISG-Rod System 8 ± 2.4 mm). No implant-specific difference in compression could be detected. Overall, the washers broke into the iliac cortex in 9% of cases. The subgroups did not differ significantly in this respect (6.0 mm sacral bar: 4 [13%], 7.3 mm screw 1 [1%], 7.5 mm ISG-Rod System (5 [10%], p = 0.581). A correlation between the degree of osteoporosis and the compressive effect could not be demonstrated. Significant implant-specific differences were found in the incision-suture time, with only ø0:39 ± 0:13 h required for implantation of the 7.5 mm ISG Rod System (6.0 mm sacral bar: ø1:09 ± 0:22 h, 7.3 mm screw: ø0:55 ± 0:20 h). The fluoroscopy time was significantly lower with the 7.3 mm screw (ø0:57 ± 0:23 min) and the 7.5 mm ISG Rod System (ø0:42 ± 00:17 min) than with the 6.0 mm sacral bar (ø1:36 ± 0:46 min).

CONCLUSION

A significant compressive effect was demonstrated with all three implants. No implant-specific complications or surgical site complications were identified in either the overall cohort or the subgroups. The 7.5 mm ISG Rod System shows advantages with regard to the duration of surgery and fluoroscopy.

Characteristics and outcomes of inpatients aged 85 and older with thoracolumbar vertebral fractures: impact on hospital stay and mortality

BACKGROUND

There is a gap in evidence about medical outcomes in oldest-old patients (aged 85 and older) with vertebral fractures (VFs). The aim of this study was to evaluate the impact of patient and fracture characteristics on "short-term" hospital outcomes.

METHODS

All patients aged ≥ 85 presenting an acute or subsequent VF at our single level I spine center between 2019 and 2021 requiring hospital treatment were included. The data collection was conducted retrospectively. The primary parameters of interest were length of stay (LOS) and in-hospital mortality. Further outcome parameters were the occurrence of general (non-operative) complications and Intensive Care Unit (ICU) admission. For statistical analysis, linear and binary logistic regression modeling were performed.

RESULTS

A total of 153 patients with an average age of 88.5 (range 85 to 99) met the inclusion criteria. Our patients were mostly female (68.6%) and moderately comorbid according to a Charlson Comorbidity Index (CCI) of 2.9. 58.8% had diagnosed osteoporosis. Fracture morphologies represented as "Osteoporotic Fracture" (OF) classification types were of central importance for undergoing operative treatment (OP) (p < 0.001), necessity for intensive care (p = 0.023), LOS (p = 0.014), and mortality (p = 0.018). 38.6% had OP. We recorded a complication rate of 59.5%, which highly influenced (p < 0.001) both primary outcome parameters. Overall, patients stayed 14.6 days with a mortality of 11.1%.

CONCLUSION

VFs are a severe event in oldest-old patients with a crucial risk of poor medical outcomes during hospitalization. The fracture morphologies are of central importance. However, little is known about the hospital stay of oldest-old inpatients with VFs. Considering an aging population, further investigations would be recommended.

The DAIR-procedure in fracture-related infection-When and how

This narrative review discusses treatment strategies and key considerations guiding decisions in the surgical management of fracture-related infections (FRI). Treatment options primarily revolve around two approaches: debridement antibiotics and implant retention (DAIR), or implant exchange, either in a one or multiple-stage strategy. Several considerations, including time since infection onset, implant type, stability, causative pathogens, host physiology, and soft tissue conditions, inform the choice of surgical intervention for FRI. Current literature supports the preference for a DAIR approach in cases with a short duration of ongoing symptoms, a stable implant with satisfactory fracture reduction, and a viable soft tissue envelope. Conversely, one- or multiple-stage implant exchange is deemed beneficial in instances of compromised local and systemic host physiology, mature biofilm, difficult-to-treat pathogens, intramedullary implants, and cases involving reinfections or failed DAIR procedures. Notably, these recommendations draw parallels from periprosthetic joint infection treatment strategies, constrained by the limited availability of randomized controlled trials comparing these options specifically in acute FRI. In conclusion, future perspectives call for extensive investigations into biofilm maturation and the impact of time on treatment outcomes. Additionally, there is a need for a standardized classification system for FRI to enhance the comparability of treatment outcomes in FRI management.

In-Hospital Mortality Among Elderly Patients Hospitalized for Femur Fracture with and Without Diabetes Mellitus: A Multicenter Case-Control Study

Purpose: The aim of the present study was to explore whether diabetes mellitus (DM) is associated with in-hospital mortality in patients admitted for femur fractures. Methods: Our multicenter case-control study included patients aged ≥65 with a primary diagnosis of femur fracture with and without DM treated in 36 German hospitals between January 2019 and December 2023. Patients with DM were matched to patients without DM (1:3) using propensity scores based on age and sex. Multivariable logistic regression analyses were conducted to assess the associations between DM and in-hospital mortality. Results: A total of 3220 patients with diabetes and 9660 patients without diabetes were included (mean age: 83 years). The overall in-hospital mortality rate was higher in DM patients (6.4%) than in those without DM (5.4%). However, the association between DM and in-hospital mortality was not significant after adjustment for other co-diagnoses. In particular, atrial fibrillation, heart failure, and CKD attenuated the effect of DM on in-hospital mortality. Conclusions: Our data show that DM is not significantly associated with in-hospital mortality in femur fracture patients. However, the presence of other comorbidities may influence mortality outcomes, highlighting the need for early intervention and targeted treatment to improve patient outcomes.

Development and Evaluation of the OF Pelvis Score for Osteoporotic Pelvic Ring Fractures - A Retrospective Assessment of Therapy Recommendations for 107 Patients

The aim of this study was to develop a simple and reliable score which supports decision making between non-operative and operative treatment in patients with osteoporotic pelvic fractures.Between 2018 to 2020, the OF Pelvis Score was developed during a total of 5 meetings of the Working Group on Osteoporotic Fractures of the Spine Section of the German Society of Orthopaedics and Trauma. The OF Pelvis Score as a decision aid between non-surgical and surgical treatment was developed by expert consensus after analysis of numerous geriatric sacral and pelvic ring fractures from several hospitals. Subsequently, retrospective evaluation of the score was performed on consecutive patients from three hospitals.The following parameters were considered relevant to decision making between non-surgical and surgical treatment and were incorporated into the score: fracture morphology using the OF Pelvis Classification, pain status, level of mobilisation, fracture-related neurological deficits, health status, and the modifiers already integrated into the OF Pelvis classification. If the score is < 8, non-surgical therapy is recommended; if the score is > 8, surgical therapy is recommended; if the score is 8, there is a relative indication for surgery. The OF Pelvis Score was then evaluated retrospectively in a total of 107 patients, according to records. The OF Pelvis Score was 8 points in 4 patients (3.7%), all of whom received surgical treatment. Of the remaining 103 patients, 93 received score-compliant therapy (90.3%). Among these, 4 of the patients who did not receive score-compliant care refused the recommended surgery, so the actual therapy recommendation was score-compliant in 94.2%.The OF Pelvis Score can be used to derive a therapy recommendation in many patients in clinical practice. Because of the possible change of clinical parameters during the course of the disease, the score has a dynamic character. In the retrospective evaluation, the recommendations from the OF Pelvis Score were in close accordance with the therapy actually performed.

Orthogeriatric co-management in pelvic and acetabular fractures

BACKGROUND

Osteoporosis, age and frailty significantly impacts outcomes in fragility fractures of the pelvis, increasing morbidity and mortality. Identifying frailty aids in risk stratification and personalized care plans, enhancing recovery and reducing complications in older adults. Orthogeriatric co-management, an interdisciplinary approach combining orthopedics and geriatrics, optimizes care for older adults with fragility fractures. This model improves outcomes through integrated preoperative and postoperative care. This study examines the current literature for orthogeriatric co-management in pelvic ring or acetabular fractures, aiming to improve outcomes for older adults.

CONCLUSION

Orthogeriatric co-management can be an effective tool to significantly enhances clinical care and reduces complications in older adults with pelvic ring and acetabular fractures. Studies demonstrate increased detection of urological complications and earlier patient mobilisation, alongside a notable decrease in revision surgery rates. The implementation of a specialized framework underscores the necessity for standardised orthogeriatric protocols, optimizing patient outcomes and satisfaction. Integrating geriatric expertise in surgical treatment addresses comorbidities more effectively and minimizes postoperative complications. The certification of such centers ensures adherence to quality standards, fostering continuous improvement in care. Standardised orthogeriatric management should extend to all older fracture patients.

Hemoglobin level, degree of mobilization, and pneumonia are associated with the development of postoperative delirium in cemented hemiarthroplasty after femoral neck fracture

PURPOSE

The aim of this retrospective study was to identify independent prognostic factors for developing a postoperative delirium (POD) in patients suffering from a proximal femoral neck fracture and treated by implantation of a hemiprosthesis.

METHODS

A retrospective study, including patients with hip hemiarthroplasty due to a femoral neck fracture between 2011 and 2020 was performed. Demographic data, preexisting conditions, intra-/postoperative complications, mobilization and laboratory results were extracted from the patients' charts. The different parameters were analyzed comparing patients with and without POD.

RESULTS

412 patients, mean age of 81 ± 9.58 years were included, 66.5% (n = 274) were female, 18.2% (n = 75) of them developed a POD. Significantly higher incidence of POD was associated with older age (p < 0.001), lower level of haemoglobin (p < 0.001), higher post-surgery interleukin 6 (IL 6) level (p = 0.008), higher postoperative level of leukocytes (p = 0.01). Patients with POD received more units of packed red blood cells (PRBC) (p = 0.007). Patients with no mobility limitations pre-operatively developed POD less frequently (p = 0.01), whereas suffering from pneumonia (p = 0.03) or limited mobility postoperatively increased the risk of POD (p < 0.001).

CONCLUSION

This study could help to identify patients with a risk for developing POD after a hemiarthroplasty in femoral neck fractures. As a consequence, frequent controls of Hb, IL 6 and leucocytes levels to avoid anemia and infections, as well as the well surgical treatment to guarantee a good postoperative outcome.

[Rotationally stable screw anchor (RoSA) vs. Gamma3 Nail (G3N) in pertrochanteric femoral fractures : A functional outcome analysis]

BACKGROUND

The pertrochanteric femoral fracture (PFF) represents one of the most common fracture types throughout Germany. To enable early mobilization of patients, the primary surgical goal is load-stable osteosynthesis. Implant failure still represents the largest group of implant-related complications (>80%).

OBJECTIVE

The aim of the study was to document and analyze the influence of the implant on the functional outcome and an evaluation of the rotationally stable screw anchor (RoSA) vs. Gamma3 nail.

MATERIAL AND METHODS

In a retrospective study 43 patients with PFF (AO 31A1-A3) were included in the study. The influence of the implant on the functional outcome was assessed by 2 standardized questionnaires (SF-36, NMS (New Mobility Score)) and analyzed in a retrospective evaluation.

RESULTS

In the study no significant differences in functional outcome scores ≥ 1 year after osteosynthesis of the PFF could be shown depending on the implant used. There is an overall tendency for a better outcome in the G3N group.

DISCUSSION/CONCLUSION

In the literature the superiority of intramedullary nailing over extramedullary implants is continually discussed. Implant failure is still the most frequent complication. In intramedullary implants, such as the G3N, the primary cause is failure of the head-neck component. For conventional extramedullary implants the biomechanical properties on the femoral shaft also pose a challenge in the case of unstable PFF. The further development of the RoSA to an intramedullary implant could combine the advantages of intramedullary load carriers with the advantages of the blade-screw combination in the head-neck fragment and lead to a reduction in implant-associated complications.

B7-1 and PlGF-1 are two possible new biomarkers to identify fracture-associated trauma patients at higher risk of developing complications: a cohort study

BACKGROUND

Around 10% of fractures lead to complications. With increasing fracture incidences in recent years, this poses a serious burden on the healthcare system, with increasing costs for treatment. In the present study, we aimed to identify potential 'new' blood markers to predict the development of post-surgical complications in trauma patients following a fracture.

METHODS

A total of 292 trauma patients with a complete three-month follow-up were included in this cohort study. Blood samples were obtained from 244 of these patients. Two complication groups were distinguished based on the Clavien-Dindo (CD) classification: CD grade I and CD grade III groups were compared to the controls (CD 0). The Mann-Whitney U test was used to compare the complication groups to the control group.

RESULTS

Analysis of the patients' data revealed that risk factors are dependent on sex. Both, males and females who developed a CD III complication showed elevated blood levels of B7-1 (p = 0.015 and p = 0.018, respectively) and PlGF-1 (p = 0.009 and p = 0.031, respectively), with B7-1 demonstrating greater sensitivity (B7-1: 0.706 (male) and 0.692 (female), PlGF-1: 0.647 (male) and 0.615 (female)). Further analysis of the questionnaires and medical data revealed the importance of additional risk factors. For males (CD 0: 133; CD I: 12; CD III: 18 patients) alcohol consumption was significantly increased for CD I and CD III compared to control with p = 0.009 and p = 0.007, respectively. For females (CD 0: 107; CD I: 10; CD III: 12 patients) a significantly increased average BMI [kg/m2] from 25.5 to 29.7 with CD III was observed, as well as an elevation from one to three comorbidities (p = 0.003).

CONCLUSIONS

These two potential new blood markers hold promise for predicting complication development in trauma patients. Nevertheless, further studies are necessary to evaluate the diagnostic utility of B7-1 and PlGF-1 in predicting complications in trauma patients and consider sex differences before their possible use as routine clinical screening tools.