Audit of geriatric hip fracture care - a Slovenian trauma center analysis.

BACKGROUND: The aim was to describe an audit of hip fracture patient care and outcomes in a Slovenian healthcare setting prior to the implementation of the Geriatric Fracture Center (GFC) model of care. METHODS: The Fragility Fracture Network (FFN) hip fracture audit database was used to collect data on hip fracture care in elderly patients. Epidemiological data were submitted as well as fracture type, prefracture residence and mobility prior to the fracture. The timeline of events and acute care data were also collected. Follow-up after 30 days included hip-related readmission, mobility, residence and life status. RESULTS: Included were 495 patients with a mean age of 81 years of which 20% were preoperatively seen by a physician or geriatrician, 93.1% had surgical repair, 58.5% of them within 48 h of admission. The mortality rate in hospital was 5.4% and 10.1% at follow-up, 61.8% patients were able to return to prefracture residency and 23% could walk with minor assistance. CONCLUSION: This comprehensive and detailed audit report provides baseline data on case-mix, care and outcomes following hip fractures in Slovenia, in advance of planned quality improvement work in geriatric fracture care and provides a strong basis for the assessment of the impact of the GFC model of care.

Evaluation of major trauma in elderly patients - a single trauma center analysis.

BACKGROUND: The objective of the study was to gather information about elderly major trauma patients admitted to one particular Slovenian trauma centre in Celje and examine this group of polytrauma patients, specifically with respect to mechanisms of injury, injury severity and distribution of injuries. Further on, to identify morbidity and mortality rates and compare these to the younger population and, finally, to determine the factors that have the most impact on treatment results. METHODS: The study gathered and evaluated data of 532 patients included in the Trauma Register DGU® of the German Trauma Society (TR-DGU) during a 10-year period and two distinct groups of patients were established, separated on account of age as older or younger than 65 years. The differences between these two groups were analyzed with respect to demographics, comorbidities, preclinical management, injury patterns, relevant clinical and laboratory findings. Furthermore, differences between deceased and surviving elderly patients were also analyzed. RESULTS: The majority of elderly patients suffered from a blunt mechanism of trauma (96.6%) and of these simple falls represented 47.9% within this injury mechanism. There were two body regions, which were most frequently represented, namely head and thorax injuries, accounting for 54.7% each. Complications were more frequent among the elderly, with sepsis being present in 29.9% and multiple organ failure (MOF) in 19.7% of cases. Cardiovascular failure was also high in both the elderly and young, accounting for 45.3% of the elderly and 31.3% of the younger population. The in-hospital mortality rate for the elderly group was 25.6% and was significantly higher compared to the younger counterparts (14.7%). Low fall mechanism of injury, coma and the new injury severity score (NISS) were statistically important factors for the mortality of seriously injured elderly patients during the acute phase of treatment. CONCLUSIONS: Despite advances in care, morbidity and mortality in elderly patients after major trauma remains considerably higher than in younger populations with head injuries accounting for the majority of fatalities. The elderly patient population in this study mostly suffered from blunt mechanisms of injury, with simple falls representing a high proportion of injury mechanisms. Generally, the injury severity scale (ISS) in the elderly is not statistically higher than with the younger population. Likewise, the distribution of injuries according to body regions is also similar; however, the elderly are more prone to complications (e. g. sepsis and MOF), which is likely due to a lower physiological reserves.

Scapula fractures: interobserver reliability of classification and treatment.

OBJECTIVES: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN: Web-based reliability study. SETTING: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS: Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons. RESULTS: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA. CONCLUSIONS: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

Chronic rupture of Achilles tendon: is the percutaneous suture technique effective?

BACKGROUND: We report the long-term results of the surgical treatment of chronic rupture of the Achilles tendon using percutaneous suturing under local anesthesia. PATIENTS AND METHODS: We operated on 22 patients with median age of 50 years (29-72) with chronic rupture of Achilles tendon between 1991 and 2005. The median time from injury to surgery was 7.1 weeks (4-40). We used percutaneous surgical technique similar to a technique described by Ma and Griffith (1977, Clin Orthop Relat Res 128:247-255) and Kosanovic (1994, Arch Orthop Trauma Surgery 113:177-179). Eighteen (82%) patients attended the clinical review at a mean of 67 months (14-176). During follow up, patients were asked about pain, stiffness, weakness of the calf, footwear restrictions, occupation and level of activity before and after injury (Tegner score), influence of injury on ADL activities and satisfaction with treatment. The passive and active range of movement of the ankle and the power of isometric plantar flexion were measured, and the endurance test was performed. Functional assessment was performed using a Leppilahti clinical scoring scale and a modified Merkel score RESULTS: Complete healing of the tendon was achieved in 21 patients (95%). In 17 patients (77%) the postoperative course was complications free. There were no reruptures during the observation period. All were able to stand on the tiptoe of the injured leg. The operated leg had a mean of 87.5% of the isometric power compared with the uninjured leg (p = NS). On an average they could stand on toes and raise the heel 13 times on side with the ruptured tendon. The Leppilahti scoring scale revealed a result that was excellent for 11 patients (62%), good for 2 (11%), fair for 5 (28%) and no one had poor result. The average score was 83.3 (60-100). Eighty-three percent of patients stated that the result of surgery was very good and 11% rated it as good. Fourteen patients (78%) returned to same level of activity at median 7 months after surgery. CONCLUSIONS: Our series is one of the largest to be reported for the treatment of chronic rupture. Our technique offers a considerable advantage; it is minimal invasive, easy to perform with no associated harvesting morbidity and increased patient acceptance. We recommend this technique for the treatment of chronic rupture of Achilles tendon.

Halo jacket in odontoid fractures type II and III.

The treatment of odontoid fractures remains controversial. The late results of 14 patients with Anderson D'Alonzo type II and III treated with halo jacket from 1995 to 1999 are presented. The fractures were reduced under image intensifier and stabilized by halo jacket. The immobilization period was 12 weeks. After 1 year, the fracture was roentgenologically consolidated in 12 out of 14 patients (85.7%), and all the patients were without neurological deficit. Nine patients (64.3%) were without subjective complaints, five had a reduced range of motion. Painful motion appeared in four patients (28.6%), and cervical stiffness was noted in five (35.7%). We recommend halo jacket for the treatment of most type II and III odontoid fractures which are unstable or displaced 6 mm and more, except for patients with tetraplegia. Fractures with minimal displacement and without neurological deficit were treated conservatively with rigid collars. In our institution, internal fixation was performed in selected cases. The presence of neurological deficit and the anatomic properties of the fracture site crucially influence the choice of treatment.

Operative treatment of avulsion fractures of the anterior superior iliac spine according to the tension band principle.

BACKGROUND: Avulsion fractures of the anterior superior iliac spine are uncommon injuries. Most of them occur in adolescent athletes. Traditionally, they have been treated conservatively. We describe operative treatment of avulsion fractures that might shorten the period of rehabilitation. METHODS AND RESULTS: Six patients with avulsion fractures of the anterior superior iliac spine were treated operatively by open reduction and osteosynthesis with two Kirschner wires and a wire loop. After 6 weeks, all of them had resumed their sports activities. No complications were recorded. CONCLUSIONS: Operative treatment of anterior superior iliac spine avulsions may reduce the time to full recovery. It should be considered for athletes requiring a short period of rehabilitation.