Effectiveness of autonomous home hazard reduction on fear of falling in community-dwelling older women.

BACKGROUND: Many falls in older people occur at home, and home hazards (HOHA) are often involved. Fear of falling (FOF) is a frequent and serious consequence of falls. This study aimed to analyze the effectiveness of an autonomous reduction of HOHA on FOF. METHODS: In this single-blinded, prospective cohort study design, the inclusion criteria were female sex, age ≥60 years, no known dementia, community-dwelling, and written informed consent. Using a 54-item room-by-room checklist, the participants identified and autonomously reduced as many HOHA as possible, within 14 days. The FOF was measured using a dichotomous scale (D-FOF) and the Falls Efficacy Scale International (FES-I). Logistic regression models were used to identify the predictors of a substantial reduction of HOHA (≥50%) and FOF (≥25%). RESULTS: A total of 782 women fulfilled the inclusion criteria, and 431 (60.5%) returned the complete checklist on time. The mean age was 72.5 [SD 7.1] years. 43.8% of participants reduced ≥50% of the HOHA. The D-FOF (odds ratio 22.4 [95% confidence interval 11.0-45.3]), age ≥ 75 years (14.1 [7.5-26.4]), polypharmacy (3.0 [1.4-6.5]), and assumed improvability of housing conditions (2.4 [1.3-4.3]) were identified as predictors for substantially reducing HOHA with an area under the curve of 0.91. The initial FES-I score decreased from 24.5 to 19.5. Prior to the intervention, 53.1% showed a high FOF (>22 FES-I scores). Of these, 70.7% participants reduced their high FOF to low FOF. 29.2% of all participants reduced FOF ≥25% postinterventionally, associated with a substantial reduction in HOHA (3.5 [2.2-5.7]) as the strongest independent factor in the multiple logistic regression analysis. CONCLUSION: The use of a self-administered checklist led to a substantial reduction of HOHA and subsequently to a clinically relevant reduction of FOF in older community-dwelling women. Autonomous competence of older people should be considered when developing fall prevention strategies.

Missed foot fractures in multiple trauma patients.

BACKGROUND: Missed or underestimated injuries are one of the central problems in trauma care. Foot injuries can easily be missed because they lay beyond the regularly screened field of a trauma computer tomography scan (CT scan). During primary and secondary survey a careful examination of the extremities often becomes of secondary interest in the severely injured patient. METHODS: Thirty-four thousand ninety-one multiple trauma patients of the TraumaRegister DGU® were evaluated from 2002 to 2014. We differentiated between patients with foot injuries, patients with missed foot injuries and patients without foot injuries. Included were ankle fractures, calcaneus fractures, talus fractures, metatarsal fractures, toe fractures, amputation, soft tissue injuries and/or ligamentous injuries. RESULTS: Summarized evaluation of 34,091 trauma patients showed a share of 2532 patients with foot injuries. Time of diagnosis was documented in 2199 cases. 2055 patients had early diagnosed foot injuries and 144 patients had initially missed foot injuries. Missed foot injuries were especially found in patients with car accidents or fall from ≥3 m. Patients with higher Abbreviated Injury Scale (AIS) or lower Glasgow Coma Scale (GCS) were not significantly more affected by missed foot injuries. Missing foot injuries was also not caused by injury severity or higher age. CONCLUSIONS: Our data highlights the need of careful evaluation of the feet during primary and secondary survey particularly when a tibia or femur fracture is diagnosed. Special attention should be turned to patients after car accidents or fall from great height. Suicide victims also need major attention. Patients with early operations also need careful examination and tertiary survey is highly recommended.

The treatment of intra-articular calcaneus fractures with severe soft tissue damage with a hinged external fixator or internal stabilization: long-term results.

We developed a hinged external fixator for the treatment of dislocated intra-articular calcaneus fractures with severe soft tissue damage. The external fixation was performed with a known external fixator system. The screw insertion points were biomechanically tested by defining a virtual rotation axis through the center of the talus to allow early active motion in the ankle joint. Long-term follow-up was performed after an average of 7.3 years. Results were graded with the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographs were reviewed according to Sanders classification. Four open fractures and 33 cases with extremely swollen soft tissue, blisters, or compartment syndromes were treated. In 24 cases (64.9%), the hinged fixator was the final method of treatment (group I). A change to open reduction with internal fixation was performed in 13 fractures (35.1%) when soft tissue problems were minimal (group II). There were no late amputations, osteomyelitis, or malunions. According to Sanders classification, group I consisted of 14 type II, 8 type III, and 2 type IV fractures. Pin loosening or pin infection was seen in 4 cases, but there was no redislocation. The Böhler's angle improved in 43%, gaps in the posterior facet were closed in 41%, and any shortening or deviation of the axis was corrected in 82% of the cases. The AOFAS score for the group averaged 66.5. According to Sanders classification, group II consisted of 8 type II and 5 type III fractures. The Böhler's angle improved in 88%, and gaps in the posterior facet were closed in 87%. Any shortening or deviation of the axis was corrected in 95%, and the AOFAS score averaged 61.3. Significant differences in patient outcome scores between open reduction with internal fixation and hinged fixator were not found. P value was > .05. The hinged external fixator frame can be used in all calcaneus fracture types without soft tissue limitation. The hinged fixator allows early movement in the ankle joint, the risk of infection is minimized, and secondary plate fixation remains possible.

Hemiarthroplasty of the shoulder after four-part fracture of the humeral head: a long-term analysis of 34 cases.

OBJECTIVE: To assess the treatment outcomes of patients with four-part fracture of the humeral head after primary and secondary hemiarthroplasty. PATIENTS: Retrospective long-term analysis of 46 patients from 1996 to 2002 of patients with 47 four-part fractures of humeral head. Patients with malignant disease were excluded. INTERVENTION: Aequalis (Tornier, Burscheid, Germany). MAIN OUTCOME MEASUREMENTS: Absolute and relative constant scores at 5-year follow-up examination without age or sex normalization, radiographic parameters of calcification, dislocation of tuberosities, prosthetic loosening, and dislocation of joint. RESULTS: Eighteen patients treated by primary and 16 patients treated by secondary arthroplasty were assessed clinically and radiologically after a mean follow-up of 64 (60-96) months. The absolute Constant scores at follow-up were 54.9 to 48.5 points, respectively. The relative scores were 61.4% and 57.3%, respectively. Dislocation of tuberosities with severe loss of function was found in five cases treated by primary arthroplasty (13.5%) and in 12 treated by secondary arthroplasty (75.0%). CONCLUSIONS: The majority of patients in both groups was free of pain or suffered minor pain as determined by the Constant score. Safe fixation of the tuberosities is a prerequisite for functional exercises and is better achieved in primary arthroplasty. A computed tomography scan before operative therapy aids in making the decision between open reduction and internal fixation or hemiarthroplasty.

Dynamic and functional gait analysis of severely displaced intra-articular calcaneus fractures treated with a hinged external fixator or internal stabilization.

The purpose of this article was to assess functional gait outcome. Fifty-five patients with severely displaced intra-articular calcaneus fractures and soft tissue damage were evaluated prospectively with computerized dynamic pedography and a clinical scoring scale. The treatment protocol assigned 30 patients to open reduction and internal fixation (ORIF) and 25 to closed reduction and stabilization with a biomechanically tested hinged external fixator. Gait parameter was evaluated by measuring plantar pressure distribution, length of a double-step, double-step duration, standing duration, effective foot length, and width of gait. Pedographic measurements were performed with a custom-made gait analysis system (medilogic Gangas, Berlin, Germany). Results were graded by an extended protocol of questionnaires and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scales. Radiographs were reviewed according to the Sanders classification at the time of follow-up (7.3 years). All measurements were statistically analyzed (t test; Mann-Whitney U test). Aberrations were associated with all calcaneal fractures in both groups. Dynamic gait analysis showed gait asymmetry in all patients. The type of treatment (ORIF or a hinged fixator) of severely displaced calcaneus fractures did not affect gait analysis nor result in significantly different (P > .05) patient outcome scores. The gait analysis system allows a valid dynamic pedographic measurement. The hinged external fixator can be recommended in displaced intra-articular calcaneal fractures with severe soft tissue damage to reduce complications associated with ORIF. ACFAS Level of Clinical Evidence: 2c.

A biomechanical evaluation to optimize the configuration of a hinged external fixator for the primary treatment of severely displaced intraarticular calcaneus fractures with soft tissue damage.

The purpose of this investigation was to develop an optimized hinged external fixator for the primary treatment of dislocated, intra-articular calcaneus fractures with associated soft tissue damage. To this end, a calcaneus model was made out of a polyurethane block, and a steel cylinder served as the ankle joint and was connected to a synthetic model of the tibia via a metal clamp. A saw cut served as the fracture in the model. A Steinmann nail and Schanz screw were placed in defined positions in the model and connected medially and laterally with longitudinal support rods. The fixator allowed a total of 20 degrees of plantar- and dorsiflexion, with rotation in the virtual axis of the upper ankle joint. Changes in the model fracture were measured during cyclical strain, and at different screw positions in the model tibia and calcaneus. Miniature force sensors located on the longitudinal support rods, and a plantar tension spring, were used to measure pressure and tension. Reproducible values were determined and, with the optimal configuration, shifting within the osteotomy was minimal. In the experimental configuration, optimal tibial screw placement was 70 mm proximal to the rotation axis of the upper ankle joint, and optimal placement of the Steinmann nail was in the posterior surface of the calcaneus. These findings indicated that the hinged fixator allows 20 degrees of ankle movement without alteration of the rotation axis, and suggest that this type of external fixator can be used in all types of calcaneal fracture regardless of the soft tissue damage. ACFAS Level of Clinical Evidence: 5c.