Proximal femoral fractures in patients with COVID-19 : Pneumonia and admission from a nursing home are the strongest predictors of mortality.

BACKGROUND: Proximal femoral fractures are severe injuries in geriatric patients. Additionally, geriatric patients are at a high risk of death due to coronavirus disease 2019 (COVID-19). OBJECTIVE: To identify predictors of mortality in geriatric patients with COVID-19 and concurrent proximal femoral fractures. MATERIAL AND METHODS: Patients who underwent surgical treatment for proximal femoral fractures and also tested positive for COVID-19 were included. The age, gender, the American Society of Anesthesiology (ASA) score and the admission from a nursing home were considered as variables. The rate of reoperations, the mortality at 3 months and discharge home were evaluated as outcomes. RESULTS: In this study 46 patients with COVID-19 (female/male 31/15, median age 87.0 years with an interquartile range [IQR] of 9.8 years) met the inclusion criteria. Of these, 32 patients (69.6%) had to be cared for in the intensive care unit and 26 patients (56.5%) had a severe course of COVID-19 with pneumonia. The median length of hospital stay for survivors was 19 (IQR 17.5) days and 4 of the patients (8.7%) required surgical revision. The in-hospital and 3­month mortality were 40.0% (n = 17) and 43.5% (n = 20), respectively. The factors which influenced the in-hospital and 3­month mortality rates were admission from a nursing home, the presence of pneumonia (increased the risk of death) and female gender (protective). CONCLUSION: The occurrence of COVID-19 in patients with proximal femoral fractures has a high mortality. Admission from a nursing home and the presence of pneumonia increased the risk of death, whereas women were at lower risk.

Postoperative recreational sports and subjective shoulder function: a comprehensive analysis following intramedullary stabilization of displaced midshaft clavicular fractures.

Introduction Sports-related outcomes and the role of recreational sports activities for shoulder function after intramedullary stabilization (IMS) of displaced midshaft clavicular fractures (DMCFs) in the general population are not well known. In this study, we aimed to determine the sport-related outcomes (return-to-sports [RTS] rate, type of sports, time until RTS, and intensity) and to explore the role of sports after IMS of DMCFs. Materials and Methods This single-center, retrospective, cohort study included patients who underwent IMS of DMCFs between 2009 and 2022 at a Level II trauma center in Germany, experienced no major complications, and had completed at least 1 year of follow-up. Propensity score matching was conducted to obtain a balanced sample of patients who did not engage (cases) and engaged (controls) in postoperative sports activities by adjusting for age and fracture complexity. Groups were compared to assess the impact of regular sports activities on subjective shoulder functioning at follow-up, as evaluated using the Disabilities of the Arm, Shoulder, and Hand and Oxford Shoulder Score (OSS) questionnaires, after controlling for the patient- (i.e., sex and smoking) and treatment- (i.e., surgery duration and physical therapy) factors. Results Among the 199 patients included, the RTS rate was 97.5%, and 160 patients practiced regular postoperative activity, mostly in the same sport and intensity. In the matched cohort (39 cases and 39 controls), practicing regular sports activities postoperatively was the only independent factor associated with a higher OSS in the multiple regression analysis (unstandardized regression coefficient = 2.40; Bias-corrected and accelerated 95% confidence interval [0.28, 4.69]). Conclusions The sport-related outcomes after IMS of DMCFs in our cohort were comparable to those achieved after plate osteosynthesis, and IMS reported in the literature. Recreational sports activities benefitted subjective shoulder function, thereby encouraging further research and potentially influencing management policies. Level of evidence Grade IV - a retrospective observational cohort study.

Factors affecting duration of inability to work after intramedullary stabilization of displaced midshaft clavicular fractures.

BACKGROUND: Duration of inability to work (DIW) after displaced midshaft clavicular fractures (DMCF) is an important clinical and socioeconomic treatment outcome. However, evidence on DIW after DMCF intramedullary stabilization (IMS) is still limited. We aimed to examine DIW and identify medical and socioeconomic predictors with direct or indirect impact on DIW after IMS of DMCF. HYPOTHESIS: Socioeconomic predictors can explain the unique proportion of the DIW variance after IMS of DMCF above the variance explained by medical predictors. PATIENTS AND METHODS: Using a retrospective cohort unicentric design, we included patients surgically treated with IMS after DMCF from 2009-2022 with employment status subject to compulsory social security contributions, and without major postoperative complications, in one level II trauma center in Germany. In total, we tested the impact of 17 different medical (i.e., smoking, body mass index [BMI], operative duration, etc.) and socioeconomic predictors (i.e., health insurance type, physical workload, etc.) on DIW. Statistics included multiple regression and path analyses. RESULTS: A total of 166 patients met the eligibility criteria, with DIW 35.1±31.1days. Operative duration, physical workload, and physical therapy prolonged the DIW (p<0.001). In contrast, enrollment in private health insurance reduced the DIW (p<0.05). Furthermore, the effect of BMI and fracture complexity on DIW was fully mediated by operative duration. The model explained 43% of the DIW variance. DISCUSSION: Socioeconomic factors were found to directly predict the DIW, even after controlling for medical predictors, which confirmed our research question. This is in line with previous findings and highlights the relevance of socioeconomic predictors in this context. We believe that the proposed model can serve surgeons and patients as an orientation guide to estimate the DIW after IMS of DMCF. LEVEL OF EVIDENCE: IV - retrospective observational cohort study with no control group.

Surgical treatment of proximal femoral fractures in centenarians: prevalence and outcomes based on a German multicenter study.

PURPOSE: This study aimed to estimate the survival rate after proximal femoral fracture insult and identify the subgroup of centenarians with a high risk. METHODS: Records of patients (≥ 65 years) who underwent surgery for PFF between 2006 and 2020 were retrieved from the electronic databases of three hospitals. Overall, 22 demographic, perioperative, and postoperative variables were analyzed for all patients > 99 years of age. The effect of anemia, time to surgery, surgical procedure, place of residence, and dementia on complications and survival were evaluated. RESULTS: The study included 85 patients (women n = 71; men n = 14; median age, 100 years; range 100-106 years). Over the study period, the prevalence of centenarians with PFF increased (0.94%). The overall complication rate was 28% (in-hospital death, n = 16; infection, n = 1; hematoma, n = 1; implant failure, n = 1; cardiac decompensation, n = 3; pneumonia with delirium, n = 1; urinary tract infection, n = 1). The 30-day, 3-month, 6-month, and 1-year mortality rates for the study group were 27.1%, 42.4%, 55.3%, and 61.2%, respectively. Median survival was 150 days (range 1-1942 days). Patients with dementia (n = 47) had a shorter survival time than patients without dementia (n = 38) (hazard ratio 1.75; 95% confidence interval 1.04, 2.95). Preoperative anemia, time to surgery, or necessary surgical procedure had no impact on survival. CONCLUSIONS: The prevalence of centenarians undergoing surgery for PFF is increasing. In-hospital mortality is high, and dementia is a risk factor impacting survival. The rates of surgical revision and general complications are low, and the chosen predictors had no significant impact on these outcomes. The survival rate after discharge from hospital seems to be comparable to the estimated survival rate of uninjured centenarians.

Unipolar versus bipolar hemiarthroplasty for hip fractures in patients aged 90 years or older: A bi-centre study comparing 209 patients.

BACKGROUND: This study aimed to evaluate the outcome of unipolar and bipolar hemiarthroplasty to treat hip fractures in patients aged ≥ 90 years. METHODS: We conducted this study from 2007 to 2018 based on the electronic databases of two hospitals. Patients aged ≥ 90 years, treated for Arbeitsgemeinschaft Osteosynthese 31-B3 type fractures, were included. One hospital conducted the treatment only with unipolar prostheses; the other hospital used only bipolar prostheses. We assessed 23 peri­ and postoperative variables including any revision, dislocation, and survival. The follow-up was completed after a minimum of 2 years postoperatively. At follow-up, the functional status was evaluated via telephone using the Parker score for every living patient. RESULTS: One-hundred unipolar prostheses, and 109 bipolar prostheses were examined. The patients' mean age was 92.9 years (range 90-102). Dementia was differently distributed between the groups (p < 0.001), with a lower survival risk (Odds Ratio 1.908; Confidence Interval 1.392 - 2.615; log rank <0.001). Based on this result, unipolar demonstrated significantly higher mortality rates compared with bipolar prostheses (log rank < 0.001). No effects were found for dislocation, revision and overall complication rate. At follow-up, 37 patients were available for functional status. The mean Parker score was 3.7 (range 0-9), with no effect. CONCLUSIONS: Intracapsular hip fractures in patients aged ≥ 90 years can be treated with unipolar or bipolar hemiarthroplasty. The type of prostheses did not influence dislocation, revision, general complication, or functional status. The groups were significantly affected by dementia, a risk factor for shorter survival.

Injuries in supercross - Evaluation of trauma during a two-day international indoor motocross event.

INTRODUCTION: Supercross is characterized by fast and skillful movements, with high concentration being required on an indoor competition circuit, due to the demanding jumps and short distances to the next obstacle. The injuries can turn out to be diverse, including polytraumatization. This paper aims to evaluate the accidents and possible injuries in a single Supercross competition. To what extent is the presence of medical staff required? METHODS: During the 17th International Supercross Event in Chemnitz, 93 participants started in 5 classes. Severe injuries were treated at the track, through the emergency department and hospital stay to their discharge. RESULTS: Overall 5 participants (4.65%) had to be admitted to the clinic. CONCLUSION: Injuries from risky jumps at relatively high speed can range from minor contusions to fractures and serious injuries. The permanent readiness of medical staff and emergency doctors at the site is therefore justified and required. The variety of injuries in a Supercross event can affect the head and face, the upper- and lower extremities, thoracal- and abdominal traumas and especially the spine. In addition, a special training concept in terms of preventive measures to prevent falls would be desirable.

S-shaped titanium endomedullary nail reduces telescoping of comminuted midshaft clavicular fractures.

BACKGROUND: The surgical treatment of displaced midshaft clavicular fractures (DMCF) is clinically relevant and a much discussed topic. The axial stability of DMCF after intramedullary nailing (IMN) is still a matter of debate. OBJECTIVE: Our objective was to present a modification of IMN of DMCF with S-shaped titanium endomedullary nail (TEN) and determine fracture telescoping from day one after surgery to the time of fracture healing. METHOD: In a prospective analytic cohort study over a 6-year period (2012-2017) at a Level II trauma care centre, a total of 128 patients with DMCF were included and classified according to the AO/OTA classification system. Group I was AO/OTA type 15.2A/15.2B (N = 68) and group II was AO/OTA type 15.2C (N = 60). After a modified open stabilization technique of each DMCF with IMN (S-shaped TEN), the dynamics of radiological assessed telescoping until union and rate of surgical adverse events were measured. Significance was assumed for p < 0.05. RESULTS: One day after surgery, fractured clavicles were lengthened slightly in both groups compared to the unfractured clavicules (group I: 1.2%; group II: 0.9%). After osseus consolidation, the fractured clavicules were significantly shortened in both groups (group I: - 2.9%; group II: - 3.6%). Measurement of the clavicular shortening at one day postsurgically and at consolidation revealed a mean telescoping of - 3.99% in group I and of - 4.6% in group II. The difference between the two groups was not significant (P = 0.522). The overall rate of major surgical adverse events was 2.3%. CONCLUSION: The proposed operative technique of IMN (stabilization of the DMCF with a long, S-shaped, tight-fitting TEN) provides enough axial stability to prevent significant telescoping of the comminuted fractures. The rate of nonunion is low and the overall rate of major adverse events is similar to the reported events after plate fixation in the literature.

Peri-operative antibiotic treatment of bacteriuria reduces early deep surgical site infections in geriatric patients with proximal femur fracture.

PURPOSE: The aim of this study was to conduct a re-evaluation of current strategies for peri-operative prophylaxis of infections in orthopaedic surgery of geriatric patients (≥65 years) with proximal femoral fractures (PFF). METHODS: Between 01/2010 and 08/2014 all post-operative infections after stabilization of PFF of 1,089 geriatric patients were recorded retrospectively. All patients pre-operatively received a single dose of 1.5 g cefuroxime (group 1). These were compared to prospectively determined post-operative rates of surgical site infection (SSI) of 441 geriatric patients, which were operated on between 09/2014 and 03/2017 due to PFF. In this second group we investigated the urinary tract on admission. Bacteriuria was treated with the pre-operative single dose of 1.5 g cefuroxime along with ciprofloxacin for five days, beginning on admission. Level of significance was set to p < 0.05. RESULTS: A total of 141 patients of group 2 had a bacteriuria. Seventy-seven of these patients revealed biochemical signs of manifest urinary tract infection. Multi-resistant pathogens were found in 15 patients and pathogens were cefuroxime-resistant in 37. The differences of SSI after at least three months were 2.1% in group 1 and 0.45% in group 2 for all patients with surgery of PFF (p < 0.02) and for those with arthroplasty (p < 0.037) significant. CONCLUSIONS: The immediate antibiotic therapy of a prevalent bacteriuria for five days decreases the risk of SSI after surgery of PFF. Our single-centre study can only point out the problem of prevalent reservoirs of pathogens and the need for treatment. Evidence-based therapy concepts (indications of antibiotics, classes, duration) have to be developed in multi-centric and prospective studies.

Atypical cardioversion in unstable arrhythmia caused by clavicle surgery.

We report on a 54-year old male with traumatic brain injury, flail chest and floating shoulder undergoing intramedullary stabilization of a midshaft clavicle fracture in beach chair position. Intraoperatively the patient developed instable atrial fibrillation triggered by implantation of intramedullary nail. Secondary this case shows feasibility of cardioversion in latero-lateral electrode-position due to inaccessible standard positions and patient fixation between the operation table and the X-ray apparatus.

Osteomyelitis: A rare complication of pancreatitis and PPP-syndrome.

Pancreatic diseases can be accompanied by periarthritis with bone necrosis and panniculitis (PPP-syndrome). It is postulated that this is caused by systemic activity of pancreatic enzymes leading to microcirculatory disturbances and fat necrosis. The morbidity and mortality of the PPP-syndrome is high. Successful treatment of pancreatitis can lead to resolution of accompanying panniculitis and periarthritis without adverse sequelae, but weeks or months after pancreatitis, asymptomatic necrosis of the bone may become symptomatic by fracturing spontaneously. In this report, we also describe osteomyelitis as a severe septic complication of bone necrosis caused by pancreatitis, in one case as acute tissue necrosis and in another case months after pancreatitis spread haematogenously.

Arthroscopically assisted reduction and internal fixation of a femoral anterior cruciate ligament osteochondral avulsion fracture in a 14-year-old girl via transphyseal inside-out technique.

Femoral avulsion fracture of the anterior cruciate ligament (ACL) in children and adolescents is rare, and its arthroscopic treatment is even more so. A femoral avulsion fracture of the ACL of a 14-year-old girl was arthroscopically reduced and fixed by a Kirschner wire (K-wire) via an inside-out technique. A 1.4-mm K-wire was drilled inside-out into the osseous defect of the lateral femoral condyle under arthroscopic visualization. The avulsed fragment was reduced and then drilled retrograde by the wire. After bending the intra-articular visible end of the K-wire by a knot pusher, the fragment was gently fixed by pulling the wire from outside. At 24 months, both knee stability and range of motion were the same in the operated and the healthy opposite leg. Magnetic resonance imaging evaluation and conventional radiographs showed an intact ACL without detectable disturbance in the growth plate. Only seven cases of a proximal avulsion of the ACL in children and adolescents have been published. Six were treated by open reduction and internal fixation, one by arthroscopic reduction without fixation.

Postoperative functional rehabilitation after repair of quadriceps tendon ruptures: a comparison of two different protocols.

PURPOSE: Early functional rehabilitation after surgical tendon repair facilitates the healing process and leads to improved joint function. There is a paucity of studies commenting on rehabilitation after surgical repair of ruptured quadriceps tendons, and most surgeons prefer a prolonged period of immobilization and protected weight bearing. The purpose of the present study is to compare the clinical outcome after a more functional and after a rather restrictive postoperative rehabilitation protocol. METHODS: All consecutive patients were included who had a surgical repair of a primary unilateral quadriceps tendon rupture in one of the two participating hospitals and a minimum follow-up of 24 months. Patients of site A were only allowed limited flexion and weight bearing while patients from site B were allowed early functional rehabilitation with full weight bearing. Clinical outcome was measured with the subjective IKDC form. Fisher's exact test and Mann-Whitney U test were used for statistical analysis. RESULTS: Sixty-six patients were included in the study. Twenty-eight patients (Group A) were treated with restrictive and 38 patients (Group B) with early functional postoperative rehabilitation. The two groups did not differ in terms of demographic characteristics. Clinical follow-up was available for 95% of patients after an average of 4.5 years. No clinical difference was identified with the use of IKDC form. Patients of group A returned to work an average of 10 days later than patients from group B, but this difference was not significant. Two re-ruptures were observed in each group. There was no significant difference in terms of complication quality or quantity. CONCLUSION: Early functional postoperative mobilization with full weight bearing after primary repair of a quadriceps tendon rupture is safe and will not lead to inferior clinical outcome or an increased complication rate. LEVEL OF EVIDENCE: Therapeutic, III.

Aggressive surgical treatment of periprosthetic femur fractures can reduce mortality: comparison of open reduction and internal fixation versus a modular prosthesis nail.

OBJECTIVES: The purpose of this study was to determine if immediate full weightbearing after surgical treatment for periprosthetic femur fractures can decrease perioperative and total mortality. DESIGN: Retrospective review. SETTING: Level II trauma center. PATIENTS: Fifty-two consecutive patients with a periprosthetic femur fracture during a 16-year time period. INTERVENTION: Comparison of open reduction and internal fixation with a plate (non- or partial postoperative weightbearing) versus stem exchange to a modular prosthesis nail (immediate full postoperative weightbearing). MAIN OUTCOME MEASUREMENTS: Six-month and total mortality using a Kaplan-Meier survival analysis. An additional matched subanalysis was performed for Vancouver Type B1 fractures. RESULTS: Patients permitted immediate postoperative full weightbearing had a significantly decreased total (P < 0.001) and 6-month mortality (P = 0.007). Subanalysis of patients with Vancouver Type B1 fractures also showed decrease in mortality, which was significant for total (P < 0.005) but not for 6-month mortality (P = 0.121). CONCLUSION: Treatment of periprosthetic femur fractures with femoral component exchange to a modular prosthetic nail that allows immediate postoperative full weightbearing may decrease mortality.