Continuous improvement process: ortho-geriatric co-management of proximal femoral fractures.

OBJECTIVE: The objective of the current study was to evaluate the effect of a quality management system on treatment and care delivery of proximal femoral fractures. Specifically, our hypothesis was that the "plan-do-check-act (PDCA)" philosophy of the ISO 9001 quality management system results in a continuous improvement process. METHODS: 1015 proximal femoral fractures were prospectively included into a hip fracture database over a 5-year period, after a restructuring process with implementation of clinical pathways and standard operation procedures. A close and structured ortho-geriatric co-management (certified ortho-geriatric center) was the basis for treatment. ISO 9001 certification was granted for the first time in 2012. Procedural and patient outcome parameters were analyzed by year and evaluated statistically using SPSS 25.0. RESULTS: In both categories (procedural and outcome) significant changes could be detected during the 5-year period, e.g., significant reduction of time to surgery for the first 2 years, improvement in discharge management, and reduction of surgical complications. However, no significant changes could be demonstrated for mortality or internal complications such as pneumonia, urinary tract infections, or postoperative delirium. However, the incidence of the latter was already on a very low level at the onset of the quality improvement process. CONCLUSION: We could show a relevant and continuous improvement of several quality indicators during a 5-year period after implementation of a quality management system based on the PDCA philosophy for the treatment of proximal femoral fractures in elderly patients. However, other parameters (internal complications, cost-effectiveness, etc.) need our close attention in the future.

Bionic plate design for calcaneal fracture treatment. A biomechanical analysis and first clinical results.

PURPOSE: Calcaneal fracture treatment is challenging. Implant failure is one problem encountered with plate osteosynthesis. Therefore a new "bionic" plate was developed, which imitates the trabecular orientation of the human calcaneus. The aim of this study was to biomechanically test this new plate in comparison to a "standard" calcaneal locking plate and present the first clinical results. METHODS: Six "bionic" and six "standard" calcaneal plates were biomechanically tested for stability and fatigue using synthetic calcanei. Between 4/2012 and 04/2013 the first ten consecutive patients meeting the inclusion criteria were treated with the novel implant and followed-up clinically and radiologically. The 12-month follow-up results are reported. RESULTS: The "bionic" plate design showed significantly higher fatigue life (68%), load to failure (100%) and reduced displacement under load (90%) if compared to a "standard" locking plate. No major complications were seen; most notably there was no implant failure and no loss of reduction. Mean AOFAS/hindfoot score was 79 (69-86). CONCLUSIONS: The novel plate architecture offers higher stability and load tolerance while being more resistant to fatigue. The preliminary clinical results are promising. These findings will have to be proved by larger clinical trials.

Temperature profile of radiofrequency probe application in wrist arthroscopy: monopolar versus bipolar.

PURPOSE: The purpose of this study was to investigate the changes in temperature during wrist arthroscopy comparing monopolar and bipolar radiofrequency energy (RFE). METHODS: A standard wrist arthroscopy was performed on 14 arms of 7 cadavers without irrigation or with continuous irrigation with 0.9% saline solution and gravity-assisted outflow through an 18-gauge needle. We treated 7 wrists with a bipolar device (VAPR II with 2.3-mm side effect electrodes; DePuy Mitek, Westwood, MA) and 7 wrists with a monopolar device (OPES Ablator for small joints, 45°; Arthrex, Naples, FL). The temperature was recorded simultaneously from 7 predefined anatomic landmarks. RESULTS: We observed an increase in the temperature corresponding to the time of energy application. The highest measured peak temperatures were 52°C (monopolar) and 49.5°C (bipolar) without irrigation. Continuous irrigation led to a significant reduction in the temperature at the site of the energy application. The mean temperature decreased by 7°C for the monopolar system and 5°C for the bipolar system when irrigation was used. For both radiofrequency devices, we found a decrease in the temperature proportional to the distance of the sensors to the radiofrequency probe. CONCLUSIONS: Monopolar and bipolar RFE can be safely used in wrist arthroscopy if a continuous irrigation system is applied and the energy impulse does not exceed 5 to 10 seconds. However, it should be used with great care to avoid local heat damage especially at the cartilage. CLINICAL RELEVANCE: This basic science study was performed to gain data concerning the temperature in wrist arthroscopy and to broaden the knowledge about the risks when using RFE. Furthermore, we sought to control side effects of RFE by finding the best applied form of RFE regarding duration and pulsation (monopolar/bipolar).

Midterm results after modified Epping procedure for trapeziometacarpal osteoarthritis.

BACKGROUND AND PURPOSE: Various surgical procedures have been proposed for the treatment of trapeziometacarpal joint (TMJ) osteoarthritis. Despite an overall satisfactory outcome in most cases, some patients complain about inadequate performance at work, due to instability of the TMJ. We present a cross-sectional study of patients with TMJ arthritis who underwent a modified Epping procedure for increased TMJ stability. METHODS: 71 patients underwent a modified Epping procedure with a flexor carpi radialis tendon sling stabilizer. 59 patients were followed up after a mean time of 38 months. Residual pain was evaluated by visual analog scale. Functional outcome was quantified by pinch and grip strength, static two-point discrimination test, as well as DASH outcome scoring. Quality of life measures included patients' perceived satisfaction, activities of daily living (ADL), grip/pinch force and manual performance at work. RESULTS: 85 % of the patients regained full or partial manual performance during labor. Strength and ADL improved or remained the same in 81 %. In cases of a unilateral treatment, no difference in grip between the operated and nonoperated hand was observed. Mean tip pinch strength was 2.8 kg for the operated and 3.6 kg for the nonoperated hand. Mean pain level during rest was 0.98, 0.95 during mild activity, and 3.70 during strenuous activity. Mean DASH score was 26.6. CONCLUSION: The great majority of patients who underwent this novel procedure benefited from an unaffected or improved work performance, due to good TMJ stability combined with adequate motion for ADL. Less favorable results were seen in patients with accompanying hand pathologies.

Outcome after complex trauma of the foot.

BACKGROUND: In 1997, H. Zwipp. proposed a 5-point scoring system for the classification of complex trauma of the foot. However, outcome and quality of life after this type of injury have not been studied systematically. PATIENTS: Seventy-four patients with a complex injury of the foot were treated between 2001 and 2007. Fifty patients met the inclusion criteria for a prospective cross-sectional study. American Foot and Ankle Society score, the Short Form 12, and the Visual Analogue Scale-Foot and Ankle Score were recorded. All patients were examined by an experienced orthopedic surgeon and a certified pedorthist. Functional assessment was completed by dynamic baropedography. RESULTS: Primary amputation was necessary in 11, secondary amputation in 7 patients. A compartment syndrome was diagnosed in 29 patients. Soft tissue coverage was achieved in eight patients using a free vascular flap. The complication rate was 32%. Mean follow-up was 4 years (1-7 years). At that time, the American Foot and Ankle Society score was 66.2, the Short Form 12 score 38.2 (physical health component scale), and the Visual Analogue Scale-Foot and Ankle score was 51.9. Orthopedic shoes were necessary in 44% of the patients; however, compliance was low, and 52% of the orthopedic devices were insufficient. Pedographic evaluation demonstrated changes in gait in 82% of the patients. CONCLUSION: Early outcome after complex trauma of the foot was essentially determined by soft tissue injury, whereas long-term outcome was determined more by the trauma of the bones and joints. Objective measurements such as dynamic pedography helped to better understand patients' limitations. Orthotic supply could be improved in a reasonable number of the patients.

How reliable are CT scans for the evaluation of calcaneal fractures?

INTRODUCTION: CT scans are deemed to be the gold standard for the evaluation of calcaneal fractures. However, the reliability of the interpretation has not been studied systematically. PATIENTS AND METHODS: In a prospective multicenter study, the CT data set of five different fractures was presented to 57 evaluators. The participating surgeons were asked to assess calcaneal fractures on the basis of a multiple choice questionnaire. The CT scans were validated by the intraoperative findings. The questionnaires were compared to the model solution of three foot and ankle surgeons. The intra- and interrater reliability was calculated. RESULTS: The proportion of intraobserver agreement was 82%. Cohen's kappa was κ = 0.748 with P < 0.0001. In total, 61% of the items were answered similarly to the model answer. Only 27% of the evaluators were able to correctly classify the fracture according to Sanders and 63% of the evaluators agreed that surgical procedure was necessary. The more experienced the surgeon, the higher was the interrater agreement. CONCLUSION: This is the first study to systematically analyze the reliability of the interpretation of CT scans of calcaneal fractures. This was found to be unsatisfactory. Future studies must show, if specific interventions, e.g., teaching programs or image procession modalities (e.g., 3D reconstructions), are capable of improving the quality of interpretation of CT scans for calcaneal fractures.

Calcaneocuboid joint involvement in calcaneal fractures.

BACKGROUND: The reported incidence of calcaneocuboid joint (CCJ) involvement in calcaneal fractures varies considerably. It is largely unknown to what extent CCJ involvement accounts for outcome in these fractures. Therefore, the goal of this study was to analyze the incidence and effects of CCJ involvement in calcaneal fractures. METHODS: The clinical records of 106 patients, treated between 2000 and 2004, were reviewed for fracture classification, injury mechanism, surgical treatment, and complications. In a prospective cross-sectional study, 44 patients were assessed clinically (SF-36 American Orthopaedic Foot and Ankle Society score) and radiographically. Gait analysis was performed using dynamic pedography. RESULTS: Sixty-eight percent of all fractures had involvement of the CCJ. Fractures with CCJ involvement were caused by a more severe injury than fractures without CCJ involvement (Mann-Whitney U test, p = 0.03); this is reflected by a strong association between CCJ involvement and fracture classification (Spearman, p < 0.006). Patients with involvement of the CCJ-especially those with a postoperative step in the CCJ-achieved a lower SF-36 score as well as a lower American Orthopaedic Foot and Ankle Society score than patients without CCJ involvement. CCJ involvement was associated with more difficulties in walking on rough surface (Spearman, p = 0.020). Limitations during gait were confirmed by dynamic pedography. Grading of posttraumatic osteoarthritis was associated with fracture classification (chi test p < 0.02) and quality of reduction (chi test p < 0.01). CONCLUSIONS: These results indicate that calcaneal fractures with involvement of the CCJ are associated with more severe trauma and worse outcome. Thus, the CCJ should be given more credit during surgery and in our research efforts.

Clinical pathways for geriatric patients with proximal femoral fracture improve process and outcome.

OBJECTIVE: The objective of the current study was to evaluate the implementation of clinical pathways (CPs) in hip fracture management. METHODS: Six hundred and five proximal femoral fractures were prospectively included into a hospital data-base. The effects of CPs were evaluated using a pre-during-post design. Different procedural (time to surgery, length of stay, discharge, etc.) and patient outcome parameters (mortality, complications, etc.) were evaluated. RESULTS: In both categories significant changes could be detected during the three-year period. E.g. significant reduction of time to surgery, improvement of discharge management, reduction of internal complications. However, no significant changes could be demonstrated for mortality or revision rate. CONCLUSION: We could show a relevant improvement with the implementation of clinical pathways for the treatment of proximal femoral fractures in elderly patients. LEVEL OF EVIDENCE: III, prospective non-randomised cohort study.

Comparative analysis of non-simultaneous bilateral fractures of the proximal femur.

PURPOSE: We performed a monocenter cohort study to determine surgical revision and mortality after sustaining an initial and a non-simultaneous contralateral proximal femoral fracture. METHODS: We identified all patients surgically treated for a contralateral femoral fracture between 2006 and 2015. Patient demographic characteristics and follow-up were identified by our electronic database; failed information regarding revision and mortality were obtained by telephone, as well as the evaluation of the mobility for all alive patients. The endpoint of the study was set for every patient at least 2 years postoperatively. RESULTS: Within a total of 2296 patients, we identified 250 patients (10.8%) treated for a contralateral fracture. The mean interval between the two occurrences was 5.2 years and the mean age at the time of contralateral fracture was 84.4 years. Almost every third fracture occurred later than 5 years after the initial fracture, and even every tenth fracture later than 10 years. More than 50% of the patients also had dementia at this time. The total surgical revision rate was 17.2% after initial, and 20.4% after contralateral fracture, but this difference was statistically not significant (p = 0.31). However, revisions for infection or hematoma were more than twice after contralateral fracture (p = 0.006). The 1-year mortality rate was 36%, and dementia (log rank p < 0.001) and male gender (log rank p < 0.001) were significant negative predictors for the survival rate. After a mean of 42 months, the follow-up of the 67 alive patients recorded a mean Parker Score of 5.2 items. CONCLUSION: Contralateral femoral fracture was accompanied by a higher revision and mortality rate-but patients were also 5 years older. Dementia and male gender were significant negative variables for the survival time. In the future, the highest priority will be the prophylaxis of falling to avoid or at least to decline the number of these fractures in geriatric patients.

Latest Evidence on the Impact of Smoking, Sports, and Sexual Activity as Modifiable Lifestyle Risk Factors for Prostate Cancer Incidence, Recurrence, and Progression: A Systematic Review of the Literature by the European Association of Urology Section of Oncological Urology (ESOU).

CONTEXT: Smoking, sexual activity, and physical activity (PA) are discussed as modifiable lifestyle factors associated with prostate cancer (PCa) development and progression. OBJECTIVE: To evaluate the available evidence concerning the association of smoking, sexual activity, and sports and exercise on PCa risk, treatment outcome, progression, and cancer-specific mortality. EVIDENCE ACQUISITION: A systematic review of studies published between 2007 and 2017 using MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials, and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement criteria was conducted. EVIDENCE SYNTHESIS: While data concerning the impact of smoking on PCa development remain conflicting, there is robust evidence that smoking is associated with aggressive tumor features and worse cancer-related outcome, which seems to be maintained for 10 yr after smoking cessation. Less convincing and limited evidence exists for the association of sexual activity with PCa risk. The findings related to PA and PCa support the inference that exercise might be a useful factor in the prevention of PCa and tumor progression, while it is not finally proved under which specific conditions PA might be protective against disease development. CONCLUSIONS: Smoking is associated with aggressive tumor features and worse cancer-related prognosis; as this negative impact seems to be maintained for 10yr after smoking cessation, urologists should advise men to quit smoking latest at PCa diagnosis to improve their prognosis. As several studies indicate a positive impact of exercise on tumor development, progression, and treatment outcome, it is certainly reasonable to advocate an active lifestyle. Least convincing evidence is available for the interaction of sexual activity and PCa, and well-conducted and longitudinal studies are clearly necessary to evaluate whether the suggested associations between PCa risk and sexual behavior are real or spurious. PATIENT SUMMARY: In this systematic review, we looked at the impact of smoking, sexual activity, and sports and exercise on prostate cancer risk and outcome after treatment. While the evidence for sexual activity is not overall clear, we found that smoking might lead to more aggressive cancers and result in worse treatment outcome. Physical activity might prevent prostate cancer and improve cancer-related outcomes as well. Hence, it is certainly reasonable to advocate an active lifestyle and advise men to quit smoking.

Infection Versus Hematoma Following Surgical Treatment of Proximal Femoral Fractures in Geriatric Patients.

INTRODUCTION: The surgical treatment of proximal femoral fractures predominantly involves geriatric patients and is associated with high morbidity and mortality. However, analyses on postoperative infections or hematoma are rare. METHODS: Patients requiring surgical revision due to infection (n = 90) or hematoma (n = 77) in the postoperative phase were identified from an electronic database of 2000 consecutive patients surgically treated for proximal femoral fractures between 2006 and 2014. Demographic and clinical data were retrieved, including information on the pathogens in patients with infection. A follow-up on morbidity and mortality was conducted via telephone for at least 2 years postsurgery. RESULTS: The follow-up rate was 100%, and the mean age was 81.9 years. The incidence rate of infection was 4.1% (90/2000), and women were commonly affected. Staphylococcus aureus and Staphylococcus epidermidis were the most commonly detected pathogens (35.5% and 25.5%, respectively). Mixed infections were observed in 15 patients, and Methicillin-resistant Staphylococcus aureus infections were observed in only 4 patients. A total of 77 (85.6%) infections occurred within 30 days postsurgery. The implant was preserved in 76 (84.4%) patients, and resection arthroplasty was required in 14 patients. Dementia and pertrochanteric fractures were significantly more common in the infection than in the hematoma group. Although infections were associated with high mortality rates for up to 2 years postsurgery, the rates did not significantly differ from those in the hematoma control group. CONCLUSION: One of every 2 patients who developed an infection following the surgical treatment of a proximal femoral fracture died within 2 years postsurgery. In addition, infections were significantly associated with dementia. Avoiding postoperative infection should be a high priority in the surgical treatment of proximal femoral fractures.

Psychological factors as risk factors for poor hip function after total hip arthroplasty.

Recovery after total hip arthroplasty (THA) is influenced by several psychological aspects, such as depression, anxiety, resilience, and personality traits. We hypothesized that preoperative depression impedes early functional outcome after THA (primary outcome measure). Additional objectives were perioperative changes in the psychological status and their influence on perioperative outcome. This observational study analyzed depression, anxiety, resilience, and personality traits in 50 patients after primary unilateral THA. Hip functionality was measured by means of the Harris Hip Score. Depression, state anxiety, and resilience were evaluated preoperatively as well as 1 and 5 weeks postoperatively. Trait anxiety and personality traits were measured once preoperatively. Patients with low depression and anxiety levels had significantly better outcomes with respect to early hip functionality. Resilience and personality traits did not relate to hip functionality. Depression and state anxiety levels significantly decreased within the 5-week stay in the acute and rehabilitation clinic, whereas resilience remained at the same level. Our study suggests that low depression and anxiety levels are positively related to early functionality after THA. Therefore, perioperative measurements of these factors seem to be useful to provide the best support for patients with risk factors.

Value of 3D Reconstructions of CT Scans for Calcaneal Fracture Assessment.

BACKGROUND: The interpretation of CT scans for the evaluation of calcaneal fractures is difficult. Three-dimensional (3D) reconstruction (volume rendering technique [VRT]) has been valuable in the evaluation of irregularly shaped bones. However, their value for the analysis of calcaneal fractures is still debated. Therefore, the objective of this study was to assess the effect of additional use of 3D CTs in calcaneal fractures. METHODS: In a prospective multicenter study, the CT data set of 5 different fractures was presented to 57 evaluators. First, the participating surgeons were asked to assess the fractures on the basis of axial, coronal, and sagittal reconstructions using a multiple-choice questionnaire. Second, 3D reconstructions (VRT) were presented. The CT scans were validated by the intraoperative findings and the results were compared to the model solution of 3 foot and ankle surgeons. Intra- and interrater reliabilities were calculated. RESULTS: The proportion of intraobserver agreement was 82%, with Cohen kappa of κ = 0.748 (P < .001). Interrater agreement varied between 0.772 (P = .006) for the assessment of concomitant fractures and 0.987 (P < .001) for the suggested approach. The evaluation of several items improved after presentation of the 3D CTs (Cochrane Q test, P < .001). The benefit of 3D imaging was higher in inexperienced surgeons and complex fractures (Friedman test P < .001). CONCLUSION: The evaluation of CT scans of calcaneal fractures was improved by the additional use of 3D images (VRT). LEVEL OF EVIDENCE: Level II, prospective comparative study.

Influence of the growth factors PDGF-BB, TGF-beta1 and bFGF on the replicative aging of human articular chondrocytes during in vitro expansion.

Decreasing replicative potential and dedifferentiation of articular chondrocytes during expansion in cell culture are essential limitations for tissue engineering and cell therapy approaches. Telomeres and telomerase play a key role in cell development, aging, and tumorigenesis. There is evidence that growth factors are involved in regulating telomerase activity. Therefore, the objective was to evaluate the effect of selected growth factors on telomere biology of serially passaged chondrocytes. Human articular chondrocytes were isolated from cartilage of three patients undergoing total knee arthroplasty. The chondrocytes were cultured in monolayer with the growth factors PDGF-BB, TGF-beta1, and bFGF. Telomere length was measured by telomere restriction fragment length assay, and telomerase activity was determined by quantifying the gene expression of its catalytic subunit hTERT by rtPCR. Chondrocytes cultured with PDGF-BB and TGF-beta1 showed a significantly higher proliferation rate than control cells. None of the growth factor cultures revealed an accelerated rate of telomere shortening. Telomerase was not expressed in significant amounts in any of the chondrocyte cultures. Growth factor treatment of chondrocyte cell cultures for cell therapy purposes can be regarded as safe in terms of telomere biology.

The use of 'fasciocutaneous' and 'osteofasciocutaneous' parascapular flaps for lower limb reconstruction: a retrospective study of 20 patients.

BACKGROUND: The parascapular flap is a widely accepted and suitable option for covering defects in almost all anatomical areas. Here, we report our experience with the microvascular transfer of parascapular flaps for the coverage of large lower leg defects with reference to our retrospective study. PATIENTS AND METHODS: Twenty patients with free parascapular flaps (17 male, three female, age: 43+/-17 years, BMI 26.1+/-3.5) were examined 3 months to 3 years after free tissue transfer. All procedures and examinations were performed by the same experienced surgeon (2002-2005). Flap dimensions ranged from 8 x 4 cm to 30 x 13 cm, with an average of 20.4+/-6.6 cm x 8.9+/-2.6 cm. The parameters studied included perioperative morbidity, donor site morbidity, flap vitality, complications, functional shoulder tests, patient satisfaction (visual analog scale, VAS), the duration of the hospital stay and the long-term outcome. RESULTS: All of the 20 flaps remained vital. Adequate coverage and complete healing were obtained in all patients during the follow-up period and all patients were physically mobile. General patient satisfaction with the intervention was high (VAS: median 7.5; x(25)=6.0; x(75)=9.5); donor site morbidity was low, that is, only one patient presented with reduced range of motion and shoulder function compared to the preoperative status. The hospital stay after flap transfer was 20.8+/-9.8 days and the overall hospital stay was 32.1+/-15.0 days. CONCLUSIONS: Our study confirms that the parascapular flap is a very versatile and safe flap for lower limb reconstruction with low donor morbidity.

Functional donor-site morbidity following (osteo-) fasciocutaneous parascapular flap transfer.

PROBLEM: The parascapular flap is extremely versatile in the armamentarium of the plastic surgeon. However, little is known about the donor-site morbidity. Our purpose was to investigate limitations and problems arising at the donor site of parascapular flaps. METHODS: Twenty patients with free parascapular flaps were followed up over a period of 3 years. Donor-site morbidity was evaluated using standardized evaluation forms. Constant score was calculated to judge shoulder function, SF-36 score was used to evaluate patient satisfaction. RESULTS: All flaps survived in our series. In 2 patients, delayed wound healing was recorded at the donor site. In 3 patients, shoulder function was limited. In 1 patient, the brachial plexus was affected, and another had preexisting rotator cuff disease. Scar dimensions varied considerably; however, cosmetic aspects of the donor site were not a complaint. DISCUSSION: This is the first report evaluating donor-site morbidity of parascapular flaps. Limitations in shoulder function are low if correct operative technique with refixation of the musculature is maintained. In general, patients did not have any complaints about the cosmetic appearance of the donor site.