Impact of subtrochanteric fractures in the geriatric population: better pre-fracture condition but poorer outcome than pertrochanteric fractures: evidence from the Spanish Hip Fracture Registry.

BACKGROUND: Clinical management in orthogeriatric units and outcome indicators are similar for extracapsular fragility hip fractures, without discriminating between subtrochanteric and pertrochanteric fractures. HYPOTHESIS: Geriatric patients, 75 years or older, with subtrochanteric fractures have worse clinical and functional outcomes than those with pertrochanteric fractures. MATERIALS AND METHODS: Retrospective observational study of data prospectively collected by the Spanish Hip Fracture Registry including patients 75 years or older, admitted for extracapsular hip fractures from January 2017 to June 2019. Demographic and baseline status, pre-operative, post-operative and 30-day follow-up data were included. RESULTS: A total of 13,939 patients with extracapsular hip fractures were registered: 12,199 (87.5%) pertrochanteric and 1740 (12.5%) subtrochanteric. At admission, patients with subtrochanteric fractures were younger (86.5 ± 5.8 versus 87.1 ± 5.6 years old), had better pre-fracture mobility (3.7 ± 2.7 versus 3.9 ± 2.8) (1-to-10 scale, 1 being independent) and were more likely to be living at home; those with pertrochanteric fractures had worse cognitive function (Pfeiffer 3.3 ± 3.3 versus 3.8 ± 3.5). The subtrochanteric fracture group showed worse post-fracture mobility (7.3 ± 2.7 versus 6.7 ± 2.7) and greater deterioration of mobility (3.7 ± 3.0 versus 2.9 ± 2.7). Among individuals living at home at baseline, those with subtrochanteric fractures were more likely to remain in an assisted facility at 30-day follow-up. In-hospital mortality during acute admission was higher for the subtrochanteric group (5.6% versus 4.5%) (p = 0.028). To our knowledge, this is the first paper highlighting the differences between these two fracture groups in the geriatric population. CONCLUSIONS: Subtrochanteric fractures in the older population are a different and worse entity, with greater morbimortality and functional decline than pertrochanteric fractures. Despite being younger and fitter at admission, older patients with subtrochanteric fractures have a higher risk of remaining non-weight bearing and undergoing re-operation and institutionalization. Orthogeriatric units should be aware of this and manage subtrochanteric fractures accordingly. LEVEL OF EVIDENCE: IV.

Does an early mobilization and immediate home-based self-therapy exercise program displace proximal humeral fractures in conservative treatment? Observational study.

BACKGROUND: Nonoperative management of proximal humeral fractures (PHFs) is the most common treatment, but its functional outcome may improve with early mobilization. In frail osteoporotic patients, quick recovery of prefracture independency is mandatory. This study assessed fracture displacement in PHFs managed with conservative treatment after early mobilization and a home-based self-exercise program. METHODS: We retrospectively analyzed the radiologic displacement of fracture fragments of PHFs treated conservatively with early mobilization and a home-based self-exercise program. RESULTS: Included were 99 patients with 26 one-part, 32 two-part, 32 three-part, and 9 four-part PHFs managed conservatively, followed by early mobilization and a home-based self-exercise program. In the x-ray examinations, the head displaced from varus into valgus 55° ± 23° to 42° ± 22°, in the normal range of anatomic values. The medial hinge displaced from medial to the diaphysis (+1 ± 6 mm) to lateral to the head (-0.6 ± 6 mm). The greater tuberosity displaced cranially from -1 ± 7 mm to 2 ± 5 mm. The Constant score at the 1-year follow-up was 79.69 ± 16.3. DISCUSSION AND CONCLUSIONS: The home-based self-exercise program for conservative treatment of PHFs displaces the head-diaphysis angle and the medial hinge toward anatomic reduction, but there is a risk of greater tuberosity cranial displacement. Functional results are fairly good, allowing frail patients to keep on with their independency and life style. Because a large number of patients might need further physiotherapy, the quality of the home-based self-exercises should be supervised.

Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession.

PURPOSE: The purpose of this study was to compare results of partial proximal fasciotomy (PPF) with proximal medial gastrocnemius release (PMGR) in the treatment of chronic plantar fasciitis (CPF). METHOD: This retrospective study compares 30 patients with CPF that underwent PPF with 30 that underwent isolated PMGR. Both groups were matched in terms of previous treatments and time from onset of symptoms to surgery. Different standardised evaluation scales (VAS, Likert, AOFASh) were used to evaluate results. RESULTS: Plantar fasciotomy had satisfactory results in just 60 % of patients, with an average ten weeks needed to resume work and sports. Patient satisfaction in the PMGR group reached 95 %, being back to work and sports at three weeks on average. Functional and pain scores were considerably better for PMGR and fewer complications registered. CONCLUSION: In our series, isolated PMGR is a simple and reliable procedure to treat patients with CPF. It provides far better results than conventional fasciotomy with less morbidity and better patient satisfaction, and thus has become our surgical procedure of choice in recalcitrant CPF.

Prevalence of sarcopenia in patients older than 75 years admitted for hip fracture.

BACKGROUND: Hip fracture in the population aged 75 years and older is one of the most disabling pathologies. Likewise, disease related malnutrition (DRM) and sarcopenia are two frequent diagnoses in this age group, whose prevalence may be increased in patients with hip fracture. AIMS: To determine the prevalence of malnutrition and/or sarcopenia in patients admitted for hip fracture and evaluate the existence of malnutrition related to disease and sarcopenia, and the differences between the sarcopenic and non-sarcopenic group. METHODS: 186 patients aged 75 years or over, hospitalised for hip fracture from March 2018 to June 2019 were included. Demographic, nutritional and biochemical variables were collected. Nutritional screening was carried out with the Mini-Nutritional Assessment (MNA), the presence of DRM was established with The Global Leadership Initiative on Malnutrition (GLIM) criteria. For sarcopenia screening, the Strength, Assistance with walking, Rising from a chair, Climbing stairs and Falls (SARC-F) was used and the diagnosis of sarcopenia was made using the criteria from the European Working Group on Sarcopenia in Older People (EWGSOP) reviewed in 2019 (EWGSOP2). Muscle strength was determined by hand-grip strength, body composition by measurement of bioelectrical impedance. RESULTS: The mean age was 86.2 years, most of the patients were women (81.7%). 37.1% of patients were at nutritional risk (MNA 17-23.5) and 16.7% were malnourished (MNA < 17). 72.4% of women and 79.4% of men, were diagnosed with DRM. 77.6% of the women and 73.5% of the men had low muscle strength. The appendicular muscle mass index was below the cut-off points for sarcopenia in 72.4% of the women and 79.4% of the men. Patients with sarcopenia had a lower body mass index, older age, poorer previous functional status and higher disease burden. The relationship between weight loss and hand grip strength (HGS) was significant (p = 0.007). CONCLUSIONS: 53.8% of patients admitted for hip fracture present malnutrition or are at risk after screening with MNA. Sarcopenia and DRM affects at least three out of four patients older than 75 years admitted for hip fracture. Older age, worse functional status, lower body mass index and high number of comorbidities, are associated with these two entities. There is a relationship between DRM and sarcopenia.

AO/OTA type C3 distal humeral fractures in patients aged 75 years and older: Is ORIF with double precontoured anatomical locking plates a reliable treatment?

INTRODUCTION: The incidence of osteoporotic distal humeral fractures (DHF) is on the rise. Their operative management is demanding. Fixation with non-locking reconstruction plates was associate with a high number of complications. Elbow arthroplasty (total or hemi) has been proposed as an alternative treatment, in spite of lifetime activity restrictions, and risk of complications, unknown implant survival and problematic revision surgery. Precontoured anatomical locking plates have increased the strength of the fixation in complex fractures. HYPOTHESIS: double plating ORIF with precontoured anatomical locking plates is a safe and reliable treatment option for the management of AO/OTA type C3 DHF in patients aged 75 and older. PATIENTS AND METHODS: A retrospective case series study of patients aged 75 years old and older with an AO/OTA type C3 DHF treated with ORIF with double precontoured anatomical locking plates between 2007 and 2021. Pathologic fractures were excluded. Patients' demographic, surgical, clinical, and radiological data were reviewed. RESULTS: A total of 27 women and 3 men, mean age of 80.1 years (range 75-93 years), were included. Mean Charlson index was 5 (range 3-8). Out of 30 patients, 19 had already died. Mean survival time after the surgical treatment was 72.3 months. Mean Mayo elbow performance score was 88.9 (range 60-100); 23 patients scored excellent or good. All fractures healed with no cases of delay union or non-union, hardware failure or loss of reduction. No patient needed a revision surgery to arthroplasty. The total number of complications was 12 (40%), mainly ulnar neuropathy (5) and cerclage removal (4). CONCLUSION: ORIF with double pre-contoured locking plates may be a safe and reliable treatment for type C3 DHF in patients aged 75 years and older, with a good functional outcome. Complications are expected but not related to loss of reduction, fixation failure or revision to elbow arthroplasty.

MIPO helical pre-contoured plates in diaphyseal humeral fractures with proximal extension. Surgical technique and results.

INTRODUCTION: The aim of this study was to determine the feasibility of applying the MIPO technique with a helical-shaped plate in the treatment of humeral shaft fractures with proximal extension. PATIENTS AND METHODS: We present an observational prospective study of patients with a humeral shaft fracture involving the proximal humerus fixed with a long proximal humerus polyaxial locking plate with an anterior curvature and helical shape (ALPS® Zimmerbiomet, Warsaw, Indianapolis, USA), using a MIPO technique. Between January 2017 and July 2020, 15 patients were treated at our institution. Proximally a 4-5 cm anterolateral transdeltoid approach was made. And distally, a 5-7 cm incision was made 4 cm proximal to the elbow crease. At each follow-up, radiographs were taken to evaluate fracture healing. Funtional scales were applied to evaluate clinical results. RESULTS: Ten women and five men were included, with a mean age of 62 yo (range 26-86). All but one fracture healed uneventfully. The mean time to union was 28 weeks (range 12-48 weeks). Two out of 15 patients presented complications (an atrophic nonunion and a peri­implant distal fracture). None of the patients had a nerve palsy prior neither after the surgery. No other complications, including infection, were registered during follow-up. Shoulder range of motion showed the following means: abduction of 147° (range 50°-180°), anterior flexion of 144° (range 80°-180°), external rotation of 77,5 ° (range 70°-80°) and internal rotation of 54.5° (range 45°-60°). All patients recovered their pre-fracture elbow range of motion. All patients presented less than 10° of angular deviation in varus/valgus or ante/recurvatum after the surgical procedure. At the end of the follow-up, all final functional scores were "good" or "excellent": mean Constant-Murley score was 72 ± 13 (range 38-91), ASES score was 73 ± 12 (range 41-88), UCLA shoulder scale was 30 ± 3,5 (range 10-35), and Q-DASH score was 16.5 ± 0,11 (range 4-57). CONCLUSION: When applied correctly, the treatment of diaphyseal humeral fractures involving the proximal humerus using a polyaxial locking helical plate with a MIPO technique is a reliable treatment method. It has high union rates with low complications.

Patient Satisfaction Using a Home-Based Rehabilitation Protocol for the Non-Surgical Treatment of Proximal Humeral Fractures: A Prospective Longitudinal Cohort Study.

Supervised, center-based, daily physiotherapy presents limitations: transport, need for an accompanying person, or risk of infection. Home-based rehabilitation protocols (HBRP) can be effective alternatives. We use a HBRP for the non-surgically treated proximal humeral fractures (PHF) in older patients. OBJECTIVES: To assess patient satisfaction and preferences of using a booklet, videos, or an app to guide physiotherapy. PATIENTS AND METHODS: Prospective, single-center observational study of patients ≥55 years old who sustained a non-surgically treated PHF. The HBRP consisted of immediate mobilization, followed by 5 physiotherapist-guided, weekly sessions of rehabilitation and standard physiotherapy after 3 months, if needed. A booklet with images, videos, or a smartphone application were offered to guide the patients. RESULTS: Mean degree of satisfaction (1-5) was 4.66 ± .9: 84 patients (82.4%) were very satisfied, 11 patients (10.8%) were satisfied, and 5 patients (4.9%) were not satisfied at all. Mean Oxford Shoulder Score achieved was 40.5 ± 6.6. 59.8% patients preferred the booklet and 29.4% the videos. Exercise compliance was considered very high in 87.3% of patients, while 4% hardly never followed the HBRP. Only 17.7% patients needed center-based physiotherapy after the HBRP. DISCUSSION: Reasons for satisfaction were good final functional outcome, no need for transportation, being away from hospital, immediate rehabilitation availability and being capable of maintaining independence. Adherence is a major concern. Videos are more didactic explaining the exercises. CONCLUSION: If standard physiotherapy is not available, the HBRP can be a valid treatment option for PHF management in older patients, with a high degree of patient satisfaction. Older patients preferred the booklet to guide physiotherapy.