Validation of the Geriatrics at Risk Score (GeRi-Score) on 120-day follow-up, the influence of preoperative geriatric visits, and the time to surgery on the outcome of hip fracture patients: an analysis from the Registry for Geriatric Trauma (ATR-DGU).

A validation of the GeRi-Score on 120-day mortality, the impact of a pre-operative visit by a geriatrician, and timing of surgery on the outcome was conducted. The score has predictive value for 120-day mortality. No advantage was found for surgery within 24 h or a preoperative geriatric visit. PURPOSE: Numerous tools predict mortality among patients with hip fractures, but they include many variables, require time-consuming assessment, and are difficult to calculate. The GeRi-Score provides a quick method of pre-operative assessment. The aim of this study is to validate the score in the 120-day follow-up and determine the impact of a pre-operative visit by a geriatrician and timing of surgery on the patient outcome. METHODS: A retrospective analysis of the AltersTraumaRegister DGU® from 2017 to 2021 was conducted, including all proximal femur fractures. The patients were divided into low-, moderate-, and high-risk groups based on the GeRi-Score. Mortality was analyzed using logistic regression. To determine the influence of the time to surgery and the preoperative visit by a geriatrician, matching was performed using the exact GeRi-Score, preoperative walking ability, type of fracture, and the time to surgery. RESULTS: The study included 38,570 patients, divided into 12,673 low-risk, 18,338 moderate-risk, and 7,559 high-risk patients. The moderate-risk group had three times the mortality risk of the low-risk group (OR 3.19 (95% CI 2.68-3.79; p<0.001)), while the high-risk group had almost eight times the mortality risk than the low-risk group (OR 7.82 (95% CI 6.51-9.93; p<0.001)). No advantage was found for surgery within the first 24 h across all groups. There was a correlation of a preoperative geriatric visit and mortality showing an increase in the moderate and high-risk group on in-house mortality. CONCLUSIONS: The GeRi-Score has predictive value for 120-day mortality. No advantage was found for surgery within 24 h. The analysis did not demonstrate a benefit of the preoperative geriatric visit, but more data are needed.

Knot holding capacity of two different high-strength sutures-a biomechanical analysis.

PURPOSE: The number of seven required throws per knot was previously reported as providing sufficient security against slippage. A novel high-strength suture featuring dynamic tightening may allow for throw number reduction without compromising stability. The aims of this study were to (1) investigate the influence of the throw number and the effect of different ambient conditions on the knot security of two different high-strength sutures, and (2) compare their biomechanical competence. METHODS: Two sutures (FiberWire (FW) and DynaCord (DC)) were considered for preparing alternating surgical knots. The specimens were stratified for exposure to different media during biomechanical testing-namely air (dry), saline solution (wet), and fat (fatty-wet). A monotonic tensile ramp loading to failure was applied in each test run. For each suture and ambient condition, seven specimens with three to seven throws each were tested (n = 7), evaluating their slippage and ultimate force to failure. The minimum number of throws preventing suture unraveling was determined for each suture type and condition. RESULTS: For each suture type and condition, failure occurred via rupture in all specimens for the following minimum number of throws: FW-dry-7, wet-7, fatty-wet-7; DC-dry-6, wet-4, fatty-wet-5. When applying seven throws, FW demonstrated significantly larger slippage (6.5 ± 2.2 mm) versus DC (3.5 ± 0.4 mm) in wet (p = 0.004) but not in dry and fatty-wet conditions (p ≥ 0.313). CONCLUSIONS: The lower number of throws providing knot security of DC versus FW in the more realistic wet and fatty-wet conditions indicates that the novel DC suture may allow to decrease the foreign body volume and save surgical time without compromising the biomechanical competence.

The Geriatrics at Risk Score (GeRi-Score) for mortality prediction in geriatric patients with proximal femur fracture - a development and validation study from the Registry for Geriatric Trauma (ATR-DGU).

This study developed an easy-to-use mortality prediction tool, which showed an acceptable discrimination and no significant lack of fit. The GeRi-Score was able to predict mortality and could distinguish between mild, moderate and high risk groups. Therefore, the GeRi-Score might have the potential to distribute the intensity of medical care. PURPOSE: Several mortality-predicting tools for hip fracture patients are available, but all consist of a high number of variables, require a time-consuming evaluation and/or are difficult to calculate. The aim of this study was to develop and validate an easy-to-use score, which depends mostly on routine data. METHODS: Patients from the Registry for Geriatric Trauma were divided into a development and a validation group. Logistic regression models were used to build a model for in-house mortality and to obtain a score. Candidate models were compared using Akaike information criteria (AIC) and likelihood ratio tests. The quality of the model was tested using the area under the curve (AUC) and the Hosmer-Lemeshow test. RESULTS: 38,570 patients were included, almost equal distributed to the development and to the validation dataset. The AUC was 0.727 (95% CI 0.711 - 0.742) for the final model, AIC resulted in a significant reduction in deviance compared to the basic model, and the Hosmer-Lemeshow test showed no significant lack of fit (p = 0.07). The GeRi-Score predicted an in-house mortality of 5.3% vs. 5.3% observed mortality in the development dataset and 5.4% vs. 5.7% in the validation dataset. The GeRi-Score was able to distinguish between mild, moderate and high risk groups. CONCLUSIONS: The GeRi-Score is an easy-to-use mortality-predicting tool with an acceptable discrimination and no significant lack of fit. The GeRi-Score might have the potential to distribute the intensity of perioperative medical care in hip fracture surgery and can be used in quality management programs as benchmark tool.

Return to sport after arthroscopic surgery for femoroacetabular impingement.

BACKGROUND: Femoroacetabular impingement (FAI) is common among the active and young population. The present study analysed the rate of return to sport, related influencing factors, and the sport activity level according to the Hip Outcome Score - Sport-Specific Subscale (HOS-SSS). METHODS: The literature search was performed in December 2020. All clinical trials investigating HOS-SSS and/or return to sport after arthroscopic treatment for FAI were considered for inclusion. The outcomes of interest were to analyse the rate of return to sport and the sport activity level according to the HOS-SSS in patients who underwent arthroscopic osteoplasty for FAI. RESULTS: Data from 41 studies (4063 procedures) were retrieved. A total of 88.75% (581 of 655) of patients returned to sports within a mean of 37.4 ± 16.5 months. The HOS-SSS score improved from 45.0 ± 10.6 to 73.1 ± 9.5 (P < 0.0001) at last follow-up. The following baseline characteristics evidenced positive association with post-operative activity level: lighter weight (P = 0.01), younger age (P = 0.001), Tönnis angle grade I (P = 0.009), greater HHS (P = 0.01), NAHS (P < 0.0001) and HOS-ADL (P = 0.01). CONCLUSION: Arthroscopic treatment for FAI resulted in excellent results in terms of return to sport. Moreover, lighter weight and younger age, greater HHS, NAHS, HOS-ADL at baseline were positively associated with post-operative sport activity level. LEVEL OF EVIDENCE: IV, systematic review.

The use of the chimeric conjoint flap technique for complex defects reconstruction throughout the body: Clinical experience with 28 cases.

BACKGROUND: Large soft tissue defects reconstruction represents a frequent and complex challenge in plastic surgery. A critical point regards the equilibrium between the need of large amount of tissue, while minimizing donor site morbidity. This is a common issue that plastic surgeons face in their clinical practice. In this context, the chimeric conjoint flap technique can be a valuable option, allowing to better exploit many well-known procedures. The purpose of the present work is to show the reconstructive efficacy and reliability of this technique resorting to many different well-known flaps. No such a comprehensive collection of cases is available so far dealing with this procedure. PATIENTS AND METHODS: Twenty-eight patients presenting large defects throughout the body were treated by means of different flaps, designed according to the chimeric conjoint flap concept. Patients' mean age was 61.9 years old (range 18-82 years), 20 were males and 8 females. The size of the defects ranged from 7 cm × 6 cm to 25 cm × 18 and presented shapes or localizations that were complex to be covered with a regular flap. The defects were located in 11 cases in the lower limbs, in 9 cases in the head and neck region, in 5 cases in the groin, and in 2 cases in the thorax. Cause of the defect was tumor resection in 20 cases, trauma-induced necrosis in 5 cases, Fournier's gangrene in 2 cases, and a chronic ulcer in 1 case. Fourteen flaps were free flaps while 14 were pedicled flaps. The chimeric conjoint flap technique consists in splitting the skin paddle a flap into two smaller island that can be rearranged in order to match the particular requirements of the recipient site. Different flaps were employed: the anterolateral thigh (ALT) flap was used in 19 cases, latissimus dorsi (LD) musculocutaneous flap in 4 cases, deep inferior epigastric (DIEP) in 3 cases, medial sural artery perforator (MSAP) in 1 case, free radial forearm flap (RFFF) in 1 case. RESULTS: All the 28 patients were successfully treated. In 6 cases minor complications were encountered, 5 at recipient site and 1 at donor site, who were all managed conservatively. No second procedures were required. The mean follow-up period was 8.4 months (range 3-12 months). At the last follow-up evaluation all the patients reached an acceptable cosmetic result and, when limbs were affected, complete range of motion restoration. CONCLUSIONS: The present case series provide promising evidence regarding the reliability and versatility of the chimeric conjoint flap technique for large and delicate defect reconstructions throughout the body.

Rib fractures in the elderly population: a systematic review.

BACKGROUND: Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in this subgroup of patients. This systematic review compares conservative treatment to surgical fixation in elderly patients (older than 60 years) with multiple rib fractures. The primary outcome is mortality. Secondary outcomes include hospital and intensive care length of stay (HLOS and ILOS), duration of mechanical ventilation (DMV) and pneumonia rates. METHODS: Multiple databases were searched for comparative studies reporting on conservative versus operative treatment for rib fractures in patients older than 60 years. Both observational studies and randomised clinical trials were considered. RESULTS: Five observational studies (n = 2583) were included. Mortality was lower in operatively treated patients compared to conservative treatment (4% vs. 8%). Pneumonia rate and DMV were similar (5/6% and 5.8/6.5 days) for either treatment modality. Overall ILOS and HLOS of stay were longer in operatively treated patients (6.5 ILOS and 12.7 HLOS vs. 2.7 ILOS and 6.5 ILOS). There were only minimal reports on perioperative complications. Notably, the median number of rib fractures (8.4 vs. 5) and the percentage of flail chest were higher in operatively treated patients (47% vs. 39%). CONCLUSION: It remains unknown to what extent conservative and operative treatment contribute individually to reducing morbidity and mortality in the elderly with multiple rib fractures. To date, the quality of evidence is rather low, thus well-performed comparative observational studies or randomised controlled trials considering all confounders are needed to determine whether operative treatment can improve a patient's outcome.

Biomechanical analysis of helical versus straight plating of proximal third humeral shaft fractures.

BACKGROUND: Proximal humeral shaft fractures are surgically challenging and plate osteosynthesis with a long straight plate is one operative treatment option in these patients although endangering the radial nerve distally. Helical plates potentially avoid the radial nerve by twisting around the humeral shaft. Aim of the study was to investigate in a human cadaveric model the biomechanical competence of helical plates versus straight lateral plates used for fixation of proximal third comminuted humeral shaft fractures. METHODS: Eight pairs of humeral cadaveric humeri were instrumented using either a long 90°-helical plate (Group1) or a straight long PHILOS plate (Group2). An unstable proximal humeral shaft fracture was simulated by means of a 5 cm osteotomy gap. All specimens were tested under quasi-static loading in axial compression, internal and external rotation, and bending in four directions. Subsequently, progressively increasing cyclic loading in internal rotation until failure was applied and interfragmentary movements were monitored by motion tracking. RESULTS: During static testing flexion/extension deformation in Group1 was significantly higher, however, varus/valgus deformation as well as shear and torsional displacement under torsional load remained statistically indifferent between both groups. During cyclic testing shear and torsional displacements were both significantly higher in Group1 compared to Group 2. However, cycles to catastrophic failure remained statistically indifferent between the groups. CONCLUSIONS: From a biomechanical perspective, although 90°-helical plating is associated with higher initial stability against varus/valgus collapse and comparable endurance under dynamic loading, it demonstrates lower resistance to flexion/extension and internal rotation with bigger shear interfragmentary displacements versus straight lateral plating and, therefore, cannot be considered as its real alternative. Alternative helical plate designs should be investigated in the future.

Statistical Morphology and Fragment Mapping of Complex Proximal Humeral Fractures.

Background and Objectives: Proximal humerus fractures (PHFs) are common in the elderly, but the treatment results are often poor. A clear understanding of fracture morphology and distribution of cortical bone loss is important for improved surgical decision making, operative considerations, and new implant designs. The aim of this study was to develop a 3D segmentation fracture mapping technique to create a statistical description of the spatial pattern and cortical bone loss of complex PHFs. Materials and Methods: Fifty clinical computed tomography (CT) scans of complex PHFs and their contralateral intact shoulders were collected. In-house software was developed for semi-automated segmentation and fracture line detection and was combined with manual fracture reduction to the contralateral template in a commercial software. A statistical mean model of these cases was built and used to describe probability maps of the fracture lines and cortical fragments. Results: The fracture lines predominantly passed through the surgical neck and between the tuberosities and tendon insertions. The superior aspects of the tuberosities were constant fragments where comminution was less likely. Some fracture lines passed through the bicipital sulcus, but predominantly at its edges and curving around the tuberosities proximally and distally. Conclusions: A comprehensive and systematic approach was developed for processing clinical CT images of complex fractures into fracture morphology and fragment probability maps and applied on PHFs. This information creates an important basis for better understanding of fracture morphology that could be utilized in future studies for surgical training and implant design.

Comparable outcome for autografts and allografts in primary medial patellofemoral ligament reconstruction for patellofemoral instability: systematic review and meta-analysis.

PURPOSE: This study updates the current evidence on the role of allografts versus autografts for medial patellofemoral ligament (MPFL) reconstruction in patients with patellofemoral instability. METHODS: The study was performed according to the PRISMA guidelines. In March 2021, a literature search in the main online databases was performed. Studies reporting quantitative data concerning primary MPFL reconstruction using an allograft were considered for inclusion. The Coleman Methodology Score was used to assess the methodological quality of the selected articles. RESULTS: Data from 12 studies (474 procedures) were retrieved. The mean follow-up was 42.2 (15-78.5) months. The mean age was 21.1 ± 6.2 years. 64.9% (285 of 439) of patients were female. At the last follow-up, the Tegner (p < 0.0001), Kujala (p = 0.002) and the Lysholm (p < 0.0001) scores were minimally greater in the autografts. The similarity was found in the rate of persistent instability sensation and revision. The allograft group evidenced a lower rate of re-dislocations (p = 0.003). CONCLUSION: Allografts may represent a feasible alternative to traditional autograft for MPFL reconstruction in selected patients with patellofemoral instability. Allograft tendons yielded similar PROMs, rates of persistent instability, and revision. Allograft reconstructions tended to have modestly lower re-dislocation rates. LEVEL OF EVIDENCE: IV.

Prognostic factors for isolated medial patellofemoral ligament reconstruction: A systematic review.

BACKGROUND: Evidence concerning the influence gender, age, and the time elapsed from the first dislocation to surgery in the outcomes of Medial Patella Femoral Ligament (MPFL) reconstruction are lacking. This systematic review was conducted to investigate whether patient characteristics have an influence in the clinical outcomes of MPFL reconstruction for patients with patellofemoral instability. MATERIAL AND METHODS: This study followed the PRISMA guidelines. The main databases were accessed in February 2021. All the studies reporting outcomes of primary MPFL reconstruction in patients with recurrent patellofemoral instability were considered for inclusion. A multivariate analysis diagnostic tool was used to analyse the association between age, gender and time from injury to surgery and the surgical outcomes at last follow-up. RESULTS: A total of 50 articles (2037 procedures) were included. The mean follow-up was 40.90 ± 24.8 months. The mean age was 23.6 ± 3.9 years. 64.3% (1309 of 2037 patients) were female. The mean time from injury to surgery was 64.5 ± 48.9 months. Women showed no statistically significant association with the Kujala score or complications. Older patients had a reduced risk to incur re-dislocations (P = 0.01) and revisions (P = 0.01). Longer time from injury to surgery was associated with greater risk to incur re-dislocations (P = 0.01), and with lower Kujala score (P < 0.0001). No other statistically significant association was evidenced. CONCLUSION: The time span from the first patellar dislocation to the surgical reconstruction was a negative prognostic factor, while sex had no influence on surgical outcomes. The role of patients age on surgical outcomes remains unclear.

Arthroscopic labral repair for femoroacetabular impingement: A systematic review.

BACKGROUND: The present systematic review investigated return to sport, patient reported outcome measures (PROMs), complications and subsequent progression to total hip arthroplasty (THA) in patients undergoing arthroscopic labral repair for FAI. MATERIAL AND METHODS: Following the PRISMA statement, the literature search was performed in February 2021. The outcomes of interest were: rate of return to sport, modified Harris Hip Score (mHHS), the subscales Activities of Daily Living and Sport-Specific Subscale of the Hip Outcome Score (HOS-ADL and HOS-SSS, respectively). Complications, revision surgeries and progression to total hip arthroplasty were recorded. RESULTS: Data from 210 procedures were retrieved. The mean follow-up was 34.0 (24.0-42.5) months. The mean age of the patients was 32.0 (20.0-47.0) years, while the mean BMI was 20.9 (20.1-21.7) kg/m2. 52.8% (111 of 210 patients) were women. At 24-month follow-up, 100% of the patients had returned to sport. At a mean of 34 months follow-up, the mean mHHS increased by 25.5% (P = 0.02), the mean HOS-ADL by 23.0% (P = 0.03), the mean HOS-SSS by 32.8% (P = 0.001). No complications were observed. The rate of revision was 4.3% (9 of 210 procedures). At a mean of 37.9 ± 7.5 months, 1.9% of patients (4/210) underwent THA. CONCLUSION: Arthroscopic labral refixation for FAI yields reliably positive clinical outcomes, with a low rate of revision and conversion to THA.

Tourniquet use during knee arthroplasty: A Bayesian network meta-analysis on pain, function, and thromboembolism.

BACKGROUND: The role of a tourniquet for knee arthroplasty remains controversial. The present Bayesian network meta-analysis investigated the role of various protocols for tourniquet inflation for knee arthroplasty, assessing data on pain control, clinical and functional outcomes, and the rate of deep vein thrombosis (DVT). MATERIAL AND METHODS: The present Bayesian network meta-analysis was conducted according to the PRISMA guidelines. In March 2021, all clinical trials investigating the role of tourniquet use for knee arthroplasty were considered for inclusion. Groups were divided into those which used a tourniquet in knee arthroplasty procedures versus those which completed the procedure without tourniquet, or with varying protocols of tourniquet use. The hierarchical random-effects model analysis was adopted in all comparisons. RESULTS: Data from 54 articles (5497 procedures) were retrieved. The absence of tourniquet group evidenced the lowest rate of DVT, and scored the lowest in the visual analogic scale (VAS) at 24-48 h, 1, 3, and 12 months follow-up. The same group evidenced the greatest gain of motion at 3-days, 1 week, 1 month, 3 months, 6 months, and 12 months follow-up, and the highest Knee Society Rating System scores at 1, 3, and 12 months follow-up. Of the outcome data assessed, the straight-leg-raise test was markedly inconsistent: therefore, no recommendations from this test can be made. CONCLUSION: With regards to the endpoints considered in the present study, knee arthroplasties undertaken without the use of a tourniquet perform better overall.

Surgery goes EPA (Entrustable Professional Activity) - how a strikingly easy to use app revolutionizes assessments of clinical skills in surgical training.

OBJECTIVE: Entrustable Professional Activities (EPAs) are increasingly being used in competency-based medical education approaches. A general lack of time in clinical settings, however, prevents supervisors from providing their trainees with adequate feedback. With a willingness for more administrative tasks being low in both trainees and educators, the authors developed a radical user-friendly mobile application based on the EPA concept called "Surg-prEPAred". DESIGN: Surg-prEPAred is designed to collect micro-assessment data for building competency profiles for surgical residents according to their curriculum. The goal of Surg-prEPAred is to facilitate the performance and documentation of workplace-based assessments. Through aggregated data the app generates a personalized competency profile for every trainee. During a pilot run of 4 months, followed by ongoing usage of the application with a total duration of 9 months (August 2019 to April 2020), 32 residents and 33 consultants made daily use of the application as a rating tool. Every rating included knowledge, skills and professional attitudes of the trainees. Before the initiation of the App and after the 9-month trial period trainees and supervisors where both sent questionnaires to evaluate the user friendliness and effectiveness of the App. RESULTS: Five hundred ten App based assessments were generated. Out of 40 pre-defined EPAs, 36 were assessed. 15 trainees and 16 supervisors returned the questionnaires and stated the surg-prEPAred App as very valuable, effective and feasible to evaluate trainees in a clinical setting providing residents with an individual competence portfolio to receive precision medical education. CONCLUSIONS: The authors expectation is that the Surg-prEPAred App will contribute to an improvement of quality of medical education and thus to the quality of patient care and safety. In the future the goal is to have the App become an integral part of the official Swiss surgical curriculum accepted by the Swiss professional surgical society.

Versatility of perforator flaps for lower extremity defect coverage: Technical highlights and single center experience with 87 consecutive cases.

BACKGROUND: Lower extremity defects have been and remain one of the greatest challenges in reconstructive surgery. Perforator flaps have been accepted as a valid procedure to cover such a defect. Different techniques have been described and nowadays many options are available. However, there were not studies that comprehensively review the most modern techniques and clinical application of the use of perforator flaps in the lower extremity reconstruction. In the present report, we gathered most of them, presenting an updated and large case series where different pedicled and free perforators flaps were employed in simple and complex scenarios in a large series of cases. PATIENTS AND METHODS: Eighty-seven patients presenting soft tissue defects of the lower extremities were treated by means of different perforator-based flaps, in either free or pedicled fashion. The flaps were based on different perforator vessels, namely deep lateral circumflex femoral artery, profunda femoris artery, superficial femoral artery, medial sural artery, peroneal artery, posterior tibial artery, anterior tibial artery, and medial plantar artery. Patients' mean age was 61.9 years old (range 21-87 years old), 58 were males and 29 females. The 12 patients received sequential flaps and 9 received double free flaps, for a total sum of 106 flaps. The causes of the defects were trauma in 41 patients and tumors in 46 patients, located throughout the lower limbs. Size of the defect ranged from 3 cm × 4 cm to 25 cm × 9 cm. RESULTS: The dimensions of the flap skin paddles ranged from 3 cm × 4 cm to 16 cm × 5 cm for the pedicled flaps (42 cases) and from 6 cm × 4 cm to 25 cm × 8 cm for the free ones (45 cases). Mean flap's size was 48 cm2 (range 12-80 cm2 ) for the pedicle flaps and 104 cm2 (range 24-200 cm2 ) for free flaps. In two pedicled cases, a distal congestion was encountered, requiring a second surgery. Debulking procedures were performed in 2 patients. All the patients were successfully treated and no flaps were lost. Mean follow-up period was 8.4 months (range 3-12 months). No range of motion impairment was encountered after surgery and all the patients were able to return to habitual life. CONCLUSIONS: The present case series highlights the reliability and versatility of perforator flaps for lower extremity defect coverage. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap can be potentially successful in the most disparate circumstances.

Biomechanical analysis of recently released cephalomedullary nails for trochanteric femoral fracture fixation in a human cadaveric model.

BACKGROUND: Recently, two novel concepts for intramedullary nailing of trochanteric fractures using a helical blade or interlocking dual screws have demonstrated advantages as compared to standard single-screw systems. However, these two concepts have not been subjected to a direct biomechanical comparison so far. The aims of this study were to investigate in a human cadaveric model with low bone quality (1) the biomechanical competence of nailing with the use of a helical blade versus interlocking screws, and (2) the effect of cement augmentation on the fixation strength of the helical blade. METHODS: Twelve osteoporotic and osteopenic human cadaveric femoral pairs were assigned for pairwise implantation using either a short TFN-ADVANCED Proximal Femoral Nailing System (TFNA) with a helical blade head element or a short TRIGEN INTERTAN Intertrochanteric Antegrade Nail (InterTAN) with interlocking screws. Six osteoporotic femora, implanted with TFNA, were augmented with bone cement. Four groups were created: group 1 (TFNA) paired with group 2 (InterTAN), both consisting of osteopenic specimens, and group 3 (TFNA augmented) paired with group 4 (InterTAN), both consisting of osteoporotic specimens. An unstable trochanteric AO/OTA 31-A2.2 fracture was simulated and all specimens were tested until failure under progressively increasing cyclic loading. RESULTS: Stiffness in group 3 was significantly higher versus group 4, p = 0.03. Varus (°) and femoral head rotation around the femoral neck axis (°) after 10,000 cycles were 1.9 ± 1.0/0.3 ± 0.2 in group 1, 2.2 ± 0.7/0.7 ± 0.4 in group 2, 1.5 ± 1.3/0.3 ± 0.2 in group 3 and 3.5 ± 2.8/0.9 ± 0.6 in group 4, being significantly different between groups 3 and 4, p = 0.04. Cycles to failure and failure load (N) at 5° varus or 10° femoral head rotation around the neck axis in groups 1-4 were 21,428 ± 6020/1571.4 ± 301.0, 20,611 ± 7453/1530.6 ± 372.7, 21,739 ± 4248/1587.0 ± 212.4 and 18,622 ± 6733/1431.1 ± 336.7, being significantly different between groups 3 and 4, p = 0.04. CONCLUSIONS: Nailing of trochanteric femoral fractures with use of helical blades is comparable to interlocking dual screws fixation in femoral head fragments with low bone quality. Bone cement augmentation of helical blades provides significantly greater fixation strength compared to interlocking screws constructs.

Inter-rater agreement in pPOSSUM scores of geriatric trauma patients: a prospective evaluation.

PURPOSE: Risk prediction models are widely used in the perioperative setting to identify high-risk patients who may benefit from additional care and to aid clinical decision-making. pPOSSUM is such a prediction model, however, little is known about the inter-rater agreement when scoring subjective parameters. This study assessed the inter-rater agreement between clinicians of different specialties and work-level when scoring 30 clinical case reports of geriatric hip fracture patients with pPOSSUM. METHODS: Eighteen clinicians of the department of Surgery (three specialists, four residents), Anaesthesiology (four specialists, two residents) and Emergency Medicine (three specialists, two residents) who were familiar with the pPOSSUM scoring system were asked to calculate the scores. The kappa statistic and the statistical method of Fleiss were used to analyse inter-rater agreement. RESULTS: The response rate was 100%. Among surgeons, Anaesthesiologists and Emergency department doctors (ED), the overall mean kappa values were 0.42, 0.08 and 0.20, respectively. Among surgery, anaesthesiology and ED residents the overall mean kappa values were 0.21, 0.33 and 0.37, respectively. Within the department of Surgery, Anaesthesiology and Emergency Medicine the overall mean kappa values were 0.23, 0.12 and 0.22, respectively. An overall mean kappa value of 0.19 was seen among all specialists. All residents had an overall mean kappa value of 0.21 and all clinicians had an overall mean kappa value of 0.21. CONCLUSION: The overall inter-rater agreement of clinicians and interdisciplinary agreement when scoring geriatric hip fracture patients with pPOSSUM was low and prone to subjectivity in our study. A higher work-experience level did not lead to better agreement. When pPOSSUM is calculated without clinical assessment by the same clinician, caution is advised to prevent over-reliance on the pPOSSUM risk prediction model. LEVEL OF EVIDENCE: III.

Iatrogenic Damage to Neurovascular and Soft Tissue Structures During Lateral Release of Hallux Valgus: A Comparative Anatomical Study of Minimally Invasive Versus Open Surgical Techniques.

Lateral release is often an integral step in surgical correction of hallux valgus and can be performed using open or minimally invasive techniques. We investigated whether these techniques cause iatrogenic damage to arteries, nerves, tendons, or joint capsules. In this cadaver study, lateral release was performed on 9 pairs of specimens by a specialized foot surgeon. The specimens were randomly assigned to each group. The operations were followed by anatomical preparation, data collection, photo documentation, and statistical analysis. Iatrogenic damage to arteries, nerves, tendons, or joint capsules was rare, regardless of the surgical technique used. However, with the minimally invasive technique, the tendon of the extensor hallucis longus muscle and the sensitive terminal branches of the fibular nerve were at risk due to their anatomical proximity to the access portal. The deep transverse metatarsal ligament was potentially at risk if the adductor hallucis muscle was completely detached from the lateral sesamoid. When the deep transverse metatarsal ligament was transected there was risk of damaging the underlying plantar neurovascular structures. Both surgical techniques are safe in terms of the risk of injury to neighboring neurovascular and soft tissue structures.

Validity of a Novel Digitally Enhanced Skills Training Station for Freehand Distal Interlocking.

Background and Objectives: Freehand distal interlocking of intramedullary nails is technically demanding and prone to handling issues. It requires precise placement of a screw through the nail under fluoroscopy guidance and can result in a time consuming and radiation expensive procedure. Dedicated training could help overcome these problems. The aim of this study was to assess construct and face validity of new Digitally Enhanced Hands-On Surgical Training (DEHST) concept and device for training of distal interlocking of intramedullary nails. Materials and Methods: Twenty-nine novices and twenty-four expert surgeons performed interlocking on a DEHST device. Construct validity was evaluated by comparing captured performance metrics-number of X-rays, nail hole roundness, drill tip position and drill hole accuracy-between experts and novices. Face validity was evaluated with a questionnaire concerning training potential and quality of simulated reality using a 7-point Likert scale. Results: Face validity: mean realism of the training device was rated 6.3 (range 4-7). Training potential and need for distal interlocking training were both rated with a mean of 6.5 (range 5-7), with no significant differences between experts and novices, p ≥ 0.234. All participants (100%) stated that the device is useful for procedural training of distal nail interlocking, 96% wanted to have it at their institution and 98% would recommend it to colleagues. Construct validity: total number of X-rays was significantly higher for novices (20.9 ± 6.4 versus 15.5 ± 5.3, p = 0.003). Success rate (ratio of hit and miss attempts) was significantly higher for experts (novices hit: n = 15; 55.6%; experts hit: n = 19; 83%, p = 0.040). Conclusion: The evaluated training device for distal interlocking of intramedullary nails yielded high scores in terms of training capability and realism. Furthermore, construct validity was proven by reliably discriminating between experts and novices. Participants indicate high further training potential as the device may be easily adapted to other surgical tasks.

Impact of Anterior Malposition and Bone Cement Augmentation on the Fixation Strength of Cephalic Intramedullary Nail Head Elements.

Background and Objectives: Intramedullary nailing of trochanteric fractures can be challenging and sometimes the clinical situation does not allow perfect implant positioning. The aim of this study was (1) to compare in human cadaveric femoral heads the biomechanical competence of two recently launched cephalic implants inserted in either an ideal (centre-centre) or less-ideal anterior off-centre position, and (2) to investigate the effect of bone cement augmentation on their fixation strength in the less-ideal position. Materials and Methods: Fourty-two paired human cadaveric femoral heads were assigned for pairwise implantation using either a TFNA helical blade or a TFNA screw as head element, implanted in either centre-centre or 7 mm anterior off-centre position. Next, seven paired specimens implanted in the off-centre position were augmented with bone cement. As a result, six study groups were created as follows: group 1 with a centre-centre positioned helical blade, paired with group 2 featuring a centre-centre screw, group 3 with an off-centre positioned helical blade, paired with group 4 featuring an off-centre screw, and group 5 with an off-centre positioned augmented helical blade, paired with group 6 featuring an off-centre augmented screw. All specimens were tested until failure under progressively increasing cyclic loading. Results: Stiffness was not significantly different among the study groups (p = 0.388). Varus deformation was significantly higher in group 4 versus group 6 (p = 0.026). Femoral head rotation was significantly higher in group 4 versus group 3 (p = 0.034), significantly lower in group 2 versus group 4 (p = 0.005), and significantly higher in group 4 versus group 6 (p = 0.007). Cycles to clinically relevant failure were 14,919 ± 4763 in group 1, 10,824 ± 5396 in group 2, 10,900 ± 3285 in group 3, 1382 ± 2701 in group 4, 25,811 ± 19,107 in group 5 and 17,817 ± 11,924 in group 6. Significantly higher number of cycles to failure were indicated for group 1 versus group 2 (p = 0.021), group 3 versus group 4 (p = 0.007), and in group 6 versus group 4 (p = 0.010). Conclusions: From a biomechanical perspective, proper centre-centre implant positioning in the femoral head is of utmost importance. In cases when this is not achievable in a clinical setting, a helical blade is more forgiving in the less ideal (anterior) malposition when compared to a screw, the latter revealing unacceptable low resistance to femoral head rotation and early failure. Cement augmentation of both off-centre implanted helical blade and screw head elements increases their resistance against failure; however, this effect might be redundant for helical blades and is highly unpredictable for screws.

Surgical Management and Outcomes following Pathologic Hip Fracture-Results from a Propensity Matching Analysis of the Registry for Geriatric Trauma of the German Trauma Society.

Background and Objectives: The outcomes of patients with pathologic hip fractures remain unclear. Data from a large international geriatric trauma registry were analyzed to examine the outcomes of patients with pathologic hip fractures compared with patients with typical osteoporotic hip fractures. Materials and Methods: Data from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) were analyzed. All patients treated surgically for osteoporotic or pathologic hip fractures were included in this analysis. Across both fracture types, a 2:1 optimal propensity score matching and multivariate logistic regression analysis were conducted. In-house mortality rate and mortality at the 120-day follow-up, as well as mobility after 7 and 120 days, reoperation rate, discharge management from the hospital and readmission rate to the hospital until the 120-day follow-up were analyzed as outcome parameters for the underlying fracture type-pathologic or osteoporotic. Results: A total of 29,541 cases met the inclusion criteria. Of the patients included, 29,330 suffered from osteoporotic fractures, and 211 suffered from pathologic fractures. Multivariate logistic regression analysis revealed no differences between the two fracture types in terms of mortality during the acute hospital stay, reoperation during the initial acute hospital stay, walking ability after seven days and the likelihood of being discharged back home. Walking ability and hospital readmission remained insignificant at the 120-day follow-up as well. However, the odds of passing away within the first 120 days were significantly higher for patients suffering from pathologic hip fractures (OR: 3.07; p = 0.003). Conclusions: Surgical treatment of pathologic hip fractures was marked by a more frequent use of arthroplasty in per- and subtrochanteric fractures. Furthermore, the mortality rate among patients suffering from pathologic hip fractures was elevated in the midterm. The complication rate, as indicated by the rate of readmission to the hospital and the necessity for reoperation, remained unaffected.