Management of pertrochanteric fractures in patients over 90 years: In-hospital mortality rate, complications and associated risk factors.

PURPOSE: This study aims primarily to investigate the outcome following surgical management of pertrochanteric fractures of patients over 90 years compared to the outcome of a control group below 90 years under special consideration of the timing of surgery. The second aim was to analyze potential risk factors for early deaths in very old patients. This study allows us to draw conclusions to minimize complications linked to this particular age segment. METHODS: The study group consisted of very old patients aged 90 years and older. Geriatric patients aged between 60 and 89 years of age were part of the control group. Type A1 pertrochanteric fractures were typically treated by dynamic hip crews, type A2 and A3 fractures by femoral nails. Full weight bearing physiotherapy was initiated on the day after surgery to improve mobility and muscle strength. RESULTS: A total of 71 patients belonged to the study group (mean age: 92.5 years ±2.3 years), whereas 223 patients formed the control group (mean age: 79.9 ± 7.4 years). The mortality rate and the number of detected and documented complications were significantly higher in the study group (p = 0.001; p = 0.009, respectively). Despite the significantly higher complication rate in the > 90-year-old patients, there was no significant difference in the mean length of in-hospital-stay between the both groups (> 90 yrs.: 12.1d; < 90 yrs.: 13.1 d) and the timing of surgery. CONCLUSION: The number of co-morbidities, number of daily-administered medications and the time between admission and surgery have no impact on the outcome. We noticed a longer period between admission and surgery in very old patients who survived. Patients with pertrochanteric fractures should be screened for multimorbidity and cognitive disorders in a standardized manner.

[Which factors influence the inpatient course for patients with spondylodiscitis?] / Welche Parameter haben Einfluss auf den stationären Verlauf bei Patienten mit Spondylodiszitis?

BACKGROUND: Spondylodiscitis is a rare disease with an increasing incidence. METHODS: In this retrospective study 112 patients with spondylodiscitis surgically treated from 1 January 2005 to 31 December 2012 in a level I spine center were investigated with respect to potential prognostic criteria. The time period covered by the investigation was the duration of hospitalization. The parameters analyzed were mortality, age, localization of the spondylodiscitis, detection of abscesses and pathogens, neurological status and body mass index (BMI). RESULTS: The average age of the patients was 68.3 years (±12.9 years). The mortality rate during hospitalization was 10.7% (N = 12). Older patients had a significantly higher in-hospital mortality rate (p = 0.008). Abscess formation was found in 49.1% of the patients and was associated with a significantly longer hospital stay (p = 0.001) and in the intensive care unit (ICU, p = 0.001) as well as a higher risk of revision surgery (p = 0.018). In addition, obese patients had a significantly higher occurrence of abscesses (p = 0.034). Pathogen detection was successful in 60.7 % of the cases with Staphylococcus aureus as the most frequent pathogen. Detection of pathogens was associated with a longer hospital stay (p = 0.006) and a greater need of intensive care monitoring (p = 0.017). Patients with a nephropathy had a significantly increased mortality, longer duration of hospitalization and a more frequent occurrence of multilevel afflictions. CONCLUSION: Old age, abscess formation, positive detection of pathogens and renal failure can be used as prognostic criteria. Risk factors for formation of abscesses include a lumbar localization of spondylodiscitis, nephropathy as well as detection of a pathogen and obesity.

[Minimally invasive stabilization of thoracolumbar osteoporotic fractures]. / Minimal-invasive Stabilisierung bei thorakolumbalen osteoporotischen Frakturen.

BACKGROUND: Minimally invasive stabilization of thoracolumbar osteoporotic fractures (OF) in neurologically intact patients is well established. Various posterior and anterior surgical techniques are available. The OF classification and OF score are helpful for defining the indications and choice of operative technique. OBJECTIVE: This article gives an overview of the minimally invasive stabilization techniques, typical complications and outcome. MATERIAL AND METHODS: Selective literature search and description of surgical techniques and outcome. RESULTS: Vertebral body augmentation alone can be indicated in painful but stable fractures of types OF 1 and OF 2 and to some extent for type OF 3. Kyphoplasty has proven to be an effective and safe procedure with a favorable clinical outcome. Unstable fractures and kyphotic deformities (types OF 3-5) should be percutaneously stabilized from posterior. The length of the pedicle screw construct depends on the extent of instability and deformity. Bone cement augmentation of the pedicle screws is indicated in severe osteoporosis but increases the complication rate. Restoration of stability of the anterior column can be achieved through additional vertebral body augmentation or rarely by anterior stabilization. Clinical and radiological short and mid-term results of the stabilization techniques are promising; however, the more invasive the surgery, the more complications occur. CONCLUSION: Minimally invasive stabilization techniques are safe and effective. The specific indications for the individual procedures are guided by the OF classification and the individual clinical situation of the patient.

Current Minimally Invasive Surgical Concepts for Sacral Insufficiency Fractures. / Aktuelle minimalinvasive operative Konzepte für Insuffizienzfrakturen des Sakrums.

An increasing incidence of sacral insufficiency fractures in geriatric patients has been documented, representing a major challenge to our healthcare system. Determining the accurate diagnosis requires the use of sectional imaging, including computed tomography and magnetic resonance imaging. Initially, non-surgical treatment is indicated for the majority of patients. If non-surgical treatment fails, several minimally invasive therapeutic strategies can be used, which have shown promising results in small case series. These approaches are sacroplasty, percutaneous iliosacral screw fixation (S1 with or without S2), trans-sacral screw fixation or implantation of a trans-sacral bar, transiliac internal fixator stabilisation, and spinopelvic stabilisation. These surgical strategies and their indications are reported in detail. Generally, treatment-related decision making depends on the clinical presentation, fracture morphology, and attending surgeon's experience.

Imaging in the Diagnosis of Nonspecific Pyogenic Spondylodiskitis.

The prevalence of nonspecific pyogenic spondylodiskitis, associated with both a high morbidity and a high mortality, has increased in the last few decades. The diagnosis is often delayed because of the nonspecific clinical manifestation at the early stage. The reliability of radiographs is limited, particularly in early stage after the onset of infection. Computed tomography (CT) can reliably assess the bony condition with the possibility of spatial visualization. Contrast enhancement supports the detection of affected soft tissue. Magnetic resonance imaging (MRI) continues to be the gold standard in the diagnosis of spondylodiskitis. Sophisticated investigation protocols supported by gadolinium enhancement secure the diagnosis. MRI has a high resolution without radiation exposure. Different nuclear investigation techniques extend the diagnostic options. Reports of 18F-fluorodeoxyglucose-positron emission tomography (18-FDG-PET) are particularly promising to confirm the diagnosis. The drawback of the reduced image quality with respect to detailed anatomical information can be overcome by a combined simultaneous acquisition of CT or MRI. With respect to one of the greatest challenges, the differentiation between degenerative changes (Modic type 1) and infection at an early stage using differentiated MRI protocols and FDG-PET is promising. This overview presents a concise state-of-the-art look at radiologic investigations in case of suspected nonspecific pyogenic spondylodiskitis with the focus on a pragmatic approach.

Risk factors for intraoperative greater trochanteric fractures in hemiarthroplasty for intracapsular femoral neck fractures.

PURPOSE: Hemiarthroplasty is widely accepted as the treatment of choice in elderly patients with a displaced intracapsular femoral neck fracture. Intraoperative greater trochanteric fractures thwart this successful procedure, resulting in prolonged recovery, inferior outcome, and increased risk of revision surgery. Hence, this study analyzed factors potentially associated with an increased risk for intraoperative greater trochanteric fracture. METHODS: This retrospective study included 512 hemiarthroplasties in 496 patients with a geriatric intracapsular femoral neck fracture from July 2010 to March 2020. All patients received the same implant type of which 90.4% were cemented and 9.6% non-cemented. Intra- and postoperative radiographs and reports were reviewed and particularly screened for greater trochanteric fractures. RESULTS: Female patients accounted for 74% and mean age of the patients was 82.3 (± 8.7) years. 34 (6.6%) intraoperative greater trochanteric fractures were identified. In relation to patient-specific factors, only a shorter prothrombin time was found to be significantly associated with increased risk of intraoperative greater trochanteric fracture (median 96%, IQR 82-106% vs. median 86.5%, IQR 68.8-101.5%; p = 0.046). Other factors associated with greater trochanteric fracture were a shorter preoperative waiting time and changes in perioperative settings. Outcome of patients with greater trochanteric fracture was worse with significantly more surgical site infection requiring revision surgery (17.6% vs. 4.2%, p = 0.005). CONCLUSION: Prolonged prothrombin time, a shorter preoperative waiting time, and implementing new procedural standards and surgeons may be associated with an increased risk of a greater trochanteric fracture. Addressing these risk factors may reduce early periprosthetic infection which is strongly related to greater trochanteric fractures.

Halo Fixator and Halo Traction - Value for the Treatment of Spinal Disorders in Childhood. / Halofixateur und Halotraktion ­ Stellenwert bei Erkrankungen und Verletzungen der Wirbelsäule im Kindesalter.

The application of the Halo fixateur in case of spinal pathologies in childhood is a standardized technique. The halo fixateur may be used for treatment of injuries of the cervical spine, for additional stabilization following extended surgery at the cervical spine and their transitional regions as well as to achieve preoperative reduction in case of severe and rigid deformity. These indications are, referred to the early age, rare. However, the successful use of the Halo fixateur presumes a certain familiarity with the device and experiences regarding the underlying diseases to minimize related risks and to avoid possible complications. In this article the use and specific features regarding the application of the halo fixateur in childhood based on presented cases and the literature will be discussed.

Value of MRI imaging prior to a kyphoplasty for osteoporotic insufficiency fractures.

Previous studies have shown the safety and effectiveness of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures (OVCFs). MRI and particularly the short tau inversion recovery (STIR) sequence are very sensitive for detecting vertebral edema as a result of fresh fractures or micro-fractures. Therefore, it has a great therapeutic relevance in differentiating vertebral deformities seen by conventional X-ray and CT scans. Although an MRI scan is expensive, to my knowledge no study has evaluated the benefits of preoperative MRI in evaluating a therapeutic plan for kyphoplasty. This is a prospective study evaluating the benefit of a preoperative MRI scan regarding changes of kyphoplasty therapy. Twenty-eight patients were included in this study. Twenty-four patients were treated by balloon kyphoplasty, in a total of 40 vertebral bodies. The mean age was 73 years. All patients suffered from OVCFs. As a first step, all patients got a CT scan. The individual therapeutic plan was then defined by the patients' history, complaints and the results of the CT scan. As far as all criteria for kyphoplasty were fulfilled, an MRI examination including the STIR sequences was performed preoperatively. The number of times a change was made in therapy as a result from the additional information from the MRI was then evaluated. By performing a preoperatively MRI examination, the therapy plan was changed in 16 out of 28 (57%) patients. Eight patients underwent additional levels of kyphoplasty at the same procedure. In five patients, lesions were found to be old fractures and therefore were not treated operatively. Two of these patients received no kyphoplasty at all. Another patient only a part of the originally intended levels was treated. The other two cases received a kyphoplasty at different vertebral levels, as these vertebral bodies showed signs of an acute fracture in the MRI scan. Additionally, an incidental diagnosis of carcinoma of the kidney was made in two patients. Kyphoplasty was deferred and they were referred for further evaluation. One patient was found to have an aortic aneurysm. Kyphoplasty was performed and after that the patient was referred in order to treat the aneurysm. This study confirms the diagnostic benefits of an MRI scan before performing a kyphoplasty. For 16 out of 28 patients, the therapeutic plan was changed because of the information obtained by preoperative MRI. Preoperative MRI helped to generate the correct surgical strategy, by demonstrating the correct location of injury and by detecting concomitant diseases.

Imaging of Sacral Stress and Insufficiency Fractures. / Radiologische Diagnostik von Stress- und Insuffizienzfrakturen des Sakrums.

Fractures of the os sacrum without relevant trauma history are defined as stress or insufficiency fractures and often affect the anterior pelvis. Sacral insufficiency fractures are associated with osteoporosis and occur under physiological load. In contrast, sacral stress fractures are caused by mechanical overloading. Diagnostic confirmation is delayed in many of these patients. Thus, MRI and/or CT should be performed early. Fracture stability should be evaluated by CT. MRI is the better approach to rule out fractures and is highly sensitive. It is indicated in young patients and in patients with non-specific lumbosacral pain. Nuclear imaging techniques are viable alternatives in patients with a contraindication for MRI.

Recommendations for the Diagnostic Testing and Therapy of Atlas Fractures. / Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen: Atlasfrakturen.

In a consensus process with four sessions in 2017, the working group on "the upper cervical spine" of the German Society for Orthopaedic and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Fractures to the Upper Cervical Spine", incorporating their own experience and current literature. The following article describes the recommendations for the atlas vertebra. About 10% of all cervical spine injuries include the axis vertebra. The diagnostic process primarily aims to detect the injury and to determine joint incongruency and integrity of the atlas ring. For classification purposes, the Gehweiler classification and the Dickman classification are suitable. The Canadian c-spine rule is recommended for clinical screening for c-spine injuries. CT is the preferred imaging modality; MRI is needed to determine the integrity of the Lig. transversum atlantis in complete atlas ring fractures. Conservative treatment is appropriate in very many atlas fractures. Surgical treatment is recommended in existing or potential joint incongruity or instability, which are frequently seen in Gehweiler IIIB or Gehweiler IV fractures. Posterior atlanto-axial stabilisation and fusion using transarticular screws or an internal fixator are regarded as a gold standard in the majority of surgical cases. Especially in young patients, the possibility of isolated atlas osteosynthesis should be checked. A possible option for Gehweiler IV fractures is halo-fixation with mild distraction for ligamentotaxis. Secondary dislocation should be checked for frequently. Involvement of the occipito-atlantal joint complex requires stabilisation of the occiput as well.

Recommendations for Diagnosis and Treatment of Fractures of the Ring of Axis. / Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen: Axisringfrakturen.

In a consensus process with four sessions in 2017, the working group "upper cervical spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Upper Cervical Fractures", taking their own experience and the current literature into consideration. The following article describes the recommendations for axis ring fractures (traumatic spondylolysis C2). About 19 to 49% of all cervical spine injuries include the axis vertebra. Traumatic spondylolysis of C2 may include potential discoligamentous instability C2/3. The primary aim of the diagnostic process is to detect the injury and to determine potential disco-ligamentous instability C2/3. For classification purposes, the Josten classification or the modified Effendi classification may be used. The Canadian C-spine rule is recommended for clinical screening for C-spine injuries. CT is the preferred imaging modality and an MRI is needed to determine the integrity of the discoligamentous complex C2/3. Conservative treatment is appropriate in case of stable fractures with intact C2/3 motion segment (Josten type 2 and 2). Patients should be closely monitored, in order to detect secondary dislocation as early as possible. Surgical treatment is recommended in cases of primary severe fracture dislocation or discoligamentous instability C2/3 (Josten 3 and 4) and/or secondary fracture dislocation. Anterior cervical decompression and fusion (ACDF) C2/3 is the treatment of choice. However, in case of facet joint luxation C2/3 with looked facet (Josten 4), a primary posterior approach may be necessary.

Vertebral Artery Caught in the Fracture Gap after Traumatic C2/3 Spondylolisthesis.

BACKGROUND CONTEXT: Patient with a C2 fracture and entrapment of the right vertebral artery in the fracture gap. PURPOSE: Presentation of a case with follow-up until end of treatment. STUDY DESIGN: Case report. METHODS: A 25-year-old woman was brought into our emergency room after falling while riding a horse. She complained of pain in the cervical spine. Clinical examinations showed local tenderness at the upper cervical spine and painful impairment of the mobility of the neck, with no signs of neurological impairment. Radiological diagnostics revealed a traumatic C2/3 spondylolisthesis. A computer tomography (CT) angiographic scan showed a dislocation of the right vertebral artery into the fracture gap without injury to the artery. Open reduction and osteosynthesis were considered of too high risk. Therefore, we conducted fracture treatment with closed reduction and halo fixation. After removal of the halo fixator, the patient was given a soft cervical collar and was advised to rest for additional 6 weeks before beginning gradual activity. RESULTS: Conventional follow-up revealed osseous consolidation and a CT angiographic scan showed consistent blood flow to the artery. CONCLUSION: Halo fixation was a safe and effective therapy strategy in the case of vertebral artery entrapment after traumatic C2 spondylolisthesis.