Therapy aspects of peri-implant femoral fractures-a retrospective analysis of 64 patients.

PURPOSE: The incidence of peri-implant femoral fractures (PIFF) is increasing. Information regarding outcomes, timing of surgery, risk factors, and a clinically applicable treatment algorithm are lacking. The aim of this study was to identify outcome-related risk factors and to derive a treatment algorithm. METHODS: Sixty-four PIFFs treated between 01.01.2006 and 31.12.2020 in a level I trauma centre were evaluated retrospectively for fracture pattern, surgical technique, risk factors, complications, and 1-year mortality. The study was approved by the ethics committee (No. 21-2714-104). RESULTS: One-year mortality was 24.1%. Surgical complications occurred in 4.7%, and general complications in 15.6% of the patients. General complications, low haemoglobin level at admission, elevated CHA2DS2-VASc, and Charlson score resulted in increased 1-year mortality. Time to surgery > 24 h did not increase complication or mortality rates. The three predominant fracture patterns were fractures close or distal to cephalomedullary nails, close or proximal to distal lateral plates, and close or distal to sliding hip screws. Recommendations for surgical treatment were derived: Osteosynthesis should enable as much weight-bearing as possible; the initial implant should only be removed, if this is essential for the new osteosynthesis; lateral locking plates should span the whole femur; antegrade nails should have a cephalomedullary component to avoid consecutive femoral neck fractures; implants should overlap to reduce the risk of consecutive inter-implant fractures. CONCLUSION: Risk factors for 1-year mortality in patients with PIFFs were identified. A treatment algorithm and general principles for surgery of PIFFs were developed.

Surgery Within 24 Hours Reduces Mortality and General Complication Rates in Patients Who Have Periprosthetic Femoral Fractures at the Hip.

BACKGROUND: In patients who have hip fractures, treatment within 24 hours reduces mortality and complication rates. A similar relationship can be assumed for patients who have hip periprosthetic femoral fractures (PPFs) owing to the similar baseline characteristics of the patient populations. This monocentric retrospective study aimed to compare the complication and mortality rates in patients who had hip PPF treated within and after 24 hours. METHODS: In total, 350 consecutive patients who had hip PPF in a maximum-care arthroplasty and trauma center between 2006 and 2020 were retrospectively evaluated. The cases were divided into 2 groups using a time to surgery (TTS) of 24 hours as the cutoff value. The primary outcome variables were operative and general complications as well as mortalities within 1 year. RESULTS: Overall, the mean TTS was 1.4 days, and the 1-year mortality was 14.6%. The TTS ≤ 24 hours (n = 166) and TTS > 24 hours (n = 184) groups were comparable in terms of baseline characteristics and comorbidities. Surgical complications were equally frequent in the 2 groups (16.3 versus 15.2%, P = .883). General complications occurred significantly more often in the late patient care group (11.4 versus 28.3%, P < .001). In addition, the 30-day mortality (0.6 versus 5.5%, P = .012), and 1-year mortality (8.3 versus 20.5%, P = .003) rates significantly increased in patients who had TTS > 24 hours. Cox regression analysis yielded a hazard ratio of 4.385 (P < .001) for the TTS > 24 hours group. CONCLUSIONS: Prompt treatment is required for patients who have hip PPF to reduce mortality and overall complications.

Locking plate for periprosthetic femoral fractures according to Vancouver C: Outcome and radiological subanalysis of 40 patients.

PURPOSE: Periprosthetic femoral fractures (PFF) according to type Vancouver C are less common and outcome is limited reported. Therefore, we conducted this retrospective single center study. METHODS: We performed analysis of patients who underwent open reduction and internal fixation (ORIF) with locking plates for PPF occurring distally of a primary standard hip stem. Data on demographics, revisions, fracture patterns, and mortality were evaluated. At least two years after operation, we examined outcome using the Parker and Palmer mobility score. Primary aim of this study was revision, outcome and mortality. Secondary aim was evaluation of fracture subtypes within type Vancouver C fractures. RESULTS: Between 2008 and 2020, 383 patients with periprosthetic femoral fracture after hip replacement were surgically treated according to our database. Among them, 40 patients (10.4%) with type Vancouver C fractures were enrolled for this study. The mean patient age was 81.5 years (59-94) at the time of fracture. Thirty-three patients were women, and 22 fractures were on the left side. Without exception, locking plates were used. The 1-year mortality rate for the sample was 27.5% (n = 11). Three revisions (7.5%) were performed for plate breakage. Rate of infection and non-union was zero. Three different fracture patterns were assessed: (1) transverse or oblique fractures below the tip of the stem (n = 9); (2) spiral-shaped fractures within the diaphysis (n = 19); and (3) burst fractures at the supracondylar region (n = 12). Demographic or outcome effects between fracture patterns were not found. On average of 4.2 years (2.0-10.4) after treatment, the mean reported Parker score was 5.5 (1-9). CONCLUSION: ORIF with a single lateral locking plate is safe for type Vancouver C fractures with a well-fixed hip stem. Therefore, we do not recommend routinely revision arthroplasty or orthogonal double plating. Three subtypes of fractures within Vancouver C demonstrated no significant differences in baseline data and outcome.

[Treatment aspects of interprosthetic femur fractures-retrospective analysis of 70 patients]. / Therapieaspekte interprothetischer Femurfrakturen ­ retrospektive Analyse von 70 Patienten.

BACKGROUND: Interprosthetic femur fractures (IFF) are rare injuries, whose surgical treatment is basically with osteosynthesis or revision arthroplasty. Various therapy algorithms have been proposed based on very small study collectives. Factors influencing the outcome are not known. OBJECTIVES: The aim of the retrospective monocentric study is to derive a treatment algorithm based on a large number of cases and to identify factors influencing the outcome. MATERIALS AND METHODS: Between 2006 and 2020, 70 IFF were identified. The surgical treatment comprised 38 osteosyntheses, 30 revision arthroplasties and 2 amputations. With classification and time to surgery, 69 perioperative variables were recorded. General and operative complications, as well as mortality, were determined in the follow-up period of 1 year. RESULTS: ASA and Charlson score correlated with 1­year-mortality. In addition, preoperatively increased CRP levels, reduced hemoglobin and the CHA2DS2-VASc score were identified as factors influencing mortality. Surgery within 24 h showed a trend towards fewer general complications. Transferred patients indicated an increased mortality. Based on classification according to Pires et al. or Füchtmeier et al. no clear treatment decision could be made. Relevant criteria for the surgical treatment were fracture localization, implant stability, bone vitality, anchoring possibility of the revision stem, as well as general condition of the patient. CONCLUSIONS: The identified factors influencing the outcome correspond to those of patients with hip fractures. IFF should be treated timely. A treatment path was developed on the basis of the largest patient group to date.

[Survival of proximal femoral fractures vs. mean life expectancy of the general population : Retrospective analysis of 1000 geriatric patients minimum 10 years after operation]. / Überlebenszeit proximaler Femurfrakturen vs. mittlere Lebenserwartung der Allgemeinbevölkerung : Retrospektive Analyse 1000 geriatrischer Patienten mindestens 10 Jahre postoperativ.

BACKGROUND: Surgery for geriatric proximal femoral fractures (PF) is associated with high mortality rates within the first year. Studies with follow-up of at least 10 years after surgery are lacking. MATERIAL AND METHODS: Based on our database, we reviewed patients with PF who underwent surgery and were followed for a minimum of 10 years. Only patients aged 65-99 years were included. The primary endpoint was survival compared to the mean life expectancy of the general population evaluated by the German Federal Statistical Office. The secondary endpoint was any revision later than 1 year after surgery. After a minimum of 10 years telephone calls were conducted with living patients or their relatives. RESULTS: From a total of 1203 consecutive patients 1000 patients with 1000 PF were evaluated after a mean of 12.2 years (range 10.0-14.0 years). The mean survival was 4.5 ± 1.6 years, and the 10-year survival rate was 13.1%. A total of 7 periods with a range of 5 years were analyzed, starting from 65-69 years up to 95-99 years. Compared to the mean life expectancy of the general population, the survival rate of the sample was significantly shorter up to 9 years. Both genders were equally affected. With increasing age, this gap declined based on shorter life expectancy. A subgroup analysis revealed that patients with survival > 1 year did not demonstrate significantly better results. Revisions later than 1 year after the index surgery were infrequent, and only 27 (2.7%) were recorded. CONCLUSION: Geriatric patients with PF have significantly shorter life expectancy than the general population evaluated by the German Federal Statistical Office. This reflects fragility and morbidity of patients with PF.

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

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

Factors associated with infection recurrence after two-stage exchange for periprosthetic hip infection.

PURPOSE: Two-stage exchange is the treatment of choice for periprosthetic joint infection (PJI). Factors and outcomes associated with infection recurrence for hip PJI are limited. The primary aim of this study was to determine factors associated with infection recurrence after two-stage exchange. Secondary aims were survival, mobility, and the EuroQol five-dimension scale (EQ-5D-5L) health state. METHODS: We retrospectively investigated patients with two-stage exchange for hip PJI at our institution from 2006 to 2017. Follow-up was conducted for a minimum of four years after the reimplantation. RESULTS: We included 135 patients with 139 hip PJIs. The mean age of the patients was 69.6 years (range 32-88). The infection recurrence rate was 14.4% (n = 20) after a mean follow-up of 8.0 years (range 4.0-13.1). Four factors for recurrence were identified at the time of the first stage: previous orthopaedic diagnoses (p < 0.001), type of explanted prosthesis (p = 0.004), cultured microorganisms (p = 0.033), and sinus tract (p = 0.035). A longer surgical reimplantation time (p = 0.015) was the only one factor found at the second stage. The estimated Kaplan-Meier survival for the total sample was 9.0 years (95% confidence interval 8.3-9.8), without significant difference for those with infection recurrence compared to recurrence-free patients (log-rank 0.931). At the time of follow-up, 89 patients were alive. For these patients, Parker mobility score (p = 0.102), EuroQol five-dimensional scale (p = 0.099), and EQ Visual Analogue Scale (EQ-VAS) (p = 0.027) were inferior in those with infection recurrence, but significance was found only for VAS. CONCLUSION: In this study with mid- to long-term follow-up, five factors for infection recurrence were identified. Recurrence did not affect survival, but health-related quality of life was inferior compared to recurrence-free patients. The results suggest that the period of the first stage including previous orthopaedic diagnoses requires more consideration in the future.

Two-thousand hip fractures treated within 12 h and > 12-24 h after admission: Are survival and adverse events affected?

BACKGROUND: The effects of immediate operation on hip fracture (HF) are unclear. Therefore, we investigated the influence of time to operation within 12 h vs. > 12-24 h on survival and adverse events. METHODS: This retrospective study was based on our database from 2006 to 2019. Patients ≥ 20 years of age with operations for HF were included. A total of 40 characteristics were analyzed for operations within 12 h (group 1) and > 12-24 h (group 2) after admission. The primary endpoint was survival at 1 year after operation. Secondary endpoints were revision surgery for any reason, infection, and serious adverse events. RESULTS: A total of 1015 patients received operations within 12 h (group 1), and 985 patients received operations > 12-24 h (group 2) after admission. The mean age of the patients was 78.8 ± 12.3 years. Patients in group 1 were younger and had better health status and shorter hospitalizations than those in group 2. However, no differences were found for revision surgery, infection or adverse events. The mortality rates at 30 days, 90 days, 6 months, and 1 year were 6.2, 11.8, 15.9, and 21.0%, respectively. The mortality rate at day 30 was significantly better (p = 0.04) in group 1, but no further differences in survival were observed (hazard ratio 1.071; 95% confidence interval 0.864-1.328; log rank 0.179). A subgroup analysis of geriatric patients ≥ 65 years assessed no differences according the primary and secondary endpoints. CONCLUSIONS: Within the limits of single-center analysis, the patients receiving treatment for HF within 12 h were younger and healthier and had the benefits of shorter hospitalizations and a higher 30-day survival rate than patients treated > 12-24 h after admission. At the endpoint 1 year after operation, no differences were observed in adverse events or survival rates.

[Endoprosthetic treatment of pertrochanteric femoral fractures with concomitant coxarthrosis : A consecutive observational study with a control group]. / Endoprothetische Versorgung pertrochantärer Femurfrakturen bei konkomitierender Koxarthrose : Eine konsekutive Beobachtungsstudie mit Vergleichsgruppe.

INTRODUCTION: Hip replacement for pertrochanteric femoral fractures (PF) is challenging due to its complexity. Studies regarding this procedures are limited, therefore this monocentric study was conducted. The null hypothesis was no effect between replacement and internal fixation according to revision and mortality. MATERIAL AND METHODS: Using an electronic database, patients who had received a hip replacement between 2007 and 2016 for a PF with a concomitant coxarthrosis were included in the study. The comparison group consisted of 1000 osteosyntheses for the treatment of PF. With the exception of coxarthrosis, the same inclusion and exclusion criteria were defined. Surgical revision and mortality with endpoint 2 years after the operation were the primary outcomes. At least 2 years postoperatively, a telephone follow-up was done with living patients who underwent replacement. RESULTS: Records of 90 hip replacements and 15 baseline characteristics were reviewed (e.g., age, sex, body mass index, preoperative blood values, ASA classification, dementia, fracture classification). Replacement was significantly associated with a delay to operation (p < 0.001), a longer duration of operation (p < 0.001), an increased blood loss (p < 0.001), more blood transfusions (p < 0.001), and a longer inpatient stay (p = 0.026). According to the primary outcome, the mortality rate (p = 0.002) and the rate of infection in a subgroup analysis (p = 0.031) were also significantly increased. Using Cox regression, replacement was associated with a significantly higher probability of a shorter survival rate (odds ratio: 1.438, confidence interval: 1.054-1.962). Therefore, the null hypothesis was rejected. At the follow-up 6.1 years postoperatively (3.2-8.6 years), only 17 patients with replacement (20%) were still alive. The mean Parker mobility score was 5.0 points (range 3-9 points). CONCLUSION: In this study, a significantly higher rate of infection and mortality was observed in patients with hip replacement for a PF and with a concomitant coxarthrosis; compared to osteosynthesis of PF without coxarthrosis. Further studies are mandatory to provide the appropriate treatment for patients with this fracture pattern.

[Residency program under scrutiny (part 2)-How do residents prepare for emergency operations?] / Weiterbildung unter der Lupe (Teil 2) ­ Wie bereiten sich Weiterbildungsassistenten auf Notfalloperationen vor?

BACKGROUND: Postgraduate medical education in trauma and orthopedic surgery residents largely relates to learning and teaching surgery. During this crucial stage of surgical development some of the didactic challenges are caused by heterogeneous and contradictory expectations of trainees and trainers alike. So how do residents prepare for emergency surgery? To date there is neither an expert consensus nor scientific investigations in the clinical context on this topic. METHODS: Between February and April 2015 questionnaires were issued to all physicians active in the field of trauma and orthopedic surgery within the Trauma Network East Bavaria (27 clinics, 255 physicians). The participants were asked to rate the importance of certain elements functioning in the preparation of two emergency operations using a Likert scale. The intensity with which residents generally realize these elements of preparation was also documented. The aim was to objectify if and to what extent the presumed normal practices diverge from clinical reality. RESULTS: A total of 150 questionnaires were analyzed (return rate 59%). Discussion with the consultant (85.3%, n = 128), examination of the patient (80.0%, n = 120), surgical approach (76.0%, n = 114) and study of patient files (68.0%, n = 102) were considered to be the most important elements; however, many of the participants admitted that these elements of preparation are not sufficiently performed. CONCLUSION: The personal preparation of residents for an emergency operation should be classified as extremely important; however, the requirements and reality do not seem to hold true in the clinical environment. This seems to be most likely due to structural and organizational issues.

Parkinson's disease and hip fractures: Are complications and mortality rates increased?

PURPOSE: The aim of this study was to assess patients with Parkinson's disease (PD) in comparison with patients without PD for the treatment of hip fractures. Therefore, we performed a mono-centre study including 145 patients with PD and 2135 consecutive patients without PD as a concurrent group (C). METHODS: For analysis, we used our database, in which any type of hip fracture was enrolled. The study period ranged from 2007 to 2017, and the patient age was ≥ 60 years. Overall, 10 variables were included. The primary measures were operations for any reason, infection, dislocation, failure, and mortality. The secondary outcome was any de novo fracture based on a new fall. The follow-up period for every living patient was 2 years after the operation. Any missing data were retrospectively evaluated via telephone. The hypothesis was no effect between the two groups. RESULTS: No significant differences were observed regarding revision (p = 0.348), infection (p = 0.207), dislocation (p = 0.785), failure of internal fixation (p = 0.368), failure of replacement (p = 0.174), and de novo fractures (p = 0.287). However, patients with PD sustained a contralateral hip fracture significantly more often (p < 0.001). Kaplan-Meier survival analysis demonstrated no effects up to 2 years after the operation (log rank 0.259). CONCLUSION: Compared to a concurrent group, patients with PD demonstrated no more complications and similar mortality rates within 2 years after surgery. The rate of dislocation after hip replacement was also not increased. A contralateral hip fracture was the most common de novo fracture in PD. Further studies should investigate measures reducing the risk for any new falls in PD.

Internal fixation and revision arthroplasty for interprosthetic femoral fractures: a case series of fifty patients.

PURPOSE: The aim of this study was to assess patients treated for interprosthetic femoral fractures (IFFs). METHOD: Based on our database, we performed a retrospective single-center analysis of patients who underwent surgery for the treatment of IFFs. We evaluated patient demographics, fracture patterns, type of surgery, revision, and mortality for a minimum of one year after treatment. Outcomes were assessed via telephone using the Parker score. RESULTS: Fifty consecutive patients were enrolled. An analysis of fracture patterns revealed three different types: proximal (n = 19), intermediate (n = 13), and distal (n = 18). Treatment included internal fixation for stable components and revision arthroplasty for loose implants; and a lateral locking plate was the most commonly applied device. The mean follow-up time of the total sample was 5.7 years after the operation. The total revision rate was 22%, and the highest revision rate was documented for revision arthroplasty. The one year mortality rate for the sample was 14%, and fracture patterns and treatment revealed no effects on mortality. Living patients (n = 23) were followed up for an average of 4.9 years after treatment. Only six patients reported the best Parker score (mean, 5.0; range 0-9). CONCLUSION: IFFs can be divided into three groups irrespective of the type of stem or bone quality, but fixation (stable or loose) must also be considered to determine the treatment. Fracture patterns and treatment revealed no effects on mortality. There are many treatment options but no single solution for IFFs.

PFNA and DHS for AO/OTA 31-A2 fractures: radiographic measurements, morbidity and mortality.

PURPOSE: For this retrospective cohort study, we assessed pertrochanteric fracture types AO/OTA 31-A2. PFNA and DHS were the devices used. We determined both devices in relation to peri-operative variables, postoperative radiographic measurements, implant-related complications and mortality up to 2 years. The null hypothesis was no effect between the two devices. METHODS: This single-centre study was conducted based on our computerized data. The treatment period ranged from 2006 to 2015. Only patients with type AO/OTA 31-A2 fractures and an age ≥ 65 years were included. Apart from descriptive variables, the following measurements were assessed: (1) duration of surgery, (2) blood loss, (3) transfusion, (4) hospitalization, (5) tip-apex distance (TAD), (6) fracture reduction, (7) screw position, (8) implant-related complications, and (9) mortality. The follow-up was 2 years for each living patient. Missing data were evaluated by telephone call. RESULTS: A total of 375 consecutive patients were enrolled into three groups: (1) 75 patients treated with DHS and antirotation screw (ARS); (2); 100 patients treated with DHS + ARS + TSP (trochanteric stabilization plate); and (3) 200 patients treated with PFNA. Apart from dementia, the descriptive data (e.g., age and BMI) demonstrated no effects between the three groups. Compared to PFNA, DHS with or without TSP was adversely affected by a longer operation time, higher blood loss, increase in transfusion, and more implant-related complications including cut-out, infection and failure. The rate of cut-out was significantly higher in TAD ≥ 25 mm (p = 0.005), and PFNA demonstrated significantly better TAD measurements (p = 0.001), better fracture reduction (0.002), more central-central screw positions (p = 0.014), and less poor screw placement (p = 0.001). The mortality rate was without effect between the three groups (log rank 0.698). CONCLUSIONS: DHS with or without TSP was associated with significantly higher rates of implant-related complications based on inferior radiographic measurements. Therefore, we only recommend PFNA for the treatment of proximal type AO/OTA 31-A2 femoral fractures. LEVEL OF EVIDENCE: Therapeutic level III.

Total Hip Arthroplasty for Hip Fractures: Time to Surgery With Respect to Surgical Revision, Failure, and Mortality.

INTRODUCTION: There are increasing demands to perform surgery of hip fractures without delay. However, few studies have assessed the time to surgery in relation to outcome measurements. METHODS: A total of 643 consecutive patients with a minimum age of 60 years underwent total hip arthroplasty (THA) for an intracapsular hip fracture. For this retrospective case series, demographic data and the outcome measurements-(1) any surgical revision, (2) implant failure, and (3) mortality-were documented from a prospective clinical database. The time from admission to surgery was also documented prospectively and then data were divided into 4 groups according to the time of surgery: (1) within 12 hours, (2) >12 to 24 hours, (3) >24 to 48 hours, and (4) later than >48 hours. The study end point was 2 years after surgery. Final evaluation was conducted for any missing data through a telephone interview. RESULTS: The patients comprised 456 women (70.9%) and 187 men (29.1%) with a mean age of 80.2 years (range 60-104 years; standard deviation ±7.4). Descriptive data were without effect in all 4 groups. Time to surgery did not significantly influence revision for any reason (P = .323), implant failure (P = .521), and mortality (P = .643). Cox regression analysis identified male sex (P < .001; 95% confidence interval (CI), 1.27-2.44), American Society of Anesthesiologists score ≥3 (P < .001; 95% CI, 2.12-21.59), C-reactive protein level >21 mg/L (P < .018; 95% CI, 1.09-2.60), hemoglobin level <12.0 g/dL (P = .033; 95% CI, 1.04-2.68), and dementia (P < .000; 95% CI, 1.50-2.86) as independent significant risk factors for mortality. CONCLUSION: Time to surgery had no effect on revision for any reason, implant failure, and mortality in patients undergoing THA for an intracapsular hip fracture.

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.

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.

[Analysis of 2000 surgically treated proximal femoral fractures : Multiple variables influence mortality]. / Analyse von 2000 operativ versorgten proximalen Femurfrakturen : Multiple Variablen beeinflussen die Mortalität.

BACKGROUND: Due to demographic change, more proximal femoral fractures can be expected in the future. However, accurate growth rates as well as follow-up research extending more than 1 year postsurgery are still lacking. MATERIALS AND METHODS: First, we defined inclusion and exclusion criteria for the retrospective cohort study. Based on these, we collected all surgical interventions conducted between 1 January 2006 and 31 December 2015. For a total of 2000 consecutive procedures, we retrieved and analysed a total of 12 variables influencing mortality. Data were retrieved from the prospectively established database; all patients still alive were contacted by phone, and missing data were collected. The endpoint of the study was consistently set for all patients at 2 years postsurgery. RESULTS: The follow-up rate was 100%. Growth rate increased by 74.1% over a period of 10 years. Mean age of the total population was 79.4 years, and women were predominantly affected (71.7%). Surgical treatment was based on osteosynthesis procedures (57%) using DHS, PFN, or screws, as well as on arthroplasty (43%) performing total hip arthroplasty or implanting large-head prostheses. The revision rate was 14.5%, and mortality 2 years postsurgery was 32.4%. Through a multivariate analysis (Cox regression), the following seven influence factors showed statistically significant impact on mortality: age >82 years, male gender, CRP >10 mg/dl, haemoglobin <12 g/dl, ASA 3 or 4, dementia, and postoperative infection-but not timing of surgery. CONCLUSION: The growth rate of proximal femoral fractures progressed more rapidly than expected. Through a multivariate analysis, a total of six intrinsic variables were verified, which influenced the mortality. The prevention of infection-as the only additional extrinsic factor in this study-represents a more important role than early surgical treatment.

Total hip arthroplasty after failed osteosynthesis of proximal femoral fractures: Revision and mortality of 80 patients.

PURPOSE: Total hip arthroplasty (THA) after failed osteosynthesis for proximal femoral fractures is associated with higher revision rates, particularly for dislocation. The purpose of this study was to report our results with THA after failed osteosynthesis within a treatment period of 10 years. METHODS: A retrospective cohort study including 80 consecutive patients was conducted. After a minimum follow-up of 1 year, we evaluated revision for any cause including dislocation, outcome, and mortality. RESULTS: We performed 48 THAs with standard components only and 32 THAs with revision implants. Routinely, a 36-mm femoral head was used, and trochanteric fixation was performed in one-third of the cases. Total revision rate for any cause was 21%, which included six infections, six periprosthetic fractures, and five hematomas. One hip dislocation was also treated. Treatment with uncemented revision stem revealed significantly higher number of revisions-compared to standard cemented or uncemented stem. The mortality rate after 1 year was 9%, and the mean Parker score at follow-up was 6.6 (range: 0-9). CONCLUSIONS: THA was associated with an increased surgical revision rate, but hip dislocation was documented only once. In most cases, a standard implant with a large 36-mm femoral head size was sufficient. Uncemented revision stem revealed significantly higher number of revisions-compared to standard cemented or uncemented stem. One-year mortality was lower than expected.

Long-term results of surgically treated calcaneal fractures: an analysis with a minimum follow-up period of twenty years.

PURPOSE: Long-term results after treatment of calcaneal fractures are rare. For this reason, we conducted a retrospective follow-up after a minimum of 20 years post surgery. METHODS: Between 1990 and 1994, a total of 66 patients received surgical treatment for displaced calcaneal fractures. At that time, osteosynthesis was performed using small, one-third tubular plates. After collecting empirical data, we conducted a follow-up at least 20 years post surgery using X-ray imaging and clinical questionnaires (AOFAS and SF-36 questionnaire). RESULTS: It was possible to recruit a total of 22/66 patients (33 %) after a mean of 22 years (range, 20-24) post surgery. With regard to the AOFAS scores (mean value, 74 points), 12 showed very good or good results, four showed average and six poor results. Patients with orthopaedic shoes also had low AOFAS scores. The Boehler's angle had been increased from +2° prior to surgery to +21° post-operatively. At the time of follow-up, the mean value was +17°. The angle correlated with the AOFAS score. Also, the SF-36 physical score was clearly reduced when compared to a general population, and correlated significantly with the AOFAS score. CONCLUSION: There is still no evidence that open reduction and internal fixation of calcaneal fractures results in better outcomes than conservative therapy. This has been confirmed by our long-term results that provided disillusioning results: in a small population, only 55 % of the patients showed very good or good clinical overall results. Furthermore, SF-36 showed impaired physical subscores, which correlated significantly with the AOFAS.