Factors associated with dislocation after bipolar hemiarthroplasty through an (antero-)lateral approach in elderly patients with a femoral neck fracture: a retrospective cohort study with a nested case-control subanalysis of radiographic parameters.

INTRODUCTION: Dislocations of hip hemiarthroplasty (HHA) are serious complications. The aim of the study was to identify clinical aspects and radiographic parameters of the hip that put patients at risk for dislocation after HHA for femoral neck fractures. METHODS: This retrospective analysis included elderly patients with a femoral neck fracture treated with a HHA. A lateral (90.7%) and an anterolateral (9.3%) approach was applied. On pelvic radiographs, a nested-controlled analysis was performed. Two control patients were matched to one patient suffering a dislocation with respect to age, sex, and body-mass-index (BMI). RESULTS: In 527 HHA, 10 dislocations (1.9%) were identified. In the dislocation group (DG), all patients were female (100% vs. 73.5%, p = 0.071). No significant differences between the DG and the control group (CG) were found with respect to age, body-mass-index (BMI), ASA Score, routine laboratory parameters, and comorbidity. Radiographic analysis revealed a smaller center edge angle (CEA, 39.0, IQR 33.0-42.5 vs. 43.0, IQR 41.0-46.0, p = 0.013), a more varus neck-shaft angle (NSA, 130.0, IQR 125.8-133.5 vs. 135.0, IQR 134.0-137.0, p = 0.011) of the contralateral side and a higher femoral head extrusion index (FHEI) in the DG (FHEI, 11.5, IQR 9.8-16.3 vs. 2.0 IQR 0.0-9.0, p = 0.003). In addition, a greater trochanteric fracture was associated with an increased likelihood for HHA dislocations (30.0% vs 6.0%, p = 0.022). CONCLUSION: A smaller radiographic center edge angle, a more varus neck-shaft angle of the contralateral side, a higher femoral head extrusion index and intraoperative fractures of the greater trochanter are associated with an increased risk of HHA dislocation.

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.

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.

Free Flap Reconstruction of the Extremities in Patients Who are ≥65 Years Old: A Single-Center Retrospective 1-to-1 Matched Analysis.

PURPOSE: Demographic changes are leading to population aging, and free flap reconstructions for various indications are expected to become increasingly common among older patients. Therefore, this study evaluated free flap reconstruction of the extremities in older patients and compared the outcomes to those from younger patients who underwent similar procedures during the same period. PATIENTS AND METHODS: This single-center retrospective study used a case-control design to compare older and younger patients who underwent free flap reconstruction of soft tissue defects in the extremities. One-to-one matching was performed for older patients (≥65 years) and younger patients (≤64 years) according to indication, flap recipient site, and flap type. The parameters of interest were clinico-demographic characteristics, flap type, defect location, indication for free flap reconstruction, number of venous anastomoses, and postoperative complications (flap loss, infection, and wound healing disorders). RESULTS: The study included 48 older patients and 133 younger patients, with a mean follow-up of 12 months after discharge. The free flap reconstruction was performed at a mean interval of 19.8±22.8 days (range: 0-88 days). The 1:1 matching created 38 pairs of patients, which revealed no significant differences in the rates of flap necrosis and flap failure. CONCLUSION: This study failed to detect a significant age-related difference in the flap necrosis rate after free flap reconstruction of extremity defects. Therefore, with careful perioperative management and patient selection, microsurgical free flap reconstruction is a feasible option for older patients.

Outcomes of tissue reconstruction in distal lower leg fractures: a retrospective cohort study.

BACKGROUND: Open and closed fractures can be associated with posttraumatic or postoperative soft tissue defects caused by initial trauma, operative procedures, or infections. This study evaluated the postoperative outcomes in patients with open or closed lower leg fractures, related soft tissue defects, and subsequent flap coverage. METHODS: We performed a retrospective single-center cohort study in a level 1 trauma center. We analyzed the patients treated from January 2012 through December 2017 and recorded demographics, treatment, and outcome data. The outcome data were measured via patient-reported Foot and Ankle Outcomes Scores (FAOS) and EQ-5D-5L scores. RESULTS: We included 22 patients with complicated fractures (11 open and 11 closed) and subsequent soft tissue defects and flap coverages. The mean follow-up time was 41.2 months. Twenty-one patients developed infections, and necrosis at the site of surgery manifested in all closed fractures. Therefore, all patients needed soft tissue reconstructions. Preoperatively, 16 patients underwent arterial examinations via angiography and six underwent ultrasound examinations of the venous system. Ten patients had complications involving the flaps due to ischemia and consequent necrosis. The mean EQ-5D index was 0.62 ± 0.27, and EQ-5D VAS score was 57.7 ± 20.2. The mean FAOS was 60.7 ± 22.2; in particular, quality of life was 32.3 ± 28.8. The rate of returning to work in our patient group was 37.5% after 1 year. CONCLUSIONS: Distal tibial fractures often require revisions and soft tissue reconstruction. The evaluated patient population had poor outcomes in terms of function, quality of life, and return to work. Furthermore, patients suffering from flap ischemia have worse outcomes than those without flap ischemia.

Technical limitations of REBOA in a patient with exsanguinating pelvic crush trauma: a case report.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective adjunct in hemodynamic unstable patients with uncontrolled and non-compressible torso hemorrhage promoting temporary stability during injury repair. The aim of our study was to analyze real life usability of REBOA based on a case report and to review the literature with respect to its possibilities and limitations. CASE PRESENTATION: We present the case of a 17-years old female patient who sustained a severe roll-over trauma and pelvic crush injury as a bicyclist by a truck. Upon arrival of the first responders, the patient was awake, alert, and following commands.Subsequent to lifting the truck, the patient became hypotensive and required cardiopulmonary resuscitation, application of a pelvic binder, and endotracheal intubation at the accident scene. She was then admitted by ambulance to our trauma center under ongoing resuscitative measures. After primary survey, it was decided to perform a REBOA with surgical approach to the left femoral artery. Initial insertion of the catheter was successful but could not be advanced beyond the inguinal region. Hence, the patient was transferred to the operating room (OR) but died despite maximum therapy. In the OR and later autopsy, we found a long-distance ruptured and dehiscent external iliac artery with massive bleeding into the pelvis in the context of a bilateral vertical shear fractured pelvic bone. CONCLUSION: REBOA can be a useful adjunct but there is a major limitation with potential vascular injury after pelvic trauma. In these situations, cross-clamping the proximal aorta or pre-peritoneal pelvic packing as "traditional" approaches of hemorrhage control during resuscitation may be the most considerable methods for temporary stabilization in severely injured trauma patients. More clinical and cadaveric studies are needed to further understand indications and limitations of REBOA after severe pelvic trauma.