Minimally invasive cerclage at the tibia using a modified Goetze technique: An anatomical study.

INTRODUCTION: The use of minimally invasive cerclages at the tibia is not very common. First, clinical results of a new operative technique published recently showed no increased complication rate. The aim of this anatomical study was to determine, if it is possible to introduce a minimally invasive cerclage at different levels of the tibia without encasing relevant nerves, vessels or tendons into the cerclage using this technique. HYPOTHESIS: The minimally invasive introduction of a cerclage at the tibia is possible without encasing relevant anatomical structures. MATERIAL AND METHODS: Using the minimally invasive operative technique in 10 human cadaveric lower legs, cerclages were inserted at 4 different levels of each tibia. They were defined from proximal to distal as level 1-4. The legs were severed at the levels of the cerclages and examined for any relevant encased anatomical structures. Afterwards, the shortest distance between each relevant anatomical structure and the cerclage was measured. RESULTS: There was no encasing of any relevant anatomical structures in any specimen at any level. In the proximal half of the lower leg, the closest anatomical structures to the inserted cerclage were arteria et vena tibialis posterior (at level 1: 5.2 resp. 4.3mm, at level 2: 4.0 resp. 5.5mm). In the distal half of the lower leg arteria et vena tibialis anterior (level 3: 1.8 and 2.0mm, level 4: 1.6 and 1.5mm), nervus fibularis profundus (level 3: 2.2mm, level 4: 1.2mm) and the tendon of musculus tibialis posterior (level 3: 0.8mm, level 4: 1.1mm) were in closest proximity of the cerclage. DISCUSSION: The results of this anatomical study suggest that the minimally invasive insertion of cerclages at the tibia without encasing relevant anatomical structures is possible but requires a correct operative technique. The structures at highest risk are arteria et vena tibialis posterior in the proximal half of the tibia and arteria et vena tibialis anterior, nervus fibularis profundus and the tendon of musculus tibialis posterior in the distal half. LEVEL OF EVIDENCE: Not applicable; experimental anatomical study.

Clinical effects of different center of rotation reconstructions in total hip arthroplasty after femoral neck fractures: a cohort study including a follow-up analysis on patient's mobility and daily living ability.

BACKGROUND: The aim of this study is a clinical evaluation of the center of rotation (COR) placement towards a patient's recovery with respect to daily living ability and mobility. In past experiments based on three-dimensional (3D) models, medialization of the COR in total hip arthroplasty (THA) showed a negative influence on muscle strength of the abductors and reaction force of the hip joint. This contradicts paradigms, where reduced hip loading forces are claimed to increase functional outcomes. METHODS: The plain X-rays of 110 patients who underwent THA after a femoral neck fracture between January 2019 and January 2021 were retrospectively evaluated. A Barthel Index on discharge was obtained in 69 cases. 47 patients were available for a follow-up interview concerning the Barthel Index, Parker mobility score (PMS), and pain levels (NRS) 6 and 12 months after surgery. RESULTS: Medialization of the COR had a significantly negative effect on the need for care (Barthel Index) at patient discharge (Spearman correlation 0.357, p = 0.013). The effect on the PMS is still existent at 6 and 12 months (Spearman correlation 0.471, p = 0.009 at 6 months; 0.472, p = 0.008 at 12 months). Mann-Whitney U tests showed that the groups with medialized COR performed significantly worse than the lateralized groups. This was seen for the Barthel Index at discharge and at 6 months after surgery and for the PMS at 6 and 12 months. The accurately reconstructed CORs showed no significant differences from the lateralized rotation centers in need of care and mobility. The superior COR placement group showed significantly reduced mobility at 12 months in contrast to the inferior COR placement group (p = 0.008), and the group of accurately reconstructed rotation centers showed significantly less pain than the inferior COR placement group (p = 0.007 after 6 months, p = 0.026 after 12 months). Especially the combination of both (superomedialization) leads to reduced mobility (Spearman correlation 0.67, p = < 0.001). CONCLUSIONS: COR superior displacement, COR medialization, and the combination of both (superomedialization, Spearman p = < 0.001) lead to reduced mobility while inferior displacement showed increased pain. According to our results, we recommend an exact vertical COR restoration, while horizontal medial displacement needs to be avoided. LEVEL OF EVIDENCE: III.

A rare case of periprosthetic joint infection of the hip due to Kocuria spp.

BACKGROUND: Kocuria spp. are ubiquitous bacteria that have gained recent attention as potential infectious agents. The most common bacteria in PJI are S. aureus und S. epidermidis. CASE PRESENTATION: We present the case of a 72-year-old woman who received total hip arthroplasty after a traumatic medial femoral neck fracture. Postoperatively, due to the clinical presentation of periprosthetic joint infection (PJI) revision surgery was performed twice. The microbiological tissue samples were positive for Kocuria spp. Initially, this was considered contamination and the patient was treated with various antibiotic regimens as well as prednisolone due to the differential diagnosis of pyoderma gangraenosum. However, a specialized histopathology lab performed further testing which substantiated the suspicion of a rare case of PJI due to Kocuria spp. CONCLUSIONS: To our knowledge, this is the first reported case of a PJI caused by Kocuria spp. Further clinical research is necessary to assess whether Kocuria spp. are an underestimated cause of PJI.

A comprehensive analysis of intraoperative factors associated with acute-on-chronic kidney injury in elderly trauma patients: blood loss as a key predictor.

BACKGROUND: Postoperative acute kidney injury (AKI) is a critical issue in geriatric patients with pre-existing chronic kidney disease (CKD) undergoing orthopedic trauma surgery. The goal of this study was to investigate modifiable intraoperative risk factors for AKI. METHODS: A retrospective study was conducted on 206 geriatric patients with CKD, who underwent orthopedic trauma surgery. Several variables, including intraoperative blood loss, postoperative hypoalbuminemia, intraoperative blood pressure and long-term use of potentially nephrotoxic drugs, were analyzed. RESULTS: Postoperative AKI (KIDGO) was observed in 25.2% of the patients. The 1-year mortality rate increased significantly from 26.7% to 30.8% in patients who developed AKI. Primary risk factors for AKI were blood loss (p < 0.001), postoperative hypoalbuminemia (p = 0.050), and potentially nephrotoxic drugs prior to admission (angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, diuretics, antibiotics, NSAIDs) (p = 0.003). Furthermore, the AKI stage negatively correlated with propofol dose per body weight (p = 0.001) and there was a significant association between AKI and the use of cement (p = 0.027). No significant association between intraoperative hypotension and AKI was observed in any statistical test. Femur fracture surgeries showed the greatest blood loss (524mL ± 357mL, p = 0.005), particularly intramedullary nailing at the proximal femur (598mL ± 395mL) and revision surgery (769mL ± 436mL). CONCLUSION: In geriatric trauma patients with pre-existing CKD, intraoperative blood loss, postoperative hypoalbuminemia, and pre-admission use of potentially nephrotoxic drugs are associated with postoperative AKI. The findings highlight the necessity to mitigate intraoperative blood loss and promote ortho-geriatric co-management to reduce the incidence and subsequent mortality in this high-risk population.

Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial.

PURPOSE: Tibial shaft spiral fractures and fractures of the distal third of the tibia (AO:42A/B/C and 43A) frequently occur with non-displaced posterior malleolus fractures (PM). This study investigated the hypothesis that plain X-ray is not sufficient for a reliable diagnosis of associated non-displaced PM fractures in tibial shaft spiral fractures. METHODS: 50 X-rays showing 42A/B/C and 43A fractures were evaluated by two groups of physicians, each group was comprised of a resident and a fellowship-trained traumatologist or radiologist. Each group was tasked to make a diagnosis and/or suggest if further imaging was needed. One group was primed with the incidence of PM fractures and asked to explicitly assess the PM. RESULTS: Overall, 9.13/25 (SD ± 5.77) PM fractures were diagnosed on X-ray. If the posterior malleolus fracture was named or a CT was requested, the fracture was considered "detected". With this in mind, 14.8 ± 5.95 posterior malleolus fractures were detected. Significantly more fractures were diagnosed/detected (14 vs. 4.25/25; p < 0.001/14.8 vs. 10.5/25; p < 0.001) in the group with awareness. However, there were significantly more false positives in the awareness group (2.5 vs. 0.5; p = 0.024). Senior physicians recognized slightly more fractures than residents (residents: 13.0 ± 7.79; senior physicians: 16.5 ± 3.70; p = 0.040). No significant differences were demonstrated between radiologists and trauma surgeons. The inner-rater reliability was high with 91.2% agreement. Inter-rater reliability showed fair agreement (Fleiss-Kappa 0.274, p < 0.001) across all examiners and moderate agreement (Fleiss-Kappa 0.561, p < 0.001) in group 2. CONCLUSION: Only 17% of PM fractures were identified on plain X-ray and awareness of PM only improved diagnosis by 39%. While experiencing improved accuracy, CT imaging should be included in a comprehensive examination of tibial shaft spiral fractures. LEVEL OF EVIDENCE: II. Diagnostic prospective cohort study. TRAIL REGISTRATION NUMBER: DRKS00030075.

Early surgery? In-house mortality after proximal femoral fractures does not increase for surgery up to 48 h after admission.

PURPOSE: The economic cost linked to the increasing number of proximal femur fracture and their postoperative care is immense. Mortality rates are high. As early surgery is propagated to lower mortality and reduce complication rates, a 24-h target for surgery is requested. It was our aim to determine the cut-off for the time to surgery from admission and therefore establish a threshold at which the in-house mortality rate changes. METHODS: A retrospective single-center cohort study was conducted including 1796 patients with an average age of 82.03 years treated operatively for a proximal femoral fracture between January 2016 and June 2020. A single treatment protocol was performed based on the type of anticoagulant, surgery, and renal function. Patient data, surgical procedure, time to surgery, complications, and mortality were assessed. RESULTS: In-house mortality rate was 3.95%, and the overall complication rate was 22.7%. A prolonged length of hospital stay was linked to patient age and occurrence of complications. Mortality is influenced by age, number of comorbidities BMI, and postoperative complications of which the most relevant is pneumonia. The mean time to surgery for the entire cohort was 26.4 h. The investigation showed no significant difference in mortality rate among the two groups treated within 24 h and 24 to 48 h while comparing all patients treated within 48 h and after 48 h revealed a significant difference in mortality. CONCLUSIONS: Age and number of comorbidities significantly influence mortality rates. Time to surgery is not the main factor influencing outcome after proximal femur fractures, and mortality rates do not differ for surgery up to 48 h after admission. Our data suggest that a 24-h target is not necessary, and the first 48 h may be used for optimizing preoperative patient status if necessary.

Arthroscopic rod technique compared to stress ultrasound in the dynamic evaluation of lateral ligament instabilities of the elbow.

INTRODUCTION: The purpose was to compare the arthroscopic rod technique to stress ultrasound in the dynamic assessment of lateral elbow instabilities. MATERIALS AND METHODS: Fifteen elbows of eight specimen with a mean age of 66.4 ± 13.3 years were assessed in a prone position following a defined dissection setup. After evaluation of the native status, an arthroscopic dissection of the radial collateral ligament (RCL) or lateral ulnar collateral ligament (LUCL), and finally of entire capsuloligamentous structures was performed. Three raters examined each state (native, RCL or LUCL lesion, complete lesion) with the arthroscopic rod technique in 90° flexion and with stress ultrasound in 30 and 90° flexion. The intra-class correlation coefficient (ICC) was calculated to assess the interrater reliability as well as test-retest reliability for each testing modality (arthroscopy and ultrasound). RESULTS: The arthroscopic rod technique showed a superior interrater and test-retest reliability of 0.953 and 0.959 (P < 0.001), respectively, when compared to stress ultrasound with an ICC of 0.4 and 0.611 (P < 0.001). A joint space opening during arthroscopy of > 6 mm humero-ulnar or > 7 mm humero-radial was indicative for a lateral collateral ligament lesion. However, a differentiation between an isolated RCL or LUCL tear was not possible. A lateral joint opening of ≥ 9 mm was only observed in complete tears of the lateral capsuloligamentous complex. CONCLUSIONS: The arthroscopic rod technique showed a superior interrater and test-retest reliability when compared to stress ultrasound. Arthroscopic assessment for radial elbow instability was found to be reliable and reproducible. A joint gapping ≥ 9 mm in the arthroscopic evaluation is a sign for a complete insufficiency of the radial capsuloligamentous complex. However, it is not possible to precisely distinguish between a lesion of the RCL or LUCL by arthroscopy. On the basis of our results, dynamic ultrasound testing may be inappropriate to objectify lateral elbow instability.

Anticoagulants and fracture morphology have a significant influence on total blood loss after proximal femur fractures.

INTRODUCTION: Blood loss after proximal femoral fractures is an important risk factor for postoperative outcome and recovery. The purpose of our study was to investigate the total blood loss depending on fracture type and additional risks, such as anticoagulant use, to be able to recognize vulnerable patients depending on planned surgery and underlying comorbidities. MATERIALS AND METHODS: A retrospective single center study including 1478 patients treated operatively for a proximal femoral fracture between January 2016 and June 2020 at a level I trauma center. Patient data, surgical procedure, time to surgery, complications and mortality were assessed. Lab data including hemoglobin and transfusion rates were collected. The Mercuriali formula was implemented to calculate total blood loss. Linear regression was performed to identify influencing factors. RESULTS: One thousand four hundred seventy-eight mainly female patients were included in the study (mean age: 79.8 years) comprising 667 femoral neck fractures, 704 pertrochanteric- and 107 subtrochanteric fractures. Nearly 50% of the cohort were on anticoagulants or anti- platelet therapy. At time of admission average hemoglobin was 12.1 g/l. Linear regression proved fracture morphology, age, BMI, in-house mortality and anticoagulant use to have crucial influence on postoperative blood loss. Femoral neck fractures had a blood loss of 1227.5 ml (SD 740.4 ml), pertrochanteric fractures lost 1,474.2 ml (SD 830 ml) and subtrochanteric femoral fractures lost 1902.2 ml (SD 1,058 ml). CONCLUSIONS: Hidden blood loss is underestimated. Anticoagulant use, fracture type, gender and BMI influence the total blood loss. Hemoglobin levels should be monitored closely. Within 48 h there was no increased mortality, so adequate time should be given to reduce anticoagulant levels and safely perform surgery.

Do anticoagulants impact the "in-house mortality" after surgical treatment of proximal femoral fractures-a multivariate analysis.

PURPOSE: The prevalence of proximal femur fractures is increasing with rising population age. Patients are presenting with more comorbidities. Anticoagulants create a challenge for the necessary early surgical procedure (osteosynthesis or arthroplasty). Our aim was to investigate the influence of anticoagulants on in-house mortality after surgical treatment of proximal femoral fractures. METHODS: A retrospective single-centre study was conducted including 1933 patients with an average age of 79.8 years treated operatively for a proximal femoral fracture between January 2016 and June 2020. One treatment protocol was performed based on type of anticoagulant, surgery, and renal function. Patient data, surgical procedure, time to surgery, complications and mortality were assessed. RESULTS: On average, patients with anticoagulants had a delay to surgery of 41.37 hours vs 22.1 hours for patients without (p < 0.000). Anticoagulants were associated with the occurrence of complications. The total complication rate was 22.4%. Patients with complications showed a prolonged time to surgery in comparison to those without (28.9 h vs 24.9 h; p < 0.00). In-house mortality rate was 4% and twice as high for patients on anticoagulants (7.7%; p < 0.00). Whilst there was no significant difference in the mortality rate between surgery within 24 and 48 hours (2.9% vs. 3.8%; p < 0.535), there was a significant increase in mortality of patients waiting more than 48 hours (9.8%; p < 0.001). CONCLUSIONS: Pre-existing anticoagulant therapy in patients with proximal femur fractures is associated with a higher mortality rate, risk of complications and prolonged hospital stay. Further influential factors are age, gender, BMI and time to surgery.

Orthogeriatric co-management: differences in outcome between major and minor fractures.

PURPOSE: Literature shows that orthogeriatric co-management improves the outcomes of patients with hip fractures. Corresponding research with more diverse fragility fracture groups is lacking. Therefore, an examination was performed prospectively as a 2 year-follow-up on an orthogeriatric co-managed ward, comparing relevant outcome parameters for major and minor fragility fractures. METHODS: All patients treated on an orthogeriatric co-managed ward from February 2014 to January 2015 were included and their injuries, orthogeriatric parameters such as the Barthel Index (BI), Parker Mobility Score (PMS) and place of residence (POR). Patients were separated into two groups of either immobilizing major (MaF) or non-immobilizing minor (MiF) fractures. 2 years later, a follow-up was conducted via telephone calls and questionnaires mailed to patients and/or their relatives. RESULTS: 740 (574 major vs. 166 minor injuries) patients were initially assessed, with a follow-up rate of 78.9%. The in-house, 1-year, and 2-year-mortality rates were 2.7, 27.4, and 39.2%, respectively. Mortality was significantly higher for MaF in the short term, but not after 2 years. On average, during the observation period, patients regained their BI by 36.7 points (95% CI: 33.80-39.63) and PMS was reduced by 1.4 points (95% CI: 1.16-1.68). No significant differences were found in the readmission rate, change in BI, PMS or POR between the MaF and MiF groups. CONCLUSION: The relevance of orthogeriatric treatment to improving functional and socioeconomic outcomes was confirmed. The similarity of the results from both fracture groups emphasizes the need for a multidisciplinary approach also for minor fractures.

Accompanying injuries in tibial shaft fractures: how often is there an additional violation of the posterior malleolus and which factors are predictive? A retrospective cohort study.

INTRODUCTION: An undislocated fracture of the posterior malleolus is a common concomitant injury in tibial shaft spiral fractures. Nevertheless, these accompanying injuries cannot always be reliably assessed using conventional X-rays. Thus, the aim of the study is to evaluate how often a fracture of the posterior malleolus occurs with tibial shaft fractures (AO:42A/B/C and AO:43A) and which factors-identifiable in conventional X-rays-are predictive. METHODS: Retrospective evaluation of X-ray and CT images revealed a total of 103 patients with low-energy tibial shaft fractures without direct joint involvement. Proximal fractures and fractures involving the knee were excluded. Basic data on injury, the trauma mechanism, the path of the fracture, bony avulsions of the posterior syndesmosis and the procedures performed were evaluated. RESULTS: Thirty-nine fractures were located in the middle third of the tibia, 64 in the distal third. In 65 cases, a spiral fracture (simple or wedge fracture) was found. In 31/103 fractures, an additional osseous avulsion of the posterior syndesmosis could be detected, 5 (16.1%) of them were not recognized preoperatively due to an absence of CT imaging. In three of these patients, a fracture of the posterior malleolus was only recognized postoperatively, and an additional surgery was necessary. The spiral fractures were classified in the a.p. X-ray according to their path from lateral proximal to medial distal (Type A) or from medial proximal to lateral distal (Type B). A Pearson chi-square test and Fisher's exact test showed a highly significant accumulation of accompanying posterior malleolus fractures for type A fractures (p = 0.001), regardless of the location of the fracture. In addition, the fractures with involvement of the posterior malleolus had a significantly higher proportion in the fractures of the distal third (p = 0.003). There was no statistically significant relationship between the height of the fracture and the path of the fracture (type A or B). These two factors seem to be independent factors for participation of the posterior malleolus. CONCLUSION: In 40.6% of the tibial shaft fractures in the distal third, in 56.9% of the type A spiral fractures and in 67.6% of the type A fractures in the distal third, the ankle joint is involved with bony avulsion of the posterior syndesmosis, which is not always recognized in conventional X-rays. To avoid complications such as additional operations, instability and post-traumatic arthrosis, we recommend preoperative imaging of the ankle using CT for these fractures. LEVEL OF EVIDENCE: III, retrospective cohort study. TRAIL REGISTRATION NUMBER: DRKS00024536.

Supplemental cerclage wiring in angle stable plate fixation of distal tibial spiral fractures enables immediate post-operative full weight-bearing: a biomechanical analysis.

PURPOSE: Distal tibial fractures generally require post-operative weight-bearing restrictions. Especially geriatric patients are unable to follow these recommendations. To increase post-operative implant stability and enable early weight-bearing, augmentation of the primary osteosynthesis by cerclage is desirable. The purpose of this study was to identify the stabilizing effects of a supplemental cable cerclage following plate fixation of distal tibial spiral fractures compared to solitary plate osteosynthesis. METHODS: In eight synthetic tibiae, a reproducible spiral fracture (AO/OTA 42-A1.1c) was stabilized by angle stable plate fixation. Each specimen was statically loaded under combined axial and torsional loads to simulate partial (200 N, 2 Nm) and full (750 N, 7 Nm) weight-bearing. Tests were repeated with supplemental cable cerclage looped around the fracture zone. In a subsequent stepwise increased dynamic load scenario, construct stiffness and interfragmentary movements were analyzed. RESULTS: With supplemental cable cerclage, construct stiffness almost tripled compared to solitary plate osteosynthesis (2882 ± 739 N/mm vs. 983 ± 355 N/mm; p < 0.001). Under full weight-bearing static loads, a supplemental cerclage revealed reduced axial (- 55%; p = 0.001) and shear movement (- 83%; p < 0.001), and also lowered shear movement (- 42%; p = 0.001) compared to a solitary plate under partial weight-bearing. Under dynamic loads supplemental cerclage significantly reduced axial (p = 0.005) as well as shear movements (p < 0.001). CONCLUSION: Supplemental cable cerclage significantly increases fixation stiffness and reduces shear movement in distal tibial spiral fractures. This stabilizing effect enables from a biomechanical point of view immediate mobilization without any weight-bearing restrictions, which may improve the quality of care of orthopedic patients and may trigger a change towards early weight-bearing regimes, especially geriatric patients would benefit from.

Prognostic value of orthogeriatric assessment parameters on mortality: a 2-year follow-up.

INTRODUCTION: Since the arise of orthogeriatric co-management patients' outcome and survival has improved. There are several assessment parameters that screen the precondition of orthogeriatric patients including mobility, activities of daily living, comorbidities, place of residence and need for care just to name a few. In a 2-year follow-up on an orthogeriatric co-managed ward the fracture-independent predictive value of typical assessment parameters and comorbidities on the associated mortality was examined. METHODS: All patients treated on an orthogeriatric co-managed ward from February 2014 to January 2015 were included. No fracture entity was preferred. Emphasis was set on following parameters: age, gender, Parker-Mobility Score (PMS), Barthel Index (BI), Charlson-Comorbidity Index (CCI), dementia, depression, sarcopenia, frequent falling, length of stay (LOS), care level (CL) and place of residence (POR). In a 2-year follow-up the patients' death rates were acquired. SPSS (IBM Corp., Armonk, New York, USA) and Cox regression was used to univariately analyze the expression of the mentioned parameters and mortality course over 2 years from discharge. In a multivariate analysis intercorrelations and independent relationships were examined. RESULTS: A follow-up rate of 79.6% by assessing 661 patients was achieved. In the univariate analysis linear inverse correlation between PMS and BI and mortality and a linear positive correlation between CCI and higher mortality were observed. There was also a significant relationship between lower survival and age, dementia, sarcopenia, frequent falling, higher institutionalized place of residence and higher CL. No univariate correlation between 2-year mortality and gender, depression and LOS was found. In the multivariate Cox regression, the only independent risk factors remaining were lower PMS (HR: 1.81; 95%CI: 1.373-2.397), lower BI (HR: 1.64; 95%CI: 1.180-2.290) and higher age per year (HR: 1.04; 95%CI: 1.004-1.067). CONCLUSION: Age, PMS, BI, CCI, preexisting dementia, sarcopenia, frequent falling, POR and CL are univariate predictors of survival in the orthogeriatric context. An independency could only be found for PMS, BI and age in our multivariate model. This underlines the importance of preexisting mobility and capability of self-support for the patient's outcome in terms of survival.

A minimally invasive cerclage of the tibia in a modified Goetze technique: operative technique and first clinical results.

INTRODUCTION: In spiral fractures of the tibia, the stability of an osteosynthesis may be significantly increased by additive cerclages and, according to biomechanical studies, be brought into a state that allows immediate full weight bearing. As early as 1933, Goetze described a minimally invasive technique for classic steel cerclages. This technique was modified, so that it can be used for modern cable cerclages in a soft part saving way. METHOD: After closed reduction, an 8 Fr redon drain is first inserted in a minimally invasive manner, strictly along the bone and placed around the tibia via 1 cm incisions on the anterolateral and dorsomedial tibial edges using a curette and a tissue protection sleeve. Via this drain, a 1.7 mm cable cerclage can be inserted. The fracture is then anatomically reduced while simultaneously tightening the cerclage. Subsequently, a nail or a minimally invasive plate osteosynthesis is executed using the standard technique. Using the hospital documentation system, data of patients that were treated with additional cerclages for tibial fractures between 01/01/2014 and 06/30/2020 were subjected to a retrospective analysis for postoperative complications (wound-healing problems, infections and neurovascular injury). Inclusion criteria were: operatively treated tibial fractures, at least one minimally invasive additive cerclage, and age of 18 years or older. Exclusion criteria were: periprosthetic or pathological fractures and the primary need of reconstructive plastic surgery. SPSS was used for statistical analysis. RESULTS: 96 tibial shaft spiral fractures were treated with a total of 113 additive cerclages. The foregoing resulted in 10 (10.4%) postoperative wound infections, 7 of which did not involve the cerclage. One lesion of the profundal peroneal nerve was detected, which largely declined after cerclage removal. In 3 cases, local irritation from the cerclage occurred and required removal of material. CONCLUSION: In the described technique, cerclages may be inserted additively at the tibia in a minimally invasive manner and with a few complications, thus significantly increasing the stability of an osteosynthesis. How this ultimately affects fracture healing is the subject of an ongoing study.

New ways of treatment of fractures of the humeral shaft: does the combination of intramedullary nail osteosynthesis and cerclage improve the healing process?

INTRODUCTION: The humeral shaft fracture is a rare fracture of the long bones with various treatment options. Dreaded complications such as lesions of the radial nerve or non-unions make the decision for what kind of therapy option more difficult. Biomechanically the upper arm is mostly exposed to rotational forces, which affect intramedullary nail osteosynthesis. Additive cerclage may compensate for these in spiral fractures. The aim of this study is to investigate what effect a combination of intramedullary nail osteosynthesis and limited invasive cerclage has on the rate of healing. In addition, this study addresses the question if complications arise as a result of cerclage. METHODS: In this retrospective study, 109 patients were evaluated, who, during a period of 6 years, underwent operative treatment of a humerus shaft fracture with a combination of intramedullary nail osteosynthesis and additive cerclage. The primary end point was to establish the rate of healing. A secondary end point was to evaluate complications such as infections and damage to the nerve. This was followed by an examination of patient files and X-ray images and a statistical analysis with SPSS. RESULTS AND CONCLUSION: The healing process shows a non-union rate of 2.6%, and complications such as secondary radial nerve lesions of 4.6%. The antegrade intramedullary nail osteosynthesis with limited invasive, additive cerclage reduces the risk of non-union and does not lead to an increased risk of iatrogenic damage to the radial nerve. Wound healing was not impaired and there were no infections through the cerclage in our patient cohort.

Beyond Hip Fractures: Other Fragility Fractures' Associated Mortality, Functional and Economic Importance: A 2-year-Follow-up.

BACKGROUND: Hip fractures are well researched in orthogeriatric literature. Equivalent investigations for fragility-associated periprosthetic and periosteosynthetic femoral, ankle joint, pelvic ring, and rib fractures are still rare.The purpose of this study was to evaluate mortality, functional outcome, and socioeconomic parameters associated to the upper-mentioned fragility fractures prospectively in a 2-year follow-up. METHODS: Over the course of a year, all periprosthetic and periosteosynthetic femoral fractures (PPFF), ankle joint fractures (AJ), pelvic ring fractures (PR), and rib fractures (RF), that were treated on a co-managed orthogeriatric ward, were assessed. Parker Mobility Score (PMS), Barthel Index (BI), place of residence, and care level were recorded. After 2 years, patients and/or relatives were contacted by mailed questionnaires or phone calls in order to calculate mortality and reevaluate the mentioned parameters. RESULTS: Follow-up rate was 77.7%, assessing 87 patients overall. The relative mortality risk was significantly increased for PR (2.9 (95% CI: 1.5-5.4)) and PPFF (3.5 (95% CI: 1.2-5.8)) but not for RF (1.5 (95% CI: 0.4-2.6)) and AJ (2.0 (95% CI: 0.0-4.0)). Every fracture group except AJ showed significantly higher BI on average at follow-up. PMS was, respectively, reduced on average for PR and RF insignificantly, but significantly for PPFF and AJ in comparison to pre-hospital values. 10.0-27.3% (each group) of patients had to leave their homes permanently; care levels were raised in 30.0-61.5% of cases. DISCUSSION: This investigation provides a perspective for further larger examinations. PR and PPFF correlate with significant increased mortality risk. Patients suffering from PPFF, PR, and RF were able to significantly recover in their activities of daily living. AJ and PPFF conclude in significant reduction of PMS after 2 years. CONCLUSION: Any fragility fracture has its impact on mortality, function, and socioeconomic aspects and shall not be underestimated. Despite some fractures not being the most common, they are still present in daily practice.

Incidence, Risk-Factors and Associated Mortality of Complications in Orthogeriatric Co-Managed Inpatients.

INTRODUCTION: Pneumonia, thromboembolic and ischemic events, urinary tract infections (UTI), delirium and acute kidney injury (AKI) are common complications during the treatment of fragility fractures. In a 2 years-follow-up we determined the according incidence and risk factors of these and other complications in orthogeriatric inward patients, as well as the respective associated mortality. METHODS: All patients treated on an orthogeriatric co-managed ward over the course of a year were included. Besides injury, therapy and geriatric assessment parameters, we evaluated the inward incidence of common complications. In a 2 years-follow-up the associated death rates were aquired. SPSS (IBM) was used to determine the importance of risk factors predisposing to the respective occurrence of a complication and accordingly determine it's impact on the patients' 1- and 2-years-mortality. RESULTS: 830 orthogeriatric patients were initially assessed with a remaining follow-up cohort of 661 (79.6%). We observed very few cases of thrombosis (0.6%), pulmonary embolism (0.5%), apoplex (0.5%) and myocardial infarction (0.8%). Pneumonia was seen in 42 (5.1%), UTI in 85 (10.2%), delirium in 186 (22.4%) and AKI in 91 (11.0%) patients. Consistently ADL on admission was found to be a relevant risk factor in the development of each complication. After adjustment only AKI showed a significant increased mortality risk of 1.60 (95%CI:1.086-2.350). DISCUSSION: In our fracture-independent assessment of complications in the orthogeriatric treatment of inward patients we've seen very rare cases of cardiac and thrombotic complications. Typical fragility-fracture associated common events like pneumonia, UTI, delirium and AKI were still more incidental. No complication except AKI was associated to significant increased mortality risk. CONCLUSIONS: The relevance of orthogeriatric care in prevention and outcome of inward complications seems promising, needing still more controlled studies, evaluating not just hip fracture patients but more diverse groups. Consensus is needed in the scholar evaluation of orthogeriatric complications.

[Importance of surgical treatment of thoracolumbar vertebral fractures for the survival probability of orthogeriatric patients]. / Stellenwert der operativen Behandlung thorakolumbaler Wirbelkörperfrakturen für die Überlebenswahrscheinlichkeit alterstraumatologischer Patienten.

BACKGROUND: Osteoporotic vertebral compression fractures (VCF) are a common injury among older patients. The optimal treatment option (operative or conservative) is still discussed. The literature describes a reduced mortality following operative augmentation of VCF compared to conservative treatment. We examined our orthogeriatric patient cohort to find out whether there is a positive correlation between surgical treatment of VCF and the survival rate. METHODS: We performed an assessment of all patients with an osteoporotic spinal fracture who were treated on an orthogeriatric care unit due to VCF between 1 February 2014 and 31 January 2015. The treatment associated-mortality was examined in a 2-year follow-up, with a special focus on the influence of the treatment. RESULTS: A total of 74 patients (74% follow-up) with an average age of 83.2 years were included, 40 having been treated conservatively and 34 surgically. Overall, the 1­year and 2­year mortalities were 29.7% and 35.1%, respectively. Surgical treatment was associated with 1­year and 2­year mortalities of 20.6% and 23.5% compared to 37.5% and 45%, respectively, after conservative treatment (p = 0.113 and 0.086, χ2-test). The adjusted hazard ratio was 2.0 (95% confidence interval, CI 0.686-6.100). DISCUSSION: Although no statistically significant difference between the treatment groups could be detected (possibly due to the small sample size), the analysis showed a tendency towards an improved survival after surgical treatment. This is in accordance with international studies. Further investigations in the literature suggest that the reduction of kyphosis by surgery could represent an important causal association.

Improved outcome in hip fracture patients in the aging population following co-managed care compared to conventional surgical treatment: a retrospective, dual-center cohort study.

BACKGROUND: Hip fracture patients in the aging population frequently present with various comorbidities, whilst preservation of independency and activities of daily living can be challenging. Thus, an interdisciplinary orthogeriatric treatment of these patients has recognized a growing acceptance in the last years. As there is still limited data on the impact of this approach, the present study aimed to evaluate the long-term outcome in elderly hip fracture patients, by comparing the treatment of a hospital with integrated orthogeriatric care (OGC) with a conventional trauma care (CTC). METHODS: We conducted a retrospective, two-center, cohort study. In two maximum care hospitals all patients presenting with a hip fracture at the age of ≥ 70 years were consecutively assigned within a 1 year period and underwent follow-up examination 12 months after surgery. Patients treated in hospital site A were treated with an interdisciplinary orthogeriatric approach (co-managed care), patients treated in hospital B underwent conventional trauma care. Main outcome parameters were 1 year mortality, readmission rate, requirement of care (RC) and personal activities of daily living (ADL). RESULTS: A total of 436 patients were included (219 with OGC / 217 with CTC). The mean age was 83.55 (66-99) years for OGC and 83.50 (70-103) years for CTC (76.7 and 75.6% of the patients respectively were female). One year mortality rates were 22.8% (OGC) and 28.1% (CTC; p = 0.029), readmission rates were 25.7% for OGC compared to 39.7% for CTC (p = 0.014). Inconsistent data were found for activities of daily living. After 1 year, 7.8% (OGC) and 13.8% (CTC) of the patients were lost to follow-up. CONCLUSIONS: Interdisciplinary orthogeriatric management revealed encouraging impact on the long-term outcome of hip fracture patients in the aging population. The observed reduction of mortality, requirements of care and readmission rates to hospital clearly support the health-economic impact of an interdisciplinary orthogeriatric care on specialized wards. TRIAL REGISTRATION: The study was approved and registered by the bavarian medical council (BLAEK: 7/11192) and the local ethics committee of munich university (Reg. No. 234-16) and was conducted as a two-center, cohort study at a hospital with integrated orthogeriatric care and a hospital with conventional trauma care.

Locking nail versus locking plate for proximal humeral fracture fixation in an elderly population: a prospective randomised controlled trial.

BACKGROUND: Proximal humeral fractures (PHFs) are the third most common fracture in older patients. The purpose of the study was to prospectively evaluate the outcomes of PHF fixation with a locking blade nail (LBN) or locking plate (PHILOS) osteosynthesis in a homogeneous elderly patient population. METHODS: Inclusion criteria were an age > 60 years and the capacity to give informed consent. Patients with isolated tuberosity fractures, previous trauma or surgery, advanced osteoarthritis, fracture dislocation, pathological fractures, open fractures, neurological disorders, full-thickness rotator cuff tears, fracture line at the nail entry point or severely reduced bone quality intra-operatively were excluded. Eighty one patients with PHFs were randomised to treatment using LBN or PHILOS. Outcome measures comprised Constant score, age and gender adjusted Constant score, DASH score, VAS for pain, subjective overall condition of the shoulder (1-6) and active shoulder range-of-motion in flexion and abduction. Plain radiographs were obtained in two planes. All data were collected by an independent observer at 3, 6 and 12 months postoperatively. RESULTS: Thirteen patients were excluded intra-operatively due to rotator cuff tears, fracture morphology or poor bone-quality. Of the remaining 68 patients, 27 in the LBN and 28 in the PHILOS group completed the full follow-up. Mean age at surgery was 75.6 years and the majority of PHFs were three-part fractures (49 patients). Baseline demographics between groups were comparable. All outcome measures improved between assessments (p < 0.001). The LBN group showed improved DASH scores as compared to PHILOS at 12 months (p = 0.042) with fewer incidences of secondary loss of reduction and screw cut-out (p = 0.039). A total of 29 complications (in 23 patients) were recorded, 13 complications (in 12 patients) in the LBN group and 16 complications (in 11 patients) in the PHILOS group (p = 0.941). No significant inter-group difference was observed for any other outcome measures, nor was fracture morphology seen to be associated with clinical outcome or complication rate. CONCLUSIONS: At short-term follow-up, LBN osteosynthesis yielded similar outcomes and complication rates to PHILOS plate fracture fixation in an elderly patient population, though with a significantly lower rate of secondary loss of reduction and screw cut-out. REGISTRATION TRIAL: No. DRKS00015245 at Deutsches Register Klinischer Studien, registered: 22.08.2018, retrospectively registered.