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.

Concomitant fractures in patients with proximal femoral fractures lead to a prolonged hospital stay but not to increased complication rates or in-house mortality if treated surgically: a matched pair analysis.

BACKGROUND: Impact of concomitant fractures on patients sustaining a proximal femur fracture remains unclear. Rising numbers and patient need for rehab is an important issue. The objective of our study was to investigate the impact of concomitant fractures, including all types of fractures, when treated operatively, for proximal femur fractures on the length of hospital stay, in-house mortality and complication rate. METHODS: Observational retrospective cohort single-center study including 85 of 1933 patients (4.4%) with a mean age of 80.5 years, who were operatively treated for a proximal femoral and a concomitant fracture between January 2016 and June 2020. A matched pair analysis based on age, sex, fracture type and anticoagulants was performed. Patient data, length of hospital stay, complications and mortality were evaluated. RESULTS: The most common fractures were osteoporosis-associated fractures of the distal forearm (n = 34) and the proximal humerus (n = 36). The group of concomitant fractures showed a higher CCI than the control group (5.87 vs. 5.7 points; p < 0.67). Patients with a concurrent fracture had a longer hospital stay than patients with an isolated hip fracture (15.68 vs. 13.72 days; p < 0.056). Complications occurred more often in the group treated only for the hip fracture (11.8%, N = 20), whilst only 7.1% of complications were recorded for concomitant fractures (p < 0.084). The in-house mortality rate was 2.4% and there was no difference between patients with or without a concomitant fracture. CONCLUSIONS: A concomitant fracture to a hip fracture increases the length of hospital stay significantly but does not increase the complication rate or the in-house mortality. This might be due to the early mobilization, which is possible after early operative treatment of both fractures.

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.

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.

Midterm follow-up of elderly patients with fragility fractures of the pelvis: A prospective cohort-study comparing operative and non-operative treatment according to a therapeutic algorithm.

INTRODUCTION: The treatment of fragility fractures of the pelvis (FFP) is a challenge. The variations of non-operative- and of operative treatment are manifold and a structured treatment algorithm is lacking. The purpose of this study was to evaluate the outcome of elderly patients with a FFP who were treated with a therapeutic algorithm based on the FFP-classification. PATIENTS AND METHODS: In a prospective cohort study 154 patients (mean age: 81.8 ±.61 (65-96); female: (86.8%; 131/154). BMI: 23.7 ±.34 (15-43)) with a FFP after inadequate mono trauma were treated according to a strict therapeutic algorithm between 04/2016 and 12/2018. According to a classification based on CT-scans either a standardized operative treatment or conservative therapy was induced and the outcome regarding objective measurements of mobility, pain, need for analgesics and mortality during hospital stay and after one year was analyzed. RESULTS: 82/154 participants (53.2%) were assigned to the conservative treatment group and 72 participants (46.8%) to the operative treatment group. The overall one-year survival rate was 78.1% (118/151). The survival of the operative treatment group was 90.7% (49/54) and significantly higher than the survival of the conservative treatment group (74.7%; 56/75; p=.023). The one-year follow up showed a high dispersion of the pain level in the operatively treated patients and a significantly higher mean in comparison to conservatively treated patients. Both treatment groups showed increasing numbers of patients with unlimited mobilization but also immobile patients. Overall in 31.0% (18/58) of the operative participants and in 14.9% (14/93) of the non-operatively treated participants complications occurred (p=.04). CONCLUSION: The strict compliance to the presented treatment algorithm of FFP with an operative strategy starting from FFP IIc leads to a significantly lower mortality within one year in comparison to the conservatively treated patients. The worst outcome and the highest mortality was seen in patients who refused the recommendation of operative stabilization. The results of this study justify to proceed with the strict classification dependent treatment algorithm and also support the early switch-over to operative treatment of patients with failed conservative therapy in FFP I to FFP IIb.