The effect of different alignment strategies on trochlear orientation after total knee arthroplasty.

PURPOSE: When planning and delivering total knee arthroplasty (TKA), there are multiple coronal alignment strategies such as functional alignment (FA), kinematic alignment (KA), mechanical and adjusted mechanical alignment (MA, aMA). Recent three-dimensional and robotic-assisted surgery (RAS) studies have demonstrated that KA potentially better restores the trochlear anatomy than MA. The purpose of this study was to compare the restoration of the native trochlear orientation in patients undergoing RAS TKA using four different alignment strategies. It was hypothesised that FA would result in the lowest number of outliers. METHODS: This is a prospective study of 200 patients undergoing RAS-TKA with a single implant. All patients were analysed for MA and KA prebalancing, and 157 patients received aMA and 43 patients FA with intraoperative balancing. Preoperative transverse computed tomography scans were used to determine the posterior condylar axis (PCA), lateral trochlear inclination (LTI) angle, sulcus angle (SA) and anterior trochlear line (ATL) angle. Implant measurements were obtained using a photographic analysis. Intraoperative software data combined with implant data and preoperative measurements were used to calculate the differences. Outliers were defined as ≥3° of alteration. Trochlea dysplasia was defined as LTI < 12°. RESULTS: Native transepicondylar PCA had a median of 2°, LTI 18°, SA 137°, ATL 4°. LTI outliers were observed in 47%-60% of cases, with KA < FA < aMA < MA. For ATL, the range of outliers was 40.5%-85%, KA < FA < aMA < MA. SA produced 81% of outliers. Of all median angle values, only LTI when using KA was not significantly altered compared to the native knee. CONCLUSION: There is a significant alteration of trochlear orientation after TKA, regardless of the alignment strategy used. KA produced the lowest, but a substantial, number of outliers. The uniform design of implants causes the surgeon to compromise on balance in flexion versus trochlear position. The clinical relevance of this compromise requires further clinical investigations. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Nail fixation of unstable trochanteric fractures with or without cement augmentation: A cost-utility analysis in the United States: Cost-utility of cement augmentation.

OBJECTIVES: Recent clinical studies have shown favorable outcomes for cement augmentation for fixation of trochanteric fracture. We assessed the cost-utility of cement augmentation for fixation of closed unstable trochanteric fractures from the US payer's perspective. METHODS: The cost-utility model comprised a decision tree to simulate clinical events over 1 year after the index fixation surgery, and a Markov model to extrapolate clinical events over patients' lifetime, using a cohort of 1,000 patients with demographic and clinical characteristics similar to that of a published randomized controlled trial (age ≥75 years, 83 % female). Model outputs were discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) over a lifetime. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainty on results. RESULTS: Fixation with augmentation reduced per-patient costs by $754.8 and had similar per-patient QALYs, compared to fixation without augmentation, resulting in an ICER of -$130,765/QALY. The ICER was most sensitive to the utility of revision surgery, mortality risk ratio after the second revision surgery, mortality risk ratio after successful index surgery, and mortality rate in the decision tree model. The probability that fixation with augmentation was cost-effective compared with no augmentation was 63.4 %, 58.2 %, and 56.4 %, given a maximum acceptable ceiling ratio of $50,000, $100,000, and $150,000 per QALY gained, respectively. CONCLUSION: Fixation with cement augmentation was the dominant strategy, driven mainly by reduced costs. These results may support surgeons in evidence-based clinical decision making and may be informative for policy makers regarding coverage and reimbursement.

No Benefit of Robotic-Assisted over Computer-Assisted Surgery for Achieving Neutral Coronal Alignment in Total Knee Arthroplasty.

The use of robotic-assisted surgery (RAS) in total knee arthroplasty (TKA) is becoming increasingly popular due to better precision, potentially superior outcomes and the ability to achieve alternative alignment strategies. The most commonly used alignment strategy with RAS is a modification of mechanical alignment (MA), labeled adjusted MA (aMA). This strategy allows slight joint line obliquity of the tibial component to achieve superior balancing. In the present study, we compared coronal alignment after TKA using RAS with aMA and computer-assisted surgery (CAS) with MA that has been the standard in the center for more than 10 years. We analyzed a prospectively collected database of patients undergoing TKA in a single center. Lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) were compared for both techniques. In 140 patients, 68 CASs and 72 RASs, we observed no difference in postoperative measurements (median 90 degrees for all, LDFA p = 0.676, MPTA p = 0.947) and no difference in outliers <2 degrees (LDFA p = 0.540, MPTA p = 0.250). The present study demonstrates no benefit in eliminating outliers or achieving neutral alignment of both the femoral and the tibial components in robotic-assisted versus computer-assisted TKA if MA is the target. To utilize the precision of RAS, it is recommended to aim for more personalized alignment strategies. The level of evidence is level III retrospective study.

Increased Femoral Component Flexion and No Difference in Slope in Robotic- versus Computer-Assisted Total Knee Arthroplasty When Targeting Mechanical Alignment.

Robotic-assisted surgery (RAS) in total knee arthroplasty (TKA) is becoming popular due to better precision, when compared with other instrumentation. Although RAS has been validated in comparison with computer-assisted surgery (CAS), data from clinical settings comparing these two techniques are lacking. This is especially the case for sagittal alignment. Whereas pure mechanical alignment (MA) aims for 0 to 3 degrees of flexion of the femoral component and 3° of posterior slope for the tibial component, adjusted MA (aMA) mostly used with RAS allows for flexing of the femoral component for downsizing and increase of slope for an increase of the flexion gap. In the present study, we compared sagittal alignment after TKA using RAS with aMA and CAS targeting MA, which has been the standard in the center for more than 10 years. We analyzed a prospectively collected database of patients undergoing TKA in a single center. Femoral component flexion and tibial slope were compared for both techniques. In 140 patients, 68 CAS and 72 RAS, we found no difference in tibial slope (p = 0.661), 1° median femoral component flexion (p = 0.023), and no difference in outliers (femur, p = 0.276, tibia, p = 0.289). RAS slightly increases femoral component flexion, but has no influence on tibial slope, when compared with CAS in TKA. If MA is the target, RAS provides no benefit over CAS for achieving the targeted sagittal alignment. LEVEL OF EVIDENCE: Level III retrospective study.

Diagnostic value of protein S100b as predictor of traumatic intracranial haemorrhage in elderly adults with low-energy falls: results from a retrospective observational study.

PURPOSE: The objectives of this study were to analyse the clinical value of protein S100b (S100b) in association with clinical findings and anticoagulation therapy in predicting traumatic intracranial haemorrhage (tICH) and unfavourable outcomes in elderly individuals with low-energy falls (LEF). METHODS: We conducted a retrospective study in the emergency department (ED) of the LMU University Hospital, Munich by consecutively including all patients aged ≥ 65 years presenting to the ED following a LEF between September 2014 and December 2016 and receiving an emergency cranial computed tomography (cCT) examination. Primary endpoint was the prevalence of tICH. Multivariate logistic regression models and receiver operating characteristics were used to measure the association between clinical findings, anticoagulation therapy and S100b and tICH. RESULTS: We included 2687 patients, median age was 81 years (60.4% women). Prevalence of tICH was 6.7% (180/2687) and in-hospital mortality was 6.1% (11/180). Skull fractures were highly associated with tICH (odds ratio OR 46.3; 95% confidence interval CI 19.3-123.8, p < 0.001). Neither anticoagulation therapy nor S100b values were significantly associated with tICH (OR 1.14; 95% CI 0.71-1.86; OR 1.08; 95% CI 0.90-1.25, respectively). Sensitivity of S100b (cut-off: 0.1 ng/ml) was 91.6% (CI 95% 85.1-95.9), specificity was 17.8% (CI 95% 16-19.6), and the area under the curve value was 0.59 (95% CI 0.54 - 0.64) for predicting tICH. CONCLUSION: In conclusion, under real ED conditions, neither clinical findings nor protein S100b concentrations or presence of anticoagulation therapy was sufficient to decide with certainty whether a cCT scan can be bypassed in elderly patients with LEF. Further prospective validation is required.

The influence of vitamin D on handgrip strength in elderly trauma patients.

BACKGROUND AND OBJECTIVES: The treatment of elderly patients is an increasing challenge and the long-term sequelae often affect activities of daily living and quality of life in those patients. Handgrip strength (HGS) appears as a promising value to predict the outcome after trauma in elderly patients and to assess the overall muscle strength. Besides the possible role of psychological and hormonal factors, vitamin D may have a positive influence. Furthermore, some data suggest that Vitamin D is beneficial regarding muscle strength and possibly prevents further falls and injuries in orthogeriatric patients. The purpose of this study was to identify if Vitamin D is an influencing factor for HGSin elderly trauma patients. MATERIALS AND METHODS: 94 elderly patients in a Level I Trauma Center aged 60 years or older were prospectively enrolled and HGS as well as serum 25-OH Vitamin D concentration (VDC) were measured. In addition, the standardized questionnaires Barthel Index (BI), Parker Mobility Score (PMS), Short Physical Performance Battery (SPPB), Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls (SARC-F) and European Quality of Life 5 Dimensions 5 Levels Questionnaire (EQ-5D-5L), were used to record mental health status and demographic data. RESULTS: HGS is mainly related to age and sex in elderly trauma patients. HGS was higher in men (meanmale = 27.31 kg (± 8.11), meanfemale = 15.62 kg (± 5.63), p < 0.001 and decreased with age (ßage = - 0.58, p < 0.001). A significant negative correlation between HGS and VDC exists in the overall sample (ßVDC = - 0.27, pVDC < 0.008), which still remains after adjusting for age (pVDC < 0.004), but is not significant after adjustment for both main confounders, age and sex (pVDC < 0.08). Furthermore, the HGS was lower in pateints who reported frequent falls, stumbling, dizziness or a late onset of menopause, and decreased if patients felt anxious or depressed during measurements (ßanxiety+depression = - 0.26, panxiety+depression < 0.01). CONCLUSIONS: These results do not support the hypothesis that Vitamin D has a positive influence on muscle strength measured by HGS. Nevertheless, this study could confirm the usefulness of HGS as a tool to detect the risk for frequent falls or stumbling. Furthermore, HGS seems to be associated with dizziness and age at onset of menopause. A significant decrease of HGS could also be shown in patients with anxiety and depression. This underlines the importance of interdisciplinary treatment of elderly trauma patients and needs to be taken into account for further studies, as especially the psychological motivation seems to have a significant influence and is sometimes not considered enough in elderly musculo-skeletal patients.

Clinical Acuity in the Emergency Department and Injury Severity Determine Hospital Admission of Older Patients with Low Energy Falls: Outcomes from a Prospective Feasibility Study.

BACKGROUND: Low energy falls (LEF) in older adults constitute a relevant cause for emergency department (ED) visits, hospital admission and in-hospital mortality. Patient-reported outcome measures containing information about patients' medical, mental and social health problems might support disposition and therapy decisions. We investigated the value of a tablet-based (self-)assessment in predicting hospital admission and in-hospital mortality. METHODS: Patients 65 years or older, consecutively presenting with LEF to our level I trauma center ED (from November 2020 to March 2021), were eligible for inclusion in this prospective observational study. The primary endpoint was hospital admission; secondary endpoints were in-hospital mortality and the use of the tablet for self-reported assessment. Multivariate logistic regression models were calculated to measure the association between clinical findings and endpoints. RESULTS: Of 618 eligible patients, 201 patients were included. The median age was 82 years (62.7% women). The hospital admission rate was 45.3% (110/201), with an in-hospital mortality rate of 3.6% (4/110). Polypharmacy (odds ratio (OR): 8.48; 95% confidence interval (95%CI) 1.21-59.37, p = 0.03), lower emergency severity index (ESI) scores (OR: 0.33; 95%CI 0.17-0.64, p = 0.001) and increasing injury severity score (ISS) (OR: 1.54; 95%CI 1.32-1.79, p < 0.001) were associated with hospital admission. The Charlson comorbidity index (CCI) was significantly associated with in-hospital mortality (OR: 2.60; 95%CI: 1.17-5.81, p = 0.03). Increasing age (OR: 0.94; 95%CI: 0.89-0.99, p = 0.03) and frailty (OR: 0.71; 95%CI: 0.51-0.99, p = 0.04) were associated with the incapability of tablet use. CONCLUSIONS: The severity of fall-related injuries and the clinical acuity are easily accessible, relevant predictors for hospital admission. Tablet-based (self-)assessment may be feasible and acceptable during ED visits and might help facilitate comprehensive geriatric assessments during ED stay.

Cost-Effectiveness of Cement Augmentation Versus No Augmentation for the Fixation of Unstable Trochanteric Fractures.

BACKGROUND: A previous randomized controlled trial (RCT) demonstrated a trend toward a reduced risk of implant-related revision surgery following fixation with use of a Proximal Femoral Nail Antirotation (PFNA) with TRAUMACEM V+ Injectable Bone Cement augmentation versus no augmentation in patients with unstable trochanteric fractures. To determine whether this reduced risk may result in long-term cost savings, the present study assessed the cost-effectiveness of TRAUMACEM V+ cement augmentation versus no augmentation for the fixation of unstable trochanteric fractures from the German health-care payer's perspective. METHODS: The cost-effectiveness model comprised 2 stages: a decision tree simulating clinical events, costs, and utilities during the first year after the index procedure and a Markov model extrapolating clinical events, costs, and utilities over the patient's lifetime. Sources of model parameters included the previous RCT, current literature, and administrative claims data. Outcome measures were incremental costs (in 2020 Euros), incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Model uncertainty was assessed with deterministic and probabilistic sensitivity analyses. RESULTS: The base-case analysis showed that fixation with cement augmentation was the dominant strategy as it was associated with cost savings (€50.3/patient) and QALY gains (0.01 QALY/patient). Major influential parameters for the ICER were the utility of revision, rates of revision surgery within the first year after fixation surgery, and the costs of augmentation and revision surgery. Probabilistic sensitivity analyses demonstrated that estimates of cost savings were more robust than those of increased QALYs (66.4% versus 52.7% of the simulations). For a range of willingness-to-pay thresholds from €0 to €50,000, the probability of fixation with cement augmentation being cost-effective versus no augmentation remained above 50%. CONCLUSIONS: Fixation with use of cement augmentation dominated fixation with no augmentation for unstable trochanteric fractures, resulting in cost savings and QALY gains. Given the input parameter uncertainties, future analyses are warranted when long-term costs and effectiveness data for cement augmentation are available. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II . See Instructions for Authors for a complete description of levels of evidence.

Effect of angular correction during posterior instrumentation of spinal fractures on postoperative outcomes and quality of life.

BACKGROUND: Posterior instrumentation using pedicle screws and rods is the most commonly used technique for the treatment of thoracolumbar fractures of the spine. The procedure aims to restore the neurologic and biomechanical functions of the spine and allows for early mobilization and rapid reintegration into society. It is unclear whether the magnitude of correction has an effect on postoperative outcomes. OBJECTIVE: We aimed to determine whether the magnitude of sagittal angular correction during posterior instrumentation of the spine had an effect on postoperative quality of life, pain and function outcomes as measured using the EQ5D-3L and the Core Outcome Measures Index (COMI) instruments. We also aimed to quantify the correlation between EQ5D-3L and COMI scores. METHODS: We analyzed the pre- and postoperative radiographs of 52 patients who underwent percutaneous pedicle screw placement for thoracolumbar fractures, as well as their self-reported EQ5D-3L and COMI quality of life, pain and functional outcome scores. Regression models were constructed to estimate the effect that the magnitude of Cobb angle correction had on postoperative outcomes. We also estimated the correlation between EQ5D-3L and COMI scores. RESULTS: The median EQ5D-3L TTO score was 0.9 (range, -0.1 to 1). The median COMI score was 3.1 (range, 0 to 10). There was no significant effect of the magnitude of correction on EQ5d-3L TTO scores (p= 0.3379; R= 0.36) or on COMI scores (p= 0.3379; R= 0.15). Age and bone mineral density were not found to be significant predictors of outcome (p= 0.05). There was a strong correlation between the EQ5D-3L TTO and COMI scores (r=-0.62). CONCLUSION: The magnitude of Cobb angle correction during pedicle screw instrumentation of thoracolumbar fractures did not influence quality of life, pain or function outcomes. There was good correlation between EQ5D-3L TTO scores and COMI scores.

Incidental CT Findings in the Elderly with Low-Energy Falls: Prevalence and Implications.

BACKGROUND: Computed tomography (CT) is commonly used in trauma care, with increasing implementation during the emergency work-up of elderly patients with low-energy falls (LEF). The prevalence of incidental findings (IFs) resulting from CT imaging and requiring down-stream actions in this patient cohort is unknown. We have investigated the prevalence and urgency of IFs from emergency CT examinations in these patients. METHODS: A total of 2871 patients with LEF and emergency CT examinations were consecutively included in this retrospective cohort study. The primary endpoint was the prevalence of IFs; the secondary endpoint was their urgency. RESULTS: The median age was 82 years (64.2% were women). IFs were identified in 73.9% of patients, with an average of 1.6 IFs per patient. Of all IFs, 16.4% were classified as urgent or relevant, predominantly in the abdomen, chest and neck. Increasing age was associated with the prevalence of an IF (odds ratio: 1.053, 95% confidence interval: 1.042-1.064). Significantly more IFs were found in female patients (75.2% vs. 71.5%). CONCLUSION: IFs resulting from CT examinations of the elderly are frequent, but in more than 8 out of 10, they are harmless or currently asymptomatic. For the benefit of an accurate diagnosis of traumatic lesions, concerns about IFs with respect to disease burden, further work-up and resource utilisation might be disregarded.

A Novel Device for Closed Reduction and Percutaneous Fixation of Thoracolumbar Fractures.

BACKGROUND/AIM: Open surgical reduction/fixation of thoracolumbar fractures results in significant soft-tissue trauma and related complications. Minimally-invasive technical developments could deliver similar radiological outcomes, while avoiding the related complications. We evaluated radiological and perioperative outcomes in thoracolumbar fractures by using a novel minimally-invasive device. PATIENTS AND METHODS: Twenty-six patients with 29 thoracolumbar fractures using the NForce device were analyzed. Postoperative reduction and alignment were assessed by radiographic measurement of the local kyphosis angle (LKA) up until a follow-up period of 9 months. RESULTS: Postoperative imaging revealed an average reduction of traumatic kyphosis of 8.25° (±7.72°) with an average postoperative LKA of 3.24° (±8.97°). The highest degree of reduction was 27.39°. The mean LKA had increased to 5.08° (±5.17°) at 3 months postoperative, 5.43° (±4.32°) at 6 months and 6.21° (±3.82°) at 9 months. CONCLUSION: The minimally invasive NForce system is effective in performing anatomic percutaneous reduction/fixation.

Immediate Postoperative Improvement in Gait Parameters following Primary Total Knee Arthroplasty Can Be Measured with an Insole Sensor Device.

Total knee arthroplasty (TKA) improves the quality of life in those suffering from debilitating arthritis of the knee. However, little is known about the influence of TKA on restoring physical function. Prior studies have used artificial means, such as instrumented treadmills, to assess physical function after TKA. In this study an insole sensor device was used to quantify parameters of gait. The purpose of this study was to evaluate the ability of a wearable insole sensor device to measure immediate postoperative gait parameters at 2 weeks and 6 weeks following primary TKA and to determine if the device was suitable and sensitive enough to identify and measure potentially subtle changes in these measures at these early postoperative time periods. Twenty-nine patients with unilateral TKA, without contralateral knee pain, and aid-free walking before surgery were evaluated. An insole force sensor measured the postoperative parameters while walking a distance of 40 m on level ground at 2 and 6 weeks after TKA. The loading rate of the operated lower extremity was an average of 68.7% of the contralateral side at 2 weeks post-surgery and increased to 82.1% at 6 weeks post-surgery (p < 0.001). The mean gait speed increased from 0.75 to 1.02 m/s, (p < 0.001) and cadence increased from 82.9 to 99.9 steps/min (p < 0.001), while the numeric pain scale at rest decreased from 3.5/10 to 2.2/10, (p < 0.001) and the pain while walking from 3.9/10 to 2.4/10, (p < 0.001) from 2 to 6 weeks post-surgery. A significant improvement in gait parameters is detectable in the first 6 weeks after surgery with the use of a wearable insole device. As the gait speed and cadence increase and the VAS pain level decreases, the loading rate and average peak force begin to normalize. This device may allow for early gait analysis and have potential clinical utility in detecting early differences in patients' functional status following TKA.

Jumper's fracture of the sacrum: a novel and reproducible way for successful reduction and fixation.

PURPOSE: Surgical treatment of jumper's fractures is a highly demanding situation for the surgeon due to its rareness and frequent association with severe concomitant injuries. There is no current consensus regarding a standard treatment approach, thus reducing quality of care. Our objectives were to describe, apply and assess a novel surgical technic. METHODS: The presented research is an observational retrospective study of patients who underwent the described novel surgical intervention in a level 1 trauma center. We conducted analyses of the patient cohort using patient-related outcome measures at least 1 year after surgery, as well as investigating pain, quality of life and the clinical effectiveness of the procedure. RESULTS: A total of 24 patients (17 male and 7 female) with an average age 47 ± 16.3 years were included. ISS scores ranged from 9 to 66 with a mean ISS of 40 ± 15. Clinical scores exist of 15 out of 24 patients (62.5%). The mean VAS score was 53.7 ± 12.9. The mean EQ-5D index was 0.68 ± 0.22. Significant negative correlation existed between the ISS value and the EQ-5D index (r = - 0.704; p < 0.005) and EQ-5D VAS (r = - 0.809; p < 0.001). Anatomical reduction was achieved in all patients (n = 24). Radiological follow-up was performed in 58%. CONCLUSION: We present one of the largest studies with operatively treated jumper's fractures of the sacrum. The technique is capable of reproducibly restoring the physiological anatomy of the patient and allows pain-adapted mobilization.

Intraoperative torsion control using the cortical step sign and diameter difference in tibial mid-shaft fractures.

AIM: Intramedullar nailing of tibial mid-shaft fractures is a common surgical treatment. Fracture reduction, however, remains challenging and maltorsion is a common discrepancy which aggravates functional impairment of gait and stability. The use of radiographic tools such as the cortical step sign (CSS) and the diameter difference sign (DDS) could improve fracture reduction. Therefore, the validity of the CSS and DDS was analyzed to facilitate detection of maltorsion in tibial mid-shaft fractures. METHODS: Tibial mid-shaft fractures were induced in human cadaveric tibiae according to the AO classification type A3. Torsional discrepancies from 0° to 30° in-/external direction were enforced after intramedullary nailing. Fluoroscopic-guided fracture reduction was assessed in two planes via analysis of the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD), anterior cortical thickness (ACT), posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and distal fracture fragment. RESULTS: The TD, LCT and ACT have shown a highly significant correlation to predict tibial maltorsion. While a model combining ACT, LCT, PCT and TD lateral was most suitable model to identify tibial maltorsion, a torsional discrepancy of 15°was most reliably detected with use of the TD and ACT. CONCLUSION: The present study has shown, that maltorsion can be reliably assessed by the CSS and DDS during fluoroscopy. Thus, torsional discrepancies in tibial mid-shaft fractures can be most reliably assessed in the lateral plane by analysis of the LCT and TD.

Identification of hip fracture patients at risk for postoperative mobilisation complications via handgrip strength assessment.

INTRODUCTION: Treatment of older adult hip fracture patients can be challenging and requires early postoperative mobilisation to prevent complications. Simple clinical tools to predict mobilisation/weight-bearing difficulties after hip fracture surgery are scarcely available and analysis of handgrip strength could be a feasible approach. In the present study, we hypothesised that patients with reduced handgrip strength show incapability to follow postoperative weight-bearing instructions. MATERIALS AND METHODS: Eighty-four patients aged ≥ 65 years with a proximal femur fracture (trochanteric, n = 45 or femoral neck, n = 39), who were admitted to a certified orthogeriatric center, were consecutively enrolled in a prospective study design. Five days after surgery (intramedullary nailing or arthroplasty), a standardised assessment of handgrip strength and a gait analysis (via insole forcesensors) was performed. RESULTS: Handgrip strength showed positive correlation with average peak force during gait on the affected limb (0.259), postoperative Parker Mobility Score (0.287) and Barthel Index (0.306). Only slight positive correlation was observed with gait speed (0.157). These results were congruent with multivariate regression analysis. CONCLUSION: Assessment of handgrip strength is a simple and reliable tool for early prediction of postoperative mobilisation complications like the inability to follow weight-bearing instructions in older hip fracture patients. Follow-up studies should evaluate if these findings also match with other fracture types and result in personalised adjustment of current aftercare patterns. In addition, efforts should be made to combine objectively collected data as handgrip strength or gait speed in a prediction model for long-term outcome of orthogeriatric patients.

How relevant is lumbar bone mineral density for the stability of symphyseal implants? A biomechanical cadaver study.

PURPOSE: Osteoporotic bone tissue appears to be an important risk factor for implant loosening, compromising the stability of surgical implants. However, it is unclear whether lumbar measured bone mineral density (BMD) is of any predictive value for stability of surgical implants at the pubic symphysis. This study examines the fixation strength of cortical screws in human cadaver specimens with different BMDs. METHODS: The lumbar BMD of ten human specimens was measured using quantitative computed tomography (qCT). A cut-off BMD was set at 120 mg Ca-Ha/mL, dividing the specimens into two groups. One cortical screw was drilled into each superior pubic ramus. The screw was withdrawn in an axial direction with a steady speed and considered failed when a force decrease was detected. Required force (N) and pull-out distance (mm) were constantly tracked. RESULTS: The median peak force of group 1 was 231.88 N and 228.08 N in group 2. While BMD values differed significantly (p < 0.01), a comparison of peak forces between both groups showed no significant difference (p = 0.481). CONCLUSION: Higher lumbar BMD did not result in significantly higher pull-out forces at the symphysis. The high proportion of cortical bone near the symphyseal joint allows an increased contact of pubic screws and could explain sufficient fixation. This condition is not reflected by a compromised lumbar BMD in a qCT scan. Therefore, site-specific BMD measurement could improve individual fracture management.

Mobility improvement in the first 6 postoperative weeks in orthogeriatric fracture patients.

BACKGROUND: Physical activity is a relevant outcome parameter in orthopedic surgery, that can be objectively assessed. Until now, there is little information regarding objective gait parameters in the orthogeriatric population. This study focuses on the first 6 weeks of postoperative rehabilitation, and delivers objective data about gait speed and step length in typical orthogeriatric fracture patterns. METHODS: Thirty-one orthogeriatric fracture patients [pertrochanteric femur fractures (PFF), femoral neck (FN), and proximal humerus fractures (PHF)] were consecutively enrolled in a maximum care hospital in a prospective study design. All patients wore an accelerometer placed at the waist during the postoperative stay (24 h/d) and at 6-week follow-up, to measure real gait speed and step length. In addition, self-assessment of mobility (Parker mobility score) and activities of daily living (Barthel index) were collected at baseline, during the inpatient stay, and at 6-week follow-up. RESULTS: During postoperative hospitalization, significantly higher gait speed (m/s) was observed in the PHF group (0.52 ± 0.27) compared with the FN group (0.36 ± 0.28) and PFF group (0.19 ± 0.28) (p < 0.05). Six weeks postoperatively, gait speed improved significantly in all groups (PHF 0.90 ± 0.41; FN 0.72 ± 0.13; PFF 0.60 ± 0.23). Similarly, step length (m) differed between groups postoperatively [FN 0.16 ± 0.13; PFF 0.12 ± 0.15; PHF 0.31 ± 0.05 (p < 0.005)] and improved over time significantly (FN 0.47 ± 0.01; 0.39 ± 0.19; 0.50 ± 0.18). Self-assessment scores indicate that the majority of the patients had minor restrictions in mobility before the fracture. These values decreased immediately postoperatively and improved in the first 6 weeks, but did not reach the initial level. CONCLUSIONS: Gait speed, step length, and self-assessment in terms of mobility and activities of daily living improve significantly in the first 6 postoperative weeks in orthogeriatric fracture patients. As very low postoperative mobility during hospitalization was observed, this collective shows great potential in postoperative rehabilitation regardless of their fracture pattern. For this reason, specific aftercare concepts similar to the "fast track" concepts in primary arthroplasty are crucial for orthogeriatric patients in clinical practice. LEVEL OF EVIDENCE: Prospective cohort study, 2.

Increased Geriatric Treatment Frequency Improves Mobility and Secondary Fracture Prevention in Older Adult Hip Fracture Patients-An Observational Cohort Study of 23,828 Patients from the Registry for Geriatric Trauma (ATR-DGU).

Interdisciplinary orthogeriatric care of older adult hip fracture patients is of growing importance due to an ageing population, yet there is ongoing disagreement about the most effective model of care. This study aimed to compare different forms of orthogeriatric treatment, with focus on their impact on postoperative mobilization, mobility and secondary fracture prevention. In this observational cohort study, patients aged 70 years and older with a proximal femur fracture requiring surgery, were included from 1 January 2016 to 31 December 2019. Data were recorded from hospital stay to 120-day follow-up in the Registry for Geriatric Trauma (ATR-DGU), a specific designed registry for older adult hip fracture patients. Of 23,828 included patients from 95 different hospitals, 72% were female, median age was 85 (IQR 80-89) years. Increased involvement of geriatricians had a significant impact on mobilization on the first day (OR 1.1, CI 1.1-1.2) and mobility seven days after surgery (OR 1.1, CI 1.1-1.2), initiation of an osteoporosis treatment during in-hospital stay (OR 2.5, CI 2.4-2.7) and of an early complex geriatric rehabilitation treatment (OR 1.3, CI 1.2-1.4). These findings were persistent after 120 days of follow-up. Interdisciplinary treatment of orthogeriatric patients is beneficial and especially during in-patient stay increased involvement of geriatricians is decisive for early mobilization, mobility and initiation of osteoporosis treatment. Standardized treatment pathways in certified geriatric trauma departments with structured data collection in specific registries improve outcome monitoring and interpretation.

Self-Assessment of Mobility of People over 65 Years of Age.

BACKGROUND AND OBJECTIVES: Nowadays, various clinical scoring systems are used in the medical care of the elderly to assess the quality of mobility. However, people often tend to under- or overestimate themselves in many aspects. Since this can have serious consequences in their treatment and care, the aim of this study was to identify differences in the self and external assessment of mobility of persons over 65 years of age. MATERIALS AND METHODS: 222 participants over 65 years of age and one external, closely-related relative or professional caregiver were interviewed by a unique study assistant using a standardized questionnaire. Participants were divided into people living in nursing homes and independent people living at home, where either the caregivers or the relatives provided the external assessment of mobility, respectively. The questionnaire included demographics, cognitive abilities (Mini Mental Status Test); fall risk (Hendrich 2 Fall Risk Model); as well as the Parker Mobility Score, Barthel Index, and EQ-5D-5L to measure mobility, activities of daily life and quality of life. In each case, the participant and the external person were asked for their assessment to the participants' mobility situation. Statistical significance of the difference between self and external assessment was calculated with a Wilcoxon rank-sum test and assumed with a p-value of ≤ 0.05. RESULTS: Self-assessment indicated a significantly higher value, when compared to an external assessment for the Parker Mobility Score for females in nursing homes (p ≤ 0.01), as well as for the Barthel Index for females (p ≤ 0.01) and males (p ≤ 0.01) in nursing homes. The EQ-5D-5L received a significantly higher self-assessment value for females (p ≤ 0.01) and males (p ≤ 0.01) living at home and females (p ≤ 0.01) and males (p ≤ 0.05) in nursing homes. CONCLUSIONS: Persons over 65 years of age tend to overestimate their level of mobility, quality of life and activities of daily life. Especially for people living in nursing homes, these scoring systems should be treated with caution due to the differences between the verbal statements. It is important to properly assess the mobility situation of elderly patients to ensure correct medical treatment and prevention of falls.