Sarcopenia and Related Functional Outcomes Following Hip Surgery Among Egyptian Geriatric Patients With Hip Fracture.

Background Sarcopenia is highly prevalent among elderly patients with hip fracture. Studies reported a significant association between sarcopenia and clinical outcomes in patients with hip fractures. The current study aimed to determine the prevalence of sarcopenia among elderly patients with hip fracture and its effect on short-term functional outcomes, highlighting predictors of postoperative functional decline.  Methods This is a cross-sectional study followed by a prospective cohort. Elderly patients (60 years and above) with hip fractures were recruited from the orthopedic department. Patients were followed by the ortho-geriatric team in the perioperative period and for three postoperative months. Patients were subjected to comprehensive geriatric assessment including a full history and physical examination. In the preoperative state and after three months of follow-up the following were assessed: functional independence using the Barthel index (BI); nutritional state using a checklist named DETERMINE Your Nutritional Health; sarcopenia using the SARC-F questionnaire assessing strength, ambulation, rising from a chair, climbing stairs, and fall history. Perioperative risk assessment and post-discharge care were obtained through medical records and by questioning patients or families. Preoperative sarcopenia was confirmed using the Ishii equation which is an equation that includes (age, calf circumference, and hand grip strength). Results Preoperative sarcopenia screening showed that 29.3% of patients suffered sarcopenia by SARC-F questionnaire and 28.6% by Ishii equation score. At the end of the follow-up, 57.9% of patients suffered sarcopenia by SARC-F questionnaire. There was a marked post-fracture decline in independence level; 52.1% had slight dependence in function, 27.1% had moderate dependence in function, and 20.7% had total dependence in function. Conclusion This study gives us the chance for a greater understanding of the negative effects of sarcopenia on the outcomes following hip fracture surgery in the geriatric population. It shows a prevalence of sarcopenia among the elderly with hip fractures at 29.3%. The elderly experience a marked post-fracture decline in their level of independence concerning basic activities of daily living. Those with older age, higher comorbidities, cognitive impairment, and functional dependence with poor nutritional state are more vulnerable to functional decline. Other perioperative risks include delayed surgery, surgery type, postoperative complications, longer hospital stays, lack of planned rehabilitative and nutritional plans, and postoperative depression. Early detection of sarcopenia helps establish early interventional plans to reverse such poor outcomes.

Augmentation plate without bone graft in the management of distal tibial diaphyseal non-union.

PURPOSE: The objective of this study was to assess the efficacy of augmentation plating with retaining of previous implant in situ in cases of non-united oligotrophic or atrophic aseptic distal tibial diaphyseal and metaphyseal fractures without bone grafting depending on the unified bone healing and non-union theory. METHODS: Through the period between December 2019 and December 2022, twelve patients with distal third tibial non-unions who were fixed at time of fracture either by intramedullary interlocking nails (seven cases) or by minimally invasive plate osteosynthesis (five cases) were included. Non-union was diagnosed on basis of absence of any healing progression in three months period or absence of fracture healing after six months from index surgery. All patients had oligotrophic or atrophic non-union. Augmentation plating through an anterolateral approach was done on average of 7.25 months after initial surgery (6-9 months). Circumferential exposure of the fracture site and debridement of fibrous tissue were not necessary. No bone grafting was done as no cases had major bone defect. RESULTS: All patients achieved complete radiological union with a mean time of 21.8 weeks (range 18-30 weeks) that mean full callus formation in all cortices. All patients were walking independently after three months (13weeks) from surgery and returned to work even in cases of absent complete radiological union. No cases had been complicated with wound healing problems (infection or dehiscence). One patient had incomplete ankle dorsiflexion (10°) due to tight calf muscles and one patient had paresthesia on the dorsum of the foot that was not improved at last follow up (one year after surgery). CONCLUSION: Augmentation plating is a safe and effective option for management of distal tibial diaphyseal nonunion even in cases of oligotrophic or atrophic non-union.

Clinical Efficacy of Preoperative CT-Assisted Planning for Primary Total Knee Arthroplasty: A Pilot Randomized Clinical Trial.

This study aims to determine the mean posterior condylar angle (PCA) in the included population and its relation to coronal alignment; and to know the clinical importance of the use of preoperative computed tomography (CT) scan in total knee arthroplasty (TKA). We randomized 50 patients with primary knee osteoarthritis into 2 groups. We used CT scan axial images to measure the PCA. In the first group we followed the CT scan plan (group 1), but in the second we did not follow the plan and adjusted rotation to the standard three degrees (group 2). The mean age of the included patients was 63 years. The radiological data of the included patients showed 5 patients with valgus deformity and 45 patients with varus deformity with the mean coronal alignment of 7.5 degrees. CT scan showed the mean PCA of 3.7 degrees (1.3 degrees). The axial knee postoperative X-ray showed the mean patellar tilt angle of 2.1 degrees (0.5 degrees) and 1.9 degrees (0.5 degrees) in groups 1 and 2, respectively. The congruence angle was 4 degrees (2.6 degrees) in group 1 and 5.5 degrees (3.2 degrees) in group 2. The median Knee Society functional score in group 1 was 85 (12), while it was 84 (7.5) in group 2. The median postoperative Western Ontario and McMaster Universities Arthritis Index score in group 1 was 84 (18.6) whereas 80.2 (13.6) in group 2. The median postoperative Bartlett score in group 1 was 30 (5), while it was 30 (6) in group 2. The use of preoperative CT scan did not improve the patient functional scores after TKA.

Solving the enigma of posterolateral tibial plateau fractures, the clue protocol.

The study aim is to evaluate functional and radio- logical outcomes following a suggested protocol based on the four-column classification for management of posterolateral column tibial plateau fractures. A prospective cohort study was performed in level I academic center on 42 patients with mean age of 36 years (22-59). Eleven patients had isolated posterolateral column fractures whereas 31 patients had associated columns fractures. According to the suggested protocol, all cases of isolated posterolateral column fracture started treatment via arthroscopic evaluation of soft tissue injuries (menisci and liga- ments), arthroscopically assisted reduction and inter- nal fixation by rafting screws followed by ORIF if plating was needed. If associated with other columns fractures, columns were fixed sequentially in an anti-clockwise direction starting from anteromedial column. Average follow up was 26 months. Mean time to union was 16.3 (12-22) weeks. No radiological evidence of loss of coronal or sagittal alignment was detected at final follow up. Five patients had an average depression of 5 millimeters that did not need further intervention at this short-term follow up. Mean KOOS was 81 (72- 88). The average knee range of motion was (0° - 127°). One patient had temporary common peroneal nerve injury, one patient had deep infection and two had superficial wound infection. implementing the suggested protocol gives good to excellent radiological and functional results as regard posterolateral tibial plateau fracture. A larger study group with longer follow up is needed.

Plate augmentation combined with bone grafting for aseptic non-union of femoral shaft fractures following interlocking nails.

TThe aim of this study was to evaluate plate augmentation over previously inserted interlocking nails, combined with iliac bone grafting in treating aseptic femoral shaft non-unions. The research was conducted prospectively on 34 patients. A narrow dynamic compression plate was placed while the nail was retained. All the screws were directed posterior to the nail. There were 25 males and 9 females with mean age of 36.6 years old. The mean operative time was 95 minutes with 320ml blood loss. 28 patients showed solid healing by 6 months postoperatively (82%). By 8 months, all patients showed solid union (mean 6.3 months). Full range was regained in both hips and knees and all patients could walk bearing full weight without supportive devices by 8 months. Where non-union occurs over an interlocking nail, augmenting it with a plate and bone grafting appears to be an effective treatment method to obtain solid union.

Insight into the possible role of miR-214 in primary osteoporosis via osterix.

Osteoporosis is a bone disease characterized by chronic pain and recurrent fractures. Osterix is a transcription factor regulating bone formation. miR-214 was found to have a role in skeletogenesis. Our goal was to investigate the possible role of miR-214 in primary osteoporosis through osterix. Their expression was determined in bone samples obtained from primary osteoporotic patients (n = 26) and age- and sex-matched controls (n = 14). Additionally, their expression was correlated to the laboratory and clinical parameters of the study participants. Differential expression of osterix and miR-214 was detected in the osteoporotic group compared to controls. While miR-214 was significantly higher, osterix was significantly lower. In primary osteoporotic patients, relative quantification value of osterix was positively correlated with sex, body mass index, and ionized calcium and negatively correlated with miR-214 and C-reactive protein. Thus, the role of miR-214 in primary osteoporosis could be through inhibiting osterix expression in bones and therefore both miR-214 and osterix could be targets for future therapeutic intervention.

Autophagy in osteoporosis: Relation to oxidative stress.

Impaired autophagy and oxidative stress are implicated in the development of many diseases. This study aimed to investigate the involvement of autophagy represented by autophagy-related gene 7 (Atg7) and oxidative stress represented by superoxide dismutase 2 (SOD2) gene expression and enzyme activity in the pathogenesis of osteoporosis. Atg7 and SOD2 gene relative expression were evaluated by SYBR green quantitative real-time-polymerase chain reaction in the osteoporotic group (n = 26) versus the osteoporosis free group (n = 14). SOD2 enzyme activity was evaluated by colorimetric method in both study groups. Both Atg7 and SOD2 relative expression showed highly significant decrease (P < 0.01) between both groups. However, SOD2 enzyme activity showed no significant difference between the two groups. There was a significant direct correlation between Atg7 and SOD2 gene expression in both study groups. Atg7 relative expression showed significant ( P < 0.01) direct correlation with vitamin D serum levels and body mass index in osteoporotic group. In conclusion, both genes are involved in the pathogenesis of osteoporosis and this could be amenable to future therapeutic intervention.

Single-Incision Double-Plating Approach in the Management of Isolated, Closed Osteoporotic Distal Femoral Fractures.

INTRODUCTION: Distal femoral fractures in elderly population had recorded an increase in incidence in the last 2 decades. Lateral distal femoral locking plating is considered one of the best options especially when dealing with comminuted fractures but varus collapse of the medial femoral condyle occurs frequently in patients with osteoporosis. Anatomical reduction of the fracture with stable rigid fixation using double-plating approach allows early mobilization of geriatric population and prevents varus collapse minimizing the comorbidities in such fractures. PATIENTS AND METHODS: Between September 2014 and January 2017, a prospective study on 23 patients with comminuted osteoporotic distal femoral fractures managed through the double-plating approach through a single parapatellar approach has been conducted. Only osteoporotic geriatric patients with isolated distal femoral fractures were included. Polytraumatized, open fractures, and fracture type 33-A1, 33-A2, and 33-B were excluded. The mean age was 69.6 years (61-80). All patients have been evaluated as regard duration of procedure, time to union, EQ-5D-5L score, the need of autologous bone grafts, range of knee motion, and presence of complications. RESULTS: The average follow-up was 14.1 months. The majority of fractures were type 33-C2 (13 patients). Average procedure time was 148 minutes (117-193 minutes). Mean EQ-5D-5 L score was 83.8 (72-82). Average time to union was 9 months (3-12 months). Four (17.4%) cases needed autologous bone graft after 6 months. No loss of reduction in any of the cases was evident, although 6 (26%) cases had screw breakage or cutout in one of the plate fixation. Two (8.7%) patient developed superficial wound infection and 1 (4.3%) developed DVT. DISCUSSION: This study aimed at evaluation of the success of double plating of distal femoral fractures in geriatric population. different fixation methods were studied for reduction and fixation of such a fracture such as external fixation, intramedullary nails and lateral plating. the quality of fracture reduction, functional and radiological outcomes, time to union, the need for bone grafting and complication are the main debatable issues. CONCLUSION: Single-incision double-plating approach for distal femoral osteoporotic fractures is effective and provides stable construct without reduction loss allowing early rehabilitation. Delayed union and the need for bone graft are the major drawbacks for this technique.

Biplanar fixation of acromio-clavicular joint dislocation associated with coracoid process fracture: Case report.

INTRODUCTION: Acromioclavicular (AC) joint injury associated with coracoid process (CP) fracture is a rare injury and only case reports had been published in the literature. Although AC joint injury is not uncommon, there is controversy as regard the best stabilization method whether to use wires, hook plate, arthroscopic reconstruction or the recently described techniques of anatomic restoration of both the coracoclavicular (CC) and acromioclavicular (AC) ligaments to add stability in both the vertical as well as the horizontal plane for the AC joint. Isolated CP fracture rarely necessitates surgical intervention; but in association with AC joint injury; a controversy as regard best management, surgical approach, technique of stabilization and implant used is present due to paucity of literature. PATIENT AND METHOD: A 36 years old manual worker who sustained a combined injury of AC joint (grade III) and CP comminuted base fracture had been treated surgically in our hospital using a biplanar fixation technique; blind 4 mm cannulated screw for the CP fracture and anatomic reconstruction of the AC ligament using FibreTape (Arthrex, Naples, FL); to add stability in both the vertical and horizontal plane. Follow up was done for one year. RESULTS: After completion of rehabilitation program, patient could return to work with no shoulder pain in ten weeks postoperatively. Till the last follow up there was no evidence of loss of reduction or shoulder pain with a Constant score of 86. CONCLUSION: Our technique in combined AC joint and CP fracture, address both injuries to add biplanar AC joint stability allowing accelerated rehabilitation and avoids metal hardware complications.