Risk factors for in-hospital mortality in geriatric patients aged 80 and older with axis fractures: a nationwide, cross-sectional analysis of concomitant injuries, comorbidities, and treatment strategies in 10,077 cases.

PURPOSE: To investigate the association between treatment, comorbidities, concomitant injuries, and procedures with in-hospital mortality in patients aged 80 years or older with axis fractures. METHODS: Data were extracted from the German InEK (Institut für das Entgeltsystem im Krankenhaus) GmbH database (2019-2021) for patients aged 80 years or older with axis fractures and the in-hospital mortality rate was calculated. Differences in comorbidities and concomitant diseases and injuries were analyzed using the Chi-square test. In surgically treated patients, odds ratios (OR) with 95% confidence intervals (95% CI) were used to analyze potential risk factors for in-hospital mortality. RESULTS: Among 10,077 patients, the in-hospital mortality rate was 8.4%, with no significant difference between surgically (9.4%) and non-surgically treated patients (7.9%; p = 0.103). The most common comorbidities were essential hypertension (67.3%), atrial fibrillation (28.2%), and chronic kidney disease (23.3%), while the most common concomitant injuries were head and face wounds (25.9%), concussions (12.8%), and atlas fractures (11.6%). In surgically treated patients, spinal cord injury (OR = 4.62, 95% CI: 2.23-9.58), acute renal failure (OR = 3.20, 95% CI: 2.26-4.53), and acute bleeding anemia (OR = 2.06, 95% CI: 1.64-2.59) were associated with increased in-hospital mortality (all p < 0.01). Screw-rod-system fixation of one segment (OR = 0.74, 95% CI: 0.56-0.97) and intraoperative navigation (OR = 0.45, 95% CI: 0.16-0.71) were identified as potential protective factors (both p < 0.05). CONCLUSION: Comprehensive geriatric assessment and optimization of comorbidities during treatment are crucial. The indication for surgical treatment must be carefully individualized. Future studies should focus on the choice of surgical technique, perioperative blood management, and intraoperative navigation as potential protective factors.

Intramedullary nailing of proximal humerus fractures does not achieve superior functional results to non-operative treatment in the long term.

INTRODUCTION: Non-operative treatment (NOT) of proximal humerus fractures (PHF) has regained significance due to recent evidence. Additionally, positive outcomes of plate osteosynthesis and fracture arthroplasty prompt a reassessment of the role of intramedullary nailing (IMN). While favorable short and medium-term results have been documented following IMN, little is known regarding functional outcomes and quality of life in the long-term. METHODS: Data from 180 patients with dislocated PHF of Neer types III, IV and V, treated at our level-I trauma center between 2004 and 2014 using IMN or NOT therapy, were scanned. Patients were re-evaluated after a minimum of 5 years to assess functional outcomes (age- and sex-adapted Constant Score, QuickDASH), quality of life (SF12), and complications or reoperations. RESULTS: Out of the initially identified 180 patients, 51 were unavailable for follow-up (FU) and 71 had deceased during the FU period. Functional outcomes and quality of life was, therefore, assessed in 58 patients (30 IMN, 28 NOT) with an average age at injury of 68 years after a mean FU time of 10.3 ± 3.4 years. Epidemiological patient characteristics did not exhibit significant differences between the two groups (p > .05). The functional outcome assessed by age- and sex-adapted Constant Score (NOT: 74 ± 28; IMN: 68 ± 24; p = .438), QuickDASH (NOT: 25 ± 27; IMN: 31 ± 23; p = .374) or quality of life using the SF12 (p > .05) revealed no significant disparities in long-term outcomes between the treatment groups. 10 of 30 patients in the IMN group underwent surgical revision to address complications, exceeding mere implant removal. Conversely, no patient in the NOT group underwent a revision surgery during the FU period. CONCLUSIONS: In the long-term, functional and quality of life-related outcomes of IMN did not diverge significantly from those of NOT, while causing a higher incidence of follow-up interventions.

Factors influencing choice of treatment for proximal humeral fractures elaborated in a Delphi consensus process.

INTRODUCTION: Hitherto, the decision-making process for treatment of proximal humerus fractures (PHF) remains controversial, with no established or commonly used treatment regimens. Identifying fracture- and patient-related factors that influence treatment decisions is crucial for the development of such treatment algorithms. The objective of this study was to define a Delphi consensus of clinically relevant fracture- and patient-related factors of PHF for clinical application and scientific research. METHODS: An online survey was conducted among an international panel of preselected experienced shoulder surgeons. An evidence-based list of fracture-related and patient-related factors affecting treatment outcome after PHF was generated and reviewed by the members of the committee through online surveys. The proposed factors were revised for definitions, and suggestions from the first round mentioned in the free text were included as possible factors in the second round of surveys. Consensus was defined as having at least a two-thirds majority agreement. RESULTS: The Delphi consensus panel consisted of 18 shoulder surgeons who completed 2 rounds of online surveys. There was an agreement of more than two-thirds of the panel for three fracture-related factors affecting treatment decision in the case of PHF: head-split fracture, dislocated tuberosities, and fracture dislocation. Of all patient-related factors, a two-thirds consensus was reached for two factors: age and rotator cuff tear arthropathy. CONCLUSION: This study successfully conducted a Delphi consensus on factors influencing decision-making in the treatment of proximal humeral fractures. The documented factors will be useful for clinical evaluation and scientific validation in future studies.

[Bone transplantation or biomaterials? : An analysis of 99,863 surgical procedures in orthopedic and trauma surgery in Germany from 2018]. / Knochentransplantation oder Biomaterial? : Eine Analyse von 99.863 Operationen in Orthopädie und Unfallchirurgie aus dem Jahr 2018 in Deutschland.

BACKGROUND: The aims of this study were (1) to analyze the total number of interventions with autologous or allogeneic bone transplantation as well as biomaterials, (2) to investigate the different types of biomaterials, autologous and allogeneic bone transplantations and (3) to analyze the additional use of an antibiotic additive in biomaterials. METHODS: Data were obtained from the Federal Statistical Office for the year 2018. The surgery and procedure codes 5­784 "bone transplantation and transposition" and 5­785 "implantation of alloplastic bone substitutes" were used to analyze the procedure frequency of implantation of biomaterials, such as calcium phosphate ceramics, calcium sulphate, calcium phosphate cements and polymethyl methacrylate as well as autologous and allogeneic bone for defect reconstruction of the extremities and pelvis. RESULTS: In 2018 a total of 99,863 procedures were performed using autografts (54,784, 55%), biomaterials (23,838, 24%) and allografts (21,241, 21%). For both autografts and allografts cancellous bone grafting was used most frequently (77% and 79%, respectively). For biomaterials, ceramics (42%) were used more frequently than bone cements (37%, other biomaterials 21%). In 16,027 cases (67%) with biomaterials no antibiotic supplement was used. Antibiotic supplementation was mainly used for bone cements (6612 cases, 75%). CONCLUSION: In 2018 bone transplants or biomaterials were used in a considerable number of the 99,863 bone defect reconstruction procedures. Autologous bone was used in more than half of the cases (55%), biomaterials in approximately one quarter (24%) and allogenic bone in approximately one fifth (21%). Ceramics (42%) were more often used as biomaterials than cements (37%). The addition of antibiotics was mainly used with cements (75%).

Time to Positivity in Blood Culture Bottles Inoculated with Sonication Fluid from Fracture-Related Infections.

The timely and accurate identification of causative agents is crucial for effectively managing fracture-related infections (FRIs). Among various diagnostic methods, the "time to positivity" (TTP) of cultures has emerged as a valuable predictive factor in infectious diseases. While sonication of implants and inoculation of blood culture bottles with sonication fluid have enhanced sensitivity, data on the TTP of this microbiological technique remain limited. Therefore, patients with ICM criteria for confirmed FRI treated at our institution between March 2019 and March 2023 were retrospectively identified and their microbiological records were analyzed. The primary outcome parameter was TTP for different microorganism species cultured in a liquid culture collected from patients with confirmed FRI. A total of 155 sonication fluid samples from 126 patients (average age 57.0 ± 17.4 years, 68.3% males) was analyzed. Positive bacterial detection was observed in 78.7% (122/155) of the liquid culture pairs infused with sonication fluid. Staphylococcus aureus was the most prevalent organism (42.6%). Streptococcus species exhibited the fastest TTP (median 11.9 h), followed by Staphylococcus aureus (median 12.1 h) and Gram-negative bacteria (median 12.5 h), all of which had a 100% detection rate within 48 h after inoculation. Since all Gram-negative pathogens yielded positive culture results within 24 h, it could be discussed if empirical antibiotic therapy could be de-escalated early and limited towards the Gram-positive germ spectrum if no Gram-negative pathogens are detected up to this time point in the context of antibiotic stewardship.

Injury Pattern and Current Early Clinical Care of Pediatric Polytrauma Comparing Different Age Groups in a Level I Trauma Center.

Introduction: Pediatric polytrauma is a complex condition with unique characteristics and requirements for early clinical care. This study aimed to analyze the injury patterns, early clinical care, and outcomes of pediatric polytrauma patients in a Level I trauma center. The focus was on evaluation between different age groups and the recognition of injuries as potential factors influencing outcomes. Methods: A prospective cohort study model of pediatric polytrauma patients (ISS ≥ 16) was conducted over a 13-year period, stratified by age groups (Group A: 0-5 years; Group B: 6-10 years; Group C: 11-15 years; and Group D: 16-18 years). A comparison of the groups was conducted to examine variations in early clinical care, trauma mechanisms, distribution of affected body regions (as per AIS and ISS criteria), and trauma-related mortality. Additionally, factors contributing to mortality were evaluated. Results: The median age of patients was 16 years, with a male predominance (64.7%). The Injury Severity Score (ISS) varied across age groups, with no significant difference. The 30-day mortality rate was 19.0%, with no significant age-related differences. Trauma mechanisms varied across age groups, with motor vehicle accidents being the most common mechanism in all age groups except 0-5 years, where falls were prevalent. Analysis of injury patterns by AIS body regions indicated that head trauma was a significant predictor of mortality (Hazard Ratio 2.894, p < 0.001), while chest, abdominal, and extremity trauma showed no significant association with mortality. Multiple regression analysis identified the ISS and preclinical GCS as valid predictors of mortality (p < 0.001 and p = 0.006, respectively). Conclusions: While age-related differences in injury severity and clinical interventions were limited, head trauma emerged as a critical predictor of mortality. Early recognition and management of head injuries are crucial in improving outcomes. Additionally, the ISS and preclinical GCS were identified as valid predictors of mortality, emphasizing the importance of early assessment and resuscitation. A tailored approach to pediatric polytrauma care, considering both age and injury patterns, might contribute to survival benefits in this vulnerable population.

Anterior Column Reconstruction of Destructive Vertebral Osteomyelitis at the Thoracolumbar Spine with an Expandable Vertebral Body Replacement Implant: A Retrospective, Monocentric Radiological Cohort Analysis of 24 Cases.

BACKGROUND: Vertebral osteomyelitis (VO) often necessitates surgical intervention due to bone loss-induced spinal instability. Anterior column reconstruction, utilizing expandable vertebral body replacement (VBR) implants, is a recognized approach to restore stability and prevent neurological compromise. Despite various techniques, clinical evidence regarding the safety and efficacy of these implants in VO remains limited. METHODS: A retrospective cohort analysis, spanning 2000 to 2020, was conducted on 24 destructive VO cases at a Level 1 orthopedic trauma center. Diagnosis relied on clinical, radiological, and microbiological criteria. Patient demographics, clinical presentation, surgical interventions, and radiological outcomes were assessed. RESULTS: The study included 24 patients (62.5% male; mean age 65.6 ± 35.0 years), with 58% having healthcare-associated infections (HAVO). The mean radiological follow-up was 137.2 ± 161.7 weeks. Surgical intervention significantly improved the bi-segmental kyphotic endplate angle (BKA) postoperatively (mean -1.4° ± 13.6°). However, a noticeable loss of correction was observed over time. The study reported a mortality rate of 1/24. CONCLUSIONS: Anterior column reconstruction using expandable VBR effectively improved local spinal alignment in destructive VO. However, the study underscores the necessity for prolonged follow-up and continuous research to refine surgical techniques and postoperative care. Addressing long-term complications and refining surgical approaches will be pivotal as the field progresses.

Is the Tendon-to-Groove Ratio Associated with Elevated Risk for LHB Tendon Disorders?-A New Approach of Preoperative MR-Graphic Analysis for Targeted Diagnosis of Tendinopathy of the Long Head of Biceps.

Background: Pathologies of the long head of the biceps (LHB) tendon are a common cause of anterior shoulder pain. While the influence of the anatomical morphology of the intertubercular groove (ITG) on the development of LHB tendon instability has been investigated with ambiguous results, the relationship of the LHB to ITG anatomy has not yet been considered in this context. The objective of this study was to reliably extract the tendon-to-groove ratio from MRI scans of symptomatic patients and examine its potential influence on the occurrence of certain causes for LHB-associated symptoms. Methods: In this retrospective study, preoperative MRI scans of 35 patients (mean age of 46 ± 14 years) presenting with anterior shoulder pain and clinical indications of LHB tendinopathy were analyzed in transversal planes. Long and short diameters of the LHB tendon and ITG were measured, cross-sectional areas of the LHB tendon and ITG were calculated from these measurements, and the ratio of cross-sectional areas (LHB/ITG) was introduced. All measurements were repeated independently by three investigators and inter-rater reliability was assessed using intraclass correlation coefficient (ICC). Thereafter, tendon-to-groove ratios were compared in patients with and without intraoperative signs of LHB tendon instability. Results: All patients exhibited intraoperative signs of LHB tendinitis, with additional findings including pulley lesions and SLAP lesions. Analysis revealed variations in the dimensions of the LHB tendon and ITG cross sections, with the tendon-to-groove ratio decreasing from 37% at the pulley to 31% at the deepest point of the sulcus. Very good inter-rater reliability was observed for all measurements. The tendon-to-groove ratio did not significantly differ (p > 0.05) in patients with or without pulley lesions or SLAP lesions. Conclusions: Our study introduced the novel parameter of the tendon-to-groove ratio of cross-sectional areas as a reproducible parameter for the description of local anatomy in the field of targeted diagnosis of LHB tendon disorders. While our findings do not yet support the predictive value of the tendon-to-groove ratio, they underscore the importance of further research with larger cohorts and control groups to validate these observations.

[Elbow joint dislocation : Frequent concomitant injuries and current treatment concepts]. / Ellenbogengelenkluxation : Häufige Begleitverletzungen und aktuelle Therapiekonzepte.

Dislocations of the elbow joint are among the most prevalent dislocation injuries in the human body after shoulder joint dislocations and represent a challenge in the clinical routine because of the concomitant injuries and complications. They predominantly affect young adults who become injured during athletic or daily activities. A distinction is generally made between a simple elbow dislocation and a dislocation fracture of the elbow; however, a uniform classification or treatment algorithm has not yet been established, especially for simple elbow dislocations with associated ligamentous, muscular and capsular concomitant injuries. Due to this and the complexity of this injury, a standardized approach is needed to initiate the optimal treatment at an early stage and to correctly select the narrow treatment pathway between impending chronic instability and elbow stiffness.

Predictors of Mortality in Head-Preserving Treatment for Dislocated Proximal Humerus Fractures: A Retrospective Analysis of 522 Cases with a Minimum Follow-Up of 5 Years.

PURPOSE: Proximal humerus fractures (PHFs) are among the most common fractures in elderly patients, but there is still inadequate knowledge about mortality risk factors after such injuries. In order to provide the best possible therapy, individual risk factors have to be considered and evaluated thoroughly. There is still controversy regarding treatment decisions for proximal humerus fractures, particularly for the elderly. METHODS: In this study, patient data from 522 patients with proximal humerus fractures were obtained from 2004 to 2014 at a Level 1 trauma centre. After a minimum follow-up of 5 years, the mortality rate was assessed, and independent risk factors were evaluated. RESULTS: A total of 383 patients (out of 522) were included in this study. For our patient collective, the mean follow-up was at 10.5 ± 3.2 years. The overall mortality rate was 43.8% in our respondent group and was not significantly impacted by concomitant injuries. The binary logistic regression model showed an increased risk for mortality by 10% per life year, a 3.9 times higher mortality risk for men and a 3.4 times higher risk for conservative treatment. The most powerful predictor was a Charlson Comorbidity Index of more than 2, with a 20 times higher mortality risk. CONCLUSIONS: Outstanding independent predictors of death in our patient collective were serious comorbidities, male patients, and conservative treatment. This patient-related information should influence the process of decision making for the individual treatment of patients with PHFs.

The clinical use of bone graft substitutes in orthopedic surgery in Germany-A 10-years survey from 2008 to 2018 of 1,090,167 surgical interventions.

Aim of the study was to evaluate (1) the overall use of bone graft substitutes, autografts and allografts, (2) of different types of bone graft substitutes (calcium sulfate, calcium phosphate, calcium phosphate ceramics or polymethyl methacrylate) and of different bone grafts (cancellous vs. cortical), and (3) the use of antibiotic-loading of bone graft substitutes in orthopedic surgery in Germany. Gross data were provided from the Federal Statistical Office of Germany and revealed an overall increase in bone defect reconstruction procedures using bone graft substitutes, autografts and allografts from 86,294 in 2008 to 99,863 cases in 2018 (+15.7%). The relative use of bone graft substitutes for these interventions strongly increased from 11.8% in 2008 (10,163 cases) to 23.9% in 2018 (23,838 cases) with an increase of +134.4%. Furthermore, antibiotic-loaded bone graft substitutes were implanted more frequently with an overall increase of +194% (2008: n = 2,657; 2018: n = 7,811). The work shows an increasing use of bone graft substitutes and antibiotic-loaded bone graft substitutes over the last 10 years in Germany.

Displacement of the Greater Tuberosity in Humeral Head Fractures Does Not only Depend on Rotator Cuff Status.

It is assumed that dorsocranial displacement of the greater tuberosity in humeral head fractures is caused by rotator cuff traction. The purpose of this study was to investigate the association between rotator cuff status and displacement characteristics of the greater tuberosity in four-part humeral head fractures. Computed tomography scans of 121 patients with Neer type 4 fractures were analyzed. Fatty infiltration of the supra- and infraspinatus muscles was classified according to Goutallier. Position determination of the greater tuberosity fragment was performed in both coronary and axial planes to assess the extent of dorsocranial displacement. Considering non-varus displaced fractures, the extent of the dorsocranial displacement was significantly higher in patients with mostly inconspicuous posterosuperior rotator cuff status compared to advanced fatty degenerated cuffs (cranial displacement: Goutallier 0-1: 6.4 mm ± 4.6 mm vs. Goutallier 2-4: 4.2 mm ± 3.5 mm, p = 0.020; dorsal displacement: Goutallier 0-1: 28.4° ± 32.3° vs. Goutallier 2-4: 13.1° ± 16.1°, p = 0.010). In varus displaced humeral head fractures, no correlation between the displacement of the greater tuberosity and the condition of the posterosuperior rotator cuff could be detected (p ≥ 0.05). The commonly accepted theory of greater tuberosity displacement in humeral head fractures by rotator cuff traction cannot be applied to all fracture types.

The Tibial Plateau Map: Fracture Line Morphology of Intra-Articular Proximal Tibial Fractures.

The purpose of this study was to characterize the patterns of a large series of tibial plateau fractures with the use of fracture mapping, with regard to different fracture types using the OTA/AO and Schatzker classification. Patients with intra-articular fractures of the tibial plateau were evaluated, using the OTA/AO and Schatzker classification on CT scans. For fracture mapping, the axial slice that completely displayed the tibial joint plane was first identified, then matched to a template congruently, and the fracture lines were identified and reproduced. In addition to epidemiological data (age and gender), the trauma mechanism (high-energy, low-energy, and pathological fracture) was recorded. In total, 271 patients with 278 intra-articular fractures of the tibial head were analyzed, including seven patients with both sides affected. The mean age was 49.1 years (men 46.3 years, women 53.5 years). The majority of fractures was caused by high-energy trauma. No significant difference could be shown with respect to trauma mechanism and resulting fracture type in terms of OTA/AO (p = 0.352) or Schatzker classification (p = 0.884). A significant difference could be found with respect to gender and resulting fracture type in terms of OTA/AO (p = 0.031). 170 (61.2%) were OTA/AO type B fractures, and 108 (38.8%) were type C fractures. Using the Schatzker classification, we found 53 type I (19.1%), 60 type II (21.6%), 27 type III (9.7%), 32 type IV (11.5%), 16 type V (5.8%), and 90 type VI (32.4%) fractures. The main affection was found in the lateral and intermedial column of the tibial plateaus, concerning both OTA/AO and Schatzker classification. The variability of intra-articular tibial head fractures is very high. In consequence, an individual analysis of fracture patterns and therapy planning by using CT scans is crucial.

Clinical Value of CT for Differentiation between Ascites and Hemorrhage: An Experimental In-Vitro Study.

BACKGROUND: Abdominal trauma, leading to intra-abdominal bleeding, is a life-threatening condition that might need emergency surgical intervention. Sonography and Computed Tomography (CT) are most commonly used to detect free intra-abdominal fluid. This study investigates the accuracy of CT to distinguish between ascites and intra-abdominal hemorrhage. METHODS: Ascites were collected during a clinical routine. Three serial dilutions, mixing ascites with whole blood samples of the patient and with two blood group identical donors, were prepared. Laboratory-chemical analysis and radiological evaluation using CT with measurement of average Hounsfield Units (HU) were performed. RESULTS: Between ascites and whole blood as well as between ascites and the 1:1-ratio-samples, HU values differed significantly (p < 0.001). All further dilutions showed HU values with no significant difference compared to ascites (p ≥ 0.42). Whole blood showed significantly higher HU values than ascites and every step of the serial dilutions (p < 0.001). Measured HU values were also dependent on time and the exact point of measurement in the micro reaction vessels. CONCLUSIONS: In patients suffering from blunt abdominal trauma with preexisting ascites, HU values in CT imaging are not valid enough to exclude an acute hemorrhage.