Current Trends in Orthopaedics and Trauma in Germany.

During the Guest Nation Symposium (cobranded with the Deutsche Gesellschaft für Orthopädie und Unfallchirurgie, Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie, and Deutsche Gesellschaft für Unfallchirurgie) at the 2023 American Academy of Orthopaedic Surgeons Congress in Las Vegas, the goal was to compile nationally important content from German orthopaedics and trauma surgery. This resulted in a mix of content on the latest developments in trauma care, knee arthroplasty, spinopelvic importance for hip arthroplasty, stemless shoulder endoprostheses, joint preservation for ankle osteoarthritis, trauma education, and research. Of course, this is only a small selection of the important issues that are being driven forward in Germany.

Health-related quality of life (EQ-5D) after revision arthroplasty following periprosthetic femoral fractures Vancouver B2 and B3 in geriatric trauma patients.

INTRODUCTION: The aim of this study was to determine the outcome parameters of revision arthroplasties for periprosthetic femoral fractures (PPFF) with a particular attention to quality of life (QoL) and mobility. MATERIALS AND METHODS: Retrospective single-center study of PPFF with loose implants that underwent revision arthroplasty. Depending on individual patient characteristics, either an uncemented or cemented revision stem was chosen. Data collection included demographics, complications, clinical course and outcome parameters. Follow-up took place at least one year postoperatively. RESULTS: Between 2008 and 2016, 43 patients could be included. Most patients (63%) were able to walk independently or with a walking aid after one year and amongst the surveyed patients 77% were able to reside at home. Concerning the QoL assessment, a high index of 0.8 ± 0.1 has been reached after one year. Mortality pointed out to be 9% after one year and 28% in general. CONCLUSION: The treatment of PPFF remains challenging. Although complication rates and mortality are high in this frail collective of geriatric patients, revision arthroplasty leads to good postoperative results regarding mobility and quality of life.

Surgical management and outcomes following atypical subtrochanteric femoral fractures - results from a matched-pair analysis of the registry for geriatric trauma of the German Trauma Society.

BACKGROUND AND OBJECTIVES: The outcomes of patients with atypical subtrochanteric fractures (ASFs) remain unclear. Data from a large international geriatric trauma registry were analysed to examine the outcome of patients with ASFs compared to patients with typical osteoporotic subtrochanteric fractures (TSFs). MATERIALS AND METHODS: Data from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (ATR-DGU) were analysed. All patients treated surgically for ASFs or TSFs were included in this analysis. Across both fracture types, a paired matching approach was conducted, where statistical twins were formed based on background characteristics sex, age, American Society of Anesthesiologists (ASA) score and walking ability. In-house mortality and mortality rates at the 120-day follow-up, as well as mobility at 7 and 120 days, the reoperation rate, hospital discharge management, the hospital readmission rate at the 120-day follow-up, health-related quality of life, type of surgical treatment and anti-osteoporotic therapy at 7 and 120 days, were assessed as outcome measures using a multivariate logistic regression analysis. RESULTS: Amongst the 1,800 included patients, 1,781 had TSFs and 19 had ASFs. Logistic regression analysis revealed that patients with ASFs were more often treated with closed intramedullary nailing (RR = 3.59, p < 0.001) and had a higher probability of vitamin D supplementation as osteoporosis therapy at 120 days (RR = 0.88, p < 0.002). Patients with ASFs were also more likely to live at home after surgery (RR = 1.43, p < 0.001), and they also tended to continue living at home more often than patients with TSFs (RR = 1.33, p < 0.001). Accordingly, patients with TSFs had a higher relative risk of losing their self-sufficient living status, as indicated by increased rates of patients living at home preoperatively and being discharged to nursing homes (RR = 0.19, p < 0.001) or other hospitals (RR = 0.00, p < 0.001) postoperatively. CONCLUSIONS: Surgical treatment of ASFs was marked by more frequent use of closed intramedullary fracture reduction. Furthermore, patients with ASFs were more likely to be discharged home and died significantly less often in the given timeframe. The rate of perioperative complications, as indicated by nonsignificant reoperation rates, as well as patient walking abilities during the follow-up period, remained unaffected.

Value of Proximal Femur Geometry in Predicting Occult Hip Fracture.

Background and Objectives: Patients with occult hip fractures are a difficult subgroup to treat. MRI is the gold standard for diagnosing occult proximal femur fractures but is costly and may not be readily available in an emergency setting. The purpose of this study was to determine whether changes in the proximal femur geometry can predict the likelihood of an occult hip fracture in patients presenting with hip pain following a ground-level fall. Material and Methods: Patients admitted to the hospital with a clinical suspicion of a hip fracture but initial negative radiographs over a seven-year period were included. All patients were additionally investigated with an MRI scan, and retrospectively, six radiologic parameters were obtained on plain radiographs: The cortical thickness index (CTI), the canal to calcar ratio (CCR), the canal flare index (CFI), the morphological cortical index (MCI), the canal bone ratio (CBR) and the canal bone aria ratio (CBAR). Subsequently the result of the plain radiographic indices of the patients with a negative MRI (Group A, no occult fracture) were compared to those with a positive MRI (Group B, occult fracture). Results: A total of 78 patients (59 female, 19 male) could be included in the study. The mean age was 82 years. The univariate analyses revealed a poor predictive ability of all radiological parameters with AUC values ranging from 0.515 (CBR) to 0.626 (CTI), whereas a multivariate prognostic model demonstrated improved prognosis (AUC = 0.761) for the CTI (p = 0.024), CBAR (p = 0.074) and CRR (p = 0.081) as the most promising predictive radiological parameters. Conclusions: Single radiologic indices obtained from conventional X-rays of the proximal femur have a weak predictive value in detecting occult fractures of the hip and cannot be used as clinical decision-making factors.

Self-rated health status and activities of daily living in the first 12 months after fragility fractures of the pelvis-a prospective study on 134 patients.

The aim of this study was to evaluate changes in activities of daily living and self-reported health status in the first year after fragility fractures of the pelvis. We found out that these fractures lead to a significant, long-lasting deterioration of both parameters, comparable with hip fractures. PURPOSE: The aim of this prospective study was to evaluate the development and to identify influencing factors in activities of daily living (ADL) and self-reported health status (HS) in the first year after fragility fractures of the pelvis (FFP). METHODS: A total of 134 patients with FFP ≥ 60 years were included. ADL were measured using the Barthel index (BI) and the IADL scale pre-fracture, at 6 weeks, 6 months, and 12 months. HS was evaluated using the EQ-5D questionnaire at 6 weeks, 6 months, and 12 months. Multiple regression analysis and hierarchical linear models were applied to identify influencing factors in ADL and HS. RESULTS: The BI was 95 pre-fracture, 75 at 6 weeks (p < 0.001), 80 at 6 months (p = 0.178), and 80 at 12 months (p = 0.149). The IADL was 6 pre-fracture, 3 at 6 weeks (p < 0.001), 4 at 6 months (p = 0.004), and 4 at 12 months (p = 0.711). The EQ-5D index was 0.70 at 6 weeks, 0.788 at 6 months (p = 0.158), and 0.788 at 12 months (p = 0.798). Significant influencing factors in the multiple regression analysis were pre-fracture nursing care level for all scores; pre-fracture mobility for BI; and pre-fracture IADL, ASA score, and age for IADL. Significant influencing factors in the hierarchical linear model were pre-fracture nursing care level for all scores; pre-fracture IADL, ASA score, age, and time for IADL; and pre-fracture mobility, sex, and time for the EQ-5D. CONCLUSION: Our results confirm that FFP lead to a significant, long-lasting deterioration in ADL and HS, comparable with hip fractures.

Surgical Management and Outcomes following Pathologic Hip Fracture-Results from a Propensity Matching Analysis of the Registry for Geriatric Trauma of the German Trauma Society.

Background and Objectives: The outcomes of patients with pathologic hip fractures remain unclear. Data from a large international geriatric trauma registry were analyzed to examine the outcomes of patients with pathologic hip fractures compared with patients with typical osteoporotic hip fractures. Materials and Methods: Data from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) were analyzed. All patients treated surgically for osteoporotic or pathologic hip fractures were included in this analysis. Across both fracture types, a 2:1 optimal propensity score matching and multivariate logistic regression analysis were conducted. In-house mortality rate and mortality at the 120-day follow-up, as well as mobility after 7 and 120 days, reoperation rate, discharge management from the hospital and readmission rate to the hospital until the 120-day follow-up were analyzed as outcome parameters for the underlying fracture type-pathologic or osteoporotic. Results: A total of 29,541 cases met the inclusion criteria. Of the patients included, 29,330 suffered from osteoporotic fractures, and 211 suffered from pathologic fractures. Multivariate logistic regression analysis revealed no differences between the two fracture types in terms of mortality during the acute hospital stay, reoperation during the initial acute hospital stay, walking ability after seven days and the likelihood of being discharged back home. Walking ability and hospital readmission remained insignificant at the 120-day follow-up as well. However, the odds of passing away within the first 120 days were significantly higher for patients suffering from pathologic hip fractures (OR: 3.07; p = 0.003). Conclusions: Surgical treatment of pathologic hip fractures was marked by a more frequent use of arthroplasty in per- and subtrochanteric fractures. Furthermore, the mortality rate among patients suffering from pathologic hip fractures was elevated in the midterm. The complication rate, as indicated by the rate of readmission to the hospital and the necessity for reoperation, remained unaffected.

Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®.

Background and Objectives: The increased use of direct oral anticoagulants (DOACs) results in an increased prevalence of DOAC treatment in hip fractures patients. However, the impact of DOAC treatment on perioperative management of hip fracture patients is limited. In this study, we describe the prevalence of DOAC treatment in a population of hip fracture patients and compare these patients with patients taking vitamin K antagonists (VKA) and patients not taking anticoagulants. Materials and Methods: This study is a retrospective analysis from the Registry for Geriatric Trauma (ATR-DGU). The data were collected prospectively from patients with proximal femur fractures treated between January 2016 and December 2018. Among other factors, anticoagulation was surveyed. The primary outcome parameter was time-to-surgery. Further parameters were: type of anesthesia, surgical complications, soft tissue complications, length of stay and mortality. Results: In total, 11% (n = 1595) of patients took DOACs at the time of fracture, whereas 9.2% (n = 1325) were on VKA therapy. During the study period, there was a shift from VKA to DOACs. The time-to-surgery of patients on DOACs and of patients on VKA was longer compared to patients who did not take any anticoagulation. No significant differences with regard to complications, type of anesthesia and mortality were found between patients on DOACs compared to VKA treatment. Conclusion: An increased time-to-surgery in patients taking DOACs and taking VKA compared to non-anticoagulated patients was found. This underlines the need for standardized multi-disciplinary orthopedic, hematologic and ortho-geriatric algorithms for the management of hip fracture patients under DOAC treatment. In addition, no significant differences regarding complications and mortality were found between DOAC and VKA users. This demonstrates that even in the absence of widely available antidotes, the safe management of geriatric patients under DOACs with proximal femur fractures is possible.

Simultaneous Casualty Admissions-Do they Affect Treatment in the Receiving Trauma Center?

BACKGROUND: Simultaneous trauma admissions expose medical professionals to increased workload. The impact of simultaneous trauma admissions on hospital allocation, therapy, and outcome is currently unclear. We hypothesized that multiple admission-scenarios impact the diagnostic pathway and outcome. METHODS: The TraumaRegister DGU® was utilized. Patients admitted between 2002-2015 with an ISS ≥ 9, treated with ATLS®- algorithms were included. Group ´IND´ included individual admissions, two individuals that were admitted within 60 min of each other were selected for group ´MULT´. Patients admitted within 10 min were considered as simultaneous (´SIM´) admissions. We compared patient and trauma characteristics, treatment, and outcomes between both groups. RESULTS: 132,382 admissions were included, and 4,462/3.4% MULTiple admissions were found. The SIM-group contained 1,686/1.3% patients. The overall median injury severity score was 17 and a mean age of 48 years was found. MULT patients were more frequently admitted to level-one trauma centers (68%) than individual trauma admissions were (58%, p < 0.001). Mean time to CT-scanning (24 vs. 26/28 min) was longer in MULT / SIM patients compared to individual admissions. No differences in utilization of damage control principles were seen. Moreover, mortality rates did not differ between the groups (13.1% in regular admissions and 11.4%/10,6% in MULT/SIM patients). CONCLUSION: This study demonstrates that simultaneous treatment of injured patients is rare. Individuals treated in parallel with other patients were more often admitted to level-one trauma centers compared with individual patients. Although diagnostics take longer, treatment principles and mortality are equal in individual admissions and simultaneously admitted patients. More studies are required to optimize health care under these conditions.

Height and volume restoration in osteoporotic vertebral compression fractures: a biomechanical comparison of standard balloon kyphoplasty versus Tektona® in a cadaveric fracture model.

BACKGROUND: Standard balloon kyphoplasty represents a well-established treatment option for osteoporotic vertebral compression fractures. Aim of the present study was to evaluate two different methods of percutaneous augmentation (standard balloon kyphoplasty (BKP) versus Tektona® (TEK)) with respect to height restoration. METHODS: Four-teen vertebral bodies of two female cadavers were examined. Fractures were created using a standardized protocol. CT-scans were taken before and after fracture, as well as after treatment. Afterwards two groups were randomly assigned in a matched pair design: 7 vertebral bodies (VB) were treated with BKP (Kyphon, Medtronic) and 7 vertebral bodies by TEK (Spineart, Switzerland) Anterior, central and posterior vertebral body heights were evaluated by CT-scans. Volumetry was performed using the CT-scans at three different timepoints. RESULTS: Values before fracture represent 100%. The anterior height after fracture was reduced to 75.99 (± 4.8) % for the BKP group and to 76.54 (± 9.17) % in the TEK Group. Statistically there was no difference for the groups (p = 1). After treatment the values increased to 93.06 (± 5) % for the BKP Group and 87.71 (± 6.2) % for the TEK Group. The difference before and after treatment was significant for both groups (BKP p = 0.0006; TEK p = 0.03). Within the groups, there was no difference (p = 0.13). The Volume of the vertebral body was reduced to 82.29 (± 8.4) % in the BKP Group and to 76.54 (± 8.6) % in the TEK Group. After treatment the volume was 89.26 (± 6.9) % for the BKP Group and 88.80 (± 8.7) % for the TEK Group. The difference before and after treatment was significant only for the TEK group (BKP p = 0.0728 n.s.; TEK p = 0.0175). Within the groups, there was no difference (p = 0.2). The average cement volume used was 6.1 (range 3.6-9 ml) for the BKP group and 5.3 (3-7.2 ml) for the TEK group respectively. CONCLUSIONS: Based on our results the new System Tektona® in osteoporotic compression fractures might represent a promising alternative for the clinical setting, especially preserving bone. Further biomechanical tests and clinical studies have to proof Tektona®`s capabilities.

Is cement-augmented sacroiliac screw fixation with partially threaded screws superior to that with fully threaded screws concerning compression and pull-out force in fragility fractures of the sacrum? - a biomechanical analysis.

BACKGROUND: Providing a stable osteosynthesis in fragility fractures of the pelvis can be challenging. Cement augmentation increases screw fixation in osteoporotic bone. Generating interfragmentary compression by using a lag screw also improves the stability. However, it is not known if interfragmentary compression can be achieved in osteoporotic sacral bone by cement augmentation of lag screws. The purpose of this study was to compare cement-augmented sacroiliac screw osteosynthesis using partially versus fully threaded screws in osteoporotic hemipelvises concerning compression of fracture gap and pull-out force. METHODS: Nine fresh-frozen human cadaveric pelvises with osteoporosis were used. In all specimens, one side was treated with an augmented fully threaded screw (group A), and the other side with an augmented partially threaded screw (group B) after generating a vertical osteotomy on both sides of each sacrum. Afterwards, first a compression test with fracture gap measurement after tightening of the screws was performed, followed by an axial pull-out test measuring the maximum pull-out force of the screws. RESULTS: The fracture gap was significantly wider in group A (mean: 1.90 mm; SD: 1.64) than in group B (mean: 0.91 mm; SD: 1.03; p = 0.028). Pull-out force was higher in group A (mean: 1696 N; SD: 1452) than in group B (mean: 1616 N; SD: 824), but this difference was not statistically significant (p = 0.767). CONCLUSIONS: Cement augmentation of partially threaded screws in sacroiliac screw fixation allows narrowing of the fracture gap even in osteoporotic bone, while resistance against pull-out force is not significantly lower in partially threaded screws compared to fully threaded screws.

Which factors influence treatment decision in fragility fractures of the pelvis? - results of a prospective study.

BACKGROUND: The aim of the present study was to describe specific characteristics of patients suffering from pelvic fragility fractures and evaluate factors that might influence treatment decisions which may optimize treatment pathways and patient mobility in the future. METHODS: A prospective study with patients suffering from fractures of the pelvis and aged 60 years or above was performed between 2012 and 2016. Data acquisition took place at admission, every day during hospitalization and at discharge. RESULTS: One hundred thirty-four patients (mean age of 79.93 (± 7.67) years), predominantly female (84%), were included. Eighty-six patients were treated non-operatively. Forty-eight patients underwent a surgical procedure. The main fracture types were B2 fractures (52.24%) and FFP IIb fractures (39.55%). At the time of discharge, pain level (NRS) could be significantly reduced (p <  0.001). Patients who underwent a surgical procedure had a significantly higher pain level on day three and four compared to the non-operative group (p = 0.032 and p = 0.023, respectively). Significant differences were found in the mobility level: patients treated operatively on day four or later were not able to stand or walk on day three as compared to non-operatively treated patients. Regarding B2 fractures, a significantly higher mobility level difference between time of admission and discharge was found in patients treated with a surgical procedure compared to patients treated non-operatively (p = 0.035). CONCLUSIONS: Fracture type, mobility level and pain level influence the decision to proceed with surgical treatment. Especially patients suffering from B2 fractures benefitted in terms of mobility level at discharge when treated operatively. LEVEL OF EVIDENCE: II.

More than a reposition tool: additional wire cerclage leads to increased load to failure in plate osteosynthesis for supracondylar femoral shaft fractures.

INTRODUCTION: Surgical treatment of supracondylar femoral fractures can be challenging. An additional wire cerclage is a suggested way to facilitate fracture reduction prior to plate osteosynthesis. Denudation to the periosteum remains a problematic disadvantage of this procedure. This study analyzed the effect of an additional wire cerclage on the load to failure in plate osteosynthesis of oblique supracondylar femoral shaft fractures. MATERIALS AND METHODS: On eight pairs of non-osteoporotic human femora (mean age 74 years; range 57-95 years), an unstable AO/OTA 32-A2.3 fracture was established. All specimens were treated with a polyaxially locking plate. One femur of each pair was randomly selected to receive an additional fracture fixation with a wire cerclage. A servohydraulic testing machine was used to perform an incremental cyclic axial load with a load to the failure mode. RESULTS: Specimens stabilized with solely plate osteosynthesis failed at a mean load of 2450 N (95% CI: 1996-2904 N). In the group with an additional wire cerclage, load to failure was at a mean of 3100 N (95% CI: 2662-3538 N) (p = 0.018). Compression deformation with shearing of the condyle region through cutting of screws out of the condylar bone was the most common reason for failure in both groups of specimens. Whereas axial stiffness was comparable between both groups (p = 0.208), plastic deformation of the osteosynthesis constructs differed significantly (p = 0.035). CONCLUSIONS: An additional wire cerclage significantly increased the load to failure. Therefore, an additional cerclage represents more than just a repositioning aid. With appropriate fracture morphology, a cerclage can significantly improve the strength of the osteosynthesis.

Open Reduction in Subtrochanteric Femur Fractures Is Not Accompanied by a Higher Rate of Complications.

Backgroundand Objectives: Hip fractures are among the most typical geriatric fractures. Subtrochanteric fractures are considered difficult to treat, and, to date, there is no consensus on the optimal surgical treatment. Materialisand Methods: We analyzed data from the Registry for Geriatric Trauma, which includes patients ≥ 70 years old with hip fractures or periprosthetic fractures requiring surgery (21,734 patients in 2017-2019). For this study, we analyzed only the subgroup of patients with a subtrochanteric fracture. We analyzed the difference between closed and open surgical methods on a range of outcomes, including mortality, mobility, length of acute hospital stay, and the need for surgical revisions. Results: A total of 506 patients with subtrochanteric fractures were analyzed in this study. The median age was 85 years (interquartile range of 81-89). About 21.1% (n = 107) were operated on with a closed technique, 73.3% (n = 371) with open reduction without using a cerclage, and 5.53% (n = 28) with open reduction with the additional use of one or more cerclage wires. A total of 3.56% (n = 18) of the patients had complications requiring operative revision, most commonly soft tissue interventions (open vs. closed reduction-3.26% vs. 4.67%) (p = 0.687). Patients treated with open reduction were significantly more mobile 7 days after surgery (p = 0.008), while no significant effects on mortality (p = 0.312), length of hospital stay (p = 0.968), or surgical complications (p = 0.687) were found. Conclusion: Proper reduction is the gold standard practice for successful union in subtrochanteric fractures. This study shows that open reduction is not associated with a higher complication rate but does lead to increased mobility 7 days after operation. Therefore, in case of doubt, a good reduction should be aimed for, even using open techniques.

Cement augmentation of an angular stable plate osteosynthesis for supracondylar femoral fractures - biomechanical investigation of a new fixation device.

BACKGROUND: Implant anchorage in highly osteoporotic bone is challenging, since it often leads to osteosynthesis failure in geriatric patients with supracondylar femoral fractures. Cementation of screws is presumed to prevent such osteosynthesis failure. This study aimed to investigate the effect of a newly designed, cementable fenestrated condylar screw for plate fixation in a biomechanical setting. METHODS: Eight pairs of osteoporotic cadaver femora with an average age of 77 years, ranging between 62 and 88 years, were randomly assigned to either an augmented or a non-augmented group. In both groups an instable 33-A3 fracture according to the AO / OTA classification was fixed with an angular stable locking plate. All right samples received a cement augmentation of their fenestrated condylar screws with calcium phosphate bone cement (CPC). Mechanical testing was performed at a load to failure mode by cyclic axial loading, using a servohydraulic testing machine. RESULTS: With a mean of 2475 N (95% CI: 1727-3223 N), the pressure forces resulting in osteosynthesis failure were significantly higher in specimen with cemented condylar screws as compared to non-cemented samples (1875 N (95% CI: 1320-2430 N)) (p = 0.024). In both groups the deformation of the constructs, with the distal screws cutting through the condylar bone, were the most frequent cause for failure. Analysis of axial stiffness (p = 0.889) and irreversible deformity of the specimens revealed no differences between the both groups (p = 0.161). No cement leakage through the joint line or the medial cortex was observed. CONCLUSION: Based on the present study results, the newly introduced, cementable condylar screw could be an encouraging feature for the fixation of supracondylar femoral fractures in patients with reduced bone quality in terms of load to failure accuracy of the cement application.

Association between longitudinal clinical outcomes in patients with hip fracture and their pre-fracture place of residence.

BACKGROUND: Clinical outcomes of patients with proximal femoral fracture within 1 year after hospitalization are presented. In particular, associations between the patients' clinical status and their pre-fracture residence were evaluated (community-dwelling vs nursing home). METHODS: Patients aged ≥60 years with proximal femoral fractures were included in a prospective, single-centre observational study and followed for 12 months. Patients' clinical status at baseline was compared to their health status at follow-up 12 months later. Several standardized questionnaires were used to evaluate the patients' functional and cognitive capacity (e.g. Lawton Instrumental Activities of Daily Living Scale, Barthel Index, and Mini-Mental State Examination), mobility (timed up-and-go test, Tinetti Test, and Harris Hip Score), quality of life (EuroQol-5 Dimensions index and EuroQol Visual Analogue Scale), and psychological status (Geriatric Depression Scale). RESULTS: This study included 402 patients (mean age: 81.3 ± 8.2 years, 72% women). Patients stayed in hospital for 13.7 ± 6.1 days on average. The comparison of patients' clinical status at baseline and at 12-month follow-up revealed that the Mini-Mental State Examination and Charlson Comorbidity Index remained unchanged (P = 0.527 and P = 0.705), the level of depression (Geriatric Depression Scale) significantly decreased (P < 0.001), and quality of life (EuroQol-5 Dimensions index) diminished (P < 0.001). Although patients' mobility increased after 12 months (P < 0.001 for timed up-and-go test and Harris Hip Score), their functional capacity was significantly reduced (P < 0.001 for Barthel Index and Lawton Instrumental Activities of Daily Living Scale). Nursing home residents showed a significantly higher impairment at baseline than community-dwelling individuals and less improvement in functional and cognitive tests at 12-month follow-up. CONCLUSIONS: Clinical outcomes after hip fracture are significantly associated with patients' pre-fracture residence status. Place of residence as well as functional and cognitive status on admission may lead to differences in functional recovery and affect therapeutic and rehabilitative decision-making.

Rupture of plantar fascia: Current standard of therapy: A systematic literature review.

BACKGROUND: The aim of the present systematic literature review is to give an overview of ruptures of the plantar fascia. For this purpose, a detailed description of the patient collective is provided. However, the focus of this analysis is based on the current therapy concepts. Based on the results the authors propose a standardized therapy concept. MATERIAL AND METHODS: A systematic literature review was performed using the PubMed database using the terms: ("rupture plantar fascia" OR "plantar fascia tear" OR "rupture plantar aponeurosis"). All articles published in the PubMed database until 07.11.2018 were included. The articles were evaluated with regard to three research question: (1) Which patients are affected by a rupture of the plantar fascia? (2) Which therapy concept was used to treat rupture of the plantar fascia? And (3) which result was achieved and how was this measured? RESULTS: A total of 78 studies were identified, of which the full text of 17 were analysed. 12 publications were cases reports, 5 studies were retrospective analyses. Data from 124 patients could be included. The average age of patients was 39.6 years. In 63.2% (n = 12) of the studies, patients with a high level of athletic activity or even professional athletes were analyzed. 94.4% of all patients were treated conservatively. The average duration of immobilization in a rigid walker was 2.6 weeks. In the majority of cases, pain-adapted weight-bearing was allowed in the rigid walker. CONCLUSION: There are few available studies concerning the rupture of plantar fascia. The quality of data is poor. The maximum duration of immobilization of 3 weeks in a rigid walker with pain-adapted weight-bearing appears to be the most applied therapy concept. Further studies are needed to evaluate the efficacy of the therapy and to optimize the therapy concept.

Factors affecting blood loss and blood transfusion in patients with proximal humeral fractures.

BACKGROUND: The aim of this study was to determine the amount of blood loss and the rate of blood transfusion in patients receiving surgery for proximal humeral fractures depending on the treatment and fracture classification. Moreover, factors associated with blood loss and blood transfusion were analyzed. METHODS: The study included 420 patients who had received surgery for proximal humeral fractures. Data from medical records were collected retrospectively. The calculated blood loss and the transfusion rate were analyzed depending on the type of surgery (plate fixation, arthroplasty, and others) or the fracture classification (2-, 3-, and 4-part fractures). The extent of blood loss and the need for transfusion were correlated with potential risk factors. A score to estimate the probability of blood transfusion was developed. RESULTS: Average blood loss was 284 mL, and the transfusion rate was 14.5% for all proximal humeral fractures. Shoulder arthroplasty was associated with higher blood loss (353 mL, P < .01) and a higher blood transfusion rate (27.3%, P < .01) than plate fixation (263 mL and 10.9%, respectively). The fracture classification had no effect on either factor. Significant risk factors for blood loss were male sex, body mass index, surgery time, time until surgery, and vitamin K antagonists. Age, blood loss, American Society of Anesthesiologists score greater than 2, vitamin K antagonists, coronary artery disease (CAD), peripheral artery disease (PAD), and renal disease were associated with a higher transfusion rate. CONCLUSION: Blood loss could be affected by a shorter surgery time and by choosing an adequate time until surgery. The consideration of risk factors and the use of a transfusion risk score allow more elaborate ordering of cross-matched blood units and can decrease institutional costs.

[A minimally invasive technique for removal of a firmly fixed Küntscher nail in primary hip arthroplasty]. / Eine minimalinvasive Technik zur Entfernung eines fest verklemmten Küntscher-Nagels in der primären Hüftendoprothetik.

This article reports the case of an 80-year-old male patient who presented to this hospital with symptomatic arthritis of the left hip. The special feature of this case was a Küntscher nail in the left femur that had been in situ for more than 50 years. Before implantation of the total hip arthroplasty the nail first had to be removed. As the Küntscher nail is a rarity nowadays there is no standardized procedure for the removal of such a nail. This case report describes a minimally invasive possibility to remove a Küntscher nail in total hip arthroplasty.

Operative treatment of geriatric ankle fractures with conventional or locking plates. A retrospective case-control study.

BACKGROUND: The incidence of geriatric ankle fractures continues to rise due to demographic changes. While locking plates have become standard implants for injuries of other body regions, clinical studies on their use for geriatric ankle fractures are rare. METHODS: Therefore, a retrospective case-control study, including 333 patients with a mean age of 73.5 years was performed. 263 patients underwent operative fixation with one- third tubular plates and 70 were treated with locking plates. Early outcomes and complication rates of locking plates as compared with conventional one- third tubular plates are described. RESULTS: In the present study, patients treated with locking plates were older and suffered from more severe fracture patterns. In addition, these patients had more severe comorbidities. Treatment with conventional or locking plate fixation resulted in a comparable complication and revision rate. A matched pair analysis showed significantly more complications and required revision surgeries and a trend towards more implant failures in the group that underwent conventional plating. CONCLUSIONS: Therefore, we conclude that precontoured locking plates represent an appropriate treatment option for severe ankle fractures in patients suffering from relevant co-morbidities. Prospective randomized trials are warranted to prove superiority of locking plates for treatment of geriatric ankle fractures. Level 3: Retrospective case- control study.

Medical Complications Predict Cognitive Decline in Nondemented Hip Fracture Patients-Results of a Prospective Observational Study.

OBJECTIVE: The aim of this study was to identify factors that are associated with cognitive decline in the long-term follow-up after hip fractures in previously nondemented patients. METHODS: A consecutive series of 402 patients with hip fractures admitted to our university hospital were analyzed. After exclusion of all patients with preexisting dementia, 266 patients were included, of which 188 could be examined 6 months after surgery. Additional to several demographic data, cognitive ability was assessed using the Mini-Mental State Examination (MMSE). Patients with 19 or less points on the MMSE were considered demented. Furthermore, geriatric scores were recorded, as well as perioperative medical complications. Mini-Mental State Examination was performed again 6 months after surgery. RESULTS: Of 188 previously nondemented patients, 12 (6.4%) patients showed a cognitive decline during the 6 months of follow-up. Multivariate regression analysis showed that age ( P = .040) and medical complications ( P = .048) were the only significant independent influencing factors for cognitive decline. CONCLUSIONS: In our patient population, the incidence of dementia exceeded the average age-appropriate cognitive decline. Significant independent influencing factors for cognitive decline were age and medical complications.