Fractures In Older Patients Research Articles

Should Femoral Shaft fractures in Patients Age Over 60 Years be Managed Using a Hip Fracture Pathway?

The British Orthopaedic Association published 2019 guidelines 'The Older or Frail Orthopaedic Trauma Patient'. This implements principles of the hip fracture pathway to all fragility fractures. Like hip fractures, femoral shaft fractures in the elderly are also suggested to represent fragility fractures. Femoral shaft fractures in older patients are rare and there is scarce literature detailing their outcomes. We aim to review outcomes of femoral shaft fractures in patients age 60 years and over at our institution and compare them to that of the hip fracture population. We retrospectively reviewed clinical records of a consecutive cohort of patients aged 60 years and over, who sustained a femoral shaft fracture, over a five-year period at our institution. Outcome measures studied were time to surgery, mean length of admission, readmission rate within 30 days, medical and orthopaedic complications, one month and one year mortality. We identified 53 patients with a mean age of 78.7 years. On average patients each had 2.7 medical comorbidities. Mean length of admission was 20.0 days and readmission rate within 30 days was 19.1% (n=9). Medical complications affected 41.5% of patients (n=22) and orthopaedic complications affected 9.4% of patients (n=5). Two patients demonstrated nonunion and one patient required revision surgery. Thirty day mortality rate was 13.2% (n=7) which increased to a one year mortality of 26.4% (n=14). Patients age 60 years and over with femoral shaft fractures have poor medical outcomes and prolonged length of admission. Compared to patients with hip fractures, medical complication rates are at least twice the 13-20% reported for hip fractures. The 30 day mortality rate in patients with femoral shaft fractures was also more than double the 6.1% reported for hip fracture patients by The National Hip Fracture Database in 2018. Femoral shaft fractures are associated with high medical morbidity and mortality. The hip fracture pathway is encompassed in the British Orthopaedic Association guidelines and emphasizes early medical input and a multidisciplinary approach to patient management. Hence, our study supports implementation of these guidelines with aim to improve morbidity and mortality of this vulnerable patient group.

Effect of renal dialysis on mortality and complications following hip fracture surgery in elderly patients: A population based retrospective cohort study.

Hip fractures in older patients requiring dialysis are associated with high mortality. The primary aim of this study was to evaluate the specific burden of dialysis on 30-day mortality following hip fracture surgery. The secondary aim was to determine the burden of dialysis on overall survival as well as several postoperative complications.A retrospective cohort study was conducted using data from the Korean National Health Insurance Research Database. Patients were aged ≥65 years and underwent hip fracture surgery during the period from 2009 to 2015. To construct a matched cohort, each dialysis patient was matched to 4 non-dialysis patients based on age, sex, hospital type, anesthesia type, and comorbidities. Survival status was determined 30 days after surgery and at the end of the study period.In total, 96,289 patients were identified. Among them, 1614 dialysis patients were included and matched to 6198 non-dialysis patients. During the 30-day postoperative period, there were 102 mortality events in the dialysis group and 127 in the non-dialysis group, for an adjusted hazard ratio of 3.12 (95% confidence interval, 2.42–4.09). Overall, by the end of the study period, there were 1120 mortality events in the dialysis group and 2731 in the non-dialysis group, for an adjusted hazard ratio of 1.97 (95% confidence interval, 1.83–2.1). These findings may be limited by the characteristics of the administrative database.The 30-day mortality rate was 3-fold higher in the dialysis group than in the non-dialysis group, while the overall mortality rate was approximately 2-fold higher in the dialysis group than in the non-dialysis group. These findings suggest that caution in the perioperative period is required in dialysis patients undergoing hip fracture surgery. The results of our study represent only an association between dialysis and mortality. Further studies are necessary to investigate the possible causal effect of dialysis on mortality and complications after hip fracture surgery.

Hip Fractures in Older Patients: The Case for Geriatrics Comanagement.

AORN JournalVolume 112, Issue 2 p. 187-189 Column Hip Fractures in Older Patients: The Case for Geriatrics Comanagement First published: 27 July 2020 https://doi.org/10.1002/aorn.13100Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume112, Issue2August 2020Pages 187-189 RelatedInformation

Attributable Mortality of Hip Fracture in Older Patients: A Retrospective Observational Study.

Hip fracture (HF) in older patients is associated with a high six-month mortality rate. Several clinical conditions may affect outcome, including baseline characteristics, co-existing acute illnesses, perioperative factors, and postoperative complications. Our primary objective was to estimate the respective effect of these four domains on six-month mortality after HF. A retrospective observational study using a monocentric cohort of older patients was conducted. All patients ≥ 70 years old admitted to the emergency department for HF and hospitalized in our perioperative geriatric care unit from June 2009 to September 2018 were included. Among 1015 included patients, five (0.5%) were lost to follow-up, and 1010 were retained in the final analysis (mean age 86 ± 6 years). The six-month mortality rate was 14.8%. The six-month attributable mortality estimates were as follows: baseline characteristics (including age, gender, comorbidities, autonomy, type of fracture): 62.4%; co-existing acute illnesses (including acute events present before surgery that could result from the fracture or cause it): 0% (not significantly associated with six-month mortality); perioperative factors (including blood transfusion and delayed surgery): 12.3%; severe postoperative complications: 11.9%. Baseline characteristics explained less than two-thirds of the six-month mortality after HF. Optimizing patients care by improving management of perioperative factors and thus decreasing postoperative complications, could reduce by a maximum of one quarter of the six-month mortality rate after HF.

Isolated rib cage fractures in the elderly: Do all patients belong to the intensive care unit? A retrospective nationwide analysis.

Western Trauma Association guidelines recommend admitting patients 65 years or older with two or more rib fractures diagnosed by chest radiograph to the intensive care unit (ICU). Increased use of computed tomography has led to identification of less severe, "occult" rib fractures. We aimed to evaluate current national trends in disposition of older patients with isolated rib cage fractures and to identify characteristics of patients initially admitted to the ward who failed ward management. A retrospective cohort study of patients 65 years or older with isolated two or more blunt rib cage fractures using the 2010 to 2016 American College of Surgeons Trauma Quality Improvement Program database was performed. Ward failure was defined as patients initially admitted to the ward with subsequent need for unplanned ICU admission or intubation. Multivariable analyses were derived to study the independent predictors of failure of ward management. Propensity score matching sub-analysis was used to assess outcomes in patients admitted to the ward versus ICU. There were 5,021 patients included in the analysis. Of these patients, 1,406 (28.0%) were admitted to the ICU. On multivariable analysis, age was an independent predictor of ICU admission. Of the 3,577 patients admitted directly to the ward, 38 (1.1%) patients required unplanned intubation or ICU admission. Independent predictors of failure of ward management included chronic renal failure (odds ratio [OR], 7.20; p ≤ 0.001; 95% confidence interval [CI], 2.50-20.76), traumatic pneumothorax (OR, 8.70; p = 0.008; 95% CI, 1.76-42.93), concurrent sternal fracture (OR, 6.52; p ≤ 0.001; 95% CI, 2.53-16.80), drug use disorder (OR, 6.58; p = 0.032; 95% CI, 1.17-36.96), and emergency department oxygen requirement or oxygen saturation less than 95% (OR, 2.38; p = 0.018; 95% CI, 1.16-4.86). Mortality was higher in patients with delayed ICU care versus patients with successful ward disposition (21.1% vs. 0.8%; p < 0.001). Our results suggest that the majority of isolated rib cage fractures in older patients are safely managed on the ward with exceedingly low ward failure rates (1.1%). Patients with failure of ward management have significantly higher mortality, and we have identified predictors of failing the ward. Therapeutic/Care Management, level IV; Prognostic III.

Early Mobilization After Volar Locking Plate Osteosynthesis of Distal Radial Fractures in Older Patients—A Randomized Controlled Trial

To investigate if early mobilization after open reduction internal fixation of distal radius fractures improved the functional outcome. We hypothesized that early mobilization would lead to improved patient-reported outcome. Second, we aimed to assess whether early mobilization increased the risk of postoperative implant loosening or breakage. All included patients were treated with a volar locking plate. After surgery, patients were randomized to either early mobilization (E-MOB) with a removable orthosis (wrist lacer) and daily wrist exercises or to late mobilization (L-MOB) with a standard dorsal plaster cast for 2 weeks and, after that, a removable orthosis and exercises. We measured all patients at 4 weeks and at 3, 6, and 12 months after surgery. At each postoperative visit, we measured range of motion and grip strength and patients filled out the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Radiographic implant loosening or breakage was assessed 14 days after surgery. A total of 47 patients were allocated to E-MOB and 48 to L-MOB. The DASH score improved substantially throughout the follow-up period with no significant differences between the 2 groups at any time point. Implant loosening and fracture redisplacement was observed in 1 patient in the E-MOB group. Range of motion and grip strength were similar between the 2 groups at all time points. Early mobilization after surgical treatment of distal radius fractures does not lead to improved patient-reported outcome. Therapeutic I.

Chronicity of Uncorrected Hyponatremia and Clinical Outcomes in Older Patients Undergoing Hip Fracture Repair.

Background: Chronic hyponatremia is a risk factor for hip fracture but remains uncorrected in most patients. This study evaluated if preoperative chronicity of uncorrected hyponatremia influences outcomes after hip fracture repair.Materials and Methods: Evaluated were older patients hospitalized for hip fracture repair between 2007 and 2012 with plasma sodium measured at admission and ≥1 preadmission outpatient measurement. Patients were classified as being normonatremic (NN; plasma sodium 135–145 mmol/L), chronic prolonged hyponatremia (CPH; ≥2 consecutive plasma sodium values <135 mmol/L over >90 days), or recent hyponatremia (one plasma sodium <135 mmol/L within 30 days before admission with previously normal plasma sodium). Length of hospital stay, in-hospital death, post-operative complications, 30-day readmission, and long-term mortality were the evaluated outcomes. Multivariable Cox regression was used to evaluate the association of hyponatremia status with outcomes.Results: Among 1,571 eligible patients, 76.7% were NN, 14% had CPH, and 9.1% had RH. Compared with NN patients, CHN patients were older and had more prior heart failure, alcoholism, and anticonvulsant drug use. In multivariable analyses, neither CPH or RH was associated with hospital length of stay, in-hospital or 30-day death, or 30-day readmission, while RH was associated with post-operative sepsis [adjusted odds ratio (aOR) 1.84, 95% CI: 1.01–3.35). Only CPH was independently associated with long-term all-cause death (OR 1.53, 95% CI: 1.12–2.09).Conclusions: Hyponatremia affects nearly 25% of patients undergoing hip fracture repair. Preoperative chronic untreated hyponatremia is associated with increased post-operative mortality following surgical repair of a hip fracture in older patients. Future studies should evaluate if correction of hyponatremia could decrease long-term mortality after hip fracture repair.

Peripheral IL-6 Levels but not Sarcopenia Are Predictive of 1-Year Mortality After Hip Fracture in Older Patients.

Sarcopenic patients may have an increased risk of poor outcomes after a hip fracture. The objective of this study was to determine whether sarcopenia and a set of biomarkers were potential predictors of 1-year-mortality in older patients after a hip fracture. About 150 patients at least 80 years old were hospitalized for the surgical treatment of a hip fracture. The primary outcome measure was the death in the first year after the hip fracture. Sarcopenia was defined at baseline by having both low muscle mass (bioimpedance analysis) and handgrip and using the updated European Working Group on Sarcopenia in Older People (EWGSOP2) definition of probable sarcopenia. Janssen's (J) and Masanés (M) cutoff points were used to define low muscle mass. Mortality 1 year after the hip fracture was 11.5%. In univariate analyses, baseline sarcopenia was not associated with mortality, using neither of the muscle mass cutoff points: 5.9% in sarcopenic (J) versus 12.4% in non-sarcopenic participants (p = .694) and 16% in sarcopenic (M) versus 9.6% in non-sarcopenic participants (p = .285). Probable sarcopenia (EWGSOP2) was not associated with mortality. Peripheral levels of IL-6 at baseline were significantly higher in the group of participants who died in the year after the hip fracture (17.14 ± 16.74 vs 11.42 ± 7.99 pg/mL, p = .026). TNF-α peripheral levels had a nonsignificant trend to be higher in participants who died. No other biomarker was associated with mortality. Sarcopenia at baseline was not a predictor of 1-year mortality in older patients after a hip fracture. IL-6 was associated with a higher risk of mortality in these patients, regardless of sarcopenia status.

Cervical spine fragility fractures in older people: 5-year experience at a regional spine centre.

cervical spine fractures are particularly prevalent in older people and commonly occur following a fall from standing height or less. Atlanto-axial complex (AAC) and, particularly, odontoid process (OP) fractures are the most prevalent injuries. to investigate the incidence and characteristics of cervical spine fractures in older patients presenting to a regional spine centre. a retrospective review of the clinical records and imaging of all patients aged 70years and over presenting to a regional spinal unit with a cervical injury over a 5-year period was performed. Patient demographics, mechanism of injury, level of fracture, stability of the fracture, treatment modality, imaging modality and mortality rates were collected and analysed. during the period between 2015 and 2019, a total of 209 patients aged 70years and over were presented to the regional spine unit. The mean age at presentation was 82.4 (±7.5) years. Low-energy trauma was the commonest mechanism of injury (n= 169; 80.9%). MRI was undertaken in a quarter of the patients. One-hundred and fifty-one patients (72.2%) suffered an AAC Injury with OP fractures forming the majority of this group (n= 119; 78.8%). One-hundred and ninety-nine patients were treated conservatively, and the overall 30-day mortality rate was 8.1%. cervical spine fractures are not uncommon amongst older people and are mostly the result of low-energy trauma and predominantly affect the axial cervical spine. The majority of these injuries are managed conservatively with an orthosis. The fractures nevertheless are a serious injury, with a high mortality rate at 30days.

Volar locking plate: Age related outcomes and complications

BackgroundThere is no unanimity for the treatment of distal radius fractures in older people. The purpose of our study is to assess the efficacy of volar locking plate for the treatment of unstable distal radius fractures in older independent individuals. MethodsA retrospective comparative study of 105 patients. 58 patients were below the age of 55 years and 47 above the age of 55 years. Mean follow-up was 18.4 months in patients below the age of 55 years and 18.1 months above the age of 55 years. Wrist movements, complications, reoperations, grip strength, Visual Analogue Score (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (DASH) score, and Mayo wrist score were analysed. ResultsThere was no statistical difference in the wrist movements, grip strength, complications, reoperations, VAS, QuickDASH and Mayo scores. Mean grip strength under 55 was 84.1 and above 55 was 84.5 (p = 0.87). The complication rate was 19.1% above 55 years of age and 17.2% below the age of 55years (p = 0.79). The reoperation rate above 55 years was 8.5% and below 55 years was 8.6% (p = 0.50). Mean VAS under 55 years of age was 1.6 and above 55 years was 1.7 (p = 0.58). Mean Mayo score in under 55 was 80.7 and 80.1 in above 55 (p = 0.78). Mean Quick DASH score under 55 was 20.9 and above 55 was 21.0 (p = 0.97). ConclusionOur results indicate that outcomes in older independent patients are satisfactory with a comparable complication and reoperation rate with younger individuals. We conclude that a volar locking plate is a favourable modality for the treatment of unstable distal radius fractures in older patients.

Risk of osteoporotic fracture in older patients under antihypertensive treatment.

Risk of osteoporotic fracture in older patients under antihypertensive treatment.

Bipolar hemiarthroplasty versus total hip replacement in displaced femoral neck fracture in elderly

Introduction: Fractures of the neck of the femur are commonly seen in the geriatric population resulting in significant morbidity and mortality. Primary arthroplasty helps in rapid mobilization while decreasing the chances of implant failure and complications such as deep vein thrombosis, pulmonary complications, infection, and bedsores. The purpose of this can be fulfilled either by Bipolar Hemiarthroplasty as well as by Total Hip arthroplasty. The aim of this study is to determine whether total hip replacement is clinically and functionally better than bipolar hemiarthroplasty in the neck of femur fracture in older patients. Method: It is a prospective study done at Sri Ramachandra Medical College, Chennai, and Velammal Medical College, Madurai on 70 patients diagnosed with the unstable neck of femur fractures who were treated with bipolar hemiarthroplasty and total hip replacement from April 2018 to September 2019. The inclusion criteria were age more than 60 years and Unstable neck of femur fractures as per the Garden classification. The exclusion criteria were pathological fractures, associated fracture of lower limbs, and non-ambulatory patients prior to the injury. A functional assessment was carried out using the Harris Hip Score. Results: In the group that underwent a total hip replacement, the mean Harris Hip Score was 70.6, 74.4, 77.68 and 80.95 at the follow-up visits at week 6, 3 months, 6 months and 1 year respectively. In the group that underwent bipolar hemiarthroplasty, the mean Harris Hip Scores were 63.50, 66.25, 68.72, and 71.26 at the follow-up visits at week 6, 3 months, 6 months and 1 year respectively. Conclusion: Total hip arthroplasty is recommended over hemiarthroplasty for the displaced neck of femur fractures in elderly patients owing to the higher Harris Hip Scores and lower re-operation rates.

Prospective study of the functional outcome of uncemented bipolar hemiarhroplasty in displaced fracture neck of femur in elderly

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Hip fractures in older patients are associated with impaired mobility, excess morbidity, mortality and loss of independence. To avoid the drawbacks of internal fixation and for early mobilization, hemiarthroplasty is performed in elderly. The bipolar prosthesis was developed to overcome the shortcomings of the unipolar fixed-head prosthesis. An additional site of motion would be expected to decrease the amount of loosening, dislocation, and head migration. The aim of the study is to assess the functional outcome of the patients with fracture neck of femur treated with bipolar hemiarthroplasty.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this study, 20 patients above the age of 60 years with acute displaced fracture neck of femur underwent hemireplacement arthroplasty with bipolar prosthesis in Department of Orthopaedics, KIMS, Bangalore. The patients were followed up on 6th, 12th, 18th, 24th week post operatively. Functional outcome was assessed with Harris hip score.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In our study, mean average age was 72.3 years with predominantly female patients with 75% of the patients with left sided fracture. 95% of the patients had slight or no pain, 85% of patients had slight or no limp. 50% of the patients could walk without support, 65% of the patients could walk a distance of 6 blocks or more. Average Harris hip score was 82%.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; These results suggest functional outcome following bipolar hemiarthroplasty is good. Early mobilisation, pain free hip and with good level of activity is obtained following bipolar hemiarthroplasty.&lt;/p&gt;

What is a reasonable rate for specific osteoporosis drug therapy in older fragility fracture patients?

Osteoporosis is the most common condition contributing to 95% of fractures in older patients hospitalized for fracture treatment. Despite the significant impact of fragility fractures on patient morbidity and mortality, efforts in optimizing osteoporotic treatment and prevention remain inadequate. In contrast, in patients with limited life expectancy, withholding specific osteoporosis drug treatment appears reasonable. The threshold between under- and overtreatment is still unclear. In 2016, we implemented a fracture liaison service (FLS) for 18months to improve the quality of osteoporosis care. We collected prospectively the patient's history, current treatment for osteoporosis, and risk factors for fragility fractures using a standardized protocol. Recommendations for drug therapy are discussed during the interdisciplinary ward round. The primary outcome parameter was a recommendation for specific osteoporosis drug treatment. We included 681 patients (mean age 82.5years, 502 (73.7%) females). The inclusion criteria were the following: age of 70years or older, admission to geriatric fracture center between April 2016 and December 2018. Based on our data, specific osteoporosis drug therapy was recommended in 467 (68.6%) patients. Six hundred fifty-one (95.6%) patients received vitamin D3, and 546 (80.2%) calcium. After adjustment, only age (every 5years, OR 0.57; 95% CI 0.45-0.72; p < 0.0001), cognitive impairment (OR 0.41; 95% CI 0.23-0.74; p = 0.003), pre-fracture mobility (OR 1.54; 95% CI 1.34-1.75; p < 0.0001), and living in a nursing home (OR 0.52; 95% CI 0.27-0.99; p = 0.049) remained as independent predictors for an indication of specific osteoporosis drug therapy. We found a higher rate of recommendations for specific osteoporosis drug therapy compared with usual treatment rates in literature. Though in some cases withholding of specific osteoporosis drug therapy seems reasonable, the main proportion of fragility fracture patients is undertreated. Our results could be a benchmark for the quality of osteoporosis care in older fragility fracture patients treated in a geriatric fracture center.

Hyponatremia, Hypokalemia, and Fragility Fractures in Old Patients: More than an Association?

Hyponatremia and hypokalemia are common among elderly and have been associated with osteoporosis, we evaluate the role of these electrolytes as risk for fragility fractures. This study is divided in two parts: one retrospective and one prospective. We retrospectively collected data on urgently admitted patients for femoral fragility fractures (Fx) or for acute myocardial infarction (AMI), and patients admitted for elective hip/knee replacement surgery for osteoarthrosis (OA). Age, sex, serum sodium, potassium, creatinine, and comorbidities were recorded. We enrolled prospectively in-patients from our unit: age, sex, comorbidities, drugs, and fragility fractures were recorded. Blood electrolytes were measured. Cognitive function, nutrition, muscular strength, and balance were evaluated by standard tests. The mortality rate was recorded with a follow-up after hospital discharge. The retrospective study included 2166 subjects: 702 Fx and 1464 controls (907 AMI, 557 OA): the prevalence of hyponatremia was similar in Fx and AMI, whereas it was higher in Fx with respect to OA (p < 0.001) as well as hypokalemia (p < 0.001). Sodium decrease was associated with higher fracture risk. Among the 284 subjects included in the prospective study, 50 patients were hyponatremic, more likely malnourished, and presented a higher prevalence of fragility fractures (p = 0.008). They had a higher mortality after hospital discharge (HR = 1.80, p = 0.005), however, this association disappears after correction for confounding variables. We suggest that hyponatremia and hypokalemia have to be considered as a marker of poor health more than an independent fracture risk.

The Association Between Orthogeriatric Co-Management and Mortality Following Hip Fracture.

To meet the special needs of older patients with fragility fractures, models for collaborative orthogeriatric care have been developed. The objective of our study was to analyze the association of orthogeriatric co-management with mortality following hip fracture in older patients in Germany. This observational study was based on health insurance claims data from 58 001 patients (79.4% women) aged ≥80 years admitted to the hospital with hip fracture between January 2014 and March 2016. They were treated in 828 German hospitals with or without orthogeriatric co-management. The outcome measure was cumulative mortality with adjustment of the regression analyses. The crude 30-day mortality was 10.3% for patients from hospitals with orthogeriatric co-management and 13.4% for patients from hospitals without orthogeriatric co-management. The adjusted 30-day mortality was 22% lower for patients in hospitals with orthogeriatric co-management (rate ratio 0.78; 95% CI [0.74; 0.82]; adjusted absolute difference -2.48%; 95% CI [-2.98; -1.98]). The difference in 30-day mortality remained nearly unchanged over the first 6 months. The risk reduction with orthogeriatric co-management was consistently observed in both women and men, across age groups, and in patients with and without care needs. The mean length of the index stay was 19.8 days in hospitals with orthogeriatric co-management and 14.4 days in hospitals without orthogeriatric co-management. A multidisciplinary orthogeriatric approach is associated with lower mortality and a longer index stay in hospital after hip fracture.

Study protocol: HipSTHeR - a register-based randomised controlled trial \u2013 hip screws or (total) hip replacement for undisplaced femoral neck fractures in older patients

BackgroundFemoral neck fractures (FNFs), which are common in the older population, are associated with high mortality and morbidity. Some 20% of FNFs are undisplaced (uFNFs). The routine surgical procedure for uFNFs is internal fixation (IF) with 2–3 screws/pins with a reported reoperation rate in older patients (age ≥ 75 years) of up to 21%. The reoperation rate for hemiarthroplasties for displaced fractures is lower than for undisplaced fractures operated with IF. This study will aim to determine whether the outcome for older patients with an uFNF can be improved by replacing the hip instead of preserving it.MethodsA national multicentre, register-based, randomised controlled trial (rRCT) will be conducted. For this trial, 1440 patients, ≥75 years with an acute uFNF, will be allocated. Eligible patients will be identified by the Swedish Fracture Register (SFR) platform, which will notify the admitting orthopaedic surgeon of eligibility. After informed consent has been given and documented, patients will be randomised to either IF (control group) or arthroplasty (intervention group) within the SFR platform. Injury mechanism, fracture classification, date of injury, and type of treatment are registered in the SFR. Type and brand of arthroplasty, surgical approach, and fixation are obtained from the Swedish Hip Arthroplasty Register (SHAR). The study cohort from the SFR will be cross-checked with the National Patient Register and the SHAR for outcome variables at 2, 5, and 10 years.The primary outcome will be a composite variable comprising reoperation rate and mortality at 2 years postoperatively. Secondary endpoints will include reoperation rate and mortality as stand-alone variables. In addition, secondary endpoints will be patient-reported outcomes as measured by the Short Musculoskeletal Functional Assessment questionnaire at 1 year postoperatively as routinely collected within the SFR. Further secondary endpoints will include the occurrence of adverse events such as pneumonia, stroke or myocardial infarction and evaluation of the external validity of the study.DiscussionThis large, multicentre, register-based randomised controlled trial could potentially shift the treatment of uFNFs in older patients towards primary hip arthroplasty in order to improve the outcome.Trial registrationThe trial is registered at www.clinicaltrials.gov (NCT03966716); May 29, 2019.

Primary bipolar hemiarthroplasty as a treatment option for unstable intertrochanteric fractures.

Management of unstable intertrochanteric fractures is challenging, especially in patients with osteoporosis. Comminuted unstable intertrochanteric fractures require postoperative immobilization. Several recent reports have recommended hemiarthroplasty for treatment of unstable intertrochanteric fractures to avoid various immobilization-associated complications. The purpose of this study was to evaluate the functional and clinical outcomes of bipolar hemiarthroplasty for unstable intertrochanteric fractures in older persons. Sixty patients aged over 75 years underwent hemiarthroplasty to treat unstable intertrochanteric fractures and were followed up over 12 months. All surgeries were performed by the same surgical team using the standard posterolateral approach. Wires, cables, and plates were used as required. Use of cemented protheses was considered when the lesser trochanter had been displaced. All patients were allowed full weight-bearing as tolerated. Clinical evaluation was based on Harris Hip Scores. The cohort comprised 16 men and 44 women (aged 75-96 years). According to the Jensen classification, 24 fractures were type III, 14 type IV, and 22 type V. Cement was used in 24 patients. At 12 months follow-up, Harris Hip Scores were excellent in 18%, good in 42%, fair in 25%, and poor in 15%. No radiological abnormalities were detected. Primary bipolar hemiarthroplasty for treating unstable intertrochanteric fractures eliminates the need for prolonged immobilization and permits early ambulation. As reported by others, hip hemiarthroplasty is an effective treatment choice for unstable intertrochanteric femoral fracture in older patients.

Clinical characteristics of mandibular fractures in patients over 50 years of age

Introduction/Objective. The most commonly used methods of treatment of mandibular fracture are not always successful in older patients. This is due to decreased regenerative ability, impaired vascularization, osteoporosis, and atrophic changes. The corresponding changes are often found in patients over 50 years of age, especially accompanied with teeth loss. The objective was to review the clinical characteristics of mandibular fractures in older patients based on a retrospective analysis of medical records. Methods. A group of patients over 50 years of age was selected and analyzed among patients with mandibular fractures who had been treated for 10 years. Results. A total of 642 patients over 50 years with 1,003 fracture lines were identified. This represents 8.53% of the total number of patients with mandibular fractures. Comorbidities were diagnosed in 67% of cases. Significant differences in the distribution of the frequency of fracture lines by localization were identified, depending on the presence or absence of occlusal contact. A high incidence rate of open fractures and bone fragment dislocation was observed both in individuals with or without occlusive contact. Conclusion. Patients over 50 years of age are a statistically important group in the general population of patients with mandibular fractures with a number of clinical features. To the author?s knowledge, this study comprises the largest number of patients over the age of 50 with mandibular fractures, including those with edentulous mandible, which ensures the required level of representation, allowing reliable clinical characterization of this contingent of patients.

Prevalence of Fractures and Diagnostic Accuracy of Emergency X-ray in Older Adults Sustaining a Low-Energy Fall: A Retrospective Study.

Background: Plain radiography (XR) series are standard of care for detection of fall-related fractures in older patients with low-energy falls (LEF) in the emergency department (ED). We have investigated the prevalence of fractures and diagnostic accuracy of XR imaging in the ED. Methods: 2839 patients with LEF, who were presented to two urban level I trauma centers in 2016 and received XR and computed tomography (CT), were consecutively included in this retrospective cohort study. The primary endpoint was the prevalence of fractures of the vertebral column, rib cage, pelvic ring, and proximal long bones. Secondary endpoints were diagnostic accuracy of XR for fracture detection with CT as reference standard and cumulative radiation doses applied. Results: Median age was 82 years (range 65–105) with 64.1% female patients. Results revealed that 585/2839 (20.6%) patients sustained fractures and 452/2839 (15.9%) patients received subsequent XR and CT examinations of single body regions. Cross-tabulation analysis revealed sensitivity of XR of 49.7%, a positive likelihood ratio of 27.6, and negative likelihood ratio of 0.5. Conclusions: XR is of moderate diagnostic accuracy for ruling-out fractures of the spine, pelvic ring, and rib cage in older patients with LEF. Prospective validations are required to investigate the overall risk–benefit of direct CT imaging strategies, considering the trade-off between diagnostic safety, health care costs, and radiation exposure.