Pre-injury Mobility Status Research Articles

Distal Femur Replacement: An Option for Osteoporotic Fractures in the Elderly.

Background A distal femur fracture (DFF) around the native or prosthetic knee is commonly seen in the osteoporotic elderly population. Surgical management is required to restore the function. Fracture fixation requires a period of restricted weight-bearing; however, distal femoral replacement (DFR) allows immediate weight-bearing and quicker recovery. Methods All patients who underwent distal femur replacement from 2020 to 2023 at our hospital were retrospectively reviewed. Data related to the patient's demographics, medical comorbidities, preinjury mobility status, perioperative managementand length of stay were collected. Results Eleven patients with 13 distal femoral replacements were included. There were 10 periprosthetic and 3 native fractures around the distal femur. Two patients had bilateral periprosthetic fractures. The medianage was 84 years (range 62-95) with all patients being females. Eight patients were living in their homes while three were care home residents. The median duration of surgery was 120 min. The mean blood loss was 350 ml. Patients were mobilised out of bed at a median of three days and were able to walk for 2 meters with a frame at a mean of 10 days (range 3-15) except for two patients whose mobility was limited to the chair. The mean length of hospital stay was 32 days (range 8-54). All patients were discharged back to their original destination except for one who was shifted to a care home instead of her own home. Conclusion In our opinion, distal femur replacement provided a more favourable outcome with respect to pain management, early rehabilitation with full weight-bearing immediately following the surgery and fewer complications. Furthermore, in our hands, the surgical time was shortwith limited blood loss.

Use of the 95-degree angled blade plate with biological and mechanical augmentation to treat proximal femur non-unions: a case series

BackgroundIntertrochanteric and subtrochanteric non-union are rare but challenging complications. In the present study, we investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions.MethodsBetween October 2015 and February 2021, a retrospective cohort study was conducted at our institution to investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions, following the mechanical failure of the first device. All the patients underwent a clinical and radiographic follow-up at 6 weeks, 3, 6, 9, 12 and 18 months; at each follow-up, a plain radiograph of the femur was performed and patients were assessed using Harris Hip Score (HHS) and the Short Form-12 (SF-12) questionnaire.ResultsFrom October 2015 and February 2021, 40 proximal femur non-unions were managed at our Institution. Fifteen patients out of forty (37.5%) met the inclusion criteria. The main data of the study are summarized in Table 1; patients’ mean was 57 years old (range 19–83); 10 males and 5 females were included in the study. All the patients completely healed clinically and radiologically at an average of 6.1 months (range 4–13). All these patients returned to their pre-injury mobility status. During an average follow-up period of 25 months (range 8–60), the observed complications included wound dehiscence, which was treated with a superficial surgical debridement, a below-the-knee deep vein thrombosis, and a blade plate failure 3 months after the first revision surgery.ConclusionsThis study shows the treatment of inter-and sub-trochanteric non-unions with a 95° blade plate, medial strut allograft, and bone autograft obtained with RIA system, together with a varus malalignment correction, leads to a high percentage of bone healing, with a low incidence of complications and good clinical outcome.

Management of intertrochanteric fracture in a bilateral below knee amputee

<p class="abstract">Intertrochanteric fracture in a patient with bilateral below knee amputation is rare and the management is challenging. The major difficulty is in applying optimal amount of traction for reduction of the fracture due to absence of foot. We present the case of an elderly female with bilateral below knee amputation presenting with a minimally displaced right intertrochanteric fracture. The patient was managed using reverse boot technique for applying traction, obtaining reduction and fixed with right proximal femoral nail. The patient was able to return to her pre-injury mobility status on the third postoperative day. We highlight a method of traction application using this simple modification of the fracture table so that adequate amount of traction can be applied safely.</p>

Analysis of therapeutic effect of multidisciplinary orthogeriatric management for geriatric hip fractures

Objective To investigate the therapeutic effect of multidisciplinary orthogeriatric management for geriatric hip fractures. Methods The 492 consecutive patients aged 65~99 years(mean, 79.6 years)with woman 69.9%(344/492)were recruited between May 2015 and April 2016 in the retrospective study.Clinical data, time from admission to initiation of surgery, in-hospital mortality and mobility status of patients receiving orthogeriatric co-management were analyzed. Results The operation was performed in 434 patients(88.2%). The 49.8%(216/434)of patients underwent surgery within 48 hours after admission.The average time between admission and operation was 66.5 hours(6~246 hours). In-hospital mortality was 0.7%(3/434). The 382 patients(88.0%)were followed up, with mean follow-up of 21.2 months(range, 16~27 months). The total mortality was 9.9%(38/382)and one-year mortality was 6.5%(25/382). The average Parker mobility score of 344 survived patients was significantly reduced from 8.4 before injury to 6.6 at final follow up(P<0.01). The 42.4%(162/382)of patients returned to their pre-injury mobility status.Re-operation was performed in 8 patients(2.1%)during follow up. Conclusions Multidisciplinary orthogeriatric management for geriatric hip fractures is effective with a low in hospital and one-year mortality, while the mobility status is deteriorated significantly and more than half of the patients cannot return to their pre-injury mobility status. Key words: Hip fractures; Disease management

Effect of age, sex, co morbidities, delay in surgery and complications on outcome in elderly with proximal femur fractures

Introduction: Intertrochanteric and femoral neck fractures account for nearly 90% of proximal femur fractures. It is customary to use 65 years of age to define the elderly. One year mortality in these elderly patients ranges from 12%-36%. The main objective of this prospective study is to study the effect of age, sex, co morbidities, delay in surgery and complications on outcome in elderly with proximal femur fractures and to identify optimal measures that can be taken to improve outcome in these patients. It was presumed that early surgery within 48 hours after stabilization of co morbid conditions improves outcome in these elderly patients with proximal femur fractures. Materials and Methods:In this prospective study elderly patients with proximal femur fractures were selected, after careful selection with inclusion and exclusion criteria. They underwent surgery after preoperative assessment and followed for up to one year at a tertiary referral centre.Results: Increasing age and male sex are not significant factors affecting outcome. Increasing number of co morbidities (2, 3 or more) is associated with significant increase in mean length of hospital stay (p values .006, and .001), increased incidence in number of complications (p value .008) and mortality (p value .028). Presence of complications is significantly associated with increase in mean length of hospital stay (p values .000, .001), decline in recovery of pre injury mobility status (p value 0.018), increased incidence in number of deaths (p value .01). Delay in surgery more than 48 hours is associated with significant increase in mean length of hospital stay (p value .001) and increased incidence in number of complications (p value .028).Conclusion: Early surgery within 48 hours after stabilization of co morbid conditions is associated with improvement of outcome in elderly patients with proximal femur fractures is proved correct in terms of decreasing mean length of hospital stay and decreasing incidence of number of complications.

Intraoperative lateral wall fractures during Dynamic Hip Screw fixation for intertrochanteric fractures-Incidence, causative factors and clinical outcome

IntroductionThe intact lateral wall plays a key role in stabilization of trochanteric fracture. Hence extreme precaution should be taken to prevent lateral wall damage during DHS fixation. Present study is aimed at evaluating the determinants of lateral wall fracture and its effect on outcome in intertrochanteric fracture femur treated with DHS. Material and methodsThis is a prospective study involving intertrochanteric fractures treated with DHS fixation from July 2013 to June 2014. Out of 135 patients 49(36.3%) had stable fractures and 86(63.7%) unstable fractures. Cortical thickness index (CTI) was measured to evaluate osteoporosis. Lateral wall thickness in anteroposterior radiograph was also measured.All patients underwent 135° DHS fixation.Postoperative x-rays are assessed for implant position, intactness of the lateral wall, tip apex distance (TAD) and medialization. Functional outcome was measured at the end of fracture union by modified Harris hip score and Parkers mobility score. Clinical information including age, gender, fracture classification, TAD, lateral wall thickness and functional outcome of the patients were subjected to statistical analysis. Results34 (19.5%) patients had lateral wall fractures. Medialization was found in 22 out of these 34 (64.7%) patients. The mean preoperative lateral wall thickness of these patients is 19.2mm, compared with 26.8mm in patients with intact lateral wall (p<0.001). The mean values of CTI and TAD are comparable in both the groups. In patients with intact lateral wall, mean Harris hip score is 73.1 compared to 65.5 in lateral wall fracture group (p<0.001). Preinjury mobility status was achieved in 70.2% of intact lateral wall patients, whereas only 32.3% (11) achieved that in lateral wall fracture group. Threshold for lateral wall thickness that could predict lateral wall fracture was found to be 21mm with 95% sensitivity and 88.2% specificity. ConclusionLateral wall fractures during DHS fixation are not uncommon and osteoporosis has no bearing on its occurrence. It alone can lead to poor radiological and functional outcome independent of TAD. Lateral wall thickness is a reliable predictor of intra operative lateral wall fracture during DHS fixation and nailing is a good option especially when lateral wall thickness is <21mm.

Implementation of a standardized protocol to manage elderly patients with low energy pelvic fractures: can service improvement be expected?

PurposeThe incidence of low energy pelvic fractures (FPFs) in the elderly is increasing. Comorbidities, decreased bone-quality, problematic fracture fixation and poor compliance represent some of their specific difficulties. In the absence of uniform management, a standard operating procedure (SOP) was introduced to our unit, aiming to improve the quality of services provided to these patients.MethodsA cohort study was contacted to test the impact of (1) using a specific clinical algorithm and (2) using different antiosteoporotic drugs. Multivariate regression analysis was used to determine prognostic factors. Study endpoints were the time-to-healing, length-of-stay, return to pre-injury mobility, union status, mortality and complications.ResultsA total of 132 elderly patients (≥65 years) admitted during the period 2012–2014 with FPFs were enrolled. High-energy fractures, acetabular fractures, associated trauma affecting mobility, pathological pelvic lesions and operated FPFs were used as exclusion criteria. The majority of included patients were females (108/132; 81.8%), and the mean age was 85.8 years (range 67–108). Use of antiosteoporotics was associated with a shorter time of healing (p = 0.036). Patients treated according to the algorithm showed a significant protection against malunion (p < 0.001). Also, adherence to the algorithm allowed more patients to return to their pre-injury mobility status (p = 0.039).ConclusionsThe use of antiosteoporotic medication in elderly patients with fragility pelvic fractures was associated with faster healing, whilst the adherence to a structured clinical pathway led to less malunions and non-unions and return to pre-injury mobility state.

A Comparison of the Clinico-Radiological Outcomes with Proximal Femoral Nail (PFN) and Proximal Femoral Nail Antirotation (PFNA) in Fixation of Unstable Intertrochanteric Fractures.

Management of unstable intertrochanteric fractures poses challenges in terms of obtaining stable fixation and good postoperative outcomes. There is a paucity of clinical data comparing the commonly used Proximal Femoral Nail (PFN) and Proximal Femoral Nail Antirotation (PFNA) implants, especially in relation to osteoporosis. To assess comparative performance of PFN and PFNA in the setting of osteoporosis. Patients presenting with unstable intertrochanteric fractures (AO 31.A2 and 31.A3) were included and treated with either PFN or PFNA. Preoperative radiographs of normal side were used to grade osteoporosis by Singh's index. Grade 3 or less was considered significant. Postoperative radiographs were assessed for tip-apex distance, Cleveland index and quality of reduction. Patients were followed up for a minimum of nine months and any complications noted. Comparison of functional outcomes was done using the Harris Hip Score and Parker-Palmer mobility score at final follow up. Statistical analysis was done using the unpaired t-test/Mann-Whitney U test and Chi-square test/Fisher's-exact test. A p-value of < 0.05 was considered significant. The study included 48 patients with unstable intertrochanteric fractures, of which 23 were treated with PFN and 25 with PFNA. Average age of PFN group was 60.78 years and of PFNA group was 74.12 years. In PFN group 8 patients (38.09%) and in PFNA group 13 patients (54.1%) had Singh's osteoporotic index of ≤ 3. The average Harris Hip Score was 75.37 and 78.85 in PFN and PFNA groups (p=0.54) respectively. From PFN and PFNA groups, 35% and 32% patients respectively were able to return to pre-injury mobility status as assessed by the Parker-Palmer mobility score (p=0.83). Out of eight implant related complications; seven were in patients treated with PFN (p=0.02). Among patients with Singh's grade ≤ 3, 3 (37.5%) in PFN group suffered from implant failure whereas all 13 patients in PFNA group had successful outcome (p=0.04). Although functional outcomes achieved with both implants are similar (p=0.83), number of implant related complications were fewer with PFNA (p=0.02), even in osteoporotic group (p=0.04). We recommend use of the PFNA in unstable fractures, especially in the elderly osteoporotic population.

Fragility fractures of the ankle in the elderly: Open reduction and internal fixation versus tibio-talo-calcaneal nailing: Short-term results of a prospective randomized-controlled study

IntroductionThe management of ankle fractures in the elderly remains unpredictable, secondary to their various co-morbidities. Although tibiotalocalcaneal (TTC) nailing has been an effective option for ankle arthrodesis due to ankle arthritis or Charcot arthropathy there are few reports regarding the use of TTC nail for the treatment of ankle fractures. PurposeAim of this study was to compare the results of ORIF versus TTC nailing for the treatment of unstable ankle fractures in the elderly. We hypothesized that the elderly may benefit from TTC nailing, as it allows the patient to be mobilized immediately after surgery and minimizes the risk of wound or bone problems. Patients and methodsThis was a prospective, randomized-controlled, comparative study. Between 2009 and 2015, 43 patients were treated with a TTC nail (Group A) and 44 with ORIF (Group B). The Olerud-Molander ankle score was obtained and intraoperative-postoperative complications, length of hospital stay, mobility status and reoperation rate were recorded. The nail fixation was performed with the TrigenR hindfoot nail after closed reduction. ORIF was performed, using a 1/3 tubular plate and 3.5mm screws for the lateral malleolus and two 4.0 mm cannulated screws for the medial. ResultsMortality rate at one year was 13.9% for Group A and 18.1% for Group B. Mean follow-up was 14 months (12–18m). There were no intraoperative complications. Three complications in Group A (8.1%) and twelve (33.3%) in Group B were encountered postoperatively (p<0.05). There was significant shorter hospital stay in Group A (5.2±3.1d) than in Group B (8.4±5.2d). In Group A, 28 patients returned to their pre-injury mobility status (75.6%) while 9 declined one level of the mobility scale (24.3%). In Group B, 26 patients remained at the same mobility level (72.2%) and 10 declined one level (27.7%). There was no significant difference between the postoperative OMAS scores in the two Groups (56.9±9.85 and 56.6±9.3 respectively). ConclusionsWe believe that TTC nailing is a safe and effective method of treatment of unstable ankle fractures in the elderly because it has a low risk of complications and restores function and mobility allowing an immediate return to full weight-bearing.

Cemented or cementless THA in patients over 80 years with fracture neck of femur: a prospective comparative trial

Total hip arthroplasty is associated with a better long term outcome and lesser reoperation rates in the elderly but the risk of complications are believed to be higher in very elderly patients. The study aims to compare the short-term results of cemented and cementless total hip arthroplasty (THA) in active patients >80 years of age with femoral neck fractures. Sixty-two consecutive patients underwent THA during the study period (cemented--31 and cementless--31). The mean age was 84 years (81-94 years). Patients in both groups were comparable in their preoperative variables. Functional and radiological assessments were carried out using validated outcome measures. Complications were recorded. Fifty-one patients were available for final analysis after accounting for deaths and cases lost in follow-up. Of the 51 patients, 25 (49%) regained their pre-injury mobility status and 36 (70%) were community ambulant. Cementless THA was associated with significantly less surgical time, blood loss, transfusion rates and hospital stay. The overall mortality rates, complications, functional and radiological results were similar in both groups though the number of deaths in the perioperative period was significantly high in patients undergoing cemented THA. Satisfactory improvement in function with low reoperation rates can be achieved irrespective of the technique used. Complication rates are higher when compared to younger patients undergoing the procedure. Risks and benefits should be carefully assessed and explained before subjecting these patients to THA.

Operative Fixation of Unstable Ankle Fractures in Patients Aged over 80 Years

Controversy exists regarding the surgical treatment of unstable ankle fractures in the very elderly age group of over 80 years. However, the literature regarding the prognosis of surgery in this elderly group is limited. The purpose of our study was to evaluate the results of patients above 80 years old who underwent operative fixation for unstable ankle fractures. Ninety-two consecutive patients, 80 females and 12 males, above 80 years of age had open reduction and internal fixation for unstable ankle fractures during the period of January 1998 to August 2007. The data was collected retrospectively from the case records and radiographs. The complications were noted and the risk factors for poor outcome were analyzed. The average age was 85.2 (range, 80.1 to 95.1) years. The minimum duration of followup was 9 months, with an average of 15 (range, 9 to 28) months. The most common fracture pattern was Danis-Weber B type. The superficial wound infection rate was 7% (6 cases) and the deep infection rate was 4.6% (4 cases). The 30 day postoperative mortality was 5.4% (five cases). Eighty-six percent (75 out of 87 cases) were able to return back to their pre injury mobility at the last followup. Diabetes, dementia, peripheral vascular disease and smoking were found to be statistically significant risk factors associated with wound complications. The results of operative fixation of unstable ankle fractures were encouraging with good functional recovery and return to pre injury mobility status in most cases.

Unipolar versus Bipolar Uncemented Hemiarthroplasty for Elderly Patients with Displaced Intracapsular Femoral Neck Fractures

To compare outcomes of unipolar versus bipolar uncemented hemiarthroplasty and determine factors affecting outcomes. 433 and 274 elderly patients with displaced intracapsular femoral neck fractures underwent uncemented unipolar hemiarthroplasty and uncemented bipolar hydroxyapatite-coated hemiarthroplasty, respectively. Surgical options were based on the patient's general condition and preinjury mobility status. In the respective groups, the mortality of 377 and 242 patients and the mobility of 270 and 217 patients were reviewed at the 4-month follow-up. Patient age, sex, American Society of Anesthesiologists [ASA] score, mobility, and mortality of the 2 groups were compared. Patients who underwent unipolar hemiarthroplasty were significantly older, less fit, and less mobile (p<0.001). Patients who underwent bipolar hemiarthroplasty achieved better outcomes for mortality and mobility (p<0.001). Among patients who were able to walk unaided before injury, more of those having bipolar hemiarthroplasty were able to do so at month 4 than those having unipolar hemiarthroplasty (13% vs. 33%, p<0.001). Mortality within 4 months was associated with age, male gender, and ASA score. When patients were stratified according to age groups, mortality within 4 months was lower in patients having bipolar hemiarthroplasty. In elderly patients with femoral neck fractures who were fit and physiologically young, uncemented bipolar hemiarthroplasty seemed to achieve better functional outcome.

Complex proximal femoral fractures in the elderly managed by reconstruction nailing – complications & outcomes: a retrospective analysis

BackgroundUnstable proximal femoral fractures and pathological lesions involving the trochanteric region in the elderly comprise an increasing workload for the trauma surgeon as the ageing population increases. This study aims to evaluate use of the Russell-Taylor reconstruction nail (RTRN) in this group with regard to mortality risk, complication rates and final outcome.MethodsRetrospective evaluation of 42 patients aged over 60 years who were treated by reconstruction nailing for proximal femoral fractures over a 4 year period.ResultsOver two-thirds of patients were high anaesthetic risk (ASA > 3) with ischemic heart disease the most common co-morbidity. 4 patients died within 30 days of surgery and 4 patients required further surgery for implant related failure. Majority of patients failed to regain their pre-injury mobility status and fewer than half the patients returned to their original domestic residence.ConclusionFavourable fixation of unstable complex femoral fractures in the elderly population can be achieved with the Russell-Taylor reconstruction nail. However, use of this device in this frail population was associated with a high implant complication and mortality rate that undoubtedly reflected the severity of the injury sustained, co-morbidity within the group and the stress of a major surgical procedure.