Paradigm shift in geriatric fracture treatment

Anterior variable angle locking neutralisation plate superiority over traditional tension band wiring for treating transverse patella fractures

Purpose

This paper investigates the biomechanical benefits of using hybrid constructs that combine cannulated screws with tension band wiring (TBW) cerclage compared to cannulated screws with anterior Variable Angle locking neutralisation plates (VA LNP). These enhancements can bear heavier loads and maintain the repaired patella's integrity, in contrast to traditional methods.

Method

Eighteen fresh-frozen human cadaver patellae were carefully fractured transversely at their midpoints using a saw. They were then divided into two groups of nine for subsequent utilisation. Fixation methods included Cannulated Screw Fixation added with either TBW or VA LNP Fixation Technique. Cyclic loading simulations (500 cycles) were conducted to mimic knee motion, tracking fracture displacement with Optotrak. After that, the constructs were secured over a servo-hydraulic testing machine to determine the load-to-failure on axial mode.

Results

The average fracture displacement for the anterior neutralisation plate group was 0.09 ± 0.12 mm, compared to 0.77 ± 0.54 mm for the tension band wiring with cannulated screw group after 500 cyclic loading. This result is statistically significant (p = 0.004). The anterior neutralisation plate group exhibited a mean load-to-failure of 1359± 21.53 N, whereas the tension band wiring group showed 780.1 ± 22.62 N, resulting in a significant difference between the groups (p = 0.007).

Conclusion

This research highlights the superior biomechanical advantage of VA LNP over TBW for treating simple transverse patella fractures with two cannulated screws. It also highlights how the TBW is still a valuable option considering the load-to-failure limit.

Level of Evidence

Not Applicable.

Systemically administered zoledronic acid activates locally implanted synthetic hydroxyapatite particles enhancing peri-implant bone formation: A regenerative medicine approach to improve fracture fixation

Fracture fixation in an ageing population is challenging and fixation failure increases mortality and societal costs. We report a novel fracture fixation treatment by applying a hydroxyapatite (HA) based biomaterial at the bone-implant interface and biologically activating the biomaterial by systemic administration of a bisphosphonate (zoledronic acid, ZA). We first used an animal model of implant integration and applied a calcium sulphate (CaS)/HA biomaterial around a metallic screw in the tibia of osteoporotic rats. Using systemic ZA administration at 2-weeks post-surgery, we demonstrated that the implant surrounded by HA particles showed significantly higher peri‑implant bone formation compared to the unaugmented implants at 6-weeks. We then evaluated the optimal timing (day 1, 3, 7 and 14) of ZA administration to achieve a robust effect on peri‑implant bone formation. Using fluorescent ZA, we demonstrated that the uptake of ZA in the CaS/HA material was the highest at 3- and 7-days post-implantation and the uptake kinetics had a profound effect on the eventual peri‑implant bone formation. We furthered our concept in a feasibility study on trochanteric fracture patients randomized to either CaS/HA augmentation or no augmentation followed by systemic ZA treatment. Radiographically, the CaS/HA group showed signs of increased peri‑implant bone formation compared with the controls. Finally, apart from HA, we demonstrated that the concept of biologically activating a ceramic material by ZA could also be applied to β-tricalcium phosphate. This novel approach for fracture treatment that enhances immediate and long-term fracture fixation in osteoporotic bone could potentially reduce reoperations, morbidity and mortality. STATEMENT OF SIGNIFICANCE: • Fracture fixation in an ageing population is challenging. Biomaterial-based augmentation of fracture fixation devices has been attempted but lack of satisfactory biological response limits their widespread use. • We report the biological activation of locally implanted microparticulate hydroxyapatite (HA) particles placed around an implant by systemic administration of the bisphosphonate zoledronic acid (ZA). The biological activation of HA by ZA enhances peri‑implant bone formation. •Timing of ZA administration after HA implantation is critical for optimal ZA uptake and consequently determines the extent of peri‑implant bone formation. • We translate the developed concept from small animal models of implant integration to a proof-of-concept clinical study on osteoporotic trochanteric fracture patients. • ZA based biological activation can also be applied to other calcium phosphate biomaterials.

Do we need to fix the anterior fracture component in insufficiency fractures of the pelvis? A biomechanical comparison on an FFP type IIIc fracture in an osteoporotic pelvic bone model

There is a growing understanding of the specific characteristics of insufficiency fractures of the pelvis and of general requirements for the treatment of affected patients with focus on early mobilization and effective pain reduction as the main goals of therapy. While there is consensus on the significance of achieving stability of the dorsal pelvic ring structures there is still an open discussion about the potential benefits of additional stabilization of an anterior fracture component. Within a biomechanical test setup, two established methods of dorsal fracture fixation were tested under axial loading (25-1200 N; 1000 test cycles) on an explicit osteoporotic bone model (n = 32) with a standardized FFP type IIIc fracture with and without additional fixation of the anterior fracture component. Dorsal fixation was performed with and long and a short 7.3 mm cannulated screw in S1 in one group (n = 16), and a trans sacral bar with an additional short 7.3 mm cannulated screw in S1 in the other group (n = 16). Half of the samples received a 7.3 mm cannulated retrograde transpubic screw for anterior fixation. The fixation with the trans sacral bar and the additional anterior screw fixation showed the highest rate of stability (p = 0.0014), followed by the double SI-screw fixation with stabilization of the anterior fracture (p = 0.0002). During testing, we observed the occurrence of new sacral fractures contralateral to the initial fracture in 22/32 samples. The results let us assume that stabilization of an additional anterior fracture component relevantly improves the stability of the entire ring construct and might prevent failure of the dorsal stabilization or further fracture progression.

Exposing the Care Conundrum of Low-Energy Pelvic Ring Fractures in Older Adults: A Review of 322 Patients

Introduction

A care conundrum for low-energy pelvic ring fracture patients in which they face financial burden after not qualifying for an inpatient stay of 3 days or more has been noted in the literature. The purpose of this study was to identify factors that lead to inpatient length of stay (IP LOS) ≥3 days in older adults with nonoperative pelvic ring fragility fractures and to highlight the challenging financial decision-making of those with IP LOS <3 days in the context of the Medicare 3-day rule.

Methods

This was a retrospective review of 322 patients aged ≥65 presenting from March 2016 and February 2019 to either of 2 emergency departments (EDs) after a ground-level fall resulting in a pelvic ring fracture. Patient demographic, IP LOS, and mortality data were extracted. Case management notes were analyzed to summarize financial decision-making for patients with IP LOS <3 days. Multivariate logistic regression analysis was conducted to identify factors that predicted IP LOS ≥3 days and mortality.

Results

IP LOS ≥3 days was associated with presentation to level I hospital (OR .30 [.19, 0.50]) and being single (OR 2.50 [1.10, 5.68]). 70.3% required a post-acute skilled nursing facility (SNF) stay. Of patients with LOS <3 days, 25.0% were financially responsible for their SNF stay, while 7.9% elected home care due to financial reasons. Overall 30-day, 90-day, and 1-year mortality were 2.5%, 8.1%, and 20.8%, respectively. For patients with LOS <3 days, returning to assisted living compared to discharging to a SNF increased 90-day mortality risk (HR 8.529, P = .0451). Having Medicare trended towards increased 90-day mortality risk compared to commercial insurance (HR 4.556, P = .0544).

Conclusion

The current system is failing older adult patients who sustain nonoperative low-energy pelvic ring fractures in terms of financial coverage of necessary post-acute treatment. This care conundrum has yet to be solved.

Odontoid fracture in geriatric patients - analysis of complications and outcome following conservative treatment vs. ventral and dorsal surgery

BACKGROUND

Different treatment options are discussed for geriatric odontoid fracture. The aim of this study was to compare the treatment options for geriatric odontoid fractures.

METHODS

Included were patients with the following criteria: age ≥ 65 years, identification of seniors at risk (ISAR score ≥ 2), and odontoid fracture type A/B according to Eysel and Roosen. Three groups were compared: conservative treatment, surgical therapy with ventral screw osteosynthesis or dorsal instrumentation. At a follow-up examination, the range of motion and the trabecular bone fracture healing rate were evaluated. Furthermore, demographic patient data, neurological status, length of stay at the hospital and at the intensive care unit (ICU) as well as the duration of surgery and occurring complications were analyzed.

RESULTS

A total of 72 patients were included and 43 patients could be re-examined (range: 2.7 ± 2.1 months). Patients with dorsal instrumentation had a better rotation. Other directions of motion were not significantly different. The trabecular bone fracture healing rate was 78.6%. The patients with dorsal instrumentation were hospitalized significantly longer; however, their duration at the ICU was shortest. There was no significant difference in complications.

CONCLUSION

Geriatric patients with odontoid fracture require individual treatment planning. Dorsal instrumentation may offer some advantages.

Outcomes of Angular Stable Locking System in Femoral Diaphyseal Fractures of Elderly Patients: A Multicenter Comparative Study

Background

The angular stable locking system (ASLS) was developed to provide additional stability to the distal interlocking screw of the intramedullary (IM) nail. Effects of ASLS on the treatment of femoral diaphyseal fractures in the elderly remain unknown. The aim of this study was to compare radiological outcomes of IM nailing using ASLS screws to IM nails with conventional interlocking screws in elderly patients with femoral shaft fractures.

Methods

A multicenter retrospective review of 129 patients (average age, 73.5 years; 98 women and 31 men) aged 65 years or older who underwent IM nail fixation for femoral diaphyseal fractures (AO/Orthopaedic Trauma Association [OTA] classification 32) was conducted. Demographic information of patients, fracture site (subtrochanteric or shaft), fracture type (traumatic or atypical), and AO/OTA fracture classification were investigated. Reduction status was evaluated by postoperative plain radiography. Presence of union and time to union were evaluated through serial plain radiograph follow-up. Reoperation due to nonunion or implant failure was also evaluated.

Results

ASLS was used in 65 patients (50.3%). A total of 118 patients (91.5%) achieved union without additional surgery and the mean union time was 31.8 ± 13.0 weeks. In terms of reduction status, angulation was greater in the group using ASLS. There were no statistically significant differences of union rate, time to union, and reoperation rate according to the use of ASLS (p > 0.05). There was no difference in the outcomes according to the use of ASLS even when the analysis was divided in terms of fracture site or fracture type (p > 0.05). In further subgroup analysis, only the traumatic subtrochanteric area group showed statistically significantly shorter time to union when ASLS was used (p = 0.038).

Conclusions

In geriatric patients with femoral diaphyseal fractures, the use of ASLS was not considered to have a significant effect on fracture healing. Fracture healing seemed to be more affected by surgical techniques such as minimizing the gap and fracture characteristics such as atypical femoral fractures, rather than implants.

Open lower extremity fractures in the geriatric population

INTRODUCTION

Open fractures in the elderly are distinct compared to younger populations. The purpose of this study is to follow a series of open fractures of the lower extremity in the geriatric population to better prognosticate outcomes.

METHODS

We performed a retrospective chart review of patients over the age of 65 years old who were treated for an open, lower extremity fracture across two level I trauma medical systems. Patients were included if they had documented wound healing problems in the postoperative period, or 6 months of follow-up, or if they had a definitive radiographic outcome. Sixty-four patients were included of an average age of 76.23, of whom 73.4% were female.

RESULTS

The fracture types were midshaft femur in 3, distal femur in 9, patella in 2, proximal tibia in 3, proximal fibula in 1, midshaft tibia in 14, distil tibia in 8, ankle in 23, and talar neck/calcaneus in 1. Forty-two fractures were the result of low energy mechanism and 22 fractures were from high energy mechanism. Fourteen fractures were type 1, 32 were type 2, 11 were type 3A, 6 were type 3B, and 1 was type 3C. At final follow-up, 13 wounds were well healed, 39 wounds were healed following a delay of more than 6 weeks to achieve healing, 3 were infected, 3 had been treated with amputation, 2 had chronic ulceration, 2 with active draining, and 2 had draining sinuses.

DISCUSSION

Open lower extremity fractures are serious injuries with high rates of morbidity. Such risks are even higher in the geriatric population, particularly with regard to wound healing. This study provides important prognostic information in counseling geriatric patient with an open lower extremity fracture, as well as informs treatment in terms of wound surveillance and care in the postoperative period.

Safety and efficacy of two ilioiliac tension band plates osteosynthesis of fragility fractures of the pelvis

The study retrospectively determined the efficacy and safety of fixation of the pelvis (FFP) fragility fractures type IV using two tension band ilioiliac locking compression plates. Forty-one patients with FFP were treated in 2017-2020. 16 patients with FFP type IV, unable to walk weight-bearing, were treated by fixation using two tension band ilioiliac locking compression plates without fixing the anterior ring. Preoperatively and one year postoperatively, the functional outcome and performance were assessed using Pelvic Discomfort Index (PDI) and Timed Up and Go (TUG) test. Pre- and postoperative hemoglobin level was evaluated. Operation time and intra-and postoperative complications were documented. One year postoperatively, an X-ray was taken. The arithmetic mean (x) and standard deviations (±) of quantitative variables were calculated. T-test for dependent samples was used for pre-and postoperative results comparison. The PDI improved (p < 0.001) from x = 81.42 ± 4.04 to x = 36.19 ± 15.58. Preoperatively none of the patients was able to perform the TUG test. Postoperatively, the result exceeded x = 13.13 ± 3.99 s. The operation lasted x = 42.80 ± 8.90 min. Hemoglobin decreased (p < 0.001) from 11.63 ± 1.11 to 9.07 ± 1.21 g/dL. No complications nor fixation loosening were noted. The study support fixation using two tension band ilioiliac locking compression plates as an efficient and safe treatment of the FFP type IV.

Creative bracing: A descriptive overview of an alternative technique for non-operative fracture management of frail older adults

As the world population ages, a higher proportion of older and frailer patients will sustain fragility fractures. Considering their depleted physiologic reserve and potentially different goals of care at their stage in life, these patients; especially those enrolled in hospice care, with profound dementia, or at end-of-life care; may not benefit from traditional surgical methods of fracture care. Non-operative treatment using standard immobilization or casting techniques in older and frailer patients can still render them susceptible to complications and adverse events. Here we describe our alternative non-operative treatment method of creative bracing to address the needs of this specific population. Creative bracing can be done with simple supplies available in almost all healthcare settings. Through patient-specific pre-treatment assessment, a creative brace tailored to the patient's risk factors and goals of care can be designed to provide sufficient fracture immobilization and comfort. Creative bracing is a low-cost, low-technical demand modality for non-operative treatment of some fragility fractures. Its benefit can be appreciated to greatest effect in the frailest patients for whom standard, surgical treatment does not represent best care.

Intraoperative Computed Tomography in Orthopaedic Trauma Surgery

BACKGROUND

When using mobile 3D C-arms, impairments in image quality occur due to artefacts caused by metal implants as well as to the limited field of view. To avoid these restrictions, special computed tomography devices were designed, in order to improve image quality and to meet requirements for intraoperative usage.

OBJECTIVES

To analyse practicability and benefits of a mobile intraoperative CT device (Airo, Brainlab, Munich, Germany) on the basis of several parameters that were obtained during a 40-month period.

MATERIALS AND METHODS

All procedures that were performed with usage of intraoperative CT between January 2017 and April 2020 were analysed with respect to anatomical region, count of scans, duration of scans, consequences drawn from the scans and use of navigation.

RESULTS

354 CT-scans were performed in 171 patients (mean 2.07 [1 - 6] scans per procedure). 47.81% of the procedures were spinal, 52.19% affected the pelvis. 83% of the procedures were navigated. In 22% of patients, improvement in implant placement or reduction was achieved; in most patients (55%), a guidewire for pedicle screws was corrected. The mean scan duration was 10.33 s (3.54 - 21.72).

CONCLUSIONS

Use of intraoperative CT was reliable and helpful. Integration in OR standards requires more effort than mobile 3D C-arms. Image quality was outstanding for intraoperative conditions and allowed proper assessment of implant placement and reduction in all cases. Due to the high financial outlay of the system and the good image quality of 3D C-arms in the extremities, we assume that this procedure can be applied in intraoperative CT in traumatological cases in spinal and pelvic surgery in high-level trauma centres.

[Sacral fractures in geriatric patients]

Sacral fractures in geriatric patients are increasing and form a distinct entity. Clinical findings can be unspecific, which is why they are easily overlooked. It is mandatory to analyze the whole pelvic ring for evaluation of pelvic stability and for making treatment decisions. The primary diagnostics are made using plain X‑radiography; however, for assessment of the posterior pelvic ring an examination using sectional imaging is regularly necessary. The fragility fractures of the pelvis (FFP) classification is suitable as a guideline for the surgical treatment to be used. Stable fractures without relevant displacement after initial mobilization should be treated conservatively. Instability, failure of mobilization and persistent pain are, however, common reasons for surgical treatment. Fracture displacement determines if minimally invasive procedures for posterior and anterior pelvic ring stabilization are possible. Otherwise, complex open procedures such as spinopelvic fixation may be necessary.

Operative treatment of fragility fractures of the pelvis: a critical analysis of 140 patients

Background

Fragility fractures of the pelvis (FFP) are a clinical entity with an increasing frequency. Indications for and type of surgical treatment are still a matter of debate.

Purpose

This retrospective study presents and critically analyses the results of operative treatment of 140 patients with FFP.

Setting

Level-I trauma center.

Materials and methods

Demographic data, comorbidities, FFP-classification, type of surgical stabilization (percutaneous (P-group) versus open procedure (O-group)), length of hospital stay (LoS), general in-hospital complications, surgery-related complications, living environment before admission, mobility and destination at discharge were retracted from the medical and radiographic records. Patients were asked participating in a survey by telephone call about their quality of life. SF-8 Physical Component Score (PCS) and SF-8 Mental Component Score (MCS) were calculated as well as the Parker Mobility Score (PMS) and the Numeric Rating Scale (NRS).

Results

Mean age was 77.4 years and 89.3% of patients were female. 92.1% presented with one comorbidity, 49.3% with two or more comorbidities. Median length of hospital stay was 18 days, postoperative length of hospital stay was 12 days. 99 patients (70.7%) received a percutaneous operative procedure, 41 (29.3%) an open. Patients of the O-group had a significantly longer LoS than patients of the P-group (p = 0.009). There was no in-hospital mortality. There were significantly more surgery-related complications in the O-group (43.9%) than in the P-group (19.2%) (p = 0.006). Patients of the O-group needed more often surgical revisions (29.3%) than patients of the P-group (13.1%) (p = 0.02). Whereas 85.4% of all patients lived at home before admission, only 28.6% returned home at discharge (p < 0.001). The loss of mobility at discharge was not influenced by the FFP-classes (p = 0.47) or type of treatment (p = 0.13). One-year mortality was 9.7%. Mortality was not influenced by the FFP-classes (p = 0.428) or type of treatment (p = 0.831). Median follow-up was 40 months. SF-8 PCS and SF-8 MCS were moderate (32.43 resp. 54.42). PMS was 5 and NRS 4. Follow-up scores were not influenced by FFP-classes or type of treatment.

Conclusion

Patients with FFP, who were treated operatively, suffered from a high rate of non-lethal general, in-hospital complications. Open surgical procedures induced more surgery-related complications and surgical revisions. Mental and physical follow-up scores are low to moderate. Condition at follow-up is not influenced by FFP-classes or type of treatment. Indications for operative treatment of FFP must be critically examined. Surgical fixation should obtain adequate stability, yet be as less invasive as possible. The advantages and limitations of different surgical techniques have to be critically evaluated in prospective studies.

The FFP-classification: From eminence to evidence

Fragility fractures of the pelvis (FFP) are a clinical entity with a rapidly growing incidence among elderly women. The characteristics of these fractures are different from those appearing after high-energy trauma. In 2013, the comprehensive FFP-classification provided a new framework for analysis of these fractures. It is based on the estimation of loss of stability in the pelvic ring. It is connected with recommendations for surgical treatment, justified by the fact that higher instabilities will need surgical stabilization. Since ist appearance, we can observe an increasing clinical-scientific interest in FFP. Multiple publications use the FFP-classification studying the characteristics of fractures, choice of treatment and outcome. Other studies focus on minimal-invasive techniques for stabilization. The actual knowledge describes higher mortality rates as the reference population, lower mortality rates after operative treatment but for the price of surgery-related complications. Mobility, independency and quality of life are worse than before the fracture, independent of the FFP-classification and the type of treatment. The classification triggered a rapid increase of expertise. This publication gives a detailed overview on the evolution from eminence to evidence.

Hypoxia in Bone and Oxygen Releasing Biomaterials in Fracture Treatments Using Mesenchymal Stem Cell Therapy: A Review

Bone fractures have a high degree of severity. This is usually a result of the physical trauma of diseases that affect bone tissues, such as osteoporosis. Due to its highly vascular nature, the bone is in a constant state of remodeling. Although those of younger ages possess bones with high regenerative potential, the impact of a disrupted vasculature can severely affect the recovery process and cause osteonecrosis. This is commonly seen in the neck of femur, scaphoid, and talus bone. In recent years, mesenchymal stem cell (MSC) therapy has been used to aid in the regeneration of afflicted bone. However, the cut-off in blood supply due to bone fractures can lead to hypoxia-induced changes in engrafted MSCs. Researchers have designed several oxygen-generating biomaterials and yielded varying degrees of success in enhancing tissue salvage and preserving cellular metabolism under ischemia. These can be utilized to further improve stem cell therapy for bone repair. In this review, we touch on the pathophysiology of these bone fractures and review the application of oxygen-generating biomaterials to further enhance MSC-mediated repair of fractures in the three aforementioned parts of the bone.

Does surgical treatment for unstable fragility fracture of the pelvis promote early mobilization and improve survival rate and postoperative clinical function?

PURPOSE

This retrospective multicenter study aimed to compare rates of early mobilization and survival and functional outcome of surgical treatment (S) with that of conservative treatment (C) according to each unstable fragility fracture of the pelvis (FFP) classification type with displacement of the posterior component ≥ 5 mm.

METHODS

We analyzed 64 patients with unstable type III and IV FFP who could move and transfer themselves before injury and had ≥ 5 mm displacement of the posterior component. We compared survival rate, early mobilization, walking ability at final follow-up, and complications at admission for each type of surgical and conservative treatment.

RESULTS

Most of the unstable FFP were type IIIa and IVb in the study population. Type III comprised 40 cases (group S:13/group C:27) and type IV comprised 24 cases (group S:7/group C:17). There were no significant differences in 3 month and 1 year survival rates, although group C (III) had the tendency of higher mortality rate (p = 0.08). Mobilization (transferring to a wheelchair) was enabled significantly earlier in group S (III) than in group C (III) (p = 0.02), but in type IV, most patients enabled early mobilization even without surgical intervention. There were no significant differences in hospital complications and walking ability at final follow-up.

CONCLUSION

In this study, the superiority of surgical treatment for unstable FFP was not proven. However, the results suggest that type IVb may be a relatively stable type compared to type III and that type IVb should be considered separately from bilaterally complete unstable sacral fractures due to high-energy trauma.

Percutaneous operative treatment of fragility fractures of the pelvis may not increase the general rate of complications compared to non-operative treatment

Purpose

Despite an increasing number of fragility fractures of the pelvis (FFP) over the last 2 decades, controversy persists on their therapy with special regard to potential complications. Therefore, the present study compared the complication rates and in-hospital mortality of non-operative therapy, percutaneous treatment and open reduction and internal fixation (ORIF) of pelvic fractures in elderly patients.

Methods

All consecutive patients treated for FFP between January 2013 and December 2017 aged 65 years or older were retrospectively identified from an institutional database. Demographic data and specific patient data were collected with a special focus on pre-existing comorbidities. General and surgical complications, hospital length of stay (LOS) and mortality rates were compared.

Results

379 patients (81.3 ± 7.5 years; 81% female) were identified, 211 (55.7%) were treated non-operatively, 74 (19.5%) percutaneously and 94 (24.8%) with ORIF. The rate of general complications did not differ between treatment groups (non-operative: 21.8%; percutaneous: 28.4%; ORIF: 33.0%; p = 0.103). Surgery-related complications were twofold more frequent in the ORIF group as than in the percutaneously treated group (18.1% vs. 9.5%). The LOS differed significantly (non-operatively: 8.9 ± 7.1 days; percutaneous: 16.6 ± 8.2 days; ORIF: 19.3 ± 12.8 days; p < 0.001). Hospital mortality rate was higher in patients with ORIF (5.3%) than percutaneous treatment (0%) (p = 0.044).

Conclusions

Complication rates and hospital mortality in elderly patients with FFPs are high and associated with long LOS. For surgical treatment of FFPs, the complication rate and mortality can be significantly reduced using percutaneous procedures compared to ORIF. Therefore, percutaneous surgery should be preferred where possible.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01660-w.

Iliac intramedullary stabilization for Type IIIA fragility fractures of the pelvis

There have been few reports on fixation of Rommens classification Type IIIA fragility fractures of the pelvis (FFPs). Here, we present our less invasive surgical technique, called iliac intramedullary stabilization (ILIS), for the internal fixation of Type IIIA FFPs. The technique involves a closed reduction, termed the femur internal rotation reduction method (FIRM), whereby the fracture fragments are repositioned using lateral rotators by internally rotating the femur while the patient is in the prone position. Two iliac screws are inserted on the ilium bilaterally via the supra-acetabular bone canal during FIRM and connected with two transverse rods and two cross connectors. We refer to this internal fixation procedure as ILIS. We retrospectively recruited patients with Type IIIA fractures, treated using this procedure, at our institute between October 2017 and October 2019. We evaluated operative and post-operative outcomes. We enrolled 10 patients (9 women and 1 man; mean age, 85.2 years) who were followed up for over 6 months. All patients suffered FFPs after falling from a standing position. The mean operative time was 145.1 (range, 94-217) minutes, and the mean blood loss was 258.5 (range, 100-684) ml. All patients were allowed full weight bearing from post-operative day 1. All patients achieved bone union and regained their pre-injury walking ability at 6 months after surgery without evident secondary displacement. In conclusion, our ILIS technique allows less invasive internal fixation of Type IIIA FFPs with adequate stability for full weight bearing from post-operative day 1.

Characteristics of medial condyle sagittal fracture of distal femur involving intercondylar notch in geriatric patients

INTRODUCTION

Unicondylar femoral fractures are uncommon injuries, known to occur primarily in young people, with high energy trauma. However, according to our experiences, unicondylar femoral fractures in geriatric patients generally involved the medial femoral condyle, unlike previously reported. In addition, the fractures of medial femoral condyle (FMFC) showed a characteristic fracture pattern. To date, there has been no published article focusing on the FMFC in geriatric patients. Thus, the aim of this study was to determine the characteristics of FMFC in geriatric patients and to present their outcomes.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 13 patients over age of 65 who underwent surgery for FMFC (AO-OTA 33B2). Of the 13, 10 patients were treated with Tomofix medial distal femoral plate (MDF) (Synthes GmbH, Switzerland) and additional screws fixation; the other three were treated with screw fixation and cast application.

RESULTS

The mean age of patients was 76.8 years, and 10 patients were females. The fracture was due to low-energy trauma in all of the cases. Eight patients had medial knee osteoarthritis, and 2 patients were on osteoporosis treatment. A characteristic fracture pattern was observed. The fracture line extended from the lateral aspect of the intercondylar notch to the posteromedial column of the distal femur, with a characteristic medial beak. All fractures belonged to AO classification 33B2.1; there were no cases of AO classification 33B2.2 or 33B2.3. The postoperative joint function was graded according to the Kolmert functional criteria: ten cases were excellent, one case was good, one case was fair, and one case was poor.

CONCLUSION

FMFC caused by low-energy trauma in geriatric patients tend to have a characteristic pattern. We believe that anatomic reduction and firm fixation with Tomofix MDF plate and cannulated screw for low-energy trauma FMFC in geriatric patients would yield good outcomes.

Osteosynthesis of a Multifragment Femoral Shaft Fracture and Peri-Implant Refracture in an 83-Year-Old Patient with Osteogenesis Imperfecta

Introduction. Osteogenesis imperfecta (OI) is the term for a heterogenic group of conatal diseases that affect the bone formation. Eight different OI types are known. Patients with types III and IV frequently suffer from fractures without adequate trauma. The literature gives plenty advice for fracture treatment in pediatric OI patients, but there is less for adults, and no recommendations can be found for geriatric OI patients. Case Presentation. We report on an 83-year-old male who suffered from OI type IV. He was able to walk with an individually adapted gait orthosis. In an accident, the patient sustained a distal, multifragment, femoral shaft fracture. The fracture was openly reduced and fixated with a retrograde inserted elastic stable intramedullary nail (ESIN). Three months later, the patient was capable of walking without crutches. Due to another accident, he sustained a peri-implant refracture without failure of the ESIN. We immobilized the leg, and it achieved bony healing without reosteosynthesis. Eleven weeks later, he was again able to mobilize himself with full weight bearing. Discussion. We present a unique case of osteosynthesis in a distal, multifragment, femoral shaft fracture in a geriatric OI patient. No recommendations for the treatment of mature patients with OI can be found in the literature. We present our treatment concept and technique of osteosynthesis with an ESIN. Despite another accident with a peri-implant refracture, sufficient bony healing occurred, which allowed the patient to freely mobilize himself again.

High rate of maintaining self-dependence and low complication rate with a new treatment algorithm for proximal humeral fractures in the elderly population

BACKGROUND

We modified our treatment algorithm for proximal humeral fractures in elderly patients in 2013 to a more conservative approach avoiding locking plates. This study assesses the impact of this change on patient self-dependence.

METHODS

We carried out an observational comparative study including both retrospectively and prospectively collected data. For the former, 147 isolated proximal humeral fracture patients older than 65 years were treated between 2011 and 2013 at our hospital and included in a historical group. The revised treatment algorithm was applied in a similar non-concurrent, comparative patient group (n = 160) prospectively enrolled between 2015 and 2017. The primary outcome was any loss of self-dependence, with secondary outcomes including documentation of shoulder functional scores, quality of life, and adverse events.

RESULTS

Historical and prospective patients had similar baseline characteristics. Nonoperative treatment was performed in 53 historical patients (36%) and 83 prospective patients (78%). Prospective patients were 1.6 times less likely to lose some level of self-dependence (risk ratio, 0.62; 95% confidence interval, 0.25-1.5; P = .292), and the local adverse event risk dropped from 12.2% to 5.7% (P = .078). Mean shoulder function and quality of life were similar between the 2 groups.

CONCLUSION

By applying our revised algorithm, a higher proportion of elderly patients maintained their premorbid level of self-dependence and returned to their previous social environment.

Biomechanics of Osteoporotic Fracture Fixation

PURPOSE OF REVIEW

Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation stability with a particular focus on fractures that frequently occur in elderly individuals with osteoporosis and require full load-bearing capacity, i.e., pelvis, hip, ankle, and peri-implant fractures.

RECENT FINDINGS

Elderly individuals benefit immensely from immediate mobilization after fracture and thus require stable fracture fixation that allows immediate post-operative weight-bearing. However, osteoporotic bone has decreased holding capacity for metallic implants and is thus associated with a considerable fracture fixation failure rate both short term and long term. Modern implant technologies with dedicated modifications provide sufficient mechanical stability to allow immediate weight-bearing for elderly individuals. Depending on fracture location and fracture severity, various options are available to reinforce or augment standard fracture fixation systems. Correct application of the basic principles of fracture fixation and the use of modern implant technologies enables mechanically stable fracture fixation that allows early weight-bearing and results in timely fracture healing even in patients with osteoporosis.

[Osteoporotic bone fractures: intramedullary augmentation and hybrid osteosynthesis]

The increasing number of people who are living longer and have a far more active lifestyle is inevitably associated with greater numbers of fractures. Stabilization of these fractures in older patients with plates and screws is complicated by fragile bone substance, especially in osteoporotic bone, since osteosynthesis with a conventional plate depends exclusively on the holding power of the screws. Therefore, treatment requires new stabilization technologies designed for these specific tasks. A small diameter polyethylene terephthalate (PET, Dacron®) balloon is delivered in a minimally invasive fashion and placed within the canal, transversing the fracture. Once positioned, the balloon is expanded with a liquid monomer to fill the medullary canal. The liquid monomer is then rapidly cured using visible blue light, forming a patient-customized intramedullary implant that stabilizes the entire length of the bone in contact with the implant. The described intramedullary implant can be easily drilled in any position or location, providing a substantial increase in screw holding power. Thus, a major advantage of the technique is the possibility to augment the newly formed balloon "nail" with a conventional plate and screws at the primary stabilization or at any later time.