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Hallberg S, Söreskog E, Borgström F, Cederholm T, Hedström M. Association between institutionalization by 4 months post-discharge walking capacity and lean body mass in elderly hip fracture patients: Evidence from a Swedish Registry Based Study. SAGE Open Med 2024; 12:20503121241258409. [PMID: 38881593 PMCID: PMC11179511 DOI: 10.1177/20503121241258409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 05/13/2024] [Indexed: 06/18/2024] Open
Abstract
Background and purpose Losing independence is a main concern for hip fracture patients, and particularly not being able to return home. Given the large impact on quality of life by loss of independence and the high risk for institutionalization after hip fracture, it is of importance to identify modifiable risk factors for such negative outcomes. This study aimed to investigate the association between two such factors, that is, lean body mass and 4 months post-discharge walking capacity, and the risk of institutionalization in previously independent living older people who suffer a hip fracture. Patients and methods A retrospective cohort study was conducted using Swedish national-based population registers. Patients ⩾60 years with a hip fracture during 2008-2017 were included from the Swedish National Registry for Hip Fractures. Risk of institutionalization over the 1-year period following a hip fracture was analyzed using logistic regression analyses adjusted for potential predictors and characteristics. Results In total, 11,265 patients were included. Over the first year, 8% (95% CI: 8-9) of the patients with a hip fracture had lost independence, increasing to 15% (95% CI: 14-16) after 5 years. Poor recovery of post-discharge walking ability was associated with a higher odds ratio of losing independence compared with good recovery (OR 12.0; 95% CI: 7.8-18.4; p < 0.001). Having higher estimated lean body mass than 45 kg at index was associated with lower odds of losing independence. Conclusion Maintaining lean body mass and mobility after a hip fracture is likely important from an individual as well as public health perspective.
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Affiliation(s)
| | - Emma Söreskog
- Quantify Research, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institute, Stockholm, Sweden
| | | | - Tommy Cederholm
- Theme Ageing, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Center for Alzheimer Research, Karolinska Institutet, Stockholm, Sweden
| | - Margareta Hedström
- Trauma and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Hakami IA. An Outline on the Advancements in Surgical Management of Osteoporosis-Associated Fractures. Cureus 2024; 16:e63226. [PMID: 39070522 PMCID: PMC11280975 DOI: 10.7759/cureus.63226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 07/30/2024] Open
Abstract
Osteoporosis significantly impairs bone density and increases fracture risk, representing a substantial global health challenge. The effectiveness of traditional treatments such as calcium supplementation and exercise in completely preventing fractures is limited. This review explores recent advancements in surgical techniques and treatment modalities to manage osteoporotic fractures better and improve patient outcomes. Osteoporotic fractures demand specialized surgical techniques due to compromised bone quality. Vertebroplasty and kyphoplasty are minimally invasive procedures that provide rapid pain relief and structural support using bone cement. While vertebroplasty is effective, it carries risks of cement leakage and new fractures. Kyphoplasty, with added balloon inflation, reduces leakage risk and improves vertebral height restoration but is costlier. Cement-augmented screws enhance fixation but can increase adjacent fracture risk and pose long-term complications. Surgical advancements encompass robotic-assisted surgery, offering precision and accelerated recovery, alongside biologic agents like bone morphogenetic proteins (BMPs), which enhance bone healing while reducing secondary interventions and eliminating donor site morbidity. Bone graft substitutes such as calcium phosphate cements enhance biomechanical compatibility, decrease morbidity, and reduce fracture loss and pain. Balloon kyphoplasty aids in height restoration and pain relief and diminishes the risk of subsequent vertebral fractures. Bioglass scaffolds promote bone regeneration by improving bone mineral density and lowering the incidence of new fractures. Optimal perioperative care, including patient selection, nutritional management, and early mobilization strategies, is crucial for mitigating risks in vulnerable populations. While current surgical interventions provide significant pain relief and functional benefits, ongoing research and multidisciplinary collaboration are crucial to prospectively refine these techniques and reduce the burden of osteoporosis. New technologies, such as tissue engineering and gene editing, hold potential for future treatment paradigms.
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Affiliation(s)
- Ibrahim A Hakami
- Department of Orthopedic Surgery, College of Medicine, Shaqra University, Dawadmi, SAU
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3
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Patterson JT, Parry JA, Working ZM, McKibben NA, Baca J, Duong A, Senior J, Kim A, Marchand LS, O'Hara N. Patient Preferences for Operative Versus Nonoperative Treatment of LC1 Pelvis Fracture: A Discrete Choice Experiment. J Orthop Trauma 2024; 38:291-298. [PMID: 38442188 DOI: 10.1097/bot.0000000000002794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVES To quantify how patients with lateral compression type 1 (LC1) pelvis fracture value attributes of operative versus nonoperative treatment. METHODS DESIGN Discrete choice experiment. SETTING Three US Level 1 trauma centers. PATIENT SELECTION CRITERIA Adult survivors of an LC1 pelvis treated between June 2016 and March 2023 were identified from institutional registries. The choice experiment was administered as a survey from March through August 2023. OUTCOME MEASURES AND COMPARISONS Participants chose between 12 hypothetical comparisons of treatment attributes including operative or nonoperative care, risk of death, severity of pain, risk of secondary surgery, shorter hospital stay, discharge destination, and independence in ambulation within 1 month of injury. The marginal utility of each treatment attribute, for example, the strength of participants' aggregate preference for an attribute as indicated by their survey choices, was estimated by multinomial logit modeling with and without stratification by treatment received. RESULTS Four hundred forty-nine eligible patients were identified. The survey was distributed to 182 patients and collected from 72 patients (39%) at a median 2.3 years after injury. Respondents were 66% female with a median age of 59 years (IQR, 34-69 years). Before injury, 94% ambulated independently and 75% were working; 41% received operative treatment. Independence with ambulation provided the highest relative marginal utility (21%, P < 0.001), followed by discharge to home versus skilled nursing (20%, P < 0.001), moderate versus severe postdischarge pain (17%, P < 0.001), shorter hospital stay (16%, P < 0.001), secondary surgery (15%, P < 0.001), and mortality (10%, P = 0.02). Overall, no relative utility for operative versus nonoperative treatment was observed (2%, P = 0.54). However, respondents strongly preferred the treatment they received: operative patients valued operative treatment (utility, 0.37 vs. -0.37, P < 0.001); nonoperative patients valued nonoperative treatment (utility, 0.19 vs. -0.19, P < 0.001). CONCLUSIONS LC1 pelvis fracture patients valued independence with ambulation, shorter hospital stay, and avoiding secondary surgery and mortality in the month after their injury. Patients preferred the treatment they received rather than operative versus nonoperative care.
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Affiliation(s)
- Joseph T Patterson
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Joshua A Parry
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
| | | | | | - Joseph Baca
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Andrew Duong
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Joshua Senior
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Annabel Kim
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | | | - Nathan O'Hara
- University of Maryland Medical Center, Baltimore, MD
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4
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Katz D, Geftler A, Abu-Ajaj A, Makulin E, Star E, Zikrin E, Shacham D, Velikiy N, Freud T, Press Y. Intensive rehabilitation after pelvic and hip fractures: a comparative retrospective study. Front Med (Lausanne) 2024; 11:1346354. [PMID: 38818387 PMCID: PMC11137187 DOI: 10.3389/fmed.2024.1346354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/25/2024] [Indexed: 06/01/2024] Open
Abstract
Purpose Pelvic fracture (PF) is common, especially among older patients, and its prevalence increases over time. In contrast to hip fracture (HF), the literature on rehabilitation after PF is scant, mandating a study of the outcomes of rehabilitation in patients with PF. The present study compared patients who underwent intensive rehabilitation following HF or PF. Methods A retrospective study of patients 65 years of age and older who underwent intensive rehabilitation in the Geriatrics Department. Data were collected on patients with PF, while data on patients with HF were taken from an earlier study. All patients in both groups suffered from low-energy trauma. Rehabilitation outcomes were measured using the Montebello Rehabilitation Factor Score-revised (MRSF-R). Results 144 PF patients were compared with 138 HF patients. The mean age of the patients in the HF group was 82.5 ± 7.1 compared to 81.5 ± 6.9 in the PF group (p = 0.230). Females comprised 77.5% of the patients in the HF group and 90.3% in the PF group (p = 0.04). All patients in the HF group underwent surgical repair of their fracture, while all patients in the PF group had non-surgical treatment. More patients in the HF sample had a nursing caregiver prior to the fracture (92.0% vs. 60.4%, p < 0.001), had a higher Charlson Co-morbidity Index total score (2.1 ± 1.9 vs. 1.6 ± 1.7, p = 0.13), developed more delirium (21.7% vs. 8.3%, p = 0.16), more infections (29.0% vs. 11.1%, p < 0.002), and more cardiovascular complications (23.9% vs. 5.6%, p < 0.001) during hospitalization. They had longer hospital stays (20.9 ± 7.5 vs. 18.2 ± 7.7 days, p = 0.0007), and had a higher mortality rate (13.8% vs. 6.3%, p = 0.037) over the first year following the fracture than the PF group. A similar rate of patients in both groups (64.5% vs. 60.4%, p = 0.483) had successful intensive rehabilitation. In the PF group only cognitive state was an independent predictor of successful rehabilitation, with each additional point in the Mini Mental State Examination (MMSE) increasing the patient's chance of reaching an MRFS-R score ≥ 50 by 20.5%. Conclusion Despite slightly different characteristics in the two groups, the results of intensive rehabilitation were similar. Cognitive state was the only independent factor that affected achievement of a better rehabilitation outcome. With the increasing rate of PF, more studies should focus on rehabilitation in this patient population.
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Affiliation(s)
- Dori Katz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Be'er Sheva, Israel
| | - Alex Geftler
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Orthopedics, Soroka Medical Center, Be'er Sheva, Israel
| | - Ahmed Abu-Ajaj
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Be'er Sheva, Israel
| | - Evgeni Makulin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Be'er Sheva, Israel
| | - Eva Star
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Evgeniya Zikrin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Be'er Sheva, Israel
| | - David Shacham
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Be'er Sheva, Israel
| | - Natalia Velikiy
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Be'er Sheva, Israel
| | - Tamar Freud
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Yan Press
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Be'er Sheva, Israel
- Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Unit for Community Geriatrics, Division of Health in the Community, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Center for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Be'er Sheva, Israel
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Cook E, Laycock J, Sivapathasuntharam D, Maturana C, Hilton C, Doherty L, Hewitt C, McDaid C, Torgerson D, Bates P. Surgical versus non-surgical management of lateral compression type-1 pelvic fracture in adults 60 years and older: the L1FE RCT. Health Technol Assess 2024; 28:1-67. [PMID: 38512076 PMCID: PMC11017634 DOI: 10.3310/lapw3412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
Background Lateral compression type-1 pelvic fractures are a common fragility fracture in older adults. Patients who do not mobilise due to ongoing pain are at greater risk of immobility-related complications. Standard treatment in the United Kingdom is provision of pain relief and early mobilisation, unlike fragility hip fractures, which are usually treated surgically based on evidence that early surgery is associated with better outcomes. Currently there is no evidence on whether patients with lateral compression type-1 fragility fractures would have a better recovery with surgery than non-surgical management. Objectives To assess the clinical and cost effectiveness of surgical fixation with internal fixation device compared to non-surgical management of lateral compression type-1 fragility fractures in older adults. Design Pragmatic, randomised controlled superiority trial, with 12-month internal pilot; target sample size was 600 participants. Participants were randomised between surgical and non-surgical management (1 : 1 allocation ratio). An economic evaluation was planned. Setting UK Major Trauma Centres. Participants Patients aged 60 years or older with a lateral compression type-1 pelvic fracture, arising from a low-energy fall and unable to mobilise independently to a distance of 3 m and back due to pelvic pain 72 hours after injury. Interventions Internal fixation device surgical fixation and non-surgical management. Participants, surgeons and outcome assessors were not blinded to treatment allocation. Main outcome measures Primary outcome - average patient health-related quality of life, over 6 months, assessed by the EuroQol-5 Dimensions, five-level version utility score. Secondary outcomes (over the 6 months following injury) - self-rated health, physical function, mental health, pain, delirium, displacement of pelvis, mortality, complications and adverse events, and resource use data for the economic evaluation. Results The trial closed early, at the end of the internal pilot, due to low recruitment. The internal pilot was undertaken in two separate phases because of a pause in recruitment due to the coronavirus disease 2019 pandemic. The planned statistical and health economic analyses were not conducted. Outcome data were summarised descriptively. Eleven sites opened for recruitment for a combined total of 92 months. Three-hundred and sixteen patients were assessed for eligibility, of whom 43 were eligible (13.6%). The main reason for ineligibility was that the patient was able to mobilise independently to 3 m and back (n = 161). Of the 43 eligible participants, 36 (83.7%) were approached for consent, of whom 11 (30.6%) provided consent. The most common reason for eligible patients not consenting to take part was that they were unwilling to be randomised to a treatment (n = 10). There were 11 participants, 5 randomised to surgical management with internal fixation device and 6 to non-surgical management. The average age of participants was 83.0 years (interquartile range 76.0, 89.0) and the EuroQol-5 Dimensions, five-level version utility score at 6 months post randomisation (n = 8) was 0.32 (standard deviation 0.37). A limitation of the trial was that study objectives were not addressed due to poor recruitment. Conclusions It was not feasible to recruit to this trial in the current context. Further research to understand the treatment and recovery pathways of this group of patients, along with their outcomes, would be needed prior to undertaking a future trial. Future work Exploration of equipoise across different healthcare professional groups. Investigate longer-term patient outcomes. Trial registration This trial is registered as ISRCTN16478561. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/167/57) and is published in full in Health Technology Assessment; Vol. 28, No. 15. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Elizabeth Cook
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Joanne Laycock
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Camila Maturana
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Laura Doherty
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Peter Bates
- Bart's Health NHS Trust, The Royal London Hospital, London, UK
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6
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Ramchand SK, Leder BZ. Sequential Therapy for the Long-Term Treatment of Postmenopausal Osteoporosis. J Clin Endocrinol Metab 2024; 109:303-311. [PMID: 37610985 DOI: 10.1210/clinem/dgad496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 08/25/2023]
Abstract
Osteoporosis is a chronic condition characterized by decreased bone mass, loss of skeletal integrity, and increased susceptibility to fracture. Drugs used to treat osteoporosis can be classified as those that block bone resorption (antiresorptive), stimulate bone formation (anabolic), or do both. While all currently approved medications reduce the risk of fragility fractures in high-risk populations, they are generally unable to fully restore bone strength in most patients with established disease. Thus, the majority of patients require disease management over many years. Unfortunately, the continuous use of a single drug has limitations, both in terms of efficacy and safety, and so sequential therapy is commonly required. Given the expanding list of pharmacological agents currently available, careful consideration needs to be given as to which drugs to use and in what sequence. This review will evaluate the differential effects of antiresorptive, bone-forming, and dual-acting drugs when used in specific sequences and will explore the current evidence favoring the initial use of bone-forming/dual-acting drugs followed by antiresorptive medications. This review will also examine the notion that long-term treatment with an antiresorptive drug may diminish the efficacy of subsequent treatment with a bone-forming/dual-acting drug. Finally, this review will explore the current evidence pertaining to the specific issue of how to best prevent the clinical ramifications of denosumab cessation.
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Affiliation(s)
- Sabashini K Ramchand
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA 02114, USA
| | - Benjamin Z Leder
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA 02114, USA
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7
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Pickering ME, Javier RM, Malochet S, Pickering G, Desmeules J. Osteoporosis treatment and pain relief: A scoping review. Eur J Pain 2024; 28:3-20. [PMID: 37403555 DOI: 10.1002/ejp.2156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 05/11/2023] [Accepted: 06/17/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Anti-osteoporosis (OP) drugs have been suggested to contribute to pain reduction during OP management. This scoping review aimed at mapping the literature on pain relief with anti-OP drugs in OP treatment. DATABASES AND DATA TREATMENT Medline, Pubmed and Cochrane databases were searched by two reviewers with keywords combinations. Randomized controlled and real-life English studies, pain as an endpoint, antiosteoporosis drugs were inclusion criteria. Case reports, surveys, comment letters, conference abstracts, animal studies and grey literature were excluded. Predetermined data were extracted by two reviewers and disagreement solved through discussion. RESULTS A total of 130 articles were identified, 31 publications were included, 12 randomized clinical trials and 19 observational studies. Pain reduction was assessed by different tools: Visual Analogue Scale, Verbal Rating Scale, Facial Scale or as a domain of quality of life questionnaires including Short form 8, 36, mini-OP, Japanese OP, Qualeffo, Roland Morris Disability questionnaires. Collective data show that anti-OP drugs may display an analgesic effect that may be linked to the local mode of action of drugs on bone and consecutive modulation of pain sensitization. The methodology of the studies showed a heterogeneity of endpoints, comparators, statistical approaches and follow-up duration. CONCLUSION Considering the limitations of the literature, there is a need for more rigorous trials and larger real-life studies taking into account the recommendations published for research in rheumatology and in pain medicine. The identification of responders, patient subtypes, and of analgesic-effect doses would allow optimization and individualization for pain relief in patients with OP. SIGNIFICANCE STATEMENT This scoping review shows that anti-OP drugs may improve pain and quality of life of patients with OP. The heterogeneity in design, choice of endpoints, methodology, comparators and follow-up duration of included randomized clinical trials and real-life studies does not allow so far to identify a predominant antiosteoporosis drug or an optimal dosage for pain relief. These gaps need to be addressed and warrant further research in the future for optimizing pain improvement in the course of OP drug treatment.
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Affiliation(s)
| | - Rose-Marie Javier
- Centre d'Evaluation et de Traitement de la Douleur et Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Sandrine Malochet
- Rheumatology Department, CHU Gabriel Montpied, Clermont-Ferrand, France
| | - Gisele Pickering
- Clinical Investigation Center, PIC/CIC, University Hospital, CHU, Clermont-Ferrand, France
| | - Jules Desmeules
- Service de Pharmacologie et Toxicologie Cliniques, Centre multidisciplinaire de la douleur, Hôpitaux Universitaires de Genève, Geneva, Switzerland
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Mennen AHM, Oud S, Halm JA, Peters RW, Willems HC, Van Embden D. Pelvic Ring Fractures in Older Adult Patients-Assessing Physician Practice Variation among (Orthopedic) Trauma Surgeons. J Clin Med 2023; 12:6344. [PMID: 37834988 PMCID: PMC10573883 DOI: 10.3390/jcm12196344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
PURPOSE Pelvic fractures in older adults are a major public health problem and socioeconomic burden. The standard of care has changed over the past years, and there is limited consensus on which patients benefit from surgical fixation. There is currently no nationwide treatment protocol to guide the decision-making process. Therefore, the aim of this survey was to provide more insight into if, when, and why patients with a fragility fracture of the pelvis (FFPs) would be considered for additional imaging and surgical fixation by treating physicians. METHODS An online clinical vignette-based survey of hypothetical scenarios was sent out to all orthopedic and trauma surgeons in the Netherlands. The questionnaire comprised multiple-choice questions and radiographic images. Differences between subgroups were calculated using the X2 test or the Fisher exact test. RESULTS 169 surgeons responded to the survey, with varying levels of experience and working in different types of hospitals. In a patient with a simple pubic ramus fracture and ASA 2 or ASA 4, 32% and 18% of the respondents would always advise a CT scan for further analysis. In the same patients, 11% and 31% of the respondents would not advise a CT scan, respectively. When presented with three cases of increasing severity of co-morbidity (ASA) and/or increasing age and/or different clinical presentation of an FFP type 3c on a CT scan, an increasing number of respondents would not consider surgical fixation. There was significant variation in practice patterns between the respondents who do not work in a hospital performing pelvic and acetabular (P&A) fracture surgery and those who do work in a P&A referral hospital. Most respondents (77%) refer patients 1-5 times a year to an expert center for surgical fixation. CONCLUSION There is currently a wide variety of clinical practices regarding the imaging and management of FFPs, which seems to be influenced by the type of hospital the patients are presented to. A regional or national evidence-based treatment protocol should be implemented to ensure a more uniform approach.
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Affiliation(s)
- Anna H. M. Mennen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Sharon Oud
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jens A. Halm
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rolf W. Peters
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Hanna C. Willems
- Department of Internal Medicine and Geriatrics, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Daphne Van Embden
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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9
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Hsieh SL, Lin TL, Lo YS, Chen CY, Chang HW, Chen HT, Fong YC, Tsai CH. Trends and treatments of pelvic and acetabular fractures in Taiwan: facing an aging society. Arch Osteoporos 2023; 18:66. [PMID: 37162585 PMCID: PMC10172239 DOI: 10.1007/s11657-023-01255-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/21/2023] [Indexed: 05/11/2023]
Abstract
Pelvic-acetabular fractures lead to high mortality in elders and their association between different groups is not known. Our results indicate that older age with pelvic-acetabular fracture was significantly associated with mortality. This finding may help planning and allocating healthcare resources, risk stratification, and optimizing the treatment of pelvic fractures. PURPOSE Pelvic or acetabular fractures are among main outcomes of low-energy trauma such as falls, especially in older adults. They represent approximately 3-8% of all fractures and are associated with a high mortality rate ranging from 4 to 28%. This study is aimed at comparing the incidence and trends of hip fractures and pelvic-acetabular fractures in the Taiwanese general population, gender differences in adults aged over 65 years, and mortality risk between pelvic or acetabular fractures and hip fractures and surgery trends in patients with these fractures. METHODS A retrospective study was conducted extracting data from the National Health Insurance Research Database of patients diagnosed with hip fracture and pelvic acetabular fracture between 2000 and 2018. RESULTS Older age with pelvic-acetabular fracture was significantly associated with increased mortality. No significant differences were found in comorbidities between the two fracture groups. Results provide clear epidemiological evidence for trends in pelvic-acetabular fractures in Taiwan and demonstrate the need for better strategies to manage these fractures and comorbidities, particularly in older adults. CONCLUSION Findings of this study may aid in planning and allocating healthcare resources, risk stratification, and optimizing the treatment of pelvic fractures among older adults in Taiwan.
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Affiliation(s)
- Shang-Lin Hsieh
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Tsung-Li Lin
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
- Department of Sports Medicine, China Medical University, Taichung City, Taiwan
| | - Yuan-Shun Lo
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan
- Department of Orthopedic Surgery, China Medical University Bei Gang Hospital, Beigang, Yunlin County, Taiwan
| | - Chun-Yen Chen
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan
- Department of Orthopedic Surgery, Wei Gong Memorial Hospital, Toufen, Miaoli County, Taiwan
| | - Hao Wei Chang
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan
- Department of Orthopedic Surgery, Wei Gong Memorial Hospital, Toufen, Miaoli County, Taiwan
| | - Hsien-Te Chen
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan
- Department of Sports Medicine, China Medical University, Taichung City, Taiwan
- Department of Biomedical Engineering, College of Biomedical Engineering, Taichung, Taiwan
| | - Yi-Chin Fong
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan
- Department of Sports Medicine, China Medical University, Taichung City, Taiwan
- Department of Biomedical Engineering, College of Biomedical Engineering, Taichung, Taiwan
| | - Chun-Hao Tsai
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan.
- Department of Sports Medicine, China Medical University, Taichung City, Taiwan.
- Department of Biomedical Engineering, College of Biomedical Engineering, Taichung, Taiwan.
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10
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Cook E, Laycock J, Acharya M, Backhouse MR, Corbacho B, Doherty L, Forward D, Hewitt C, Hilton C, Hull P, Kassam J, Maturana C, Mcdaid C, Roche J, Sivapathasuntharam D, Torgerson D, Bates P. Lateral compression type 1 fracture fixation in the elderly (L1FE): study protocol for a randomised controlled trial (with internal pilot) comparing the effects of INFIX surgery and non-surgical management for treating patients with lateral compression type 1 (LC-1) fragility fractures. Trials 2023; 24:78. [PMID: 36732808 PMCID: PMC9893645 DOI: 10.1186/s13063-022-07063-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/30/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Lateral compression type1 (LC-1) fragility fractures are a common, painful injury in older adults resulting in reduced mobility. The incidence of these fractures is increasing with the growing older adult population. The current standard of care is non-surgical management; however, patients with this injury are at risk of long-term immobility and related complications. INFIX is a pelvic fixation device used in younger patients with high-energy fractures. The device is fitted via a percutaneous technique with no external pin sites and has good purchase even in osteoporotic bone. It therefore has the potential to be well tolerated in patients with LC-1 fragility fractures. INFIX could improve patients' ability to mobilise and reduce the risk of immobility-related complications. However, there is a risk of complications related to surgery, and robust evidence is required on patient outcomes. This study will investigate the clinical and cost-effectiveness of surgical fixation with INFIX compared to non-surgical management of LC-1 fragility fractures in older adults. METHODS A multi-centre randomised controlled trial of 600 patients allocated 1:1 to non-surgical management or INFIX surgery. The study will have a 12-month internal pilot to assess recruitment and trial feasibility. The primary outcome will be the patient quality of life over 6 months, measured by the patient-reported EQ-5D-5L. The secondary outcomes will include physical function, mental health, pain, delirium, imaging assessment, resource use, and complications. DISCUSSION The L1FE study aims to compare the clinical and cost-effectiveness of surgical and non-surgical management of people aged 60 years and older with LC-1 fragility fractures. The trial is sufficiently powered and rigorously designed to inform future clinical and patient decision-making and allocation of NHS resources. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number Registry ISRCTN16478561. Registered on 8 April 2019.
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Affiliation(s)
- Elizabeth Cook
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Joanne Laycock
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Mehool Acharya
- grid.416201.00000 0004 0417 1173Pelvic and Acetabular Reconstruction Unit, Southmead Hospital, Bristol, BS10 5NB UK
| | - Michael Ross Backhouse
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK ,grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Belen Corbacho
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Laura Doherty
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Daren Forward
- grid.240404.60000 0001 0440 1889Nottingham University Hospitals, Derby Road, Nottingham, NG7 2UH UK
| | - Catherine Hewitt
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Catherine Hilton
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
| | - Peter Hull
- grid.24029.3d0000 0004 0383 8386Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ UK
| | - Jamila Kassam
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
| | - Camila Maturana
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Catriona Mcdaid
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Jenny Roche
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Dhanupriya Sivapathasuntharam
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
| | - David Torgerson
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Peter Bates
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
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11
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Internal fixation of radiation-induced fragility fractures of the pelvis: a case series. Arch Orthop Trauma Surg 2023; 143:865-871. [PMID: 35107637 DOI: 10.1007/s00402-022-04358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 01/14/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND The optimal treatment for radiation-induced fragility fractures of the pelvis (RI-FFP) is not well evaluated due to the rarity of the condition. PURPOSE The aim of this retrospective study was to assess the prevalence of RI-FFP, the radiological and clinical outcomes as well as the complications of patients treated with internal fixation. METHODS A retrospective review of our database was performed to identify all surgically treated patients with RI-FFP. Surgical stabilization was recommended for patients with FFP type III and FFP type IV. Surgical stabilization was also recommended after 5-7 days for patients with FFP type II in case of unsuccessful conservative treatment. Demographic data, fracture patterns according to the FFP classification of Rommens and Hofmann, type of treatment and surgery-related complications including nonunion, hardware failure, fracture progression (secondary fracture) or infection were documented. RESULTS Among 500 patients with FFP, the prevalence of patients with RI-FFP was 1% (5/500): 5 patients with a median age of 79 years (76-79). The median time interval from radiation to fracture was 18 months (18-24). All of them underwent internal fixation. Two patients experienced surgery-related complications, one due to hardware failure and one due to fracture progression. At median follow-up of 27 months, all fractures had healed. Patients reached a good level of mobility with a median Parker Mobility Score of 7 and suffered moderate pain with a median value of 2.5 on the numeric rating scale. CONCLUSION RI-FFP remains a rare injury (1%). In our experience, patients, who underwent surgical treatment, obtained a high level of mobility and a moderate pain score after 2 years of follow-up. Internal fixation can be recommended in RI-FFP. Because bone healing may be impaired due to previous irradiation, highly stable constructs are required to avoid fracture progression or revision surgery. LEVEL OF EVIDENCE III, retrospective study.
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12
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Albers CE, Zderic I, Kastner P, Gueorguiev B, Tosounidis TH, Keel MJB, Bastian JD. The ideal site of cement application in cement augmented sacroiliac screw fixation: the biomechanical perspective. Eur J Trauma Emerg Surg 2022; 49:1449-1458. [DOI: 10.1007/s00068-022-02187-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
Abstract
Purpose
To compare construct stability of cement augmented sacroiliac screws using two different cementation sites in a biomechanical fragility fracture model of the pelvis.
Methods
A fracture model with an incomplete fracture of the sacral ala and complete fracture of the anterior pelvic ring mimicking a FFP IIB fragility fracture of the pelvis was established in five fresh frozen human cadaveric pelvises. Sacral fracture stabilization was achieved with bilateral 7.3 mm fully threaded sacroiliac screws. Cement augmentation was performed at the tip of the screw (body of S1; Group A) on one side, and at the midshaft of the screw (sacral ala; Group B) on the contralateral side. Biomechanical testing was conducted separately on both sides comprising cyclic loading of axial forces transferred through the tested hemipelvis from L5 to the ipsilateral acetabulum. Combined angular displacement in flexion and internal rotation (“gap angle”), angular displacement of the ilium in relation to the screw (“screw tilt ilium”), and screw tip cutout were evaluated.
Results
Relative interfragmentary movements were associated with significantly higher values in group A versus group B for “gap angle” (2.4° vs. 1.4°; p < 0.001), and for “screw tilt ilium” (3.3° vs. 1.4°; p < 0.001), respectively. No significant difference was indicated for screw tip cutout between the two groups (0.6 mm [Group A] vs. 0.8 mm [Group B]; p = 0.376).
Conclusion
The present study demonstrated less fragment and screw displacements in a FFP IIB fracture model under physiologic cyclic loading by cement augmentation of sacroiliac screws at the level of the lateral mass compared to the center of vertebral body of S1.
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13
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Perioperative outcome of minimally invasive stabilisation of bilateral fragility fractures of the sacrum: a comparative study of bisegmental transsacral stabilisation versus spinopelvic fixation. Eur J Trauma Emerg Surg 2022; 49:1001-1010. [PMID: 36255462 PMCID: PMC10175409 DOI: 10.1007/s00068-022-02123-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/27/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Pelvic fragility fractures have steadily risen over the past decades. The primary treatment goal is the fastest possible mobilisation. If conservative therapy fails, surgical fixation is a promising approach. This study compares the outcome of bisegmental transsacral stabilisation (BTS) and spinopelvic fixation (SP) as minimally invasive techniques for bilateral fragility fractures of the sacrum (BFFS). METHODS We performed a prospective, non-randomised, case-controlled study. Patients were included if they remained bedridden due to pain despite conservative treatment. Group assignment depended on sacral anatomy and fracture type. The outcome was estimated by blood loss calculation, cut-seam time, fluoroscopy time, complications, duration of stay at the intensive/intermediate care unit (ICU/IMC), and total inpatient stay. The mobility level at discharge was recorded. RESULTS Seventy-three patients were included (SP: 49, BTS: 24). There was no difference in blood loss (BTS: 461 ± 628 mL, SP: 509 ± 354 mL). BTS showed a significantly lower cut-seam time (72 ± 23 min) than SP (94 ± 27 min). Fluoroscopy time did not differ (BTS: 111 ± 61 s vs. 103 ± 45 s). Thirteen percent of BTS and 16% of SP patients required ICU/IMC stay (BTS: 0.6 ± 1.8 days, SP: 0.5 ± 1.5 days) during inpatient stay (BTS: 9 ± 4 days, SP: 8 ± 3 days). Fourteen patients suffered from urinary tract infections (BTS: 8%; SP: 25%). In-patient mortality was low (BTS: 4.2%, SP: 4.1%). At discharge, the BTS group was almost back to the initial mobility level. In SP patients, mobility was significantly lower than before complaints (p = 0.004). CONCLUSION Both methods allow early mobilization of BFFS patients. Blood loss can be kept low. Hence, transfusion requirement is correspondingly low. The IMC/ICU and the total inpatient stay are lower than reported in the literature. Both BTS and SP can be recommended as safe and low-complication methods for use in BFFS patients. BTS is superior to SP with respect to surgery duration and level of mobility at discharge.
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14
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Ramser M, Vach W, Strub N, Cadosch D, Saxer F, Eckardt H. The impact of specific fracture characteristics of low-energy fractures of the pelvis on mortality. BMC Geriatr 2022; 22:669. [PMID: 35971065 PMCID: PMC9377136 DOI: 10.1186/s12877-022-03223-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 06/13/2022] [Indexed: 11/17/2022] Open
Abstract
Background Pelvic fractures in older patients are associated with relevant morbidity and mortality. Both might be determined by fracture morphology and/or patient characteristics. The aim of this project is to investigate the prognostic value of specific fracture characteristics with respect to overall survival and to compare it with an established classification system. Methods Retrospective analysis of patients ≥ 60 years, treated conservatively for a CT-scan verified, low-energy pelvic ring fracture between August 2006 and December 2018. Survival data was available from patients’ charts and cantonal or national registries. The prognostic value of fracture characteristic describing the anterior and posterior involvement of the pelvic ring was investigated. This analysis was repeated after patients were stratified into a high-risk vs a low-risk group according to patient characteristic (age, gender, comorbidities, mobility, living situation). This allowed to assess the impact of the different fracture morphologies on mortality in fit vs. frail senior patients separately. Results Overall, 428 patients (83.4% female) with a mean age of 83.7 years were included. Two thirds of patients were still living in their home and mobile without walking aid at baseline. In-hospital mortality was 0.7%, overall, one-year mortality 16.9%. An independent and significant association of age, gender and comorbidities to overall survival was found. Further, the occurrence of a horizontal sacral fracture as well as a ventral comminution or dislocation was associated with an increased mortality. The effect of a horizontal sacral fracture was more accentuated in low-risk patients while the ventral fracture components showed a larger effect on survival in high-risk patients. Conclusion Specific fracture characteristics may indicate a higher risk of mortality in conservatively treated patients with a low-energy pelvic ring fracture. Hence, they should be taken into account in future treatment algorithms and decisions on patient management.
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Affiliation(s)
- Michaela Ramser
- Department of Orthopaedic and Traumatology Surgery, University Hospital Basel, 4031, Basel, Switzerland.
| | - Werner Vach
- University of Basel, Basel, Switzerland.,Basel Academy for Quality and Research in Medicine, Basel, Switzerland
| | | | - Dieter Cadosch
- Department of Orthopaedic and Traumatology Surgery, University Hospital Basel, 4031, Basel, Switzerland
| | - Franziska Saxer
- University of Basel, Basel, Switzerland.,Novartis Institutes for Biomedical Research, Novartis Campus, Basel, Switzerland
| | - Henrik Eckardt
- Department of Orthopaedic and Traumatology Surgery, University Hospital Basel, 4031, Basel, Switzerland
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15
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Mohseni M, Eisen S, Stum S, Civitelli R. The Association of Pelvic Bone Mineral Density and With Proximal Femoral and Spine Bone Mineral Density in Post-menopausal Women. J Clin Densitom 2022; 25:328-333. [PMID: 35177349 DOI: 10.1016/j.jocd.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/01/2021] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
Abstract
Pelvic fragility fractures result in significant morbidity and their incidence has increased over the past 30 years. One of the main risk factors in skeletal fragility is bone mineral density (BMD). Most of the current literature has focused on understanding spine and hip BMD. We aimed to measure the BMD of pelvis in a cohort of post-menopausal women and compare it to BMD at other skeletal sites. A questionnaire regarding risk factors for osteoporosis was completed by each participant. DXA scan of the pelvis was performed using research software. Three areas of the pelvis corresponding to common fractures were defined on pelvic DXA: R1 = symphysis public, R2 = inferior public rami, R3 = superior public rami. Pelvic BMD was calculated as the average BMD of R1-3. BMD at each location was reported as mean and standard deviation (SD). ANOVA was used to compare BMD between R1-R3 and pelvis, femoral neck, total hip, and spine. Pearson correlation was used to correlate pelvic BMD to BMD of proximal femur and spine. BMD was compared in four participant groups: 1- osteoporosis in spine and hip, 2- osteoporosis in spine only, 3-osteoporosis in hip only, and 4- no osteoporosis in spine and hip. The effect of diabetes and obesity on BMD at various skeletal sites was analyzed. Among the one hundred postmenopausal women enrolled in the study, age was: 64 ± 8, 31% were obese (BMI ≥ 30), and 8% had a diagnosis of type 2 diabetes. Pelvic area R3 had significantly higher BMD than R1 or R2 (p < 0.001). Pelvic BMD (0.50 ± 0.16) was significantly lower than total hip (0.70 ± 0.20) and spine BMD (0.97 ± 0.19) (p < 0.001). Pelvic BMD correlated with BMD at other skeletal locations, with the highest correlation with total hip (total hip: R2: 0.70, femoral neck R2: 0.50, spine R2: 0.65). Pelvic BMD was significantly lower in patients with osteoporosis of both hip and spine compared to the group without osteoporosis at both locations (p = 0.02). Obesity and type 2 diabetes were both associated with significantly higher BMD at pelvis, spine, and total hip. Pelvic BMD is lower than at other skeletal sites and is highly correlated with total hip area bone density. Obesity and type 2 diabetes are associated with higher pelvic BMD. To establish guidelines for the treatment pelvic BMD, studies defining the association of pelvic BMD with pelvic fracture risk are needed.
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Affiliation(s)
- Mahshid Mohseni
- Division of Bone and Mineral Disease, Department of Internal Medicine, Washington University School of Medicine, Saint Louis, MO, USA.
| | - Seth Eisen
- Division of Rheumatology, Department of Internal Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Shannon Stum
- Division of Bone and Mineral Disease, Department of Internal Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Roberto Civitelli
- Division of Bone and Mineral Disease, Department of Internal Medicine, Washington University School of Medicine, Saint Louis, MO, USA
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16
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Ramser M, Cadosch D, Vach W, Strub N, Saxer F, Eckardt H. Focusing on individual morphological fracture characteristics of pelvic ring fractures in elderly patients can support clinical decision making. BMC Geriatr 2022; 22:543. [PMID: 35768764 PMCID: PMC9245220 DOI: 10.1186/s12877-022-03222-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Pelvic ring fractures in the elderly are often caused by minor trauma. Treatment of these patients is currently based on fracture classification, clinical course, and ability to mobilize. Our aim was to identify morphological fracture characteristics with potential prognostic relevance and evaluate their association with clinical decision making and outcome, as well as their interobserver reliability. Methods Five fracture characteristics were investigated as potential variables: 1. Extent of the dorsal pelvic ring fracture (absent, unilateral, bilateral); 2. Extent of the ventral pelvic ring fracture (absent, unilateral, bilateral); 3. Presence of a horizontal sacral fracture; 4. Ventral dislocation; 5. Ventral comminution. These characteristics were assessed retrospectively in a series of 548 patients. The association of their presence with the decision to perform surgery, failure of conservative treatment and the length of hospital stay (LOS) was determined. Further, the inter-observer reliability for the specific characteristics was calculated and the relation with survival assessed. Results Four of the five evaluated characteristics showed an association with clinical decision making and patient management. In particular the extent of the dorsal fractures (absent vs. unilateral vs. bilateral) (OR = 7.0; p < 00.1) and the presence of ventral comminution/dislocation (OR = 2.4; p = 0.004) were independent factors for the decision to perform surgery. Both the extent of the dorsal fracture (OR = 1.8; p < 0.001) and the presence of ventral dislocation (OR = 1.7; p = 0.003) were independently associated with a prolonged overall LOS. The inter-observer agreement for the fracture characteristics ranged from moderate to substantial. A relevant association with increased mortality was shown for horizontal sacral and comminuted ventral fractures with hazard ratios (HR) of 1.7 (95% CI: 1.1, 2.5; p = 0.008) and HR = 1.5 (95% CI: 1.0, 2.2; p = 0.048). Conclusion In the elderly, the extent of the dorsal fractures and the presence of ventral comminution/dislocation were associated to the decision to undergo surgery, failure of conservative treatment and length of stay. Survival was related to horizontal sacral fractures and ventrally comminuted fractures. These characteristics thus represent a simplified but highly informative approach for the evaluation of pelvic ring fractures in the elderly. This approach can support clinical decision making, promote patient-centred treatment algorithms and thus improve the outcome of individualized care. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03222-0.
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Affiliation(s)
- Michaela Ramser
- University Hospital Basel, Department of Orthopaedic and Traumatology Surgery, 4031 Basel, Basel, Switzerland.
| | - Dieter Cadosch
- University Hospital Basel, Department of Orthopaedic and Traumatology Surgery, 4031 Basel, Basel, Switzerland
| | - Werner Vach
- University of Basel, Basel, Switzerland.,Basel Academy for Quality and Research in Medicine, Basel, Switzerland
| | | | - Franziska Saxer
- University Hospital Basel, Department of Orthopaedic and Traumatology Surgery, 4031 Basel, Basel, Switzerland.,Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Henrik Eckardt
- University Hospital Basel, Department of Orthopaedic and Traumatology Surgery, 4031 Basel, Basel, Switzerland
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17
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Behanova M, Haschka J, Reichardt B, Dimai HP, Resch H, Zwerina J, Kocijan R. Pelvic Fractures-An Underestimated Problem? Incidence and Mortality Risk after Pelvic Fracture in Austria, 2010-2018. J Clin Med 2022; 11:jcm11102834. [PMID: 35628960 PMCID: PMC9146576 DOI: 10.3390/jcm11102834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/16/2022] [Accepted: 05/16/2022] [Indexed: 02/05/2023] Open
Abstract
(1) Background: Pelvic fractures (PFs) are related to osteoporosis, and represent a serious individual and socioeconomic burden. (2) Methods: We examined age- and sex-standardised incidence rates (SIRs) of PF, along with rates of all-cause overall and one-year mortality among patients with PF. We compared the mortality rates between PF patients and a matched fracture-free cohort. Patients ≥50 years old in Austria hospitalised with PF in 2010−2018, along with their dates of death, were recorded. (3) Results: We identified 54,975 patients with PF, of whom 70.9% were women. Between 2010 and 2018 the SIR of PF increased in men by 10.0%—from 125.3 (95% Confidence Interval 118.9−132.0) to 137.8 (95% CI 131.8−144.0) per 100,000—and in women by 2.7%—from 218.7 (95% CI 212.0−225.6) to 224.7 (95% CI 218.3−231.3) per 100,000. The one-year post-PF mortality rate was higher in men than in women (13.0% and 11.1%, respectively; p < 0.001). Pelvic fracture patients aged ≥65 had an elevated mortality risk (Hazard Ratio 1.75, 95% CI 1.71−1.79, p < 0.001) compared to controls. (4) Conclusions: There is a clear increase in the incidence of PF in the elderly population, with a greater increase in men over time. Pelvic fracture itself contributes to increased mortality in individuals aged 65 and above.
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Affiliation(s)
- Martina Behanova
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA, Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, 1140 Vienna, Austria; (J.H.); (J.Z.); (R.K.)
- Correspondence:
| | - Judith Haschka
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA, Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, 1140 Vienna, Austria; (J.H.); (J.Z.); (R.K.)
| | - Berthold Reichardt
- Austrian Social Health Insurance Fund, Österreichische Gesundheitskasse, 7000 Eisenstadt, Austria;
| | - Hans-Peter Dimai
- Division of Endocrinology and Diabetology, Department of Medicine, Medical University of Graz, 8036 Graz, Austria;
| | - Heinrich Resch
- Metabolic Bone Diseases Unit, School of Medicine, Sigmund Freud University Vienna, 1020 Vienna, Austria;
- 2nd Department of Internal Medicine, St. Vincent Hospital Vienna, 1090 Vienna, Austria
| | - Jochen Zwerina
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA, Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, 1140 Vienna, Austria; (J.H.); (J.Z.); (R.K.)
| | - Roland Kocijan
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA, Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, 1140 Vienna, Austria; (J.H.); (J.Z.); (R.K.)
- Metabolic Bone Diseases Unit, School of Medicine, Sigmund Freud University Vienna, 1020 Vienna, Austria;
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18
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Zhang M, Chen D, Zeng N, Liu Z, Chen X, Xiao H, Xiao L, Liu Z, Dong Y, Zheng J. Hesperidin Ameliorates Dexamethasone-Induced Osteoporosis by Inhibiting p53. Front Cell Dev Biol 2022; 10:820922. [PMID: 35478958 PMCID: PMC9035638 DOI: 10.3389/fcell.2022.820922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/16/2022] [Indexed: 01/02/2023] Open
Abstract
Osteoporosis is one of the most frequent skeletal disorders and a major cause of morbidity and mortality in the expanding aging population. Evidence suggests that hesperidin may have a therapeutic impact on osteoporosis. Nevertheless, little is known about the role of hesperidin in the development of osteoporosis. Bioinformatics analyses were carried out to explore the functions and possible molecular mechanisms by which hesperidin regulates osteogenic differentiation. In the present study, we screened and harvested 12 KEGG pathways that were shared by hesperidin-targeted genes and osteoporosis. The p53 signaling pathway was considered to be a key mechanism. Our in vitro results showed that hesperidin partially reversed dexamethasone-induced inhibition of osteogenic differentiation by suppressing the activation of p53, and suggest that hesperidin may be a promising candidate for the treatment against dexamethasone-induced osteoporosis.
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Affiliation(s)
- Meng Zhang
- Department of Orthopedics, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Henan University People’s Hospital, Zhengzhou, China
- Microbiome Laboratory, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Delong Chen
- Department of Orthopaedics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ning Zeng
- Department of Plastic and Cosmetic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhendong Liu
- Microbiome Laboratory, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
- Department of Surgery of Spine and Spinal Cord, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Henan University People’s Hospital, Zhengzhou, China
| | - Xiao Chen
- Department of Orthopedics, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Henan University People’s Hospital, Zhengzhou, China
- Microbiome Laboratory, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Hefang Xiao
- Department of Orthopedics, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Henan University People’s Hospital, Zhengzhou, China
- Microbiome Laboratory, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Likang Xiao
- Department of Orthopedics, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Henan University People’s Hospital, Zhengzhou, China
- Microbiome Laboratory, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Zeming Liu
- Department of Plastic and Cosmetic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Zeming Liu, ; Yonghui Dong, ; Jia Zheng,
| | - Yonghui Dong
- Department of Orthopedics, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Henan University People’s Hospital, Zhengzhou, China
- Microbiome Laboratory, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Zeming Liu, ; Yonghui Dong, ; Jia Zheng,
| | - Jia Zheng
- Department of Orthopedics, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Henan University People’s Hospital, Zhengzhou, China
- *Correspondence: Zeming Liu, ; Yonghui Dong, ; Jia Zheng,
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19
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Pieroh P, Hohmann T, Gras F, Märdian S, Pflug A, Wittenberg S, Ihle C, Blankenburg N, Dallacker-Losensky K, Schröder T, Herath SC, Palm HG, Josten C, Stuby FM, Wagner D, Höch A. A computed tomography based survey study investigating the agreement of the therapeutic strategy for fragility fractures of the pelvis. Sci Rep 2022; 12:2326. [PMID: 35149706 PMCID: PMC8837654 DOI: 10.1038/s41598-022-04949-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 01/04/2022] [Indexed: 11/09/2022] Open
Abstract
Treatment recommendations for fragility fractures of the pelvis (FFP) have been provided along with the good reliable FFP classification but they are not proven in large studies and recent reports challenge these recommendations. Thus, we aimed to determine the usefulness of the FFP classification determining the treatment strategy and favored procedures in six level 1 trauma centers. Sixty cases of FFP were evaluated by six experienced pelvic surgeons, six inexperienced surgeons in training, and one surgeon trained by the originator of the FFP classification during three repeating sessions using computed tomography scans with multiplanar reconstruction. The intra-rater reliability and inter-rater reliability for therapeutic decisions (non-operative treatment vs. operative treatment) were moderate, with Fleiss kappa coefficients of 0.54 (95% confidence interval [CI] 0.44–0.62) and 0.42 (95% CI 0.34–0.49). We found a therapeutic disagreement predominantly for FFP II related to a preferred operative therapy for FFP II. Operative treated cases were generally treated with an anterior–posterior fixation. Despite the consensus on an anterior–posterior fixation, the chosen procedures are highly variable and most plausible based on the surgeon’s preference.
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Affiliation(s)
- Philipp Pieroh
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany. .,Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany. .,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany.
| | - Tim Hohmann
- Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Florian Gras
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Jena, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Sven Märdian
- Centre for Musculoskeletal Surgery, Charité-University Medicine Berlin, Berlin, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Alexander Pflug
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Jena, Germany
| | - Silvan Wittenberg
- Centre for Musculoskeletal Surgery, Charité-University Medicine Berlin, Berlin, Germany
| | - Christoph Ihle
- BG Trauma Center, Eberhard Karls University, Tuebingen, Germany
| | - Notker Blankenburg
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Kevin Dallacker-Losensky
- Trauma Research Group, Department of Orthopedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, Bundeswehrhospital Ulm, Ulm, Germany
| | - Tanja Schröder
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Steven C Herath
- BG Trauma Center, Eberhard Karls University, Tuebingen, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Hans-Georg Palm
- Trauma Research Group, Department of Orthopedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, Bundeswehrhospital Ulm, Ulm, Germany.,Address: Department of Orthopedic and Trauma Surgery, University Hospital Erlangen, Erlangen, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Fabian M Stuby
- Department of Trauma Surgery, BG Trauma Centre Murnau, Murnau am Staffelsee, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Daniel Wagner
- Department of Orthopedics and Traumatology, University Medical Center Mainz, Mainz, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Andreas Höch
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
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20
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Nuber S, Ritter B, Fenwick A, Förch S, Wanzl M, Nuber M, Mayr E. Midterm follow-up of elderly patients with fragility fractures of the pelvis: A prospective cohort-study comparing operative and non-operative treatment according to a therapeutic algorithm. Injury 2022; 53:496-505. [PMID: 34629169 DOI: 10.1016/j.injury.2021.09.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The treatment of fragility fractures of the pelvis (FFP) is a challenge. The variations of non-operative- and of operative treatment are manifold and a structured treatment algorithm is lacking. The purpose of this study was to evaluate the outcome of elderly patients with a FFP who were treated with a therapeutic algorithm based on the FFP-classification. PATIENTS AND METHODS In a prospective cohort study 154 patients (mean age: 81.8 ±.61 (65-96); female: (86.8%; 131/154). BMI: 23.7 ±.34 (15-43)) with a FFP after inadequate mono trauma were treated according to a strict therapeutic algorithm between 04/2016 and 12/2018. According to a classification based on CT-scans either a standardized operative treatment or conservative therapy was induced and the outcome regarding objective measurements of mobility, pain, need for analgesics and mortality during hospital stay and after one year was analyzed. RESULTS 82/154 participants (53.2%) were assigned to the conservative treatment group and 72 participants (46.8%) to the operative treatment group. The overall one-year survival rate was 78.1% (118/151). The survival of the operative treatment group was 90.7% (49/54) and significantly higher than the survival of the conservative treatment group (74.7%; 56/75; p=.023). The one-year follow up showed a high dispersion of the pain level in the operatively treated patients and a significantly higher mean in comparison to conservatively treated patients. Both treatment groups showed increasing numbers of patients with unlimited mobilization but also immobile patients. Overall in 31.0% (18/58) of the operative participants and in 14.9% (14/93) of the non-operatively treated participants complications occurred (p=.04). CONCLUSION The strict compliance to the presented treatment algorithm of FFP with an operative strategy starting from FFP IIc leads to a significantly lower mortality within one year in comparison to the conservatively treated patients. The worst outcome and the highest mortality was seen in patients who refused the recommendation of operative stabilization. The results of this study justify to proceed with the strict classification dependent treatment algorithm and also support the early switch-over to operative treatment of patients with failed conservative therapy in FFP I to FFP IIb.
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Affiliation(s)
- Stefan Nuber
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany.
| | - Benedikt Ritter
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Annabel Fenwick
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Stefan Förch
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Maximilian Wanzl
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Monika Nuber
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Edgar Mayr
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
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21
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Graul I, Strube P, Vogt S, Matziolis G, Brodt S, Hölzl A. Does Total Hip Arthroplasty Influence the Development and Localization of Sacral Insufficiency Fractures? J Bone Joint Surg Am 2022; 104:139-144. [PMID: 34807876 DOI: 10.2106/jbjs.21.00218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Sacral insufficiency fractures (SIFs) are fractures related to reduced bone strength. In a previous study, we noticed that many patients with SIF had undergone total hip arthroplasty (THA). Therefore, the purpose of the present study was to research the localization of clinically apparent SIFs in relation to unilateral THA as well as the influence of unilateral THA on bone mineral density changes in the sacrum. METHODS In this retrospective study, 171 patients with SIFs were screened for unilateral THA. In the group of patients with SIF and THA, the rate of SIF ipsilateral and contralateral to the side of the THA was determined. In a second cohort of 39 THA patients with healthy bone, changes in bone mineral density at the sacral alae ipsilateral and contralateral to the THA were analyzed by use of computed tomography immediately postoperatively and at the 1-year follow-up. RESULTS Of the 171 patients with SIF, 50 (40 female; mean age, 79 years; range, 54 to 101 years) were previously treated with THA. Of the 50, 31 patients were treated with unilateral THA. The proportion of patients with an SIF contralateral to the THA was 42% (13 of 31) and ipsilateral to the THA was 19% (6 of 31). Twelve patients had bilateral SIFs. The mean age of the THA group without SIF was 62 years (range, 49 to 79 years); 17 were female. The median bone mineral density decreased significantly (p = 0.023), from 35.0 to 13.0 HU, at the sacral ala contralateral to the THA, whereas the decrease of ipsilateral bone mineral density, from 24.0 to 17.0 HU, was not significant (p = 0.361). CONCLUSIONS The proportion of patients with an SIF contralateral to a THA was twice as high as that of patients with an SIF ipsilateral to a THA. These findings are supported by the second cohort's decrease in bone mineral density at the sacral ala contralateral to the THA at 1 year after surgery. We conclude that THA can lead to spatially different remodeling of the sacrum, possibly affecting the development of SIFs. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Isabel Graul
- Department of Orthopedics, Campus Eisenberg, University of Jena, Eisenberg, Germany
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22
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Usman M, Tarar MY, Toe KKZ, Iqbal M, Kempanna V, Gill I. Evolving Practice in Management of Pelvic-Acetabular Trauma: COVID-19 Experience From a Tertiary Referral Centre in the UK. Cureus 2021; 13:e18778. [PMID: 34796067 PMCID: PMC8590463 DOI: 10.7759/cureus.18778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction The United Kingdom was one of the hardest-hit countries during the COVID-19 Pandemic. The UK government announced three national lockdowns to control the spread of the coronavirus and prevent the NHS from getting overburdened with COVID-19 related attendances. Two of the most significant peaks in terms of COVID-19 related hospitalizations and COVID-19 related deaths were in Summer 2020 (corresponding to lockdown 1, which was in effect from 26th March to 26th May 2020) and early 2021 (corresponding to lockdown 3, which was in effect 6th January to 8th March 2021). During this time, a significant proportion of NHS resources was being diverted towards the treatment of COVID-19 patients. Measures were being taken to prevent unnecessary hospitalizations and reduce patient contact. These included but were not limited to measures to reduce attendances to Emergency departments, introducing telemedicine clinics, and pausing elective services. Our hospital is a Major Trauma Centre providing Tertiary Pelvic trauma service to the Greater Manchester area and the North West of England. We conducted this retrospective comparative study to compare the trends in presentation and Management of Pelvic trauma and identify trends in how these changed throughout the pandemic. We want to share these insights with our readers. Methodology We conducted a retrospective comparative study by comparing two cohorts of patients, patients presenting to the Pelvic Trauma service during Lockdown 1 and Lockdown 3 in the UK, named Group A and Group B, respectively. Data on patient demographics, injuries, and their management was identified from the Electronic Patient Record System. The data analysis was carried out with the aid of Stata/IC version 16.1. using descriptive Statistics. Results Group A contained 19 patients, with a mean age of 66.9 years. Group B contained 23 patients with a mean age of 67.4 years. There was no statistically significant difference in these patients' population demographics, injury patterns, and management (operative vs conservative). However, there was an absolute reduction in the complication rate from Group A to Group B of 17.2% (26.3% vs 9.1%). The higher complication rate during Lockdown 1 can be explained by conservatively managing Pelvic and Acetabular Fractures that would have been eligible for fixation, had COVID-19 not been a factor. Conclusions Within the limitations of our study, it appears that operatively managing a carefully selected cohort of acute Pelvic Trauma patients with proper precautions was safe and effective. It is unclear whether there was an added benefit to having a higher threshold to operate and adopting the watch-and-wait policy in Lockdown 1. We recommend continuing to follow the current evidence and fix these fractures early.
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Affiliation(s)
- Muhammad Usman
- Trauma and Orthopaedics, Salford Royal NHS Foundation Trust, Manchester, GBR
| | | | - Ko Ko Zayar Toe
- Trauma and Orthopaedics, Salford Royal NHS Foundation Trust, Manchester, GBR
| | - Mohammad Iqbal
- Trauma and Orthopaedics, Salford Royal NHS Foundation Trust, Manchester, GBR
| | - Vijaya Kempanna
- Trauma and Orthopaedics, Salford Royal NHS Foundation Trust, Manchester, GBR
| | - Inder Gill
- Trauma and Orthopaedics, Salford Royal NHS Foundation Trust, Manchester, GBR
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23
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Pickering ME. Cross-Talks between the Cardiovascular Disease-Sarcopenia-Osteoporosis Triad and Magnesium in Humans. Int J Mol Sci 2021; 22:ijms22169102. [PMID: 34445808 PMCID: PMC8396464 DOI: 10.3390/ijms22169102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 02/06/2023] Open
Abstract
Magnesium (Mg) is a pivotal and very complex component of healthy aging in the cardiovascular-muscle-bone triad. Low Mg levels and low Mg intake are common in the general aging population and are associated with poorer outcomes than higher levels, including vascular calcification, endothelial dysfunction, osteoporosis, or muscle dysfunction/sarcopenia. While Mg supplementation appears to reverse these processes and benefit the triad, more randomized clinical trials are needed. These will allow improvement of preventive and curative strategies and propose guidelines regarding the pharmaceutical forms and the dosages and durations of treatment in order to optimize and adapt Mg prescription for healthy aging and for older vulnerable persons with comorbidities.
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Affiliation(s)
- Marie-Eva Pickering
- Rheumatology Department, CHU Gabriel Montpied, 63000 Clermont-Ferrand, France
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24
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Saito Y, Tokutake K, Takegami Y, Yoshida M, Omichi T, Imagama S. Does surgical treatment for unstable fragility fracture of the pelvis promote early mobilization and improve survival rate and postoperative clinical function? Eur J Trauma Emerg Surg 2021; 48:3747-3756. [PMID: 34156485 DOI: 10.1007/s00068-021-01729-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 06/11/2021] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Yuki Saito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Yasuhiko Takegami
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiro Yoshida
- Department of Emergency Medicine, Fujita Health University Hospital, Nagoya, Japan
| | - Toshifumi Omichi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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25
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Roux C, Thomas T, Paccou J, Bizouard G, Crochard A, Toth E, Lemaitre M, Maurel F, Perrin L, Tubach F. Refracture and mortality following hospitalization for severe osteoporotic fractures: The Fractos Study. JBMR Plus 2021; 5:e10507. [PMID: 34258503 PMCID: PMC8260818 DOI: 10.1002/jbm4.10507] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/17/2022] Open
Abstract
Severe osteoporotic fractures (hip, proximal humerus, pelvic, vertebral and multiple rib fractures) carry an increased risk of mortality. This retrospective cohort study in the French national healthcare database aimed to estimate refracture and mortality rates after severe osteoporotic fractures at different sites, and to identify mortality‐related variables. A total of 356,895 patients hospitalized for severe osteoporotic fracture between 2009 and 2014 inclusive were analyzed. The cohort was followed for 2 to 8 years up to the study end or until the patient died. Data were extracted on subsequent hospitalizations, refracture events, treatments, comorbidities of interest and survival. Time to refracture and survival were described using Kaplan‐Meier analysis by site of fracture and overall. Mortality risk factors were identified using a Cox model. Hip fractures accounted for 60.4% of the sample (N = 215,672). In the 12 months following fracture, 58,220 patients (16.7%) received a specific osteoporosis treatment, of whom 21,228 were previously treatment‐naïve. The 12‐month refracture rate was 6.3% (95% confidence interval [CI], 6.2%–6.3%), ranging from 4.0% (95% CI, 3.7%–4.3%) for multiple rib fractures to 7.8% (95% CI, 7.5%–8.1%) for pelvic fractures. Twelve‐month all‐cause mortality was 12.8% (95% CI, 12.7%–12.9%), ranging from 5.0% (95% CI, 4.7%–5.2%) for vertebral fractures to 16.6% (95% CI, 16.4%–16.7%) for hip fractures. Osteoporosis‐related mortality risk factors included fracture site, previous osteoporotic fracture (hazard ratio 1.21; 95% CI, 1.18–1.23), hip refracture (1.74; 95% CI, 1.71–1.77), and no prior osteoporosis treatment (1.24; 95% CI, 1.22–1.26). Comorbid cancer (3.15; 95% CI, 3.09–3.21) and liver disease (2.54; 95% CI, 2.40–2.68) were also strongly associated with mortality. In conclusion, severe osteoporotic fractures, including certain non‐hip nonvertebral fractures, carry a high burden in terms of mortality and refracture risk. However, most patients received no anti‐osteoporotic treatment. The findings emphasize the importance of better management of patients with severe fractures, and of developing effective strategies to reduce fracture risk in patients with osteoporosis. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Christian Roux
- Department of Rheumatology Cochin Hospital, Assistance Publique - Hôpitaux de Paris Centre, Institut National de la Santé et de la Recherche Médicale (INSERM) Unités Mixtes de Recherche (UMR) 1153, Université de Paris Paris France
| | - Thierry Thomas
- Department of Rheumatology Hôpital Nord, Centre Hospitalier Universitaire (CHU) Saint-Etienne, INSERM U1059, Lyon University Saint-Etienne France
| | - Julien Paccou
- Department of Rheumatology Lille University, CHU Lille, Marrow Adiposity and Bone Laboratory (MABlab) ULR 4490 Lille France
| | | | | | | | | | | | | | - Florence Tubach
- Department of Public Health, Pharmacoepidemiology Center (Cephepi) Sorbonne University, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP Sorbonne University, Pitié-Salpêtrière Hospital, CIC-1422 Paris France
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26
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Mendel T, Schenk P, Ullrich BW, Hofmann GO, Goehre F, Schwan S, Klauke F. Mid-term outcome of bilateral fragility fractures of the sacrum after bisegmental transsacral stabilization versus spinopelvic fixation. Bone Joint J 2021; 103-B:462-468. [PMID: 33641427 DOI: 10.1302/0301-620x.103b3.bjj-2020-1454.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Minimally invasive fixation of pelvic fragility fractures is recommended to reduce pain and allow early mobilization. The purpose of this study was to evaluate the outcome of two different stabilization techniques in bilateral fragility fractures of the sacrum (BFFS). METHODS A non-randomized, prospective study was carried out in a level 1 trauma centre. BFFS in 61 patients (mean age 80 years (SD 10); four male, 57 female) were treated surgically with bisegmental transsacral stablization (BTS; n = 41) versus spinopelvic fixation (SP; n = 20). Postoperative full weightbearing was allowed. The outcome was evaluated at two timepoints: discharge from inpatient treatment (TP1; Fitbit tracking, Zebris stance analysis), and ≥ six months (TP2; Fitbit tracking, Zebris analysis, based on modified Oswestry Disability Index (ODI), Majeed Score (MS), and the 12-Item Short Form Survey 12 (SF-12). Fracture healing was assessed by CT. The primary outcome parameter of functional recovery was the per-day step count; the secondary parameter was the subjective outcome assessed by questionnaires. RESULTS Overall, no baseline differences were observed between the BTS and SP cohorts. In total, 58 (BTS = 19; SP = 39) and 37 patients (BTS = 14; SP = 23) could be recruited at TP1 and TP2, respectively. Mean steps per day at TP1 were median 308 (248 to 434) in the BTS group and 254 (196 to 446) in the SP group. At TP2, median steps per day were 3,759 (2,551 to 3,926) in the BTS group and 3,191 (2,872 to 3,679) in the SP group, each with no significant difference. A significant improvement was observed in each group (p < 0.001) between timepoints. BTS patients obtained better results than SP patients in ODI (p < 0.030), MS (p = 0.007), and SF-12 physical status (p = 0.006). In all cases, CT showed sufficient fracture healing of the posterior ring. CONCLUSION Both groups showed significant outcome improvement and sufficient fracture healing. Both techniques can be recommended for BFFS, although BTS was superior with respect to subjective outcome. Step-count tracking represents a reliable method to evaluate the mobility level. Cite this article: Bone Joint J 2021;103-B(3):462-468.
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Affiliation(s)
- Thomas Mendel
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Halle, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Jena, Jena, Germany
| | - Philipp Schenk
- Research Executive Department, BG Klinikum Bergmannstrost Halle, Halle, Germany
| | | | - Gunther Olaf Hofmann
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Halle, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Jena, Jena, Germany
| | - Felix Goehre
- Department of Neurosurgery, BG Klinikum Bergmannstrost Halle, Halle, Germany
| | - Stefan Schwan
- Department of Biological and Macromolecular Materials, Fraunhofer Institute for Microstructure of Materials and Systems IMWS, Halle, Germany
| | - Friederike Klauke
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Halle, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Jena, Jena, Germany
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27
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Lang P, Schwabe K, Riesner HJ, Friemert B, Stuby F, Palm HG. Epidemiological and Therapeutic Developments in Pelvic Ring Fractures Type C from 2004 to 2014 - a Retrospective Data Analysis of 2,042 Patients in the German Pelvic Register (DGU). ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021; 160:172-182. [PMID: 33477178 DOI: 10.1055/a-1298-4949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pelvic ring fractures type C present a special challenge due to their high instability, the possible accompanying injuries and the high mortality rate of up to 18.9%. The aim of this retrospective analysis was to use the data from the DGU pelvic register to identify changes in the epidemiology and therapy for type C pelvic ring fractures between 2004 and 2014. MATERIALS AND METHODS 2,042 patients with type C pelvic ring injury were retrospectively included. Three time periods with roughly equal patient groups were specified and differences in epidemiology and the type of therapy were evaluated. For the surgical cases, the time of the operation, the duration of the operation, blood loss, the location of the fracture and the type of osteosynthesis were evaluated and the reduction result was recorded. RESULTS For the period under review, there is an age shift in the incidence of a type C pelvic ring fracture towards older age. The isolated pelvic injury has increased, while the proportion of pelvic injuries in the context of polytrauma has steadily decreased. Complications and mortality decreased as a percentage. The tendency towards minimally invasive procedures could be shown in the surgical care. Navigated procedures in the area of the pelvic ring have so far not proven successful. CONCLUSIONS We were able to show that the majority of the patients are increasingly old, that there is no relevant trauma in the history and that there is an increase in the isolated pelvic fracture type C and a decrease in the number of polytraumatised or multiply injured patients. In conjunction with mortality from pelvic ring injuries, the successes of standardised, pelvic-specific emergency management, an adapted time of operation outside the vulnerable phase and stable osteosynthesis care, which enable early functional follow-up treatment, are also evident.
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Affiliation(s)
- Patricia Lang
- Clinic for Trauma Surgery and Orthopaedics, German Federal Armed Forces Hospital Ulm, Germany
| | - Kerstin Schwabe
- Clinic for General, Visceral and Thoracic Surgery, German Federal Armed Forces Hospital Ulm, Germany
| | - Hans-Joachim Riesner
- Clinic for Trauma Surgery and Orthopaedics, German Federal Armed Forces Hospital Ulm, Germany
| | - Benedikt Friemert
- Clinic for Trauma Surgery and Orthopaedics, German Federal Armed Forces Hospital Ulm, Germany
| | | | - Hans-Georg Palm
- University Surgical Clinic - Orthopaedic Surgery, University Clinics Erlangen, Germany
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Modified therapy concepts for fragility fractures of the pelvis after additional MRI. PLoS One 2020; 15:e0238773. [PMID: 33031459 PMCID: PMC7544090 DOI: 10.1371/journal.pone.0238773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fractures of the pelvic ring in elderly patients have increased in frequency over time. These injuries are associated with a high morbidity and have a socio-economic impact. The diagnostic procedures and their influence of therapy decisions are still controversial. METHODS In a retrospective study, we investigate the value of additional MRI examination on therapy decision of fragility fractures of the pelvis. The evaluation of all patients with pelvic fractures without adequate trauma and with performed CT and MRI was conducted at three large German hospitals. The imaging procedure took place within a maximum interval of 4 weeks. After evaluation of the imaging, the resulting therapeutic consequences either based on CT alone or on CT and MRI were reviewed by experienced pelvic surgeons. RESULTS Of 754 patients with pelvic injuries, 67 (age 80 +/- 9.7 years, f: m 54:13) could be included. The detection of vertical fractures in CT (n = 40 unilateral, n = 11 bilateral) could be increased by the additional MRI (n = 44 unilateral, n = 23 bilateral). A horizontal fracture component was identified in CT in 9.0% (n = 6) vs. MRI in 25.4% (n = 17) of the cases. An anterior pelvic ring injury was detected in 71.6% (n = 44; 4x bilateral) in CT, in 80.6% in MRI (n = 50, 4 bilateral). Additive MRI imaging increased the decision rate for surgical therapy from 20.9% (n = 14) to 31.3% (n = 21). CONCLUSIONS The results of this study further support the value of bone marrow edema detection by MRI diagnostics (or dual source CT which showed promising initial results) for the detection of pelvic ring fractures. For the first time, the study identifies an additional therapeutic consequence by an increased rate of surgical procedures.
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Mobility and mortality of 340 patients with fragility fracture of the pelvis. Eur J Trauma Emerg Surg 2020; 47:29-36. [PMID: 32860102 DOI: 10.1007/s00068-020-01481-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To investigate prognosis of patients with fragility fracture of the pelvis (FFP) treated in a single trauma unit in Japan. METHODS We retrospectively investigated 340 consecutive patients with FFP (40 men, 300 women; average age, 82.5 years) treated in our facility from April 2012 to April 2019. Fractures were categorized according to the Rommens classification. Patients' mechanism of injury, existence of hip implant, standing and walking abilities (using the Majeed score), and 1-year mortality rate were evaluated. RESULTS According to the Rommens classification, there were 84 type Ia, 2 type Ib, 24 type IIa, 78 type IIb, 51 type IIc, 40 type IIIa, 1 type IIIb, 4 type IIIc, 1 type IVa, 51 type IVb, and 3 type IVc fractures. Sixteen patients (4.7%) received surgical treatments. Twenty-eight patients (8.2%) had no memory of a traumatic event, and 61 (18%) had implants from a previous hip surgery. A total of 176 patients (52%) were followed up for ≥ 1 year, and 70 (39.8%) and 67 (38.1%) patients had recovery of standing and walking abilities, similar to those before the injury. The operative group (7/9 = 77.8%) had a higher proportion of patients who regained their standing and walking abilities at the 1-year follow-up than the conservative group. The 1-year mortality rate of the patients who could be followed for ≥ 1 year was 6.7%. CONCLUSION According to our data, 4.7% of patients were indicated for surgery, and only < 40% of patients were able to regain their pre-injury standing and walking abilities at 1 year after the injury. FFP may greatly affect an elderly's activities of daily living and may lead to prognosis similar to patients with proximal hip fractures. To regain the walking ability of patients with FFP, more aggressive indication of surgical treatment may be considered depending on the patient's background. Further examinations are necessary to determine the surgical indications and treatment protocol for FFP.
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Lang P, Sterneder M, Riesner HJ, Hackenbroch C, Friemert B, Palm HG. Fragility Fractures of the Pelvic Ring – Does the Evidence of Oedema Lead us to More Surgeries? ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 159:503-512. [DOI: 10.1055/a-1192-7583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abstract
Introduction The choice of therapy for fragility fractures of the pelvis (FFP) is largely determined by the diagnosed fracture morphology. It is now unclear whether the change in diagnostic options – sensitive detection of fracture oedema in the sacrum using MRI and dual-energy computed tomography (DECT) – has an impact on the therapeutic consequences. The aim of this retrospective study was therefore to evaluate the change in the diagnostics used and the resulting therapy regimen in our patient population.
Materials and Methods We performed a monocentric-retrospective analysis of 196 patients with a fragility fracture of the pelvis in our clinic (national TraumaZentrum® DGU and SAV approval) in the period from 2008 to 2017. We examined changes in epidemiology, diagnostics/classification and therapy of the pelvic ring fractures treated by us.
Results The diagnostic procedures used are subject to a clear change towards oedema detection using MRI and DECT. The graduation has changed towards more severe forms of fracture after FFP. There is now also an increasing proportion of patients treated by surgery (2008 – 2009: 5.3% vs. 2015 – 2017: 60.3%).
Conclusion We were able to show that the introduction of sensitive diagnostic procedures coincided with a higher classification of the fractures. It is also noteworthy that the increase in operations is not only due to a higher degree of classification; also in relative terms, more patients are operated on within type FFP II.
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Affiliation(s)
- Patricia Lang
- Department for Trauma and Orthopaedic, Reconstructive and Septic Surgery, Sports Traumatology, German Military Hospital in Ulm
| | - Manuel Sterneder
- Department for Trauma and Orthopaedic, Reconstructive and Septic Surgery, Sports Traumatology, German Military Hospital in Ulm
| | - Hans-Joachim Riesner
- Department for Trauma and Orthopaedic, Reconstructive and Septic Surgery, Sports Traumatology, German Military Hospital in Ulm
| | - Carsten Hackenbroch
- Clinic for Diagnostic Radiology and Neuroradiology, German Military Hospital in Ulm
| | - Benedikt Friemert
- Department for Trauma and Orthopaedic, Reconstructive and Septic Surgery, Sports Traumatology, German Military Hospital in Ulm
| | - Hans-Georg Palm
- Department for Trauma and Orthopaedic, Reconstructive and Septic Surgery, Sports Traumatology, German Military Hospital in Ulm
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Thompson JC, Wanderman N, Anderson PA, Freedman BA. Abaloparatide and the Spine: A Narrative Review. Clin Interv Aging 2020; 15:1023-1033. [PMID: 32636617 PMCID: PMC7334019 DOI: 10.2147/cia.s227611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/23/2020] [Indexed: 11/23/2022] Open
Abstract
Osteoporosis is a common and debilitating condition characterized by diminished bone mass and architecture leading to bone fragility. Antiresorptive medicines like bisphosphonates (and less commonly denosumab) are the typical first-line agents for the medical treatment of osteoporosis. However, newer anabolic agents have been shown to improve bone mass and architecture, as well as reduce fracture risk, to a greater degree than traditional antiresorptive therapies. Teriparatide (human recombinant parathyroid hormone (PTH) 1–34, Forteo, Ely Lilly, Indianapolis, IN), which was the first in class to be approved in the United States, is the most widely used anabolic osteoporosis medicine and has shown significant benefit over traditional antiresorptive therapies. However, abaloparatide (synthetic parathyroid-related peptide (PTHrP), Tymlos, Radius Health, Waltham, MA), the second drug in this family, has recently become available for use. In this narrative review, we review the mechanism, effects, and benefits of abaloparatide compared to alternative treatments as well as discuss the current literature in regard to its effect on osteoporosis-related complications in the spine.
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Affiliation(s)
| | - Nathan Wanderman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Paul A Anderson
- Department of Orthopaedic Surgery, Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin, Madison, WI 53705-2281, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Langdahl BL. Overview of treatment approaches to osteoporosis. Br J Pharmacol 2020; 178:1891-1906. [PMID: 32060897 DOI: 10.1111/bph.15024] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 01/16/2020] [Accepted: 01/31/2020] [Indexed: 12/28/2022] Open
Abstract
Efficient therapies are available for the treatment of osteoporosis. Anti-resorptive therapies, including bisphosphonates and denosumab, increase bone mineral density (BMD) and reduce the risk of fractures by 20-70%. Bone-forming or dual-action treatments stimulate bone formation and increase BMD more than the anti-resorptive therapies. Two studies have demonstrated that these treatments are superior to anti-resorptives in preventing fractures in patients with severe osteoporosis. Bone-forming or dual-action treatments should be followed by anti-resorptive treatment to maintain the fracture risk reduction. The BMD gains seen with bone-forming and dual-action treatments are greater in treatment-naïve patients compared to patients pretreated with anti-resorptive treatments. However, the antifracture efficacy seems to be preserved. Treatment failure will often lead to switch of treatment from orally to parentally administrated anti-resorptives treatment or from anti-resorptive to bone-forming or dual-action treatment. Osteoporosis is a chronic condition and therefore needs a long-term management plan with a personalized approach to treatment. LINKED ARTICLES: This article is part of a themed issue on The molecular pharmacology of bone and cancer-related bone diseases. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.9/issuetoc.
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Affiliation(s)
- Bente L Langdahl
- Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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The one-year mortality rate in elderly patients with osteoporotic fractures of the pelvis. Arch Osteoporos 2020; 15:15. [PMID: 32078053 DOI: 10.1007/s11657-020-0689-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/14/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Osteoporosis is a common condition for elderly people. The incidence of osteoporotic pelvic fractures has been increasing. Osteoporotic pelvic fractures are associated with increased mortality rates. Based on the aim of our study, we found out that one-year mortality rate after a pelvic fracture is high and depends on the fracture type. PURPOSE The aim of this study was to determine the one-year mortality rate in patients aged 65+ with osteoporotic pelvic fractures depending on the type of fracture according to AO/OTA classification. METHODS Patients aged 65+ with pelvic insufficiency fractures admitted to a single center between 1 June 2013 and 31 December 2016 were enrolled in the study. The fractures were classified according to AO/OTA classification. The start of the survival time analysis was the date of the injury. The end of the analysis was 31 December 2017 or the date of the patient's death. Mortality rates were assessed with respect to fracture types using Kaplan-Meier curves. The Cox proportional hazards model was applied to assess the dependence of mortality on the fracture type. RESULTS A total of 105 patients with 95 (90.5%) being female were enrolled in this prospective study. The average age was 80.3 years (95% CI 78.8-81.7). Mean follow-up time was 23.5 months (95% CI 20.7-26.4). According to AO/OTA classification, 30 (28.6%) patients had a type A pelvic fracture, 73 (69.5%) patients-type B fracture, and 2 (1.9%)-type C fracture. Overall, the one-year mortality rate was 23.8% (95% CI 16.8-33.2%). For patients with type A fracture, the one-year mortality rate was 13.3% (95% CI 5.2-31.7%) compared with 27.4% (95% CI 18.6-39.2%) in the group with type B fracture, and this difference was statistically significant (p < 0.001). CONCLUSIONS We found that within a year after an osteoporotic pelvic fracture, the number of deaths in the patients having type B pelvic fracture was twice higher than in the patients with type A fracture.
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Ireland E, Womack J, Foley E. Sacral plexus catheter analgesia in a patient with traumatic sacral fractures and Tarlov cysts. Anaesth Rep 2020; 7:76-78. [PMID: 32051956 DOI: 10.1002/anr3.12023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2019] [Indexed: 11/05/2022] Open
Abstract
We report the use of a sacral plexus catheter for continuous local anaesthetic infusion in a patient with a unilateral sacral ala fracture following a fall from a horse. Although sacral plexus blockade has been well described for lower limb surgery, an ultrasound-guided continuous catheter technique for conservatively managed fractures has not been described. Despite appropriate oral analgesia, the patient reported severe pain, particularly in the right gluteal region, which meant she was unable to sit upright or take deep breaths. A sacral plexus catheter was inserted with ultrasound guidance and an initial bolus of 30 ml levobupivicaine 0.25% was delivered followed by infusion of 8 ml.h-1 levobupivicaine 0.125%. Daily follow-up and assessment were provided by the acute pain team. We judged the procedure to be a success as measured by an improvement in mobilisation, deep breathing, cough and patient satisfaction.
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Affiliation(s)
- E Ireland
- Royal Victoria Infirmary Newcastle Upon Tyne UK
| | - J Womack
- Royal Victoria Infirmary Newcastle Upon Tyne UK
| | - E Foley
- Royal Victoria Infirmary Newcastle Upon Tyne UK
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Deal CL, Mitlak BH, Wang Y, Fitzpatrick LA, Miller PD. Response rates for hip, femoral neck, and lumbar spine bone mineral density in patients treated with abaloparatide followed by alendronate: Results from phase 3 ACTIVExtend. Bone Rep 2019; 11:100230. [PMID: 31799340 PMCID: PMC6883300 DOI: 10.1016/j.bonr.2019.100230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 12/13/2022] Open
Abstract
A significantly greater proportion of abaloparatide/alendronate patients had BMD increases over 0, 3 and 6 percent versus placebo/alendronate. BMD responses were higher at all anatomic sites and for all thresholds assessed for abaloparatide/alendronate versus placebo/alendronate This study provides further evidence of cumulative benefit from sequential treatment with an anabolic agent followed by an antiresorptive.
Abaloparatide is a selective activator of the parathyroid hormone type 1 receptor signaling pathway that favors the stimulation of bone formation. Here, we report a prospective, exploratory analysis of bone mineral density (BMD) response rates comparing sequential abaloparatide/alendronate vs placebo/alendronate across the ACTIVE and ACTIVExtend studies. BMD was measured at the lumbar spine, total hip, and femoral neck from the beginning of ACTIVE to the end of ACTIVExtend (18 months of abaloparatide or placebo followed by about 1 month for re-consent, followed by 24 months of alendronate treatment for a total of 43 months). Responders were defined as those patients who had improvements in BMD at 3 anatomic sites—the lumbar spine, total hip, and femoral neck. Three response thresholds, >0%, >3%, and >6%, were evaluated. Five hundred fifty-eight patients in the abaloparatide/alendronate group and 581 patients in the placebo/alendronate group from ACTIVExtend were included in the analysis. At Month 43, a significantly greater proportion of those in the abaloparatide/alendronate group compared with the placebo/alendronate group responded with BMD changes from ACTIVE baseline of >0%, >3%, and >6% at all 3 anatomic sites (p < 0.001 for each comparison). At the>3% threshold, 60.7% (307/506) vs 24.0% (121/505) of patients experienced BMD increases at all 3 sites in the abaloparatide/alendronate vs placebo/alendronate groups, respectively (p < 0.001). A significantly greater proportion of the abaloparatide/alendronate group experienced BMD increases of>0%, >3%, and >6% at each individual anatomic site compared with the placebo/alendronate group at 43 months (p < 0.001). Additionally, at each visit in ACTIVExtend, there was a significantly greater proportion of patients in the abaloparatide/alendronate group above the 3% threshold at each anatomic site compared with the placebo/alendronate group. Results are consistent with the significant BMD response with abaloparatide vs placebo observed in ACTIVE and with the continued fracture risk reduction with sequential abaloparatide/alendronate compared with placebo/alendronate treatment observed in ACTIVE through ACTIVExtend.
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Affiliation(s)
| | | | | | | | - Paul D Miller
- Colorado Center for Bone Research at Panorama Orthopedics & Spine Center, Golden, CO, USA
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Reito A, Kuoppala M, Pajulammi H, Hokkinen L, Kyrölä K, Paloneva J. Mortality and comorbidity after non-operatively managed, low-energy pelvic fracture in patients over age 70: a comparison with an age-matched femoral neck fracture cohort and general population. BMC Geriatr 2019; 19:315. [PMID: 31744463 PMCID: PMC6862845 DOI: 10.1186/s12877-019-1320-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 10/16/2019] [Indexed: 12/14/2022] Open
Abstract
Background Research on mortality and comorbidity associated with pelvic fractures in older patients is scarce. We aimed to determine the short- and long-term mortality rates of older patients with a pelvic ring fracture compared with both an age-matched cohort of patients with a femoral neck fracture and a general population, and to investigate 30- and 60-day readmission rates after pelvic fracture. Methods This was a retrospective cohort study done in an emergency department of a level II/III trauma center. All patients aged over 70 years diagnosed with a pelvic or acetabular fracture between January 2010 and December 2016 in our ED were identified. Two reference populations were used: patients operated due to femoral neck fracture in our institution between 2007 and 2008 and a general population aged 70 years or more. Results Two hundred nineteen patients were identified. 30- and 90-day mortality was 7.3 and 11.4%, respectively. Compared to the general population, a pelvic fracture was associated with an 8.5-fold (95% CI: 5.2–13.9) and 11.0-fold (95% CI: 5.4–22.3) 90-day mortality risk in females and males, respectively. We could not observe a difference in the risk of 90-day mortality between femoral neck fracture patients and patients with a pelvic fracture. Within 30 days, 28 (12.8%) pelvic fracture patients were readmitted for in-patient care in our hospital. Conclusions The mortality of older patients with pelvic ring fractures resembles that after hip fracture. Although older patients with a pelvic ring fracture rarely require operative treatment, the severity of the injury should not be considered as a class apart from hip fracture.
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Affiliation(s)
- Aleksi Reito
- Department of Orthopaedics and traumatology, Central Finland Hospital, Keskussairaalantie 19, 40620, Jyväskylä, Finland.
| | - Mari Kuoppala
- School of Medicine, University of Oulu, Oulu, Finland
| | - Hanna Pajulammi
- Department of Orthopaedics and traumatology, Central Finland Hospital, Keskussairaalantie 19, 40620, Jyväskylä, Finland.,Department of Geriatric Medicine, Central Finland Hospital, Jyväskylä, Finland
| | - Lasse Hokkinen
- Department of Radiology, Central Finland Hospital, Jyväskylä, Finland
| | - Kati Kyrölä
- Department of Orthopaedics and traumatology, Central Finland Hospital, Keskussairaalantie 19, 40620, Jyväskylä, Finland
| | - Juha Paloneva
- Department of Orthopaedics and traumatology, Central Finland Hospital, Keskussairaalantie 19, 40620, Jyväskylä, Finland.,School of Medicine, University of Eastern Finland, Kuopio, Finland
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Osterhoff G, Noser J, Held U, Werner CML, Pape HC, Dietrich M. Early Operative Versus Nonoperative Treatment of Fragility Fractures of the Pelvis: A Propensity-Matched Multicenter Study. J Orthop Trauma 2019; 33:e410-e415. [PMID: 31633644 DOI: 10.1097/bot.0000000000001584] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome. DESIGN Retrospective. SETTING Two trauma centers. PATIENTS AND METHODS Two hundred thirty consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively. MAIN OUTCOME MEASUREMENTS Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up. RESULTS At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients [23%, 95% confidence interval (CI): 17%-31%] of the early operative group and 14/82 patients (17%, 95% CI: 10%-27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38-5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910). CONCLUSION Early operative fixation of patients who cannot be mobilized within 3-5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Georg Osterhoff
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Department of Orthopaedics, Trauma, and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Jonas Noser
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | | | | | - Michael Dietrich
- Department of Orthopaedics and Traumatology, Department of Surgery, Waid City Hospital, Zurich, Switzerland
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van Berkel D, Ong T, Drummond A, Hendrick P, Leighton P, Jones M, Salem K, Quraishi N, Brookes C, Suazo Di Paola A, Edwards S, Sahota O. ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation) randomised controlled, feasibility in older people trial: a study protocol. BMJ Open 2019; 9:e032111. [PMID: 31296516 PMCID: PMC6624053 DOI: 10.1136/bmjopen-2019-032111] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Pelvic fragility fractures (PFF) are common in older people and associated with a significant burden of mortality and morbidity. This is related to the challenges of appropriate pain control and early mobilisation. The current standard for treatment of PFF is non-surgical management. Minimally invasive surgical techniques for sacral fracture stabilisation have been shown to improve outcomes in terms of pain control and mobility, and they are safe. Randomised controlled trials are required before recommendations can be made for surgical management of PFF to become the new standard of care. This feasibility study will explore several uncertainties around conducting such a trial. METHODS AND ANALYSIS ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation) is a single-site randomised controlled, parallel-arm, feasibility trial of surgical stabilisation versus non-surgical management of acute sacral fragility fractures in people aged 70 years and over. Patients will be randomised to either surgical or non-surgical group on a 1:1 ratio. Follow-up of participants will occur at 2, 4 and 12 weeks with safety data collected at 52 weeks. Primary objectives are to determine feasibility and design of a future trial, including outcomes on recruitment, adherence to randomisation and safety. This will be supplemented with a qualitative interview study of participants and clinicians. Secondary objectives will inform study design procedures to determine clinical and economic outcomes between groups, including scored questionnaires, analgesia requirements, resource use and quality of life data. Data analysis will be largely descriptive to inform outcomes and future sample size. ETHICS AND DISSEMINATION Ethical approval was granted by the North East Newcastle and North Tyneside 2 Research Ethics Committee (reference 18/NE/0212). ASSERT was approved and sponsored by Nottingham University Hospitals NHS Trust (reference 18HC001) and the Health Research Authority (reference IRAS 232791). Recruitment is ongoing. Results will be presented at relevant conferences and submitted to appropriate journals on study completion. TRIAL REGISTRATION NUMBER ISRCTN16719542; Pre-results.
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Affiliation(s)
- Dawn van Berkel
- Health Care of the Older People Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Terence Ong
- Health Care of the Older People Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Paul Hendrick
- Division of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Paul Leighton
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Matthew Jones
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Khalid Salem
- Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nasir Quraishi
- Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Cassandra Brookes
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | | | - Sarah Edwards
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Opinder Sahota
- Health Care of the Older People Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Benzinger P, Riem S, Bauer J, Jaensch A, Becker C, Büchele G, Rapp K. Risk of institutionalization following fragility fractures in older people. Osteoporos Int 2019; 30:1363-1370. [PMID: 30877349 DOI: 10.1007/s00198-019-04922-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/27/2019] [Indexed: 12/15/2022]
Abstract
UNLABELLED Previously independent living older people suffering fractures of the hip have a high risk of new admission to a nursing home during the subsequent months. This study shows that older people admitted to hospital for fractures of the pelvis and spine have a similar risk of admission to a nursing home. INTRODUCTION Fall-related fractures are a serious threat to the health and well-being of older persons. Long-term consequences of hip fractures such as institutionalization and mortality are well-known. The impact of other fragility fractures is less well-understood. The aim of this study was to estimate risks of institutionalization and death for different fragility fractures and compare them with the corresponding risks after hip fracture. METHODS Data was retrieved from a German health insurance company. Between 2005 and 2008 more than 56,000 community-dwelling people with a hospital admission or discharge diagnosis of a fracture of the femur, spine, pelvis, proximal humerus, distal radius, tibia, or fibula were included. Crude and age-adjusted 6-month incidence rates for institutionalization and death were calculated. To compare the risks of institutionalization or mortality of non-hip fractures with the risk after hip fracture, multivariate regression models were applied. RESULTS Crude institutionalization rates and mortality were highest in patients with hip fracture. However, after adjustment for age, functional status, and comorbidity, risks of institutionalization after fractures of pelvis (relative risk (RR), 0.94; 95% confidence interval (CI) 0.86; 1.02 in women and 0.89; 95% CI 0.70; 1.12 in men), and spine (RR, 0.95; 95% CI 0.87; 1.03 in women and 0.91; 95% CI 0.76; 1.08 in men) were not statistically different compared to the risk after hip fracture. CONCLUSIONS The risk of institutionalization after fractures of the spine and pelvis was similar to the risk after hip fracture. These fracture sites seem to be associated with a significant decline in physical function.
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Affiliation(s)
- P Benzinger
- Center for Geriatric Medicine, Bethanien Krankenhaus Heidelberg, University of Heidelberg, Rohrbacher Straße 149, 69126, Heidelberg, Germany.
- Faculty of Social and Health Studies, University of Applied Sciences Kempten, Bahnhofstraße 61, 87435, Kempten, Germany.
- Department of Clinical Gerontology, Robert Bosch Krankenhaus Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany.
| | - S Riem
- Department of Clinical Gerontology, Robert Bosch Krankenhaus Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany
- Klinik für Unfallchirurgie, Kreiskrankenhaus Lörrach, Spitalstraße 25, 79539, Lörrach, Germany
| | - J Bauer
- Center for Geriatric Medicine, Bethanien Krankenhaus Heidelberg, University of Heidelberg, Rohrbacher Straße 149, 69126, Heidelberg, Germany
| | - A Jaensch
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstraße 22, 89081, Ulm, Germany
| | - C Becker
- Department of Clinical Gerontology, Robert Bosch Krankenhaus Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany
| | - G Büchele
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstraße 22, 89081, Ulm, Germany
| | - K Rapp
- Department of Clinical Gerontology, Robert Bosch Krankenhaus Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstraße 22, 89081, Ulm, Germany
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Booth A, Ingoe HMA, Northgraves M, Coleman E, Harden M, Kassam J, Kwok I, Hilton C, Bates P, McDaid C. Effectiveness of surgical fixation for lateral compression type one (LC-1) fragility fractures of the pelvis: a systematic review. BMJ Open 2019; 9:e024737. [PMID: 31110085 PMCID: PMC6530388 DOI: 10.1136/bmjopen-2018-024737] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To undertake a systematic review of the evidence base for the effectiveness of surgical fixation of lateral compression (LC-1) fragility fractures of the pelvis compared with non-surgical approaches. SEARCHES MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and two international trials registers were searched up to January 2017 (MEDLINE to February 2019) for studies of internal or external fixation of fragility fractures of the pelvis. PARTICIPANTS Patients with lateral compression pelvic fractures, sustained as the result of a low-energy mechanism, defined as a fall from standing height or less. INTERVENTIONS Surgery using either external or internal fixation devices. Conservative non-surgical treatment was the defined comparator. OUTCOME MEASURES Outcomes of interest were patient mobility and function, pain, quality of life, fracture union, mortality, hospital length of stay and complications (additional operative procedures, number and type of adverse events and serious adverse events). QUALITY ASSESSMENT AND SYNTHESIS The Joanna Briggs Institute Checklist for Case Series was used to assess the included studies. Results were presented in a narrative synthesis. RESULTS Of 3421 records identified, four retrospective case series met the inclusion criteria. Fixation types were not consistent between studies or within studies and most patients had more than one type of pelvic fixation. Where reported, mobility and function improved post-surgery, and a reduction in pain was recorded. Length of hospital stay ranged from 4 days to 54 days for surgical fixation of any type. Reported complications and adverse outcomes included: infections, implant loosening, pneumonia and thrombosis. Use of analgesia was not reported. CONCLUSIONS There is insufficient evidence to support guidance on the most effective treatment for patients who fail to mobilise after sustaining an LC-1 fragility fracture. TRIAL REGISTRATION NUMBER CRD42017055872.
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Affiliation(s)
- Alison Booth
- Department of Health Sciences, University of York, York, UK
| | - Helen Margaret Ann Ingoe
- Department of Health Sciences, University of York, York, UK
- Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Melissa Harden
- Centre for Reviews and Dissemination, University of York, York, UK
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Lim PN, Ooi LJ, Ong T, Neighbour C, Sahota O. Pelvic fragility fractures in older people admitted to hospital: the clinical burden. Eur Geriatr Med 2019; 10:147-150. [PMID: 32720277 DOI: 10.1007/s41999-018-0131-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 11/13/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Pelvic fragility fractures are common in older people. To deliver better care in hospital, a better understanding of their characteristics and outcomes post-hospitalisation will allow clinicians to better design hospital services to manage their needs. METHODS Using routinely collected electronic hospital records over 3 months, data were collected and analysed on consecutive patients admitted with pelvic fragility fractures (as defined by a pelvic fracture sustaining following a fall from standing height or less) to acute medical wards for older people. RESULTS Twenty-four patients were admitted over this period. Their mean age was 87 years (SD 9.4), the majority were female (83%), a significant proportion had cognitive impairment with an abbreviated mental test score of ≤ 7 (67%), and the median number of comorbid conditions was three. These patients were at high risk of future fractures (50% with a known diagnosis of osteoporosis; significant FRAX scores; 75% had a fall) but only 50% had a bone health assessment. The median duration in hospital was 13 days. 33% of patients were discharged home directly while the rest were discharged to either a care home or another hospital for further rehabilitation. 54% had a hospital-related complication including kidney injury, delirium, and hospital-acquired infections-there were two inpatient mortalities. At 3 months post-fracture, 54% were readmitted and 33% died. CONCLUSION Pelvic fragility fractures are associated with worse inpatient and post-discharge clinical outcomes. This is an older multi-morbid cohort needing significant post-fracture rehabilitation care. Their care in hospital needs to address their management complexities.
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Affiliation(s)
- Puo Nen Lim
- Department for Healthcare of Older People, B Floor, South Block, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
| | - Li Jin Ooi
- Department for Healthcare of Older People, B Floor, South Block, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
| | - Terence Ong
- Department for Healthcare of Older People, B Floor, South Block, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK. .,Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK.
| | - Catherine Neighbour
- Department for Healthcare of Older People, B Floor, South Block, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
| | - Opinder Sahota
- Department for Healthcare of Older People, B Floor, South Block, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
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Noser J, Dietrich M, Tiziani S, Werner CML, Pape HC, Osterhoff G. Mid-term follow-up after surgical treatment of fragility fractures of the pelvis. Injury 2018; 49:2032-2035. [PMID: 30224176 DOI: 10.1016/j.injury.2018.09.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/09/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Early operative treatment of fragility fractures of the pelvis (FFP) has been suggested to reduce pain and allow for earlier mobilization. The aim of this study was to determine mortality and functional outcome after operative treatment. PATIENTS AND METHODS Patients aged ≥60 years (n = 60; mean age 79 years, 53 female) who had operative treatment of a FFP and a follow-up of at least 2 years were identified and mortality was assessed using a national social insurance database. Those who had survived were contacted by phone and a modified Majeed Score was obtained. RESULTS At final follow up (62 months, range, 29-117), 32 patients (53.3%) had deceased. One-year-mortality rate was 28.3% and 2-year mortality was 36.7%. Mortality was not linked to fracture type (p > .05). Complications during hospitalization occurred in 26/60 patients (43.3%). Patients with a bilateral FFP had a longer hospitalization (18 vs. 11 days; p = .021). The mean modified Majeed score of surviving patients was 65 points (85.5% of achievable maximum). CONCLUSION Mortality and in-hospital complications remain high among patients with FFP even when treated operatively. A longer hospitalization can be expected in patients with posterior bilateral fractures.
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Affiliation(s)
- Jonas Noser
- Department of Trauma, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Michael Dietrich
- Department of Orthopaedics and Traumatology, Clinic for Surgery, Waid City Hospital, Zurich, Switzerland
| | - Simon Tiziani
- Department of Trauma, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Clément M L Werner
- Department of Trauma, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Georg Osterhoff
- Department of Trauma, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
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Abstract
Medications for osteoporosis are classified as either antiresorptive or anabolic. Whereas antiresorptive agents prevent bone resorption, anabolic agents promote new bone formation. Anabolics should be considered in individuals with severe osteoporosis, failure of alternative osteoporosis agents, intolerability or contraindications to other osteoporosis agents, and glucocorticoid-induced osteoporosis. There are currently two approved anabolic therapies, teriparatide and abaloparatide, and a third anabolic agent, romozosumab, is under review by the US Food and Drug Administration. Teriparatide and abaloparatide are administered as daily subcutaneous injections and have been shown to reduce vertebral and nonvertebral fractures significantly. The most common side effects are headache and nausea, but teriparatide and abaloparatide are generally well tolerated. The sequence of administration of anabolic therapy is important. Benefits of anabolics are attenuated in individuals with prior antiresorptive exposure; however, antiresorptive agents administered after anabolics consolidate bone mineral density gains.
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Affiliation(s)
- Andrea V Haas
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Meryl S LeBoff
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Moral-Cuesta D, Rodríguez-Sánchez I, Menéndez-Colino R, Díaz-Sebastián J, Alarcón T, Martín Maestre I, González-Montalvo JI. [Functional consequences of fragile pelvis fracture. Description of several cases attended by a consultation Geriatrics team]. Rev Esp Geriatr Gerontol 2018; 53:81-84. [PMID: 28784246 DOI: 10.1016/j.regg.2017.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/06/2017] [Accepted: 06/09/2017] [Indexed: 06/07/2023]
Abstract
INTRODUCTION The prevalence of pelvic fracture (PF) due to frailty is increasing, leading to an increase in functional impairment in the patient, as well as increasing morbidity and mortality. The aim of the present study is to gain knowledge about the sociodemographic characteristics, as well as the functional features, of patients admitted to hospital with PF and evaluated by a Geriatrics department. The functional burden of PF and the potential influence of geriatric interventions are also assessed. MATERIAL AND METHODS A retrospective study conducted between 1995 and 2015 on all patients older than 65 years old with PF admitted to the Traumatology department, and then assessed in the Geriatrics Department. Sociodemographic information was also collected (age, gender and place of residence), as well as data from the geriatric assessment (baseline situation and at hospital admission), hospital stay, within hospital mortality, and discharge. RESULTS The study included 271 patients with a mean age of 81.1±7 years, and mainly women (81.2%). The median hospital stay was 9 days (interquartile range 5 to 14 days). The ability to walk independently decreased after PF from 72.3% to 3.6%. Severe disability cases increased in activities of daily living from 7.9% to 79.5%. Within hospital mortality was 2.2%. As regards medical follow-up consultations, the mean length of stay was significantly reduced compared to the assessment consultations (10.0±7.8 vs 16.1±12.0 days, P<.001) CONCLUSION: PF patients evaluated by the Geriatrics Department were mainly women, with advanced age, and a severe functional impairment secondary to PF. The intervention of a geriatrician could contribute to optimise hospital resources.
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Affiliation(s)
- Debora Moral-Cuesta
- Servicio de Geriatría, Instituto de Investigación del Hospital La Paz (IdiPAZ), Madrid, España.
| | | | - Rocío Menéndez-Colino
- Servicio de Geriatría, Instituto de Investigación del Hospital La Paz (IdiPAZ), Madrid, España
| | | | - Teresa Alarcón
- Servicio de Geriatría, Instituto de Investigación del Hospital La Paz (IdiPAZ), Madrid, España
| | - Isabel Martín Maestre
- Servicio de Geriatría, Instituto de Investigación del Hospital La Paz (IdiPAZ), Madrid, España
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Abstract
PURPOSE OF REVIEW Until recently, osteoporotic pelvic fractures have not been specifically studied. This review presents an update on epidemiological data of pelvic fracture, including morbidity, mortality and healthcare costs, the role of surgery and new data on sacroplasty in acute phase management. RECENT FINDINGS All studies underline the burden of osteoporotic pelvic fractures. Risk factors associated with these fractures are age, sex (women), and previous loss of autonomy. An increased mortality has been reported in all publications, similar to hip fracture for in-patient mortality and at 5 years of follow-up. Pelvic fractures often lead to transient or permanent autonomy loss, reflecting the high costs because of extended hospital stay, combined with nursing home requirement. However, recent studies report a decrease in the length of stay. Sacroplasty displays promising results to control pain and improve functional outcome. Early surgery begins to be discussed to also improve the outcome. SUMMARY Pelvic fractures display all the features of severe osteoporotic fractures: increased incidence, high morbidity, mortality, and healthcare costs that justify awareness of the practitioner on these fractures. Further studies on sacroplasty and surgery are necessary to improve pain control, functional improvement, thereby reducing the length of hospital stay and cost.
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Arduini M, Saturnino L, Piperno A, Iundusi R, Tarantino U. Fragility fractures of the pelvis: treatment and preliminary results. Aging Clin Exp Res 2015; 27 Suppl 1:S61-7. [PMID: 26264247 DOI: 10.1007/s40520-015-0430-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/14/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND With increasing life expectancy, fragility fractures of the pelvic ring (FFP) are becoming frequent. In elderly, osteoporosis leads to a decrease of bone strength and resistance to the ligament's traction; this represents the most important difference between FFP and fractures in young patients. Usually, these fractures are underestimated and treatment is often conservative. AIMS To evaluate clinical and surgical outcomes of surgically treated patients with FFP. METHODS We retrospectively enrolled 14 patients, in our Trauma Center, underwent surgery procedures for FFP between 2012 and 2014. All patients attended clinical and radiological investigation at 1, 3, and 6 months postoperatively and every year after surgery with a mean follow-up of 22 months. RESULTS At 6-month follow-up, 11 patients resulted asymptomatic: able to maintain standing position and walk without crunches. Two patients were able to walk with one crunch. The patient with history of previous acetabular fracture walks with two crunches and is still waiting for total hip arthroplasty. DISCUSSION The compromised health status and the diminished bone-healing capacity, in elderly, decrease chances for a good clinical outcome. In literature, many authors suggest that mortality rate in patients with FFP is similar to those with hip fracture. Diagnosis of FFP is very important: these fractures are highly disabling in elderly and can lead to displacement and instability. For these reasons, correct diagnosis and well-conduct preoperative plan are necessary to improve stability of fractures and support bone healing. After diagnosis, an anti-osteoporotic treatment is indicated to improve bone quality and bone healing. CONCLUSIONS Our study shows encouraging results and demonstrates that minimally or less invasive osteosynthesis technique could lead to good outcome in these patients.
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Affiliation(s)
- M Arduini
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy.
| | - L Saturnino
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - A Piperno
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - R Iundusi
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - U Tarantino
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy
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