Global Forum: Fractures in the Elderly

Geriatric proximal femur fracture updates

Proximal femur fractures in the aging population present a variety of challenges. Physiologically, patients incurring this fracture are typically frail, with significant medical comorbidities, yet require early surgical treatment to restore mobility to prevent deterioration. Socioeconomically, the occurrence of a fragility fracture may be the beginning of the loss of independence, and the burdens of rehabilitation and support are borne by the individual patient and health care systems.

Pre-existing osteoporosis and serum vitamin D levels in patients with distal radius fractures: are we missing something?

INTRODUCTION

Given the significant therapeutic gap for osteoporosis, this study aims to investigate the most common osteoporosis-related fracture. The analysis will also consider patients' serum vitamin D levels and the indications for basic osteoporosis diagnostic tests and osteoporosis therapy prior to fracture.

MATERIALS AND METHODS

This prospective clinical trial included patients with distal radius fractures who underwent surgery at our hospital between 1 April 2021 and 7 April 2022. Blood samples were taken from all participants and existing risk factors for osteoporosis were recorded. In addition, the indication for a guideline-based osteoporosis diagnosis was assessed and the risk of another future fracture with FRAX® was calculated. This information was used to decide whether there was an indication for specific osteoporosis therapy.

RESULTS

A diagnosis gap of 53% and a treatment gap of 84% were identified among the 102 patients investigated. The patients' ages ranged from 46 to 91 years, with an average vitamin D level of 57 nmol/l, which was below the recommended level of 75 nmol/l. It was noted on a monthly basis that the vitamin D level (without substitution) never exceeded the recommended value of 75 nmol/l in any month. Three-quarters of patients had indications for a baseline osteoporosis diagnosis, yet less than 50% received one. According to FRAX® data, 57% of patients had indications for specific osteoporosis treatment before experiencing the fracture.

CONCLUSION

Even without a previous distal radius fracture, many patients are in need of osteoporosis diagnosis or treatment. Our research suggests that patients with distal radius fractures should have their vitamin D levels checked via a blood test and be evaluated for osteoporosis. As endogenous vitamin D levels are often inadequate, year-round vitamin D supplementation should be considered for the prevention of osteomalacia and as a basis for the treatment of osteoporosis.

GERMAN CLINICAL TRIAL REGISTER ID

DRKS00028085.

Biomechanical analysis of titanium-alloy and biodegradable implants in dual plate osteosynthesis for AO/ASIF type 33-C2 fractures

Background and objective

Treating geriatric osteoporotic distal femur fractures has always presented challenges, but developing biodegradable materials has brought new opportunities for therapeutic intervention. Despite this progress, there currently needs to be more evidence-based biomechanical guidelines for using dual plate fixation and biodegradable materials in treating osteoporotic comminuted distal femoral fractures.In this study, finite element analysis was conducted to evaluate the mechanical effectiveness of different implant materials (titanium alloys, biodegradable materials, and combinations of both) in the fixation of physiological and osteoporotic distal femoral fractures.

Methods

We constructed finite element models of 33-C2 fractures and three types of plates: the Lateral Less Invasive Stabilization System (LISS) plate, the titanium-alloy medial plate (TAP), and the biodegradable plate (BP). To evaluate the biomechanical advantages in both physiological femur (PF) and osteoporotic femur (OF) conditions, three scenarios were developed: LISS + TAP, LISS + BP, and double biodegradable plates (DBPs). Five loading conditions were applied to measure structural stiffness, fracture micromotion, and implant stress: medio-lateral four-point bending, antero-posterior four-point bending, axial loading, torsional loading, and sideways falling. Several parameters were examined, including peak Von Mises Stress (VMS) of the femur and lateral plate, maximum displacement, bending angle, torsional angle of fracture, and risk of fracture.

Results

In four-point bending tests, the lateral plate of the DBPs group exhibited a slightly lower peak VMS compared to the LISS + TAP and LISS + BP groups. When subjected to axial loading, the stiffness values of the LISS + TAP (OF) were 1.42 times and 1.86 times higher than LISS + BP (OF) and DBPs (OF) groups, and the peak VMS of lateral plate of DBPs (OF) construct was approximately 2% and 16% lower than that of the LISS + TAP (OF) and LISS + BP (OF) constructs. Under torsional loading, DBPs (OF) demonstrated rotational stiffness that was respectively 2% and 52% greater than that of LISS + TAP (OF) and LISS + BP (OF). Regarding the peak VMS of femur, the values of DBPs (OF) were almost 8% and 15% lower than those of LISS + TAP (OF) and LISS + BP (OF).

Conclusions

The use of DBPs at 11.33 GPa facilitated early mobilization of load-bearing joints but exhibited limited ability to support full weight-bearing activities. Though LISS + TAP met practical strength requirements, one should consider the potential biological irritation and stress shielding. Thus, employing a combination of biodegradable and metal internal fixation is a valid approach to effectively treat weight-bearing joint fractures in clinical practice.

Fracture-Related Infection-Epidemiology, Etiology, Diagnosis, Prevention, and Treatment

BACKGROUND

Fracture-related infection (FRI) is a challenge to physicians and other workers in health care. In 2018, there were 7253 listed cases of FRI in Germany, corresponding to an incidence of 10.7 cases per 100 000 persons per year.

METHODS

This review is based on pertinent publications retrieved from a search in PubMed with the search terms "fracture," "infection," "guideline," and "consensus." Aside from the primary literature, international guidelines and consensus recommendations were evaluated as well.

RESULTS

FRI arise mainly from bacterial contamination of the fracture site. Staphylococcus aureus is the most commonly detected pathogen. The treatment is based on surgery and antibiotics and should be agreed upon by an interdisciplinary team; it is often difficult because of biofilm formation. Treatment options include implant-preserving procedures and single-stage, two-stage, or multi-stage implant replacement. Treatment failure occurs in 10.3% to 21.4% of cases. The available evidence on the efficacy of various treatment approaches is derived mainly from retrospective cohort studies (level III evidence). Therefore, periprosthetic joint infections and FRI are often discussed together.

CONCLUSION

FRI presents an increasing challenge. Preventive measures should be optimized, and the treatment should always be decided upon by an interdisciplinary team. Only low-level evidence is available to date to guide diagnostic and treatment decisions. High-quality studies are therefore needed to help us meet this challenge more effectively.

Outcomes after ORIF are similar in young and elderly patients with tibial plateau fractures: A minimum 2-year follow-up study

BACKGROUND

This study aimed to compare the outcomes of open reduction internal fixation in young and elderly patients with tibial plateau fractures.

METHODS

A total of 224 patients with tibial plateau fractures treated with open reduction internal fixation at a level I trauma center from 2014 to 2019 were reviewed. The patients with a minimum follow-up of 2 years were divided into two groups, with those aged 60 years and older divided into the elderly group and those under 60 years divided into the young group. The mean follow-up time was 55 months (range: 24-80), and the primary outcomes were quality of reduction and function. The secondary outcomes included complications, fracture healing time, and conversion to total knee arthroplasty.

RESULTS

The elderly group had a higher proportion of women than the young group (61.1% vs. 23.9%, p < 0.001). Diabetes was more prevalent in the elderly cohort than in the young cohort (18.9% vs. 9.0%, p = 0.030). The rate of bone grafts was higher in the elderly group (57.8% vs. 41.8%, p = 0.019), but no significant differences were found between the groups regarding fracture characteristics, the operative time or intraoperative blood loss. The reduction quality, knee function, postoperative complications, healing time, and total knee arthroplasty conversion rate were not significantly different (p > 0.05) between the groups.

CONCLUSIONS

Open reduction internal fixation remains a satisfactory technique to treat tibial plateau fractures in the elderly. Although the rate of bone grafts is higher in elderly patients, they had comparable outcomes compared with their younger counterparts.

The safety and effectiveness of enhanced recovery after surgery (ERAS) in older patients undergoing orthopedic surgery: a systematic review and meta-analysis

INTRODUCTION

To systematically review and analyze the safety and effectiveness of ERAS in older patients undergoing orthopedic surgeries.

MATERIALS AND METHODS

We searched PubMed, EMBASE, CINAHL, MEDLINE (Ovid), Web of Science, the Cochrane Library, and other databases to identify all randomized controlled studies and cohorts. We used the Cochrane Risk of Bias Assessment Tool and the Newcastle‒Ottawa Scale to assess the study quality. A meta-analysis was performed using the inverse variance weighting method.

RESULTS

This study included 15 studies involving a total of 2591 older patients undergoing orthopedic surgeries with 1480 in the ERAS group. The ERAS group had a lower incidence of postoperative complications than the control group (RR 0.52; 95% CI 0.42-0.65). Length of stay was 3.37 days lower in the ERAS group than in the control group (P < 0.01). And the ERAS protocol reduced the patient's postoperative VAS score (P < 0.01). Meanwhile, there was a lack of evidence of significant differences between the ERAS group and the control group in total bleeding and 30-day readmission rate.

CONCLUSIONS

The implementation of the ERAS program in older patients undergoing orthopedic surgeries is safe and effective. However, there is still a lack of standardization of protocols across institutions and centers for orthopedic surgery for older patients. Identifying ERAS components that are beneficial to older patients and developing ERAS protocols that are appropriate for older adults may further improve outcomes.

Clinical Outcome of Carbon Fiber Reinforced Polyetheretherketone Plates in Patients with Proximal Humeral Fracture: One-Year Follow-Up

BACKGROUND

Proximal humerus fractures are seen frequently, particularly in older patients. The development of new osteosynthesis materials is being driven by the high complication rates following surgical treatment of proximal humerus fractures. Plate osteosyntheses made of steel, titanium and, for several years now, carbon fiber-reinforced polyetheretherketone (CFR-PEEK) are used most frequently.

METHODS

A prospective, randomized study was conducted in order to evaluate whether there are differences in the functional postoperative outcome when comparing CFR-PEEK and titanium implants for surgical treatment of proximal humerus fractures. The primary outcome of shoulder functionality 1 year after surgery was measured with the DASH score, the Oxford Shoulder Score, and the Simple Shoulder Test.

RESULTS

Bony consolidation of the respective fracture was confirmed in all the patients included in the study within the scope of postoperative follow-up care. No significant differences in the DASH score, Oxford Shoulder Score, or Simple Shoulder Test were observed 1 year post-operatively when comparing the implant materials CFR-PEEK and titanium.

CONCLUSIONS

There are no differences in terms of the functional outcome between CFR-PEEK plates and titanium implants 1 year after surgery. Studies on the long-term outcomes using CFR-PEEK plates in osteoporotic bone should be the subject of further research.

Complications and associated risk factors after surgical management of proximal femoral fractures

Aims

This work aimed at answering the following research questions: 1) What is the rate of mechanical complications, nonunion and infection for head/neck femoral fractures, intertrochanteric fractures, and subtrochanteric fractures in the elderly USA population? and 2) Which factors influence adverse outcomes?

Methods

Proximal femoral fractures occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records Data Base. The Kaplan-Meier method with Fine and Gray sub-distribution adaptation was used to determine rates for nonunion, infection, and mechanical complications. Semiparametric Cox regression model was applied incorporating 23 measures as covariates to identify risk factors.

Results

Union failure occured in 0.89% (95% confidence interval (CI) 0.83 to 0.95) after head/neck fracturs, in 0.92% (95% CI 0.84 to 1.01) after intertrochanteric fracture and in 1.99% (95% CI 1.69 to 2.33) after subtrochanteric fractures within 24 months. A fracture-related infection was more likely to occur after subtrochanteric fractures than after head/neck fractures (1.64% vs 1.59%, hazard ratio (HR) 1.01 (95% CI 0.87 to 1.17); p < 0.001) as well as after intertrochanteric fractures (1.64% vs 1.13%, HR 1.31 (95% CI 1.12 to 1.52); p < 0.001). Anticoagulant use, cerebrovascular disease, a concomitant fracture, diabetes mellitus, hypertension, obesity, open fracture, and rheumatoid disease was identified as risk factors. Mechanical complications after 24 months were most common after head/neck fractures with 3.52% (95% CI 3.41 to 3.64; currently at risk: 48,282).

Conclusion

The determination of complication rates for each fracture type can be useful for informed patient-clinician communication. Risk factors for complications could be identified for distinct proximal femur fractures in elderly patients, which are accessible for therapeutical treatment in the management.

Determination of Posterior Tibial Slope Changes After Tibial Plateau Fracture Fixation: A Retrospective Case Series

Background and Aim

A tibial plateau fracture is an intra-articular fracture that affects the function and stability of the knee joint and requires careful evaluation and pre-operative planning. We determined the posterior tibial slope changes after tibial plateau fracture stabilization, aiming to help improve surgical success in maintaining the lower limb's natural axis.

Methods

This retrospective case series involved all Golestan and Imam Khomeini hospital patients (Ahvaz, Iran) with Schatzker type IV-VI tibial plateau fractures from April 1, 2017, to March 30, 2020, who underwent surgical fixation. Data on the age, gender, body mass index (BMI), surgical approach, posterior tibial slope angle in the injured and healthy knees, pain, and knee joint instability were collected. We analyzed the data using SPSS version 22 and considered a significance level of P < 0.05.

Results

Among the 31 study participants, 24 (77.4%) were males. The mean age of the patients was 39.81 ± 14.41 years (21-78), with a mean BMI of 25.4 ± 2.7 (20.3-31.2) kg/m2 and hospitalization duration of 5.8 ± 9.3 days (3-29). Most patients had type VI fractures (48.3%). The posterior tibial slope angle shared no relation with age, gender, BMI, or surgical approach (P > 0.05). After tibial plateau fracture fixation, the posterior tibial slope angle significantly increased in the injured knee compared with the healthy knee (P < 0.05). Six months after the operation, the angle of the injured knee decreased but remained higher than that of the healthy knee (P > 0.05).

Conclusion

The tibial slope's posterior column collapses more than its anterior column over time, reducing the posterior tibial slope angle. Therefore, the correct reduction of the tibial plateau's posterior slope is more important.

Cardiometabolic Disorders Are Important Correlates of Vulnerability in Hospitalized Older Adults

With an increasingly aging population worldwide, the concept of multimorbidity has attracted growing interest over recent years, especially in terms of frailty, which leads to progressive multisystem decline and increased adverse clinical outcomes. The relative contribution of multiple disorders to overall frailty index in older populations has not been established so far. This study aimed to assess the association between the vulnerable elders survey-13 (VES-13) score, which is acknowledged to be one of the most widely used measures of frailty, and the most common accompanying diseases amongst hospitalized adults aged 60 years old and more. A total of 2860 participants with an average age of 83 years were included in this study. Multiple logistic regression with adjustment for age and nutritional status was used to assess the independent impact of every particular disease on vulnerability. Diabetes mellitus type 2, coronary artery disease, atrial fibrillation, heart failure, chronic kidney disease, osteoarthritis, fractures, eyes disorders, depression, dementia, pressure ulcers, and urinary incontinence were associated with higher scores of VES-13. Hospital admission of older subjects with those conditions should primarily draw attention to the risk of functional decline, especially while qualifying older patients for further treatment in surgery and oncology. At the same time, lipid disorders, gastrointestinal diseases, higher body mass index, and albumins level were related to a lower risk of being vulnerable, which may be attributed to a younger age and better nutritional status of those patients.

Epidemiology and treatment of proximal femoral fractures in the elderly U.S. population

Proximal femoral fractures are a serious complication, especially for elderly patients. Detailed epidemiological analyzes provide a valuable resource for stakeholders in the health care system in order to foresee future development possibly influenceable by adaption of therapeutic procedures and prevention strategies. This work aimed at answering the following research questions: (1) What are the incidence rates of proximal femoral fractures in the elderly U.S. population? (2) What is the preferred treatment procedure for these fractures? Proximal femoral fractures occurred between January 1, 2009 and December 31, 2019 in patients ≥ 65 years were identified from the Medicare Physician Service Records Data Base. The 5% sample of Medicare beneficiaries, equivalent to the records from approximately 2.5 million enrollees formed the basis of this study. Fractures were grouped into head/neck, intertrochanteric, and subtrochanteric fractures. The overall incidence rate, age and sex specific incidence rates as well as incidence rate ratios were calculated. Common Procedural Terminology (CPT) codes were used to identify procedures and operations. In 2019, a total number of 7982 femoral head/neck fractures was recorded. In comparison to 9588 cases in 2009, the incidence substantially decreased by 26.6% from 666.7/100,000 inhabitants to 489.3/100,000 inhabitants (z =  - 5.197, p < 0.001). Also, in intertrochanteric fractures, a significant decline in the incidence by 17.3% was evident over the years from 367.7/100,000 inhabitants in 2009 to 304.0 cases per 100,000 inhabitants in 2019 (z =  - 2.454, p = 0.014). A similar picture was observable for subtrochanteric fractures, which decreased by 29.6% (51.0 cases per 100,000 to 35.9 cases per 100,000) over the time period (z =  - 1.612, p = 0.107). Head/neck fractures were mainly treated with an arthroplasty (n = 36,301, 40.0%). The majority of intertrochanteric fractures and subtrochanteric fractures received treatment with an intramedullary device (n = 34,630, 65.5% and n = 5870, 77.1%, respectively). The analysis indicated that the incidence of all types of proximal femoral neck fractures decreased for the population of elderly patients in the U.S. within the last decade. Treatment of head and neck fractures was mainly conducted through arthroplasty, while intertrochanteric and subtrochanteric fractures predominantly received an intramedullary nailing.

Orthogeriatric Assessment of the Elderly Patient with Fragility Hip Fracture: Preliminary Results of a Prospective Study

Nowadays, more studies deal with "OrthoGeriatrics", for the co-management of elderly patients suffering fractures, from the admission to the discharge and beyond. For the first time at Cagliari University Hospital, we introduced an orthogeriatric service, in which trained geriatricians stay in orthopedic unit alongside trained orthopedics. The primary aim of the study was to analyze the rate of death and rehospitalization in elderly femur-fractured people of 65 or more years of age, identifying possible predictive factors. The secondary aim of the study was to analyze the recovery of daily living autonomies during the months following surgery. To reach the aim, we designed a prospective study, which is currently ongoing. We evaluated femur-fractured patients aged 65 years or more with a comprehensive geriatric assessment before surgery. The most common fractures were lateral hip ones, treated with osteosynthesis. Cognitive-affective, functional, and nutritional status, mood, and comorbidities were less impaired than in the outpatient service of the same hospital devoted to frail elderly. Pain control was excellent. A significantly low delirium incidence was found. More than a third of the sample were recognized as frail (according to the Survey of Health, Ageing and Retirement in Europe-Frailty Instrument (SHARE-FI)), and over a third of the sample were identified as a moderate-high risk of hospitalization and death (according to Multidimensional Prognostic Index (MPI)). Overall mortality rate was 13.87%, and rehospitalization rate was 11.84%. Frail people were more likely to die than non-frail (HR: 5.64), and pre-frail ones (HR: 3.97); similarly, high-risk patients were more likely to die than low-risk (HR: 8.04), and moderate-risk ones (HR: 5.46). Conversely, neither SHARE-FI nor MPI predicted rehospitalization. Creatinine (OR: 2.66, p = 0.003) and folate (OR: 0.75, p = 0.03) levels were independently associated with death and rehospitalization, respectively. Finally, the patients did recover the lost autonomies later, 6 months after surgery. Our study demonstrated that SHARE-FI and MPI are reliable tools to predict mortality in an orthogeriatric setting, and that creatinine and folate levels should also be measured given their independent association with negative outcomes.

Proximal humerus fractures - epidemiology, comparison of mortality rates after surgical versus non-surgical treatment, and analysis of risk factors based on Medicare registry data

AIMS

The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?

METHODS

PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments.

RESULTS

From 2009 to 2019, the incidence decreased by 11.85% from 300.4 cases/100,000 enrollees to 266.3 cases/100,000 enrollees, although this was not statistically significant (z = -1.47, p = 0.142). In comparison to matched Medicare patients without a PHF, but of the same five-year age group and sex, a mean survival difference of -17.3% was observed. The one-year mortality rate was higher after nonoperative treatment with 16.4% compared to surgical treatment with 9.3% (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.23 to 1.36; p < 0.001) and to shoulder arthroplasty with 7.4% (HR = 1.45, 95% CI 1.33 to 1.58; p < 0.001). Statistically significant mortality risk factors after operative treatment included age older than 75 years, male sex, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, chronic kidney disease, a concomitant fracture, congestive heart failure, and osteoporotic fracture.

CONCLUSION

Mortality risk factors for distinct treatment modes after PHF in elderly patients could be identified, which may guide clinical decision-making.Cite this article: Bone Joint Res 2023;12(2):103-112.

Operative treatment of nonunions in the elderly: Clinical and radiographic outcomes in patients at minimum 75 years of age

BACKGROUND

Limited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients.

METHODS

We identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations.

RESULTS

We identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75-96). Median time to presentation was 12 months (range 4-127) after injury, median number of prior surgeries was 1 (range 0-4). Union rate was 100%, with median time to union 6 months (range 2-42). Six patients underwent revision for persistent nonunion and healed without further complications.

CONCLUSIONS

Using a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur.

LEVEL OF EVIDENCE

IV.

Predictors of hospital readmission after fractures: One-year follow-up study

OBJECTIVE

Identify the incidence and predictive factors for readmissions of elderly hospitalized with fractures.

METHOD

Prospective cohort study on 376 elderly people from a trauma referral large hospital in central Brazil. Data were collected from medical records of elderly people with radiological diagnosis of fractures. Readmission that occurs up to one year after the first discharge was defined the outcome variable. Pre- and post-admission characteristics were analyzed as predictive factors. Multiple analysis was performed using robust Poisson regression.

RESULTS

The main cause of hospitalization was fracture of the femur (53.2%) and the most frequent trauma mechanism was fall from standing height (72.9%). The incidence of readmission was 20.7%, of which 30.5% were related to the fracture itself, with emphasis on Surgical Site Infection. The predictors of readmissions were: age range 60 to 69 years, COPD, delirium and fracture of the femur.

CONCLUSIONS

The incidence of readmissions was high, with various causes and associated conditions pre-admission (age range 60-69, presenting COPD) and post-admission (delirium). The monitoring of these factors in the hospital environment is essential for prevention of readmissions.

The association of coffee consumption with the risk of osteoporosis and fractures: a systematic review and meta-analysis

To elucidate the association of coffee and bone health would help fracture risk reduction via dietary intervention. Although those who had higher coffee consumption were less likely to have osteoporosis, the associations between coffee consumption and fracture risk need further investigations with better study designs.

INTRODUCTION

The associations between coffee consumption and the risk of osteoporosis and fracture remain inconclusive. We aimed to better quantify these associations by conducting meta-analyses of observational studies.

METHODS

Relevant studies were systematically searched on PubMed, Web of Science, Cochrane library, and Embase Database up to November 25, 2021. The odds ratio (OR) or relative risk (RR) with 95% confidence intervals (CI) was pooled and a dose-response analysis was performed.

RESULTS

Four studies with 7114 participants for osteoporosis and thirteen studies with 391,956 participants for fracture incidence were included in the meta-analyses. High versus low coffee consumption was associated with a lower risk of osteoporosis [pooled OR (95% CI): 0.79 (0.65-0.92)], while it was non-significantly associated with fracture incidence [pooled OR (95% CI): 0.86 (0.67-1.05) at hip and 0.89 (0.42-1.36) at non-hip]. A non-linear association between the level of coffee consumption and hip fracture incidence was shown (P = 0.004). The pooled RR (95% CI) of hip fracture risk in those who consumed 1, 2-3, 4, and ≥ 9 cups of coffee per day was 0.92 (0.87-0.97), 0.89 (0.83-0.95), 0.91 (0.85-0.98), and 1.10 (0.76-1.59), respectively. The significance in the association between coffee consumption and the hip fracture incidence decreased in those studies that had larger sample size, higher quality, and more adjustments.

CONCLUSIONS

A dose-dependent relationship may exist between coffee consumption and hip fracture incidence. The effect of high versus low coffee consumption was influenced by study designs. Further studies with dedicated designs are needed to confirm the independent effects of coffee consumption on bone health.

The Accident Environment Resulting in Fragility Fractures: A 20-year National Epidemiologic Study

INTRODUCTION

Fragility fractures are an enduring source of morbidity in the elderly with unfortunate frequency and rising costs. Although the predominant cause of fractures is generally understood to be falls, the exact stratification of the causes of fractures presenting to the emergency department has not yet been described in the literature. We sought out to stratify the primary products associated with fractures in the elderly, further describing the anatomic location of the fracture and setting of injury.

METHODS

We queried the National Electronic Injury Surveillance System database for all fractures in patients older than 65 years from January 1, 2000, to December 31, 2019. We analyzed demographic data, patient disposition, anatomic fracture location, and injury setting for the top 20 causes of fractures. Trends, proportions and distributions were analyzed using descriptive statistics.

RESULTS

A total of 901,418 visits to the Emergency Department were reviewed. Of these, 216,657 (24%) were found to have fractures. The top 20 causes for fractures accounted for a total of 173,557 (19%) fractures. The average age in our population was 80.1 years (SD 8.7). Women constituted most of the patients (127,753 [74%]). Flooring (58,347 [33.6%]) was the most common product associated with the cause of fractures, with stairs/steps (29,804 [17.2%]) and bed/bed frames (19,004 [10.9%]) being the second and third most common, respectively. Lower extremity fractures (97,195 [56%]) were more common than upper extremity fractures (63,899 [37%]). The lower trunk (pelvis, femoral neck, and lower spine) was the most common anatomic location of fractures reported (64,132 [37.0%]). Most fractures occurred either at home (113,158 [65.2%]) or at a public setting (31,162 [18.0%]).

CONCLUSIONS

Most products associated with fractures among mature adults were related to flooring, stairs, or bedding. This study offers a detailed understanding on the common products associated with fractures in mature adults and aids in discussing preventive measures for lowering fracture risk with patients, communities, and healthcare systems.

Region-specific associations among tissue-level mechanical properties, porosity, and composition in human male femora

Region-specific differences in age-related bone remodeling are known to exist. We therefore hypothesized that the decline in tissue-level strength and post-yield strain (PYS) with age is not uniform within the femur, but is driven by region-specific differences in porosity and composition. Four-point bending was conducted on anterior, posterior, medial, and lateral beams from male cadaveric femora (n = 33, 18-89 yrs of age). Mid-cortical porosity, composition, and mineralization were assessed using nano-computed tomography (nanoCT), Raman spectroscopy, and ashing assays. Traits between bones from young and elderly groups were compared, while multivariate analyses were used to identify traits that predicted strength and PYS at the regional level. We show that age-related decline in porosity and mechanical properties varied regionally, with highest positive slope of age vs. Log(porosity) found in posterior and anterior bone, and steepest negative slopes of age vs. strength and age vs. PYS found in anterior bone. Multivariate analyses show that Log(porosity) and/or Raman 1246/1269 ratio explained 46-51% of the variance in strength in anterior and posterior bone. Three out of five traits related to Log(porosity), mineral crystallinity, 1246/1269, mineral/matrix ratio, and/or hydroxyproline/proline (Hyp/Pro) ratio, explained 35-50% of the variance in PYS in anterior, posterior and lateral bones. Log(porosity) and Hyp/Pro ratio alone explained 13% and 19% of the variance in strength and PYS in medial bone, respectively. The predictive performance of multivariate analyses was negatively impacted by pooling data across all bone regions, underscoring the complexity of the femur and that the use of pooled analyses may obscure underlying region-specific differences.

Autonomy of the elderly after a hip fracture surgery in a subsaharan country

Purpose: The aim of this study was to assess the impact of surgery on autonomy in the elderly after a fracture of the proximal femur; and the factors associated with its alteration. Materials and methods: A prospective longitudinal study was performed on 66 patients aged at least 90 years treated for a fracture of the proximal femur between 2008 and 2017. Physical autonomy was assessed using the Katz scale Results: After the surgical management, the previous level of autonomy was found progressively increasing in 9.1% at 1 month, 17.5% in the 3rd month, 23.5% in the 6th month and 22% at 1 year ( P value <0.001). The factors associated with the deterioration in patient autonomy one month postoperatively were as follows: late admission ( P = 0.02), a period of verticalization greater than 15 days ( P = 0.02), at least one complication of decubitus ( P = 0.004), anemia ( P = 0.02) and an ASA score ≥ 2 ( P = 0.05). The comparison of the autonomy between hip fixation and hip prosthetic replacement did not show a significant difference in the first postoperative month ( P = 0.83). Conclusion: Even at over 90 years of age, surgery can significantly restore previous autonomy. The early admission and management of patients, the prevention of complications in the decubitus position, the early rise after surgery and the management of anemia are key points in restoring physical autonomy.

What Is the Most Effective Empirical Antibiotic Treatment for Early, Delayed, and Late Fracture-Related Infections?

Antibiotic treatment strategies for fracture-related infections (FRI) are often extrapolated from periprosthetic joint infections (PJI), although, in contrast to PJI, detailed analysis of pathogens and their antibiotic resistance is missing. Therefore, this study aimed to investigate antibiotic susceptibility profiles to identify effective empiric antibiotic treatment for early-, delayed-, and late-onset FRI. Patients treated for FRI from 2013 to 2020 were grouped into early (<2 weeks), delayed (3−10 weeks), and late (>10 weeks) onset of infection. Antibiotic susceptibility profiles were examined with respect to broadly used antibiotics and antibiotic combinations. In total, 117 patients (early n = 19, delayed n = 60, late n = 38) were enrolled. In early-onset FRI, 100.0% efficacy would be achieved by meropenem + vancomycin, gentamicin + vancomycin, co-amoxiclav + glycopeptide, ciprofloxacin + glycopeptide and piperacillin/tazobactam + glycopeptide. For patients with delayed FRI, the highest susceptibility was revealed for meropenem + vancomycin, gentamicin + vancomycin and ciprofloxacin + glycopeptide (96.7%). Meropenem + vancomycin was the most effective empiric antimicrobial in patients with late-onset of infection with 92.1% coverage. No subgroup differences in antibiotic sensitivity profiles were observed except for the combination ciprofloxacin + glycopeptide, which was significantly superior in early FRI (F = 3.304, p = 0.04). Across all subgroups meropenem + vancomycin was the most effective empiric treatment in 95.7% of patients with confirmed susceptibility. Meropenem + vancomycin, gentamicin + vancomycin, co-amoxiclav + glycopeptide are the best therapeutic options for FRI, regardless of the onset of infection. To avoid multidrug resistance, established antibiotic combinations such as co-amoxiclav with a glycopeptide seem to be reasonable as a systemic antibiotic therapy, while vancomycin + gentamicin could be implemented in local antibiotic therapy to reduce adverse events during treatment.

Development and Internal Validation of a Nomogram to Predict Mortality During the ICU Stay of Thoracic Fracture Patients Without Neurological Compromise: An Analysis of the MIMIC-III Clinical Database

Background: This study aimed to develop and validate a nomogram for predicting mortality in patients with thoracic fractures without neurological compromise and hospitalized in the intensive care unit. Methods: A total of 298 patients from the Medical Information Mart for Intensive Care III (MIMIC-III) database were included in the study, and 35 clinical indicators were collected within 24 h of patient admission. Risk factors were identified using the least absolute shrinkage and selection operator (LASSO) regression. A multivariate logistic regression model was established, and a nomogram was constructed. Internal validation was performed by the 1,000 bootstrap samples; a receiver operating curve (ROC) was plotted, and the area under the curve (AUC), sensitivity, and specificity were calculated. In addition, the calibration of our model was evaluated by the calibration curve and Hosmer-Lemeshow goodness-of-fit test (HL test). A decision curve analysis (DCA) was performed, and the nomogram was compared with scoring systems commonly used during clinical practice to assess the net clinical benefit. Results: Indicators included in the nomogram were age, OASIS score, SAPS II score, respiratory rate, partial thromboplastin time (PTT), cardiac arrhythmias, and fluid-electrolyte disorders. The results showed that our model yielded satisfied diagnostic performance with an AUC value of 0.902 and 0.883 using the training set and on internal validation. The calibration curve and the Hosmer-Lemeshow goodness-of-fit (HL). The HL tests exhibited satisfactory concordance between predicted and actual outcomes (P = 0.648). The DCA showed a superior net clinical benefit of our model over previously reported scoring systems. Conclusion: In summary, we explored the incidence of mortality during the ICU stay of thoracic fracture patients without neurological compromise and developed a prediction model that facilitates clinical decision making. However, external validation will be needed in the future.

Preclinical and Clinical Amelioration of Bone Fractures with Mesenchymal Stromal Cells: a Systematic Review and Meta-Analysis

Even though reunion of bone fracture confronts clinicians, mesenchymal stromal cells (MSCs) are investigated to be curative in bone fracture. This study aimed to explore the application potential of MSCs for healing bone fractures. By inputting search terms and retrieving studies published up to March 2021, multiple databases, including PubMed, EMBASE, Web of Science, and Cochrane Library, were searched to identify eligible studies. The mean difference (MD) and 95% confidence interval (95% CI) were calculated to analyze the main results in the meta-analysis. Data analysis was performed using Engauge Digitizer 10.8 and R Software. Of the 31 articles, 26 were preclinical studies (n = 913), and 5 were clinical trials (n = 335). Preclinically, MSCs therapy significantly augmented the progress of bone regeneration [(bone volume over tissue volume (MD7.35, p < 0.01)], despite some non-significant effects (on the callus index, bone strength, work to failure, and stiffness). Clinically, the MSC group had a significantly reduced incidence of poor recovery (odds ratio (OR) 0.30, p < 0.01); however, a significant decrease in healing time was not observed in the MSC group (MD 2.47, p = 0.26). In summary, our data suggest that patients with bone fractures benefited from MSC administration and that MSCs are a potentially useful agent for bone regeneration. Despite these satisfactory outcomes, larger randomised clinical trials (RCTs) are necessary to confirm these findings.

Primary total knee replacement for tibial plateau fractures in older patients: a systematic review of 197 patients

INTRODUCTION

Tibial plateau fractures are typically treated with osteosynthesis. In older patients, osteosynthesis is associated with some complications, risk of post-traumatic osteoarthritis and long partial, or non-weight bearing during the recovery phase. To avoid these problems, primary total knee replacement (TKR) has become an increasingly common treatment option. The aim of this study was to evaluate all the relevant literature and summarize the current evidence-based knowledge on the treatment of tibial plateau fractures with primary TKR in older patients.

MATERIALS AND METHODS

A systematic literature search of studies on total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture was conducted using OVID Medline, Scopus, and Cochrane databases from 1946 to 18 November 2019. We included all studies without restrictions regarding total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture.

RESULTS

Of the 640 reviewed articles, 16 studies with a total of 197 patients met the inclusion criteria. No controlled trials were available, and the overall quality of the literature was low. The results, using different clinical scoring systems, were good or fair. Four-year follow-up complication (6.1%) and revision (3.6%) rates after primary TKR appeared to be lower than after secondary TKR (complication rate 20-48%, revision rate 8-20%) but higher than after elective primary TKR.

CONCLUSION

Based on low-quality evidence, TKR appears to be a useful treatment option for tibial plateau fractures in older patients. Controlled trials are mandatory to determine the relative superiority of these two options as primary treatment of tibial plateau fractures in older patients.

Surgical treatment is not cost-effective compared to nonoperative treatment for displaced distal radius fractures in patients 65 years and over

Aims

The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis.

Methods

A cost-utility analysis was performed alongside a randomized controlled trial. A total of 50 patients were randomized to each group. We prospectively collected data on resource use during the first year post-fracture, and estimated costs of initial treatment, further operations, physiotherapy, home nursing, and production loss. Health-related quality of life was based on the Euro-QoL five-dimension, five-level (EQ-5D-5L) utility index, and quality-adjusted life-years (QALYs) were calculated.

Results

The mean QALYs were 0.05 higher in the operative group during the first 12 months (p = 0.260). The healthcare provider costs were €1,533 higher per patient in the operative group: €3,589 in the operative group and 2,056 in the nonoperative group. With a suggested willingness to pay of €27,500 per QALY there was a 45% chance for operative treatment to be cost-effective. For both groups, the main costs were related to the primary treatment. The primary surgery was the main driver of the difference between the groups. The costs related to loss of production were high in both groups, despite high rates of retirement. Retirement rate was unevenly distributed between the groups and was not included in the analysis.

Conclusion

Surgical treatment was not cost-effective in patients aged 65 years and older compared to nonoperative treatment of displaced distal radius fractures in a healthcare perspective. Costs related to loss of production might change this in the future if the retirement age increases.

Level of evidence: II

Cite this article: Bone Jt Open 2021;2(12):1027–1034.

Pre-fracture Mobility Using Standardized Scale as an Early Indicator of High Health Risk in Patients with a Hip Fracture

Hip fracture in older adults is associated with poor prognosis. We tested the hypothesis that a single standardized measure, pre-fracture mobility, can be used as an early indicator of patients at high health risk after a hip fracture. Analysis of prospectively collected data of older adults admitted with a hip fracture between April-2009 and June-2019 in a single NHS hospital, UK. Pre-fracture mobility status (freely mobile, mobilising outdoors with one aid or with two aids, and limited to indoors), was used to predict length of stay (LOS) and mortality in hospital, and discharge destination. Among 3073 (2231 women, 842 men) admitted from their own home (mean ± SD age = 82.7 ± 9.3 yr), 159 died and 2914 survived to discharge: 1834 back to their home, 772 to rehabilitation, 66 to residential care, 141 to nursing care and 101 to unknown destinations. Compared with LOS of 15.9 ± 15.6 days in patients who mobilised freely before fracture (reference), those who were able to mobilise outdoors with one aid stayed 3.5 days, and those with two aids or confined to indoor mobility stayed one week longer in hospital. In-patient mortality was increased among patients who mobilised outdoors with two aids: OR = 2.1 (95%CI = 1.3–3.3), and those limited to indoors: OR = 2.1 (1.3–1.5). Finally, a change in residence on discharge was more likely in those who mobilised outdoors with two aids (OR = 1.8, 95%CI = 1.2–2.6), and those limited to indoors (OR = 1.9, 95%CI = 1.2–2.9). In conclusion, pre-fracture mobility may be a useful early indicator for identifying patients at increased risk of adverse outcomes after an acute hip fracture.

Radiological Outcome Measures Indicate Advantages of Precontoured Locking Compression Plates in Elderly Patients With Split-Depression Fractures to the Lateral Tibial Plateau (AO41B3)

Background

Split-depression fractures to the lateral tibial plateau (AO41B3) often feature severe joint surface destructions. Precontoured locking compression plates (LCPs) are designed for optimum support of the reduced joint surface and have especially been emphasized in reduced bone quality. A lack of evidence still inhibits their broad utilization in elderly patients. Thus, aim of the present study was to investigate the implant-specific radiological outcomes of AO41B3-fractures in young versus elderly patients.

Methods

The hospital’s database was screened for isolated AO41B3-factures, open reduction and internal fixation (ORIF), and radiological follow-up ≥12 months. CT-scans, radiographs, and patients’ records were analyzed. Patients were attributed as young (18–49) or elderly (≥50 years). Additional subgrouping was carried out into precontoured LCP and conventional implants. The Rasmussen Radiological Score (RRS) after 12 months was set as primary outcome parameter. The RRS postoperatively and the medial proximal tibial angle (MPTA) postoperatively and after 12 months were secondary outcome parameters.

Results

Fifty nine consecutive patients were included (26 young, 38.2 ± 7.8 years; 33 elderly, 61.3 ± 9.4 years). There were no significant differences regarding mean size and depression depth of the lateral joint surface fragments. Prior to implant-specific subgrouping, the radiological outcome measures revealed no significant differences between young (RRS = 7.7 ± 1.7; MPTA = 90.3 ± 2.3°) and elderly (RRS = 7.2 ± 1.7; MPTA = 90.5 ± 3.3°). After implant-specific subgrouping, the radiological outcome revealed significantly impaired results in young patients with conventional implants (RRS_(C) = 6.9 ± 1.6, RRS_(LCP) = 8.5 ± 1.5, P = .015; MPTA_(C) = 91.5 ± 1.9°, MPTA_(LCP) = 89.1 ± 2.1°, P = .01). The effect was even more pronounced in elderly patients, with highly significant deterioration of the radiological outcome measures for conventional implants compared to precontoured LCP (RRS_(C) = 5.7 ± 1.6, RRS_(LCP) = 8.2 ± .8, P < .001; MPTA_(C) = 92.6 ± 4.2°, MPTA_(LCP) = 89.2 ± 1.4°, P = .002).

Conclusion

Utilizing precontoured LCP in the treatment of AO41B3-fractures is associated with improved radiological outcomes. This effect is significant in young but even more pronounced in elderly patients. Consequently, precontoured LCP should closely be considered in any AO41B3-fracture, but especially in elderly patients.

The Incidence of Fractures Among the Adult Population of Germany – and Analysis From 2009 through 2019

BACKGROUND

Detailed analyses of epidemiological data on fractures are an important resource for persons and institutions providing health care services, as they yield information on the effects of current treatment strategies and on the need for preventive measures. The epidemiology of fractures in Germany, however, is unknown. The goal of this study is to determine the nationwide fracture burden from 2009 through 2019, as a function of anatomical site, age, and sex.

METHODS

Annual compilations of ICD-10 diagnosis codes for the years 2009-2019 were made available to us by the German Federal Statistical Office. The prevalence and incidence of fractures at 30 different sites were quantified, and standardized sex and age distributions were calculated.

RESULTS

A total of 688 403 fractures was registered in 2019. From 2009 to 2019, the incidence of fractures rose by 14%, to 1014 fractures per 100 000 persons per year. The most common fracture types were femoral neck fractures (120 per 100 000 persons per year), pertrochanteric femural fractures (109 per 100 000 persons per year), and distal radius fractures (106 per 100 000 persons per year). All types were more common in women, with incidences that rose with age. The highest incidence was of pertrochanteric femoral fractures in women over age 90, with an incidence of 2550 per 100 000 persons per year. The largest rises in incidence were seen with regard to acetabular fractures (+ 58.16%) and clavicular fractures (+ 44.02%).

CONCLUSION

The increasing frequency of fractures, particularly among the elderly, presents a challenge to the health care system. Given the high frequency of geriatric fractures, prophylactic measures against fractures ought to be intensified.

High bone mineral density in lifelong trained female team handball players and young elite football players

PURPOSE

Low bone mineral density (BMD) and fractures are a major concern in the female population and preventative strategies are needed. Whether team sports participation may reduce age-related bone loss in elderly women is still uncertain.

METHODS

One hundred and thirty healthy, non-smoking women participated in this cross-sectional study, i.e., elderly (60-80 years) team handball players (EH, n = 35), elderly untrained controls (EC, n = 35), young (18-30 years) elite football players (YF, n = 30) and young untrained controls (YC, n = 30). A whole-body and two regional dual-energy X-ray absorptiometry (DXA) scans were performed to evaluate BMD and a blood sample was collected for measurement of bone turnover markers (BTMs).

RESULTS

EH had higher BMD in all regions of the lumbar spine, except for L1, compared to EC (8-10%), and higher BMD in the femoral Ward's triangle (9%) and trochanter (7%) of the left leg. Furthermore, EH had higher mean leg BMD (8%) and whole-body BMD (5%) than EC. EH and YC had similar BMD in femoral trochanter, L1-L4 and mean leg despite an age difference of ~ 40 years. YF had higher BMD in all regions of the proximal femur (18-29%) and lumbar spine (12-16%) compared to YC, as well as higher mean leg BMD (20%) and whole-body BMD (13%). Sclerostin was 14% lower in EH compared to EC. YF showed higher PINP (98%), osteocalcin (57%), and CTX (83%) compared to YC.

CONCLUSION

Lifelong team handball training and elite football training are associated with superior bone mineralization and changed bone turnover in elderly and young women.

Treatment of Distal Radius Fractures in Women Older than 80 Years: A Preliminary Report of Functional and Radiographic Outcomes after Open Reduction and Internal Fixation

Background Distal radius fractures are one of the most common fractures seen in the elderly. The management of distal radius fractures in the elderly, especially patients older than 80 years, has not been well defined. The purpose of this study was to evaluate operative treatment of distal radius fractures in patients older than 80 years to determine functional outcomes and complication rates.

Materials and Methods A retrospective review was performed to identify patients 80 years or older who were treated for a distal radius fracture with open reduction and internal fixation (ORIF). Medical records were reviewed for demographics, medical history, functional outcomes including quick Disabilities of the Arm, Shoulder, and Hand (qDASH), radiographs, and postoperative complications.

Results There were 40 patients included for review. Average age was 84 years. The preoperative qDASH score was 69. At 6 months follow-up, the postoperative qDASH score was 13 (p < 0.001). There were five (12.5%) complications reported postoperatively. All fractures healed with adequate radiographic alignment and there were no hardware failures.

Conclusion Distal radius fractures in patients older than 80 years treated with ORIF have good functional outcomes and low complication rates. Increased functionality and independence of the elderly, as well as updated implant design can lead to the effective surgical management of these patients. When indicated from a clinical perspective, operative fixation of distal radius fractures should be considered in patients older than 80 years.

One Year Later: What Was the Impact of the COVID-19 Pandemic on Orthopedic Practice?

The coronavirus disease 2019 (COVID-19) pandemic is an enormous challenge for health care systems worldwide.

Although it is widely accepted that orthopedic service has been reduced during the COVID-19 pandemic, little is known about the magnitude and qualitative characteristics of this reduction. The aim of the present study is to quantify the impact of the COVID-19 pandemic on everyday orthopedic practice and to detect the qualitative details of this impact in order to provide data for appropriate planning of health care policy.

Data from the year 2020, when the COVID-19 pandemic occurred, regarding the number of patients examined in the emergency department, outpatient clinics, as well as the number of hospital admissions, were recorded for each month. The number of surgical procedures per month was also recorded and evaluated in relation to the category and the anatomical region that these procedures pertained to. Similar data from the year 2019 were used as a control group.

The mean number of patients who visited the emergency department, the outpatient clinics, and those who were admitted to the hospital per month decreased by 47.2%, 30.4%, and 9%, respectively. Overall, the mean number of orthopedic operations decreased by 11.7%, with trauma operations being reduced by 8.9% and elective operations by 13% per month.

Based on the findings of the present study, the impact of the COVID-19 pandemic on orthopedic patients is definitely negative. The establishment of new guidelines and re-distribution of resources is required to return to a normal function of orthopedic practice within hospitals.

The Association Between Cholecystectomy and the Risk for Fracture: A Nationwide Population-Based Cohort Study in Korea

Objectives

To evaluate the risk of fracture in individuals with a history of cholecystectomy in Korean population.

Methods

Individuals (n = 143,667) aged ≥ 40 y who underwent cholecystectomy between 2010 and 2015 and the controls (n = 255,522), matched by age and sex, were identified from the database of the Korean National Health Insurance Services. The adjusted hazard ratio (aHR) and 95% confidence interval (CI) of fracture were estimated following cholecystectomy, and a Cox regression analysis was performed.

Results

The incidence rates of all fractures, vertebral, and hip fractures were 14.689, 6.483 and 1.228 cases per 1000 person-years respectively in the cholecystectomy group, whereas they were 13.862, 5.976, and 1.019 cases per 1000 person-years respectively in the control group. After adjustment for age, sex, income, place of residence, diabetes mellitus, hypertension, dyslipidemia, smoking, alcohol drinking, exercise, and body mass index, patients who underwent cholecystectomy showed an increased risk of all fractures, vertebral fractures, and hip fractures (aHR [95% CI]: 1.095 [1.059-1.132], 1.134 [1.078-1.193], and 1.283 [1.139-1.444] for all fractures, vertebral fractures, and hip fractures, respectively). The risk of vertebral fractures following cholecystectomy was more prominent in the young age group (40 to 49 y) than in the old age group (≥ 65 y) (1.366 [1.082-1.724] vs. 1.132 [1.063-1.206], respectively). However, the incidence of hip fractures following cholecystectomy was not affected by age.

Conclusion

Individuals who underwent cholecystectomy have an increased risk of fracture. In the younger population, the risk of vertebral fractures may be further increased following cholecystectomy.

Long-term patient-related quality of life after fracture-related infections of the long bones

Aims

We aimed to evaluate the long-term impact of fracture-related infection (FRI) on patients’ physical health and psychological wellbeing. For this purpose, quality of life after successful surgical treatment of FRIs of long bones was assessed.

Methods

A total of 37 patients treated between November 2009 and March 2019, with achieved eradication of infection and stable bone consolidation after long bone FRI, were included. Quality of life was evaluated with the EuroQol five-dimension questionnaire (EQ-5D) and German Short-Form 36 (SF-36) outcome instruments as well as with an International Classification of Diseases of the World Health Organization (ICD)-10 based symptom rating (ISR) and compared to normative data.

Results

With a mean follow-up of 4.19 years (SD 2.7) after the last surgery, the mean SF-36 score was 40.1 (SD 14.6) regarding the physical health component and 48.7 (SD 5.1) regarding the mental health component, compared to German normative values of 48.4 (SD 9.2) (p < 0.001) and 50.9 (SD 8.8) (p = 0.143). The mean EQ-5D index reached 0.76 (SD 0.27) with a mean EQ-5D visual analogue scale (VAS) rating of 65.7 (SD 22.7) compared to reference scores of 0.88 (p < 0.001) and 72.9 (p < 0.001). Mean scores of the ISR did not reveal significant psychological symptom burden, while an individual analysis showed moderate to severe impairments in 21.6% (n = 8) of the patients.

Conclusion

Even a mean 4.2 years (SD 2.7) after surgically successful treatment of FRI of long bones, patients report significantly lower quality of life in comparison to normative data. Future clinical studies on FRIs should focus on patient-related outcome measures enabling best possible shared treatment decision-making. Prevention methods and interdisciplinary approaches should be implemented to improve the overall quality of life of FRI patients.

Cite this article: Bone Joint Res 2021;10(5):321–327.

Hip Fracture Risk in Antiepileptic Drug Initiators and Non-Initiators with Alzheimer's Disease

Objective

To determine the risk of hip fracture in persons with Alzheimer´s disease (AD) who initiated antiepileptic drugs (AEDs).

Methods

In the Medication use and AD (MEDALZ) cohort of 70,719 Finnish community dwellers with clinically verified incident AD diagnosis in 2005-2011, we identified all incident users of AEDs using national Prescription register. AEDs were classified as older (valproate, carbamazepine, clonazepam, phenytoin, levetiracetam, primidone) or newer (pregabalin, gabapentin, oxcarbazepine, lamotrigine, topiramate). We matched each user to 2 non-users. Incident hip fractures until 2015 were identified from the Care register for health care. We calculated inverse probability of treatment weighted hazard ratios (HR), with 95% confidence intervals, using Cox regression.

Results

Altogether 5522 incident users were identified and matched to 11,044 non-users (in both groups, women: 65%; median age: 81 years). Altogether 53.3% of users initiated with newer AEDs (pregabalin 79.8%, gabapentin 10.2%) while 46.7% initiated with older AEDs (valproate 67.6%, carbamazepine 13.0%). Age- and sex-adjusted IR of hip fracture per 100 person-years was 1.8 (95% CI 1.6-1.9) in non-users and 2.0 (95% CI 1.8-2.2) in users. Increased risk of hip fracture was observed in users (HR 1.17, 95% CI 1.05-1.30) compared with non-users. The risk was higher for short duration of use (<14 weeks, HR 3.64, 95% CI 2.90-4.58) than for medium duration (14 to <64 weeks, HR 1.74, 95% CI 1.48-2.05) or ≥64 weeks' use (HR 1.23, 95% CI 1.08-1.40), compared to non-users with same follow-up time. Older AEDs had HR of 1.46 (1.03-2.08) compared with newer AEDs.

Conclusion

Our results imply that AED use is associated with an increased risk of hip fracture in people with AD. These findings prompt careful consideration before prescribing AEDs to persons with AD. Persons with AD treated with antiepileptics should be carefully monitored due to their increased risk of falling and fractures.

Secular trends of patients hospitalized for major osteoporotic fractures based on a national claims database

There was a reduction in the hospitalization rate for major osteoporotic fractures. As per our analysis, hospitalization for site-specific fractures showed a declining trend for hip and vertebral fractures for both the sexes. However, an increasing trend was noted in women regarding hospitalization for forearm fracture.

PURPOSE

Major osteoporotic fractures (MOFs) constitute a large proportion of the total expenditures for public healthcare. Knowing the secular trends of MOF will allow for more efficient use of healthcare resources, but such data are insufficient for the current population of Taiwan. Therefore, we investigated the epidemiological data of MOF hospitalization from adults 50 years of age or older in Taiwan during the period 2000-2015.

METHODS

The data analyzed were acquired from the Taiwan National Health Insurance Research Database (NHIRD) entries between 2000 and 2015. All study subjects were 50 years of age or older at the time of admission and diagnosed as having MOF.

RESULTS

A general decline was observed in the incidence rate (IR) of MOF hospitalization for the whole population, from 74.52 per 10,000 person-years (PYs) in 2000 to 55.19 in 2015. Females aged ≥65 years had the highest rates of hospitalization for MOF among the subgroups analyzed. Apart from the wrist fracture hospitalization rates in both sexes, which remained steady, all other site-specific fracture hospitalization rates exponentially increased with age. Among men, the IRs of all MOF hospitalization were steady, except for a slight decrease in hip and vertebral fracture hospitalizations. In women, hip and vertebral fracture hospitalization rates gradually decreased, humerus and wrist fracture hospitalization remained steady, and forearm fracture hospitalization increased.

CONCLUSIONS

Hospitalization rates of MOF decreased. The trend of site-specific fracture hospitalization analysis showed that hip and vertebral fractures decreased for both sexes. However, an increasing trend in forearm fracture hospitalization was noticed among females.

Comparison of fracture risk between proton pump inhibitors and histamine-2 receptor antagonists in ANCA-associated vasculitis patients: a nested case-control study

OBJECTIVE

Whether acid suppressants [proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs)] are associated with bone fractures in patients with ANCA-associated vasculitis (AAV) treated with glucocorticoids remains unclear. This study compared PPIs with H2RAs in terms of the risk of bone fractures in patients with AAV who received in-hospital induction therapy with glucocorticoids.

METHODS

We retrospectively identified 149 patients with fractures among 22 821 patients newly diagnosed with AAV in 1730 hospitals using a nationwide inpatient database from July 2010 to March 2018. We conducted 1:4 case-control matching. Age, sex, duration of AAV treatment and fiscal year were matched between the cases and controls. A conditional logistic regression analysis was conducted to assess the association between acid suppressants and fractures.

RESULTS

Of all enrolled patients with fractures, the median age was 77 years, and 99 (66%) were female. The median duration from AAV treatment to fracture was 52 days. The proportion of patients using PPIs was 91.3% (136 of 149) and 80.2% (478 of 596) in the case and control groups, respectively. Compared with H2RA use, PPI use was significantly associated with fractures after adjustment for age, sex, BMI, smoking habit, Charlson comorbidity index, renal failure, bisphosphonate and same fiscal year according to a multivariate analysis (adjusted odds ratio, 3.76; 95% CI: 1.37, 10.3).

CONCLUSION

PPI users had a higher risk of fractures than H2RA users among mostly advanced-age patients with AAV with remission induction therapy.

CYP2D6-inhibiting drugs and risk of fall injuries after newly initiated antidepressant and antipsychotic therapy in a Swedish, register-based case-crossover study

Drug-drug interactions have been shown to affect the risk of fall injuries when opioids are used concomitantly with drugs inhibiting the cytochrome P450 2D6 (CYP2D6) enzyme in a previous pharmacoepidemiological study. The aim of this study was to determine whether CYP2D6-inhibiting drugs reinforce the risk of fall injuries when used concomitantly with antidepressants or antipsychotics. We identified all 252,704 adults with a first fall injury leading to hospitalisation from the National Patient Register in Sweden 2006–2013. Data on dispensed drugs was linked from the Swedish Prescribed Drug Register. We applied a case-crossover design to analyse newly dispensed (28 days preceding the fall injury, preceded by a 12-week washout period) antidepressants and antipsychotics, respectively, in relation to risk of a fall injury and according to concomitant use of CYP2D6-inhibiting drugs. Newly dispensed drugs were assessed correspondingly in a control period of equal length, 28 days prior to the 12-week washout period. Overall, the risk of fall injury was increased after newly initiated antidepressant and antipsychotic treatment. For antidepressants, concomitant CYP2D6 inhibitor use further elevated the risk estimates compared to non-use, most pronounced for the groups selective serotonin reuptake inhibitors (sertraline excluded) [OR = 1.47 (95% CI 1.19–1.80) vs. OR = 1.19 (95% CI 1.13–1.26)], and tricyclic antidepressants [OR = 1.71 (95% CI 1.17–2.51) vs. 1.27 (95% CI 1.11–1.47)] as well as for sertraline [OR = 1.61 (95% CI 1.05–2.38) vs. 1.12 (95% CI 1.00–1.26)]. For antipsychotics, the risk of fall injury was not altered by concomitant use of CYP2D6-inhibiting drugs. In conclusion, concomitant use of CYP2D6 inhibiting drugs tends to further increase the risk of fall injury in newly initiated antidepressant treatment, but not in antipsychotic treatment.

Latest Trends in the Current Treatment of Proximal Humeral Fractures - an Analysis of 1162 Cases at a Level-1 Trauma Centre with a Special Focus on Shoulder Surgery

BACKGROUND

The management of proximal humeral fracture (PHF) is not only complex but ever changing. Published epidemiological data are often dated and do not factor in demographic changes or the latest developments in implant material and surgical techniques.

AIMS

The primary aim of this study was to evaluate changes in the epidemiology and actual treatment of PHF at a level-1 trauma centre, with a special focus on shoulder surgery.

HYPOTHESES

1. Between 2009 to 2012 and 2014 to 2017, an increase in complex PHF entities can be observed. 2. In correlation with fracture complexity, an increasing number of comorbidities, especially osteoporosis, can be observed.

METHODS

Between 2014 and 2017, a total of 589 patients (73% female; mean age: 68.96 ± 14.9 years) with 593 PHFs were treated. Patient records and imaging (XRs and CTs) of all patients were analysed. Fractures with ad latus displacement of a maximum of 0,5 cm and/or humeral head angulation of less than 20° were classified as non-displaced. Patients with displaced fractures were included in the analysis of the therapeutic algorithm. These results were compared to those of a cohort 2009 to 2012 (566 patients, 569 PHFs), which used the same inclusion criteria.

RESULTS

The two cohorts showed comparable patient numbers, as well as gender and age distributions. Between 2009 to 2012 and 2014 to 2017, a decrease in 2-part fractures (13.9 to 8.6%) and a simultaneous increase in 4-part fractures (20.4 to 30%), and thus fracture complexity was observed. Further decreases were observed in conservative therapy (27.8 to 20.6%), nail osteosynthesis (10.7 to 2.7%) and anatomic shoulder arthroplasty (5,4 to 1%). Furthermore, there was an increase in the use of locking plate osteosynthesis (43.2 to 56.7%) and reverse shoulder arthroplasty (9 to 18.4%). The general trend shows an increase in surgical therapy between the years (72.2 to 79.4%), as well as an increase in osteoporosis incidence (13 to 20.6%). The greatest numbers of comorbidities were found in 3- and 4-part fractures.

CONCLUSION

There is an increase in both the complexity of fractures and the number of surgically treated fractures between 2009 and 2012. Furthermore, an increase in osteoporosis numbers can be observed. New implants (PEEK, fenestrated screws for cement augmentation) and new surgical techniques (double plating osteosynthesis) were used as a result of increasing fracture complexity. Moreover, reverse total shoulder arthroplasty was used more commonly.

Enhanced regeneration of bone defects using sintered porous Ti6Al4V scaffolds incorporated with mesenchymal stem cells and platelet-rich plasma

A new highly controlled powder sintering technique was used for the fabrication of a porous Ti6Al4V scaffold. The platelet-rich plasma (PRP) was prepared using whole blood. The PRP was used as a cell carrier to inject bone marrow mesenchymal stem cells (MSC) into the pores of the Ti6Al4V scaffold in the presence of calcium chloride and thrombin, and then the composite construct of porous Ti6Al4V loaded with PRP gel and MSC was obtained. The bare Ti6Al4V scaffold and the Ti6Al4V scaffold loaded with MSC were used as controls. The characteristics and mechanical properties of the scaffold, and the biological properties of the constructs were evaluated by a series of in vitro and in vivo experiments. The results show that the sintered porous Ti6Al4V has good biocompatibility, and high porosity and large pore size, which can provide sufficient space and sufficient mechanical support for the growth of cells and bones without an obvious stress shielding effect. However, Ti6Al4V/MSC/PRP showed a significantly higher cell proliferation rate, faster bone growth speed, more bone ingrowth, and higher interfacial strength. Therefore, the porous Ti6Al4V scaffolds incorporated with MSC and PRP may be more effective at enhancing bone regeneration, and is expected to be used for bone defect repair.

Impact of the COVID-19 lockdown period on adult musculoskeletal injuries and surgical management: a retrospective monocentric study

The coronavirus disease 2019 (COVID-19) pandemic has led to the worldwide implementation of unprecedented public protection measures. On the 17th of March, the French government announced a lockdown of the population for 8 weeks. This monocentric study assessed the impact of this lockdown on the musculoskeletal injuries treated at the emergency department as well as the surgical indications. We carried out a retrospective study in the Emergency Department and the Surgery Department of Nantes University Hospital from 18 February to 11 May 2020. We collected data pertaining to the demographics, the mechanism, the type, the severity, and inter-hospital transfer for musculoskeletal injuries from our institution. We compared the 4-week pre-lockdown period and the 8-week lockdown period divided into two 4-week periods: early lockdown and late lockdown. There was a 52.1% decrease in musculoskeletal injuries among patients presenting to the Emergency Department between the pre-lockdown and the lockdown period (weekly incidence: 415.3 ± 44.2 vs. 198.5 ± 46.0, respectively, p < .001). The number of patients with surgical indications decreased by 33.4% (weekly incidence: 44.3 ± 3.8 vs. 28.5 ± 10.2, p = .048). The policy for inter-hospital transfers to private entities resulted in 64 transfers (29.4%) during the lockdown period. There was an increase in the incidence of surgical high severity trauma (Injury Severity Score > 16) between the pre-lockdown and the early lockdown period (2 (1.1%) vs. 7 (7.2%), respectively, p = .010) as well as between the pre-lockdown and the late lockdown period (2 (1.1%) vs. 10 (8.3%), respectively, p = .004). We observed a significant increase in the weekly emergency department patient admissions between the early and the late lockdown period (161.5 ± 22.9, 235.5 ± 27.7, respectively, p = .028). A pronounced decrease in the incidence of musculoskeletal injuries was observed secondary to the lockdown measures, with emergency department patient admissions being halved and surgical indications being reduced by a third. The increase in musculoskeletal injuries during the late confinement period and the higher incidence of severe trauma highlights the importance of maintaining a functional trauma center organization with an inter-hospital transfer policy in case of a COVID-19s wave lockdown.

Incidence of postoperative complications and non- periprosthetic fractures after total hip arthroplasty: A more than 10-year follow-up retrospective cohort study

OBJECTIVE

Postoperative complications and non-periprosthetic fractures (NPPFs), which was defined as a fracture existing non- periprosthetic implant, after total hip arthroplasty (THA) have a negative effect on the patients' ability to perform activities of daily living. Thus, investigating these incidences of patients after THA will be valuable as it lead to a more strategic physical therapy interventions and advanced research to prevent these problems. The purpose of this study was to investigate the incidence of postoperative complications related to implants and NPPFs in patients after THA, a more than 10-year follow-up.

METHODS

This is a retrospective cohort study. A total 892 patients with hip osteoarthritis who underwent primary THA were analyzed (age at surgery was 45-79 years; 805 women; the average follow-up period was 12.4-year). The postoperative complications related to implants and NPPFs were calculated using data from their medical records.

RESULTS

The postoperative complications occurred in 37 patients, and NPPFs occurred in 72 patients, who were significantly older, and hip and knee OA diagnosis, compared to patients without NPPFs ( p <.05). The most common cause of NPPFs was minor trauma. In patients aged ≧ 65 years, significantly more NPPFs occurred during the first year after surgery( p <.05).

CONCLUSION

More than 10-year after THA, the incidence of NPPFs was higher than that of postoperative complications related to implants. Older patients who had hip and knee OA were a significantly higher risk of developing NPPFs due to falls within the first year after surgery.

The impact of COVID-19 prevention measures on epidemiology of orthopedic injuries: the outbreak ages fractures!

BACKGROUND

The application of stringent prevention measures for contrasting COVID-19 spread generated changes not only in the outbreak course, but also in epidemiology of traumatic fractures. The aim of this study was to report the epidemiologic characteristics of surgically-treated fractures during the COVID-19 outbreak over a six-month period, and to describe the variation in volumes and types of injuries, by comparing them with fractures which occurred during the same period in 2019.

METHODS

We retrospectively analyzed all surgically-treated fractures which were admitted from the January 1st 2020 to June 30th 2020, and compared these data to those of the corresponding timeframe in 2019. The collected data of interest included demographics, such as age and gender, fracture location, time lapse between presentation at Emergency Department and admission in the ward, length of stay.

RESULTS

A total of 117 patients were admitted with a diagnosis of facture and surgically treated, with no cases of COVID-19 positive patients. In the corresponding period of 2019, the number of patients admitted for the same reasons was 129. This decrease was more significant in the period between March and April (-30.6%), during which time prevention measures were more stringent. The only statistically significant discrepancy between the two study groups was the mean age, which was significantly higher in 2020. The location of examined injuries were similar in the two study groups, with proximal femur fractures representing the most frequent injuries.

CONCLUSIONS

This study demonstrated significant changes of epidemiologic patterns of fractures during COVID-19 outbreak. These data should provide support for clinicians and government to evaluate the management and prevention strategies of traumatic not only during outbreak but also in non-outbreak period.

Individual Antidepressants and the Risk of Fractures in Older Adults: A New User Active Comparator Study

Objective

To determine the risk of hip–pelvis and other non-vertebral fractures in older adults using antidepressants (ADs).

Methods

We conducted a case–control study nested in a cohort of new users of ADs aged ≥65 years without prior hip–pelvis or other non-vertebral fractures, identified in the German Pharmacoepidemiological Research Database (GePaRD) during 2005–2014. Cases were patients first hospitalized for hip–pelvis or other non-vertebral fractures. Up to 100 controls per case were selected using incidence density sampling. AD use was ascertained at index date (ID) based on the supply of last dispensing. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression with current users of mirtazapine as reference (active comparator).

Results

A total of 39,853 cases of hip–pelvis fracture (80% women, median age 81 years) and 31,577 cases of other fractures (84% women, median age 79 years) were matched to >3 million controls. For hip–pelvis fracture, aORs in current users were about 1.3 with little variation between individual ADs, ranging from 1.33 for citalopram (95% CI 1.27–1.39) to 1.28 for amitriptyline (1.21–1.35). For other fractures, the aORs were highest in current users of citalopram (1.50; 1.42–1.58) and duloxetine (1.54; 1.39–1.71) and lowest for amitriptyline (1.18; 1.11–1.26) and trimipramine (1.16; 1.03–1.29). For all examined ADs, the aORs were higher for other fractures than for hip–pelvis fracture.

Conclusion

The risk of fractures varies between ADs, but for most agents is higher than the risk for mirtazapine. When treating older adults with ADs, prescribers should carefully consider the risk profile of individual ADs regarding fractures, which are a major health problem in this population.

Epidemiologic characteristics of traumatic fractures in elderly patients during the outbreak of coronavirus disease 2019 in China

Purpose

This study aimed to describe the epidemiologic characteristics of fracture in the elderly during the COVID-19.

Methods

This was a retrospective multi-centre study, which included patients who sustained fractures between 20 January and 19 February 2020. The collected data included patients’ demographics (age and gender), injury-related (injury type, fracture location, injury mechanism, places where fracture occurred), and treatment modality. SPSS 23.0 was used to describe the data and perform some analysis.

Results

A total of 436 patients with 453 fractures were included; there were 153 males and 283 females, with an average age of 76.2 years (standard deviation, SD, 7.7 years; 65 to 105). For either males or females, 70–74 years was the most commonly involved age group. A total of 317 (72.7%) patients had their fractures occurring at home. Among 453 fractures, there were 264 (58.3%) hip fractures, accounting for 58.3%. Fall from standing height was the most common cause of fracture, making a proportion of 89.4% (405/453). Most fractures (95.8%, 434/453) were treated surgically, and 4.2% (19/453) were treated by plaster fixation or traction. Open reduction and internal fixation (ORIF) was the most used surgical method, taking a proportion of 49.2% (223/453).

Conclusion

These findings highlighted the importance of primary prevention (home prevention) measures and could be used for references for individuals, health care providers, or health administrative department during the global pandemic of COVID-19.

Consistency between anticholinergic burden scales in the elderly with fractures

OBJECTIVE

Falls and bone fractures are important causes of morbidity and mortality in the elderly. The objective of this study was to identify the degree of consistency between the anticholinergic scales used for patients diagnosed with fractures.

METHODS

This was an analytical agreement study conducted in patients diagnosed with vertebral and nonvertebral fractures in Colombia. The quadratic-weighted kappa coefficient was used to identify the consistency between the Anticholinergic Drug Scale-ADS, Anticholinergic Cognitive Burden Scale-ACB and Anticholinergic Risk Scale-ARS in assessing the prescriptions of fracture patients during the month prior to the fracture, during their stay as an inpatient and at discharge, according to Landis criteria.

RESULTS

220 patients with fractures were included, with a mean age of 75.3±10.3 years, and 68.2% were women. The ACB scale identified the highest anticholinergic burden (26.8%) in prescriptions made the month before the fracture, and the highest agreement was between ACB and ADS (0.717); during hospitalization and at discharge, the cholinergic antagonists were best identified with ADS (77.7% and 72.1%, respectively), with the best agreement between ACB and ARS (0.613 and 0.568, respectively). The prescription of tramadol was found in 64.1% of hospitalized patients and in 61.4% of patients at the time of discharge.

CONCLUSIONS

The scales evaluated show marked discrepancies between them, with highly variable frequencies of anticholinergic drugs identified at the different prescription times, and with low agreement among them, which is why the scales are not interchangeable in patients with bone fractures.

New score including daily life independence levels with dementia is associated with the onset of deep vein thrombosis in frail older adults

AIM

The detailed risk factors of deep vein thrombosis (DVT) remain unknown, and no efficient tool to assess the risk of the development of DVT among older adults has been established. This study aimed to clarify the risk factors, including the level of daily life independence, and develop an assessment score for DVT in older patients.

METHODS

We recruited 252 patients aged ≧65 years with suspected deep vein thrombosis. Risk factors for deep vein thrombosis, cognitive impairment, laboratory data and level of daily life independence were analyzed to calculate the odds ratios for the onset of DVT with logistic regressions. The Himi score was generated with factors significantly related to DVT by adjusting the respective odds ratios. The discrimination accuracy of the Himi score associated with the onset of DVT was compared with those of conventional scores (Wells score, Padua score) based on the area under the receiver operating characteristic curve.

RESULTS

Low levels of daily life independence, D-dimer level >3.0 μg/mL, anticoagulant use, cancer and immobilization or symptoms of the lower limbs were associated with the onset of DVT. The discrimination accuracy of Himi scores composed of these related factors was significantly higher than those of the Wells and Padua scores.

CONCLUSIONS

Achieving a better performance than did the Wells and Padua scores, the Himi score could be used to assess the risk of DVT in frail older adults. Geriatr Gerontol Int 2020; 20: 414-421.

Gustilo-Anderson type III tibial fractures have poor functional outcomes in patients over 75 years

BACKGROUND

Previous outcome studies in open tibial fractures have commonly assessed young patients and there is a paucity of data regarding outcomes in the elderly. The aim of this study is to assess functional outcomes for patients over 75 years with Gustilo-Anderson Grade III open tibial fractures, including mobility and residential status.

METHODS

Outcomes for all patients over 75 years admitted with grade III open tibial fractures to a UK level 1 trauma centre during a 5-year period (January 2010-May 2015) were analysed. Long-term follow up of surviving patients (median 44 months post injury) was undertaken in February 2016.

RESULTS

Twenty-nine patients (24 female, 5 male - median 85 years) were included. Prior to injury 48% (n = 14) patients were independently mobile and 45% (n = 13) were living at home without care. Two-thirds of injuries were low energy; all patients sustained a grade III open tibial fracture. The 12-month mortality rate was 28% (n = 8) and mortality at long-term follow-up 48% (n = 14). From pre-injury to long-term 8% (n = 1) patients did not change mobility status, 75% (n = 9) reduced by one grade (e.g. independent to walking aid) and 16% (n = 2) by two grades. Fifty eight percent (n = 7) of patients retained residential status, 17% (n = 2) reduced by one grade and 25% (n = 3) by two grades.

CONCLUSION

Grade III open tibial fractures are a significant injury in the elderly associated with poor outcomes with respect to return to mobility and pre-injury residential status. Our results suggest that a greater emphasis on intensive rehabilitation should be considered in this patient group.

Fractures after stroke-A Danish register-based study of 106 001 patients

OBJECTIVES

To estimate the incidence of fractures, possibly caused by falls, in patients aged 65 and older with first episode of stroke, and to estimate the incidence of fracture types for this group of patients. Another objective was to investigate stroke severity and marital status, as risk factors for fractures.

MATERIALS AND METHODS

A large retrospective dataset of 116 519 patients with first episode of stroke was extracted from the Danish Stroke Registry between January 2003 and December 2017. The occurrence of fractures was identified in the Danish National Patient Registry. A univariate analysis was conducted and a multivariate analysis was conducted to determine the relationship between stroke severity and fractures, and marital status and fractures, adjusting for multiple confounders. Cox regression with time-varying covariates was used, taking time-dependent variables into account.

RESULTS

The incidence rate of fractures post-stroke was 41.07 per 1000 person-years between 2003 and 2017 in Denmark. A total of 15 872 (14.86%) sustained a fracture and the mean time at risk until outcome was 3.67 years post-stroke. Femur fracture was the most common fracture type. Mild, moderate, severe, and unknown stroke severity are associated with fractures after stroke compared to very severe stroke, and living alone at the time of stroke is associated with fractures after stroke compared to living with someone.

CONCLUSIONS

The incidence rate of fractures in Denmark was 41.07 per 1000 person-years. Moreover, mild, moderate, and severe stroke severity, and living alone at the time of stroke were found to be risk factors for fracture.

Tea consumption and risk of fractures: an updated meta-analysis

This meta-analysis included 16 studies, involving seven cohort studies and nine case-control studies, and the results indicated that tea consumption may be associated with a reduced the risk of fractures.

INTRODUCTION

Regarding relationship of tea consumption with the risk of fractures remains controversial. We performed a meta-analysis to elucidate the association between tea consumption and the risk of fractures.

METHODS

Relevant articles were identified up to March 2019 by searching PubMed, Web of Science, and Embase databases. The pooled relative risks (RRs) with 95% confidence intervals (CIs) were computed utilizing fixed or random effects model based on heterogeneity.

RESULTS

Altogether 16 studies (seven cohort and nine case-control studies) were included in this meta-analysis, involving 772,707 participants with 37,166 fracture cases. The RRs (95% CIs) of fracture for the highest versus lowest category of tea consumption were 0.86 (0.78-0.94). Subgroup analysis indicated significant associations in cohort studies (0.90 (0.86-0.94)) and case-control studies (0.77 (0.69-0.85)).

CONCLUSIONS

The current meta-analysis indicates that tea consumption may be associated with a reduced the risk of fractures.

Commercially available antibiotic-laden PMMA-covered locking nails for the treatment of fracture-related infections - A retrospective case analysis of 10 cases

Introduction: Fracture-related infections (FRIs) are a devastating complication. FRIs are challenging and should be addressed with a multidisciplinary approach. An FRI should be addressed surgically by non-viable bone debridement, local antibiotic deposition, minimization of dead space and fracture stabilization. Antibiotic-laden PMMA-covered nails are a viable option to face these complications. To demonstrate the safety and utility of commercially available antibiotic-laden PMMA-covered nails, we performed a review of the cases operated in our institution and a cost analysis to compare the cost of a commercial nail to other available alternatives.

Material and methods: We designed a retrospective study of consecutive cases to demonstrate the safety and efficacy of antibiotic-laden PMMA-covered commercial nails and designed a cost analysis of commercial coated nails compared to other custom-made alternatives.

Results: We treated seven tibias and three femurs. Nine patients fully fit the criteria for FRI. There was one case of reintervention because of persistent drainage. All fractures healed, and in the first year post-intervention, there were no signs or symptoms of infection. There were no complications related to the commercially available nail that was used. There is a small increase in the direct quantifiable cost in commercially available nails, but non-quantifiable cost should be assessed individually.

Conclusions: Commercially available antibiotic-laden PMMA-covered nails are a safe and useful treatment option for complicated cases of lower limb long bone reconstruction. The low complication rate and the straightforward technique compensate for the direct cost increase in most situations.

Acute versus delayed reverse total shoulder arthroplasty for the treatment of proximal humeral fractures in the elderly population: a systematic review and meta-analysis

BACKGROUND

Recent literature has shown that acute reverse total shoulder arthroplasty (RTSA) yields good outcomes in the treatment of displaced proximal humeral fractures, and there have also been recent studies showing that delayed RTSA can be successfully used for sequelae of proximal humeral fractures such as nonunion and malunion. The use of meta-analysis affords the opportunity to formally compare the outcomes of acute RTSA for fracture and delayed RTSA for fracture sequelae.

METHODS

We searched the MEDLINE, Embase, and Cochrane Library databases. We included all studies reporting on RTSA for the treatment of proximal humeral fracture sequelae with a comparison group of acute RTSA or with no comparison group in adults with a mean age older than 65 years and at least 2 years of follow-up. We calculated weighted mean differences for range of motion, standardized mean differences for clinical outcome scores, and relative risks for dichotomous outcomes.

RESULTS

Sixteen studies met the inclusion criteria, which comprised 322 patients undergoing RTSA for fracture sequelae. Of these studies, 4 were comparative (46 patients) whereas 12 were case series (276 patients). Among studies directly comparing acute versus delayed RTSA, no differences in forward flexion (P = .72), clinical outcome scores (P = .78), or all-cause reoperation (P = .92) were found between the 2 groups. Patients undergoing delayed RTSA achieved 6° more external rotation than those undergoing acute RTSA; this difference was significant (P = .01).

CONCLUSIONS

Given the risks associated with surgery in the elderly population, consideration may be given to an initial trial of nonoperative treatment in these patients, saving RTSA for those in whom nonoperative treatment fails without compromising the ultimate outcome.