Diagnosis and therapy of osteoporosis in geriatric trauma patients: an update

Demographic changes confront clinicians with an increasing number of orthogeriatric patients. These patients present with comorbidities, which force their surgeons to take into consideration their medical condition. A major risk factor for fractures in orthogeriatric patients is osteoporosis in combination with frailty. To prevent subsequent fractures in these patients, we need to pay attention to adequate osteoporosis treatment in orthogeriatric patients. There is a huge treatment gap. In Germany, 77% of patients with osteoporosis are not treated adequately. Even after fragility fractures, a low percentage of patients receive a specific osteoporosis therapy. Secondary prevention is of great importance in the treatment of these patients. Diagnostics and treatment should be already initiated with the admission to the hospital. Treatment decisions need to be made individually based on the risk profile of the patients. After discharge, it is important to involve the patients' general practitioners and to follow up on patients regularly to improve their compliance and to ensure adequate therapy. Establishing a fracture liaison service helps coordinating osteoporosis treatment during hospitalization and after discharge. Subsequent fractures can be reduced;therefore, it is an effective service for secondary prevention. The present article provides an overview of how an efficient identification and subsequent treatment of osteoporosis can be achieved in aged trauma patients

Secondary tension pneumothorax in a COVID-19 pneumonia patient: a case report

PURPOSE Especially in elderly and multimorbid patients, Coronavirus Disease 2019 (COVID-19) may result in severe pneumonia and secondary complications. Recent studies showed pneumothorax in rare cases, but tension pneumothorax has only been reported once. CASE PRESENTATION A 47-year-old male was admitted to the emergency department with fever, dry cough and sore throat for the last 14~days as well as acute stenocardia and shortage of breath. Sputum testing (polymerase chain reaction, PCR) confirmed SARS-CoV-2 infection. Initial computed tomography (CT) showed bipulmonary groundglass opacities and consolidations with peripheral distribution. Hospitalization with supportive therapy (azithromycin) as well as non-invasive oxygenation led to a stabilization of the patient. After 5~days, sputum testing was negative and IgA/IgG antibody titres were positive for SARS-CoV-2. The patient was discharged after 7~days. On the 11th day, the patient realized pronounced dyspnoea after coughing and presented to the emergency department again. CT showed a right-sided tension pneumothorax, which was relieved by a chest drain (Buelau) via mini open thoracotomy. Negative pressure therapy resulted in regression of the pneumothorax and the patient was discharged after 9~days of treatment. CONCLUSION Treating physicians should be aware that COVID-19 patients might develop severe secondary pulmonary complications such as acute tension pneumothorax. LEVEL OF EVIDENCE V

The value of arthroscopy in the treatment of complex ankle fractures - a protocol of a randomised controlled trial

Background: An anatomical reconstruction of the ankle congruity is the important prerequisite in the operative treatment of acute ankle fractures. Despite anatomic restoration patients regularly suffer from residual symptoms after these fractures. There is growing evidence, that a poor outcome is related to the concomitant traumatic intra-articular pathology. By supplementary ankle arthroscopy anatomic reduction can be confirmed and associated intra-articular injuries can be treated. Nevertheless, the vast majority of complex ankle fractures are managed by open reduction and internal fixation (ORIF) only. Up to now, the effectiveness of arthroscopically assisted fracture treatment (AORIF) has not been conclusively determined. Therefore, a prospective randomised study is needed to sufficiently evaluate the effect of AORIF compared to ORIF in complex ankle fractures. Methods/design: We perform a randomised controlled trial at Munich University Clinic enrolling patients (18-65 years) with an acute ankle fracture (AO 44 A2, A3, B2, B3, C1 - C3 according to AO classification system). Patients meeting the inclusion criteria are randomised to either intervention group (AORIF, n = 37) or comparison group (ORIF, n = 37). Exclusion criteria are fractures classified as AO type 44 A1 or B1, pilon or plafond-variant injury or open fractures. Primary outcome is the AOFAS Score (American Orthopaedic Foot and Ankle Society). Secondary outcome parameter are JSSF Score (Japanese Society of Surgery of the Foot), Olerud and Molander Score, Karlsson Score, Tegner Activity Scale, SF-12, radiographic analysis, arthroscopic findings of intra-articular lesions, functional assessments, time to return to work/sports and complications. This study protocol is accordant to the SPIRIT 2013 recommendation. Statistical analysis will be performed using SPSS 22.0 (IBM). Discussion: The subjective and functional outcome of complex ankle fractures is regularly unsatisfying. As these injuries are very common it is essential to improve the postoperative results. Potentially, arthroscopically assisted fracture treatment can significantly improve the outcome by addressing the intra-articular pathologies. Given the absolute lack of studies comparing AORIF to ORIF in complex ankle fractures, this randomised controlled trail is urgently needed to evaluate the effectiveness of additional arthroscopy

BLADE KINETICS OF A UNILATERAL PROSTHETIC ATHLETE IN CURVE SPRINTING

In athletics sprinting longer than 100 m, athletes will run more than 50% in a curve. No data on ground reaction forces or joint kinetics of prosthetic curve sprinting can be found in the scientific literature. The purpose of this study was to analyze GRFs and moments acting on the prosthesis’ blade using a 3D motion capture system and four force plates. A left sided unilateral amputee athlete (knee exarticulation) of highest international level, ran 30 m straight and curved clockwise and counter clockwise. GRFs show differences between curve and straight running. Results show different loading applied to the blade of a prosthesis when curve running in comparison with straight running. The study gives an inside into the kinetics of amputee curve running and might affect the construction and design of future prosthesis generations as well as performance diagnostics

Jumper's fracture of the sacrum: a novel and reproducible way for successful reduction and fixation

PURPOSE Surgical treatment of jumper's fractures is a highly demanding situation for the surgeon due to its rareness and frequent association with severe concomitant injuries. There is no current consensus regarding a standard treatment approach, thus reducing quality of care. Our objectives were to describe, apply and assess a novel surgical technic. METHODS The presented research is an observational retrospective study of patients who underwent the described novel surgical intervention in a level 1 trauma center. We conducted analyses of the patient cohort using patient-related outcome measures at least 1 year after surgery, as well as investigating pain, quality of life and the clinical effectiveness of the procedure. RESULTS A total of 24 patients (17 male and 7 female) with an average age 47 ± 16.3~years were included. ISS scores ranged from 9 to 66 with a mean ISS of 40 ± 15. Clinical scores exist of 15 out of 24 patients (62.5%). The mean VAS score was 53.7 ± 12.9. The mean EQ-5D index was 0.68 ± 0.22. Significant negative correlation existed between the ISS value and the EQ-5D index (r = - 0.704; p < 0.005) and EQ-5D VAS (r = - 0.809; p < 0.001). Anatomical reduction was achieved in all patients (n = 24). Radiological follow-up was performed in 58%. CONCLUSION We present one of the largest studies with operatively treated jumper's fractures of the sacrum. The technique is capable of reproducibly restoring the physiological anatomy of the patient and allows pain-adapted mobilization

Improved outcome in hip fracture patients in the aging population following co-managed care compared to conventional surgical treatment: a retrospective, dual-center cohort study

Background: Hip fracture patients in the aging population frequently present with various comorbidities, whilst preservation of independency and activities of daily living can be challenging. Thus, an interdisciplinary orthogeriatric treatment of these patients has recognized a growing acceptance in the last years. As there is still limited data on the impact of this approach, the present study aimed to evaluate the long-term outcome in elderly hip fracture patients, by comparing the treatment of a hospital with integrated orthogeriatric care (OGC) with a conventional trauma care (CTC). Methods: We conducted a retrospective, two-center, cohort study. In two maximum care hospitals all patients presenting with a hip fracture at the age of ≥ 70 years were consecutively assigned within a 1 year period and underwent follow-up examination 12 months after surgery. Patients treated in hospital site A were treated with an interdisciplinary orthogeriatric approach (co-managed care), patients treated in hospital B underwent conventional trauma care. Main outcome parameters were 1 year mortality, readmission rate, requirement of care (RC) and personal activities of daily living (ADL). Results: A total of 436 patients were included (219 with OGC / 217 with CTC). The mean age was 83.55 (66-99) years for OGC and 83.50 (70-103) years for CTC (76.7 and 75.6% of the patients respectively were female). One year mortality rates were 22.8% (OGC) and 28.1% (CTC; p = 0.029), readmission rates were 25.7% for OGC compared to 39.7% for CTC (p = 0.014). Inconsistent data were found for activities of daily living. After 1 year, 7.8% (OGC) and 13.8% (CTC) of the patients were lost to follow-up. Conclusions: Interdisciplinary orthogeriatric management revealed encouraging impact on the long-term outcome of hip fracture patients in the aging population. The observed reduction of mortality, requirements of care and readmission rates to hospital clearly support the health-economic impact of an interdisciplinary orthogeriatric care on specialized wards

Acute, isolated and unstable syndesmotic injuries are frequently associated with intra-articular pathologies

PURPOSE Although simultaneous arthroscopy for the surgical treatment of acute isolated, unstable syndesmotic injuries has been recommended, little knowledge is present about the actual frequency of intra-articular pathologies for this injury. The aim of this study was to investigate the frequency and severity of intra-articular pathologies detected during arthroscopy and their subsequent treatment in acute isolated, unstable syndesmotic injuries. METHODS A retrospective chart review of patients treated by arthroscopic-assisted stabilization for acute isolated, syndesmotic instability was performed. The primary outcome parameter was the frequency of intra-articular pathologies. Secondary outcome parameters were the type of syndesmotic lesion (ligamentous/bony), severity of chondral lesions, MRI findings, treatment details, complications and the identification of factors associated with intra-articular pathologies. RESULTS Twenty-seven patients, 19% female, with a mean age of 37 ± 12~years met the inclusion criteria. 70% suffered isolated ligamentous injuries, the remaining suffered avulsion fractures of the syndesmosis. Chondral lesions occurred in 48% (ICRS grade II: 33%; ICRS grade IV 15%) and intra-articular loose bodies in 11% of patients. Overall, arthroscopy revealed intra-articular pathologies necessitating further treatment in 19% of patients. Neither the type of syndesmotic injury (bony vs. ligamentous; ns) nor the degree of ligamentous instability (West Point IIB vs. III; ns) had a significant influence on the occurrence of chondral lesions. One complication (SSI) occurred. Pre-operative MRI revealed a sensitivity/specificity of 100/79% for chondral lesions and 50/93% for loose bodies. CONCLUSION Intra-articular pathologies in acute isolated, unstable syndesmotic injuries occur in up to 50% of patients, 19% necessitated additional treatment. Simultaneous arthroscopy, independent of the pre-operative MRI findings, appears reasonable in highly active patients. LEVEL OF EVIDENCE Level III

Mobility improvement in the first 6 postoperative weeks in orthogeriatric fracture patients

BACKGROUND Physical activity is a relevant outcome parameter in orthopedic surgery, that can be objectively assessed. Until now, there is little information regarding objective gait parameters in the orthogeriatric population. This study focuses on the first 6~weeks of postoperative rehabilitation, and delivers objective data about gait speed and step length in typical orthogeriatric fracture patterns. METHODS Thirty-one orthogeriatric fracture patients pertrochanteric femur fractures (PFF), femoral neck (FN), and proximal humerus fractures (PHF) were consecutively enrolled in a maximum care hospital in a prospective study design. All patients wore an accelerometer placed at the waist during the postoperative stay (24~h/d) and at 6-week follow-up, to measure real gait speed and step length. In addition, self-assessment of mobility (Parker mobility score) and activities of daily living (Barthel index) were collected at baseline, during the inpatient stay, and at 6-week follow-up. RESULTS During postoperative hospitalization, significantly higher gait speed (m/s) was observed in the PHF group (0.52 ± 0.27) compared with the FN group (0.36 ± 0.28) and PFF group (0.19 ± 0.28) (p < 0.05). Six~weeks postoperatively, gait speed improved significantly in all groups (PHF 0.90 ± 0.41; FN 0.72 ± 0.13; PFF 0.60 ± 0.23). Similarly, step length (m) differed between groups postoperatively FN 0.16 ± 0.13; PFF 0.12 ± 0.15; PHF 0.31 ± 0.05 (p < 0.005) and improved over time significantly (FN 0.47 ± 0.01; 0.39 ± 0.19; 0.50 ± 0.18). Self-assessment scores indicate that the majority of the patients had minor restrictions in mobility before the fracture. These values decreased immediately postoperatively and improved in the first 6~weeks, but did not reach the initial level. CONCLUSIONS Gait speed, step length, and self-assessment in terms of mobility and activities of daily living improve significantly in the first 6 postoperative weeks in orthogeriatric fracture patients. As very low postoperative mobility during hospitalization was observed, this collective shows great potential in postoperative rehabilitation regardless of their fracture pattern. For this reason, specific aftercare concepts similar to the {\textquotedbl}fast track{\textquotedbl} concepts in primary arthroplasty are crucial for orthogeriatric patients in clinical practice. LEVEL OF EVIDENCE Prospective cohort study, 2