1- und 2-Jahres-Mortalitäten typischer Altersfrakturen, sogenannter „fragility-fractures“

Mit dem zunehmenden Alter der Bevölkerung steigt die Zahl multimorbider, immobiler Patienten, welche eine typische Altersfraktur, eine sogenannte Fragilitätsfraktur erleiden. Inwiefern eine solche Fraktur das unmittelbare Überleben dieser Patienten beeinflusst, wurde in der aktuellen Arbeit untersucht. Es wurden prospektiv alle Patienten einer alterstraumatologischen Station über ein Jahr erfasst. Die Patienten wurden im Rahmen des geriatrisch-traumatologischen Comanagements versorgt. Es erfolgte mittels Fragebögen und telefonischer Kontaktaufnahme die Ermittlung der Rate der Verstorbenen nach 2 Jahren. So konnten insgesamt und frakturspezifisch, die 1- und 2-Jahres-Mortalitäten, sowie die Sterblichkeitswahrscheinlichkeit der Patienten berechnet werden. Durch die zusätzliche Erhebung geriatrischer Funktionsparameter und aufgetretener Komplikationen, konnten diese auf ihre Wertigkeit als Risikofaktoren untersucht werden. Unter Zuhilfenahme der Daten des statistischen Bundesamtes erfolgte die Ermittlung des relativen Risikos im Vergleich zur altersadaptierten Allgemeinbevölkerung zu versterben. Bei insgesamt 830 behandelten Patienten, konnten von 661 die kompletten Sterbedaten erfasst werden, was einem Rücklauf von 79,6% entsprach. Das durchschnittliche Alter dieser Patienten betrug 84,6 Jahre. Die Gesamtmortalität über 2 Jahre betrug für alle Patienten 38,4%. Im Vergleich zur Allgemeinbevölkerung zeigte sich vor allem in den jüngeren Altersabschnitten zwischen 71-80 Jahren ein höheres relatives Risiko zu versterben. Für ältere Patienten fiel dieses Risiko trotz höherer absoluter Sterblichkeiten geringer aus. Bei der isolierten Analyse der Komplikationen zeigte sich für Harnwegsinfekte, Delir und akut auf chronisches Nierenversagen ein signifikanter Einfluss auf das Überleben. Für die Funktionsparameter ließ sich für den Grad der Mobilität, die Aktivitäten des täglichen Lebens und die Zahl der Komorbiditäten ein proportionaler Einfluss auf das Überleben feststellen. Je besser die Funktion des alten Menschen erhalten war, desto besser war dessen Überleben. Auch das Vorhandensein einer Demenz schien eine deutliche Erhöhung der Sterblichkeit zu bedingen. Bezüglich der Pflegebedürftigkeit ließ sich vor allem für Patienten, die gar keine Pflegestufe besaßen, ein besseres Outcome feststellen. Die Aufnahmesituation zeigte ein deutlich besseres Überleben der Patienten, die von zu Hause kamen, gegenüber solchen, die bereits Bewohner eines Pflegeheims waren. Es erlitten 127 Patienten (19,2%) Frakturen der oberen Extremität, 240 (36,3%) proximale Femurfrakturen und 96 (14,5%) Verletzungen der Wirbelsäule. 225 (34,0%) erlitten sonstige Frakturen oder Verletzungen. Für die 3 oben genannten typischen Fragilitätsfrakturen betrugen die Sterblichkeiten nach zwei Jahren: proximale Femurfraktur 42,9%, Wirbelkörperfrakturen 36,5%, Frakturen der oberen Extremität 34,6%. Im Vergleich dieser Sterblichkeiten untereinander waren keine signifikanten Unterschiede ersichtlich. Bezüglich der Versorgung osteoporotischer Wirbelkörperfrakturen war die operative Behandlung mit einem deutlich besseren Überleben verbunden als die konservative Behandlung, was sich mit Ergebnissen der Literatur deckt. Im Vergleich der proximalen Femurfrakturen konnte kein relevanter Unterschied der Sterblichkeit zwischen den beiden Entitäten „medialer Schenkelhalsfraktur“ und „pertrochantärer Femurfraktur“ gefunden werden. Nach Frakturen der oberen Extremität zeigten sich konträr zur Literatur vergleichbare Sterblichkeiten zwischen Unterarmfrakturen und Frakturen des Oberarms, sowie ein deutlicher Zusammenhang der Sterblichkeit mit der vorbestehenden Mobilität der Patienten. Ein positiver Einfluss des geriatrisch-rehabilitativen Komplexprogrammes auf das Überleben aller Patienten konnte nicht gezeigt werden. Die Literatur gibt trotzdem Anlass einen positiven Einfluss des geriatrisch-traumatologischen Comanagements auf das Überleben der Patienten anzunehmen. Der Einfluss der typischen Altersfrakturen auf das Überleben des geriatrischen Patienten ist nicht zu unterschätzen. In der aktuellen Analyse zeigten sich zwischen den typischen Frakturformen keine signifikanten Unterschiede der Sterblichkeit. Geriatrische Scores und das Auftreten von Komplikationen besitzen eine valide prognostische Aussagekraft. Jede Fraktur eines Patienten mit den oben genannten Risikofaktoren muss ernst genommen werden. Umso wichtiger scheint die integrierte geriatrische Betreuung und der Mehraufwand an Einsatz eines Alterstraumazentrums, um das Überleben und vor allem die Lebensqualität alter Patienten zu sichern

Fractures' associated mortality risk in orthogeriatric inpatients: a prospective 2-year survey

Purpose!#!The most common osteoporotic fragility fractures are hip, vertebral and upper extremity fractures. An association with increased mortality is widely described with their occurrence. Fracture-specific associated death rates were determined in a 2-year follow-up for patients treated on an orthogeriatric ward. These were compared amongst each other, examined for changes with age and their impact on the relative mortality risk in relation to the corresponding population.!##!Methods!#!We assessed all patients that were treated in the course of a year on an orthogeriatric ward and suffered from the following injuries: hip (HF), vertebral (VF) and upper extremity fractures (UEF). In a 2-year follow-up it was possible to determine the month of death in the case of the patient's decease. Pairwise comparisons of the three fracture type death rates were performed through Cox-Regression. We stratified the fracture-dependent absolute mortality and age-specific mortality risk (ASMR) for age groups 71-80, 81-90 and 91-95.!##!Results!#!Overall, we assessed 240 patients with HF, 96 with VF and 127 with UEF over the span of a year. 1- and 2-year-mortality was: HF: 29.6% a.e. 42.9%, VF: 29.2% a.e. 36.5%, UEF: 20.5% a.e 34.6%. Pairwise comparisons of these mortality values revealed no significant differences. In association with HF and VF, we observed a significant increase of 2-year mortality for the oldest compared to the youngest patients (HF: 60.4% vs. 22.5%; p = 0.028) (VF 70% vs. 14.3%; p = 0.033). The analogue comparison for UEF revealed no relevant difference in age-dependent mortality (40.9% vs. 31.1%; p = 0.784). Common for all fracture types ASMR's were more elevated in the younger patients and decreased with higher age.!##!Conclusion!#!The fracture-related mortality in the 2-year follow-up was comparable. We observed a reduction of relative mortality risk in the oldest patients. While a direct influence of fracture on mortality must be supposed, we support the thesis of the fracture rather being an indicator of higher susceptibility of timely death

The anterior impingement after mobile-bearing unicomparimental knee arthroplasty—a neglected problem. A clinical report of 14 cases

BACKGROUND: Mobile-bearing unicompartmental knee arthroplasty (MB-UKA) is a proven implant that has reliably delivered excellent results for decades. Based on the constrained implant design in MB-UKA, the occasional occurrence of anterior impingement should be expected. However, surprisingly, there are no clinical reports. METHODS: From 2016 to 2020, 14 patients with anterior medial knee pain were admitted to our arthroplasty center after MB-UKA implantation elsewhere. After taking the medical history and clinical examination, radiological imaging of the implant in at least 2 planes, including a whole-leg anteroposterior view, was performed. The “Knee Society Score (KSS)” and the “Knee Injury and Osteoarthritis Outcome Score (KOOS)” were recorded. Anterior impingement was diagnosed by reviewing the typical findings and specific exclusion of other diagnoses. RESULTS: The 14 patients showed a KSS of 46.6 and a KOOS of 51.5. The average pain level on the “Visual Analog Scale” was 7.8. The positioning of the implants showed consistently noticeable deviations from the standard recommendations. All 14 patients were treated by removing the MB-UKA and changing to a complete TKA. At the 12-month follow-up, the average Visual Analog Scale score was 1.8, and KOOS and KSS were 86 and 82, respectively. CONCLUSIONS: The potential risk of anterior impingement in MB-UKA can be assumed. Diagnosis requires a detailed collection of medical history and clinical details combined with accurate radiological imaging. The cause of anterior impingement in MB-UKA is multifactorial and refers in our small group to the sum of minor deviations in implant positioning compared to the general recommendations

Accompanying injuries in tibial shaft fractures: how often is there an additional violation of the posterior malleolus and which factors are predictive? A retrospective cohort study

INTRODUCTION: An undislocated fracture of the posterior malleolus is a common concomitant injury in tibial shaft spiral fractures. Nevertheless, these accompanying injuries cannot always be reliably assessed using conventional X-rays. Thus, the aim of the study is to evaluate how often a fracture of the posterior malleolus occurs with tibial shaft fractures (AO:42A/B/C and AO:43A) and which factors—identifiable in conventional X-rays—are predictive. METHODS: Retrospective evaluation of X-ray and CT images revealed a total of 103 patients with low-energy tibial shaft fractures without direct joint involvement. Proximal fractures and fractures involving the knee were excluded. Basic data on injury, the trauma mechanism, the path of the fracture, bony avulsions of the posterior syndesmosis and the procedures performed were evaluated. RESULTS: Thirty-nine fractures were located in the middle third of the tibia, 64 in the distal third. In 65 cases, a spiral fracture (simple or wedge fracture) was found. In 31/103 fractures, an additional osseous avulsion of the posterior syndesmosis could be detected, 5 (16.1%) of them were not recognized preoperatively due to an absence of CT imaging. In three of these patients, a fracture of the posterior malleolus was only recognized postoperatively, and an additional surgery was necessary. The spiral fractures were classified in the a.p. X-ray according to their path from lateral proximal to medial distal (Type A) or from medial proximal to lateral distal (Type B). A Pearson chi-square test and Fisher’s exact test showed a highly significant accumulation of accompanying posterior malleolus fractures for type A fractures (p = 0.001), regardless of the location of the fracture. In addition, the fractures with involvement of the posterior malleolus had a significantly higher proportion in the fractures of the distal third (p = 0.003). There was no statistically significant relationship between the height of the fracture and the path of the fracture (type A or B). These two factors seem to be independent factors for participation of the posterior malleolus. CONCLUSION: In 40.6% of the tibial shaft fractures in the distal third, in 56.9% of the type A spiral fractures and in 67.6% of the type A fractures in the distal third, the ankle joint is involved with bony avulsion of the posterior syndesmosis, which is not always recognized in conventional X-rays. To avoid complications such as additional operations, instability and post-traumatic arthrosis, we recommend preoperative imaging of the ankle using CT for these fractures. LEVEL OF EVIDENCE: III, retrospective cohort study. TRAIL REGISTRATION NUMBER: DRKS00024536

Beyond hip fractures: other fragility fractures' associated mortality, functional and economic importance: a 2-year-Follow-up

BACKGROUND: Hip fractures are well researched in orthogeriatric literature. Equivalent investigations for fragility-associated periprosthetic and periosteosynthetic femoral, ankle joint, pelvic ring, and rib fractures are still rare. The purpose of this study was to evaluate mortality, functional outcome, and socioeconomic parameters associated to the upper-mentioned fragility fractures prospectively in a 2-year follow-up. METHODS: Over the course of a year, all periprosthetic and periosteosynthetic femoral fractures (PPFF), ankle joint fractures (AJ), pelvic ring fractures (PR), and rib fractures (RF), that were treated on a co-managed orthogeriatric ward, were assessed. Parker Mobility Score (PMS), Barthel Index (BI), place of residence, and care level were recorded. After 2 years, patients and/or relatives were contacted by mailed questionnaires or phone calls in order to calculate mortality and reevaluate the mentioned parameters. RESULTS: Follow-up rate was 77.7%, assessing 87 patients overall. The relative mortality risk was significantly increased for PR (2.9 (95% CI: 1.5–5.4)) and PPFF (3.5 (95% CI: 1.2–5.8)) but not for RF (1.5 (95% CI: 0.4–2.6)) and AJ (2.0 (95% CI: 0.0–4.0)). Every fracture group except AJ showed significantly higher BI on average at follow-up. PMS was, respectively, reduced on average for PR and RF insignificantly, but significantly for PPFF and AJ in comparison to pre-hospital values. 10.0–27.3% (each group) of patients had to leave their homes permanently; care levels were raised in 30.0–61.5% of cases. DISCUSSION: This investigation provides a perspective for further larger examinations. PR and PPFF correlate with significant increased mortality risk. Patients suffering from PPFF, PR, and RF were able to significantly recover in their activities of daily living. AJ and PPFF conclude in significant reduction of PMS after 2 years. CONCLUSION: Any fragility fracture has its impact on mortality, function, and socioeconomic aspects and shall not be underestimated. Despite some fractures not being the most common, they are still present in daily practice

Orthogeriatric co-management: differences in outcome between major and minor fractures

PURPOSE: Literature shows that orthogeriatric co-management improves the outcomes of patients with hip fractures. Corresponding research with more diverse fragility fracture groups is lacking. Therefore, an examination was performed prospectively as a 2 year-follow-up on an orthogeriatric co-managed ward, comparing relevant outcome parameters for major and minor fragility fractures. METHODS: All patients treated on an orthogeriatric co-managed ward from February 2014 to January 2015 were included and their injuries, orthogeriatric parameters such as the Barthel Index (BI), Parker Mobility Score (PMS) and place of residence (POR). Patients were separated into two groups of either immobilizing major (MaF) or non-immobilizing minor (MiF) fractures. 2 years later, a follow-up was conducted via telephone calls and questionnaires mailed to patients and/or their relatives. RESULTS: 740 (574 major vs. 166 minor injuries) patients were initially assessed, with a follow-up rate of 78.9%. The in-house, 1-year, and 2-year-mortality rates were 2.7, 27.4, and 39.2%, respectively. Mortality was significantly higher for MaF in the short term, but not after 2 years. On average, during the observation period, patients regained their BI by 36.7 points (95% CI: 33.80–39.63) and PMS was reduced by 1.4 points (95% CI: 1.16–1.68). No significant differences were found in the readmission rate, change in BI, PMS or POR between the MaF and MiF groups. CONCLUSION: The relevance of orthogeriatric treatment to improving functional and socioeconomic outcomes was confirmed. The similarity of the results from both fracture groups emphasizes the need for a multidisciplinary approach also for minor fractures. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00068-022-01974-3

Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial

Purpose Tibial shaft spiral fractures and fractures of the distal third of the tibia (AO:42A/B/C and 43A) frequently occur with non-displaced posterior malleolus fractures (PM). This study investigated the hypothesis that plain X-ray is not sufcient for a reliable diagnosis of associated non-displaced PM fractures in tibial shaft spiral fractures. Methods 50 X-rays showing 42A/B/C and 43A fractures were evaluated by two groups of physicians, each group was comprised of a resident and a fellowship-trained traumatologist or radiologist. Each group was tasked to make a diagnosis and/ or suggest if further imaging was needed. One group was primed with the incidence of PM fractures and asked to explicitly assess the PM. Results Overall, 9.13/25 (SD±5.77) PM fractures were diagnosed on X-ray. If the posterior malleolus fracture was named or a CT was requested, the fracture was considered “detected”. With this in mind, 14.8±5.95 posterior malleolus fractures were detected. Signifcantly more fractures were diagnosed/detected (14 vs. 4.25/25; p<0.001/14.8 vs. 10.5/25; p<0.001) in the group with awareness. However, there were signifcantly more false positives in the awareness group (2.5 vs. 0.5; p=0.024). Senior physicians recognized slightly more fractures than residents (residents: 13.0±7.79; senior physicians: 16.5±3.70; p=0.040). No signifcant diferences were demonstrated between radiologists and trauma surgeons. The inner-rater reliability was high with 91.2% agreement. Inter-rater reliability showed fair agreement (Fleiss-Kappa 0.274, p<0.001) across all examiners and moderate agreement (Fleiss-Kappa 0.561, p<0.001) in group 2. Conclusion Only 17% of PM fractures were identifed on plain X-ray and awareness of PM only improved diagnosis by 39%. While experiencing improved accuracy, CT imaging should be included in a comprehensive examination of tibial shaft spiral fractures

Prognostic value of orthogeriatric assessment parameters on mortality: a 2-year follow-up

INTRODUCTION: Since the arise of orthogeriatric co-management patients’ outcome and survival has improved. There are several assessment parameters that screen the precondition of orthogeriatric patients including mobility, activities of daily living, comorbidities, place of residence and need for care just to name a few. In a 2-year follow-up on an orthogeriatric co-managed ward the fracture-independent predictive value of typical assessment parameters and comorbidities on the associated mortality was examined. METHODS: All patients treated on an orthogeriatric co-managed ward from February 2014 to January 2015 were included. No fracture entity was preferred. Emphasis was set on following parameters: age, gender, Parker-Mobility Score (PMS), Barthel Index (BI), Charlson-Comorbidity Index (CCI), dementia, depression, sarcopenia, frequent falling, length of stay (LOS), care level (CL) and place of residence (POR). In a 2-year follow-up the patients’ death rates were acquired. SPSS (IBM Corp., Armonk, New York, USA) and Cox regression was used to univariately analyze the expression of the mentioned parameters and mortality course over 2 years from discharge. In a multivariate analysis intercorrelations and independent relationships were examined. RESULTS: A follow-up rate of 79.6% by assessing 661 patients was achieved. In the univariate analysis linear inverse correlation between PMS and BI and mortality and a linear positive correlation between CCI and higher mortality were observed. There was also a significant relationship between lower survival and age, dementia, sarcopenia, frequent falling, higher institutionalized place of residence and higher CL. No univariate correlation between 2-year mortality and gender, depression and LOS was found. In the multivariate Cox regression, the only independent risk factors remaining were lower PMS (HR: 1.81; 95%CI: 1.373–2.397), lower BI (HR: 1.64; 95%CI: 1.180–2.290) and higher age per year (HR: 1.04; 95%CI: 1.004–1.067). CONCLUSION: Age, PMS, BI, CCI, preexisting dementia, sarcopenia, frequent falling, POR and CL are univariate predictors of survival in the orthogeriatric context. An independency could only be found for PMS, BI and age in our multivariate model. This underlines the importance of preexisting mobility and capability of self-support for the patient’s outcome in terms of survival