Objective This study aimed to assess the efficiency and safety of minimally invasive treatment for die-punch fractures using X-ray parameters. Methods From May 2020 to May 2022, 32 patients (32 wrists; minimally invasive group) underwent percutaneous bony distraction, followed by external fixation. For comparison, we retrospectively reviewed another 35 patients (35 wrists; plating group) who underwent open reduction and internal fixation with plate and crew systems. Wrist movement was assessed. X-ray parameters and wrist pain were assessed. Wrist function was assessed using the Mayo Wrist Score. Patient satisfaction was assessed using the Short Assessment of Patient Satisfaction. Results The mean age of the minimally invasive group was 38.6±12.3 years (range, 24–52 years). There were types B3 (n=11), C1 (n=10), C2 (n=8), and C3 (n=3). Bone healing achieved in all patients after 5.8±1.6 weeks. The mean age of the plating group was 37.1±13.2 years (range, 27–50 years). There were types B3 (n=13), C1 (n=9), C2 (n=9), and C3 (n=4). Bone healing achieved in all patients after 6.3±1.6 weeks. Two years after surgery, there were significant differences in radial height (12.1±2.6 mm versus 10±2.5 mm; p <0.05) and ulnar variance (0.7±0.5 mm versus 1.4±0.9 mm; p <0.05). There was a significant difference in wrist pain (0±1 versus 3±3; p <0.01). There was no significant difference in wrist movement ( p >0.05), grip strength ( p >0.05), Mayo Wrist Score ( p >0.05), or patient satisfaction ( p >0.05). Conclusion When treating die-punch fracture of distal radius, directly lifting the collapsed fragments through percutaneous bone distraction can effectively achieve reduction. The carpal bones can be used as a template to restore the alignment of the articular surface of the distal radius. External fixation can prevent re-collapse of the radius. The treatment can be an alternative technique, in addition to open reduction and plating.
Purpose To identify the causes of surgical delay in patients with hip fracture, as recognized in the Emergency Department, and to assess their impact on mortality and hospital length of stay. Methods A retrospective longitudinal study was conducted in a tertiary care Spanish hospital between January and June 2023, including 182 patients aged 65 years or older with hip fracture (76.9% women; mean age 836 ± 7.6 years). The reasons for surgical delay were analyzed, along with hospital length of stay and mortality during hospitalization and 10 months post-discharge. Results Dementia was present in 41.2% of cases, and the mean Barthel Index was 75.4 points. The median time to surgery was 4 days (IQR: 3–6). Surgery was performed within 72 hours in 41.8% of patients. The most frequent causes of surgical delay were admission during weekends or holidays (90.6%), lack of operating room availability (19.8%), severe renal failure (31.1%), severe infection (24.6%), neurological instability (23.6%), antiplatelet therapy (21.7%), and absence of accompanying family members (16%). Overall mortality was 18.8%. In multivariate analysis, patients operated within 72 hours showed no significant difference in mortality. However, those operated after 72 hours had a significantly longer hospital stay. Conclusions Surgical delay in hip fractures is influenced by clinical, social, and institutional factors. Familiarity with clinical practice guidelines may help reduce avoidable delays and improve overall hospital length of stay.
Objective Elderly hip fracture patients constitute a vulnerable population in whom operative management is frequently required. Comorbidities commonly exist and are often a factor leading to delays in entry to the operating room. Our regional hospital manages many hip fractures and we sought to understand the demographic and medical details of this group, and whether frailty was a factor in time-to-theatre and length of stay (LOS). Methods We conducted a retrospective cohort study of all patients over 65 years with hip fractures managed operatively at our regional hospital in Australia from 2018-2022. Demographics, and details of medical, surgical and anaesthetic management were collected. Data to allow calculation of a frailty score (the 11-item modified frailty index (mFI-11)) were collected to allow determination of a ‘frail’ and ‘non-frail’ cohort. These cohorts were compared with respect to time-to-theatre and LOS. Results Our cohort consisted of 453 subjects. Median age was 83.1 years (range 65-103). Most subjects (71.5%) were living in the community pre-fracture. 324 subjects were ‘frail’. Average time-to-theatre was longer in the frail cohort (28.9 h (frail) vs 22.0 h (non-frail), P <0.0001), as was average LOS (7.4 days (frail) vs 6.3 days (non-frail), P =0.0077). However, after adjusting for ASA score, age and sex, there was no longer evidence of these relationships (time-to-theatre, P=0.054; LOS, P =0.477). Post hoc subgroup analyses revealed that frail subjects had longer LOS if time-to-theatre was >24h, and that frail subjects had higher odds of any complication than non-frail subjects, whether time-to-theatre was <24h or >24h. Conclusions This study confirmed a demographic profile for elderly hip fracture patients at our hospital similar to that noted in large databases. Although the mFI-11 may retain value in defining clinically complex hip fracture patients, we were unable to find evidence of its utility as an independent predictor of time-to-theatre or LOS.
Background Up to 25% of patients undergoing total knee replacement (TKR) for end-stage knee osteoarthritis report persistent pain, functional limitation, and reduced health-related quality of life (HRQoL). Although depression, anxiety, and stress are recognized determinants of surgical outcomes, their postoperative impact remains poorly studied in the Arab world, with no multicenter data from Jordan. Objectives This study aimed to assess the postoperative depression, anxiety, and stress and their association with HRQoL among TKR patients in Jordan, and to identify independent predictors of HRQoL. Methods A cross-sectional descriptive correlational design was used. A total of 140 adults were recruited from two government orthopedic hospitals in Jordan. Assessments were conducted at a single postoperative time point, 6–12 weeks following TKR surgery. Postoperative depression, anxiety, and stress were measured using the validated Arabic DASS-21 (α = 0.94), and HRQoL was assessed using the Arabic SF-12 (α = 0.84). Data were analyzed using descriptive statistics, Pearson correlation, and stepwise multiple linear regression. Results Participants demonstrated moderate depression (M = 18.66, SD = 7.18) and anxiety (M = 14.13, SD = 7.63), and mild stress (M = 17.17, SD = 7.65) post-TKR. The mean HRQoL score was 39.56 (SD = 10.07). A statistically significant negative correlation was found between psychological distress and HRQoL (r = −0.27, p = 0.001). Multiple regression identified body mass index (BMI) (B = −0.382, p < 0.001) and postoperative psychological distress (DASS-21 total score; B = −0.054, p < 0.001) as independent predictors of HRQoL, explaining 17.7% of total variance. Educational level and comorbidities were significantly associated with postoperative depression, anxiety, and stress. Conclusion Postoperative TKR patients in Jordan demonstrated poor overall HRQoL alongside moderate psychological distress. Routine psychological screening and targeted multidisciplinary interventions addressing modifiable factors such as BMI and psychological distress may help improve patient outcomes following TKR.
Introduction Hip fractures are debilitating for older adults, particularly those living in long-term care (LTC) homes. While surgical repair can alleviate pain and restore function, it carries the risk of several complications, including delirium, infection and cardiovascular events. Our objectives were to compare outcomes in LTC residents who did and did not undergo surgery following hospitalization for a hip fracture and assess the utility of existing frailty indices in differentiating outcomes in this population. Methods We used a retrospective observational cohort of older adults from LTC homes in Ontario, Canada, hospitalized for hip fractures between January 1, 2015, and December 31, 2019. Primary exposure was surgery. Outcomes included in-hospital and 30-day post-discharge mortality, pain and functional mobility at 180 days post-discharge. Analyses were stratified by frailty level using four different indices. Logistic regression models were estimated to assess the associations between surgery, frailty, and outcomes. Results Among 5,279 older adults meeting inclusion criteria (mean age = 87.0 years, 74.2% female), 86.1% received surgical repair. Following adjustment across multiple models, surgery was significantly associated with reduced in-hospital (adjusted odds ratio [aOR] = 0.27-0.29) and 30-day (aOR = 0.65-0.66) mortality. While the surgical group was less likely to experience pain (aOR = 0.88-0.91) and had higher odds of preserved or improved functional mobility (aOR = 1.35-1.37) at 180 days, these differences were not statistically significant. Likewise, while the frailty indices were predictive of mortality, they were not significantly associated with the odds of experiencing pain or functional mobility at 6 months. Among those who underwent surgery, RESPECT and CHESS were strongly associated with in-hospital and 30-day mortality, suggesting utility for perioperative risk stratification. Conclusions In LTC residents with hip fractures who are eligible and fit for surgery, surgical management was associated with improved survival, which can be predicted using existing frailty indices.
Introduction Distal radius fractures are common in older women, but the optimal treatment remains debated. We compared conservative treatment, volar locking plate fixation, and external fixation in women aged ≥65 years with low-energy distal radius fractures, focusing on patient-reported outcomes (PROMs) and radiographic alignment. Materials and Methods This retrospective cohort study included consecutive women aged ≥65 years treated at a tertiary center between January 2019 and January 2024. Only low-energy mechanisms, such as falls from standing height, were included. Patients were grouped according to treatment received: conservative management (n=44), open reduction and internal fixation with a volar locking plate (ORIF; n=47), or external fixation (n=43). The primary endpoint was the PRWE total score at ≥12 months. Secondary outcomes included QuickDASH, PRWE pain and function subscores, range of motion, grip strength, and radiographic parameters. Results A total of 134 women were analyzed. The primary outcome, PRWE total score, did not differ significantly across groups: 15.40±6.71 after conservative treatment, 14.89±5.55 after volar plating, and 17.08±7.51 after external fixation (p=0.268). QuickDASH scores were 14.35±7.21, 17.86±6.57, and 15.44±7.61, respectively (p=0.058). Grip strength as a percentage of the contralateral side was also similar (88.62±5.85%, 90.09±5.54%, and 91.02±5.54%; p=0.139). Patients selected for operative treatment had better final radiographic alignment, including volar tilt (5.80±2.79°, 7.55±1.57°, and 7.07±1.65°; p<0.001) and radial height (9.73±2.42 mm, 11.77±1.91 mm, and 12.86±1.91 mm; p<0.001). Conclusions In women aged ≥65 years with low-energy distal radius fractures, PRWE total score did not differ significantly across treatment pathways, despite better radiographic alignment in patients selected for operative treatment. Because treatment allocation was not randomized and baseline fracture morphology differed substantially between groups, these comparisons should be interpreted as descriptive observational findings after individualized treatment selection in routine practice. The absence of statistically significant differences in PROMs should not be interpreted as evidence of treatment equivalence or as a causal treatment effect.
Introduction:In-hospital mortality following hip fracture surgery remains a significant outcome in elderly patients, yet perioperative determinants - particularly those modifiable during hospitalization - are incompletely characterized. Whether the prognostic impact of acute kidney injury (AKI) on in-hospital mortality differs according to fracture type has not been previously examined. Materials and Methods:This retrospective cohort study included 342 patients aged ≥65 years who underwent surgical treatment for hip fracture at a tertiary referral center between January 2018 and January 2022. The primary outcome was in-hospital mortality. Independent predictors were identified using multivariable logistic regression. Model performance was assessed by ROC analysis, Hosmer-Lemeshow calibration testing, and bootstrap internal validation with 1000 iterations. A simple additive risk score was derived from the final model. Interaction analysis evaluated whether fracture type modified the association between AKI and mortality. Results:In-hospital mortality occurred in 29 of 342 patients (8.5%). Independent predictors were postoperative AKI (OR 5.46, 95% CI 2.20-13.51), lower preoperative serum albumin (OR per 1 g/dL increase 0.38, 95% CI 0.18-0.78), and lower admission oxygen saturation (OR per 1% increase 0.86, 95% CI 0.77-0.95). The model demonstrated acceptable discrimination (AUC = 0.766, 95% CI 0.655-0.877). A three-variable additive risk score stratified mortality from 3.4% (score 0) to 39.1% (score 2-3). Interaction analysis revealed that fracture type significantly modified the prognostic impact of AKI (interaction p = 0.016), with a substantially stronger effect in extracapsular fractures (OR 14.3, 95% CI 4.0-50.0) than intracapsular fractures (OR 1.32, 95% CI 0.30-5.88). Conclusions:Postoperative AKI, hypoalbuminemia, and reduced admission oxygen saturation independently predict in-hospital mortality after hip fracture surgery. The mortality risk conferred by AKI is substantially greater in extracapsular fractures, highlighting the need for fracture-type-specific perioperative vigilance and early renal protection strategies.
Background Osteoporotic fractures represent a major public health problem, particularly in older adults. Distal femur fractures, although less frequent, have also been associated with substantial mortality, with rates approaching those of hip fractures. However, direct comparisons between both entities remain limited and heterogeneous, and it is unclear whether distal femur fractures carry a comparable prognostic burden. Methods We conducted a retrospective observational cohort study including surgically treated patients aged ≥65 years with proximal or distal femoral fractures between 2013 and 2019. Distal fracture cases were compared with a proximal femoral fracture cohort. Cases were identified using ICD codes and validated through clinical record review. The primary outcome was all-cause mortality at 30, 90, and 365 days after surgery. Survival was analyzed using Kaplan-Meier curves, compared with the log-rank test. Cox proportional hazards models were used to assess the association between fracture type and mortality, adjusting for relevant clinical variables. Results A total 234 proximal and 74 distal femoral fractures patients were included. One-year mortality was similar between groups (27.4% vs. 35.6%, p=0.176). However, mortality was significantly higher in distal fractures at 30 days (16.2% vs. 7.7%, p = 0.031) and 90 days (24.3% vs. 14.1%, p = 0.039). Kaplan-Meier analysis showed significant differences at 30 and 90 days but not at 365 days. In multivariable Cox regression, fracture type was not independently associated with mortality, while rurality was associated with lower mortality. Conclusion Although distal femoral fractures were associated with higher short- and mid-term mortality, fracture type was not an independent predictor of mortality after multivariable adjustment. Rurality emerged as an independent predictor of survival, warranting further investigation. These findings suggest that distal femur fractures may require a similar level of clinical attention.
Purpose Sleep disorder is a frequent postoperative complication after total hip arthroplasty (THA). This study aimed to characterize sleep disorder phenotypes, identify associated risk factors, and explore the relationships between sleep disturbance patterns and clinical outcomes in elderly patients aged ≥70 years. Materials and Methods A single-center retrospective analysis included 892 primary THA patients between January 2021 and December 2024. Sleep disorders were assessed via a validated 12-item questionnaire and diagnosed according to the International Classification of Sleep Disorders, 2nd Edition. Visual analog scale (VAS) pain scores and length of hospital stay (LOS) were extracted and stratified by different groups. All patients finished a minimum 6-month postoperative follow-up. Results 78.3% of patients had postoperative sleep disturbances (median 6 weeks, range 4-8 weeks). Primary insomnias (72.1%) dominated, with adjustment sleep disorder (41.5%) most common; secondary insomnias (27.9%) linked to comorbidities (19.7%) and drugs (8.2%). Elderly patients had 83.5% incidence and 3.2-fold higher risk of persistent disturbances versus non-elderly patients ( p <0.001). Patients with sleep maintenance difficulties or non-restorative sleep tended to present with higher VAS ( p <0.001) and longer LOS ( p <0.001) significantly. Discussion Pain (38.6%), psychological stress (29.4%), and intrinsic factors (16.2%) were most commonly associated with sleep disturbances. Elderly patients were more vulnerable to comorbidity-related and environmental sleep disruptors. Differences in clinical indicators were observed between patients receiving personalized perioperative management and those under routine care. Conclusions Adjustment sleep disorder is the most common postoperative sleep phenotype in THA patients. Pain, psychological factors, and intrinsic characteristics are key drivers. In addition, patients with difficulty in staying asleep and non-restorative sleep are associated with higher pain scores and prolonged LOS. Elderly patients are high-risk for persistent sleep disturbances and inferior recovery outcomes. These findings suggest potential directions for patient-centered perioperative management, while relevant associations need further verification.
Background:Postoperative constipation (POC) is common in older adults after hip fracture surgery and may be influenced by perioperative care and nutritional status. Serum albumin is an imperfect nutrition marker, whereas the Geriatric Nutritional Risk Index (GNRI) combines albumin with body weight and may better reflect nutritional reserve. The association between preoperative GNRI and POC after fixation of AO/OTA 31-A extracapsular hip fractures remains unclear. We evaluated the association of preoperative GNRI with POC and compared discrimination with other preoperative markers. Methods:We conducted a single-center retrospective cohort study of patients aged ≥65 years undergoing proximal femoral nail fixation for AO/OTA 31-A extracapsular hip fractures. POC was defined as no spontaneous bowel movement for ≥3 postoperative days or laxative/enema use within 72 hours. Multivariable logistic regression adjusted for age, sex, BMI, diabetes, prior stroke/TIA, Parkinson's disease, time to first mobilization (≥48 h), and total opioid dose (morphine-equivalent dose, MED). Discrimination was assessed using ROC AUC; analyses were complete-case. Results:Among 230 patients, 152 (66%) developed POC. In the expanded model, higher GNRI was associated with lower odds of POC (adjusted OR 0.86 per 1-unit increase, 95% CI 0.81-0.91; P<0.001). Higher BMI (OR 1.18, 95% CI 1.05-1.33; P=0.005), mobilization ≥48 h (OR 2.43, 95% CI 1.22-4.83; P=0.011), and opioid exposure (OR 1.52, 95% CI 1.24-1.85; P<0.001) were associated with higher odds. Model AUC increased from 0.758 to 0.822 after adding perioperative factors. In single-marker ROC analyses, GNRI showed modest discrimination for POC (AUC 0.724, 95% CI 0.650-0.789), higher than serum albumin (AUC 0.689), BMI (AUC 0.539), and age (AUC 0.545). Conclusions:POC was common after fixation of AO/OTA 31-A extracapsular hip fractures in older adults. Preoperative GNRI provided prognostic information, and perioperative variables further improved discrimination. GNRI may help identify patients who could benefit from proactive bowel management, opioid-sparing strategies, and early mobilization.
Objectives To compare the Trauma-Specific Frailty Index (TSFI) with an institutional Perioperative Geriatric Score (PGS) for predicting postoperative level of care, discharge disposition, and length of stay in older adults undergoing operative fixation of lower-extremity fractures. Methods Design: Retrospective cohort study. Setting: Two hospitals within a single academic health system: an urban level I and a suburban level III trauma center. Patient Selection Criteria: Patients aged ≥65 years who underwent operative fixation of lower-extremity fractures between January 1 and June 30, 2025; nonoperative fractures and encounters lacking primary outcome data were excluded. Frailty was measured with the TSFI (0–1 deficit-accumulation index). Perioperative risk was measured with an institutional PGS combining vasopressor use, blood loss, cardiac comorbidity, case duration, and delay to surgery. Outcome Measures and Comparisons: Primary outcomes were postoperative level of care, discharge disposition, and hospital length of stay; 90-day readmission and mortality were secondary. Multivariable regression adjusted for age, sex, body mass index, and fracture type. Results Among 248 patients (median age, 78 years; 64.1% female), higher TSFI values were associated with stepdown admission (odds ratio [OR] 2.43; 95% confidence interval [CI], 1.13–5.21), intensive care unit admission (OR 2.79; 95% CI, 1.16–6.70), discharge to a skilled nursing facility (OR 1.96; 95% CI, 1.11–3.47), and longer length of stay (OR 1.61; 95% CI, 1.19–2.17). The PGS showed weaker associations, reaching significance only for intensive care unit admission (OR 1.16; 95% CI, 1.07–1.26). Ninety-day readmission and mortality were too infrequent for reliable estimates. Conclusions The TSFI outperformed an institutional perioperative geriatric triage score in predicting postoperative care escalation and discharge disposition in lower-extremity fracture patients. Incorporation of frailty assessment into orthopaedic trauma workflows may improve risk stratification, counseling, and resource planning.
Background The aim of this study was to evaluate patients over 65 years old treated with an angled blade plate (ABP) for distal femoral fractures and determine if the use of ABP was reasonable in this specific population who are prone to complications. Methods Consecutive patients with distal femoral fracture who had undergone open reduction and internal fixation with ABP plate between January 2010 and December 2023 were retrospectively analyzed. Medical records were reviewed for age, sex, follow-up, injury characteristics, fracture pattern, and complications, such as malunion, non-union and infection. Clinical evaluation of patients was performed using the international Knee Documentation Committee (IKDC) score. Results Twenty-one (18 female; 85.7%) patients were included, with a median (range) age of 78.5 (65-92) years. Mean follow-up was 17 months. Four of the patients sustained high-energy trauma fractures and the remainder fractured because of a simple fall; five were admitted due to the nonunion and three because of complications related to intramedullary nail. Most (85%) had periprosthetic fracture. Only 2/21 (9.5%) had nonunion and implant failure and were revised again with ABP and iliac crest autograft. Furthermore, only 1 (4.8%) with superficial infection needed surgical debridement in the early postoperative period. After a minimum of 12 months follow up the mean IKDC score was 37 (range 21-72). Conclusion ABP appears to be a reliable device for the treatment of distal femoral fractures in patients over 65 years, including those with osteoporotic and periprosthetic fractures, and non-unions, with a 90% union rate.
Purpose Geriatric distal tibia and fibula fractures are typically treated with open reduction and internal fixation (ORIF) or prolonged cast immobilisation. These methods predispose to wound complications and delayed weight-bearing. Percutaneous fixation can offer a stable construct allowing for early weight-bearing while minimising wound complications. This case series details the management and outcomes of patients over 65 with distal tibia and fibula fractures and poor soft tissue envelope treated with percutaneous fixation. Methods A prospective observational study was conducted at two Victorian orthopaedic units, identifying patients over 65 years of age who underwent percutaneous distal tibia or fibula fracture fixation. Patient selection considered soft tissue quality and overall health. Antegrade tibial intramedullary nails and retrograde percutaneous screws were used. Surgery proceeded without delay for swelling or anticoagulation cessation. Clinical notes and radiographs were analysed for premorbid health, mobility status, injury mechanism and classification, fixation methods, post-operative mobility, and treatment complications. Results The study identified 13 ankles in 11 patients (average age 82) across two sites. Fractures included 4 trimalleolar, 5 bimalleolar, 1 lateral malleolar, and 3 distal tibia and fibula diaphyseal. Three fractures were open. Median time to operation was 3 days. Six patients were allowed immediate weight-bearing as tolerated. Median post-operative stay was 5 days. One deep infection required removal of a suture-button syndesmosis device and two minor wound breakdowns (distant to surgical site) were managed non-operatively with dressings. Conclusion Percutaneous distal tibia and fibula fracture fixation appears to be a viable alternative to ORIF in geriatric patients with poor soft tissue envelope, potentially offering reduced complications and earlier mobilisation. Level of evidence Level IV.
Background Distal radius fractures (DRFs) are the most common upper-extremity fractures in older adults. Frailty may modulate postoperative risk, but the comparative prognostic value of widely used frailty indices in DRF surgery is unclear. Objective To compare the 5-item modified Frailty Index (mFI-5), Clinical Frailty Scale (CFS), and Charlson Comorbidity Index (CCI) for predicting complications and functional outcomes after DRF surgery in patients ≥65 years, and to assess whether machine learning (ML) enhances risk stratification. Methods We retrospectively analyzed 562 patients (mean age 75.1±4.9 years; 71.7% female) undergoing open reduction and internal fixation (67.1%), closed reduction percutaneous pinning (21.2%), or external fixation (11.7%), with ≥12 months of follow-up. Preoperative mFI-5, CFS, and CCI were collected. The primary endpoint was any postoperative complication (composite of surgical site infection, wound dehiscence, loss of reduction, tendon injury, nonunion/malunion, hardware failure, reoperation, 30-/90-day readmission, venous thromboembolism, and complex regional pain syndrome). Functional outcomes were DASH, PRWE, grip strength, and return to activities of daily living (ADLs). Logistic and Cox regression were used. Exploratory ML models (random forest, gradient boosting) employed 5-fold cross-validation, an 80/20 train–test split, and isotonic calibration. Results Over 17.9±4.5 months, 195 of 562 patients (34.8%) developed ≥1 complication. mFI-5 ≥2 was associated with higher complication rates (38.2% vs 31.9%) and worse 6-month disability (DASH 55.4 vs 44.5; PRWE 47.9 vs 36.4; all p<0.001). CFS ≥4 predicted lower 12-month grip strength recovery (67.8% vs 74.1%) and reduced ADL return (65.9% vs 78.6%). Discrimination for complications was modest (AUCs: mFI-5 0.552; CFS 0.534; CCI 0.507). ML substantially improved performance (gradient boosting AUC 0.878; random forest AUC 0.812) with superior calibration. Conclusions mFI-5, CFS, and CCI are associated with postoperative complications and functional recovery after DRF surgery but have limited individual discriminative power. ML-based multivariable models achieve markedly better risk stratification and may support more accurate preoperative counseling and personalized perioperative management.
Background Hemiarthroplasty remains the gold standard for hip fracture care in displaced intracapsular fractures. There is now substantial evidence that uncemented femoral stems are associated with higher risk of perioperative fractures. Cemented composite beam (CCB) stems offer some of the lowest overall rates of perioperative fracture risk, but are not widely used in the Irish system, and concern regarding the use of new implants and associated learning curves can act as a barrier to change. Objectives We aim to assess our units experience transitioning to a cemented composite beam (CCB) and the associated learning curve and technical pitfalls. Design Retrospective, single centre, single blind review identified the first 140 cases of CCB stems. Methods Post-operative radiographs on all cases were assessed for perioperative fracture and stems were classed as being varus or valgus if the stem alignment was >3 degrees from the anatomical axis. A cemented taper slip (CTS) stem, which was in use for over 10 years in the unit, provided a control group. Results Following introduction, higher odds of malalignment were experienced with the CCB stem (OR 2.19, 1.09-4.55 p<0.031), relative to CTS. However, compared to overall rate of malalignment in the CTS group (9.3%), the learning curve for the CCB stem was short, with rates of malalignment returning to in line with our control CTS cohort within 46 cases (Cases 1-46 32% malaligned, cases 47-92 10.86% malaligned, cases 93-138 4.34% malaligned). There was no increased risk of periprosthetic fracture demonstrated with introduction of the new stem. Conclusions We have shown a relatively short learning curve associated with transitioning to a CCB stem for fragility fracture hemiarthroplasty. We highlight some of the early technical issues experienced and corrected.
Introduction Dens fractures are cervical spine injuries with high morbidity and mortality in the elderly. Many patients require discharge to rehabilitation facilities or skilled nursing care, which impacts patient recovery, healthcare system resource allocation, and prognosis. This study evaluated the effect of trauma center level designation on discharge disposition in patients with dens fractures. Materials and Methods We conducted a retrospective study using data from a Texas State Trauma Registry from 2020 to 2022. Patient demographics, injury characteristics, and outcomes were queried in patients with dens fractures. Discharge home was defined as home discharge with or without home health services. Non-home discharge (NHD) was defined as discharge to another facility. Differences in discharge disposition were analyzed using adjusted binary and multinomial logistic regressions with 95% confidence intervals. Baseline characteristics were analyzed with chi-square and Kruskal-Wallis tests with post-hoc Dunn test for pairwise comparisons. Results A total of 904 patients were included. After excluding patients who died during hospitalization or were discharged to locations not included in the analysis (e.g., against medical advice, jail, or psychiatric facilities), 433 (52.9%) patients were discharged home while 385 (47.1%) patients had a NHD. Patients treated at level II trauma centers were almost twice as likely to have a NHD compared to patients who were treated at a level I (OR=1.98; 95% CI, 1.39-2.83; p<0.001). Lower-level trauma centers combined (levels II to IV) also had higher odds of a NHD compared to patients who were treated at a level I trauma center (OR=2.03, 95% CI, 1.47-2.79; p<0.001). These findings remained significant when patients discharged from the ED without inpatient admission were excluded (OR=1.52; 95% CI, 1.08-2.14; p=0.016). Discussion Patients with dens fractures treated at Level I trauma centers were significantly more likely to undergo home discharge than those treated at lower-level centers. Trauma center level may play an important role in discharge outcomes for this high-risk population. Further research is needed to identify specific practices contributing to this difference in discharge disposition.
Introduction Proximal femur fractures are common in older adults and are associated with high morbidity and mortality. Bone cement augmentation during intramedullary nailing has been reported to improve implant stability; however, its clinical utility and safety in Japan remain unclear. Materials and Methods This multicenter prospective observational study included patients aged ≥45 years who underwent intramedullary nailing for trochanteric or basicervical femoral fractures between May 1, 2021, and July 31, 2023. Cement augmentation was applied exclusively to patients aged ≥60 years. Femoral neck fractures were excluded. Patients were treated with cement augmentation (CA group) or without augmentation (N group). The primary outcome was screw cut-out within 6 months postoperatively. Secondary outcomes included sliding distance (>5 mm), reoperation, nonunion, postoperative infection, and other complications. Group comparisons were performed using two-sided statistical tests with p < 0.05 considered significant. Results A total of 300 patients were analyzed (CA, n=97; N, n=203; mean age 86.8 years). No cut-out occurred in the CA group, whereas four cases (1.9%) occurred in the N group (p = 0.12). Sliding distance >5 mm was observed in 2 patients (2.0%) in the CA group and 12 patients (5.9%) in the N group (p = 0.108). Postoperative complications occurred in 2 patients (2.1%) in the CA group and 12 patients (5.9%) in the N group (p = 0.12). No cement-related adverse events were observed. Conclusions Cement augmentation during intramedullary nailing was safe and showed numerically lower rates of cut-out and excessive sliding compared with non-augmented fixation. Although statistical significance was not reached, these findings suggest a potential clinical role in elderly patients at high risk of fixation failure. Randomized controlled trials are warranted.
Background:Distal radius fractures are common among elderly patients and frequently pose management challenges due to advanced age, multiple comorbidities, and increased anesthesia-related risks. In high-risk individuals with limited physiological reserve, the choice between surgical and nonoperative treatment remains controversial. This study aimed to compare the functional, radiological, and complication outcomes of volar locking plate fixation and cast immobilization in elderly patients with distal radius fractures and high anesthetic risk. Methods:This retrospective, single-center comparative study included patients aged ≥65 years with acute distal radius fractures and an American Society of Anesthesiologists (ASA) class ≥III, treated either with cast immobilization or volar locking plate fixation between January 2022 and December 2023. Functional outcomes were assessed using the Patient-Rated Wrist Evaluation (PRWE), Visual Analog Scale (VAS), grip strength, and Activities of Daily Living (ADL) at 6 and 12 months. Radiological parameters, including radial height, radial inclination, volar tilt, and ulnar variance, were evaluated using standardized digital measurements. Treatment-related complications were recorded and analyzed. Statistical analyses included independent-samples t-tests, chi-square tests, and effect size calculations, with a p-value <0.05 considered statistically significant. Results:A total of 60 patients (30 treated with cast immobilization and 30 treated with volar locking plate fixation) met the inclusion criteria and were included in the final analysis. No statistically significant differences were observed between the two groups in terms of Patient-Rated Wrist Evaluation (PRWE) scores, Visual Analog Scale (VAS) scores, grip strength, or independence in activities of daily living at either 6 or 12 months of follow-up (all p > 0.05). Radiological parameters were largely comparable between groups at final follow-up; however, volar tilt and ulnar variance demonstrated significantly more favorable values in the volar locking plate group. The overall complication rates were similar between treatment modalities. Malunion and complex regional pain syndrome were observed in both groups, with higher-but not statistically significant-rates in the cast immobilization group. No major complications, including deep infection, tendon rupture, neurovascular injury, implant failure, or reoperation, were encountered during follow-up. Conclusion:In elderly high-risk patients with distal radius fractures, volar locking plate fixation provides functional and radiological outcomes comparable to those of cast immobilization. Despite the surgical nature of plate fixation, it did not demonstrate a clear functional advantage over conservative management in this frail population. Given its truly nonoperative character and low complication profile, cast immobilization remains a safe and practical first-line treatment option for elderly patients in whom surgical intervention carries substantial risk.
