Proximal femoral fractures (PFF) are a global health burden in aging populations. Evidence on the prevalence and clinical relevance of concomitant fractures in this population remains limited. This study investigated the impact of concomitant fractures on mortality, complications, transfusion requirements, and postoperative mobility in patients with geriatric PFF. This single-center cohort study included patients ≥ 65 years with a positive geriatric screening, who underwent surgery for a PFF after low-energy trauma between January 2019 and December 2023. Patients with concomitant fractures were compared with those with isolated PFF. Outcomes included mortality, perioperative parameters, complications, and mobility at discharge. Uni- and multivariable regression models were applied adjusting for age, sex, comorbidities, body mass index (BMI), and fracture type. A total of 1553 patients were analyzed; 164 (10.5

BACKGROUND:Patients who have metal allergies frequently request hypoallergenic implants. In total knee arthroplasty (TKA), coating of standard implants is commonly used, with almost 10% of all primary TKAs in Germany in 2023. Registry data, however, have shown increased revision rates for coated implants. Whether this is due to the coating itself or the characteristics of allergy-prone patients remains unclear. The aim of this study was to compare revision rates, patient-reported outcomes, and serum metal levels in patients receiving coated versus standard TKA. METHODS:In this randomized controlled trial, patients undergoing primary, unconstrained TKA were enrolled. Exclusion criteria included other metal implants, the need for constrained prosthesis, or known implant material allergy. A total of 118 patients were randomized (59 per group) to receive a coated or standard TKA. Serum metal levels were assessed up to five years. At the 10-year follow-up, 20 patients had died, and two had undergone revision. Of the remaining 96, 79 were available for clinical evaluation. Outcomes included the Oxford Knee Score, Short Form-36, and patient satisfaction. RESULTS:Overall, 10-year implant survival was 98% for both groups. A revision occurred in each group. After 10 years, both groups showed good functional outcomes, health-related quality of life, and patient satisfaction, with no significant differences. However, functional scores and the physical component summary of the Short Form-36 declined compared to the 5-year follow-up, likely due to aging. Serum metal levels after five years were mostly below detection limits and similar across groups. CONCLUSIONS:Both coated and standard TKA implants demonstrated sustained improvement in function and health-related quality of life, as well as low revision rates. In comparable patient cohorts, the use of this coated implant system does not appear to be associated with inferior outcomes.

Background Proximal femur fractures (PFF) are the most common fracture type worldwide, particularly in geriatric patients. Despite advancement in treatment, mortality rates in this patient group remain high. Aims The aim of this study was to analyze potential factors, influencing the 90-day mortality rate and complication rate after PFF surgery in a tertiary care hospital. Methods Between 2019 and 2022, all patients aged 65 and older with PFF and a positive screening as a geriatric patient were included in this prospective, single-center study. Data collected included gender, age, BMI, fracture type, type and timing of surgery, comorbidities, medication, mobilization and blood loss as well as complications and 90-day mortality. Results Out of 1217 analyzed geriatric patients, 61% underwent surgery within 24 h. The complication rate was 21.7% with 3% surgical and 20.2% non-surgical complications. Median age was 87 years and 68% were female, while mean Charlson Comorbidity Index was 2.6 points and 84% had ASA 3 or 4. 240 patients (19.7%) died within 90 days after surgery. Higher mortality rates were associated with male gender (OR 1.341), higher age (OR 1.093), lower BMI (OR 0.946), higher Charlson Comorbidity Index (OR 1.202), non-surgical complications (OR 2.541) and if mobilization was impossible (OR 10.013). A delay of surgery beyond 24 h after admission was associated with the development of wound infections ( p = 0.022) and internal medicine-related complications ( p = 0.002). Discussion While no correlation was found between surgery timing and 90 days mortality, delays in surgery were associated with adverse effects, including wound infections and internal medicine complications. Conclusion The mortality rates of patients suffering from PFF maintain high and are mainly influenced by non-modifiable patient-related factors. Clinical trials registration German Registry for Clinical Trials, ID: DRKS00034048, date of registration: 10.02.2025. Retrospectively registered.

BACKGROUND:Patients who have had prior injections, surgeries such as arthroscopies, and have existing osteosynthetic implants in the hip and knee have an increased risk of periprosthetic infections when undergoing hip (THA) or total knee arthroplasty (TKA). OSTEOSYNTHESIS:For patients with osteosynthetic implants in the knee joint, a two-stage procedure (implant removal followed by TKA) is recommended based on the available literature and the high colonization rates. A two-stage procedure is also recommended for patients with hip implants. If there is an increased risk of re-fracture between implant removal and THA, a one-stage procedure can also be used. ARTHROSCOPY:An arthroscopy before THA or TKA increases the risk of complications and reoperations, in particular with short intervals. The interval should be at least 6 months, ideally 9 months. PREOPERATIVE INJECTIONS:Preoperative injections before THA clearly increase the risk, while for TKA, there is a non-significant trend. The earliest time for a prosthesis after injection should be 6 weeks, preferably 3 months. The waiting period should be balanced against the patients' discomfort and high levels of suffering, and patients should be informed about the risks.

BACKGROUND:The burden of osteoarthritis (OA) in multiple joints is high. For patients with bilateral knee OA there is no clear recommendation when to time the second surgery. The purpose of this study was therefore to compare revision and mortality rate in bilateral unicondylar and bicondylar knee arthroplasties after different strategies of surgical timing in bilateral knee OA from the German Arthroplasty Registry (EPRD). METHODS:Data from the German Arthroplasty Registry (EPRD) was used. Since 2012 a total of 15,154 patients had bilateral knee arthroplasty within one year. Patellofemoral arthroplasties and constraint total knee arthroplasties (TKA) were excluded. 1,144 TKA and 682 unicondylar arthroplasties (UKA) were simultaneously performed, 772 TKA and 292 UKA between 1 and 90 days (short interval) and 24,496 TKA and 2,922 UKA between 91 and 365 days (intermediate interval). Revision and mortality rates were analyzed up to 7 years after surgery. Cox regression was performed to evaluate the influence of different patient characteristics on these outcomes. RESULTS:The highest cumulative revision rate for any of the bilateral TKA was found for simultaneous surgery with 3.4% (95% CI 2.1-5.5). Lower risk for revision was seen in two-staged surgery in short interval (HR 0.42; 95% CI 0.20-0.90) and intermediate interval (HR 0.58; 95% CI 0.39-0.85). The cumulative one year mortality rate for TKA was comparable in all three groups with 0.8% for simultaneous TKA, 1.3% for short interval two-staged and 0.7% for intermediate interval. In UKA there were no differences between the groups regarding cumulative revision rate and mortality rate. CONCLUSION:TKA should be performed simultaneously in selected patients only, the two-staged procedure demonstrated lower revision risks. For UKA we found no differences in timing, simultaneous surgery seems to be a safe option. TRIAL REGISTRATION:Clinical trial number not applicable. LEVEL OF EVIDENCE:III.

Bei der Implantation einer Hüft- (HTEP) oder Knietotalendoprothese (KTEP) haben Patienten mit vorangegangenen intraartikulären Injektionen, Operationen wie Arthroskopien oder mit einliegenden osteosynthetischen Implantaten ein erhöhtes Risiko für periprothetische Infektionen. Bei Patienten mit osteosynthetischen Implantaten im Kniegelenk wird basierend auf der verfügbaren Literatur und den hohen Besiedelungsraten ein zweizeitiges Verfahren (Implantatentfernung gefolgt von KTEP) empfohlen. Bei Patienten mit Hüftimplantaten wird ebenfalls ein zweizeitiges Verfahren empfohlen. Bei einem erhöhten Re-Frakturrisiko zwischen Implantatentfernung und HTEP kann auch ein einzeitiges Verfahren angewendet werden. Eine Arthroskopie vor HTEP oder KTEP erhöht das Risiko für Komplikationen und Re-Operationen. Das Intervall sollte mindestens 6 Monate, idealerweise 9 Monate betragen. Intraartikuläre Injektionen vor HTEP erhöhen eindeutig das Risiko, was bei der KTEP nur tendenziell besteht. Der frühestmögliche Zeitpunkt für eine Prothese nach Injektion sollte 6 Wochen, besser jedoch 3 Monate betragen. Dabei sollten die Wartezeit und der Leidensdruck abgewogen und die Patienten über die Risiken aufgeklärt werden.

Background The management of femoral neck fractures (FNF) in elderly patients depends on comorbidities, pre-fracture mobility, any hip joint disease, and life expectancy, with treatment typically involving either hemiarthroplasty (HA) or total hip arthroplasty (THA). While cemented femoral stem fixation is standard, there is no clear consensus regarding cemented versus cementless cup fixation in THA. This study aimed to compare revision and mortality rates between THA, divided into cemented and cementless cup fixation, and HA, following FNF. Methods Data from the German Arthroplasty Registry (EPRD) were analyzed, including all patients with fracture-related THA or HA and available follow-up. A total of 34,501 patients undergoing THA (27,757 cementless, 6,744 cemented cups) and 72,022 patients with HA were included. 5-year revision and mortality rates were compared. Results The 5-year revision rate was the lowest in the HA group (4.1%), followed by cemented cup THA (5.0%), and cementless cup THA (6.8%; p < 0.001). Dislocation, infection, and periprosthetic fracture were the leading causes of revision. The 5-year mortality rate was the lowest in cementless cup THA patients (23%), 43% in cemented cup THA patients and highest in HA patients (54%). Cementless fixation was associated with a higher revision risk (HR 1.28, 95% CI 1.14-1.44), while HA was associated with increased mortality (HR 1.26, 95% CI 1.22-1.31). Conclusion Cemented cup fixation in THA after FNF is associated with lower revision rates but higher mortality compared to cementless fixation. In patients with limited life expectancy, HA remains the preferred option.

Die Arthrofibrose ist eine häufige Komplikation nach Knie-TEP (ca. 5

Arthrofibrosis is a common complication following total knee arthroplasty (approximately 5%), characterized by painful limitation of range of motion and increased soft tissue fibrosis. Women are affected more frequently than men. A distinction is made between primary (early postoperative, global) and secondary forms (mechanical/infectious causes). Diagnosis is established clinically and confirmed histopathologically. Early non-surgical, antifibrotic treatment with physiotherapy, relaxation techniques, and, if needed, prednisolone and propranolol is recommended. If there is no improvement, mobilization under anesthesia (MUA), ideally within the first 90 days postoperatively, or arthroscopic arthrolysis should be performed. Arthrolysis, while requiring surgical intervention, shows the best improvements in range of motion, particularly at later stages. Late revision surgeries are less effective. In the future, pharmacological therapies may play a role.

Excessive consumption of nicotine and alcohol has been proven to effect the organ system. Both stimulants are consumed in the population to a not insignificant extent. The question therefore arises as to what effect the consumption of nicotine and alcohol has on the complication rates and to what extent this should be reduced or stopped before performing a joint arthroplasty? A literature search was carried out to answer these questions. An increased risk of impaired wound healing and periprosthetic infections with regard to smoking was shown. This was also proven regarding excessive alcohol consumption. Additionally, there is an alcohol related increased risk of bleeding and malnutrition. Accordingly, nicotine and alcohol consumption should be reduced at least 4 weeks before performing total joint arthroplasty.

Background: Both the cruciate-retaining (CR) and posterior-stabilized (PS) implant systems are commonplace in modern total knee arthroplasty (TKA) practice. However, there is controversy regarding functional outcomes and survivorship. The aim of the underlying study was to evaluate differences between CR and PS TKA regarding knee function, patient-reported outcome measures (PROMs) as well as complication rates. Methods: 140 patients with knee osteoarthritis scheduled for an unconstrained TKA were enrolled in a prospective, randomized study. Patients received either a CR or PS implant. Range of motion and PROMs (Oxford Knee Score, Knee Society Score, European Quality of Life 5 Dimensions 3 Level, University of California Los Angeles Activity scale and subjective satisfaction) were assessed prior to, 3 months, 1 and 2 years after surgery. Results: We found minor differences between treatment groups regarding demographic factors. Within the PS group duration of surgery was longer (mean PS 81.4 min vs CR 76.0 min, P = .006). We observed better flexion (median PS 120.0 degrees vs CR 115 degrees, P = .017) and an overall better range of motion (median PS 120.0 degrees vs CR 115.0 degrees, P =.008) for the PS group. PROMs did not differ between groups. At 2-year follow-up there were no revisions in either cohort. Five patients needed reoperations. Three patients needed manipulation under anesthesia, 2 in the CR and one in the PS group. Conclusion: While PS TKA achieved a better flexion capability, PROMs were similar in CR and PS TKA. The CR implant design continues to be a reliable option for patients with an intact posterior cruciate ligament. (c) 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Der übermäßige Konsum von Nikotin und Alkohol hat nachweislich Auswirkungen auf das Organsystem. Beide Genussmittel werden in der Bevölkerung zu einem nicht zu vernachlässigen Anteil konsumiert. Es stellt sich daher die Frage, welche Auswirkungen der Konsum von Nikotin und Alkohol auf die Komplikationsrate hat und inwiefern dieser vor der Durchführung einer Prothesenoperation reduziert oder eingestellt werden sollte. Entsprechend erfolgte eine Literaturrecherche zur Beantwortung dieser Fragen. Es zeigte sich sowohl für das Rauchen als auch für einen übermäßigen Alkoholkonsum ein erhöhtes Risiko für das Auftreten von Wundheilungsstörungen und periprothetischen Infektionen. Für den Alkoholkonsum besteht zusätzlich ein erhöhtes Risiko für das Auftreten von Blutungen und einer Mangelernährung. Dementsprechend sollte der Nikotinkonsum als auch der Konsum von Alkohol mindestens 4 Wochen vor der Implantation einer Endoprothese reduziert werden.

Background and purpose: Hemiarthroplasty (HA) is the usual treatment for displaced femoral neck fractures (FNF) in elderly patients. Patients may be unsuitable for HA due to secondary conditions such as systemic infections or severe neurological conditions, which is why Girdlestone resection arthroplasty (GRA) may be an option. We aimed to determine (1) patient survival in matched patient groups treated with either GRA or HA and (2) functional outcomes. Patients and methods: 21 patients treated with GRA for FNF in a German university hospital were retrospectively reviewed (2015–2019). After matching for age and comorbidities, a control group of 42 HA patients was established. Patient survival was determined by a Kaplan–Meier analysis. The mean follow-up (FU) was 1.5 (0–4.4) years. Function at FU was documented using the modified Harris Hip Score (mHHS) and the National Hip Fracture Database (NHFD) mobility score. Results: The 1-month-mortality was 19% in the GRA group and 12% in the HA group; the 1-year mortality was 71% and 49%, respectively (P = 0.01). The mHHS at FU was lower in the GRA group than in the HA group (22 [range 0–50] vs. 46 [11–80]). 82% of patients in the GRA group were bedridden post-surgery as opposed to 19% in the HA group. Conclusion: Patients with HA after FNF had higher survival and better functional outcomes when compared with GRA in matched patient groups. Considering this, GRA for FNF should be selected restrictively.

Periprothetische distale Femurfrakturen (PDFF) betreffen überwiegend geriatrische Patienten mit sehr ausgeprägtem Risikoprofil. Bei sehr distaler Fraktur, schlechter Knochenqualität und/oder gelockerter Knieendoprothese ist der Wechsel auf einen distalen Femurersatz (DFR) häufig nötig. Diesbezüglich existieren in der Literatur nur unzureichende Daten zum Outcome. Wie ist das Outcome hinsichtlich Revision und Mortalität nach DFR bei PDFF? Es erfolgte eine Analyse der Daten des Endoprothesenregisters Deutschland (EPRD). Bei aktuell 43.945 Wechseleingriffen am Knie konnten 629 mit DFR bei PDFF identifiziert werden. Das mittlere Alter bei Operation betrug 79,1 Jahre und 84,1

Background Despite improving the management of proximal femur fractures (PFF) with legal requirements of timing the surgery within 24 h, mortality rates in these patients remain still high. The objective of our study was to analyze potential cofactors which might influence the mortality rate within 90 days after surgery in PFF to avoid adverse events, loss of quality of life and high rates of mortality. Methods In this retrospective, single-center study all patients with PFF aged 65 years and older were included. We recorded gender, age, type of fracture, surgery and anesthesia, time, comorbidities and medication as well as complications and mortality rate at 90 days. Separate logistic regression models were used to assess which parameters were associated with patients’ mortality. The mortality rate was neither associated with timing, time and type of surgery nor time and type of anesthesia, but with higher age (OR 1.08 per year; 95% CI 1.034–1.128), lower BMI (OR 0.915 per kg/m 2 ; 95% CI 0.857–0.978), higher CCI (OR 1.170 per point; 95% CI 1.018–1.345), dementia (OR 2.805; 95% CI 1.616–4.869), non-surgical complications (OR 2.276; 95% CI 1.269–4.083) and if mobilization was impossible (OR 10.493; 95% CI 3.612–30.479). Results We analyzed a total of 734 patients (age ≥ 65 years) who had a PFF in 2019 and 2020 and received surgery. 129 patients (17.6%) died until 90 days at an median age of 89.7 years (range 65–101 years). Conclusion The proportion of patients who died until 90 days after surgery is still high. It is less extend influenced by surgical and anaesthesiologic factors than by patient-related factors like age or lower BMI. Physicians should be aware of the importance of avoiding adverse events and the importance of patients’ mobilization to reduce mortality and improve patients’ outcome.

Background Knee arthroplasty is one of the most frequently performed operations in Germany, with approximately 170000 procedures per year. It is therefore essential that physicians should adhere to an appropriate, and patient-centered indication process. The updated guideline indication criteria for knee arthroplasty (EKIT-Knee) contain recommendations, which are based on current evidence and agreed upon by a broad consensus panel. For practical use, the checklist has also been updated. Methods For this guideline update, a systematic literature research was conducted in order to analyse (inter-)national guidelines and systematic reviews focusing on osteoarthritis of the knee and knee arthroplasty, to answer clinically relevant questions on diagnostic, predictors of outcome, risk factors and contraindications. Results Knee arthroplasty should solely be performed in patients with radiologically proven moderate or severe osteoarthritis of the knee (Kellgren-Lawrence grade 3 or 4), after previous non-surgical treatment for at least three months, in patients with high subjective burden with regard to knee-related complaints and after exclusion of possible contraindications (infection, comorbidities, BMI >= 40 kg/m(2)). Modifiable risk factors (such as smoking, diabetes mellitus, anaemia) should be addressed and optimised in advance. After meeting current guideline indications, a shared decision-making process between patients and surgeons is recommended, in order to maintain high quality surgical management of patients with osteoarthritis of the knee. Conclusions The update of the S2k-guideline was expanded to include unicondylar knee arthroplasty, the preoperative optimisation of modifiable risk factors was added and the main indication criteria were specified.

Zusammenfassung Die Implantation einer Knieendoprothese zählt mit ca. 170000 Eingriffen pro Jahr zu den am häufigsten stationär durchgeführten Operationen in Deutschland. Eine einheitliche, angemessene und patientenorientierte ärztliche Indikationsstellung ist bei einem solchen Eingriff unerlässlich. Das Update der S2k-Leitlinie „Indikation Knieendoprothese“ beinhaltet auf aktueller Evidenz basierende und im breiten Konsens abgestimmte Empfehlungen und eine Checkliste im praxistauglichen Format. Für dieses Leitlinien-Update wurde eine systematische Literaturrecherche nach (inter-)nationalen Leitlinien und systematischen Übersichtsarbeiten zur Gonarthrose und Knieendoprothetik durchgeführt, um klinisch relevante Fragestellungen zu Diagnostik, Prädiktoren für das Outcome, Risikofaktoren und Kontraindikatoren zu beantworten. Eine Knieendoprothese soll nur bei radiologisch nachgewiesener fortgeschrittener Gonarthrose (Kellgren-Lawrence-Grad 3 oder 4), nach vorangegangener konservativer Therapie über mindestens 3 Monate sowie bei hohem subjektivem Leidensdruck hinsichtlich der kniebezogenen Beschwerden und nach Ausschluss möglicher Kontraindikationen (Infektionen, Begleiterkrankungen, BMI ≥ 40 kg/m2) erfolgen. Modifizierbare Risikofaktoren (wie Rauchen, Diabetes mellitus, Anämie) sollen zuvor adressiert und ggf. optimiert werden. Die Ziele der Patient*innen sollen erfragt und deren Eintrittswahrscheinlichkeit gemeinsam besprochen werden. Schließlich ist die Entscheidung zur Knieendoprothese von Patient*in und Operateur*in gemeinsam zu treffen, wenn der zu erwartende Nutzen die möglichen Risiken überwiegt. Das Update der S2k-Leitlinie wurde um die unikondyläre Knieendoprothese erweitert, die präoperative Optimierung modifizierbarer Risikofaktoren ergänzt sowie Konkretisierungen der Hauptindikationskriterien vorgenommen.

Purpose This study was initiated to analyze the outcome after distal femoral replacement (DFR) for periprosthetic distal femoral fractures (PDFF). Methods Data from the German Arthroplasty Registry (EPRD) were analyzed. A total of 626 patients could be identified with a DFR for PDFF. Mean age was 78.8 years, and 84.2% were female. Revisions and mortality were analyzed and compared with patient groups with a similar procedure (revision total knee arthroplasty) or similar general condition (fracture total hip arthroplasty, hip hemiarthroplasty). Matched-pair-analyses were performed. Results Within one year after surgery, 13.2% of the patients had died and further 9.4% were revised. Within four years, 32.7% had died and 19.7% were revised. Revisions were nearly twice as high as in the comparison groups. Periprosthetic infection (PJI) was the most frequent cause for revision, resulting in a PJI rate of 12.8%, which was lower in the comparison groups. Mortality after DFR was as similar high as after fracture hip arthroplasty. Conclusion PDFF are a serious injury, and the necessary surgical treatment has a high risk of complications. Every third patient after DFR for PDFF had died and every fifth patient needed revision within 4 years after surgery. Efforts should be undertaken to provide optimal treatment to these high-risk patients to reduce unfavorable outcomes. Level of evidence III. Registration of clinical trials As this is a registry-derived study of data of the German Arthroplasty Registry (EPRD), no registration was performed.

Background Allergies against implant materials are still not fully understood. Despite controversies about its relevance, some patients need treatment with hypoallergenic implants. This study compared coated and standard total knee arthroplasty (TKA) regarding inflammatory response and patient-reported outcome measures (PROMs). Methods 76 patients without self-reported allergies against implant materials were included in a RCT and received a coated or standard TKA of the same cemented posterior-stabilized knee system. 73 patients completed the 3-year follow-up. Two patients died and there was one revision surgery. Serum levels of cytokines with a possible role in implant allergy were measured in patient`s serum (IL-1beta, IL-5, IL-6, IL-8, IL-10, IFN γ, TNF α) prior to, one and three years after surgery. Furthermore, PROMs including knee function (Oxford Knee Score, Knee Society Score) and health-related quality of life (QoL, EuroQuol questionnaire) were assessed. Additionally, 8 patients with patch-test proven skin allergy against implant materials who received the coated implant were assessed similarly and compared to a matched-pair group receiving the same implant. Results There were no differences in function and QoL between the assessed groups at any follow-up. The majority of patients demonstrated no elevation of the measured blood cytokines. Cytokine patterns showed no differences between study groups at any follow-up. The allergy patients demonstrated slower functional improvement and minor differences in cytokine pattern. Yet these results were not significant. There were no differences in the matched-pair analysis. Conclusion We observed no relevant increase in serum cytokine levels in any group. The inflammatory response measured seems limited, even in allergy patients. Furthermore, there were no differences between coated and standard TKA in non-allergy patients in the 3-year Follow-Up period. Trial registration The study protocol was registered in the US National Institutes of Health’s database ( http://www.clinicaltrials.gov ) registry under NCT03424174 on 03/17/2016.

Current treatment strategies in hip and knee osteoarthritis (OA) involve a combined approach that includes not only modification of risk factors and conservative treatment but also joint-preserving surgical therapy in the early stages, or joint replacement in late OA. With the recent development of new etiological concepts (i.e. hip dysplasia and femoroacetabular impingement as major risk factors for hip OA), treatment alternatives for joint preservation could be extended significantly. Satisfactory results of osteotomies and other reconstructive procedures around hip and knee joints can only be expected in early OA (Kellgren/Lawrence grade 0-II). If patients with advanced radiographic OA grades III-IV do not respond to conservative treatment over at least 3 months and express a relevant burden of disease, joint replacement might be considered. Prior to surgery, potential contraindications must be excluded, patient expectations need to be discussed, and modifiable risk factors, which may negatively influence the outcome, should be optimized.