Search Results (996)

Background: Early surgical intervention is associated with improved outcomes in hip fracture care, yet in patients using Direct Oral Anticoagulants (DOACs), surgery is frequently delayed due to concerns about increased intraoperative bleeding. Despite the increasing prevalence of hip fracture patients on DOACs, no consensus exists on optimal surgical timing. This has led to substantial practice variation between hospitals, with some operating within 24 h of last DOAC intake and others delaying surgery beyond 24 h. This study hypothesizes that early surgery within 24 h results in a non-inferior blood transfusion risk compared to delayed surgery 24 h or more after last DOAC intake in hip fracture patients on DOACs. This protocol describes the design and methodological rationale of a natural experiment. Methods and analysis: A multicenter cohort study designed as a natural experiment will be conducted across seven Dutch level 2 trauma centers, using predefined and standardized prospectively collected variables from electronic health records. Centers will adhere to distinct local surgical timing protocols, forming two cohorts: early surgery within 24 h and delayed surgery 24 h or more after last DOAC intake. Patients presenting with an isolated hip fracture who are using a DOAC and have taken their last dose within 24 h before admission will be included. The primary endpoint is postoperative blood transfusion. Secondary endpoints include additional bleeding-related outcomes, thrombotic and postoperative complications, and hospital length of stay. The primary analysis will be conducted on a per-protocol basis, with an intention-to-treat analysis performed as a supplementary assessment. Non-inferiority will be established if the upper bound of the one-sided 95% confidence interval for the risk difference does not exceed the predefined margin of 5%. Ethics and dissemination: Ethical approval was obtained from the Medical Ethics Committee United, Utrecht, The Netherlands. As this is a cohort study without altering clinical care, individual informed consent is not required. All data will be pseudonymized, and findings will be disseminated through peer-reviewed journals and scientific conferences. Registration details: Medical Ethics Committee United, Utrecht, The Netherlands, registration number W25.034 Full article

Background/Objectives: Combat trauma involving large joints is associated with a high risk of thromboinflammatory complications. Early identification of laboratory markers for hypercoagulability is essential to optimise perioperative management. This study aimed to evaluate the dynamics of inflammation and haemostasis indicators in patients with combat-related joint trauma and to identify the most informative markers for preoperative risk assessment. Methods: A total of 29 patients with combat injuries to the hip, knee, elbow, or ankle joints were examined. Blood samples were taken 1–3 days prior to surgery and again on the first postoperative day. Parameters of coagulation (e.g., PT, INR, fibrinogen, D-dimer, soluble fibrin complexes, antithrombin III), fibrinolysis, and inflammation (e.g., CRP, haptoglobin, sialic acid, ESR, LSI, LII) were analysed and compared to those of 30 healthy controls. Statistical analysis included Student’s t-test and Pearson’s correlation. Results: At baseline, patients demonstrated significant increases in inflammatory markers (CRP 64.2 ± 7.3 mg/L, ↑738.9%; haptoglobin 3.25 ± 0.4 g/L, ↑164.3%; ESR 46.8 ± 5.2 mm/h, ↑313.8%) and procoagulant activity (D-dimer 1.42 ± 0.18 µg/mL, ↑136.6%; fibrinogen 6.12 ± 0.51 g/L, ↑102.4%; soluble fibrin complexes 38.7 ± 4.9 mg/L, ↑597.3%), together with a reduction in antithrombin III activity (63.5 ± 6.2%, ↓39.5%) and prolonged fibrinolysis time (increase by 197%). Postoperatively, these abnormalities intensified, indicating a sustained thromboinflammatory response. Strong correlations were found between inflammatory and haemostatic markers. Conclusions: Combat trauma of large joints is associated with preoperative thromboinflammatory dysregulation, which is exacerbated by surgery. Monitoring specific biochemical and haematological markers—such as CRP, fibrinogen, D-dimer, and soluble fibrin complexes—may support preoperative risk assessment and postoperative monitoring strategies for hypercoagulable states in this high-risk group. These findings lay the groundwork for future prospective studies aimed at developing stratified therapeutic protocols and predictive models for thromboinflammatory complications in orthopaedic trauma care. Full article

Introduction: Medial compartment knee osteoarthritis (OA) is characterized by varus deformity. A medial open-wedge high tibial osteotomy (MOWHTO), frequently invoked in the treatment of this deformity, affects the knee as well as the ankle joints. This study aims to evaluate the radiological and clinical effects of a MOWHTO on the ankle joint. Materials and Methods: A retrospective analysis was conducted with data from 110 patients (mean age: 52 years; 74.5% female) who underwent a MOWHTO between 2020 and 2023. Radiographic assessments were conducted both preoperatively and one year after surgery using full-length weight-bearing radiographs. The measurements included several alignment parameters such as the hip–knee–ankle angle (HKA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), lateral distal tibial angle (LDTA), and talar tilt. Clinical outcomes were assessed using the Lysholm knee score and the American Orthopedic Foot and Ankle Society (AOFAS) ankle score. Results: While changes in the LDTA demonstrated a small effect size (d = 0.225), moderate-to-large effect sizes were observed in key alignment parameters (MPTA (d = 0.838), the JLCA (d = 0.798), and talar tilt (d = 0.752)), all of which showed statistically significant differences indicative of a correction in the joint alignment of potential clinical significance. Median Lysholm and AOFAS scores at one year were 90 and 100, respectively, indicating favorable clinical outcomes. No significant difference in outcomes was observed based on the amount of correction. Conclusions: An MOWHTO not only restores knee alignment but also significantly improves ankle alignment in the coronal plane. These findings suggest that an MOWHTO is associated with the restoration of knee alignment and with improvements in ankle alignment in the coronal plane. Full article

Background/Objectives: Older people with hip fractures (HF) are highly heterogeneous patients at risk of adverse events, which impacts healthcare and economic systems. Tools for estimating 30-day and 1-year mortality may help optimize patient management decisions. The Nottingham Hip Fracture Score (NHFS) is one of the most reliable tools for assessing 30-day mortality after surgery. The aim is to validate the NHFS in a cohort of Italian patients hospitalized due to HF and enhance its predictive capacity against 30-day and 1-year mortality. Methods: A prospective observational study among older patients with HF who underwent surgery after a comprehensive geriatric assessment (CGA). Data about 30-day and 1-year mortality were gathered from regional registries. Logistic regression analyses were performed to assess the predictive accuracy of the NHFS against 30-day and 1-year mortality. The adapted scores were measured using ROC curves, and a nomogram was developed. Result: Among 1169 patients, 30-day and 1-year mortality rates were 4.3% and 21.3%, respectively. The NHFS was validated and recalibrated in the study sample for 30-day mortality. The recalibrated NHFS showed better predictive capacity for 30-day mortality (AUC 0.693) than the ASA score (AUC 0.547) and remained a significant predictor for 1-year mortality (AUC 0.712). BADL and METs showed an association with mortality, so the modified NHFS was integrated, resulting in a more accurate prediction compared to the original score for 1-year mortality (AUC = 0.747). Conclusions: The NHFS is a reliable tool for estimating 30-day and 1-year mortality in Italian older adults with HF. The revised NHFS, which includes METs and BADL, offers higher predictive power than the original version in our sample, and the nomogram may facilitate its clinical use. Full article

Total hip arthroplasty (THA) is a transformative procedure for managing severe hip disorders, yet implant longevity remains a critical challenge, particularly for younger, active patients. Wear-related complications are a leading cause of revision surgery, emphasizing the need for optimized design and material performance. This systematic review aims to synthesize evidence on the wear behavior, material properties, and design parameters of hip implants with a focus on finite element analysis (FEA)-based predictive approaches. A comprehensive literature search was conducted across Scopus, PubMed, ScienceDirect, MDPI, and Cochrane databases following PRISMA guidelines. Studies published between 2010 and 2025 were included if they addressed THA biomechanics, wear analysis, or material optimization using FEA, hip simulators, or radiostereometric techniques. Key findings reveal that larger femoral heads, while reducing contact pressure, increase wear due to greater sliding distance. Gravimetric wear rates ranged from 3.15 ± 0.27 mg/Mc to 2.18 ± 0.31 mg/Mc, while linear and volumetric wear reached 0.0375 mm/Mc and 33.6 mm³/Mc, respectively. Stress analysis showed custom stems exhibited markedly lower von Mises stress (194.9 MPa) compared to standard designs (664.3 MPa), and fatigue assessments confirmed a factor of safety > 1 across profiles. Patient-specific factors, such as body weight, significantly influenced wear with a 26% increase in metal wear observed between 100 kg and 140 kg. This systematic review synthesizes current research on total hip arthroplasty, emphasizing biomechanical and material factors critical for implant longevity and patient care. It uniquely integrates FEA-based wear prediction with clinical implications, bridging computational modeling, geometry optimization, and material performance to provide actionable insights for next-generation, patient-specific hip implant design. Full article

Background/Objectives: Ambulatory status at hospital discharge contributes to subsequent functional recovery in older adults following hip fracture. This study aimed to identify independent predictors of ambulatory status at hospital discharge following surgery for fragility hip fractures in a tertiary care setting in Southern Thailand. Methods: A retrospective study was conducted among patients aged 50 years and older who underwent surgery for low-energy hip fractures between 1 October 2018, and 30 September 2023. Data on preoperative, intraoperative, postoperative, and process of care factors were collected from electronic medical records. Student’s t-tests and chi-square tests compared candidate variables between groups. Univariable and multivariable risk analyses were performed to identify independent predictors of ambulation at discharge. Results: Among 532 patients (72.7% women; mean age 76.8 ± 9.7 years), 314 (59.0%) were ambulatory at hospital discharge. Multivariable analysis demonstrated that achieving rehabilitation at the ambulation training level (mRR = 24.10; 95% CI: 9.14–63.60; p < 0.001) and undergoing hip arthroplasty (mRR = 1.17; 95% CI: 1.07–1.29; p < 0.001) were significant positive predictors of ambulation. Conversely, a history of cerebrovascular disease with hemiplegic sequelae (mRR = 0.70; 95% CI: 0.53–0.91; p < 0.01) and delayed initiation of rehabilitation more than 72 h postoperatively ((mRR = 0.84; 95% CI: 0.73–0.97; p < 0.05) were associated with reduced likelihood of ambulation. Conclusions: Ambulatory status at hospital discharge was strongly associated with early, ambulation-level rehabilitation and hip arthroplasty, whereas history of stroke and delayed rehabilitation reduced mobility. These findings emphasize the importance of timely, targeted rehabilitation to optimize functional recovery after hip fracture surgery. Full article

Background: Preoperative anemia is common among patients undergoing arthroplasty and is associated with increased transfusion requirements and worse outcomes. Current perioperative pathways rely on iron studies to guide intravenous iron supplementation, but systemic inflammation triggered by surgery profoundly alters iron markers, risking misclassification of iron deficiency. This study evaluated whether adjusting iron indices for inflammatory markers improves diagnostic accuracy after total hip arthroplasty (THA). Methods: In this prospective cohort study, 20 patients undergoing elective primary THA at a single center were enrolled. Patients with preoperative inflammation were excluded. Serum iron, transferrin, transferrin saturation (TSAT), CRP, and albumin were measured preoperatively and on postoperative days (PODs) 1, 2, 3, and 90. Serum iron was adjusted for systemic inflammation using a validated regression equation incorporating CRP and albumin, and adjusted TSAT was calculated accordingly. Absolute iron deficiency was defined as serum iron < 10 µmol/L, and functional iron deficiency was defined as TSAT < 20%. Comparisons were made using Wilcoxon’s signed-rank test and ANOVA. Results: In the 20 included patients, a pronounced systemic inflammatory response was observed, with CRP peaking on POD 2 (median, 162 mg/L) and albumin falling to 32 g/L on POD 1 (both p < 0.001). Unadjusted serum iron and TSAT fell sharply, with nearly all patients classified as iron-deficient in the first three postoperative days. Adjustment for CRP and albumin significantly attenuated these declines: on POD 2, median iron was 8.2 µmol/L adjusted versus 2.0 µmol/L unadjusted (p < 0.001), and TSAT was 19% versus 4% (p < 0.001). Misclassification of iron deficiency fell by 40–50% with adjustment, and by POD 90, adjusted indices approximated baseline values. Conclusions: Systemic inflammation after THA markedly suppresses iron indices, leading to widespread misclassification of iron deficiency. Adjustment for CRP and albumin reduces this misclassification and provides a more accurate assessment of perioperative iron status. These findings complement existing evidence supporting intravenous iron supplementation by highlighting a diagnostic refinement that could improve patient selection for therapy. Full article

Walking ability is crucial for maintaining independence and healthy aging. Although joint angle measurement is important for detailed gait assessment, it is rarely performed in clinical practice due to the complexity of motion capture systems. This study investigates individual variability and cross-population generalizability of deep learning-based joint angle estimation from a single inertial measurement unit (IMU) attached to the pelvis. Gait data from three distinct populations were collected: 17 young adults, 20 healthy older adults (aged 65+), and 14 pre-operative patients scheduled for hip replacement surgery due to hip osteoarthritis (also aged 65+). A 1D ResNet-based convolutional neural network was trained to estimate bilateral hip, knee, and ankle joint angles from IMU signals. We systematically compared within-population training (trained and tested on the same population) with cross-population training (trained on combined data from all populations) using nested 5-fold cross-validation. Cross-population training showed population-specific effectiveness: older adults demonstrated consistent improvement, while young adults showed minimal change due to already high baseline performance, and pre-operative patients exhibited highly variable responses. These findings suggest that the effectiveness of cross-population learning depends on within-population gait heterogeneity, with important implications for developing clinically applicable gait analysis systems across diverse patient populations. Full article

Background: Periprosthetic joint infections (PJIs) of the hip and knee are one of the most severe complications in arthroplasty, often requiring prolonged antibiotic therapy and multiple revision surgeries. The increasing prevalence of multidrug-resistant organisms and biofilm-associated PJIs has renewed interest in bacteriophage therapy as a targeted, adjunctive treatment option in refractory cases. This investigation systematically reviews and discusses the current evidence regarding the application, outcomes, and safety profile of bacteriophage therapy in the management of PJIs. Methods: This systematic review was conducted in accordance with the 2020 PRISMA statement. PubMed, Google Scholar, EMBASE, and Web of Science were accessed in August 2025. No time constraints were used for the search. All clinical studies investigating bacteriophage therapy for bacterial PJIs were considered for eligibility. Results: A total of 18 clinical studies, comprising 53 patients treated with bacteriophage therapy for PJI, were included. The mean follow-up was approximately 13.6 months. Staphylococcus aureus was the most frequent pathogen (18 cases); phage cocktails were used in 33 patients and monophage preparations in 9, all combined with suppressive antibiotic therapy. Persistent or resistant joint pain was reported in only two patients (3.8%), while signs of ongoing infection despite phage therapy were observed in four patients (7.5%). Adverse events following BT were inconsistently reported. Conclusions: Bacteriophage therapy shows promise as an adjunctive treatment for hip and knee PJIs, especially in refractory or multidrug-resistant cases. Current evidence is limited and methodologically weak, underscoring the need for well-designed clinical trials to clarify efficacy, safety, and optimal integration into existing orthopaedic infection protocols. Full article

Background/Objectives: Unstable intertrochanteric femur fractures (IFFs) in geriatric patients are associated with high rates of morbidity and mortality due to poor bone quality, multiple comorbidities, and limited functional capacity. This study aimed to compare the clinical outcomes of cementless bipolar hemiarthroplasty (BHA) performed via a transtrochanteric approach and proximal femoral nailing (PFN) in elderly patients with unstable IFFs. Methods: This retrospective comparative study included 131 patients aged ≥70 years who underwent surgery for AO/OTA 31-A2 and 31-A3 unstable fractures between January 2021 and July 2025 were retrospectively reviewed. 64 patients received cementless BHA and 67 underwent PFN. Eligible patients were ambulatory prior to fracture (independently or with a cane/walker); patients with pathological fractures/malignancy, alternative procedures (cemented or posterolateral BHA, total hip arthroplasty, tumor prosthesis, or other osteosynthesis methods), incomplete records, or <6 months of follow-up were excluded. Demographics, perioperative variables, mechanical complications, revision requirement, time to mobilization, and 1- and 6-month mortality rates were analyzed. Primary outcomes were mortality and perioperative clinical parameters. Results: The two groups were comparable in age, sex, ASA scores, and fracture patterns. Intraoperative blood loss and transfusion requirements were significantly higher in the BHA group (both p < 0.001). Mobilization was observed earlier in patients treated with BHA (1 [1,2] vs. 3 [2,3] days; p < 0.001). Mechanical complications were more frequently observed after PFN, which was associated with a higher revision requirement (17.9% vs. 4.7%; p = 0.018). Operative time, hospital stay, and 1- and 6-month mortality rates showed no significant differences between the groups. Conclusions: In geriatric patients with unstable IFFs, cementless BHA performed via a transtrochanteric approach may be considered a viable surgical option with appropriate patient selection, taking into account its association with earlier mobilization and the observed mechanical complication profile. PFN offers advantages of reduced blood loss and lower transfusion needs. Surgical decision-making should be individualized based on fracture morphology, bone quality, and the patient’s overall medical condition. Given the heterogeneity of unstable fractures within the AO/OTA classification and the retrospective nature of the present study, larger, multicenter prospective investigations incorporating functional outcomes are warranted to further clarify optimal treatment strategies. Full article

Background and Objectives: Polypharmacy is common among older adults and its impact on the onset of dynapenia, reduced muscle strength and function, is largely unknown. Older adults hospitalized for either post-fracture or elective orthopedic surgery (knee, femur, or hip) and undergoing rehabilitation were included to investigate the association between polypharmacy and dynapenia. A further aim is to investigate associations between polypharmacy and dynapenia with outcomes including mortality, falls, and hospitalizations. Materials and Methods: On the fifth day following surgery, medical doctors administered a structured questionnaire along with physical and instrumental assessments. Polypharmacy was defined as the concurrent and regular use of 5 or more medications, dynapenia was assessed by measuring handgrip strength. The association between dynapenia and polypharmacy was detected with logistic regression, and their impact on adverse outcomes was assessed using Cox models, Kaplan–Meier curves and log-rank tests. Results: A total of 205 older adults (mean age 77.5 years; 79.5% women) were enrolled. After adjusting for sex, age, and the presence of multidimensional frailty, dynapenia was significantly associated with increased adverse outcomes such as mortality, falls, and hospitalizations (HR 2.96, 95% CI 1.22–7.20, p = 0.016). Similarly, polypharmacy was independently linked to a higher risk of mortality, falls and hospitalizations (HR 2.23, 95% CI 1.24–4.10, p = 0.007). At 6 months follow-up, polypharmacy showed a strong and significant association with dynapenia (adjusted OR 2.63, 95% CI 1.21–4.63, p = 0.019). Conclusions: These findings suggest that polypharmacy is strongly associated with dynapenia, both conditions are associated with adverse clinical outcomes in older hospitalized patients. Close monitoring and tailored interventions are recommended to mitigate these risks and improve rehabilitation outcomes in this vulnerable population. Full article

Background: Osteoporotic vertebral fractures in the thoracic–lumbar spine are common in older adults and can lead to pain, kyphotic posture, impaired postural control, and altered gait. These changes increase the risk of falls and reduce functional mobility, highlighting the need for effective assessment and intervention strategies. Objectives: To analyze stability and gait in patients who sustained a thoracic–lumbar spinal fracture and underwent minimally invasive surgery. Methods: Seventeen patients participated in this study (women = 11, age 68.36 ± 6.15 years, body weight 68.18 ± 12.8 kg, height 161.45 ± 5.26 cm; men = 6, age 62.67 ± 4.41 years, body weight 78.5 ± 20.36 kg, height 176.67 ± 12.64 cm). All participants had undergone minimally invasive spinal surgery using percutaneous screws reinforced with bone cement 12 months prior. Each patient underwent two assessments: postural stability measurement and biomechanical gait analysis. Statistical analysis was performed using Statistica software (StatSoft, PL), with significance set at p < 0.05. Results: In the stability test, seven participants could not complete the measurement due to falls (FRT = 6.45 ± 2.43), six performed within the normal range (FRT = 2.41 ± 0.9), and four were below the normal range for their age group (FRT = 2.22 ± 1.7). Patients exhibited slower walking speed, shorter stride length, and reduced hip extension during the stance phase (approximately 5° less) due to a forward-leaning posture and cautious gait. Foot placement was flat rather than heel-first, likely as a compensatory strategy to enhance safety. Conclusions: Patients after osteoporotic thoracic–lumbar vertebral fractures treated with minimally invasive surgery demonstrate shorter, wider, and slower steps, along with reduced postural stability, indicating a persistent risk of forward falls. Full article

Background/Objective: Hip fractures in older adults are a major public health concern due to their high rates of morbidity, mortality, and long-term disability. Although surgical and postoperative care have improved, recovery outcomes remain highly variable. Identifying early functional recovery patterns could support individualized rehabilitation and discharge planning. This study aimed to identify distinct early recovery trajectories of motor function within 30 days after hip fracture surgery using growth mixture modeling (GMM) and to examine patient- and hospital-level factors associated with these patterns. Methods: A retrospective cohort study was conducted using data from the Nagano Hip Fracture Database, including 2423 patients aged ≥65 years across 17 acute care hospitals in Japan (2019–2024). Functional recovery was measured using the motor subscale of the Functional Independence Measure (FIM-motor) at 0, 7, and 28 days post-admission. Latent trajectory model was used to identify distinct recovery patterns. Multinomial logistic regression analyzed predictors of class membership. Results: Three recovery trajectories were identified: high/rapid improvement (26.7%), intermediate (32.6%), and poor/flat recovery (40.7%). Older age, cognitive impairment, and lower baseline mobility were strongly associated with membership in the poor-recovery class. Early trajectory classes significantly predicted discharge outcomes, including FIM-motor scores and discharge destination. Sensitivity analysis confirmed the robustness of findings, with minimal impact from hospital-level clustering. Conclusions: Distinct early recovery trajectories exist after hip fracture surgery and are strongly influenced by baseline cognitive and functional status. Early identification of recovery patterns can enhance personalized rehabilitation and inform discharge planning, offering valuable insights for clinical practice. Full article

Orthopedic and lower limb fracture surgeries are among the most frequent emergency procedures and are commonly performed under general anesthesia (GA). Background and clinical significance: Epidemiologically, postoperative coma after GA is rare (0.005–0.08%), but delayed awakening (2–4%) and postoperative delirium or postoperative cognitive dysfunction (POCD) (15–40%) remain significant. These neurological complications increase markedly in vulnerable brain patients with psychiatric, cerebrovascular, or neurodegenerative disorders. Methods: This mechanistic narrative review synthesizes evidence from clinical and experimental studies (1990–2025) comparing the effects of general versus Regional (RA)/local (LA) or spinal anesthesia in vulnerable neuropsychiatric populations “with pre-existing brain illness” undergoing orthopedic surgery. Domains analyzed include neuropsychiatric medications effects and interactions with the GA process and with general anesthetic agents, alongside alterations in neurotransmitter modulation, cerebrovascular autoregulation, mitochondrial dysfunction, oxidative stress, redox imbalance, and neuroinflammatory activation. The review summarizes evidence on how the choice of anesthesia type influences postoperative brain outcomes in patients with known neurological conditions. Results: From previous studies, patients with psychiatric and/or chronic brain illness have a 3–5-fold increased risk of delayed emergence and up to 60% incidence of postoperative delirium. Pathophysiological mechanisms involve GABAergic overinhibition, impaired perfusion, mitochondrial energy failure, and inflammatory amplification. Regional/local and spinal anesthesia may offer physiological advantages, preserve cerebral perfusion, and lower neurological complication rates. Conclusions: General anesthesia may exacerbate pre-existing brain vulnerability, converting reversible neural suppression into irreversible dysfunction. Therefore, whenever possible, regional/local or spinal anesthesia with or without sedation should be prioritized in those neurologically vulnerable patients to reduce the length of hospital stay (LOS) and to lower postoperative neurological complications and risks in psychiatric and neurologically unstable patients. Full article

In recent years, we assisted the exploitation of Artificial Intelligence (AI) that invasively pervades in several instances of everyday life. The potential of this technology promises the automation of human tasks increasing accuracy and efficiency. The integration of AI systems in the orthopaedic field is becoming more and more a concrete reality, so this topic is gaining increasing interest by the scientific community. More and more authors are testing the power of AI in orthopaedics, exploiting the application in routine workflow, and asking if AI could improve clinical and surgical practice. In this brief narrative review, the state-of-art of AI in hip district orthopaedics is presented, particularly focusing on the application of AI tools in the context of radiological images, early diagnosis, clinical datasets, and around operative theatre. Possible future development of AI-hip pathology management is exposed too, and clear doubts about exploits of these tools in clinical practice are also exposed. Full article