Search Results (26)

Background and Objectives: Determining the mechanical stability of osteosynthesis in pertrochanteric fractures remains a critical challenge in orthopedic biomechanics. The aim of this study was to develop a mathematical model for quantifying the stability of osteosynthesis and to establish criteria for its evaluation under physiological loading conditions. Materials and Methods: A mathematical model describing the biomechanical behavior of a proximal femur with a pertrochanteric fracture stabilized using a cephalomedullary nail (CMN) was developed. The model integrates force equilibrium, stress–strain relationships, and loading conditions representative of early functional rehabilitation. The theoretical framework was implemented in MATLAB/Simulink R2025b and complemented by finite element analysis to determine stress distribution, deformation patterns, and stability-related parameters of the bone–implant system. Results: The developed mathematical model enabled a quantitative assessment of osteosynthesis stability through the evaluation of key mechanical indicators, including displacement, stress distribution, and safety factor within the fixation system. Critical stress zones in the implant and surrounding bone were identified, allowing analysis of load transfer mechanisms. Finite element simulations showed that improved fixation mechanics reduced peak implant stresses, limited displacement at the fracture site, and increased the safety factor of the fixation construct, resulting in a more uniform load distribution in the surrounding bone and enhanced overall stability of the osteosynthesis system. Conclusions: The proposed mathematical model provides a systematic approach for determining the stability of osteosynthesis in pertrochanteric fractures. It offers a theoretical basis for optimizing implant design and fixation strategies, with potential applications in preclinical evaluation and surgical planning. Full article

Background: Managing elderly patients with simultaneous acute cardiovascular and orthopedic emergencies presents a unique challenge. While ST-elevation myocardial infarction (STEMI) requires prompt revascularization and dual antiplatelet therapy (DAPT), pertrochanteric femoral fractures usually necessitate early surgical fixation to reduce morbidity and mortality. However, the combination of these conditions complicates both standard treatment pathways. Case presentation: We present the case of an 86-year-old woman admitted after a low-energy fall, with a radiologically confirmed unstable pertrochanteric fracture of the right femur (AO/OTA 31-A2). Upon routine electrocardiogram, anterior STEMI with new-onset atrial fibrillation was diagnosed. Although asymptomatic from a cardiac perspective, bedside echocardiography revealed a severely reduced left ventricular ejection fraction of 10%. Urgent coronary angiography demonstrated a critical mid-left anterior descending lesion, successfully treated with rotational atherectomy, intravascular lithotripsy, and stent implantation. She was initiated on DAPT (aspirin + clopidogrel) and anticoagulated with low-molecular-weight heparin. Given the extremely high bleeding risk, surgical intervention for the femoral fracture was deemed unsafe. Instead, conservative management with skeletal traction (6 kg) was employed. Despite optimal supportive care and early rehabilitation, the patient experienced a complicated hospital course, including delirium, hematuria, and lower respiratory tract infection. She passed away 52 days post-admission. Conclusions: This case illustrates the complexity of clinical decision-making in geriatric patients with competing acute conditions. Current evidence on how to proceed in patients requiring both antithrombotic therapy and urgent orthopedic surgery is limited. Multidisciplinary teams must carefully weigh the risks and benefits of both surgical and conservative strategies. Further guidelines addressing such scenarios in elderly patients are urgently needed. Full article

Background and Objectives: Intertrochanteric hip fractures (ITFs) are common in older adults and frequently coexist with knee osteoarthritis (KOA). Although both conditions share key biomechanical risk factors, the specific relationship between KOA severity and ITF stability has not been well defined. Recent evidence suggests that degenerative knee changes may alter lower-limb load distribution and increase susceptibility to unstable fracture patterns. This study evaluated whether KOA severity, graded using the Kellgren–Lawrence (KL) system, is associated with ITF stability according to the 2018 AO/OTA classification. Materials and Methods: A retrospective observational study was conducted on 138 patients with IHFs treated between 2018 and 2023. KOA severity was assessed using KL grades I–IV on non-weight-bearing anteroposterior knee radiographs. Lateral wall thickness (LWT) was measured using the Hsu method, with <20.5 mm indicating fracture instability. Statistical analyses included correlation, linear regression, logistic regression, and receiver operating characteristic (ROC) curve analysis to examine the association between KL grade and fracture stability. Results: Among 138 patients, 98 (71.0%) had unstable ITFs. Advanced KOA was significantly more common in the unstable group (KL III 45.9%, KL IV 48.0%; p < 0.001). KL grade showed a significant inverse correlation with LWT (Pearson’s r = −0.394, p < 0.001). Each one-grade increase in KL severity was associated with a 3.8 mm reduction in LWT (p < 0.001). In multivariable logistic regression, KL grade remained an independent predictor of fracture instability (adjusted OR = 4.9, 95% CI: 2.8–8.8, p < 0.001), whereas age and comorbidities were not significant. ROC analysis demonstrated good discriminatory power (AUC = 0.79). A KL ≥ III threshold achieved 95% sensitivity and 56% specificity for predicting instability. Conclusions: Higher KOA severity is strongly associated with unstable ITF patterns. KL grade independently predicts instability and may serve as a simple, accessible radiographic indicator of biomechanical vulnerability and fracture risk in older adults. Incorporating KOA severity into the preoperative evaluation may enhance risk stratification, guide selection of fixation strategy, and support individualized rehabilitation planning. Full article

Background: Midfacial fractures are common outcomes of facial trauma. While younger individuals typically sustain these injuries through high-energy events like assaults and traffic or sports accidents, elderly patients increasingly present with fractures from low-energy mechanisms, primarily falls. Purpose: The aim of this study was to analyze age- and gender-specific patterns in midfacial fractures over a 10-year period, with emphasis on elderly individuals and low-energy trauma. Methods: A retrospective review was performed of proven midfacial fractures between 2013 and 2022 at the Department of Oral and Maxillofacial Surgery (University of Pécs, Hungary). The patients were stratified by age (<65 vs. ≥65 years) and gender. The variables included the injury mechanism, fracture localization, the dental status, hospitalization, and the presence of associated injuries. Bivariate analyses were performed, and the significance level was set to p < 0.05. Results: A total of 957 radiologically confirmed midfacial fracture cases were evaluated, of whom 344 (35.9%) were ≥65 years old. In the elderly group, females had a 19-fold higher risk for midfacial trauma than younger females (OR: 19.1, 95%CI: 9.30–39.21). In the older group, a fall was significantly the most frequent injury mechanism (OR: 14.5; 95%CI: 9.9–21.3), responsible for 89.5% of the cases, while hospitalization (OR: 0.36; 95%CI: 0.23–0.56) was less characteristic. Most of the fractures occurred in the zygomatic bone, in the zygomaticomaxillary complex, or in the anterior wall of the maxilla. Associated injuries in the elderly group included mostly lower limb injuries—particularly pertrochanteric femoral fractures in females—and upper limb injuries, with a slight male dominance. Conclusions: Low-energy falls are the primary cause of midfacial fractures in elderly patients, particularly in women. Tailored prevention and management strategies are essential for improving the outcomes in this growing demographic group. Full article

Background: Pertrochanteric fractures of the proximal femur present a common challenge for traumatologists, with intramedullary nailing emerging as the preferred treatment. Complication rates are around 20%, including screw jamming, refractures, implant breakage, or medial migration, with cut-out being the most common. A tip–apex distance (TAD) of >25 mm and incorrect cephalic screw position are predictive factors for cut-out. This study assesses outcomes using the Elos intramedullary nail, based on the experience of the Department of Orthopedics and Traumatology at Ospedale Maggiore in Bologna. Methods: We conducted a retrospective cohort study of 344 patients treated with the Elos intramedullary nail for pertrochanteric femoral fractures from 1 January 2017 to 31 December 2022. The Elos^®-Intrauma nail was implanted using the standard technique. Initial X-rays classified fractures according to the AO-OTA classification, and postoperative X-rays confirmed the cephalic screw’s placement per Cleveland’s regions. Patients were divided into two groups: optimal cephalic screw position (positions 5-8-9) and other positions. We evaluated TAD, calcar-referred TAD (CalTAD), and postoperative reduction quality using Chang’s criteria. The incidence of cut-out and other complications were assessed in connection with these measurements. Results: Among the 344 patients, 227 (65.9%) had the screw in positions 5-8-9, while 117 (34.1%) had it in other positions. The median TAD was 19.47 ± 6.26 mm (range 3.96–46.6), with TAD ≤ 25 mm in 265 patients (77%). The median CalTAD was 22.37 ± 5.65 mm (range 8.75–45.3), with CalTAD ≤ 25 mm in 231 patients (67.1%). According to Chang’s criteria, 8 cases (2.3%) had poor reduction, 139 cases (40.4%) had acceptable reduction, and 197 cases (57.3%) had excellent reduction. Cut-out occurred in four cases (1.19%). Multivariate analysis revealed only poor reduction and TAD > 25 mm as independent predictors of cut-out (p < 0.05), while cephalic screw position, CalTAD, and fracture type did not impact cut-out incidence. Conclusions: This study indicates that optimal TAD and quality of reduction are crucial for minimizing cut-out risks. The Elos intramedullary nail shows favorable outcomes with a low cut-out incidence when these parameters are met. Emphasis should be placed on achieving a TAD ≤ 25 mm and excellent reduction quality to reduce complications. Full article

Background/Objectives: Limited surgical invasiveness is desirable in elderly patients with femur fracture. Serum cytokines have been considered as a possible marker but with inconclusive evidence. The present study aimed to assess the systemic inflammatory response to surgical trauma through the serum levels of several cytokines (IL1β, IL6, IL8, and IL-10), inflammatory markers (c reactive protein—CRP), and muscular damage markers (creatinkinase—CK) at different time intervals in a consecutive series of patients affected by pertrochanteric fractures (PFs) and treated by two different surgical devices (intramedullary nailing (IM) vs. dynamic hip screw plate—DHS). Methods: A total of 60 consecutive patients (45 female and 15 male, mean age 85.6 years) with PFs (AO31A1.2-2.2) were randomly assigned to two groups according to the surgical procedure used (IM vs. DHS). Specimens of venous blood were collected 1 h preoperatively and at 24, 48, and 72 h postoperatively. Commercial ELISA kits were used. Results: In the adjusted linear mixed model, the serum levels of IL-1β, IL-8, IL-10, CRP, and CK revealed no statistically significant correlation with the type of surgical intervention performed. A significant (p < 0.001) correlation was found for IL-6 values in patients undergoing IM, showing higher serum values than patients receiving DHSs in all postoperative blood sample collections. Conclusions: The results of this study reveal that the use of DHSs may have less biological impact than IM in frail elderly due to a more limited secretion of IL-6 cytokines deriving from the preservation of the femoral medullary canal, representing a possible guide for the choice of the surgical device. Full article

Background: The decision of the Joint Federal Committee on the treatment of hip fractures stipulates that proximal femur fractures must be treated within the first 24 h. This leads to organizational and personnel difficulties in day-to-day care. Therefore, we investigated the question at what times of day we operate to maintain this timeline and whether there is a difference in the outcome for the patients according to treatment hours. Methods: Data from the DGU’s “AltersTraumaRegister” from 2016 to 2020 were analyzed. For the analysis, the patients were divided into seven cohorts depending on the time of surgery. Pre-operative, operative, and follow-up data were analyzed. Results: A total of 29,470 patients were included in our study. The results showed that 74% of patients were treated within 24 h. 72% of patients operated on between 0–7 h had pertrochanteric fractures, while 56% of all arthroplasties were performed during normal working hours. In supra-regional trauma centers, significantly fewer operations were performed during normal working hours, while significantly more surgeries were carried out in the late evening and at night (p < 0.001). There were no significant differences in mortality and morbidity between the individual groups. Conclusions: Although we manage to treat most patients within 24 h, only 46% of patients are operated on within normal working hours. In terms of the outcome parameters, this does not appear to be a disadvantage for the patients. Nevertheless, night work and fatigue affect concentration and post-operative results in many areas, as we know. Consequently, patient care during normal working hours within 24 h creates the best possible initial situation for the patient, as significantly more personnel resources are available during normal working hours. The aim should be to create the logistical and personnel requirements for this. Full article

Background: Hip fractures and strokes are prevalent and escalating issues in geriatric healthcare. The absence of standardized surgical protocols for patients with spastic hemiparesis and multiple comorbidities presents a significant medical challenge. Methods: This case study describes a 64-year-old male patient with left-sided hemiparesis and failed surgical treatment of a pertrochanteric fracture in a spastic limb. The patient was admitted to the Department of Rehabilitation and Orthopedics in December 2022 for diagnostics and to establish a treatment plan after five months of non-ambulatory status. Results: This study emphasizes the crucial role of preoperative preparation, involving botulinum toxin injections into spastic muscles and physiotherapy, to enhance the supportive function of the paretic limb and improve locomotion before prosthetic surgery. Conclusions: The management of hip fractures in patients with spastic paralysis requires a multidisciplinary approach and the development of standardized treatment protocols. This case underscores the importance of comprehensive pre- and postoperative rehabilitation to improve patient outcomes. Further research is needed to establish standardized rehabilitation protocols for spastic patients undergoing hip arthroplasty. Randomized controlled trials could provide valuable insights into the efficacy of various interventions. Full article

Despite the implications of trochanteric and subtrochanteric intramedullary (IM) nail infection for patients with hip fracture, little is known about risk factors for therapeutic failure and mortality in this population. We performed a retrospective observational analysis including patients diagnosed with trochanteric and subtrochanteric IM nail infection at a Spanish academic hospital during a 10-year period, with a minimum follow-up of 22 months. Of 4044 trochanteric and subtrochanteric IM nail implants, we identified 35 cases of infection during the study period (0.87%), 17 of which were chronic infections. Patients with therapeutic failure (n = 10) presented a higher average Charlson Comorbidity Index (CCI) (5.40 vs. 4.21, p 0.015, CI 0.26–2.13) and higher rates of polymicrobial (OR 5.70, p 0.033, CI 1.14–28.33) and multidrug-resistant (OR 7.00, p 0.027, CI 1.24–39.57) infections. Upon multivariate analysis, polymicrobial infection and the presence of multidrug-resistant pathogens were identified as independent risk factors for therapeutic failure. Implant retention was associated with an increased risk of failure in chronic infection and was found to be an independent risk factor for overall one-year mortality in the multivariate analysis. Our study highlights the importance of broad-spectrum empirical antibiotics as initial treatment of trochanteric and subtrochanteric IM nail-associated infection while awaiting microbiological results. It also provides initial evidence for the importance of implant removal in chronic IM-nail infection. Full article

Background and Objectives: This retrospective cohort study analyzes mechanical complications in hip fracture surgery using the Trochanteric Fixation Nail-Advanced (TFNA) implant. It investigates the correlation of these complications with demographic, intraoperative, and radiological factors, aiming to identify associated risk factors and suggest improvements in clinical surveillance and treatment strategies. Materials and Methods: We enrolled 253 patients diagnosed with pertrochanteric hip fractures treated between 2017 and 2021, with 126 meeting the criteria for a minimum 6-month follow-up. Data on demographics, American Anesthesia Association Classification (ASA), comorbidities, AO/OTA [AO (Arbeitsgemeinschaft für Osteosynthesefragen)/OTA (Orthopedic Trauma Association)] fracture classification, procedural details, and time to failure were collected. Radiographs were evaluated for reduction quality, the tip–apex distance (TAD), progressive varus deviation, and identification of mechanical complications. Statistical analysis was performed using SPSS software. Results: The predominant AO/OTA fracture classification was 31A2 in 67 cases (52.7%). Reduction quality was deemed good or acceptable in 123 cases (97.6%). The mean time to failure was 4.5 months (range: 2.2–6). The average TAD was 18 mm (range: 1.2–36), with a mean progressive varus deviation of 2.44° (range: 1.30–4.14). A good or acceptable reduction quality was observed in 97.6% of cases. Mechanical complications occurred in 21.4% of patients, with significant associations found with the lateral cortex fracture, use of a TFNA implant with a 130° angle, open reduction, and absence of prior osteoporosis treatment. Conclusions: The study provides insights into mechanical complications in proximal femur fractures treated with the TFNA nail, emphasizing the need for enhanced clinical and radiographic surveillance, especially in patients without osteoporosis treatment. Our findings support the necessity for further clinical studies comparing these outcomes with other implant designs and underscore the importance of personalized treatment strategies to reduce complication rates. Full article

Background: Fragility-related pertrochanteric fractures have become a significant public health concern, with a rising incidence attributed to the expanding elderly demographic. Assessing patient-reported health-related quality of life (HRQoL), mortality, and factors correlated with them serves as a crucial metric in evaluating the effectiveness of hip fracture surgery. Methods: In a single-center retrospective study, 259 patients underwent surgical treatment with a cephalomedullary nail, with a mean follow-up of 21.7 months. Health-related quality of life (HRQoL) was assessed using SF-12 (12-item Short Form) and EQ-5D (EuroQoL-5 Dimensions) questionnaires. Mobility status was measured by the Crude Mobility Index (CMI). Surveys were administered during hospitalization and six months postoperatively. Statistical analysis involved descriptive statistics, non-parametric controls (Kendall, Mann-Whitney, and Wilcoxon), and Spearman correlation and logistic regression analysis, which were conducted using IBM SPSS version 28. Results: A statistically significant decrease was observed in the mean EQ-5D and SF-12 scores at 6 months post-op compared to the pre-fracture status. The ASA (American Society of Anaesthesiologists) score showed a significant correlation with the decrease in HRQoL measured by the SF-12 questionnaire. The 30-day post-operative mortality rate was 9.3%, increasing to 32.4% at 1 year. Notably, the 30-day mortality significantly rose during the pandemic era (5.0% vs. 12.0%; p = 0.003). Conclusions: Pertrochanteric hip fractures cause a lasting decline in quality of life. Annual mortality is high, and further investigations are needed to formulate policies that prevent hip fractures and reduce mortality rates. Full article

In March 2020, Germany imposed a nationwide lockdown to curb the spread of COVID-19, prompting questions about the impact on the incidence of common fractures. This study examined 15 fracture types in pre-outbreak (2010–2019) and post-outbreak (2020–2021) periods, using data categorized by age (18–64 years, >65 years) and sex (male, female). Linear regression assessed annual growth rates, and mean fracture numbers were compared across periods for significant differences. Results indicated a positive correlation between fracture incidence rates and time for various types, such as cervical, thoracic, lumbar, and pelvic spine fractures, rib fractures, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures. Frequencies of proximal humerus, distal radius, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures in 2020 and 2021 were within predicted ranges from previous years. However, rib fractures and spinal fractures (cervical, thoracic, lumbar, and pelvic spine) occurred less frequently during this time. Notably, this study found a consistent decline in most fracture types for individuals aged 18–64 after the pandemic’s onset, while the fracture incidence of hip fractures, often referred to as fragility fractures, for those over 65 remained unchanged. Fibula fractures showed the most considerable decrease in both age groups. In conclusion, the COVID-19 pandemic substantially impacted fracture incidence, with lower rates among individuals under 65 and unchanged fragility fractures in the elderly population. Full article

Can the financial impact of implant choice during the learning curve of inexperienced surgeons in hip fracture surgery be quantified? Hip fractures in the elderly are a significant medical concern, often requiring surgical interventions performed by orthopedic surgery residents. As healthcare costs rise, exploring cost reduction opportunities within the healthcare system becomes crucial. In this prospective analysis, we examined the financial implications of implant choices encountered by residents during their learning curve in hip fracture surgery. Our study included 278 surgically treated pertrochanteric fractures using the same locking cephalomedullary nail. Data on patients, surgeons (including their experience and seniority), and all implants charged by the hospital were collected. This encompassed documentation of any nail-related equipment that was opened on the operating table and whether it was subsequently used by the end of the procedure. By calculating the number and cost of these implants, we assessed the financial burden associated with suboptimal choices made during the learning curve. Our findings revealed that in 16.18% of surgeries, instances of suboptimal implant utilization occurred, highlighting the complexities of the learning process. Importantly, the rate of these challenges was not influenced by surgeon seniority or patient characteristics. The mean additional cost per surgery was determined to be USD 65.69 ± 157.63 for surgeries with suboptimal implant utilization, compared to USD 56.55 ± 139.13 for surgeries without such challenges. Although there was a trend towards higher implant-related costs in resident-led surgeries, the difference did not reach statistical significance. These findings underscore the feasibility of enabling residents to autonomously perform intramedullary nailing surgeries, even without specialist supervision, while incurring minimal additional expenses during the learning curve. By acknowledging the financial implications associated with the learning curve in the management of hip fractures, we can strive to optimize healthcare costs, thus addressing an important aspect of this issue. Full article

A prospective, feasibility, randomised study was performed to compare intramedullary versus extramedullary fixation of unstable pertrochanteric fractures and to assess the feasibility of including patients with dementia. From July 2016 to November 2017, 60 consecutive patients with an unstable pertrochanteric (OTA/AO 31-A2) fracture were randomized to either receive a short cephalomedullary nail (Endovis EBA², Citieffe) or a dynamic hip screw (DHS, Zimmer Biomet). Primary feasibility measures included randomisation, recruitment, and retention rates. Secondary outcomes included peri-operative parameters, patient-reported outcomes and radiographic outcomes. Patients were followed-up at two, four, and twelve weeks. There was no difference in the randomisation rate between patients with and without cognitive impairment. Significantly more patients without cognitive impairment attended the 12-week follow-up. The overall recruitment rate was 0.9 patients per week. Patients treated with the nail had less pain at 2 weeks and less neck collapse, medialisation, and leg shortening at all time points. The rest of secondary outcomes were similar. Patients with dementia can successfully be enrolled in a randomised trial on hip fractures. Patients treated with the Endovis nail had lower levels of pain at two weeks and better radiographic outcomes. Full article

Background: Early postoperative mobilization is essential for orthogeriatric patients. The prognostic nutritional index (PNI) is widely used to evaluate nutritional status. This study sought to investigate the predictive value of PNI for early postoperative mobility in patients with pertrochanteric femur fractures. Materials and methods: This study included 156 geriatric patients with pertrochanteric femur fractures treated with TFN-Advance™ (DePuy Synthes, Raynham, MA, USA). Mobility was evaluated on the third postoperative day and by discharge. Stepwise logistic regression analyses were performed to evaluate the association significance of PNI with postoperative mobility together with comorbidities. The optimal PNI cut-off value for mobility was analyzed using the receiver operating characteristic (ROC) curve. Results: Three days postoperatively, PNI was an independent predictor of mobility (OR: 1.14, 95% CI: 1.07–1.23, p < 0.01). By discharge, it was found that PNI (OR: 1.18, 95% CI: 1.08–1.30, p < 0.01) and dementia (OR: 0.17, 95% CI: 0.07–0.40, p < 0.001) were significant predictors. PNI correlated weakly with age (r = −0.27, p < 0.001). The PNI cut-off value for mobility on the third postoperative day was 38.1 (specificity = 78.5%, sensitivity = 63.6%). Conclusions: Our findings indicate that PNI is an independent predictor of early postoperative mobility in geriatric patients with pertrochanteric femur fractures treated with TFNA™. Full article