Search Results (84)

Background: Early mobilization with permission for full weight bearing is a cornerstone of postoperative care after proximal femoral fractures (PFFs). However, its biomechanical implementation during gait remains unclear. Clinical scores such as the Charlson Comorbidity Index (CCI) and the American Society of Anesthesiologists (ASA) classification describe comorbidity burden, but their relationship with actual weight bearing and functional outcome regarding activities associated with daily living is insufficiently understood. Methods: In this prospective cohort study, patients aged > 65 years treated surgically for femoral neck fractures (FNFs) or trochanteric femoral fractures (TFFs) were included. Postoperative weight bearing was assessed after 4 to 7 days using sensor-based insoles. Average peak force of the operated limb, normalized to body weight, was the primary outcome. Associations with postoperative weight bearing and functional outcome were analyzed using multivariable linear regression models. Results: Early postoperative weight bearing remained below recommended levels, with lower limb loading in TFFs. Higher CCI values were associated with increased loading in TFF patients, and higher ASA classifications with reduced loading. Higher postoperative Barthel Index (BI) was independently associated with increased limb loading. Postoperative BI was influenced by age, preoperative BI, and fracture type. Conclusions: Despite permission for full weight bearing, early postoperative limb loading after PFF remains below recommended levels, particularly in TFFs. CCI and ASA show fracture type-specific associations with actual weight bearing, whereas BI is independent of ASA and CCI. The BI may serve as a surrogate parameter to identify patients at risk of insufficient limb loading who may benefit from targeted physiotherapeutic interventions. Full article

Background/Objectives: Trochanteric pressure ulcers represent a challenging reconstructive problem due to their depth, frequent infection, and tendency for recurrence. Durable coverage with well-vascularized tissue capable of effective dead-space management is essential for long-term stability. The pedicled musculocutaneous anterolateral thigh (ALT) flap offers substantial soft-tissue volume with reliable regional vascularity. Methods: A retrospective review was performed of consecutive patients with Stage IV trochanteric pressure ulcers who underwent reconstruction using musculocutaneous pedicled island ALT flaps between January 2020 and August 2023. Ulcers were classified according to the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance International Guidelines. Patients with a minimum follow-up of 24 months were included. Demographic characteristics, ulcer etiology, prior flap history, comorbidities, flap dimensions, postoperative complications, and recurrence rates were analyzed. Results: Eight patients (4 males, 4 females; mean age 46.4 years, range 35–63) were included. Six ulcers (75%) were related to prolonged immobilization, and two (25%) developed following entrapment during the 2023 Kahramanmaraş earthquake. All donor sites were closed primarily. Minor recipient-site complications, including seroma and limited suture dehiscence, occurred in two cases. No partial or total flap necrosis was observed. During a mean follow-up of 42.4 months (minimum 24 months), no recurrence occurred. Conclusions: Musculocutaneous pedicled ALT flaps incorporating a substantial portion of the vastus lateralis muscle allowed effective dead-space obliteration and durable soft-tissue coverage in Stage IV trochanteric pressure ulcers. Primary donor-site closure was achievable without major morbidity. These findings support the use of the pedicled ALT flap as a consistent regional option in complex trochanteric defects, including both chronic immobilization-related and acute compression-related cases. Full article

Background/Objectives: Proximal femoral fractures (PFF) are associated with substantial morbidity and mortality in elderly patients. Early identification of individuals at increased risk of death remains challenging. The neutrophil-to-lymphocyte ratio (NLR) is an inexpensive and readily available biomarker reflecting systemic inflammation and physiological stress, but its role as a risk stratification tool in surgically treated PFF patients is not fully established. The aim of this study was to validate NLR as a prognostic biomarker for mortality risk stratification in elderly hip fracture patients by evaluating its independent association with mortality, establishing clinically relevant risk categories, and assessing its ability to identify distinct mortality risk groups. Methods: This retrospective cohort study included 1113 patients aged ≥ 65 years who underwent surgery for AO/OTA 31.A (trochanteric) or 31.B (femoral neck) proximal femoral fractures between January 2021 and February 2024 at a single institution. NLR was calculated from routine admission bloodwork. The primary outcome was all-cause mortality. Kaplan–Meier survival analysis stratified patients by clinically relevant NLR categories (<5, 5–10, >10). Cox proportional hazards regression identified independent predictors of mortality. ROC analysis was performed secondarily to identify an optimal binary threshold. Results: At mean follow-up of 33.9 months, overall mortality was 36.2% (352/972). Stratified survival analysis demonstrated a clear dose–response relationship, with mortality rates of 26.2%, 36.5%, and 54.4% for NLR < 5, 5–10, and >10, respectively (log-rank p < 0.001). In multivariable Cox regression, NLR remained independently associated with mortality (HR = 1.042, 95% CI: 1.032–1.053, p < 0.001) after adjusting for age and time to surgery. ROC analysis identified an optimal binary cut-off of 6.59 (AUC 0.614). Conclusions: Elevated preoperative NLR is independently associated with increased mortality following surgery for proximal femoral fractures, particularly in very elderly patients. Given its simplicity and universal availability, NLR may represent a useful adjunct for early perioperative risk stratification. Full article

Background: Reverse-oblique femoral fractures are regarded as highly unstable and are still associated with high complication and failure rates. A new classification system is said to facilitate risk assessment and decision-making. Methods: Over ten years, 7804 patients with per/subtrochanteric fractures were screened in this retrospective analysis. A total of 552 patients with a reverse-oblique fracture pattern were included. The fractures were classified according to the new classification system. The choice of implants, complication rates, revision surgery, and time of surgery were recorded. Radiological outcome parameters and dislocation were measured. Results: For the classification, a good intra-rater reliability (r = 0.77) and inter-rater reliability (k = 0.64) were calculated. The complication rate was overall 19% (n = 105). More than 60% of complications needed revision surgery. The most common complications were cut-out and implant failure (3%); only Parker’s ratio, as a radiological parameter, had prognostic value. Malreduction had a negative impact on mal- or non-unions (p < 0.01), and a trend towards higher overall complications (p = 0.52). Prolonged time of surgery increased the overall complication rate (r = 0.2, p < 0.001). The same was found after open reduction (p = 0.005, OR 2.00). The use of cerclage wires had no positive or negative effects. The use of short or long implants did not influence the outcome. Conclusions: Reverse-oblique femoral fractures are associated with a high complication rate. Short implants can be safely used in cases without severe dislocation if a sufficient working length is considered. Anatomical reduction benefits the outcome as long as it can be performed closed. The classification system presents good inter- and intra-rater reliability. Full article

Introduction: Management of trochanteric fractures in revision hip surgery has a high incidence of non-union and complications. Fixation devices are often bulky, prone to breakage, and necessitate reoperation. This study describes a novel soft tissue and bony abductor repair that reduces the forces on bony fragments without the need for prominent metalwork. Methods: This novel surgical technique involves fixation of the abductor mechanism with polyester and polyethylene sutures that are woven through the abductors and secured to the femoral shaft with a proprietary suture cerclage tape with cerclage wire supplementation in select cases. All patients undergoing fixation were retrospectively reviewed with a minimum follow-up period of 12 months. Outcomes relating to dislocation, reoperation, fracture union and the incidence of symptomatic Trendelenburg gait were recorded. Results: A total of 17 patients underwent this novel intervention. There were no dislocations or reoperations for prominent metalwork at the last follow-up. One patient had evidence of greater trochanter (GT) non-union, and three had GT displacement of over 3 mm. Eight (47.1%) patients were independently mobile and seven (41.2%) were mobile with only one walking aid. No patients required plate or bolt fixation. Conclusions: GT fractures and abductor deficiency are difficult to manage, with most reported methods utilising bulky metalwork to treat a soft tissue injury. We describe a novel combined soft tissue and bony fixation without the need for excessive metalwork. Our pilot study demonstrates satisfactory outcomes of this intervention that are technically reproducible and more appropriately addresses the deforming forces involved with a low complication profile. Full article

Background: Greater trochanteric pain syndrome (GTPS) is associated with structural tendon alterations and functional impairment. Extracorporeal shockwave therapy (ESWT) is a common treatment, but objective monitoring of tendon remodeling and motor recovery remains limited. Objective: This study aimed to integrate shear-wave elastography (SWE) expressed in m/s and wearable inertial measurement unit (IMU) as biosensing tools for the quantitative assessment of tendon elasticity, morphology, and hip motion after ESWT in GTPS. Methods: In a prospective cohort of adults with chronic GTPS, shear wave elastography (SWE) quantified gluteus medius tendon (GMT) elasticity and thickness, while hip abduction range of motion (ROM) was measured using a triaxial inertial measurement unit. Clinical scores on the Visual Analogue Scale (VAS), Harris Hip Score (HHS), Low Extremity Functional Scale (LEFS), and Roles and Maudsley score (RM) were collected at baseline (T0) and at 6 months (T1). Results: Thirty-five patients completed follow-up. Pain and function improved significantly (VAS, HHS, LEFS, RM; all p < 0.05). SWE values of the affected GMT increased, while tendon thickness decreased yet remained greater than on the contralateral side. Hip abduction ROM increased significantly from T0 to T1 (p < 0.05). Correlation analysis showed a negative association between abduction and pain at T1 (r = −0.424; p = 0.011) and, at baseline, between abduction and VAS (r = −0.428; p = 0.010) and RM (r = −0.346; p = 0.042), and a positive association with LEFS (r = 0.366; p = 0.031). SWE correlated negatively with VAS at T1 (r = −0.600; p < 0.05) and positively with HHS at T1 (r = 0.400; p < 0.05). Conclusions: Integrating elastography with inertial sensor-based motion analysis provides complementary, quantitative insights into tendon remodeling and functional recovery after ESWT in GTPS. These findings support combined imaging and wearable motion measures to monitor treatment response over time. Full article

Background: Surgical treatment of periprosthetic joint infection (PJI) after total hip arthroplasty (THA) remains challenging, with thorough debridement seen as critical for success. While revision THA is well documented as the standard treatment for PJI, data on infection spread beyond the periprosthetic joint into surrounding soft tissue remain limited—this is the focus of our study. Methods: We retrospectively reviewed 558 patients who underwent a revision THA due to PJI at a single academic institution from January 2011 to December 2023. Out of 558 patients, 46 (8.2%) underwent a Magnetic Resonance Imaging (MRI) scan of their hip joint prior to their revision THA due to suspicion of a PJI. MRI reports were manually chart-reviewed to evaluate patients for evidence of infection spread beyond the constraints of the periprosthetic joint space. Results: Out of 46 patients with hip MRI prior to rTHA, 45 (97.8%) had pathological findings, and 34 (73.9%) had reports suggestive of periprosthetic joint fluid collection. The infected joint effusion extended in 30 cases (65.2%) from the capsule into the surrounding soft tissue, including the greater trochanteric region (17.4%), iliopsoas area (15.2%), anterolateral musculature (13.0%), surrounding soft tissue (10.8%), gluteal (8.7%) and obturator muscles (8.7%), and iliotibial band (4.3%). Capsule thickening was observed in 23.9% of the cases. Conclusions: Our study found that the vast majority (97.8%) of the hip MRIs had pathological findings, with periprosthetic joint fluid collection being a predominant feature in 73.9% of the cases. The extraarticular extension of these fluid collections was observed in over two-thirds (30/34) of affected patients, suggesting that PJI is often not confined to the capsule. MRI studies can help surgeons obtain prior knowledge of these cases and develop a more comprehensive surgical approach for infection debridement, potentially helping improve surgical treatment outcomes after PJI. Full article

Background/Objectives: Lipedema is a chronic disorder that affects almost exclusively women and is characterized by bilateral, symmetrical accumulation of subcutaneous fat, typically in the buttocks, hips, and lower limbs, and in some cases the arms. The primary objective of this study was to describe the clinical and anatomical manifestations of lipedema, together with the associated physical and psychological comorbidities, in a large Spanish cohort. Methods: Descriptive study of 1803 patients aged ≥ 17 years who attended two clinics in Spain between January 2022 and November 2024. Results: The mean age was 42.9 years (SD: 11.3), and 60.6% of patients were diagnosed during their reproductive years. The mean body mass index was 28.6 (SD: 6.2), and 87.6% presented a gynoid fat distribution. A total of 46.6% were classified as Schingale stage IV or V. The most frequent comorbidities were chronic low-grade inflammatory alterations and connective tissue damage. Particularly suspected high intestinal permeability (99%), bilateral trochanteric pain region (97.4%), iliotibial band involvement, and ligamentous hyperlaxity (95.8%). Thyroid disorders, inflammatory ovarian dysfunction, and psychological impairment were also common. Conclusions: Lipedema is a complex condition that extends beyond lower-limb adipose tissue and is associated with multiple comorbidities. This study also presents a novel approach to clinical assessment that may help physicians gain a deeper understanding of this pathology and formulate etiological hypotheses that will need to be tested. Full article

Background: Hip fractures in older adults are sentinel events linked to high mortality and functional decline. Few studies have quantified long-term survival probabilities, standardized mortality ratios (SMRs), and risks of new nursing home admission alongside patient-related predictors. Methods: We retrospectively analyzed 355 patients aged ≥ 60 years who underwent hip fracture surgery at a general hospital in Japan (2020–2024). Primary outcomes were mortality and new nursing home admission. Survival probabilities and remaining life expectancy were estimated, and SMRs were calculated using age- and sex-matched national data. Cox regression identified independent predictors. Results: Mean age was 84 years; 76% were female. Mortality probabilities at 1, 2, and 3 years were 23%, 41%, and 60%, respectively; SMRs consistently exceeded 9. Median remaining life expectancy was 260 days. New nursing home admissions occurred in 42%, with cumulative probabilities of 16%, 27%, and 35% at 1, 2, and 3 years, respectively, showing a rapid rise within 9 months. Independent predictors of mortality were delayed surgery, higher Charlson Comorbidity Index, and low Geriatric Nutritional Risk Index. Older age and failure to regain ambulatory ability at 3 months predicted institutionalization. Conclusions: Older adults with hip fractures face persistently high mortality and institutionalization risks, comparable to advanced malignancies or neurodegenerative diseases. Surgical timing, comorbidities, nutrition, and functional recovery critically influence prognosis and should guide perioperative care and discharge planning. Full article

Background and Objectives: Intertrochanteric femur fractures are very common, especially in the elderly population, and cause serious morbidity and mortality. Today, the most commonly used implants in the treatment of these fractures are proximal femoral nails (PFNs). This study aimed to analyze the clinical and radiological results of patients who underwent surgical treatment with a proximal femoral nail (PFN) for intertrochanteric femur fractures and later required revision surgery for various reasons. Materials and Methods: Patients who underwent surgical treatment PFN due to intertrochanteric femur fractures between 2022 and 2025 were included in the study, and the patients were divided into revision and non-revision groups. Demographic information, postoperative radiological measurements, complications, and reasons for revision surgery were noted, and risk factors leading to revision were determined using bivariate and multivariate analyses. Results: A total of 207 patients, 97 revision (46.9%) and 110 non-revision (53.1%), were included in this study. Cut-out was identified as the most common revision cause (n = 52, 53.6%), followed by loss of reduction (n = 15, 15.5%), implant failure (n = 14, 14.4%), nonunion (n = 6, 6.2%), infection (n = 4, 4.1%), cut-through (n = 3, 3.1%), and avascular necrosis of the femoral head (n = 3, 3.1%). When bivariate analysis was performed to identify risk factors for revision, it was observed that female gender (p = 0.004), presence of posteromedial comminution (p < 0.001), operation under spinal anesthesia (p = 0.023), surgery in supine position (p < 0.001), using closed reduction techniques (p < 0.001), presence of infection (p = 0.004), and higher Charlson comorbidity index values (p < 0.001) increased the risk of revision. Additionally, positive and neutral medial cortex support (p < 0.001) decreased the risk of revision. Multivariate analysis was also applied to the parameters found to be significant in bivariate analysis. As a result of this analysis, surgery in the supine position (p < 0.001), using closed reduction techniques (p < 0.001), and higher Charlson comorbidity index values (p < 0.001) remained significant. Conclusions: Careful evaluation of the fracture morphology, ensuring optimal reduction, and considering the accompanying comorbidities of the patients in the surgical planning of unstable trochanteric fractures stand out as key elements in increasing surgical success. Full article

Background: Cephalomedullary nails are the standard treatment of trochanteric fractures, and some implants with a perforated blade allow augmentation with bone cement to increase mechanical stability. The study compares the results of PFNA and TFNA implants (DePuy Synthes) with or without cement augmentation of the blade. Methods: A retrospective study evaluated 219 trochanteric fractures. The study included 59 men (27%) and 160 women (73%), with a mean patient age of 82 years. The most common fractures were type 31A2 (56%), followed by type 31A1 (25%) and type 31A3 (19%). The monitored parameters were evaluated from anteroposterior and axial images of the proximal femur and pelvis. TAD, blade position, lateral blade prominence, fracture varus, and cut-out were evaluated. Results: Cement-augmented blade implants (CABs) in 68 patients (31%) and cement-free implants (NCABs) in 151 patients (69%) were used. The average age difference between the groups was 7 years (CAB 86.07 ± 5.85 and NCAB 79.13 ± 8.48). CABs were used more frequently in women (60 cases) than in men (8 cases). Blade position was optimal in 68% of cases and suboptimal in 32%. The risk of varus deformities was not statistically significantly affected by the blade position. The statistical significance of CABs for reducing the risk of varus deformities in stable fractures (p = 0.396) or unstable fractures (p = 0.101) was not confirmed. The average varus angulation during treatment was 2.57° (CAB 2.53° and NCAB 2.67°). A varus deformity greater than 10° was confirmed in 8 eight patients (3.7%) and cut-out in three patients (1.4%). All patients with cut-out were in the NCAB group. Cement leakage occurred in two cases and was asymptomatic. One case of deep infection, lateral blade prominence, and avascular necrosis (AVN) were recorded. Conclusions: Cement augmentation of the blade did not significantly reduce varus deformity in this cohort, regardless of blade position of fracture stability. CABs may prevent cut-out in specific subgroups, but this requires further investigation. Full article

Background and Objectives: Partial gluteal tendon tears in native hips are often misdiagnosed as greater trochanteric pain syndrome, resulting in ineffective conservative treatment and persistent symptoms. Although surgical repair techniques exist, data on objective strength outcomes in non-arthritic hips remain limited. The objective of this study was to evaluate pain reduction, patient-reported outcomes (PROMs), and isometric hip abductor strength following mini-open, knotless double-row repair using the Hip Bridge technique. Material and Methods: This retrospective, single-center cohort study (Level III) with prospective outcome evaluation included 27 patients (mean age 53 years, BMI 27 kg/m²) with partial gluteal tendon tears and no advanced osteoarthritis (Tönnis grade ≤ 1), treated between 2015 and 2022 using the mini-open, knotless double-row Hip Bridge technique. The mean follow-up was 29.3 ± 24.3 months (minimum 6 months). Diagnosis was confirmed by 3-Tesla MRI, and other sources of lateral hip pain were excluded. Clinical outcomes included the Visual Analog Scale (VAS), modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), normalized Western Ontario and McMaster Universities Osteoarthritis Index (nWOMAC), and Copenhagen Hip and Groin Outcome Score (HAGOS). Isometric hip abductor strength was assessed in 22 patients using a dynamometer, comparing the operated and contralateral limbs. Results: Postoperative satisfaction was high: 93% would undergo surgery again, 88% reported improved Trendelenburg gait, and 85% noted subjective strength gains. Pain improved significantly from VAS 8 (range, 3 to 10) preoperatively to VAS 2 (range, 0 to 7) postoperatively (p < 0.001); 100% reported pain relief. Patient-reported outcome scores were mHHS, 84.2; nWOMAC, 86.5; HOS, 80.7; and HAGOS, 70.7. Isometric strength testing showed significant improvement on the operated side (Fmax: p = 0.006; Fmean: p = 0.009). The mean limb symmetry index was 118% for Fmax and 122% for Fmean. Conclusions: Mini-open, knotless double-row repair of partial gluteal tears in non-arthritic hips yields adequate pain relief, high satisfaction, and objective strength recovery. The Hip Bridge technique could be an effective option after failed conservative treatment. Future prospective comparative studies are warranted to validate mid-term outcomes and establish long-term efficacy. Full article

Background and Clinical Significance: Vascular complications occurring in the context of trans-trochanteric fractures are rare (mean incidence 0.2–0.5%) but can be fatal if not recognized and treated promptly. Most of the previously reported vascular injuries are iatrogenic, and various mechanisms of injury and producing agents have been reported. Case Presentation: We present a rare but severe vascular complication following proximal femur fracture fixation in the case of a 77-year-old patient, specifically, a deep femoral artery injury after DHS osteosynthesis. CT angiography identified the lesion in the territory of the profunda femoris artery, precisely at the level of the most distal screw, suggesting over-drilling as the underlying cause. The case is presented in the context of a literature review, updating the most important features of the vascular complications, incidence, diagnosis and treatment. Conclusions: This case highlights the critical role of early diagnosis and prompt interdisciplinary collaboration between orthopedic and vascular surgeons in managing iatrogenic vascular complications, achieving a favorable outcome. Full article

Background/Objectives: Gluteal medius tendon tears (GTT) are a common cause of greater trochanteric pain and functional impairment. Accurate preoperative imaging is critical for diagnosis and surgical decision-making. This study aimed to evaluate and compare the diagnostic accuracy of four imaging modalities—X-ray, ultrasound (US), magnetic resonance imaging (MRI), and bone scan (BS)/SPECT/CT—in detecting and grading GTT, using perioperative findings as the reference standard. Methods: In this prospective study, a cohort of 45 patients (41 women, 4 men; mean age 62.9) with suspected GTT and failed conservative treatment had open surgical treatment by augmentation of the gluteus medius tendon. All patients underwent preoperative imaging with X-ray, US, MRI, and BS. Imaging results were compared with intraoperative findings. Results: MRI demonstrated the highest sensitivity (98%) and strong PPV (91.1%), correctly identifying nearly all true positives. Ultrasound showed similar sensitivity (95%) but yielded more false positives. X-ray and BS exhibited perfect specificity and PPV (100%) but poor sensitivity (21% and 38%, respectively), limiting their utility in ruling out GTT. Conclusions: MRI is the most sensitive and reliable single modality for diagnosing GTT, though false positives remain a concern in surgical decision-making. Ultrasound, while sensitive, lacks specificity and should not be used in isolation for surgical decision-making. A multimodal imaging approach, particularly combining MRI with X-ray and BS, may offer high diagnostic certainty and help prevent unnecessary surgical interventions. Full article

Background: Two-stage septic hip revision arthroplasty has higher mortality rates than aseptic hip revision arthroplasty, and patients over 75 years have higher fracture rates than younger patients after cementless total hip arthroplasty. Therefore, the aim of this study was to examine whether two-stage septic hip revision arthroplasty in older patients leads to higher complication and mortality rates, as well as whether changing to cementless hip prostheses in older patients could lead to higher fracture and subsidence rates of the stem prosthesis than in younger patients. Material and Methods: In total, 286 two-stage-revision procedures for periprosthetic infections of the hip in 186 patients younger and 118 patients older than 75 years were followed for a minimum of 24 (50.24 ± 20.77) months. A total of 71.3% of procedures were performed via a transfemoral approach using cementless cups and revision stems (93.7%). Complications and mortality were analyzed retrospectively. Results: There was a one-year mortality rate of 1.0% with no difference in the groups, and a general mortality rate of 2.8% with a significantly higher rate in older adults than in the younger group (5.9% vs. 0.6%; p = 0.01). The rate of fractures of the bony flap in transfemoral approaches (9.1%), fissure rate of the isthmus (2.8%), rate of subsidence of cementless stems (1.0%), and rate of reinfections (4.89%) did not differ between the two groups. The general complication rate (not associated with cementless two-stage septic revision) (22.0%) was significantly higher in the older patient group (33.9% vs. 13.7%; p < 0.001). Conclusions: Septic two-stage revision hip arthroplasty, mostly using a transfemoral approach and cementless reimplantation, does not result in a higher one-year mortality rate, reinfection rate, and rate of fissures and fractures of the bony flap, but demonstrates a generally higher mortality and complication rate in older adults. This should be taken into consideration when determining the indication and when offering advice to older adults. Full article