Geriatric Orthopaedic Surgery & Rehabilitation最新文献

Background: Malnutrition is a prevalent issue among older patients with hip fracture and is significantly associated with poor outcomes. The Geriatric Nutritional Risk Index (GNRI) and Prognostic Nutritional Index (PNI) are nutritional screening tools that may assist in predicting outcomes in older patients undergoing hip fracture surgery. This study aimed to evaluate the effects of GNRI and PNI on 1-year mortality after hip fracture surgery in older patients.

Methods: This retrospective study included 577 patients aged 60 years and older with hip fractures treated surgically at a single center from January 2018 to December 2021. Nutritional status was evaluated using GNRI and PNI. The primary outcomes were 180-day and 1-year mortality, while secondary outcomes included short-term postoperative complications and length of stay. Univariate and multivariate analyses were performed to identify independent risk factors for 1-year mortality. Subgroup analysis was employed to identify potential population heterogeneity.

Results: Patients with low GNRI and low PNI had significantly higher 1-year mortality rates and short-term postoperative complication rates compared to those with higher scores. Low GNRI was an independent risk factor for one-year mortality (95% CI 1.09 - 3.25, P = 0.022). Subgroup analyses revealed significant heterogeneity, with males patients and patients with ASA III-IV showing higher hazard ratios for 1-year mortality associated with low GNRI. Pulmonary infections and older age were also identified as independent risk factors for one-year mortality.

Conclusion: This study demonstrated that low GNRI was the risk factor for 1-year mortality after hip fracture surgery in older patients.

Background: Fragility fractures of the posterior pelvic ring are associated with osteoporosis and are becoming more common with demographic change. Known limitations of conservative therapy include a significant loss of autonomy and high mortality. Surgical stabilisation using percutaneous sacroiliac (SI) or trans-iliac trans-sacral (TITS) screws, has been established to increase mobility, but long-term results have not yet been studied.

Materials and methods: 138 patients with percutaneous SI and TITS screw fixation of the posterior pelvic ring in osteoporotic fragility fractures were followed up for more than a year postoperatively in this retrospective study. Thereby, all patients were operated in the conventional supine position in a hybrid operating room consisting of a fixed, robot-assisted 3D flat-panel detector and a navigation system.

Results: 34 patients were male and 104 female. The mean age was 77.6 ± 9 years. 26 patients were ASA 1 + 2, 93 patients ASA 3 and 19 patients ASA 4. 80 fractures were classified as FFP 2, 23 FFP 3 and 35 FFP 4. Time to surgery was 127.5 ± 113.2 hours. Hospitalisation lasted an average of 15.7 ± 8.5 days. At the time of discharge, 68.8% of the patients had regained their original mobility, while 31.2% remained limited. The home situation remained unchanged in 73.9% of the patients, worsened in 26.1% and improved in 2.8%. 90.6% of the screw fixations showed no signs of loosening. In 9.4%, loosening could not be ruled out radiologically, but a surgical revision was not necessary. The 1-year mortality rate was 10.1%.

Conclusion: Percutaneous navigated screw fixation of the posterior pelvic ring in fragility fractures is a simple, safe, minimally invasive and precise method with good clinical results in terms of rapid recovery with early mobilization of patients to maintain autonomy and reduce mortality. Further clinical studies with controlled cohorts and a large number of patients with long follow-up periods should be carried out to compare the procedure with other methods. In particular, the question of an additional standardized treatment of the anterior pelvic ring in unstable dislocated fragility fractures should be investigated.

Introduction: The posterior approach is widely used in hemiarthroplasty for femoral neck fractures. However, it has a high dislocation rate. In hemiarthroplasty, the joint capsule is commonly incised. This study aimed to identify a posterior surgical technique that completely preserves the joint capsule without incision and the use of special devices to remove the head, perform a trial, and place an implant. Further, the learning curves (LCs) of trainee surgeons and the associated complications of the posterior approach were evaluated via a retrospective case series. Materials and Methods: The LCs of trainee surgeons for surgical duration and volume of intraoperative blood loss in 60 cases were examined. The surgical procedures were conducted by three trainee surgeons for femoral neck fractures at a single institution between September 2018 and June 2021. Each surgeon consecutively performed 20 surgical procedures. Each surgeon's cases were divided into four groups, with 15 cases each: 1-5, group A; 6-10, group B; 11-15, group C; and 16-20, group D. Then, these cases were analyzed. Surgery-related complications, such as dislocation, femoral fractures, paralysis, and infection were investigated. Results: The four groups significantly differed in terms of the median operative duration (P = 0.017). In particular, there was a significant difference between groups A and C (P = 0.007) and between groups A and D (P = 0.006). There was an LC for the surgical duration. In 10 cases, the surgical duration was shorter. However, there was no significant difference in the volume of intraoperative blood loss among the four groups. None of the patients presented with dislocation or major complications. Discussion and Conclusions: An LC was observed for the surgical duration in 10 cases among the trainee surgeons. Moreover, the volume of intraoperative blood loss did not significantly increase during the LC period.

Introduction: Patients with femoral neck fractures (FNF) have reduced walking ability owing to muscle weakness. Preoperative muscle volume and quality may have an association with prolonged rehabilitation and can be useful to predict the postoperative walking ability in patients with FNF. This study aimed to compare the muscle volume and computed tomography (CT)-assessed density around the hip joint in patients with FNF with patients having hip osteoarthritis (HOA) and assess the association of these measurement with postoperative walking ability.

Materials and methods: This retrospective observational study included 15 patients with FNF and 15 with unilateral HOA who were matched for age, sex, and osteoporosis medication. Muscle volume and CT-assessed density of the gluteus maximus, gluteus medius, gluteus minimus, iliacus, psoas major, rectus femoris, and rectus abdominis on the unaffected side were measured three-dimensionally using 3D Slicer software with preoperative CT data. The associations of muscle measurement with patient background, load to FNF (measured using the finite element method), and pre- or postoperative walking ability were assessed.

Results: Muscle volume of gluteus maximus, CT-assessed density of all muscles, and femoral strength were significantly lower in the FNF group than in the OA group (P < .01, P < .01, and P = .04, respectively). Muscle volume showed a moderate-to-strong correlation with body mass index (r = 0.66-0.81) and FNF load (r = 0.51-0.70), and CT-assessed density showed a moderate correlation with serum nutritional markers (r = 0.33-0.60). Postoperative walking ability was significantly correlated with the muscle volumes of iliacus and gluteus maximus (r = 0.40 and 0.49) and CT-assessed density of all muscles (r = 0.47-0.64).

Conclusion: Muscle volume and CT-assessed density significantly correlated with femoral bone strength, serum total protein levels, and pre- and postoperative walking ability. These findings suggest that muscle CT analysis around the hip joint may serve as a valuable tool for assessing musculoskeletal status in patients with FNF.

Background: Total knee replacement (TKR) is a common surgical intervention for older adults with chronic knee osteoarthritis (KOA). Given the prevalence of comorbidities in this population, health priorities may vary, influencing decision-making regarding TKR. Despite the increasing number of TKRs, no scoping review has systematically examined the determinants shaping older adults' decisions using a biopsychosocial (BPS) model. Materials and Methods: Searches were undertaken in commercially produced and grey literature sources. Eligible studies included English-language qualitative and quantitative studies that investigated determinants influencing older adults' decision towards TKR. Two independent reviewers screened the results. The data were then independently extracted, which was then collated and synthesized, using the BPS model. Results: Out of 999 abstracts screened, 23 studies met the inclusion criteria. The included studies took place in Australia, Canada, Germany, Japan, Kuwait, Sweden, Taiwan, Turkey, the United Kingdom and the United States. Ten studies used qualitative study designs while thirteen used varying quantitative study designs. Under BPS model, these determinants were grouped into biological determinants: baseline physical health, disease severity, and pain symptoms; psychological determinants, including coping strategies, feelings of loss, mental stress, depression, and anxiety; and social determinants: support networks, financial resources, health insurance, and access to referral systems and surgery. Conclusion: The decision for TKR in older adults with chronic KOA is shaped by an intricate interplay of biological, psychological, and social factors. The most consistent determinants included the desire for pain relief and the ability to regain physical function. Religion and spirituality significantly influence stress and anxiety in older adults and transportation system also presents significant challenges for TKR surgery. A multifaceted strategy that improves the structures, processes, and outcomes of decision for TKR surgery is required among older adults with chronic KOA. Future research with large, representative samples and a focus on the BPS framework is needed to further explore this complex decision-making process.

Background: With India's aging population on the rise, the prevalence of frailty among elderly patients undergoing major orthopedic surgeries presents a significant challenge for healthcare systems. Frailty, characterized by decreased physiological reserve and increased vulnerability to adverse health outcomes, necessitates a comprehensive approach to preoperative evaluation and care. This study aims to explore the correlation between frailty and socio-demographic variables, particularly age and gender, utilizing the Edmonton Frailty Scale (EFS) to assess frailty among elderly orthopedic surgery patients. Material and Methods: A prospective cohort study was conducted, encompassing 157 patients aged 60 years and above, undergoing major orthopedic procedures between June 2019 and June 2021. The EFS was employed to evaluate frailty, categorizing patients across a spectrum from 'Not Frail' to 'Severe Frail'. Statistical analysis was performed to examine the relationship between frailty levels and socio-demographic variables. Results: The majority of participants were males (59.2%) in the age group of 60-65 years (63.7%). The distribution of frailty revealed 40.1% of patients as not frail, with a substantial proportion displaying varying degrees of frailty. A significant correlation was found between increased frailty severity and advancing age (P < .001), while gender differences in frailty distribution suggested a higher predisposition towards severe frailty among females. Conclusion: The study underscores the high prevalence of frailty among elderly orthopedic patients and its significant association with age and gender. These findings highlight the necessity for frailty-informed preoperative assessments and interventions tailored to the specific needs of elderly patients. Incorporating frailty evaluations into clinical practice can enhance surgical outcomes and improve the quality of care for this vulnerable population.

Introduction: Hip fractures are among the most common major orthopaedic injuries globally, with one in three women and one in twelve men projected to sustain a hip fracture in their lifetime. Identifying genetic factors that contribute to hip fracture risk could improve risk stratification and inform prevention strategies. This study aims to identify genetic variants associated with hip fracture susceptibility through a genome-wide association study (GWAS).

Materials and methods: A GWAS was undertaken using the UK Biobank to identify risk loci for hip fractures.

Results: At the time of analysis, 2165 neck of femur fractures were identified among the 502 507 participants. Thirteen SNPs in five putative haplotypes were identified as significantly associated with hip fracture using the stringent GWAS threshold of 5E-8. Two of these loci appear to affect HOXC8, either by influencing the 3' UTR (rs4142680[T]) or via the miRNA hsa-miR-196a (rs11614913[T]). These two SNPs were also found to be expression quantitative trait loci for homeobox-C cluster genes (HOXC6, HOXC9, and HOXC-AS1).

Conclusions: Polymorphisms affecting homeobox-C cluster genes influence hip fracture risk in the general population. Future research should focus on validating these genetic associations and exploring optimal therapeutic interventions that could mitigate fracture risk in subpopulations carrying these polymorphisms.

Background: Ankle arthrodesis, traditionally used for Charcot arthropathy or failed fracture fixation, has evolved to include techniques such as tibiotalocalcaneal (TTC) nailing and tibiotalar arthrodesis. These methods offer advantages like smaller incisions and minimal disruption of the fracture site's biology. This approach is particularly beneficial for diabetic patients, who are prone to vascular complications, diabetic foot ulcers, and infections. Early weight-bearing with implants like TTC nails is especially advantageous for patients with poor bone stock or soft tissue quality. Objective: This study aimed to evaluate the clinical and radiographic outcomes of TTC nailing in ankle fractures among diabetic patients with Charcot arthropathy. Methods : This prospective study included 84 diabetic patients with unstable, displaced ankle fractures and Charcot neuroarthropathy who underwent TTC nailing from October 2022 to June 2024. Primary outcomes were complication rates and functional outcomes, while secondary outcomes included time to weight-bearing and bone union rates. The Foot and Ankle Outcome Score (FAOS) was used to assess functional improvement. Results: At six months postoperatively, FAOS scores were classified as excellent in 54 patients (64.3%), good in 24 patients (28.6%), and poor in 6 patients (7.1%). The mean preoperative FAOS score improved significantly from 19.9 ± 3.81 to 72.6 ± 11.66 at six months (P < 0.001). Union was achieved in 63 patients (75%), delayed union occurred in 15 patients (17.9%), and non-union occurred in 6 patients (7.1%). No significant correlations were found between final FAOS scores and age, body mass index, diabetes duration, or HbA1c levels. Furthermore, postoperative complications included wound infections, which were categorized into superficial and deep infections. Superficial infections occurred in 6 patients (7.1%), characterized by localized erythema and mild discharge around the surgical site. Deep infections, on the other hand, were observed in 3 patients (3.6%), involving deeper tissues and requiring more aggressive management, including hardware removal after achieving complete bone consolidation. Advanced postoperative deformity was noted in 6 patients (7.1%), likely due to the underlying Charcot arthropathy and its associated instability. Conclusion: TTC nailing is a reliable and effective treatment for ankle fractures in diabetic patients with Charcot neuroarthropathy, offering good clinical and functional outcomes with a low complication rate. Level of Evidence: III.

Background: The incidence of femoral neck fracture is increasing as society ages. Different types of cannulated screws can be used for internal fixation of femoral neck fractures, but no screw selection protocol has been determined to reduce the risk of operation failure. This retrospective study aimed to elucidate differences in outcomes between using cannulated compression screws and headless compression screws for fixation in nondisplaced femoral neck fractures.

Methods: Adults aged 18 years and older with non-displaced femoral neck fracture, admitted between February 2016 and January 2022, and received fixation using three screws in an inverted triangle configuration were selected for this retrospective study. After exclusions, patients were separated into four groups based on using different combinations of headed cannulated compression screws and headless compression screws. Postoperative computerized tomography or magnetic resonance imaging was used to evaluate operation failure, defined as nonunion or avascular necrosis of the femoral head.

Results: After exclusions, 153 patients (median age 75.0, range 65.0-85.0) with majority of females (69.9%) were included. While the combination of one cannulated compression screw (CCS) and two headless compression screws (HCS) did not achieve statistical significance compared to other screw configurations (P = 0.073), it still demonstrated the lowest rate of operative failure (0.0%). Age was identified as the only significant factor associated with operative failure (adjusted OR: 1.10; 95% CI: 1.03-1.17; P = 0.004).

Conclusions: No significant differences are found in outcomes between different combinations of cannulated headed compression screws and headless compression screws in an inverted triangle configuration for fixation of non-displaced femoral neck fractures.

Introduction: PROMIS® Computer Adaptive Testing (CAT) is a testing tool for tracking patient-reported outcome measures (PROM) with a goal to improve individual and population outcomes. Patients' health literacy (HL) may affect how they are able to complete PROM. We hypothesized that patients with low HL were less likely both to complete surveys and to do so via online patient portal (OPP).

Methods: A retrospective cohort study of 3926 orthopaedic patients in a rural state was performed. Completion rate and completion method both were subjected to log-binomial regressions with patient demographics and HL as predictor variables.

Results: PROM surveys were completed by 2166 (55.2%) of patients, including 512 completed via OPP and 1654 completed via in-clinic tablet (ICT). Compared to high HL patients, low HL patients had a 23% higher non-completion rate, and low HL completers were 63% less likely to use OPP. Age and gender had significant (P < 0.05) associations with completion method, but not completion rate, whereas Area Deprivation Index (ADI) had significant associations with both. Compared to White patients, Black patients had a 25% higher non-completion rate, and Black completers were 49% less likely to use OPP.

Discussion: Our analysis shows that health literacy, demographics, and socioeconomic status affect both whether and how patients fill out PROM surveys. Patients with low HL were less likely to complete PROM surveys, and less likely to use the OPP when they did.

Conclusion: Our results demonstrate that patients' health literacy, demographics, and socioeconomic status affect both whether they complete their PROMIS® CAT and what method they complete it with. Additional efforts should be made to understand these factors, accommodate patients, and facilitate accurate and complete PROM responses, especially in hospitals that serve diverse and socioeconomically disadvantaged patients.