Geriatric Orthopaedic Surgery & Rehabilitation最新文献

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.

Background: Lifetime risk of an osteoporotic fracture is 50% for women and 20% for men. Of these fractures, vertebral compression fractures (VCF) are the most common. While surgery plays a crucial role in managing these fractures, preventative measures are also critical when addressing the risk of osteoporotic VCFs. Although many recent guidelines recommend osteoporosis evaluation and treatment for patients with VCFs, the true proportion of patients who undergo an osteoporosis workup following their kyphoplasty procedure is unknown. The aim of this study is to assess the frequency of osteoporosis screening and treatment in patients who undergo a kyphoplasty procedure to correct a vertebral fragility fracture.

Methods: This study utilized the TriNetX Research Network, a database containing de-identified patient information. Using this database, we identified patients from 89 institutions with non-traumatic VCFs and VCFs that resulted from low-energy trauma who subsequently underwent a kyphoplasty procedure. We then analyzed any follow-up osteoporosis treatment or screening they received.

Results: A total of 3371 patients were identified to have undergone kyphoplasty to treat a VCF for the first time. To our knowledge, this is the largest study of its kind to date. Among these patients, 71.3% never had a DEXA scan or prior medical treatment for osteoporosis within 2 years before their kyphoplasty procedure. Additionally, 56.1% of all patients with VCFs treated with kyphoplasty for the first time were never screened or treated for osteoporosis in the two years preceding and 1 year following the procedure.

Conclusion: Our results suggest that only 15.2% of patients with a vertebral fragility fracture secondary to decreased bone density are screened and treated for osteoporosis. Despite existing guidelines recommending osteoporosis evaluation and treatment for patients with VCFs, our findings highlight missed opportunities for intervention. Improving the implementation of existing screening protocols and increasing awareness among healthcare providers could reduce VCF-associated morbidity and mortality.

Background: Hip fractures are common in older adults and are associated with significant morbidity and mortality. Surgical fixation with intramedullary devices, such as proximal femoral nails (PFN), is a common treatment method. However, complications such as implant cut-out remain a challenge despite advancements in implant designs. The objective of this study was to evaluate the clinical experience with different PFN designs and lag screws and to compare implant cut-out rates. Additionally, the study aimed to identify the most important factors that could prevent complications and predict cut-out. Methods: This retrospective study included 145 patients with trochanteric fractures who had undergone surgical treatment with PFN devices between January 2015 and December 2018. Patients younger than 65 years, those with pathological fractures, ipsilateral pelvic and knee fractures, subtrochanteric fractures, and multiple traumas were excluded. Radiographs were evaluated to determine osteoporosis, fracture type, implant type, fracture reduction quality, early and late neck shaft angle (NSA), lag screw position in the femoral head, tip-apex distance (TAD), and cut-out. Fractures were classified according to the AO/OTA classification system, and the quality of fracture reduction was assessed using the Baumgaertner classification. The Cleveland method was used to record the location of the screw/blade within the head. Results: The study compared the implant features of four different PFN devices, including Double lag screw PFN, Wedge wing lag screw PFN nail, Helical blade PFN, and Integrated Dual Screw PFN. The statistical analysis indicated that early and late NSA, TAD, Reduction quality of fracture, Cleveland index, and the difference between PFN types were risk factors for Cut-out. (P ≤ .001). Patients with helical blade PFN had a significantly higher rate of cut-out compared to other PFN devices. Univariate and multivariate regression analyses identified the Cleveland Index, fracture reduction quality (P ≤ .001), TAD, and early and late NSA as significant predictors for cut-out complications (P ≤ .001). Patients with poor Cleveland Index, poor fracture reduction quality, low TAD, and low NSA had a higher risk of cut-out (P ≤ .001). Conclusion: In conclusion, careful consideration of patient and surgical factors, including implant design and placement, is crucial in minimizing the risk of complications such as cut-out.

Background: This study aimed to investigate the effect of omitting a distal locking screw in intramedullary nailing of stable intertrochanteric femur fractures on clinical outcomes.

Methods: Ninety-six patients over 65 years old with stable pertrochanteric fractures (AO/OTA 31-A1 and A2) treated with short/intermediate proximal femoral nails (PFNA-II) were randomly assigned into two groups: Group 1 (distal locked) and Group 2 (distal unlocked). Comparative analyses were conducted on operative time, total fluoroscopy time, blood loss, incision length, complications, and functional outcomes.

Results: The mean operative time was significantly shorter in Group 2 (35.73 ± 7.62 minutes) compared to Group 1 (47.40 ± 9.96 minutes) (P < 0.001). Fluoroscopy time was also shorter in Group 2 (45.92 ± 6.08 seconds) compared to Group 1 (54.02 ± 5.94 seconds) (P < 0.001). Incision length was reduced in Group 2 (9.21 ± 1.41 centimeters) compared to Group 1 (12.96 ± 1.68 centimeters) (P < 0.001). Blood loss was lower in Group 2 (187.50 ± 32.00 milliliters) than in Group 1 (208.65 ± 49.12 milliliters) (P < 0.05). There were no significant differences between the groups in fracture union time, hospital stay, fracture union weeks, or postoperative blood transfusion rates.

Conclusions: Proximal femoral nailing without distal locking offers shorter operative times, reduced fluoroscopy exposure, and lower blood loss and complications, making it a viable option for treating stable intertrochanteric fractures.

Background: Patients with geriatric neck of femur (NOF) fractures often have multiple medical conditions and compromised baseline nutrition, impacting arthroplasty outcomes. Indicators like BMI, albumin, hemoglobin, urea, creatinine, CRP, and HbA1c influence nutritional status and postoperative results. This study evaluates the impact of preoperative nutrition on surgical outcomes, including postoperative complications, mobility, and pain scores in geriatric femoral neck fractures.

Methods: A retrospective study of 141 geriatric patients with NOF fractures admitted to Kuala Lumpur General Hospital between 2022-2023, treated operatively, was conducted. Associations of age, gender, ethnicity, BMI, education, smoking status, comorbidity, pre-fracture mobility, American Society of Anesthesiologists (ASA) level, and perioperative nutritional parameters with post-surgical complications, mobility, and WOMAC scores 1-year post-surgery were analyzed using logistic regression.

Results: Higher BMI (AOR = 1.21, 95% CI: 1.07-1.42, P = 0.03) and ASA levels ≥2 (AOR = 2.53, 95% CI: 1.30-4.91, P = 0.01) were significant predictors of post-surgical complications. Abnormal hematological variables, including hemoglobin (AOR = 1.78, 95% CI: 1.45-2.45, P < 0.001), urea (AOR = 1.35, 95% CI: 1.15-1.60, P = 0.002), creatinine (AOR = 1.20, 95% CI: 1.00-1.52, P = 0.04), and HbA1c (AOR = 1.40, 95% CI: 1.25-1.67, P = 0.004), were also associated with complications. BMI (AOR = 1.12, 95% CI: 1.06-1.30, P = 0.049) and abnormal hematological variables, including hemoglobin (AOR = 1.99, 95% CI: 1.05-2.70, P = 0.003), urea (AOR = 1.58, 95% CI: 1.06-1.95, P = 0.006), creatinine (AOR = 1.21, 95% CI: 1.09-1.38, P = 0.048), and HbA1c (AOR = 1.98, 95% CI: 1.25-2.57, P = 0.002), were significant predictors of reduced post-surgical mobility. No significant factors were associated with WOMAC scores at 1 year.

Conclusion: Preoperative nutritional status significantly impacts outcomes in geriatric patients undergoing arthroplasty for femoral neck fractures. Comprehensive preoperative nutritional assessments are essential for improving postoperative outcomes.