Mid-term follow-up after surgical treatment of fragility fractures of the pelvis

IntroductionEarly operative treatment of fragility fractures of the pelvis (FFP) has been suggested to reduce pain and allow for earlier mobilization. The aim of this study was to determine mortality and functional outcome after operative treatment.Patients and methodsPatients aged ≥60 years (n = 60; mean age 79 years, 53 female) who had operative treatment of a FFP and a follow-up of at least 2 years were identified and mortality was assessed using a national social insurance database. Those who had survived were contacted by phone and a modified Majeed Score was obtained.ResultsAt final follow up (62 months, range, 29–117), 32 patients (53.3%) had deceased. One-year-mortality rate was 28.3% and 2-year mortality was 36.7%. Mortality was not linked to fracture type (p > .05). Complications during hospitalization occurred in 26/60 patients (43.3%). Patients with a bilateral FFP had a longer hospitalization (18 vs. 11 days; p = .021). The mean modified Majeed score of surviving patients was 65 points (85.5% of achievable maximum).ConclusionMortality and in-hospital complications remain high among patients with FFP even when treated operatively. A longer hospitalization can be expected in patients with posterior bilateral fractures.     

A prospective trial comparing operative and manipulative treatment of ankle fractures

A series of 42 ankle fractures have been randomised into two groups respectively undergoing either open reduction and internal fixation or manipulative reduction and plaster. Their progress after removal of all external splintage has been followed using simple gait analysis techniques. There appears to be no difference in the outcome of treatment of the two groups in the early recovery period (up to 20 weeks).     

In-screw polymethylmethacrylate-augmented sacroiliac screw for the treatment of fragility fractures of the pelvis: a prospective,observational study with 1-year follow-up

Background

The incidence of pelvic ring fractures in the elderly significantly increased. Because of persistent pain and immobilization associated with this injury, surgical treatment is recommended. To minimise comorbidities and surgical risk, percutaneous techniques are becoming more relevant. In-screw cement augmentation of sacroiliac screw fixation is a promising procedure; however, clinical follow-up data remain scarce. This study investigated the safety and possible complications of the procedure along with a 1-year follow-up.

Methods

Thirty-four patients (treated with 43 screws) were prospectively included. Data on patients’ age and sex, the mechanism of accident, fracture pattern, duration of hospital stay, surgery and adverse events were recorded. Data were obtained postoperatively on the reduction of pain and complications, such as infection, cement leakage and neurological deficits, and at 1-year follow-up on pain, quality of life according to the 12-Item Short Form Survey and mobility. Implant failure was defined as retraction or dislocation of screws and was also documented.

Results

Screw-related complications occurred with 2 of 43 screws. None of these complications were related to cement augmentation. In-hospital adverse events occurred in 6 of 34 patients. Postoperative pain, measured by the visual analogue scale, was significantly reduced from 6.7?±?1.4 preoperatively to 2.7?±?1.0 postoperatively (p?<?0.001). Although patients complained of pain at the 1-year follow-up, they reported a significant decline compared with pain at admission (3.4?±?2.3; p?<?0.001). Results on the quality of life were comparable with those for the age- and gender matched German population. All patients were mobile, and no implant failure was detected.

Conclusions

The results indicate that in-screw augmented sacroiliac screw fixation for fragility fractures of the pelvis is a safe technique. Pain was significantly reduced immediately after surgery compared to the preoperative state. Furthermore, significant pain reduction after one year compared to the preoperative state and quality of life was comparable to the age- and gender- matched German population. Thus, we recommend in-screw augmentation for screw fixation for sacral fragility fractures of the pelvis following failed conservative treatment.

     

A prospective multi-center cohort study of acute non-displaced fractures of the scaphoid: operative versus non-operative treatment [NCT00205985]

Background  

Acute scaphoid fractures are common in active adults and do lead to reasonable time lost to work. One important goal of treatment is early return to work or sport. On this background, the adequate treatment of non-displaced acute scaphoid fractures is still under discussion. The aim of this study is to compare time to return to previous activity level comparing surgical versus non-surgical treatment of non-displaced acute scaphoid fractures.     

Outcomes following operative and non-operative management of humeral midshaft fractures: a prospective,observational cohort study of 47 patients

Background  

Although the non-operative management of closed humeral midshaft fractures has been advocated for years, the increasing popularity of operative intervention has left the optimal treatment choice unclear.     

Comparison of outcomes of operative versus non-operative treatment of acetabular fractures in the elderly and severely comorbid patient

Background

Acetabular fractures in the elderly and severely comorbid patient can be associated with high morbidity and mortality; however, differences in outcomes of acute ORIF versus non-operative care of acetabular fractures in a subgroup of elderly (>75 years) and/or severely comorbid younger patients (>65) remain unclear.

Patients and methods

A retrospective review of 243 patients who sustained an acetabular fracture between April 2005 and November 2014 was performed. Eighty-seven patients met inclusion criteria: age > 75 with or without comorbidities or age > 65 if complicated by two or more medical comorbidities. Outcomes measures evaluated were 1-year mortality, duration of hospital stay, return to pre-injury ambulation status and treatment failure marked by conversion to a total hip arthroplasty (THA) within 1 year of treatment.

Results

Thirty-seven patients with acetabular fractures were treated with surgical fixation, and 49 were treated non-operatively. Operative patients did not demonstrate a statistically significant difference in mortality within 1 year of treatment compared to non-operatively treated patients. Operative patients demonstrated a statistically significant increase in treatment failure marked by a conversion to a THA within 1 year when compared to conservatively treated patients. No differences in age, duration of follow-up, or ability to return to baseline at latest clinical follow-up were found between groups. However, non-operatively treated patients had a higher incidence of Alzheimer’s disease/Dementia and Parkinson’s compared to operatively treated patients.

Conclusion

Analysis of our small cohort suggests that there may be a role for the non-operative treatment of acetabular fractures in this debilitated patient population despite a somewhat longer length of hospital stay at the time of injury. Conversion to THA was significantly higher at 1 year in our operated patients. No differences in mortality at 1 year were noted between patient groups. Return to baseline ambulation status was slightly higher in the non-operated group but not significantly so. However, a potential bias to more likely treat complex fractures operatively cannot be ruled out, as non-operative fractures were most often anterior column variants, usually more amenable to non-operative care.

Level of evidence

Prognostic Level III.

     

Fracture of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative treatment

We compared the long-term outcome in 61 patients (62 fractures) treated operatively or conservatively for an acute fracture of the carpal scaphoid. A total of 30 fractures was randomised to conservative treatment using a cast and 32 to operative treatment using a Herbert bone screw. The duration of sick leave was shorter for patients treated by operation, but this was only significant in patients with blue-collar occupations. There were no differences between the groups in respect of function, radiological healing of the fracture, or carpal arthritis after follow-up at 12 years. Those managed by operation showed radiological signs of arthritis of the scaphotrapezial joint more often, but this finding did not correlate with subjective symptoms. Operative treatment of an acute fracture of the scaphoid allows early return of function and should be regarded as an alternative to conservative treatment in patients in whom immobilisation in a cast for three months is not acceptable for reasons related to sports, social life or work.     

Achilles tendon gait dynamics after rupture: A three-armed randomized controlled trial comparing an individualized treatment algorithm vs. operative or non-operative treatment

BackgroundIndividual treatment selection has been proposed as the key to optimized treatment. The purpose was to investigate if treatment selection using the individualized treatment algorithm Copenhagen Achilles Rupture Treatment Algorithm (CARTA) differs between patients treated as usual regarding gait dynamics and tendon elongation.MethodsThe patients were randomized to one of three parallel groups: 1) intervention group: participants treated according to CARTA, 2) control group: participants treated non-operatively, 3) control group: participants treated operatively. The primary outcome was ankle peak power during push off during walking at 12 months.Results156 patients were assessed for eligibility. 21 were allocated to the intervention group, and 20 and 19 to the control groups. The results indicated no statistically significant differences between the intervention group and the control groups.ConclusionsIndividualized treatment selection based on CARTA did not demonstrate less affected gait dynamics or less tendon elongation than patients treated as usual.     

Results of non-operative and operative treatment of humeral shaft fractures. A series of 104 cases

The aim of this study was to examine the results of different modalities applied in the treatment of 104 fresh diaphyseal fractures of the adult humerus treated in the department between January 1994 and March 1997. These results were classified according to the criteria described by Stewart and Hundley. 32 patients (30.8%) were treated non-operatively using a sling and a moulded plaster splint. The type of treatment had to be changed in 12 of these patients due to 14 different complications that occurred during the course of non-operative treatment. Thus, 20 patients (62.5%) underwent non-operative treatment until fracture-union. The results in this group were: very good in 12 cases (60%), good in 5 cases (25%), fair in 3 cases (15%). 28 fractures were treated using plates and screws. 4 events (14%) occurred during in the post-operative period and, apart from 2 cases of non-union, the overall result in the 26 patients in whom the fracture united was: very good in 23 cases (88.5%) and good in 3 cases (11.5%). 22 patients (21.1%) underwent fixation using multiple flexible intramedullary wires via a supracondylar approach. Apart from one case of non-union, the final result in the 21 patients in whom the fracture united was: very good in 9 cases (42.8%), good in 9 cases (42.8%), fair in 2 cases (9.5%) and poor in 1 case (4.9%). 22 fractures were treated using an intramedullary Seidel nail. The final result in these patients was: very good in 11 cases (50%), good in 9 cases (41%) and poor in 2 cases (9%). The indications for treatment should be eclectic. Non-operative treatment remains the method of choice for undisplaced or minimally-displaced fractures or comminuted fractures with multiple parallel longitudinal fracture-lines over the middle-third, while surgical treatment is considered for displaced fractures and essentially depends upon the type and level of the fracture. Transverse and short oblique fractures are treated using a plate or a Seidel nail. Fractures with a third fragment require plate osteosynthesis. Multiple flexible intramedullary wires are used for segmental fractures or for diaphyseal fractures associated with fractures of the neck of the humerus. Comminuted fractures are realigned using an intramedullary Seidel nail or multiple flexible wires. As far as the site of fracture is concerned, those of the proximal and middle thirds of the humerus are well treated using an intramedullary nail or multiple wires or with a plate, while plating is most often the method of choice for fractures of the distal-third.     

Outcomes of elderly patients with proximal femoral fractures according to positive criteria for surgical treatment

Proximal femoral fractures in elderly patients are a serious problem in the aging society. Recently, surgical indications have changed due to advancements in medical technology. The purpose of this study was to investigate the outcome of elderly patients with displaced proximal hip fractures according to our positive criteria for surgical treatment. Exclusion criteria included (1) terminal-stage malignancy; (2) a combination of an inability to walk, a severe mental disorder, and caregiver refusal of surgery; and (3) nonapproval of the anesthesiologist for surgery. The study group comprised 666 elderly patients. They were categorized into surgically and nonsurgically treated groups, and their treatment outcomes were retrospectively analyzed. The majority of patients were treated surgically (97.0% vs 3.0%). One-year survival rate was higher among surgically treated patients (82.2%-91.8%) than non-surgically treated patients (55%). The major cause of death in nonsurgically treated patients was deterioration of comorbidities (66.7%), whereas this was the cause of death in 18.9% of surgically treated patients. One-year survival rates were worse in both groups with a lower American Society of Anesthesiologists grade. The 1-year survival rate of our patients suggests that our surgical criteria offer a reasonable outcome in surgically and nonsurgically treated patients. American Society of Anesthesiologists grade and preexisting comorbidities were strongly correlated with patient outcome.     

Ankle fractures. Supination-eversion fractures stage II. Primary and late results of operative and non-operative treatment

Sixty-nine patients with stage II supination-eversion fractures of the ankle, 34 treated by operation and 35 treated conservatively, were seen at follow-up after 3-10 years. There was no statistically significant differnce between the results of the two methods. However, larger series and perhaps a longer observation time are probably needed to decide whether the displacement of the lateral malleolus as a result of non-operative treatment affords the same possibility of unhindered ankle function as union of the lateral malleolus in the anatomical position obtained by operation.     

经皮球囊扩张后凸成形术治疗老年椎体压缩骨折的随访研究

[目的]探讨经皮球囊扩张后凸成形术治疗老年骨质疏松性椎体压缩骨折的手术效果和患者术后的生活质量.[方法]采用经皮球囊扩张后凸成形术治疗老年椎体压缩骨折病例105例.测量术前、术后3d、术后3个月和随访结束时的椎体高度;术前、术后3d、术后3个月和随访结束时对患者腰痛行VAS评分,术前、术后3个月和随访结束时对患者进行ODI评分.[结果]91例患者获随访,随访时间13 ～ 50个月,平均33.2个月.患者术前椎体平均高度为(1.45 ±0.28) cm,术后3d复查X线片测量的椎体平均高度为(1.75 ±0.23) cm,术后3个月时椎体平均高度(1.75±0.23) cm,随访结束时患者椎体平均高度为(1.74±0.24) cm.术前VAS评分为(7.53±0.68),术后3d为(2.69 ±0.49),术后3个月为(1.02±0.33),随访结束时为(1.01±0.39).术前ODI评分为(77.85 ±3.53),术后3个月为(28.67 ±5.85),随访结束时为(21.33±3.47).术前、术后的椎体高度,VAS评分,ODI评分差别有统计学意义(P＜0.01).[结论]经皮球囊扩张后凸成形术治疗老年骨质疏松性椎体压缩骨折能部分恢复椎体高度,针对压缩骨折带来的腰痛有良好的治疗效果,明显改善了患者的生活质量.     

A prospective cost analysis following operative treatment of unstable ankle fractures: 30 patients followed for 1 year

BACKGROUND: Ankle fractures remain one of the commonest injuries requiring operation. Quality of life and the overall costs associated with the treatment of such injuries are rarely reported. We did a pilot study to determine the cost of treating patients operatively with unstable ankle fractures and to measure the patients' quality of life (utility scores) over time. PATIENTS AND METHODS: 30 patients (17 men) were eligible and included in the study. They were on the average 52 (18-81) years old. All patients had type B Weber fractures (OTA 44B). RESULTS: The mean utility score from the Health Utilities Index immediately after surgery was 0.4. At 12 months follow-up, this score had increased to 0.78. The cost was, on average, USD 2,143 per patient. INTERPRETATION: Our findings indicate that patients operated on for ankle fractures had significant gains in health at an acceptable cost. These results provide data for studies of larger sample size.     

Progress of instability in fragility fractures of the pelvis: An observational study

Fragility fractures of the pelvis (FFP) are an increasing entity among elderly persons. Characteristics are different from high-energy pelvic trauma. Little is known about the natural course of FFP in conservative and after operative treatment.Materials and methodsMedical charts and radiologic data of 148 patients with an FFP, who were admitted in a 3-year period, were analysed retrospectively. Incidence and characteristics of fracture progression (FP) were noted.ResultsPatients presenting early after a traumatic event had more often non-displaced fractures, fractures with lower FFP Type classification and were more frequently treated conservatively. FP was observed in 21 cases (14.2%), twenty times after conservative and once after operative treatment. FP under conservative treatment occurred in female patients only. Patients with FP were younger than patients without. FP occurred in all fracture types, most frequently in FFP Type I. A second CT scan was positive for FP in 39.2% of patients with prolonged pain or restricted mobility.ConclusionFP is a real phenomenon, occurring in a minority of FFP patients. Female patients are at highest risk. Repeated CT scan is positive in nearly 40% of patients with continuing pain or restricted mobility. Operative treatment is a good preventive measure of FP as FP does only exceptionally occur after operative fixation of FFP.     

Long-term prospective study of osteoporotic patients treated with percutaneous vertebroplasty after fragility fractures

Summary  

This paper presents a prospective study on factors that could influence fracture risk after percutaneous vertebroplasty (PVP) in 115 osteoporotic patients. The mean follow-up was 39 months. The incidence of new fractures after PVP was 27.8%. Low body mass index (BMI), bone mineral density (BMD), and vitamin D are factors associated with increased risk of new fractures.     

Cervical spine fractures in the elderly: morbidity and mortality after operative treatment

Purpose

Although there are currently many different strategies and recommendations in the therapy of cervical spine fractures in elderly patients, there are still no generally accepted treatment algorithms. The aim of the present study was to analyze the morbidity, mortality, and outcome of operated cervical spine injuries in the elderly.

Methods

This study presents a retrospective review of 69 patients aged 65 years or older admitted to our level I trauma center with cervical spine injury, who had undergone surgical treatment. The data were acquired by analysis of the hospital inpatient enquiry system and radiological review.

Results

The ratio between male and female patients was 37:32. The average age of the patients was 76 years (ranging from 65 to 96 years) for males and 80 years (ranging from 66 to 93 years) for females. Injury to the cervical spine was caused by low-energy trauma in 71 % and high-energy trauma in 29 %, respectively. 55.1 % sustained isolated cervical spine injuries, 39.1 % injuries to two adjacent vertebrae, 2.9 % injuries to three adjacent vertebrae, and 2.9 % an odontoid fracture combined with associated fracture(s) in non-contiguous vertebra(e). Isolated spine injury level was dominated by C2 (47.8 %). The most common site for injuries to two adjacent vertebrae was observed at C6/C7 (14.5 %). The morbidity included cerebral complications, respiratory complications, Clostridium difficile-associated disease, heart failure, and acute renal failure. Operative complications included dislocation/malposition, neurovascular lesions, wound infection, and transient swallowing difficulty. The mortality rate at 3 months was 26.1 %, with an in-hospital mortality of 21.7 %. Age was associated with mortality at 3 months. A cervical fracture-induced neurological deficit was documented in 26.1 %, resulting in a mortality of 44.4 % (8/18). Twenty-seven of 33 patients living at home/nursing home at the time of injury returned to their home/nursing home after their hospitalization. The overall outcome was predominantly related to age and the severity of neurological deficit.

Conclusions

In elderly patients with cervical spine fractures, the hospital course is complicated by medical issues and early mortality rates are significant. Therefore, treatment strategies should be carefully individualized to the patients and their comorbidities.     

Results after operative treatment of intra-articular calcaneal fractures with a minimum follow-up of 2 years

Thirty-one patients with 33 displaced intra-articular fractures of the calcaneus were treated with open reduction and internal fixation in our hospital between 1989 and 1995. The fractures were classified according to the CT-classification of Crosby [Crosby, L. A. and Fitzgibbons, T., Computerized tomography scanning of acute intra-articular fractures of the calcaneus. The Journal of Bone and Joint Surgery, 1990, 72A, 852-859] and Hannover [Zwipp, H. and Tscherne, H. et al., Osteosynthesis dislozierter intraartikul?rer calcaneusfrakturen. Unfallchirurg, 1988, 91, 507-515]. The minimal follow-up was 2 years. Functional results were assessed at 6 and 12 months and in February 1997 using the Creighton calcaneal score. Overall results improved during follow-up, especially in the first year. At the final control the overall results were: excellent/good 73%, fair 21% and poor 6%. The results are comparable with larger series in the literature. The average range of motion in the subtalar joint was 65% of normal. No correlation was found between clinical outcome and the subtalar range of motion. Two patients received a secondary arthrodesis for painful arthrosis.     

早期小切口重建钉内固定治疗老年股骨粗隆间骨折

目的探讨股骨重建钉治疗老年股骨粗隆间骨折的疗效。方法2001年6月~2005年10月,采用闭合复位小切口股骨重建钉固定治疗老年股骨粗隆间骨折患者58例,均在伤后1周内施行手术,手术采用C型臂X线机透视下闭合复位,小切口将股骨重建钉置入,观察术后疗效并对该治疗方法进行评价。结果58例术后随访8~22个月,平均13.6个月。3例术后3个月股骨颈拉力钉脱出(行钉道充填骨水泥后重新固定),1例发生骨化性肌炎,2例发生髋内翻,无心、脑栓塞和坠积性肺炎发生;58例骨折均愈合,骨折愈合时间(15±5)周;按黄公怡评价标准,术后髋关节功能恢复优良率达91.6%。结论闭合复位小切口股骨重建钉固定治疗股骨粗隆间骨折,具有手术时间短、出血少且固定牢靠的优点,适用于老年股骨粗隆间骨折的治疗。     

Fractures of the femoral neck. A follow-up study after non-operative treatment of Garden's stage 1 and 2 fractures

Garden's stages and alignment index were applied on a series of 128 patients with femoral neck fractures either undisplaced or displaced into valgus. The displacement rates in stage 1 and 2 were respectively 11 and 61 per cent. There were significantly more displacements among patients in whom weight bearing was not allowed.