Clinical outcome of open ankle fractures in patients above 70 years of age

BACKGROUND Open fractures of the ankle are complex injuries requiring multidisciplinary input and are associated with significant morbidity and mortality.However,data on the clinical outcomes of open ankle fracture management in patients older than 70 is minimal.AIM To evaluate the clinical outcomes following open ankle fracture management in patients older than 70.Our secondary aim is to look at predictors of poor outcomes.METHODS Following local research and audit department registration,22 years of prospectively collated data from an electronic database in a district general hospital were assessed.All patients older than 70 years of age with an open ankle fracture requiring surgical intervention were identified.Demographic information,the nature,and the number of surgical interventions were collated.Complications,including surgical site infection(SSI),venous thromboembolic events(VTEs)during hospital stay,and mortality rate,were reviewed.RESULTS A total of 37 patients were identified(median age:84 years,range:70-98);n=30 females median age:84 years,range:70-97);n=7 males median age:74 years,range:71-98))who underwent surgical intervention after an open ankle fracture.Sixteen patients developed SSIs(43%).Superficial SSIs(n=8)were managed without surgical intervention and treated with antibiotics and regular dressing changes.Deep SSIs(n=8;20%)required a median of 3(range:2-9)surgical interventions,with four patients requiring multiple washouts and one patient having metalwork removed.VTE incidence was 5%during the hospital stay.Eight patients died within 30 d,and mortality at one year was 19%.The 10-year mortality rate was 57%.The presence of a history of stroke,cancer,or prolonged inpatient stay was found to be predictive of lower survivorship in this population(log-rank test:cancer P=0.008,stroke P=0.001,length of stay>33 d P=0.015).The presence of a cardiac history was predictive of wound complications(logistic regression,P=0.045).Age,number of operations,and diabetic history were found to be predictive of an increase in the length of stay(general linear model;age P<0.001,number of operations P<0.001,diabetes P=0.041).CONCLUSION An open ankle fracture in a patient older than 70 years has at least a 20%chance of requiring repeated surgical intervention due to deep SSIs.The presence of a cardiac history appears to be the main predictor for wound complications.

Managements of osteoporotic vertebral compression fractures:A narrative review

Osteoporotic vertebral compression fractures(OVCFs)are the most common fragility fracture and significantly influence the quality of life in the elderly.Currently,the literature lacks a comprehensive narrative review of the management of OVCFs.The purpose of this study is to review background information,diagnosis,and surgical and non-surgical management of the OVCFs.A comprehensive search of PubMed and Google Scholar for articles in the English language between 1980 and 2021 was performed.Combinations of the following terms were used:compression fractures,vertebral compression fractures,osteoporosis,osteoporotic compression fractures,vertebroplasty,kyphoplasty,bisphosphonates,calcitonin,and osteoporosis treatments.Additional articles were also included by examining the reference list of articles found in the search.OVCFs,especially those that occur over long periods,can be asymptomatic.Symptoms of acute OVCFs include pain localized to the mid-line spine,a loss in height,and decreased mobility.The primary treatment regimens are pain control,medication management,vertebral augmentation,and anterior or posterior decompression and reconstructions.Pain control can be achieved with acetaminophen or nonsteroidal anti-inflammatory drugs for mild pain or opioids and/or calcitonin for moderate to severe pain.Bisphosphonates and denosumab are the first-line treatments for osteoporosis.Vertebroplasty and kyphoplasty are reserved for patients who have not found symptomatic relief through conservative methods and are effective in achieving pain relief.Vertebroplasty is less technical and cheaper than kyphoplasty but could have more complications.Calcium and vitamin D supplementation can have a protective and therapeutic effect.Management of OVCFs must be combined with multiple approaches.Appropriate exercises and activity modification are important in fracture prevention.Medication with different mechanisms of action is a critical long-term causal treatment strategy.The minimally invasive surgical interventions such as vertebroplasty and kyphoplasty are reserved for patients not responsive to conservative therapy and are recognized as efficient stopgap treatment methods.Posterior decompression and fixation or Anterior decompression and reconstruction may be required if neurological deficits are present.The detailed pathogenesis and related targeted treatment options still need to be developed for better clinical outcomes.

Bone mineral density in fracture neck of femur patients:What's the significance?

BACKGROUND The National Institute for Health and Care Excellence(NICE)guidelines have advised further research is required into investigating the added prognostic value of bone mineral density(BMD)in the assessment of fracture risk with the Fracture Risk Assessment Tool(FRAX)score.AIM To investigate the significance of BMD in fracture neck of femur patients and compare it to the outcome of the FRAX score.METHODS Inclusion criteria for this study were all patients who underwent dual-energy Xray absorptiometry(DXA)scan following fracture neck of femur between 2015 and 2017.Analysis of BMD,FRAX scores and patient demographic data was undertaken.RESULTS A total of 69 patients were included in the study,mean age 74.1 years.There was no significant difference between mean BMD of the femoral neck in males(0.65)as compared to females(0.61)(P=0.364).Analyses showed no significant correlation between BMD and menopause age(rs=-0.28,P=0.090).A significant difference was seen of the femoral neck BMD between the different fracture pattern types(P=0.026).A stronger correlation was observed between BMD of femoral neck and FRAX major score(rs=-0.64,P<0.001)than with BMD of lumbar spine and FRAX major score(rs=-0.37,P=0.003).CONCLUSION This study demonstrated that BMD of the femoral neck measured by DXA scan is of added prognostic value when assessing patients for risk of fracture neck of femur in combination with the FRAX predictive scoring system.

Hospitalizations for Osteoporosis-Related Fractures: Analysis from Eastern Saudi Arabia

Background and Objectives: Osteoporosis causes fragility fractures which increase the morbidity and mortality in the elderly. Our objective was to look at the hospital admissions due to fragility fractures and site of fractures. Methods: This is a retrospective study of a 2-year period (2017-2018), in which we evaluated all the admissions of fragility fractures at King Fahd Hospital of the University, Al Khobar, Saudi Arabia. A Fragility Fracture is a fracture which occurs in patients with low bone mass due to a fall from a standing height. The data were gathered from the Quadru Med patient care system for patients over the age of 50 years: sex, site of fracture, previous fractures, and treatment meted out. The hospitalization rate for fragility fractures was calculated by taking into consideration of all the adult admissions to the orthopaedic department. Ethical approval was obtained from the Institutional Review Board of the Hospital and the Imam Abdul Rahman Bin Faisal University, Dammam. Results: During the study period 187 patients with fragility fractures were admitted. The mean age was 68.55 ± 12.43 years;fracture femur was the most common with 136 (72.7%), tibia 15 (8%) and spine 14 (7.5%). At the time of discharge based on the T score of spine 50 were osteopenic and 45 were osteoporotic. Overall adult admission for the study period was 1410 patients and 13.26% were patients with fragility fractures. There were 3 (1.6%) deaths within the first 30 days in the hospital. Conclusions: Fracture femur was the most common fragility fracture seen in our study. Orthopaedic surgeons should be ready to treat all fragility fractures and treat osteoporosis appropriately so that a second fracture is prevented.

Micro-computed tomography assessment of human femoral trabecular bone for two disease groups(fragility fracture and coxarthrosis):Age and gender related effects on the microstructure

The aim of this study was to identify three-dimensional microstructural changes of trabecular bone with age and gender, using micro-computed tomography. Human trabecular bone from two disease groups, osteoporosis and osteoarthritis was analyzed. A prior analysis of the effects of some procedure variables on the micro-CT results was performed. Preliminary micro-CT scans were performed with three voxel resolutions and two acquisition conditions. On the reconstruction step, the image segmentation was performed with three different threshold values. Samples were collected from patients, with coxarthrosis (osteoarthritis) or fragility fracture (osteoporosis). The specimens of the coxarthrosis group include twenty females and fifteen males, while the fragility fracture group was composed by twenty three females and seven males. The mean age of the population was 69 ± 11 (females) and 67 ± 10 years (males), in the coxarthrosis group, while in the fragility fracture group was 81 ± 6 (females) and 78 ± 6 (males) years. The 30 μm voxel size provided lower percentage difference for the microarchitecture parameters. Acquisition conditions with 160 μA and 60 kV permit the evaluation of all the volume’s sample, with low average values of the coefficients of variation of the microstructural parameters. No statistically significant differences were found between the two diseases groups, neither between genders. However, with aging, there is a decrease of bone volume fraction, trabecular number and fractal dimension, and an increase of structural model index and trabecular separation, for both disease groups and genders. The parameters bone specific surface, trabecular thickness and degree of anisotropy have different behaviors with age, depending on the type of disease. While in coxarthrosis patients, trabecular thickness increases with age, in the fragility fracture group, there is a decrease of trabecular thickness with increasing age. Our findings indicate that disease, age and gender do not provide significant differences in trabecular microstructure. With aging, some parameters exhibit different trends which are possibly related to different mechanisms for different diseases.

Total hip arthroplasty following the failure of intertrochanteric nailing:First implant or salvage surgery?

BACKGROUND Proximal femur fractures,including both intracapsular(femoral neck fractures)and extracapsular fractures(intertrochanteric femoral fractures,IFFs),affect around 1.5 million people per year worldwide.Mechanical failures of intertrochanteric nailing in IFFs could be managed with revision total hip arthroplasty(THA).AIM To describe the surgical complexity and the procedure-related complication rates in patients with trochanteric nailing failure and treated with THA.METHODS Patients referred to our level I trauma center between April 2012 and July 2018 with failed cephalomedullary nailing following trochanteric fractures were retrospectively recruited.All patients underwent a salvage surgical procedure,i.e.,cephalomedullary nail removal and conversion to THA.The same surgical and anesthesiology team performed the surgical procedures under spinal anesthesia.All patients underwent clinical and radiographic follow-ups for at least 24 mo.Complications and re-operations were recorded.RESULTS Seventy-four patients met the inclusion criteria(male:29;female:45;mean age:73.8-years-old;range:65-89)and were included in the current study.The average operative time was 117 min(76-192 min).The average blood loss was 585 mL(430-1720 mL).Among the 74 patients,43(58.1%)required transfusion of three or more blood units.Two patients died within the 4th d after surgery because of pulmonary embolism,and 1 patient died 9 mo after surgery due to ischemic myocardial infarction.The complication rate in the 71 patients who completed the minimum 24-mo follow-up was 22.5%.In 3 cases out of 71(4.2%)periprosthetic acetabular fracture was observed during the followup.One of these periacetabular fractures occurred intraoperatively.An intraoperative periprosthetic femur fracture was observed in 5 patients out of 71(7.0%).Four of these patients needed a re-operation to fix the fracture with plates and cerclages;in one of these patients,femoral stem revision was also necessary.In 4 patients out of 71(5.6%),an early THA dislocation was observed,whereas in 1 case(1.4%)a late THA dislocation was observed.Three patients out of 71(4.2%)developed a periprosthetic joint infection during the study follow-up.CONCLUSION The present study demonstrated that salvage options for IFF fixation failure are complex procedures with a relevant intraoperative and postoperative complication rate.

Managing osteoporosis in ulcerative colitis: Something new?

The authors revise the latest evidence in the literature regarding managing of osteoporosis in ulcerative colitis (UC), paying particular attention to the latest tendency of the research concerning the management of bone damage in the patient affected by UC. It is wise to assess vitamin D status in ulcerative colitis patients to recognize who is predisposed to low levels of vitamin D, whose deficiency has to be treated with oral or parenteral vitamin D supplementation. An adequate dietary calcium intake or supplementation and physical activity, if possible, should be guaranteed. Osteoporotic risk factors, such as smoking and excessive alcohol intake, must be avoided. Steroid has to be prescribed at the lowest possible dosage and for the shortest possible time. Moreover, conditions favoring falling have to been minimized, like carpets, low illumination, sedatives assumption, vitamin D deficiency. It is advisable to assess the fracture risk in all UC patient by the fracture assessment risk tool (FRAX® tool), that calculates the ten years risk of fracture for the population aged from 40 to 90 years in many countries of the world. A high risk value could indicate the necessity of treatment, whereas a low risk value suggests a follow-up only. An intermediate risk supports the decision to prescribe bone mineral density (BMD) assessment and a subsequent patient revaluation for treatment. Dual energy X-ray absorptiometry bone densitometry can be used not only for BMD measurement, but also to collect data about bone quality by the means of trabecular bone score and hip structural analysis assessment. These two indices could represent a method of interesting perspectives in evaluating bone status in patients affected by diseases like UC, which may present an impairment of bone quality as well as of bone quantity. In literature there is no strong evidence for instituting pharmacological therapy of bone impairment in UC patients for clinical indications other than those that are also applied to the patients with osteoporosis. Therefore, a reasonable advice is to consider pharmacological treatment for osteoporosis in those UC patients who already present fragility fractures, which bring a high risk of subsequent fractures. Therapy has also to be considered in patients with a high risk of fracture even if it did not yet happen, and particularly when they had long periods of corticosteroid therapy or cumulative high dosages. In patients without fragility fractures or steroid treatment, a medical decision about treatment could be guided by the FRAX tool to determine the intervention threshold. Among drugs for osteoporosis treatment, the bisphosphonates are the most studied ones, with the best and longest evidence of efficacy and safety. Despite this, several questions are still open, such as the duration of treatment, the necessity to discontinue it, the indication of therapy in young patients, particularly in those without previous fractures. Further, it has to be mentioned that a long-term bisphosphonates use in primary osteoporosis has been associated with an increased incidence of dramatic side-effects, even if uncommon, like osteonecrosis of the jaw and atypical sub-trochanteric and diaphyseal femoral fractures. UC is a long-lasting disease and the majority of patients is relatively young. In this scenario primary prevention of fragility fracture is the best cost-effective strategy. Vitamin D supplementation, adequate calcium intake, suitable physical activity (when possible), removing of risk factors for osteoporosis like smoking, and avoiding falling are the best medical acts.