To evaluate the current evidence in the literature on treatment strategies for degenerative lumbar spine fusion in patients with osteoporosis.
A systematic review of the literature from 1950 to 2015.
The review of the literature yielded 15 studies on the effect of treatment options for osteoporosis on lumbar fusion rates. This study evaluated only degenerative lumbar spine conditions and excluded deformity patients. One study demonstrated an association between low bone mass as measured by Hounsfield units and lower fusion rates. Six studies evaluated perioperative medical treatment of osteoporosis and showed higher fusion rates in patients treated with alendronate and teriparatide. The strongest evidence was for perioperative teriparatide. Eight studies evaluated surgical treatment strategies in patients with osteoporosis and showed that cement augmentation of pedicle screws and expandable pedicle screws demonstrated improved fusion rates than traditional pedicle screws. The strongest evidence was for expandable pedicle screws.
There are 15 articles evaluating osteoporosis in patients undergoing lumbar fusion and the highest level of evidence is for perioperative use of teriparatide.
The aim of this study was to investigate whether there was a difference in opioid usage during admission for hip fracture patients with continuous femoral nerve block (cFNB) when compared to patients nonfemoral nerve block (nFNB).
Patients were identified from the local database on all hip fracture patients admitted to Bispebjerg University Hospital, Denmark. Four hundred fifty-six hip fracture patients were included during the period September 2008 to October 2010.
Three hundred sixty-six hip fracture patients had cFNB. The mean time with cFNB was 3.4 days. There were no significant differences in gender, length of stay, time to surgery, mortality rate, in-hospital falls, or resurgery rates during admission between the 2 groups. The nFNB group had an insignificant higher use of morphine as needed during the first 5 days of admission (nFNB: 53.1 mg, 95% confidence interval [CI]: 34.4-71.7; cFNB: 47.7 mg, 95% CI: 40.7-64.3; P = .54) and during the whole admission (cFNB: 34.3 mg, 95% CI: 23.2-45.5; cFNB: 30.3 mg, 95% CI: 26.6-33.0; P = .4). Some 8.47% of the total morphine consumption during admission was morphine as needed for the nFNB group and 9.89% for the cFNB group.
Patients with cFNB did only have a marginally lower opioid usage during admission when compared to patients without the block, with no significance between the 2 groups. This could indicate that the cFNB is an ineffective analgesic strategy, especially in the postoperative period, but larger randomized studies are needed in order to clarify this.
To examine the prevalence and effect of cognitive impairment on treatment outcomes in elderly patients undergoing arthroplasty and to describe the feasibility of cognitive tests.
The participants were 52 patients with a mean age of 78 years 11 months (SD: 3.3), waiting for primary arthroplasty. We translated Montreal Cognitive Assessment (MoCA) into Finnish and compared it with Mini-Mental State Examination (MMSE), Mini-Cog, and clock-drawing tests prior to and 3 months after the surgery. The ability to perform activities of daily living, depression, quality of life, and years of education were evaluated.
The mean MoCA score on the first visit was 20.7 (SD: 4.1). The pre- and postoperative cognitive tests implied there were no changes in cognitive functioning. Unambiguous delirium was detected in 6 patients. Delirium was not systematically assessed and consequently hypoactive delirium cases were possibly missed. Both MMSE and Mini-Cog found 3/6 of those and clock drawing and MoCA 6/6. Low preoperative MoCA, MMSE, and Mini-Cog scores predicted follow-up treatment in health-care center hospitals (P = .02, .011, and .044, respectively). During the 5-year follow-up period, 11/52 patients died. Higher education was the only variable associated with survival. The survivors had attained the median of 8 (range: 4-19) years of education compared with 6 (range: 4-8) years among the deceased.
The prevalence of cognitive impairment among older patients presenting for arthroplasty is high and mostly undiagnosed. It is feasible to use the MoCA to identify cognitive impairment preoperatively in this group. The clock-drawing test was abnormal in all patients with postoperative delirium, which could be used as a screening test. Higher education predicted survival on a 5-year follow-up period.
Distal radius fractures account for nearly 1 of every 5 fractures in individuals aged 65 or older. Moreover, increased susceptibility to vertebral and hip fractures has been documented in patients a year after suffering a distal radius fracture. Although women are more susceptible to hip fractures, men experience a higher mortality rate in the 7 years following a distal radius fracture. Traditional approaches to distal radius fractures have included both surgical and nonsurgical treatments, with predominant complaints involving weakness, stiffness, and pain. Nonsurgical approaches include immobilization with or without reduction, whereas surgical treatments include dorsal spanning bridge plates, percutaneous pinning, external fixation, and volar plate fixation. The nature of the fracture will determine the best treatment option, and surgeons employ a multifactorial treatment approach that includes the patient’s age, nature of injury, joint involvement, and displacement among other factors. Historically, closed reduction and percutaneous pinning have been the most popular approaches. However, volar plate fixation is quickly becoming a popular option as it minimizes tendon irritation, reduces immobilization time, and decreases risk of complication. The goal of treatment is to restore mobility, reduce pain, and improve functional outcomes following rehabilitation. The aim of this review is to summarize the most common treatments and importance of early referral to hand therapy to improve functional outcomes.
To evaluate the efficacy of the use of retentive cup primary total hip replacement (THR) in high-dislocation risk subcapital fracture patients.
During the years 2008 to 2012, 354 patients with displaced subcapital fracture were operated at our institute. The patients were selected to undergo primary constrained THR according to the following criteria: (1) a preinjury grade 4 or more on the Functional Independence Measure mobility item "5. Locomotion: walking/wheelchair" and grade 4 is defined as "4. Minimal assistance Requiring incidental hands-on help only" (patient performs >75% of the task) and (2) a disease leading to poor motor control. Exclusion criteria were normal muscular control and known infection of the involved joint.
Of the 354 patients, 87 fulfilled the inclusion criteria and underwent constrained total hip. Average age was 78 years with a female predominance (73%). Fifteen patients had prior hemiparesis, 19 had Parkinson disease, and 35 had generalized sarcopenia. Eighty-five patients had an uneventful recovery, with an average Hip Disability and Osteoarthritis Outcome Score (HOOS) of 76 ± 7 at 2 years. In 2 patients, the prostheses dislocated. In both cases, the dislocation was due to ring displacement and the inner head dislocated. One case was infected and the patient was treated by a Girdlestone procedure. In the other case, the prosthetic head was revised. The patient remained asymptomatic and at 4-year follow-up had an HOOS of 85.
It appears that constrained prosthesis is a suitable treatment for patients with poor muscular control having subcapital fractures. The functional results appear to be superior to those of bipolar arthroplasty and similar to the results of primary total hip arthroplasty while the dislocation risk is <3%.
Semielective total hip arthroplasty using a retentive cup liner appears to offer good functional results with a low dislocation rate in patients with poor muscular control.
Hip fractures are common in the elderly patients with an incidence of 320 000 fractures/year in the United States, representing a health-care cost of US$9 to 20 billion. Hip fracture incidence is projected to increase dramatically. Hospitals must modify clinical models to accommodate this growing burden. Comanagement strategies are reported in the literature, but few have addressed orthopedic-hospitalist models. An orthopedic-hospitalist comanagement (OHC) service was established at our hospital to manage hip fracture patients. We sought to determine whether the OHC (1) improves the efficiency of hip fracture management as measured by inpatient length of stay (LOS) and time to surgery (TTS) and (2) whether our results are comparable to those reported in hip fracture comanagement literature.
A comparative retrospective–prospective cohort study of patients older than 60 years with an admitting diagnosis of hip fracture was conducted to compare inpatient LOS and TTS for hip fracture patients admitted 10 months before (n = 45) and 10 months after implementation (n = 54) of the OHC at a single academic hospital. Secondary outcome measures included percentage of patients taken to surgery within 24 or 48 hours, 30-day readmission rates, and mortality. Outcomes were compared to comanagement study results published in MEDLINE-indexed journals.
Patient cohort demographics and comorbidities were similar. Inpatient LOS was reduced by 1.6 days after implementation of the OHC (P = .01) without an increase in 30-day readmission rates or mortality. Time to surgery was insignificantly reduced from 27.4 to 21.9 hours (P = .27) and surgery within 48 hours increased from 86% to 96% (P = .15).
The OHC has improved efficiency of hip fracture management as judged by significant reductions in LOS with a trend toward reduced TTS at our institution.
Orthopedic-hospitalist comanagement may represent an effective strategy to improve hip fracture management in the setting of a rapidly expanding patient population.
Recent evidence supports total hip arthroplasty (THA) as compared to hemiarthroplasty (HA) for the management of displaced femoral neck fractures in a significant subset of elderly patients. The purpose of this study was to examine trends in femoral neck fracture management over the last 12 years.
Using the National Inpatient Sample database, we identified patients treated for femoral neck fractures between 1998 and 2010 with THA, HA, or internal fixation (IF). We examined treatment trends and demographic variables including patient age, gender, socioeconomic status, and payer and hospital characteristics.
We identified 362 127 femoral neck fracture patients treated between 1998 and 2010. Overall, there were statistically significant increases in rates of THA and HA, whereas rates of IF decreased. Total hip arthroplasty varied based on patient age, with significant increases occurring in age-groups 0 to 49 years, 50 to 59 years, 60 to 69 years, and 70 to 79 years. Utilization of THA varied significantly based on socioeconomic status and race. Patient sex, urban versus rural hospital location, and teaching versus nonteaching hospital status were not related to rates of THA.
Rates of THA for femoral neck fractures increased between 1998 and 2010 in patients younger than 80 years, suggesting that surgeons are responding to clinical evidence supporting THA for the treatment of elderly femoral neck fractures. This is the first study to demonstrate this change and expose disparities in practice patterns over time in response to this evidence in the United States. Further research is indicated to explore the effect of socioeconomic status and race on femoral neck fracture management.
The total hip arthroplasty (THA) as part of acute fracture management is used for acetabular fractures in elderly patients. Our objective was to assess the stability of osteosynthesis performed using 2 different techniques in combination with THA in an experimental model.
We conducted 20 experiments using the left-side hemipelves composite bone models. There were 2 testing groups: 1- and 2-stage osteosynthesis. The acetabular fractures of the anterior column and posterior hemitransverse were simulated. The same THA technique was used in both groups. The stability of osteosynthesis was explored and compared between the groups by measuring the fracture displacement of anterior and posterior columns under the standardized test load (1187 N) protocol. Load distance diagrams were generated.
The 0.680-mm gap (0.518; 1.548) of the posterior column in the 1-stage group (n = 10) was higher than the 0.370-mm gap (0.255; 0.428) in the 2-stage group (n = 10; P = .002). There was no significant difference between the gap of the anterior column in the 1- and 2-stage groups (0.135 [0.078; 0.290] mm vs 0.160 [0.120; 0.210] mm; P = .579).
The 2-stage osteosynthesis of the anterior and posterior columns in combination with THA provides better stability of posterior column when compared to 1-stage method in composite bone models.
Bone lesions from multiple myeloma may lead to pathological fracture of the proximal femur, requiring either fixation or arthroplasty. Little is known about the impact of multiple myeloma on hip fracture care. We investigated whether the patients with multiple myeloma undergoing surgical treatment of hip fractures would be at increased risk for adverse outcomes versus patients who sustain a hip fracture without multiple myeloma.
Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified 2 440 513 patients older than 50 years of age with surgically treated hip fractures. Of which, 4011 (0.2%) were found to have multiple myeloma. We compared perioperative outcomes between the patients with multiple myeloma and the nonmultiple myeloma patients using multivariable logistic regression modeling.
Patients with multiple myeloma were more likely to have several postoperative complications, such as in-hospital pneumonia (odds ratio [OR]: 1.31, 95% confidence interval [CI]: 1.14-1.51), sepsis (OR: 1.72, 95% CI: 1.32-2.25), surgical site infection (OR: 1.66, 95% CI: 1.38-2.00), and acute renal failure (OR: 1.28, 95% CI: 1.14-1.43). We found that myeloma was not associated with increased inpatient mortality, myocardial infarction, respiratory failure, thromboembolic events, or pulmonary embolism.
Patients with multiple myeloma are at increased risk for immediate postoperative complications following surgical treatment of hip fractures including in-hospital pneumonia, surgical site infection, and acute renal failure but not hospital mortality, when compared to hip fracture patients without multiple myeloma. Perioperative management of hip fractures in patients with myeloma may be optimized by increased awareness of these risks in this subset of patients.
Despite abundant sunshine, hypovitaminosis D is common in the Middle East. The aim of this study was to determine the prevalence of hypovitaminosis D and related correlates among patients with hip fracture in Assiut University Hospitals in Upper Egypt.
A cross-sectional study was carried out in 133 patients with hip fracture, aged 50 years and older, admitted to Trauma Unit of Assiut University Hospitals, from January through December 2014. Patients were selected by systematic random sampling. Serum 25-hydroxy vitamin D level was measured by enzyme-linked immunosorbent assay; bone mineral density (BMD) by dual-energy X-ray absorptiometry. Weight and height measurements were used for body mass index (BMI) calculation.
Patients’ median age was 70 years (range: 50-99); 51.9% were females. Osteoporosis (femoral neck T score: <–2.5 standard deviation) prevalence was 72.2%. Of all patients, 60.9% had vitamin D deficiency (<20 ng/mL); 15.8% reported vitamin D inadequacy (from 20 to 29 ng/mL) and vitamin D levels were normal in 23.3% (>30 ng/mL). According to univariate analysis, vitamin D deficiency was significantly associated with obesity (P = .012) and low T scores of the femoral neck (P = .001), L2 (P = .021), L3 (P = .031), L4 (P = .012), and the greater trochanter (P < .001). In a multivariable logistic regression model, high BMI and low BMD of the femoral neck and greater trochanter were associated with hypovitaminosis D.
Prevalence of hypovitaminosis D is high among patients with hip fracture and associated with low BMD and high BMI. Increasing awareness about prevention as well as detection and treatment of vitamin D deficiency is recommended.
Despite the alleviation of osteoarthritis (OA) symptoms that total knee arthroplasty (TKA) provides for patients with end-stage knee OA, recent studies have suggested that TKA may not increase physical activity levels. In this study, we compare the physical activity levels of patients with OA treated nonoperatively (non-TKA) with both patients who had received TKA (post-TKA) and patients who received TKA within 3 years of data collection (pre-TKA).
Utilizing the Osteoarthritis Initiative database, accelerometry data were collected from non-TKA, pre-TKA, and post-TKA patients. Accelerometry data were subdivided by physical activity intensity levels, yielding daily minutes of each level of activity. Physical activity levels were then compared between non-TKA and pre-TKA/post-TKA patients. Physical activity levels for each patient were also compared to the Department of Health and Human Services (DHHS) guidelines for physical activity.
There was no difference in physical activity between non-TKA and pre-TKA patients, with the exception of non-TKA patients achieving more daily minutes of vigorous activity (P < .001). There was no difference in physical activity between non-TKA and post-TKA patients. Although 11.6% of non-TKA patients met DHHS guidelines, only 4.8% of pre-TKA and 5.3% of post-TKA patients met guidelines.
Despite the improvements in patient-reported outcome measures following TKA, we found that TKA alone does not improve physical activity levels beyond those seen in the average patient with OA. In our study, the vast majority of patients with OA, treated nonoperatively or operatively, did not meet current DHHS guidelines for physical activity.
A clinical registry encompasses a selective set of rigorously collected and stored clinical data focused on a specific condition. Hip fracture is a common complication of osteoporosis in elderly patients. Hip fracture substantially increases the risk of death and major morbidity in the elderly patients. Limited data regarding hip fracture are available from Latin America and Argentina. The purpose of this project is to create an institutional registry of elderly patients with hip fracture in order to obtain data that reveal the impact of this disease in our environment, allowing us to evaluate different strategies of patient’s care and clinical outcomes.
To describe the implementation of an institutional registry of elderly patients with hip fracture in Argentina.
In this article, we described the creation, implementation, and data management of a prospective registry of elderly patients with hip fracture. The registry contains information on baseline demographics, comorbidities, laboratory, and radiological data. Follow-up at 3 and 12 months postfracture is done by phone interview to assess physical function, readmissions, and morbi-mortality. Clinical Trials registry number NCT02279550.
In this project, we have created a hip fracture registry. We hope that this registry will provide valuable data that can lead us to new lines of research, addressed to answer questions raised in clinical practice.
Life-threatening arterial bleeding from fragility fractures of the pelvis are very rare but associated with significant mortality, especially in anticoagulated patients.
We report the successful interdisciplinary management of a 78-year-old woman under anticoagulation and antiplatelet therapy who had life-threatening arterial hemorrhage from the pubic rami following a fragility fracture of the pelvis. Our management strategy included early hemorrhage control by means of selective arterial embolization followed by surgical fracture stabilization and surgical hematoma evacuation.
We identified 6 cases within the English literature, all involving females older than 70 years. All patients under anticoagulation developed hemorrhagic shock, and in 2 cases selective embolization contributed to survival of the patient. However, a combined management including fracture stabilization and hematoma evacuation has not been reported, allowing an excellent clinical outcome and discharge to geriatric rehabilitation.
This case illustrates that elderly patients with apparently benign pelvic fragility fractures might develop severe hemorrhage due to arterial injury, especially when under dual anticoagulation, and stresses the importance of a high index of suspicion. If bleeding is suspected, detailed imaging studies are necessary to determine the source of bleeding and immediate angiographic or surgical interventions in combination with volume resuscitation and coagulation therapy should be readily available.
Tibial plateau fractures are common in the elderly population following a low-energy mechanism. Initial evaluation includes an assessment of the soft tissues and surrounding ligaments. Most fractures involve articular depression leading to joint incongruity. Treatment of these fractures may be complicated by osteoporosis, osteoarthritis, and medical comorbidities. Optimal reconstruction should restore the mechanical axis, provide a stable construct for mobilization, and reestablish articular congruity. This is accomplished through a variety of internal or external fixation techniques or with acute arthroplasty. Regardless of the treatment modality, particular focus on preservation and maintenance of the soft tissue envelope is paramount.
Previous smaller studies suggest that anemia is a risk factor for mortality in patients with hip fracture. The purpose of this investigation was to assess the correlation between hemoglobin at admission with 30-day mortality following a hip fracture in a large-scale study.
From January 1996 to December 2012, all patients with hip fracture (>60 years of age) admitted to Bispebjerg Hospital, Copenhagen, were identified from a local hip fracture database. We excluded conservatively treated patients and patients who died preoperatively.
Seven thousand four hundred twenty-one consecutive patients with hip fracture were identified. Of those 7319 had a hemoglobin measurement on admission and were thus eligible for further analysis. Mean hemoglobin for patients alive at 30 days was 7.6 (standard deviation [SD]: 1.0) and for deceased patients 7.4 (SD: 1.1), P < .0001. Mean age was 82.6 years (SD: 8.5), and 76.5% of the population were female (Nfemales = 5600). The 30-day mortality decreases for every increase in hemoglobin of 1.0 mmol/L in a univariate analysis (P < .0001). The hazard ratio (HR) with 95% confidence interval (CI) for 30-day mortality in patients with anemia (<7.3 mmol/L for females and <8.3 mmol/L for males; Nanemic = 3235) was 1.66 (CI: 1.43-1.91, P < .0001). Adjusting for age, type of fracture, gender, and comorbidities (Charlson score) slightly attenuated the risk estimate (HR: 1.21, CI: 1.03-1.41, P = .02).
This study demonstrates increased 30-day mortality in patients with low hemoglobin at admission, even after adjusting for comorbidities.
Elderly patients are at risk of fracture nonunion, given the potential setting of osteopenia, poorer fracture biology, and comorbid medical conditions. Risk factors predicting fracture nonunion may compromise the success of fracture nonunion surgery. The purpose of this study was to investigate the effect of patient age on clinical and functional outcome following long bone fracture nonunion surgery.
A retrospective analysis of prospectively collected data identified 288 patients (aged 18-91) who were indicated for long bone nonunion surgery. Two-hundred and seventy-two patients satisfied study inclusion criteria and analyses were performed comparing elderly patients aged ≥65 years (n = 48) with patients <65 years (n = 224) for postoperative wound complications, Short Musculoskeletal Functional Assessment (SMFA) functional status, healing, and surgical revision. Regression analyses were performed to look for associations between age, smoking status, and history of previous nonunion surgery with healing and functional outcome. Twelve-month follow-up was obtained on 91.5% (249 of 272) of patients.
Despite demographic differences in the aged population, including a predominance of medical comorbidities (P < .01) and osteopenia (P = .02), there was no statistical differences in the healing rate of elderly patients (95.8% vs 95.1%, P = .6) or time to union (6.2 ± 4.1 months vs. 7.2 ± 6.6, P = .3). Rates of postoperative wound complications and surgical revision did not statistically differ. Elderly patients reported similar levels of function up to 12 months after surgery. Regression analyses failed to show any significant association between age and final union or time to union. There was a strong positive association between smoking and history of previous nonunion surgery with time to union. Age was associated (positively) with 12-month SMFA activity score.
Smoking and failure of previous surgical intervention were associated with nonunion surgery outcomes. Patient’s age at the time of surgery was not associated with achieving union. Advanced age was generally not associated with poorer nonunion surgery outcomes.
Hip fracture is a leading cause of mortality, morbidity, and disability in older people. The aim of the present study was to prospectively assess the development of physical performance in patients with hip fracture after surgery.
Prospective, observational study in a Swedish university hospital.
Assessment of 102 consecutive patients (65 females), with a mean age of 82 years (range 35-98) without specific inclusion or exclusion criteria. Seven physical functions were assessed using the following 4 measuring methods and 3 rating scales at baseline 7 to 10 days after surgery and follow-up after 4 months (F4): 10-m habitual walking speed (HWS), timed up and go (TUG), 30-second chair stand test (CST), handgrip strength (HGS), Berg balance scale (BBS), functional ambulation category (FAC), and general mobility.
The 47% dropout patients were significantly older and more often lived alone or in nursing homes and used indoor walking aids. At baseline, the mean HWS was 0.4/0.5 (females/males) m/s; TUG 53/30 s; CST 4/5 kg, and HGS 17.4/31.2 kg. The medians of BBS and FAC were 20/20 and 4/4, respectively. There were significant mean improvements at F4 for all 4 measured functions, except for HGS in males but for neither of the rating scales. There was a large heterogeneity in all assessed variables, both at baseline and regarding change at 4 months. Therefore, the mean/median results are depicted in figures, showing all individual results at baseline and F4, compared to reference values and discussed in relation to degree of improvement.
The observed large heterogeneity at baseline as well as F4 makes it essentially meaningless to report means and median data of functional assessment of patients with hip fracture. There is a strong need for individualization in both health analysis and how the treatment program is targeted, carried through, and evaluated over time in patients with hip fracture.
Anticoagulation reversal is a common cause of operative delay. We sought to establish for the first time the impact this has on best practice tariff (BPT) for patients with hip fracture admitted on warfarin. All patients with hip fracture treated operatively over a 32-month period were reviewed. Basic demographics, time to theater, length of stay, and mortality were recorded for all patients. Independent samples t-tests were used to identify statistically significant differences between patients on warfarin and those not taking the drug. A total of 83 patients were admitted anticoagulated with a mean international normalized ratio of 2.65 and a median time to theater of 49.7 hours. Of these patients, 79% breached BPT, incurring significant financial loss. In the control group, 908 patients took a median 24.5 hours, a 28% breach of BPT (P < .01). Length of stay, Nottingham Hip Fracture Score, and predicted 30-day mortality were similar for both the groups. As well as affecting clinical outcome following hip fracture, delay due to anticoagulation causes considerable loss of BPT. Potential loss of revenue due to delays over the study period was £80 000, inspiring the establishment of an "early trigger" anticoagulation protocol. Although it is accepted that there are limitations to this work, it should raise awareness of the real impact of warfarin on patients with hip fracture both in terms of outcome and for the first time, loss of potential revenue.
The aim of this study was to assess the cost of hospital care related to fractures among the elderly patients.
The aim was to conduct a study over a 12-month period involving patients aged 60 and older with at least 1 musculoskeletal fracture. The population under investigation included 314 patients, mainly female, with 319 fractures. Only 25.47% of the patients had access to government financial assistance. The cost of hospital treatment was assessed on the basis of 3 expense items; the standard currency used was the African Financial Community Franc (CFA franc) and 1 CFA franc equals 656 euros.
Expense item No. 1: It related to the cost of diagnostic services that included surgical consultation and x-rays.
Expense item No. 3: It is related to the duration of the stay at the hospital.
The cost of diagnostic services amounted to 5625 euros. The cost of the second item was put at 43 054 euros:
conservative treatment: 43 118 euros; surgical treatment: 41 053 euros. Cost of the hospital stay amounted to 2607 euros. Proximal femur fractures accounted for 43.46% of the overall cost of the care provided.
Our patients’ medical history is similar to the data provided in developed countries:
female predominance; predominance of proximal femoral fractures. The cost of the care provided was boosted by the surgical treatment and proximal femur fractures, whereas the cost of hospital stay was rather insignificant. Medical care is a problem among our patients, as few of them have access to government financial assistance.
Among elderly people, fractures will soon become a public health issue in our context.
Fragility fractures of the distal humerus in elderly patients, especially the low transcondylar fracture pattern, can be difficult to optimally manage. Although the fractures are typically low energy resulting in either extra-articular or simple intra-articular patterns, gaining fixation into the distal fragments can be difficult with open reduction internal fixation (ORIF) using traditional 90-90 or parallel plating techniques. Anatomy preserving reconstruction with ORIF is preferred over total elbow arthroplasty (TEA) if possible. In this study, 15 patients were managed with a bicolumnar 90-90 plating construct as a novel method of enhancing distal fixation in these fractures. Fourteen patients went on to radiographic union at an average of 77 days after surgery with an average arc of motion of 105°. One patient was lost to follow-up. Bicolumnar 90-90 plating of distal humerus fractures in elderly patients may represent a viable alternative to traditional ORIF or TEA.
Our goal was to determine whether the pullout strength of stripped screw holes in osteoporotic bone could be increased with readily available materials from the operating room. We inserted 3.5-mm stainless steel nonlocking self-tapping cortical screws bicortically into 5 osteoporotic humeri. Each screw was first stripped by rotating it 1 full turn past maximum torque. In the control group, the screw was pulled out using an MTS machine (858; MTS Inc, Eden Prairie, Minnesota). In the treatment groups, the screw was removed, the hole was augmented with 1 of the 3 materials (stainless steel wire, polysorb suture, or polyethylene terephthalate glycol plastic sheet), and the screws were replaced and then pulled out. The effect of material on pullout strength was checked for significance (P < .05) using a general linearized latent and mixed model (Stata10; StataCorp, College Station, Texas). The mean (95% confidence interval) pullout strength for the unaugmented hole was 138 N (range 88-189), whereas the holes augmented with plastic, suture, or wire had mean pullout strengths of 255 N (range 177-333), 228 N (range 149-308), and 396 N (range 244-548), respectively. Although wire augmentation resulted in pullout strength that was significantly greater than that of the unaugmented screw, it was still below that of the intact construct.