Objectives. The objective of this study was to assess the association between whole body sagittal balance and risk of falls in elderly patients who have sought treatment for back pain. Balanced spinal sagittal alignment is known to be important for the prevention of falls. However, spinal sagittal imbalance can be markedly compensated by the lower extremities, and whole body sagittal balance including the lower extremities should be assessed to evaluate actual imbalances related to falls. Methods. Patients over 70 years old who visited an outpatient clinic for back pain treatment and underwent a standing whole-body radiograph were enrolled. Falls were prospectively assessed for 12 months using a monthly fall diary, and patients were divided into fallers and non-fallers according to the history of falls. Radiological parameters from whole-body radiographs and clinical data were compared between the two groups. Results. A total of 144 patients (120 female patients and 24 male patients) completed a 12-month follow-up for assessing falls. A total of 31 patients (21.5%) reported at least one fall within the 12-month follow-up. In univariate logistic regression analysis, the risk of falls was significantly increased in older patients and those with more medical comorbidities, decreased lumbar lordosis, increased sagittal vertical axis, and increased horizontal distance between the C7 plumb line and the centre of the ankle (C7A). Increased C7A was significantly associated with increased risk of falls even after multivariate adjustment. Conclusion. Whole body sagittal balance, measured by the horizontal distance between the C7 plumb line and the centre of the ankle, was significantly associated with risk of falls among elderly patients with back pain. Cite this article: J. Kim, J. Y. Hwang, J. K. Oh, M. S. Park, S. W. Kim, H. Chang, T-H. Kim. The association between whole body sagittal balance and risk of falls among elderly patients seeking treatment for back pain. Bone Joint Res 2017;6:–344. DOI: 10.1302/2046-3758.65.BJR-2016-0271.R2

Aims. The aims of this study were to evaluate the incidence of reoperation (all cause and specifically for periprosthetic femoral fracture (PFF)) and mortality, and associated risk factors, following a hemiarthroplasty incorporating a cemented collarless polished taper slip stem (PTS) for management of an intracapsular hip fracture. Methods. This retrospective study included hip fracture patients aged 50 years and older treated with Exeter (PTS) bipolar hemiarthroplasty between 2019 and 2022. Patient demographics, place of domicile, fracture type, delirium status, American Society of Anesthesiologists (ASA) grade, length of stay, and mortality were collected. Reoperation and mortality were recorded up to a median follow-up of 29.5 months (interquartile range 12 to 51.4). Cox regression was performed to evaluate independent risk factors associated with reoperation and mortality. Results. The cohort consisted of 1,619 patients with a mean age of 82.2 years (50 to 104), of whom 1,100 (67.9%) were female. In total, 29 patients (1.8%) underwent a reoperation; 12 patients (0.7%) sustained a PFF during the observation period (United Classification System (UCS)-A n = 2; UCS-B n = 5; UCS-C n = 5), of whom ten underwent surgical management. Perioperative delirium was independently associated with the occurrence of PFF (hazard ratio (HR) 5.92; p = 0.013) and surgery for UCS-B PFF (HR 21.7; p = 0.022). Neither all-cause reoperation nor PFF-related surgery was independently associated with mortality (HR 0.66; p = 0.217 and HR 0.38; p = 0.170, respectively). Perioperative delirium, male sex, older age, higher ASA grade, and pre-fracture residential status were independently associated with increased mortality risk following hemiarthroplasty (p < 0.001). Conclusion. The cumulative incidence of PFF at four years was 1.1% in elderly patients following cemented PTS hemiarthroplasty for a hip fracture. Perioperative delirium was independently associated with a PFF. However, reoperation for PPF was not independently associated with patient mortality after adjusting for patient-specific factors. Cite this article: Bone Jt Open 2024;5(4):269–276

Distal humeral fractures are difficult fractures to treat. In the elderly population the problems are compounded by gross comminution and osteoporosis. Concurrent presence of rheumatoid arthritis makes the problem more difficult. Open reduction and internal fixation of such fractures have been shown to give poor results. Total elbow replacement has been recommended as an alternative solution to this difficult problem. We present the results of a retrospective review of a small group of elderly patients who underwent total elbow arthroplasty in our unit for comminuted fractures of the distal end of the humerus. We have followed up seven patients (seven elbows) with a mean age of 81. 7 years (range 74. 1 to 87. 8) at the time of injury. The presence of rheumatoid arthritis in three of them influenced the choice of treatment. All replacements were performed using the semiconstrained Coonrad-Morrey elbow replacement prosthesis. The duration of follow up at present is between two and four years. None of the patients have been lost to follow up. At the latest follow up the mean arc of flexion was 20 to 130 degrees. 6 of the patients had no pain while 1 complained of mild pain. All elbows were stable. The Mayo Elbow Performance Score (MEPS) for five elbows was excellent, two scored good. The mean MEPS for all the elbows was 92/100. There were 2 cases of superficial wound infection and no cases of deep infection, ulnar nerve neuritis or component failure. These results suggest that a semiconstrained total elbow replacement has a role to play in the treatment of carefully selected distal humeral fractures, which cannot be treated by internal fixation due to extensive intraarticular comminution and gross osteopenia. Although these are short-term follow up results they are encouraging outcomes for treatment of one of the most challenging fractures

Current evidence suggests that we should be moving away from Thompson's hemiarthroplasties for patients with intracapsular hip fractures. Furthermore, the use of cement when inserting these prostheses is controversial. This study aims to show the Inverness experience. We performed a retrospective review of all NHS Highland patients who underwent a hemiarthroplasty for an intracapsular neck of femur fracture over the last 15 years. Demographics and the use of cement were documented. Further analysis of this group was performed to identify any of these patients who required revision of their prosthesis. Patients requiring revision had their case-notes reviewed to identify the cause for further surgery. From 1996 until present 2221 patients from the Highland area had a hemiarthroplasty for an intracapsular neck of femur fracture. 1708 where female (77%) and 513 male (23%). The ages ranged from 28 years to 104 years (mean 80 years, median 81). 2180 of this group had their operations in Raigmore Hospital with the remaining 41 at various centres throughout Scotland. 623 (28%)had a cemented hemiarthroplasty, with the remaining 1578 (72%) having an uncemented Thompson's hemiarthroplasty. The revision rate for the cemented group was 2% (13 of 623 patients). In the uncemented group it was 0.4% (6 of 1578). Reasons from revision included dislocation, periprosthetic fracture, infection and pain. Current evidence from some joint registers regarding the use of Thompson's hemiarthroplasty in the elderly is discouraging. The use of bone cement in this group with multiple co-morbidities is not without it's risks. Our data suggests that uncemented Thompson's hemiarthroplasties in low demand elderly patients with multiple co-morbidities can yield excellent results with less risk to the patients

Following fixation of proximal femoral fractures in the elderly the operating surgeon may request that the patient be mobilised partially weight bearing on the injured limb. This instruction is most likely if the bone quality is very poor or the fracture pattern unstable, despite evidence that full weight bearing does not affect outcome. 98 elderly patients with proximal femoral fractures treated by either hip screw device, cannulated screws or hemiarthroplasty, who were previously independently mobile, have been followed prospectively to determine their ability to comply with partial weight bearing instructions. A specially designed capacitance foot pressure device was used to determine percentage body weight transferred through the injured limb on mobilising under physiotherapy instruction over 5 days, and factors thought to be predictive of success in partially weight bearing were measured using simple ward tests. 14 patients failed to mobilise independently prior to discharge from hospital and were excluded from further analysis. Of the remaining 84 patients only 24 (28%) successfully managed to partially weight bear 30-50% of their body weight on the injured limb. Only six of those who were unable to partially weight bear on starting to walk after surgery had learnt to do so by the fifth day. Factors indicating success or failure were mental test score, grip strength and straight leg raise on the unaffected side. This study has shown that the majority of elderly hip fracture patients are unable to partially weight bear but, if required, success can be predicted by a few simple ward tests. It is hoped that this information will lead to the more appropriate use of inpatient physiotherapy resources

Objective: To study potential predictors of functional outcome six months after the injury in elderly patients who sustained a hip fracture and who had been able to go out alone. Design: Prospective Multi-center Cohort Study. Setting: 14 Hospitals in Japan. Patients and Methods: A cohort was consisted of 387 patients with a mean age of 81 who had a hip fracture, between December 2004 and January 2006. Inclusion criteria were that patients were at least sixty-five years old and who had been able to go out independently. Level of activity of daily living, medical complications, residential environment and family structure at injury was interviewed from the patient, the relatives and a nursing caretaker and recorded. Advancement of mobility was also recorded during the hospital stay. Patients were contacted or interviewed again by the investigator at six months following injury to assess functional outcomes. Primary outcome of interest was changes in mobility to go out independently at six months after injury. Results: 178 patients (46%) lost their independency to go out at six month following surgery. Logistic multivariant regression showed that age, cognitive function, hemiplegia and mobile ability at discharge were the independent predictable factors for losing independency of mobility. At hospital discharge, T-cane walk was accomplished in only 53% for looser group but 86% for maintain group. Conclusions: We believe that it would be the key factor to improve the mobility of the healthy patient with hip fracture that we lead them to T-cane walk before hospital discharge

Purpose: The age of patients presenting with acetabular fracture has increased over the last ten years. Older patients tend to have patterns involving the anterior column with comminution of the quadrilateral plate. Our goal was to investigate the appropriateness of open reduction and internal fixation using the modified Stoppa approach for geriatric acetabular fractures.

Method: A retrospective review of patients over the age of 60 having presented to an academic level I trauma center over the course of four years. Twenty patients were identified and treated using the modified Stoppa approach with plating of the quadrilateral surface. Patients were evaluated clinically using both SF-36 and Harris Hip Score. Records and radiographs (using criteria described by Matta) were reviewed retrospectively.

Results: All patients were followed for a minimum of two years with no lost at follow-up. Mean age for patients at time of intervention was 68 years. Average blood lost was 800cc and surgical time was 130 minutes (range, 55–210). There was one traumatic injury to the obturator nerve and two patients were noted to have temporary weakness of the hip adductors postoperatively. Average Harris Hip Score and the SF-36 were improved significantly (p< 0.05). Significant lost of reduction was seen in two patients and was correlated to superior dome impaction (p < 0.0001). Three patients required re-intervention with a Total Hip Arthroplasty.

Conclusion: Internal fixation using the modified Stoppa approach to buttress the quadrilateral plate should be considered a viable alternative to total hip arthroplasty for the initial treatment of acetabular fractures of the anterior column in the elderly.

Purpose of the study: Hemi-arthroplasty, osteosynthesis, and ball-and-socket implants provide well-known results for the management of displaced joint fractures of the proximal humerus in elderly subjects. The purpose of this work was to assess the reversed Grammont prosthesis for these indications.

Material and methods: From 1993 to 1999, eighteen Delta III prostheses were implanted by the same operator in recent trauma victims. The patients, 17 women and one man, mean age 75 years, presented four-fragment fractures (n=15) or fracture dislocation (n=3). The dominant side was involved in nine cases. These patients presented infiltrative rotator cuff tendinopathy (n=4), type 1 diabetes mellitus (n=2), exogenosis (n=2), morbid obestity (n=2), homelessness (n=2), and dementia (n=2). Surgery was performed under general anesthesia in the semi-sitting position via a trapezodeltoid approach without acromion osteotomy and with 20° humeral implant retroversion in all cases except one, cemented in 17 cases. The tubercles could be reinserted in four patients. Rehabilitation was not always possible. The Constant score and the anteroposterior and Lamy lateral views were used to assess clinical and radiographic outcome.

Results: There were two deaths, so the analysis included 16 shoulders. Complications were: shoulder-hand syndrome (n=1), early deep Acinetobacter infection with revision and preservation of the arthroplasty (n=1), anterior dislocation at one month due to voluntary 10° anterotation of the humeral stem requiring reorientation (n=1). At mean follow-up of 85 months, the Constant score was 60, with a weighted score of 83%. The results were not influenced by reinsertion of the tubercles and were considered good for pain and activity, fair for strength, and disappointing for rotations. The x-rays did not reveal any sign of humeral loosening. There was one lucent line between the glenoid and the metaglenoid, four cases with pillar notches, and nine infraglenoid ossifications.

Discussion and conclusion: For displaced joint fractures of the proximal humerus, endomedullary osteosynthesis and the ball-and-socket implant have shown their efficacy as an alternative to hemiarthroplasty. The reverted prosthesis also appears to be a valid therapeutic option for elderly persons with osteoporotic bone compromising the reinsertion of the tubercules. This option enables good results for pain, activity, strenth and active mobility except for rotation, with only five signs of gravity for the glenoid with one involving the glenoid and none the humerus at 85 months follow-up. These results should be further confirmed with a larger series and longer follow-up.

Objective: To study the effect in health status of telephone contact 2+10 weeks after total hip replacement (THR) during the first nine months after surgery. Not all of patient have improvement in their health status and quality of life, that the surgery benefits them. Method: A randomised clinical trial enrolled 180 patients aged 65+ focusing on patients’ health status using SF-36, 4 weeks pre–to 3 and 9 months postoperative were carried out. Patients were randomised 4 weeks preoperative either to control or intervention group. Both groups received the conventional treatment. Furthermore the intervention group had postoperative telephone monitoring two and ten weeks after surgery Patients were given counselling by using an interview-guide within eight main themes referring to patients’ actual situation after THR. Results: All patients experienced increase in their health status after THA. The intervention significantly reduced the time for patients to reach their habitual level as patients in the intervention group reached their habitual level at three months whereas patients in the control group reached this level after nine months. Conclusion: Support by phone contact after THR seems to benefit patients’ outcome. The presentation is based on the results of the nursing intervention program by using telephone contact to elderly patients with hip replacement after discharge

Background. Malnutrition has been suggested to increase the risk of falls in frail elderly. It has been hypothesised that elderly, orthopaedic trauma patients may be malnourished. We conducted an observational study to identify if this was the case. Methods. 30 trauma patients (? 65 years) admitted for surgical intervention for a fracture were recruited. Consent/ethical approval was obtained. Serum markers (LFTs, CRP, U&Es, FBC, magnesium), anthropometric measurements (triceps skin-fold thickness [TSF], mid-arm circumference [MAC], body mass index [BMI]) and short form mini-nutritional assessment (MNA-SF®) were carried out at presentation and at 3 months post-operation. Serum markers were also repeated at day 1 and day 3 post-operation. Results. 60% had an initial MNA-SF® score of ?11 points indicating that they were at risk from possible malnutrition. However, median BMI at presentation was normal at 22.79 kg/m. 2. (WHO) (Interquartile range 19.8–28). Interestingly, a higher proportion of the group (67%) were below the 50. th. centile for age related BMI centiles. At follow-up (15 patients), there was no significant difference in anthropometric measures (BMI p=0.884; BMI Centile p=0.687; MAC p=0.095; TSF p=0.260) or with the MNA-SF® (p=0.121). The mean MNA-SF® had increased, but not significantly. Conclusions. This study indicates that elderly trauma patients may be at risk of malnutrition regardless of their BMI at presentation and should be screened and monitored. The MNA-SF® has been shown to be 100% specific and 98% sensitive in predicting malnutrition. Our study correlates with others illustrating that patients may have normal BMI and albumin levels, but have poor nutritional intake, highlighting the need to identify patients at risk of malnutrition prior to detectable changes in BMI. Screening should be given to all elderly trauma patients being admitted to a trauma unit. We would suggest that it become the standard. Further research is needed using larger sample sizes

Abstract. Introduction. Revision total knee arthroplasty (rTKA) in elderly patients (>85 years) is associated with increased mortality, hospital stay and a high rate (55%) of complications. The objective was to assess PROMs in elderly patients undergoing rTKA. Methods. A retrospective cohort study of consecutive patients undergoing rTKA at an arthroplasty centre from 2001–2022 were compared to a control group (aged 50–79y) matched for gender, diagnosis & surgery year. The commonest reasons for revision in elderly patients was aseptic loosening (53/100), infection (21/100) and fracture (7/100). One-year patient-reported outcome data was available for 64%. Results. 100 patients underwent rTKA with a mean age of 84 years (range 80–97 years, SD 3) compared to a matched control group of younger patients (mean age 69y). Preoperative function was poor, with a mean Oxford knee score (OKS) of 40/100 in elderly and 43/100 in younger patients (p=0.164). At one-year postop, mean OKS was comparable between elderly and young patients (81 and 84/100 respectively, p=0.289). The number of patients with severe pain at one year was also comparable (4% elderly and 7% young respectively, p=0.177). The improvement in OKS for elderly patients was sustained at three (82 95% CI 58–100, 14/100 known) and five years. Overall complication rate was 54%. 14% were dead at 1 year and 56% were dead at five-years. Conclusion. Elderly patients undergoing elective revision TKA show a mean improvement in Oxford knee score of +38 at one year. This is the same as younger patients and is sustained at three and five years

Aim. Currently, gram-negative bacteria (GNB), including multidrug-resistant (MDR-GNB) pathogens, are gaining importance in the aetiology of prosthetic joint infection (PJI). To characterize the antimicrobial resistance patterns of Gram-negative bacteria (GNB) causing hip prosthetic joint infections in elderly patients treated at a Brazilian tertiary academic hospital. Method. This is a retrospective, cross-sectional study of patients over 60 years of age undergoing hip arthroplasty from 2018 to 2023 at a tertiary academic trauma, which were diagnosed with hip prosthetic joint infection. PJI diagnosed was based on EBJIS criteria, in which intraoperative tissue cultures identified the pathogens. Demographics, reason for arthroplasty, type of implant and susceptibility patterns using disk diffusion method were analysed. Results. Overall, among 17 elderly patients diagnosed with hip infected arthroplasty, 45 bacterial isolated were identified. Debridement, irrigation, antibiotic and implant retention (DAIR) procedures due to uncontrolled infection occurred in 47.0% (n=8/17), and five patients underwent more than two DAIR surgeries. Tissue cultures yielded eleven different bacterial species, with GNB accounted for 64.4% (n=29/45) of pathogens. Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli, and Pseudomonas aeruginosa were identified in 34.5% (n=10/29), 17.25% (n=5/29), 13.8% (n=4/29), and 13.8% (n=4/29), respectively. In the resistance profile analysis, E. coli was most sensitive to antibiotics, whereas K. pneumoniae showed resistance rates higher than 70% for cephalosporins, carbapenems, and quinolones. All A. baumannii isolates were resistant to meropenem, and 80% of these isolates were resistant to amikacin. Conclusions. This study emphasizes the role of GNB in the microbiological profile of PJI among elderly patients at a tertiary hospital in a Brazilian centre. The present study portrays a worryingly higher rates of MDR-GNB, mainly to quinolones and cephalosporins resistance which have been the cornerstone of PJI antibiotic treatment. In addition, higher rates carbapenems and aminoglycosides resistance shows a threat to antibiotic treatment of PJI. More global studies need to be carried out to show a likely change in the microbial epidemiology of PJI

Aim. Prosthetic joint replacement is more commonly done in the elderly group of patients due to an increase pathology related to joint degeneration that comes with age. In this age group is also more frequent having underling condition that may predispose to a prosthetic joint infection. Also, the pharmacological intervention in those patients may play an important role as a risk factor for infection after joint replacement surgery. The use of oral anticoagulants seems to be particularly increased in elderly patients but there aren't enough data published to support an association between prosthetic joint infection and the use of oral anticoagulants. Identifying risk factors in elderly patients age >75 years old with a special focus on the oral anticoagulation therapy is the aim of the study. Methods. In a retrospective study from 2011 till 2018 all the patients >75 years old with knee and hip replacement surgery have been review looking for acute prosthetic infection and risk factors that may be predispose to it. Patients with previous surgery or any other mechanical complication that needed intervention on the same area have been excluded. Results. A total of 1220 patients have been included (801 knee replacement surgery and 419 hip replacement surgery). The mean age was 79.5 ± 3.44 years and most of the patients were women (72,6%). The infection rate was 2,5%. Several factors have been identified to be associated with acute infection. (Table.1.). The patients receiving oral anticoagulants had an increased risk of infection (OR 3.63 (1.60–7.74), p=0.002). Conclusions. Even all the risk factors associated with risk infection have been described previously, the relevant aspect is the increased risk of prosthetic joint infection in patients receiving oral anticoagulants

Regeneration of bone defects in elderly patients is limited due to the decreased function of bone forming cells and compromised tissue physiology. Previous studies suggested that the regenerative activity of stem cells from aged tissues can be enhanced by exposure to young systemic and tissue microenvironments. The aim of our project was to investigate whether extracellular matrix (ECM) engineered from human induced pluripotent stem cells (hiPSCs) can enhance the bone regeneration potential of aged human bone marrow stromal cells (hBMSCs). ECM was engineered from hiPSC-derived mesenchymal-like progenitors (hiPSC-MPs), as well as young (<30 years) and aged (>70 years) hBMSCs. ECM structure and composition were characterized before and after decellularization using immunofluorescence and biochemical assays. Three hBMSCs of different ages were cultured on engineered ECMs. Growth and differentiation responses were compared to tissue culture plastic, as well as to collagen and fibronectin coated plates. Decellularized ECMs contained collagens type I and IV, fibronectin, laminin and < 5% residual DNA, suggesting efficient cell elimination. Cultivation of young and aged hBMSCs on the hiPSC-ECM in osteogenic medium significantly increased hBMSC growth and markers of osteogenesis, including collagen deposition, alkaline phosphatase activity, bone sialoprotein expression and matrix mineralization compared to plastic controls and single protein substrates. In aged BMSCs, matrix mineralization was only detected in ECM cultures in osteogenic medium. Comparison of ECMs engineered from hiPSC-MPs and hBMSCs of different ages suggested similar structure, composition and potential to enhance osteogenic responses in aged BMSCs. Engineered ECM induced a higher osteogenic response compared to specific matrix components. Our studies suggest that aged BMSCs osteogenic activity can be enhanced by culture on engineered ECM. hiPSCs represent a scalable cell source, and tissue engineering strategies employing engineered ECM materials could potentially enhance bone regeneration in elderly patients

The early revision rate in elective Total Hip Arthroplasty (THA) three years after surgery in elderly patients over 80 years is significantly lower for cemented stems in the German Arthroplasty Register (EPRD): cemented 3,1% (3.0 – 3.2) vs. uncemented 4.2% (4.1 – 4.3; p < 0.001). However, the mortality rate in elderly patients is elevated for cemented fixation. This study presents a detailed analysis of the influence of stem type and fixation on revision and mortality rate in this patient cohort. Elective primary THA cases for primary Coxarthrosis using uncemented cups from the EPRD data base were analysed (n. 0. = 37,183). Four stem type groups were compared: cementless, cementless with collar, cementless short, and cemented. Stems with at least 300 cases at risk three years after surgery were analysed individually. The reference stem was determined as the stem with the lowest revision rate and at least 1000 cases under surveillance 3 years after surgery (n. 3. = 28,637). The revision rate for cemented stems (2.5% [2.2–1.81] was lower than for uncemented (4.5% [4.2–4.9]; p<0.001) and uncemented short stems (4.2% [3.1–5.7]; p=0.002). The revision rate of uncemented collared stems (2.3% [1.5–3.6]) was similar to cemented stems (p=0.89) and lower than for uncemented stems (p=0.02). One year mortality showed no sig. differences between the groups (p>0.17): cemented 3.2% [2.9–3.6], uncemented 3.4% [3.1–3.7], uncemented short 3.5% [2.5–4.9], uncemented collar 2.0% [1.2–3.2]. “Cementless” and “cementless short” stems should not be used in patients over 80 years due to the higher revision risk. If cementing should be avoided, “cementless collared” stems seem to be a good alternative combined with a tendency for a lower one year mortality rate

Aims. To describe the epidemiology of acetabular fractures including patient characteristics, injury mechanisms, fracture patterns, treatment, and mortality. Methods. We retrieved information from the Swedish Fracture Register (SFR) on all patients with acetabular fractures, of the native hip joint in the adult skeleton, sustained between 2014 and 2020. Study variables included patient age, sex, injury date, injury mechanism, fracture classification, treatment, and mortality. Results. In total, 2,132 patients with acetabular fractures from the SFR were included in the study. The majority of the patients were male (62%) and aged over 70 years old (62%). For patients aged > 70 years, the 30-day mortality was 8% and one-year mortality 24%. For patients aged ≤ 70 years, the 30-day mortality was 0.2% and one-year mortality 2%. Low-energy injuries (63%) and anterior wall fractures (20%) were most common. Treatment was most often non-surgical (75%). Conclusion. The majority of patients who sustain an acetabular fracture are elderly (> 70 years), of male sex, and the fracture most commonly occurs after a simple, low-energy fall. Non-surgical treatment is chosen in the majority of acetabular fracture patients. The one-year mortality for elderly patients with acetabular fracture is similar to the mortality after hip fracture, and a similar multidisciplinary approach to care for these patients should be considered. Cite this article: Bone Jt Open 2023;4(9):652–658

Aims. This work aimed at answering the following research questions: 1) What is the rate of mechanical complications, nonunion and infection for head/neck femoral fractures, intertrochanteric fractures, and subtrochanteric fractures in the elderly USA population? and 2) Which factors influence adverse outcomes?. Methods. Proximal femoral fractures occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records Data Base. The Kaplan-Meier method with Fine and Gray sub-distribution adaptation was used to determine rates for nonunion, infection, and mechanical complications. Semiparametric Cox regression model was applied incorporating 23 measures as covariates to identify risk factors. Results. Union failure occured in 0.89% (95% confidence interval (CI) 0.83 to 0.95) after head/neck fracturs, in 0.92% (95% CI 0.84 to 1.01) after intertrochanteric fracture and in 1.99% (95% CI 1.69 to 2.33) after subtrochanteric fractures within 24 months. A fracture-related infection was more likely to occur after subtrochanteric fractures than after head/neck fractures (1.64% vs 1.59%, hazard ratio (HR) 1.01 (95% CI 0.87 to 1.17); p < 0.001) as well as after intertrochanteric fractures (1.64% vs 1.13%, HR 1.31 (95% CI 1.12 to 1.52); p < 0.001). Anticoagulant use, cerebrovascular disease, a concomitant fracture, diabetes mellitus, hypertension, obesity, open fracture, and rheumatoid disease was identified as risk factors. Mechanical complications after 24 months were most common after head/neck fractures with 3.52% (95% CI 3.41 to 3.64; currently at risk: 48,282). Conclusion. The determination of complication rates for each fracture type can be useful for informed patient-clinician communication. Risk factors for complications could be identified for distinct proximal femur fractures in elderly patients, which are accessible for therapeutical treatment in the management. Cite this article: Bone Jt Open 2023;4(10):801–807

Aims. The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?. Methods. PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments. Results. From 2009 to 2019, the incidence decreased by 11.85% from 300.4 cases/100,000 enrollees to 266.3 cases/100,000 enrollees, although this was not statistically significant (z = -1.47, p = 0.142). In comparison to matched Medicare patients without a PHF, but of the same five-year age group and sex, a mean survival difference of -17.3% was observed. The one-year mortality rate was higher after nonoperative treatment with 16.4% compared to surgical treatment with 9.3% (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.23 to 1.36; p < 0.001) and to shoulder arthroplasty with 7.4% (HR = 1.45, 95% CI 1.33 to 1.58; p < 0.001). Statistically significant mortality risk factors after operative treatment included age older than 75 years, male sex, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, chronic kidney disease, a concomitant fracture, congestive heart failure, and osteoporotic fracture. Conclusion. Mortality risk factors for distinct treatment modes after PHF in elderly patients could be identified, which may guide clinical decision-making. Cite this article: Bone Joint Res 2023;12(2):103–112

Aims. There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA). Methods. We retrospectively reviewed the records of 26 elbows of 21 patients with RA who were aged less than 50 years who underwent primary TEA with an unlinked elbow prosthesis. The mean patient age was 46 years (35 to 49), and the mean follow-up period was 13.6 years (6 to 27). Outcome measures included pain, range of motion, Mayo Elbow Performance Score (MEPS), radiological evaluation for radiolucent line and loosening, complications, and revision surgery with or without implant removal. Results. The mean MEPS significantly improved from 47 (15 to 70) points preoperatively to 95 (70 to 100) points at final follow-up (p < 0.001). Complications were noted in six elbows (23%) in six patients, and of these, four with an ulnar neuropathy and one elbow with postoperative traumatic fracture required additional surgeries. There was no revision with implant removal, and there was no radiological evidence of loosening around the components. With any revision surgery as the endpoint, the survival rates up to 25 years were 78.1% (95% confidence interval 52.8 to 90.6) as determined by Kaplan-Meier analysis. Conclusion. The clinical outcome of primary unlinked TEA for young patients with RA was satisfactory and comparable with that for elderly patients. A favourable survival rate without implant removal might support the use of unlinked devices for young patients with this disease entity, with a caution of a relatively high complication rate regarding ulnar neuropathy. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Jt Open 2023;4(1):19–26

Introduction. Most common osteoporotic fracture. 20-30% of patients with OVFs are presented to hospital while 2.2 million remain undiagnosed, as diagnosis is usually opportunistic. 66,000 OVFs occur annually in the UK with increase by 18,000 cases a year until 2025. 20% chance of another OVF in next 12 months and 3 times risk of hip fracture. Acute painful OVFs poorly tolerated by infirm elderly patients, leading to significant morbidity and 8 times increase in age-adjusted mortality. Materials and Methods. Classify fracture severity and patents with ovfs in 12-month period. To assess follow-up status and if kyphoplasty was offered within 6 weeks as per NICE guidelines. To introduce Royal Osteoporosis Society and GIRFT guidelines on management of symptomatic osteoporotic vertebral fractures. Results. Total no. of patients- 62. Initial pain assessment=40. Pain assessed at ≤6 weeks- 21. Duration from decision to operate to kyphoplasty 8.7 weeks. 11% had kyphoplasty of which 50% noted improvement in pain. 11 deaths. Nearly similar findings to NoSH study. Conclusion. To improve pain assessment on admission of patients with acute osteoporotic vertebral fractures. To follow GIRFT guidelines for early assessment and intervention in patients with acute osteoporotic vertebral fractures to improve pain, mobility and early discharge from hospital. Conflicts of interest. None. Sources of funding. None