Aims. Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort. Methods. We have prospectively monitored a series of 22 cases (21 patients) with a mean follow-up of 32 months (13 to 59). Results. The mean patient age was 79 years (67 to 87), and the mean ASA score was 3.3 (3 to 5). Three patients had high-energy injuries and 18 had low-energy injuries. All cases were associated fractures (Letournel classification: anterior column posterior hemitransverse, n = 13; associated both column, n = 6; transverse posterior wall, n = 3) with medialization of the femoral head. Mean operative time was 93 minutes (61 to 135). There have been no revisions to date. Of the 21 patients, 20 were full weight-bearing on day 1 postoperatively. Mean length of hospital stay was 12 days (5 to 27). Preoperative mobility status was maintained in 13 patients. At one year, mean Merle d’Aubigné score was 13.1 (10 to 18), mean Oxford Hip Score was 38.5 (24 to 44), mean EuroQol five-dimension five-level (EQ-5D-5L) health score was 68 (30 to 92), and mean EQ-5D-5L index score was 0.68 (0.335 to 0.837); data from 14 patients. Mortality was 9.5% (2/21) at one year. There have been no thromboembolic events, deep infections, or revisions. Conclusion. The coned hemipelvis reconstruction bypasses the fracture, creating an immediately stable construct that allows immediate full weight-bearing. The posterior approach minimizes the operative time and physiological insult in this vulnerable patient population. Early results suggest this to be a safe addition to current surgical options, targeted at the most medically frail elderly patient with a complex displaced acetabular fracture. Cite this article: Bone Joint J 2020;102-B(2):155–161

We describe the outcome of tibial diaphyseal fractures in the elderly (≥ 65 years of age). We prospectively followed 233 fractures in 225 elderly patients over a minimum ten-year period. Demographic and descriptive data were acquired from a prospective trauma database. Mortality status was obtained from the General Register Office database for Scotland. Diaphyseal fractures of the tibia in the elderly occurred predominantly in women (73%) and after a fall (61%). During the study period the incidence of these fractures decreased, nearly halving in number. The 120-day and one-year unadjusted mortality rates were 17% and 27%, respectively, and were significantly greater in patients with an open fracture (p < 0.001). The overall standardised mortality ratio (SMR) was significantly increased (SMR 4.4, p < 0.001) relative to the population at risk, and was greatest for elderly women (SMR 8.1, p < 0.001). These frailer patients had more severe injuries, with an increased rate of open fractures (30%), and suffered a greater rate of nonunion (10%). . Tibial diaphyseal fractures in the elderly are most common in women after a fall, are more likely to be open than in the rest of the population, and are associated with a high incidence of nonunion and mortality. Cite this article: Bone Joint J 2013;95-B:1255–62

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls. Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively. Cite this article: Bone Joint J 2014;96-B:366–72

Aims. The aim of this study was to test the null hypothesis that there is no difference, from the payer perspective, in the cost of treatment of a distal radial fracture in an elderly patient, aged > 65 years, between open reduction and internal fixation (ORIF) and closed reduction (CR). Materials and Methods. Data relating to the treatment of these injuries in the elderly between January 2007 and December 2015 were extracted using the Humana and Medicare Advantage Databases. The primary outcome of interest was the cost associated with treatment. Secondary analysis included the cost of common complications. Statistical analysis was performed using a non-parametric t-test and chi-squared test. Results. Our search yielded 8924 patients treated with ORIF and 5629 patients treated with CR. The mean cost of an uncomplicated ORIF was more than a CR ($7749 versus $2161). The mean additional cost of a complication in the ORIF group was greater than in the CR group ($1853 versus $1362). Conclusion. These findings show that there are greater payer fees associated with ORIF than CR in patients aged > 65 years with a distal radial fracture. CR may be a higher-value intervention in these patients. Cite this article: Bone Joint J 2018;100-B:205–11

We present the prevalence of multiple fractures in the elderly in a single catchment population of 780 000 treated over a 12-month period and describe the mechanisms of injury, common patterns of occurrence, management, and the associated mortality rate. A total of 2335 patients, aged ≥ 65 years of age, were prospectively assessed and of these 119 patients (5.1%) presented with multiple fractures. Distal radial (odds ratio (OR) 5.1, p <  0.0001), proximal humeral (OR 2.2, p < 0.0001) and pelvic (OR 4.9, p < 0.0001) fractures were associated with an increased risk of sustaining associated fractures. Only 4.5% of patients sustained multiple fractures after a simple fall, but due to the frequency of falls in the elderly this mechanism resulted in 80.7% of all multiple fractures. Most patients required admission (> 80%), of whom 42% did not need an operation but more than half needed an increased level of care before discharge (54%). The standardised mortality rate at one year was significantly greater after sustaining multiple fractures that included fractures of the pelvis, proximal humerus or proximal femur (p < 0.001). This mortality risk increased further if patients were < 80 years of age, indicating that the existence of multiple fractures after low-energy trauma is a marker of mortality

Aims

“Get It Right First Time” (GIRFT) and NHS England’s Best Practice Tariff (BPT) have published directives advising that patients over the ages of 65 (GIRFT) and 69 years (BPT) receiving total hip arthroplasty (THA) should receive cemented implants and have brought in financial penalties if this policy is not observed. Despite this, worldwide, uncemented component use has increased, a situation described as a ‘paradox’. GIRFT and BPT do, however, acknowledge more data are required to support this edict with current policies based on the National Joint Registry survivorship and implant costs.

Aims

The aim of this study was to compare the rate of perioperative complications following aseptic revision total hip arthroplasty (THA) in patients aged ≥ 80 years with that in those aged < 80 years, and to identify risk factors for the incidence of serious adverse events in those aged ≥ 80 years using a large validated national database.

Aims

The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years.

Abstract. Introduction. Displaced olecranon fractures in the elderly are challenging due to associated comorbidities, poor tissue quality, high risk of complications, and the possible need for implant removal. Treatment options with such fractures range from non-operative management to internal fixation with various types of implants. Currently, there is no consensus on the treatment of olecranon fractures in the elderly with relatively low functional demand. Aim. The aim of this systematic review was to analyse the clinical outcomes of various treatment modalities for olecranon fracture in the elderly. Methods. We systematically reviewed the literature covering the treatment of olecranon fractures in the elderly according to PRISMA guidelines. We used search tools of Medline, Embase, Wiley online library, Cochrane and Scopus. Keywords used in the search were Olecranon fracture and Elderly OR Geriatric in all fields. Studies involving patients older than 60 years of age and all modalities of treatment were included. Results. 14 papers studying 270 patients were identified of which, 112 were treated non-operatively, 25 with limited fixation, 98 with tension band wire fixation, 34 with plate fixation, and 1 patient was treated with excision. Conclusions. Nonoperative as well as limited fixation were shown to provide satisfactory results in the elderly. Treatment decisions in this age group should be individualised to factors such as fracture stability, quality of bone & soft tissues, and patient's functional demand. We recommend a treatment protocol for treating olecranon fracture in the elderly based on the above factors

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

It is known that the gait dynamics of elderly substantially differs from that of young people. However, it has not been well studied how this age-related gait dynamics affects the knee biomechanics, e.g., cartilage mechanical response. In this study, we investigated how aging affects knee biomechanics in a female population using subject-specific computational models. Two female subjects (ages of 23 and 69) with no musculoskeletal disorders were recruited. Korea National Institute for Bioethics Policy Review Board approved the study. Participants walked at a self-selected speed (SWS), 110% of SWS, and 120% of SWS on 10 m flat ground. Three-dimensional marker trajectories and ground reaction forces (Motion Analysis, USA), and lower limbs’ muscle activities were measured (EMG, Noraxon USA). Knee cartilage and menisci geometries were obtained from subjects’ magnetic resonance images (3T, GE Health Care). An EMG-assisted musculoskeletal finite element modeling workflow was used to estimate knee cartilage tissue mechanics in walking trials. Knee cartilage and menisci were modeled using a transversely isotropic poroviscoelastic material model. Walking speed in SWS, 110%, and 120% of SWS were 1.38 m/s, 1.51 m/s, and 1.65 m/s for the young, and 1.21 m/s, 1.34 m/s and 1.46 m/s for the elderly, respectively. The maximum tensile stress in the elderly tibial cartilage was ~25%, ~33%, and ~32% lower than the young at SWS, 110%, and 120% of SWS, respectively. These preliminary results suggest that the cartilage in the elderly may not have enough stimulation even at 20% increases in walking speed, which may be one reason for tissue degeneration. To enhance these findings, further study with more subjects and different genders will investigate how age-related gait dynamics affects knee biomechanics. Acknowledgments: Australian NHMRC Ideas Grant (APP2001734), KITECH (JE220006)

Aim. The treatment of fracture-related infections (FRI) focuses on obtaining fracture healing and eradicating infection to prevent osteomyelitis. Treatment guidelines include removal, exchange, or retention of the implants used according to the stability of the fracture and the time from the infection. Infection of a fracture in the process of healing with a stable fixation may be treated with implant retention, debridement, and antibiotics. Nonetheless, the retention of an intramedullary nail is a potential risk factor for failure, and it is recommended to exchange or remove the nail. This surgical approach implies additional life-threatening risks in elderly fragile hip fracture patients. Our study aimed to analyze the results of implant retention for the treatment of infected nails in elderly hip fracture patients. Methods. Our retrospective analysis included patients 65 years of age or older with an acute fracture-related infection treated with implant retention from 2012 to 2020 in 6 Spanish hospitals with a minimum 1-year follow-up. Patients that required open reduction during the initial fracture surgery were excluded. Variables included in our analysis were patient demographics, type of fracture, date of FRI diagnosis, causative microorganism, and outcome. Treatment success was defined as fracture healing with infection eradication without the need for further hospitalization. Results. A total of 48 patients were identified. Eight patients with open reduction were excluded and 11 did not complete a 1-year follow-up. Out of the 29 remaining patients, the mean age was 81.5 years, with a 21:9, female to male ratio. FRI was diagnosed between 10 and 48 days after initial surgery (mean 26 days). Treatment success was achieved in 24 patients (82.7%). Failure was objectivated in polymicrobial infections or infections caused by microorganisms resistant to antibiofilm antibiotics. Seven patients required more than one debridement with a success rate of 57%. Twelve patients had an infection diagnosed after 21 days from the initial surgery and implant retention was successful in all of them. Conclusion. Our results suggest implant retention is a valid therapeutic approach for fracture-related infection in elderly hip fracture patients treated by closed reduction and intramedullary nailing

Current recommendations advocate for surgery within 48 hours from time of injury as a keystone in care for elderly patients with hip fractures. A spare population density within regional Australia provides physical challenges to meet time critical care parameters. This study aims to review the impact of delays to timely surgery for elderly hip fracture patients within a regional Australian population. A retrospective, comparative analysis was undertaken of 140 consecutive hip fracture patients managed at a single rural referral hospital, from June 2020 until June 2021. Factors such as age, time to transfer, time to surgery, 30-day complication and 6-month complication rates were collected. Statistical analysis was performed where applicable. Mean time to surgery was 33.9 hours. A greater proportion of patients whom directly presented underwent surgery within the recommended 48 hours (91.5% vs 75.3%). The statistically significant delay in time to surgery was found to be 6.4 hours. Lower 180-day morbidity and mortality rates were observed in patients undergoing surgery within 48 hours (13.8% vs 36%), This is in comparison to the overall mortality rate of 19.2%. Delay to surgery for elderly hip fracture patients was associated with an increase 30-day and 180-day morbidity and mortality rate. A greater proportion of patients transferred from peripheral hospitals experienced a delay in surgery. Early transfer and prioritization of such patients is recommended to achieve comparative outcomes for rural and remote Australians

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

This systematic review and meta-analysis aimed to compare the outcome of operative and non-operative management in adults with distal radius fractures, with an additional elderly subgroup analysis. The main outcome was 12-month PRWE score. Secondary outcomes included DASH score, grip strength, complications and radiographic parameters. Randomised controlled trials of patients aged ≥18yrs with a dorsally displaced distal radius fractures were included. Studies compared operative intervention with non-operative management. Operative management included open reduction and internal fixation, Kirschner-wiring or external fixation. Non-operative management was cast/splint immobilisation with/without closed reduction. Version 2 of the Cochrane risk-of-bias tool was used. After screening 1258 studies, 16 trials with 1947 patients (mean age 66yrs, 76% female) were included in the meta-analysis. Eight studies reported PRWE score and there was no clinically significant difference at 12 weeks (MD 0.16, 95% confidence interval [CI] −0.75 to 1.07, p=0.73) or 12 months (mean difference [MD] 3.30, 95% CI −5.66 to −0.94, p=0.006). Four studies reported on scores in the elderly and there was no clinically significant difference at 12 weeks (MD 0.59, 95% CI −0.35 to 1.53, p=0.22) or 12 months (MD 2.60, 95% CI −5.51 to 0.30, p=0.08). There was a no clinically significant difference in DASH score at 12 weeks (MD 10.18, 95% CI −14.98 to −5.38, p<0.0001) or 12 months (MD 3.49, 95% CI −5.69 to −1.29, p=0.002). Two studies featured only elderly patients, with no clinically important difference at 12 weeks (MD 7.07, 95% CI −11.77 to −2.37, p=0.003) or 12 months (MD 3.32, 95% CI −7.03 to 0.38, p=0.08). There was no clinically significant difference in patient-reported outcome according to PRWE or DASH at either timepoint in the adult group as a whole or in the elderly subgroup

Aims. To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years. Methods. A total of 100 patients were randomized in this non-inferiority trial, comparing cast immobilization with operation with a volar locking plate. Patients with displaced AO/OTA A and C fractures were eligible if one of the following were found after initial closed reduction: 1) dorsal angulation > 10°; 2) ulnar variance > 3 mm; or 3) intra-articular step-off > 2 mm. Primary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) after 12 months. Secondary outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE), EuroQol-5 dimensions 5-level questionnaire (EQ-5D-5L), range of motion (ROM), grip strength, “satisfaction with wrist function” (score 0 to 10), and complications. Results. In all, 89 women and 11 men were included. Mean age was 74 years (65 to 91). Nonoperative treatment was non-inferior to operation with a five-point difference in median QuickDASH after 12 months (p = 0.206). After three and six months QuickDASH favoured the operative group (p = 0.010 and 0.030). Median values for PRWHE were 19 (interquartile range (IRQ) 10 to 32) in the operative group versus ten (IQR 1 to 31) in the nonoperative group at three months (p = 0.064), nine (IQR 2 to 20) versus five (IQR 0 to 13) (p = 0.020) at six months, and two (IQR 0 to 12) versus zero (IQR 0 to 8) (p = 0.019) after 12 months. Range of motion was similar between the groups. The EQ-5D-5L index score was better (mean difference 0.07) in the operative group at three and 12 months (p = 0.008 and 0.020). The complication rate was similar (p = 0.220). The operated patients were more satisfied with wrist function (median 8 (IQR 6 to 9) vs 6 (IQR 5 to 7) at three months, p = 0.002; 9 (IQR 7 to 9) vs 8 (IQR 6 to 8) at six months, p = 0.002; and 10 (IQR 8 to 10) vs 8 (IQR 7 to 9) at 12 months, p < 0.001). Conclusion. Nonoperative treatment was non-inferior to operative treatment based on QuickDASH after one year. Patients in the operative group had a faster recovery and were more satisfied with wrist function. Results from previous trials comparing operative and nonoperative treatment for displaced distal radius fractures in the elderly vary between favouring the operative group and showing similar results between the treatments. This randomized trial suggests that most elderly patients may be treated nonoperatively. Cite this article: Bone Joint J 2021;103-B(2):247–255

Aims. Fracture of the odontoid process (OP) in the elderly is associated with mortality rates similar to those of hip fracture. The aim of this study was to identify variables that predict mortality in patients with a fracture of the OP, and to assess whether established hip fracture scoring systems such as the Nottingham Hip Fracture Score (NHFS) or Sernbo Score might also be used as predictors of mortality in these patients. Patients and Methods. We conducted a retrospective review of patients aged 65 and over with an acute fracture of the OP from two hospitals. Data collected included demographics, medical history, residence, mobility status, admission blood tests, abbreviated mental test score, presence of other injuries, and head injury. All patients were treated in a semi-rigid cervical orthosis. Univariate and multivariate analysis were undertaken to identify predictors of mortality at 30 days and one year. A total of 82 patients were identified. There were 32 men and 50 women with a mean age of 83.7 years (67 to 100). Results. Overall mortality was 14.6% at 30 days and 34.1% at one year. Univariate analysis revealed head injury and the NHFS to be significant predictors of mortality at 30 days and one year. Multivariate analysis showed that head injury is an independent predictor of mortality at 30 days and at one year. The NHFS was an independent predictor of mortality at one year. The presence of other spinal injuries was an independent predictor at 30 days. Following survival analysis, an NHFS score greater than 5 stratified patients into a significantly higher risk group at both 30 days and one year. Conclusion. The NHFS may be used to identify high-risk patients with a fracture of the OP. Head injury increases the risk of mortality in patients with a fracture of the OP. This may help to guide multidisciplinary management and to inform patients. This paper provides evidence to suggest that frailty rather than age alone may be important as a predictor of mortality in elderly patients with a fracture of the odontoid process. Cite this article: Bone Joint J 2019;101-B:253–259

Aims. Displaced, comminuted acetabular fractures in the elderly are increasingly common, but there is no consensus on whether they should be treated non-surgically, surgically with open reduction and internal fixation (ORIF), or with acute total hip arthroplasty (THA). A combination of ORIF and acute THA, an approach called ’combined hip procedure’ (CHP), has been advocated and our aim was to compare the outcome after CHP or ORIF alone. Patients and Methods. A total of 27 patients with similar acetabular fractures (severe acetabular impaction with or without concomitant femoral head injury) with a mean age of 72.2 years (50 to 89) were prospectively followed for a minimum of two years. In all, 14 were treated with ORIF alone and 13 were treated with a CHP. Hip joint and patient survival were estimated. Operating times, blood loss, radiological outcomes, and patient-reported outcomes were assessed. Results. No patient in the CHP group required further hip surgery, giving THA a survival rate of 100% (95% confidence interval (CI) 100 to 100) after three years, compared with 28.6% hip joint survival in the ORIF group (95% CI 12.5 to 65.4; p = 0.001). No dislocations or deep infections occurred in the CHP group. No patient died within the first year after index surgery, but patient survival was lower in the CHP group after three years. There were no relevant differences in patient-reported outcomes. Conclusion. The CHP confers a considerably reduced need of further surgery when compared with ORIF alone in elderly patients with complex acetabular fractures. These findings encourage both further use of, and larger prospective studies on, the CHP. Cite this article: Bone Joint J 2019;101-B:478–483

We compared case-mix and outcome variables in 1310 patients who sustained an acute fracture at the age of 80 years or over. A group of 318 very elderly patients (≥ 90 years) was compared with a group of 992 elderly patients (80 to 89 years), all of whom presented to a single trauma unit between July 2007 and June 2008. The very elderly group represented only 0.6% of the overall population, but accounted for 4.1% of all fractures and 9.3% of all orthopaedic trauma admissions. Patients in this group were more likely to require hospital admission (odds ratio 1.4), less likely to return to independent living (odds ratio 3.1), and to have a significantly longer hospital stay (ten days, p = 0.01). The 30- and 120-day unadjusted mortality was greater in the very elderly group. The 120-day mortality associated with non-hip fractures of the lower limb was equal to that of proximal femoral fractures, and was significantly increased with a delay to surgery > 48 hours for both age groups (p = 0.04). This suggests that the principle of early surgery and mobilisation of elderly patients with hip fractures should be extended to include all those in this vulnerable age group

Complex proximal humerus fractures account for 10% of fractures in patients over 65 years of age. With the emergence of new implants, there is growing trend towards surgical management of these types of fractures, despite the lack of clinical evidence of its superiority over a conservative option. Orthopaedic surgeons' perception plays a large role in the surgical decision making for complex proximal humerus fractures in the elderly. No studies have been conducted to date to examine factors that influence the surgical decision-making in orthopaedic surgeons in regards to these types of fractures. A self-administered questionnaire was sent to orthopaedic surgeons. It included demographic questions as well as clinical vignettes assessing the risk / benefit perception of orthopaedic surgeons in different situations. Orthopaedic surgeons self-reported the proportion of proximal humerus fractures that were treated surgically in patients during the last year. Univariate analyzes were conducted to identify the factors that influenced the operation rates. A total of 127 orthopaedic surgeons completed the questionnaire. The response rate was 37%. The risk / benefit perception of surgical management varied according to the type of practice, year of training, operation rate as well as the ease of the surgeon in performing shoulder procedures (p < 0.05). According to the queried surgeons, the most important factors affecting their decision-making were patient's age, the type of fracture, co-morbidities, level of independence and potential for rehabilitation. The type of surgery proposed varied depending on the training and familiarity of the surgeon with the procedure. The risk / benefit perception of orthopaedic surgeons regarding surgical treatment of proximal humerus fractures in elderly patients appears to vary widely. The decision to opt for surgical management is influenced by the surgeon's familiarity with the procedure, their year of training and their subspecialty. This study demonstrates the need to establish a decision-making tool to assist orthopaedic surgeons and patients with this clinical decision

Introduction. Distal femur fracture fixation in elderly presents significant challenges due to osteoporosis and associated comorbidities. There has been an evolution in the management of these fractures with a description of various surgical techniques and fixation methods; however, currently, there is no consensus on the standard of care. Non-union rates of up to 19% and mortality rates of up to 26 % at one year have been reported in the literature. Delay in surgery and delay in mobilisation post-operatively have been identified as two main factors for high rate of mortality. As biomechanical studies have proved better stability with dual plating or nail-plate combination, a trend has been shifting for past few years towards rigid fixation to allow early mobilisation. Our study aims to compare outcomes of distal femur fractures managed with either single plate (SP), dual plating (DP) or nail-plate construct (NP). Methods. A retrospective review of patients aged above 65 years with distal femur fractures (both native and peri-prosthetic) who underwent surgical management between June 2020 and May 2023 was conducted. Patients were divided into three groups based on mode of fixation - single plate or dual plating or nail-plate construct. AO/OTA classification was used for non-periprosthetic, and Unified classification system (UCS) was used for periprosthetic fractures. Data on patient demographics, fracture characteristics, surgical details, postoperative complications, re-operation rate, radiological outcomes and mortality rate were evaluated. Primary objective was to compare re-operation rate and mortality rate between 3 groups at 30 days, 6 months and at 1 year. Results. A cohort of 32 patients with distal femur fractures were included in this study. 91% were females and mean age was 80.97 (range 68–97). 18 (53%) were non-periprosthetic fracture and 14 (47%) were periprosthetic fractures.18 patients underwent single plate fixation (AO/OTA 33A – 8, 33B/C – 2, UCS V3B – 5, V3C – 3),10 patients had dual plate fixation (AO/OTA 33A – 1, 33B/C – 4, UCS V3B – 3, V3C – 2) and 4 patients underwent nail-plate combination fixation (AO/OTA 33A – 4). 70.5% patients had surgery within 36 hours of admission and 90% within 48 hours. Analysis showed no re-operation at 30 days, 6 months in all 3 groups. At 1 year one patient had re-operation in dual-plating periprosthetic group (Distal femur replacement done for failed fixation). Three patients (16%) in single plate group had re-operation at 2 years (2 for peri-implant fracture and 1 for infection). None of the patients treated with Nail-plate combination had re-operation. Mortality rate at 30 days was 0% in among all the 3 groups. At 6 months, it was 16% in single plate group and 0% in DP and NP groups at 6 months and at 1 year mortality rate was 27% in SP group, 10% in DP and 0% in NP group. Combined mortality rate was 0% at 30 days, 9% at 6 months and 18.7% at one year. Conclusion. Our analysis provides insights into fixation methods of distal femur fractures in elderly patients. We conclude that a lower re-operation rate and mortality rate can be achieved with early surgery and rigid fixation with either dual plating or nail-plate construct to allow early mobilisation. Further prospective studies are warranted to confirm these findings and guide the selection of optimal surgical strategies for these challenging fractures

Aims. The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip. Methods. In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day. Results. Homogeneity with respect to baseline characteristics was ensured between groups. The mean total blood loss was significantly lower in patients who received TXA (902.4 ml (-279.9 to 2,156.9) vs 1,226.3 ml (-269.7 to 3,429.7); p = 0.003), while the likelihood of requiring a transfusion of at least one unit of red blood cells was reduced by 22%. Subgroup analysis showed that these differences were larger in patients who had an IT fracture compared with those who had a subcapital fracture. Conclusion. Elderly patients who undergo intramedullary nailing for an IT fracture can benefit from a single dose of 15 mg/kg TXA before the onset of surgery. A similar tendency was identified in patients undergoing hemiarthroplasty for a subcapital fracture but not to a statistically significant level. Cite this article: Bone Joint J 2021;103-B(3):442–448

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

Management of acetabular fractures in the elderly population remains somewhat controversial in regards to when to consider is open reduction internal fixation (ORIF) versus acute primary total hip. study aims to (1) describe outcome of this complex problem and investigate predictors of successful outcome. This retrospective study analyzes all acetabular fractures in patients over the age of 60, managed by ORIF at a tertiary trauma care centre between 2007 and 2018 with a minimum follow up of one year. Of the 117 patients reviewed, 85 patients undergoing ORIF for treatment of their acetabular fracture were included in the analysis. The remainder were excluded based management option including acute ORIF with THA (n=10), two-stage ORIF (n=2), external fixator only (n=1), acute THA (n=1), and conservative management (n=1). The remainder were excluded based on inaccessible medical records (n=6), mislabelled diagnosis (n=6), associated femoral injuries (n=4), acetabular fracture following hemiarthroplasty (n=1). The mean age of the cohort is 70±7 years old with 74% (n=62) of patients being male. Data collected included: demographics, mechanism of injury, Charlson Comorbidity Index (CCI), ASA Grade, smoking status and reoperations. Pre-Operative Radiographs were analyzed to determine the Judet and Letournel fracture pattern, presence of comminution and posterior wall marginal impaction. Postoperative radiographs were used to determine Matta Grade of Reduction. Outcome measures included morbidity-, mortality- rates, joint survival, radiographic evidence of osteoarthritis and patient reported outcome measures (PROMs) using the Oxford Hip Score (OHS) at follow-up. A poor outcome in ORIF was defined as one of the following: 1) conversion to THA or 2) the presence of radiographic OA, combined with an OHS less than 34 (findings consistent with a hip that would benefit from a hip replacement). The data was analyzed step-wise to create a regression model predictive of outcome following ORIF. Following ORIF, 31% (n=26) of the cohort had anatomic reduction, while 64% (n=54) had imperfect or poor reduction. 4 patients did not have adequate postoperative radiographs to assess the reduction. 31 of 84 patients undergoing ORIF had a complication of which 22.6% (n=19) required reoperation. The most common reason being conversion to THA (n=14), which occurred an average of 1.6±1.9 years post-ORIF. The remainder required reoperation for infection (n=5). Including those converted to THA, 43% (n=36) developed radiographic OA following acetabular fracture management. The mean OHS in patients undergoing ORIF was 36 ± 10; 13(16%) had an OHS less than 34. The results of the logistic regression demonstrate that Matta grade of reduction (p=0.017), to be predictive of a poor outcome in acetabular fracture management. With non-anatomic alignment following fixation, patients had a 3 times greater risk of a poor outcome. No other variables were found to be predictive of ORIF outcome. The ability to achieve anatomic reduction of fracture fragments as determined by the Matta grade, is predictive of the ability to retain the native hip with acceptable outcome following acetabular fracture in the elderly. Further research must be conducted to determine predictors of adequate reduction in order to identify candidates for ORIF

Aims. Low haemoglobin (Hb) at admission has been identified as a risk factor for mortality for elderly patients with hip fractures in some studies. However, this remains controversial. This study aims to analyze the association between Hb level at admission and mortality in elderly patients with hip fracture undergoing surgery. Patients and Methods. All consecutive patients (prospective database) admitted with hip fracture operated in a tertiary hospital between 2012 and 2016 were analyzed. We collected patient characteristics, time to surgery, duration and type of surgery, comorbidities, Hb at admission, nadir of Hb after surgery, the use and amount of red blood cells (RBCs) transfusion products, postoperative complications, and death. The main outcome measures were mortality at 30 days, 90 days, 180 days, and one year after surgery. Results. We included 829 patients; the mean age was 81 years (. sd. 11). Mortality at 30 days, 90 days, 180 days, and one year was 5.7%, 12.3%, 18.1%, and 23.5%, respectively. The highest mortality was observed in patients aged over 80 years (162/557, 29%) and in male patients (85/267, 32%). Survival at 90 days, 180 days, and one year after surgery was significantly lower in patients with a Hb level below 120 g/l at admission. In multivariate analysis, Hb level below 120 g/l at admission was found to be an independent factor associated with mortality (adjusted hazard ratio (aHR) 1.68 (95% confidence interval (CI) 1.22 to 2.31); p = 0.001), along with age (aHR 1.06 (95% CI 1.04 to 1.06); p < 0.001), male sex (aHR 2.19 (95% CI 1.61 to 2.96); p < 0.001), and need for RBC transfusions (aHR 1.10 (95% CI 1.02 to 1.19); p = 0.01). Conclusion. Our results suggest that low Hb at admission along with age and RBC transfusions is significantly associated with short- and long-term mortality after hip fracture surgery, independently of comorbidity confounders. Further studies should be performed to understand how preoperative Hb could be taken into account in perioperative management. Cite this article: Bone Joint J 2019;101-B:1122–1128

Fracture neck of femur (NOF) in elderly is a serious debilitating injury and has been presenting in increasing proportions. Some of these patients are unfortunate to come back with a contralateral injury. We attempted at looking into the incidence of these episodes in a cohort attending our trust and compared various parameters. We retrospectively assessed our hospital theatre data for fracture NOF in patients over 60 years in the last 3 years. We reviewed their demographics, mode of injury, time to contralateral injury, incidence of any other insufficiency fracture, operative procedure and any complications. There were 1435 patients who underwent surgery for fracture NOF over the 3 years. Forty-three of these had bilateral fractures. Females had 3 times more incidence as compared to males; average age at first injury was 84 years and at contralateral side was 85 years. Time between the two injuries ranged from 20 to 855 days (Median 242 days). Almost equal incidence of intra / extracapsular fractures was noted. Contralateral fracture pattern (Intra vs Extracapsular) for the was similar in 34 patients. Twelve patients had an associated insufficiency fracture. Fracture NOF in elderly is a rising epidemic. Only 3% of these patients suffer a contralateral fracture NOF which usually occurs within a year. The fracture pattern is frequently similar to the first fracture in and hence similar implants have been used. Only 21% patients were on bone protection medications. It is rather difficult to identify this small group and hence prevent a second contralateral incident

We have examined the accuracy of reduction and the functional outcomes in elderly patients with surgically treated acetabular fractures, based on assessment of plain radiographs and CT scans. There were 45 patients with such a fracture with a mean age of 67 years (59 to 82) at the time of surgery. All patients completed SF-36 questionnaires to determine the functional outcome at a mean follow-up of 72.4 months (24 to 188). All had radiographs and a CT scan within one week of surgery. The reduction was categorised as ‘anatomical’, ‘imperfect’, or ‘poor’. Radiographs classified 26 patients (58%) as anatomical,13 (29%) as imperfect and six (13%) as poor. The maximum displacement on CT showed none as anatomical, 23 (51%) as imperfect and 22 (49%) as poor, but this was not always at the weight-bearing dome. SF-36 scores showed functional outcomes comparable with those of the general elderly population, with no correlation with the radiological reduction. Perfect anatomical reduction is not necessary to attain a good functional outcome in acetabular fractures in the elderly

The aim was to predict the number and incidence of distal radius fractures in Scotland over the next two decades according to age group, categorised into under 65yrs(<65) and 65yrs and older (≥65), and estimate the potential increased operative burden of this. The number of distal radius fracture in Scotland was isolated from the Global Burden of Disease database and this was used, in addition to historic population data and population estimates, to create a multivariable model allowing incorporation of age group, sex and time. A Negative Binomial distribution was used to predict incidence in 2030 and 2040 and calculate projected number of fractures according to the population at risk. A 20.4% operative intervention rate was assumed in the ≥65 group (local data). In terms of number of fractures, there was a projected 61% rise in the ≥65 group with an overall increase of 2099 fractures per year from 3417 in 2020 (95% confidence interval (CI) 2960 – 3463) to 5516 in 2040 (95% CI 4155–5675). This was associated with 428 additional operative interventions per year for those ≥65yrs. The projected increase between 2020 and 2040 was similar in both sexes (60% in females, 63% in males), however the absolute increase in fracture number was higher in females (2256 in 2020 [95% CI 1954–2287] to 3620 in 2040 [95% CI 2727–3721]) compared to males (1160 [95% CI 1005–1176] to 1895 [95% CI 1427–1950]). There was a 4% projected fall in the number of fractures in those <65. Incidence of distal radius fractures is expected to considerably increase over the next two decades due to a projected increase in the number of fractures in the elderly. This has implications for the associated morbidity and healthcare resource use

Abstract. Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities

Abstract. Background. Fractures Proximal humerus account for nearly 10 % of geriatric fractures. The treatment options varies. There is no consensus regarding the optimal treatment, with almost all modalities giving functionally poor outcomes. Hence literature recommends conservative management over surgical options. MULTILOC nail with its design seems to be a promising tool in treating these fractures. We hereby report our early experience in the treatment of 37 elderly patients. Objectives. To evaluate the radiological outcome with regards to union, collapse, screw back out/cut through, implant failures, Greater tuberosity migration. To evaluate the functional outcome at the end of 6 months using Constant score. Study Design & Methods. All patients aged >65 years who underwent surgery for 3,4-part fracture proximal humerus using the MULTILOC nail were included in the study after consent. Pre – existing rotator cuff disease were excluded. Within the time frame, a total of 39 patients underwent the said surgery. 2 patients were lost to follow up. All the measurements were taken at the end of 6 months and results tabulated and analysed. Results. Union was achieved in all the 37 patients. There were no varus collapse or screw backout/cut through seen in any of the patients. There was Greater tuberosity migration in 1 patient who underwent revision surgery at 6 weeks. All the patients got a minimum of 70 degrees of abduction and forward flexion. We had 29 excellent, 6 good, 2 fair and none poor results as per Constant scoring system. Study done in Tejasvini Hospital & SSIOT Mangaluru India

Background. Polypharmacy of elderly trauma patients entails further difficulties in addition to the fracture treatment. Impaired renal function, altered metabolism and drugs that are potentially delirious or inhibit ossification, are only a few examples which must be carefully considered for the medication in elderly patients. The aim of this study was to investigate, if medication errors could be prevented by orthogeriatric comanagement compared to conventional trauma treatment. Material and methods. In a superregional traumacenter based on two locations in Munich, all patients ≥ 70 years with proximal femur fracture were consecutively recorded in a period of 3 months. After the end of the treatment the medical records of each patient were analyzed. At the hospital location 1 the treatment was carried out without orthogeriatric comanagement, at the hospital location 2 with this concept (DGU-certified orthogeriatric center). In addition to the basic medication all newly added drugs were recorded as well as changes in the medication plan and also wether treatment was carried out by the geriatrician or the trauma surgeon. Based on the START / STOPP criteria for the medication of geriatric patients, we defined “no-go” drugs with the geriatrician of the orthogeriatric center which should be avoided in the orthogeriatric patient (including benzodiazepines, gyrase inhibitors, NSAID like Ibuprofen with impaired GFR). The statistical analysis was done with the chi-square-test (IBM SPSS Statistics 24). Results and conclusion. A total of 46 patients were included, 37 of them female and 9 male with an average age of 84,5 years (SD±6.8). At the location without a geriatrician (18 patients), a prescription of one or more “no-go” drugs was found in 9 patients, whereas in location 2 (28 patients) only in 3 patients (p=0.003). Besides that, at the location with the geriatrician, a change in the medication was made for 17 patients during their stay in hospital. This shows that with the fixed integration of the geriatrician into the trauma surgical team, errors in the medication of the patients could be significantly more frequent avoided or faster detected and corrected. Although this should not limit the responsibility of the rest of the team, there is no doubt about the importance of the interdisciplinary treatment of elderly trauma patients

Traditionally, open reduction and internal fixation (ORIF) and hemiarthroplasty (HA) have been the surgical treatments of choice for displaced proximal humerus fractures (PHF) despite high rates of fixation failure and tuberosity nonunion, especially in the elderly population with poor bone quality. Recently, there has been a significant increase in the use of reverse total shoulder arthroplasty (RTSA) as a treatment option in both acute fractures, as well as a salvage procedure for fracture sequelae (i.e., malunion, nonunion, fixation failure, tuberosity non-union). Despite the growing enthusiasm it remains unknown whether functional outcomes after RTSA as a salvage procedure are similar to those following acute RTSA. As a result, the purpose of this systematic review was to compare functional outcomes after RTSA as a primary versus salvage procedure for displaced PHF in the elderly. A literature search of the electronic databases EMBASE, MEDLINE, and PubMed was conducted to identify all studies comparing RTSA as a primary treatment for displaced PHF and as a salvage procedure for failed initial management. Only studies with a minimum follow-up of two years were included. Data pertaining to range of motion, patient reported outcome measures and complications were extracted from eligible studies and entered into a meta-analysis software package (RevMan version 5.1, The Cochrane Collaboration) for pooled analysis. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of eligible studies. The search identified four studies consisting of 200 patients with a mean age of 73.3 years and a mean follow-up of 3.2 years. There were a total of 76 patients (75% female) who underwent acute RTSA following displaced PHF, while 124 patients (77% female) required salvage RTSA for failure of initial treatment. Primary RTSA was found to have significantly higher American Shoulder and Elbow (ASES) (P = 0.04), Constant (P = 0.01) and University of California at Los Angeles (UCLA) (P = 0.0004) scores compared to salvage RTSA. Forward flexion (P = 0.001) and external rotation (P< 0.0001) were significantly greater amongst those undergoing RTSA acutely versus as a salvage procedure. The odds of having a complication (e.g., infection, dislocation, fracture) were 76% lower amongst those who had primary RTSA compared to salvage RTSA (P = 0.02). The overall quality of eligible studies was moderate to high. Based on the current available evidence, elderly patients with displaced PHF have significantly greater range of motion, higher patient reported outcomes and lower risk of complications with primary RTSA compared to those undergoing RTSA as a salvage procedure. Additional prospective studies are warranted to confirm these findings

Background. Recently, a larger number of elderly individuals with osteoporosis has undergone total knee arthroplasty (TKA). Intuitively, such vulnerable bone condition should deteriorate post-TKA functional recovery compared to a non-osteoporotic condition, but this hypothesis has not been directly examined. Methods. To address this issue, we analysed prognosis of patients who underwent TKA in Toranomon Hospital in Japan between April 2016 and March 2017 (27 of 40 cases, age 75.0±8.2 years old, BMI 24.5±3.1), and evaluated effects of osteoporosis on the changes in functions of the knees three/six/twelve months after the operation. The knee functions were quantified based on Knee Society Score (KSS), and the severity of the pre-operative osteoporosis was evaluated by T-score. We examined the relationships between these scores using multiple regression analyses with age, BMI, and sex as covariates. We excluded patients with rheumatoid arthritis. Results. The multiple regression analyses revealed that the severity of osteoporosis (T-score) before TKA did not have sufficient explanatory powers for either type of KSS (for Knee Score, adjusted R2 ≤ 0.16; for Functional Score, adjusted R2 ≤ 0.15). In addition, Pearson correlation coefficients between the pre-operative osteoporosis severity and KSS were weak (for Knee Score, |r| < 0.07, P > 0.78; for Functional Score, |r| < 0.27, P > 0.21; Fig 1). This tendency was qualitatively preserved even when we repeated these analyses for each sex group. Conclusions. These analyses suggest that counterintuitively, pre-operative osteoporosis does not significantly deteriorate the functional outcome of TKA in the elderly population. Although longer observations of larger samples will be needed, the current findings indicate the possibility that we may not have to hesitate over TKA even for osteoporotic patients. For any figures or tables, please contact the authors directly

Aim. European population is ageing concurrently with an increase number of arthroplasties. Prosthetic joint infection (PJI) in the elderly is considered more severe. The aim of this study is to describe PJI's management of patients over 79 years of age. Methods. We conducted a retrospective study including all patients aged over 79 years old consulting for a suspected hip or knee PJI in our community hospital where a complex bone and joint unit is present. Results. From 2007 to 2015, among the 366 patients who consulted for a PJI suspicion, 44 were older than 79. In this group, median age was 81.5 and 52% were women. A significant comorbidity was present in 24 patients among them 9 were diabetic. Location of suspected PJI was hip for 24 patients and 52% of the patients had a PJI background. Median time from the first arthroplasty was 8 years, however 17 had already an exchange. We classified the presentation as early (before 3 months after surgery, n=7), delayed (3 to 24 months, n=9) and late (more than 24 months, n=28). Pain was the first symptom, 9 presented fever and 10 had a sinus tract communication. Median C-reactive protein rate was 64 mg/l. Pre-operative synovial fluid analysis was performed in 34 patients, the concordance with intra-operative samples was 44%. A surgery was performed in 86% of the patients corresponding in five retentions, 17 one-time and 13 two-time exchange, 2 arthrodesis and one resection of arthroplasty. Coagulase-negative Staphylococcus (n=14), Staphylococcus aureus (n=10) and Enterobacteriaceae (n=5) were the principal microorganisms identified. Antibiotherapy median duration was 10 days for intravenous regimens and 45 days for total treatment. We noted 4 catheter-related infections and 9 side effects of antibiotics. A prolonged antibiotic suppressive therapy was performed for 8 patients (18%). With a median time of follow-up of 21.5 months, we notified 13 failures (30%) and 5 deaths (11%). After the episode, 5 patients could not standup, a walking stick was necessary for 11 patients, 2 for 5 patients while 13 recovered a relatively good autonomy. Conclusion. PJI in elderly people is a severe complication with a significant morbidity but palliative treatment is not the first alternative. We showed acceptable outcomes with more invasive managements. These data need to be compared with younger population in a second analysis

This study aims to investigate that a single dose of tranexamic acid (TXA) will reduce blood loss and transfusion rates in elderly patients, undergoing intertrochanteric (IT) or femoral neck fractures surgery. Consecutive elderly patients receiving hip fracture surgery for stable or unstable IT fracture, treated with short intramedullary nail (IMN) insertion as well as cemented hemiarthroplasty for acute femoral neck (subcapital) hip fracture, were screened for inclusion in this single-centre randomized trial. Patients were randomly allocated to a study group by sealed envelope. One TXA dose of 15 mg/kg i.v. diluted in 100 ml N/S or one placebo dose i.v. in 100 ml N/S were administered 5 mins before the skin cut. Haemoglobin (Hb) concentration was measured at admission time and prior to surgery. Post-operatively it was measured on a daily basis until day 4, giving a total of four Hb measurements (days 1 to 4). The transfusion trigger point was determined in accordance with the French guidelines for erythrocyte blood transfusion. The transfusion trigger was 10 g/dl for patients at risk, while in all other cases, it was 9 g/dl. Information regarding the transfusions number was assessed directly by the hospital blood bank database. Blood loss was calculated by the Hb dilution method. Nadler's formula was used to calculate patients' blood volume. For calculation of total blood loss (TBL) expressed to total Hb loss and total Volume loss, the number of transfusions (55 grams of Hb per transfusion), the Hb concentration on preoperatively (Hgbi) and the Hb concentration on the last measure (Hgbe) were used. (Hb balance method). The primary efficacy outcome was the number of transfusions of allogeneic RBC from surgery up to day 4. The secondary ones were the total blood loss from surgery to day 4 as it was calculated by Hb-balance method. After randomization, 35 patients with femoral neck fracture and 30 patients with IT fracture received TXA prior to surgery. Respectively, 30 patients with femoral neck fracture and 55 with IT fracture didn't receive TXA. The groups did not differ significantly in their basic demographics (age, gender, BMI, injury mechanism, ASA score, co-morbidities). Results showed that patients undergoing hemiarthroplasty after receiving TXA, were transfused with less allogeneic RBC and had less total blood loss than patients that didn't receive TXA, but without statistical significance. While patients treated with IMN in the TXA group received a significantly lower number of RBC units than the control group (1.28 ± 1.049 vs 2.075 ± 1.685), (P = 0.0396), had a significantly lower loss of Hb (98.59 ± 55.24 vs 161.6 ± 141.7), (P = 0.0195) and a lower total blood volume loss (951.3 ± 598.9 ml vs 1513 ± 1247 ml), (P = 0.023). This trial confirmed TXA administration efficacy in reducing blood loss and transfusion rate in elderly patients undergoing hip fracture surgery. A TXA single dose may be a safer option, taking into account these patients' physiological status and co-morbidities

Introduction. Aged trauma patients with proximal femur fractures are prone to various complications. They may be associated with their comorbidities which also need to be adressed. These complications limit the patient”s postoperative health status and subsequently their activity and independency. As an attempt to improve the postoperative management of aged hip fracture patients a better understanding of the postoperative condition in these patients is necessary. Therefore, this meta-analysis is intended to provide an overview of postoperative complications in the elderly hip fracture patients and to improve the understanding of an adequate postoperative management. Material and method. Medline was used to screen for studies reporting on the complication rates of hip fracture patients > 65 years. The search criteria were: “proximal femur fracture, elderly, complication”. In addition to surgical studies, internal medicine and geriatric studies were also included. Randomized studies, retrospective studies as well as observation studies were included. Furthermore, reoperation rates as well as treatment-related complications were recorded. The 1-year mortality was calculated as outcome parameter. Results. Overall 54 studies were enrolled, published between 2011 and 2016. The mean age of the 9812 patients was 81 years (65–99 years). Follow-up was at least one year. The reoperation rate after osteosynthesis of pertrochanteric femur fractures was 8.7%. The reoperation rate was dependent on the type of fracture and the surgical method. Pneumonia (9,5%) and urinary tract infections (27%) were the most common postoperative infections. With 23%, delirium was one of the most common medical complications. The 1-year mortality rate was 18.7%. Conclusion. Orthogeriatric patients represent a complex patient population. Addressing the special needs of elderly patients reduces postoperative complications. Establishing comanagement or orthogeriatric wards can also be helpful to manage comorbidities and postoperative complications. It is important to not only choose the proper surgical procedure but to monitor orthogeriatric patients closely during their hospitalization

The number of Americans over the age of 80 is increasing at a faster rate than that of the 65–80 population. The cohort age 85–94 years had the fastest rate of growth from 2000–2010. The number of Americans older than 95 years grew at approximately 26% during the same period. This rapid growth has been associated with an increasing incidence of osteoarthritis of the hip and knee in this population. This surge in the growth rate of the elderly population has coincided with an increasing demand for primary and revision total joint arthroplasty. Surgeons need to be prepared to perform safely and appropriately these procedures in this rapidly growing segment of the population. Surgeons need to be aware of the 1) clinical outcomes that can be expected when total joint procedures are performed in this group of patients; 2) the morbidity and mortality associated with the performance of these procedures; and 3) the relative cost effectiveness of these interventions. Clinical outcomes of TJA in this population are generally good. Pain and satisfaction scores are similar to those of younger patients. Although pre-operative pain and functional impairment scores are higher pre-operatively in elderly patients, these improve significantly following TJA. However, functional outcome scores decline noticeably after 5 years, reflecting the impact of coexistent comorbidities. The continued need for assistive devices is greater in this age group than in younger total joint patients. The risk of falls, a particular issue of concern in this age group, is reduced after total hip and knee surgery. The rate of complications, including mortality, following TJA in this age group is greater than in the 65–79-year-old group. The use of hospitalists to co-manage peri-operative care is particularly important in this age group. The increased rate of complications is associated with longer lengths of stay. However, the length of stay for this age group after primary total joint replacement is decreasing significantly; reflecting the widespread streamlining of peri-operative care that is being incentivised and implemented nationwide. The use of extended care facilities is also greater in this age group. The performance of revision TJA in this age group is particularly challenging. The rates of revision in elderly patients are anticipated to rise significantly in coming years. Although revision TJA is associated with significant pain relief and patient satisfaction, it is accompanied by mortality and complication rates that are substantially greater than those in younger age groups

Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail. The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open. . The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture. . A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices. Cite this article: Bone Joint J 2014; 96-B:817–22

This study describes the epidemiology and outcome of 637 proximal humeral fractures in 629 elderly (≥ 65 years old) patients. Most were either minimally displaced (n = 278, 44%) or two-part fractures (n = 250, 39%) that predominantly occurred in women (n = 525, 82%) after a simple fall (n = 604, 95%), who lived independently in their own home (n = 560, 88%), and one in ten sustained a concomitant fracture (n = 76, 11.9%). The rate of mortality at one year was 10%, with the only independent predictor of survival being whether the patient lived in their own home (p = 0.025). Many factors associated with the patient’s social independence significantly influenced the age and gender adjusted Constant score one year after the fracture. More than a quarter of the patients had a poor functional outcome, with those patients not living in their own home (p = 0.04), participating in recreational activities (p = 0.01), able to perform their own shopping (p < 0.001), or able to dress themselves (p = 0.02) being at a significantly increased risk of a poor outcome, which was independent of the severity of the fracture (p = 0.001). A poor functional outcome after a proximal humeral fracture is not independently influenced by age in the elderly, and factors associated with social independence are more predictive of outcome. Cite this article: Bone Joint J 2014;96-B:970–7

Introduction. Electrolyte imbalance in the elderly is a clinical problem faced by both elderly care physicians and orthopaedic surgeons alike. Hyponatraemia is a common condition with a vague clinical profile and severe consequences if untreated. Recent medical editorials have criticised orthopaedic handling of this problem. We therefore sought to establish the incidence of hyponatraemia within our orthopaedic population and a similar age-matched elderly care population in the light of changing attitudes to fluid management. Methods. Retrospective, consecutive analysis of the serum sodium concentrations and fluid regimes of all patients admitted with a fractured neck of femur during a three-month period. An age-matched control group of elderly care patients was used for comparison. Data was analysed using paired t-test and independent t-test as appropriate. Results. 200 patients were identified, 100 in each group. There was no loss to follow-up. The mean admission serum sodium of all patients studied was 135.7mmol/L (SD=5.4). Comparison of two groups showed no statistical significant difference between them (t(198)=0.70, p=0.49). The mean follow-up sodium was 136.6mmol/L (SD=4.5). Comparison of two groups again showed no difference (t(198)=0.64, p=0.52). While the mean levels were greater than 135.0mmol/L in both groups the actual percentage of cases presenting to hospital with hyponatraemia were 29% in the hip fracture group and 33% in the elderly care group. This compared poorly with previously quoted levels of approximately 15% elderly admissions in other studies. We also noted that of those patients that were hyponatraemic on admission, the majority remained hyponatraemic during their hospital stay. Discussion. This study underlines the high incidence of hyponatraemia within the elderly orthopaedic population. It also demonstrates that there is no statistically significant difference in the incidence of hyponatraemia between the elderly orthopaedic population and the general elderly population, both before operative intervention and thereafter

Aims. As the population ages, there is projected to be an increase in the level of demand for total knee arthroplasty (TKA) in octogenarians. We aimed to explore whether those aged ≥ 80 years achieved similar improvements in physical function to younger patients while also comparing the rates of length of stay (LOS), discharge to rehabilitation, postoperative complications, and mortality following TKA in older and younger patients. Patients and Methods. Patients from one institution who underwent primary elective TKA between 1 January 2006 and 31 December 2014 were dichotomized into those ≥ 80 years old (n = 359) and those < 80 years old (n = 2479) for comparison. Multivariable regression was used to compare the physical status component of the 12-Item Short-Form Health Survey (SF-12), LOS, discharge to rehabilitation, complications, and mortality between the two groups. Results. Both age groups demonstrated a clinically meaningful improvement in their self-reported physical health relative to their baseline with no clinically relevant difference noted between them. Being ≥ 80 years old was associated with a 0.58-day increase in LOS and older patients were more likely to be discharged to rehabilitation (odds ratio (OR) 3.06, p < 0.001). Medical complications and mortality were higher in elderly patients (OR 1.92 for complications, p < 0.001; hazard ratio 3.40 for death, p < 0.001). There was no statistically significant association between age group and experiencing a postoperative surgical or wound-related complication. Conclusion. Those aged over 80 years achieved a statistically significant lower median SF-12 physical score than the younger group, after adjusting for the preoperative score, but this difference of 4.46 was not considered to be clinically meaningful. However, clinicians should be aware that the elderly are at a higher risk of experiencing longer hospital stays, postoperative medical complications, and mortality. Cite this article: Bone Joint J 2018;100-B:1463–70

Aims. Rates of mortality as high as 25% to 30% have been described following fractures of the odontoid in the elderly population. The aim of this study was to examine whether easily identifiable variables present on admission are associated with mortality. . Patients and Methods. A consecutive series of 83 elderly patients with a fracture of the odontoid following a low-impact injury was identified retrospectively. Data that were collected included demographics, past medical history and the results of blood tests on admission. Radiological investigations were used to assess the Anderson and D’Alonzo classification and displacement of the fracture. The mean age was 82.9 years (65 to 101). Most patients (66; 79.5%) had a type 2 fracture. An associated neurological deficit was present in 11 (13.3%). All were treated conservatively; 80 (96.4%) with a hard collar and three (3.6%) with halo vest immobilisation. Results. The rate of mortality was 16% (13 patients) at 30 days and 24% (20 patients) at one year after injury. A low serum level of haemoglobin and the presence of a neurological deficit on admission were independent predicators of mortality at 30 days on binary logistic regression analysis. A, low level of haemoglobin, admission from an institution, a neurological deficit and type 3 fractures were independent predictors of mortality at one year. . Conclusion. We suggest that these easily identifiable predictors present on admission can be used to identify patients at high risk and guide management by a multidisciplinary team. Cite this article: Bone Joint J 2017;99-B:116–21

Open lower limb fractures are resource-intensive fractures, accounting for a significant proportion of the workload and cost of orthopaedic trauma units. A recent study has evaluated that the median cost of direct inpatient treatment of open lower-limb fractures in the National Health Service (NHS) is steep, at £19189 per patient. Healthcare providers are expected to be aware of the costs of treatments, although there is very limited dissemination of this information, neither on a national or local level. Older adults (>65 years old) are at an increased risk of the types of high-energy injuries that can result in open lower limb fractures. Generally, there remains a significant lack of literature surrounding the cost of open fracture management, especially in specific patient groups that are disproportionately affected by these fractures. This study has calculated the direct inpatient care costs of older adults with open lower limb fractures. Open lower limb fractures in adult patients over 65 years old treated at Addenbrooke's Hospital of Cambridge University Hospitals NHS Trust were identified over the period of March 2014-March 2019. Isolated fractures of the femur, tibia and fibula over this time period were included. Direct inpatient care costs were calculated using information about the sustained fracture, operative time, implant(s) and theatre kit(s) used, the number of patient bed-days on the orthopaedic ward and critical care unit, and the number of hours of inpatient physiotherapy received. Direct inpatient care costs were compared with the income received by our centre for each of these cases, according to Healthcare Resource Group (HRG) cost codes. Our data was also compared with existing literature on Patient Level Costing (PLC) figures for open lower limb fractures. We extracted data from 58 patients over the age of 65 years treated for open isolated lower limb fractures at Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, between March 2014 and March 2019. The median cost of inpatient care calculated in this study was £20,398 per patient, resulting in a financial loss to the hospital of £5113 per patient. When the results were disaggregated by sex, the median cost for an open lower limb fracture in a male patient was £20,886 compared to £19,304 in a female patient. Data were also disaggregated by the site of injury, which produced a median cost for an open femur fracture of £23,949, and £24,549 and £15,362 for open tibia and ankle fractures, respectively. The absence of published primary literature and clinical audits on this topic continues to hinder the inclusion of cost-effectiveness as an important factor in clinical decision-making. This study provides valuable insight into the true cost of open lower limb fractures in a key patient population in a Major Trauma Centre in England and highlights the large losses incurred by hospitals in treating these cases. These results support the revision of the remuneration structures in the NHS for the treatment of elderly patients with these injuries

Background. This clinical study aims to establish the rate of operative inadvertent hypothermia (IH) in elderly hip fracture patients (>65 years old). We postulate that differences exist in risk factors and hypothesised poorer outcomes in patients with IH. Methods. A single centre, retrospective study of 929 hip fracture patients managed operatively between June 2015 and July 2017 was conducted. Patients’ demographic, anaesthetic and surgical variables were analysed together with outcomes for length of stay (LOS), 30-day re-admissions, and 30-day mortality. Results. Overall rates of IH in elderly hip fracture patients undergoing surgery were 10%, with increasing age as a risk factor (p = 0.005). There was trend towards IH in patients receiving sliding hip screw (SHS) (p = 0.079). No difference in LOS was observed between IH and normothermic patients (8.9 ± 7.1 versus 8.6 ± 4.9, p= 0.51). 30-day re-admissions were 18.5% for IH patients versus 7.8% in normothermic patients (p<0.001). There was a trend towards a higher 30-day mortality (p = 0.089), and a significantly higher mortality in IH patients undergoing SHS (p = 0.014). Conclusion. Rates of IH are high in operatively managed hip fracture patients. IH is significantly associated with a higher 30-day readmission rate with a trend towards higher 30-day mortality. This study mandates an examination of strategies for maintaining normothermia in operatively managed elderly hip fracture patients

We studied the effect of vitamin C on fracture healing in the elderly. A total of 80 elderly Osteogenic Disorder Shionogi rats were divided into four groups with different rates of vitamin C intake. A closed bilateral fracture was made in the middle third of the femur of each rat. Five weeks after fracture the femora were analysed by mechanical and histological testing. The groups with the lower vitamin C intake demonstrated a lower mechanical resistance of the healing callus and a lower histological grade. The vitamin C levels in blood during healing correlated with the torque resistance of the callus formed (r = 0.525). Therefore, the supplementary vitamin C improved the mechanical resistance of the fracture callus in elderly rats. If these results are similar in humans, vitamin C supplementation should be recommended during fracture healing in the elderly

Aim: An epidemiological analysis of spontaneous community acquired septic arthritis cases in an elderly population at a university teaching hospital. Method: We studied confirmed cases of spontaneous septic arthritis in the over 65 population. Patients with prosthetic joint infections were excluded from the study. We analysed data relating to initial presenting complaint and clinical examination, haematological and microbio-logical tests along with ultimate patient outcome. Results: There were 7 confirmed cases of spontaneous septic arthritis in over 65 population in the last 6 months (2 hips, 5 knees). The mean age was 72.14 (range 65–82) with a mean length of stay of 49 days. Those with septic arthritis of the knee presented with swelling, pain and immobility. Hip cases presented with pain and immobility. All patients were systemically well at time of presentation, with no other foci of infection detected after septic screening. All patients had aspirate and arthroscopic/arthrotomy confirmed infection. Staphylococcus Aureus was isolated from 6 joint aspirations and Pseaudomonas Auruginosa from one patient. Complications of treatment included acute renal failure, cardio/respiratory failure, disseminated infection and death (1 case). Conclusion: Septic arthritis must be considered as a differential diagnosis in all patients with joint pain, swelling and immobility. This diagnosis is not confined to the paediatric population. A backround of degenerative disease and the occult presentation in the elderly may delay diagnosis. Sepsis must be considered in the elderly with joint pathology, with treatment initiated in a prompt and aggressive manner to prevent the sequelae that ensues

Internal fixation remains the treatment of choice for non-displaced femoral neck fractures in elderly patients, whereas, arthroplasty is preferred for displaced fracture patterns. Given technological advancements in implant design and excellent long-term outcomes, arthroplasty may provide improved outcomes for the treatment of non-displaced femoral neck fractures. The aim of our study was to conduct a systematic review of the orthopaedic literature (1) to investigate the outcomes of internal fixation for the treatment of non-displaced and minimally displaced femoral neck fractures in elderly patients and (2) to compare the outcomes of patients treated with internal fixation to arthroplasty in this patient population. Relevant articles were identified using PubMed, Embase, and CENTRAL databases. Manuscripts were included only if they contained (1) patients 60 years or older with (2) nondisplaced or minimally displaced (Garden I or II) femoral neck fractures (3) treated with internal fixation or arthroplasty or (4) separately reported outcomes in this patient population. The primary outcome was reoperation. Secondary outcomes included mortality, patient reported outcomes, length of hospital stay, infection, and transfusions. An a priori decision was made to classify studies into comparative or non-comparative groups. Comparative studies directly compared arthroplasty to internal fixation in the specific study population while the non-comparative studies included separate cohorts of patients treated with arthroplasty or internal fixation. A fixed-effects model was used to quantitatively pool study outcomes. Twenty-five non-comparative studies were identified with a total of 22,020 patients, all of which were treated with internal fixation. The pooled incidence of reoperation after internal fixation was 14.4% (95% CI: 10.8 – 18.8). The incidence of mortality within one-year of injury was 14.4% (95% CI: 6.7 – 28.3), based on the reporting in 14 studies. Three comparative studies were identified with a total of 360 patients (128 treated with arthroplasty and 232 treated with internal fixation). All three studies reported reoperation rates. The overall risk of reoperation was 3.1% in the arthroplasty group compared to 9.5% in the internal fixation group (relative risk: 0.30, 95% CI: 0.10 – 0.84, p= 0.02). Only two studies reported mortality. The relative risk of mortality in patients treated with arthroplasty compared to internal fixation was 2.54 (95% CI: 1.38 – 4.70, p= 0.003). Internal fixation of minimally displaced femoral neck fractures in the elderly is associated with a risk of reoperation and mortality that exceeds 14%. Treatment with arthroplasty may reduce the risk of reoperation by 70%. However, this benefit maybe tempered by a potential increased risk of mortality associated with arthroplasty in this patient population

Background. pelvic fractures in elderly patients often result in poor prognosis due to immobilization associated complications. Thus, the target of the treatment in this patient group is early mobilization in order to reduce the risk of these complications. We report outcomes of 4 cases of pelvic fracture in elderly patients, who were treated with percutaneous screw fixation. Material and method. We examined medical records and images of 4 elderly patients between January 2012 and May 2012 in our center. Mean age of the patients was 88.8 years old (range 86–92 years). The causes of injury were motor vehicle accident in 3 patients, and a fall in 1 patient. Fracture types were ao type a in 1 patient, type b in 2 patients and type c in 1 patient. Mean injury severity score was 25 (10–57). We assessed functional status after the follow-up period using majeed. s. grading score for pelvic fractures. Result. No major complication including sever infection and deep vein thrombosis was observed during the follow-up period. Minor complication observed was screw loosening in 1 case, and screw prominence in another. Functional outcome by majeed. s. score were excellent in 1 case, and fair in 3 cases. The mean period between the operation and the first ride on the wheel chair was 3.5 (2–6) days. Conclusion. Early mobilization significantly affects the prognosis in multiple trauma patients. Percutaneous screw fixation may improve the prognosis in elderly patients with pelvic fracture

Fractures of the odontoid peg are common spinal injuries in the elderly. This study compares the survivorship of a cohort of elderly patients with an isolated fracture of the odontoid peg versus that of patients who have sustained a fracture of the hip or wrist. A six-year retrospective analysis was performed on all patients aged > 65 years who were admitted to our spinal unit with an isolated fracture of the odontoid peg. A Kaplan–Meier table was used to analyse survivorship from the date of fracture, which was compared with the survivorship of similar age-matched cohorts of 702 consecutive patients with a fracture of the hip and 221 consecutive patients with a fracture of the wrist. A total of 32 patients with an isolated odontoid fracture were identified. The rate of mortality was 37.5% (n = 12) at one year. The period of greatest mortality was within the first 12 weeks. Time made a lesser contribution from then to one year, and there was no impact of time on the rate of mortality thereafter. The rate of mortality at one year was 41.2% for male patients (7 of 17) compared with 33.3% for females (5 of 15). . The rate of mortality at one year was 32% (225 of 702) for patients with a fracture of the hip and 4% (9 of 221) for those with a fracture of the wrist. There was no statistically significant difference in the rate of mortality following a hip fracture and an odontoid peg fracture (p = 0.95). However, the survivorship of the wrist fracture group was much better than that of the odontoid peg fracture group (p < 0.001). Thus, a fracture of the odontoid peg in the elderly is not a benign injury and is associated with a high rate of mortality, especially in the first three months after the injury. Cite this article: Bone Joint J 2014;96-B:88–93

Aims

Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery.