Osteoarthritis (OA) of the knee joint is a complex peripheral joint disorder with multiple risk factors. We aimed to examine the relationship between the grade of knee OA and anterior thigh length (ATL). A total of 64 geriatric patients who had no total hip or knee replacement with a BMI of ≥30 were evaluated. Patients' OA severity was determined by two independent experts from bilateral standing knee radiographs according to the Kellgren-Lawrence (KL) grade. Joint cartilage structure was assessed using ultrasonography (US). The ATL, the gastrocnemius medialis (GC), the rectus femoris (RF) and the rectus abdominis (RA) skeletal muscle thicknesses as well as the RF cross-sectional area (CSA) were measured with US. Sarcopenia was diagnosed using the handgrip strength (HGS), 5× sit-to-stand test (5xSST) and bioelectrical impedance analysis. The median (IQR) age of participants was 72 (65–88) years. Seventy-one per cent of the patients (n=46) were female. They were divided into the sarcopenic obese (31.3 %) and the non-sarcopenic obese (68.8%) groups. KL grade of all patients correlated negatively with the ATL (mm) and the thickness of GC (mm) (r= -0,517, p<0.001 and r= -0.456, p<0.001, respectively). In the sarcopenic obese and the non-sarcopenic obese groups, KL grade of the all patients was negatively correlated with ATL (mm) and thickness of GC (mm) (r= -0,986, p<0.001; r= -0.456, p=0.05 and r= -0,812, p=0.002; r= −0,427, p=0.006). KL grade negatively correlated with the RF thickness in the sarcopenic obese group (r= -0,928, p=0.008). In conclusion, OA risk may decrease as the lower extremity skeletal muscle mass increases. Acknowledgments: Feza Korkusuz MD is a member of the Turkish Academy of Sciences (TÜBA)

Fragility ankles fractures in the geriatric population are challenging to manage, due to fracture instability, soft tissue compromise, patient co-morbidities. Traditional management options include open reduction internal fixation, or conservative treatment, both of which are fraught with high complication rates. We aimed to present functional outcomes of elderly patients with fragility ankle fractures treated with tibiotalocalcaneal nails. 171 patients received a tibiotalocalcaneal nail over a six-year period, but only twenty met the inclusion criteria of being over sixty and having poor bone stock, verified by radiological evidence of osteopenia or history of fragility fractures. Primary outcome was mortality risk from co-morbidities, according to the Charlson co-morbidity index (CCI), and patients’ post-operative mobility status compared to pre-operative mobility. Secondary outcomes include intra-operative and post-operative complications, six-month mortality rate, time to mobilisation and union. The mean age was 77.82 years old, five of whom are type 2 diabetics. The average CCI was 5.05. Thirteen patients returned to their pre-operative mobility state. Patients with low CCI are more likely to return to pre-operative mobility status (p=0.16; OR=4.00). Average time to bone union and mobilisation were 92.5 days and 7.63 days, respectively. Mean post-operative AOFAS ankle-hindfoot and Olerud-Molander scores were 53.0 (range 17-88) and 50.9 (range 20-85), respectively. There were four cases of broken distal locking screws, and four cases of superficial infection. Patients with high CCI were more likely to acquire superficial infections (p=0.264, OR=3.857). There were no deep infections, periprosthetic fractures, nail breakages, non-unions. TTC nailing is an effective treatment methodology for low-demand geriatric patients with fragility ankle fractures. This technique leads to low complication rates and early mobilisation. It is not a life-changing procedure, with many able to return to their pre-operative mobility status, which is important for preventing the loss of socioeconomic independence

Objectives. Aged trauma patients are at high risk for various comorbidities and loss of function following hip fracture. Consequently a multidisciplinary approach for the treatment of these patients has become more famous in order to maintain the patients” activity level and health status prior to trauma. This study evaluates the effect of a multidisciplinary inpatient rehabilitation on the short- and long-term functional status of geriatric patients following hip fracture surgery. Methods. A collective of 158 hip fracture patients (> 80 years) who underwent surgery were included in this study. An initial Barthel Index lower than 30 points was a criteria to exclude patients from this study. Two subgroups, depending on the availability of treatment spots at the rehabilitation center were made. No other item was used to discriminated between the groups. Group A (n=95) stayed an average of 21 days at an inpatient rehabilitation center specialized in geriatric patients. Group B (n=63) underwent the standard postoperative treatment. As main outcome parameter we used the Barthel Index, which was evaluated for every patient on the day of discharge and checkups after three, six and twelve months. Results. After three months, the average Barthel Index was 82,27 points for group A and 74,68 points for group B (p=0,015). In the six-months-checkup group A”s average Barthel Index was 84,05 points and group B”s was 74,76 points (p=0,004). After twelve months, patients from group A had an average Barthel Index of 81,05 while patients from group B had an average Barthel Index of 71,51 (p=0,010). Conclusion. This study reveals a significant better outcome in both, the short-term and the long-term functional status for geriatric hip-fracture patients, who underwent an inpatient treatment in a rehabilitation center following the initial surgical therapy. This is shown at the timepoints three, six and twelve month after discharge. To maintain quality of life and mobility as well as the patient”s independence in daily life, a treatment in a rehabilitation center specialized in geriatric patients is highly recommendable

Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation (ORIF). Tibiotalocalcaneal (TTC) fusion is an alternative option for the geriatric patient. This systematic review and meta-analysis provides a detailed analysis of the functional and clinical outcomes of hindfoot nailing for fragility ankle fractures presented so far in the literature. A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, identifying fourteen studies for inclusion. Studies including patients over 60 with a fragility ankle fracture, treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded. Subgroup analyses were performed according to (1) open vs closed fractures, (2) immediate post-operative FWB vs post-operative NWB, (3) majority of cohort are diabetics vs minority of cohort are diabetics. Meta-regression analyses were done to explore sources of heterogeneity, and publication bias was assessed using Egger's test. The pooled proportion of superficial infection, deep infection, implant failure, malunion, and all-cause mortality was 0.10 (95%CI:0.06-0.16; I2=44%), 0.08 (95%CI:0.06-0.11, I2=0%), 0.11 (95%CI:0.07-0.15, I2=0%), 0.11 (95%CI:0.06-0.18; I2=51%), and 0.27 (95%CI:0.20-0.34; I2=11%), respectively. The pooled mean post-operative OMAS score was 54.07 (95%CI:48.98-59.16; I2=85%). The best-fitting meta-regression model included age and percentage of male patients as covariates (p=0.0263), and were inversely correlated with higher OMAS scores. Subgroup analyses showed that studies with a majority of diabetics had a higher proportion of implant failure (p=0.0340) and surgical infection (p=0.0096), and a lower chance of returning to pre-injury mobility than studies with a minority of diabetics (p=0.0385). Egger's test (p=0.56) showed no significant publication bias. TTC nailing is an adequate alternative option for fragility ankle fractures. However, current evidence includes mainly case series with inconsistent outcome measures reported and post-operative rehabilitation protocols. Prospective RCTs with long follow-up times and large cohort sizes are needed to clearly guide the use of TTC nailing for ankle fractures

Introduction and Objective. Geriatric patients with a fragility fracture of the hip (FFH) are especially prone to sarcopenia with poor functional outcomes and quality of life. We assessed the prevalence of sarcopenia in older South African patients with FFH. Risk factors for sarcopenia were also investigated. Materials and Methods. From August 1 to November 30, 2018, all older patients with FFH were invited to participate. Sarcopenia was diagnosed based on the revised criteria of the European Working Group on Sarcopenia in Older People (EWGSOP2). Handgrip strength (HGS) and muscle strength were assessed. Muscle quantity was determined by dual-energy X-ray absorptiometry. Demographic information was collected, and 25-hydroxyvitamin D (25[OH]D) status was determined. Results. Of the 100 hip fracture cases, 65 were enrolled, and 52% (34/65) were sarcopenic (women: 62%; men: 38%). HGS accurately identified sarcopenia (sensitivity and specificity: 100%). Patients >80 years of age had a prevalence of sarcopenia twice (18/21 [83%]) that of younger patients (18/44 [36%]). Women with sarcopenia were smaller than those without (weight: p < 0.001; height: p < 0.001; body mass index: p¼0.018). Low 25(OH)D was almost universally present, with median 25(OH)D levels significantly lower in the patients with sarcopenia (27 nmol/L [interquartile range {IQR}: 20–39] vs. 40 nmol/L [IQR: 29–53]). Several risk factors, including advanced age; female sex; a smaller body size, especially among women; limited physical activity; and low 25(OH)D levels, were identified. Conclusions. The accuracy of HGS testing in this cohort underscores EWGSOP2's recommendation that muscle strength is key to sarcopenia. Further study and follow-up are required to determine the clinical relevance of sarcopenia among FFH patients. The prevalence of sarcopenia in our FFH population is high. Sarcopenia is associated with poor patient outcomes following surgical intervention. Orthopaedic surgeons should therefore be cognisant of the presentation and associated risk of sarcopenia as our patient populations age

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

With around 20–40% of our bodyweight, skeletal muscles are the biggest organ complex of the human body. Being a metabolic active tissue, muscle mass, function and fibertype composition is highly regulated in a tight spatial-temporal manner. In geriatric patients, it is essentially important to understand the underlying mechanisms of the age related losses of fiber size and total number of fibers, as well as fibertype shifting. To date, there have been few studies dealing with gene expression profiling of skeletal muscles, mostly focusing on age related differences in whole-muscle specimen. Being carried out on mouse or rat limb muscles, most other studies do not represent the conditions of human muscle, due to the differences in fibertype composition. Our study provides a fibertype-specific approach for whole-genome expression analysis in human skeletal muscle. 22 fresh frozen biceps brachii and quadriceps femoris muscle samples were acquired from the muscle bank of the Friedrich-Baur-Institut, Department of Neurology, Ludwig-Maximilians-University, Munich, Germany. Consecutive cross-sections were used for immunohistochemical myosine-heavy-chain-staining and individual fibers were acquired by laser-capture-microdissection. Around 100 cells of each fibertype of each biopsy were dissected, reversely transcribed, pre-amplified and labeled for microarray analysis. Fiber type-specific gene expression was analyzed with ANOVA. Correction for multiple testing was performed using the Benjamini-Hochberg procedure with a conservative threshold and the pathway analysis was carried out using the Ingenuity Pathway Analysis program (QIAGEN). By comparing type I vs. type IIa, type I vs. type IIx and type IIa vs. type IIx, we could identify 2855, 2865 and 510 differentially expressed genes. As expected, many differentially regulated genes belong to functional groups like cytoskeleton, muscle contraction and energy metabolism, proving the feasibility of our study. However, many genes that are involved in the response to oxidative stress were also differently regulated, showing distinct mechanisms of the different fiber types, of coping with oxidative stress. In consensus with available literature, the relative proportion of type I fibers seemed to increase with age. Despite higher levels of oxidative stress, type I fibers seem to have more efficient antioxidative mechanisms in comparison to type IIa and IIx fibers, which might explain the higher vulnerability of members of the type II family to oxidative stress. Furthermore, genes that are involved in fibertype specification were also regulated differently. However, we could not verify an age-specific activation of pathways involved in fibertype shifting. Whether fibertype shifting is solely due to disproportionate loss of type II fibers, or also in vivo - transdifferentiation of fibers, has to be investigated further

Capturing objective data of the postoperative changes in the mobility of patients is expected to generate a better understanding of the effect of postoperative treatment. Until recently, the collection of gait-related data was limited to controlled clinical environments. The emergence of accurate wearable accelerometers with sufficient runtime, however, enables the long-term measurement and extraction of mobility parameters, such as “real-world walking speed”. An interim analysis of 1967 hours of actibelt data (3D accelerometer, 100 Hz) from 5 patients (planned total 20) with a femur fracture and 5 patients (planned total 20) with a humerus fracture from a geriatric population at two different sites of the university hospital of the Ludwigs-Maximilian-University in Munich was performed. Mobility data was captured during several days of stationary treatment starting directly after surgery and during a short follow-up visit six weeks after the surgery. Preliminary results show an increase of the mean walking speed between the two visits independent of the type of fracture. Patients with a humerus fracture tended to walk faster than patients with a femur fracture during both visits. The data also reveals an unexpected low level of mobility during the stationary stay. Mobile accelerometry can be used to evaluate different postoperative mobilisation strategies and even provide near-time feedback in geriatric trauma patients

Abstract. In aged trauma patients the basic prerequisite is early mobilization and full weight-bearing, as immobilization can trigger various complications such as pressure ulcers, pneumonia, urinary tract infections and others. Mortality of elderly patients increases significantly in fracture patients with partial weight-bearing compared to populations with total weight-bearing. Besides the limited physical strength in these patients, partial-weight bearing is however frequently used for the aftercare of hip fracture patients. Therefore, the present study aims to evaluate mobility of aged hip fracture patients with regards to weight-bearing and postoperative mobility. Methods. An insole mobile force sensor was used to measure the post-operative weight-bearing by assessing the compressive forces between foot and shoe. Only patients (n=15) that suffered a trochanteric fracture >75 years of age were included and compared to a study group of patients (n=18) with fractures of the lower limb <40 years of age. Patients with cognitive disorders such as delirium and other diseases limiting the realization of partial weight-bearing were excluded. Both groups were instructed to maintain partial weight bearing of the affected limb following surgery. Following five days of training by our department of physiotherapy, the patients were requested to perform a gait analysis with the insole mobile force sensor. During gait analysis the maximum load was measured (kg) and the time over which the partial load could be maintained was determined. Results. None of the aged patients in the test group could meet the partial load at all times. 73.33% of patients (11 out of 15) exceeded the specified load by more than twice (> 40 kg). In the control group, 55.56% (10 of 18) of the patients were able to meet the partial load. A further 22.22% of the young patients (4 out of 18) were able to exceed only slightly (<120%, <24 kg). It was also shown that only 11.11% (2 of 18) put more than double of the allowed weight (> 40 kg) on the affected leg in the younger group. Only one of the aged patients was able to exceed the pre-determined weight-bearing restrictions for less than 10% of the measured time. In comparison, significantly more patients in the control group (88,89%; 16 of 18; p<0,05) were able to maintain the partial load for more than 90.0% of the time of gait analysis. Conclusion. Elderly patients seem to be unable to follow partial weight-bearing restrictions as proven in the present trial. As early mobilization of geriatric trauma patients is an important element for a successful rehabilitation, the relict of postoperative partial weight-bearing in these patients should be abandoned. Thus, the surgical therapy should allow immediate full weight bearing following surgery of aged hip fracture patients