[Individual aspects in eldery patients with fragility fractures]. / Individuelle Besonderheiten bei hochbetagten Patienten mit Fragilitätsfrakturen.

BACKGROUND: Due to our ageing population, the number of elderly patients who are treated in the emergency department due to low-energy trauma (e.g., tripping) continues to rise. These minor accidents often result in fragility fractures classically located in the proximal humerus, distal radius, spine, pelvis, and near the hip joint. Pre-existing conditions, polypharmacy, and general frailty increase the risk of fragility fractures in this patient population. METHODS: Geriatric trauma fractures and especially insufficiency fractures of the posterior pelvic ring are often difficult to diagnose by plain X­ray. Therefore, in geriatric trauma patients, cross-sectional imaging, e.g., computed tomography (CT), dual-energy CT (DECT), or magnetic resonance imaging (MRI), should be considered early for reliable evaluation of a suspected fracture. This also allows for the identification of older fractures. Particularly in cognitively impaired elderly patients, difficult examination conditions or an unclear fall event, cross-sectional imaging is often indicated. However, this may also involve risks, e.g., use of contrast medium in patients with impaired renal function, so that each case must be considered individually. Furthermore, the diagnosis and treatment of osteoporosis, which is an underlying disease that leads to fragility fractures, is of particular importance. In the diagnostic workup, measurement of bone density using dual energy X­ray absorptiometry (DXA) is the standard method according to guidelines. In specific situations, high-resolution peripheral quantitative CT (HR-pQCT) may also be used. CONCLUSION: Due to the special challenges of correctly detecting fragility fractures and being able to quickly initiate adequate therapy, good cooperation between radiologists and trauma surgeons is necessary.

[Treatment of patients with fragility fractures]. / Versorgung von Patienten mit Fragilitätsfrakturen.

BACKGROUND: Fragility fractures are fractures in multimorbid, geriatric patients. Currently, their number is already high and is likely to increase in the future. OBJECTIVE: This article gives an overview of the principles in the management of patients with fragility fractures. MATERIAL AND METHODS: A selective literature review was performed to describe the epidemiology and relevance of fragility fractures. In addition, the principles of the perioperative management and surgical treatment of patients with fragility fractures are shown. RESULTS: Due to the significant number of comorbidities, the treatment of patients with fragility fractures represents an interdisciplinary challenge. Ideally, treatment should be carried out in an interdisciplinary team under the leadership of orthopedic surgeons and geriatricians. Treatment should be based on consensus guidelines, which have been adapted to the local circumstances. Attention should be paid to some special aspects of the surgical treatment in this vulnerable patient cohort. Important are optimal soft tissue management, cement augmentation procedures and joint replacement in cases of periarticular fractures. CONCLUSION: There is evidence that with optimal care the treatment of patients with fragility fractures can be significantly improved.

[Detection of malnutrition in geriatric trauma patients : A reassessment]. / Erfassung von Mangelernährung bei geriatrischen Traumapatienten : Eine erneute Bestandsaufnahme.

BACKGROUND AND OBJECTIVE: Malnutrition in geriatric trauma patients is associated with an increased risk of complications and mortality and is therefore a key risk factor. The assessment of the affected patients plays an important role in improving the outcome of this growing patient group. MATERIAL AND METHODS: In 2016 a questionnaire was sent to 571 departments specialized in traumatology and orthopedics throughout Germany. The following were recorded: level of care, expertise in geriatric trauma, nutrition-based screening procedures and nutritional ward round procedures. RESULTS: The response rate was 57% (n = 325) and closely reflected the treatment reality in Germany with respect to the level of care (superregional, regional or local trauma center and those without special qualifications). In 14% (n = 45) the participants were German Society for Trauma Surgery(DGU)-certified centers for age-related traumatology, while a further 5% (n = 15) were in the process of certification. The nutritional status was assessed in 56% (n = 181) of the clinics. Most frequently used was the body mass index (74%) followed by the mini nutritional assessment (30%), laboratory parameters (29%) and nutritional risk screening 2002 (19%). Some additional methods were specified. In approximately half of the departments nutritional ward rounds took place in regular wards (50%) and intensive care units (57%). DISCUSSION: The high response rate of this study seems to show the particular interest for malnutrition in geriatric trauma patients. This is reflected in an increase in the participating clinics compared to past surveys and also the more regularly performed assessment of nutritional status and implementation of nutritional visits. CONCLUSION: The establishment of suitable and time-effective screening instruments and their implementation are still a challenge.

[Geriatric Trauma Center DGU®: Evaluation of clinical and economic parameters : A pilot study in a german university hospital]. / AltersTraumaZentrum DGU®: Evaluation klinischer und ökonomischer Parameter : Eine Pilotstudie an einer deutschen Universitätsklinik.

BACKGROUND: Previous studies on orthogeriatric models of care suggest that there is substantial variability in how geriatric care is integrated in the patient management and the necessary intensity of geriatric involvement is questionable. OBJECTIVE: The aim of the current prospective cohort study was the clinical and economic evaluation of fragility fracture treatment pathways before and after the implementation of a geriatric trauma center in conformity with the guidelines of the German Trauma Society (DGU). METHODS: A comparison of three different treatment models (6 months each) was performed: A: Standard treatment in Orthopaedic Trauma; B: Special care pathways with improvement of the quality management system and implementation of standard operating procedures; C: Interdisciplinary treatment with care pathways and collaboration with geriatricians (ward round model). RESULTS: In the 151 examined patients (m/w 47/104; 83.5 (70-100) years; A: n = 64, B: n = 44, C: n = 43) pathways with orthogeriatric comanagement (C) improved frequency of postoperative mobilization (p = 0.021), frequency of osteoporosis prophylaxis (p = 0.001) and the discharge procedure (p = 0.024). In comparison to standard treatment (A), orthogeriatric comanagement (C) was associated with lower rates of mortality (9% vs. 2%; p = 0.147) and cardio-respiratory complications (39% vs. 28%; p = 0.235) by trend. In this context, there were low rates of myocardial infarction (6% vs. 0%), dehydration (6% vs. 0%), cardiac dysrhythmia (8% vs. 0%), pulmonary decompensation (28% vs. 16%), electrolyt dysbalance (34% vs. 19%) and pulmonary edema (11% vs. 2%). Duration of stay in an intensive care unit was 29 h (A) and 18 h (C) respectively (p = 0.205), with consecutive reduction in costs. A sole establishment of a special care pathway for older hip fracture patients (B) showed a lower rate of myocardial infarction (A: 11%, B: 0%, C: 0%; p = 0.035). CONCLUSION: There was a clear tendency to a better overall result in patients receiving multidisciplinary orthogeriatric treatment using a ward visit model of orthogeriatric comanagement, with lower rates of cardiorespiratory complications and mortality. While special care pathways could reduce the rate of myocardial infarction in hip fracture patients, costs and revenues showed no difference between all care models evaluated. However, patients with hip fracture or periprosthetic fracture represent cohorts at clinical and economic risk as well.

[Evaluation of a simple screening tool for ambulant fall prevention]. / Evaluation eines einfachen Testverfahrens in der ambulanten Sturzprävention.

BACKGROUND: An individual's risk of falling is generally difficult to detect and it is likely to be underestimated. Thus, preventive measures are challenging and they demand sufficient integration and implementation into aftercare and outpatient management. The Aachen Falls Prevention Scale (AFPS) is a quick and easy tool for patient-driven fall risk assessment. Older adults' risk of falling is identified in a suitable manner and they then have the opportunity to independently assess and monitor their risk of falling. OBJECTIVES: The aim of the current study was to evaluate the AFPS as a simple screening tool in geriatric trauma patients via the identification of influencing factors, e.g. objective or subjective fall risk, fear of falling (FOF) and demographic data. In this context, we investigated older adults' willingness to take part in special activities concerning fall prevention. METHODS: Retrospectively, all patients over 70 years of age who received in-hospital fracture treatment between July 2014 and April 2016 were analyzed at a level I trauma center. After identification of 884 patients, participants completed a short questionnaire (47 questions, yes/no, Likert scale) comprising the AFPS. A history of falls in the past year was considered an indicator of a balance disorder. In addition, ambulant patients were invited to participate between July and August 2016. RESULTS: In total, 201 patients (mean 80.4 years, range 63-97 years) performed a self-assessment based on the AFPS. After steps 1 and 2 of the AFPS had been completed, 95 (47%) participants rated their subjective risk of falling as high (more than 5 points). Of the participants 84 (42%) were objectively classified as "fallers" with significant effects on their AFPS evaluation and rating of their subjective risk of falling. Furthermore, 67% of the participants identified a general practitioner as their main contact person, and 43% of the respondents viewed the AFPS as a beneficial screening tool in fall risk evaluation (8% negative attitudes). Only 12% of the participants could imagine using the AFPS app version as a feasible option. CONCLUSION: It would be advantageous to pretest at-risk individuals in their environment using a simple self-assessment approach, with the main purpose of identifying potential balance problems. With this approach, cost savings in the healthcare system are possible, combined with a higher health-related quality of life in the geriatric population.

[Teriparatide as a therapy approach in sacral insufficiency fractures]. / Teriparatid als Therapieansatz bei Sakruminsuffizienzfrakturen.

As a result of immense heterogeneity with regard to morphology and stability, the recent literature lacks consensus concerning the treatment of sacral insufficiency fractures. We report the case of a 79-year-old woman with bilateral sacral insufficiency fractures following anterior pelvic ring fractures who was treated with teriparatide. During a two-week hospital stay, the patient was successfully mobilised and the regularly conducted pelvic X­ray controls showed full consolidation of the fractures.

[Interdisciplinary treatment in geriatric traumatology from the trauma surgeons' perspective : Results of a survey in Germany]. / Interdisziplinäre Behandlung in der Alterstraumatologie aus unfallchirurgischer Sicht : Ergebnisse einer deutschlandweiten Umfrage.

BACKGROUND: Many patients treated on trauma surgery wards are geriatric trauma patients. To improve treatment of these often multimorbid patients, various interdisciplinary treatment concepts have been established in Germany between trauma surgeons and geriatricians. OBJECTIVES: The aim of this study was to evaluate the dissemination and the impact of the different orthogeriatric treatment concepts for geriatric trauma in Germany. Material and methods In March and April 2014 an electronic questionnaire for assessing the interdisciplinary treatment of geriatric trauma patients was sent to 691 medical directors of trauma surgery departments in Germany. RESULTS: A total of 259 (37 %) fully answered questionnaires could be analyzed. The analysis revealed that 70 % of all responding trauma surgery departments had an orthogeriatric treatment cooperation. Most of them reported having patient discharge agreements to geriatric rehabilitation facilities (59 %). Geriatric counseling services were reported by 39 % while 24 % reported having regular interdisciplinary visits and orthogeriatric wards were available in 13 %. The need for orthogeriatric services was considered to be high by 79 % of the participants and benefits especially for the patients were expected. These expectations were largely fulfilled. More than 70 % of respondents planned to intensify the orthogeriatric cooperation. In this context difficulties were seen in the lack of personnel resources, especially in a lack of geriatricians. CONCLUSION: The results of this survey underline the impact and the positive experiences in orthogeriatric services. Solutions have to be found to address the emerging problem of capacity constraints.

[The rotationally stable screw-anchor with trochanteric stabilizing plate (RoSA/TSP) : First results in unstable trochanteric femur fractures]. / Der Rotationsstabile Schraubanker mit winkelstabiler Stützplatte (RoSA/TAP) : Erste klinische Evaluation bei instabilen trochantären Frakturen.

BACKGROUND: In unstable trochanteric fractures, the extramedullary rotationally stable screw-anchor (RoSA) combines the benefits of the load and rotational stability of the blade with the advantages of the screw (pull-out resistance, compression capability) in a single load carrier, and was designed to prevent femoral neck shortening by using an additional locked trochanteric stabilizing plate (TSP). OBJECTIVES: The aim of the current prospective cohort study was the clinical evaluation of the RoSA/TSP system regarding the mechanical re-operation rate and the amount of postoperative femoral neck shortening. METHODS: From September 2011 to January 2014 80 patients with unstable trochanteric fractures underwent internal extramedullary fixation with the RoSA/TSP (Königsee Implantate GmbH, Allendorf, Germany). Due to fracture stability and after induction of compression, additional long locked antitelescoping screws (AT, n = 1-4) were placed reaching the femoral head. Radiological (femoral neck shortening) and clinical re-examination of patients (n = 61) was performed 6-10 weeks and 6-10 months later. RESULTS: In the 61 re-examined patients (76 %) femoral neck shortening was very low with 2 mm 6-10 months after operation. Re-operations occurred in 8 % (n = 6) and in 4 % (n = 3) as prophylactic surgical intervention. Whereas one-third (4 %) of re-operations occurred due to iatrogenic surgical problems from the first operation two-thirds of patients (8 %) had a re-operation due to delay of bone union (3× nonunion, 3 planned removals of AT-screws to improve healing). The in-hospital mortality was 3 % (n = 2). CONCLUSIONS: The fixation of unstable trochanteric femur fractures using the RoSA/TSP in a first clinical setting led to a great primary stability, with significant advantages with regard to limited femoral neck shortening. However, the rigidity of the construct with its consequences regarding bone healing can be challenging for the surgeon. Nevertheless, in some cases of revision it could be beneficial for stability.

Patient factors associated with increased acute care costs of hip fractures: a detailed analysis of 402 patients.

The aim of the present study was to identify patient factors associated with higher costs in hip fracture patients. The mean costs of a prospectively observed sample of 402 patients were 8853 €. The ASA score, Charlson comorbidity index, and fracture location were associated with increased costs. PURPOSE: Fractures of the proximal end of the femur (hip fractures) are of increasing incidence due to demographic changes. Relevant co-morbidities often present in these patients cause high complication rates and prolonged hospital stays, thus leading to high costs of acute care. The aim of this study was to perform a precise cost analysis of the actual hospital costs of hip fractures and to identify patient factors associated with increased costs. METHODS: The basis of this analysis was a prospectively observed single-center trial, which included 402 patients with fractures of the proximal end of the femur. All potential cost factors were recorded as accurately as possible for each of the 402 patients individually, and statistical analysis was performed to identify associations between pre-existing patient factors and acute care costs. RESULTS: The mean total acute care costs per patient were 8853 ± 5676 € with ward costs (5828 ± 4294 €) and costs for surgical treatment (1972 ± 956 €) representing the major cost factors. The ASA score, Charlson comorbidity index, and fracture location were identified as influencing the costs of acute care for hip fracture treatment. CONCLUSION: Hip fractures are associated with high acute care costs. This study underlines the necessity of sophisticated risk-adjusted payment models based on specific patient factors. Economic aspects should be an integral part of future hip fracture research due to limited health care resources.

[Anticoagulation medication for proximal femoral fractures: prospective validation study of new institutional guidelines]. / Gerinnungshemmende Medikation bei proximaler Femurfraktur: Prospektive Validierungsstudie einer neuen institutionellen Leitlinie.

BACKGROUND: Under current guidelines surgical care of hip fractures has to be initiated within 48 h which is a challenge for the management of patients on medical anticoagulation. The aim of this study was to evaluate the in-house standard operation procedure (SOP) concerning these patients. METHODS: All geriatric hip fracture patients were included in this prospective study. Data concerning medical anticoagulation and hemoglobin levels on admission and at discharge, the start and duration of surgery, transfusion rates and postoperative complications were collected RESULTS: A total of 154 (62%) out of 247 patients were on anticoagulants. Patients on acetylsalicylic acid (ASA) demonstrated a significant increase in the rate of transfusion (62%, 95% CI, range 53%-72%, p<0.05) but lost significantly less hemoglobin during hospitalization (1.25 g/dl, 95% CI 0.62-1.88g/dl, p<0.05) in comparison to the control group (40% transfused, hemoglobin loss 3.00 g/dl). Patients on phenprocoumon were operated on later (26 h versus 20 h,95% CI 22-30, p<0.001). There were no significant differences concerning complications. CONCLUSION: Under this SOP anticoagulation has no impact on complication rates after hip fracture. The increased transfusion rates under ASS can be attributed to early blood transfusions. Antagonization of coumarin with vitamin K delays surgery but seems adequate. An analysis of more patients over a longer period of time should be conducted.