Assessment of Complication Risk in the Treatment of Proximal Humerus Fractures: A Retrospective Analysis of 4019 Patients.

(1) Background: The treatment of proximal humeral fractures (PHFs) is debated controversially. Current clinical knowledge is mainly based on small single-center cohorts. The goal of this study was to evaluate the predictability of risk factors for complications after the treatment of a PHF in a large clinical cohort in a multicentric setting. (2) Methods: Clinical data of 4019 patients with PHFs were retrospectively collected from 9 participating hospitals. Risk factors for local complications of the affected shoulder were assessed using bi- and multivariate analyses. (3) Results: Fracture complexity with n = 3 or more fragments, cigarette smoking, age over 65 years, and female sex were identified as predictable individual risk factors for local complications after surgical therapy as well as the combination of female sex and smoking and the combination of age 65 years or older and ASA class 2 or higher. (4) Conclusion: Humeral head preserving reconstructive surgical therapy should critically be evaluated for patients with the risk factors abovementioned.

Tenomodulin knockout mice exhibit worse late healing outcomes with augmented trauma-induced heterotopic ossification of Achilles tendon.

Heterotopic ossification (HO) represents a common problem after tendon injury with no effective treatment yet being developed. Tenomodulin (Tnmd), the best-known mature marker for tendon lineage cells, has important effects in tendon tissue aging and function. We have reported that loss of Tnmd leads to inferior early tendon repair characterized by fibrovascular scaring and therefore hypothesized that its lack will persistently cause deficient repair during later stages. Tnmd knockout (Tnmd-/-) and wild-type (WT) animals were subjected to complete Achilles tendon surgical transection followed by end-to-end suture. Lineage tracing revealed a reduction in tendon-lineage cells marked by ScleraxisGFP, but an increase in alpha smooth muscle actin myofibroblasts in Tnmd-/- tendon scars. At the proliferative stage, more pro-inflammatory M1 macrophages and larger collagen II cartilaginous template were detected in this group. At the remodeling stage, histological scoring revealed lower repair quality in the injured Tnmd-/- tendons, which was coupled with higher HO quantified by micro-CT. Tendon biomechanical properties were compromised in both groups upon injury, however we identified an abnormal stiffening of non-injured Tnmd-/- tendons, which possessed higher static and dynamic E-moduli. Pathologically thicker and abnormally shaped collagen fibrils were observed by TEM in Tnmd-/- tendons and this, together with augmented HO, resulted in diminished running capacity of Tnmd-/- mice. These novel findings demonstrate that Tnmd plays a protecting role against trauma-induced endochondral HO and can inspire the generation of novel therapeutics to accelerate repair.

Total Hip Arthroplasty for Hip Fractures: Time to Surgery With Respect to Surgical Revision, Failure, and Mortality.

INTRODUCTION: There are increasing demands to perform surgery of hip fractures without delay. However, few studies have assessed the time to surgery in relation to outcome measurements. METHODS: A total of 643 consecutive patients with a minimum age of 60 years underwent total hip arthroplasty (THA) for an intracapsular hip fracture. For this retrospective case series, demographic data and the outcome measurements-(1) any surgical revision, (2) implant failure, and (3) mortality-were documented from a prospective clinical database. The time from admission to surgery was also documented prospectively and then data were divided into 4 groups according to the time of surgery: (1) within 12 hours, (2) >12 to 24 hours, (3) >24 to 48 hours, and (4) later than >48 hours. The study end point was 2 years after surgery. Final evaluation was conducted for any missing data through a telephone interview. RESULTS: The patients comprised 456 women (70.9%) and 187 men (29.1%) with a mean age of 80.2 years (range 60-104 years; standard deviation ±7.4). Descriptive data were without effect in all 4 groups. Time to surgery did not significantly influence revision for any reason (P = .323), implant failure (P = .521), and mortality (P = .643). Cox regression analysis identified male sex (P < .001; 95% confidence interval (CI), 1.27-2.44), American Society of Anesthesiologists score ≥3 (P < .001; 95% CI, 2.12-21.59), C-reactive protein level >21 mg/L (P < .018; 95% CI, 1.09-2.60), hemoglobin level <12.0 g/dL (P = .033; 95% CI, 1.04-2.68), and dementia (P < .000; 95% CI, 1.50-2.86) as independent significant risk factors for mortality. CONCLUSION: Time to surgery had no effect on revision for any reason, implant failure, and mortality in patients undergoing THA for an intracapsular hip fracture.

Comparative analysis of non-simultaneous bilateral fractures of the proximal femur.

PURPOSE: We performed a monocenter cohort study to determine surgical revision and mortality after sustaining an initial and a non-simultaneous contralateral proximal femoral fracture. METHODS: We identified all patients surgically treated for a contralateral femoral fracture between 2006 and 2015. Patient demographic characteristics and follow-up were identified by our electronic database; failed information regarding revision and mortality were obtained by telephone, as well as the evaluation of the mobility for all alive patients. The endpoint of the study was set for every patient at least 2 years postoperatively. RESULTS: Within a total of 2296 patients, we identified 250 patients (10.8%) treated for a contralateral fracture. The mean interval between the two occurrences was 5.2 years and the mean age at the time of contralateral fracture was 84.4 years. Almost every third fracture occurred later than 5 years after the initial fracture, and even every tenth fracture later than 10 years. More than 50% of the patients also had dementia at this time. The total surgical revision rate was 17.2% after initial, and 20.4% after contralateral fracture, but this difference was statistically not significant (p = 0.31). However, revisions for infection or hematoma were more than twice after contralateral fracture (p = 0.006). The 1-year mortality rate was 36%, and dementia (log rank p < 0.001) and male gender (log rank p < 0.001) were significant negative predictors for the survival rate. After a mean of 42 months, the follow-up of the 67 alive patients recorded a mean Parker Score of 5.2 items. CONCLUSION: Contralateral femoral fracture was accompanied by a higher revision and mortality rate-but patients were also 5 years older. Dementia and male gender were significant negative variables for the survival time. In the future, the highest priority will be the prophylaxis of falling to avoid or at least to decline the number of these fractures in geriatric patients.

Infection Versus Hematoma Following Surgical Treatment of Proximal Femoral Fractures in Geriatric Patients.

INTRODUCTION: The surgical treatment of proximal femoral fractures predominantly involves geriatric patients and is associated with high morbidity and mortality. However, analyses on postoperative infections or hematoma are rare. METHODS: Patients requiring surgical revision due to infection (n = 90) or hematoma (n = 77) in the postoperative phase were identified from an electronic database of 2000 consecutive patients surgically treated for proximal femoral fractures between 2006 and 2014. Demographic and clinical data were retrieved, including information on the pathogens in patients with infection. A follow-up on morbidity and mortality was conducted via telephone for at least 2 years postsurgery. RESULTS: The follow-up rate was 100%, and the mean age was 81.9 years. The incidence rate of infection was 4.1% (90/2000), and women were commonly affected. Staphylococcus aureus and Staphylococcus epidermidis were the most commonly detected pathogens (35.5% and 25.5%, respectively). Mixed infections were observed in 15 patients, and Methicillin-resistant Staphylococcus aureus infections were observed in only 4 patients. A total of 77 (85.6%) infections occurred within 30 days postsurgery. The implant was preserved in 76 (84.4%) patients, and resection arthroplasty was required in 14 patients. Dementia and pertrochanteric fractures were significantly more common in the infection than in the hematoma group. Although infections were associated with high mortality rates for up to 2 years postsurgery, the rates did not significantly differ from those in the hematoma control group. CONCLUSION: One of every 2 patients who developed an infection following the surgical treatment of a proximal femoral fracture died within 2 years postsurgery. In addition, infections were significantly associated with dementia. Avoiding postoperative infection should be a high priority in the surgical treatment of proximal femoral fractures.

[Analysis of 2000 surgically treated proximal femoral fractures : Multiple variables influence mortality]. / Analyse von 2000 operativ versorgten proximalen Femurfrakturen : Multiple Variablen beeinflussen die Mortalität.

BACKGROUND: Due to demographic change, more proximal femoral fractures can be expected in the future. However, accurate growth rates as well as follow-up research extending more than 1 year postsurgery are still lacking. MATERIALS AND METHODS: First, we defined inclusion and exclusion criteria for the retrospective cohort study. Based on these, we collected all surgical interventions conducted between 1 January 2006 and 31 December 2015. For a total of 2000 consecutive procedures, we retrieved and analysed a total of 12 variables influencing mortality. Data were retrieved from the prospectively established database; all patients still alive were contacted by phone, and missing data were collected. The endpoint of the study was consistently set for all patients at 2 years postsurgery. RESULTS: The follow-up rate was 100%. Growth rate increased by 74.1% over a period of 10 years. Mean age of the total population was 79.4 years, and women were predominantly affected (71.7%). Surgical treatment was based on osteosynthesis procedures (57%) using DHS, PFN, or screws, as well as on arthroplasty (43%) performing total hip arthroplasty or implanting large-head prostheses. The revision rate was 14.5%, and mortality 2 years postsurgery was 32.4%. Through a multivariate analysis (Cox regression), the following seven influence factors showed statistically significant impact on mortality: age >82 years, male gender, CRP >10 mg/dl, haemoglobin <12 g/dl, ASA 3 or 4, dementia, and postoperative infection-but not timing of surgery. CONCLUSION: The growth rate of proximal femoral fractures progressed more rapidly than expected. Through a multivariate analysis, a total of six intrinsic variables were verified, which influenced the mortality. The prevention of infection-as the only additional extrinsic factor in this study-represents a more important role than early surgical treatment.

Performance Monitoring of Chilled-Water Distribution Systems Using HVAC-Cx.

In this research we develop, test, and demonstrate the newest extension of the software HVAC-Cx (NIST and CSTB 2014), an automated commissioning tool for detecting common mechanical faults and control errors in chilled-water distribution systems (loops). The commissioning process can improve occupant comfort, ensure the persistence of correct system operation, and reduce energy consumption. Automated tools support the process by decreasing the time and the skill level required to carry out necessary quality assurance measures, and as a result they enable more thorough testing of building heating, ventilating, and air-conditioning (HVAC) systems. This paper describes the algorithm, developed by National Institute of Standards and Technology (NIST), to analyze chilled-water loops and presents the results of a passive monitoring investigation using field data obtained from BACnet® (ASHRAE 2016) controllers and presents field validation of the findings. The tool was successful in detecting faults in system operation in its first field implementation supporting the investigation phase through performance monitoring. Its findings led to a full energy retrocommissioning of the field site.

Total hip arthroplasty after failed osteosynthesis of proximal femoral fractures: Revision and mortality of 80 patients.

PURPOSE: Total hip arthroplasty (THA) after failed osteosynthesis for proximal femoral fractures is associated with higher revision rates, particularly for dislocation. The purpose of this study was to report our results with THA after failed osteosynthesis within a treatment period of 10 years. METHODS: A retrospective cohort study including 80 consecutive patients was conducted. After a minimum follow-up of 1 year, we evaluated revision for any cause including dislocation, outcome, and mortality. RESULTS: We performed 48 THAs with standard components only and 32 THAs with revision implants. Routinely, a 36-mm femoral head was used, and trochanteric fixation was performed in one-third of the cases. Total revision rate for any cause was 21%, which included six infections, six periprosthetic fractures, and five hematomas. One hip dislocation was also treated. Treatment with uncemented revision stem revealed significantly higher number of revisions-compared to standard cemented or uncemented stem. The mortality rate after 1 year was 9%, and the mean Parker score at follow-up was 6.6 (range: 0-9). CONCLUSIONS: THA was associated with an increased surgical revision rate, but hip dislocation was documented only once. In most cases, a standard implant with a large 36-mm femoral head size was sufficient. Uncemented revision stem revealed significantly higher number of revisions-compared to standard cemented or uncemented stem. One-year mortality was lower than expected.

The fate of proximal femoral fractures in the 10th decade of life: an analysis of 117 consecutive patients.

INTRODUCTION: To date, there is a lack of valid data with larger populations of patients in their 10th decade of life in the analyses of proximal femoral fractures. MATERIAL AND METHODS: The inclusion criteria focused on all proximal femoral fractures in patients 90-99 years of age who underwent surgical treatment between 2009 and 2012. After a period of at least 2 years post-surgery, a retrospective collection of empiric data, including the survival time and surgical revision rate, was performed. Missing data were collected per telephone interview. RESULTS: A total of 121 proximal femoral fractures in 117 patients in their 10th decade of life were treated. The mean age was 92.3 years. 61 fractures of the femoral neck received hemi- or total hip arthroplasty, while 60 pertrochanteric or subtrochanteric fractures were treated by osteosynthesis using proximal femoral nail (PFN) or dynamic hip screw (DHS). At the time of follow-up, 83/117 patients (71%) were already deceased. The mortality after 30 days, 6 months, 1 year and 2 years was 16%, 37%, and 43%, and 55%, respectively. A total of 22 surgical revisions (19%) were performed: 10 due to early infections, 8 due to haematomas, and 4 due to implant failures with a "cut out" of the femoral neck screw exclusively in DHS. The duration of surgery (with regard to surgical revision) and ASA classification (with regard to survival rate) were significant influence factors. Contralateral proximal femoral fractures were identified in 24/117 patients (20%), irrespective of study period. CONCLUSIONS: The proximal femoral fractures in the 10th decade of life are associated with high postoperative mortality within the first 6 months. Surgical revision due to complications did not result in a statistically significant reduction of the survival time. From the osteosynthetic perspective, the DHS was associated with a significantly higher "cut-out" rate compared to PFN procedure. With regard to the alloarthoplasty, there were no significant differences observed between hemi- and total hip arthroplasty. A contralateral femoral fractures was observed in 20% of the total study population, but peri-implant or periprosthetic femoral fractures have not been observed in any of the cases thus far.

Mid-Term Results of 121 Periprosthetic Femoral Fractures: Increased Failure and Mortality Within but not After One Postoperative Year.

Periprosthetic femoral fractures are associated with high failure rates and mortality, particularly within one postoperative year. However, mid-term results related to this issue are lacking. Thus, we performed a retrospective follow-up evaluation. Between 2007 and 2012, we treated a total of 121 consecutive patients for periprosthetic femoral fractures. After a mean of 57.2 postoperative months, we documented a total surgical revision rate of 16.5% within the first year, and the one-year mortality rate was 13.2%. Between one year and up to 7.3 postoperative years, only one surgical revision was necessary, and the mortality rate also decreased. No significant factors related to surgical revisions were detected. However, the initial hip fracture, older age, higher ASA score and dementia were associated with a higher mortality rate.

Clinical and radiological results of patients treated with orthogonal double plating for periprosthetic femoral fractures.

PURPOSE: The aim of this study was to determine the outcome of surgically-treated periprosthetic femoral fractures with an orthogonal double plate system. METHODS: We performed a retrospective study of ten patients (mean age 79.5 years) surgically treated for periprosthetic femoral fractures using orthogonal double plating (lateral and additional anterior plate position) from 2010 to 2013. The patients' demographic characteristics, complications and initial follow-up data were retrieved from our institutional database. After a minimum of six months post-surgery, we performed a radiological and clinical follow-up. RESULTS: The surgical indications for orthogonal plating were heterogenic; five patients were treated for periprosthetic fractures around their total hip prosthesis. One was treated for a fracture around a total knee prosthesis and one for an interprosthetic fracture. Additionally, three patients were treated for postoperative implant failure after the stabilisation of periprosthetic fractures around a total hip prosthesis (one) or total knee prosthesis (two). Osteosynthesis was performed using locking compression plates exclusively (length between eight and 20 holes). After a mean follow-up of 22.6 months (range, six to 42 months), two patients died, but their deaths were due to old age morbidity and were unrelated to the surgery. Surgical revision for implant failure was necessary for only one female patient due to a breakage of the lateral plate. In addition, no other failures, such as infection or non-union, were observed. At the time of follow-up, seven out of ten patients were mobile and subjectively satisfied in regards to their outcome. CONCLUSIONS: Based on a small number of cases, we were able to show for the first time that the use of orthogonal double plating is not associated with an increased rate of complications in patients with periprosthetic femoral fractures and stable components. Moreover, orthogonal double plating can be used successfully as a salvage procedure. At the time of follow up, seven out of ten patients were mobile. More cases must be investigated to validate our findings.

Radial oxygen gradients over rat cortex arterioles.

PURPOSE: We present the results of the visualisation of radial oxygen gradients in rats' cortices and their potential use in neurocritical management. METHODS: PO2 maps of the cortex of ten sedated, intubated and controlled ventilated Wistar rats were obtained with a camera (SensiMOD, PCO, Kelheim, Germany). Those pictures were analysed and edited by a custom-made software. A virtual matrix, designed to evaluate the cortical O2 partial pressure, was placed vertically to the artery under investigation, and afterwards multiple regions of interest were measured (width 10 pixels, length 15-50 pixels). The results showed a map of the cerebral oxygenation, which allowed us to calculate radial oxygen gradients over arterioles. Three groups were defined according to the level of the arterial pO2: PaO2 < 80, PaO2 80-120 and PaO2 > 120. Gradients were analysed from the middle of the vessel to its border (1), from the border into the parenchyma next to the vessel (2) and a combination of both (3). RESULTS: Gradient 1 showed significantly different cortical pO2 values between the three different groups. The mean pO2 values were 2.62, 5.29 and 5.82 mmHg/mm. Gradient 2 measured 0.56, 0.90 and 1.02 mmHg/mm respectively. Gradient 3 showed significant results between the groups with values of 3.18, 6.19 and 6.84 mmHg/mm. CONCLUSION: Using these gradients, it is possible to describe and compare the distribution of oxygen to the brain parenchyma. With the presented technique, it is possible to detect pO2 changes in the oxygen supply of the brain cortex.