Effects of exercise training on bone mineral density and some health-related outcomes in HIV conditions: A randomized controlled trial.

INTRODUCTION: Human Immunodeficiency Virus (HIV) infection remains prevalent co-morbidity, and among fracture patients. Few studies have investigated the role of exercise interventions in preventing bone demineralization in people who have fractures and HIV. If exercise exposed, HIV-infected individuals may experience improved bone health outcomes (BMD), function, quality of life (QoL). The study will aim to assess the impact of home based exercises on bone mineral density, functional capacity, QoL, and some serological markers of health in HIV infection among Nigerians and South Africans. METHODS AND DESIGN: The study is an assessor-blinded randomized controlled trial. Patients managed with internal and external fixation for femoral shaft fracture at the study sites will be recruited to participate in the study. The participants will be recruited 2 weeks post-discharge at the follow-up clinic with the orthopaedic surgeon. The study population will consist of all persons with femoral fracture and HIV-positive and negative (HIV-positive medically confirmed) aged 18 to 60 years attending the above-named health facilities. For the HIV-positive participants, a documented positive HIV result, as well as a history of being followed-up at the HIV treatment and care center. A developed home based exercise programme will be implemented in the experimental group while the control group continues with the usual rehabilitation programme. The primary outcome measures will be function, gait, bone mineral density, physical activity, and QoL. DISCUSSION: The proposed trial will compare the effect of a home-based physical exercise-training programme in the management of femoral fracture to the usual physiotherapy management programmes with specific outcomes of bone mineral density, function, and inflammatory markers. TRIAL REGISTRATION: The study was prospectively registered with the Pan African Clinical Trials Registry (Reference number - PACTR201910562118957) on October 21, 2019. (https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9425).

Fracturas del extremo proximal de fémur tratadas con Sistema Dinámico de Cadera. Evaluación de resultados / Fractures of the proximal end of femur treated with Dynamic Hip System. Evaluation of results

RESUMEN Introducción: el tratamiento ideal en las fracturas estables del extremo proximal de fémur lo constituye el Sistema Dinámico de cadera. Objetivo: Evaluar la efectividad de su uso en dichas fracturas. Diseño metodológico: se realizó un estudio observacional, descriptivo, de tipo longitudinal de los pacientes intervenidos quirúrgicamente por fractura del extremo proximal de fémur en el Hospital Provincial José Ramón López Tabrane, de Matanzas en el periodo comprendido entre enero del 2013 y diciembre del 2015, quedando la muestra constituida por 128 pacientes. Resultados: encontramos un predominio de las femeninas (60%) y el grupo de edades más representado el de 70 a 79 años con 50 pacientes. Predominaron las fracturas extracapsulares con 122 pacientes, siendo dentro de la variedad del DHS la placa de 130 grados la más usada en 81% de los casos. Se operó el 78 % de los pacientes antes de las 2 horas, presentando 12 complicaciones locales, dentro de las cuales resaltó el colapso de la fractura con 4 pacientes. El 70 % de los pacientes apoyó antes de las 12 semanas, presentando 33 % de fallecidos en el primer año de operado. El 92 % de los pacientes fueron evaluados de bien al final de los resultados. Conclusiones: el Sistema Dinámico de Cadera constituye el método de osteosíntesis ideal en fracturas estables con muy buenos resultados funcionales y con temprana indicación de carga de peso; recomendamos su uso en las fracturas estables del extremo proximal de fémur por sus buenos resultados (AU).

SUMMARY Introduction: the ideal treatment for stable fractures of the proximal end of the femur is the Dynamic Hip System. Objective: to evaluate the effectiveness of its use in such fractures. Methodological design: a longitudinal, descriptive, observational study of patients operated on for fractures of the proximal end of the femur was carried out at the José Ramón López Tabrane Provincial Hospital, Matanzas, between January 2013 and December 2015. The sample consisted of 128 patients. Results: we found a predominance of females (60%) and the most represented age group was 70-79 years old with 50 patients. Extracapsular fractures predominated with 122 patients, being within the DHS variety the 130 degree plate the most used in 81% of the cases. Seventy-eight percent of the patients were operated before 2 hours, presenting 12 local complications, among which the collapse of the fracture stood out with 4 patients. Seventy percent of the patients supported before 12 weeks, presenting 33% of deaths in the first year of surgery. Ninety-two percent of the patients were evaluated as being well at the end of the results. Conclusions: The Dynamic Hip System constitutes the ideal method of osteosynthesis in stable fractures with very good functional results and with early indication of weight load;we recommend its use in stable fractures of the proximal end of the femur because of its good results (AU).

Systematic review of clinical practice guidelines for adults with fractures: identification of best evidence for rehabilitation to develop the WHO's Package of Interventions for Rehabilitation.

BACKGROUND: The identification of existing rehabilitation interventions and related evidence represents a crucial step along the development of the World Health Organization's (WHO) Package of Interventions for Rehabilitation (PIR). The methods for such identification have been developed by the WHO Rehabilitation Programme and Cochrane Rehabilitation under the guidance of the WHO's Guideline Review Committee secretariat. The aim of this paper is to report on the results of the systematic search for clinical practice guidelines (CPGs) relevant to the rehabilitation of adults with fractures and to present the current state of evidence available from the identified CPGs. METHODS: This paper is part of the Best Evidence for Rehabilitation (be4rehab) series, developed according to the methodology presented in the World Health Organization's (WHO) Package of Interventions for Rehabilitation (PIR) introductory paper. It is a systematic review of existing CPGs on fractures in adult population published from 2009 to 2019. RESULTS: We identified 23 relevant CPGs after title and abstract screening. According to inclusion/exclusion criteria, we selected 13 CPGs. After checking for quality, publication time, multiprofessionality, and comprehensiveness, we finally included five CPGs dealing with rehabilitative management of fractures in adult population, two CPGs addressing treatment of distal radius fracture and three the treatment of femoral/hip fracture. CONCLUSION: The selected CPGs on management of distal radius and femoral/hip fracture include few recommendations regarding rehabilitation, with overall low to very low quality of evidence and weak/conditional strength of recommendation. Moreover, several gaps in specific rehabilitative topics occur. Further high-quality trials are required to upgrade the quality of the available evidence. LEVEL OF EVIDENCE: Level 1.

No rest for elderly femur fracture patients: early surgery and early ambulation decrease mortality.

BACKGROUND: Literature has shown a significant correlation between early treatment and mortality in femur fractures, but the influence of time to ambulation on mortality has not been studied. The purpose of the present study is to evaluate whether time to ambulation is correlated to femur fracture mortality independently from time to surgery. PATIENTS AND METHODS: All patients older than 65 years admitted at a level I trauma center with proximal femoral fracture during a 1-year period were included. The following data were collected: age, gender, date and time of admission to emergency department, height, weight, body mass index, type and side of fracture, ASA score, date and time of surgery, surgical time, time to ambulation, length of hospitalization, death during hospitalization, and mortality at 6 and 12 months. RESULTS: The study sample comprises 516 patients. The mean age was 83.6 years; ASA score was 3-5 in 53% of patients; 42.7% presented with medial fracture; mean time between admission and surgery was 48.4 h; 22.7% of patients were not able to walk during the first 10 days after fracture; mean duration of hospitalization was 13 days; and mortality was 17% at 6 months and 25% at 1 year. Early surgery and walking ability at 10 days after trauma were independently and significantly associated with mortality at 6 months (p = 0.014 and 0.002, respectively) and at 1 year (0.027 and 0.009, respectively). CONCLUSIONS: Early surgery in femur fracture became a priority in health systems, but early postoperative physiotherapy also plays a major role in prevention of mortality: independently from surgical timing, patients who did not walk again within 10 days from surgery showed mortality rates higher than those of patients who did. LEVEL OF EVIDENCE: IV.

Rehabilitation Following Fracture in Dystrophinopathy, A Case Series.

BACKGROUND: Boys with dystrophinopathies (DMD) are at increased risk of low bone mineral density and fracture. Femoral fracture is the most common extremity fracture and is accompanied by significant risk of functional loss. Care considerations for DMD have stressed that aggressive management may be needed to maintain ambulation and that surgical fixation allows early mobilization. OBJECTIVES: Describe 5 cases of femoral fracture in ambulatory boys with DMD and the course of care undertaken to optimize function. PATIENTS: Five boys with DMD median age 15y (12-16) who were independently ambulatory. Median 10m walk speed prior to their first fracture was 8 sec (7-17.37) and 4 of 5 were less than the 9 seconds predictive of 2 year ambulation retention. Three of the cases had a single incident causing fracture; the remaining cases had 2 and 3 incidents respectively representing a total of 8 fractures 6 of which were surgically stabilized. RESULTS: Following the first fracture, all 5 subjects regained some form of ambulation. Three patients regained independent ambulation and 2 with hand held support or contact guard. Two subjects went on to have additional falls with associated fracture. No patient regained the ability to rise from the floor and only one of the 5 regained the ability to climb steps and all demonstrated a decline in walking speed. CONCLUSION: Prompt orthopedic intervention, early mobility, and intensive rehabilitation even in the end stage ambulatory patient, were factors in helping preserve function in these patients with dystrophinopathies.

Long-term care use after a stroke or femoral fracture and the role of family caregivers.

BACKGROUND: There has been a shift from institutional care towards home care, and from formal to informal care to contain long-term care (LTC) costs in many countries. However, substitution to home care or informal care might be harder to achieve for some conditions than for others. Therefore, insight is needed in differences in LTC use, and the role of potential informal care givers, across specific conditions. We analyze differences in LTC use of previously independent older patients after a fracture of femur and stroke, and in particular examine to what extent having a partner and children affects LTC use for these conditions. METHODS: Using administrative data on Dutch previously independent older people (55+) with a fracture of femur or stroke in 2013, we investigate their LTC use in the year after the condition takes place. We use administrative treatment data to select individuals who were treated by a medical specialist for a stroke or femoral fracture in 2013. Subsequent LTC use is measured as using no formal care, home care, institutional care or being deceased at 13 consecutive four-weekly periods after initial treatment. We relate long-term care use to having a partner, having children, other personal characteristics and the living environment. RESULTS: The probability to use no formal care 1 year after the initial treatment is equally high for both conditions, but patients with a fracture are more likely to use home care, while patients with a stroke are more likely to use institutional care or have died. Having a spouse has a negative effect on home care and institutional care use, but the timing of the effect, especially for institutional care, differs strongly between the two conditions. Having children also has a negative effect on formal care use, and this effect is consistently larger for patients with a fracture than patients with a stroke. CONCLUSION: As the condition and the effect of potential informal care givers matter for subsequent long-term care use, policy makers should take the expected prevalence of specific conditions within the older people population into account when designing long-term care policies.

Body mass index and recovery of activities of daily living in older patients with femoral fracture: An analysis of a national inpatient database in Japan.

OBJECTIVE: To evaluate the effects of body mass index (BMI) on recovery of activities of daily living (ADL) in older Asian patients with femoral fracture registered in a nationwide inpatient database in Japan. METHODS: We retrospectively analyzed data of patients aged ≥65 years with acute femoral fracture between April 2014 and November 2017 in the Diagnosis Procedure Combination database. Patients were classified into the following categories based on BMI (kg/m2): underweight (<18.5); normal weight (18.5-22.9); overweight (23-27.4); obese (≥27.5); and missing data. Demographic data included age, sex, type of fracture, comorbidities, and Barthel Index (BI). The primary outcome was BI at discharge and secondary outcomes were the overall complication rate and discharge to home. RESULTS: In total, data for 13,348 patients were extracted from the database, of whom 80.3 % were female. At discharge, underweight patients had lower BI than overweight or obese patients. In multivariable analysis, underweight and missing BMI data were associated with lower BI at discharge (partial regression coefficients -2.324 and -5.763, respectively). In contrast, overweight and obese were correlated with higher BI (3.080 and 5.732, respectively). Underweight was independently associated with a higher overall complication rate (odds ratio 1.195) and a lower rate of discharge to home (odds ratio 0.865). CONCLUSIONS: Underweight was associated with poorer performance in ADL, higher risk of complications, and lower rate of discharge to home in older Asian patients with femoral fracture. Overweight and obese had positive effects on ADL.

Use of a morcellized fragment of bone as a bone graft in a femoral fracture repair / Uso de fragmento ósseo morcelizado como enxerto ósseo no reparo de fratura femoral

As one of the most frequent reasons for presentation at the orthopedic services in veterinary practice, long bone fractures need bone continuity for consolidation to take place. This case report has demonstrates the use of a morcellized fragment of bone as a bone graft in a femoral fracture with major bone loss. A mixed-breed adult cat with a segmental femoral fracture with a large longitudinal fissure in the central bone fragment was submitted to an interlocking nail osteosynthesis. During the procedure a fracture occurred along the fissure resulting in two bone fragments with significant bone loss. Fragments were morcellized and applied over the defect to act as a bone graft. By the 15th day after the surgery, the cat had a normal gait and showed no pain response, and bone consolidation occurred after 7 months. Once harvesting of humeral, femoral and tibial bone grafts can be frustrating in cats, resulting in just small amounts of bone, the morcellation of the central fragments was vital to provide sufficient graft to cover the big defect in the femoral shaft. The authors suggest that autologous fresh morcellized cortical bone fragments can be an adjunct to the treatment of comminuted fractures in cats, as an alternative to more traditional repairs of comminuted fracture.

Fraturas de ossos longos necessitam de continuidade óssea para que a consolidação ocorra. Este relato de caso tem como objetivo demonstrar o uso de um fragmento ósseo morcelizado com a função de enxerto ósseo em uma fratura de fêmur com presença de uma grande falha óssea entre os fragmentos. Um gato adulto, sem raça definida, com uma fratura múltipla em fêmur com presença de uma fissura longitudinal no fragmento central foi submetido à osteossíntese com uso de haste bloqueada. Durante o processo, ocorreu uma fragmentação a partir da fissura, o que resultou na presença de dois fragmentos ósseos com uma grande porção de perda óssea entre os dois. Os fragmentos ósseos restantes do fragmento central foram morcelizados e aplicados no defeito para atuar com enxerto ósseo. Quinze dias após a cirurgia o paciente apresentou apoio normal e ausência de dor, e consolidação óssea ocorreu em 7 meses pós operatórios. Uma vez que a coleta de enxerto nos gatos resulta em pouca quantidade de osso, a morcelização do fragmento central foi vital para promover enxerto suficiente para cobrir o defeito ósseo. Os autores sugerem que o uso de enxerto cortical autólogo fresco morcelizado pode ser um adjuvante no tratamento de fraturas cominutivas em gatos, como um tratamento alternativo à terapia convencional.

Double-plate fixation together with bridging bone grafting in nonunion of femoral supracondylar, subtrochanteric, and shaft fractures is an effective technique.

PURPOSE: The aims of the present study were to evaluate and report the therapeutic outcomes of double-plate fixation in combination with autogenous bridging bone grafting in treatment of nonunion fractures of femur. METHODS: In this retrospective case series study, 41 patients with nonunion fracture of femur who underwent surgery by double-plate fixation and autogenous bridging bone grafting in academic referral center from July 2010 to July 2015 were enrolled. Totally, 32 males and 9 females with mean age of 35 years were evaluated. They were evaluated for related risk factors, previous therapeutic methods, time interval between injury to nonunion surgery and surgery to full clinical and radiological union, duration of follow-up, levels of postoperative limb shortening, and movement limitations. RESULTS: Ten patients had open fractures and eight patients had infected nonunion in the femoral supracondylar, subtrochanteric, and shaft fractures. Nailing was the most common used method as the primary treatment of femoral shaft fractures. In addition, the mean follow-up time was 37 months. Full union was obtained even in infected cases. Deep vein thrombosis was found in one patient and pulmonary thromboembolism in another patient, and both patients were treated successfully. Moreover, limitations of articular movements were seen in seven patients. CONCLUSION: Double-plate fixation in combination with bridging bone grafting is an effective method in the treatment of nonunion of femoral supracondylar, subtrochanteric, and shaft fractures even in the infected cases.

The value of nonoperative versus operative treatment of frail institutionalized elderly patients with a proximal femoral fracture in the shade of life (FRAIL-HIP); protocol for a multicenter observational cohort study.

BACKGROUND: Proximal femoral fractures are strongly associated with morbidity and mortality in elderly patients. Mortality is highest among frail institutionalized elderly with both physical and cognitive comorbidities who consequently have a limited life expectancy. Evidence based guidelines on whether or not to operate on these patients in the case of a proximal femoral fracture are lacking. Practice variation occurs, and it remains unknown if nonoperative treatment would result in at least the same quality of life as operative treatment. This study aims to determine the effect of nonoperative management versus operative management of proximal femoral fractures in a selected group of frail institutionalized elderly on the quality of life, level of pain, rate of complications, time to death, satisfaction of the patient (or proxy) and the caregiver with the management strategy, and health care consumption. METHODS: This is a multicenter, observational cohort study. Frail institutionalized elderly (70 years or older with a body mass index < 18.5, a Functional Ambulation Category of 2 or lower pre-trauma, or an American Society of Anesthesiologists score of 4 or 5), who sustained a proximal femoral fracture are eligible to participate. Patients with a pathological or periprosthetic fractures and known metastatic oncological disease will be excluded. Treatment decision will be reached following a structured shared decision process. The primary outcome is quality of life (Euro-QoL; EQ-5D-5 L). Secondary outcome measures are quality of life measured with the QUALIDEM, pain level (PACSLAC), pain medication use, treatment satisfaction of patient (or proxy) and caregivers, quality of dying (QODD), time to death, and direct medical costs. A cost-utility and cost-effectiveness analysis will be done, using the EQ-5D utility score and QUALIDEM score, respectively. Non-inferiority of nonoperative treatment is assumed with a limit of 0.15 on the EQ-5D score. Data will be acquired at 7, 14, and 30 days and at 3 and 6 months after trauma. DISCUSSION: The results of this study will provide insight into the true value of nonoperative treatment of proximal femoral fractures in frail elderly with a limited life expectancy. The results may be used for updating (inter)national treatment guidelines. TRIAL REGISTRATION: The study is registered at the Netherlands Trial Register (NTR7245; date 10-06-2018).

Inferior clinical outcomes after femur fracture in the obese are potentially preventable.

INTRODUCTION: Obese patients with operative orthopedic trauma have increased risk of adverse outcomes, although the mechanisms accounting for the relationship remain unknown. This study examines the effect of body mass index (BMI) on outcomes after femur fracture fixation, and explores the mediating effects of pathophysiologic factors and clinical management. METHODS: A retrospective chart review was performed of adult patients with femur fractures undergoing surgical fixation at a Level 1 trauma center from 2010 to 2016. Demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) and mechanism of injury (MOI) were collected along with operative data and complications. Primary outcomes were hospital length of stay (HLOS), ICU length of stay (ICU-LOS), mortality, complications, and time to mobility (time first out of bed, TFOB). Bivariate correlations and multiple regression models were used to examine the relationship between BMI and outcomes. Path analysis tested whether the relationship between BMI and clinical outcomes was mediated by differences in 1) clinical management, or 2) physiologic variables. RESULTS: Of 333 patients included, the majority were male (57.4%) with a mean age of 43.4 (22.7) years and ISS of 12.5 (6.8). Predominant MOIs were motor vehicle crashes (42.8%) and falls (34.5%). There was no association between BMI category and age, ISS, or GCS. In univariate analysis, higher BMI was linked to longer HLOS (r = .12), longer ICU-LOS (r = .15), longer TFOB, (r = .18), and higher number of complications (r = .12), p < 0.05. Controlling for age and ISS, obese patients had 6.66 times the odds of respiratory failure (p = 0.021, 95% CI 1.3,33.3) and a 3.88 odds of any complication (p = 0.020, 95% CI 1.24,12.1) compared to their normal weight counterparts. For every one point increase in BMI, time first out of bed was delayed 2.3 h (p < 0.001; 95% CI 1.08, 3.62). The effect BMI on poor outcomes was accounted for by delayed mobility (longer TFOB) in a mediation model. CONCLUSIONS: Higher BMI increases the risk of longer hospital stays and systemic complications. Mediation models indicate that the adverse clinical outcomes associated with obesity are explained by delays in mobility, an intervenable factor. Clinical strategies should be directed at early mobilization to minimize morbidity.

A qualitative study of patients' experience of recovery after a distal femoral fracture.

PURPOSE: This qualitative study was conducted as part of a feasibility study for TrAFFix, (ISRCTN92089567), a randomised controlled trial that will compare two surgical interventions used to fix distal femoral fractures. Our aim was to understand patients' experiences of treatment and the early phase of recovery after a distal femoral fracture. While, much is known about the experience of recovery from hip fracture, little is known about whether patients with other lower limb fragility fractures experience the same concerns and challenges. MATERIALS AND METHODS: Semi-structured interviews were conducted with 11 patients participating in TrAFFix or their relative. Interviews were conducted face to face or by telephone. With agreement from participants, interviews were audio recorded and transcribed. Transcripts were analysed inductively using thematic analysis. As part of the user involvement for TrAFFix, we held a focus group with PPI representatives who had experience or knowledge of lower limb fractures, to learn about factors that might influence patients' recovery after a fragility facture. Data from the focus group relevant to themes from our thematic analysis are also presented. RESULTS: Three themes were identified within patients' accounts of their experience. Our data revealed that: i) being informed about treatment and recovery was important to patients; ii) patients muddled through and found ways to manage at home, often needing the support of others; and iii) rehabilitation was arduous for patients who received limited rehabilitative support and at times lacked confidence to follow the instructions that they were given. CONCLUSIONS: Our findings highlight the struggle patients endure while recovering after a distal femoral fracture and the limited rehabilitative support they receive after discharge from hospital. They reinforce the need to ensure a patient feels informed about their treatment and recovery and the need for greater support for patients to manage at home and move with confidence.

Early versus delayed weight bearing after surgical fixation of distal femur fractures: a non-randomized comparative study.

Distal femur fractures are rare injuries with a bimodal distribution (high-energy injury in young males and low-energy fragility fractures in old females). Their management can be challenging: open reduction and internal fixation (ORIF) with distal femur locking plates is a commonly performed procedure especially in comminuted fractures with articular involvement. Anxiety regarding the stability of the fixation, especially in osteoporotic bone, leads to post-operative restrictive instructions with limitations regarding the weight-bearing status. Early weight bearing (EWB), however, was shown to enhance bone healing and was not correlated with an increased risk of fracture displacement or implant failure in previous published studies, which reported the results of proximal femur, tibia and ankle fractures surgical treatment. The current study analysed the results of a series of distal femur fractures (51 patients, mean age 64.3 ± 20.7) all treated with ORIF in a level-I major trauma centre, but differently rehabilitated. Group A was, in fact, instructed not to weight bear or to touch weight bear, while group B started to weight bear soon after surgery without specific restrictions. The objective was to compare the outcome and the complication rate in the two groups at 6 and 12 weeks after surgery. The results showed no statistically significant differences in the two groups and no post-operative complications in the EWB group. Six complications were observed in the non-weight-bearing group (four fractures displacement and two implants failure at 12-week follow-up). Distal femur fractures treated with locking plates can be rehabilitated with EWB to allow early return to function. There is no evidence that EWB increases the risk of fracture displacement or implant failure in distal femur fractures treated with distal locking plates. Instead, it is possible that post-operative non-weight-bearing status delays the fracture-healing process increasing the risk of failure of the fixation.

Increased therapy demand and impending loss of previous residence status after proximal femur fractures can be determined by continuous gait analysis - A clinical feasibility study.

Proximal femur fractures account for increased healthcare costs whenever patients are unable to return to their previous state of residence. Studies suggest that patients benefit from early weight-bearing, yet compliance to weight-bearing regimes is poorly investigated. Aim of the study was thus to show the clinical feasibility of a new measurement tool able to determine continuous weight-bearing behavior after intramedullary nail osteosynthesis of intertrochanteric femur fractures, assess the influence of weight-bearing on clinical outcome and determine rehabilitation demand based on early postoperative gait performance. In an observational study, gait data of 22 patients with intertrochanteric femur fractures were evaluated. During the inpatient stay patients were continuously monitored with a gait analysis insole. Primary outcome was the amount of weight-bearing reached. Short-term functional outcome, as well as return to the previous state of living were evaluated in relation to weight-bearing and activity during the inpatient stay. With the presented technique continuous gait data of all patients during postoperative mobilization could be obtained. Only 13 patients reached full weight-bearing. The technique was feasible to determine correlations between weight-bearing and outcome, as well as between gait activity and outcome. Significant gait differences between patients able to return to their previous state of living and those who could not were seen. Dynamic insole measurements are feasible to continuously determine the postoperative gait performance. Their postoperative use showed, that the continuous compliance to permissive weight-bearing after intertrochanteric fractures is low. The presented measurement technique has the potential to identify patients at risk for reduced outcome and impending loss of previous residence status. Further studies will have to investigate the effects of technology assisted "patient at risk" identification and adapted therapy on clinical outcome.

Outcome of femoral fractures in poliomyelitis patients.

BACKGROUND AND PURPOSE: As patients who were afflicted with poliomyelitis during the outbreaks in the past are aging, lower extremity osteoporotic fractures are becoming more frequent. Fixation in deformed, porotic bone, coupled with muscle weakness and imbalance creates a unique challenge when treating these fractures as does their reduced rehabilitation potential. The aim of this study was to investigate the outcome of femoral fractures in surviving poliomyelitis patients. PATIENTS AND METHODS: Sixty-five patients with 74 femoral fractures were treated between 1990 and 2014. Clinical outcome was assessed using the Parkland and Palmer mobility score, and quality-of-life was assessed using the SF-12® score. RESULTS: Some 84% of the fractures were a result of low-energy mechanisms and occurred in the polio-affected limbs, but nonaffected limbs were also injured owing to low-energy mechanisms in all cases. Fifty-seven fractures were treated operatively. There were nine re-operations (16%), including implant removals, nonunion, peri-implant fractures, and malunion. Some 60% of the patients did not regain their previous ambulatory capacity. Post-operative weight-bearing status did not correlate with the final functional outcome. CONCLUSIONS: Polio patients with femoral fractures have a guarded prognosis for regaining their pre-injury ambulatory capacity. A higher re-operation rate than that with "normal" osteoporotic fractures is expected.

Disparities in follow-up care for ballistic and non-ballistic long bone lower extremity fractures.

OBJECTIVES: To describe differences in follow-up compliance and emergency department (ED) visits between ballistic and non-ballistic operative lower extremity fracture patients. DESIGN: Retrospective study. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: Patients age ≥18 years with ≥1 tibia or femur fractures treated with ORIF or intramedullary nailing (IMN) between September 1, 2013 and August 31, 2015. MAIN OUTCOME MEASURE: A compliance fraction calculated as ([number of attended follow-up visits] / [number of attended follow-up visits + number of missed follow-up visits]) and ED visits in the post-operative period. RESULTS: 612 patients were studied. Patients with ballistic lower extremity fractures had a younger mean age (30.8 years v. 41.6 years; p < 0.0001); a shorter length of stay (5.00 days v. 8.00 days; p < 0.0001); and were more likely to be male (92.6% v. 68%; p < 0.0001) and African-American (90.1% v. 63.1%; p < 0.0001) when compared to non-ballistic long bone injuries. Increased follow-up compliance (defined as a compliance fraction ≥0.75) was associated with having a non-ballistic fracture (OR 1.73, 1.13-2.64; p = 0.01), not having an ED visit (OR 2.08, 1.30-3.33; p = 0.002), and being female (OR 1.82, 1.27-2.61; p = 0.001). Increased ED utilization (≥ 1 ED visit) was associated with ballistic mechanism (OR 1.95, 1.20-3.16; p = 0.006), a low follow-up compliance fraction (OR 2.08, 1.30-3.33; p = 0.0019), homelessness (OR 3.91, 1.53-9.98; p = 0.006), and African-American race (OR 2.26, 1.26-4.05; p = 0.05). Scheduling a specific follow-up visit on the discharge summary did not predict higher compliance (OR 1.51, 0.98-2.33; p = 0.06). Conversely, the lack of a specific follow-up visit scheduled on the discharge summary did not predict ED utilization (OR 0.63, 0.34-1.17; p = 0.14). CONCLUSION: The results of this study demonstrate that increased utilization of the ED was associated with ballistic fractures, homelessness, decreased clinic compliance, and African American race. Furthermore, patients with non-ballistic injuries, women, and those without any ED visit were more likely to have higher outpatient clinic compliance.

Routine early post-operative X-ray following internal fixation of intertrochanteric femoral fractures is unjustified: a quality improvement study.

BACKGROUND: There is no consensus regarding the proper radiographic protocol following closed or open reduction and internal fixation for intertrochanteric femoral fractures. The objective of this study was to assess the role of early postoperative imaging studies when deciding about weight bear limitations and reoperations. METHODS: A prospective cohort study of 100 patients (26 men and 74 women, at a mean age of 79.8 years) treated by closed or open reduction and internal fixation for AO31A fractures was conducted. According to the AO classification, there were 25 cases of 31A1, 54 cases of 31A2, and 21 cases of 31A3. For every patient, the intraoperative fluoroscopy studies were recorded and post-operative radiograms were taken during the first week. Excluded were patients for whom the early X-rays were clinically indicated. The intraoperative AP and axial fluoroscopy studies were compared with the radiograms taken during the first post-operative week. The investigators compared the decisions regarding weight-bearing limitations and the need for re-operation before and after conducting the radiograms. RESULTS: The early post-operative imaging studies did not change weight-bearing limitations nor did they lead to consecutive surgical treatments. CONCLUSIONS: Unless indicated by physical examination, there is no value to routine post-operative radiograms within the first few days after closed reduction and internal fixation of intertrochanteric femoral fractures with regard to weight-bearing limitations and re-operation decisions. TRIAL REGISTRATION: Identifier: NCT02868125 .

[Physical medical aspects of early rehabilitation after proximal femoral fractures]. / Physikalisch-medizinische Aspekte der Frührehabilitation nach proximaler Femurfraktur.

Proximal femoral fractures in old age are known as fragility fractures. They are the sequelae of osteoporosis and an expression of a general reduced capacity and an increase in sensory and functional deficits against the background of multimorbidity. They are often caused by reduced compensation strategies. Simultaneously, for many older people they represent a life event. Despite modern osteosynthesis techniques and less stressful anesthesia procedures, the occurrence of a proximal femoral fracture shakes the labile equilibrium of those affected. Proximal femoral fractures are associated with a high risk of mortality. Only some 50% of those affected achieve the pretraumatic functional level again. Therefore, a comprehensive, multiprofessional and interdisciplinary management of these patients is required. The rehabilitation has to start at the time of diagnosis and at the latest after the operation with a comprehensive interdisciplinary management. Pain and complaints during the rehabilitation have to be clarified and targeted, mostly multimodal interventions, must be included.