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1.
Praxis (Bern 1994) ; 113(1): 15-19, 2024 Jan.
Artículo en Alemán | MEDLINE | ID: mdl-38381105

RESUMEN

INTRODUCTION: Osteoanabolic osteoporosis drugs have become better available. The osteoanabolic therapeutic principle has a stronger, faster-onset fracture-reducing effect than the antiresorptive preparations. It has also been newly recognized that the significance of a first fragility fracture as a risk factor is time-dependent: the less time that has elapsed since the first fracture, the higher the resulting re-fracture risk. Patients older than 65 years whose index fragility fracture occurred less than two years before are therefore grouped in a separate "Imminent Fracture Risk" category. These innovations were implemented by updating the osteoporosis therapy guideline. According to this guideline, patients in the "Imminent Fracture Risk" category should be offered osteoporosis therapy as soon as possible, in order to avoid as many fractures as possible. We are critical of an overly strict implementation of this algorithm in very old fracture patients. Our own data indicate that more than 30 % of this subpopulation do not experience the effect of a newly started osteoporosis therapy. We advocate a clinically based indication for osteoporosis therapy. For this, we propose a "Question Surprise" modified for osteological purposes. "Would I be surprised if I had to treat the same patient for a fracture again in a year?" If the question is answered with "No," then that patient could be a candidate for specific osteoporosis treatment.


Asunto(s)
Fracturas Óseas , Osteoporosis , Humanos , Osteoporosis/tratamiento farmacológico , Algoritmos , Pacientes , Factores de Riesgo
4.
Clin Pract ; 11(1): 47-57, 2021 Jan 29.
Artículo en Inglés | MEDLINE | ID: mdl-33573004

RESUMEN

Nonunion is known to occur in up to 10% of all bone fractures. Until recently, the treatment options considered in cases of delayed union and nonunion focused on revision surgery and improvement of local healing. Lately, teriparatide has been introduced as an osteoanabolic factor that induces fracture healing in cases with delayed or nonunions. We report on a series of five cases of delayed and nonunions treated with teriparatide: delayed unions of an atypical femoral fracture, of a multifragmentary clavicle fracture, and of a periprosthetic humeral fracture; nonunion of a tibial and fibular fracture; and infected nonunion of a tibial and fibular fracture. Based on this series, the indications and limits of application of teriparatide in cases of impaired fracture healing are discussed. Due to the "off-label" character of this application, informed consent, and cost coverage from the healthcare insurance must be obtained prior to treatment. In our experience and according to the limited existing literature, teriparatide is a safe feasible treatment in cases of delayed and nonunions with a reasonable need of resources. While adequate biomechanical stability remains the cornerstone of fracture healing, as well as healing of nonunions, teriparatide could help avoid repetitive surgeries, especially in atrophic delayed and nonunions, as well as in patients with impaired fracture healing undergoing bisphosphonate therapy. There is an urgent need for widely accepted definitions, standardized protocols, as well as further clinical trials in the field of impaired fracture healing.

5.
J Shoulder Elbow Surg ; 29(6): 1127-1135, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-32057657

RESUMEN

BACKGROUND: We modified our treatment algorithm for proximal humeral fractures in elderly patients in 2013 to a more conservative approach avoiding locking plates. This study assesses the impact of this change on patient self-dependence. METHODS: We carried out an observational comparative study including both retrospectively and prospectively collected data. For the former, 147 isolated proximal humeral fracture patients older than 65 years were treated between 2011 and 2013 at our hospital and included in a historical group. The revised treatment algorithm was applied in a similar non-concurrent, comparative patient group (n = 160) prospectively enrolled between 2015 and 2017. The primary outcome was any loss of self-dependence, with secondary outcomes including documentation of shoulder functional scores, quality of life, and adverse events. RESULTS: Historical and prospective patients had similar baseline characteristics. Nonoperative treatment was performed in 53 historical patients (36%) and 83 prospective patients (78%). Prospective patients were 1.6 times less likely to lose some level of self-dependence (risk ratio, 0.62; 95% confidence interval, 0.25-1.5; P = .292), and the local adverse event risk dropped from 12.2% to 5.7% (P = .078). Mean shoulder function and quality of life were similar between the 2 groups. CONCLUSION: By applying our revised algorithm, a higher proportion of elderly patients maintained their premorbid level of self-dependence and returned to their previous social environment.


Asunto(s)
Algoritmos , Vida Independiente , Autonomía Personal , Autoeficacia , Fracturas del Hombro/terapia , Anciano , Placas Óseas , Estudios de Cohortes , Tratamiento Conservador , Femenino , Fijación Interna de Fracturas , Hemiartroplastia , Humanos , Masculino , Calidad de Vida
6.
Arch Orthop Trauma Surg ; 140(3): 321-329, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31332508

RESUMEN

INTRODUCTION: A recent randomized controlled trial has reported full patient compliance and no adverse events from therapy with parathyroid hormone (PTH) for osteoporosis and accelerated healing of fragility fractures of the pelvis. The purpose of the presented study was to evaluate if similar results can be achieved with comprehensive PTH therapy in routine clinical practice. We hypothesised that patients' burden of PTH therapy is underestimated in the literature. PATIENTS AND METHODS: Osteoanabolic PTH therapy was recommended to 79 patients suffering from an acute fragility fracture of the pelvis (FFP). Case finding, initiation of therapy and follow-up were performed by a fracture liaison service team. Primary outcome was PTH initiation rate. Secondary outcomes were implementation rate of alternative antiresorptive pharmaceutical therapy for osteoporosis and participation rate in a bone metabolic workup. Adverse events and effects potentially related to the therapy with bone-active drugs were documented as exploratory outcomes. RESULTS: Osteoanabolic PTH therapy as suggested was accepted by 32%, whereas antiresorptive therapy was implemented in another 14% of the patients. DEXA scans were available in 38% of the patients (+ 27% when compared to baseline). A bone-specific laboratory analysis was done in 18 patients, uncovering 7 pathological findings. Two patients terminated PTH therapy early because of side effects. CONCLUSION: The experiences with PTH therapy in FFP patients with respect to, implementation rate, frequency of side effects and of pathological findings in laboratory controls as reported from a previous RCT could not be reproduced in routine clinical practice.


Asunto(s)
Conservadores de la Densidad Ósea/uso terapéutico , Fracturas de Cadera/tratamiento farmacológico , Fracturas Osteoporóticas/tratamiento farmacológico , Cooperación del Paciente/estadística & datos numéricos , Teriparatido/uso terapéutico , Anciano , Anabolizantes/administración & dosificación , Anabolizantes/uso terapéutico , Conservadores de la Densidad Ósea/administración & dosificación , Femenino , Humanos , Masculino , Osteoporosis/tratamiento farmacológico , Estudios Retrospectivos , Teriparatido/administración & dosificación
7.
Knee Surg Sports Traumatol Arthrosc ; 28(2): 408-417, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31273410

RESUMEN

PURPOSE: The purpose of this study was to determine the efficacy and tolerability of different antiresorptive therapeutic regimens for treating symptomatic bone marrow lesions (BML) of the knee. METHODS: Patient records of 34 patients with radiologically diagnosed, painful BML of the knee treated with either a bisphosphonate (zoledronic, ibandronic, or alendronic acid) or with a human monoclonal antibody (denosumab) were retrospectively evaluated. Response to treatment was assessed, as change in patient-reported pain, by evaluation of BML expansion on MRI using the Whole-Organ Magnetic Resonance Imaging Score (WORMS), and by laboratory analysis of bone turnover markers: C-terminal cross-linking telopeptide (CTx) and procollagen type 1 amino-terminal propeptide (P1NP). Tolerability was evaluated by documentation of adverse reactions. RESULTS: Zoledronic acid was more or at least equally effective as the other treatment regimens with response to treatment in 11 of 12 patients (92%). The highest rate of adverse events was noted in 4 of 12 patients (33%) treated with zoledronic acid. CTx and WORMS differentiated well between responders and non-responders, whereas P1NP failed to do so. Changes in pain correlated moderately with change in WORMS (r = - 0.32), weakly with change in CTx (r = - 0.07), and not at all with change in P1NP. CONCLUSION: Zoledronic acid appeared to be more effective than other antiresorptive medications-at the cost of more frequent adverse events. While radiological and laboratory evaluation methods may allow for objective treatment monitoring, they appear to capture different dimensions than patient-reported pain. LEVEL OF EVIDENCE: III.


Asunto(s)
Conservadores de la Densidad Ósea/uso terapéutico , Enfermedades de la Médula Ósea/tratamiento farmacológico , Ácido Ibandrónico/uso terapéutico , Ácido Zoledrónico/uso terapéutico , Anciano , Artralgia/etiología , Artralgia/prevención & control , Biomarcadores/metabolismo , Enfermedades de la Médula Ósea/complicaciones , Enfermedades de la Médula Ósea/diagnóstico por imagen , Colágeno Tipo I/metabolismo , Denosumab/uso terapéutico , Suplementos Dietéticos , Difosfonatos/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fragmentos de Péptidos/metabolismo , Péptidos/metabolismo , Procolágeno/metabolismo , Estudios Retrospectivos , Vitamina D/uso terapéutico
8.
BMC Geriatr ; 18(1): 222, 2018 09 21.
Artículo en Inglés | MEDLINE | ID: mdl-30241509

RESUMEN

BACKGROUND: The relevance of femoral neck fractures (FNFs) increases with the ageing of numerous societies, injury-related decline is observed in many patients. Treatment strategies have evolved towards primary joint replacement, but the impact of different approaches remains a matter of debate. The aim of this trial was to evaluate the benefit of an anterior minimally-invasive (AMIS) compared to a lateral Hardinge (LAT) approach for hemiarthroplasty in these oftentimes frail patients. METHODS: Four hundred thirty-nine patients were screened during the 44-months trial, aiming at the evaluation of 150 patients > 60 yrs. of age. Eligible patients were randomised using an online-tool with completely random assignment. As primary endpoint, early mobility, a predictor for long-term outcomes, was evaluated at 3 weeks via the "Timed up and go" test (TUG). Secondary endpoints included the Functional Independence Measure (FIM), pain, complications, one-year mobility and mortality. RESULTS: A total of 190 patients were randomised; both groups were comparable at baseline, with a predominance for frailty-associated factors in the AMIS-group. At 3 weeks, 146 patients were assessed for the primary outcome. There was a reduction in the median duration of TUG performance of 21.5% (CI [- 41.2,4.7], p = 0.104) in the AMIS-arm (i.e., improved mobility). This reduction was more pronounced in patients with signs of frailty or cognitive impairment. FIM scores increased on average by 6.7 points (CI [0.5-12.8], p = 0.037), pain measured on a 10-point visual analogue scale decreased on average by 0.7 points (CI: [- 1.4,0.0], p = 0.064). The requirement for blood transfusion was lower in the AMIS- group, the rate of complications comparable, with a higher rate of soft tissue complications in the LAT-group. The mortality was higher in the AMIS-group. CONCLUSION: These results, similar to previous reports, support the concept that in elderly patients at risk of frailty, the AMIS approach for hemiarthroplasty can be beneficial, since early mobilisation and pain reduction potentially reduce deconditioning, morbidity and loss of independence. The results are, however, influenced by a plethora of factors. Only improvements in every aspect of the therapeutic chain can lead to optimisation of treatment and improve outcomes in this growing patient population. TRIAL REGISTRATION: www.clinicaltrials.gov : NCT01408693 (registered August 3rd 2011).


Asunto(s)
Nalgas/cirugía , Fracturas del Cuello Femoral/cirugía , Hemiartroplastia/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Músculo Esquelético/cirugía , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/métodos , Artroplastia de Reemplazo de Cadera/normas , Femenino , Fracturas del Cuello Femoral/diagnóstico , Estudios de Seguimiento , Hemiartroplastia/normas , Humanos , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos/normas , Estudios Prospectivos , Resultado del Tratamiento
9.
Injury ; 48(12): 2717-2723, 2017 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-29122281

RESUMEN

BACKGROUND: Low energy pelvic ring fractures in the elderly have traditionally been treated conservatively, a treatment with potential long-term complications and loss of self-independence. Percutaneous screw stabilisation of the posterior pelvic ring is a new treatment modality that enables immediate mobilisation. The aim of this study was to assess the functional outcome after sacroiliac stabilisation in the elderly. METHODS: All elderly patients with a surgically stabilised low energy pelvic fracture between 2010 and 2015 were included. In 2016 a radiographic follow up and functional test was performed at least one year postoperative. RESULTS: The 50 operated patients had a mean age of 79 years and a one-year mortality of 10% (5/50). Only six patients lost independency after the pelvic fracture and moved to nursing home. The mean Timed Up and Go test was 16s at follow-up. The operation of the posterior pelvic ring averaged 63min with a radiation equal to a diagnostic pelvic CT. One intra-foraminally placed screw was immediately removed and 9 patients were later re-operated on due to symptomatic loosening of one or more screws. No loosening of screws was seen in 11 patients where both S1 and S2 were stabilised and out of 23 trans-sacral screws (crossing both sacroiliac joints) only two loosened. DISCUSSION: CT guided stabilisation of the posterior pelvis is safe and most patients resumed good function and independent living. The risk of a revision operation was 20%, but trans-sacral screw stabilisation in both S1 and S2 could reduce the risk of implant loosening.


Asunto(s)
Densidad Ósea/fisiología , Fijación Interna de Fracturas , Fracturas Óseas/cirugía , Inestabilidad de la Articulación/cirugía , Huesos Pélvicos/cirugía , Articulación Sacroiliaca/fisiopatología , Sacro/cirugía , Anciano , Anciano de 80 o más Años , Tornillos Óseos , Comorbilidad , Femenino , Estudios de Seguimiento , Fracturas Óseas/fisiopatología , Humanos , Inestabilidad de la Articulación/diagnóstico por imagen , Masculino , Tempo Operativo , Huesos Pélvicos/diagnóstico por imagen , Huesos Pélvicos/lesiones , Huesos Pélvicos/fisiopatología , Complicaciones Posoperatorias , Reoperación , Articulación Sacroiliaca/diagnóstico por imagen , Sacro/diagnóstico por imagen , Sacro/lesiones , Sacro/fisiopatología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento
10.
Swiss Med Wkly ; 147: w14484, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-28871570

RESUMEN

Antiosteoporotic drugs are recommended in patients with fragility fractures and in patients considered to be at high fracture risk on the basis of clinical risk factors and/or low bone mineral density. As first-line treatment most patients are started with an antiresorptive treatment, i.e. drugs that inhibit osteoclast development and/or function (bisphosphonates, denosumab, oestrogens or selective oestrogen receptor modulators). In the balance between benefits and risks of antiresorptive treatment, uncertainties remain regarding the optimal treatment duration and the management of patients after drug discontinuation. Based on the available evidence, this position statement will focus on the long-term management of osteoporosis therapy, formulating decision criteria for clinical practice.


Asunto(s)
Conservadores de la Densidad Ósea/uso terapéutico , Denosumab/uso terapéutico , Difosfonatos/uso terapéutico , Práctica Clínica Basada en la Evidencia , Osteoporosis/tratamiento farmacológico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Femenino , Humanos , Fracturas Osteoporóticas/prevención & control , Factores de Riesgo , Factores de Tiempo
11.
Arch Orthop Trauma Surg ; 136(8): 1099-106, 2016 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-27236584

RESUMEN

INTRODUCTION: Geriatric hip fracture patients are a highly heterogeneous collective, what distinctly aggravates the best possible treatment. Consequently, it is becoming more important to identify selection criteria that can distinguish those patients who can benefit the most from treatment in a geriatric fracture center. In our pilot study, we assessed the 2007 published Penrod score for its utility as a useful selection tool by prospectively comparing our own patient's outcome with the Penrod study. METHODS: 77 patients treated for geriatric hip fracture were preoperatively classified according to the Penrod score. Patients were divided into three clusters by age (1: <75 years, 2: 75-84 years, 3: ≥85 years). Clusters 2 and 3 were then classified according to their ability to perform activities of daily living (ADL's) and cognitive status (presence or absence of dementia). In 51 out of these 77 patients, the ability to perform ADLs could be assessed 6 months postoperatively and was compared with the Penrod scores. RESULTS: 58 % of cluster 1 patients were able to perform 4 ADLs independently 6 months postoperatively (52.9 % Penrod study). In clusters 2A and 3A, 48 and 50 %, respectively, were able to perform 4 ADLs independently, compared with 40.6 and 31.5 % (Penrod collective). 22 % of our patients in 2B performed all ADLs independently (3.6 % Penrod) and 25 % in cluster 3B (9.4 % Penrod). CONCLUSION: Our preliminary results support the prognostic value of the Penrod score in the treatment of geriatric hip fracture patients. With the help of the Penrod score, it may be possible to identify patients, who are expected to significantly profit from an intensified treatment in a geriatric fracture center (clusters 2B, 3A, and 3B). By utilizing this score, improved outcomes and simultaneously a more effective utilization of valuable health care resources could be achieved.


Asunto(s)
Toma de Decisiones Clínicas , Evaluación de la Discapacidad , Evaluación Geriátrica , Fracturas de Cadera/cirugía , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera , Femenino , Fijación Interna de Fracturas , Humanos , Masculino , Pronóstico , Estudios Prospectivos , Suiza
13.
Injury ; 46(12): 2384-8, 2015 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-26454629

RESUMEN

BACKGROUND: The importance of the greater trochanter and its attached abductor muscles for physiological gait is well accepted. However the influence of a displaced greater trochanter fracture after a pertrochanteric fracture is unknown. The aim of this study is to determine if there is an association between the greater trochanter position and the level of patient mobility following internal fixation of pertrochanteric fractures. METHODS: One hundred and thirty-three consecutive elderly patients with a median age of 85 (interquartile range [IQR] 79-91) years, who were treated for pertrochanteric fractures at a level I trauma centre, were recruited. AO 31 A3.1 and A3.2 fracture types were excluded from the statistical analysis. Patient mobility was prospectively assessed before the fracture and one year following fracture treatment using the Parker mobility score. In a multivariable analysis, the influence of a displaced greater trochanter on patient mobility at one-year follow-up was assessed. The analysis was adjusted for age, gender, body mass index, Charlson comorbidity index, AO fracture classification, varus-/valgus malposition of the neck-shaft fragments, and Parker mobility score before fracture. RESULTS: Post-operative X-rays were available in 125 patients, out of which 66 (53%) patients were identified with a displaced or migrated greater trochanter. One year mortality rate was 22% (n=27). In the 82 patients who had functional assessment one year post-operatively, the median Parker mobility score before fracture and at one-year follow-up was 7 (IQR 4-9) and 7 (IQR 3-9) in patients without, and 7 (IQR 4-9) and 3 (IQR 2-5) in patients with a displaced greater trochanter. In multivariable analysis, a displaced greater trochanter was significantly associated with a lower Parker mobility score (-1.74, 95% confidence interval -2.37, -1.12, p<0.01). CONCLUSION: Greater trochanter displacement following internal fixation of extracapsular hip fractures with a cephalomedullary nail is associated with a poor functional outcome. Greater attention to achieve adequate reduction and stabilisation of this fragment during internal fixation of pertrochanteric hip fractures should be aimed for despite the inability of current cephalomedullary implants to do so. LEVEL OF EVIDENCE: III prognostic and epidemiological study.


Asunto(s)
Fémur/cirugía , Fijación Intramedular de Fracturas , Fracturas de Cadera/cirugía , Complicaciones Posoperatorias/cirugía , Anciano , Anciano de 80 o más Años , Clavos Ortopédicos , Análisis de Falla de Equipo , Femenino , Fémur/diagnóstico por imagen , Fémur/fisiopatología , Fracturas de Cadera/diagnóstico por imagen , Fracturas de Cadera/fisiopatología , Humanos , Masculino , Selección de Paciente , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento
14.
J Orthop Res ; 33(11): 1680-6, 2015 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-25929756

RESUMEN

This study assessed whether mechanically measured trabecular bone strength is an independent predictor of dynamic hip screw (DHS) stability, i.e., DHS migration (DHSM) after the fixation of proximal femoral fractures. One-hundred and seven patients older than 50 years with proximal femoral fractures were included. During fracture fixation, a mechanical probe (DensiProbe™ Hip) was inserted at the site where the DHS tip would ultimately be positioned. Peak torque to breakaway the trabecular bone was measured. Fracture reduction, primary implant position and postoperative DHSM were assessed by radiographs taken postoperatively, at 6 and 12 weeks after surgery. Univariate regression analysis revealed no association between peak torque and DHSM (R(2) = 0.025, p = 0.135). DHSM correlated with the primary DHS position, i.e., the distance between the DHS and (i) the central femoral neck axis (CNFAD, R(2) = 0.230; p < 0.0001) and (ii) the apex of the femoral head (R(2) = 0.110; p = 0.001). DHSM did not correlate with areal BMD of the contralateral proximal femur. Multivariable regression modeling revealed the CFNAD as predictive factor for screw migration. The primary implant position measured by the CFNAD, rather than DensiProbe™ Hip measured bone strength, is an independent predictor of DHSM.


Asunto(s)
Tornillos Óseos/efectos adversos , Migración de Cuerpo Extraño/etiología , Fijación Interna de Fracturas/efectos adversos , Fracturas de Cadera/cirugía , Complicaciones Posoperatorias/etiología , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Estudios Prospectivos , Análisis de Regresión
15.
J Clin Densitom ; 18(1): 109-16, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-25087043

RESUMEN

Reduced bone stock can result in fractures that mostly occur in the spine, distal radius, and proximal femur. In case of operative treatment, osteoporosis is associated with an increased failure rate. To estimate implant anchorage, mechanical methods seem to be promising to measure bone strength intraoperatively. It has been shown that the mechanical peak torque correlates with the local bone mineral density and screw failure load in hip, hindfoot, humerus, and spine in vitro. One device to measure mechanical peak torque is the DensiProbe (AO Research Institute, Davos, Switzerland). The device has shown its effectiveness in mechanical peak torque measurement in mechanical testing setups for the use in hip, hindfoot, and spine. In all studies, the correlation of mechanical torque measurement and local bone mineral density and screw failure load could be shown. It allows the surgeon to judge local bone strength intraoperatively directly at the region of interest and gives valuable information if additional augmentation is needed. We summarize methods of this new technique, its advantages and limitations, and give an overview of actual and possible future applications.


Asunto(s)
Densidad Ósea , Densitometría , Fracturas Óseas/cirugía , Cuidados Intraoperatorios , Complicaciones Intraoperatorias/prevención & control , Osteoporosis/diagnóstico , Complicaciones Posoperatorias/prevención & control , Investigación sobre la Eficacia Comparativa , Densitometría/instrumentación , Densitometría/métodos , Equipo para Diagnóstico , Diseño de Equipo , Fijación de Fractura/métodos , Fracturas Óseas/complicaciones , Humanos , Cuidados Intraoperatorios/instrumentación , Cuidados Intraoperatorios/métodos , Ensayo de Materiales , Osteoporosis/complicaciones
16.
Eur J Orthop Surg Traumatol ; 24(8): 1383-7, 2014 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-24085655

RESUMEN

AIM: The purpose of the article is to highlight a specific fracture pattern encountered by us in the osteoporotic upper humerus. We present our results of management of such metadiaphyseal fractures of the upper humerus with less invasive plating. The additional steps taken to improve final outcome and the reasoning behind each are discussed. PATIENTS AND METHODS: In our department, a total of 13 fractures (in 12 patients) were managed for a metadiaphyseal fracture of the upper humerus between 2010 and 2013. There were 2 males and 10 females. The average age in the cohort was 74.3 (52-95) years. In 9 fractures, the fracture line was extending above the surgical neck. All patients were managed with a locking compression plate (long PHILOS or LCP) using two approach windows (proximal deltopectoral and a distal anterior or lateral). Patients were evaluated for clinical outcome using the Quick DASH score and assessed for radiological union, complications or re-operations retrospectively. RESULTS: The mean follow-up was 14.3 months (4-36). All fractures were united, and there was no evidence of avascular necrosis or non-union. Two patients showed varus collapse of the anatomical head of which one patient needed change of screws at 12 weeks from index surgery. In patients, when a distal lateral window was used, 2 patients out of 4 had radial nerve palsy post-operatively. In the rest, when the plate was twisted by 45° to allow anterior placement using the brachialis split, none had radial nerve injury. CONCLUSION: The osteoporotic bone failing under a low-energy mechanism seemed to dictate this fracture pattern. The fracture is either a bending wedge or a long spiral with or without a large butterfly and often extends into the humeral head. The fractures are better managed surgically, a primary reduction allowing contact of fragments is essential, and using an anterior window distally with a 45° contoured plate will achieve good plate placement as well as decreases the risk of radial nerve injury considerably compared to total lateral plate positioning.


Asunto(s)
Placas Óseas , Fijación Interna de Fracturas/instrumentación , Fracturas del Húmero/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Fijación Interna de Fracturas/métodos , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento
17.
Int Orthop ; 38(4): 839-45, 2014 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-24146176

RESUMEN

PURPOSE: This study aimed to propose a technique to quantify dynamic hip screw (DHS®) migration on serial anteroposterior (AP) radiographs by accounting for femoral rotation and flexion. METHODS: Femoral rotation and flexion were estimated using radiographic projections of the DHS® plate thickness and length, respectively. The method accuracy was evaluated using a synthetic femur fixed with a DHS® and positioned at pre-defined rotation and flexion settings. Standardised measurements of DHS® migration were trigonometrically adjusted for femoral rotation and flexion, and compared with unadjusted estimates in 34 patients. RESULTS: The mean difference between the estimated and true femoral rotation and flexion values was 1.3° (95% CI 0.9-1.7°) and -3.0° (95% CI - 4.2° to -1.9°), respectively. Adjusted measurements of DHS® migration were significantly larger than unadjusted measurements (p = 0.045). CONCLUSION: The presented method allows quantification of DHS® migration with adequate bias correction due to femoral rotation and flexion.


Asunto(s)
Tornillos Óseos , Fracturas del Fémur/cirugía , Migración de Cuerpo Extraño/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Fémur/fisiopatología , Articulación de la Cadera/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Rotación
18.
Swiss Med Wkly ; 143: w13859, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-24089312

RESUMEN

OBJECTIVE: To evaluate the patient characteristics and natural history of pubic rami fractures in geriatric patients, with a special focus on the frequency of concomitant posterior pelvic ring lesions and the percentage of secondarily operated patients as a result of conservative treatment failure. STUDY DESIGN: Retrospective cohort study. Patients were treated in a university hospital that is equivalent to a level I Trauma centre. PATIENTS AND METHODS: We analysed 132 consecutive patients (113 women, 19 men), >65 years old, presenting with low energy-trauma pubic rami fractures at our emergency department from January 2009 to December 2011. RESULTS: Mean age of patients was 84 years (range 66-100). Women were affected six times more frequently than men. Almost 30% of patients lost their previous independence permanently owing to the injury. Ninety eight percent of previously independent patients (community dwellers) required temporary hospital care for a median duration of 39 days (interquartile range [IQR] 28-52). One-year mortality was 18.5%. A concomitant posterior pelvic ring lesion was identified by computed tomography in 54% of patients. In 4% of the patients secondary operative fracture stabilisation was performed. DISCUSSION: Pubic rami fractures are frequently associated with concomitant posterior pelvic ring injuries, making these injuries more unstable than generally assumed. Based on this fact and the long duration of hospital stay, more aggressive management of these injuries may be considered. The principle aims in this patient population are satisfying pain management, early mobilisation, conservation of independence and return to previous place of residence.


Asunto(s)
Tiempo de Internación/estadística & datos numéricos , Osteoporosis/epidemiología , Fracturas Osteoporóticas/epidemiología , Hueso Púbico/lesiones , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Vida Independiente/estadística & datos numéricos , Masculino , Traumatismo Múltiple , Osteoporosis/diagnóstico por imagen , Osteoporosis/terapia , Osteoporosis Posmenopáusica/diagnóstico por imagen , Osteoporosis Posmenopáusica/epidemiología , Osteoporosis Posmenopáusica/terapia , Fracturas Osteoporóticas/diagnóstico por imagen , Fracturas Osteoporóticas/terapia , Huesos Pélvicos/diagnóstico por imagen , Huesos Pélvicos/lesiones , Hueso Púbico/diagnóstico por imagen , Estudios Retrospectivos , Tomografía Computarizada por Rayos X
19.
Injury ; 43(10): 1712-7, 2012 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-22795727

RESUMEN

INTRODUCTION: Bone strength determines fracture risk and fixation strength of osteosynthesis implants. In vivo, bone strength is currently measured indirectly by quantifying bone mineral density (BMD) which is however only one determinant of the bone's biomechanical competence besides the bone's macro- and micro-architecture and tissue related parameters. We have developed a measurement principle (DensiProbe™ Hip) for direct, mechanical quantification of bone strength within the proximal femur upon hip fracture fixation. Previous cadaver tests indicated a close correlation between DensiProbe™ Hip measurements, 3D micro-CT analysis and biomechanical indicators of bone strength. The goal of this study was to correlate DensiProbe™ Hip measurements with areal bone mineral density (BMD). METHODS: Forty-three hip fracture patients were included in this study. Intraoperatively, DensiProbe™ Hip was inserted to the subsequent hip screw tip position within the femoral head. Peak torque to breakaway of local cancellous bone was registered. Thirty-seven patients underwent areal BMD measurements of the contralateral proximal femur. Failure of fixation was assessed radio graphically 6 and 12 weeks postoperatively. RESULTS: Peak torque and femoral neck BMD showed significant correlations (R=0.60, P=0.0001). In regression analysis, areal BMD explained 46% of femoral neck BMD variance in a quadratic relationship. Throughout the 12-week follow-up period, no failure of fixation was observed. CONCLUSIONS: DensiProbe™ Hip may capture variations of bone strength beyond areal BMD which are currently difficult to measure in vivo. A multicenter study will clarify if peak torque predicts fixation failure.


Asunto(s)
Tornillos Óseos , Fracturas del Fémur/fisiopatología , Fémur/fisiopatología , Fijación Interna de Fracturas/métodos , Torque , Absorciometría de Fotón , Anciano , Fenómenos Biomecánicos , Densidad Ósea , Cadáver , Femenino , Fracturas del Fémur/diagnóstico por imagen , Fracturas del Fémur/cirugía , Fémur/diagnóstico por imagen , Fémur/cirugía , Estudios de Seguimiento , Fijación Interna de Fracturas/instrumentación , Humanos , Masculino , Valor Predictivo de las Pruebas , Interpretación de Imagen Radiográfica Asistida por Computador , Soporte de Peso
20.
Ther Umsch ; 69(1): 61-8, 2012 Jan.
Artículo en Alemán | MEDLINE | ID: mdl-22198939

RESUMEN

The postoperative management after open reduction and internal fixation (ORIF) of fractures is addressed with this article. The topics selected focus on topics that are of relevance for the family practitioner. Because of large differences in the treatment of adult - and geriatric fracture patients these two groups are separately looked at in Part 1 and Part 2 of the article. Fractures in children or fractures of the growing skeleton are not addressed. In the early postoperative phase, the fracture patient might seek for advice in case of complications, such as wound infection or complex regional pain syndrome (CRPS). After fracture healing, the decision on implant removal has to be made. Geriatric fracture patients mostly cannot return back home directly from the hospital. Instead they are transferred to a rehabilitation center. In these patients secondary fracture prevention should be in the focus of the family practitioner. This means osteoporosis diagnostics and treatment shall be initiated, if not done before. Another important task is to guarantee for compliance with the therapy once it is initiated.


Asunto(s)
Conducta Cooperativa , Fijación Interna de Fracturas , Comunicación Interdisciplinaria , Grupo de Atención al Paciente , Cuidados Posoperatorios/métodos , Adolescente , Adulto , Factores de Edad , Anciano , Artroplastia de Reemplazo de Cadera , Síndromes de Dolor Regional Complejo/diagnóstico , Síndromes de Dolor Regional Complejo/etiología , Síndromes de Dolor Regional Complejo/terapia , Remoción de Dispositivos , Falla de Equipo , Humanos , Osteoporosis/diagnóstico , Osteoporosis/terapia , Fracturas Osteoporóticas/cirugía , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Prevención Secundaria , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/terapia
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