BACKGROUND:Geriatric femoral neck fractures are associated with substantial morbidity and medical cost. We evaluated the incidence and management trends of femoral neck fractures in recent years in ...the U.S.
METHODS:Patient data from 2003 through 2013 were obtained from the Nationwide Inpatient Sample database. Femoral neck fractures in patients ≥65 years old were identified and grouped using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for internal fixation, hemiarthroplasty, or total hip arthroplasty (THA). The nationwide incidence of femoral neck fractures was calculated and presented as an age-adjusted population rate. Univariable methods were used for trend analysis and comparisons between groups. Logistic regression modeling was used to analyze complications.
RESULTS:From 2003 to 2013, we identified 808,940 femoral neck fractures in patients ≥65 years old. The national age-adjusted incidence of femoral neck fractures decreased from 242 per 100,000 U.S. adults in 2003 to 146 in 2013. The proportion of fractures managed operatively with THA increased over time (5.9% in 2003 versus 7.4% in 2013; p < 0.001). Concurrently, the use of hemiarthroplasty declined (65.1% versus 63.6%; p < 0.001). In 2013, the median age of the patients treated with THA was significantly younger (77.3 years) compared with that in the hemiarthroplasty and internal fixation groups (83.2 and 82.0 years). The THA group had significantly higher median initial hospital costs ($17,097) compared with the hemiarthroplasty and internal fixation groups ($14,776 and $10,462).
CONCLUSIONS:In the last decade, the total number and population rate of femoral neck fractures in the elderly declined significantly. There was a modest but significant increase in the utilization of THA.
CLINICAL RELEVANCE:This report identifies the changing trends in clinical practice in the treatment of geriatric femoral neck fractures in the U.S. Treating physicians should be aware of these trends, which include a decreasing national incidence of geriatric femoral neck fractures as well as an increase in the use of THA.
BackgroundOptimal surgical management of three and four-part proximal humeral fractures in osteoporotic patients is controversial, with many advocating prosthetic replacement of the humeral head. ...Fixed-angle locked plates that maintain angular stability under load have been proposed as an alternative to hemiarthroplasty for the treatment of some osteoporotic fracture types.MethodsThe records of 122 consecutive patients who were fifty-five years of age or older and in whom a Neer three or four-part proximal humeral fracture had been treated surgically between January 2002 and November 2005 were studied retrospectively. After exclusions, thirty-eight patients treated with a locked-plate construct were compared with forty-eight patients who had undergone hemiarthroplasty. All patients had radiographic and clinical follow-up at a minimum of twenty-four months and an average of thirty-six months. Reduction and implant placement were evaluated radiographically. Clinical outcomes were measured with use of the Constant-Murley system.ResultsThe mean Constant score (and standard deviation) at the time of final follow-up was significantly better in the locked-plate group (68.6 ± 9.5 points) than in the hemiarthroplasty group (60.6 ± 5.9 points) (p < 0.001). The Constant scores for the three-part fractures in the locked-plate and hemiarthroplasty groups were 71.6 and 60.4 points (p < 0.001), respectively, and the scores for the four-part fractures in those groups were 64.7 and 60.1 points (p = 0.19), respectively. Patients with an initial varus extension deformity in the locked-plate group had significantly worse outcomes than those with a valgus impacted pattern (Constant score, 63.8 compared with 74.6 points, respectively; p < 0.001). Complications in the group treated with locked-plate fixation included osteonecrosis in six patients, screw perforation of the humeral head in six patients, loss of fixation in four patients, and wound infection in three patients. Loss of fixation was seen only in patients with >20° of initial varus angulation of the humeral head. Complications in the hemiarthroplasty group included nonunion of the tuberosity in seven patients and wound infection in three patients.ConclusionsIn this series, open repair with use of a locked plate resulted in better outcome scores than did hemiarthroplasty in similar patients, especially in those with a three-part fracture, despite a higher overall complication rate. Open reduction and internal fixation of fractures with an initial varus extension pattern should be approached with caution.Level of EvidenceTherapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.
Background Displaced intra-articular distal humeral fractures are a challenging injury in elderly patients. High rates of complications have led to the increasing use of total elbow arthroplasty ...(TEA) for primary treatment. This study presents US nationwide trends in primary TEA for distal humeral fractures in elderly patients (65 years and older) from 2002 to 2012. We hypothesized that there was an increase in the rate of TEA utilization. Methods Data were obtained from the Nationwide Inpatient Sample for the years 2002 to 2012. All inpatients 65 years and older with distal humeral fractures were identified and were divided into 2 subgroups based on the operation they received: (1) TEA and (2) open reduction–internal fixation (ORIF). Results Between 2002 and 2012, the annual frequency of TEA for elderly patients with distal humeral fractures increased 2.6-fold, with 147 patients in 2002 and 385 in 2012. In 2012, TEA was performed in 13% of operatively treated distal humeral fractures compared with only 5.1% in 2002 ( P < .05). Mean hospital charges increased significantly for both the ORIF and TEA groups from 2002 to 2012. The average hospital charge for TEA in 2012 was $85,365, which was $16,358 higher than that for patients who underwent ORIF ( P < .05). Conclusion The national rate of primary TEA for the acute management of distal humeral fractures in elderly patients has increased significantly over the past 10 years. Given the significant complexity, long-term restrictions, and risks associated with TEA, this increasing trend should be analyzed closely.
γ-aminobutyric acid (GABA) begins as the key excitatory neurotransmitter in newly forming circuits, with chloride efflux from GABA type A receptors (GABAARs) producing membrane depolarization, which ...promotes calcium entry, dendritic outgrowth and synaptogenesis. As development proceeds, GABAergic signaling switches to inhibitory hyperpolarizing neurotransmission. Despite the evidence of impaired GABAergic neurotransmission in neurodevelopmental disorders, little is understood on how agonist-dependent GABAAR activation controls the formation and plasticity of GABAergic synapses. We have identified a weakly depolarizing and inhibitory GABAAR response in cortical neurons that occurs during the transition period from GABAAR depolarizing excitation to hyperpolarizing inhibitory activity. We show here that treatment with the GABAAR agonist muscimol mediates structural changes that diminish GABAergic synapse strength through postsynaptic and presynaptic plasticity via intracellular Ca2+ stores, ERK and BDNF/TrkB signaling. Muscimol decreases synaptic localization of surface γ2 GABAARs and gephyrin postsynaptic scaffold while β2/3 non-γ2 GABAARs accumulate in the synapse. Concurrent with this structural plasticity, muscimol treatment decreases synaptic currents while enhancing the γ2 containing benzodiazepine sensitive GABAAR tonic current in an ERK dependent manner. We further demonstrate that GABAAR activation leads to a decrease in presynaptic GAD65 levels via BDNF/TrkB signaling. Together these data reveal a novel mechanism for agonist induced GABAergic synapse plasticity that can occur on the timescale of minutes, contributing to rapid modification of synaptic and circuit function.
•Depolarizing and inhibitory GABAAR responses control early circuit development.•GABAAR agonist treatment results in delayed ERK activation.•Muscimol treatment reduces GABAAR synaptic currents while enhancing tonic current.•GABAAR agonist treatment produces rapid GABAergic synaptic plasticity.
Purpose
To explore the relationship between retinal fluid status and best-corrected visual acuity (BCVA) in patients treated with intravitreal aflibercept (IVT-AFL) treat-and-extend (T&E) in the ...ALTAIR study.
Methods
Outcomes were investigated according to overall fluid status at week 16 (predefined) and the relationship between any fluid, intraretinal fluid (IRF), subretinal fluid (SRF), or pigment epithelial detachment with BCVA at baseline, and weeks 16, 52, and 96 (post-hoc). The analyses involved treatment-naïve patients (N = 246) with exudative age-related macular degeneration (AMD), aged ≥ 50 years with BCVA of 73–25 Early Treatment Diabetic Retinopathy Study letters, who participated in the ALTAIR study.
Results
The mean (standard deviation) change in BCVA from baseline to week 52 was + 10.6 (10.9) and + 6.5 (16.0) letters in patients without and with fluid at week 16, respectively; and to week 96 was + 9.1 (14.3) and + 4.3 (16.1) letters in patients without and with fluid at week 16, respectively. The last injection interval was 16 weeks in 33.6% and 2.0% (week 52), and 62.9% and 17.6% (week 96) of patients without or with fluid at week 16, respectively. At baseline, 35.7% of patients had IRF and 85.2% of patients had SRF, which decreased to 11.8% (IRF) and 31.7% (SRF) of patients, 8.5% (IRF) and 18.7% (SRF), and 6.5% (IRF) and 20.7% (SRF) at weeks 16, 52, and 96, respectively. Presence of IRF at all timepoints was associated with poorer BCVA than if IRF was absent, while the presence of SRF was not associated with poorer BCVA compared with the absence of SRF.
Conclusion
IVT-AFL T&E dosing was effective at clearing fluid regardless of fluid type in ~ 80% of patients with exudative AMD. Patients without fluid at week 16 had numerically better BCVA than those with fluid at week 16. Over 60% of patients without fluid at week 16 achieved the maximum treatment interval of 16 weeks by study end, compared with < 20% of patients with fluid at week 16. IRF (weeks 16, 52, 96), although evident in a small number of patients, was associated with poorer BCVA, whereas SRF was not.
Trial registration
ClinicalTrials.gov Identifier: NCT02305238
OBJECTIVES:The use of locked plates in repairing osteopenic 3- and 4-part proximal humerus fractures remains controversial. The purpose of this article was to report the outcomes of open reduction ...and internal fixation in low-energy proximal humerus fractures treated with locked plating in patients older than 55 years and stratify risk of failure or complication based on initial radiographic features.
DESIGN:Retrospective.
SETTING:Level I Trauma Center.
METHODS:Seventy patients older than 55 years undergoing locked plate fixation for Neer 3- or 4-part proximal humerus fractures were studied retrospectively. All patients had standardized, true size digital radiographs of the injured and normal shoulder in the axillary, scapular Y, and 20-degree external rotation views with a minimum of 18 monthsʼ clinical follow-up. Two groups were identified based on the initial direction of the humeral head deformityvarus or valgus impaction. There were no statistical differences between treatment groups with regard to age, sex, Neer classification, follow-up, or dislocation. Radiographic measurements included humeral head angulation, tuberosity displacement, and length of the intact metaphyseal segment. Clinical outcomes measured Constant scores (CS) using active range of motion at latest follow-up.
RESULTS:Twenty-four patients with initial varus fracture patterns healed with an average of 16-degree varus head angulation and an overall CS of 63 at an average of 34 monthsʼ follow-up. Forty-six patients with initial valgus fracture patterns healed with an average of 6 degrees of varus angulation and an overall CS of 71 at an average of 37 monthsʼ follow-up (P < 0.01). Complications of avascular necrosis, humeral head perforation, loss of fixation, tuberosity displacement >5 mm, and varus subsidence >5 degrees were encountered in 19 of 24 (79%) in the varus group compared with 9 of 46 (19%) in the valgus group (P < 0.01). Final CSs for 3-part fractures were 65 versus 72 (P < 0.01) for varus and valgus groups, respectively, and 61 versus 69 (P = 0.19) for 4-part fractures.
CONCLUSIONS:Neer 3- and 4-part proximal humeral fractures in older patients with initial varus angulation of the humeral head had a significantly worse clinical outcome and higher complication rate than similar fracture patterns with initial valgus angulation. Two factors had significant influence on final outcome in these fracture patternsinitial direction of the humeral head angulation and length of the intact metaphyseal segment attached to the articular fragment. The best clinical outcomes were obtained in valgus impacted fractures with a metaphyseal segment length of greater than 2 mm, and this was independent of Neer fracture type. Humeral head angulation had the greatest effect on final outcomes (P < 0.001), whereas metaphyseal segment length of less than 2 mm was predictive of developing avascular necrosis (P < 0.001).
This study described surgical treatment patterns for proximal humerus fractures among elderly patients, focusing on reverse total shoulder arthroplasty (TSA), and evaluated how the type of fixation ...affects inpatient factors (cost, length of stay), transfusion rates, and patient disposition (home vs skilled nursing facility). With Nationwide Inpatient Sample data from 2011 to 2013, the authors identified patients 65 years and older who had proximal humerus fractures and divided them into 3 groups: (1) open reduction and internal fixation (ORIF); (2) hemiarthroplasty; and (3) reverse TSA. From 2011 to 2013, 38,729 surgically treated proximal humerus fractures were identified. The rate of reverse TSA increased 1.8-fold during this time, from 13% of operative cases in 2011 to 24% of operative cases in 2013 (P<.001). At the same time, the rates of hemiarthroplasty and ORIF decreased (hemiarthroplasty, from 28% to 21%; ORIF, from 59% to 55%). Although reverse TSA accounted for 32.2% of arthroplasty procedures for proximal humerus fractures in 2011, this value was 53.3% in 2013 (P<.001). In 2013, mean total hospital cost for reverse TSA was $24,154, which was significantly higher than that for ORIF ($16,269) or hemiarthroplasty ($19,175) (P<.001). In a multivariable model, patients undergoing reverse TSA were less likely than those undergoing hemiarthroplasty to be discharged to a skilled nursing facility (odds ratio, 0.75; P=.027). The national rate of reverse TSA nearly doubled from 2011 to 2013. As of 2013, reverse TSA replaced hemiarthroplasty as the most commonly performed arthroplasty procedure for proximal humerus fractures for patients 65 years and older. Patients undergoing reverse TSA were more likely than those undergoing hemiarthroplasty to be discharged home. Orthopedics. 2017; 40(6):e982-e989..
Ankle malunions with a shortened fibula and syndesmosis widening can pose challenges to the patient and treating physician. Indications for revision-operative intervention include persistent pain and ...disability. Shortened fibula malunions can be addressed using a lengthening fibular osteotomy and revision fixation. Chronic syndesmotic injuries can be addressed with syndesmotic debridement, open reduction, and suture button fixation. In this video, we present our surgical technique and rationale for the management of a shortened fibular malunion with persistent syndesmotic widening.
BACKGROUND:Fascia iliaca nerve blocks (FIBs) anesthetize the thigh and provide opioid-sparing analgesia for geriatric patients with hip fracture awaiting a surgical procedure. FIBs are recommended ...for preoperative pain management; yet, block administration is often delayed for hours after admission, and delays in pain management lead to worse outcomes. Our objective was to determine whether opioid consumption and pain following a hip fracture are affected by the time to block (TTB). We also examined length of stay and opioid-related adverse events.
METHODS:This prospective cohort study included patients who were ≥60 years of age, presented with a hip fracture, and received a preoperative FIB from March 2017 to December 2017. Individualized care timelines, including the date and time of admission, block placement, and surgical procedure, were created to evaluate the effect that TTB and time to surgery (TTS) had on outcomes. Patterns among TTB, TTS, and morphine milligram equivalents (MME) were investigated using the Spearman rho correlation. For descriptive purposes, we divided patients into 2 groups based on the median TTB. Multivariable regression for preoperative MME and length of stay was performed to assess the effect of TTB.
RESULTS:There were 107 patients, with a mean age of 83.3 years, who received a preoperative FIB. The median TTB was 8.5 hours. Seventy-two percent of preoperative MME consumption occurred before block placement (pre-block MME). A longer TTB was most strongly correlated with pre-block MME (rho = 0.54; p < 0.001), and TTS was not correlated. Patients with a faster TTB consumed fewer opioids preoperatively (12.0 compared with 33.1 MME; p = 0.015), had lower visual analog scale scores for pain on postoperative day 1 (2.8 compared with 3.5 points; p = 0.046), and were discharged earlier (4.0 compared with 5.5 days; p = 0.039). There were no differences in preoperative pain scores, postoperative opioid consumption, delirium, or opioid-related adverse events. Multivariate regression showed that every hour of delay in TTB was associated with a 2.8% increase in preoperative MME and a 1.0% increase in the length of stay.
CONCLUSIONS:Faster TTB in geriatric patients with hip fracture may reduce opioid use, pain, and length of stay.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Abstract Introduction Surgical management of calcaneus fractures is technically demanding and has a high risk of wound complications. These fractures are traditionally managed with splinting until ...swelling has subsided, which can take weeks and leaves the fracture fragments displaced. We describe a novel protocol for the management of displaced intraarticular calcaneus fractures that utilises a temporising external fixator and staged conversion to plate fixation through a sinus tarsi approach. The goal of this technique was to enable earlier treatment with open reduction and internal fixation, minimise the amount of manipulation required at the time of definitive fixation and reduce the wound complication rate seen with the traditional extensile approach. Methods The records of patients with displaced calcaneus fractures from 2010–2014 were reviewed retrospectively. A total of nine patients with 10 calcaneus fractures were treated using this protocol. All patients underwent ankle-spanning medial external fixation within 48 hours after injury. Patients underwent conversion to open plate fixation through a sinus tarsi approach when skin turgor had returned to normal. Time to surgery, infection rate, wound complications, radiographic alignment, and time to radiographic union were recorded. Results The average Bohler's angle improved from 13.2 (range −2 to 34) degrees preoperatively to 34.3 (range 26 to 42) degrees postoperatively. The average time from external fixation to conversion to internal fixation was 4.8 (range 3 to 7) days. There were no immediate post-surgical complications. The average time to weight-bearing was 8.5 weeks. The average time to radiographic union was 9.5 (range 8 to 12) weeks. There were no infections or wound complications at the time of last follow-up. Conclusion Early temporising external fixation for the acute management of displaced calcaneus fractures is a safe and effective method to reduce and stabilise the foot and may decrease the time to definitive fixation. There were no complications related to the use of the external fixator in this series.
PDF
