Urinary tract infections are one of the most frequent healthcare-associated infections representing a relevant postoperative complication in orthopedics patients. These infections are associated with increased morbidity, prolonged hospitalizations, and higher rates of readmission. In selected settings, they may coexist with or precede surgical site infections, including periprosthetic joint infections. This review aims to summarize and evaluate recent evidence from the last five years in regards to epidemiology, risk factors, clinical consequences, and preventative strategies for patients undergoing orthopaedic interventions. A narrative literature review was conducted using the PubMed/MEDLINE database utilizing English-language publications from January 2021 to February 2026. Particular emphasis was placed on systematic reviews, meta-analyses, cohort studies, and large database analyses related to hip fracture surgery, total joint arthroplasty, and spine surgery. These studies indicate that urinary tract infections remain particularly common among the geriatric population undergoing hip fracture surgery. Major modifiable risk factors include urinary catheterization and postoperative urinary retention. Symptomatic urinary tract infections briefly prior to surgery are associated with an increased risk of postoperative complications compared to asymptomatic bacteriuria. Avoidance of unnecessary urinary catheterization and routine urine testing in asymptomatic patients reduces the use of unnecessary antibiotics while preserving surgical outcomes. Urinary tract infections continue to represent a significant clinical issue in orthopaedic patients. Evidence supports catheter stewardship, targeted diagnostic strategies, and integrated preventive approaches to reduce infection-related complications.
The aim of this study was to describe and compare the structure and organization of orthopaedic and traumatology residency training across European countries. A descriptive, cross-sectional survey (31 items) of national teaching experts across Europe (≥10 years of experience in training residents) focused on: specialty integration, training model (time-based/competency-based/hybrid), program duration and duty hours was conducted from October 2023 to February 2025. Standardized extraction by three blinded reviewers was done and the answers were transformed into a consensus dataset. Responses were obtained from 33/40 countries (82.5%). In 31/33 countries (94%), orthopaedic surgery and musculoskeletal traumatology form a unified specialty. Only 9/33 (27%) countries delineate fixed elective-orthopaedics versus trauma blocks during the course of the residency. Training models were predominantly hybrid-having both features of competency and time-based learning criteria (26/33; 78%), with 7/33 (21%) time-based and none fully competency-based. Program length was mostly 5 years (16/33; 48%) or 6 years (11/33; 33%) long. Extremes ranged from 2 to 8 years. Average weekly hours varied from 37 to 70+, with nearly half of countries reporting practice that exceeds the European Working Time Directive 48-h limit via legal exceptions or weak enforcement by hospital. Flexible (less than full time training) pathways exist in 19 (58%) countries (unrestricted in 8; restricted in 11), but remain unavailable in 14 (42%). European orthopaedic and trauma training programs show great similarity in terms of training duration and being a unified specialty. However, there still is a relevant difference in training models, duty hours and flexibility of prolonged training duration. There is a clear movement toward competency-based training in most of the European countries. Level IV.
The association between surgical timing and clinical outcomes in older adults with distal femur fractures remains unclear. We conducted a systematic review and meta-analysis to evaluate whether earlier surgery is associated with improved outcomes in this population. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent reviewers searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to October 8, 2024. The primary outcome was 30-day mortality, and secondary outcomes included longer-term mortality and postoperative complications. Risk of bias was assessed using the Quality in Prognosis Studies tool, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. Of 6,101 records screened, 16 retrospective cohort studies comprising 31,213 patients met the inclusion criteria. Early surgery was not associated with reduced 30-day mortality (adjusted odds ratio [OR]: 0.77, 95% confidence interval [CI]: 0.56-1.05; low-certainty evidence) or with longer-term mortality at 90 days (crude OR: 0.91, 95% CI: 0.51-1.60), 180 days (crude OR: 0.46, 95% CI: 0.12-1.77), or 1 year (crude OR: 0.61, 95% CI: 0.34-1.09). Similar findings were observed for postoperative complications: cardiac complications (OR: 0.71, 95% CI: 0.48-1.07), pulmonary complications (OR: 1.07, 95% CI: 0.77-1.47), and pulmonary embolism (OR: 1.14, 95% CI: 0.62-2.16). Heterogeneity across outcomes was low to moderate, and definitions of early surgery varied among studies. Overall, this meta-analysis did not demonstrate a clinically meaningful association between surgical timing and short-term clinical outcomes in older adults with distal femur fractures. Sensitivity analyses consistently suggested lower mortality with earlier surgery, likely reflecting stricter definitions of early surgery and improved control of time-related bias. This meta-analysis did not demonstrate a clinically meaningful association between surgical timing and short-term clinical outcomes in older adults with distal femur fractures. Given the heterogeneity in definitions and study designs, high-quality prospective studies with standardized timing are warranted.
AIMS: To evaluate the impact of standardized early weight-bearing training on postoperative rehabilitation in older adults with intertrochanteric femoral fractures. METHODS: A total of 54 older adults with intertrochanteric femoral fractures admitted to the Department of Orthopedics, Huashan Hospital, Fudan University, between October 2023 and April 2025 were randomly allocated to a control group (n = 27) or an intervention group (n = 27). The control group received routine orthopedic rehabilitation, with weight-bearing initiated 4 weeks postoperatively, whereas the intervention group additionally received a standardized early weight-bearing program beginning 2–3 days after surgery. Outcomes including hip function, pain, quality of life, exercise adherence, Functional Independence Measure (FIM) scores, and weight-bearing duration were assessed at baseline, one day before discharge, and one month after discharge. RESULTS: Baseline characteristics did not differ significantly between the two groups. Compared with the control group, the intervention group demonstrated significantly greater improvement in hip function, with higher Harris Hip Scores at one day before discharge (Z = − 2.506, PFDR= 0.018, r = 0.34) and at one month after discharge (Z = − 3.239, PFDR= 0.003, r = 0.44), linear mixed-effects modeling revealed a significant group-by-time interaction (β = 6.34, 95% CI: 2.88–9.80; P < 0.001), with the between-group difference reaching approximately 9.6 points at follow-up. Resting pain scores were significantly lower in the intervention group at pre-discharge (Z = − 2.770, PFDR = 0.010) and one month after discharge (Z = − 2.326, PFDR= 0.024), with a significant group-by-time interaction indicating greater early pain relief. At follow-up, the intervention group achieved higher FIM scores, including the motor subscale (Hedges’ g = − 0.892), cognitive subscale (Hedges’ g = − 1.097), and total score (Hedges’ g = − 0.993). Weight-bearing duration was significantly longer in the intervention group (15.52 ± 8.02 vs. 10.59 ± 7.86 min; PFDR = 0.027). The intervention group demonstrated significantly higher scores in the psychological domain of quality of life (P < 0.05). CONCLUSION: Standardized early weight-bearing training was associated with improved hip function, pain relief, functional independence, exercise compliance, psychological well-being, and weight-bearing performance in older adults with intertrochanteric femoral fractures. TRIAL REGISTRATION: The trial was registered at the Chinese Clinical Trials Registry; retrospectively registered; registration number: ChiCTR2500095906; date of registration:2025/01/15.
BACKGROUND Total knee arthroplasty (TKA) is increasingly performed in older patients to manage severe osteoarthritis. Given the aging population, optimizing surgical techniques for this age group has become increasingly important. The surgical approach impacts postoperative outcomes, particularly in patients aged 75 years and over, who are prone to immobilization-related complications. This study compared the subvastus (SV) and medial parapatellar (MP) approaches, focusing on rehabilitation, early mobilization, and complications. MATERIAL AND METHODS A retrospective trial included 60 patients aged over 75 years with stage IV osteoarthritis, undergoing TKA. Patients were divided into SV or MP approaches. Outcomes included time to straight leg raise (SLR), range of motion (ROM), pain (visual analog scale, VAS), length of hospital stay, and complications. RESULTS The SV group achieved earlier SLR (1.7 vs 3.4 days, P=0.001), better ROM at 1 week (94° vs 79°, P=0.008), lower VAS scores at day 3 (4.0 vs 6.0, P=0.02), and shorter hospital stay (5.0 vs 6.7 days, P=0.03). Blood loss was slightly higher in the SV group (360.5 vs 340.2 mL, P=0.76). Immobilization-related complications were lower in the SV group (3.3% vs 10%, P=0.24). CONCLUSIONS The SV approach enhanced early mobilization and rehabilitation in older patients, potentially reducing immobilization-related complications, despite slightly higher blood loss. These findings suggest that the subvastus approach may be preferable in geriatric patients to enhance recovery outcomes.
Geriatric distal femur fractures are associated with mortality rates exceeding 20%, comparable to hip fractures. Traditional single implant fixation often requires weight-bearing restrictions that delay recovery. This pilot study aims to assess the feasibility of conducting a multicentre randomised controlled trial comparing dual vs single implant fixation for geriatric distal femur fractures. This multicentre, prospective, randomised controlled pilot trial will enrol 80 participants aged 60 years or older with displaced distal femur fractures at five US level 1 trauma centres. Patients will be randomly allocated 1:1 to receive either single implant (lateral plate or retrograde nail) or dual implant (nail-plate or dual plate) fixation. All patients will be permitted immediate weight-bearing. The primary outcome is feasibility assessed through enrolment rate (80 patients in 12 months), protocol adherence (≥90%) and follow-up retention (≥85% at 12 months). Secondary outcomes include post-surgical mobility (AM-PAC, TUG), patient-reported outcomes (PROMIS-PF, PROMIS-29), mortality (90-day and 1 year) and complication rates. Analyses will be on an intention-to-treat basis. The protocol was approved by the University of Utah Institutional Review Board (IRB_00149119) and IRBs at all participating centres. Written informed consent will be obtained from participants or legally authorised representatives. Findings will be disseminated through peer-reviewed publications and conference presentations. NCT05292313.
Indwelling nerve catheters are commonly used for postoperative analgesia following limb fracture surgeries. This multicenter, randomized, single-blind, active-controlled parallel trial aimed to compare the novel Tuoren catheter-over-needle assembly with the Contiplex D catheter-through-needle assembly for postoperative pain management. The trial was conducted at three centers in China. Patients undergoing elective limb fracture surgery were randomly assigned (1:1) to either the Tuoren group or the Contiplex D group for postoperative analgesia. The primary outcome was the noninferiority of the Tuoren assembly compared to that of the Contiplex D assembly in terms of the 24-h postoperative analgesia effectiveness rate. Secondary outcomes were patient and surgeon satisfaction, safety, and the time required for puncture and catheter insertion. The rate of local anesthetic leakage and the incidence of catheter kinking and dislodgement during analgesia were also evaluated. Between June 2019 and June 2021, 232 patients were randomized. The 24-h postoperative analgesia effectiveness rate was 99.1% in both groups. After adjusting for surgery types and centers, the difference was 0.06% [-2.36%, 2.49%] with a 95% CI. The lower boundary was above the noninferiority limit of -10%. The insertion time for the Tuoren assembly was significantly shorter compared to that of the Contiplex D assembly. Other outcomes did not show statistical differences. The novel Tuoren assembly was noninferior to the Contiplex D catheter-through-needle assembly in terms of analgesic effectiveness and safety. Chinese Registry of Clinical Trials: ChiCTR1900022980.
The necessity for targeted strategies to prevent and manage multidrug-resistant organism infections in intensive rehabilitation settings is driven by the heightened vulnerability of patients, exacerbated by the unique organizational and technical aspects of these environments. This study aimed to establish an interpretative framework of internationally validated interventions to enhance infection prevention in intensive rehabilitation facilities. A systematic review, conducted following PRISMA guidelines, categorized interventions into three key domains: Antimicrobial Stewardship, Behavioural Prevention, and Sanitation and Environmental Cleaning. The 17 articles selected for review provide a comprehensive overview of interventions within the three domains. Antimicrobial Stewardship interventions demonstrated potential in reducing Clostridioides difficile colonization through decreased antimicrobial use. Behavioural Prevention interventions were associated with reduced multidrug-resistant organism colonization and infections. Sanitation and Environmental Cleaning interventions, including hand hygiene, correlated with a decreased incidence of Clostridioides difficile cases. This systematic review underscores the importance of implementing multi-component interventions, encompassing both pharmacological and non-pharmacological approaches, across this critical setting.
Background/Objectives: Older patients with fractures often present with a complex interplay of factors associated with frailty and functional decline. The emerging concept of Orthogeriatric Fracture Syndrome (OFS) aims to characterize these distinct relationships of pathologies and outcomes. Despite increasing recognition of OFS in clinical practice, due to the distributed nature of fragility factors across medical disciplines, it remains poorly defined in the literature. Methods: We used large-scale text mining of 26 million PubMed abstracts to quantify the occurrence and interrelationship of OFS-related concepts across all disciplines in biomedical research. Results: OFS terms were more prevalent in fragility fractures than in other fracture types, particularly osteoporosis (0.52 vs. 0.09, p < 0.05). In pairwise keyword correlation (Pearson φ), the correlations presented between OFS keywords are comparable to the ones in the more established metabolic syndrome (e.g., φ = 0.07 between stroke and hypertension, p < 0.05). For OFS, osteoporosis emerged as the central node linking OFS outcomes and pathologies, correlating with fragility fracture (φ = 0.176, p < 0.05) and sarcopenia (φ = 0.03, p < 0.05). Sarcopenia in turn correlated with gait (φ = 0.04, p < 0.05), malnutrition (φ = 0.05, p < 0.05), and frailty (φ = 0.032, p < 0.05). Old age keywords showed substantially higher association with OFS keywords (e.g., φ = 0.06 for elderl* and hip fracture, p < 0.05) than with metabolic syndrome terms (elderl* and insulin resistance, p > 0.05). Conclusions: Overall, the analysis showed statistically significant associations between keywords representing OFS outcomes, pathologies and old age. The combined occurrence of osteoporosis, sarcopenia, frailty and risk of falls may help conceptually identify older adults at risk and inform preventive measures. This large-scale bibliometric analysis supports OFS as a conceptually coherent, proposed theoretical framework for cross-disciplinary awareness and coordinated care, with a literature-level organizational pattern comparable to metabolic syndrome, however, pending prospective clinical validation. This study reframes fragility fractures as the endpoint of a broader, potentially modifiable risk constellation and underscores the need for further clinical and epidemiological validation.
As the number of older adults undergoing spine surgery grows, it is important to better understand the risks of this procedure, including associated costs. The authors recently reported that undergoing more complex spine surgeries is strongly associated with postoperative delirium (POD). The goal of this study was to examine the costs associated with POD among patients undergoing spine surgeries of varying complexity. Data from a prospective observational cohort study of 256 adults aged ≥ 65 years who underwent spine surgery were analyzed. Preoperative, intraoperative, and postoperative variables were collected. The primary outcome of POD was defined as a positive score on any of three measures (Confusion Assessment Method for the Intensive Care Unit, Nursing Delirium Screening Scale, and chart review). The authors conducted univariable and multivariable analyses to examine factors associated with POD and estimated costs of POD stratified by tier of surgery. Risk factors associated with POD included age, lower education level, baseline cognitive impairment, American Society of Anesthesiologists class ≥ III, tier 4 surgery, high estimated blood loss, intensive care unit admission, postoperative complications, and hospital length of stay. In multivariable analyses, age, baseline cognitive impairment, postoperative complications, and length of hospitalization remained significantly associated with POD. The mean total costs were significantly higher in the group with delirium versus without delirium ($99,543 vs $67,892). Additionally, more patients who developed delirium required discharge to an acute rehabilitation facility (47.0% vs 21.5%, p < 0.001). In analyses stratified by tier of surgery, the greatest difference in mean costs between those with delirium versus without delirium was observed in tier 4 ($164,902 vs $116,579, p < 0.001). Spine surgeries with greater complexity are associated with an increased risk of POD, with higher costs and rates of intensive care unit admissions, more postoperative complications, and discharge to acute rehabilitation facilities. Delirium prevention interventions targeted to older adults at high risk for POD have the potential to optimize outcomes and decrease healthcare costs.
Background: Clinical controversy persists regarding the optimal weight-bearing strategy for elderly patients following hip fractures. Whilst early unrestricted weight-bearing may improve functional outcome and reduce the risk of bed-related complications, concerns about implant stability and failure often lead clinicians to adopt restricted weight-bearing protocols. To address this, we conducted a systematic review and meta-analysis to identify the effects of unrestricted weight-bearing compared with restricted weight-bearing on clinical outcomes in this patient population. We hypothesized that unrestricted weight-bearing may be associated with lower all-cause mortality without increasing postoperative complications, reoperation rates or length of hospital stay (LOS). Methods: This systematic review was conducted based on a study protocol registered on the PROSPERO platform and reported strictly in accordance with the PRISMA guidelines. We included clinical studies involving patients aged ≥65 years with hip fractures undergoing surgical treatment that directly compared the effects of different postoperative weight-bearing strategies on outcomes. Patients were further classified into unrestricted and restricted weight-bearing groups according to the postoperative weight-bearing protocols reported in each study. The primary outcome was all-cause mortality. Secondary outcomes included postoperative complications, reoperation rates, and LOS. A random-effects model was used for meta-analysis. Dichotomous variables were expressed as risk ratios (RRs), continuous variables as mean differences (MDs), and study heterogeneity was assessed using the I2 statistic. The certainty of evidence of each outcome was assessed by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: Ten studies (one randomized controlled trial and nine cohort studies) were included with 5806 patients in total. Extra-capsular fractures (intertrochanteric/subtrochanteric fractures) were the most common, with 3694 patients, followed by femoral neck fractures, with 1929 patients. Unrestricted weight-bearing was significantly associated with lower long-term mortality compared with restricted weight-bearing (RR = 0.67, 95% CI 0.51-0.88, p = 0.004, I2 = 34%; 95% PI 0.52-0.83), with an absolute risk difference of -0.10%. Short-term mortality did not differ significantly in the primary analysis (RR = 0.58, 95% CI 0.14-2.34, p = 0.44, I2 = 70%; 95% PI 0.00-126.98). Furthermore, the corresponding absolute risk difference was only -0.03%. No significant differences were observed for short-term complications, long-term complications, reoperation risk, or LOS between the two groups (all p > 0.05). GRADE assessment showed low certainty of evidence for long-term mortality and short-term complications, and very low certainty of evidence for the remaining outcomes. Conclusions: This meta-analysis suggests that unrestricted weight-bearing may be a feasible postoperative rehabilitation approach in selected patients. However, the results should be interpreted with caution. Further well-designed prospective studies are required to confirm these findings.
OBJECTIVES: To investigate factors associated with hospitalization length in older adults after hip fracture surgery. DESIGN: Prospective observational cohort study. A total of 172 older adults (mean age 79.01 ± 8.66 years; 70.30% women) hospitalized for fragility hip fractures. Data were collected within the first 24 hours post-surgery. PRIMARY OUTCOME MEASURES: Hospitalization length (in days). Factors investigated for the association with length of stay included sociodemographic, surgical, and laboratory variables, as well as multimorbidity, polypharmacy, self report of pain, cognitive, emotional, nutritional, and functional status. A generalized linear model adjusted for age and sex was used, with a significance level of 5% (p ≤ 0.05). RESULTS: The mean hospitalization length was 5.4 days. Cognitive impairment was observed in 86.9% of participants, depressive symptoms in 63.6%, and 68.8% were at risk of malnutrition. Mean handgrip strength was 18.48 kg. Generalized linear model analysis indicated that a longer interval (in days) from fracture to surgery, delayed surgery, higher ferritin and urea levels, lower Cumulated Ambulation Score (CAS). and lower handgrip strength were associated with longer hospitalization (p < 0.05). CONCLUSIONS: A longer fracture-to-surgery interval (including delayed surgery), higher urea and ferritin levels, and poorer early functional status (lower CAS and reduced handgrip strength) were independently associated with a longer hospital stay among older adults with hip fracture. These findings support hospital strategies to minimize surgical delays, monitor renal-related and inflammatory markers, and incorporate early functional assessments to identify patients at risk of prolonged hospitalization. Addressing system-level contributors to surgical delay (e.g., access barriers, transportation, bed availability) may also improve the continuum of care.
This study aims to assess the perception of urinary catheter use in older patients undergoing urologic and orthopaedic surgery and to explore the associated factors, specifically functional independence and knowledge. A cross-sectional research design. Patients were eligible if they were aged 65 and older, had received urological or orthopaedic surgery, were able to communicate independently, and had a urinary catheter. Data collection included demographics, voiding function history, health conditions, and the knowledge and perception of urinary catheter use. Multiple regression analysis was employed to investigate the variables associated with the perception of urinary catheter use. A total of 204 older patients were enrolled. The mean score of perception was 41.8 ± 2.7 (range 13-65). Lower perception scores (indicating a preference for catheterization) were observed for items related to mobility difficulties and incontinence. Multiple regression analysis revealed that older patients with greater independence in activities of daily living (ADLs) and better knowledge were significantly more likely to have a positive perception (i.e., recognizing the benefits of catheter removal and its risks). Older surgical patients' perceptions of urinary catheter use are significantly shaped by their ADL status and knowledge levels. Although catheters are often viewed as a convenience for mobility and incontinence, such perceptions frequently misalign with evidence-based safety standards. To optimize perioperative care, it is imperative to implement structured preoperative education and shared decision-making frameworks that prioritize function-based urinary management. This study incorporates older patients' perspectives by assessing their perceptions and knowledge of catheterization. The findings advocate for a transition toward function-based management, where catheter alternatives are tailored to individual ADL status. By aligning clinical practice with patients' functional needs and informed preferences, healthcare providers can empower patients and reduce the risk of iatrogenic harm.
Intramedullary nailing remains the standard treatment for Association Osteosynthesis/Orthopaedic Trauma Association (AO/OTA) 31-A2.3 intertrochanteric fractures, however, there are still high failure rates when managing those with large displaced coronal fragments. This study presents a modified cable-plate augmentation technique for optimizing coronal fragment stabilization during proximal femoral nail antirotation (PFNA) fixation. We conducted a double-center retrospective cohort study of geriatric patients diagnosed with AO/OTA type A2.3 intertrochanteric fractures combined with large displaced coronal fragments, who underwent either standard PFNA fixation or modified cable-plate augmentation combined with PFNA fixation between January 2023 and March 2025. These two cohorts were compared in terms of surgical parameters and complication profiles. 84 geriatric patients with type A2.3 intertrochanteric fractures with displaced large coronal fragments were analyzed. 40 patients received the conventional fixation protocol, and 44 received the augmented fixation protocol. The cohorts demonstrated comparable demographics in terms of age, comorbidity index and bone mineral density. The operative outcomes revealed prolonged surgical duration in the augmented fixation group (86.6 ± 16.9 min vs. 69.7 ± 14.0 min, p < 0.01), with higher intraoperative blood loss (134.2 ± 31.6 mL vs. 112.7 ± 43.1 mL, p = 0.011). Rehabilitation metrics significantly favored augmented fixation, as indicated by a lower VAS postoperation (3.4 ± 2.1 vs. 4.5 ± 2.3, p = 0.026), earlier weight-bearing initiation (2.2 ± 0.8 days vs. 5.1 ± 1.2 days, p < 0.01) and accelerated radiographic union (10.5 ± 1.3 weeks vs. 13.2 ± 1.7 weeks,p < 0.01). The conventional fixation group presented higher complication rates (20% vs. 4.8%, p < 0.05). At the 12-month follow-up, functional recovery was superior in the augmented cohort (HHS: 92.3 ± 12.3 vs. 84.7 ± 13.8, p < 0.01) despite equivalent pain scores. Compared with conventional PFNA fixation, the cable-plate augmentation technique significantly enhances the fixation stability in type A2.3 intertrochanteric fractures with large coronal fragments, resulting in a reduction in complications, acceleration of fracture union, and improvement in functional outcomes.
Adult spinal deformity (ASD) significantly impacts quality of life in geriatric populations due to severe sagittal imbalance, degenerative scoliosis, and associated neurological compression that usually requires surgery when conservative treatment fails. To evaluate the clinical and radiological outcome of a modified transforaminal lumbar interbody fusion (TLIF) technique in the three-planar correction of severe adult spinal deformity (ASD). This was a single-center case series study. We recruited 72 ASD patients (mean age 64.5 years) with at least one of the following criteria met (SRS-Schwab sagittal modifier ++; Cobb angle >30°; Coronal vertical axis >3cm) operated between January 2020 and May 2025. The surgical protocol involved four modifications: (1) bilateral facetectomy and posterior column resection; (2) a concave-side approach to the disc space; (3) anterior positioning of the PEEK cage; and (4) supplemental bone grafting posterior to the cage. Clinical and radiological outcomes were evaluated at a mean follow-up of 2.3 years. Significant improvements were observed in SRS-22 (2.6 to 3.7) and NCOS (43 to 74.5) scores (p < 0.05). After surgery, both PI-LL mismatch and the Cobb angle have been markedly improved (35° down to 17° and 21.5° down to 5°, respectively). The fusion rate was 90% at 1 year. Univariate analysis identified osteoporosis (OR = 13.4, p<0.05), "pear-shaped" disc morphology (OR = 14, p<0.05), and PI > 65° (OR = 13.7, p<0.05) as significant risk factors for unchanged sagittal modifier after surgery. Early complications included infection (2.7%) and pneumonia (2.7%) whereas the main mid-term adverse event was PJK (15%). Modified TLIF is associated with improvement of mid-term radiographic and clinical outcomes and an acceptable complication rate. Additional research involving larger cohorts and extended follow-up, preferably with a control group, is required to reach more definitive conclusions.
This study provides the first international benchmarking of postoperative hip fracture care in Chinese tertiary hospitals using the UK Fracture Liaison Service (FLS) Key Performance Indicators within a "cascade of care" framework. This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. We conducted a retrospective audit of 2,689 patients aged ≥60 years who received hip fracture surgery in an orthogeriatric co-managed ward from 2016 to 2018. Performance was measured against seven validated FLS KPIs: bone mineral density (BMD) screening, anti-osteoporosis medication initiation, falls risk assessment, rehabilitation provision, follow-up adherence, and secondary fracture incidence at specified time points. Inpatient metrics were excellent: 97.1% (2,610/2,689) underwent BMD screening and 94.0% (2,454/2,610) received bone-protective medication prior to discharge, both exceeding UK benchmarks. Post-discharge follow-up declined sharply: 50.7% (1,363/2,689) at 90 days, 17.7% (477/2,689) at 12-16 weeks, and 9.5% (255/2,689) at 12 months. Secondary fracture rates remained high (11.0-13.4%) across follow-up intervals despite strong treatment initiation. International comparison highlighted strengths in acute inpatient management but exposed deficits in community-based coordination and long-term adherence relative to integrated FLS models. This pioneering international comparison demonstrates that Chinese hospital-centric orthogeriatric co-management delivers outstanding acute care but struggles with sustained secondary fracture prevention due to fragmented healthcare pathways and limited primary care integration. Implementation of dedicated FLS coordinators, digital engagement tools, and structured hospital-community partnerships is essential to build a comprehensive secondary prevention network and reduce long-term fracture risk in China's aging population.
Background: Over the past 25 years, advances in knee surgery have been driven by an improved understanding of fracture morphology and associated injuries, as well as by significant technological progress. The introduction of novel classification systems has led to the refinement of treatment strategies, particularly with respect to the selection of surgical approaches. Furthermore, advances in biomechanical understanding have facilitated the development of new osteosyntheses designed to promote earlier rehabilitation while simultaneously reducing complication rates. Research Question: Which key milestones over the last 25 years have significantly influenced treatment strategies for knee joint fractures, with a perspective on unresolved issues? Results: Recent advances in fracture management, osteosynthesis, imaging techniques, and biomechanical research have substantially improved clinical outcomes, including a reduction in infection rates and improved postoperative results. The implementation of new classification systems has enabled more precise preoperative planning, allowing surgeons to define approaches that ensure adequate visualization of the articular surface while facilitating optimal positioning of the osteosynthesis. In terms of osteosynthesis, the introduction of locking plate technology has become widely established and supported by biomechanical evidence and has largely replaced traditional methods such as tension-band wiring of the patella. Despite these advances, fracture management in geriatric patients remains a considerable challenge, as compromised bone quality frequently limits the ability to achieve sufficiently load-stable osteosynthesis. Direct visualization of the articular surface is essential for adequate assessment and reduction of the affected articular segment. However, there is currently no consensus on which surgical approach or possible extension is most appropriate while simultaneously ensuring a low complication rate.
Drug-induced QT interval prolongation is a well-recognized safety concern in hospitalized patients. Clinical decision support systems (CDSS) generate alerts to identify high-risk drug combinations, but their impact on clinical management remains uncertain. This study evaluated clinical responses from prescribing clinicians to QT prolongation alerts, focusing on electrocardiogram (ECG) monitoring and treatment modifications. We conducted a 10-month prospective study in two hospital wards (acute geriatrics and orthopedics) at Geneva University Hospitals. The CDSS embedded within the electronic health record used a pharmacodynamic risk scoring system (Riskbase) that assigns scores to individual drugs based on pharmacological and clinical evidence and generates alerts when cumulative risk exceeds a predefined threshold. Clinical interventions were assessed within 7 days following high-risk QT alerts. A total of 154 patients were included (123 in geriatrics and 31 in orthopedics). Intervention rates ranged from 60.2% to 91.9% in geriatrics and from 45.2% to 80.6% in orthopedics, depending on the time window. However, these interventions were almost exclusively driven by ECG monitoring. Treatment modifications were rare, occurring in only 2.0% of patients. Most alerts were associated with combinations of low- or moderate-risk drugs, particularly antipsychotics, antidepressants, and antiemetics, some of which may have alternatives with lower QT-prolongation potential and may be considered depending on the clinical context. In addition, medications prescribed on an as-needed basis contributed substantially to QT risk scores, despite limited recent administration. In clinical practice, QT prolongation alerts are associated with frequent monitoring but rarely lead to therapeutic changes. These findings highlight a gap between risk identification and pharmacological risk mitigation and suggest opportunities to improve medication safety through more targeted prescribing and optimization of alert systems.
Danis-Weber Type A lateral malleolus fractures are conventionally deemed stable and managed nonoperatively, yet prognostic heterogeneity leads to chronic complications in subsets of patients, revealing limitations in uniform treatment paradigms. This study introduces a novel subclassification to identify soft-tissue-driven risks and refine surgical thresholds in a nonoperative cohort. In this retrospective cohort of 434 skeletally mature patients with acute Danis-Weber Type A fractures initially treated nonoperatively, we subclassified injuries via 3D-CT into Subtype A1 (simple avulsion without medial involvement; n = 350) and Subtype A2 (with medial deltoid ligament injury or medial malleolus fracture; n = 84). Demographics, fracture metrics (e.g., displacement), treatment variables (e.g., brace duration), and ligament status (via MRI in 233 cases) were analyzed. Primary outcomes-nonunion and severe long-term pain (composite: VAS ≥4, ≥2 sprains, or AOFAS <70)-were assessed at ≥ 12 months, using multivariable logistic regression and Kaplan-Meier survival analysis. Overall union was 95%, but Subtype A2 exhibited markedly worse prognosis: lower union (83% vs. 98%; p < 0.001), inferior 3-month AOFAS scores (82.5 ± 11.8 vs. 90.2 ± 9.5; p < 0.001), and elevated rate of severe pain (35% vs. 20%; p < 0.001) compared to A1. Within A2, A2.2 (medial malleolus fracture; n = 34) fared worse than A2.1 (deltoid injury; n = 50) in union (79% vs. 87%; p = 0.02) and function. Multivariable models pinpointed anterior talofibular ligament (ATFL) injury (OR=3.50, 95% CI 1.40-8.70; p = 0.037) and deltoid injury (OR=4.50, 95% CI 1.80-11.00; p = 0.021) as independent drivers of pain. Displacement associated with nonunion univariately (r = 0.18, p = 0.02) but not multivariately (OR=1.40, p = 0.059). Kaplan-Meier curves confirmed delayed union in A2 (median 6 vs. 4 months; log-rank p = 0.012). Danis-Weber Type A fractures harbor hidden instability, with medial soft-tissue integrity-via A1/A2 subclassification-outweighing displacement as the cardinal outcome predictor. This framework advocates stability-focused strategies, including targeted imaging, cautious rehabilitation, or early surgery for ligamentous compromise, to avert chronic pain and post-traumatic osteoarthritis (PTOA). Prognostic Level III (retrospective cohort study).
BACKGROUND: Hip fractures represent a major public health concern due to their increasing incidence in the aging population and their association with significant morbidity and mortality. Comorbidities are known to complicate both the surgical management and rehabilitation process, yet their specific impact on outcomes remains variable across studies. OBJECTIVE: This study aimed to determine the prevalence and distribution of comorbidities in patients who presented with hip fractures and underwent surgical treatment, to evaluate perioperative and postoperative risk factors retrospectively, and to compare these findings with the existing literature. METHODS: A retrospective descriptive analysis was conducted on 589 patients aged ≥ 60 years who were surgically treated for hip fractures between 2013 and 2024 at a tertiary university hospital. Demographic characteristics, surgical protocols, anesthesia types, revision rates, infection, dislocation, mobilization outcomes, hospital stay, intensive care admissions, and mortality were systematically analyzed in relation to comorbidity profiles and the number of comorbidities. Statistical analyses included chi-square, Fisher’s exact test, Mann-Whitney U, and Kruskal-Wallis tests, with p < 0.05 considered significant. RESULTS: Hypertension (59.1%), diabetes mellitus (33.6%), coronary artery disease (21.4%), and Alzheimer’s disease (21.4%) were the most frequent comorbidities. Revision surgery was significantly associated with diabetes mellitus and congestive heart failure. Diabetes mellitus, coronary artery disease, and chronic renal failure were strong predictors of postoperative infection. While the mean hospital stay was significantly prolonged in patients with ≥ 3 comorbidities, mortality was significantly associated only with oncological diseases and chronic renal failure. Contrary to expectations, no significant association was found between overall mortality and the number of comorbidities. CONCLUSION: Comorbidities, particularly diabetes mellitus, congestive heart failure, oncological diseases, and chronic renal failure, substantially influence surgical outcomes, postoperative complications, and hospitalization in hip fracture patients. However, the number of comorbidities alone was not a predictor of mortality, highlighting the importance of the type rather than the quantity of comorbid conditions. These findings underscore the need for individualized perioperative planning and comprehensive patient counseling to reduce risks and improve postoperative outcomes.