Explore the vast range of titles available.

Background/Objectives: Proximal femoral fractures (PFF) are associated with substantial morbidity and mortality in elderly patients. Early identification of individuals at increased risk of death remains challenging. The neutrophil-to-lymphocyte ratio (NLR) is an inexpensive and readily available biomarker reflecting systemic inflammation and physiological stress, but its role as a risk stratification tool in surgically treated PFF patients is not fully established. The aim of this study was to validate NLR as a prognostic biomarker for mortality risk stratification in elderly hip fracture patients by evaluating its independent association with mortality, establishing clinically relevant risk categories, and assessing its ability to identify distinct mortality risk groups. Methods: This retrospective cohort study included 1113 patients aged ≥ 65 years who underwent surgery for AO/OTA 31.A (trochanteric) or 31.B (femoral neck) proximal femoral fractures between January 2021 and February 2024 at a single institution. NLR was calculated from routine admission bloodwork. The primary outcome was all-cause mortality. Kaplan–Meier survival analysis stratified patients by clinically relevant NLR categories (<5, 5–10, >10). Cox proportional hazards regression identified independent predictors of mortality. ROC analysis was performed secondarily to identify an optimal binary threshold. Results: At mean follow-up of 33.9 months, overall mortality was 36.2% (352/972). Stratified survival analysis demonstrated a clear dose–response relationship, with mortality rates of 26.2%, 36.5%, and 54.4% for NLR < 5, 5–10, and >10, respectively (log-rank p < 0.001). In multivariable Cox regression, NLR remained independently associated with mortality (HR = 1.042, 95% CI: 1.032–1.053, p < 0.001) after adjusting for age and time to surgery. ROC analysis identified an optimal binary cut-off of 6.59 (AUC 0.614). Conclusions: Elevated preoperative NLR is independently associated with increased mortality following surgery for proximal femoral fractures, particularly in very elderly patients. Given its simplicity and universal availability, NLR may represent a useful adjunct for early perioperative risk stratification.

Background Knee varus alignment represents a notorious cause of knee osteoarthritis. It can be caused by tibial deformity, combined tibial–femoral deformity and/or ligament imbalance. Understanding malalignment is crucial in total knee arthroplasty to restore frontal plane neutral mechanical axis. The aim of this study was to determine which factor contributes the most to varus osteoarthritic knee and its related surgical implications in performing a total knee arthroplasty. Methods We retrospectively evaluated 140 patients operated for total knee arthroplasty due to a varus knee. Full-leg hip to ankle preoperative X-rays were taken. Radiological parameters recorded were: mechanical axis deviation, hip–knee–ankle, anatomical–mechanical angle, medial neck shaft angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), lateral proximal femoral angle, lateral distal tibial angle (LDTA), femoral bowing, and length of tibia and femur. We also determined ideals tibial and femoral cuts in mm according to mechanical alignment technique. A R2 was calculated based on the linear regression between the predicted values and the observed data. Results The greatest contributor to arthritic varus ( R  = 0.444) was MPTA. Minor contributors were mLDFA ( R  = 0.076), JLCA ( R  = 0.1554), LDTA ( R  = 0.065), and femoral bowing ( R  = 0.049). We recorded an average of 7.6 mm in lateral tibial cut thickness to restore neutral alignment. Conclusions The radiological major contributor to osteoarthritic varus knee alignment is related to proximal tibia deformity. As a surgical consequence, during performing total knee arthroplasty, the majority of the correction should therefore be made on tibial cut.

Aim of the present study was to investigate the effects of ongoing treatment with DOACs on time from trauma to surgery and on in-hospital clinical outcomes (blood losses, need for transfusion, mortality) in patients with hip fracture. Moreover we evaluated the adherence to current guidelines regarding the time from last drug intake and surgery. In this observational retrospective study clinical records of patients admitted for hip fracture from January 2016 to January 2019 were reviewed. 74 patients were in treatment with DOACs at hospital admission. Demographic data, comorbidities and functional status before trauma were retrieved. As control group we evaluated 206 patients not on anticoagulants matched for age, gender, type of fracture and ASA score. Time to surgery was significantly longer in patients treated with DOACs (3.6 + 2.7 vs. 2.15 ± 1.07 days, p < 0.0001) and treatment within 48 h was 47% vs. 80% in control group (p < 0.0001). The adherence to guidelines’ suggested time from last drug intake to surgery was 46%. Neither anticipation nor delay in surgery did result in increased mortality, length of stay or complication rates with the exception of larger perioperative blood loss (Hb levels < 8 g/dl) in DOACs patients (34% vs 9% p < 0.0001). Present results suggest that time to surgery is significantly longer in DOAC patients in comparison to controls and adherence to guidelines still limited.

Introduction: Octogenarians undergoing unicompartmental knee arthroplasty (UKA) face increased risks of complications due to reduced bone support following osteoporosis. The aim of this study was to describe our preferred technique to balance robotic-assisted UKA in this specific patient population and to present its results. Methods: This retrospective analysis of prospectively collected data examined 121 consecutive octogenarian patients (median age 84 years, IQR 82–86) who underwent robotic-assisted medial UKA between September 2018 and December 2022 with ≥24 months follow-up. Patients aged ≤80 years, with ≤2 years of follow-up, or without informed consent were excluded. Data collection included radiographic measurements (HKA, LDFA, MPTA, joint line height), patient-reported outcome measures (Oxford Knee Score, Knee Society Score), and complications. Statistical analysis employed descriptive statistics, paired t-tests, Cohen’s d for effect sizes, and the McNemar test for categorical variables. Results: The hip–knee–ankle angle improved significantly from 174.43° to 178.04° (mean difference 3.61°, 95% CI 3.13–4.09, p < 0.001). Patient-reported outcomes demonstrated substantial improvements: the Knee Society Score increased by 83.09 points (95% CI 79.76–86.42, p < 0.001, Cohen’s d = 4.53), and the Oxford Knee Score increased by 17.09 points (95% CI 15.42–18.76, p < 0.001), with both exceeding minimal clinically important differences. Only 7.4% (9/121) of cases exhibited joint line lowering of >2 mm, with 1.7% (2/121) having both post-operative HKA <175° and joint line lowering of >2 mm. The implant survival rate was 100% with minimal complications, including two conservatively managed tibial plateau fractures and two cases of wound dehiscence with no further surgery needed. Conclusions: Robotic-assisted medial UKA can consistently preserve joint line height while achieving excellent alignment correction and clinical outcomes in octogenarians, potentially addressing failure risks in this specific population.

Background: In elderly patients with hip fracture, the prevalence of severe aortic stenosis (valve area <1 [cm.sup.2]) is close to 5%. Few studies have evaluated the prognostic role of aortic stenosis in hip fracture surgery and none has considered the effects of the postoperative setting (intensive care unit vs general ward) on clinical outcome. Purpose: The aim of the present study was to evaluate the factors affecting mortality in patients with severe aortic stenosis undergoing surgery for hip fracture. We also evaluated whether postoperative monitoring in the intensive care unit may affect the prognosis in comparison to return to the general ward after surgery. Patients and Methods: All 2274 patients referred for hip fracture to our tertiary teaching hospital between January 1 2015 and December 31 2019 were screened for the presence of severe aortic stenosis, defined by an aortic valve area <1.0 [cm.sup.2]. Results: The study included 66 patients (27 males, 39 females) with a mean[+ or -]SD age of 85[+ or -]7 years. The average time between trauma and surgery was 2.6[+ or -]3 days. The mean aortic valve area was 0.74[+ or -]0.15 [cm.sup.2]. Seven patients died during hospitalization (10.4%). Diabetes, having two or more comorbidities, a low degree of autonomy, heart failure, history of coronary artery disease, atrial fibrillation, postoperative delirium and pulmonary hypertension were associated with poorer outcome. In logistic multivariate analysis, the number of diseases and values of pulmonary artery pressure were the only independent factors related to mortality. In hospital mortality (12 and 9%, respectively) and complication rates were not statistically different between patients referred to the intensive care unit for postoperative monitoring and patients returned to the general ward after surgery. Conclusion: In patients undergoing hip fracture surgery, severe aortic stenosis is associated with high hospital mortality, and two or more comorbidities and pulmonary hypertension are associated with a worse prognosis. The postoperative setting (intensive care unit or general ward) does not affect outcome. Keywords: aortic stenosis, prognosis, hip fracture, elderly

Purpose The aim of this study was to evaluate the outcomes of an integrated multidisciplinary hip fracture unit through the following parameters: time to surgery, mortality, return to activities of daily living, adherence to re-fractures prevention programs. Methods Six hundred seventy-seven consecutive patients with hip fracture were included in the study. We calculated the time to surgery as the time in hours from admission until surgery. The in-hospital mortality was calculated as the number of deaths that occurred before discharge. Each patient was then evaluated post-operatively at six weeks, three months, and one year. We studied basic activity of daily living (BADL) and the New Mobility Scale (NMS). Adherence to re-fractures prevention programs was also evaluated. Results 88.9% of patients underwent surgery within two calendar days from admission. In-hospital mortality was 2.4%, and the overall mortality at one year from the intervention was 18.7%. Full mobility status or a low impairment of the mobility status was reached in 32.1% of the patients at one year and a level ≥ 3 of autonomy in BADL was reached in 62.4% (338/542) of patients. Three hundred forty-two patients were prescribed a specific therapy for secondary prevention of re-fracture. Conclusions An integrated, multidisciplinary model for the treatment of hip fragility fractures was effective in reducing time to surgery and mortality, increasing the level autonomy and mobility status and promoting adherence to re-fracture therapy.

Cardiovascular complications are the main cause of early mortality in elderly patients after hip fracture surgery. Echocardiography, although suggested by guidelines to improve risk stratification, is frequently omitted due to the risk of delaying surgery. The aim of the study was to evaluate whether in a multidisciplinary hip fracture unit, echocardiography can be performed without a delay in surgery. The secondary endpoint was to research the possible association between echocardiographic abnormalities and in-hospital mortality. The study included hip fracture patients aged > 70 admitted in the period 1 January 2019 to 31 December 2024, to the hip fracture unit of a tertiary teaching hospital. Echocardiography was indicated according to clinical criteria (detection of heart murmur, pathological electrocardiographic changes, known heart disease and the presence of ≥3 coronary risk factors). In the study, there were 2272 patients; 1593 had indications for preoperative echocardiography, which was performed in 1502. Mean age was significantly higher in the ECHO group than in the NO ECHO group (85.4 ± 8 vs. 80.5 ± 11 years, < 0.0001). ECHO group patients more frequently had at least two comorbidities and more severe functional impairment. In-hospital mortality was 7.3% in ECHO patients compared to 2.3% in NO ECHO patients. Multivariate analysis showed that decreased left ventricular ejection fraction and pulmonary hypertension, as well as age, anemia, and reduced functional capacity expressed as lost BADL, were associated with in-hospital mortality. Echocardiography identifies a population at a high risk of in-hospital mortality, three times higher compared to the group of NO ECHO patients. In those who underwent echocardiography, a reduced left ventricular ejection fraction and an increase in pulmonary pressure were associated with in-hospital mortality.

Purpose Robotic-assisted surgery has been recently introduced to improve biomechanical restoration, and thus better clinical and functional outcomes, after knee joint arthroplasty operations. Robotic-assisted uni-compartmental knee arthroplasty (UKA) aims indeed to improve surgical bone resection and alignment accuracy, optimized component positioning and knee balancing, relying on a series of calibration measurements performed during the surgery. These advantages focus therefore on improving the reproducibility of UKA surgeries, reducing (if not eliminating) eventual differences among high- and low-volume surgeons. The purpose of this study is to investigate and quantify the reproducibility of in-vivo measurements performed with a robotic system: the intra- and inter-observer variability of a series of measurements was therefore analyzed and compared among differently experienced operators. Methods Five patients were analyzed and underwent robotic-assisted UKA using a semi-active robotic system. Three different observers with different experience levels were involved to independently perform the measurements of two parameters of the preoperative knee (Hip-Knee-Ankle angle [HKAa], Internal-External Rotation) at different degrees of knee flexion. Inter-observer and intra-observer comparisons were performed. Results The average variability in the measurements obtained from the intra-observer and inter-observer comparisons were always < 0.68° for HKAa and < 2.59° for internal-external rotation, and the ICCs showed excellent agreement (> 0.75) for most cases and good agreement (> 0.60) in the remaining ones. Conclusion This study demonstrated high reproducibility of the measurements obtainable in clinical environment with the robotic system. The inter-observer results furthermore showed that the level of confidence with the robotic system is not significantly influencing the measurement.

Purpose This study aimed to evaluate the clinical outcomes, failure rates, and complications associated with a second revision anterior cruciate ligament reconstruction using an Achilles tendon allograft in a mono-loop fashion, which allows simultaneous reconstruction of the anterior cruciate ligament and the anterolateral ligament. The hypothesis was that this combined technique is safe and leads to satisfactory clinical outcomes at mid-term follow-up. Methods A retrospective analysis was conducted on 20 patients who underwent a second revision ACL reconstruction between January 2018 and December 2022. All patients received an Achilles tendon allograft with a bone plug, used in a mono-loop technique to reconstruct both ACL and ALL. Exclusion criteria included multi-ligament injuries, posterior tibial slope > 12°, or follow-up shorter than 24 months. Clinical evaluation included pre- and postoperative scores: Tegner, subjective IKDC, Lysholm, and KOOS, as well as physical examination and Rolimeter testing. Mean follow-up was 32.2 months. Results The mean patient age was 36.8 ± 6.3 years. All clinical scores improved postoperatively: Tegner (from 64.3 to 87), subjective IKDC (55.1 to 64.4), Lysholm (58.2 to 76.9), and KOOS (59.7 to 70.1). Anteroposterior laxity decreased from 7.2 ± 2.1 mm preoperatively to 1.2 ± 1.3 mm postoperatively. A total of 55% of patients returned to their desired sports level, 25% to a lower level, and only one patient (5%) did not return owing to residual laxity. No postoperative complications or re-revisions were reported. Conclusions The mono-loop technique for simultaneous ACL and ALL reconstruction using an Achilles tendon allograft during a second revision procedure is safe and effective. It results in satisfactory mid-term outcomes, low failure rates, and no significant complications, providing a viable single-stage alternative for complex revision cases. Study design Cohort study; Level of evidence, 3.

Aim of the present study was to evaluate whether monitoring direct oral anticoagulant (DOAC) levels may improve management of anticoagulated patients who need surgery for hip fracture. A total of 147 out of 2231 (7.7%) patients with hip fracture admitted to a tertiary teaching hospital were on DOACs (group A), whereas 206 patients matched for age, sex, and type of fracture not on anticoagulant or P2Y12 platelet inhibitors were considered as control group (group B). Patients on DOACs were divided into two subgroups: A1 in which intervention was scheduled in relation to the last drug intake according to current guidelines, and A2 included patients in whom time of surgery (TTS) was defined according to DOAC levels. Neuraxial anesthesia was considered with DOAC levels <30 ng/mL, general anesthesia for levels in the range 30-50 ng/mL. TTS was significantly lower in controls than in DOAC patients: surgery within 48 hours was performed in 80.6% of group B versus 51% in group A ( <0.0001). In A2, 41 patients underwent surgery within 48 hours (56%) in comparison to 32 A1 patients (45.1%; =0.03). TTS and length of hospitalization were on average 1 day lower in patients with assay of DOAC levels. Finally, 35/39 (89%) patients with DOAC levels <50 ng/mL had surgery within 48 hours (26 under neuraxial anesthesia, without any neurological complication, and 13 in general anesthesia). DOAC assay in patients with hip fracture may be useful for correct definition of time to surgery, particularly in patients who are candidates for neuraxial anesthesia. Two-thirds of patients with DOAC levels <50 ng/mL at 48 hours from last drug intake underwent uneventful neuraxial anesthesia, saving at least 24 hours in comparison to guidelines.