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A 78-year-old female patient sustained a left-sided proximal femoral fracture due to a fall. Since childhood the patient had suffered from ankylosis of unknown origin in the ipsilateral hip joint. The recommended intramedullary osteosynthesis could restore the original status quo before the fracture. It needs less time in the operating room (OR) and includes a lower risk for intraoperative complications than a hip joint endoprosthesis. Arthroplasty can lead to a significant improvement in mobility of the hip joint but requires more time in the OR for the surgical procedure and anesthesia time and includes a higher risk for intraoperative and postoperative complications. The antetorsion angle of 76° in this patient deviated extremely from the standard and made the intramedullary osteosynthesis for this type of fracture a challenge. Using improvised techniques led to a load-stable fracture treatment that ultimately led to a satisfactory result., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Perioperative infection prophylaxis with cephalosporins is standard in surgical treatment of proximal femoral fractures (PFF). Geriatric patients (pat.) are at risk of chronic infections and the bacteria from these can lead to unknown hygienic problems in an early operation. We therefore characterised the colonisation of the urinary tract in pat. (≥ 65 years) with PFF and observed bacterial development in deep wound infections over a period of 10 years. The aim was to discover gaps in perioperative infection prophylaxis. Patients and Methods: Between September 2013 and November 2015, colonisation of the urinary tract and microbial resistance were investigated on admission of all pat. (≥ 65 years) with the diagnosis of PFF (n = 351; f/m 263/88; median age [∅] 83.57 [65-100] years). Between 2005 and 2014, 2161 pat. with a PFF were operated in our clinic (f/m 1623/538; ∅ 82.35 [65-101] years). 991 pat. (∅ 81.84 [65-101] years) with femoral neck fracture [FNF] were treated with endoprosthesis/osteosynthesis, 1170 pat. (∅ 82,78 [65-101] years) with per-/subtrochanteric fracture [PTF] were treated with osteosynthesis. In a retrospective data analysis, deep wound infections, microbiological composition and changes in microbial resistances over time were identified. Results: Bacteriuria (BU) was detected in the urine sediment of 35.61 % (n = 125) of our pat. In 47.2 % of these pat., BU was accompanied by laboratory signs of manifest urinary tract infection. In 10.4 % of these pat., colonisation of the urinary tract with multi-resistant pathogens was detected; 26.4 % were resistant to cefuroxime. The rate of deep infections in pat. with endoprosthesis/osteosynthesis in FNF was 2.8 % (n = 28; f/m 19/9; ∅ 81.35 [67-92] years), with osteosynthesis in PTF 1,1 % (n = 14; f/m 10/4; ∅ 81.0 [70-91] years). A comparison of the periods 2005-2009 and 2010-2014 showed a shift in the spectrum of pathogens from cephalosporin-sensitive to cephalosporin-resistant enterococci. Resistance of pathogens against cephalosporins increased from 43 to 81 %. Conclusion: We found an increasing risk in geriatric pat. from multiresistant pathogens in the urinary tract and from an increase in the cephalosporin resistance of pathogens in urinary tract infections and in deep wound infections. This indicates that perioperative infection prophylaxis with a cephalosporin is not effective. Especially in nursing homes, development of resistance to antibiotics is an increasing problem. Thus, concepts of perioperative infection prophylaxis in geriatric patients should be reconsidered., (Georg Thieme Verlag KG Stuttgart · New York.)

In a retrospective study, 1.173 fractures of the proximal femur, which had been treated surgically, were analysed in two periods from 1975 to 1991 and from 1992 to 2000. The influence on mortality of preoperative risk factors and primary treatment with total hip replacement (THR), even in cases of pertrochanteric fractures, was analysed by stepwise logistic regression. In the later period, mortality within 90 days was 13.1%, and within 1 year 22.2%. Rejection of hemiendoprosthesis in high-risk patients with intracapsular fractures increased the mortality rate from 6.3% to 11.8%. The introduction of dynamic hip screws instead of Ender nails led to a reduction of mortality from 16.5 to 7.1%. Higher mortality after THR (27.6%) compared to osteosynthesis (15.5%) in pertrochanteric femur and lateral neck fractures was due to higher age and increased risk factors. Although the influence of some risk factors could be reduced, age, sex and morbidity influenced the outcome more than surgical treatment. THP, even after pertrochanteric fractures, is reasonable if it guarantees a quick and enduring mobilisation of the patient. Bicentric bipolar prostheses are recommended for high risk patients.

We rarely see trauma patients with secondary hyperparathyroidism. We report about a case of a 68-year-old African female with a pertrochanteric femur fracture after a falling accident. As a secondary result we noted a Looser zone (pseudofracture) in the fractured femur. Extended diagnostic work-up including determination of vitamin D metabolites indicated the existence of a secondary hyperparathyroidism. The dark tanned phenotype of the African patient in combination with usually less solar radiation in central Europe seems to be the causative factor for the secondary hyperparathyroidism. Thus, this resulted in reduced cutaneous vitamin D synthesis. The fracture of the proximal femur was stabilized by osteosynthesis with a gamma nail; we thereby bridged the Looser zone.

55 patients aged 65 years and older with a fracture of the proximal end of femur caused by a fall who have been admitted to the Medizinisch-Geriatrische Klinik Albertinen-Haus Hamburg for rehabilitation during the period of half a year took part in the study. Aim of the study was to describe the success of treatment as well as to prevent further falls by identifying the reason for their recent fall. Three defined moments are the basis of this analysis: admission and discharge of the Albertinen-Haus and a follow-up research four years later by interviewing their general practitioners. In addition the general physical condition and life surroundings prior to the fall have been evaluated by an anamnestic questionnaire. The average age was 81.1 years. All but three had been living at home prior to the fall and 72% could be discharged to their home after rehabilitation. Five patients died while still at hospital. The reason for falling has been classified into intrinsic and extrinsic factors. Twenty-six patients (47.3%) toppled due to an extrinsic and 20 (36.4%) due to an intrinsic cause. In nine cases (16.4%) no reason could be identified. No correlation between the patient's age and the success of treatment was found. However, the fear to fall again had a significant negative influence on the success of treatment. The inquiry of 45 patients four years later showed that 42.2% were living at home and 31.1% in a nursing home. Within the four years 26.7% died; 93.7% of the surviving patients were able to walk.

Over a 6-year period we treated 119 pertrochanteric fractures using dynamic hip screws (DHS). During the following 3 years we stabilized 112 per-, sub- and intertrochanteric, as well as "trochanter-associated" fractures by means of intramedullary hip screws (IMHS) or gamma nails (GN). Within comparable patient groups we encountered the following complications: DHS vs IMHS/GN: secondary varus malalignment of the collum femoris with "cut out": 1.7% vs. 1.8%; secondary varus malalignment without "cut out": 0.8% vs. 1.8%; infections: 5.0% vs. 2.7%; hematomas needing revision operations: 2.5% vs. 0%; torn out plate: 1.7% vs. 0%; intraoperative fissures of the shaft: 0% vs. 1.8%; intraoperative perforations of the shaft: 0% vs. 0.9%. Thus, the rate of reoperation for complications within the DHS series was 11.8%, while the rate within the IMHS/GN series was 6.3%. For stable pertrochanteric fractures we therefore acknowledge DHS as the ideal implant in our opinion, while for all other extraarticular proximal fractures of the femur we recommend IMHS or GN.

Driven by the aging population, the proximal femoral fracture is a rising fracture entity, challenging trauma surgeons as well as the German healthcare system as a whole. The rising average age of the population is accompanied by a rising BMI in the German population, resulting in longer operation times, longer average length of stay (ALOS) as well as more postoperative complications.The aim of this study was to demonstrate the economic correlation between body mass index and hospital costs. The retrospective analysis of 950 patient cases suffering from a proximal femoral fracture resulted in the finding of rising treatment costs being positively associated with rising BMI due to longer operation times and longer length of hospitalization (10,452 €, 11,505 €, 12,085 € and 13,681 € for patients with BMI < 18.5 kg/m 2 , BMI = 18.5-24.9 kg/m 2 , BMI = 25.0-29.9 kg/m 2 and BMI ≥ 30.0 kg/m 2 , respectively)., (© 2022. The Author(s).)

Background: Regional anesthesia (RA) techniques such as femoral nerve block (FNB) or fascia iliaca compartment block (FICB) are effective analgesia techniques in the treatment of pain from proximal femoral fractures (PFF). While in Great Britain (GB) these are already frequently used in the emergency department for preoperative analgesia, in the German-speaking D‑A-CH area (Germany, Austria, Switzerland) this seems to occur much less frequently. Therefore, the aim of this study was to survey the type and frequency of RA procedures used and to compare international practice., Material and Methods: In the D‑A-CH area as well as in GB, registered emergency departments were contacted and invited to participate in an online survey. The survey included questions on the frequency and type of RA procedures, reasons for non-use, equipment used, person performing the procedure and medications used., Results: The participation rate was 17.4% (142/818 emergency departments). RA procedures for preoperative analgesia in PFF were used in 18.3% (21/115) of hospitals in the D‑A-CH region and in 96.3% (26/27) in GB. The most commonly used block was the FICB in GB at 96.2% (25/26) and the FNB in Germany at 66.7% (14/21). In the D‑A-CH area, RA procedures are primarily performed by anesthesiology specialists 71.4% (15/21), and in GB by emergency department residents 65.4% (17/26)., Discussion: RA procedures are still performed too rarely following PFF in emergency departments in the D‑A-CH area. In international comparison with GB there is potential for improvement., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background and Objective: Every year in Germany over 100,000 people, mostly of older age, suffer a proximal femoral fracture. Increasing case numbers in connection with an aging population and a relatively large number of concomitant diseases requiring treatment make everyday care more difficult. It is therefore of great importance to observe the quality of care for these patients using relevant quality parameters in order to be able to derive implications for everyday treatment practice., Material and Methods: The data of the external inpatient quality assurance from North Rhine-Westphalia for the years 2007-2008 and 2017-2018 were analyzed and the time periods compared. In addition, based on the documented secondary diagnosis and other influencing parameters, a risk adjustment was carried out with the aid of a logistic regression model with respect to the outcomes of general and surgical complications and mortality. Both osteosynthetically and endoprosthetically treated patients were taken into account. A total of 61,249 cases were included in the study., Results: Positive developments could be observed in the area of surgical complications and wound infections with decreases of 1.2% and 0.8%, respectively. Patients with cardiovascular diseases had a particularly poor outcome. Here, improvements in the subcategory of cardiovascular events were found for general complications. The mortality remained unchanged at 6%. Operative activity on the weekends increased significantly. Patients whose hospital admission was related to the weekend did not show an increased risk of complications or mortality. Although the proportion of patients who were operated on after more than 48 h was reduced from 11.4% to 8.2%, the operation (> 24 h) was still delayed in 26.8% of cases., Conclusion: Against the background of increasing performance demands on the healthcare system, the results document improvements in some central areas of inpatient treatment. Nevertheless, the development of strategies for the further reduction of the preoperative waiting times in a medically justifiable manner is required. Internal concomitant diseases have a decisive influence on patient outcome. Thus, an adequate treatment of the multimorbid patient collective is to be established in everyday practice on the basis of close cooperation between geriatric traumatology and geriatric internal medicine departments., (© 2021. The Author(s).)

Background: Proximal femoral fractures belong to the most common fractures, especially of the elderly. There is a high load of cases and most of them have to be treated surgically. With 20% and above, the rate of complications is very high. On the one hand these are due to limited biological healing competence as well as to surgical pitfalls., Methods: Based on the literature and our own clinical experience we want to demonstrate a standard surgical treatment of proximal femoral fractures, draw attention to the most frequent complications and provide an overview of salvage procedures., Conclusions: Because of the aging population and increasing morbidity, trauma surgery will become even more difficult. Excellent training and knowledge about the patient are becoming more important to avoid manifold complications. Once present, these complications need a detailed analysis and further diagnostics to determine which salvage procedure should be preferred. Due to the fact that there are so many different complications and procedures, evidenced based studies with large numbers cannot be found in literature., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt vorliegt., (Georg Thieme Verlag KG Stuttgart · New York.)