IntroductionHip fracture surgery is associated with high in-hospital and 30-day mortality rates and serious adverse patient outcomes. Evidence from randomised controlled trials regarding effectiveness of spinal versus general anaesthesia on patient-centred outcomes after hip fracture surgery is sparse.Methods and analysisThe iHOPE study is a pragmatic national, multicentre, randomised controlled, open-label clinical trial with a two-arm parallel group design. In total, 1032 patients with hip fracture (>65 years) will be randomised in an intended 1:1 allocation ratio to receive spinal anaesthesia (n=516) or general anaesthesia (n=516). Outcome assessment will occur in a blinded manner after hospital discharge and inhospital. The primary endpoint will be assessed by telephone interview and comprises the time to the first occurring event of the binary composite outcome of all-cause mortality or new-onset serious cardiac and pulmonary complications within 30 postoperative days. In-hospital secondary endpoints, assessed via in-person interviews and medical record review, include mortality, perioperative adverse events, delirium, satisfaction, walking independently, length of hospital stay and discharge destination. Telephone interviews will be performed for long-term endpoints (all-cause mortality, independence in walking, chronic pain, ability to return home cognitive function and overall health and disability) at postoperative day 30±3, 180±45 and 365±60.Ethics and disseminationiHOPE has been approved by the leading Ethics Committee of the Medical Faculty of the RWTH Aachen University on 14 March 2018 (EK 022/18). Approval from all other involved local Ethical Committees was subsequently requested and obtained. Study started in April 2018 with a total recruitment period of 24 months. iHOPE will be disseminated via presentations at national and international scientific meetings or conferences and publication in peer-reviewed international scientific journals.Trial registration numberDRKS00013644; Pre-results

Epidemiologic study, level III. Therapeutic/care management study, level IV.

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We set out to clarify whether in hospitals with a large volume morbidity and mortality rates after total knee arthroplasty (TKA) can be improved, whether the effects are consistent, and whether minimum recommendable caseloads can be inferred. We conducted a systematic review using MEDLINE, EMBASE, CENTRAL, and CINAHL and performed a hand search without restrictions on language or publication types. We identified 1406 citations, of which 13 studies including 1,110,962 patients met our inclusion criteria. Of these, six studies explored the same administrative data source. Five studies enrolling 448,897 were eligible for quantitative analysis. All studies corresponded to evidence level 2b (prospective or retrospective cohort study with >80% follow-up). We found homogeneous results about hospital mortality. Between 2551 and 821 TKA must be performed by high-volume rather than by low-volume providers to prevent 1 extra death. Absolute event rates are notably small.

Distal fracture of the radius is an injury to a complex joint that is comprised functionally of four partial joints and makes it possible for the hand to move in all directions. The injuries to bone and cartilage and to the stabilizing ligamentous structures and the surrounding soft tissue vary as functions of the impact responsible, the mechanism of injury, and any previous illnesses. The objectives of treatment are restoration of pain-free, unrestricted and lasting function of the wrist and lower arm and avoidance of the typical complications. Stable fractures are treated by conservative means, while unstable fractures with fragmentation are realigned in a closed procedure and then stabilized by internal or external fixation. In the case of fractures in bones affected by osteoporosis it is usually not necessary to make good a metaphyseal defect when specially adapted fixed-angle plates are used. Complex intraarticular AO type C3 fractures with multiple fragments frequently require a two-step procedure with primary closed realignment, an external fixator spanning the joint, and subsequent extensive diagnostic examinations to ascertain any concomitant injuries and allow a decision on the definitive treatment that is most suitable for the type of injury present.

The TraumaNetwork DGU(®) audits all hospitals participating in the care for severely injured patients and establishes a structured network between all the players involved in trauma care. Thirty TNWs will be certified by the end of 2011, covering 75% of Germany. The nationwide covering will be completed by the middle of 2012.

Patients with medial hip neck fracture should receive operative treatment without delay, if no medical contra-indications for immediate surgery. In particular appropriate organizational measures should be taken to ensure an early surgical treatment even during weekends.

The indications for the surgical treatment of fractures in elderly patients should consider the individual's general health status, the specific pattern of injury, and the ability of the patient to actively participate in the rehabilitation process. Intramedullary systems are the gold standard for shaft and metaphyseal fractures due to the decreased operative trauma and the possibility of early weight bearing and functional treatment. Minimally invasive locking plate systems can frequently be applied, offer decreased risk of secondary fracture displacement, and have great advantages in the treatment of periprosthetic fractures with firm implants. The possible reasons for falls should be diagnosed in order to allow their prevention. An exact assessment of the severity of osteoporosis in important in allowing adequate treatment for associated pain and for decreasing the risk of future osteoporosis related fractures.