Functional recovery after fracture of the hip

Validation of a decision model for preventive pharmacological strategies in postmenopausal women

BACKGROUND

Benefits and risks of a combined hormone replacement therapy (HRT) based on randomized clinical trial emerged on various disease endpoints in 2002. The Women's Health Initiative (WHI) provides an important health answer for healthy postmenopausal women, such as do not use combined HRT to prevent chronic disease, because of the elevated risk of coronary artery disease (CHD), stroke and venous thromboembolism. In March 2004, the NIH stopped the drugs in the estrogen-alone trial after finding an increase risk of stroke and no effect, neither an increase or a decrease, on risk of CHD after an average of 7 years in the trial. On the other hand, raloxifene, which does not seem to significantly increase the risk of cardiovascular events and could retain skeletal benefits without stimulating endometrial and breast tissue, requires decision-makers since no current data on these disease clinical endpoints have been published.

OBJECTIVE

To construct a multi-disease model based on patient-specific risk factor profiles, and to validate the multi-disease model with several tools of internal and external validities.

METHODS

A Markov state model was developed. The risks of these various diseases (including coronary artery disease, stroke, hip fracture and breast cancer) are derived from published hazards proportional models which take into account significant risk factors. Canadian-specific rates and data sources for these transition probabilities are derived from published studies and Canadian Health Statistics. The validation of our model were based on several tools of internal and external validities, such as Canadian life expectancy, population-based incidence rate of diseases, clinical trials and other published life expectancy models.

RESULTS

First, presumably, small changes in the lifetime probability of dying support the hypothesis that the disease states operate in a largely independent fashion. For instance, the difference in the probability of dying from a particular disease by the complete elimination of a selected disease, such as CHD, stroke or breast cancer, ranged from 0.2 to 2.2% of difference in the lifetime probability of dying of these diseases. Second, we demonstrated that the model adequately predicted the Canadian population lifetable and disease-incidence rates from population-based data among women from 45 to 75 years old. The predictions of the model were cross-checked from non-source data, such as predicted outcomes versus observed outcomes from results of clinical trials. Predicted relative risks of CHD event, breast cancer and hip fracture fell in the reported 95% confidence interval of clinical trials. Finally, predicted treatment benefits are comparable with those of published life expectancy models.

CONCLUSIONS

The results of the study demonstrated that this multi-disease model, including coronary artery disease, stroke, hip fracture and breast cancer, is a valid model to predict the impact on life expectancy or number of events prevented for preventive pharmacological interventions.

Can functional status, after rehabilitation, independently predict long-term mortality of hip-fractured elderly patients?

BACKGROUND AND AIMS

Hip fractures are one of the most serious causes of functional impairment and death in the elderly. The aim of this study was to evaluate prospectively the predictive value of functional performance, after rehabilitation, of hip fracture on long-term mortality in community-dwelling patients.

METHODS

One hundred and seventy-one patients aged 60 years and over, admitted to a geriatric rehabilitation day unit after inpatient rehabilitation, were followed for up to 4 years. Main outcome measures were Functional Independent Measure (FIM), Timed Get Up and Go test (GUAG), cognitive status using the Mini-Mental State Examination on admission, and mortality during the follow-up period. Kaplan-Meier analysis was carried out on survival curves.

RESULTS

All 24 deceased patients performed the GUAG test in > 20 seconds. Although approaching significance, the survival curves were not statistically different between patients performing the test in < or = 20 and those performing it in > 20 seconds (p = 0.08). Survival curves were significantly higher in patients with a FIM score of > or = 90 (p = 0.004), no cardio-cerebrovascular (CCV) diseases (p = 0.001) and no diabetes mellitus (p = 0.01). There were no differences in survival according to age, gender, educational level, marital status, surgical vs conservative treatment, and cognition. A multivariate analysis including FIM score, CCV diseases and diabetes mellitus, demonstrated that only CCV disease was an independent variable for survival (p = 0.02).

CONCLUSIONS

Performance, as evidenced by FIM scores after rehabilitation for hip fracture, may provide additional useful information on long-term survival. However, since functional status after rehabilitation is not an independent risk factor for long-term mortality, its predictive value must be interpreted in view of the comorbidities, mainly CCV diseases, which are more important to the risk of mortality than the event of hip fracture itself.

Functional comparison between uncemented Austin-Moore hemiarthroplasty and osteosynthesis with three screws in displaced femoral neck fractures--a matched-pair study of 168 patients

There is no consensus as to whether osteosynthesis (OS) or hemiarthroplasty (HA) should be used as the primary treatment of displaced femoral-neck fracture. In a prospective matched-pair study, we compared 84 patients treated with OS with three screws and 84 patients treated with uncemented Austin-Moore HA focusing on functional parameters, reoperations and mortality. At 4 months after the fracture, functional recovery was not significantly different between the study groups. However, OS patients tended to have slightly better functional ability than HA patients, as more of them were able to walk out of doors (45.2% versus 39.2%), more were able to walk without walking aids (23.7% versus 16.7%), and more returned to live in their own homes (80%versus 72.9%). OS patients used slightly but not significantly less painkillers and had less hip pain than HA patients. OS patients had had 15.4% more reoperations by 4 months and 14.2% more by 1 year compared to the HA group. The 4-month and 1-year mortality rates of the study groups were of the same order. Functional recovery was slightly better after OS with three screws than after uncemented HA, although no significant differences were seen in a sample of this size. On the other hand, OS was associated with a higher reoperation rate.

Post-operative mortality related to waiting time for hip fracture surgery

In this retrospective study, we looked at the difference in 1 year mortality between two groups of patients who were operated for fracture of the hip.

PATIENTS AND METHODS

In cohort 1, 72% of the patients underwent surgery on the same day of admission, 15% of the patients were operated on the next day, the remaining 13% of the patients waited more than 1 day for surgery. The mean waiting time was 0.47 day. The percentage of patients who were operated on the same day of admission in cohort 2 was 18%. Sixty-nine percent of the patients had to wait 1 day before they were operated and 13% waited 2 days or more. The average waiting time was 1.01 days. The date of death for both the 166 patients in cohort 1 and the 197 patients in cohort 2, was obtained from the national mortality register and the 1 year mortality was calculated. These two groups of patients were from separate 12 month periods and the operations performed were either Dynamic Hip Screw (DHS) or hemiarthroplasty. The two groups were comparable in gender, age distribution and the types of operations.

RESULTS

There was an increase of 10.1% (P<0.025, chi(2), 1 d.f.; 95% CI 1.7-18.5) in the mortality of patients in cohort 2. The mortality data of the two cohorts was also analysed after dividing the patients into three groups according to their age. A statistically significant increase in mortality of 16.9% in patients over 80 years of age in cohort 2 was found. The difference in mortality was still statistically significant when only patients over 80 years of age and having a DHS operation were compared. Total mortality at 2 years after the operation was the same in the two cohorts. Mortality rate for patients in cohort 2 was less than that for cohort 1 patients during the second post-operative year.

CONCLUSION

This study shows that survival at 1 year is better when patients who are medically fit for surgery are operated on the same day of admission. This survival advantage is more pronounced for patients who are over 80 years of age.

Fractured neck of femur in the mobile independent elderly patient: should we treat with total hip replacement?

PURPOSE

To report the outcome of displaced sub-capital neck of femur fractures in the independent elderly (>70 years) managed with total hip arthroplasty through a modified Hardinge approach.

METHODS

Between 1998 and 2000, a surgeon performed a cemented hip replacement using a modified lateral approach in 36 consecutive patients in the Hawke's Bay Regional Hospital, Hastings. Medical charts and out-patient follow-up clinic records were reviewed with respect to outcomes, with particular reference to complications. Independent review of functional outcome was completed at one year postsurgery using a questionnaire.

RESULTS

At an average follow-up of 1.8 years (range, 1-3 years), no patient needed further surgery. One patient had died, giving a mortality rate at one year of 2.9%. All other medical complications were successfully treated. The overall prevalence of early medical complications was 43%. There were no dislocations, and 80% of patients had a good clinical outcome at their first follow-up.

CONCLUSION

The modified lateral approach of Hardinge minimises the incidence of postoperative dislocation. However, there was a high incidence of medical complications and aggressive treatment of such complications was necessary, both preoperatively and postoperatively. The number of pre-existing medical conditions was a significant factor influencing patient morbidity.

Functional outcome after hip fracture. A 1-year prospective outcome study of 275 patients

Two hundred and seventy-five consecutive patients over the age of 50 years admitted with a hip fracture were prospectively studied in detail, to assess the impact of a hip fracture on their functional ability and their need for social support. One hundred and eighty-three (66.9%) patients survived to 1 year. Mortality was highest amongst those least able to perform the recorded activities. One hundred and fifty-eight (86%) of the survivors were resident in the same level of accommodation after 1 year. There was a reduction in mobility and related functions of 20-25% and a reduction of 5% in tasks not related to hip function. It is therefore estimated that in the year after a hip fracture there will be decline in functionally abilities of about 5% unrelated to the hip fracture and about 15-20% directly related to the hip fracture. There was an increase in the requirement for social support amongst survivors individually, but overall the total economic burden on social services and institutional care was not significantly changed by hip fracture.

The impact of a simple fracture clinic intervention in improving the diagnosis and treatment of osteoporosis in fragility fracture patients

We examined the effect of a fracture clinic intervention in reducing previously documented undertreatment of osteoporosis (OP) in individuals with fragility fractures. Fragility fracture patients presenting to five community fracture clinics with no prior diagnosis of, or treatment for OP, and whose radiographic appearance was consistent with fragility fracture, were included. These individuals (intervention group) were informed of their OP risk, and advised to follow up with their physician for assessment. A standardized letter, intended for the physician and outlining the same was provided. Three months later, a telephone interview determined whether a physician visit had occurred, and if so, what investigation and treatment recommendations were made. These outcomes were compared with those for an equal number of age- and sex-matched fragility fracture "controls," selected from among fracture clinic attendees in the 6-9 months preceding the intervention. Logistic regression was used to examine the effect of having received the intervention on physician follow-up, bone density testing, and OP treatment recommendations. The mean age of the 278 participants (139 per group) was 66.0 years; 74% were female. Adjusting for age, sex, hospital, and perceived diagnosis of OP, those who received the intervention were more likely to follow up with a physician (adjusted OR 1.85, p=0.02) and to be recommended bone density testing (adjusted OR 5.22, p<0.0001), but were not more likely to receive an OP treatment recommendation (adjusted OR 2.07, p=0.07). It is concluded that a simple fracture clinic intervention increased follow-up and investigation, but not treatment for OP, in fragility fracture patients. Individuals recommended treatment for OP were more likely to perceive themselves as having OP and to have had a previous fragility fracture. Our findings suggest that future interventions should incorporate assessment of patients' OP health beliefs and education about risk factors for fracture, and should be coupled with physician education to achieve optimal results.

The economic impact of medical complications in geriatric patients with hip fracture

The records of 510 elderly patients with hip fractures admitted to our institution between January 1995 and December 2000 were retrospectively reviewed to determine the incidence and type of developed medical complications and their economic implications. Of those 510 patients, 217 (43%) developed at least 1 medical complication, most frequently electrolyte imbalance (11%), urinary tract infection (10%), respiratory failure (10%), and delirium (9%). Patients who developed medical complications had significantly longer mean hospital stays (10 days) and higher mean hospital costs ($16,203) than patients without such complications (5 days and $10,284, respectively) (P<.001).

Early discharge of hip fracture patients from hospital: transfer of costs from hospital to nursing home

Hip fracture patients occupy more and more hospital beds. One of the strategies for coping with this problem is early discharge from the hospital to institutions with rehabilitation facilities. We studied whether early discharge affects outcome and costs. 208 elderly patients with a hip fracture were followed up to 4 months after the fracture. First, a group of 102 patients stayed in our hospital for the usual period (median 18 days). Then, 106 patients were assigned to a group for early discharge (median 11 days). We measured disabilities, health-related quality of life and cognition at 1 week, 1, and 4 months after hospitalization. To calculate total societal costs, inpatient days, the efforts of professionals in- and outside institutions, and interventions/examinations were recorded during this 4-month period. At 4 months, we found no differences in mortality, ADL level, complications, quality of life, and type of residence. More patients in the early discharge group were discharged to nursing homes with rehabilitation facilities (76% versus 53%), but the median total stay in hospital and nursing home was the same (26 days). Early discharge from hospital did not substantially reduce the total costs (conventional management Euro 15,338 per patient and early discharge Euro 14,281 per patient), but merely shifted them from the hospital to the nursing home.

Percutaneous compression plating for intertrochanteric hip fractures: treatment rationale

Percutaneous compression plating was developed after thorough consideration of each stage in the surgical procedure for intertrochanteric fractures and the ways in which they might be improved. This system represents a minimally invasive method of fracture stabilization and fixation, providing enhanced rotational stability and bone sparing, which reduces both peri- and postoperative complications including cut outs and fracture collapse.

Outcome of hip fracture in older Irish women: a 2-year follow-up of subjects in a case-control study

To assess outcome after hip fracture in older Irish women, 106 consecutive females aged over 50 years admitted to a general hospital with a hip fracture were compared to 89 age- and gender-matched controls from the same catchment area. Interview-based data were collected on socio-demographic factors, mobility and activities of daily living before recruitment and 2 years later. Information was also collected on residence, further falls and fractures and use of health and community support services during the 2-year period. Mortality at 2 years was higher in cases (23.6%) compared to controls (10.1%; P = 0.01). Cases were significantly less mobile and more dependent in the activities of daily living. Of the cases who were community dwellers at baseline, 26.6% were institutionalised at 2 years compared with 9.2% of controls (P = 0.01). During the 2 years cases were significantly more likely to have multiple falls and a further hip or pelvic fracture. Hospital and nursing home admissions and use of physiotherapy, day centre and home help services were also significantly greater among cases. The marked adverse impact of hip fracture reported in this study underlines the importance of public health strategies to prevent these injuries in older people.

Nonoperative treatment of intracapsular fractures of the proximal femur

Of 2776 intracapsular fractures of the proximal femur, 18% of the patients were treated nonoperatively. Included in the group of patients who were treated conservatively were children, patients with cardiac problems or mental problems, stroke, renal failure, multiple disseminated malignancies, and patients who chose nonoperative treatment. The medical treatment protocol can be divided into two stages: Initially, (1) nursing of a bedridden patient with emphasis on the prevention of complications; and (2) once partial bone union has occurred, the attempted rehabilitation to independent ambulation. Paramedical services provide a major contribution during inpatient therapy and during the preparation for returning the patient to the community. A multidisciplinary medical team evaluates and assesses the patient's needs and rehabilitation potential and in cooperation with the patient and the family, an operative plan then is established.

Functional gain of hip fracture patients in different cognitive and functional groups

OBJECTIVE

To follow up six months post hip fracture and to compare functional gain of patients in different cognitive and functional groups.

DESIGN

Prospective longitudinal study of hip fracture patients with functional evaluation pre-fracture, prior to discharge from orthopaedic department and one, three and six months post fracture.

SETTING

Department of Orthopaedics, Rabin Medical Center, Golda Campus with follow-up at Beit-Rivka Geriatric Rehabilitation Hospital, both in Petach Tikvah, Israel, with a minority of patients followed at home or nursing home.

MEASUREMENT

Cognition evaluated by Mini-Mental State Examination, pre-fracture functioning by Functional Independence Measure and Katz Index of ADL. Functional outcome assessed by Functional Independence Measure gain defined as the difference between Functional Independence Measure scores at six months and just prior to discharge from the Department of Orthopaedics.

RESULTS

Moderately cognitively impaired and normal patients had the same Functional Independence Measure-A (self-care) and Functional Independence Measure-B (motor) gains. Pre-fracture independent patients had significantly higher Functional Independence Measure-A and Functional Independence Measure-B gains. A multiple regression analysis examining age, sex, Mini-Mental State Examination score, Katz score, type of fracture, surgery versus conservative treatment and the pre-fracture Functional Independence Measure score showed that only the pre-fracture Functional Independence Measure-B scores and Katz scores are the independent variables for motor and self-care gains, respectively.

CONCLUSIONS

Pre-fracture motor and not cognitive level has been the most important predictive factor for motor gain after hip fracture. Cognitively impaired hip fracture patients can achieve and maintain the same motor functional gain as normal patients, if they were mobile pre-fracture.

A combined intracapsular and extracapsular fracture of the hip

We report a case of an unusual hip fracture that involved the intracapsular area and continued vertically to the extracapsular region below the trochanteric line. The division between these two types of fractures is based on the anatomical site, the blood supply and the mechanical forces that act on the hip. This division is important and influences the different surgical techniques to treat these individual fractures. Femoral neck fractures (intracapsular), particularly those with displacement, can disrupt the blood supply to the femoral head and may be associated with an increased incidence of complications, especially non-union and avascular necrosis (AVN) of the femoral head. These fractures are usually treated either by reduction and fixation, or by hemiarthroplasty. Non-union and avascular necrosis following extracapsular fractures are rare. Treatment involves reduction of the fracture and insertion of a dynamic hip screw. The combination of these two types of fractures is extremely rare and creates a surgical problem without any optimal solution. The focus of this case report is placed on the mechanical axis and weight-bearing forces that play a role in the hip and on the optional surgical techniques in such a rare type of fracture in an elderly osteoporotic patient. (Hip International 2002; 1: 43-6).

Further experience of nonagenarians with hip fractures

Our purpose was to investigate the factors after predictive outcome 3 months after the injury in terms of mortality and effective independent walking of nonagenarians with hip fracture. A prospective study was carried out for 2 yr in the orthopaedic wards on patients referred to geriatricians. The data were subjected to logistic regression forward stepwise analysis. Eighty-nine patients were included in the study; 55 (61.8%) had a trochanteric fracture and 86 required a surgical procedure. Before the fracture, 83 patients (93.3%) were able to walk by themselves or with minimal supervision. Forty-three patients (48.3%) had an American Society of Anaesthesiologists' of III-IV score. The mean number of postoperative complications was four. Mean hospital stay was 18.2 days. Within 3 months, 19 patients (21.3%) had died and 58 (69%) were living in their previous residence. Thirty-three (50% of living patients) were able to walk by themselves or with minimal help within 3 months of the fracture. Predictive variables for 3-month mortality were pre-fracture dependence on others for personal toilet and the presence of cognitive impairment. Predictive variables for independent efficient walking were bowel control and absence of cognitive impairment before the fracture, as well as no development of bed sores during hospitalization.These nonagenarian patients with hip fractures show low perioperative mortality, frequently return to their previous accommodation and present a limited recovery of walking ability.

Outcome of medically unstable elderly patients admitted to a geriatric ward after hip fracture

Outcome of surgical treatment is superior to that of conservative treatment for hip fractures. Nevertheless, for a number of patients, the operation is either delayed or unfit due to their unstable medical conditions. We retrospectively reviewed patients admitted to a geriatric ward after hip fracture, and investigated complications, functional outcome and survival in different cognitive, pre-fracture functional and treatment groups. Patients hospitalized (N=78) from January 1993 to June 1999 were included (1/2 demented, 1/3 fully dependent in Basic Activities of Daily Living, and 2/5 high operative risk patients). Following stabilization, 14 subjects (17. 9%) were operated. The mean and range of surgical delay was 9+/-7.2, and 3 to 30 days, respectively. Comparison between surgical and conservative treatment groups, and cognitive and pre-fracture functional groups showed no differences in age, gender, chronic medical conditions, fracture type, reasons for surgical delay or conservative approach, complications, survival curves and laboratory results. Thirteen operated patients were in ASA I + II grades, only 1 in ASA grades III + IV (low and high operative risk, American Society of Anesthesiologists grading system) (p=0.004). Functional outcome was similar in the surgical vs the conservative group, and intracapsular vs extracapsular fractures. ASA I + II patients had a higher survival rate compared to ASA III + IV patients (p=0. 02). We conclude that after stabilization of acute medical conditions, the most important preoperative consideration is the anesthetic risk, and surgical and conservative approaches may be equally considered in selected groups of elderly, frail patients with hip fracture who are medically unstable for more than a few days.

Surgical outcomes of a randomized prospective trial involving patients with a proximal femoral fracture

BACKGROUND

An orthopaedic management/patient-focused care unit (OMPFCU) involving a dedicated orthopaedic-geriatrics liaison team was established at the Royal Brisbane Hospital in 1994 in an effort to safely accelerate rehabilitation of patients with proximal femoral fractures.

METHODS

The surgical outcomes of the patients were monitored in order to determine whether accelerated rehabilitation had any significant adverse effects on the surgical outcomes, measured by mortality, readmission to hospital, deep wound infection, fracture union delay, mobility and the revision surgery rate.

RESULTS

No significant difference was recorded in mortality and morbidity, deep wound infection and revision surgery rates between patients in the Royal Brisbane Hospital OMPFCU and those in standard care in the orthopaedic surgery wards.

CONCLUSION

Accelerated rehabilitation for patients with a proximal femoral fracture in a major teaching hospital can be accomplished safely.

Acute hospital admissions from nursing homes: some may be avoidable

A retrospective survey of acute hospital admissions from nursing homes over a year to a district hospital revealed high overall hospital admission rates and wide variations of admission rates from similar homes. Medical admissions dominated, infections and poorly controlled heart failure being notably common. A significant proportion of admissions may have been avoided by active chronic disease management, together with better information for doctors responding to emergency calls and specialist support programmes facilitating in situ treatment.

Outcomes of older persons receiving rehabilitation for medical and surgical conditions compared with hip fracture and stroke

OBJECTIVE

Older persons with general medical and surgical conditions increasingly receive posthospital rehabilitation care in nursing homes and rehabilitation hospitals. This study describes the characteristics of such patients, contrasted with patients with traditional rehabilitation diagnoses of hip fracture and stroke.

DESIGN

Prospective cohort study.

SETTING

Seventeen skilled nursing facilities and six rehabilitation hospitals in seven states.

PARTICIPANTS

Medicare patients age 65 or older receiving posthospital rehabilitation.

METHODS

A total of 290 medical/surgical patients were compared with 336 hip fracture and 429 stroke patients. Data were collected prospectively from charts, nursing assessments, and patient interviews. Patient characteristics associated with functional recovery and mortality were estimated using multivariate regression.

RESULTS

Medical/surgical patients had greater premorbid activities of daily living (ADL) (P < .001) and instrumental activities of daily living (IADL) (P < .01) disability, but suffered less decline with the acute event than hip fracture or stroke patients (P < .001). Medical/surgical patients were more likely to recover premorbid ADL function (P < .05) but 1-year mortality was significantly greater (30% vs. 14% hip fracture; 18% stroke; P < .001). Predictors of functional recovery and mortality differed between the three groups. Among medical/surgical patients, premorbid ADL difficulty, cognitive impairment, a pressure ulcer at rehabilitation admission, and depression were associated with failure to recover premorbid function whereas increasing comorbidity and incontinence were associated with mortality.

CONCLUSIONS

Medical/surgical patients represent a unique rehabilitation population. They experienced greater premorbid functional disability, less acute decline, but greater mortality than patients with traditional rehabilitation diagnoses. Further study of this distinct rehabilitation population may help identify patients most likely to benefit from rehabilitation.

Percutaneous compression plating of intertrochanteric hip fractures

OBJECTIVE

To present the principles of a surgical technique for percutaneous compression plating of intertrochanteric hip fractures and to report the clinical results of treatment using this method.

DESIGN

Retrospective.

SETTING

University hospital.

PATIENTS

Ninety-eight intertrochanteric hip fractures in ninety-seven patients with a minimum follow-up of twelve months.

MAIN OUTCOME MEASURES

Radiographic and clinical evidence of functional outcome and complications including fracture collapse and implant failure.

RESULTS

Mean perioperative blood loss was 92.4 milliliters (range 14 to 245 milliliters), and the mean postoperative hospital stay was 8.7 days (range 4 to 20 days). Complications included two minor wound hematomas and one soft tissue infection. Radiographically, one fracture with a varus deformity of 8 degrees and two fractures had minor screw pullout that did not affect the final results. No collapses, screw cutouts, or head penetrations were seen. Three patients required reoperation: one for avascular necrosis after a fracture at the base of the neck and two, after fracture healing, for trochanteric bursitis requiring plate removal. All surviving patients (80 of 98; 82 percent) had uneventful fracture healing with union achieved by six months in all patients.

CONCLUSIONS

Use of the percutaneous compression plating for intertrochanteric hip fractures resulted in reduced complications, event-free fracture healing, and improved rehabilitation.

Reliability, validity, and responsiveness of the lower extremity measure for patients with a hip fracture

BACKGROUND

The purpose of this study was to determine whether currently published outcome measures of physical function would be suitable for use for older adults with a hip fracture. The measures that were considered were the Musculoskeletal Function Assessment (MFA) Instrument, the Older Americans' Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire physical function subscale, the Toronto Extremity Salvage Score (TESS), and the Short Form-36 (SF-36). Following suggestions by an expert panel and patient interviews, the MFA was not tested further. The TESS was modified and renamed the Lower Extremity Measure (LEM).

METHODS

Forty-three community-dwelling patients with a hip fracture completed the LEM, OARS, and SF-36 in the hospital so that the prefracture status could be obtained; they were then followed prospectively at six weeks and at six months. All patients were interviewed twice in the hospital to assess the reliability of the LEM (intraclass correlation coefficient = 0.85). To establish criterion validity, the measures were compared with the Timed Up and Go (TUG) test at six weeks. We tested a number of hypotheses to determine construct validity.

RESULTS

Only the LEM scores were significantly correlated with the TUG scores (r = -0.53, p = 0.03). The LEM scores were significantly correlated with the SF-36 subscale scores and the OARS scores. Patients with at least one comorbidity had a lower mean prefracture LEM score (90.0 +/- 9.7) than patients with no comorbidity (96.9 +/- 8.1) (p = 0.02). Patients who had used no walking aids before the fracture had a higher mean prefracture LEM score than those who had used a cane (95.5 +/- 5.8 compared with 85.5 +/- 12.7; p = 0.0007). Both the LEM and the SF-36 scores changed significantly between all of the time-periods (p < 0.05). Measures of responsiveness indicated that the LEM was the best measure for detecting changes in physical function.

CONCLUSIONS

The LEM can detect clinically important changes in physical function over time in patients with a hip fracture and would be most useful for clinical trials or cohort studies. Orthopaedists who are currently utilizing the SF-36 can be reassured that the physical function subscale is a valid measure for patients with a hip fracture.

Major life events as antecedents to hip fracture

BACKGROUND

This study sought to determine whether the number of antecedent life events reported in the year before hip fracture among elderly patients was normal for the population from which these patients derive. Major life events are events such as births, deaths, major financial dealings, and major health changes.

METHODS

Life events reported in the year before a fall and hip fracture for 111 hip fracture patients were compared with those of a control sample of 90 nonfracture, community-dwelling ambulatory elderly.

RESULTS

The total number of life events was higher in the hip fracture group (p = 0.0001) than in the community control group. Fracture was also associated with the number of events experienced (adjusted OR, 2.1; 95% CI, 1.6-2.7; p < 0.0007), notwithstanding age, marital status, and education.

CONCLUSION

Older persons who had sustained a fall-related traumatic hip fracture experienced an increased number of major life events compared with a nonfracture population sample of community-dwelling elderly controls.

Changes in bone mineral density of the proximal femur after total knee arthroplasty

This study investigates the relationship between total knee arthroplasty (TKA) and bone mineral density (BMD) in the same and opposite hips. The study prospectively evaluated 24 consecutive patients undergoing TKA (31 knees, 47 hips). The mean follow-up was 48 months. The mean age at latest follow-up was 69 years, and all patients had the preoperative diagnosis of osteoarthritis. BMD of the hip was measured by dual-energy x-ray absorptiometry. Despite a predicted age-related loss of 4% during 2 years, 45% of the hips on the operative side and 59% of the hips on the nonoperative side had BMD higher than preoperative levels. Of hips, 81% on the operative side and 82% on the nonoperative side had BMD that was within the expected 4% age-related loss. Assuming that higher hip BMD may be protective against later hip fractures, the results infer that, by increasing hip BMD, TKA may be protective against later hip fractures. The increase with TKA in patient mobility and the increased hip loading may be a mechanism whereby the hip BMD increases.

Determining factors of mortality in the elderly with hip fractures

We conducted a retrospective study of the influence of various factors on the mortality of 114 patients with hip fractures. The mortality rate one year after surgery was 18%, which was 2.5 times larger than that of the general population. It was related to age, ECG abnormality, and post-operative complications.

Costs and outcomes of hip fracture and stroke, 1984 to 1994

OBJECTIVES

This study quantified changes in Medicare payments and outcomes for hip fracture and stroke from 1984 to 1994.

METHODS

We studied National Long Term Care Survey respondents who were hospitalized for hip fracture (n = 887) or stroke (n = 878) occurring between 1984 and 1994. Changes in Medicare payment and survival were primary outcomes. We also assessed changes in functional and cognitive status.

RESULTS

Medicare payments within 6 months increased following hip fracture (103%) or stroke (51%). Survival improved for stroke (P < .001) and to a lesser extent for hip fracture (P = .16). Condition-specific improvements were found in functional and cognitive status.

CONCLUSIONS

During the period 1984 to 1994, Medicare payments for hip fracture and stroke rose and there were some improvements in survival and other outcomes.

A reinforced rigid fixation device for unstable intertrochanteric fractures

A 120 degrees blade plate reinforced by a strut is introduced for the treatment of unstable intertrochanteric and proximal subtrochanteric fractures. Mechanical tests showed that the strength of this reinforced resistance device was 11,758 N. This strength is two and three times greater than that of the Gamma nail and sliding hip screw, respectively, and five times greater with the strut than without it. Three hundred fifty-eight patients older than 60 years of age were treated with this method between 1987 and 1991 (mean followup, 16 months). Six months after surgery the fracture had united in 82% of the patients who were walking without aid or using only a cane. Weightbearing began when the patient's general overall condition allowed such activity (average, 5 days; mode, 3 days). A chi squared test showed no difference regarding the results between stable and unstable fractures. Intraoperative and postoperative complication rates were 3% and 7.1%, respectively. The failure of fixation rate was 5.4%. Mechanical tests and clinical results showed that immediate weightbearing can be allowed in all types of intertrochanteric fractures. This reinforced device is effective in treating unstable intertrochanteric fractures and is especially indicated for the most unstable types (Evans' Grades 4 and 5).

Development and validation of a clinical prediction rule for prolonged nursing home residence after hip fracture

OBJECTIVES

To develop and validate a clinical prediction rule for nursing home residence 6 months after a hip fracture.

DESIGN

Two prospective cohort studies, a development study (DS) and a validation study (VS).

SETTING

The DS included hip fracture patients admitted to 92 rehabilitation units or skilled nursing facilities; the VS included hip fracture patients from 11 integrated healthcare systems.

PARTICIPANTS

A total of 344 community-dwelling hip fracture patients aged 65 and older participated in the DS; 239 similar patients were enrolled in the VS.

INTERVENTION

None.

MEASUREMENTS

The acute hospital record, nursing evaluations, and patient questionnaires provided information about demographics, physical and neuropsychological function, and comorbidity. Residence 6 months after fracture was determined by phone interview. Multivariate analysis identified predictors for a risk score to assess the likelihood of nursing home residence.

RESULTS

18.7% of patients in the DS resided in nursing homes 6 months after hip fracture. The four independent risk factors for institutionalization were (1) being unmarried (OR = 6.7 [95% CI 2.4 to 19]), (2) incontinence (OR = 2.3 [CI 1.2 to 4.7]), (3) dependence in ambulation (OR = 5.0 [CI 2.1 to 12.3]), and (4) cognitive impairment (OR = 6.6 [CI 3.3 to 13.2]). Of patients with all four risk factors, 73.2% were institutionalized at 6 months, compared with 0% of patients with no risk factors. In the VS, 6.1% of patients resided in nursing homes after 6 months, with a range from 50.0% of patients with four risk factors to 0% of those with no risk factors. Areas under receiver-operating characteristic curves for the prediction rule were 0.84 +/- .03 in the DS, and 0.81 +/- .06 in the VS.

CONCLUSION

A clinical prediction rule using four easily measurable characteristics can identify individuals at high or low risk of nursing home residence 6 months after hip fracture.

Clinical outcomes and treatment of hip fractures

The worldwide prevalence of hip fracture is increasing as the mean age of the population increases. Despite advances in anesthesia, nursing care, and surgical techniques, however, the outcome of treatment is often poor, and hip fractures remain a significant source of morbidity and mortality for the elderly population. For these patients, operative treatment is considered to be optimal and most cost-effective for displaced intracapsular fractures and all extracapsular fractures. Undisplaced intracapsular fractures can be treated with bed rest and 6-8 weeks' delay of weight bearing in the "younger" elderly (< or = 70 years). The timing of surgery remains controversial, and evidence that a delay in operating leads to increased morbidity is inconclusive. In general, early surgery is indicated in premorbidly fit patients, whereas surgery should be delayed if correctable comorbidities are present. Methods of intracapsular fracture repair very geographically and according to surgeon preference. Prospective, randomized, case-controlled studies are needed to compare repair methods, including internal fixation versus hemiarthroplasty for intracapsular fractures and use of uncemented versus cemented hemiarthroplasty protheses. Extracapsular fractures are usually repaired using a dynamic hip screw or other variant of sliding nail fixation. The mortality rate after hip fracture appears to vary in association with poorly controlled systemic disease (particularly if multiple comorbidities are present); cognitive disorders; operative intervention before stabilization if > or = 3 comorbidities are present; and, in the absence of prophylaxis, deep vein thrombosis; the associations between mortality and male sex, advanced age, and anesthetic type are less clear. The factors associated with the recovery of walking ability include young age, male sex, absence of dementia, absence of postoperative confusional state, and use of a walking aid before the fracture. Many determinants of outcome are independent of the level of care given and are dependent on prefracture status. To maximize rehabilitation potential, a multidisciplinary approach using skilled medical, nursing, and paramedical care appears to be optimal. Prospective case-controlled studies are required to demonstrate the long-term effectiveness of specialist rehabilitation units. In today's cost-cutting environment, caution must be taken to prevent short-term cost-saving measures from compromising long-term outcome for elderly hip fracture patients.

Femoral neck and ipsilateral neck and shaft fractures in the young adult

Femoral neck and ipsilateral neck and shaft fractures in the young adult represent a significant source of morbidity and mortality. This article reviews the anatomy, pathophysiology, radiographic evaluation, timing of surgery, and complications in an attempt to increase recognition of these injuries and provide better patient care.

Femoral neck fracture fixation. Clinical decision making

Femoral neck fractures continue to pose significant decision making problems for the busy practitioner. Indirect factors over which the orthopaedic surgeon has little control include the patient's preinjury medical status, metabolic bone quality, and fracture classification. Direct factors that fall on the decision making ability of the surgeon include surgical timing, capsular hematoma, quality of reduction, and mechanics of fixation. Early, rigid anatomic reduction with 6.5-mm compression screws in patients with few comorbidities will achieve the optimum outcomes using fixation techniques. Anterolateral open approaches afford capsular hematoma decompression and anatomic access for fixation in the young or irreducible fracture pattern.

Predictors of mortality after acute hip fracture

To identify determinants of mortality after hip fracture, we performed a multicenter, retrospective study of 390 Medicare beneficiaries. Independent predictors of 30-day mortality included a history of congestive heart failure (odds ratio [OR] 32; 95% confidence interval [CI] 5, 192), angina (OR 26; 95% CI 4, 184), or chronic pulmonary disease (OR 11; 95% CI 2, 62). Postoperative use of aspirin was associated with a reduced risk of mortality (OR 0.24; 95% CI 0.08, 0.70). Cardiovascular events were the presumed cause of 63% of in-hospital deaths. Aspirin may have significant potential to reduce mortality in this population and deserves further study.

Rehabilitation in joint and connective tissue diseases. 3. Limb disorders

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in joint and connective tissue diseases in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the following: differential features, diagnostic strategy, and rehabilitation management of hip, knee, foot, and shoulder pain; indications, contraindications, and postsurgical management for joint arthroplasty; management of gout and chondrocalcinosis; and rehabilitation issues related to hip and shoulder fracture.