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Crosby JM, Parker MJ. Femoral neck collapse after internal fixation of an intracapsular hip fracture: Does it indicate a poor outcome? Injury 2016; 47:2760-2763. [PMID: 28340943 DOI: 10.1016/j.injury.2016.10.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/14/2016] [Accepted: 10/17/2016] [Indexed: 02/02/2023]
Abstract
The degree of femoral neck collapse that occurred after 519 patients with an intracapsular hip fracture treated by internal fixation with a Targon FN implant was measured. Mean femoral neck collapse was 8.0mm and this was increased for displaced fractures in comparison to undisplaced fractures (9.5mm versus 5.9mm, p<0.0001) and for those patients that subsequently developed fracture healing complications (11.6mm versus 7.1mm, p<0.0001). At one year from injury femoral neck collapse in excess of 15mm was associated with an increase in the degree of residual pain (p=0.01). A clear relationship between increased collapse and increased loss of mobility was demonstrated (P<0.0001). This study confirms previous smaller studies that excessive femoral neck collapse (of more than 15mm) is more common for displaced fractures and presents new data to demonstrate that excessive femoral neck collapse is associated with an increased risk of fracture healing complications and increased loss of function. Future studies are now justified that consider methods to reduce fracture collapse.
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Affiliation(s)
- Jonathan M Crosby
- Peterborough and Stamford Hospital NHS Foundation Trust, Department of Orthopaedics, Peterborough City Hospital, CBU PO Box 211, Core C, Bretton Gate, Peterborough PE3 9GZ, England, United Kingdom
| | - Martyn J Parker
- Peterborough and Stamford Hospital NHS Foundation Trust, Department of Orthopaedics, Peterborough City Hospital, CBU PO Box 211, Core C, Bretton Gate, Peterborough PE3 9GZ, England, United Kingdom.
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Absolute and Relative Reliability of the Timed 'Up & Go' Test and '30second Chair-Stand' Test in Hospitalised Patients with Stroke. PLoS One 2016; 11:e0165663. [PMID: 27798686 PMCID: PMC5087865 DOI: 10.1371/journal.pone.0165663] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 10/14/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The timed 'Up & Go' test and '30second Chair-Stand' test are simple clinical outcome measures widely used to assess functional performance. The reliability of both tests in hospitalised stroke patients is unknown. The purpose was to investigate the relative and absolute reliability of both tests in patients admitted to an acute stroke unit. METHODS Sixty-two patients (men, n = 41) attended two test sessions separated by a one hours rest. Intraclass correlation coefficients (ICC2,1) were calculated to assess relative reliability. Absolute reliability was expressed as Standard Error of Measurement (with 95% certainty-SEM95) and Smallest Real Difference (SRD) and as percentage of their respective means if heteroscedasticity was observed in Bland Altman plots (SEM95% and SRD%). RESULTS ICC values for interrater reliability were 0.97 and 0.99 for the timed 'Up & Go' test and 0.88 and 0.94 for '30second Chair-Stand' test, respectively. ICC values for intrarater reliability were 0.95 and 0.96 for the timed 'Up & Go' test and 0.87 and 0.91 for '30second Chair-Stand' test, respectively. Heteroscedasticity was observed in the timed 'Up & Go' test. Interrater SEM95% ranged from 9.8% to 14.2% with corresponding SRD% of 13.9-20.1%. Intrarater SEM95% ranged from 15.8% to 18.7% with corresponding SRD% of 22.3-26.5%. For '30second Chair-Stand' test interrater SEM95 ranged between 1.5 and 1.9 repetitions with corresponding SRD of 2 and 3 and intrarater SEM95 ranged between 1.8 and 2.0 repetitions with corresponding SRD values of 3. CONCLUSION Excellent reliability was observed for the timed 'Up & Go' test and the '30second Chair-Stand' test in hospitalised stroke patients. The thresholds to detect a real change in performance were 18.7% for the timed 'Up & Go' test and 2.0 repetitions for the '30second Chair-Stand' in groups of patients and 26.5% and 3 repetitions in individual patients, respectively.
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Bowers TM, Parker MJ. Assessment of outcome after hip fracture: development of a universal assessment system for hip fractures. SICOT J 2016; 2:27. [PMID: 27259572 PMCID: PMC4893153 DOI: 10.1051/sicotj/2016018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/20/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim of the study was to refine current evaluation systems used to assess outcome after a hip fracture and to devise a simple and practical system to assess all hip fracture patients. METHODS Three continuous scales were defined for pain, mobility and functional independence. These were all found to have an acceptable degree of inter-observer agreement. The pre-fracture mobility and independence scores were related to the one-year mortality for a consecutive series of 381 patients. RESULTS Scores for mobility and functional independence were highly predictive of mortality (p < 0.0001). CONCLUSIONS It is recommended that the outcome after hip fracture should be standardised to these principle outcomes of pain, regain of mobility and independence and mortality. These scores can be use to assess progress and identify those who may require additional assessment or intervention.
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Affiliation(s)
| | - Martyn J. Parker
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Peterborough City Hospital, Edith Cavell Campus Bretton Gate Peterborough Cambridgeshire
PE3 9GZ UK
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Overgaard JA, Larsen CM, Holtze S, Ockholm K, Kristensen MT. Interrater Reliability of the 6-Minute Walk Test in Women With Hip Fracture. J Geriatr Phys Ther 2016; 40:158-166. [PMID: 27213999 DOI: 10.1519/jpt.0000000000000088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE The 6-minute walk test (6MWT) is widely used as a clinical outcome measure. However, the reliability of the 6MWT is unknown in individuals who have recently experienced a hip fracture. The aim of this study was to evaluate the relative and absolute interrater reliability of the 6MWT in individuals with hip fracture. METHODS Two senior physical therapy students independently examined a convenience sample of 20 participants in a randomized order. Their assessments were separated by 2 days and followed the guidelines of the American Thoracic Society. Hip fracture-related pain was assessed with the Verbal Ranking Scale. RESULTS Participants (all women) with a mean (standard deviation) age of 78.1 (5.9) years performed the test at a mean of 31.5 (5.8) days postsurgery. Of the participants, 10 had a cervical fracture and 10 had a trochanteric fracture. Excellent interrater reliability (intraclass correlation coefficient [ICC2.1] = 0.92; 95% confidence interval, 0.81-0.97) was found, and the standard error of measurement and smallest real difference were calculated to be 21.4 and 59.4 m, respectively. Bland-Altman plots revealed no significant difference (mean of 3.2 [31.5] m, P = .83) between the 2 raters, and no heteroscedasticity was observed (r = -0.196, P = .41). By contrast, participants walked an average of 21.7 (22.5) m longer during the second trial (P = .002). Participants with moderate hip fracture-related pain walked a shorter distance than those with no or light pain during the first test (P = .04), but this was not the case during the second test (P = .25). CONCLUSION The interrater reliability of the 6MWT is excellent, and changes of more than 21.4 m (group level) and 59.4 m (individual participants with hip fracture) indicate a real change in the 6MWT. Measuring hip fracture-related pain during testing is recommended for individuals with hip fracture who undergo the 6MWT.
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Affiliation(s)
- Jan Arnholtz Overgaard
- 1Department of Rehabilitation, Municipality of Lolland, Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Maribo, Denmark. 2Research Unit of Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark. 3Health Sciences Research Centre, University College Lillebaelt, Denmark. 4Department of Rehabilitation, Municipality of Lolland, Maribo, Denmark. 5Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Departments of Physiotherapy and Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Leegwater NC, Nolte PA, de Korte N, Heetveld MJ, Kalisvaart KJ, Schönhuth CP, Pijnenburg B, Burger BJ, Ponsen KJ, Bloemers FW, Maier AB, van Royen BJ. The efficacy of continuous-flow cryo and cyclic compression therapy after hip fracture surgery on postoperative pain: design of a prospective, open-label, parallel, multicenter, randomized controlled, clinical trial. BMC Musculoskelet Disord 2016; 17:153. [PMID: 27059990 PMCID: PMC4826534 DOI: 10.1186/s12891-016-1000-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 03/30/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The number of hip fractures and resulting post-surgical outcome are a major public health concern and the incidence is expected to increase significantly. The acute recovery phase after hip fracture surgery in elder patients is often complicated by severe pain, high morphine consumption, perioperative blood loss with subsequent transfusion and delirium. Postoperative continuous-flow cryocompression therapy is suggested to minimize these complications and to attenuate the inflammatory reaction that the traumatic fracture and subsequent surgical trauma encompass. Based on a pilot study in patients undergoing total hip arthroplasty for osteoarthritis, it is anticipated that patients treated with continuous-flow cryocompression therapy will have less pain, less morphine consumption and lower decrease of postoperative hemoglobin levels. These factors are associated with a shorter hospital stay and better long-term (functional) outcome. METHODS/DESIGN One hundred and sixty patients with an intra or extracapsular hip fracture scheduled for internal fixation (intramedullary hip nail, dynamic hip screw or cannulated screws) or prosthesis surgery (total hip or hemiarthroplasty) will be included in this prospective, open-label, parallel, multicenter, randomized controlled, clinical superiority trial. Patients will be allocated to two treatment arms: group 'A' will be treated with continuous-flow cryocompression therapy and compared to group 'B' that will receive standard care. Routine use of drains and/or compressive bandages is allowed in both groups. The primary objective of this study is to compare acute pain the first 72 h postoperative, measured with numeric rating scale for pain. Secondary objectives are: (non-) morphine analgesic use; adjusted postoperative hemoglobin level; transfusion incidence; incidence, duration and severity of delirium and use of psychotropic medication; length of stay; location and duration of rehabilitation; functional outcome; short-term patient-reported health outcome; general and cryotherapy related complications and feasibility. DISCUSSION This is the first randomized controlled trial that will assess the analgesic efficiacy of continuous-flow cryocompression therapy in the acute recovery phase after hip fracture surgery. TRIAL REGISTRATION www.trialregister.nl, NTR4152 (23(rd) of August 2013).
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Affiliation(s)
- Nick C. Leegwater
- />Department of Orthopedics, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Peter A. Nolte
- />Department of Orthopedics, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Niels de Korte
- />Department of Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | | | | | - Casper P. Schönhuth
- />Department of Orthopedics, VU University Medical Center, Amsterdam, The Netherlands
| | - Bas Pijnenburg
- />Department of Orthopedics, Amstelland Hospital, Amstelveen, The Netherlands
| | - Bart J. Burger
- />Department of Orthopedics, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Kees-Jan Ponsen
- />Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Frank W. Bloemers
- />Department of Surgery, Section of Traumasurgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Andrea B. Maier
- />Department of Internal Medicine, Section of Gerontology and Geriatrics, VU University Medical Center, Amsterdam, The Netherlands
| | - Barend J. van Royen
- />Department of Orthopedics, VU University Medical Center, Amsterdam, The Netherlands
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Pedersen MM, Petersen J, Beyer N, Damkjær L, Bandholm T. Supervised progressive cross-continuum strength training compared with usual care in older medical patients: study protocol for a randomized controlled trial (the STAND-Cph trial). Trials 2016; 17:176. [PMID: 27039381 PMCID: PMC4818542 DOI: 10.1186/s13063-016-1309-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/22/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Hospitalization in older adults is characterized by physical inactivity and a risk of losing function and independence. Systematic strength training can improve muscle strength and functional performance in older adults. Few studies have examined the effect of a program initiated during hospitalization and continued after discharge. We conducted a feasibility study prior to this trial and found a progression model for loaded sit-to-stands feasible in older medical patients. This study aims to determine whether a simple supervised strength training program for the lower extremities (based on the model), combined with post-training protein supplementation initiated during hospitalization and continued at home for 4 weeks, is superior to usual care on change in mobility 4 weeks after discharge in older medical patients. METHODS Eighty older medical patients (65 years or older) acutely admitted from their own homes will be included in this randomized, controlled, parallel-group, investigator-blinded, superiority trial. After baseline assessments patients will be randomized to (1) intervention: progressive strength training during hospitalization and after discharge (home-based), or (2) control: usual care. Shortly after discharge, 4 weeks after discharge (primary end point) and 6 months after discharge patients will be assessed in their own homes. The intervention encompasses strength training consisting of two lower extremity exercises (sit-to-stand and heel raise) daily during hospitalization and three times per week for 4 weeks after discharge. Both exercises follow pre-defined models for progression and will be performed for three sets of 8-12 repetitions maximum in each training session. Thereafter, the patient will be asked to consume a protein supplement given orally containing 18 g milk-based protein. The primary outcome will be change in the de Morton Mobility Index score from baseline to 4 weeks after discharge. Secondary outcomes will be 24-h mobility level, isometric knee extension strength, the 30-sec sit-to-stand test, habitual gait speed, hand-grip strength, and Activities of Daily Living. DISCUSSION We chose to investigate the effect of a minimal time-consuming treatment approach, i.e. two well-performed strength training exercises combined with protein supplementation, to facilitate implementation in a busy clinical care setting, given a positive trial outcome. TRIAL REGISTRATION ClinicalTrials.gov: NCT01964482 .
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Affiliation(s)
- Mette Merete Pedersen
- Optimed, Clinical Research Centre and Physical Medicine Research-Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital, Hvidovre, Denmark.
| | - Janne Petersen
- Optimed, Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark.,Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nina Beyer
- Musculoskeletal Rehabilitation Research Unit, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Damkjær
- Department of Rehabilitation, Copenhagen Municipality Health Administration, Copenhagen, Denmark
| | - Thomas Bandholm
- Optimed, Clinical Research Centre and Physical Medicine Research-Copenhagen (PMR-C), Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
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Zhang J, Ang ML, Kwek EBK. Who Will Walk Again? Effects of Rehabilitation on the Ambulatory Status in Elderly Patients Undergoing Hemiarthroplasty for Femoral Neck Fracture. Geriatr Orthop Surg Rehabil 2015; 6:168-72. [PMID: 26328231 PMCID: PMC4536504 DOI: 10.1177/2151458515583111] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Femoral neck fractures in elderly patients result in significant reduction in mobility. Deconditioning takes place quickly without early ambulation postsurgery. A recent Cochrane review found inconclusive evidence on the rehabilitation protocol required to effectively restore patients’ prefracture mobility status. This study was conducted to determine the effects of different rehabilitation approaches on the functional and mobility outcomes of elderly patients after hip hemiarthroplasty for femoral neck fractures. Materials and Methods: We enrolled consecutive patients aged >65 years, admitted into a tertiary orthopedic unit from January to December 2010, who had undergone hip hemiarthroplasty. They were divided into 3 cohorts: (a) home with outpatient rehabilitation, (b) intensive short rehabilitation, and (c) extended slow-stream rehabilitation. Clinical variables were collected along with outcome variables of Modified Harris Hip Score, Parker Mobility Score (PMS), and the return to near premorbid ambulatory status at 1 year (PMS decrease of ≤2). Results: A total of 133 patients were recruited and followed up for a year. The 3 cohorts were found to be comparable for prefall cardiovascular diseases, PMS, and Katz Index, although it was found that in the slow-stream cohort, there was a greater percentage of patients with previous cerebrovascular accidents. Patients in the intensive short rehabilitation cohort were found to have a higher proportion of patients returning to prefracture mobility, with the odds ratio of 2.3478 (95% confidence interval: 1.0667 to 5.1674; P = .042) after multivariate analysis. Conclusions: Elderly patients >65 years who had undergone hemiarthroplasty would likely benefit most from an intensive inpatient rehabilitation program.
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Affiliation(s)
- Junren Zhang
- Department of Orthopedic Surgery, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Mu Liang Ang
- Department of Orthopedic Surgery, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Ernest Beng Kee Kwek
- Department of Orthopedic Surgery, Tan Tock Seng Hospital, Singapore, Republic of Singapore
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Parker MJ, Griffiths R. General versus regional anaesthesia for hip fractures. A pilot randomised controlled trial of 322 patients. Injury 2015; 46:1562-6. [PMID: 26049662 DOI: 10.1016/j.injury.2015.05.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/10/2015] [Accepted: 05/01/2015] [Indexed: 02/02/2023]
Abstract
Uncertainty remains regarding the optimum method of anaesthesia for hip fracture surgery. We randomised 322 patients with a hip fracture to receive either general anaesthesia or regional (spinal) anaesthesia. Surviving patients were followed up to 1 year from injury. There was no notable difference in the outcomes of hospital stay, need for blood transfusion or post-operative complications between groups. 30-day mortality was marginally reduced for spinal anaesthesia 7/164(4.3%) versus 5/158(3.2%) (p=0.57), whilst at 1 year it was less for general anaesthesia 20/163(12.1%) versus 32/158(20.2%) (p=0.05). Within the confines of the limited patient numbers studied we conclude that there are no marked differences in outcome between the two techniques.
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Affiliation(s)
- Martyn J Parker
- Department of Orthopaedics, Peterborough and Stamford Hospital NHS Foundation Trust, Peterborough City Hospital, United Kingdom.
| | - Richard Griffiths
- Department of Anaesthesia, Peterborough and Stamford Hospital NHS Foundation Trust, Peterborough City Hospital, United Kingdom.
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Concomitant upper limb fractures and short-term functional recovery in hip fracture patients: does the site of upper limb injury matter? Am J Phys Med Rehabil 2015; 94:366-72. [PMID: 25251255 DOI: 10.1097/phm.0000000000000191] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate functional recovery in a subgroup of hip fracture patients who sustained a simultaneous fracture at the upper limb, taking into account the site of upper limb injury. DESIGN Of 760 patients admitted consecutively to the authors' rehabilitation hospital because of a fall-related hip fracture, 700 were retrospectively investigated. Functional outcome was assessed using Barthel Index scores. RESULTS In 49 of the 700 patients, a single fall resulted in both a hip fracture and a fracture of either wrist (n = 34) or proximal humerus (n = 15). The patients with concomitant shoulder fractures had lower median Barthel Index scores after rehabilitation (70 vs. 90, P = 0.003), lower median Barthel Index effectiveness (57.1 vs. 76.9, P = 0.018), and prolonged median length of stay (42 vs. 36 days, P = 0.011) than did the patients with isolated hip fractures. Significant differences persisted after adjustment for six potential confounders. The adjusted odds ratio for achieving a Barthel Index score lower than 85 was 6.71 (95% confidence interval, 1.68-26.81; P = 0.007) for the patients with concomitant shoulder fractures. Conversely, no prognostic disadvantages were associated with concomitant wrist fractures. CONCLUSIONS Data show a worse functional recovery and a prolonged length of stay in the subgroup of hip fracture patients who sustained a concomitant fracture at the proximal humerus, but not at the wrist.
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Parker MJ. Lateral versus posterior approach for insertion of hemiarthroplasties for hip fractures: A randomised trial of 216 patients. Injury 2015; 46:1023-7. [PMID: 25769196 DOI: 10.1016/j.injury.2015.02.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/13/2015] [Accepted: 02/19/2015] [Indexed: 02/02/2023]
Abstract
Continued debate exists about the merits of the different surgical approaches for arthroplasty of the hip. For hemiarthroplasty to the hip the two most commonly used approaches are lateral and posterior. 216 patients with an intracapsular hip fracture being treated with a cemented hemiarthroplasty were randomised to surgery using either a lateral or posterior approach. Surviving patients were followed up for one year with pain and functional outcomes assessed by an assessor blinded to the treatment allocation. No statistically significant differences were observed for any of the outcome measures including mortality, degree of residual pain and regain of walking ability. A subjective assessment of the ease of surgery favoured the lateral approach. In conclusion both surgical approaches appear to produce comparable function outcomes.
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Affiliation(s)
- Martyn J Parker
- Peterborough and Stamford Hospital NHS Foundation Trust, Department of Orthopaedics, Peterborough City Hospital, CBU PO Box 211, Core C, Bretton Gate, Peterborough PE3 9GZ, England, United Kingdom.
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Feasibility and inter-rater reliability of physical performance measures in acutely admitted older medical patients. PLoS One 2015; 10:e0118248. [PMID: 25706553 PMCID: PMC4338133 DOI: 10.1371/journal.pone.0118248] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 01/06/2015] [Indexed: 12/23/2022] Open
Abstract
Objective Physical performance measures can be used to predict functional decline and increased dependency in older persons. However, few studies have assessed the feasibility or reliability of such measures in hospitalized older patients. Here we assessed the feasibility and inter-rater reliability of four simple measures of physical performance in acutely admitted older medical patients. Design During the first 24 hours of hospitalization, the following were assessed twice by different raters in 52 (≥ 65 years) patients admitted for acute medical illness: isometric hand grip strength, 4-meter gait speed, 30-s chair stand and Cumulated Ambulation Score. Relative reliability was expressed as weighted kappa for the Cumulated Ambulation Score or as intra-class correlation coefficient (ICC1,1) and lower limit of the 95%-confidence interval (LL95%) for grip strength, gait speed, and 30-s chair stand. Absolute reliability was expressed as the standard error of measurement and the smallest real difference as a percentage of their respective means (SEM% and SRD%). Results The primary reasons for admission of the 52 included patients were infectious disease and cardiovascular illness. The mean± SD age was 78±8.3 years, and 73.1% were women. All patients performed grip strength and Cumulated Ambulation Score testing, 81% performed the gait speed test, and 54% completed the 30-s chair stand test (46% were unable to rise without using the armrests). No systematic bias was found between first and second tests or between raters. The weighted kappa for the Cumulated Ambulation Score was 0.76 (0.60–0.92). The ICC1,1 values were as follows: grip strength, 0.95 (LL95% 0.92); gait speed, 0.92 (LL95% 0.73), and 30-s chair stand, 0.82 (LL95% 0.67). The SEM% values for grip strength, gait speed, and 30-s chair stand were 8%, 7%, and 18%, and the SRD95% values were 22%, 17%, and 49%. Conclusion In acutely admitted older medical patients, grip strength, gait speed, and the Cumulated Ambulation Score measurements were feasible and showed high inter-rater reliability when administered by different raters. The feasibility and inter-rater reliability of the 30-s chair stand were moderate, complicating the use of the 30-s chair stand in acutely admitted older medical patients. However, the predefined modified version of the chair stand test was both feasible and with high inter-rater reliability in this population.
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Abstract
We aim to compare trends in characteristics and outcomes for 131 patients with evidence of excess alcohol intake at the time of admission with a hip fracture against 6,892 hip fracture patients with no evidence of alcohol excess. Alcohol excess was determined by a finding of abnormal liver function tests in association with a history of excessive alcohol consumption. Patients who consumed excess alcohol were younger (64 versus 80 years mean age), more likely to be male (47% versus 22%), smoke cigarettes (54% versus 11%), be more mobile and less likely to use a walking aid (28% versus 46%). They were also more likely to sustain an extracapsular fracture (53% versus 39%) and to be living in their own homes at the time of injury (85% versus 66%). Hypertension and cardiac disease were less common in those with alcohol excess. Postoperatively those with alcohol abuse had a shorter hospital stay (mean nine days versus 16 days) but were at a greater risk of developing deep wound infections (2.3% versus 0.6%). For those patients who sustained intracapsular fractures treated by internal fixation there was an increased risk of fracture non-union occurring (29% versus 16%) but there were no other differences in operative complications.
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Hulsbæk S, Larsen RF, Troelsen A. Predictors of not regaining basic mobility after hip fracture surgery. Disabil Rehabil 2014; 37:1739-44. [PMID: 25350664 DOI: 10.3109/09638288.2014.974836] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Regaining basic mobility after hip fracture surgery is a milestone in the in-hospital rehabilitation. The aims were to investigate predictors for not regaining basic mobility at the fifth post-operative day and at discharge after undergoing hip fracture surgery. METHOD In a prospective cohort study 274 hip fracture patients were included. Patients with compromised ability to exercise were excluded leaving 167 patients for analysis. Patient demographics, functional level, method of operation, post-operative hemoglobin and the completion of physiotherapy was registered. Basic mobility was assessed by the Cumulated Ambulation Score. Multivariate logistic regression was performed. RESULTS Age >80 years (OR = 7.5), low prefracture functional level (OR = 3.0), not completed the physiotherapy on first post-operative day (OR = 4.6) and hemoglobin <6 mmol/L measured on first post-operative day (OR = 5.8) were significant predictors of not regaining basic mobility within the fifth post-operative day (p values: 0.04 - <0.0001). Predictors of not regaining basic mobility at discharge were: Age >80 years (OR = 4.3), prefracture functional level (OR = 7.0) and not completed the physiotherapy on first post-operative day (OR = 3.3) (p values: 0.009-<0.0001). CONCLUSIONS This study shows that patients undergoing hip fracture surgery, who are not able to complete physiotherapy on first post-operative day, are at a greater risk of not regaining basic mobility during hospitalization. This highlights the importance of physiotherapy as part of the interdisciplinary treatment. IMPLICATIONS FOR REHABILITATION Regaining abilities in basic mobility after hip fracture surgery is a primary goal of rehabilitation during hospitalization in the acute ward. The following factors are indentified to predict patients not regaining their previous level of basic mobility: Age >80 years, low prefracture functional level, patients not being able to complete the physiotherapy on the first post-operative day and hemoglobin value <6 mmol/l on the first post-operative day. In future strategies, the findings regarding both modifiable and unmodifiable factors, can be used to conduct early planning of discharge and to take actions in relation to patients who are at a risk of not regaining basic mobility.
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Affiliation(s)
- Signe Hulsbæk
- Department of Physiotherapy, Køge Hospital , Køge , Denmark and
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Kronborg L, Bandholm T, Palm H, Kehlet H, Kristensen MT. Feasibility of progressive strength training implemented in the acute ward after hip fracture surgery. PLoS One 2014; 9:e93332. [PMID: 24699276 PMCID: PMC3974729 DOI: 10.1371/journal.pone.0093332] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 03/02/2014] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Patients with a hip fracture lose more than 50% knee-extension strength in the fractured limb within one week of surgery. Hence, immediate progressive strength training following hip fracture surgery may be rational, but the feasibility unknown. OBJECTIVE To examine the feasibility of in-hospital progressive strength training implemented in the acute ward following hip fracture surgery, based on pre-specified criteria for feasibility. DESIGN, SETTING AND PATIENTS A prospective cohort study conducted in an acute orthopedic hip fracture unit at a university hospital. A consecutive sample of 36 patients, 18 with a cervical and 18 with a trochanteric hip fracture (27 women and 9 men, mean (SD) age of 79.4 (8.3) years) were included between June and December 2012. INTERVENTION A daily (on weekdays) program of progressive knee-extension strength training for the fractured limb, using ankle weight cuffs in 3 sets of 10 repetition maximum loadings. MAIN OUTCOMES AND MEASURES The primary outcome was the change in training load (kg) during the knee-extension strength training. The secondary outcomes were changes in hip fracture-related pain and maximal isometric knee-extension strength. RESULTS The strength training was commenced at a mean of 2.4 (0.7) days after surgery. The training loads (kilograms lifted) increased from 1.6 (0.8) to 4.3 (1.7) kg over 4.3 (2.2) training sessions (P<.001). The maximal isometric knee-extension strength of the fractured limb increased from 0.37 (0.2) to 0.61 (0.3) Nm/kg (P<.001), while the average strength deficit in the fractured limb decreased from 50% to 32% (% non-fractured, P<.001). Only 3 of 212 sessions were not performed because of severe hip fracture-related pain. CONCLUSION AND RELEVANCE Progressive knee-extension strength training of the fractured limb commenced in the acute ward seems feasible, and may reduce strength asymmetry between limbs without hip pain interfering. The clinical efficacy needs confirmation in a randomized controlled design. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT01616030.
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Affiliation(s)
- Lise Kronborg
- Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Copenhagen University Hospital, Hvidovre, Denmark
- Department of Physical Therapy, Copenhagen University Hospital, Hvidovre, Denmark
- * E-mail:
| | - Thomas Bandholm
- Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Copenhagen University Hospital, Hvidovre, Denmark
- Department of Physical Therapy, Copenhagen University Hospital, Hvidovre, Denmark
- Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Henrik Palm
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Morten Tange Kristensen
- Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Copenhagen University Hospital, Hvidovre, Denmark
- Department of Physical Therapy, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
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Chua ITH, Rajamoney GN, Kwek EBK. Cephalomedullary nail versus sliding hip screw for unstable intertrochanteric fractures in elderly patients. J Orthop Surg (Hong Kong) 2013; 21:308-12. [PMID: 24366790 DOI: 10.1177/230949901302100309] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To compare the short-term ambulatory function of elderly patients after fixation of unstable intertrochanteric fractures with either the AO-ASIF proximal femoral nail anti-rotation (PFNA) device or the dynamic hip screw (DHS). METHODS 63 patients aged 60 years or older underwent fixation for unstable intertrochanteric fractures (AO types A2 and A3) using the PFNA (n=25) or DHS (n=38). The decision for the type of implant used was based on the lead surgeon's preference, according to perceived fracture stability and clinical experience. In patients having PFNA fixation, weight bearing ambulation and rehabilitation was commenced on day 2. The extent of weight bearing was decided by the lead surgeon based on the stability of the fracture. In patients having DHS fixation, non-weight bearing and ambulation with a walking aid was commenced on day 2. Ambulatory function before injury and after surgery was measured using the Parker Mobility Score (PMS). The 2 groups were compared in terms of the PMS, ambulatory independence, and environmental mobility. RESULTS Respectively in PFNA and DHS patients, 32% and 13% (p=0.035) were ambulant with a walking frame at discharge; the remainder were wheelchair bound. Patients treated with PFNA had significantly higher median PMS at 6 months (4 vs. 2, p=0.002), median ambulatory independence score at 6 months (4 vs. 3, p=0.004) and at 12 months (5 vs. 4, p=0.001), and median environmental mobility score at 6 months (2 vs. 1, p=0.007). They also had significantly higher percentage of patients able to ambulate outdoor and in community at 6 months (64% vs. 29%, p=0.02) and able to walk independently or with a walking aid at 12 months (96% vs. 69%, p=0.01). There were 3 complications. Two patients treated with PFNA had blade cut-out, owing to poor fracture reduction. One patient treated with DHS had screw cut-out and subsequently developed avascular necrosis of the femoral head. CONCLUSION Unstable intertrochanteric fractures in elderly patients with good pre-fracture ambulatory function stabilised with the PFNA resulted in better short-term ambulatory function.
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Overgaard J, Kristensen MT. Feasibility of progressive strength training shortly after hip fracture surgery. World J Orthop 2013; 4:248-258. [PMID: 24147260 PMCID: PMC3801244 DOI: 10.5312/wjo.v4.i4.248] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 07/15/2013] [Accepted: 09/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the feasibility of a 6-wk progressive strength-training programme commenced shortly after hip fracture surgery in community-dwelling patients.
METHODS: This prospective, single-blinded cohort study evaluated 31 community-dwelling patients from four outpatient geriatric health centres aged 60 years or older, who started a 6-wk programme at a mean of 17.5 ± 5.7 d after hip fracture surgery. The intervention consisted primarily of progressive fractured knee-extension and bilateral leg press strength training (twice weekly), with relative loads commencing at 15 and increasing to 10 repetitions maximum (RM), with three sets in each session. The main measurements included progression in weight loads, hip fracture-related pain during training, maximal isometric knee-extension strength, new mobility score, the timed up and go test, the 6-min walk test and the 10-meter fast speed walk test, assessed before and after the programme.
RESULTS: Weight loads in kilograms in the fractured limb knee-extension strength training increased from 3.3 ± 1.5 to 5.7 ± 1.7 and from 6.8 ± 2.4 to 7.7 ± 2.6, respectively, in the first and last 2 wk (P < 0.001). Correspondingly, the weight loads increased from 50.3 ± 1.9 to 90.8 ± 40 kg and from 108.9 ± 47.7 to 121.9 ± 54 kg in the bilateral leg press exercise (P < 0.001). Hip fracture-related pain was reduced, and large improvements were observed in the functional outcome measurements, e.g., the 6-min walk test improved from 200.6 ± 79.5 to 322.8 ± 68.5 m (P < 0.001). The fractured limb knee-extension strength deficit was reduced from 40% to 17%, compared with the non-fractured limb. Ten patients reported knee pain as a minor restricting factor during the last 10 RM knee-extension strength-training sessions, but with no significant influences on performance.
CONCLUSION: Progressive strength training, initiated shortly after hip fracture surgery, seems feasible and does not increase hip fracture-related pain. Progressive strength training resulted in improvement, although a strength deficit of 17% persisted in the fractured limb compared with the non-fractured limb.
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Parker M, Cawley S, Palial V. Internal fixation of intracapsular fractures of the hip using a dynamic locking plate. Bone Joint J 2013; 95-B:1402-5. [DOI: 10.1302/0301-620x.95b10.31511] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A consecutive series of 320 patients with an intracapsular fracture of the hip treated with a dynamic locking plate (Targon Femoral Neck (TFN)) were reviewed. All surviving patients were followed for a minimum of two years. During the follow-up period 109 patients died. There were 112 undisplaced fractures, of which three (2.7%) developed nonunion or re-displacement and five (4.5%) developed avascular necrosis of the femoral head. Revision to an arthroplasty was required for five patients (4.5%). A further six patients (5.4%) had elective removal of the plate and screws. There were 208 displaced fractures, of which 32 (15.4%) developed nonunion or re-displacement and 23 (11.1%) developed avascular necrosis. A further four patients (1.9%) developed a secondary fracture around the TFN. Revision to a hip replacement was required for 43 patients (20.7%) patients and a further seven (3.3%) had elective removal of the plate and screws. It is suggested that the stronger distal fixation combined with rotational stability may lead to a reduced incidence of complications related to the healing of the fracture when compared with other contemporary fixation devices but this needs to be confirmed in further studies. Cite this article: Bone Joint J 2013;95-B:1402–5.
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Affiliation(s)
- M. Parker
- Peterborough and Stamford Hospital NHS
Foundation Trust, Department of Orthopaedics, Peterborough
City Hospital, CBU PO Box 211, Core
C, Bretton Gate, Peterborough
PE3 9GZ, UK
| | - S. Cawley
- Peterborough and Stamford Hospital NHS
Foundation Trust, Department of Orthopaedics, Peterborough
City Hospital, CBU PO Box 211, Core
C, Bretton Gate, Peterborough
PE3 9GZ, UK
| | - V. Palial
- Peterborough and Stamford Hospital NHS
Foundation Trust, Department of Orthopaedics, Peterborough
City Hospital, CBU PO Box 211, Core
C, Bretton Gate, Peterborough
PE3 9GZ, UK
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Kristensen MT. Hip fracture-related pain strongly influences functional performance of patients with an intertrochanteric fracture upon discharge from the hospital. PM R 2012. [PMID: 23182336 DOI: 10.1016/j.pmrj.2012.10.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To examine whether functional performance upon hospital discharge is influenced by pain in the region of the hip fracture or related to the fracture type. DESIGN Prospective observational study. SETTING A 20-bed orthopedic hip fracture unit. PATIENTS Fifty-five cognitively intact patients (20 men and 35 women; ages 75.8 ± 10 years), 33 with a cervical hip fracture and 22 with an intertrochanteric hip fracture, all of whom were allowed to bear full weight after surgery. METHODS All patients were evaluated upon discharge from the hospital to their own homes at a mean of 10 ± 6 days after surgery. MAIN OUTCOME MEASUREMENTS The Timed Up & Go (TUG) test, supervised by a physical therapist, was used to evaluate functional performance, and a 5-point verbal ranking scale (0 = no pain to 4 = intolerable pain) was used to evaluate pain. RESULTS Patients took an average of 22.7 ± 11.7 seconds to perform the TUG. No significant differences were observed in baseline characteristics or pain medication given for patients with a cervical versus an intertrochanteric fracture (P ≥ .22), but patients with an intertrochanteric fracture presented more often with moderate to severe pain during testing (P < .001), with associated poorer performances on the TUG test (29.4 ± 12.8 seconds versus 18.3 ± 8.5 seconds). Univariate analysis showed that TUG scores were associated with age, prefracture function evaluated by the New Mobility Score, fracture type, day of TUG performance, and pain intensity. Multivariate linear regression analyses (fracture type not included) showed that only greater age (B = 0.34), low prefracture function (B = 7.9), and experiencing moderate to severe pain (B = 8.7) were independently associated with having a poorer TUG score. CONCLUSIONS Hip fracture-related pain primarily compromises the functional performance of patients with an intertrochanteric hip fracture upon discharge from hospital. Physical therapists should be involved in new and optimized fracture-type stratified pain management strategies.
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Affiliation(s)
- Morten Tange Kristensen
- Department of Physical Therapy, 236, and Orthopedic Surgery, Hvidovre University Hospital, Kettegaard Alle 30, Copenhagen DK-2650, Denmark.
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Robinson PM, Harrison T, Cook A, Parker MJ. Orthopaedic injuries associated with hip fractures in those aged over 60 years: a study of patterns of injury and outcomes for 1971 patients. Injury 2012; 43:1131-4. [PMID: 22465517 DOI: 10.1016/j.injury.2012.03.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 01/17/2012] [Accepted: 03/04/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There has been little research into the consequence of suffering a hip fracture and associated orthopaedic injures. The aim of this research paper is to describe the patient characteristics, patterns of injury and to define the effect on outcomes of orthopaedic injuries occurring simultaneously with hip fractures. PATIENTS AND METHODS Hip fracture data was collected prospectively. Patients under 60 years of age were excluded from the study. Between 2004 and 2010 we treated 1971 consecutive patients aged 60 years or older with a hip fracture. RESULTS 81 (4.1%) patients sustained a simultaneous fracture or dislocation. 90% (73/81) of these injuries were in the upper limb and 88% (71/81) were ipsilateral, with the wrist (34 cases) and the proximal humerus (21 cases) being the commonest site of injury. Median hospital stay was significantly longer for those with additional injures. Pubic rami fractures were not seen in association with a hip fracture. Those patients who sustained a concomitant wrist fracture tended to be slightly fitter than those without associated injuries whist those with an associated humeral fracture were slightly frailer. Mortality was increased for those with an associated proximal humeral fracture but was lower with an associated wrist fracture. DISCUSSION AND CONCLUSION Simultaneous injuries occurring with hip fractures are mainly seen in the ipsilateral upper limb. They present a greater challenge to the multidisciplinary team than a solitary hip fracture, experiencing a longer hospital stay and inevitably a higher financial cost. Those patients with wrist fractures have the best prognosis in terms of mortality, whereas a proximal humerus fracture may indicate a higher risk of mortality.
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Affiliation(s)
- P M Robinson
- Department of Orthopaedics, Peterborough City Hospital, Edith Cavell Campus, Bretton Gate, Peterborough PE3 9GZ, United Kingdom.
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Parker MJ. Cemented Thompson hemiarthroplasty versus cemented Exeter Trauma Stem (ETS) hemiarthroplasty for intracapsular hip fractures: a randomised trial of 200 patients. Injury 2012; 43:807-10. [PMID: 22000824 DOI: 10.1016/j.injury.2011.09.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Revised: 09/13/2011] [Accepted: 09/18/2011] [Indexed: 02/02/2023]
Abstract
Numerous different designs of hemiarthroplasty are available but few have been compared within the context of a randomised controlled trial. Two-hundred patients presenting with a displaced intracapsular fracture of the hip were randomised to receive either a cemented Thompson hemiarthroplasty or a cemented smooth tapered stem hemiarthroplasty (Exeter Trauma Stem). All operations were undertaken or directly supervised by one surgeon using the same operative approach. Patients were followed up for 1 year from injury by a research nurse blinded to the treatment used. The smooth tapered stem was felt to present less operative difficulties compared to the Thompson prosthesis. There were no other statistically significant differences in outcomes between the two prostheses.
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Affiliation(s)
- Martyn J Parker
- Orthopaedic Department, Peterborough and Stamford Hospital NHS Foundation Trust, Peterborough City Hospital, Peterborough PE3 9GZ, United Kingdom.
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Parker MJ, Bowers TR, Pryor GA. Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip: a randomised trial of 600 fractures. ACTA ACUST UNITED AC 2012; 94:391-7. [PMID: 22371549 DOI: 10.1302/0301-620x.94b3.28406] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In a randomised trial involving 598 patients with 600 trochanteric fractures of the hip, the fractures were treated with either a sliding hip screw (n = 300) or a Targon PF intramedullary nail (n = 300). The mean age of the patients was 82 years (26 to 104). All surviving patients were reviewed at one year with functional outcome assessed by a research nurse blinded to the treatment used. The intramedullary nail was found to have a slightly increased mean operative time (46 minutes (sd 12.3) versus 49 minutes (sd 12.7), p < 0.001) and an increased mean radiological screening time (0.3 minutes (sd 0.2) versus 0.5 minutes (sd 0.3), p < 0.001). Operative difficulties were more common with the intramedullary nail. There was no statistically significant difference between implants for wound healing complications (p = 1), or need for post-operative blood transfusion (p = 1), and medical complications were similarly distributed in both groups. There was a tendency to fewer revisions of fixation or conversion to an arthroplasty in the nail group, although the difference was not statistically significant (nine versus three cases, p = 0.14). The extent of shortening, loss of hip flexion, mortality and degree of residual pain were similar in both groups. The recovery of mobility was superior for those treated with the intramedullary nails (p = 0.01 at one year from injury). In summary, both implants produced comparable results but there was a tendency to better return of mobility for those treated with the intramedullary nail.
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Affiliation(s)
- M J Parker
- Peterborough City Hospital, Orthopaedic Department, Peterborough and Stamford Hospital NHS Foundation Trust, Peterborough PE3 9GZ, UK.
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Sawalha S, Parker MJ. Characteristics and outcome in patients sustaining a second contralateral fracture of the hip. ACTA ACUST UNITED AC 2012; 94:102-6. [PMID: 22219256 DOI: 10.1302/0301-620x.94b1.27983] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We compared 5341 patients with an initial fracture of the hip with 633 patients who sustained a second fracture of the contralateral hip. Patients presenting with a second fracture were more likely to be institutionalised, female, older, and have lower mobility and mental test scores. There was no significant difference between the two groups with regards to the change in the level of mobility or return to their original residence at one year follow-up. However, the mortality rate in the second fracture group was significantly higher at one year (31.6% vs 27.3%, p = 0.024). In two thirds of patients, the second fracture was in the same anatomical location as the first. In an analysis of 293 patients, approximately 70% of second fractures occurred within three years of the first. This is the largest study to investigate the outcome of patients who sustain a second contralateral hip fracture. Despite the higher mortality rate at one year, the outcome for surviving patients is not significantly different from those after initial hip fractures.
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Affiliation(s)
- S Sawalha
- Leighton Hospital, Department of Orthopaedics, Mid Cheshire Hospitals NHS Foundation Trust, Crewe CW1 4QJ, UK.
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Kristensen MT, Ekdahl C, Kehlet H, Bandholm T. How many trials are needed to achieve performance stability of the Timed Up & Go test in patients with hip fracture? Arch Phys Med Rehabil 2010; 91:885-9. [PMID: 20510979 DOI: 10.1016/j.apmr.2010.01.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Revised: 01/23/2010] [Accepted: 01/26/2010] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To examine the number of trials needed to achieve performance stability of the Timed Up & Go (TUG) test using a standardized walking aid in patients with hip fracture who are allowed full weight bearing (FWB). DESIGN Prospective methodologic study. SETTING An acute 14-bed orthopedic hip fracture unit. PARTICIPANTS Patients (N=122; 89 women, 33 men) with hip fracture with a median age (25%-75%, quartiles) of 80 (67-85) years performed the TUG on hospital discharge to their own home (n=115) or further inpatient rehabilitation (n=7). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES After a demonstration by a physical therapist how to perform the TUG with a standardized walking aid (a 4-wheeled rollator), the patients performed 6 timed TUG trials with up to 1-minute seated rest intervals. The participants were given a few minutes to familiarize with the rollator before commencing the timed trials. Repeated-measures analysis of variance (ANOVA) with Bonferroni corrections were used to examine the number of trials needed to ensure statistically stable TUG scores. RESULTS A total of 106 (87%) patients performed all 6 TUG trials, while 120 patients performed a minimum of 3 timed trials. Repeated-measures ANOVAs of both groups showed that TUG scores improved significantly (P< or =.007) up to and including the third TUG trial. CONCLUSIONS These results suggest that the original TUG manual, described as 1 practice trial followed by 1 timed trial, needs modification when used in patients with hip fracture who are allowed FWB. The best (fastest) of 3 timed TUG trials performed with a standardized walking aid is recommended.
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Affiliation(s)
- Morten T Kristensen
- Division of Physical Therapy, Health Sciences Center, Lund University, Lund, Sweden.
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Kristensen MT, Foss NB, Ekdahl C, Kehlet H. Prefracture functional level evaluated by the New Mobility Score predicts in-hospital outcome after hip fracture surgery. Acta Orthop 2010; 81:296-302. [PMID: 20450426 PMCID: PMC2876830 DOI: 10.3109/17453674.2010.487240] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Clinicians need valid and easily applicable predictors of outcome in patients with hip fracture. Adjusting for previously established predictors, we determined the predictive value of the New Mobility score (NMS) for in-hospital outcome in patients with hip fracture. PATIENTS AND METHODS We studied 280 patients with a median age of 81 (interquartile range 72-86) years who were admitted from their own homes to a special hip fracture unit. Main outcome was the regain of independence in basic mobility, defined as. independence in getting in and out of bed, sitting down and standing up from a chair, and walking with an appropriate walking aid. The Cumulated Ambulation score was used to evaluate basic mobility. Predictor variables were NMS functional level before fracture, age, sex, fracture type, and mental and health status. RESULTS Except for sex, all predictor variables were statistically significant in univariate testing. In multiple logistic regression analysis, only age, NMS functional level before fracture, and fracture type were significant. Thus, patients with a low prefracture NMS and/or an intertrochanteric fracture would be 18 and 4 times more likely not to regain independence in basic mobility during the hospital stay, respectively, than patients with a high prefracture level and a cervical fracture, respectively. The model was statistically stable and correctly classified 84% of cases. INTERPRETATION The NMS functional level before fracture, age, and fracture type facilitate prediction of the in-hospital rehabilitation potential after hip fracture surgery.
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Affiliation(s)
| | - Nicolai B Foss
- Anesthesiology, Hvidovre Hospital, Copenhagen University
| | - Charlotte Ekdahl
- Division of Physical Therapy, Health Sciences Center, Lund UniversitySweden
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen UniversityDenmark
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Parker MJ, Stedtfeld HW. Internal fixation of intracapsular hip fractures with a dynamic locking plate: initial experience and results for 83 patients treated with a new implant. Injury 2010; 41:348-51. [PMID: 19818958 DOI: 10.1016/j.injury.2009.09.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Revised: 08/24/2009] [Accepted: 09/03/2009] [Indexed: 02/02/2023]
Abstract
The results of treatment for 83 patients treated with a new implant designed specifically for the internal fixation of intracapsular hip fractures are reported. Nonunion occurred in one out of the 37 undisplaced fractures (3%) and seven out of the 46 displaced fractures (15%). In addition, four patients developed avascular necrosis (5%), one developed a fracture around the distal screws and another developed deep wound infection. The functional recovery at patients at 1 year was excellent. The results to date for this new implant suggest that it may lead to reduced fracture-healing complications in comparison to the currently used methods of internal fixation.
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Affiliation(s)
- Martyn J Parker
- Peterborough & Stamford NHS Foundation Trust, Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK.
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Kristensen MT, Andersen L, Bech-Jensen R, Moos M, Hovmand B, Ekdahl C, Kehlet H. High intertester reliability of the cumulated ambulation score for the evaluation of basic mobility in patients with hip fracture. Clin Rehabil 2010; 23:1116-23. [PMID: 19923208 DOI: 10.1177/0269215509342330] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To examine the intertester reliability of the three activities of the Cumulated Ambulation Score (CAS) and the total CAS, and to define limits for the smallest change in basic mobility that indicates a real change in patients with hip fracture. DESIGN An intertester reliability study. SETTING An acute 20-bed orthopaedic hip fracture unit. SUBJECTS Fifty consecutive patients with a median age of 83 (25-75% quartile, 68-86) years. INTERVENTIONS The CAS, which describes the patient's independency in three activities - (1) getting in and out of bed, (2) sit to stand from a chair, and (3) walking ability - was assessed by two independent physiotherapists at postoperative median day 3. Each activity was assessed on a three-point ordinal scale from 0 (not able to) to 2 (independent of human assistance). The cumulated score for each activity provides a total CAS from 0 to 6, with 6 indicating independent ambulation. MAIN MEASURES Reliability was evaluated using weighted kappa statistics, the standard error of measurement (SEM) and the smallest real difference (SRD). RESULTS The kappa coefficient, the SEM and the SRD in the three activities and the total CAS were >or=0.92, <or=0.20 and <or=0.55 CAS points, respectively. CONCLUSIONS The intertester reliability of the CAS is very high, and a change of more than 0.20 and 0.55 CAS points for the total CAS indicates a real change in basic mobility, at group level and for an individual patient, respectively.
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Parker MJ. Iron supplementation for anemia after hip fracture surgery: a randomized trial of 300 patients. J Bone Joint Surg Am 2010; 92:265-9. [PMID: 20124051 DOI: 10.2106/jbjs.i.00883] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anemia as a consequence of surgery is often treated with iron therapy. The evidence base for this practice is limited. To determine if oral iron therapy is beneficial for the treatment of anemia after surgery for the treatment of a hip fracture, we undertook a prospective, randomized controlled trial. METHODS Three hundred patients with a hemoglobin level of <110 g/L after treatment for a hip fracture were randomized to receive either a twenty-eight-day course of ferrous sulfate therapy or no iron therapy. Hemoglobin levels were measured at six weeks after surgery. The length of the hospital stay and the mortality rate at one year were compared between groups. RESULTS The mean rise in hemoglobin levels six weeks after discharge from the hospital was 21 g/L in the iron group, compared with 18 g/L in the no-iron group (p = 0.07). There was no significant difference between the two groups with regard to the length of hospital stay or the mortality rate. Seventeen percent of the patients who were allocated to iron therapy reported adverse effects of the medication. CONCLUSIONS The present study demonstrated that iron therapy had no clinically relevant benefit when used to treat anemia associated with a hip fracture.
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Parker MI, Pryor G, Gurusamy K. Cemented versus uncemented hemiarthroplasty for intracapsular hip fractures: A randomised controlled trial in 400 patients. ACTA ACUST UNITED AC 2010; 92:116-22. [PMID: 20044689 DOI: 10.1302/0301-620x.92b1.22753] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We undertook a prospective randomised controlled trial involving 400 patients with a displaced intracapsular fracture of the hip to determine whether there was any difference in outcome between treatment with a cemented Thompson hemiarthroplasty and an uncemented Austin-Moore prosthesis. The surviving patients were followed up for between two and five years by a nurse blinded to the type of prosthesis used. The mean age of the patients was 83 years (61 to 104) and 308 (77%) were women. The degree of residual pain was less in those treated with a cemented prosthesis (p < 0.0001) three months after surgery. Regaining mobility was better in those treated with a cemented implant (p = 0.005) at six months after operation. No statistically significant difference was found between the two groups with regard to mortality, implant-related complications, re-operations or post-operative medical complications. The use of a cemented Thompson hemiarthroplasty resulted in less pain and less deterioration in mobility than an uncemented Austin-Moore prosthesis with no increase in complications.
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Affiliation(s)
- M I Parker
- Peterborough and Stamford Hospital NHS Trust, England.
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Kristensen MT, Bandholm T, Holm B, Ekdahl C, Kehlet H. Timed up & go test score in patients with hip fracture is related to the type of walking aid. Arch Phys Med Rehabil 2009; 90:1760-5. [PMID: 19801068 DOI: 10.1016/j.apmr.2009.05.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 05/04/2009] [Accepted: 05/04/2009] [Indexed: 12/21/2022]
Abstract
UNLABELLED Kristensen MT, Bandholm T, Holm B, Ekdahl C, Kehlet H. Timed Up & Go test score in patients with hip fracture is related to the type of walking aid. OBJECTIVE To determine the relationship between Timed Up & Go (TUG) test scores and type of walking aid used during the test, and to determine the feasibility of using the rollator as a standardized walking aid during the TUG in patients with hip fracture who were allowed full weight-bearing (FWB). DESIGN Prospective methodological study. SETTING An acute orthopedic hip fracture unit at a university hospital. PARTICIPANTS Patients (N=126; 90 women, 36 men) with hip fracture with a mean age +/- SD of 74.8+/-12.7 years performed the TUG the day before discharge from the orthopedic ward. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The TUG was performed with the walking aid the patient was to be discharged with: a walker (n=88) or elbow crutches (n=38). In addition, all patients also performed the TUG using a rollator. RESULTS Patients who performed the TUG with a walker were on average 13.6 (95% confidence interval [CI], 11.2-16.1) seconds faster using a rollator compared with the walker (P<.001). Correspondingly, patients who performed the TUG with crutches were on average 3.5 (95% CI, 1.5-5.4) seconds faster using a rollator compared with elbow crutches (P=.001). In both patient groups, the between walking-aid scores were strongly correlated (r>.833, P<.001). CONCLUSIONS TUG scores are significantly related to the type of walking aid used during the test in patients with hip fracture who are allowed FWB when discharged from the hospital, but all patients were able to perform the TUG using the rollator as a standardized walking aid. Our findings indicate the importance of using a standardized walking aid when evaluating changes or comparing TUG scores in patients with hip fracture.
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Affiliation(s)
- Morten T Kristensen
- Department of Health Sciences, Division of Physical Therapy, Lund University, Lund, Sweden.
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Kristensen MT, Foss NB, Kehlet H. Factors with independent influence on the 'timed up and go' test in patients with hip fracture. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2009; 14:30-41. [PMID: 18646243 DOI: 10.1002/pri.414] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Data on performance times for the 'timed up and go' (TUG) test with analyses of factors, that eventually could affect the result in patients with hip fracture, have not been published to date. The aims of the present study, therefore, were to assess normative reference values of TUG performances and determine the influence of individual and clinical factors on TUG-test scores in patients with hip fracture. METHOD In this prospective, descriptive study, a total of 196 consecutive patients over the age of 60, and able to perform the TUG when discharged directly to their own homes from a specialized orthopaedic hip fracture unit, were evaluated. The association between TUG scores and categorical variables were examined, and linear regression was used to investigate the factors influencing performance times. RESULTS Univariate analysis showed significant differences between all categorical variables, except gender, but multivariate linear regression analyses showed that only a high pre-fracture function level, evaluated by the New Mobility Score (B = -11), was independently associated with having a good TUG score, while older age (B = 0.49), having an intertrochanteric fracture (B = 7), performing TUG with a walker (B = 15), and performing TUG in the later postoperative period (B = 0.39) were independently associated with having a poorer TUG score. CONCLUSIONS These preliminary normative reference values of TUG performances in patients with hip fracture can be used as references, to which individuals can expect to perform. Multivariate testing suggests that clinicians should use age, pre-fracture function, fracture type and walking-aid specific data when interpreting the TUG test results. Physiotherapists should be aware of this if TUG scores are to be used predictively or as an outcome measure in patients with hip fracture, especially in research.
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Affiliation(s)
- Morten Tange Kristensen
- Lund University, Department of Health Sciences, Division of Physiotherapy, Lund University Hospital, Lasarettsgatan 7, SE-221 85 Lund, Sweden.
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Kristensen MT, Bandholm T, Bencke J, Ekdahl C, Kehlet H. Knee-extension strength, postural control and function are related to fracture type and thigh edema in patients with hip fracture. Clin Biomech (Bristol, Avon) 2009; 24:218-24. [PMID: 19091449 DOI: 10.1016/j.clinbiomech.2008.10.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Revised: 10/20/2008] [Accepted: 10/21/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Post-surgery thigh edema, loss of knee-extension strength, and reduced physical performance are common following a hip fracture. It is not known if knee-extension strength and physical performance are related to the edema and fracture type. The aim of this study was to examine the influence of fracture type and post-surgery edema on physical performances in patients with hip fracture. METHODS Fifteen women and five men admitted from their own home to an acute orthopedic hip fracture unit were examined. Ten had cervical and ten had intertrochanteric fractures. Correlations between fracture type and thigh edema in the fractured limb (% non-fractured) to physical performances of basic mobility, postural control (sway), and isometric knee-extension strength were examined. All measures, except those of basic mobility, were conducted at the time of discharge, 8.5 days post-surgery. FINDINGS Patients with intertrochanteric fractures had greater edema (111% non-fractured limb) compared with cervical fractures (104% non-fractured, P<0.001). Thigh edema was significantly correlated to lower scores of basic mobility (r=-0.61, P=0.004), reduced postural control (r=0.67, P=0.001), and fractured limb knee-extension strength deficit ([% non-fractured], r=-0.77, P<0.001), explaining between 32% and 59% of the variance (r(2)) in performances. INTERPRETATION Our results indicate that fracture type and the corresponding thigh edema are important factors influencing physical performances after hip fracture. These findings have important implications for rehabilitation programs and for further research in patients with hip fracture.
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Affiliation(s)
- Morten T Kristensen
- Lund University, Department of Health Sciences, Division of Physical Therapy, Lund University Hospital, Sweden.
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