A critical review of the long-term disability outcomes following hip fracture

Caring for the injured: Exploring the immediate and long-term consequences of injury in medieval Cambridge, England

OBJECTIVE

To combine paleopathological and biomechanical analysis to reconstruct the impact that a severe skeletal injury had on an individual's ability to function and participate in medieval society.

MATERIALS

Three medieval individuals from Cambridge, England with ante-mortem fractures to the lower limb were analyzed.

METHODS

Plain X-rays were used to determine the degree of malunion, rotation and overlap of each fracture. Cortical bone architecture of the injured individuals and 28 uninjured controls were analyzed using micro-computed tomography (µCT). Clinical and functional consequences were examined using the Bioarcheology of Care framework.

RESULTS

The mechanism of injury, the secondary complications, and the extent of the care received was reconstructed for each individual. Bilateral asymmetry in the cortical bone architecture revealed the long-term alterations to each individual's gait.

CONCLUSION

Each of these individuals survived a severe injury resulting in chronic physical impairment, though not all would have been considered 'disabled'.

SIGNIFICANCE

This research contributes to the discussion about medieval care provision and social constructions of disability by illustrating how an interdisciplinary approach provides insight into the experiences of those with physical impairments. The integration of µCT imaging within the Bioarcheology of Care model is a novel approach with great potential for application across the field.

LIMITATIONS

Biomechanical analysis was restricted to cortical geometry.

SUGGESTIONS FOR FUTURE RESEARCH

Further study of bilateral asymmetry in trabecular architecture could complement our understanding of altered loading modalities in past societies.

Extensive and Differential Deterioration of Hip Muscles May Preexist in Older Adults with Hip Fractures: Evidence from a Cross-Sectional Study

Hip muscles play an increasingly important role in lower limb function with aging. Investigating the deterioration of hip muscles and its relationship with hip fracture (HF) may help identify older adults prone to fall. In this study, patients with fall-related HF within 48 h and non-fracture controls aged ≥ 60 years were enrolled. The cross-sectional area (size) and attenuation (density) of the hip flexors, extensors, adductors, and abductors were calculated after segmentation on computed tomography images. The correlation of muscle parameters with HF and age were evaluated using logistic and multiple regression, respectively. Discrimination of HF was analyzed by receiver-operating characteristic analyses. A total of 220 patients and 91 controls were included. The size of the flexors, extensors, and abductors, and the density of the flexors, adductors, and abductors were lower in patients with HF after adjustment for sex, age, and body mass index (BMI). However, decreased muscle size was only observed in hip extensors in patients aged 60-74 years. Decreased muscle size was associated with HF independent of sex, age, BMI, and hip trabecular bone mineral density. Abductor size exhibited a significantly larger negative correlation with age in patients compared to controls. Including abductor size or all muscle size was effective for discrimination of HF in patients aged ≥ 75 years. In conclusion, older adults with HF may have sustained extensive and differential hip muscle deterioration before the injury; extensor atrophy in younger-old age and consideration of a closer relationship between abductor size and age deserve attention.

The Hospital to Home study (H2H): smartwatch technology-enabled rehabilitation following hip fracture in older adults, a feasibility non-randomised trial

Introduction

Hip fractures are associated with significant morbidity and mortality. This study assessed the feasibility of smartwatches supporting rehabilitation post-surgical fixation.

Methods

This UK-based non-randomised intervention study recruited patients who had sustained a hip fracture (age ≥65 and Abbreviated Mental Test Score ≥8/10), following surgical fixation, at one hospital to the intervention group, and at a second hospital to a usual care group. The intervention group received a smartwatch (Fitbit Charge 4) and app (CUSH Health©). Feasibility measures included retention and completion of outcome measures.

Results

Between November 2020 and November 21, 66 participants were recruited (median age 78 (IQR 74-84)). The intervention cohort were younger, with no significant differences in frailty or multi-morbidity between the cohorts. Hospital stay was shorter in the intervention cohort (10 days (7-16) versus 12 (10-18), p=0.05). There were 15 falls-related readmissions in the control cohort, including 11 fractures, with none in the intervention cohort (p=0.016). In the intervention group, median daily step counts increased from 477 (320-697) in hospital, to 931 (505-1238) 1 week post-discharge, to 5,352 (3,552-7,944) at 12-weeks (p=0.001). Of the intervention cohort, 12 withdrew.

Conclusion

This study found that smartwatch-supported rehabilitation was feasible in this cohort. A significant proportion of patients either chose not to participate or withdrew; such a decrease in participants must be addressed to avoid digital exclusion. Falls and fracture-related readmissions were more frequent at the control site compared with the intervention site.

The Effect of Omega-9 on Bone Viscoelasticity and Strength in an Ovariectomized Diet-Fed Murine Model

Few studies have investigated the effect of a monosaturated diet high in ω-9 on osteoporosis. We hypothesized that omega-9 (ω-9) protects ovariectomized (OVX) mice from a decline in bone microarchitecture, tissue loss, and mechanical strength, thereby serving as a modifiable dietary intervention against osteoporotic deterioration. Female C57BL/6J mice were assigned to sham-ovariectomy, ovariectomy, or ovariectomy + estradiol treatment prior to switching their feed to a diet high in ω-9 for 12 weeks. Tibiae were evaluated using DMA, 3-point-bending, histomorphometry, and microCT. A significant decrease in lean mass (p = 0.05), tibial area (p = 0.009), and cross-sectional moment of inertia (p = 0.028) was measured in OVX mice compared to the control. A trend was seen where OVX bone displayed increased elastic modulus, ductility, storage modulus, and loss modulus, suggesting the ω-9 diet paradoxically increased both stiffness and viscosity. This implies beneficial alterations on the macro-structural, and micro-tissue level in OVX bone, potentially decreasing the fracture risk. Supporting this, no significant differences in ultimate, fracture, and yield stresses were measured. A diet high in ω-9 did not prevent microarchitectural deterioration, nevertheless, healthy tibial strength and resistance to fracture was maintained via mechanisms independent of bone structure/shape. Further investigation of ω-9 as a therapeutic in osteoporosis is warranted.

Factors predictive of functional outcomes and quality of life in patients with fragility hip fracture: A retrospective cohort study

To determine the predictors of functional outcomes and quality of life (QoL) of patients who were surgically treated for fragility hip fracture. This was a retrospective cohort study performed in the 3 tertiary rehabilitation facilities. A total of 165 patients who had undergone surgery for fragility hip fracture were followed up to 6 months postoperatively. The factors expected to be related to the functional outcomes and QoL at 6 months post-surgery were as follows: baseline demographics, fracture site, operation type, fall characteristics including fall location and fall direction, comorbidities, and initial functional status. The following were comorbidities: hypertension, diabetes mellitus, dementia, cerebrovascular accident, and osteoporosis. Functional outcome and QoL measures were represented using the Koval grade, functional ambulatory category (FAC), Berg balance scale, 4-m walking speed test, the Korean version of Mini-Mental State Examination, EuroQol 5-dimension (EQ-5D) questionnaire, the Korean version of Modified Barthel Index, and the Korean version of instrumental activities of daily living (K-IADL). For all tests, each patient was assessed immediately after transfer and at 6 months post-surgery. Multivariable regression analyses adjusting for factors mentioned above were as follows. Old age led to a significantly less favorable outcome on FAC and K-IADL at 6 months. Intertrochanteric fracture had a significantly positive impact on Koval at 6 months compared to femur neck and intertrochanteric fractures. Total hip replacement arthroplasty and bipolar hemiarthroplasty had a significantly positive impact on EQ-5D and FAC at 6 months respectively compared to other operation types. Fall characteristics didn't reveal any significant impact on functional outcomes and QoL. Patients with hypertension and diabetes mellitus had a significantly negative outcome on EQ-5D and K-IADL respectively. Among initial assessments of function and QoL, initial 4-m walking speed test, Korean version of Mini-Mental State Examination, K-IADL, and Korean version of Modified Barthel Index were independent predictors of function and QoL at 6 months. This study confirmed that age, fracture site, operation type, comorbidities, and initial physical and cognitive function significantly influenced recovery of function and QoL at 6 months in patients with fragility hip fractures.

[Result of the update of the clinical pathway for hip fracture in the elderly at a university hospital in Madrid]

BACKGROUND AND OBJECTIVES

Orthogeriatric management with clinical pathways (CP) in hip fracture (HF) has been shown to be superior to other models. We studied whether updating the CP, through prioritization of admission and surgery, improvement in the prevention and treatment of delirium, management of anticoagulants and antiplatelet agents and the use of perioperative peripheral nerve block, modifies surgical delay, stay, readmissions, mortality, suffering delirium and functional status at discharge.

MATERIAL AND METHOD

A retrospective observational study of unicenter cohorts of 468 patients with HF, 220 from 2016 (old VC) and 248 from 2019 (new VC). The variables are: intervention in the first 48hours, surgical delay (hours), stay (days), stay less than 15 days, delirium, functional loss at discharge (Barthel prefracture scale less Barthel scale at discharge), readmission at one month, and mortality at admission, month and year.

RESULTS

Median age: 87.0 [interquartile range 8.0], mostly women (76.7%). Significantly, with the new VC, there was a greater number of patients operated on in the first 48hours (27,7% vs 36,8% p=0.036), less surgical delay (72.5 [47,5-110,5] vs 64.0 [42,0-88,0] p<0.001), shorter stay (10,0 [7,0-13,0] vs 8,0 [6,0-11,0] p<0.001), greater number of discharges in 15 days (78,2% vs 91,5% p<0.001), lower delirium (54,1% vs 43,5% p=0.023). No significant changes in readmissions, functional loss at discharge, mortality at admission, 3 months or year.

CONCLUSIONS

Updating the VC brings benefits to the patient (less surgical delay, equal functional status at discharge with fewer days of admission) and benefits in management (lower admission) without modifying mortality.

Geriatric rehabilitation care after hip fracture

PURPOSE

After acute hospital admission, patients with a hip fracture are frequently discharged to skilled nursing homes providing geriatric rehabilitation (GR). There are few evidence-based studies regarding specific treatment times and assessments during GR. This study aims to provide a description of care for hip fracture patients during GR in the Netherlands.

METHODS

Descriptive study analyzing the care pathways from GR facilities, regarding healthcare professionals involved, allocated treatment time per profession, total length of rehabilitation stay, and assessment instruments. Based on the reimbursement algorithm (diagnostic treatment combination = DBCs), of 25 patients, the registered actual treatment time per profession was calculated.

RESULTS

The care pathways pivoted on three groups of health care professionals: medical team (MT), physiotherapy (PT), and occupational therapy (OT). There was some discrepancy between the allocated time in the care pathways and the calculated mean actual treatment time from the DBCs. First week: MT 120-180 min, DBC 120 (SD: 59) minutes; PT 120-230 min, DBC 129 (SD: 58) minutes; and OT 65-165 min, DBC 93 (SD: 61) minutes. From week two onwards, MT 15-36 min, DBC 49 (SD: 29) minutes; PT 74-179 min, DBC 125 (SD: 50) minutes; and OT 25-60 min, DBC 47 (SD: 44) minutes. Dieticians, psychologists, and social workers were sporadically mentioned. There was heterogeneity in the assessment and screening tools.

CONCLUSIONS

It is difficult to define current standard care in GR after hip fracture in the Netherlands due to the diversity in care pathways and large practice variation. This is a problem in conducting randomized effectiveness research with care provided as control.

TRIAL REGISTER AND DATE OF REGISTRATION

NL7491 04-02-2019.

Temporal Trends (from 2008 to 2017) in Functional Limitations and Limitations in Activities of Daily Living: Findings from a Nationally Representative Sample of 5.4 Million Older Americans

This study's objectives are as follows: (1) to identify the temporal trends in the prevalence and the odds of activities of daily living (ADL) limitations and functional limitations (FLs) among Americans aged 65 and older; (2) to explore if these trends vary by gender and age cohort; (3) to determine if generational differences in educational attainment play a role in the observed temporal trends. A secondary analysis of the American Community Survey (ACS) was conducted for ten consecutive waves of the annual cross-sectional survey (2008-2017). The respondents were community-dwelling and institutionalized adults aged 65 and older (n = 5.4 million). The question on ADLs was "Does this person have difficulty dressing or bathing?". The question on FLs was "Does this person have serious difficulty walking or climbing stairs?". There was a substantial decline over the decade in the prevalence of ADL limitations, from 12.1% to 9.6%, and FLs, from 27.3% to 23.5%. If the 2017 prevalence rates had remained at the same level as the 2008 prevalence rates, there would have been an additional 1.27 million older Americans with ADL limitations and 1.89 million with FLs. Adjusting for educational attainment substantially attenuated the odds of the decline for both ADL limitations and FLs.

Health-related quality of life and associated factors after hip fracture. Results from a six-month prospective cohort study

Background

Hip fractures are a major public health problem with increasing relevance in aging societies. They are associated with high mortality rates, morbidity, and loss of independence. The aim of the EMAAge study was to determine the impact of hip fractures on patient-reported health-related quality of life (HRQOL), and to identify potential risk factors for worse outcomes.

Methods

EMAAge is a multicenter, prospective cohort study of patients who suffered a hip fracture. Patients or, if necessary, proxies were interviewed after initial treatment and after six months using standardized questionnaires including the EQ-5D-5L instrument, the Oxford Hip Score, the PHQ-4, the Short Nutritional Assessment Questionnaire, and items on patients living situation. Medical data on diagnoses, comorbidities, medications, and hospital care were derived from hospital information systems.

Results

A total of 326 patients were included. EQ-5D index values decreased from a mean of 0.70 at baseline to 0.63 at six months. The mean self-rated health on the EQ-VAS decreased from 69.9 to 59.4. Multivariable linear regression models revealed three relevant associated factors with the six-months EQ-5D index: symptoms of depression and anxiety, pre-fracture limitations in activities of daily living, and no referral to a rehabilitation facility had a negative impact. In addition, the six-months EQ-VAS was negatively associated with polypharmacy, living in a facility, and migration background.

Conclusions

Hip fractures have a substantial negative impact on patients HRQOL. Our results suggest that there are modifying factors that need further investigation including polypharmacy and migration background. Structured and timely rehabilitation seems to be a protective factor.

Role of calcium &/or vitamin D supplementation in preventing osteoporotic fracture in the elderly: A systematic review & meta-analysis

Background & objectives

Calcium and vitamin D, separately or in combination are usually prescribed to prevent fragility fractures in elderly population. However, there are conflicting results regarding the ideal dosage and overall efficacy obtained from randomized controlled trials (RCTs) conducted in the past. The objective of this study was to assess the fracture risk with the administration of calcium or vitamin D alone or in combination in elderly population (>60 yr).

Methods

PubMed, Cochrane and Embase databases were searched to identify the studies from inception to February 2021 with keywords, 'vitamin D', 'calcium' and 'fracture' to identify RCTs. The trials with comparing vitamin D, calcium or combination with either no medication or placebo were included for final analyses. The data were extracted and the study quality was assessed by two reviewers. The principal outcome measure was fractures around hip joint and secondary outcomes assessed were vertebral and any other fracture.

Results

Eighteen RCTs were considered for the final analysis. Neither calcium nor vitamin D supplementation was associated with risk of fractures around hip joint [risk ratio (RR) 1.56; 95% confidence interval (CI), 0.91 to 2.69, I[2]=28%; P=0.11]. In addition, the combined administration of calcium and vitamin D was also not associated with fractures around the hip joint in comparison to either no treatment or placebo. The incidence of vertebral (RR 0.95; 95% CI, 0.82 to 1.10, I[2]=0%; P=0.49) or any other fracture (RR 0.83; 95% CI 0.65 to 1.06, I[2]=0%; P=0.14) was not significantly associated with the administration of calcium and vitamin D either individually or in combination. Further subgroup analysis of the results did not vary with the dosage of calcium or vitamin D, dietary calcium intake sex, or serum 25-hydroxyvitamin D levels.

Interpretation & conclusions

The present meta-analysis of RCTs on calcium, vitamin D or a combination of the two in comparison to no treatment or placebo did not support the routine administration protocol of calcium and vitamin D either alone or in combination to lower the risk of fractures in elderly population.

Conservative Management of Stable, Minimally Displaced Pertrochanteric Fractures: A Case Series

Background

Hip fractures are common, and account for significant morbidity and mortality. While surgical intervention remains the gold standard, nonoperative treatment protocols are seldom analysed and may be of value in select settings.

Objectives

We sought to review our conservatively treated pertrochanteric fractures and present a case series that outlined indications, treatment protocol and early outcomes.

Materials and Methods

A retrospective review of medical records and radiographic imaging of all patients who presented with stable pertrochanteric fractures and were treated nonoperatively, from September 2017 to February 2021, at a Level 2 District Hospital in South Africa.

Results

Of the 242 patients who were admitted with pertrochanteric fractures, 12 (4.9%) fractures were radiographically classified as AO 31A1.2 (stable, minimally displaced) and eligible for active nonoperative management. Within 6 weeks of injury, 10 (84%) of the patients who received active nonoperative treatment achieved union. Two patients (16%) failed the treatment protocol and required surgery, with one failing during the hospital phase of the treatment protocol and the other on follow up. In the group of united fractures, the neck shaft angle was on average within 3 degrees of the contralateral hip with a range of 0 to 5 degrees. At follow-up, two (16%) patients had a measurable shortening of 5 mm at union. There was no medical morbidity associated with this protocol.

Conclusions

In our case series, the active nonoperative management protocol, involving early mobilisation and serial radiographs, in select cases of stable pertrochanteric fractures yielded acceptable outcomes. This is of relevance in low-middle income countries with limited surgical capacity.

Older patients' perspectives on participating in multimodal rehabilitation including anabolic steroids following hip fracture: a qualitative study embedded within a pilot RCT

PURPOSE

To explore patient perspectives of participating in a pilot RCT evaluating feasibility and effect of anabolic steroid, physiotherapy and nutritional supplement following hip fracture.

METHODS

Semi-structured telephone-based interviews of 16 women and three men (average age 73 years) were conducted at baseline and after a 12-week intervention. Qualitative content analysis was performed.

RESULTS

Two main categories were identified: (1) Trust and hope for a positive change with three sub-categories; reflections on anabolic steroids, anticipation of extra attention, lack of energy. (2) Curiosity, care, and commitment with four sub-categories; a sense of anabolic steroids, feeling of exclusivity and privileges, challenges and sense of obligation, and perspectives on personal gain.

CONCLUSIONS

Findings suggest high acceptability of the intervention. Participants motivated their participation on a trust that the intervention would "do more good than harm". They found the randomization and possibility of receiving anabolic steroids intriguing, and especially valued trial participation because of their experience of getting extra care and "deluxe" rehabilitation including close contact and support by health professionals. Our findings may help inform future research recruiting older patients and generally considered relevant for health professionals in rehabilitation, emphasizing the impact of professional guidance and social support to encourage self-efficacy.Implications for rehabilitationWith muscle enhancing medicine being suggested as a supplement in rehabilitation following hip fracture, exploring patients' perspectives is warranted and may help inform future trials in this area.Factors reported as important by older adults for engaging in rehabilitation trials are: simple but thorough information, friendly and trustful relation with study staff and opportunities of extra care and attention.Older patients with hip fracture highly valued professional guidance and support by health professionals during the rehabilitation intervention. High acceptability was identified for the supervised outpatient rehabilitation, where especially the individually structured progressive strength training was highlighted as the "active ingredient" accelerating recovery and potentially promoted self-efficacy.

The association between multimorbidity and osteoporosis investigation and treatment in high-risk fracture patients in Australia: A prospective cohort study

BACKGROUND

Multimorbidity is common among fracture patients. However, its association with osteoporosis investigation and treatment to prevent future fractures is unclear. This limited knowledge impedes optimal patient care. This study investigated the association between multimorbidity and osteoporosis investigation and treatment in persons at high risk following an osteoporotic fracture.

METHODS AND FINDINGS

The Sax Institute's 45 and Up Study is a prospective population-based cohort of 267,153 people in New South Wales, Australia, recruited between 2005 and 2009. This analysis followed up participants until 2017 for a median of 6 years (IQR: 4 to 8). Questionnaire data were linked to hospital admissions (Admitted Patients Data Collection (APDC)), emergency presentations (Emergency Department Data Collection (EDDC)), Pharmaceutical Benefits Scheme (PBS), and Medicare Benefits Schedule (MBS). Data were linked by the Centre for Health Record Linkage and stored in a secured computing environment. Fractures were identified from APDC and EDDC, Charlson Comorbidity Index (CCI) from APDC, Dual-energy X-ray absorptiometry (DXA) investigation from MBS, and osteoporosis treatment from PBS. Out of 25,280 persons with index fracture, 10,540 were classified as high-risk based on 10-year Garvan Fracture Risk (age, sex, weight, prior fracture and falls) threshold ≥20%. The association of CCI with likelihood of investigation and treatment initiation was determined by logistic regression adjusted for education, socioeconomic and lifestyle factors). The high-risk females and males averaged 77 ± 10 and 86 ± 5 years, respectively; >40% had a CCI ≥2. Only 17% of females and 7% of males received a DXA referral, and 22% of females and 14% males received osteoporosis medication following fracture. A higher CCI was associated with a lower probability of being investigated [adjusted OR, females: 0.73 (95% CI, 0.61 to 0.87) and 0.43 (95% CI, 0.30 to 0.62); males: 0.47 (95% CI, 0.33 to 0.68) and 0.52 (0.31 to 0.85) for CCI: 2 to 3, and ≥4 versus 0 to 1, respectively] and of receiving osteoporosis medication [adjusted OR, females: 0.85 (95% CI, 0.74 to 0.98) and 0.78 (95% CI, 0.61 to 0.99); males: 0.75 (95% CI, 0.59 to 0.94) and 0.37 (95% CI, 0.23 to 0.53) for CCI: 2 to 3, and ≥4 versus 0 to 1, respectively]. The cohort is relatively healthy; therefore, the impact of multimorbidity on osteoporosis management may have been underestimated.

CONCLUSIONS

Multimorbidity contributed significantly to osteoporosis treatment gap. This suggests that fracture risk is either underestimated or underprioritized in the context of multimorbidity and highlights the need for extra vigilance and improved fracture care in this setting.

Preventive Care and Outcomes of Interprofessional Medicare Annual Wellness Visits for Older Adults

As we anticipate a growing population of older adults, we will see an increase in chronic conditions such as dementia and falls. To meet these public health needs, we must systematically provide screening, education, preventive care, and supportive care for older patients and their caregivers in a primary care setting. This will require a workforce trained in providing for the complex medical and psychosocial needs of an older adult population in an interprofessional and collaborative fashion. By integrating geriatric screening tools into an interdisciplinary Annual Wellness Visit teaching clinic, we were able to successfully improve rates of geriatric screening for dementia, depression, falls, medication reconciliation and advance care planning. We also saw improvements in patient care and satisfaction and provided the opportunity for interprofessional collaboration and education for students in medicine, nursing, pharmacy and social work.

Two-country comparison of the prescription of bone protection medication before and early after hip fracture

Pharmacological management of bone health warrants investigation into factors influencing initiation of bone protection medication (BPM) at discharge after a hip fracture. This sprint audit identified reasons attributed to low BPM treatment levels at hospital discharge which can guide improvement in the prevention of future fractures.

PURPOSE

To compare patient characteristics and Australian and New Zealand approaches to prescribing bone protection medication (BPM) pre- or post-hip fracture, determine reasons why BPM was not prescribed earlier post-fracture, and assess the generalisability of sprint audit and the Australian and New Zealand Hip Fracture Registry (ANZHFR) patient cohorts.

METHODS

A retrospective cohort study of hip fracture patients from the ANZHFR aged ≥ 50 years (2016-2020) and consecutive patients from the 2021 BPM sprint audit. Multivariable logistic regression was used to examine factors associated with not prescribing BPM.

RESULTS

Of 55,618 patients admitted with a hip fracture in the ANZHFR, less than 10% of patients in Australia and New Zealand were taking BPM on admission, increasing to 22.4% in Australia and 27.8% in New Zealand on discharge. Registry patients who were younger (50-69 years), healthy (ASA grade 1), lived in a residential aged care facility, had impaired cognition, delirium identified, or were awaiting a specialist falls assessment were less likely to take BPM. Within the audit, 46.2% of patients in Australia and 39.2% in New Zealand did not have BPM in their discharge prescription. The most common reason for not prescribing BPM in Australia was low level of vitamin D (13.3%), and in New Zealand, renal impairment (14.8%). Sprint and registry patient characteristics were comparable in terms of patient age, sex, usual place of residence, and ASA grade.

CONCLUSIONS

BPM prescription early after hip fracture is low. Opportunities exist to increase the rate of prescription of medications known to prevent future fractures in this high-risk population.

Optimizing fixation methods for stable and unstable intertrochanteric hip fractures treated with sliding hip screw or cephalomedullary nailing: A comparative biomechanical and finite element analysis study

BACKGROUND

Despite recent advances in implants and surgical techniques, catastrophic and clinical failures in the treatment of intertrochanteric fractures continue to occur, with dire consequences in an overall frail population subset. The aim of the current study is to evaluate the effect of the factors under the surgeons' control, namely fracture reduction and implant selection, on the biomechanical behavior of fracture fixation constructs.

MATERIAL-METHODS

An experimental protocol was conducted with the use of instrumented sawbones, in order to validate the finite element models. The implants used were the Gamma3®and DHS systems. Subsequently, a series of scenaria were considered, including various reduction and implant angle combinations. Data were retrieved concerning the peak cancellous bone stresses around the hip screw and the volume of cancellous bone in the femoral head stressed at critical levels, as well as implant stresses and stresses on the cortical bone of the distal fragment.

RESULTS

All stable fracture models displayed significantly decreased cancellous bone stresses and implant stresses compared to their unstable counterparts, regardless of implant used. The effect of increasing implant angle led to a decrease in implant stresses in all models studied, but had a beneficial effect on the stresses in the cancellous bone of the proximal fragment only in the subgroups of stable fractures with both implants and unstable fractures treated with a cephalomedullary nail (CMN). In unstable fractures anatomically reduced, the use of CMN led to significantly lower peak stresses in the cancellous bone and a smaller volume of bone stressed at critical levels. Increasing the reduction angle by 5 ° led to a significant decrease in both peak stresses and volume of bone stressed at critical levels, more prominent in the sliding hip screw (SHS) models. Decreasing the reduction angle into varus by 5 or 10 ° led to a significant increase in bone and implant stresses regardless of implant used.

CONCLUSIONS

In stable two-part (AO31.A2) fractures the use of the SHS appears to be biomechanically equivalent to CMN. In unstable, anatomically reduced fractures, the use of CMN leads to significantly reduced cancellous bone stresses and decreased rotation of the proximal fragment during loading. A reduction in varus should be avoided at all costs. In unstable fractures treated with SHS a reduction in slight valgus appears to be biomechanically beneficial. The highest implant angle that allows for proper screw position and trajectory in the femoral head should be used for stable fractures with both implants and unstable fractures treated with Gamma3®.

Trajectories and prognostic factors for recovery after hip fracture: a longitudinal cohort study

PURPOSE

The aim of this study was to determine recovery trajectories and prognostic factors for poor recovery in frail and non-frail patients after hip fracture.

METHODS

Patients with a hip fracture aged 65 years and older admitted to a hospital in the Netherlands from August 2015 to November 2016 were asked to complete questionnaires at one week and one, three, six, 12, and 24 months after injury. The questionnaires included the ICEpop CAPability measure for older people, Health Utility Index, and the Hospital Anxiety Depression Scale. Latent class trajectory analysis was used to determine trajectories of recovery. Patient and injury characteristics for favourable and unfavourable outcome were compared with logistic regression.

RESULTS

In total, 696 patients were included of which 367 (53%) patients were frail. Overall, recovery trajectories in frail patients were worse compared to trajectories in non-frail patients. In frail patients, poor recovery was significantly associated with dementia. Lower age was a prognostic factor for good recovery. Immobility, loneliness and weight loss were prognostic for respectively poor capability and symptoms of anxiety and depression. In non-frail patients, recovery after hip fracture was associated with loneliness and the type of hip fracture.

CONCLUSION

Although frailty is associated with poor recovery in older patients with hip fracture, a large proportion of frail patients show good recovery. Loneliness determines poor recovery with anxiety and depressive symptoms.

TRAIL REGISTRATION

ClinicalTrials.gov identifier: NCT02508675 (July 27, 2015).

Pericapsular nerve group block for hip fracture is feasible, safe and effective in the emergency department: A prospective observational comparative cohort study

OBJECTIVES

The pericapsular nerve group (PENG) block was first described for analgesia of hip fracture in 2018. We hypothesised that the PENG block is safe and effective for patients with hip fracture when provided by emergency physicians and trainees in the ED.

METHODS

This was an observational study of routine care. Consecutive patients receiving regional anaesthesia for hip fracture at a single ED were prospectively enrolled. Pain scores were assessed prior to regional anaesthesia then at 15, 30 and 60 min after administration. Maximal reduction in pain scores within 60 min were assessed using the Visual Analogue Scale (at rest and on movement) or the Pain Assessment IN Advanced Dementia tool (at rest). Patients were followed for opioid use for 12 h after regional anaesthesia and adverse events over the duration of admission.

RESULTS

There were 67 eligible patients during the enrolment period, with 52 (78%) prospectively enrolled. Thirty-three received femoral blocks (19 fascia iliaca compartment blocks, 14 femoral nerve blocks) and 19 received a PENG block. Inexperienced providers were able to successfully perform the PENG block. There was no difference in maximum pain score reduction between the groups. There was no difference in adverse effects between groups. Opioid use was similar between the groups. More patients were opioid-free after a PENG block.

CONCLUSIONS

The present study demonstrated that the PENG block can be provided safely and effectively to patients with hip fracture in the ED. On the basis of this pilot study, a larger randomised controlled study should now be designed.

Delphi-Based Consensus to Determine Core Aspects of Post-Hip-Fracture Surgery Rehabilitation Based on the International Classification of Functioning, Disability, and Health

A hip fracture is a major adverse event for older individuals that has extremely high rates of mortality and morbidity, specifically functional decline. Thus, effective post-hip fracture rehabilitation is crucial to enable patients to regain function and improve their quality of life. Most post-hip fracture rehabilitation programs focus only on physical functioning, but rehabilitation goals related to the quality of life, social participation, and environmental issues are also crucial considerations. This study aimed to develop a core set of considerations based on the International Classification of Functioning, Disability, and Health (ICF) for use as a reference in designing comprehensive rehabilitation programs for patients with hip fractures. For this purpose, we recruited 20 experts from related fields working at a university hospital to complete a three-round Delphi-based questionnaire. Before beginning this process, a literature review related to ICF category selection was conducted. Next, a 5-point Likert scale was employed to rate the importance of each proposed category, and Spearman's rank correlation coefficient and semi-interquartile range indices were analyzed to rate the consensus status. Categories for the ICF core set of considerations for post-hip-fracture rehabilitation were chosen on the basis of a high level of consensus and a mean score of ≥4.5 in the third Delphi-based questionnaire round. After selection, the ICF core set comprised 34 categories, namely 15 for bodily functions, 5 for bodily structures, 13 for activities and participation, and 1 for environmental factors. The proposed post-hip-fracture rehabilitation ICF core set can serve as a reference for developing effective rehabilitation strategies and goal setting by interdisciplinary teams. However, further feasibility evaluation is recommended for individualized rehabilitation program design.

Self-perceived functioning and (instrumental) activities of daily living questionnaires after a hip fracture: Do they tell the same story?

BACKGROUND

(Instrumental) activities of daily living ((I)ADL) questionnaires are often used as a measure of functioning for different purposes. Depending on the purpose, a measurement of functioning that includes subjective patient perspectives can be relevant. However, it is unclear to what extent (I)ADL instruments capture self-perceived functioning.

OBJECTIVE

Explore what functioning means to older persons after a hip fracture and assess the extent to which (I)ADL instruments align with self-perceived functioning.

DESIGN

Qualitative interview study with framework analysis.

SETTING

Prospective cohort study on recovery after a hip fracture among older persons in a hospital in a large city in the west of the Netherlands.

SUBJECTS

Eighteen home-dwelling older persons (≥70 years) who had a hip fracture 6-12 months ago.

METHODS

Telephone interviews about functioning before and after the hip fracture were coded and analysed using the framework method.

RESULTS

The activities mentioned by participants to be part of their self-perceived functioning could be split into activities necessary to maintain the desired level of independence, and more personal activities that were of value to participants. Both the 'independence activities' and the 'valued activities' mentioned went beyond the activities included in (I)ADL questionnaires. Due to various coping strategies, limitations in activities that are measured in the (I)ADL questionnaires did not necessarily lead to worse self-perceived functioning.

CONCLUSION

Self-perceived functioning differs from functioning measured with (I)ADL questionnaires in the items included and the weighing of limitations in activities. Thus, (I)ADL instruments alone are not enough to measure functioning from the perspective of the older person.

Association Between Frailty and Time Alive and At Home After Cancer Surgery Among Older Adults: A Population-Based Analysis

BACKGROUND

Although frailty is known to impact short-term postoperative outcomes, its long-term impact is unknown. This study examined the association between frailty and remaining alive and at home after cancer surgery among older adults.

METHODS

Adults aged ≥70 years undergoing cancer resection were included in this population-based retrospective cohort study using linked administrative datasets in Ontario, Canada. The probability of remaining alive and at home in the 5 years after cancer resection was evaluated using Kaplan-Meier methods. Extended Cox regression with time-varying effects examined the association between frailty and remaining alive and at home.

RESULTS

Of 82,037 patients, 6,443 (7.9%) had preoperative frailty. With median follow-up of 47 months (interquartile range, 23-81 months), patients with frailty had a significantly lower probability of remaining alive and at home 5 years after cancer surgery compared with those without frailty (39.1% [95% CI, 37.8%-40.4%] vs 62.5% [95% CI, 62.1%-63.9%]). After adjusting for age, sex, rural living, material deprivation, immigration status, cancer type, surgical procedure intensity, year of surgery, and receipt of perioperative therapy, frailty remained associated with increased hazards of not remaining alive and at home. This increase was highest 31 to 90 days after surgery (hazard ratio [HR], 2.00 [95% CI, 1.78-2.24]) and remained significantly elevated beyond 1 year after surgery (HR, 1.56 [95% CI, 1.48-1.64]). This pattern was observed across cancer sites, including those requiring low-intensity surgery (breast and melanoma).

CONCLUSIONS

Preoperative frailty was independently associated with a decreased probability of remaining alive and at home after cancer surgery among older adults. This relationship persisted over time for all cancer types beyond short-term mortality and the initial postoperative period. Frailty assessment may be useful for all candidates for cancer surgery, and these data can be used when counseling, selecting, and preparing patients for surgery.

Geriatric Domains in Patients with Heart Failure with Preserved Ejection Fraction

Because heart failure with preserved ejection fraction (HFpEF) is closely linked to aging processes and disproportionately affects older adults, consideration of geriatric domains is paramount to ensure high-quality care to older adults with HFpEF. Multimorbidity, polypharmacy, cognitive impairment, depressive symptoms, frailty, falls, and social isolation each have important implications on quality of life and clinical events including hospitalization and mortality. There are multiple strategies to screen for these conditions. This narrative review underscores the importance of screening for multiple geriatric conditions, integrating these conditions into decision making, and addressing these conditions when caring for older adults with HFpEF.

Femoral neck structural properties are altered in adults with type 1 diabetes

AIMS

To determine differences in hip geometry in adults with type 1 diabetes (T1D) compared with healthy adults without diabetes.

METHODS

In this cross-sectional study, 43 adults with T1D (mean age 56 years, 84 % female, 92 % White, mean duration of diabetes of 39 years, A1c of 7.8 %) and 40 adults without diabetes (mean age 60 years, 80 % female, 77 % white) who had hip dual-energy x-ray absorptiometry (DXA) scans from previous studies were included. Areal bone mineral density (aBMD) and measures of hip structural properties at the narrow neck, intertrochanteric and femoral shaft regions of the left proximal femur were analyzed between adults with T1D and controls using linear models controlled for age, sex, and body mass index.

RESULTS

There were no significant differences in DXA-based aBMD at the hip (0.769 ± 0.132 vs. 0.900 ± 0.139 g/cm2, p = 0.07) or femoral neck (0.722 ± 0.116 vs. 0.849 ± 0.114 g/cm2, p = 0.09) regions between adults with T1D and controls. When controlling for age, sex, and BMI, DXA-based aBMD at the hip (0.880 ± 0.022 vs. 0.943 ± 0.020 g/cm2, p = 0.02) and femoral neck (0.750 ± 0.021 vs. 0.812 ± 0.020 g/cm2, p = 0.02) regions were significantly lower in adults with T1D than controls. Cortical thickness was significantly lower in all three hip regions in adults with T1D than in controls (narrow-neck: 0.169 ± 0.005 vs. 0.186 ± 0.005 cm, p = 0.011; intertrochanteric: 0.388 ± 0.013 vs. 0.425 ± 0.012 cm, p = 0.017; femoral shaft: 0.529 ± 0.017 vs. 0.586 ± 0.016 cm, p = 0.006). Moreover, adults with T1D had a smaller cross-sectional area at the narrow-neck (3.06 ± 0.09 vs. 3.32 ± 0.08 cm2, p = 0.015), a higher femoral shaft endocortical diameter (2.23 ± 0.07 vs. 2.02 ± 0.06 cm, p = 0.011), and higher buckling ratios (an indicator of cortical instability) at the intertrochanteric (9.22 ± 0.34 vs. 8.23 ± 0.32, p = 0.016) and femoral shaft (3.32 ± 0.15 vs. 2.89 ± 0.14, p = 0.016) regions.

CONCLUSIONS

Adults with T1D have several significant differences in proximal femur morphology compared with controls. These morphological differences may adversely affect the mechanical integrity of the proximal femur, thereby contributing to an increased risk of fracture in the event of a fall.

Mobilisation and physiotherapy intervention following hip fracture: snapshot survey across six countries from the Fragility Fracture Network Physiotherapy Group

PURPOSE

Hip fracture guidelines recommend early mobilisation, multidisciplinary care, physiotherapy and fall prevention interventions. This study documents mobilisation practices and physiotherapy interventions provided post-hip fracture in six countries.

MATERIALS AND METHODS

Physiotherapists from orthopaedic wards in Denmark, Australia, Spain, Brazil, Norway and Ireland provided information regarding mobilisation and physiotherapy for 10 consecutive hip fracture patients (>60 years), between 2014 and 2018.

RESULTS

Physiotherapists (n = 107) entered data on 426 patients. Two-thirds of patients (283, 66%) attempted standing 0-1 days after surgery (range: 0% of patients in Spain to 92% in Norway). Fewer patients (199, 47%) attempted walking on day 0-1 (range: 0% Spain/Brazil to 69% Norway). Physiotherapy to mobilise every weekday was provided to 356 patients (84%, range: 60% Ireland to 100% Spain). On weekends, physiotherapy to mobilise was limited (175, 40%, range: 0% Spain to 81% Brazil) but 298 patients (70%) mobilised with non-physiotherapy staff (range: 0% Spain to 96% Denmark/Ireland). Physiotherapy treatments included mobility, gait training, and range-of-motion exercises. Referral to fall prevention interventions was low (93, 22%, range: 0% Spain to 76% Ireland).

CONCLUSION

Stronger compliance with guideline recommendations on early mobilising, weekend mobilising and referral to fall prevention interventions post hip-fracture is needed in some countries.Implications for rehabilitation This study provides a snapshot of mobilisation and physiotherapy practice for hip fracture patients in six countries. The results suggest a need to improve systems and approaches in some countries to enhance compliance with recommendations specifically relating to: • early attempts at standing and walking post-surgery. • opportunities to mobilise on weekends (with physiotherapist and/or other staff). • broader range of multidisciplinary care e.g., geriatric review, occupational therapy and nutrition advice. • use of standardised tests by physiotherapists post-surgery. • referral to fall prevention interventions.

The economic burden of osteoporosis in Iran in 2020

Osteoporosis, the most common metabolic bone disease, leads to increased susceptibility to fractures. In 2020, about 150,000 osteoporotic fractures occurred in Iran. Osteoporosis and related fractures cost the community US$ 393 million. Introduction The present study aimed at estimating the economic burden of osteoporosis in Iran in 2020.

METHODS

We estimated the annual economic burden of osteoporosis in the above 50 years old population using a prevalence-based approach and from a societal perspective. The incidence of osteoporosis and related fractures were estimated based on meta-analysis reports in Iran and international comparisons. The direct medical and non-medical costs as well as the monetary value of quality-adjusted life-years (QALYs) lost because of fractures were estimated. Cost data were extracted from patient records, medical services prices, and previous literature.

RESULTS

A total of 154,530 osteoporotic fractures were estimated in Iran in 2020. The shares of the hip, vertebral, forearm, and other fractures were 14%, 15%, 17%, and 54%, respectively. There were also 3554 deaths from osteoporotic fractures. The economic burden of osteoporosis in Iran was estimated at US$ 393.24 million (US$ 2165 million purchasing power parity 2020). Direct medical and non-medical cost (47.44%), QALY loss (29.65%), and long-term care for prior hip fracture costs (9.4%) were the main component of the economic burden of osteoporosis.

CONCLUSION

The economic burdens of osteoporosis are significant in Iran. Interventions to prevent osteoporosis and especially associated fractures, such as screening and prophylaxis, can reduce the cost of the disease and improve patients' quality of life. Further studies are needed to identify cost-effective and feasible interventions in Iran.

Reduced Awareness for Osteoporosis in Hip Fracture Patients Compared to Elderly Patients Undergoing Elective Hip Replacement

Background: Osteoporotic fractures are associated with a loss of quality of life, but only few patients receive an appropriate therapy. Therefore, the present study aims to investigate the awareness of musculoskeletal patients to participate in osteoporosis assessment and to evaluate whether there are significant differences between acute care patients treated for major fractures of the hip compared to elective patients treated for hip joint replacement.; Methods: From May 2015 to December 2016 patients who were undergoing surgical treatment for proximal femur fracture or total hip replacement due to osteoarthritis and were at risk for an underlying osteoporosis (female > 60 and male > 70 years) were included in the study and asked to complete a questionnaire assessing the awareness for an underlying osteoporosis. ASA Score, FRAX Score, and demographic information have also been examined. Results: In total 268 patients (female = 194 (72.0%)/male = 74 (28%)), mean age 77.7 years (±7.7) undergoing hip surgery were included. Of these, 118 were treated for fracture-related etiology and 150 underwent total hip arthroplasty in an elective care setting. Patients were interviewed about their need for osteoporosis examination during hospitalization. Overall, 76 of 150 patients receiving elective care (50.7%) considered that an examination was necessary, whereas in proximal femur fracture patients the awareness was lower, and the disease osteoporosis was assessed as threatening by significantly fewer newly fractured patients. By comparison, patients undergoing trauma surgery had a considerably greater risk of developing another osteoporotic fracture than patients undergoing elective surgery determined by the FRAX® Score (p ≤ 0.001).; Conclusions: The patients’ motivation to endure additional osteoporosis diagnostic testing is notoriously low and needs to be increased. Patients who underwent acute care surgery for a fragility proximal femur fracture, although acutely affected by the potential consequences of underlying osteoporosis, showed lower awareness than the elective comparison population that was also on average 6.1 years younger. Although elective patients were younger and at a lower risk, they seemed to be much more willing to undergo further osteoporosis assessment. In order to better identify and care for patients at risk, interventions such as effective screening, early initiation of osteoporosis therapy in the inpatient setting and a fracture liaison service are important measures.

Evaluation of risk factors and outcomes associated with mortality after hip fracture surgery in eldery patients

Objective: In this retrospective study, it was aimed to compare mortality related risk factors and outcomes in patients who underwent proximal femoral nail and partial hip prosthesis for hip fracture. Material and Method: In our study, a total of 618 patient files who underwent hip fracture operations, including partial hip replacement (n=350) and proximal femoral nail (n=268) were retrospectively analyzed. Age, gender, fracture side, cause, type of fracture, type of operation, blood transfusion, hospital stay, anesthesia type and one-year survival times of the patients were examined. Results: Gender, age, side, mechanism, anesthesia, comorbid diseases, cause of mortality, one-year mortality and survival time differences between patient groups were not statistically significant (p>0.05). However, fracture type, blood transfusion and hospital stay differences between groups were statistically significant (p

The interdisciplinary fracture liaison service improves health-related outcomes and survival of older adults after hip fracture surgical repair

Due to the high burden of fragility fractures, we developed an interdisciplinary FLS care pathway for early management and monitoring of older adults discharged from a high-volume trauma center after hip fracture repair. Interdisciplinary FLS effectively improves up to 1-year adherence to treatments for secondary prevention of fragility fractures, reduces health facility admission, and improves long-term survival.

PURPOSE

To compare adherence to secondary fragility fracture prevention, falls, healthcare facility admissions, and mortality between hip fracture older adults who entered the fracture liaison services pathway of care (FLS-CP) and those managed according to the usual traumatologist model of care (U-CP).

METHODS

Prospective observational study enrolling subjects aged ≥ 65 years discharged by high-volume trauma center after hip fracture repair from February 2016 to February 2017, who consecutively entered FLS-CP or U-CP according to their preference and goals.

RESULTS

Compared to U-CP, those in FLS-CP had higher initiation rate and up to 1-year adherence to secondary prevention of fragility fracture, including vitamin D and calcium (87.7% vs 36.9%; p &lt; 0.0001), specific anti-osteoporosis drugs (75.1% vs 8.0%; p &lt; 0.0001), and complete anti-fracture therapy (72.3% vs 5.7%; p &lt; 0.0001). Older adults belonging to FLS-CP showed a lower likelihood of healthcare facility admission (RR 0.597; 95% CI 0.398-0.895; p = 0.0125), with a longer re-hospitalization-free survival (176.4 vs 88.7 days; p = 0.0152) than those in U-CP. One-year incidence of falls and fractures was similar between groups, with a lower tendency of the subjects in the FLS-CP to be multiple fallers (19% vs 34.8%; OR 0.057; 95% CI 0.004-0.876; p = 0.0690). The FLS-CP group experienced a lower 1-year (87.2% vs 74.3%; p = 0.001) and 3-year mortality (67.9% vs 55.6%; p = 0.0245) and a lower adjusted 5-year mortality hazard ratio (50.2% vs 58%; HR = 0.76; 95% CI 0.60; 0.96).

CONCLUSION

The FLS-CP may improve initiation and adherence to secondary prevention of fragility fractures, reduces healthcare facility admission, and improves long-term survival.

Relationship between the neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio and deep venous thrombosis (DVT) following femoral neck fractures in the elderly

Purpose

This study aimed to investigate whether the neutrophil-to-lymphocyte ratio (NLR) or platelet-to-lymphocyte ratio (PLR) was associated with deep venous thrombosis (DVT) following femoral neck fractures in the elderly.

Method

This was a retrospective cohort study and used data extracted from the hospitalization electronic medical record and the laboratory biomarker reports. Patients were included if they were aged above 60 years with a definite diagnosis of femoral neck fracture caused by low-energy trauma. Duplex ultrasound scanning was routinely performed to detect the potential DVT. Two independent multivariate logistic regression models were constructed to identify the association of NLR or PLR with the risk of DVT.

Results

A total of 708 patients with femoral neck fractures were included, and 112 were found to have DVT, indicating an incidence rate of 15.8%. There were significant differences across five subgroups for NLR or PLR, in terms of age (p = 0.020, 0.006), white blood cell (p < 0.001, =0.006), hemoglobin (p < 0.001, <0.001), and albumin (p < 0.001, <0.001). BMI was tested to be significantly different across subgroups for NLR (p = 0.030) and prevalence of cerebrovascular disease for PLR (p = 0.014). The multivariate analyses demonstrated that not NLR but PLR in Q3 (range, 179–238) was associated with an increased risk of DVT, and the risk for the latter was 1.86 (95%CI, 1.07–3.36).

Conclusion

We concluded that a PLR value of 179–238 was associated with a 1.86-fold increased risk of DVT after femoral neck fracture. This study paves the way toward further exploration of inflammatory/immune biomarkers with the risk of DVT in the elderly with trauma.

Debilitating Fracture Hampering the Regular Chores of an 80-Year-Old Female and the Post-operative Rehabilitation for the Same: A Case Report

In the geriatric population, intertrochanteric fractures are exceptionally high because they have osteoporosis. Extracapsular fractures of the proximal section of the femur are known as intertrochanteric fractures. The surgical intervention combined with physiotherapy aids in the achievement of functional objectives. After a fall in the restroom, an X-ray revealed an intertrochanteric fracture of the left hip in an 80-year-old female patient. The concern regarding the surgical intervention was the age and associated co-morbidities. The patient was given physiotherapy for ten weeks after surgical intervention and skeletal traction, which comprised the multidisciplinary approach. The intervention is substantially directed toward balance retraining and improving functional independence. The case report suggests that a structured physiotherapy rehabilitation protocol improved the patient's functional abilities and successful recovery.

Malnutrition diagnosed by the Global Leadership Initiative on Malnutrition criteria as a predictor of gait ability in patients with hip fracture

AIM

Malnutrition is common in patients with hip fractures and is associated with poor clinical outcomes. The Global Leadership Initiative on Malnutrition (GLIM) and the European Society for Clinical Nutrition and Metabolism (ESPEN) criteria are widely used to diagnose malnutrition. However, the criteria regarding the prediction of gait ability in patients with hip fractures during the acute phase remain unclear. We aimed to determine whether GLIM or ESPEN criteria were more appropriate for predicting gait ability at discharge from an acute hospital.

METHODS

This retrospective observational study included hip fracture patients aged ≥ 65 years. Patients were classified as malnourished or non-malnourished according to the GLIM and ESPEN criteria at admission. The primary outcome was gait ability, which was evaluated using functional ambulation categories (FAC) at discharge. We categorized into those with (FAC score ≥ 3 points) and without (< 3 points) improved gait ability. Logistic regression analysis for FAC was performed to determine whether GLIM or ESPEN was predictive of gait ability at discharge.

RESULTS

Overall 157 patients were included; the median age was 84 years, and 75.3% were female. The prevalence of malnutrition was 73.9% and 25.5% according to the GLIM and ESPEN criteria, respectively. Logistic regression analysis showed that malnutrition evaluated using the GLIM criteria were predictive of lower FAC at discharge (odds ratio, 0.394; 95% CI, 0.164-0.946), while ESPEN criteria did not show statistically significant differences (odds ratio, 0.625; 95% CI, 0.292-1.335).

CONCLUSION

GLIM criteria are useful for predicting gait ability at discharge during acute hospitalization in patients with hip fractures.

The clinician's guide to prevention and treatment of osteoporosis

Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.

Psychometric properties of the Chinese version of the Positive Thinking Scale in individuals after hip fracture surgery

Positive thinking is a form of positive cognition and a coping strategy. The Positive Thinking Scale (PTS) is used to measure positive thinking, but the reliability and validity of the PTS-Chinese have yet to be tested. This study aims to examine the psychometric properties of the PTS-Chinese. A total of 154 patients post-hip fracture surgery completed the questionnaire in a hospital in Taiwan between April 2020 and December 2020. The scales in the questionnaire included the PTS, Automatic Thoughts Questionnaire-Positive, Automatic Thoughts Questionnaire-Negative, Barthel Index, and items related to happiness, demographics, and disease treatment. The results of the confirmatory factor analysis and average variance extracted show that the PTS-Chinese version exhibits construct validity. Scores on the PTS-Chinese version are positively related to scores on the Automatic Thoughts Questionnaire-Positive and happiness items and negatively related to scores on the Automatic Thoughts Questionnaire-Negative. This finding indicates that the PTS-Chinese demonstrates concurrent, predictive, and discriminant validity. The scale also presents acceptable reliability and test–retest reliability. Overall, the PTS-Chinese can be used to evaluate and track the positive thinking of patients. Further studies are needed to assess the psychometric properties of the PTS-Chinese in different cultures and ethnic groups.

Association of pharmacotherapy with the second hip fracture incidence in women: A retrospective analysis of the National Database of Health Insurance Claims and Specific Health Checkups of Japan

AIM

Second hip fractures worsen the quality of life and are associated with increased mortality. We clarified the association between the pharmacotherapy and second hip fracture prevention.

METHODS

The relationship between the incidence of second hip fracture and the presence, type and medication possession ratio (MPR) of pharmacotherapy was investigated using medical insurance data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan during April 2012 to March 2019.

RESULTS

Data of 776 040 female patients were analyzed. The 2-year rate of second hip fractures was 3.31% (n = 25 684). Bisphosphonates (n = 148 138, 19.1%) were the most commonly used medications after primary hip fracture. Patients receiving selective estrogen receptor modulators (SERMs) had the lowest age, followed by those receiving bisphosphonates, denosumab and parathyroid hormone (PTH). The second hip fracture crude incidence was lowest in patients administered SERMs (n = 859, 2.44%), followed by those administered bisphosphonates (n = 4451, 3.00%), denosumab (n = 484, 3.19%), no medication (n = 19 017, 3.39%) and PTH (n = 873, 5.35%); however, the age-adjusted incidence was the lowest in patients administered denosumab (2.22%), followed by those administered bisphosphonates (2.35%), SERMs (2.39%), no medications (3.39%) and PTH (3.67%). The MPR was highest in patients administered denosumab (60.0%). Among patients without a second hip fracture, the rate of patients with MPR ≥80% was highest among those administered SERMs (40.8%), followed by those administered bisphosphonates (38.0%), denosumab (35.4%) and PTH (12.2%).

CONCLUSION

Differences in patient background characteristics and the rate of patients with MPR ≥80% might underlie the observed differences in the crude incidence of second hip fracture among the medication groups. Geriatr Gerontol Int 2022; ••: ••-••.

Geographic variation in hip fracture surgery rate, care quality and outcomes: a comparison between national registries in Ireland and Denmark

Ireland and Denmark have similar hip fracture surgery rates but differences in care quality indicators and patterns of intracapsular fracture repair. Very high variation in total hip arthroplasty rate within both countries and higher observed early mortality in Denmark require further investigation.

PURPOSE

To explore and compare geographic variation of hip fracture surgery rate, care quality and outcomes in Ireland and Denmark.

METHODS

Patients aged ≥ 65 years with surgically treated hip fracture were included from the Irish Hip Fracture Database (years = 2017-2020, n = 12,904) and the Danish Multidisciplinary Hip Fracture Registry (years = 2016-2017, n = 12,924). The age and sex standardised rate of hip fracture surgery and the proportion of patients with seven process quality indicators, three surgery types and four outcomes were calculated. Systematic components of variation (SCV) were calculated based on hospital area (6 Irish hospital groups, 5 Danish regions).

RESULTS

The age and sex standardised rate of hip fracture surgery per 1000 older population in 2017 was 4.7 (95% CI = 4.4-5.1) in Ireland and 5.3 (95% CI = 5.1-5.5) in Denmark. Ireland had lower rates of surgery within 36 h (59% versus 84%), nutritional assessment (27% versus 84%) and pre-discharge mobility recording (52% versus 92%). Patterns of intracapsular fracture repair also differed between countries (hemiarthroplasty: Ireland = 85%, Denmark = 52%). Both countries had very high variation for total hip arthroplasty (THA) provision (SCV Ireland = 10.6, Denmark = 97.9). Ireland had longer hospital stays (median 12 versus 7 days), but lower 7-day (1.0% versus 3.1%) and 14-day (2.0% versus 5.5%) mortality.

CONCLUSION

Ireland and Denmark have similar hip fracture surgery rates, but differences in care quality, surgery patterns and outcomes. High variation in THA provision and observed differences in mortality require further exploration. In Ireland, there is scope for improvement regarding early surgery, mobility, nutrition assessment and improved post-discharge follow-up.

Proximal Femoral Fractures in the Elderly: A Few Things to Know, and Some to Forget

Hip fractures are a leading cause of hospitalisation in elderly patients, representing an increasing socioeconomic problem arising from demographic changes, considering the increased number of elderly people in our countries. Adequate peri-operative treatment is essential to decrease mortality rates and avoid complications. Modern management should involve a coordinated multidisciplinary approach, early surgery, pain treatment, balanced fluid therapy, and prevention of delirium, to improve patients' functional and clinical outcomes. The operative treatment for intertrochanteric and subtrochanteric fractures is intramedullary nail or sliding/dynamic hip screw (DHS) on the basis of the morphology of the fracture. In the case of neck fractures, total hip replacement (THR) or hemiarthroplasty are recommended. However, several topics remain debated, such as the optimum thromboprophylaxis to reduce venous thromboembolism or the use of bone cement. Postoperatively, patients can benefit from early mobilisation and geriatric multidisciplinary care. However, during the COVID-19 pandemic, a prolonged time to operation with a subsequent increased complication rate have burdened frail and elderly patients with hip fractures. Future studies are needed with the aim to investigate better strategies to improve nutrition, postoperative mobility, to clarify the role of home-based rehabilitation, and to identify the ideal analgesic treatment and adequate tools in case of patients with cognitive impairment.

Interventions for improving mobility after hip fracture surgery in adults

BACKGROUND

Improving mobility outcomes after hip fracture is key to recovery. Possible strategies include gait training, exercise and muscle stimulation. This is an update of a Cochrane Review last published in 2011.

OBJECTIVES

To evaluate the effects (benefits and harms) of interventions aimed at improving mobility and physical functioning after hip fracture surgery in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, trial registers and reference lists, to March 2021.

SELECTION CRITERIA

All randomised or quasi-randomised trials assessing mobility strategies after hip fracture surgery. Eligible strategies aimed to improve mobility and included care programmes, exercise (gait, balance and functional training, resistance/strength training, endurance, flexibility, three-dimensional (3D) exercise and general physical activity) or muscle stimulation. Intervention was compared with usual care (in-hospital) or with usual care, no intervention, sham exercise or social visit (post-hospital).

DATA COLLECTION AND ANALYSIS

Members of the review author team independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We used the assessment time point closest to four months for in-hospital studies, and the time point closest to the end of the intervention for post-hospital studies. Critical outcomes were mobility, walking speed, functioning, health-related quality of life, mortality, adverse effects and return to living at pre-fracture residence.

MAIN RESULTS

We included 40 randomised controlled trials (RCTs) with 4059 participants from 17 countries. On average, participants were 80 years old and 80% were women. The median number of study participants was 81 and all trials had unclear or high risk of bias for one or more domains. Most trials excluded people with cognitive impairment (70%), immobility and/or medical conditions affecting mobility (72%). In-hospital setting, mobility strategy versus control Eighteen trials (1433 participants) compared mobility strategies with control (usual care) in hospitals. Overall, such strategies may lead to a moderate, clinically-meaningful increase in mobility (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; 7 studies, 507 participants; low-certainty evidence) and a small, clinically meaningful improvement in walking speed (CI crosses zero so does not rule out a lack of effect (SMD 0.16, 95% CI -0.05 to 0.37; 6 studies, 360 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to short-term (risk ratio (RR) 1.06, 95% CI 0.48 to 2.30; 6 studies, 489 participants; low-certainty evidence) or long-term mortality (RR 1.22, 95% CI 0.48 to 3.12; 2 studies, 133 participants; low-certainty evidence), adverse events measured by hospital re-admission (RR 0.70, 95% CI 0.44 to 1.11; 4 studies, 322 participants; low-certainty evidence), or return to pre-fracture residence (RR 1.07, 95% CI 0.73 to 1.56; 2 studies, 240 participants; low-certainty evidence). We are uncertain whether mobility strategies improve functioning or health-related quality of life as the certainty of evidence was very low. Gait, balance and functional training probably causes a moderate improvement in mobility (SMD 0.57, 95% CI 0.07 to 1.06; 6 studies, 463 participants; moderate-certainty evidence). There was little or no difference in effects on mobility for resistance training. No studies of other types of exercise or electrical stimulation reported mobility outcomes. Post-hospital setting, mobility strategy versus control Twenty-two trials (2626 participants) compared mobility strategies with control (usual care, no intervention, sham exercise or social visit) in the post-hospital setting. Mobility strategies lead to a small, clinically meaningful increase in mobility (SMD 0.32, 95% CI 0.11 to 0.54; 7 studies, 761 participants; high-certainty evidence) and a small, clinically meaningful improvement in walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; 14 studies, 1067 participants; high-certainty evidence). Mobility strategies lead to a small, non-clinically meaningful increase in functioning (SMD 0.23, 95% CI 0.10 to 0.36; 9 studies, 936 participants; high-certainty evidence), and probably lead to a slight increase in quality of life that may not be clinically meaningful (SMD 0.14, 95% CI -0.00 to 0.29; 10 studies, 785 participants; moderate-certainty evidence). Mobility strategies probably make little or no difference to short-term mortality (RR 1.01, 95% CI 0.49 to 2.06; 8 studies, 737 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to long-term mortality (RR 0.73, 95% CI 0.39 to 1.37; 4 studies, 588 participants; low-certainty evidence) or adverse events measured by hospital re-admission (95% CI includes a large reduction and large increase, RR 0.86, 95% CI 0.52 to 1.42; 2 studies, 206 participants; low-certainty evidence). Training involving gait, balance and functional exercise leads to a small, clinically meaningful increase in mobility (SMD 0.20, 95% CI 0.05 to 0.36; 5 studies, 621 participants; high-certainty evidence), while training classified as being primarily resistance or strength exercise may lead to a clinically meaningful increase in mobility measured using distance walked in six minutes (mean difference (MD) 55.65, 95% CI 28.58 to 82.72; 3 studies, 198 participants; low-certainty evidence). Training involving multiple intervention components probably leads to a substantial, clinically meaningful increase in mobility (SMD 0.94, 95% CI 0.53 to 1.34; 2 studies, 104 participants; moderate-certainty evidence). We are uncertain of the effect of aerobic training on mobility (very low-certainty evidence). No studies of other types of exercise or electrical stimulation reported mobility outcomes.

AUTHORS' CONCLUSIONS

Interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post-hospital settings, compared with conventional care. Interventions that include training of gait, balance and functional tasks are particularly effective. There was little or no between-group difference in the number of adverse events reported. Future trials should include long-term follow-up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies.

Osteoporosis management and secondary fragility fracture rates in patients with multiple sclerosis: a matched cohort study

This study highlights the persistent osteoporosis treatment gap following fragility fractures. Patients with multiple sclerosis sustained more primary hip fractures than controls and exhibited significantly higher rates of falls within three years post-fracture. However, multiple sclerosis (MS) patients were significantly more likely to be diagnosed with osteoporosis and treated with medications.

INTRODUCTION

The purpose of this study was to compare rates of osteoporosis management, falls, and secondary fractures following primary fragility fractures among patients with MS versus matched controls.

MATERIALS AND METHODS

A retrospective matched cohort study was conducted using the PearlDiver database. Patients aged ≥ 50 years with primary fragility fractures were identified (n = 120,368). Within this population, patients with MS were matched 1:10 with controls across age, sex, and US region. Rates of osteoporosis diagnoses and pharmacologic treatment, low-energy falls, and secondary fragility fractures were compared at three years post-fracture via logistic regression.

RESULTS

A total of 1,232 patients with MS (mean age, 65.7 years) with primary fragility fractures were matched with 12,320 controls (mean age, 65.8 years). Primary hip fractures were significantly more common in the MS cohort (47.4% vs. 34.2%, p < 0.001). After the initial fracture, patients with MS were significantly more likely to receive a formal osteoporosis diagnosis (12.9% vs. 9.7%; OR 1.35; 95% CI, 1.13-1.61) and osteoporosis pharmacotherapy (14.4% vs. 11.9%; OR 1.24; 95% CI, 1.04-1.46). The MS cohort also exhibited significantly higher rates of falls (27.8% vs 22.7%; OR 1.15; 95% CI, 1.01-1.32). Rates of secondary fractures were comparable (6.3% vs. 5.0%; OR 1.10; 95% CI, 0.85-1.40).

CONCLUSION

Primary hip fragility fractures were significantly more common in patients with MS compared to matched controls. Following an initial fracture, patients with MS exhibited a significantly higher rate of falls but were more likely to be diagnosed with osteoporosis and treated with medications.

Safety profile and outcome after ultrasound-guided suprainguinal fascia iliaca catheters for hip fracture: a single-centre propensity-matched historical cohort study

PURPOSE

Peripheral nerve blocks improve analgesia following hip fracture; however, there are little published data on safety and outcomes of continuous regional anesthetic techniques. Our institution offers pre- and perioperative, anesthesiologist-delivered ultrasound-guided suprainguinal fascia iliaca catheters (FICs) to patients with hip fracture. We aimed to document the safety profile of this technique and establish whether there are any significant clinical benefits in outcomes measured by the UK National Hip Fracture Database.

METHODS

We performed a single-centre historical cohort study of 2,187 patients admitted to our institution with hip fracture over a 5.75-year period. Of these, 915 were treated with FIC and 1,272 received standard care (single-shot block). To control for baseline differences between these two cohorts, we used propensity score matching and exact matching, resulting in two well-matched groups of 728 patients treated with an FIC and standard care.

RESULTS

No serious complications were observed as a result of an FIC. Unplanned removal occurred in 146/852 (17.1%) patients with documented data. No differences in 30-day mortality, pressure ulcer rates, or hospital length of stay were observed between the matched groups. The percentage of patients who were discharged to their usual residence was 79.3% in the FIC cohort vs 75.1% in the standard care cohort (difference, 4.2%; 95% confidence interval, -0.1 to 8.4; P = 0.06).

DISCUSSION

Our single-centre propensity-matched historical cohort study suggests that ultrasound-guided suprainguinal fascia iliaca catheterization is a safe technique for patients with hip fracture and that our service is deliverable and sustainable within the UK's National Health Service. This study did not show statistically significant differences in outcomes between patients treated with FIC and standard care. An adequately powered multicentre randomized controlled trial comparing these approaches is warranted.

Risk for osteoporosis and fracture with glucocorticoids

Glucocorticoid use is ubiquitous and is associated with multiple adverse reactions. Among them, osteoporosis and bone fractures are of our concern. In this review, we present current evidence on the effect of glucocorticoids on bone mineral density and the risk of fractures, the mechanisms underlying those effects, and the recommendations for monitoring and treating patients who take them. The bone mineral density of the lumbar spine and total hip is lower, and the risk of fractures is higher in glucocorticoid users than non-users. These effects have a rapid onset, are dose-dependent, and improve soon after discontinuation of glucocorticoids. They also appear to occur even with non-systemic routes of administration and with low doses. Glucocorticoids reduce bone mineral density by increasing osteoclast activity and decreasing osteoblast and osteocyte activity. Calcium metabolism and parathyroid hormone activity are less important than was initially thought. Treatment decisions are on risk stratification using clinical, radiographic, and prediction tools. Our armamentarium for the treatment and prevention of glucocorticoid-induced osteoporosis includes calcium and vitamin D, bisphosphonates, recombinant parathyroid hormone, monoclonal antibodies against receptor activator of nuclear factor kappa-B ligand, and hormone treatments.

Clinical Score for Predicting the Risk of Poor Ambulation at Discharge in Fragility Femoral Neck Fracture Patients: A Development Study

Surgical treatment in patients with fragility femoral neck fractures often leads to a longer length of hospital stay (LOS) and higher costs. Intensive rehabilitation is one of the choices to reduce LOS, but patient selection criteria are controversial. We intended to develop a clinical score to predict the risk of poor ambulation at discharge. This study was based on a retrospective cohort of patients diagnosed with fragility femoral neck fractures surgically managed from January 2010 to December 2019 at Chiang Mai University (CMU) Hospital. Pre-, intra-, and post-operative factors that affect rehabilitation training were candidate predictors. All patients were categorized into able or unable groups based on their ability to bear self-weight at discharge. Logistic regression was used for score derivation. Five hundred and nine patients were included in this study. Male sex, end-stage kidney disease (ESRD), cerebrovascular disease, psychiatric disorders, pre-fracture ambulation with gait aids, concomitant fracture, post-operative intensive care unit (ICU) admission or ventilator use, and urinary catheter use at second day post-operation were identified as the prognostic factors. The score showed an AuROC of 0.84 with good calibration. The score can be used for risk stratification on the second day post-operation. External validation is encouraged before clinical implementation.

The Impact of Hip Fracture on Geriatric Care and Mortality Among Older Swedes: Mapping Care Trajectories and Their Determinants

In this study, we examined the impact of hip fractures on trajectories of home care, nursing home residence, and mortality among individuals aged 65 years or more and explored the impacts of living arrangements, cohabitation, frailty, and socioeconomic position on these trajectories. Based on a linkage of nationwide Swedish population registers, our study included 20,573 individuals with first hip fracture in 2014-2015. Care trajectories during the 2 years following the fracture were visualized and compared with those of 2 hip-fracture-free control groups drawn from the general population: age- and sex-matched controls and health-matched controls identified through propensity score matching. Multistate modeling was employed to identify sociodemographic and health-related factors associated with care trajectories among hip fracture patients. We found that hip fracture patients already had worse health than the general population before their fracture. However, when controlling for prefracture health, hip fractures still had a considerable impact on use of elder-care services and mortality. Comparisons with the health-matched controls suggest that hip fractures have an immediate, yet short-term, impact on care trajectories. Long-term care needs are largely attributable to poorer health profiles independent of the fracture itself. This emphasizes the importance of adequate comparison groups when examining the consequences of diseases which are often accompanied by other underlying health problems.

Synthesis of the evidence on the impact of pre-operative direct oral anticoagulants on patient health outcomes after hip fracture surgery: rapid systematic review

PURPOSE

To synthesise the evidence on the impact of pre-operative direct oral anticoagulants (DOACs) on health outcomes for patients who sustain a hip fracture.

METHOD

A rapid systematic review of three databases (MEDLINE, Embase and Scopus) for English-language articles from January 2000 to August 2021 was conducted. Abstracts and full text were screened by two reviewers and articles were critically appraised. Data synthesis was undertaken to summarise health outcomes examined for DOAC users versus a no anticoagulant group. Key information was extracted for study type, country and time frame, population and sample size, type of DOACs, comparator population(s), key definitions, health outcome(s), and summary study findings.

RESULTS

There were 21 articles identified. Of the 18 studies that examined time to surgery, 12 (57.1%) found DOAC users had a longer time to surgery than individuals not using anticoagulants. Five (83.3%) of six studies identified that DOAC users had a lower proportion of surgery conducted within 48 h Four (40.0%) of ten studies reporting hospital length of stay (LOS) identified a higher LOS for DOAC users. Where reported, DOAC users did not have increased mortality, blood loss, transfusion rates, complication rates of stroke, re-operation or readmissions compared to individuals not using anticoagulants.

CONCLUSIONS

The effect of DOAC use on hip fracture patient health was mixed, although patients on DOACs had a longer time to surgery. The review highlights the need for consistent measurement of health outcomes in patients with a hip fracture to determine the most appropriate management of patients with a hip fracture taking DOACs.

Handgrip Strength as a Predictor of Successful Rehabilitation After Hip Fracture in Patients 65 Years of Age and Above

Purpose

It is important to identify factors associated with the outcome of rehabilitation after hip fracture as an aid to planning the rehabilitation framework and the future discharge of patients. Previous studies have shown that handgrip strength (HGS) is one of the factors associated with the success of rehabilitation.

Materials and Methods

A retrospective study among patients 65 years of age and above who underwent surgical repair of a hip fracture followed by rehabilitation in the Geriatrics ward between September 2019 and December 2021. Successful rehabilitation was determined as Montebello Rehabilitation Factor Score Revised (MRFS-R) ≥50%. Associations were assessed between various sociodemographic and clinical variables, including HGS, and rehabilitation success. HGS was tested as a continuous and dichotomous variable, in accordance with various definitions of low muscle strength.

Results

Data were collected for 173 patients. The mean age was 81.2 ± 7.2 years and 68.2% were women. In a logistic regression model only HGS, as a continuous variable, was independently associated with rehabilitation success, with each increase of 1 kg increasing the chance for successful rehabilitation by 6.8%.

Conclusion

HGS is a simple tool for the planning of the rehabilitation process among patients with hip fracture.

Community Reintegration After Rehabilitation for Hip Fracture: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the effect of rehabilitation on the physical, social, and psychological dimensions of community reintegration after hip fracture.

DATA SOURCES

Electronic databases Embase, EMCare, MEDLINE, PsycINFO, Cumulative Index to Nursing and Allied Health, and SPORTDiscus were searched from the earliest date available to second June 2021.

STUDY SELECTION

Searching identified 1844 potentially relevant articles. Twenty randomized controlled trials evaluating physical retraining, cognitive retraining, and model of care interventions on physical, social and psychological aspects of community reintegration for 3075 adults after hip fracture were included.

DATA EXTRACTION

Data were extracted using predetermined templates for participant characteristics, intervention type and setting, and outcomes related to community reintegration. Methodological quality was assessed using the Physiotherapy Evidence Database scale, and the Grading of Recommendations, Assessment, Development, and Evaluations approach was applied to each meta-analysis.

DATA SYNTHESIS

Post intervention data were pooled to calculate risk ratios (RRs), mean differences, standardized mean differences, and 95% confidence intervals (CIs) using inverse variance methods and a random-effects model. Compared with usual care or no rehabilitation, there was moderate-quality evidence to suggest that physical retraining interventions improved outdoor mobility (RR, 1.45; 95% CI, 1.09-1.91; I2=0%) and moderate-quality evidence to suggest that physical retraining improved Nottingham Extended Activities of Daily Living Scale scores (physical and social reintegration) by a mean 3.5 units (95% CI, 0.99-6.01; I2=0%). Meta-analyses showed no significant effect for cognitive retraining and model of care interventions on any dimension of community reintegration.

CONCLUSIONS

Preliminary evidence suggests that physical rehabilitation after hip fracture improves physical and social aspects of community reintegration. The effect of psychological and home-based interventions on community reintegration is currently unclear. Further research is needed to determine the effect of rehabilitation on community reintegration, using interventions and measures that encompass all dimensions of community reintegration.

[Development of the inpatient quality of care of surgically treated patients with a proximal femoral fracture in North Rhine-Westphalia : Analysis of 61,249 treatment courses based on data from external inpatient quality assurance]

BACKGROUND AND OBJECTIVE

Every year in Germany over 100,000 people, mostly of older age, suffer a proximal femoral fracture. Increasing case numbers in connection with an aging population and a relatively large number of concomitant diseases requiring treatment make everyday care more difficult. It is therefore of great importance to observe the quality of care for these patients using relevant quality parameters in order to be able to derive implications for everyday treatment practice.

MATERIAL AND METHODS

The data of the external inpatient quality assurance from North Rhine-Westphalia for the years 2007-2008 and 2017-2018 were analyzed and the time periods compared. In addition, based on the documented secondary diagnosis and other influencing parameters, a risk adjustment was carried out with the aid of a logistic regression model with respect to the outcomes of general and surgical complications and mortality. Both osteosynthetically and endoprosthetically treated patients were taken into account. A total of 61,249 cases were included in the study.

RESULTS

Positive developments could be observed in the area of surgical complications and wound infections with decreases of 1.2% and 0.8%, respectively. Patients with cardiovascular diseases had a particularly poor outcome. Here, improvements in the subcategory of cardiovascular events were found for general complications. The mortality remained unchanged at 6%. Operative activity on the weekends increased significantly. Patients whose hospital admission was related to the weekend did not show an increased risk of complications or mortality. Although the proportion of patients who were operated on after more than 48 h was reduced from 11.4% to 8.2%, the operation (> 24 h) was still delayed in 26.8% of cases.

CONCLUSION

Against the background of increasing performance demands on the healthcare system, the results document improvements in some central areas of inpatient treatment. Nevertheless, the development of strategies for the further reduction of the preoperative waiting times in a medically justifiable manner is required. Internal concomitant diseases have a decisive influence on patient outcome. Thus, an adequate treatment of the multimorbid patient collective is to be established in everyday practice on the basis of close cooperation between geriatric traumatology and geriatric internal medicine departments.

Evaluation of a Novel Multidisciplinary Preoperative Workup Strategy for Geriatric Hip Fractures

OBJECTIVE

To determine the financial and clinical impact of a standardized, multidisciplinary team for surgical clearance and optimization in geriatric hip fracture patients.

DESIGN

Retrospective case series.

SETTING

Level-1 trauma center.

PATIENTS

One hundred twenty-four geriatric patients (age >65 years old) in the preprotocol group (cohort 1; January 2017-December 2018) and 98 geriatric patients in the postprotocol group (cohort 2; October 2019-January 2021) with operative hip fractures.

INTERVENTION

Implementation of a multidisciplinary team protocol consisting of Anesthesiology, Internal Medicine and Orthopedic Surgery departments for the assessment of medical readiness and optimization for surgical intervention in geriatric hip fractures.

MAIN OUTCOME MEASURES

Rate of cardiology consultation, need for cardiac workup (echocardiography stress testing, heath catheterization), time to medical readiness (TTMR), time to surgery, case-cancellation rate, length of stay (LOS), and total hospitalization charges.

RESULTS

Following implementation of the new protocol, there were significant ( P < 0.001) decreases in TTMR (19 vs. 11 hours), LOS (149 vs. 120 hours), case cancellation rate, and total hospital charges ($84,000 vs. $62,000). There were no significant differences with respect to in-hospital complications or readmission rates/mortality rates at 1 year.

CONCLUSIONS

Following implementation of a protocolized, multidisciplinary approach to optimizing geriatric fracture patients, we were able to demonstrate a reduction in unnecessary preoperative testing, TTMR for surgery, case cancellation rate, LOS, and total hospitalization charge-without a concomitant increase in complications or mortality. This study highlights that standardization of the perioperative care for geriatric hip fracture patients can provide effective patient care while also lowering financial and logistical burden in care for these injuries.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The potential of assessment based on the WHO framework of intrinsic capacity in fragility fracture prevention

The risk of falls associated with population ageing and the burden of chronic diseases increase the risk of fragility fractures. Globally, a large increase in the numbers of people sustaining fragility fractures is predicted. The management of highly vulnerable older persons who present and/or are at risk of fragility fractures is challenging given their clinical complexity and the fragmentation of the healthcare services. Fragility fractures frequently result in reduced functional ability and quality of life. Therefore, it is essential to implement person-centered models of care to address the individual's priorities and needs. In this context, the multidimensional construct of intrinsic capacity, composed of the critical functions on which the individual's functional ability rely, becomes of particular interest.In this article, the potential of current models to meet the global challenge is considered, particularly where healthcare systems are less integrated and poorly structured. It then describes how assessment of intrinsic capacity might provide the clinician with a holistic picture of an older individual's reserves before and after a fragility fracture and the implications of implementing this approach based on the construct of intrinsic capacity in healthcare systems, in both well-developed and low-resourced settings. It suggests that optimization of intrinsic capacity and functional ability is a credible conceptual model and might support a generally feasible approach to primary and secondary fracture prevention in older people.

Hypoxia Preconditioned Serum (HPS) Promotes Osteoblast Proliferation, Migration and Matrix Deposition

Interest in discovering new methods of employing natural growth factor preparations to promote bone fracture healing is becoming increasingly popular in the field of regenerative medicine. In this study, we were able to demonstrate the osteogenic potential of hypoxia preconditioned serum (HPS) on human osteoblasts in vitro. Human osteoblasts were stimulated with two HPS concentrations (10% and 40%) and subsequently analyzed at time points of days 2 and 4. In comparison to controls, a time- and dose-dependent (up to 14.2× higher) proliferation of osteoblasts was observed after 4 days of HPS-40% stimulation with lower lactate dehydrogenase (LDH)-levels detected than controls, indicating the absence of cytotoxic/stress effects of HPS on human osteoblasts. With regards to cell migration, it was found to be significantly faster with HPS-10% application after 72 h in comparison to controls. Further osteogenic response to HPS treatment was evaluated by employing culture supernatant analysis, which exhibited significant upregulation of OPG (Osteoprotegerin) with higher dosage (HPS-10% vs. HPS-40%) and longer duration (2 d vs. 4 d) of HPS stimulation. There was no detection of anti-osteogenic sRANKL (soluble Receptor Activator of NF-κB Ligand) after 4 days of HPS stimulation. In addition, ALP (alkaline phosphatase)-enzyme activity, was found to be upregulated, dose-dependently, after 4 days of HPS-40% application. When assessing ossification through Alizarin-Red staining, HPS dose-dependently achieved greater (up to 2.8× higher) extracellular deposition of calcium-phosphate with HPS-40% in comparison to controls. These findings indicate that HPS holds the potential to accelerate bone regeneration by osteogenic promotion of human osteoblasts.