[One-year outcomes for proximal femoral fractures: Posthospital analysis of mortality and care levels based on health insurance data]

Prognostic Equations and Accuracy of a Total Score of Functional Independence Measure at Discharge for Different Diseases in a Convalescent Rehabilitation Ward

OBJECTIVES

Prognosis and goal setting from admission in the convalescent rehabilitation ward, supported by a multidisciplinary team, enhance rehabilitation and discharge support. Predicting functional independence measure (FIM) outcomes can further optimize these processes. This study aimed to develop prognostic equations for the motor FIM at discharge for stroke, hip fracture (HF), vertebral compression fractures (VCFs), and total knee arthroplasty (TKA), which are common diseases in patients admitted to convalescent rehabilitation wards, using multiple regression analysis, and to clarify the difference in the accuracy of the predicted motor FIM according to the disease.

METHODS

This study included 965 patients admitted to our hospital. The objective variable consists of the motor FIM at discharge, and the explanatory variables were age, sex, days from onset to admission, total admission motor FIM, and total admission cognitive FIM. A stepwise multiple regression analysis was performed. The analysis of the difference in the accuracy of predicted motor FIM by disease used the absolute value of the residuals.

RESULTS

The total motor FIM and cognitive FIM at admission were extracted for all four diseases included in this study. The absolute value of the residuals appeared to be more accurate for TKA, HF, stroke, and VCF in that order.

CONCLUSIONS

Although differences in the accuracy of the prediction equation were observed by disease, this prediction equation can be used as an approach to review the details of rehabilitation and discharge and can be tailored to each case.

Anticoagulant Medication in Endoprosthetically Treated Proximal Femur Fracture - Complications and Mortality Considering the Time of Treatment as a Quality Criterion

There is an international debate on the optimal time to surgery following hip fracture in older patients. Pre-existing anticoagulation seems to be a major concern when it comes to a delay in operative fracture treatment. The aim of this study was to examine complication and mortality rates for elderly anticoagulated hip fracture patients considering early (< 24 h) vs. delayed (> 24 h) surgery.Our Analysis is based on data of the external inpatient quality assurance of North Rhine Westphalia as the most populous German federal state. We identified 13,201 hip fracture patients with antithrombotic medication and a minimum age of 65 years treated from January 2015 to December 2017.Delayed surgery was associated with significantly higher rates of general and surgical complications as well as mortality. Except for pre-existing heart failure, we were not able to identify certain comorbidities that could clearly indicate, why there might have been a delay.In most cases, patients with antithrombotic medication have a poor outcome to be expected due to serious comorbidity. If there was a delay in surgery for those patients, treatment results were even worse. Thus, surgery with a delay of > 24 h must be avoided to reduce the risk of complications.

[One-year outcomes after proximal humeral fractures : A risk-adjusted regression analysis of routine data based on 17,322 cases]

BACKGROUND

Proximal humeral fractures (PHF) are the third most common fracture in geriatric traumatology. No standard evidence-based treatment has been established so far. The epidemiology and economic burden highlight the importance of a targeted treatment strategy.

OBJECTIVE

Epidemiology of PHF and analysis of the influence of preoperative length of stay, comorbidities and quality of patient life. Additionally, a comparison to the more frequently studied proximal femoral fractures.

MATERIAL AND METHODS

A routine data analysis of 17,322 cases admitted for inpatient treatment with an observational period of 1 year was performed following an established model. Descriptive statistics included comorbidities, treatment procedures and mortality. Analytical statistics using logistic regression with the primary endpoints of early revision, mortality and decubitus within 1 year.

RESULTS

In the investigated PHFs there was a mortality of 13% within 1 year, which is increased three-fold in patients with comorbidities such as cancer. There was an increase of 57% in patients who first received a care level following PHF. A preoperative care level in general significantly decreased survival. The most frequently used surgical procedure was fixation via stable-angle plate (used in 43%). The preoperative length of stay did not impact survival.

DISCUSSION

Intrinsic factors such as preoperative comorbidities are crucial for the mortality after PHF. The PHF affects patients' lives less than proximal femoral fractures. With comparable comorbidity profiles, possible reasons are the lower levels of immobilization and less dependency on care before the fracture in comparison to proximal femoral fractures.

Delay of total joint replacement is associated with a higher 90-day revision rate and increased postoperative complications

PURPOSE

Delay of elective surgeries, such as total joint replacement (TJR), is a common procedure in the current pandemic. In trauma surgery, postponement is associated with increased complication rates. This study aimed to evaluate the impact of postponement on surgical revision rates and postoperative complications after elective TJR.

METHODS

In a retrospective analysis of 10,140 consecutive patients undergoing primary total hip replacement (THR) or total knee replacement (TKR) between 2011 and 2020, the effect of surgical delay on 90-day surgical revision rate, as well as internal and surgical complication rates, was investigated in a university high-volume arthroplasty center using the institute's joint registry and data of the hospital administration. Moreover, multivariate logistic regression models were used to adjust for confounding variables.

RESULTS

Two thousand four hundred and eighty TJRs patients were identified with a mean delay of 13.5 ± 29.6 days. Postponed TJR revealed a higher 90-day revision rate (7.1-4.5%, p < 0.001), surgical complications (3.2-1.9%, p < 0.001), internal complications (1.8-1.2% p < 0.041) and transfusion rate (2.6-1.8%, p < 0.023) than on-time TJR. Logistic regression analysis confirmed delay of TJRs as independent risk factor for 90-day revision rate [OR 1.42; 95% CI (1.18-1.72); p < 0.001] and surgical complication rates [OR 1.51; 95% CI (1.14-2.00); p = 0.04].

CONCLUSION

Alike trauma surgery, delay in elective primary TJR correlates with higher revision and complication rates. Therefore, scheduling should be performed under consideration of the current COVID-19 pandemic.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

[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.

Prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO): study protocol for a randomized, controlled, outcome assessor-blinded trial

BACKGROUND

Frailty is expressed by a reduction in physical capacity, mobility, muscle strength, and endurance. (Pre-)frailty is present in up to 42% of the older surgical population, with an increased risk for peri- and postoperative complications. Consequently, these patients often suffer from a delayed or limited recovery, loss of autonomy and quality of life, and a decrease in functional and cognitive capacities. Since frailty is modifiable, prehabilitation may improve the physiological reserves of patients and reduce the care dependency 12 months after surgery.

METHODS

Patients ≥ 70 years old scheduled for elective surgery or intervention will be recruited in this multicenter, randomized controlled study, with a target of 1400 participants with an allocation ratio of 1:1. The intervention consists of (1) a shared decision-making process with the patient, relatives, and an interdisciplinary and interprofessional team and (2) a 3-week multimodal, individualized prehabilitation program including exercise therapy, nutritional intervention, mobility or balance training, and psychosocial interventions and medical assessment. The frequency of the supervised prehabilitation is 5 times/week for 3 weeks. The primary endpoint is defined as the level of care dependency 12 months after surgery or intervention.

DISCUSSION

Prehabilitation has been proven to be effective for different populations, including colorectal, transplant, and cardiac surgery patients. In contrast, evidence for prehabilitation in older, frail patients has not been clearly established. To the best of our knowledge, this is currently the largest prehabilitation study on older people with frailty undergoing general elective surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04418271 . Registered on 5 June 2020. Universal Trial Number (UTN): U1111-1253-4820.

[Survival of proximal femoral fractures vs. mean life expectancy of the general population : Retrospective analysis of 1000 geriatric patients minimum 10 years after operation]

BACKGROUND

Surgery for geriatric proximal femoral fractures (PF) is associated with high mortality rates within the first year. Studies with follow-up of at least 10 years after surgery are lacking.

MATERIAL AND METHODS

Based on our database, we reviewed patients with PF who underwent surgery and were followed for a minimum of 10 years. Only patients aged 65-99 years were included. The primary endpoint was survival compared to the mean life expectancy of the general population evaluated by the German Federal Statistical Office. The secondary endpoint was any revision later than 1 year after surgery. After a minimum of 10 years telephone calls were conducted with living patients or their relatives.

RESULTS

From a total of 1203 consecutive patients 1000 patients with 1000 PF were evaluated after a mean of 12.2 years (range 10.0-14.0 years). The mean survival was 4.5 ± 1.6 years, and the 10-year survival rate was 13.1%. A total of 7 periods with a range of 5 years were analyzed, starting from 65-69 years up to 95-99 years. Compared to the mean life expectancy of the general population, the survival rate of the sample was significantly shorter up to 9 years. Both genders were equally affected. With increasing age, this gap declined based on shorter life expectancy. A subgroup analysis revealed that patients with survival > 1 year did not demonstrate significantly better results. Revisions later than 1 year after the index surgery were infrequent, and only 27 (2.7%) were recorded.

CONCLUSION

Geriatric patients with PF have significantly shorter life expectancy than the general population evaluated by the German Federal Statistical Office. This reflects fragility and morbidity of patients with PF.

[Risk factors affecting mortality in patients with hip fractures at a regional trauma center]

BACKGROUND

Primary care hospitals and regional trauma centers play an essential role in the treatment of hip fractures.

OBJECTIVE

This study investigated the relationship between patient-related parameters and in-hospital mortality as well as complications of hip fractures at a regional trauma center.

METHODS

In a retrospective study, data were collected from all patients > 60 years admitted over 2 years to a regional trauma center with a hip fracture. Patient-related parameters included age, sex, fracture location, method of surgical treatment, time of surgery, duration of surgery, length of inpatient stay, blood transfusion, complications, comorbidities, use of anticoagulant medication and need for postoperative intensive care treatment. The relationship between these parameters and hospital mortality as well as complications was investigated.

RESULTS

Data were collected from 360 patients undergoing 335 surgeries (f:m 225:110) with a mean age of 83 ± 8 years. The total in-hospital mortality rate was 7.76% (n = 26). Factors increasing in-hospital mortality included: age > 85 years (odds ratio [OR] 5.126; 95% confidence interval [CI] 0.665-39.498; p = 0.1167); male sex (OR 1.85 95%-CI [0.82-4.14]; p = 0.0555); time of surgery > 24 h (OR 1.896 95%-CI [0.661-5.441]; p = 0.2341); ≥ 3 comorbidities (OR 10.61 95%-CI [3.681-27.501]; p < 0.0001); intake of anticoagulants (OR 6.19 95%-CI [2.69-14.24]; p < 0.0001) and postoperative intensive care (OR 5.9 95%-CI [2.56-13.76]; p < 0.0001).

CONCLUSION

In the present study a statistically significant influence of the number of comorbidities or Charlson comorbidity index, the intake of anticoagulant drugs and need for postoperative intensive care treatment on the in-hospital mortality of patients with proximal femoral fractures in a regional trauma center was found.

Time to Surgery and Outcome in the Treatment of Proximal Femoral Fractures

BACKGROUND

It has not been conclusively established whether, or to what extent, the time to surgery affects mortality and the risk of complications after the surgical treatment of proximal femoral fractures.

METHODS

Data on 106 187 hospitalizations over the period 2015-2017 involving insurees of the German AOK health insurance company aged 20 and above were drawn from pseudonymized billing data and stratified in three subgroups: osteosynthesis for pertrochanteric fracture (PTF-OS: N = 52 358), osteosynthesis for femoral neck fracture (FNF-OS: N = 7970), and endoprosthesis for femoral neck fracture (FNF-EP: N = 45 859). Multivariate regression models were used to analyze the relation between preoperative in-hospital stay (time to surgery, TTS: 0 days [reference category], 1, 2, 3, 4-7 days) and mortality and general complications within 90 days, with risk adjustment for fracture site, operative method, age, sex, accompanying illnesses, and antithrombotic medication in the preceding year.

RESULTS

Mortality was significantly elevated only with PTF-OS, and only with a TTS of 2 days (odds ratio: 1.12 [95% confidence interval: (1.02; 1.23)]). General complications in relation to TTS were significantly elevated in the following situations: PTF-OS: 2 days: OR 1.24 [1.13; 1.37], 3 days: OR 1.33 [1.11; 1.60], 4-7 days: OR 1.47 [1.21; 1.78]; FNF-EP: 3 days: OR 1.21 [1.06; 1.37], 4-7 days: OR 1.42 [1.25; 1.62]; FNF-OS: 4-7 days: OR 1.86 [1.26; 2.73].

CONCLUSION

A prolonged time to surgery is associated with an elevated general complication risk depending on the site of the fracture and the type of surgical procedure used.

Cost-effectiveness of group-based exercise to prevent falls in elderly community-dwelling people

BACKGROUND

Clinical studies indicate that strength-balance training for active fall prevention can prevent fractures in older people. The present modelling study evaluates the cost-effectiveness of fall prevention exercise (FPE) provided to independently living older people compared to no intervention in Germany.

METHOD

We designed a Markov model to evaluate the cost-effectiveness of a group-based FPE-program provided to independently living people ≥75 years from the perspective of the German statutory health insurance (SHI). Input data was obtained from public databases, clinical trials and official statistics. The incremental cost-effectiveness ratio (ICER) was presented as costs per avoided hip fracture. Additionally, we performed deterministic and probabilistic sensitivity analyses and, estimated monetary consequences for the SHI in a budget impact analysis (BIA).

RESULTS

For women, the costs per hip fracture avoided amounted to €52,864 (men: €169,805). Results of deterministic and probabilistic sensitivity analyses confirmed the robustness of the results. According to the BIA, for the reimbursement of FPE additional costs of €3.0 million (women) and €7.8 million (men) are expected for the SHI.

CONCLUSIONS

Group-based FPE appears to be no cost-effective option to prevent fall-related hip fractures in independently living elderly. To allow a more comprehensive statement on the cost effectiveness of FPE fracture types other than hip should be increasingly evaluated in clinical trials.

[Routine Practice Data for Evaluating Intervention Effects: Part 2 of the Manual]

The evaluation of intervention effects is an important domain of health services research. The ad hoc commission for the use of routine practice data of the German Network for Health Services Research (DNVF) therefore provides this second part of its manual focusing on the use of routine practice data for the evaluation of intervention effects. First, we discuss definition issues and the importance of contextual factors. Subsequently, general requirements for planning, data collection and analysis as well as concrete examples for the evaluation of intervention effects for the 3 fields of application regarding pharmacotherapy, nonpharmaceutical interventions as well as complex interventions are elaborated. We consider scenarios in which no information from randomized controlled trials (RCTs) comparing the two groups directly is yet available or in which RCTs are already available but an extension of the research question is required. In all examples either with or without randomization, the first and foremost question is always whether the data source is suitable for the specific research question. Most of the examples chosen are from oncology trials, because the necessary data are already available for Germany, at least in some form. Finally, the manual discusses possible challenges for future use of these data.

Two-thousand hip fractures treated within 12 h and > 12-24 h after admission: Are survival and adverse events affected?

BACKGROUND

The effects of immediate operation on hip fracture (HF) are unclear. Therefore, we investigated the influence of time to operation within 12 h vs. > 12-24 h on survival and adverse events.

METHODS

This retrospective study was based on our database from 2006 to 2019. Patients ≥ 20 years of age with operations for HF were included. A total of 40 characteristics were analyzed for operations within 12 h (group 1) and > 12-24 h (group 2) after admission. The primary endpoint was survival at 1 year after operation. Secondary endpoints were revision surgery for any reason, infection, and serious adverse events.

RESULTS

A total of 1015 patients received operations within 12 h (group 1), and 985 patients received operations > 12-24 h (group 2) after admission. The mean age of the patients was 78.8 ± 12.3 years. Patients in group 1 were younger and had better health status and shorter hospitalizations than those in group 2. However, no differences were found for revision surgery, infection or adverse events. The mortality rates at 30 days, 90 days, 6 months, and 1 year were 6.2, 11.8, 15.9, and 21.0%, respectively. The mortality rate at day 30 was significantly better (p = 0.04) in group 1, but no further differences in survival were observed (hazard ratio 1.071; 95% confidence interval 0.864-1.328; log rank 0.179). A subgroup analysis of geriatric patients ≥ 65 years assessed no differences according the primary and secondary endpoints.

CONCLUSIONS

Within the limits of single-center analysis, the patients receiving treatment for HF within 12 h were younger and healthier and had the benefits of shorter hospitalizations and a higher 30-day survival rate than patients treated > 12-24 h after admission. At the endpoint 1 year after operation, no differences were observed in adverse events or survival rates.

Cement augmentation of the proximal femur nail antirotation: is it safe?

BACKGROUND

Cement augmentation of the proximal femur nail antirotation (PFNA; Fa. DePuy Synthes) showed good biomechanical and clinical results regarding increased stability and functional outcome [Linden et al. in J Orthop Res 24:2230-2237, 2006;Kammerlander et al. in Injury 49:1436-1444, 2018;]. Cement-associated complications are well known in orthopedic procedures like hip arthroplasty, vertebra- and kyphoplasty. This study investigates outcome and safety of augmentation of the proximal femur nail blade.

MATERIALS AND METHODS

The retrospective review of the 299 patients (mean age 80 ± 13 years; 205 women and 94 men) focused on perioperative complications after augmentation which was performed with Traumacem V+ Cement (Fa. DePuy Synthes) in 152 cases. The decision for augmentation of the blade was made by the attending surgeon and based on the factors age, bone quality, and fracture pattern. Primary outcome measures were changes in blood pressure, heart rate or oxygen saturation, and the number of needed vasoactive drugs during augmentation. Secondary outcome measures where the rate of cement leakage into the joint, mechanical failure, and perioperative complications like pulmonary embolism, stroke, or heart attack.

RESULTS

In 152 augmented cases, no leakage of cement into the joint could be detected. No signs of mechanical failure like cut-out of the blade were seen after 6 weeks and 3 months. Also, augmentation did not show a higher rate of mortality or postoperative complications like stroke, heart attack, embolism, or infection. 57 of 152 augmented cases received an intraoperative intervention with vasoactive medication at the time of augmentation either prophylactically or because of a blood pressure fall. Out of the non-augmented cases, 21 of 147 needed vasoactive medication in the second half of the operation. The difference between these groups was significant (p < 0.05). In the cases without an intervention, there was a significant blood pressure fall of about 8 ± 7.4 mmHg during the augmentation (p < 0.001). Still, none of the augmented cases showed a change in heart rate or oxygen saturation.

CONCLUSION

The augmentation of the PFNA blade proved to be a safe procedure. Cement augmentation will not increase postoperative complications or mortality. The risk for leakage of cement into the joint is low and mechanical cut-out might be prevented. The decision for augmentation should be made carefully and always be declared loud and in advance to allow the anesthetist to prepare, because blood pressure changes can occur.

[Influence of timing of surgery on complication rates after cemented hemiarthroplasty for treatment of medial femoral neck fractures]

BACKGROUND

The optimal timing of the implantation of a cemented hemiarthroplasty in the management of displaced medial femoral neck fractures is still the subject of current research. According to the current recommendations, these cases should be surgically treated within 24 h. The aim of this study was to evaluate the impact of the timing of surgery on operation-specific and nonspecific complications, intensive care treatment as well as mortality.

MATERIAL AND METHODS

Overall, 152 cases were retrospectively investigated regarding several parameters (demographic data, comorbidities, surgery time, duration of hospital stay, intensive care treatment, general, bleeding, operation-specific and nonspecific complications). The statistical analysis was performed using the χ²-test and the unpaired Student's t‑test as well as logistic regression analyses.

RESULTS

A total of 152 patients were included and 71.1% of the operations were performed within 24 h and the remaining 28.9% after 24 h. All groups showed a similar profile of comorbidities. The analysis of the intensive care treatment showed no significant differences between the individual groups. The rate of postoperative pneumonia was moderately higher among the patients with a procedure after 24 h; however, with no severe courses. There were no significant differences regarding all other complications and the mortality rate between the individual time points of surgery.

CONCLUSION

The present study demonstrated that patients operated on after 24 h showed no disadvantages regarding other complications, intensive care treatment or mortality, except from an increased postoperative pneumonia rate. These results could be taken into consideration for the next update of the treatment guidelines.

[Subtrochanteric femur fractures-epidemiology, surgical procedures, influence of time to surgery and comorbidities on complications : A risk-adjusted regression analysis of routine data from 2124 cases]

BACKGROUND

There are approximately 12,000 subtrochanteric femur fractures in Germany per year with a rising trend but studies about the epidemiology and the surgical outcome are rare. Furthermore, there are no guidelines from expert societies and there is no adequate quality assurance.

OBJECTIVE

Presentation of the epidemiology and the current treatment situation with respect to the patient collective, comorbidities, time to surgery and surgical procedures used as well as the identification of modifiable risk factors with respect to complications.

MATERIAL AND METHODS

Analysis of routine data based on an established data model in 2124 cases. The descriptive statistics contain data on basic patient characteristics, such as age, comorbidities, surgical procedure, time to surgery and mortality. In the analytical statistics the impact of risk factors (surgical procedure, time to surgery etc.) on the endpoints mortality, complications and decubitus was investigated by logistical regression analyses.

RESULTS

Of the patients 55% were operated on within the first 24h. Intramedullary osteosynthesis (89%) is the most frequently used surgical method (prostheses 2%, extramedullary procedures 5%). Within the first postoperative year 37% of the patients received a higher level of care, where the care was moved from outpatient to inpatient treatment. The mortality in the first postoperative year was 26%, while early complications were observed in 6%. A delay in surgical treatment was associated with an increased mortality and intrinsic factors, which were difficult to influence. Intramedullary osteosynthesis had the lowest mortality and revision rates.

CONCLUSION

Concerning the epidemiological data, the patient collectives of subtrochanteric fractures and femoral neck or pertrochanteric fractures were very similar. Major delays in the time to surgery of subtrochanteric fractures can be associated with increased complication rates and mortality. Therefore, programs to prevent older patients from falling have a high priority.

When does hip fracture surgery delay affects the length of hospital stay?

PURPOSE

To define factors influencing length of hospital stay (LOS) besides surgery delay.

METHODS

We retrospectively analyzed 634 patients operated for hip fractures in 1-year period. Investigated characteristics were age, gender, American Society of Anesthesiologists score (ASA), time to surgery (first 48 h was considered early), type of surgery, anticoagulant therapy and non-routine pre-operative tests. Univariate and multivariable analysis were performed. p values < 0.05 were considered statistically significant.

RESULTS

Median LOS was 12 days. Patients operated within 48 h had a LOS of 10 days, while patients operated after 48 h had 4 days longer LOS (p < 0.01). In multiple regression analyses, it was predicted that patients operated after 48 h with every 10 h delay to surgery had 7.3 h longer hospitalizations. All other factors did not influence the LOS. In early operation group, patients with hip arthroplasty had 3.3 days longer hospitalization compared to patients with osteosynthesis, every higher ASA score was associated with 1.4 days longer hospitalization, patients on anticoagulant therapy had 2.6 days longer LOS but surgery delay had no influence on LOS. Preinjury residence at a nursing home was associated with 4.4 days shorter hospitalizations compared to preinjury residence at home in both time frames.

CONCLUSIONS

In patients operated in first 48 h longer LOS is associated with ASA, anticoagulant therapy and operation type but not with delay to surgery. If patients are operated after 48 h, surgery delay is the only factor increasing LOS.

[Osteosynthetic treatment of proximal femoral fractures: the timing of treatment is delayed in cases of pre-existing anticoagulation : Results of the data of external inpatient quality assurance from North Rhine-Westphalia with 24,786 cases within the framework of using secondary data]

Hintergrund und Fragestellung

Proximale Femurfrakturen stellen mit ca. 100.000 Betroffenen/Jahr in Deutschland ein häufiges Krankheitsbild dar. Durch eine zeitnahe Versorgung (<24 h) konnte die Mortalität erheblich gesenkt werden. Ziele der Arbeit waren, die Prävalenz der Antikoagulation und hiermit assoziierte Komplikationen bei osteosynthetisch versorgter, proximaler Femurfraktur und deren Impact auf die präoperative Verweildauer zu analysieren und Potenziale zum optimalen perioperativen Gerinnungsmanagements aufzuzeigen.

Material und Methoden

Die Daten der externen vergleichenden Qualitätssicherung Nordrhein-Westfalen für die Jahre 2015 und 2016 wurden ausgewertet. Dabei wurden ausschließlich Fälle analysiert, bei denen eine hüftgelenknahe Femurfraktur osteosynthetisch versorgt wurde. Insgesamt wurden 24.786 Fälle hüftgelenknaher Femurfrakturen in die Studie eingeschlossen.

Ergebnisse

Von den Patienten mit einer antithrombotischen Dauertherapie (ATDT) wurden in der größten Subgruppe mit ASS-Medikation (n = 4005) 17 %, in der zweitgrößten Gruppe mit Vitamin-K-Antagonisten-Einnahme (n = 2157) 44,6 % und in der drittgrößten Gruppe mit Einnahme von direkten oralen Antikoagulanzien (DOAKs, n = 994) 18,2 % verzögert operiert.

Schlussfolgerungen

Das größte Potenzial zur Verkürzung der präoperativen Verweildauer ergibt sich in der Gruppe der Patienten, die ASS (17 % auffällig) oder einen Vitamin-K-Antagonisten (VKA, 44,6 % auffällig) einnehmen. Eine Antagonisierung der Wirkung von VKA lässt sich innerhalb kurzer Zeit durch die Gabe von Prothrombinkomplex (PPSB) erreichen. Auch unter der Einnahme von DOAKs muss das noch gängige Prozedere einer verzögerten operativen Versorgung kritisch hinterfragt werden. Die Etablierung eines Gerinnungsmanagements ist zu fordern. Neben der medizinischen Intervention (Gabe von Antidota) müssen Strukturen geschaffen werden, die eine zeitnahe Versorgung ermöglichen.

[120-day follow-up after proximal femoral fractures-first results from the Geriatric Trauma Registry DGU®]

BACKGROUND

Geriatric trauma centers which are certified to the status of a Geriatic Trauma Center DGU® based on the criteria catalogue as outlined by the German Trauma Society (DGU), are required to participate in the Geriatric Trauma Register (ATR-DGU) for quality management and outcome analyses. The evaluation is pseudoanonymous and includes data on all treated hip fracture patients over 70 years old. This has been in regular use since 2016. This study analyzed the postoperative evaluation of gait, mortality, quality of life, hospital readmission and treatment of osteoporosis after 120 days.

METHODS

A voluntary retrospective data evaluation of the ATR-DGU 120-day follow-up from 2017 was carried out. Written consent for the analysis and publication of the data was obtained from six clinics that already participated in the follow-up. The primary target parameters were mortality rate, readmission and revision rates, gait quality, osteoporosis treatment and quality of life according to EQ-5D-3L. The patient data were completely pseudonymized and a descriptive analysis was carried out.

RESULTS

In this study 957 patients from the 6 hospitals were included. The average age was 84.5 years (±6.8 years). The mortality rate during the acute treatment phase was 5%. The 120-day follow-up could be evaluated in 412 patients, 10% of these required hospital readmission due to complications oft he same fracture and of these 6% required revision surgery. The mortality rate at 120 days was 12%. In 54% of the patients the fracture led to deterioration of mobility and 49% of patients received osteoporosis treatment after 120 days. The results of the EQ-5D-3L at 120 days revealed improvement as compared to the values on postoperative day 7; however, the preoperative status with respect to mobility and quality of life could not be regained.

CONCLUSION

Despite the clear advantages of interdisciplinary treatment, the results are still limited concerning mobilization and quality of life. Further analysis of causative and influencing factors is necessary.

Improved outcome in hip fracture patients in the aging population following co-managed care compared to conventional surgical treatment: a retrospective, dual-center cohort study

BACKGROUND

Hip fracture patients in the aging population frequently present with various comorbidities, whilst preservation of independency and activities of daily living can be challenging. Thus, an interdisciplinary orthogeriatric treatment of these patients has recognized a growing acceptance in the last years. As there is still limited data on the impact of this approach, the present study aimed to evaluate the long-term outcome in elderly hip fracture patients, by comparing the treatment of a hospital with integrated orthogeriatric care (OGC) with a conventional trauma care (CTC).

METHODS

We conducted a retrospective, two-center, cohort study. In two maximum care hospitals all patients presenting with a hip fracture at the age of ≥ 70 years were consecutively assigned within a 1 year period and underwent follow-up examination 12 months after surgery. Patients treated in hospital site A were treated with an interdisciplinary orthogeriatric approach (co-managed care), patients treated in hospital B underwent conventional trauma care. Main outcome parameters were 1 year mortality, readmission rate, requirement of care (RC) and personal activities of daily living (ADL).

RESULTS

A total of 436 patients were included (219 with OGC / 217 with CTC). The mean age was 83.55 (66-99) years for OGC and 83.50 (70-103) years for CTC (76.7 and 75.6% of the patients respectively were female). One year mortality rates were 22.8% (OGC) and 28.1% (CTC; p = 0.029), readmission rates were 25.7% for OGC compared to 39.7% for CTC (p = 0.014). Inconsistent data were found for activities of daily living. After 1 year, 7.8% (OGC) and 13.8% (CTC) of the patients were lost to follow-up.

CONCLUSIONS

Interdisciplinary orthogeriatric management revealed encouraging impact on the long-term outcome of hip fracture patients in the aging population. The observed reduction of mortality, requirements of care and readmission rates to hospital clearly support the health-economic impact of an interdisciplinary orthogeriatric care on specialized wards.

TRIAL REGISTRATION

The study was approved and registered by the bavarian medical council (BLAEK: 7/11192) and the local ethics committee of munich university (Reg. No. 234-16) and was conducted as a two-center, cohort study at a hospital with integrated orthogeriatric care and a hospital with conventional trauma care.

Hip Fractures: Therapy, Timing, and Complication Spectrum

Objective

Investigation of the treatment of femur fractures and the type of femur fracture‐associated complications regarding timing of surgery and length of hospital stay.

Methods

In this retrospective cohort study, a total of 358 hip fractures were evaluated retrospectively from 1 January 2008 until 31 December 2010 at a level I trauma center in Germany. Inclusion criteria was age >18 years and a proximal femur fracture. Both sexes were evaluated. Mean age was 75.5 years, most patients were female (63.7%). Intervention was the operative treatment of proximal femur fracture. Outcome parameters were time until surgery, complications, reoperations, mortality, and length of hospital stay.

Results

Among the proximal femur fractures (n = 358), 46.6% were pertrochanteric, 11.2% subtrochanteric, and 42.2% femoral neck fractures. Operation upon hip fractures was managed regularly within 24 hours of injury (73%; mean for femoral neck: 28.3 hrs.; mean for pertrochanteric fractures: 21.4 hrs.; mean for subtrochanteric fractures: 19.5 hrs.). Delayed treatment, as well as implantation of hip total endoprosthesis (TEP), increased the overall length of hospital stay (15.4 vs 17.6 days; 18.1 vs 15.8 days). Accordingly, surgical procedures performed within 24 hours of injury resulted in a shorter hospital residence. Longest delay of operation was measured for hip fractures (28.3 hrs.).

In 351 patients, secondary injuries were detected in 94 individuals (26%), with fractures being the most common secondary injury (n = 40). We recorded postoperative complications of nonsurgical and surgical origin, and 33.6% of our patient cohort displayed complications. Complications were distributed among 118 patients. There was no significant difference in complications regarding the time of operation, with most nonsurgical and surgical complications appearing within 24 hours after operation (n = 110 vs n = 31). Nonsurgical complications, such as anemia (n = 49) and electrolyte imbalances (n = 30), were observed more frequently than surgical complications (n = 107 vs n = 34); however, these complications were reduced by delay in surgery (82.0% in 6–24 hrs. vs 74.2% in ≥24 hrs.). Anticoagulant therapy and age did not affect postoperative complications. The hospital mortality of patients was 6.2%. Follow‐up was restrained to ambulatory visits in the clinic.

Conclusions

Surgical management of hip fractures performed within 24 hours of injury minimizes hospital stay. We did not detect significant differences in the spectrum or number of complications regarding delay of surgery. Surgical complications mainly occur with rapid primary care, and medical complications can be reduced by more intensive preparation of patient and operation procedures.

[Management of pre-existing anticoagulation for timely treatment of proximal femoral fractures]

Proximal femoral fractures are urgent indications for surgery. In cases of delayed surgical treatment more than 48 h after hospital admittance, increased rates of general complications, local complications and mortality have been proven. Since 2015, the quality target for the external quality assurance by order of the Federal Joint Committee (G-BA) is surgical treatment within 24 h after hospital admittance for osteosynthesis and within 48 h for joint replacement. The foundations for these time intervals are the S2e guidelines for the treatment of femoral neck fractures of adults from the German Society of Trauma Surgery (DGU) and the Austrian Society of Trauma Surgery (ÖGU) and several other international guidelines. The distinction of the temporal specifications between osteosynthesis and joint replacement in Germany is unusual in comparison with other countries. For 15% of each group of patients a prolonged preoperative preparation is accepted. In the structured dialog within the external quality management anticoagulants are quoted as the most frequent reason for delayed surgery. The present review provides a way to achieve compliance with statutory provisions, to minimize the risks of both bleeding and thromboembolism and to achieve surgical treatment of proximal femoral fractures within the agreed time limit.

[Online survey for assessment of geriatric early rehabilitation complex treatment in geriatric trauma centers of the DGU by the medical services of the health funds]

BACKGROUND

Orthogeriatric co-management of proximal femoral fractures has been proven to effectively reduce mortality rates. This involves extending resources in hospitals treating these patients as well as dealing with the possibility of prolonged periods of hospitalization. The increase in costs of orthogeriatric co-management are best illustrated by the implementation of geriatric early rehabilitation complex treatment. In view of the problems concerning billing this complex treatment, an online survey was carried among certified geriatric trauma centers of the German Trauma Society (DGU®).

METHODS

Based on a trauma-geriatric consensus 20 questions were formulated by the Academy of Trauma Surgery (AUC) as an online questionnaire and sent to all 75 certified geriatric trauma centers. Apart from a description of the results, a subanalysis based on the figures presented by the case closing departments (geriatrics or trauma surgery) was included. The questions covered a 2-year period of experiences from 2016 to 2018.

RESULTS

A total of 26 of the 75 certified geriatric trauma centers participated (35%). A continuous increase in cost analysis evaluations by the medical services of the health funds was observed. A rise from 38% in 2016 to 45% in 2018 was seen. An analogous rejection trend from 16% to 24% during this period was evident as well. Subanalysis revealed significantly higher cost evaluation by the medical services of the health funds and cost rejection rates if trauma departments were the case closing disciplines.

CONCLUSION

The online survey revealed significantly higher assessment and rejection rates when compared to other hospital services. This could prove potentially detrimental to the future of orthogeriatric co-management.

[Elderly trauma patients with proximal femur fractures : Statistical evaluation of regular process data from a trauma center for the elderly]

BACKGROUND/AIMS

Proximal femoral fractures are one of the most frequently occurring injuries among elderly people. High rates of inpatient treatment indicate the importance of optimized clinical care.

OBJECTIVES

Based on selected outcome parameters in elderly trauma patients with proximal femoral fractures, the current situation of medical care in a trauma center for geriatric patients is presented.

METHODS

For a descriptive evaluation of outcome parameters, 250 patients aged 70 years and older have been included. A clinical register of a trauma center for the elderly served as the database.

RESULTS

The average length of stay was approximately 25 days. Sixty-seven percent of the patients underwent surgical treatment within 24 h of admission to the hospital. More than half of the patients were taking anticoagulant drugs. Around 18 % of patients presented with one or more complications. Mortality rate was 5.2 %. Thirty-two percent of those patients who had been living at home before admission had been discharged to a nursing home.

DISCUSSION AND CONCLUSIONS

Analyzing the data of a trauma registry enables critical reflection upon the clinical outcome of interdisciplinary treatment procedures. The low rate of mortality may be a result of the geriatric co-treatment, starting right from admission. It remains unclear whether the influence of preoperative interdisciplinary treatment outweighs the effect of a timely surgical procedure.

Orthogeriatric treatment reduces potential inappropriate medication in older trauma patients: a retrospective, dual-center study comparing conventional trauma care and co-managed treatment

Background

Multimorbidity and polypharmacy are common challenges in the treatment of older trauma patients. Therefore, various integrated care models were developed over the last few years, merging the expertise of geriatricians and trauma surgeons. The aim of this study was to evaluate, if the number of prescriptions of potentially inappropriate medication (PIM) could be reduced in these patients by an interdisciplinary co-managed concept compared to conventional trauma care.

Methods

We conducted a retrospective, dual-center cohort study, including all patients aged 70 years and older admitted with a fracture of the hip or the proximal humerus within the study period. Patients were treated in the universities department of trauma surgery with two different hospital sites, one with conventional trauma care (CTC) and the other one with a certified orthogeriatric trauma unit (OGC). Based on the STOPP/START criteria by O´Mahony et al., PIMs were defined, which should be avoided in (ortho)geriatric patients. Medical records of each patient were analyzed at discharge. Besides patients basic information, all prescribed drugs, changes in the medication plan and who carried out these changes were collected. For statistical analysis based on the data quality and distribution, the t test, Mann–Whitney U test and the Chi-square test were used.

Results

A total of 95 patients were included, 73 of them females, with an average age of 82.59 years (SD ± 6.96). Mean length of hospital stay was 12.98 at CTC and 13.36 days at OGC (p = 0.536). Among conventional care (41 patients), prescription of one or more PIMs was found in 85.4% of the patients, whereas at the orthogeriatric ward (54 patients) only in 22.2% (p < 0.001). Besides that, changes in medication were made for 48.1% of the patients during their stay on the orthogeriatric ward.

Conclusions

Our findings show that an integrated care concept can reduce the number of prescriptions of PIMs significantly and potentially avoids adverse drug reactions and additional burdens in older trauma patients.

Total Hip Arthroplasty for Hip Fractures: Time to Surgery With Respect to Surgical Revision, Failure, and Mortality

Introduction

There are increasing demands to perform surgery of hip fractures without delay. However, few studies have assessed the time to surgery in relation to outcome measurements.

Methods

A total of 643 consecutive patients with a minimum age of 60 years underwent total hip arthroplasty (THA) for an intracapsular hip fracture. For this retrospective case series, demographic data and the outcome measurements-(1) any surgical revision, (2) implant failure, and (3) mortality-were documented from a prospective clinical database. The time from admission to surgery was also documented prospectively and then data were divided into 4 groups according to the time of surgery: (1) within 12 hours, (2) >12 to 24 hours, (3) >24 to 48 hours, and (4) later than >48 hours. The study end point was 2 years after surgery. Final evaluation was conducted for any missing data through a telephone interview.

Results

The patients comprised 456 women (70.9%) and 187 men (29.1%) with a mean age of 80.2 years (range 60-104 years; standard deviation ±7.4). Descriptive data were without effect in all 4 groups. Time to surgery did not significantly influence revision for any reason (P = .323), implant failure (P = .521), and mortality (P = .643). Cox regression analysis identified male sex (P < .001; 95% confidence interval (CI), 1.27-2.44), American Society of Anesthesiologists score ≥3 (P < .001; 95% CI, 2.12-21.59), C-reactive protein level >21 mg/L (P < .018; 95% CI, 1.09-2.60), hemoglobin level <12.0 g/dL (P = .033; 95% CI, 1.04-2.68), and dementia (P < .000; 95% CI, 1.50-2.86) as independent significant risk factors for mortality.

Conclusion

Time to surgery had no effect on revision for any reason, implant failure, and mortality in patients undergoing THA for an intracapsular hip fracture.

Patient Characteristics as Indicator for Care Dependence after Hip Fracture: A Retrospective Cohort Study Using Health Insurance Claims Data From Germany

OBJECTIVES

Hip fractures are common consequences of falls in older adults and, among other negative health outcomes, often lead to care dependence in the long term. Until 2016, the German long-term care insurance classified care recipients according to a standardized classification system consisting of 3 care levels. It was based on required assistance in performing activities of daily living and assessed by a qualified physician or nurse. Thus, care level reflects the degree of care dependence. The aim of this study was to determine relevant patient characteristics, which are related to the likelihood of increasing care dependence in terms of worsening care level after hip fracture.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Statutory health insurance claims data including 122,922 insured individuals living in Germany and aged 65 years or older, who sustained a hip fracture from 2009 through 2011.

MEASURES

The association of patient characteristics with worsening care level in the quarterly period after hip fracture was investigated by means of multinomial logit regression analysis. Death constitutes a competing risk and was modeled as additional nominal outcome.

RESULTS

Among all patients, crude rates were 30.9% for worsening care level, 54.8% for unchanged care level, and 14.4% for death after hip fracture. The multivariate analysis revealed that patient factors male sex, increasing age, increasing comorbidity, increasing inpatient length of stay, and a lack of inpatient rehabilitation were significantly associated with a worsening care level.

CONCLUSIONS/IMPLICATIONS

This study uses the German standardized measurement of care dependence in terms of worsening care level after hip fracture and finds various related patient characteristics. Knowledge of these characteristics helps to identify possible risk groups for care dependence after hip fracture, for which special attention can be provided regarding treatment and prevention of hip fractures.

Cost-effectiveness of a home safety intervention to prevent falls in impaired elderly people living in the community

PURPOSE

Among others, the German National Prevention Conference recently recommended the provision of preventive options for elderly to maintain their independent living. Because a home safety assessment and modification program (HSM) has shown to be effective in avoiding falls and risk of falling in elderly, the aim of this analysis was to evaluate the cost-effectiveness of HSM in patients aged ≥ 80 years who receive non-institutionalized long-term care.

METHODS

In order to reflect quality-adjusted life years (QALYs) and costs resulting from HSM, a Markov-model with a time horizon of 20 years was performed from the perspective of the German statutory health insurance (SHI) and statutory long-term care insurance (LCI). The model assumed that HSM reduces fall-related hip fractures in accordance with the reduction of the rate of falls. Data was obtained from public databases and from various literature searches. The robustness of the results was assessed in deterministic and probabilistic sensitivity analyses.

RESULTS

In women, the incremental cost-effectiveness ratio of HSM compared to no prevention was €9580 per QALY, while in men, it was €57,589. For the German SHI/LCI, in total, the provision of HSM to patients ≥ 80 years who receive non-institutionalized long-term care would result in annual costs of €7.7 million. The results were robust in several sensitivity analyses.

CONCLUSIONS

Provided that the rate of falls is a valid surrogate endpoint for the rate of fall-related hip fractures, HSM could be a promising approach for investments in preventive options targeting the reduction of fall-related fractures in elderly women.

Comparative analysis of non-simultaneous bilateral fractures of the proximal femur

PURPOSE

We performed a monocenter cohort study to determine surgical revision and mortality after sustaining an initial and a non-simultaneous contralateral proximal femoral fracture.

METHODS

We identified all patients surgically treated for a contralateral femoral fracture between 2006 and 2015. Patient demographic characteristics and follow-up were identified by our electronic database; failed information regarding revision and mortality were obtained by telephone, as well as the evaluation of the mobility for all alive patients. The endpoint of the study was set for every patient at least 2 years postoperatively.

RESULTS

Within a total of 2296 patients, we identified 250 patients (10.8%) treated for a contralateral fracture. The mean interval between the two occurrences was 5.2 years and the mean age at the time of contralateral fracture was 84.4 years. Almost every third fracture occurred later than 5 years after the initial fracture, and even every tenth fracture later than 10 years. More than 50% of the patients also had dementia at this time. The total surgical revision rate was 17.2% after initial, and 20.4% after contralateral fracture, but this difference was statistically not significant (p = 0.31). However, revisions for infection or hematoma were more than twice after contralateral fracture (p = 0.006). The 1-year mortality rate was 36%, and dementia (log rank p < 0.001) and male gender (log rank p < 0.001) were significant negative predictors for the survival rate. After a mean of 42 months, the follow-up of the 67 alive patients recorded a mean Parker Score of 5.2 items.

CONCLUSION

Contralateral femoral fracture was accompanied by a higher revision and mortality rate-but patients were also 5 years older. Dementia and male gender were significant negative variables for the survival time. In the future, the highest priority will be the prophylaxis of falling to avoid or at least to decline the number of these fractures in geriatric patients.

Odontoid Fracture in Patients Age >75 Years Surgically Managed by the Harms Technique: Bone Healing and 1-Year Mortality Rate in 57 Cases

BACKGROUND

Odontoid fracture is the most common lesion of the cervical spine in persons age >70 years. Management of these fractures has become a public health issue. In this study, we evaluated bone fusion, early complications, and mortality in a cohort of patients age >75 years who underwent surgical management of odontoid fracture using the Harms technique.

METHODS

This study is a retrospective analysis of 57 patients treated surgically between 2002 and 2016 in a single spine surgery institution. Age at diagnosis, comorbidities, and American Society of Anesthesiologists (ASA) score were analyzed. At a 6-month follow-up, bone healing was evaluated with computed tomography scans.

RESULTS

The mean patient age was 85.5 ± 6.6 years, and 53% of the patients had an ASA score ≥3. According to the Anderson classification, 70% of the patients had a type 2 odontoid fracture. The average duration of follow-up was 15.7 months. Ten patients were lost to follow-up. The rate of early complications was 19%, with no mechanical complications reported. At a 6-month follow-up, a solid bony union was seen in all patients. The 1-year mortality was 14%.

CONCLUSIONS

Surgical management of odontoid fractures in elderly patients using the Harms technique is associated with an excellent rate of bone healing with acceptable rates of early complications and mortality.

A prospective study with ten years follow-up of two-hundred patients with proximal femoral fracture

BACKGROUND

The proximal femoral fracture is one of the most common injuries in the elderly. Nevertheless, no results beyond the second year post surgery have been reported in the literature. Therefore, the purpose of this study was to evaluate any revision and mortality within 10 years follow-up as well as the walking ability of still alive patients.

METHODS

A total of 200 consecutive patients were included. A prospective database was first used to collect the demographic data. Exactly ten years after the surgery, a final evaluation was conducted by telephone for every patient. Any revision, any contralateral as well as other fractures and the date of death were recorded. For all patients who were still alive, the mobility score according to Parker was also surveyed.

RESULTS

The average age was 79.0 years (SD: 12.5); women were affected at higher numbers (73.5%). The total surgical revision rate was 17.5% (35/200), due in particular to hematoma (9×) or infection (7×). A surgical revision later than two years was only needed in three patients (1.5%). The risk of another fracture caused by a fall was 19% (38/200), most often a contralateral femoral fracture (22/200; 11%) that happened on average 51.9 months (1-97) after the initial surgery. The risk of a contralateral femoral fracture was 15.4% (22/143) in patients who survived the first year post surgery. The postoperative mortality was 1, 2, 5 and 10 years or 23.5%, 32.5%, 55% as well as 81.5%, respectively. An average Parker's mobility score of 6.3 points (0-9) was determined for the 37 patients (18.5%) who were still alive at the time of the follow-up.

CONCLUSION

The long-term study showed that revision surgery was only required in 3/200 patients (1.5%) beyond the second year of that surgery. On the other hand, more than half of all patients had already passed away five years after the initial surgery. The exact incidence of a contralateral femoral fracture was 11.9%, climbing to 15.4% if the patient survived at least one year. Nearly every fifth patient experienced another fall resulting in a severe fracture requiring treatment during the long-term course.

Total hip arthroplasty after failed osteosynthesis of proximal femoral fractures: Revision and mortality of 80 patients

PURPOSE

Total hip arthroplasty (THA) after failed osteosynthesis for proximal femoral fractures is associated with higher revision rates, particularly for dislocation. The purpose of this study was to report our results with THA after failed osteosynthesis within a treatment period of 10 years.

METHODS

A retrospective cohort study including 80 consecutive patients was conducted. After a minimum follow-up of 1 year, we evaluated revision for any cause including dislocation, outcome, and mortality.

RESULTS

We performed 48 THAs with standard components only and 32 THAs with revision implants. Routinely, a 36-mm femoral head was used, and trochanteric fixation was performed in one-third of the cases. Total revision rate for any cause was 21%, which included six infections, six periprosthetic fractures, and five hematomas. One hip dislocation was also treated. Treatment with uncemented revision stem revealed significantly higher number of revisions-compared to standard cemented or uncemented stem. The mortality rate after 1 year was 9%, and the mean Parker score at follow-up was 6.6 (range: 0-9).

CONCLUSIONS

THA was associated with an increased surgical revision rate, but hip dislocation was documented only once. In most cases, a standard implant with a large 36-mm femoral head size was sufficient. Uncemented revision stem revealed significantly higher number of revisions-compared to standard cemented or uncemented stem. One-year mortality was lower than expected.

Infection Versus Hematoma Following Surgical Treatment of Proximal Femoral Fractures in Geriatric Patients

Introduction

The surgical treatment of proximal femoral fractures predominantly involves geriatric patients and is associated with high morbidity and mortality. However, analyses on postoperative infections or hematoma are rare.

Methods

Patients requiring surgical revision due to infection (n = 90) or hematoma (n = 77) in the postoperative phase were identified from an electronic database of 2000 consecutive patients surgically treated for proximal femoral fractures between 2006 and 2014. Demographic and clinical data were retrieved, including information on the pathogens in patients with infection. A follow-up on morbidity and mortality was conducted via telephone for at least 2 years postsurgery.

Results

The follow-up rate was 100%, and the mean age was 81.9 years. The incidence rate of infection was 4.1% (90/2000), and women were commonly affected. Staphylococcus aureus and Staphylococcus epidermidis were the most commonly detected pathogens (35.5% and 25.5%, respectively). Mixed infections were observed in 15 patients, and Methicillin-resistant Staphylococcus aureus infections were observed in only 4 patients. A total of 77 (85.6%) infections occurred within 30 days postsurgery. The implant was preserved in 76 (84.4%) patients, and resection arthroplasty was required in 14 patients. Dementia and pertrochanteric fractures were significantly more common in the infection than in the hematoma group. Although infections were associated with high mortality rates for up to 2 years postsurgery, the rates did not significantly differ from those in the hematoma control group.

Conclusion

One of every 2 patients who developed an infection following the surgical treatment of a proximal femoral fracture died within 2 years postsurgery. In addition, infections were significantly associated with dementia. Avoiding postoperative infection should be a high priority in the surgical treatment of proximal femoral fractures.

Trends in the surgical management of odontoid fractures in patients above 75 years of age: Retrospective study of 70 cases

BACKGROUND

Odontoid fractures are the most common upper cervical spine fracture in adults over 70 years of age. Hence, treatment of these fractures has public health implications.

OBJECTIVES

Evaluate the early complications, bone healing and mortality in patients above 75 years of age who undergo surgical treatment of an odontoid fracture. Compare the results between patients operated with the Harms technique or anterior screw fixation.

METHODS

This was a retrospective study of 70 patients with an odontoid fracture who were treated surgically between 2000 and 2015 at the Hôpital de la Timone in France. The age at the time of diagnosis, comorbidities, ASA score and autonomy were evaluated. Bone healing was determined using computed tomography.

RESULTS

In the cohort, 22 patients underwent anterior screw fixation, 38 were treated using the Harms technique and 10 with other procedures. The average age was 85.1 years. Fifty-four percent of patients had an ASA score above 3. The average follow-up was 23.4 months. An Anderson type II fracture was present in 80.6% of patients. In the anterior screw fixation group, the operative time was significantly shorter than in the Harms group and no blood transfusions were needed. However, 13.6% of these patients had to be re-operated because the initial construct was unstable; no patients in the Harms group underwent revision surgery. There were more complications in the anterior screw fixation group than in the Harms group: 41% versus 13.2% (P<0.02). The fractures had healed in all patients reviewed after 1 year. The 3-month survival in the anterior screw fixation group was 64.7% and it was 81.3% in the Harms group. These rates were stable at 1 year with no statistical differences between groups.

CONCLUSION

Surgical treatment of odontoid fractures in the elderly results in an excellent union rate. The mortality rate is stable after 3 months. In our experience, the Harms technique has a lower risk of complications and better mechanical stability than anterior screw fixation. Despite the steep learning curve, we believe the Harms technique is probably the best choice for treating odontoid fractures in the elderly.

LEVEL OF EVIDENCE

IV.

Orthogeriatric Combined Management of Elderly Patients With Proximal Femoral Fracture: Results of a 1-Year Follow-Up

Introduction:

According to the expected demographical changes, the number of elderly trauma patients will increase exponentially over the next decades. Different models of an interdisciplinary orthogeriatric care have been developed. But there is only limited evaluation of their benefit without clear and evidence-based results. In 2011, we monitored the results of our orthogeriatric combined management by conducting a 1-year follow-up.

Methods:

We treated 231 patients presenting a proximal femoral fracture on our orthogeriatric ward. We obtained the epidemiological data and the geriatric assessments from all these patients. One year after discharge, we sent them a written questionnaire. Primary end points were the mortality and the functional outcome, measured by Barthel score, the requirement of care, and the residential status.

Results:

One hundred sixty-seven (72%) of the 231 patients completed the follow-up. The average age at admission was 81.5 years (70-99 years). The mortality rate was 2.4% during hospital stay and 31.4% after 1 year. The average Barthel score was 44 points at the time of admission, 55 points at discharge, and 72 points after 1 year. Forty-five percent of the patients were in requirement of care at the time of their admission. At the 1-year follow-up, 63% of the patients had some form of care, thus showing an increase of 18%. At the moment of the fracture, 77% of the patients were living in their own home and 23% in a nursing home. After 1 year, the surviving patients show nearly unchanged conditions (75% own home vs 25% nursing home). Eighty-six percent of the patients coming from their own home were able to continue living there independently.

Conclusion:

The orthogeriatric care is successful in reducing the short-time mortality without showing any effect on 1-year mortality. But the surviving patients seem to benefit from an improved functional outcome.

[Length of hospital stay for patients with proximal femoral fractures : Influencing factors]

BACKGROUND

In departments of orthopedic and trauma surgery patients with proximal femoral fractures constitute the largest proportion of trauma patients. The length of stay (LOS) has economic consequences and prolonged LOS leads to a shortage in bed capacity.

OBJECTIVES

In this study treatment and patient-related factors that influence the LOS of patients with proximal femoral fractures were investigated.

MATERIAL AND METHODS

Treatment and patient-related data of 242 patients (age >64 years) were recorded retrospectively and included residential aspects, legal guardianship, time of admission and surgery, hospital mortality, LOS, diagnosis, comorbidities, medication, surgical treatment, general and surgical complications, intensive care therapy and American Society of Anesthesiologists (ASA) classification.

RESULTS

Of the patients, one fifth came from a nursing home and were under supervised care or a healthcare proxy at the time of admission. Two thirds were admitted to hospital and operated on during on-call service periods. One half of the patients did not return to their previous domestic environment and were usually admitted to a nursing home. Patients who came from or were admitted to nursing homes, who were under healthcare supervision as well as patients who rapidly underwent surgery had a shorter LOS. Hospitalization and surgery during on-call service periods did not extend the LOS and showed a tendency towards reduction. Older age correlated with a longer LOS and surgical complications doubled the LOS.

DISCUSSION

Surgical treatment during on-call service periods, short preoperative waiting times and avoidance of surgical complications shortened LOS and thus had an impact on costs and bed capacity.

Peri-implant femoral fractures: The risk is more than three times higher within PFN compared with DHS

INTRODUCTION

Information is lacking regarding incidence rates, treatment regimens, and outcomes concerning peri-implant femoral fractures (PIF). Therefore, we performed a retrospective study to provide scientific data concerning incidence and outcome of PIF following osteosynthesis of proximal femoral fractures (PFF).

MATERIAL AND METHODS

We retrospectively included all patients who received osteosynthesis for PFF between 2006 and 2015 and in whom PIF was confirmed postoperatively. All available patients with PIF were contacted minimum one year post-surgery.

RESULTS

A total of 1314 osteosynthesis procedures were performed, of which 705 were proximal femoral nails (PFNs), 597 were dynamic hip screws (DHSs), and 12 were screws appliances only. During the same period, 18 PIFs (1.4%) were reported. However, PIF was 3.7 times higher within PFN when compared to DHS (15/705:2.1% versus 3/597:0.5%; odds ratio: 3.7). The following analysis also included 8 patients with PIF who were referred from other hospitals, resulting in a total of 26 patients. Mean patient age was 84.8 years (range, 57-95), with a predominance in female (23×) and in the left femur (19×). PIF occurred after an average of 23.6 months (range, 1-81) post-surgery. The fractures, most of which were spiral-shaped, were most commonly treated with locking plate osteosynthesis. The surgical revision rate was 7.7%, and the one-year mortality was 23.1%. At an average of 43.0 months (range, 12-100) post-surgery, it was possible to contact 18/26 patients (69.2%), and their mean Parker Mobility Score was 5.2 points (range 2-9).

CONCLUSIONS

Peri-implant femoral fracture is a rare incident within the old age traumatology of PFF. However, based on our small number of cases, it occurred within PFN much more frequently compared with DHS. Locking plate osteosynthesis has been shown to be effective and reliable. Surgical revision and mortality rates do not appear to be increased when compared to those with the initial treatment of proximal femoral fractures.

[Factors influencing course of hospitalization in patients with hip fractures: Complications, length of stay and hospital mortality]

BACKGROUND

Time of surgery, age, sex, and co-morbidities influence the complication and mortality rate in patients with hip fractures. Patients with relevant co-morbidities, who were hospitalized at the weekend have a higher mortality rate. Complications prolong length of stay (LOS), which results in higher costs and shortage of bed capacity.

OBJECTIVES

The influence of various factors on hospitalization with emphasis on complications, LOS, and clinical mortality should be observed.

MATERIALS AND METHODS

Retrospectively, 242 patients with hip fractures (>64a) were observed. In addition to age and sex, time of hospitalization and surgery, intensive care therapy, hospital mortality, LOS, comorbidities, ASA, and complications were recorded. Times were assigned to the work week or the weekend or regular or on-call duty service.

RESULTS

29.8 % were hospitalized at the weekend, 66.1% on on-call duty, 24.1% were operated on the weekend, 67.4% on on-call duty. 86.3% were operated <48 h after admission. The mortality rate was 8.3%. Longer time to surgery results in more frequent intensive care therapy, prolongs the LOS, and increases overall complications. Advanced age increases mortality and LOS. A higher value of the ASA classification leads to increased mortality; co-morbidities lead to more frequent intensive care therapy. Surgical complications prolong LOS of 10.8d (86.4%).

CONCLUSION

Hospitalization is influenced by age, ASA and co-morbidities as well as by time to surgery and operation in day or late and nighttime service. Early surgery and prevention of surgical complications reduce LOS.

Predictors for 1-year mortality following hip fracture: a retrospective review of 465 consecutive patients

INTRODUCTION

In Europe, trauma admissions and in particular hip fractures are on the rise. In recent years, health care systems have placed particular emphasis, including financial incentives, on delivering patients quickly and safely to surgery. At our unit, we have observed that hip fracture patients appear to be at significant risk of mortality even up to a year following injury. This study reviews a consecutive population of hip fracture patients to identify predictors of excess risk.

MATERIALS AND METHODS

Four hundred and sixty-five consecutive patients were treated over a 2-year period at our district general hospital with no ward-based orthogeriatricians. Follow-up was for 1 year following hip fracture admission. Statistical analysis of variables and their influence on 1-year mortality were performed by calculating odd's ratio (OR) using a logistic regression model and a p value <0.05 was considered statistically significant.

RESULTS

Four patients were lost to follow-up, 18 patients (4.1 %) were managed conservatively, 16 were too unwell for surgery and their mortality rate at 1 year was 50 %. Following hip fracture, we found an overall 1-year mortality rate of 15.1 %. Patients with a time to surgery ≥36 h were at significantly increased risk of mortality even up to 1 year. We did not identify a further reduction in mortality in those operated on within 24 h. Raised ORs (p > 0.05) were found with increasing comorbidity, surgery type, independence on discharge, alcohol ingestion, history of smoking, readmission and several biochemical markers.

CONCLUSION

Minimising mortality risk, even over the longer term, should begin on admission with prompt optimisation of any acute medical or biochemical abnormalities, followed by early surgery and intensive rehabilitation to maintain patients' functional independence.