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Liu SY, Li C, Zhang PX. Enhanced recovery after surgery for hip fractures: a systematic review and meta-analysis. Perioper Med (Lond) 2021; 10:31. [PMID: 34511117 PMCID: PMC8436561 DOI: 10.1186/s13741-021-00201-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 06/22/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs have achieved promising results in many surgical specialties. However, uncertainty still remains regarding the effect of ERAS on hip fractures. The objective of this review was to investigate the clinical prognosis of ERAS programs in terms of (1) hospital-related endpoints (time to surgery [TTS], length of stay [LOS]), (2) readmission rate, (3) complications, and (4) mortality. METHODS Published literature was searched in the PubMed, EMBASE, and Cochrane Library databases. All of the included studies met the inclusion criteria. The primary outcomes were TTS and LOS. The secondary outcomes included the 30-day readmission rate, overall complication rate, specific complication rate (delirium and urinary tract infection), and 30-day and 1-year mortality. Language was restricted to English. The data analysis was carried out by Review Manager 5.3. RESULTS A total of 7 published studies (9869 patients) were finally included, and these were all cohort studies. The meta-analysis showed that the TTS, LOS, and overall complication rate were significantly reduced in the ERAS group compared with the control group (p < 0.01). Moreover, no significant change was found in the 30-day readmission rate or 30-day and 1-year mortality. CONCLUSIONS ERAS significantly decreases the TTS, LOS, and complication rate without increasing readmission rate and mortality, which adds to the evidence that the implementation of ERAS is beneficial to patients undergoing hip fracture repair surgeries.
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Affiliation(s)
- Song-Yang Liu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Ci Li
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Pei-Xun Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China.
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2
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Wilson N, Hurkmans E, Adams J, Bakkers M, Balážová P, Baxter M, Blavnsfeldt AB, Briot K, Chiari C, Cooper C, Dragoi R, Gäbler G, Lems W, Mosor E, Pais S, Simon C, Studenic P, Tilley S, de la Torre J, Stamm TA. Prevention and management of osteoporotic fractures by non-physician health professionals: a systematic literature review to inform EULAR points to consider. RMD Open 2021; 6:rmdopen-2019-001143. [PMID: 32144136 PMCID: PMC7059534 DOI: 10.1136/rmdopen-2019-001143] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/02/2020] [Accepted: 02/05/2020] [Indexed: 12/29/2022] Open
Abstract
Objective To perform a systematic literature review (SLR) about the effect of non-pharmacological interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures. Methods Eight clinical questions based on two criteria guided the SLR: (1) adults≥50 years at high risk of osteoporotic fracture and (2) interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures. Interventions focused on diagnostic procedures to identify risk of falling, therapeutic approaches and implementation strategies. Outcomes included fractures, falls, risk of falling and change in bone mineral density. Systematic reviews and randomised controlled trials were preferentially selected. Data were synthesised using a qualitative descriptive approach. Results Of 15 917 records, 43 articles were included. Studies were clinically and methodologically diverse. We identified sufficient evidence that structured exercise, incorporating progressive resistance training delivered to people who had undergone hip fracture surgery, and multicomponent exercise, delivered to people at risk of primary fracture, reduced risk of falling. The effectiveness of multidisciplinary fracture liaison services in reducing refracture rate was confirmed. There was insufficient evidence found to support the effectiveness of nutrients and falls prevention programmes in this patient population. Conclusion Despite study heterogeneity, our SLR showed beneficial effects of some interventions delivered by non-physician health professionals and the positive impact of multidisciplinary team working and patient educational approaches to prevent and manage osteoporotic fractures. These results informed a EULAR taskforce that developed points to consider for non-physician health professionals to prevent and manage osteoporotic fractures.
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Affiliation(s)
- Nicky Wilson
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Emailie Hurkmans
- Department Social Affaire and Health, ECORYS Nederland BV, Rotterdam, Zuid-Holland, Netherlands
| | - Jo Adams
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Margot Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe, Zurich, Switzerland
| | - Petra Balážová
- EULAR Young PARE, Zurich, Switzerland.,Slovak League Against Rheumatism, Piestany, Slovakia
| | - Mark Baxter
- Medicine for Older People, University Hospital Southampton, Southampton, UK
| | | | - Karine Briot
- INSERM U1153, Paris Descartes University, Reference Center for Genetic Bone Diseases, Department of Rheumatology, Cochin Hospital, Paris, France
| | - Catharina Chiari
- Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Wien, Austria
| | - Cyrus Cooper
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Razvan Dragoi
- Department of Balneology, Rehabilitation and Rheumatology, University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
| | - Gabriele Gäbler
- Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Wien, Austria
| | - Willem Lems
- Department of Rheumatology, VU University Medical Centre Amsterdam, Amsterdam, Noord-Holland, Netherlands
| | - Erika Mosor
- Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Sandra Pais
- School of Health (ESSUAlg), University of Algarve, Faro, Portugal
| | - Cornelia Simon
- Department of Balneology, Rehabilitation and Rheumatology, University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
| | - Paul Studenic
- Department of Internal Medicine 3, Division of Rheumatology, Medical University Vienna, Vienna, Austria
| | - Simon Tilley
- Trauma & Orthopaedics, University Hospital Southampton, Southampton, UK
| | - Jenny de la Torre
- Centre for Biomedical Research, Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Tanja A Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
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3
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Morri M, Forni C, Guberti M, Chiari P, Pecorari A, Orlandi AM, Gazineo D, Bozzo M, Ambrosi E. Post-hospital care pathway for individuals with hip fracture: what is the optimal setting and rehabilitation intensity? An observational study. Disabil Rehabil 2021; 44:4241-4248. [PMID: 33725460 DOI: 10.1080/09638288.2021.1897692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Health systems are using ever-increasing resources on treating hip fractures. Optimal post-hospital care needs to be defined to design an effective care pathway. The aim of the present study was to describe the post-hospital care pathway of individuals with hip fracture and to assess its association with the degree of recovery of independence achieved four months after surgery. MATERIALS AND METHODS A prognostic multicentric cohort study was conducted. All patients aged 65 years and over who were admitted with a diagnosis of fragility hip fracture were enrolled. After the hospital discharge, the patients were followed either at an inpatient rehabilitation facility with an intensive or extensive regimen, a nursing home, a long-term care facility or at home. Among the various care pathways, the intensity of rehabilitation differed according to its duration, frequency of sessions, and activities proposed. Primary outcome was the patient's degree of independence achieved four months after surgery, as measured with Activities of Daily Living scale. Several covariates were collected to test the correlation between the different post-hospital care pathways and the recovery of independence. RESULTS A total of 923 patients completed the follow-up. A post- hospital rehabilitation pathway was indicated for 88.2% of the patients. The extensive rehabilitation pathway, indicated for 36.7% of the patients, was the most common. The intensive rehabilitation pathway gave better results in terms of independence at four-month follow up, leading to a median ADL score of 1.4 (95% CI 1.0-2.0). The other care pathways did not show significant difference between each other. CONCLUSIONS High-intensity rehabilitation was associated to better results in terms of recovering of Activities of Daily Living.IMPLICATIONS FOR REHABILITATIONPost-hospital care pathways that include an intensive rehabilitation treatment should be improved/supported to make them available to a larger number of hip fracture patients.Patient selection criteria for post-hospital rehabilitation pathways should be standardized to optimize available healthcare resources.A cost-effectiveness analysis should be performed to analyze the economic sustainability of each post-hospital care pathway.
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Affiliation(s)
- Mattia Morri
- Servizio di Assistenza Infermieristica, Tecnica e Riabilitativa, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
| | - Cristiana Forni
- Servizio di Assistenza Infermieristica, Tecnica e Riabilitativa, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
| | - Monica Guberti
- Azienda USL- IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Paolo Chiari
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italia
| | | | - Antonella Magli Orlandi
- Servizio di Assistenza Infermieristica, Tecnica e Riabilitativa, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
| | - Domenica Gazineo
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italia
| | - Maria Bozzo
- Azienda USL- IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Elisa Ambrosi
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italia
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Adams J, Wilson N, Hurkmans E, Bakkers M, Balážová P, Baxter M, Blavnsfeldt AB, Briot K, Chiari C, Cooper C, Dragoi RG, Gäbler G, Lems W, Mosor E, Pais S, Simon C, Studenic P, Tilley S, de la Torre-Aboki J, Stamm TA. 2019 EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older. Ann Rheum Dis 2021; 80:57-64. [PMID: 32332077 PMCID: PMC7788058 DOI: 10.1136/annrheumdis-2020-216931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To establish European League Against Rheumatism (EULAR) points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older. METHODS Points to consider were developed in accordance with EULAR standard operating procedures for EULAR-endorsed recommendations, led by an international multidisciplinary task force, including patient research partners and different health professionals from 10 European countries. Level of evidence and strength of recommendation were determined for each point to consider, and the mean level of agreement among the task force members was calculated. RESULTS Two overarching principles and seven points to consider were formulated based on scientific evidence and the expert opinion of the task force. The two overarching principles focus on shared decisions between patients and non-physician health professionals and involvement of different non-physician health professionals in prevention and management of fragility fractures. Four points to consider relate to prevention: identification of patients at risk of fracture, fall risk evaluation, multicomponent interventions to prevent primary fracture and discouragement of smoking and overuse of alcohol. The remaining three focus on management of fragility fractures: exercise and nutritional interventions, the organisation and coordination of multidisciplinary services for post-fracture models of care and adherence to anti-osteoporosis medicines. The mean level of agreement among the task force for the overarching principles and the points to consider ranged between 8.4 and 9.6. CONCLUSION These first EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older serve to guide healthcare practice and education.
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Affiliation(s)
- Jo Adams
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Nicky Wilson
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Emalie Hurkmans
- Department Care I, Musculoskeletal System & Neurology, Dutch National Health Care Institute, Diemen, The Netherlands
| | - Margot Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Petra Balážová
- EULAR Young PARE, Zurich, Switzerland
- Slovak League Against Rheumatism, Piestany, Slovakia
| | - Mark Baxter
- Medicine for Older People, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Karine Briot
- INSERM U1153, Paris Descartes University, Reference Center for Genetic Bone Diseases - Department of Rheumatology, Cochin Hospital, Paris, France
| | - Catharina Chiari
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Razvan Gabriel Dragoi
- Rehabilitation, Physical Medicine and Rheumatology, 'Victor Babes' University of Medicine and Pharmacy, Timisoara, Timisoara, Romania
| | - Gabriele Gäbler
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Willem Lems
- Department of Rheumatology, VU University Medical Centre Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Erika Mosor
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Sandra Pais
- Centre for Biomedical Research, Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Cornelia Simon
- Department of Balneology, Rehabilitation and Rheumatology, 'Victor Babes' University of Medicine and Pharmacy, Timisoara, Timisoara, Romania
| | - Paul Studenic
- Internal Medicine 3, Division of Rheumatology, Medical University Vienna, Vienna, Austria
| | - Simon Tilley
- Medicine for Older People, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Trauma & Orthopaedics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Tanja A Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute Arthritis and Rehabilitation, Vienna, Austria
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Lee KJ, Um SH, Kim YH. Postoperative Rehabilitation after Hip Fracture: A Literature Review. Hip Pelvis 2020; 32:125-131. [PMID: 32953704 PMCID: PMC7476786 DOI: 10.5371/hp.2020.32.3.125] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/06/2020] [Accepted: 05/06/2020] [Indexed: 01/15/2023] Open
Abstract
As the proportion of elderly individuals within the population grows, the incidence of hip fractures increases. Traditionally, orthopedic surgeons used to focus on surgical treatment of hip fractures; however, the field's appreciation for the importance of postoperative rehabilitation has been increasing recently. Many studies have shown that proper rehabilitation after hip fracture surgery can shorten hospital stays and improve clinical outcomes. However, such studies use different methods and published rehabilitation protocols address varying aspects that do not always overlap. Here, we review and summarize the latest guidelines and studies on postoperative rehabilitation of elderly patients with hip fractures.
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Affiliation(s)
- Kyung-Jae Lee
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Sang-Hyun Um
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Young-Hun Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
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6
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Effectiveness of regional clinical pathways on postoperative length of stay for hip fracture patients: A retrospective observational study using the Japanese Diagnosis Procedure Combination database. J Orthop Sci 2020; 25:127-131. [PMID: 30799165 DOI: 10.1016/j.jos.2019.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/29/2019] [Accepted: 02/04/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Regional clinical pathways, a new type of clinical pathway, are practiced with the aim of standardizing and optimizing medical care by cooperation among multiple medical institutions in a region. However, current evaluation of the effectiveness of regional clinical pathways for hip fracture, a major health problem requiring hospitalization for orthopedic surgery, is insufficient. This study aimed to determine the association between regional clinical pathways and postoperative hospital length of stay (LOS) among hip fracture patients. In particular, we focused on the variation in postoperative LOS of hip fracture patients among hospitals and the contribution of regional clinical pathways to this variation. METHODS Using data from the Diagnosis Procedure Combination (DPC) database in Japan from April 2011 to March 2013, patients who were diagnosed with "fracture of head and neck of femur" (ICD10 code S72.0) or "pertrochanteric fracture" (S72.1) and received "bipolar hip arthroplasty" or "open reduction and internal fixation" were extracted. A total of 110,133 patients were included. Associations between regional clinical pathways and postoperative LOS were analyzed using cross-sectional analysis with multilevel regression models. RESULTS Hospitals that implemented a regional clinical pathway showed a significant reduction (13 days) in the postoperative LOS of hip fracture patients. We found a 16% inter-hospital variation in postoperative LOS, which might be explained by hospital-level implementation of regional clinical pathways. Application of regional clinical pathways at the patient level resulted in a 4-day decrease in postoperative LOS. CONCLUSIONS Implementation of regional clinical pathways for hip fracture patients at the hospital level was associated with reduced postoperative LOS, regardless of whether or not pathways were implemented at the patient level. This suggests that regional clinical pathways are effective for patient care management in hospitals.
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Kalmet PHS, de Joode SGCJ, Fiddelers AAA, Ten Broeke RHM, Poeze M, Blokhuis T. Long-term Patient-reported Quality of Life and Pain After a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture: A Retrospective Comparative Cohort Study. Geriatr Orthop Surg Rehabil 2019; 10:2151459319841743. [PMID: 31218092 PMCID: PMC6557012 DOI: 10.1177/2151459319841743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 03/01/2019] [Accepted: 03/13/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction There is an increase in incidence of hip fractures in the ageing population. The implementation of multidisciplinary clinical pathways (MCP) has proven to be effective in improving the care for these frail patients, and MCP tends to be more effective than usual care (UC). The aim of this study was to analyze potential differences in patient-reported outcome among elderly patients with hip fractures who followed MCP versus those who followed UC. Materials and Methods This retrospective cohort study included patients aged 65 years or older with a low-energy hip fracture, who underwent surgery in the Maastricht University Medical Center, Maastricht, the Netherlands. Two cohorts were analyzed; the first one had patients who underwent UC in 2012 and the second one contained patients who followed MCP in 2015. Collected data regarded demographics, patient-reported outcomes (Short Form 12 [SF-12] and the Numeric Rating Scale [NRS] to measure pain), and patient outcome. Results This cohort study included 398 patients, 182 of them were included in the MCP group and 216 were in the UC group. No differences in gender, age, or American Society of Anesthesiologists classification were found between the groups. No significant differences were found in SF-12 and the NRS data between the MCP group and UC group. In the MCP group, significantly lower rates of postoperative complications were found than in the UC group, but mortality within 30 days and one year after the hip fracture was similar in both groups. Discussion Although the effects of hip fractures in the elderly on patient-reported outcome, pain and quality of life have been addressed in several recent studies, the effects of MCP on long-term outcome was unclear. Conclusion A multidisciplinary clinical pathway approach for elderly patients with a hip fracture is associated with a reduced time to surgery and reduced postoperative complications, while no differences were found in quality of life, pain, or mortality.
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Affiliation(s)
- Pishtiwan H S Kalmet
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stijn G C J de Joode
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Audrey A A Fiddelers
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rene H M Ten Broeke
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martijn Poeze
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Taco Blokhuis
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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8
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery. Anesth Analg 2019; 128:1107-1117. [PMID: 31094775 DOI: 10.1213/ane.0000000000003925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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Affiliation(s)
- Ellen M Soffin
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Samantha S Ko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher L Wu
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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9
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Tedesco D, Gibertoni D, Rucci P, Hernandez-Boussard T, Rosa S, Bianciardi L, Rolli M, Fantini MP. Impact of rehabilitation on mortality and readmissions after surgery for hip fracture. BMC Health Serv Res 2018; 18:701. [PMID: 30200950 PMCID: PMC6131904 DOI: 10.1186/s12913-018-3523-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 09/05/2018] [Indexed: 12/15/2022] Open
Abstract
Background Hip fracture in elderly patients is a rising global public health concern because of population ageing, and increasing frailty. Long-term morbidity related to poor management of hip fracture is associated with decreased quality of life, survival, and increase in healthcare costs. Receiving postoperative rehabilitation is associated with better outcomes and a higher likelihood of returning to pre-existing level of functioning. However little is known about which postoperative rehabilitation pathways are more effective to optimize patient outcomes. Few studies have analyzed postoperative rehabilitation pathways in a universal healthcare system. The aim of this study is to analyze the impact of post-acute rehabilitation pathways on mortality and readmission in elderly patients undergoing surgery for hip fracture in a large metropolitan area in Italy. Methods In this retrospective cohort study, we analyzed 6-month mortality from admission and 6-month readmission after hospital discharge in patients who underwent surgical repair for hip fracture in the hospitals of the Bologna metropolitan area between 1.1.2013 and 30.6.2014. Data were drawn from the regional hospital discharge records database. Kaplan-Meier estimates and multiple Cox regression were used to analyze mortality as a function of rehabilitation pathways. Multiple logistic regression determined predictors of readmission. Results The study population includes 2208 patients, mostly women (n = 1677, 76%), with a median age of 83.8 years. Hospital rehabilitation was provided to 519 patients (23.5%), 907 (41.1%) received rehabilitation in private inpatient rehabilitation facilities (IRF) accredited by the National Health System, and 782 (35.4%) received no post-acute rehabilitation. Compared with patient receiving hospital rehabilitation, the other groups showed significantly higher mortality risks (no rehabilitation, Hazard Ratio (HR) = 2.19, 95%CI = 1.54–3.12, p < 0.001; IRF rehabilitation, HR = 1.66, 95%CI = 1.54–1.79, p < 0.001). The risk of readmission did not differ significantly among rehabilitation pathways. Conclusions Intensive hospital rehabilitation was significantly associated with a lower risk of mortality compared to IRF rehabilitation and no rehabilitation. Our results may help in the development of evidence-based recommendations aimed to improve resource utilization and quality of care in hip fracture patients. Further research is warranted to investigate the impact of the rehabilitation pathway on other outcomes, such as patients’ functional status and quality of life.
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Affiliation(s)
- Dario Tedesco
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy.
| | - Dino Gibertoni
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy
| | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University, 1265 Welch Road, 94305, Stanford, California, USA
| | - Simona Rosa
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy
| | - Luca Bianciardi
- Rizzoli Orthopedic Institute, Via Giulio Cesare Pupilli, 40138, Bologna, Italy
| | - Maurizia Rolli
- Rizzoli Orthopedic Institute, Via Giulio Cesare Pupilli, 40138, Bologna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy
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10
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Su B, Newson R, Soljak H, Soljak M. Associations between post-operative rehabilitation of hip fracture and outcomes: national database analysis (90 characters). BMC Musculoskelet Disord 2018; 19:211. [PMID: 29986698 PMCID: PMC6038238 DOI: 10.1186/s12891-018-2093-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 05/15/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Rehabilitation programmes are used to improve hip fracture outcomes. There is little published trial clinical trial or population-based data on the effects of the type or provider of rehabilitation treatments on hip fracture outcomes. We evaluated the associations of rehabilitation interventions with post-operative hip fracture outcomes. METHODS Cross-sectional (2013-2015) analysis of data from the English National Hip Fracture Database (NHFD) from all 191 English hospitals treating hip fractures. Of 62,844 NHFD patients, we included 17,708 patients with rehabilitation treatment and 30-day mobility data, and 34,142 patients with rehabilitation treatment and discharge destination data. The intervention was early mobilisation rehabilitation treatments delivered by a physiotherapist (PT, physical therapist in North America) or other clinical staff as identifiable in NHFD. We used ordinal logistic and propensity scoring regression models to adjust for confounding variables including age, sex, pre-fracture mobility, operative delay, and cognitive function and peri-operative risk scores. RESULTS In both the adjusted multivariate and propensity-weighted analyses, mobilisation on the day or the day following surgery is associated with better mobility function 30 days after discharge. However patients mobilised by a PT did not have better mobility compared to mobilisation by other professionals. Patients who received a PT assessment were not protected from poorer mobility 30 days after discharge, compared with those who did not receive an assessment. The discharge destination outcome is also better in mobilised than unmobilised patients, whether done by a PT or another health professional, and the difference persists, slightly attenuated, after propensity weighting. CONCLUSIONS In addition to the type of health professional initiating mobilisation, data on rehabilitation treatment activity and post-operative gait speed is needed to determine optimum rehabilitation dosage and functional outcome. After adjustment patients mobilised by non-PTs did as well as patients mobilised by PTs, suggesting that PTs' current roles in very early rehabilitation should be reconsidered, with a view to redeploying them to more specialised later rehabilitation activity.
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Affiliation(s)
- Bowen Su
- Department of Primary Care & Public Health, School of Public Health, Imperial College London, W6 8RP, London, UK
| | - Roger Newson
- Department of Primary Care & Public Health, School of Public Health, Imperial College London, W6 8RP, London, UK
| | - Harry Soljak
- Department of Anaesthetics, St Peter's Hospital, Chertsey, KT16 0PZ, UK
| | - Michael Soljak
- Department of Primary Care & Public Health, School of Public Health, Imperial College London, W6 8RP, London, UK.
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 308232, Singapore.
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11
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Morri M, Chiari P, Forni C, Orlandi Magli A, Gazineo D, Franchini N, Marconato L, Giamboi T, Cotti A. What Factors Are Associated With the Recovery of Autonomy After a Hip Fracture? A Prospective, Multicentric Cohort Study. Arch Phys Med Rehabil 2018; 99:893-899. [DOI: 10.1016/j.apmr.2018.01.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/10/2018] [Accepted: 01/17/2018] [Indexed: 11/30/2022]
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12
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Silent slips, trips and broken hips in the under 60s: A review of the literature. Int J Orthop Trauma Nurs 2018; 30:23-30. [PMID: 29807819 DOI: 10.1016/j.ijotn.2018.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 01/22/2018] [Accepted: 02/22/2018] [Indexed: 11/24/2022]
Abstract
This critical review of the literature regarding the recovery experiences and healthcare needs of people under 60 following a fragility hip fracture seeks to identify the associated implications for nursing practice and inform care delivery. Forty papers were included following a structured database, citation and grey literature search and filtering of results in line with specified inclusion criteria. Hip fracture is a common, serious and complex injury and an important cause of morbidity, mortality and rising healthcare costs worldwide. This review indicates that although commonly associated with the elderly, incidence and impact in the under 60s has been under-explored. Current health policy, professional and social norms almost exclusively focus on the elderly, surgical interventions and short-term outcomes, rendering the under 60s an inadvertently marginalised, relatively 'silent' sub-set of the hip fracture population. Nurses must be aware, however, of the different recovery needs of this younger group. The limited evidence available indicates these include work related needs and long term physical and psychosocial limitations in this socially and economically active group. Priorities are identified for research to inform policy and practice. Meanwhile, nurses can address the needs of this group by listening to and involving them and their families as healthcare partners.
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13
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Kristensen PK, Thillemann TM, Søballe K, Johnsen SP. Are process performance measures associated with clinical outcomes among patients with hip fractures? A population-based cohort study. Int J Qual Health Care 2017; 28:698-708. [PMID: 27591269 DOI: 10.1093/intqhc/mzw093] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 07/19/2016] [Indexed: 12/21/2022] Open
Abstract
Objectives To examine the association between process performance measures and clinical outcome among patients with hip fracture. Design Nationwide, population-based follow-up study. Setting Public Danish hospitals. Participants A total of 25 354 patients 65 years or older who were admitted with a hip fracture in Denmark between 2010 and 2013. Intervention The process performance measures, including systematic pain assessment, early mobilization, basic mobility assessment at arrival and at discharge, post-discharge rehabilitation program, anti-osteoporotic medication and prevention of future fall accidents measures, were analysed individually as well as an opportunity-based score defined as the proportion of all relevant performance measures fulfilled for the individual patient (0-50%, 50-75% and 75-100%). Main Outcome Measures Thirty-day mortality, 30-day readmission after discharge and length of stay (LOS). Results Fulfilling 75-100% of the relevant process performance measures was associated with lower 30-day mortality (22.6% vs. 8.5%, adjusted odds ratio (OR) 0.31 (95% CI: 0.28-0.35)) and lower odds for readmission (21.7% vs. 17.4%, adjusted OR 0.78 (95% CI: 0.70-0.87)). The overall opportunity score for quality of care was not associated with LOS (adjusted OR 1.00 (95% CI: 0.98-1.04)). Mobilization within 24 h postoperatively was the process with the strongest association with lower 30-day mortality, readmission risk and shorter LOS. Conclusions Higher quality of in-hospital care and in particular early mobilization was associated with a better clinical outcome, including lower 30-day mortality, among patients with hip fracture.
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Affiliation(s)
- Pia Kjaer Kristensen
- Department of Orthopedic Surgery, Horsens Hospital, Sundvej 30, DK-8700 Horsens, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Tage-Hansens Gade, DK-8200 Aarhus N, Denmark
| | - Theis Muncholm Thillemann
- Department of Orthopedic Surgery, Aarhus University Hospital, Tage-Hansens Gade , DK-8200 Aarhus N, Denmark
| | - Kjeld Søballe
- Department of Orthopedic Surgery, Aarhus University Hospital, Tage-Hansens Gade , DK-8200 Aarhus N, Denmark
| | - Søren Paaske Johnsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, DK-8200 Aarhus N, Denmark
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14
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Smith WR, Stoneback JW, Morgan SJ, Stahel PF. Is immediate weight bearing safe for periprosthetic distal femur fractures treated by locked plating? A feasibility study in 52 consecutive patients. Patient Saf Surg 2016; 10:26. [PMID: 27980675 PMCID: PMC5142343 DOI: 10.1186/s13037-016-0114-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 12/01/2016] [Indexed: 12/27/2022] Open
Abstract
Background Periprosthetic distal femur fractures associated with total knee replacement are increasing in incidence. We hypothesized that a standardized management protocol would result in few implant failures and a low rate of postoperative complications. Methods Retrospective observational cohort study at an urban level 1 trauma center and academic level 2 trauma center. Consecutive patients with periprosthetic distal femur fractures and stable total knee arthroplasty were included between January 1, 2011 and December 31, 2014. Patients were managed by a standardized protocol of co-management by a hospitalist service, fracture fixation within 24 h of admission by less-invasive locked bridge plating, and immediate unrestricted postoperative weight bearing. The primary outcome measure was the rate of postoperative complications. Secondary outcome measures included time to surgery, intraoperative blood loss, duration of surgery, length of hospital stay, time to full weight bearing, and time to radiographic fracture healing. Results Fifty four fractures were treated in 52 patients. There were three implant failures, one deep infection, one nonunion and two patients with symptomatic malunion. One patient had knee pain due to patellar component instability associated with valgus alignment. There were ten thromboembolic complications despite consistent anticoagulation. Two patients died within 12 months of injury. Thirty-eight patients had returned to their pre-injury ambulation status at 1 year follow-up. Conclusion A standardized approach of less-invasive locked plating fixation and immediate unrestricted weight bearing appears safe and feasible in the management of this vulnerable patient cohort. Trial registration number This is a retrospective observational study without a Trial registration number.
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Affiliation(s)
- Wade R Smith
- Mountain Orthopaedic Trauma Surgeons (MOTUS), Swedish Medical Center, Englewood, CO USA
| | - Jason W Stoneback
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO USA
| | - Steven J Morgan
- Mountain Orthopaedic Trauma Surgeons (MOTUS), Swedish Medical Center, Englewood, CO USA
| | - Philip F Stahel
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO USA ; Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, Denver, CO 80204 USA
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15
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Gesar B, Hommel A, Hedin H, Bååth C. Older patients' perception of their own capacity to regain pre-fracture function after hip fracture surgery - an explorative qualitative study. Int J Orthop Trauma Nurs 2016; 24:50-58. [PMID: 27554953 DOI: 10.1016/j.ijotn.2016.04.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 03/29/2016] [Accepted: 04/03/2016] [Indexed: 10/21/2022]
Abstract
AIMS AND OBJECTIVES To explore healthy older patients' perceptions of their own capacity to regain pre-fracture function in the acute phase following hip fracture surgery. BACKGROUND The incidence of hip fractures is expected to increase. In Sweden, of the patients who sustain a hip fracture, 40 per cent are healthy and lived independently pre fracture. However, a hip fracture often results in declined functional outcomes for 40 per cent of these patients. DESIGN The study had an explorative inductive qualitative design. METHODS Semi-structured interviews (n = 30) were conducted two to five days after hip fracture surgery. Data were analysed using manifest inductive content analysis. RESULTS As a description of patients' perception of their own capacity to regain pre-fracture function after a hip fracture, one main category emerged: To end up in a new situation with or without control. Patients expressed that they believed in recovery and thought nothing would be altered. However, since they had to adapt to the ward culture at the acute hospital, they became passive and became insecure about their future life situation. CONCLUSION The attitudes of staff at the acute hospital can influence the outcome for hip fracture patients. Patients believe in recovery but do not receive psychological support to regain physical capacity.
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Affiliation(s)
- Berit Gesar
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Ami Hommel
- Department of Health Sciences, Lund University, Lund, Sweden.
| | - Hanne Hedin
- Department of Orthopaedics, Falun Hospital, Falun, Sweden
| | - Carina Bååth
- Department of Health Sciences, Karlstad University, Karlstad, Sweden; County Council of Varmland, Karlstad, Sweden
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16
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Kalmet PHS, Koc BB, Hemmes B, Ten Broeke RHM, Dekkers G, Hustinx P, Schotanus MG, Tilman P, Janzing HMJ, Verkeyn JMA, Brink PRG, Poeze M. Effectiveness of a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture: A Multicenter Comparative Cohort Study. Geriatr Orthop Surg Rehabil 2016; 7:81-5. [PMID: 27239381 PMCID: PMC4872184 DOI: 10.1177/2151458516645633] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: The use of a multidisciplinary clinical pathway (MCP) for patients with hip fracture tends to be more effective than usual care (UC). The aim of this study was to evaluate the effects of an MCP approach on time to surgery, length of stay, postoperative complications, and 30-day mortality, compared to UC. Materials and Methods: This multicenter retrospective cohort study included patients aged 50 years or older with a proximal hip fracture who underwent surgery in one of the 6 hospitals in the Limburg trauma region of the Netherlands in 2012. Data such as demographics, process outcome measures, and clinical outcome were collected. Results: This study included a total of 1193 patients (665 and 528 patients in the MCP and UC groups, respectively). There were no differences in patient demographics present. Time to surgery was significantly shorter in the MCP compared to the UC group (19.2 vs 24.4 hours, P < .01). The mean length of stay was 10 versus 12 days (P < .01). In the MCP group, significantly lower rates of postoperative complications were observed and significantly more patients were institutionalized than in the UC group. Mortality within 30 days after admission was comparable between the groups (overall mortality 6%). Conclusion: An MCP approach is associated with reduced time to surgery, postoperative complications, and length of stay, without a significant difference in 30-day mortality. The institutionalization rate was significantly higher in the MCP group.
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Affiliation(s)
- P H S Kalmet
- Department of Surgery and Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - B B Koc
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Sittard Geleen, the Netherlands
| | - B Hemmes
- Department of Surgery and Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - R H M Ten Broeke
- Department of Orthopaedic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - G Dekkers
- Department of Orthopaedic Surgery, Laurentius Hospital, Roermond, the Netherlands
| | - P Hustinx
- Department of Surgery and Trauma Surgery, Zuyderland Medical Centre, Heerlen, the Netherlands
| | - M G Schotanus
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Sittard Geleen, the Netherlands
| | - P Tilman
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Sittard Geleen, the Netherlands
| | - H M J Janzing
- Department of Surgery and Trauma Surgery, VieCuri Medical Centre, Venlo, the Netherlands
| | - J M A Verkeyn
- Department of Surgery and Trauma Surgery, St Jans Gasthuis, Weert, the Netherlands
| | - P R G Brink
- Department of Surgery and Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M Poeze
- Department of Surgery and Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
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