Dedicated orthogeriatric service reduces hip fracture mortality. Ir J Med Sci. 2017;186:179-184. [PMID: 27059996 DOI: 10.1007/s11845-016-1453-3]

Comorbidity Patterns in Older Patients Undergoing Hip Fracture Surgery: A Comorbidity Network Analysis Study

Comorbidity network analysis (CNA) is a technique in which mathematical graphs encode correlations (edges) among diseases (nodes) inferred from the disease co-occurrence data of a patient group. The present study applied this network-based approach to identifying comorbidity patterns in older patients undergoing hip fracture surgery. This was a retrospective observational cohort study using electronic health records (EHR). EHR data were extracted from the one University Health System in the southeast United States. The cohort included patients aged 65 and above who had a first-time low-energy traumatic hip fracture treated surgically between October 1, 2015 and December 31, 2018 (n = 1,171). Comorbidity includes 17 diagnoses classified by the Charlson Comorbidity Index. The CNA investigated the comorbid associations among 17 diagnoses. The association strength was quantified using the observed-to-expected ratio (OER). Several network centrality measures were used to examine the importance of nodes, namely degree, strength, closeness, and betweenness centrality. A cluster detection algorithm was employed to determine specific clusters of comorbidities. Twelve diseases were significantly interconnected in the network (OER > 1, p-value < .05). The most robust associations were between metastatic carcinoma and mild liver disease, myocardial infarction and congestive heart failure, and hemi/paraplegia and cerebrovascular disease (OER > 2.5). Cerebrovascular disease, congestive heart failure, and myocardial infarction were identified as the central diseases that co-occurred with numerous other diseases. Two distinct clusters were noted, and the largest cluster comprised 10 diseases, primarily encompassing cardiometabolic and cognitive disorders. The results highlight specific patient comorbidities that could be used to guide clinical assessment, management, and targeted interventions that improve hip fracture outcomes in this patient group.

Perceptions regarding the multidisciplinary treatment of patients with severe trauma in Korea: a survey of trauma specialists

Purpose

Patients with multiple trauma necessitate assistance from a wide range of departments and professions for their successful reintegration into society. Historically, the primary focus of trauma treatment in Korea has been on reducing mortality rates. This study was conducted with the objective of evaluating the current state of multidisciplinary treatment for patients with severe trauma in Korea. Based on the insights of trauma specialists (i.e., medical professionals), we aim to suggest potential improvements.

Methods

An online questionnaire was conducted among 871 surgical specialists who were members of the Korean Society of Traumatology. The questionnaire covered participant demographics, current multidisciplinary practices, perceived challenges in collaboration with rehabilitation, psychiatry, and anesthesiology departments, and the perceived necessity for multidisciplinary treatment.

Results

Out of the 41 hospitals with which participants were affiliated, only nine conducted multidisciplinary meetings or rounds with nonsurgical departments. The process of transferring patients to rehabilitation facilities was not widespread, and delays in these transfers were frequently observed. Financial constraints were identified by the respondents as a significant barrier to multidisciplinary collaboration. Despite these hurdles, the majority of respondents acknowledged the importance of multidisciplinary treatment, especially in relation to rehabilitation, psychiatry, and anesthesiology involvement.

Conclusions

This survey showed that medical staff specializing in trauma care perceive several issues stemming from the absence of a multidisciplinary system for patient-centered care in Korea. There is a need to develop an effective multidisciplinary treatment system to facilitate the recovery of trauma patients.

Orthogeriatric co-managements lower early mortality in long-lived elderly hip fracture: a post-hoc analysis of a prospective study

OBJECTIVE

To evaluate the clinical effectiveness of orthogeriatric co-management care in long-lived elderly hip fracture patients (age ≥ 90).

METHODS

Secondary analysis was conducted in long-lived hip fracture patients between 2018 to 2019 in 6 hospitals in Beijing, China. Patients were divided into the orthogeriatric co-management group (CM group) and traditional consultation mode group (TC group) depending on the management mode. With 30-day mortality as the primary outcome, multivariate regression analyses were performed after adjusting for potential covariates. 30-day mobility and quality of life were compared between groups.

RESULTS

A total of 233 patients were included, 223 of whom completed follow-up (125 in CM group, 98 in TC group). The average age was 92.4 ± 2.5 years old (range 90-102). The 30-day mortality in CM group was significantly lower than that in TC group after adjustments for (2.4% vs. 10.2%; OR = 0.231; 95% CI 0.059 ~ 0.896; P = 0.034). The proportion of patients undergoing surgery and surgery performed within 48 h also favored the CM group (97.6% vs. 85.7%, P = 0.002; 74.4% vs. 24.5%, P < 0.001; respectively). In addition, much more patients in CM group could walk with or without aids in postoperative 30 days than in the TC group (87.7% vs. 60.2%, P < 0.05), although differences were not found after 1-year follow-up. And there was no significant difference in total cost between the two groups (P > 0.05).

CONCLUSIONS

For long-lived elderly hip fracture patients, orthogeriatric co-management care lowered early mortality, improved early mobility and compared with the traditional consultation mode.

The integrated structure of care: evidence for the efficacy of models of clinical governance in the prevention of fragility fractures after recent sentinel fracture after the age of 50 years

Randomized clinical trials and observational studies on the implementation of clinical governance models, in patients who had experienced a fragility fracture, were examined. Literature was systematically reviewed and summarized by a panel of experts who formulated recommendations for the Italian guideline.

PURPOSE

After experiencing a fracture, several strategies may be adopted to reduce the risk of recurrent fragility fractures and associated morbidity and mortality. Clinical governance models, such as the fracture liaison service (FLS), have been introduced for the identification, treatment, and monitoring of patients with secondary fragility fractures. A systematic review was conducted to evaluate the association between multidisciplinary care systems and several outcomes in patients with a fragility fracture in the context of the development of the Italian Guidelines.

METHODS

PubMed, Embase, and the Cochrane Library were investigated up to December 2020 to update the search of the Scottish Intercollegiate Guidelines Network. Randomized clinical trials (RCTs) and observational studies that analyzed clinical governance models in patients who had experienced a fragility fracture were eligible. Three authors independently extracted data and appraised the risk of bias in the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random-effects models. Primary outcomes were bone mineral density values, antiosteoporotic therapy initiation, adherence to antiosteoporotic medications, subsequent fracture, and mortality risk, while secondary outcomes were quality of life and physical performance.

RESULTS

Fifteen RCTs and 62 observational studies, ranging from very low to low quality for bone mineral density values, antiosteoporotic initiation, adherence to antiosteoporotic medications, subsequent fracture, mortality, met our inclusion criteria. The implementation of clinical governance models compared to their pre-implementation or standard care/non-attenders significantly improved BMD testing rate, and increased the number of patients who initiated antiosteoporotic therapy and enhanced their adherence to the medications. Moreover, the treatment by clinical governance model respect to standard care/non-attenders significantly reduced the risk of subsequent fracture and mortality. The integrated structure of care enhanced the quality of life and physical function among patients with fragility fractures.

CONCLUSIONS

Based on our findings, clinicians should promote the management of patients experiencing a fragility fracture through structured and integrated models of care. The task force has formulated appropriate recommendations on the implementation of multidisciplinary care systems in patients with, or at risk of, fragility fractures.

Functional autonomy and 12-month mortality in older adults with proximal femoral fractures in an orthogeriatric setting: risk factors and gender differences

BACKGROUND

Proximal femur fractures have a negative impact on loss of functional autonomy and mortality.

OBJECTIVE

The aim of this retrospective study was to evaluate functional autonomy and mortality in a group of older adults with hip fractures managed in an orthogeriatric setting 12 months after discharge and to determine if gender affected outcome.

METHODS

In all participants, we assessed clinical history, functional pre-fracture status using activities of daily living (ADL) and in-hospital details. At 12 months after discharge, we evaluated functional status, place of residence, hospital readmissions and mortality.

RESULTS

We studied 361 women and 124 men and we observed a significant reduction in the ADL score at 6 months (1.15 ± 1.58/p < 0.001 in women and 1.45 ± 1.66/p < 0.001 in men). One-year mortality (33.1% in men and 14.7% in women) was associated with pre-fracture ADL score and reduction in ADL at 6 months (HR 0.68/95%, CI 0.48-0.97/p < 0.05 and HR 1.70/95%, CI 1.17-2.48/p < 0.01, respectively) in women, and new hospitalisations at 6 months and polypharmacy in men (HR 1.65/95%, CI 1.07-2.56/p < 0.05 and HR 1.40/95%, CI 1.00-1.96/p = 0.05, respectively) in Cox's regression model.

DISCUSSION AND CONCLUSIONS

Our study suggests that functional loss in older adults hospitalised for proximal femur fractures is greatest in the first 6 months after discharge, and this increases the risk of death at 1 year. Cumulative mortality at 12 months is higher in men and appears to be related to polypharmacy and new hospital admissions 6 months after discharge.

Long-term outcome collection after hip fracture in Ireland: a systematic review of traditional and grey literature

This review aimed to describe the methods and results from recent Irish research about post-acute hip fracture outcomes. Meta-analyses estimate the 30-day and 1-year mortality rate at 5% and 24% respectively. There is a need for standardised recommendations about which data should be recorded to aid national and international comparisons.

PURPOSE

Over 3700 older adults experience hip fracture in Ireland annually. The Irish Hip Fracture Database national audit records acute hospital data but lacks longer-term outcomes. This systematic review aimed to summarise and appraise recent Irish studies that collected long-term hip fracture outcomes and to generate pooled estimates where appropriate.

METHODS

Electronic databases and grey literature were searched in April 2022 for articles, abstracts, and theses published from 2005 to 2022. Eligible studies were appraised by two authors and outcome collection details summarised. Meta-analyses of studies with common outcomes were conducted where the sample was generalisable to the broad hip fracture population.

RESULTS

In total, 84 studies were identified from 20 clinical sites. Outcomes commonly recorded were mortality (n = 48 studies; 57%), function (n = 24; 29%), residence (n = 20; 24%), bone-related outcomes (n = 20; 24%), and mobility (n = 17; 20%). One year post-fracture was the most frequent time point, and patient telephone contact was the most common collection method used. Most studies did not report follow-up rates. Two meta-analyses were performed. The pooled estimate for one-year mortality was 24.2% (95% CI = 19.1-29.8%, I² = 93.8%, n = 12 studies, n = 4220 patients), and for 30-day mortality was 4.7% (95% CI = 3.6-5.9%, I² = 31.3%, n = 7 studies, n = 2092 patients). Reports of non-mortality outcomes were deemed inappropriate for meta-analysis.

CONCLUSION

Hip fracture long-term outcomes collected in Irish research are broadly in line with international recommendations. Heterogeneity of measures and poor reporting of methods and findings limits collation of results. Recommendations for standard outcome definitions nationally are warranted. Further research should explore the feasibility of recording long-term outcomes during routine hip fracture care in Ireland to enhance national audit.

Preoperative Comorbidities Associated With Early Mortality in Hip Fracture Patients: A Multicenter Study

OBJECTIVE

Multiple comorbidities in hip fracture patients are associated with increased mortality and complications. The goal of this study was to characterize the relationship between specific patient factors including comorbidities and outcomes in geriatric hip fractures, including length of stay, unplanned ICU admission, discharge disposition, complications, and mortality.

METHODS

This is a retrospective review of a trauma database from five Level 1 and Level 2 trauma centers of patients with hip fractures of the femoral neck and intertrochanteric region who underwent treatment using hip pinning, hemiarthroplasty, total hip arthroplasty, cephalomedullary nailing, or dynamic hip screw fixation. Mortality was the primary outcome variable (including in-hospital mortality, 30-day mortality, 60-day mortality, and 90-day mortality). Secondary outcome variables included in-hospital adverse events, unplanned transfer to the ICU, postoperative length of stay, and discharge disposition. Regression analyses were used for evaluation of relationships between comorbidities as independent variables and primary and secondary outcomes as dependent variables.

RESULTS

Two thousand three hundred patients were included. The mortality was 1.8%, 7.0%, 10.9%, and 14.1% for in-hospital, 30-day, 60-day, and 90-day mortality, respectively. Diabetes and cognitive impairment present on admission were associated with mortality at all-time intervals. COPD was the only comorbidity that signaled in-hospital adverse event with an odds ratio of 1.67 (P = 0.012). No patient factors, time to surgery, or comorbidities signaled unplanned ICU transfer. Patients with renal failure and COPD had longer hospital stays after surgery.

CONCLUSION

Geriatric hip fractures continue to have high short-term morbidity and mortality. Identifying patients with increased odds of early mortality and adverse events can help teams optimize care and outcomes. Patients with diabetes, cognitive impairment, renal failure, and COPD may benefit from continued and improved medical optimization during the perioperative period as well as being more closely managed by a medicine team without delaying time to the operating room.

Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021

Background

Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field.

Purpose

This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline.

Methods

The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations.

Results

Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively.

Conclusions

The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.

Hypobaric Unilateral Spinal Anesthesia Versus General Anesthesia for Hip Fracture Surgery in the Elderly: A Randomized Controlled Trial

BACKGROUND

Hypotension during surgery is frequent in the elderly population and is associated with acute kidney and myocardial injury, which are, themselves, associated with increased 30-day mortality. The present study compared the hemodynamic effects of hypobaric unilateral spinal anesthesia (HUSA) to general anesthesia (GA) in patients ≥70 years of age undergoing hip fracture surgery.

METHODS

We conducted a single-center, prospective, randomized study. In the HUSA group, patients were positioned with the operated hip above, and the hypobaric anesthetic solution was composed of 9 mg ropivacaine, 5 µg sufentanil, and 1 mL of sterile water. Anesthesia was adjusted for the GA group. Mean arterial pressure (MAP) was measured with a noninvasive blood pressure upper arm cuff every 3 minutes. Hypotension was treated with a bolus of ephedrine and then a continuous intravenous of norepinephrine to obtain a MAP ≥65 mm Hg. Primary outcome was the occurrence of severe hypotension, defined as a MAP <65 mm Hg for >12 consecutive minutes.

RESULTS

A total of 154 patients were included. Severe hypotension was more frequent in the GA group compared to the HUSA group (odds ratio, 5.6; 95% confidence interval, 2.7-11.7; P < .001). There was no significant difference regarding the short-term outcomes between the HUSA and GA groups: acute kidney injury (respectively, 5.1% vs 11.3%; P = .22), myocardial injury (18.0% vs 14.0%; P = .63), and 30-day mortality (2.4% vs 4.7%; P = .65).

CONCLUSIONS

HUSA leads to fewer episodes of severe intraoperative hypotension compared to GA in an elderly population undergoing hip fracture surgery.

Evaluation of Whether Emergency Physicians Should Join the Multidisciplinary Team for Older Hip Fracture Patients

Background

Geriatric hip fracture is one of the most common end-stage events in older patients with osteoporosis. We aimed to improve the original co-management process by engaging emergency physicians in the preoperative multidisciplinary management team (MDT). We evaluated this intervention in terms of reducing patient waiting time before surgery.

Methods

Emergency Department data and hospitalization data for patients diagnosed with geriatric hip fractures in Beijing Jishuitan Hospital (JSTH) were collected and sorted into the intervention group, for whom the MDT included emergency physicians (from January 2019 to December 2019), and the control group (from January 2017 to December 2017). The percentage of patients treated with surgery within 48 h of admission was used as the primary outcome. The secondary outcomes included the time from emergency visit to admission (hours), the time from admission to discharge (days), the percentage of patients receiving surgical treatment after admission, the rate of perioperative medical complications during hospitalization, postoperative admission to the Intensive Care Unit, and total deaths during hospitalization.

Results

A total of 2,152 patients were enrolled. The rate of hypertension (58.5% vs 52.1%), coronary heart disease (24.6% vs 19.9%), and cerebrovascular disease (19.4% vs 15.5%) was higher in the intervention group than in the control group. The percentage of patients receiving surgical treatment in the intervention group (98.3%) was significantly higher than in the control group (96.3%, p = 0.004). The proportion of patients receiving surgical treatment within 48 h of admission was significantly higher in the intervention group (82.4%) than in the control group (60.4%, p < 0.001). The hospital stay was significantly shorter in the intervention group compared with the control group (p < 0.001). The incidence of perioperative medical complications and mortality during hospitalization was similar in the two groups.

Conclusions

Involving emergency physicians in the MDT can reduce the waiting time before surgery and the hospital stay for older hip fracture patients.

The use of Nottingham Hip Fracture score as a predictor of 1-year mortality risk for periprosthetic hip fractures

AIMS

The primary aim was to determine if the Nottingham Hip Fracture Score (NHFS) could be used to stratify 1-year mortality risk amongst periprosthetic hip fracture patients. The secondary aim was to identify 1year mortality rates amongst surgically managed periprosthetic hip fractures.

METHODS

Our electronic fracture database was interrogated for all Vancouver B or C periprosthetic fractures between September 2009 to April 2019; 83 patients were identified. All available data was then collected from radiographic, electronic and paper notes. The NHFS was retrospectively calculated for each patient. Statistical analysis was performed to identify factors significantly affecting 12month mortality using Akaike's information criterion corrected for small sample sizes (AICc), binomial logistic regression was performed using each variable; the p-values presented are for the coefficients of the regressor.

RESULTS

Periprosthetic fractures have a 1year mortality risk of 26.5%, 30 day mortality was 4.82%. The NHFS was found to be highly predictive of 1-year mortality amongst this patient cohort (p = 0.0001). We find that each unit increase in the NHFS is correlated with a 2.7times increase in mortality rate. There was no evidence that time lag from presentation to surgery led to an increased mortality (p = 0.455).

CONCLUSION

The NHFS can be used to stratify the 1-year mortality risk amongst patients who have periprosthetic hip fracture; this is a new finding not previously published to our knowledge. Given that time to surgery does not correlate with mortality, patients should be risk stratified on admission with NHFS. Time is then available to conduct a multi-disciplinary approach to optimize the patient, personnel and equipment. The introduction of a parallel multidisciplinary pathway to neck of femur fractures is long overdue and must be expedited.

Mortality after chronic subdural hematoma is associated with frailty

PURPOSE

Chronic subdural hematoma (CSDH) is a common neurological disease often affecting the elderly. Long-term excess mortality for patients after CSDH has been suggested but causes of death are unknown. We hypothesize that excess mortality of CSDH patients is related to frailty. In this article, we describe mortality rates and causes of death of CSDH patients compared with the general population and assess the association of frailty with mortality.

METHODS

A cohort study in which consecutive CSDH patients were compared to the general population regarding mortality rates. Furthermore, the association of six frailty indicators (cognitive problems, frequent falling, unable to live independently, unable to perform daily self-care, use of benzodiazepines or psychotropic drugs, and number of medications) with mortality was assessed.

RESULTS

A total of 1307 CSDH patients were included, with a mean age of 73.7 (SD ± 11.4) years and 958 (73%) were male. Median follow-up was 56 months (range: 0-213). Compared with controls CSDH patients had a hazard ratio for mortality of 1.34 (95% CI: 1.2-1.5). CSDH patients more often died from cardiovascular diseases (37% vs. 30%) and falls (7.2% vs. 3.7%). Among CSDH patients frequent falling (HR 1.3; 95% CI: 1.0-1.7), inability to live independently (HR 1.4, 95% CI: 1.1-1.8), inability to perform daily self-care (HR 1.5; 95% CI: 1.1-1.9), and number of medications used (HR 1.0; 95% CI: 1.0-1.1) were independently associated with mortality.

CONCLUSIONS

CSDH patients have higher mortality rates than the general population. Frailty in CSDH patients is associated with higher mortality risk. More attention for the frailty of CSDH patients is warranted.

Patients Lacking the Capacity to Consent to Hip Fracture Surgery May Be Undergoing Major Operations Without Their Next of Kin Being Involved in Best-Interests Decisions: A Quality Improvement Report

Background Cognitively impaired patients with a hip fracture may be undergoing major operations without attempts being made to involve their next of kin (NoK) in best-interest decisions. Methods We used the Plan-Do-Study-Act (PDSA) methodology to guide our quality improvement (QI) project. Cognitively impaired hip fracture patients were identified retrospectively by searching the hip fracture database of a medium-sized district general hospital (DGH). Their medical notes were reviewed for documented attempts at contacting their NoK prior to surgery as well as on completion of the NoK section of the Consent Form Four. Intervention A simple feedback intervention was delivered in the form of a mixed verbal and visual presentation to the orthopaedic registrars responsible for obtaining consent from these patients. Results Post-intervention, there were documented attempts at contacting the NoK before surgery for all patients, a significant improvement from only 80%. There was also a significant increase in completion of the NoK section of the consent form, from 30% to 64.3%. Conclusions Simple audit and feedback interventions can produce significant positive changes in communication between clinicians and the NoK of cognitively impaired patients with hip fractures. Further interventions have been implemented to sustain these improvements.

Development of a new comprehensive preoperative risk score for predicting 1-year mortality in patients with hip fracture: the HULP-HF score. Comparison with 3 other risk prediction models

PURPOSE

The aim of this study was to develop a new comprehensive preoperative risk score for predicting mortality during the first year after hip fracture (HF) and its comparison with 3 other risk prediction models.

METHODS

All patients admitted consecutively with a fragility HF during 1 year in a co-managed orthogeriatric unit at a university hospital were assessed and followed for 1 year. Factors independently associated with 1-year mortality were used to create the HULP-HF (Hospital Universitario La Paz - Hip Fracture) score. The predictive validity, discrimination and calibration of the HULP-HF score, the American Society of Anesthesiologists (ASA) scale, the abbreviated Charlson comorbidity index (a-CCI) and the Nottingham Hip Fracture score (NHFS) were compared. Discriminative performance was assessed using the area under the curve (AUC) and calibration by the Hosmer-Lemeshow goodness-of-fit-test.

RESULTS

509 patients were included. 1-year mortality was 23.2%. The 8 independent mortality risk factors included in the HULP-HF score were age >85 years, baseline functional and cognitive impairment, low body mass index, heart disease, low hand-grip strength, anaemia on admission, and secondary hyperparathyroidism associated with vitamin D deficiency. The AUC was 0.79 in the HULP-HF score, 0.66 in the NHFS, 0.61 in the abbreviated CCI and 0.59 in the ASA scale. The HULP-HF score, the NHFS and the abbreviated CCI all presented good levels of calibration (p > 0.05).

CONCLUSIONS

The HULP-HF score has a predictive capacity for 1-year mortality in HF patients slightly superior to that of other previously existing scores.

The impact of fracture liaison services on subsequent fractures and mortality: a systematic literature review and meta-analysis

This systematic review and meta-analysis suggests that fracture liaison service (FLS) is associated with a significantly lower probability of subsequent fractures and mortality although the latter was only found in studies comparing outcomes before and after the introduction of an FLS.

INTRODUCTION

To systematically review and evaluate the impact of fracture liaison services (FLSs) on subsequent fractures and mortality using meta-analysis.

METHODS

A literature search was performed within PubMed and Embase to identify original articles published between January 1, 2010, and April 30, 2020, reporting the effect of FLSs on subsequent fractures and/or mortality. Only studies comparing FLS to no-FLS were included. A meta-analysis using random-effects models was conducted. The quality of studies was appraised after combining and modifying criteria of existing quality assessment tools.

RESULTS

The search retrieved 955 published studies, of which 16 studies fulfilled the inclusion criteria. Twelve studies compared outcomes before (pre-FLS) and after (post-FLS) FLS implementation, two studies compared outcomes between hospitals with and without FLS, and two other studies performed both comparisons. In total, 18 comparisons of FLS and no-FLS care were reported. Follow-up time varied from 6 months to 4 years. Sixteen comparisons reported on subsequent fractures and 12 on mortality. The quality assessment revealed methodological issues in several criteria. Excluding studies with very high selection bias, the meta-analysis of nine comparisons (in eight papers) revealed that the FLS care was associated with a significantly lower probability of subsequent fractures (odds ratio: 0.70, 95% CI: 0.52-0.93, P=0.01). In studies with a follow-up > 2 years, a significantly lower probability of subsequent fractures was captured for FLS care (odds ratio: 0.57, 95% CI: 0.34-0.94, P=0.03), while in studies ≤ 2 years, there was no difference in the odds of subsequent fractures. No significant difference in the odds of mortality was observed (odds ratio: 0.73, 95% CI: 0.49-1.09, P=0.12) in the meta-analysis of eight comparisons (in seven papers). However, a significantly lower probability of mortality was identified in the six pre-post FLS comparisons (odds ratio: 0.65, 95% CI: 0.44-0.95, P=0.03), but not in studies comparing hospitals with and without FLS. No difference was observed in mortality stratified by follow-up time.

CONCLUSION

This systematic review and meta-analysis suggests that FLS care is associated with a significantly lower probability of subsequent fractures and mortality although the latter was only found in studies comparing outcomes before and after the introduction of an FLS. The quality assessment revealed that some important methodological issues were unmet in the currently available studies. Recommendations to guide researchers to design high-quality studies for evaluation of FLS outcomes in the future were provided.

A Bibliometric Analysis of Fragility Fractures: Top 50

Background and Objectives: The population is aging and fragility fractures are a research topic of steadily growing importance. Therefore, a systematic bibliometric review was performed to identify the 50 most cited articles in the field of fragility fractures analyzing their qualities and characteristics. Materials and Methods: From the Core Collection database in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to fragility fractures were identified in February 2021 using a multistep approach. Year of publication, total number of citations, average number of citations per year since year of publication, affiliation of first and senior author, geographic origin of study population, keywords, and level of evidence were of interest. Results: Articles were published in 26 different journals between 1997 and 2020. The number of total citations per article ranged from 12 to 129 citations. In the majority of publications, orthopedic surgeons and traumatologists (66%) accounted for the first authorship, articles mostly originated from Europe (58%) and the keyword mostly used was “hip fracture”. In total, 38% of the articles were therapeutic studies level III followed by prognostic studies level I. Only two therapeutic studies with level I could be identified. Conclusions: This bibliometric review shows the growing interest in fragility fractures and raises awareness that more high quality and interdisciplinary studies are needed.

Trends in hip fracture care in the Republic of Ireland from 2013 to 2018: results from the Irish Hip Fracture Database

Hip fractures continue to be one of the most serious and costly injuries suffered by older people globally. This paper describes the development of a national hip fracture audit and summarises the first 6 years of data from the Republic of Ireland. This can help inform care, standards and outcomes of hip fracture patients.

INTRODUCTION

Ireland has one of the highest standardised rates of hip fracture in the world behind northern European countries. The Irish Hip Fracture Database (IHFD) was established in 2012 to drive clinical and organisational improvements in quality and effectiveness of hip fracture care. This paper describes the progression of the IHFD between 2013 and 2018 and identifies trends and areas for improvement.

METHODS

The IHFD is a clinically led, web-based audit, with data collected through the national Hospital Inpatient Enquiry (HIPE) electronic system, the principal source of information from publicly funded acute hospitals in Ireland. Eligible cases are aged ≥ 60 years with hip fracture as defined by IHFD or with other specified hip fracture excluding periprosthetic fractures. As of 2015, all 16 trauma-receiving hospitals within Ireland submitted data. Demographics and adherence to six national quality standards are described.

RESULTS

A total of 17,983 cases were included in the analysis. National coverage has increased from 63% in 2013 to 99% in 2018. Demographic characteristics are unchanged, but higher levels of comorbidity are seen. Internal fixation and hemiarthroplasty are the most common modes of surgical repair with two-thirds of cases receiving spinal rather than general anaesthesia. Increasingly patients are being assessed by a geriatrician (11% in 2013 to 69% in 2018) and receive a bone health assessment (65% in 2013 to 84% in 2018).

CONCLUSION

While some hip fracture standards have improved, further improvements are required to compare favourably internationally. Reduction of surgical delay and ensuring early mobilisation post-operatively are immediate priorities for the IHFD.

Impact of an orthogeriatric collaborative care model for older adults with hip fracture in a community hospital setting

Background

Studies have shown that the incidence of postoperative delirium, the hospital length of stay and time to surgery are reduced when older adults with a hip fracture are cared for by a multidisciplinary team providing comprehensive geriatric assessments. Most of these studies have been conducted in academic centres. We sought to determine if implementation of an orthogeriatric collaborative care model would improve key quality of care metrics in a community hospital setting.

Methods

This retrospective pre- and postintervention single-site study was conducted in a community hospital in Ontario, Canada. We included consecutive patients aged 65 years or older who were admitted for a hip fracture between June 2015 and June 2017. In the intervention period, a new postoperative order set included a referral to a geriatrician for comprehensive geriatric assessment, with direct implementation of recommendations. Primary outcomes were the incidence of postoperative delirium and length of stay. Secondary outcomes included Health Quality Ontario’s quality standards for hip fracture.

Results

A total of 212 consecutive patients (95 in the preintervention group and 117 in the postintervention group) were included in the study. The incidence of postoperative delirium (26.3% v. 26.5%, p = 0.98) and length of stay (interquartile range 4–10 v. 5–10 d, p = 0.32) were similar in the preintervention and postintervention groups. There were improvements (p < 0.001) in the rates of asssessment of mental status, falls and bone health; identification of delirium prevention strategies; prescription of vitamin D or calcium or both; and recommendations for antiresorptive therapy. Despite systemic implementation of the orthogeriatric model, only 74.4% of patients in the postintervention group were seen by a geriatric medicine consultant.

Conclusion

Although the implementation of an orthogeriatric collaborative care model for older adults with a hip fracture did not reduce the incidence of postoperative delirium or length of stay, there were improvements in the rates at which several other key quality standards for hip fracture care were met. Earlier proactive, comprehensive geriatric assessment in a community hospital setting will be the target for further quality improvement initiatives.

Orthogeriatrics prevents functional decline in hip fracture patients: report from two randomized controlled trials

Background

The incidence of hip fractures are expected to increase in the following years. Hip fracture patients have in addition to their fracture often complex medical problems, which constitute a substantial burden on society and health care systems. It is thus important to optimize the treatment of these patients to reduce negative outcomes. The aim of this study was to assess the effect of comprehensive orthogeriatric care (CGC) on basic and instrumental activities of daily living (B-ADL and I-ADL).

Methods

This study is based on two randomized controlled trials; the Oslo Orthogeriatric Trial and the Trondheim Hip Fracture Trial. The two studies were planned in concert, and data were pooled and analyzed using linear mixed models. I-ADL function was assessed by the Nottingham Extended ADL Scale (NEADL) and B-ADL by the Barthel ADL (BADL) at four and twelve months after surgery.

Results

Seven hundred twenty-six patients were included in the combined database, of which 365 patients received OC and 361 patients received CGC. For the primary endpoint, I-ADL at four months was better in the CGC group, with a between-group difference of 3.56 points (95 % CI 0.93 to 6.20, p = 0.008). The between-group difference at 12 months was 4.28 points (95 % CI 1.57 to 7.00, p = 0.002). For B-ADL, between-group difference scores were only statistically significant at 12 months. When excluding the patients living at a nursing home at admission, both I-ADL and B-ADL function was significantly better in the CGC group compared to the OC group at all time points.

Conclusions

Merged data of two randomized controlled trials showed that admitting hip fracture patients to an orthogeriatric care unit directly from the emergency department had a positive effect on ADL up to twelve months after surgery.

Increased perioperative mortality for femoral neck fractures in patients with coronavirus disease 2019 (COVID-19): experience from the United Kingdom during the first wave of the pandemic

BACKGROUND

The coronavirus disease 19 (COVID-19) pandemic has presented modern healthcare with an unprecedented challenge. At the peak of the pandemic, trauma and orthopaedic services at our institutions undertook internal restructuring, diverting resources to frontline medical care. Consequently, we sought to assess the impact on the elderly and comorbid patients presenting with femoral neck fractures, with a particular focus on 30-day mortality, length of stay, multidisciplinary team involvement and departmental structuring.

METHOD

A retrospective analysis of patients presenting with femoral neck fractures at three separate West London NHS Trusts was undertaken between March 11, 2020, to April 30, 2020. Length of stay, 30-day mortality and adherence to parameters constituting the best care evidence-based practice tariffs were compared between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive and negative patients. A similar comparison was also conducted between our cohort and the equivalent period in 2018 using data from the National Hip Fracture Database.

RESULTS

A total of 68 patients presenting with femoral neck fractures were identified, mean age 81 (range 38-98), 73% female. There were 10 confirmed/suspected cases of COVID-19 on admission and a further seven confirmed as inpatients. The 30-day mortality within our cohort was 11.76% compared to 6% nationally in 2018 (p = 0.045). Orthogeriatric reviews occurred within 72 h in 71% of cases compared to 88% in the equivalent 2018 period. Within the cohort, mean length of stay was 17.13 days (SD 5.6, range 8-27 days) for SARS-CoV-2 positive patients compared to 10 days (SD 8.7, range 1-53 days) for negative patients (p < 0.05). Thirty-two patients (47%) required increased packages of care on discharge or rehabilitation.

CONCLUSIONS

The increase in 30-day mortality for SARS-CoV-2 positive patients presenting with femoral neck fractures is multifactorial, resulting from a combination of the direct effects of COVID-19 pneumonia as well as changes to the delivery of orthopaedic services. The provision of multidisciplinary care was directly affected by staff redeployment, particularly reorganisation of orthogeriatric services and lack of continuity of ward based clinical care. Our experiences have re-directed efforts towards the management of theatre teams, patient services and staffing, should we be faced with either a resurgence of COVID-19 or a future pandemic.

Association Between Delays in Radiography and Surgery With Hip Fracture Outcomes in Elderly Patients

Appropriate waiting time for hip fracture surgery is disputed. The American Academy of Orthopaedic Surgeons recommends surgery within 48 hours of presentation, although evidence suggests that earlier surgery (within 24 hours) reduces the risks of complications and death. The authors asked: (1) Do patients who receive earlier radiographic evaluation of hip fracture undergo surgery earlier? and (2) Is "surgery delay" (time from presentation to surgery) associated with postoperative opioid use, duration of hospital stay, and 30-day and 1-year mortality rates? The authors identified 511 adults 60 years or older who were admitted to their emergency department with hip fractures from 2015 through 2017. Patients were divided into 6 cohorts according to length of surgery delay and 3 cohorts according to length of radiography delay (time from presentation to first hip radiograph). The authors found that medium radiography delay (>2 to 4 hours) was associated with an additional 11 hours of surgery delay compared with short radiography delay (≤2 hours; P=.026). Longer surgery delay (>12 hours) was associated with use of 9.6 more morphine equivalents (95% confidence interval, 0.7 to 8.6) during the first 24 hours postoperatively compared with shorter surgery delay (≤12 hours). Surgery delay of greater than 36 hours was an independent risk factor for longer hospital stay (odds ratio, 2.8; 95% confidence interval, 1.7 to 4.8). Thirty-day and 1-year mortality rates were significantly higher among patients who experienced a surgery delay of greater than 36 hours compared with those who experienced a surgery delay of 36 hours or less. [Orthopedics. 2020;43(6):e609-e615.].

Post-discharge complications in postoperative patients with hip fracture

Hip fractures often occur in elderly people and are a major global health challenge causing many consequences, both in health and socioeconomic costs. This review aimed to identify complications that occur in patients with postoperative hip fracture between 30 days and 60 months after discharge. This review was conducted on articles published from 2005 to 2017 obtained from the EBSCO, PubMed, ProQuest and Google Scholar databases. The literature search followed PRISMA Guidelines. Key search words included the terms: hip fracture, complication, postoperative, community, and nursing. Articles were considered eligible if discussed the complications of hip fracture with surgical treatment, occurring post hospital discharge and the patient was in the community. In this review, 23 articles were included that met the inclusion criteria. There were 16 articles that cohort studies, 3 were retrospective studies, 3 were randomized control trials and 1 article was an observational study. The time of observation varied from 30 days to the longest of 5 years. Quality assessment of the levels of evidence used the Oxford CEBM recommendations. The review results found that postoperative hip fracture patients after discharge still experienced various complications after 30 days and up to 1-3 years post-operation.

[Prognostic factors of mortality one year after a hip fragility fracture. Anoia hip study]

INTRODUCTION

Most of the patients who had a hip fragility fracture are characterized by advanced age, frailty, multimorbidity and high mortality rate into the first year. Our aim is to describe the prognostic factors of mortality one year after a hip fragility fracture.

MATERIAL AND METHODS

Observational prospective study. During the study period we included patients older than 69 years with hip fragility fracture who were admitted to the Acute Geriatric Unit.

RESULTS

We have followed 364 patients, 100 of them died (27.5%). The independent prognostic factors of mortality one year after a hip fragility fracture had been: have a less basis score in Lawton and Brody Scale 0.603 (0.505-0.721) (p< 0.001); have a higher score in Charlson Comorbidity Index 2.332 (1.308-4.157) p = 0.04); have a surgical waiting time ≥ 3 days 3.013 (1.330-6.829) p = 0.008); finding hydroelectrolytic disorders and/or deterioration of glomerular filtration 1.212 (1.017-1.444) p = 0.031) during hospital stay; discriminatory capacity of the area under the curve (AUC) (± 95%): 0.888 (0.880-0.891).

CONCLUSIONS

Prognostic predictors of mortality at one year after a hip fragility fracture are those variables that reflect a worse state of health, complications during hospital stay and a longer surgical waiting time.

Validation of a prospective mortality prediction score for hip fracture patients

PURPOSE

Although mortality prediction tools are the subject of significant interest as components of comprehensive hip fracture protocols, few have been applied or validated to prospectively inform ongoing patient management. Five regional hospitals are currently generating real-time mortality risk scores for all adults at the time of admission using available laboratory and comorbidity data (Cowen et al. J Hosp Med 9(11):720-726, 2014). Although results for aggregated conditions have been published, the primary aim of this study is to determine how well prospectively calculated scores predict mortality for hip fracture patients specifically.

METHODS

Using a five-hospital database, 1376 patients who were prospectively scored on admission were identified from January 2013 to April 2017, cross-referencing ICD9/10 diagnosis and procedure codes for AO/OTA 31A1 through 31B3 fractures. Prospective mortality scores have been previously divided into 5 risk categories to facilitate ease of clinical use. Vital status was determined from hospital data, Social Security and Michigan Death Indices.

RESULTS

Prospective scores demonstrated good mortality prediction, with AUCs of 0.80, 0.73, 0.74 and 0.74 for in hospital, 30-, 60- and 90-day mortality, respectively. Patients in the top 2 mortality risk categories represented 30% (410/1376) of the cohort and accounted for 78% (25/32) of the inpatient and 59% (57/97) of the 30 day deaths.

CONCLUSIONS

Implementation of this real-time mortality risk tool is feasible and valid for the prediction of short- to medium-term mortality risk for hip fracture patients, and potentially offers valuable information to guide ongoing patient management decisions such as admitting service or level of care.

What is the Role of Coordinators in the Secondary Fracture Prevention Program?

Background

The purpose of this study is to search for reports on the clinical effectiveness of FLS being implemented worldwide through the systematic review, analyze the roles of coordinators in each study, and provide basic data for the development of future coordinator education programs.

Methods

A systematic search of the literature using the Medline, PubMed, and EMBASE databases and the Cochrane Library was conducted for using the following keywords: ‘osteoporosis’ AND ‘fractures’ AND ’secondary prevention’. Finally, 65 studies are included in this study.

Results

At the coordinator-based fracture liaison service (FLS) center, the coordinator (often a nurse) acts as a central player in the establishing of patient connections, orthopedic surgeons, radiologists, and attending physicians. Coordinators help bridge the nursing gap by supporting identification, investigation, initiation of treatment, and patient follow-up. Medics has opened the way to effectively manage patients at high risk of developing another fracture. In addition, nurses are in a unique and important role as nurses responsible for enhancing their daily lives by building relationships with patients and families.

Conclusions

The coordinator in the FLS program plays an important role in the multidisciplinary management of vulnerable fractures, as well as in the diagnosis and treatment of osteoporosis and in maintaining continuity of treatment. In the future, the broader role of coordinators should be systematically organized and developed into accredited educational programs.

Geriatric patients with dementia show increased mortality and lack of functional recovery after hip fracture treated with hemiprosthesis

PURPOSE

Operative timing, perioperative management and postoperative rehabilitation are rising challenges in orthopedic geriatric trauma. The aim of this study was to determine the outcome of patients with dementia or with a high number of comorbidities treated with hemiprosthesis after hip fracture. Literature regarding patients with high comorbidities is scarce, leaving nothing but endoprosthetic treatment for even the sickest, immobile patients.

METHODS

A retrospective chart review of 326 patients (mean age 81 ± 9 years; 230 women and 96 men) with hip fractures treated between 2012 and 2017 with a hemiprosthesis was performed. Primary outcome measures were surgical and nonsurgical complication rates, best achievable mobilisation during the hospital stay and mortality.

RESULTS

Patients with dementia had 20-fold increased risk to be bedridden after surgery and ninefold increased risk of dying (p < 0.005). Furthermore, they needed significantly more revision surgeries because of surgical complications. Patients classified ASA IV and V had significantly lower postoperative mobilization levels with only 10% able to walk with crutches and 53% bedridden. They also had significantly more non-surgical complications while dementia had no effect on non-surgical complication rate.

CONCLUSION

Patients classified ASA IV and V or suffering dementia show poor outcome after hip fracture treated with hemiprosthesis. Multidisciplinary approaches including surgeons, geriatricians, physiotherapists and psychiatrists are needed to improve the outcome of these patients. Especially in a subgroup of patients, where no mobilization is expected, alternative treatment options may be considered.

Multidisciplinary inpatient rehabilitation improves the long-term functional status of geriatric hip-fracture patients

BACKGROUND

As the world population ages, the number of hip-related fractures in the elderly is steadily increasing. These fractures generate a major worldwide healthcare problem and frequently lead to deterioration of life quality, mobility and independence in activity of daily life of geriatric patients. At present, many studies have investigated and proved benefits of multidisciplinary orthogeriatric care for elderly hip-fracture patients. Only few studies however, have analyzed treatment concepts for those patients directly following discharge from hospital in specialized rehabilitation centers. The aim of this study was to evaluate effects of a multidisciplinary inpatient rehabilitation on the short- and long-term functional status of geriatric patients who suffered from hip fracture.

METHODS

A total of 161 hip-fracture patients aged 80 years and above, or additionally 70 years and above suffering from age-typical multimorbidity were included in this study. Patients who had an initial Barthel Index lower than 30 points were excluded from this study, as most of these patients were not able to attend a therapy at the rehabilitation center due to a poor functional status. The patients were separated into two subgroups dependent on the availability of treatment spots at the rehabilitation center. No other item was used to discriminate between the groups. Group A (n = 95) stayed an average of 21 days at an inpatient rehabilitation center that specialized in geriatric patients. Group B (n = 66) underwent the standard postoperative treatment and were sent home with further treatment by their general practitioner, nursing staff and physiotherapists. To evaluate the patients' functional status over the course of time we used the Barthel Index, which was evaluated for every patient on the day of discharge, as well as during checkups after 3, 6 and 12 months.

RESULTS

The average Barthel Index at the day of discharge was 57.79 ± 14.92 points for Group A and 56.82 ± 18.76 points for Group B (p = 0.431). After 3 months, the average Barthel Index was 82.43 points for Group A and 73.11 points for group B (p = 0.005). In the 6-month checkup Group A's average Barthel Index was 83.95 points and Group B's was 74.02 points (p = 0.002). After 12 months, patients from Group A had an average Barthel Index of 81.21 while patients from Group B had an average Barthel Index of 69.85 (p = 0.005).

CONCLUSION

The results of this study reveal a significantly better outcome concerning both, short-term and long-term functional status after 3, 6 and 12 months for geriatric hip-fracture patients, who underwent an inpatient treatment in a rehabilitation center following the initial therapy.

The BOAST recommendations for care of the older or frail orthopaedic trauma patient

Safe and effective care for the elderly or physiologically frail patient in cases of trauma requires a multidisciplinary perioperative approach. This article expands upon the British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines for the management of the older or frail orthopaedic trauma patient. Optimisation of the patient is key to a successful surgical outcome, because these patients often have significant comorbidities involving bone health, nutrition, cognitive function and cardiovascular stability. This article discusses the evidence base for tailoring the management of these patients and the importance of doing so in an ageing population. It considers the requisite preoperative procedures and investigations, guidelines for specific cases such as comatose patients or those with complex fractures, and ceiling of care discussions, and then focuses on the postoperative period, including physiotherapy, rehabilitation goals and medical management.

Holistic Management of Older Patients With Hip Fractures

As the silver tsunami hits the world, older patients with hip fractures are expected to increase to 6.3 million by the year 2050, of which the majority will occur in Asia. The estimated global cost of hip fractures in the year 2050 is estimated to reach U.S. $130 billion. Hence, in addition to implementation of prevention strategies, it is important to develop an optimal model of care for older patients with hip fracture to minimize the huge medical and socioeconomic burden, especially in rapidly aging nations. This review summarizes the complications of hip fractures, importance of comprehensive geriatric assessment, and multidisciplinary rehabilitation, as well as predictors of rehabilitation outcome in older patients with hip fracture.

Fewer patients undergo surgery when adding a comprehensive geriatric assessment in older patients with a hip fracture

INTRODUCTION

Geriatricians have been increasingly involved in the pre-operative process in frail elderly patients with a hip fracture which can benefit re-hospitalization, post-operative functional performance, and mortality. The objective of this study was to compare the number of older patients with hip fractures who opted for non-surgical management after the addition of pre-operative comprehensive geriatric assessment (CGA) with shared decision making by a geriatrician to usual care. Secondary objectives were: reasons for non-surgical management, duration of life, and location of death.

MATERIALS AND METHODS

A single-center, with a level 2 trauma center, retrospective study comparing care before and after introducing pre-operative CGA with shared decision making in September 2014. Patients ≥ 70 years with a hip fracture, admitted from January 2014 to September 2015, were included. The percentages of patients elected for non-surgical management and palliative care without or with CGA were compared. Differences in secondary objectives (age, sex, medical history, medication use, functional, and social status) were compared descriptively and qualitatively.

RESULTS

With pre-operative CGA significantly more patients (or representatives) elected the non-surgical management option after hip fracture (respectively, 9.1% vs 2.7%, p = 0.008). Patient characteristics were comparable. Reported reasons not to undergo surgery include aversion to be more dependent on others, and severe dementia.

CONCLUSION

The geriatrician can have an important role in decisions for non-surgical management by shared decision making in the pre-operative period in patients ≥ 70 years with a hip fracture in the emergency room.

[Perioperative patient blood management in the aged-more than only transfusion? : Review of the 4th symposium of the working group on anemia on the occasion of the annual meeting of the German Geriatric Society in Frankfurt 2019]

Anemia is frequent in older people with one in two geriatric inpatients being affected. Therefore, in elective surgery, such as endoprosthetic treatment it is very likely that anemia is already present in a preoperative setting. So far there are no particular guidelines about perioperative management of anemia in geriatric patients. The existing recommendations of the Patient Blood Management (PBM) network cooperation and the current Association of the Scientific Medical Societies in Germany (AWMF) S3 guidelines on preoperative anemia refer to all patients aged >18 years but without particular consideration of the growing number of oldest old orthogeriatric patients. This is more problematic as anemia in the aged has been shown to be different from anemia in younger patients in terms of diagnostics and treatment. Based on several interdisciplinary lectures, this year the symposium of the working group on anemia of the German Geriatric Society (DGG) focused on the problems of perioperative PBM in orthogeriatric patients and encouraged the discussion about developing PBM treatment recommendations for this patient group.

Outcomes in Multidisciplinary Team-based Approach in Geriatric Hip Fracture Care: A Systematic Review

INTRODUCTION

This systematic review analyzes the literature on the treatment of geriatric hip fractures by a multidisciplinary hip fracture service including geriatricians/internists and orthopaedic surgeons and what impact this has on patient outcomes.

METHODS

A systematic review of several databases was conducted according to PRISMA guidelines. Studies comparing an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model to treat hip fractures with reported outcomes for time to surgery, length of stay, readmission rates, and postoperative mortality were included.

RESULTS

Seventeen articles fitting the inclusion criteria were included. Differences between the results of an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model were assessed using chi-squared tests. With patients admitted under a coordinated orthogeriatrics care model or a geriatrics-led care model, there is a statistically significant decrease in time to surgery (P = 0.045), length of stay (P = 0.0036), and postoperative mortality rates (P = 0.0034).

CONCLUSIONS

Although a heterogeneous group of studies, the aggregate data from several studies using an orthogeriatrics care model or a geriatrics-led care model trend toward improvements across several clinical and cost-related outcome measures: decreased time to surgery, shorter length of stay, improved postoperative clinical outcomes, decreased mortality, and lower cost.

Multiple simultaneous fractures are associated with higher all-cause mortality: results from a province-wide fracture liaison service

Mortality rates in our fracture liaison service ranged from 2.7% at year 1 to 14.8% at year 5 post-screening. Presentation with multiple simultaneous fractures at screening was associated with higher risk of death. This finding indicates the need for increased focus on this high-risk group.

PURPOSE

To examine all-cause mortality rates in a provincial fracture liaison service (FLS) and the association between the index fracture type, particularly multiple simultaneous fractures, and the risk of death at follow-up.

METHODS

This cohort study includes fragility fracture patients aged 50+, enrolled in a provincial FLS in Ontario, Canada, between 2007 and 2010. All-cause mortality was assessed using administrative data. Multivariable Cox proportional hazards model was used to examine the risk of death 5 years after screening.

RESULTS

Crude mortality rates for 6543 fragility fracture patients were 2.7% at year 1, 5.6% at year 2, and 14.8% at year 5 after screening. After adjusting for age and sex, and relative to distal radius fracture, patients with multiple (simultaneous) fractures at screening had a higher risk of dying (HR = 1.8, 95%CI 1.3-2.4), followed by those with a hip fracture (HR = 1.5, 95%CI 1.3-1.8), a proximal humerus fracture (HR = 1.4, 95%CI 1.2-1.7), and other single fractures (HR = 1.4, 95%CI 1.1-1.7). Having an index ankle fracture was not associated with the risk of death over a distal radius fracture. As compared to the 50-65 age group, patients 66 years and older had a higher risk of death (for 66-70 age group: HR = 2.5, 95%CI 1.9-3.3; for 71-80: HR = 4.3, 95%CI 3.5-5.4; and for 81+: HR = 10.6, 95%CI 8.7-13.0). Females had a lower risk of death (HR = 0.5, 95%CI 0.5-0.6) than males.

CONCLUSIONS

Presenting with multiple fractures was an indicator of higher risk of death relative to a distal radius fracture. This finding indicates the need for increased focus on this high-risk group.

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.

Changing trends in the mortality rate at 1-year post hip fracture - a systematic review

BACKGROUND

Traditionally, the mortality rate at 1-year post hip fracture was quoted as approximately 30% of all hip fractures. There have been recent improvements in hip fracture care in the main driven by national hip fracture registries with reductions in 30-d mortality rates reported.

AIM

To address recent 1-year post hip fracture mortality rates in the literature.

METHODS

Systematic literature review, national hip fracture registries/databases, local studies on hip fracture mortality, 5 years limitation (2013-2017), cohorts > 100, studies in English. Outcome measure: Mortality rate at 1-year post hip fracture.

RESULTS

Recent 1-year mortality rates were reviewed using the literature from 8 National Registries and 36 different countries. Recently published 1-year mortality rates appear lower than traditional figures and may represent a downward trend.

CONCLUSION

There appears to be a consistent worldwide reduction in mortality at 1-year post hip fracture compared to previously published research. Globally, those which suffer hip fractures may currently be benefiting from the results of approximately 30 years of national registries, rigorous audit processes and international collaboration. The previously quoted mortality rates of 10% at 1-mo and 30% at 1-year may be outdated.

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.

The Sensitivity of Orthopaedic Surgeons to the Secondary Prevention of Fragility Fractures

BACKGROUND

Orthopaedic surgeons must play an important role in the secondary prevention of fragility fractures; however, some surgeons are more aware than others of their responsibility regarding fracture prevention. The purpose of the present study was to identify which factors can lead to a higher sensitivity for fracture prevention.

METHODS

A cross-sectional survey was distributed to orthopaedic surgeons via online invitation or at academic conferences in China from July through October 2015. A total of 452 surgeons responded. As the primary outcome measure, we created a sensitivity scoring system for fracture prevention based on the respondents' answers to 5 questions regarding behavior in the following areas: risk-factor evaluation, pharmacologic therapy, nonpharmacologic therapy, patient education, and follow-up. Multivariable linear regression and multivariable logistic regression analyses were used to identify factors related to surgeon sensitivity to fracture prevention.

RESULTS

Very few surgeons reported having received adequate training regarding fracture prevention or reading guidelines or other fracture prevention literature (22% and 30%, respectively). Most respondents initiated pharmacologic or nonpharmacologic therapy (82% and 75%, respectively) for the treatment of confirmed osteoporosis among patients with fragility fractures, but only half performed a risk-factor evaluation, patient education, or timely patient follow-up (51%, 52%, and 48%, respectively). In the multivariable linear regression model, the orthopaedic surgeon's age (β = 0.09, p = 0.003), self-rated knowledge level regarding osteoporosis or related issues (β = 0.16, p < 0.001), self-perceived effectiveness in using preventive measures for patients with a fragility fracture (β = 0.62, p < 0.001), and use of clinical pathways for fragility fractures in his or her workplace (β = 1.24, p < 0.001) were independently associated with sensitivity scores for fracture prevention. Similar results were obtained from a multivariable logistic regression model.

CONCLUSIONS

In China, the sensitivity of orthopaedic surgeons to the secondary prevention of fragility fractures is relatively low. Implementation of a comprehensive prevention approach and targeted continuing medical education are required to encourage surgeons to take greater responsibility for screening, treating, educating, and following their patients with fragility fractures.

Efficacy of a multidisciplinary approach on postoperative morbidity and mortality of elderly patients with hip fracture

STUDY OBJECTIVE

We evaluated the efficacy of a multidisciplinary approach to reduce postoperative complications and 1-year mortality in patients, undergoing hip fracture surgery and the impact of surgical delay on mortality.

DESIGN

A non-randomized intervention study with a historical control group (CG).

SETTING

During the hospital stay of patients undergoing hip fracture surgery and subsequent follow-up during 12 months post-discharge.

PATIENTS

240 patients undergoing hip fracture surgery were included in the CG. 272 patients were included in the intervention group (IG).

INTERVENTIONS

CG patients received the standard care given at our hospital. Patients in the IG received a new model of multidisciplinary approach to care.

MEASUREMENTS

The following variables were collected: study group, age, gender, ASA physical status, comorbidity, type of fracture, type of anaesthesia, surgical delay, postoperative complications, hospital stay, destination after discharge and postoperative mortality.

MAIN RESULTS

512 patients (CG = 240; IG = 272). Mean age was 83.8 years in CG and 84.9 years in IG. Patients in the IG had a worse health status according to ASA (III-IV: 68.8% vs 51.7%; p < 0.001) and took more drugs (p < 0.001). Surgery was performed within 48 h of admission in 55.1% of patients of the IG (38.3% CG; p < 0.001). Incidence of postoperative complications (67.3% IG vs 76.2% CG p = 0.025) and hospital stay was shorter in the IG (p < 0.001). A surgical delay of >48 h (HR = 0.61; CI95%: 0.42-0.88) and allocation to the IG (HR = 0.64; CI95%: 0.44-0.93) were the protective factors for mortality.

CONCLUSIONS

The multidisciplinary approach could be associated with a decrease in postoperative complications, hospital stay and mortality. Surgical delay may not increase the risk of mortality. The main objective in the management of these patients should be the optimization of their general health status before surgery rather than surgical delay.

Oral bisphosphonate prescription and non-adherence at 12 months in patients with hip fractures treated in an acute geriatric unit

A poorer functional status at the time of fracture is a predictor of non-adherence to oral bisphosphonates initiated after a hip fracture, and suggests further opportunities for optimization of secondary fracture prevention in this high-risk population.

INTRODUCTION

Low adherence to treatment is a problem in post-fracture secondary prevention. We aimed to analyze the prognostic factors (related and predictive) associated with non-adherence to oral bisphosphonate prescription for hip fracture due to bone fragility (HFBF) 12 months after discharge from an acute geriatric unit.

METHODS

Prospective study of bivariate data analyzing related and multivariate factors predicting non-adherence of oral bisphosphonates at 12 months after treatment for HFBF. The statistical study was performed with SPSS 19.0.0.

RESULTS

We attended 368 patients with HFBF. At discharge, oral bisphosphonates were prescribed to 226 (61.42%) patients. At 12 months, we followed up 160 (70.7%) patients, 104 (65%) of whom had non-adherence to oral bisphosphonates. Bivariate analysis (adherent vs. non-adherent): age (83.79 ± 5.82 vs. 85.78 ± 5.80, p = .029); Lawton and Brody Index (4.29 ± 3.40 vs. 2.67 ± 3.31, p = .004); baseline Barthel Index (BI) (85.89 ± 21.99 vs. 74.18 ± 26.70) (p = .004); BI at admission (18.84 ± 10.00 vs. 14.47 ± 11.71, p = .004); BI at discharge (34.20 ± 15.40 vs. 27.45 ± 16.71, p = .011); baseline Functional Ambulation Classification (5.66 ± 0.98 vs. 5.43 ± 0.99, p = .025). Multivariate analysis: BI 0.980 (0.965-0.995, p = .007). Discriminatory capacity of the AUC model (± 95% CI): 0.634 (0.545-0.722).

CONCLUSIONS

At 12 months, there was low adherence to treatment with oral bisphosphonates in our model. A lower BI prior to treatment is a predictive factor for non-adherence treatment with oral bisphosphonate.

Orthogeriatrics and Hip Fracture Care in the UK: Factors Driving Change to More Integrated Models of Care

In the United Kingdom (UK), approximately 80,000 hip fractures each year result in an estimated annual cost of two billion pounds in direct healthcare costs alone. Various models of care exist for collaboration between orthopaedic surgeons and geriatricians in response to the complex medical, rehabilitation, and social needs of this patient group. Mounting evidence suggests that more integrated models of orthogeriatric care result in superior quality of care indicators and clinical outcomes. Clinical governance through national guidelines, audit through the National Hip Fracture Database (NHFD), and financial incentives through the Best Practice Tariff (providing a £1335 bonus for each patient) have driven hip fracture care in the UK forward. The demanded improvement in quality indicators has increased the popularity of collaborative care models and particularly integrated orthogeriatric services. A significant fall in 30-day mortality has resulted nationally. Ongoing data collection by the NHFD will lead to greater understanding of the impact of all elements of hip fracture care including models of orthogeriatrics.

Beyond orthogeriatric co-management model: benefits of implementing a process management system for hip fracture

Hip fracture is a major health care problem worldwide. Business process management systems (PMSs) have made significant contributions in health care environments to improve patient care standards. The effectiveness of PMS applied to hip fracture in older adults in the acute phase has been demonstrated.

INTRODUCTION

Fragility fracture is a major health care problem worldwide. Business PMSs have made significant contributions in health care environments to improve patient care standards. It is a new way of management that defines a homogeneous application procedure involving eliminating steps that add no value and developing explicit supervision criteria, in addition to identifying the appropriate managers.

PURPOSE

The aim of our trial was to assess the effectiveness of the PMS applied to hip fracture versus the orthogeriatric co-management model in the acute phase.

METHODS

All consecutive patients aged ≥ 65 who were admitted to Hospital Universitario Infanta Leonor between January 1, 2009, and December 31, 2016, for acute hip fracture surgery were included. We compared the effectiveness indicators in the acute phase between the preprocess period (orthogeriatric co-management) and the process period.

RESULTS

One thousand two hundred twenty-two patients were included (76.6% women). Mean age (SD) was 83.9 (6.4) years. Effectiveness management indicators are the following: length of hospital stay, time to admission to the ward from the emergency department, preoperative stay, surgery in < 48 h, and the operating room availability which were all improved in the process period with statistical significance. Effectiveness clinical indicators are the following: the numbers of patients with operated limb loading approved after surgery, discharged to home, and with osteoporosis treatment postfracture at the time of discharge which were statistically significantly higher in the process period, and the number of patients who suffered from delirium was statistically significantly lower in the process period. The number of in-hospital deaths was lower during the process period without statistical significance.

CONCLUSION

Our results demonstrated the effectiveness of the PMS applied to hip fracture in older adults compared with an orthogeriatric co-management model in the acute phase, based on both management indicators and clinical indicators.

Upper gastrointestinal bleeding in neck of femur fracture patients: a single tertiary centre experience

This study aimed to identify the incidence of perioperative acute upper gastrointestinal bleeding (UGIB) in our hip fracture patients; to evaluate the characteristics, management and clinical outcomes of these patients; and to explore risk factors and protective factors. Of the 1691 consecutive patients admitted for surgical management of hip fractures, 11 (0.65%) had UGIB and a further four patients for each case were selected as controls for evaluation of risk factors and protective factors. Pre-existing peptic ulcer disease was identified as a risk factor for acute UGIB (odds ratio 7.9; 95% confidence interval: 1.1-54.9). This study reported a very low incidence of UGIB in hip fracture patients. Despite being a high-risk population, timely endoscopic evaluation can be safely undertaken to optimise patient outcome. When risk factors such as history of peptic ulcer disease are present, additional precaution including gastro-protective agent and nutritional support should be undertaken.

Identifying characteristics of an effective fracture liaison service: systematic literature review

Fracture liaison services (FLS) have been demonstrated to improve outcomes following osteoporotic fracture. The aim of this systematic literature review (SLR) was to determine the characteristics of an FLS that lead to improved patient outcomes. We conducted a SLR, including articles published between 2000 and February 2017, using global (Medline, EMBASE, PubMed and Cochrane Library) and local databases. Studies including patients aged ≥ 50 years with osteoporotic fractures enrolled in an FLS were assessed. Information extracted from each article included key person coordinating the FLS (physician, nurse or other healthcare professional), setting (hospital vs community), intensity (single vs multiple), duration (long vs short term), fracture type and gender. A meta-analysis of randomised controlled trials was conducted based on the key person coordinating the FLS. Out of 7236 articles, 57 were considered to be high quality and identified for further analysis. The SLR identified several components which contributed to FLS success, including multidisciplinary involvement, driven by a dedicated case manager, regular assessment and follow-up, multifaceted interventions and patient education. Meta-analytic data confirm the effectiveness of an FLS following an osteoporotic fracture: approximate 27% increase in the likelihood of BMD testing and up to 21% increase in the likelihood of treatment initiation compared with usual care. The balance of evidence indicates that the multifaceted FLS and dedicated coordination are important success factors that contribute to effective FLS interventions which reduce fracture-related morbidity and mortality.

Association of orthogeriatric services with long-term mortality in patients with hip fracture

PURPOSE

To assess the impact of the comprehensive orthogeriatric care model (OGM) on 2-year survival, length of stay (LOS), discharges to nursing homes, and antiosteoporotic treatment (AOT) in patients with hip fracture.

METHODS

Retrospective cohort study. Hospitals were classified as OGM if the patient was cared for in a comprehensive orthogeriatric unit. We included data from patients ≥ 65 years old discharged between 2012 and 2013. The main outcome was 12- and 24-month mortality. The variables collected were sex, type of fracture, comorbidities, AOT, LOS, and discharge to nursing homes. Survival analysis was performed with Kaplan-Meier method and comparison with Mantel-Haenszel test. Factors associated with death were determined by logistic regression.

RESULTS

First admissions in the 12 (out of 32) hospitals with OGM were 3580 of 9215 (38.8%). Patients in OGM had more comorbidities and discharges to nursing homes, shorter LOS, and less prescription of AOT. Two years after the admission the deceased patients were 3000 (32.6%). The survival was lower in males (p < 0.001), in the older age groups (p < 0.001), and in patients with Charlson > 1 (p < 0.001). Factors associated with increased risk of death at 12 and 24 months (logistic regression) were male gender, age and Charlson > 1, while care in the OGM decreased the risk. OGM benefited more patients > 80 years and those with Charlson < 1.

CONCLUSIONS

Patients admitted in OGM have shorter stays, more discharges to nursing homes, lower prescription of AOT, and better 12- and 24-month survival adjusted by sex, age, and comorbidities compared to non-OGM care.

The impact of age on major orthopaedic trauma: an analysis of the United Kingdom Trauma Audit Research Network database

AIMS

To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries.

PATIENTS AND METHODS

The Trauma Audit Research Network database was reviewed to identify eligible patients admitted between April 2012 and June 2015. Distribution and severity of injury, interventions, comorbidity, critical care episodes and mortality were recorded. The population was divided into young (64 years or younger) and older (65 years and older) patients.

RESULTS

Of 142 765 adults sustaining major trauma, 72 942 (51.09 %) had long bone or pelvic fractures and 45.81% of these were > 65 years old. Road traffic collision was the most common mechanism in the young (40.4%) and, in older people, fall from standing height (80.4%) predominated. The 30 day mortality in older patients with fractures is greater (6.8% versus 2.5%), although critical care episodes are more common in the young (18.2% versus 9.7%). Older people are less likely to be admitted to critical care beds and are often managed in isolation by surgeons. Orthopaedic surgery is the most common admitting and operating specialty and, in older people, fracture surgery accounted for 82.1% of procedures.

CONCLUSION

Orthopaedic trauma in older people is associated with mortality that is significantly greater than for similar fractures in the young. As with the hip fracture population, major trauma in the elderly is a growing concern which highlights the need for a review of admission pathways and shared orthogeriatric care models. Cite this article: Bone Joint J 2017;99-B:1677-80.

Comparing mortality risk of patients with acute hip fractures admitted to a major trauma centre on a weekday or weekend

Proximal femoral fractures are a major public health concern with estimated annual direct and social costs amounting to £2 billion and average 30-day mortality risk of 7.5%. In response to the recent debate over out-of-hours hospital provision we investigated the ‘weekend effect’ at a major trauma centre, caring for acute injuries. A single centre, multi-surgeon review of 2060 patients performed. The distribution of patient and treatment variables compared in patients admitted on a weekday or the weekend. Fewer patients met performance indicators during weekend admission, time to surgery (63 vs. 71%) and time to geriatric review (86 vs. 91%). Weekend admission 30-day mortality was marginally lower than weekday (9.7% vs. 10.2%, OR 0.94, 95% CI 0.67 to 1.32, p = 0.7383). Increasing age, female gender, co-morbidities and confusion increased mortality risk. Binary regression analysis including these variables found no significant ‘weekend effect’. Despite the unit observing an increasing workload in the last five years, with meticulous workforce planning, senior doctor provisions and careful use of resources, it is possible to provide a seven-day fracture neck of femur service with no variation in thirty-day mortality by the day of admission.

Osteoporosis: a discussion on the past 5 years

PURPOSE OF THE REVIEW

The purposes of this study are to examine the literature within the past 5 years regarding osteoporosis and offer a discussion on new topics and controversies.

RECENT FINDINGS

Patient compliance with therapy remains an issue. The effectiveness of Vitamin D and calcium are being called into question Atypical femur fractures have been associated with bisphosphonate and denosumab use. Treatment is both surgical and pharmaceutical. A multidisciplinary approach to osteoporotic fractures is important and having some form of fracture liaison service (FLS) improves the efficacy of osteoporotic care and decreases secondary fractures. Screening for osteoporosis remains low. Ultrasound may be cost-effective for diagnosis. Understanding of osteoporosis has come a long way in the medical community, but the translation to the lay community has lagged behind. Patients often take a laissez-faire attitude toward osteoporosis that can affect compliance. Information read by patients often focuses on complications, such as atypical femur fractures and myocardial infarctions. It is essential for providers to be able to discuss these issues with patients. Newer medications and more cost-effective diagnostic tests exist, but availability may be limited. FLS are effective, but the most cost-effective model for therapy still eludes us. Areas for further investigation include FLS models, the effectiveness of vitamin supplementation, and more ubiquitous and cost-effective diagnostic tools.