A plea for an early mobilization after hip fractures. The geriatric point of view

Early mobilisation following fragility hip fracture surgery: current trends and association with discharge outcomes in a local tertiary hospital

Introduction

Postoperative day 1 (POD 1) mobilisation is a key clinical indicator for the fragility hip fracture surgery population. This study aimed to evaluate the current trends of POD 1 mobilisation at our institution and to review the relationships between early mobilisation and outcomes of early functional recovery, length of stay (LOS) and discharge destination.

Methods

In this preliminary observational study, data pertaining to demographics, premorbid function, health status, injury and surgical factors, POD 1 mobilisation status and clinical outcomes of interest were retrieved from eligible patients. Patients who attained POD 1 ambulation formed the early ambulation (EA) group, while the remaining patients formed the delayed ambulation (DA) group. Data were analysed for any significant difference between the groups.

Results

One hundred and fifteen patients were included in the analysis. The rate of patients achieving at least sitting out of bed on POD 1 was 80.0% (n=92), which was comparable to the data available from international hip fracture audit databases. There were 55 (47.8%) patients in the EA group and 60 (52.5%) patients in the DA group. The EA group was approximately nine times more likely to achieve independence in ambulation at discharge compared to the DA group (adjusted odds ratio 9.20, 95% confidence interval 1.50-56.45; P = 0.016). There were observed trends of shorter LOS and more proportion of home discharge in the EA group compared to the DA group (P > 0.05).

Conclusion

This is the first local study to offer benchmark of the POD 1 mobilisation status for this population. Patients who attained POD 1 ambulation had better early functional recovery.

Is Immediate Weight-Bearing Safe After Single Implant Fixation of Elderly Distal Femur Fractures?

OBJECTIVES

To compare early complications in elderly patients with extra-articular distal femur fractures (DFFs) allowed to weight-bear as tolerated (WBAT) immediately versus patients prescribed initial touchdown weight-bearing (TDWB).

DESIGN

Retrospective cohort study.

SETTING

Level 1 academic trauma center.

PATIENTS

One hundred thirty-five patients 60 years or older who underwent surgical fixation of an extra-articular DFF, including the OTA/AO fracture classification of 33-A1-3, and periprosthetic fractures with a stable knee prosthesis (Lewis and Rorabeck type I or II) with at least 6 months follow-up.

INTERVENTION

Immediate WBAT or TDWB after surgical fixation of an extra-articular DFF with either an intramedullary nail or locked plate.

MAIN OUTCOME MEASUREMENTS

The primary outcome was a major adverse event within the first 6 months, defined as (1) early fixation failure or change in alignment leading to reoperation, (2) nonunion, or (3) deep infection. Secondary outcomes included postoperative inpatient length of stay, discharge disposition (secondary facility vs. home), malunion, mortality, and patient-reported outcomes.

RESULTS

The rate of early adverse events requiring reoperation was similar between the WBAT group (6, 10.7%) and the TDWB group (15, 19.0%; P = 0.23). There was no difference between groups with respect to length of stay, discharge disposition, malunion, and patient-reported outcomes.

CONCLUSIONS

This study supports allowing carefully selected elderly patients, based on surgeon preference, to immediately weight-bear after operative fixation of an extra-articular DFF regardless of implant choice.

LEVEL OF EVIDENCE

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

Nurses and physiotherapists' experience in mobilising postoperative orthopaedic patients with altered mental status: A phenomenological study

BACKGROUND

A major goal of care for orthopaedic surgical patients is the achievement of their pre-morbid functional level or at least an improvement of their functional ability. However, patients with altered mental status can significantly impact this and other outcomes and influence the delivery of care. Patient mobilisation is a role shared by both nurses and physiotherapists.

AIMS

To enhance the understanding of nurses and physiotherapists' experience in mobilising postoperative orthopaedic patients with altered mental status.

METHOD

Three nurses and three physiotherapists were recruited using purposive sampling. Data was collected through interviews and analysed using Burnard's 14 stages of thematic content analysis.

RESULTS

Four main categories emerged from the study: altruism, interprofessional specialist practice, patient dynamics and challenges. Nurses and physiotherapists' experience have more similarities than differences under the four categories.

CONCLUSION

Nurses and physiotherapists experience numerous challenges from both patient and resources related factors such as environment, staffing and time limitations; safety risks to patient and staff; and communication barriers due to patient's altered mental state. While tensions and variations in priorities of care delivery exist between the two groups, interdisciplinary collaboration of both professional groups was clearly evident and enabled optimisation of mobilisation goals for this patient population and revealed more similarities than differences in their experience. Patient and staff safety takes precedence over mobilisation and safety risks in this patient group can be mitigated by adequate resources, competence, and teamwork.

Exploring Canadian surgeons' decisions about postoperative weight bearing for their hip fracture patients

For older adults with osteoporosis, a fall resulting in hip fracture is a life-changing event from which only one-third fully recover. Current best evidence argues strongly for elderly patients to bear weight on their repaired hip fracture immediately after their surgery to maximize their chances of full or nearly full recovery. Patient stakeholders in Canada have argued that some surgeons fail to issue "weight-bearing-as-tolerated" (WBAT) orders in all eligible cases, protecting their bony repair but contributing to increased mortality and long-term disability rates. In collaboration with a national stakeholder organization, Bone and Joint Canada, we interviewed 20 orthopedic surgeons across Canada who perform hip fracture repair surgery, with the aim of understanding their attitudes and behavior toward patient management regarding weight bearing. Qualitative content analysis, in which themes are identified and agreed by multiple coders, suggested that both patient characteristics and surgeon factors influence surgeons' postoperative weight-bearing orders. While almost all respondents agreed that weight bearing as tolerated is indeed therapeutic for most hip fracture repair or replacement patients, surgeons also described certain patient characteristics that would diminish the value of immediate weight bearing, including poor bone quality and certain types of fracture pattern. Surgeon factors that affect postoperative mobilization orders include choice of construct, previous experience of construct failure, and lack of local audit data regarding past weight-bearing decisions and patient outcomes. Thus, although familiar with best practice guidelines, surgeons also have "rules to break the rules." In an era when "good" medicine leans toward science rather than art, the role of individual experience in decision making with regard to hip fracture care continues to be important and would benefit from being discussed openly.