A comparison of treatment setting for elderly patients with hip fracture, is the geriatric ward superior to conventional orthopedic hospitalization?

A comparison between the femoral neck system and other implants for elderly patients with femoral neck fracture: A preliminary report of a newly developed implant

BACKGROUND

Femoral neck system (FNS) is an implant for patients with femoral neck fracture. It has superior angular and rotatory stability; it is less invasive because of its established locking plate system. To the best of our knowledge, there are no studies yet concerning the clinical outcomes of elderly patients with femoral neck fracture who have been treated using the FNS.

METHODS

Data of patients with femoral neck fracture aged >65 years and who had undergone internal fixation with the FNS and other implants were retrospectively analyzed in this study. The follow-up period was a minimum of six months between January 2006 and November 2020. In total, 52 patients were included in the clinical evaluations, using the FNS (group F) was 25 and using other implants (group O) was 27. Outcome measurements were surgical time, the amount of blood loss, union rate and the cases that underwent reoperation.

RESULTS

The average surgical time in the group F was 42 ± 13 min (range: 26-83 min) and was shorter than that in the group O (53 ± 21 min, range: 13-111 min, P = 0.032). The average blood loss in the group F was calculated to 36 ± 25 g (range: 0-91 g), while it was 41 ± 40 g (range: 0-169 g) in group O. No significant difference among the groups. The union rate of the group F was 100%, and the reoperation rate of the group F was significantly less than that of the group O (0% vs 22%, P = 0.023).

CONCLUSION

Internal fixation using the FNS can be an alternative option with shorter surgical time and lower reoperation rate for elderly patients with femoral neck fracture.

High Charlson Comorbidity Index Score is associated with early fracture-related complication for internal fixation of neck of femur fractures

The incidence of geriatric hip fractures continues to rise in our aging population and has become a major public health concern globally. The primary outcome of this study was to determine whether Age-adjusted Charlson Comorbidity Index (ACCI) is associated with increased fracture-related complications in neck of femur fractures treated by internal fixation. This was a cohort study between January 2014 to June 2018. All patients ≥ 50 years old with an acute neck of femur fracture after low-energy trauma fixed with cannulated hip screws were included and followed-up for 1 year at a tertiary centre. Primary outcome was to determine whether ACCI was associated with increased fracture-related complications. Secondary outcomes were revision rate, mortality, and function after surgery. Further analysis were performed within a “younger” group (age 50–65) and “elder” group (age > 65), as displaced fractures (Garden Type III/IV) were in “younger” group. 233 hip fractures (68 males; 165 females) with a mean age of 73.04 ± 12.89 were included in the study. Surgical outcomes showed that the complication rate of hip screw fixation for all patients was 21.5% (50 patients) at 1 year. ACCI was significantly higher in all patients with complications (p = 0.000). Analysis within “younger” (p = 0.000) and “elder” groups (p = 0.006) both showed significance. Stepwise logistic regression modelling showed ACCI had positive correlation with complications with ACCI = 6 (OR 4.27, p = 0.02). R² values were comparatively better after controlled by Garden Type III/IV at ACCI = 4 (OR 6.42 (1.70, 24.25), p = 0.01). The authors recommend that for patients with a Garden Type I/II and ACCI ≥ 6 or a Garden Type III/IV and ACCI ≥ 4, a direct arthroplasty surgery should be considered.

Effects of Orthogeriatric Care Models on Outcomes of Hip Fracture Patients: A Systematic Review and Meta-Analysis

Orthogeriatrics is increasingly recommended in the care of hip fracture patients, although evidence for this model is conflicting or at least limited. Furthermore, there is no conclusive evidence on which model [geriatric medicine consultant service (GCS), geriatric medical ward with orthopedic surgeon consultant service (GW), integrated care model (ICM)] is superior. The review summarizes the effect of orthogeriatric care for hip fracture patients on length of stay (LOS), time to surgery (TTS), in-hospital mortality, 1-year mortality, 30-day readmission rate, functional outcome, complication rate, and cost. Two independent reviewers retrieved randomized controlled trials, controlled observational studies, and pre/post analyses. Random-effects meta-analysis was performed. Thirty-seven studies were included, totaling 37.294 patients. Orthogeriatric care significantly reduced LOS [mean difference (MD) - 1.55 days, 95% confidence interval (CI) (- 2.53; - 0.57)], but heterogeneity warrants caution in interpreting this finding. Orthogeriatrics also resulted in a 28% lower risk of in-hospital mortality [95%CI (0.56; 0.92)], a 14% lower risk of 1-year mortality [95%CI (0.76; 0.97)], and a 19% lower risk of delirium [95%CI (0.71; 0.92)]. No significant effect was observed on TTS and 30-day readmission rate. No consistent effect was found on functional outcome. Numerically lower numbers of complications were observed in orthogeriatric care, yet some complications occurred more frequently in GW and ICM. Limited data suggest orthogeriatrics is cost-effective. There is moderate quality evidence that orthogeriatrics reduces LOS, in-hospital mortality, 1-year mortality, and delirium of hip fracture patients and may reduce complications and cost, while the effect on functional outcome is inconsistent. There is currently insufficient evidence to recommend one or the other type of orthogeriatric care model.

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.

A comparative epidemiologic study of fractures among people in rural and urban areas

PURPOSE

This study aimed to comparatively analyse the epidemiologic characteristics of fractures among inpatients from rural and urban areas.

METHODS

This study retrospectively analysed patients with traumatic fractures of the limbs, pelvis and spine treated in our hospital from January 2017 to December 2017. Patients from rural and urban areas were classified into Group A and Group B, respectively. Data on age, sex, distribution of fracture locations, injury mechanism, season, date and time when the fracture occurred, length of hospital stay, chronic comorbidities and in-hospital mortality were collected, and compared between both groups.

RESULTS

A total of 10,046 patients (Group A: 4,440; 3,062 males and 1,378 females and Group B: 5,606; 3,374 males and 2,232 females) with traumatic fractures were included. The male-to-female ratio was significantly different between both groups (P<0.001). In Groups A and B, the patients aged 41.9 ± 21.6 and 45.0 ± 23.5 years old, respectively, showing significant difference (P<0.05). As for injury mechanism, the most common one was low-energy injury (Group A: 2110, accounting for 47.5%; Group B: 3422, accounting for 61.0%) in both Groups, followed by traffic accidents (Group A: 921, accounting for 20.7%; Group B: 973, accounting for 17.4%). In patients with multiple injuries, the most common mechanism of injury is traffic accidents (354, 46.1%). There were 178 patients in Group A (4.0%) and 141 patients in Group B (2.5%) combined with head injury. As for season, both groups had most of the fractures in autumn (Group A: 1449, accounting for 32.6%; Group B: 1518, accounting for 27.3%).

CONCLUSION

The epidemiological features of patients with traumatic fractures in rural and urban areas are somewhat different in terms of age distribution, injury mechanism, injured body site and season. Patients with high risk of fractures in rural areas were younger than those in urban areas. Fractures more frequently occurred in the wrist and hips in rural and urban areas, respectively. Prevention of low-energy-induced osteoporotic fractures has become very critical for both rural and urban populations. Reducing the risk of traffic accident remains critical to prevent multiple injuries.

Surgical Site Infections in Elderly Fragility Hip Fractures Patients Undergoing Warfarin Treatment

OBJECTIVES

Surgical site infection (SSI) is a devastating complication of proximal femoral fracture surgery, related with an increased morbidity and mortality. As warfarin treatment has been described as a risk factor for SSI, we aimed to compare patient and SSI characteristics in warfarin and nonanticoagulated patients.

DESIGN

Retrospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS

Individuals 65 years of age and older with fragility hip fractures.

INTERVENTION

Patients were divided into 2 cohorts: warfarin treated (n = 85) or nonanticoagulated (n = 771). Demographics, in-hospital characteristics, laboratory data, prior hospitalizations, recent antibiotic use, and 1-year incidence of SSIs and their characteristics were gathered.

MAIN OUTCOME MEASURES

Postoperative SSIs.

RESULTS

Twelve patients (14.1%) from the warfarin group and 21 patients (2.7%) from the noncoagulated group had SSI (P < 0.001). Both groups were comparable in terms of demographics and Charlson comorbidity score. Warfarin-treated patients had reduced white blood and neutrophils counts (10.1 ± 3.2 vs. 11.6 ± 4.0 cells/mm and 8.1 ± 3.2 vs. 9.6 ± 3.9 cells/mm for both comparisons respectively; P < 0.001 for both). They were more likely to be admitted to a geriatric ward than to orthopedics ward and were delayed to theater (58.5 ± 44.5 vs. 30.6 ± 27.4 hours; P < 0.001). Following surgery, there was no difference in blood transfusions required, in-hospital complications, or time to infection. Rates of prior hospitalizations, antibiotic use, or type of bacteria did not differ.

CONCLUSIONS

Warfarin treatment in fragility hip fracture surgery is correlated with an increased risk for SSI, regardless of in-hospital complications, and hospitalizations before surgery or to the infection itself.

LEVEL OF EVIDENCE

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

Urinary retention as a postoperative complication associated with functional decline in elderly female patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort

Urinary retention (UR) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of UR in elderly female patients with femoral neck fractures.We recruited 221 female patients (age 85.3 ± 7.0 years) with a history of hip surgery carried out at Toyama Municipal Hospital. UR occurred in 34 out of 221 cases (15.4%). Multiple logistic regression analysis was conducted to investigate the risk factors for UR, including age, body mass index (BMI), serum albumin, cognitive impairment, and activities of daily living (ADL).The results showed significant association of UR with cognitive impairment (P = .005, odds ratio [OR] 4.11, 95% confidence interval [CI] 1.53-11.03), and ADL (P = .029, OR 2.61, 95% CI 1.11-6.18), under adjustment with age and BMI.This study demonstrated that cognitive function and ADL were the important risk factors for UR, suggested that the postoperative management of UR is important with taking account of neurofunctional assistance and nursing care in daily living, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.

Different approaches towards geriatric trauma care for hip fracture patients: an inter-hospital comparison

PURPOSE

Hip fractures in geriatric patients have high morbidity and mortality rates. The implementation of a multidisciplinary geriatric care pathway (GCP) may improve treatment for this patient population. This study focusses on two level II hospitals with a different treatment protocols. A comparison was made between a multidisciplinary GCP and extensive standard care with a focus on geriatric hip fracture patients to assess if a multidisciplinary GCP leads to lower mortality and morbidity.

METHODS

This retrospective cohort study included patients aged 70 years or older with a unilateral proximal hip fracture who underwent surgery between January 2014 and December 2015. The primary outcome measures complications and 30-day mortality. Secondary outcome measures were time to surgery, hospital length of stay (HLOS) and secondary surgical interventions.

RESULTS

This study included a total of 898 patients. No differences were found between major postoperative complications, 30-day mortality, HLOS or the amount of secondary surgical interventions.

CONCLUSIONS

Mortality, major complications, HLOS and the amount of secondary surgical interventions showed no differences between both hospitals. This inter-hospital comparison of two types of geriatric care models showed no outcome that favours one specific geriatric care model over another. This provides opportunities for future studies to get a better understanding of what specific factors of geriatric care models contribute most to an improvement in the treatment of this patient population and decide which approach is most cost effective.

Acute Kidney Injury in Patients Undergoing Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

Background: The number of total hip arthroplasties (THA) performed across the world is growing rapidly. We performed this meta-analysis to evaluate the incidence of acute kidney injury (AKI) in patients undergoing THA. Methods: A literature search was performed using MEDLINE, EMBASE and Cochrane Database from inception until July 2018 to identify studies assessing the incidence of AKI (using standard AKI definitions of RIFLE, AKIN, and KDIGO classifications) in patients undergoing THA. We applied a random-effects model to estimate the incidence of AKI. The protocol for this meta-analysis is registered with PROSPERO (no. CRD42018101928). Results: Seventeen cohort studies with a total of 24,158 patients undergoing THA were enrolled. Overall, the pooled estimated incidence rates of AKI and severe AKI requiring dialysis following THA were 6.3% (95% CI: 3.8%–10.2%) and 0.5% (95% CI: 0.1%–2.3%). Subgroup analysis based on the countries by continent was performed and demonstrated the pooled estimated incidence of AKI following THA of 9.2% (95% CI: 5.6%–14.8%) in Asia, 8.1% (95% CI: 4.9%–13.2%) in Australia, 7.4% (95% CI: 3.2%–16.3%) in Europe, and 2.8% (95% CI: 1.2%–17.0%) in North America. Meta-regression of all included studies showed significant negative correlation between incidence of AKI following THA and study year (slope = −0.37, p <0.001). There was no publication bias as assessed by the funnel plot and Egger’s regression asymmetry test with p = 0.13 for the incidence of AKI in patients undergoing THA. Conclusion: The overall estimated incidence rates of AKI and severe AKI requiring dialysis in patients undergoing THA are 6.3% and 0.5%, respectively. There has been potential improvement in AKI incidence for patients undergoing THA over time.

Prediction of readmissions in the first post-operative year following hip fracture surgery

PURPOSE

To define risk factors for rehospitalization following fragility hip fractures and to create a predictive model.

METHODS

A retrospective cohort study of patients 65 years and older, who were treated operatively following fragility hip fractures between 01.2011 and 06.2016. Patients were allocated into two study groups based on the occurrence of recurrent hospitalizations in the year following surgery. Demographic information, comorbidities, and in-hospital characteristics were collected, as was information regarding 1-year readmissions. Multivariate analysis of factors predictive of rehospitalizations was performed, followed by a logistic regression using all predictors with p < 0.05. A stepwise backwards elimination method was used to create the predictive model.

RESULTS

Eight hundred and fifty-one patients were included; 369 (43.4%) had recurrent hospitalizations within the first post-operative year. Patients who were rehospitalized were more likely to be males, to use a walking aid and to live dependently. They had a higher age-adjusted Charlson's comorbidity index (ACCI) score, a higher perveance of atrial fibrillation, lower hemoglobin, worse renal function, less platelets, and longer time to surgery. Prevalence of in-hospital complications was similar. Six variables were found to independently influence the chance for readmissions: male gender, the use of a walking aid, higher ACCI score, lower hemoglobin, atrial fibrillation, and a longer surgical delay. Only the first four were found to be adequate predictors and were added to the prediction formula.

CONCLUSION

High 1-year readmission rates are seen following discharge in patients with fragility hip fractures. Addressing risk factors might aid to better rehabilitate patients and reduce morbidity.