Orthogeriatric co-management - managing frailty as well as fragility

Health-economic evaluation of orthogeriatric co-management for patients with forearm or humerus fractures: an analysis of insurance claims data from Germany

Orthogeriatric co-management (OGCM) describes a collaboration of orthopedic surgeons and geriatricians for the treatment of fragility fractures in geriatric patients. While its cost-effectiveness for hip fractures has been widely investigated, research focusing on fractures of the upper extremities is lacking. Thus, we conducted a health economic evaluation of treatment in OGCM hospitals for forearm and humerus fractures.In a retrospective cohort study with nationwide health insurance claims data, we selected the first inpatient stay due to a forearm or humerus fracture in 2014-2018 either treated in hospitals that were able to offer OGCM (OGCM group) or not (non-OGCM group) and applied a 1-year follow-up. We included 31,557 cases with forearm (63.1% OGCM group) and 39,093 cases with humerus fractures (63.9% OGCM group) and balanced relevant covariates using entropy balancing. We investigated costs in different health sectors, length of stay, and cost-effectiveness regarding total cost per life year or fracture-free life year gained.In both fracture cohorts, initial hospital stay, inpatient stay, and total costs were higher in OGCM than in non-OGCM hospitals. For neither cohort nor effectiveness outcome, the probability that treatment in OGCM hospitals was cost-effective exceeded 95% for a willingness-to-pay of up to €150,000.We did not find distinct benefits of treatment in OGCM hospitals. Assigning cases to study groups on hospital-level and using life years and fracture-free life years, which might not adequately reflect the manifold ways these fractures affect the patients' health, as effectiveness outcomes, might have underestimated the effectiveness of treatment in OGCM hospitals.

Effectiveness of fracture liaison service in reducing the risk of secondary fragility fractures in adults aged 50 and older: a systematic review and meta-analysis

To determine and appraise the certainty of fracture liaison service (FLS) in reducing the risk of secondary fragility fractures in older adults aged ≥ 50 years and to examine the nature of the FLS and the roles of various disciplines involved in the delivery of the FLS. Medline, EMBASE, PubMed, CINAHL, SCOPUS, and The Cochrane Library were searched from January 1st, 2010, to May 31st, 2022. Two reviewers independently extracted data. The risk of bias was evaluated using the Newcastle-Ottawa Scale for cohort studies and the PEDro scale for randomized trials, while the GRADE approach established the certainty of the evidence. Thirty-seven studies were identified of which 34 (91.9%) were rated as having a low risk of bias and 22 (59.5%) were meta-analyzed. Clinically important low certainty evidence at 1 year (RR 0.26, CI 0.13 to 0.52, 6 pooled studies) and moderate certainty evidence at ≥ 2 years (RR 0.68, CI 0.55 to 0.83, 13 pooled studies) indicate that the risk of secondary fragility fracture was lower in the FLS intervention compared to the non-FLS intervention. Sensitivity analyses with no observed heterogeneity confirmed these findings. This review found clinically important moderate certainty evidence showing that the risk of secondary fragility fracture was lower in the FLS intervention at ≥ 2 years. More high-quality studies in this field could improve the certainty of the evidence. Review registration: PROSPERO-CRD42021266408.

Association of frailty with adverse outcomes in surgically treated geriatric patients with hip fracture: A meta-analysis and trial sequential analysis

OBJECTIVE

Some studies have associated frailty and prognostic outcomes in geriatric hip fracture patients, but whether frailty can predict postoperative outcomes remains controversial. This review aims to assess the relationship between frailty and adverse postoperative outcomes in geriatric patients with hip fracture.

METHODS

Based on electronic databases, including PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, Chinese National Knowledge Infrastructure, and WanFang Data, we systematically searched for studies that investigated the association between frailty and adverse outcomes among patients aged 60 or over after hip fracture surgery. Stata 17.0 and Trial Sequential Analysis viewer software were used to obtain pooled estimates and verify whether the sample size was sufficient and the evidence robust.

RESULTS

Twenty-one studies involving 49,196 patients were included for quantitative analysis. Compared with nonfrail patients, frail patients had a higher risk of inpatient mortality (risk ratio [RR] = 1.93, 95% confidence interval [CI]: 1.66-2.23), 30-day mortality (RR = 2.13, 95% CI: 1.23-3.70), and 1-year mortality (RR = 2.44, 95% CI: 1.47-4.04). Frailty can significantly predict postoperative complications (RR = 1.76, 95% CI: 1.38-2.23), including delirium, pneumonia, cardiac complications, urinary tract infection, and surgical site infection; the association between frailty and deep venous thrombosis/pulmonary embolism and acute kidney injury needs further analysis. Trial sequential analysis showed that the findings regarding mortality were reliable and robust.

CONCLUSION

This meta-analysis provides detailed information indicating that frailty is a substantial predictor of mortality and selected postoperative complications.

Reverse Shoulder Arthroplasty for Proximal Humeral Fractures: Is the Bigliani-Flatow Stem Suitable for Tuberosity Fixation and Healing?

Background/Objectives: The aim of the study was to investigate the clinical, functional, and radiographic results of patients affected by three- or four-part proximal humeral fractures treated with reverse total shoulder arthroplasty, to investigate whether a prosthetic stem nonspecifically designed for fractures (i.e., the Bigliani-Flatow stem) promotes tuberosities' healing, and to evaluate the impact of tuberosity fixation and healing on the outcomes. Methods: Patients' data such as gender, age, side and dominancy, comorbidities, complications during or after surgery, and time lapse between trauma and surgery were prospectively collected. The type of fixation of the stem, the thickness and type of liner, and whether the tuberosities were fixed or not were also recorded. The Constant score weighted on the contralateral limb, QuickDASH, Oxford Shoulder Score, and Subjective Shoulder Value were collected. Tuberosities' healing was assessed with X-rays (anteroposterior, Grashey, and axillary views). Results: Overall, 34 patients were included, with an average follow-up of 42 months. Tuberosities were reinserted in 24 cases and their healing rate was 83%. The mean values were the following: a Constant score of 64, Oxford Shoulder Score of 39, Subjective Shoulder Value of 71, and QuickDASH score of 27. There were no significant differences in the scores or range of motion between patients with tuberosities healed, reabsorbed, or not reattached. There was a better external rotation in the group with healed tuberosities and a longer duration of surgery to reattach tuberosities. Conclusions: The treatment of proximal humerus fractures with the Bigliani-Flatow stem is associated with good clinical and functional results. The healing rate of the tuberosities was high and comparable, if not even better, than the mean rates reported for the stems dedicated to fractures of the proximal humerus and was, therefore, also appropriate for this indication.

Dementia and Hip Fractures: A Comprehensive Review of Management Approaches

» The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.» Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.» Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.» Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.» Coordination of care within a "orthogeriatric" team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.

Orthogeriatric care-outcome of different fragility fractures

INTRODUCTION

Fragility fractures (FF) are associated with increased morbidity and mortality and reflect a dramatic turning point in the life of older adults. The scientific discourse is dominated by proximal femoral fractures, but FF affect multiple parts of the body and often precede hip fractures. Orthogeriatric co-management has multiple shown to improve patient's outcome. We hypothesize that all geriatric patients with FF benefit from orthogeriatric co-management.

MATERIALS AND METHODS

We retrospectively evaluated all patients over 70 years with FF (hip joint, periprosthetic, spine, pelvic ring, and humerus) of our geriatric trauma center for the years 2019-2021, who received orthogeriatric co-management. Demographic data, fracture type, complications, discharge modality and in-hospital mortality were recorded. For patients transferred to geriatrics, the Barthel Index (BI) and the discharge modality were recorded. Primary outcome parameters were discharge modality and BI difference. Secondary outcome parameters were complication rates and in-hospital mortality. Logistic regression analysis was performed.

RESULTS

555 patients (83.8 ± 6.5 years, 182 males, 373 females) were evaluated. 245 (44.1%) patients were referred to geriatrics for further orthogeriatric treatment. Positive predictors were age, surgery, and a high Charlson Comorbidity Index. The overall in-hospital mortality was 8.6% (n = 48) (5.8% (n = 32) during acute trauma care and 6.5% (n = 16) during stay in geriatrics). The mortality rate of nursing home residents was significantly higher compared to patients living at home (10.4% vs. 5.6%). The rate of non-surgical complications was 44.5%. 26.9% of patients living at home were discharged to a nursing home, while 51.3% were able to return home. The risk of admission to a nursing home was reduced for thoracolumbar fractures (OR = 0.22) and increased markedly for periprosthetic fractures (OR = 3.95). During orthogeriatric treatment, all fractures showed a significant increase in BI. Patients living at home benefited more than nursing home residents (20.5 ± 19.5 vs. 8.7 ± 18.0 points). The chance of a BI increase (> 19 points) was increased for hip and pelvic ring fractures. Devastating results showed patients with dementia. In comparison, mentally healthy patients had a 4.5-fold increased chance of increasing their BI (> 19 points).

CONCLUSIONS

Presented data shows that all patients with FF are at high risk for complications and could benefit from standardized orthogeriatric management. Modern patient care requires a holistic orthogeriatric approach to improve patient's outcome.

Investigation and analysis of frailty and nutrition status in older adult patients with hip fracture

BACKGROUND

To analyze the current situation of frailty and the main influencing factors of frailty of older patients with hip fracture.

METHODS

Using a fixed-point consecutive sampling method, we investigated older adult patients with hip fracture aged ≥60 years who were hospitalized in an orthopedic ward of a tertiary hospital from January 2021 to March 2022. We also assessed the prevalence of frailty and malnutrition by trial of the fatigue, resistance, aerobic capacity, illnesses, and loss of weight (FRAIL) scale and the Global Leadership Initiative on Malnutrition criteria to analyze the factors influencing frailty.

RESULTS

A total of 216 older adult patients with hip fracture were collected, 106 (49.08%) were frail, 72 (33.33%) were prefrail, 38 (17.59%) were nonfrail, 103 (47.69%) were at overall nutrition risk, and 76 (35.19%) were malnourished. The results of bivariate correlation analysis showed that frailty score was correlated with age, the Activity of Daily Living Scale (ADL) score, body mass index (BMI), C-reactive protein, hemoglobin (Hb), serum albumin (ALB), and serum prealbumin, and was negatively correlated with ADL score, BMI, Hb, and ALB (r = -0.399, -0.420, -0.195, -0.283, respectively; P < 0.05). The results of multiple linear regression analysis showed that age, number of underlying diseases, ADL score, BMI score, and nutrition status were important influencing factors of frailty (P < 0.05).

CONCLUSION

Older adult patients with hip fracture are frail and prefrail, with a high prevalence of malnutrition. Advanced age, combined underlying diseases, and a low BMI score were risk factors for preoperative frailty.

The role of neutrophil percentage to albumin ratio in predicting 1-year mortality in elderly patients with hip fracture and external validation

Objectives

This study aimed to investigate the association between the neutrophil percentage to albumin ratio (NPAR) on the day of admission and mortality 1 year after surgery in elderly patients with hip fractures.

Methods

Clinical characteristics and blood markers of inflammation were retrospectively collected from October 2016 to January 2022 in elderly patients with hip fractures at two different regional tertiary medical centers. It is divided into a training set and an external validation set. Multivariate Nomogram models such as NPAR were constructed using the least absolute shrinkage and selection operator (LASSO) regression results and multi-factor logistic regression analysis. In addition, multivariate Cox regression analysis and Kaplan-Meier survival curves were used to explore the relationship between NPAR values and mortality within 1 year in elderly patients with hip fractures. The predictive performance of the Nomogram was evaluated using the concordance index (C Index) and receiver operating characteristic curve (ROC) and validated by Bootstrap, Hosmer-Lemesow goodness of fit test, calibration curve, decision curve, and clinical impact curve analysis.

Results

The study included data from 1179 (mean age, 80.34 ± 8.06 years; 61.4[52.1%] male) patients from the Guangzhou Red Cross Hospital affiliated with Jinan University and 476 (mean age, 81.18 ± 8.33 years; 233 [48.9%] male) patients from the Xiaogan Central Hospital affiliated with Wuhan University of Science and Technology. The results showed that NPAR has good sensitivity and specificity in assessing patients' prognosis 1 year after surgery. Multivariate logistic regression models based on influencing factors such as NPAR have good discrimination and calibration ability (AUC=0.942, 95% CI:0.927-0.955; Hosmer-Lemeshow test: P >0.05). Kaplan-Meier survival curves for the training and validation sets showed that patients in the high NPAR group had a higher mortality rate at 1 year compared to the low NPAR group (P< 0.001). Multivariate Cox regression showed that high NPAR values were an independent risk factor for death within 1 year in elderly hip fracture patients (P< 0.001, HR =2.38,95%CI:1.84-3.08).

Conclusion

Our study showed that NPAR levels were significantly higher in patients who died within 1 year after surgery in both the training and validation sets. NPAR has good clinical value in assessing 1-year postoperative prognosis in elderly patients with hip fractures.

Multidimensional prognostic index predicts short- and long-term mortality and rehospitalizations in older patients with hip fracture

BACKGROUND

Multidimensional Prognostic Index (MPI), calculated on cognitive, functional, nutritional, social, pharmacological and comorbidity domains, strongly correlates with mortality in older patients. Hip fractures are a major health problem and are associated with adverse outcomes in those affected by frailty.

AIM

We aimed at evaluating whether MPI is a predictor of mortality and rehospitalization in hip fracture older patients.

METHODS

We investigated the associations of MPI with all-cause 3- and 6-month mortality and rehospitalization in 1259 older patients admitted for hip fracture surgical treatment and managed by an orthogeriatric team [age 85 years (65-109); male gender: 22%].

RESULTS

Overall mortality was 11,4%, 17% and 23,5% at 3, 6 and 12 months from surgery (rehospitalizations: 15, 24,5 and 35,7%). MPI was associated (p < 0.001) with 3-, 6- and 12- month mortality and readmissions; Kaplan-Meier estimate for rehospitalization and survival according to MPI risk classes confirmed these results. In multiple regression analyses these associations were independent (p < 0.05) of mortality and rehospitalization-associated factors not included in the MPI, such as gender, age and post-surgical complications. Similar MPI predictive value was observed in patients undergoing endoprosthesis or other surgeries. ROC analysis confirmed that MPI was a predictor (p < 0.001) of both 3- and 6- month mortality and rehospitalization.

CONCLUSIONS

In hip fracture older patients, MPI is a strong predictor of 3-, 6- and 12- months mortality and rehospitalization, independently of surgical treatment and post-surgical complications. Therefore, MPI should be considered a valid pre-surgical tool to identify patients with higher clinical risk of adverse outcomes.

The correlates of post-surgical haematoma in older adults with proximal femoral fractures

BACKGROUND

Little is known about the incidence of haematoma, and clinical correlates among orthogeriatric patients.

AIMS

This study aims to describe the incidence of haematoma after surgical repair of hip fracture and to identify the clinical correlates of haematoma among orthogeriatric patients.

METHODS

Two orthopaedic surgeons and a dedicated operator using ultrasound technique, each other in blindness, evaluated 154 orthogeriatric patients during their hospital stay. All patients received a comprehensive geriatric assessment. We investigated the concordance between clinical diagnosis and ultrasound detection of haematoma, and then we explored the clinical correlates of the onset of post-surgical haematoma.

RESULTS

Blood effusion at the surgical site was detected in 77 (50%) patients using ultrasound technique; orthopaedic surgeons reached a clinical agreement about post-surgical haematoma in 18 (23%) patients. The sensitivity of clinical evaluation was 0.66, and the specificity was 0.70. Independent of age, clinical, pharmacological, and surgical confounders, proton pump inhibitors (PPIs) were associated with post-surgical haematoma (OR 2.28; 95% CI 1.15-4.49). A tendency towards association was observed between selective serotonin reuptake inhibitors and post-surgical haematoma (OR 2.10; 95% CI 0.97-4.54), CONCLUSIONS: Half of older patients undergoing surgical repair of proximal femoral fracture develop a post-surgical haematoma. Clinical assessment, even if made by senior orthopaedic surgeons, underestimates the actual occurrence of post-surgical haematoma compared to ultrasound detection. Ultrasound technique may help to detect haematoma larger than 15 mm better than clinical assessment. PPIs's use is a risk factor for post-surgical haematoma independent of several medical and surgical confounders.

Geriatric care for surgical patients: results and reflections from a cross-sectional survey in acute Belgian hospitals

PURPOSE

To explore geriatric care for surgical patients in Belgian hospitals and geriatricians' reflections on current practice.

METHODS

A web-based survey was developed based on literature review and local expertise, and was pretested with 4 participants. In June 2021, the 27-question survey was sent to 91 heads of geriatrics departments. Descriptive statistics and thematic analysis were performed.

RESULTS

Fifty-four surveys were completed, corresponding to a response rate of 59%. Preoperative geriatric risk screening is performed in 25 hospitals and systematically followed by geriatric assessment in 17 hospitals. During the perioperative hospitalisation, 91% of geriatric teams provide non-medical and 82% provide medical advice. To a lesser extent, they provide geriatric protocols, geriatric education and training, and attend multidisciplinary team meetings. Overall, time allocation of geriatric teams goes mainly to postoperative evaluations and interventions, rather than to preoperative assessment and care planning. Most surgical patients are hospitalised on surgical wards, with reactive (73%) or proactive (46%) geriatric consultation. In 36 hospitals, surgical patients are also admitted on geriatric wards, predominantly orthopaedic/trauma, abdominal and vascular surgery. Ninety-eight per cent of geriatricians feel that more geriatric input for surgical patients is needed. The most common reported barriers to further implement geriatric-surgical services are shortage of geriatricians and geriatric nurses, and unadjusted legislation and financing.

CONCLUSION

Geriatric care for surgical patients in Belgian hospitals is mainly reactive, although geriatricians favour more proactive services. The main opportunities and challenges for improvement are to resolve staff shortages in the geriatric work field and to update legislation and financing.

Effectiveness of integrated care for elderly patients with hip fractures: A systematic review and meta-analysis

Hip fractures in the elderly often cause many complications after surgery. Although ample evidence shows that integrated care can effectively improve postoperative conditions, the effectiveness of specific interventions remains inconsistent across studies. This study was conducted following the Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The database was from November 1998 to July 2022. Twelve studies (3,010 participants) implemented integrated care for elderly patients with hip fractures. Overall, integrated care improved Activities of Daily Living (ADL) levels within 6 months, at 12 months, Quality of Life (QoL) at 6 months, and decreased Length of Stay (LOS) and mortality rate at 3 months. At least 3 months of integrated care intervention for hip fractures in the elderly to reduce patient complications and medical costs, can be used as a reference for future policies and clinical care.

An Augmented Reality (AR) App Enhances the Pulmonary Function and Potency/Feasibility of Perioperative Rehabilitation in Patients Undergoing Orthopedic Surgery

Perioperative rehabilitation is crucial for patients receiving surgery in order to reduce complications and mortality. Conventional methods such as verbal instructions and pre-recorded video are commonly used, but several disadvantages exist. Therefore, we developed an augmented reality (AR) app that includes respiration training, resistance muscle training, and walking training for surgery preparation. The aim of this pilot study was to compare the effects of AR-based training rehabilitation programs with conventional (non-AR-based) programs considering the objective pulmonary function and subjective feasibility and potency in orthopedic patients. This prospective study was conducted in a medical center in Taiwan between 2018 to 2021. Sixty-six patients undergoing elective orthopedic surgery were allocated with a 1:1 ratio to non-AR or AR groups according to their wishes. After training, the inspiratory flow rate of the AR group was higher than that of the non-AR group pre-operatively. As for the subjective assessment, the feasibility (level of confidence and anxiety reduction) and potency (cooperation and educative effect) were superior in AR-based training, compared with the conventional training model. Our study showed that patients using our AR app had better subjective and objective outcomes compared with a conventional model for perioperative rehabilitation.

Preoperative dehydration identified by serum calculated osmolarity is associated with severe frailty in patients with hip fracture

BACKGROUND & AIMS

Preoperative dehydration is a well-known predictor of in-hospital complications and poor functional outcomes in older patients with hip fractures. In an orthopedic and geriatric cooperative setting, we aimed to investigate whether preoperative dehydration was associated with frailty, prolonged hospital stays and short-term mortality in older patients with hip fractures.

METHODS

This retrospective cohort study was conducted in a Danish university hospital. The study population consisted of patients 65+ years surgically treated for hip fracture. Dehydration was defined as serum calculated osmolarity above 295 mmol/L. Outcomes were frailty at discharge measured by the Multidimensional Prognostic Index, hospital stay of 7 days or more and 90-day mortality.

RESULTS

In total, 214 patients were consecutively included in the study from March 11, 2018, to August 31, 2020. The mean age was 81.2 (SD: 7.6) and 69% of the patients were women. The prevalence of preoperative dehydration was 40%. It was associated with severe frailty (Odds Ratio (OR): 2.08 [95% confidence interval (CI): 1.11-3.90]; p = 0.02) and prolonged hospital stay (OR: 2.28 [95% CI: 1.29-4.04]; p = 0.02). Seven percent died when dehydrated compared to 5% in the non-dehydrated (p = 0.91).

CONCLUSION

Prevalence of preoperative dehydration is high among older patients with hip fractures and is associated with severe frailty and length of hospital stay. Systematic screening for dehydration on admission is advisable and may contribute to more adequate fluid management in the perioperative phase.

The Impact of Socioeconomic Factors and Geriatric Syndromes on Frailty among Elderly People Receiving Home-Based Healthcare: A Cross-Sectional Study

Purpose: To evaluate frailty and its relationship with geriatric syndromes in the context of socioeconomic variables. Patients and Methods: In this cross-sectional study, elderly people aged 65 years old and over who received homecare in the reference region of Crete, Greece, were enrolled. Geriatric syndromes such as frailty, dementia, and depression were evaluated using the SHARE-Frailty Index (SHARE-Fi), the Montreal Cognitive Assessment (MoCA), and the Geriatric Depression Scale (GDS), respectively. Level of education, annual individual income, disability in Activities of Daily Living (ADL) and homebound status were also assessed as ‘socioeconomic factors.’ Results: The mean age of 301 participants was 78.45 (±7.87) years old. A proportion of 38.5% was identified as frail. A multiple logistic regression model revealed that elderly people with cognitive dysfunction were more likely to be frail (OR = 1.65; 95% CI: 0.55−4.98, p = 0.469) compared to those with normal cognition, but this association was not significant. Although elderly people with mild depression were significantly more likely to be frail (OR = 2.62; CI: 1.33−5.17, p = 0.005) compared to those with normal depression, the association for elderly people with severe depression (OR = 2.05, CI: 0.80−5.24, p = 0.134) was not significant. Additionally, comorbidity (OR = 1.06, CI: 0.49−2.27, p = 0.876) was not associated with frailty, suggesting that comorbidity is not a risk factor for frailty. In addition, patients with mild depression were significantly more likely to report frailty (OR = 2.62, CI:1.33−5.17, p = 0.005) compared to those with normal depression, whereas elders with an annual individual income (>EUR 4500) were less likely to be frail (OR = 0.45, CI: 0.25−0.83, p = 0.011) compared to those with <EUR 4500 per year. Conclusions: Our data analysis shows that higher annual individual income and mild depression were independently associated with frailty, suggesting that a lower poverty threshold and mild depression are risk factors for frailty.

The interdisciplinary fracture liaison service improves health-related outcomes and survival of older adults after hip fracture surgical repair

Due to the high burden of fragility fractures, we developed an interdisciplinary FLS care pathway for early management and monitoring of older adults discharged from a high-volume trauma center after hip fracture repair. Interdisciplinary FLS effectively improves up to 1-year adherence to treatments for secondary prevention of fragility fractures, reduces health facility admission, and improves long-term survival.

PURPOSE

To compare adherence to secondary fragility fracture prevention, falls, healthcare facility admissions, and mortality between hip fracture older adults who entered the fracture liaison services pathway of care (FLS-CP) and those managed according to the usual traumatologist model of care (U-CP).

METHODS

Prospective observational study enrolling subjects aged ≥ 65 years discharged by high-volume trauma center after hip fracture repair from February 2016 to February 2017, who consecutively entered FLS-CP or U-CP according to their preference and goals.

RESULTS

Compared to U-CP, those in FLS-CP had higher initiation rate and up to 1-year adherence to secondary prevention of fragility fracture, including vitamin D and calcium (87.7% vs 36.9%; p &lt; 0.0001), specific anti-osteoporosis drugs (75.1% vs 8.0%; p &lt; 0.0001), and complete anti-fracture therapy (72.3% vs 5.7%; p &lt; 0.0001). Older adults belonging to FLS-CP showed a lower likelihood of healthcare facility admission (RR 0.597; 95% CI 0.398-0.895; p = 0.0125), with a longer re-hospitalization-free survival (176.4 vs 88.7 days; p = 0.0152) than those in U-CP. One-year incidence of falls and fractures was similar between groups, with a lower tendency of the subjects in the FLS-CP to be multiple fallers (19% vs 34.8%; OR 0.057; 95% CI 0.004-0.876; p = 0.0690). The FLS-CP group experienced a lower 1-year (87.2% vs 74.3%; p = 0.001) and 3-year mortality (67.9% vs 55.6%; p = 0.0245) and a lower adjusted 5-year mortality hazard ratio (50.2% vs 58%; HR = 0.76; 95% CI 0.60; 0.96).

CONCLUSION

The FLS-CP may improve initiation and adherence to secondary prevention of fragility fractures, reduces healthcare facility admission, and improves long-term survival.

Risk factors for a second nonsimultaneous hip fracture in a prospective cohort study

INTRODUCTION

The risk factors for a second nonsimultaneous hip fracture are unclear, and in general, it is empirically assumed that they are similar to those associated with the first hip fracture. We aimed to determine the incidence of a second hip fracture and define the characteristics of the patients sustaining the event in a prospective cohort study in a Spanish population.

MATERIALS AND METHODS

We conducted a multicentric, prospective cohort study in a representative sample of 45 hospitals from 15 autonomic regions in Spain. In total, the study included 994 patients. One hundred and one patients presented a nonsimultaneous contralateral hip fracture, constituting the intervention group. The remaining 893 patients presenting with a hip fracture formed the control group. The main outcome measures of this study were sociodemographic characteristics of the patient, comorbid conditions, and baseline and postfracture clinical outcomes (inpatient complications and acute mortality).

RESULTS

The key fracture risk factors were a history of fragility fractures, the need for assistance when walking outdoors and a history of falls. There were no associations between the groups in any of the common fragility risk factors, including rheumatoid arthritis, secondary osteoporosis, or steroid consumption. The results showed that patients suffering a nonsimultaneous hip fracture had an increased risk of mortality after discharge compared with the control group.

CONCLUSION

A nonsimultaneous second hip fracture leads to a near-significant increase in four-month mortality. In our study, this fracture was associated with a history of falls, prior fragility fractures, and the need for a walking aid.

Second hip fracture in older adults: incidence and risk factors

PURPOSE

A second hip fracture can occur in older adults who have already suffered an initial hip fracture. The aim of this study was to determine the incidence, mortality and risk factors for second hip fractures in older adults with hip fractures.

METHODS

Between 2009 and 2019, 2013 patients (mean age: mean age 76.5 ± 5.4 SD) who were admitted to a tertiary care hospital for a hip fracture surgery were retrospectively analyzed. The patients were divided into two groups: those with a second hip fracture and those without a second hip fracture within the following two years after the initial fracture.

RESULTS

321 patients (15.9%, mean age: 85.3 ± 4.9 SD) sustained a second contralateral hip fracture, the first two years after the initial hip fracture whereas 136 patients (6.8%) sustained a contralateral hip fracture within 12 months. In total 274 (13.6%) died in the first two years after the initial hip fracture; among these, 139 patients (43.3%) had a contralateral second hip fracture. The mean time from the first hip fracture to second hip fracture was 13.2 ± 7.6 months. The advance age, female gender, living alone, dementia, chest and urinary tract infection, chronic heart failure, peripheral vascular disease were identified as risk factors for a second contralateral hip fracture.

CONCLUSIONS

Identifying risk factors for a second contralateral hip fracture can be particularly helpful in providing focused medical assistance.

The Phenotype of Bone Turnover in Patients with Fragility Hip Fracture: Experience in a Fracture Liaison Service Population

Background: Hip fragility fractures are becoming one of the main health care problems in countries with an aging population. This study aimed to evaluate the clinical characteristics and the usefulness of bone turnover markers in patients with a hip fracture. Methods: In a cohort of 363 patients (84.1 ± 9.2 years) with hip fractures we measured 25-hydroxyvitamin D (25OHD), bone alkaline phosphatase, type I collagen β carboxy telopeptide (βCTX), and parathyroid hormone (PTH). We recorded patients’ Charlson Comorbidity Index (CCI) and previous history of fragility fractures. Results: Vitamin D and PTH levels were inversely correlated (r = −024; p < 0.001). The prevalence of 25OHD deficiency was 57.8%, the PTH levels greater than 65 pg/mL was in 47.0 %, and in those who had βCTX values the upper limit was 61.8%. Moreover, 62% of patients with a fragility hip fracture had a history of a previous fracture. The 25OHD serum levels were inversely associated with CCI and a previous fragility fracture. On the contrary, PTH and βCTX serum levels showed a positive significant correlation with CCI and previous fragility fractures. Conclusion: This study confirmed the usefulness of a bone turnover markers assessment, along with the comorbidities and history of previous fragility fractures in order to better identify the risk of hip fracture.

Patients experience a need for informal care after a fragility fracture

In this qualitative secondary analysis, patients with a fragility fracture described needing informal care post-fracture. A significant proportion reported receiving no care or not enough care, often devising strategies to care for themselves. Requesting help from multiple individuals allowed patients to minimize the burden to family and friends.

INTRODUCTION

In individuals with fragility fractures, our objectives were to examine (1) the experience of receiving informal care post-fracture; and (2) how these care experiences influenced post-fracture recovery and subsequent management of bone health.

METHODS

A secondary analysis of six primary qualitative studies was conducted. Individuals in the primary studies were English-speaking women and men, 45 years and older, who were living in the community and had sustained a recent fragility fracture or reported a history of previous fragility fractures. Participants who reported at least one instance of needing informal care were categorized as receiving "enough care", "insufficient care", or "no care".

RESULTS

Of 145 participants in the primary studies, 109 (75%) described needing informal care after their fracture. Of those needing care, 62 (57%) were categorized as receiving enough care while 47 (43%) were categorized as receiving insufficient or no care. The care needed affected the management of participants' fracture and bone health, including access to health care services. Participants who received insufficient or no care, especially those living alone, devised strategies to care for themselves and often requested help from multiple individuals to minimize the burden to family and friends. Compared with men, women appeared to report needing help with personal daily activities, such as bathing, and transportation to appointments related to bone health.

CONCLUSION

Informal care needs are an additional burden of fragility fractures. Post-fracture interventions should consider the broader context of patients' lives and potentially support the care needs of patients as part of their services.

Orthogeriatric co-management: differences in outcome between major and minor fractures

PURPOSE

Literature shows that orthogeriatric co-management improves the outcomes of patients with hip fractures. Corresponding research with more diverse fragility fracture groups is lacking. Therefore, an examination was performed prospectively as a 2 year-follow-up on an orthogeriatric co-managed ward, comparing relevant outcome parameters for major and minor fragility fractures.

METHODS

All patients treated on an orthogeriatric co-managed ward from February 2014 to January 2015 were included and their injuries, orthogeriatric parameters such as the Barthel Index (BI), Parker Mobility Score (PMS) and place of residence (POR). Patients were separated into two groups of either immobilizing major (MaF) or non-immobilizing minor (MiF) fractures. 2 years later, a follow-up was conducted via telephone calls and questionnaires mailed to patients and/or their relatives.

RESULTS

740 (574 major vs. 166 minor injuries) patients were initially assessed, with a follow-up rate of 78.9%. The in-house, 1-year, and 2-year-mortality rates were 2.7, 27.4, and 39.2%, respectively. Mortality was significantly higher for MaF in the short term, but not after 2 years. On average, during the observation period, patients regained their BI by 36.7 points (95% CI: 33.80-39.63) and PMS was reduced by 1.4 points (95% CI: 1.16-1.68). No significant differences were found in the readmission rate, change in BI, PMS or POR between the MaF and MiF groups.

CONCLUSION

The relevance of orthogeriatric treatment to improving functional and socioeconomic outcomes was confirmed. The similarity of the results from both fracture groups emphasizes the need for a multidisciplinary approach also for minor fractures.

Incidence and risk factors for postoperative pneumonia following surgically treated hip fracture in geriatric patients: a retrospective cohort study

Objective

Large sample investigations for risk factors for pneumonia in elderly patients after hip fracture surgeries are lacking. The purpose of this study is to determine the incidence and risk factors for postoperative pneumonia in geriatric patients following hip fracture operations.

Methods

A retrospective study of incidence and risk factors in a tertiary referral center between 2016 and 2020 was conducted. Geriatric patients who developed postoperative pneumonia after surgeries of hip fracture during hospitalization stay were defined as cases and those without as controls. Multivariate logistic regression model was used to evaluate risk factors for postoperative pneumonia.

Results

This study included 3147 patients, and 182 developed postoperative pneumonia, denoting the rate of 5.8%. In the multivariate analyses, age (OR 1.04; 95% CI 1.02–1.06), sex (males) (OR 2.27; 95% CI 1.64–3.13), respiratory disease (OR 3.74; 95% CI 2.32–6.04), heart disease (OR 1.68; 95% CI 1.14–2.47), cerebrovascular disease (OR 1.58; 95% CI 1.11–2.27), liver disease (OR 2.61; 95% CI 1.33–5.15), preoperative stay (OR 1.08; 95% CI 1.05–1.11) and general anesthesia (OR 1.61; 95% CI 1.15–2.27) were identified as independent risk factors for postoperative pneumonia.

Conclusions

This study identified several risk factors for pneumonia in geriatric patients after hip fracture operations, providing a viable preventive strategy for optimizing clinical conditions for reduction of postoperative pneumonia.

Effects of Frailty on Outcomes Following Surgery Among Patients With Hip Fractures: A Systematic Review and Meta-Analysis

Background

Frailty is a syndrome of multisystem dysfunction in the elderly. The association between preoperative frailty and postoperative outcomes in patients with hip fractures is unclear. To address this issue, we performed a meta-analysis to determine the association of frailty with postoperative mortality, complications, and readmission in patients with hip fractures.

Methods

We searched PubMed, Web of Science, Embase, and The Cochrane Library for cohort studies of frailty associated with postoperative adverse events in patients with hip fractures from inception to November 6, 2021. The Newcastle-Ottawa Scale was used to evaluate the quality of the included literature. Statistical analysis of meta-analysis was performed using Review Manager 5.3.

Results

Twelve retrospective cohort studies and seven prospective cohort studies involving a total of 62,132 patients met the inclusion criteria for this meta-analysis. Compared with non-frail patients, the pooled results showed that frailty was associated with patient in-hospital mortality (relative risk [RR] = 2.93; 95% confidence intervals [CI]: 2.56–3.34), 30-day mortality (RR = 2.85, 95%CI: 1.67–4.85) and total complications (RR = 1.79, 95%CI: 1.50–2.15). Subgroup analysis showed that the type of study design and frailty assessment tool had no significant effect on the results. Sensitivity analysis showed that the polled results of frailty predicted one-year mortality and 30-day readmission was unstable.

Conclusions

In this meta-analysis, we found that preoperative frailty may be associated with postoperative adverse events in patients with hip fractures, including in-hospital mortality, 30-day mortality, and postoperative complications.

Systematic Review Registration: PROSPERO, identifier: CRD42021287739.

Postoperative Dehydration Is Associated with Frailty and Decreased Survival in Older Patients with Hip Fracture

BACKGROUND

Hyperosmolar dehydration (HD) is a risk factor for severe complications in hip fracture in older patients. However, evidence for recommending screening of dehydration is insufficient and its relation with frailty and mortality is unclear. We tested the hypothesis that postoperative HD is associated with frailty and increased mortality.

METHODS

We recruited 625 older (>65 years) patients surgically treated for hip fracture and co-managed by an orthogeriatric team over one year in 2017. Pre- and postoperative HD (serum osmolarity > 300 mmol/L) was diagnosed. Frailty and associated mortality risk were assessed by the Multidimensional Prognostic Index (MPI).

RESULTS

The prevalence of preoperative HD was 20.4%. Compared with no-HD, MPI was similar in HD patients despite higher (p < 0.05) prevalence of polypharmacy, arterial hypertension, diabetes, chronic kidney disease and heart failure. After surgery the incidence of HD decreased to 16.5%, but increased (p = 0.003) in the MPI high-risk subgroup. Postoperative HD was associated with more complications and was an independent determinant of adjusted hospital length of stay (LOS) and of 60- to 365-days mortality.

CONCLUSIONS

Older frail patients with hip fracture are prone to developing postoperative HD, which independently predicts prolonged hospital LOS and mortality. Systematically screening older patients for frailty and dehydration is advisable to customize hydration management in high-risk individuals.

Impact of orthogeriatric care management by orthopedic surgeons and physicians on in-hospital clinical outcomes: A difference-in-difference analysis

AIM

The orthopedic surgery unit in our suburb serves a large elderly trauma population in addition to providing elective surgeries. As patients with hip fractures have become older and at higher risk of medical complications, our hospital has initiated integrated co-management of these patients by orthopedic surgeons and geriatricians from the point of hospital admission. The aim of this study was to evaluate the impact of the hospital policy change on hip fracture management and clinical outcome indicators.

METHODS

Using the difference-in-difference approach, in total, 288 consecutive patients with hip fractures treated during the 1 year before and 2 years after transition to orthogeriatric care from a geriatric consultation model to integrated orthogeriatric care model were compared with 576 patients from other local hospitals.

RESULTS

Despite a seasonal trend toward increased length of hospital stay in winter, the intervention significantly reduced the change in mean length of stay (mean difference [95% confidence interval], -12.9 days [-21.5 to -4.3]; P = 0.007) and discharge to home tended to change less frequently (-12.6%; P = 0.10). There was no significant reduction in mean time to surgery (-0.2 days; P = 0.83), mortality (-0.8%; P = 0.62), or complications (-1.0%; P = 0.85).

CONCLUSIONS

Changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly reduced length of hospital stay probably due to a lower chance of discharge to home. To our knowledge, this is the first study in Japan to compare two orthogeriatric care models considering the nationwide improvement in hip fracture management.

AUTHOR

Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2022; ••: ••-••.

Independent, Differential Effects of Delirium on Disability and Mortality Risk After Hip Fracture

OBJECTIVES

To assess the independent effect of delirium on mortality and disability after 1 year of follow-up, in consecutive older patients with hip fracture hospitalized for surgical repair.

DESIGN

This is a prospective observational study.

SETTING AND PARTICIPANTS

Patients aged older than 65 years consecutively admitted for hip fracture to the Trauma and Orthopedics Centre of a third-level hospital, between March and October 2014.

METHODS

Patients were evaluated by a multidisciplinary team. A comprehensive geriatric assessment was performed on admission. Delirium was assessed before and after surgical repair according to the Confusion Assessment Method. Mortality and disability status were collected at 3 months and 1 year after hospital discharge.

RESULTS

Of 411 patients with hip fracture, 387 (mean age 82 years, female 72%) were enrolled. Delirium was assessed in 50% of the enrolled population. Patients with delirium were older, frequently affected by dementia, severe prefracture disability, history of falls, and polypharmacy. One-year mortality was 19% in all populations, and higher in patients with delirium, although delirium did not show an independent association with mortality, in multivariable analysis. Conversely, delirium was identified as an independent prognostic factor of long-term disability (B-1.605, SE 0.211, P < .001).

CONCLUSION AND IMPLICATIONS

This study identifies delirium as an independent long-term disability generator, regardless of associated clinical conditions and premorbid cognitive and functional status. This emphasises the importance of delirium prevention through a multidisciplinary approach and the potential role of systematic treatment of risk factors in reducing functional decline, even in subjects with preexistent disability and dementia. Moreover, these data call for research on rehabilitation interventions specifically targeted to these complex patients, with the aim of identifying approaches effective in reducing long-term disability. Conversely, a high level of clinical alertness is required in patients with delirium, as an appropriate treatment of acute diseases should reduce their high mortality risk.

Improving bone health: addressing the burden through an integrated approach

As people age, maintaining mobility becomes increasingly imperative, therefore addressing bone health is the most important way to preserve mobility. Poor bone health encompasses a broad spectrum of diseases, but it is most often quantified as the cumulative burden of osteoporosis and osteoporotic fractures. Rates of these fractures have been increasing and are expected to continue rising globally, attributed to increasing life expectancy worldwide. No single strategy will be sufficient to address this global public health issue. Co-ordination across a wide array of stakeholders is vital to decrease the health and socioeconomic burden of poor bone health. Stakeholders include an assortment of specialists ranging from health professionals (primary and secondary care clinicians, nurses, physical therapists, and social care workers), policy-makers, government bodies (including departments of health and social services), employers, civil society, as well as patients and their caregivers.  We need to ensure that there is a better understanding of the socioeconomic and health consequences of poor bone health to promote better policies to address needs. Building a more resilient health system approach to bone health based on the evidence and sound decision-making will not only improve population health, but will provide cost savings to health systems by preventing poor bone health in the first place. Health systems around the world must prioritise bone health to preserve mobility and wellbeing in advance of the impending surge in demand from ageing populations. Poor bone health is not an inevitable part of ageing. Working across the lifespan, we can all benefit from improved bone health throughout our lives.

Reviewing acute hip fractures in adults

ABSTRACT

Hip fractures are considered a significant public health issue, representing a substantial burden on our healthcare system and society. They are one of the leading causes of disability among older adults, especially women. Globally, an estimated 18% of women and 6% of men will be affected by hip fractures at some time in life. Hip fractures are a major cause of long-term disability among older adults and more significant than mortality, as only 60% of patients regain their preinjury level of mobility. This has detrimental effects on quality of life and activities of daily living, imposing a level of dependence that has personal, social, and systemic consequences.

Optimization of transdisciplinary management of elderly with femur proximal extremity fracture: A patient-tailored plan from orthopaedics to rehabilitation

Fractures of femur proximal extremity (FFPE) are the most common fragility fractures requiring hospitalization, with a high risk of mortality, low independence in the activities of daily living and severe consequences on health-related quality of life. Timing for surgery has a key role in the management of elderly patients with FFPE as recommended by the Australian and New Zealand guidelines and the National Institute for Health and Care Excellence guidelines. Early surgery (within 48 h from hospital admission) allows significant benefits in terms of lower rates of postoperative complications and risk of death and can provide better functional outcomes. Therefore, time for surgery could be considered as a comorbidity marker. The choice between conservative or surgical approach surprisingly seems to be still not strongly supported by available literature, but it seems that both 30 d and 1 year risk of mortality is higher with the conservative treatment rather than with surgery. In light of these considerations, the optimization of FFPE management care is mandatory to improve functional outcomes and to reduce sanitary costs. Albeit it is widely accepted that transdisciplinary approach to patients suffering from FFPE is mandatory to optimize both short-term and long-term outcomes, the feasibility of a comprehensive approach in clinical practice is still a challenge. In particular, the large variability of figures involved could be considered both a resource and an additional disadvantage taking into account the difficulty to coordinate multidisciplinary approach covering care in all settings. Therefore, the aim of the present article was to summarize current evidence supporting transdisciplinary management of patients with FFPE, highlighting the benefits, feasibility and limitations of this approach.

Clinical Practice Guideline for Postoperative Rehabilitation in Older Patients With Hip Fractures

OBJECTIVE

The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries.

METHODS

Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method.

RESULTS

A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost.

CONCLUSION

This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

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.

Effect of Covid-19 on best practice care of hip fracture patients: An analysis from the National Hip Fracture Database (NHFD)

BACKGROUND

Best practice tariff (BPT) has brought significant improvements in hip fracture care; the 2019 report showing a 30-day mortality of 6.1%. Data relating to more than 65,000 patients who sustain a fractured neck of femur (FNOF) are recorded each year in the National Hip Fracture Database (NHFD). The aim of our study was to review the impact of COVID-19 on BPT.

METHODS

Data was extracted from the NHFD for England, Wales and Northern Ireland. The months of March to June 2020 (lockdown period related to COVID-19) were compared to the same period in 2019. Data used in this study was collated and analysed between 14th and 17th October 2020.

RESULTS

Data for more than 40,000 patients was reviewed. BPT dropped -4.3% in March, -12.6% in April, -12.9% in May 2020, and -7.2% in June. Prompt surgery remained stable (four-month average + 0.1%). The most significant changes were noted for timely orthogeriatric review (-7.6%, p < 0.001), bone health assessment (-7.3%, p < 0.001) and post-operative delirium assessment (-6.6%, p < 0.001). 30-day mortality increased to 13.7% in March 2020 and remained high in April 2020 (11.3%) and May (7.3%). Acute hospital length of stay was lowest in May 2020 (11.7 days).

CONCLUSION

Patients sustaining FNOF in March 2020 had an associated 30-day mortality of 13.7%. During the COVID-19 pandemic, there was a significant reduction in BPT. The most significant changes were observed in timely orthogeriatric review. Maintaining a high standard of multidisciplinary care for this vulnerable group of patients is crucial during future spikes of COVID-19.

Impact of orthogeriatric management on the average length of stay of patients aged over seventy five years admitted to hospital after hip fractures

INTRODUCTION

Hip fracture is a frequent and serious condition in the elderly. We conducted a retrospective cohort study to answer the following questions: (1) Could treatment in an orthogeriatric unit help to reduce the average length of stay for patients aged over 75 years admitted to hospital for the treatment of a hip fracture?; and (2) Could such treatment influence the post-operative outcomes of patients with hip fracture?

METHODS AND MATERIALS

Our study included 534 patients admitted to hospital between January 2017 and December 2018 for surgical treatment of a hip fracture. We compared 246 patients who received traditional orthopaedic care with 288 patients treated in an orthogeriatric unit.

RESULTS

Our cohort included 410 women (77%). The average age was 87.5 ± six years, and 366 patients (68%) were living at home prior to the fracture. A statistically significant difference in median length of stay (from 10 to 9 days) was observed between patients who did and did not receive orthogeriatric unit treatment (groups 1 and 2; 95% CI: 0.64; 2.59; p = 0.001). There was no difference in pre-operative delay, intra-hospital mortality rate, place of recovery, rate of institutionalisation after six months, or the number of new fractures at 6 months between the groups. The mortality rate after six months was 23.6% and 21.3% in groups 1 and 2, respectively; the difference was not significant.

DISCUSSION

Orthogeriatric unit treatment reduced the median length of stay by one day, in line with most previous studies. According to Pablos-Hernandez et al., multifaceted orthogeriatric treatment is most effective. In our study, only 38% of the patients received surgical treatment within 48 hours, where early surgery is key for reducing the length of hospital stay. The intrahospital mortality rate was 2.6%, which is comparable to literature data. The discharge rate did not differ by orthogeriatric treatment status, which is also consistent with previous findings (e.g. Gregersen et al.). Lastly, the mortality rate after six months was slightly reduced by orthogeriatric care. In line with this, Boddaert et al. reported a difference in mortality rate after six months between groups who did and did not receive orthogeriatric treatment (15% vs. 24%).

Secondary Prevention of Hip Fragility Fractures During the COVID-19 Pandemic: Service Evaluation of "MRS BAD BONES"

Background

Management of osteoporosis is an important consideration for patients with femoral neck fractures due to the morbidity and mortality it poses. The input of orthogeriatric teams is invaluable in coordinating secondary fragility fracture prevention. The COVID-19 pandemic resulted in the rapid restructuring of health care teams and led to the redeployment of orthogeriatricians.

Objective

This study aimed to determine the impact COVID-19 had on the secondary prevention of fragility fractures among patients with femoral neck fractures, and to optimize management in this population.

Methods

A retrospective audit was conducted of patients with femoral neck fractures before and after the lockdown in response to the COVID-19 pandemic in the United Kingdom. A reaudit was conducted following the development of our new mnemonic, “MRS BAD BONES,” which addressed key factors in the assessment and management of osteoporosis: medication review, rheumatology/renal advice, smoking cessation; blood tests, alcohol limits, DEXA (dual energy X-ray absorptiometry) scan; bone-sparing medications, orthogeriatric review, nutrition, exercise, supplements. The Fisher exact test was used for comparison analyses between each phase.

Results

Data for 50 patients were available in each phase. The orthogeriatric team reviewed 88% (n=44) of patients prelockdown, which fell to 0% due to redeployment, before recovering to 38% (n=19) in the postintervention period. The lockdown brought a significant drop in the prescription of vitamin D/calcium supplements from 81.6% (n=40) to 58.0% (n=29) (P=.02); of bone-sparing medications from 60.7% (n=17) to 18.2% (n=4) (P=.004), and DEXA scan requests from 40.1% (n=9) to 3.6% (n=1) (P=.003). Following the implementation of our mnemonic, there was a significant increase in the prescription of vitamin D/calcium supplements to 85.7% (n=42) (P=.003), bone-sparing medications to 72.4% (n=21) (P<.001), and DEXA scan requests to 60% (n=12) (P<.001).

Conclusions

The redeployment of the orthogeriatric team, due to the COVID-19 pandemic, impacted the secondary prevention of fragility fractures in the study population. The “MRS BAD BONES” mnemonic significantly improved management and could be used in a wider setting.

[Research progress of multidisciplinary team co-management models for geriatric hip fracture treatment]

Objective

To summarize the research progress of multidisciplinary team (MDT) co-management models in the clinical treatment of geriatric hip fractures.

Methods

The literature about types and characteristics of MDT for geriatric hip fracture treatment were extensively reviewed, and the advantages of its clinical application were analysed and summarised. Finally, the MDT model and characteristics of geriatric hip fracture in the Zhongda Hospital affiliated to Southeast University were introduced in detail.

Results

Clinical models of MDT are diverse and have their own characteristics, and MDT can shorten the length of stay and waiting time before operation, reduce the incidence of internal complications, save labor costs, and reduce patient mortality.

Conclusion

The application of MDT in the treatment of geriatric hip fracture has achieved remarkable results, which provides an optimal scheme for the treatment of geriatric hip fracture.

Orthopaedic surgeons' perceptions of frailty and frailty screening

Background

Over the past decade, there has been significant growth in the awareness and understanding of fragility among orthopaedic surgeons in the context of osteoporotic fractures and with it, improvements in the recognition and management of fragility fractures. Emerging as a major clinical and research focus in aged care is the concept of frailty and its associations with fragility, sarcopenia, falls and rehabilitation. Currently, research is lacking on how orthopaedic surgeons perceive frailty and the role of frailty screening. A baseline understanding of these perceptions is needed to inform integration of frailty identification and management for patient optimization in orthopaedic practices, as well as research and education efforts of patients and healthcare professionals in orthopaedic contexts.

Methods

We used an exploratory design guided by qualitative description to conduct 15 semi-structured telephone and in-person interviews across three orthopaedic surgeon subgroups (Registrars, Junior Consultants, and Senior Consultants). Data collection and analysis occurred iteratively and was guided by thematic saturation.

Results

Orthopaedic surgeons have a disparate understanding of frailty. Between colleagues, frailty is often referred to non-specifically to suggest a general state of risk to the patient. Frailty screening is regarded positively but its specific utility in orthopaedic environments is questioned. Easy-to-administer frailty screening tools that are not exclusive assessments of functional status are viewed most satisfactorily. However these tools are rarely used.

Conclusions

There is little understanding among orthopaedic surgeons of frailty as a phenotype. Beliefs around modifiability of frailty were dissimilar as were the impact of related risk factors, such a cognitive status, chronic disease, social isolation, and environmental influences. This in turn may significantly impact on the occurrence and treatment outcomes of fragility fracture, a common orthopaedic problem in older populations. This study highlights need for knowledge translation efforts (e.g. education) to achieve cohesive understanding of frailty among health professionals.

Pay less and spend more-the real value in healthcare procurement

Healthcare performances have been for long evaluated according to outcomes and costs. What still needs to be defined is which outcomes are the most relevant to the patient, and which costs any supplier is capable to reduce, or increase, to the funder. If technical efficiencies during healthcare production and delivery may continue to evolve, the opportunities for further savings are likely to decrease. Major improvement could be achieved from better definition of outcomes that really matters to patients and stakeholders, that is measuring the real value. Many purchasers are shifting from a traditional approach based on single-unit cost-saving to a more holistic approach, encompassing long-lasting performance evaluation, including the highest possible number of stakeholders and wider sets of indicators. Value-based procurement (VBP) has been defined as achieving "outcomes that matter to people at the lowest possible cost". Although this approach may appear complicated in practice, it was already proven successful in different countries, medical and surgical applications, and has also been endorsed by some important international institutions. The scope of this review is to introduce VBP from a theoretical and an empirical level, referring to relevant practices and challenges which emerged in the current institutional, clinical and academic debate. VBP seems to be a promising solution to improve healthcare efficiency and fairness, provided a clear conception of what is value and a permanent collaboration between clinicians and scientists. When different dimensions of value (i.e., personal, technical, allocative and societal) are supported by well-designed study to identify the respective outcomes, it becomes easier to find better solutions in support of healthcare quality and sustainability.

The Looming Geriatrician Shortage: Ramifications and Solutions

Objective: Geriatricians are skilled in the recognition of asymptomatic and atypical presentations that occur in the elderly and provide comprehensive medication management including recognizing adverse drug events, reducing polypharmacy, and de-prescribing. However, despite the increasing average age of the U.S. population, with the number of individuals above 65 years old predicted to increase 55% by 2030, the geriatric workforce capacity in the United States has actually decreased from 10,270 in 2000 to 8,502 in 2010. Method: We describe physiologic changes in older adults, historical trends in geriatric training, and propose solutions for this looming crisis. Results: Many factors are responsible for the shortage of skilled geriatric providers. Discussion: We discuss the historical context of the lack of geriatricians including changes to the training system, describe the impact of expert geriatric care on patient care and health system outcomes, and propose methods to improve recruitment and retention for geriatric medicine.

[Research progress in treatment of femoral neck fracture in the elderly]

Objective

To introduce the research progress of conservative treatment, internal fixation, hip arthroplasty, and multidisciplinary team (MDT) modes in the treatment of femoral neck fracture in the elderly.

Methods

By consulting domestic and foreign literature in recent years, the characteristics and application of various treatment methods and new treatment modes for femoral neck fracture in the elderly were summarized and analyzed.

Results

The elderly non-displaced femoral neck fracture should be treated surgically, and conservative treatment has a high risk of secondary displacement. The displaced fracture should be operated as soon as possible. There is no difference in long-term functional outcome between hemiarthroplasty and total hip arthroplasty. Hemiarthroplasty has less intraoperative blood loss, shorter operation time, and is suitable for the elderly patients with poor basic condition. Total hip arthroplasty is suitable for the elderly patients with better basic condition and higher demand of life quality. MDT can effectively reduce preoperative waiting time and length of stay, reduce the incidence of medical complications, improve the nutritional status of patients, and reduce the mortality of patients.

Conclusion

Significant results have been achieved in the treatment of femoral neck fractures in the elderly by methods such as internal fixation, hip arthroplasty, and MDT.

Predictors of mortality in the elderly patient with a fracture of the odontoid process

Aims

Fracture of the odontoid process (OP) in the elderly is associated with mortality rates similar to those of hip fracture. The aim of this study was to identify variables that predict mortality in patients with a fracture of the OP, and to assess whether established hip fracture scoring systems such as the Nottingham Hip Fracture Score (NHFS) or Sernbo Score might also be used as predictors of mortality in these patients.

Patients and Methods

We conducted a retrospective review of patients aged 65 and over with an acute fracture of the OP from two hospitals. Data collected included demographics, medical history, residence, mobility status, admission blood tests, abbreviated mental test score, presence of other injuries, and head injury. All patients were treated in a semi-rigid cervical orthosis. Univariate and multivariate analysis were undertaken to identify predictors of mortality at 30 days and one year. A total of 82 patients were identified. There were 32 men and 50 women with a mean age of 83.7 years (67 to 100).

Results

Overall mortality was 14.6% at 30 days and 34.1% at one year. Univariate analysis revealed head injury and the NHFS to be significant predictors of mortality at 30 days and one year. Multivariate analysis showed that head injury is an independent predictor of mortality at 30 days and at one year. The NHFS was an independent predictor of mortality at one year. The presence of other spinal injuries was an independent predictor at 30 days. Following survival analysis, an NHFS score greater than 5 stratified patients into a significantly higher risk group at both 30 days and one year.

Conclusion

The NHFS may be used to identify high-risk patients with a fracture of the OP. Head injury increases the risk of mortality in patients with a fracture of the OP. This may help to guide multidisciplinary management and to inform patients. This paper provides evidence to suggest that frailty rather than age alone may be important as a predictor of mortality in elderly patients with a fracture of the odontoid process. Cite this article: Bone Joint J 2019;101-B:253–259.

The hospital cost of hip replacement for old inpatients in Belgium

INTRODUCTION

The objectives of this research are (i) to describe the medico-administrative characteristics of inpatients aged 65 and more who are hospitalized for hip joint replacement, (ii) to evaluate the complete hospital cost into costs of medical procedures, drugs costs, prostheses costs, and the administrative costs, and (iii) to identify and to evaluate from administrative database predictors influencing the complete hospital costs.

METHODS

The study was based on 961 inpatient stays aged 65 and more, with the APR-DRG 301 "Hip joint replacement". The sample for this study was based on data collected in 2014 among nine Belgian general hospitals. We used the linear regression method for isolating predictors of hospital cost.

RESULTS

The study highlights three different types of patients hospitalized for hip replacement, depending on the primary diagnosis: osteoarthritis problems (57%), femur neck fracture (30%), or other reasons (13%) (complications, infections, or problems with the existing hip prosthesis). The median length of stay (P25-P75) was 9 days (6.29-20.91). The median cost (P25-P75) was 8,023.91 EUR (6678.32-13,670.78). The total cost was composed of the direct hospital cost (30%), the cost of medical procedures (31%), cost of drugs (4%), the cost of hip prosthesis (18%), and other costs (17%). The linear regression reveals that an extreme SOI or risk of mortality, an ICU stay, an in-hospital death, an index of Charlson comorbidities of 4 or 5, to be hospitalized for a hip replacement because of complications, infections, or problems with the existing hip prosthesis, and the length of stay, were predictors of an increase in hospital cost.

CONCLUSION

The cost is not increasing with the age of the patient, but mainly with the length of stay and the comorbidities linked to the age which are considered in the severity of illness and the Charlson comorbidities index. The hospital cost is higher for patients hospitalized for complications linked to an existing hip prosthesis than for a hip replacement linked to osteoarthritis problems.