Clinical pathways for geriatric patients with proximal femoral fracture improve process and outcome

Can the prognostic score proposed by Elliot serve as an educational tool to shorten the time to surgery for hip fractures in geriatric patients?

INTRODUCTION

Hip fractures require surgical treatment within 48hours to decrease the risk of postoperative complications. Elliott proposed a prognostic score to identify which patients should be prioritized for surgery. This study was designed to answer the following questions: 1- Does using this score shorten the time to surgery? 2- Does shortening the time to surgery reduce mortality at 6 months and 1 year? 3- What factors delay the surgical procedure? We hypothesized that using this score as an educational tool would reduce the time to surgery in patients over 75 years of age who have a hip fracture.

MATERIAL AND METHODS

This single-center study involved two populations: 244 patients were included prospectively who had the score applied with the aim of optimizing the time to surgery; 476 patients were included from a historical cohort to serve as a reference group.

RESULTS

The mean time to surgery was 2.5 days±1.9 [95% CI: 2.41-2.77] and the median was 2 days (minimum 0, maximum 18 days) in the reference group; the mean was 1.4 days±1.0 [95% CI: 1.46-1.67] and the median was 1 day (min. 0, max 6 days) in the prospective cohort, which was a significant reduction (p<0.001). At 6 months, the mortality rate was 22.5% in the reference population and 23% in the prospective cohort. At 1 year, the mortality rate was 47% and 46%, respectively, with no significant difference. Surgical delays were attributed to lack of OR availability, management of anticoagulants, request for cardiac ultrasound and administrative reasons.

DISCUSSION/CONCLUSION

Elliot's prognostic at-risk score for hip fracture can shorten the time to surgery when used an educational tool to raise the medical staff's awareness of the benefits of rapid surgical care.

LEVEL OF EVIDENCE

IV; retrospective study without control group.

Proximal femoral fracture and female gender are risk factors for recurrent fracture: Cohort study of 292 patients over 75 years-old with iterative osteoporotic fractures

PURPOSE

The purpose of this study was to: 1/ describe the characteristics of a cohort of patients over 75 years of age hospitalized in perioperative geriatric units (UPOG) for iterative fractures; 2/ investigate the risks of institutionalization related to the first fracture; and 3/ search for potential risk factors for iterative fracture.

METHODS

This is a retrospective single-center study analyzing patients over 75 years old, hospitalized in UPOG.

RESULTS

Of the 3207 patients hospitalized, 292 patients had a refracture (9.1%), with a mean age of 85.4+/-5.8 years. Initial fractures were mainly intertrochanteric (43.2%) and the femoral neck (32.9%). Refractures occurred mainly in the first year (55.5%), with a median delay of 9.6 months. Refractures were mainly intertrochanteric (29.5%), peri‑implant (prosthesis, osteosynthesis) (28.8%), and femoral neck (26.7%). Dementia was the only factor for institutionalization after the first fracture episode (p = 0.0002). Proximal femoral fracture (PFF) and female gender were risk factors for iterative fracture (10.2% vs. 6.8%, p = 0.003; 10.7% vs. 6.8%, p = 0.005 respectively), but not age (85.4 vs. 85.8 years, p = 0.24). PFF were more likely to result in the same fracture type in the second episode (58.1% vs 7.1%, p<0.0001). The time to refracture was shorter in case of peri‑implant fracture (p = 0.0002), or discharge directly to home (p = 0.04).

CONCLUSION

PFF and female gender are risk factors for recurrent fracture, which is even more likely to occur early in case of home discharge or peri‑implant fracture.

[The proximal femur fracture epidemic continued during the COVID-19 pandemic: Results of an observational study]

Introduction

L’objectif de cette étude était de comparer le volume et les caractéristiques des chirurgies urgentes traumatologiques réalisées dans notre institution entre le 20 mars et le 20 avril 2020, correspondant au premier mois de confinement, et de les comparer aux données de la période équivalente de 2019. Notre hypothèse de travail reposait sur le fait qu’il existe une part de traumatologie non évitable pour laquelle des mesures de prévention spécifique pourraient être nécessaires.

Méthodes

Il s’agit d’une étude continue mono-centrique observationnelle. Tous les patients ayant nécessités une prise en charge chirurgicale traumatologique entre le 20 mars et le 20 avril 2020 ont été inclus, et les données de la même période de 2019 étaient récupérées. L’ensemble des chirurgies était réalisé dans notre institution qui est un centre de traumatologie de niveau 2 de notre région.

Résultats

Pendant le premier mois de confinement, 70 patients ont été pris en charge chirurgicalement pour une urgence traumatologique, contre 109 patients sur la période de 2019, représentant une baisse d’activité globale de 36 %. Sur l’ensemble des patients, l’âge moyen était significativement plus élevé en 2020 (68,4 SD = 22 vs 60,3 SD = 24 p = 0,0210). Les accidents de loisirs et les accidents de la circulation étaient moins nombreux en 2020 (34 vs. 10), ainsi que les accidents liés au travail (7vs. 2) alors que les accidents domestiques restaient globalement stables (65 vs. 55).

Conclusion

En période d’urgence sanitaire, la poursuite des activités de traumatologie est essentielle, même si elle nécessite une organisation spécifique pour la prise en charge des patients. La période de confinement et les modifications de comportements associées ont changé le spectre global de la traumatologie. La réduction majeure de la traumatologie routière, de loisirs et celle liée au travail constitue une part évitable de cette activité chirurgicale justifiant d’une prévention spécifique en période crise sanitaire. À l’inverse, les traumatismes gériatriques et notamment les fractures de l’extrémité proximale du fémur n’étaient globalement que peu modifiées traduisant la nécessité de mesures de prévention supplémentaires pour ces patients.

Niveau de preuve

V ; étude observationnelle.

The proximal femur fracture epidemic continued during the COVID-19 pandemic: Results of an observational study

INTRODUCTION

The aim of this study was to compare the volume and characteristics of emergency trauma surgery procedures done at our hospital between March 20 and April 20, 2020 (the first month of the national lockdown in France) and to compare these data to the same period in 2019. We hypothesized that a portion of fractures are unavoidable, thus specific preventative measures will be needed to reduce their incidence.

METHODS

This was a continuous, observational and single center study. All patients who required urgent surgery for a fracture between March 20 and April 20, 2020, were included. Data for the same period in 2019 was retrieved. All the procedures were done at our hospital, which is a regional level II trauma center.

RESULTS

During the first month of the lockdown, 70 patients underwent emergency surgery because of a fracture, versus 109 patients in the same period in 2019, thus an overall 36% drop. The mean age of the patients was higher in 2020 (68.4 years SD=22) than in 2019 (60.3 years SD=24, p=0.0210). There were fewer recreational and motor vehicle accidents in 2020 (34 vs. 10) and fewer work-related accidents (7 vs. 2) although the number of accidents at home were similar (65 vs. 55).

CONCLUSION

During a public health emergency, it is vital to continue doing trauma surgery procedures, even though it requires a specific care pathway. The lockdown and associated behavioral changes have altered the spectrum of trauma surgery. A major decrease in motor vehicle, recreation and work-related accidents is the avoidable portion of this surgical activity, justifying specific preventative measures during a public health crisis. Conversely, the incidence of geriatric fractures - particularly of the proximal femur - did not change much overall, thus there is need for additional preventative measures in these patients.

LEVEL OF EVIDENCE

V, observational study.

Usefulness of nutritional assessment using Geriatric Nutritional Risk Index as an independent predictor of 30-day mortality after hip fracture surgery

INTRODUCTION

The Geriatric Nutritional Risk Index (GNRI) is an objective nutritional status assessment tool used for predicting mortality risk in hospitalized patients. However, it is unclear whether GNRI reflects short-term mortality for hip fracture patients after surgery. We examined the usefulness of the nutritional status assessed by the GNRI and identified cutoff scores that predict mortality risk. Does GNRI on admission predict the mortality after surgery for hip fracture?

HYPOTHESIS

Evaluation of GNRI could help identify patients at higher risk of 30-day mortality after hip fracture surgery.

MATERIALS AND METHODS

This retrospective study used data from 1040 patients who underwent hip fracture surgery. Fatalities within 30 days after hip fracture surgery were investigated. The GNRI was calculated on admission in all patients as follows: 14.89×serum albumin (g/dL)+41.7×body mass index/22. Receiver operating characteristic (ROC) curves were used to calculate the area under the curve (AUC) and the optimal cutoff score that could predict 30-day mortality after hip fracture surgery. This cutoff score was used for comparing the mortality rates between patient groups with a GNRI higher and lower than the cutoff score using Fisher's exact test. Logistic regression analysis was used to determine risk factors of 30-day mortality.

RESULTS

There were 17 fatalities (1.6%) in the cohort. The ROC-AUC value was 0.811, and the cutoff GNRI was 75.4. Mortality was significantly higher in the group with a GNRI<75.4 compared with the group with a GNRI≥75.4 (odds ratio [OR], 22.99; 95% confidence interval [95% CI], 7.55-78.05; p=0.00000004). A GNRI<75.4 was a significant predictor of mortality within 30-days after hip fracture surgery (OR, 27.1; 95% CI, 8.57-85.9; p≤0.0001).

DISCUSSION

Our results show that nutritional status assessment using GNRI can help predict 30-day mortality among geriatric patients undergoing surgery for hip fracture. The GNRI is a simple and accurate tool for predicting the risk of mortality after hip fracture surgery.

LEVEL OF EVIDENCE

IV; case series study.

Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review

IMPORTANCE

Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors.

OBJECTIVE

To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS.

EVIDENCE REVIEW

A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components.

FINDINGS

Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements.

CONCLUSIONS AND RELEVANCE

In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.

Differences between intertrochanteric and femoral neck fractures in resuscitative status and mortality rates

INTRODUCTION

Hip fracture mortality remains a challenge for orthopedic surgeons. The purpose of this study was to compare resuscitative mean arterial pressures (MAPs), intravenous fluid (IVF) administration, and mortality rates between intertrochanteric (IT) and femoral neck (FN) fracture patients.

HYPOTHESIS

We hypothesized that IT fracture patients would receive less aggressive fluid resuscitation than FNF patients given the perceived less invasive nature of intra-medullary nails compared with hemiarthroplasty.

MATERIALS AND METHODS

An institutional database was queried to identify all hip fractures managed surgically over a 2-year period. Preoperative and intraoperative MAPs and IVF administration, as measures of resuscitation, were compared between IT fracture patients treated with open reduction internal fixation and FN fracture patients treated with hemiarthroplasty.

RESULTS

Six hundred and ninety-eight hip fractures, including 531 IT and 167 FN fractures, were analyzed. There were no differences between IT and FN fracture cohorts for age, sex distribution, or Charlson Comorbidity Index scores. IT fracture patients were found to have lower MAP upon admission (103.7±20.1 vs. 107.8±18.4mmHg; p=0.026), and lower average, minimum, and maximum MAP values preoperatively and intraoperatively. Despite lower MAPs, IT fracture patients received less total IVF (581.9±472.5 vs. 832.9±496.5cc; p<0.001) and lower IVF rates intraoperatively (306.5±256.8 vs. 409.8±251.0 cc/h; p<0.001). IT fracture patients experienced higher 30-day (7.9% vs. 3.6%; p=0.040) and 90-day (10.6% vs. 5.4%; p=0.035) mortality rates and trended towards higher inpatient mortality (3.0% vs. 0.6%; p=0.088). Multivariate regression demonstrated IT pattern to be independently predictive of 30-day mortality with 2.459 increased odds relative to FN fracture (p=0.039).

DISCUSSION

IT fracture patterns are associated with decreased perioperative MAP values, yet received lower perioperative IVF rates. IT fracture patients suffered higher 30- and 90-day mortality rates, despite similar age and comorbidities.

LEVEL OF EVIDENCE

III; retrospective cohort study.

Effect of Low-Dose Dexmedetomidine Combined with Lumbosacral Plexus Block Guided by Ultrasound Imaging Based on Image Segmentation Algorithm in Fracture Surgery

The aim of this study was to analyze the application of ultrasound-guided low-dose dexmedetomidine combined with lumbosacral plexus block based on artificial intelligence algorithm in the surgical treatment of proximal femoral fractures. 104 patients with proximal femoral fractures were divided into 52 cases in the experimental group (ultrasound-guided lumbosacral plexus block combined with dexmedetomidine based on local fitting image segmentation algorithm) and 52 cases in the routine group (endotracheal intubation and inhalation combined with general anesthesia). An image segmentation algorithm based on local fitting was constructed to enhance the ultrasound image. It was found that in the routine group, the heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) at the beginning of intravenous injection of dexmedetomidine, during skin incision, and half an hour after skin incision were significantly lower than those at admission (P < 0.05). The pressing times of patient-controlled intravenous analgesia (PCIA) in the conventional group (17.05 ± 6.85 times) were significantly higher than that in the experimental group (8.55 ± 4.12 times), and the difference was statistically significant (P < 0.05). The visual analogue scale (VAS) scores at 1, 5, 10, and 15 after operation in the routine group were significantly higher than those in the experimental group (P < 0.05). The number of dizziness, nausea, and vomiting, venous thrombosis of lower limbs, cardiovascular events, and pulmonary infection in the routine group on the 1st, 2nd, and 3rd days after operation were significantly higher than those in the experimental group (P < 0.05). In summary, the ultrasound-guided lumbar plexus-sacral plexus block combined with dexmedetomidine anesthesia based on image segmentation algorithm can effectively maintain the hemodynamic stability of patients, with remarkable analgesic effect and high safety.

Implementation of a Geriatrics-Focused Orthopaedic and Hospitalist Fracture Program Decreases Perioperative Complications and Improves Resource Utilization

OBJECTIVE

To evaluate whether the implementation of a geriatrics-focused orthopaedic and hospitalist comanagement program can improve perioperative outcomes and decrease resource utilization.

DESIGN

A retrospective chart review study was conducted before and after the implementation of a geriatrics-focused orthopaedic and hospitalist comanagement program, based on the American Geriatrics Society (AGS) AGS CoCare:Ortho.

SETTING

A large urban, academic tertiary center, located in the greater New York metropolitan area.

PARTICIPANTS

Patients 65 years and older hospitalized for operative hip fracture. Those with pathologic or periprosthetic fractures and chronic substance use were excluded.

MAIN OUTCOME MEASUREMENTS

Outcome measures included time to operating room (TtOR), length of stay, daily and total morphine milligram equivalents, use of preoperative transthoracic echocardiogram and blood transfusions, perioperative complications (eg, urinary tract infections), and 6-month mortality.

RESULTS

Our study included 290 patients hospitalized with hip fracture, before (N = 128) and after (N = 162) implementation. When compared with the preimplementation group, the postimplementation comanagement group had a lower TtOR (36.2 vs. 30.0 hours, P = 0.026) and hospital length of stay, decreased use of indwelling bladder catheters preoperatively and postoperatively (68.0% vs. 46.9%, P < 0.001, and 83.6 vs. 58.0%, P < 0.001, respectively), reduced daily opiate use (16.0 vs. 11.1 morphine milligram equivalents, P = 0.011), and decreased 30-day complications (32.8% vs. 16.7%, P = 0.002). There was no difference in 6-month mortality between the 2 groups.

CONCLUSIONS

The implementation of an AGS CoCare:Ortho-based comanagement program led to decreased perioperative complications and resource utilization. Comanagement programs are essential to improving and standardizing hip fracture care for older adults.

LEVEL OF EVIDENCE

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

Orthogeriatric co-management for proximal femoral fractures. Can two additions make a big difference?

BACKGROUND

Proximal femoral fractures are a major socioeconomic burden and they occur mainly in geriatric patients. High mortality and complication rates are reported. To reduce the mortality and morbidity of these patients, co-management with geriatricians has been recommended. Most previous studies have focused on relatively comprehensive care models. Models with only a few additions to the usual care have not been extensively evaluated.

METHODS

This retrospective observational study included all patients aged ≥70 years (mean age: 84.5 ± 7.1 years, 70% women) with an isolated proximal femoral fracture treated surgically in our institution from May 2018 to October 2019. In the first 9 months, patients were treated with the usual care (control group, n = 103). In the second 9 months, patients were treated with our multidisciplinary care model (intervention group, n = 104), which included the usual care, plus: (1) one multidisciplinary ward round per week and (2) one "elective" operation slot per day reserved for proximal femoral fractures. Baseline characteristics and outcome measures of the hospital stay were extracted from electronic health records. A 3-month follow-up was conducted by phone.

RESULTS

Baseline characteristics were comparable between groups (p > 0.05). The hospital stay was shorter in the intervention group than in the control group (7.8 ± 4.3 vs. 9.1 ± 4.5; p = 0.022). The intervention reduced the waiting time for surgery by more than 10 h (intervention: 25.4 ± 24.5 vs. control: 35.8 ± 34.1 h; p = 0.013). A structured phone interview was not performed in 30.9% of the cases. The model reduced the overall dissatisfaction rate by more than half (12.9% vs. 32.4%; p = 0.008). On the other hand, the groups had similar perioperative complication rates (25% vs. 24.3%; p > 0.9999) and mortality (4.8% vs. 3.9%; p > 0.9999) and they remained similar at the 3-month follow-up (complications: 20.3% vs. 17.6% p = 0.831, mortality: 18.2% vs. 15.0% p = 0.573).

CONCLUSION

We found that two additions to the usual proximal femoral fracture regimen could significantly improve the overall satisfaction rate, reduce the length of hospital stay and shorten the waiting time for surgery. In contrast to previous studies, we observed no significant improvements in complication or mortality rates. Further changes in the standard care might be needed for this purpose.