Functional recovery and length of stay after recurrent hip fracture

Management of hip fracture in the older people: rationale and design of the Italian consensus on the orthogeriatric co-management

BACKGROUND

Hip fracture (HF) is a burdening health problem in older people. The orthogeriatric approach has been shown to favour functional recovery and reduce mortality, but its implementation in clinical practice cannot rely upon shared management protocols and greatly varies among different healthcare systems. Here, we present the rationale and design of the Italian consensus document on the management of HF in older people.

METHODS

A panel of multidisciplinary experts from ten Italian scientific societies involved in the care of HF and including geriatricians, orthopaedics, anaesthesiologists, physiatrists and general practitioners, will join to establish the content validity of a list of statements. A Delphi consensus methodology will be applied to obtain the opinions of the panel and to provide the final recommendations.

OBJECTIVES

The document will include indications on the following relevant topics: (1) optimal care path of older subjects with HF; (2) management of comorbidities and pre-operative alteration of physiological parameters; (3) management of selected categories of patients at expected increased risk of adverse outcomes; (4) continuity of care out of hospital; (5) screening and correction of risk factors for HF in older subjects; (6) information and divulgation of shared management strategies. The objective of the consensus will be to inform clinicians, patients, researchers, and health policy makers about the best management strategies for HF in older people and their inherent limitations, thus facilitating communication between stakeholders and promoting the most cost/effective models of care.

Simultaneous Hip and Distal Radius Fractures-Does It Make a Difference with Respect to Rehabilitation?

INTRODUCTION

A minority of patients with hip fractures sustain concomitant wrist fractures. Little is known about the rehabilitation outcome in this group of patients.

AIM OF STUDY

Prospective investigation of functional outcome and survival in patients with combined hip and wrist fractures compared with patients who sustain an isolated hip fracture.

METHODS

341 patients who presented with an acute hip fracture during a 12 month period were included in the study. Outcome at discharge and 4 months follow-up was compared between patients with isolated hip fractures and those patients who sustained simultaneous distal wrist fractures.

RESULTS

The actual incidence of concurrent hip and wrist fractures in our cohort was 4.7%. Patients who sustained a concurrent hip and wrist fracture showed no differences regarding short- and long-term functional outcome and survival.

CONCLUSION

Our results imply that patients with simultaneous hip and wrist fractures have no difference in rehabilitative outcome. Future studies should further investigate the distinctive characteristics of this patient subgroup.

Predictors of In-Hospital Ambulatory Status Following Low-Energy Hip Fracture Surgery

Introduction:

Twenty-five percent to seventy-five percent of independent patients do not walk independently after hip fracture (HF), and many patients experience functional loss. Early rehabilitation of functional status is associated with better long-term outcomes; however, predictors of early ambulation after HF have not been well described.

Purposes:

To assess the impact of perioperative and patient-specific variables on in-hospital ambulatory status following low-energy HF surgery.

Methods:

This is a retrospective analysis of 463 geriatric patients who required HF surgery at a metropolitan level-1 trauma center. The outcomes were time to transfer (out of bed to chair) and time to walk.

Results:

Three hundred ninety-two (84.7%) patients were able to transfer after surgery with a median time of 43.8 hours (quartile range: 24.7-53.69 hours), while 244 (52.7%) patients were able to walk with a median time of 50.86 hours (quartile range: 40.72-74.56 hours). Preinjury ambulators with aids (hazard ratio [HR]: 0.70, confidence interval [CI]: 0.50-0.99), age >80 years (HR: 0.66, CI: 0.52-0.84), peptic ulcer disease (HR: 0.57, CI: 0.57-0.82), depression (HR: 0.66, CI: 0.49- 0.89), time to surgery >24 hours (HR: 0.77, CI: 0.61-0.98), and surgery on Friday (HR: 0.73, CI: 0.56-0.95) were associated with delayed time to transfer. Delayed time to walk was observed in patients over 80 years old (HR: 0.74, CI: 0.56-0.98), females (HR: 0.67, CI: 0.48-0.94), peptic ulcer disease (HR: 0.23, CI: 0.84-0.66), and depression (HR: 0.51, CI: 0.33-0.77).

Conclusions:

Operative predictors of delayed time to transfer were surgery on Friday and time to surgery >24 hours after admission. Depression is associated with delayed time to transfer and time to walk. These data suggest that is important to perform surgeries within 24 hours of admission identify deficiencies in care during the weekends, and create rehabilitation programs specific for patient with depression. Improving functional rehabilitation after surgery may facilitate faster patient discharge, decrease inpatient care costs, and better long-term functional outcomes.

The clinical results of a novel method for minimal invasive dynamic hip screw fixation of intertrochanteric fractures compared to the conventional one

PURPOSE

Hip intertrochanteric fractures are very frequent. Early mobilization reduces the associated mortality and morbidity rate. DHS is still commonly used in many centers. We describe a new minimal invasive DHS technique (MIDHS) depending on radiological land marks, facilitating the application of DHS in a proper way without the use of an angle guide and we retrospectively compared the functional results of the new technique with that of the conventional DHS (CDHS) technique.

METHODS

116 patients (MIDHS n = 56; CDHS n = 60) with stable intertrochanteric fractures were followed up for at least 12 months. The motoric function using the Barthel index, the post-operative pain using the VAS, and the time of bone healing of the new MIDHS group were compared to that of the CDHS group.

RESULTS

The 1st, 2nd, 3rd, 7th, 15th, and 45th days showed a higher motoric function of the MIDHS compared with the CDHS, P (0.001, 0.032, 0.012, 0.001, 0.028 and 0.041), respectively. VAS demonstrated less scores of the MIDHS group in the 1st, 2nd, 3rd, 7th, 15th, and 45th days when compared with that of the CDHS group, P (0.001, 0.032, 0.012, 0.001, 0.028, and 0.041), respectively. However, no statistical significance was detected in bone-healing time between the two groups.

CONCLUSIONS

The new MIDHS technique is a trustable procedure that may help the surgeon to perform DHS fixation in a proper way. It offers a better motoric function, less pain. However, further studies should be conducted to evaluate the validity of such radiological land marks in proximal femoral surgery.

Optimizing physical activity among older adults post trauma: Overcoming system and patient challenges

BACKGROUND

By 2050 it is anticipated that close to half (40%) of all trauma patients will be over the age of 65. Recovery for these individuals is more complicated than among younger individuals. Early mobilization has been shown to improve outcomes. Unfortunately, there are many challenges to early mobilization. The Function Focused Care Intervention was developed to overcome these challenges.

PURPOSE

The purpose of this paper was to describe the initial recruitment of the first 25 participants and delineate the challenges and successes associated with implementation of this intervention.

RESULTS

Overall recruitment rates were consistent with other studies and the intervention was implemented as intended. Most patients were female, white and on average 79 years of age. Optimizing physical activity of patients was a low priority for the nurses with patient safety taking precedence. Patients spent most of the time in bed. Age, depression and tethering were the only factors that were associated with physical activity and functional outcomes of patients.

CONCLUSION

Ongoing work is needed to keep patients physically active in the immediate post trauma recovery period.

Restoration of hip architecture with bipolar hemiarthroplasty in the elderly: does it affect early functional outcome?

INTRODUCTION

Reconstruction of the anatomic architecture correlates with functional outcome in patients receiving elective total hip arthroplasty. In theory similar rules should apply for bipolar hemiarthroplasty in femoral neck fractures. The influence of anatomic restoration after bipolar hemiarthroplasty on short-term clinical and functional outcome is explored in this study.

PATIENTS AND METHODS

Patients receiving bipolar hemiarthroplasty for intracapsular femoral neck fractures between 2010 and 2012 were included into a retrospective cohort study. Radiologic and functional outcome parameters were recorded during the acute care phase and geriatric rehabilitation. Postoperative mobilization data were recorded and co-morbidities documented for each case. Outcome parameters were obtained during geriatric rehabilitation: Barthel index, Tinetti score, Timed up and go test, Mini-Mental State Examination. The FO-ratio (ratio of femoral offset to the body weight lever arm), HC-ratio (ratio of the height of the hip center to the pelvic height) and the BWLA ratio (ratio of the body weight lever arm to the pelvic height) were obtained from postoperative radiographs.

RESULTS

A total of 193 patients with a median age of 84 (IQR = 78-94, 72% female) were analyzed. The in-hospital mortality rate was 5.7%. There was a high proportion of patients with prior co-morbidities (96% with at least one co-morbidity). During rehabilitation the Barthel index improved significantly (p < 0.001) from 40 to 55. The median Tinetti score on rehabilitation discharge was 15.5 (IQR = 10-19.5). The patients significantly improved in the timed up and go test from a median of 22 to 19 s. A significant difference (p < 0.001) was found comparing the FO ratios of the operated vs. non-operated side. None of the radiographic measures, representing the reconstructed anatomic hip geometry, significantly influenced the clinical and geriatric outcome.

CONCLUSIONS

Applying the short-term functional outcome scores used in this study, optimized anatomic restoration in hemiarthroplasty may not be a major influencing factor in a cohort of elder, multi-morbid patients.

Modified direct anterior approach in minimally invasive hip hemiarthroplasty in a geriatric population: a feasibility study and description of the technique

INTRODUCTION

The direct anterior approach (DAA) is generally accepted method for minimal invasive arthroplasty of the hip. As good results for total hip arthroplasty are already published, there is a lack of evidence for the implantation of bipolar hip hemiarthroplasty (BHH) in elderly patients with osteoporosis after femoral neck fracture.

MATERIALS AND METHODS

For hip arthroplasty using a direct anterior approach (DAA) in elderly patients with femoral neck fractures, a number of modifications of the original technique are being described. The modified DAA considers in particular the co-morbidity and the bone quality of the geriatric patient population. A consecutive series of 16 hemiarthroplasties using this technique is presented. In all 16 cases, the BHH was implanted in modified DAA technique. Mobility measured by 4-item Barthel Index, pain via visual analogue scale (VAS), duration of surgery, external length of incision and blood loss were evaluated.

RESULTS

There was no major operative complication during the procedures. The pain level decreased from 7 (preoperatively) to 0 at postoperative day 40. The Barthel Index increased from 5 at first postoperative day to 40 at day 40. Early postoperative mobilisation is efficiently accelerated. Mean operating time was 71 min; the medium skin incision length was 8 cm. The mean haemoglobin level decreased from 118 g/dl preoperatively to 101 g/dl at first postoperative day.

CONCLUSION

The described modifications of the DAA help to implant a BHH gently in elderly patients with increasing risk of complications like iatrogenic fractures, wound or prosthesis infections and haematoma. This will hopefully lead to a faster rehabilitation and lower mortality rate for patients with femoral neck fractures in the future.

Early functional results after hemiarthroplasty for femoral neck fracture: a randomized comparison between a minimal invasive and a conventional approach

BACKGROUND

A minimal invasive approach for elective hip surgery has been implemented in our institution in the past. It is widely hypothesized that implanting artificial hips in a minimal invasive fashion decreases surgical trauma and is helpful in the rehabilitation process in elective hip surgery. Thereby geriatric patients requiring emergency hip surgery also could theoretically benefit from a procedure that involves less tissue trauma.

METHODS

Sixty patients who sustained a fractured neck of femur were randomly assigned into two groups. In the minimal invasive arm, the so called "direct anterior approach" (DAA) was chosen, in the conventional arm the Watson-Jones-Approach was used for implantation of a bipolar hemi-arthroplasty.Primary outcome parameter was the mobility as measured by the four-item-Barthel index. Secondary outcome parameters included pain, haemoglobin-levels, complications, duration of surgery, administration of blood transfusion and external length of incision. Radiographs were evaluated.

RESULTS

A statistically significant difference (p = 0,009) regarding the mobility as measured with the four-item Barthel index was found at the 5th postoperative day, favouring the DAA. Evaluation of the intensity of pain with a visual analogue scale (VAS) showed a statistically significant difference (p = 0,035) at day 16. No difference was evident in the comparison of radiographic results.

CONCLUSIONS

Comparing two different approaches to the hip joint for the implantation of a bipolar hemi-arthroplasty after fractured neck of femur, it can be stated that mobilization status is improved for the DAA compared to the WJA when measured by the four-item Barthel index, there is less pain as measured using the VAS. There is no radiographic evidence that a minimal invasive technique leads to inferior implant position.

LEVEL OF EVIDENCE

Level II therapeutic study.

Proximal femoral fractures in the elderly: how are we measuring outcome?

INTRODUCTION

Patients with proximal femoral fractures present a difficult problem to health care systems in view of their complex presentations and co-morbidities. Traditionally, the focus of outcome measurement for this patient group has been on mortality and surgical implant success. Increasing recognition of the need to diversify outcome measurements has led to the creation and use of a number of outcome scales. We sought to examine how these scales are being used in the current literature.

METHODS

Abstracts to over 4000 papers related to proximal femoral fracture research were screened to identify commonly used scales in the five main categories of general quality of life measures (QoL), Activities of Daily Living scales (ADL), mobility and physical performance scales, disease-specific scales and hip-specific scales. The 14 identified scales were then searched for directly, and papers analysed for scale usage, timing and interpretation.

RESULTS

ADL scales were the most commonly used group, followed by QoL measures, which are validated for elderly patients. Scale timing and use varied widely between studies. A large number of scales were found in addition to the 14 identified scales. None of the 14 identified scales were validated for the proximal femoral fracture population.

DISCUSSION

A good scale must be appropriate in content, method and clinical utility. Its method of application must be reliable, responsive, and validated for the population in question. Outcome scale usage was difficult to assess in proximal femoral fracture research due to difficulties in isolating the relevant research, and in differences in scale timing and interpretation. Scale prevalence was skewed by use by specific research groups.

CONCLUSION

There is no single unifying scale in widespread use for proximal femoral fracture patients. We would recommend the validation of commonly used scales for this population, and would advise the use of scales from more than one category to assess outcome.

Gender and race/ethnicity differences in hip fracture incidence, morbidity, mortality, and function

BACKGROUND

Hip fracture is an international public health problem. Worldwide, approximately 1.5 million hip fractures occur per year, with roughly 340,000 in the United States in individuals older than 65 years. In 2050, there will be an estimated 3.9 million fractures worldwide, with more than 700,000 in the United States. However, whether there are disparities in morbidity, mortality, and function between men and women or between races/ethnicities is unclear.

QUESTIONS/PURPOSES

The purpose of this article is to review the gender and racial/ethnicity differences in hip fracture epidemiology, mortality, and function and to ask what more information is needed and how can it be attained.

METHODS

A PubMed literature review was performed and appropriate articles selected for inclusion in the review. WHERE ARE WE NOW?: Overall, men with hip fracture are younger, are less healthy, and have a higher postoperative mortality and morbidity. African American and Hispanics patients with hip fractures are younger than whites and have a higher incidence of fracture in men. Non-Hispanic black, Hispanic, and Asian race/ethnicity were all associated with higher odds of discharge home but a longer stay when discharged to rehabilitation. WHERE DO WE NEED TO GO?: Expanded knowledge of the influence of gender and race/ethnicity on hip fracture epidemiology, mortality, and outcomes is necessary. HOW DO WE GET THERE?: Additional focused research on gender and racial/ethnic differences in patients with hip fractures is needed. Improving database capture of race/ethnicity data will aid in population studies. Finally, journal editors should require authors to include gender and race/ethnicity data or explain the absence of this information.

A retrospective analysis of bilateral fractures over sixteen years: localisation and variation in treatment of second hip fractures

The aim of this study was the evaluation of contralateral hip fractures after a previous hip fracture. For this retrospective analysis patients were selected from the database of the LUMC, a teaching hospital in the south-west of the Netherlands. We analyzed all patients with a second fracture of a hip between 1992 and 2007. The exclusion criteria were high impact trauma and patients with diseases or medication known to have a negative effect on bone metabolism. A total of 1,604 hip fractures were identified. The possible predictive factors for the second fracture and descriptive statistics related to surgery (Hb and HT before and after the operation, total amount of intra- and postoperative blood loss, type of osteosynthesis, complications, time of death after the last fracture, time between arrival in the hospital and operation and hospital stay for both fractures) were recorded. A total of 32 second hip fractures were identified (2%) at a mean of 27.5 (SD 28.9) months after the initial hip fracture. The mean age at the first fracture was 77.2 years (SD 11.7), and 27 of 32 patients were female. Of these 32 patients (64 bilateral hip fractures), 32 fractures were intracapsular (1 femoral neck, 31 subcapital) and 32 were extracapsular fractures (6 subtrochanteric, 26 transtrochanteric). Although 24 of the 32 patients had identical first and second hip fractures, only eight out of 32 hips were treated with the same implants. There was a significant difference in Singh index between both hips at the time of the first fracture. There was also a significant difference in Singh index between the hip which was not fractured compared with its subsequent index when it was broken. All other studied patient and fracture characteristics were not significantly different. In this population the percentage of second hip fractures was relatively low compared to other studies. The choice of implants in this study shows that implants were chosen randomly. Because there is a significant difference in the Singh index during first and second hip fracture, osteoporosis medication might help reduce the incidence of second hip fractures.

Validation on Efficiency Pattern Analysis for Geriatric Hip Fractures Rehabilitation

Seven hundred and sixty-three elderly patients with hip fractures were recruited in the study. The Functional Independence Measure (FIM) was used to measure their functional status on admission and upon discharge, and their difference was defined as functional change. An Efficiency Pattern Analysis Matrix was formed with Efficiency Pattern Analysis (EPA) and was used for in-depth matrix characteristics analysis. A validation study was also conducted with another group of patients (n = 455) so that the stability of EPA across time was affirmed. We found that 23.3% of patients are in “higher efficiency” group [higher motor-FIM gains with shorter length of stay (LOS)], 8.5% in “higher gain and longer stay” group (higher motor-FIM gains with longer LOS), 32.5% in “average efficiency” group, 12% in “lower gain and shorter stay” (lower motor-FIM gain and shorter LOS), and 23.7% of patients in “lower efficiency” group (intermediate motor-FIM gains with longer LOS). The demographic and functional characteristics among these groups would be also analysed.

Gender differences influence the outcome of geriatric rehabilitation following hip fracture

Hip fracture represents the most dramatic expression of the disease, in terms of morbidity, medical cost and mortality. The incidence of hip fracture increases substantially with age. The purpose of this study was to evaluate the association between gender and geriatric rehabilitation outcome after traumatic hip fracture. Ninety-nine community-dwelling elderly patients (older than 65 years), 64 women and 35 men, who were admitted to geriatric rehabilitation after operated hip fracture were studied. We assessed the patients' clinical and demographic data, preoperative risk (ASA), type of fracture and orthopedic repair, pain intensity (VAS), cognitive (MMSE), mood (Zung IDS), and functional status (FIM) on admission and at the end of geriatric rehabilitation. Men had higher mean number of comorbid conditions at the time of the fracture. Men recovered more from depressed mood in comparison with women during the rehabilitation. Significant improvement in FIM motor subscore on discharge was found in both groups. The FIM motor subscore gain was higher in men (24.47) in comparison with women (19.22, p=0.036). Those differences were demonstrated in mean subscores of transfers (p=0.004), and locomotion (p=0.019). Women were more functionally dependent in locomotion, transfers and sphincter control. There were no differences between the groups by duration on rehabilitation stay. Recovery after hip fracture depends in large part on the pre-fracture health and functional ability of the patient. Gender differences in functional recovery may affect therapeutic and rehabilitative decision making. Functional recovery after traumatic hip fracture was better in men in comparison with women.

Outcome of bilateral hip hemiarthroplasty for displaced fracture of the hip

Our aim was to evaluate the outcome in patients with bilateral non-simultaneous hip fracture treated with hemiarthroplasty at our institution between 1997 and 2003. We looked for any important modification factor that could change the devastating functional and social results. Twenty-two patients with a mean age of 79 at the initial fracture and 82 at the subsequent fracture were evaluated; all were Garden grade III-IV. The second fracture happened a mean of 28 months after the first one. The outcome measurement was the incidence of hip pain, recovery of pre-injury level of ambulation and activities of daily living at a minimum follow-up of one year. Following the first hemiarthroplasty patients deteriorated in their walking capacity and other activities of daily life, and this happened to an even greater extent after the second operation. With respect to walking ability (measured in metres) we concluded that it improved if a modular hemiarthroplasty was used after both fractures (p<0.05) and that worse functional outcomes were observed when different kinds of hemiarthroplasties were used in the same patient.;

Gender differences in functioning after hip fracture

BACKGROUND

Hip fracture is a significant health problem for men and women; between 25 and 30 percent of all hip fractures are sustained by men. Relatively little is known about gender differences in functional outcomes after hip fracture. The purpose of the current study is to compare post-hip fracture functional recovery of men and women.

METHODS

A sample of 674 patients age 65 or older were recruited as part of the Baltimore Hip Studies and were followed longitudinally for 1 year following fracture. Information on prefracture status and hospital course of treatment was collected as well as functional data at baseline, 2, 6, and 12 months postfracture. Data were analyzed longitudinally using Generalized Estimating Equations (GEEs).

RESULTS

Men in the study were generally younger and suffered greater comorbidity at time of fracture. Men further suffered higher mortality in the year following fracture. Among survivors, little difference between men and women was seen in patterns of recovery of function following fracture.

CONCLUSIONS

Hip fracture is not a problem affecting just women. Recovery following fracture for men is probably no better than that for women, even after mortality differentially eliminates the frailest male participants. However, psychosocial factors, greater comorbidity, and higher rates of certain complications among men may require adjustments to interventions designed to restore function. Further research into the consequences of hip fracture for men and women is needed.

Body mass index and functional recovery after hip fracture: a survey study of 510 women

BACKGROUND AND AIMS

Low body mass index (BMI) is associated with high risk of osteoporosis and fractures, but its impact on functional recovery after fractures is unknown. Our aim was to investigate the association between BMI and both functional recovery and period of rehabilitation in hip-fractured women.

METHODS

510 out of 580 Caucasian women with hip fracture, admitted consecutively to a rehabilitation hospital, were investigated in this retrospective study. Functional recovery was assessed using the Barthel index score.

RESULTS

In the 510 women, BMI was 22.8 +/- 4.1 kg/m2 (mean +/- SD). After adjustment for age, femur bone mineral density, and the Barthel index assessed on admission to rehabilitation, a significant negative association was found between BMI and both the Barthel index score after rehabilitation and changes in it resulting from rehabilitation (p < 0.001). After adjustment for age and the Barthel index assessed on admission to rehabilitation, a significant positive association was found between BMI and period of rehabilitation (p < 0.001). The results were similar when BMI was evaluated either as individual values or after categorization according to World Health Organization criteria.

CONCLUSIONS

In a sample of hip-fractured women, BMI was negatively associated with Barthel index scores and positively associated with period of rehabilitation. BMI may affect function after hip fracture, apart from hip fracture risk: subjects with higher BMI and low hip fracture risk may have poorer functional recovery in case of hip fracture, despite prolonged rehabilitation. Conversely, subjects with lower BMI and high hip fracture risk may have better functional recovery in case of hip fracture.

Functional recovery and length of stay after hip fracture in patients taking corticosteroids

OBJECTIVE

To evaluate the functional recovery and the length of stay after hip fracture in patients receiving corticosteroids.

DESIGN

A total of 796 inpatients with hip fracture consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 36 of 796 were currently treated with either oral (n = 23) or inhaled (n = 13) corticosteroids.

RESULTS

No significant differences were shown between corticosteroid users and controls for Barthel index score at admission or discharge, change in Barthel index score resulting from rehabilitation, and length of stay. Multiple regression, including 11 confounding variables, showed that several factors, but not the treatment with corticosteroids, were significantly associated with the Barthel index score or the length of stay. The results were similar when the two subgroups of patients receiving corticosteroids were evaluated separately. In the subgroup of the patients receiving oral corticosteroids, no meaningful correlations were observed between the daily dose (milligrams of prednisone equivalent) and the Barthel index score, the change in the Barthel index score attributable to rehabilitation, or the length of stay.

CONCLUSIONS

After hip fracture, neither the functional recovery nor the length of stay were significantly affected by the current treatment with corticosteroids.

The second hip fracture--an analysis of 84 elderly patients

OBJECTIVES

Evaluation of patients with a second hip fracture, which means a fracture of the contralateral hip.

DESIGN

Retrospective database analysis.

SETTINGS

Academic teaching hospital.

PATIENTS

All patients who were admitted for their second hip fractures between November 1999 and September 2001 and had their first hip fracture treated in our institution.

INTERVENTION

In this study, we epidemiologically analyzed the fracture types, the interval between the two fractures, general status of the patients, type of operation performed, and the postfracture independence level.

RESULTS

This survey comprises 84 patients (65 females and 19 males). Their ages ranged from 57 to 91 years (mean: 79) and 58 to 93 years (mean: 82) for the first and the second operation, respectively. The interval between the operations ranged from 2 to 297 months (mean: 35 months, median: 30 months). Twenty-three patients had subcapital fractures in both hips. In 54 patients, bilateral intertrochanteric fractures were noted. Only 7 patients had a previous subcapital fracture and a second intertrochanteric fracture. The general status of the patients' health was defined by the number of pre-existing major medical conditions and was found to be between 0 and 4 (mean: 2.15). Thirty-two patients (38%) had additional fractures somewhere between 1 and 8 years prior to the hip fracture (vertebra, proximal humerus, or distal radius). Sixty-eight and 56 out of the 84 patients reached the same mobility status after the first and second operation, respectively.

CONCLUSIONS

A tendency was found for the second hip fracture to be of the same type as the previous one. Most patients showed a good potential for rehabilitation and for maintaining their prefall functional level.

Functional recovery and length of stay after hip fracture in patients with neurologic impairment

OBJECTIVE

To evaluate the functional recovery and the length of stay after hip fracture in patients with neurologic impairment.

DESIGN

A total of 577 inpatients with hip fracture consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 71 of 577 were affected by neurologic impairment caused by stroke with hemiplegia (n = 37), Parkinson's disease (n = 25), or other diseases (n = 9).

RESULTS

Mean Barthel index was significantly lower in the patients with neurologic impairment than in the controls: 10.8 (95% confidence interval, 5.9-15.6; P < 0.001) at admission and 13.1 (95% confidence interval, 5.55-20.65; P < 0.001) at discharge. Multiple regression including eight confounding variables showed that neurologic impairment was negatively associated with the Barthel index. However, the mean increase in Barthel index through the course of rehabilitation was not affected by neurologic impairment. The length of stay was significantly higher in the patients with neurologic impairment, 3.84 days (95% confidence interval, 0.51-7.17; P < 0.05), and multiple regression showed that neurologic impairment was positively associated with the length of stay.

CONCLUSIONS

After hip fracture, the presence of neurologic impairment was associated with lower Barthel index and longer length of stay, but it did not affect the increase in Barthel index due to a course of rehabilitation.

Health-related quality of life and pressure ulceration assessment in patients treated in the community

Little is known of the impact of pressure ulceration on adult patients' health-related quality of life. The purpose of this study was to determine the impact pressure ulceration has on pressure ulcer patients cared for in the community. A case control study design was used by drawing a random sample from patients receiving community nursing care, stratified by the presence of pressure ulceration. In all, 75 patients with pressure ulcers were compared with 100 controls without ulcers using the four-point ulcer grading scale described by United Kingdom consensus guidelines. Patients were interviewed using the Short Form-36 (SF-36) questionnaire and activities of daily living assessed using the modified Barthel scale. Patients with pressure ulcers had significantly poorer physical function (mean difference (d) = 37.6, 95% CI 28.6-46.6, p < 0.001) and social functioning (d = 33.9, 95 % CI 24.0-43.9, p < 0.001) than published age- and sex-matched normative data from the United Kingdom. The difference between cases and controls was much smaller in these domains, with neither approaching statistical significance. After adjustment for age and gender, scores for bodily pain were poorer in patients with no ulceration (d = -10.5, 95% CI - 20.6 to - 0.4, p = 0.042) indicating greater pain in these patients compared with the cases with ulceration. Activities of daily living determined by the modified Barthel scale showed reduced self-care (d = -7.6, 95% CI -12.5 to - 2.7, p = 0.010) and mobility (d = -9.2, 95% CI -14.6 to - 3.8, p = 0.001) in patients with pressure ulceration. The overall ability to perform these activities was also significantly poorer in this group (d = -16.3, 95% CI -27.3 to -5.3, p = 0.004). While patients with pressure ulceration experience some deficits in their health-related quality of life compared with a normal population, these differences are similar to those experienced by other patients receiving community nursing care.