Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare

Establishment and validation of a nomogram for predicting the risk of hip fracture in patients with stroke: A multicenter retrospective study

PURPOSE

There are currently no models for predicting hip fractures after stroke. This study wanted to investigate the risk factors leading to hip fracture in stroke patients and to establish a risk prediction model to visualize this risk.

PATIENTS AND METHODS

We reviewed 439 stroke patients with or without hip fractures admitted to the Affiliated Hospital of Xuzhou Medical University from June 2014 to June 2017 as the training set, and collected 83 patients of the same type from the First Affiliated Hospital of Harbin Medical University and the Affiliated Hospital of Xuzhou Medical University from June 2020 to June 2023 as the testing set. Patients were divided into fracture group and non-fracture group based on the presence of hip fractures. Multivariate logistic regression analysis was used to screen for meaningful factors. Nomogram predicting the risk of hip fracture occurrence were created based on the multifactor analysis, and performance was evaluated using receiver operating characteristic curve (ROC), calibration curves, and decision curve analysis (DCA). A web calculator was created to facilitate a more convenient interactive experience for clinicians.

RESULTS

In training set, there were 35 cases (7.9 %) of hip fractures after stroke, while in testing set, this data was 13 cases (15.6 %). In training set, univariate analysis showed significant differences between the two groups in the number of falls, smoking, hypertension, glucocorticoids, number of strokes, Mini-Mental State Examination (MMSE), visual acuity level, National Institute of Health stroke scale (NIHSS), Berg Balance Scale (BBS), and Stop Walking When Talking (SWWT) (P<0.05). Multivariate analysis showed that number of falls [OR=17.104, 95 % CI (3.727-78.489), P = 0.000], NIHSS [OR=1.565, 95 % CI (1.193-2.052), P = 0.001], SWWT [OR=12.080, 95 % CI (2.398-60.851), P = 0.003] were independent risk factors positively associated with new fractures. BMD [OR = 0.155, 95 % CI (0.044-0.546), P = 0.012] and BBS [OR = 0.840, 95 % CI (0.739-0.954), P = 0.007] were negatively associated with new fractures. The area under the curve (AUC) of nomogram were 0.939 (95 % CI: 0.748-0.943) and 0.980 (95 % CI: 0.886-1.000) in training and testing sets, respectively, and the calibration curves showed a high agreement between predicted and actual status with an area under the decision curve of 0.034 and 0.109, respectively.

CONCLUSIONS

The number of falls, fracture history, low BBS score, high NIHSS score, and positive SWWT are risk factors for hip fracture after stroke. Based on this, a nomogram with high accuracy was developed and a web calculator (https://stroke.shinyapps.io/DynNomapp/) was created.

Frailty Is More Predictive of Mortality than Age in Patients With Hip Fractures

OBJECTIVES

To investigate the association between the Comprehensive Geriatric Assessment-based Frailty Index and adverse outcomes in older adult patients undergoing hip fracture surgery.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Academic Level 1 Trauma Center.

PATIENTS

All patients aged 65 or older who underwent surgical repair of a hip fracture between May 2018 and August 2020 were identified through institutional database review.

OUTCOME MEASURES AND COMPARISONS

Data including demographics, FI, injury presentation, and hospital course were collected. Patients were grouped by FI as nonfrail (FI < 0.21), frail (0.21 ≤ FI < 0.45), and severely frail (FI > 0.45). Adverse outcomes of these groups were compared using Kaplan Meier survival analysis. Risk factors for 1-year rehospitalization and 2-year mortality were evaluated using Cox hazard regression.

RESULTS

Three hundred sixteen patients were included, with 62 nonfrail, 185 frail, and 69 severely frail patients. The total population was on average 83.8 years old, predominantly white (88.0%), and majority female (69.9%) with an average FI of 0.33 (SD: 0.14). The nonfrail cohort was on average 78.8 years old, 93.6% white, and 80.7% female; the frail cohort was on average 84.5 years old, 92.4% white, and 71.9% female; and the severely frail cohort was on average 86.4 years old, 71.0% white, and 55.1% female. Rate of 1-year readmission increased with frailty level, with a rate of 38% in nonfrail patients, 55.6% in frail patients, and 74.2% in severely frail patients (P = 0.001). The same pattern was seen in 2-year mortality rates, with a rate of 2.8% in nonfrail patients, 36.7% in frail patients, and 77.5% in severely frail patients (P < 0.0001). Being classified as frail or severely frail exhibited greater association with mortality within 2 years than age, with hazard ratio of 17.81 for frail patients and 56.81 for severely frail patients compared with 1.19 per 5 years of age.

CONCLUSIONS

Increased frailty as measured by the Frailty Index is significantly associated with increased 2-year mortality and 1-year hospital readmission rates after hip fracture surgery. Degree of frailty predicts mortality more strongly than age alone. Assessing frailty with the Frailty Index can identify higher-risk surgical candidates, facilitate clinical decision making, and guide discussions about goals of care with family members, surgeons, and geriatricians.

LEVEL OF EVIDENCE

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

Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study

Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.

Mortality after major lower extremity amputation and association with index level: a cohort study based on 11,205 first-time amputations from nationwide Danish databases

BACKGROUND AND PURPOSE

Mortality after major lower extremity amputations is high and may depend on amputation level. We aimed to examine the mortality risk in the first year after major lower extremity amputation divided into transtibial and transfemoral amputations.

METHODS

This observational cohort study used data from the Danish Nationwide Health registers. 11,205 first-time major lower extremity amputations were included from January 1, 2010, to December 31, 2021, comprising 3,921 transtibial amputations and 7,284 transfemoral amputations.

RESULTS

The 30-day mortality after transtibial amputation was overall 11%, 95% confidence interval (CI) 10-12 (440/3,921) during the study period, but declined from 10%, CI 7-13 (37/381) in 2010 to 7%, CI 4-11 (15/220) in 2021. The 1-year mortality was 29% overall, CI 28-30 (1,140 /3,921), with a decline from 31%, CI 21-36 (117/381) to 20%, CI 15-26 (45/220) during the study period. For initial transfemoral amputation, the 30-day mortality was overall 23%, CI 22-23 (1,673/7,284) and declined from 27%, CI 23-31 (138/509) to 22%, CI 19-25 (148/683) during the study period. The 1-year mortality was 48% overall, CI 46-49 (3,466/7,284) and declined from 55%, CI 50-59 (279/509) to 46%, CI 42-50 (315/638).

CONCLUSION

The mortality after major lower extremity amputation declined in the 12-year study period; however, the 1-year mortality remained high after both transtibial and transfemoral amputations (20% and 46% in 2021). Hence, major lower extremity amputation patients constitute one of the most fragile orthopedic patient groups, emphasizing an increased need for attention in the pre-, peri-, and postoperative setting.

Clinical Outcomes of Orthopedic Surgery Co-Management by Internal Medicine Advanced Practice Clinicians: A Cohort Study

BACKGROUND

Comanagement of orthopedic surgery patients by internal medicine hospitalists is associated with improvements in clinical outcomes including complications, length of stay, and cost. Clinical outcomes of orthopedic comanagement performed solely by internal medicine advanced practice clinicians have not been reported. Our objecyive was to compare clinical outcomes between advanced practice clinician-based comanagement and usual orthopedic care.

METHODS

This is a retrospective cohort study in patients 18 years or older, hospitalized for orthopedic joint or spine surgery between May 1, 2014 and January 1, 2022. Outcomes assessed were length of stay, intensive care unit (ICU) transfer, return to operating room, in-hospital and 30-day mortality, 30-day readmission, and total direct cost, excluding surgical implants. Generalized boosted regression and propensity score weighting was used to compare clinical outcomes and health care cost between usual care and advanced practice clinician comanagement.

RESULTS

Advanced practice clinician comanagement was associated with a 5% reduction in mean length of stay (rate ratio = 0.95, P = .009), decreased odds of returning to the operating room (odds ratio [OR] 0.51, P = .002), and a significant reduction in 30-day mortality (OR 0.32, P = .037) compared with usual orthopedic care in a weighted analysis. Need for ICU transfer was higher with advanced practice clinician comanagement (OR 1.54, P = .009), without significant differences in 30-day readmission or in-hospital mortality.

CONCLUSIONS

We observed reductions in length of stay, health care costs, return to the operating room, and 30-day mortality with advanced practice clinician comanagement compared with usual orthopedic care. Our findings suggest that advanced practice clinician-based comanagement may represent a safe and cost-effective model for orthopedic comanagement.

Implementation of a Fascia Iliaca Compartment Block Program in Geriatric Hip Fractures: The Experience at a Level I Academic Trauma Center

OBJECTIVES

Determine adherence to a newly implemented protocol of fascia iliaca compartment block (FICB) in geriatric hip fractures.

METHODS

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Patients with a hip fracture treated with cephalomedullary nailing or hemiarthroplasty (CPT codes 27245 or 27236).

OUTCOME MEASURES AND COMPARISONS

Adherence to a protocol for FICB, time intervals between emergency department arrival, FICB, and surgery stratified by time of admission.

RESULTS

Three hundred eighty patients were studied (average age 78 years, 70% female). Approximately 53.2% of patients received an FICB, which was less than a predefined acceptable adherence rate of 75% ( P < 0.001). Approximately 5.0% received an FICB within 4 hours and 17.3% within 6 hours from admission. Admission during daylight hours (7 am -7p m ) when compared with evening hours (7 pm -7 am ) was associated with improved timeliness ([8.3% vs. 0% within 4 hours, P < 0.001] [27.5% vs. 2.4% within 6 hours, P < 0.001]). Improved adherence to the protocol was observed over time (odds ratio: 1.0013, 95% confidence interval, 1.0001-1.0025, P = 0.0388).

CONCLUSIONS

FICB implementation was poor but gradually improved over time. Few patients received an FICB promptly, especially during night hours. Overall, this study demonstrates that implementation of an FICB program at a Level I academic trauma center can be difficult; however, many hurdles can be overcome with institutional support and dedication of resources such as staff, space, and additional training.

An orthogeriatric service can reduce prolonged hospital length of stay in hospital for older adults admitted with hip fractures: a monocentric study

BACKGROUND

The Blue Book (2005), recommended guidelines for patients care with fragility fractures. Together with introduction of a National Hip Fracture Database Audit and Best Practice Tariff model to financially incentivise hospitals by payment of a supplement for patients whose care satisfied six clinical standards), have improved hip fracture after-care. However, there is a lack of data-driven evidence to support its effectiveness. We aimed to verify the impact of an orthogeriatric service on hospital length of stay (LOS)-duration from admission to discharge.

METHODS

We conducted a repeated cross-sectional study over a 10 year period of older individuals aged ≥ 60 years admitted with hip fractures to a hospital.

RESULTS

Altogether 2798 patients, 741 men and 2057 women (respective mean ages; 80.5 ± 10.6 and 83.2 ± 8.9 years) were admitted from their own homes with a hip fracture and survived to discharge. Compared to 2009-2014, LOS during 2015-2019, when the orthogeriatric service was fully implemented, was shorter for all discharge destinations: 10.4 vs 17.5 days (P < 0.001). Each discharge destination showed reductions: back to own homes, 9.7 vs 17.7 days (P < 0.001); to rehabilitation units: 10.8 vs 13.1 days (P < 0.001); to residential care: 15.4 vs 26.2 days (P = 0.001); or nursing care, 24.4 vs 53.1 days (P < 0.001). During 2009-2014, the risk of staying > 3 weeks in hospital was greater by six-fold and pressure ulcers by three-fold. The number of bed days for every thousand patients per year was also shortened during 2015-2019 by: 1665 days for discharge back to own homes; 469 days with transfer to rehabilitation units; 1258 days for discharge to residential care, and 5465 days to nursing care. Estimated annual savings (2017 costs) per thousand patients after complete establishment of the service was about £2.7 m.

CONCLUSIONS

Implementation of an orthogeriatric service generated significant reductions in hospital LOS for all patients, with associated cost-savings, especially for those discharged to nursing care.

Effects of hospitalist co-management on rate of initiation of osteoporosis treatment in patients with vertebral compression fractures: Retrospective cohort study

BACKGROUND

Vertebral compression fractures are common in elderly people and most are due to osteoporosis. Osteoporosis treatment is effective for secondary prophylaxis, so initiation is recommended. Despite the clear benefits, the rate of initiation of osteoporosis treatment is very low. It is reported to be due to several factors including insufficient systems-based approaches for hospitals and post-acute care. Hospitalists, who are physicians dedicated to the treatment of patients in hospital and whose activity is generalist rather than specialized, are reported to be associated with higher-quality inpatient care because of, among other things, closer adherence to guidelines. Co-management by hospitalists for patients with vertebral compression fractures has potential benefits towards improving the outcomes. We compared the rate of initiation of osteoporosis treatment for patients with vertebral compression fractures between conventional orthopedic surgeon-led care (conventional group) and hospitalist co-management care (co-management group).

METHODS

This is a single-center retrospective cohort study to evaluate the rate of initiation of osteoporosis treatment and reasons for non-initiation of osteoporosis treatment. Other clinical indicators were also evaluated, including length of hospital stay, preventable complications during hospitalization, and rate of 30-day readmission.

RESULTS

We identified 55 patients in the conventional group and 93 patients in the co-management group. The rate of initiation of osteoporosis treatment was higher in the co-management group (45.2% vs. 3.6%, OR 21.5; 95%CI 5.12-192.0; P < 0.01). Most of the patients with non-initiation in the co-management group had reasons for it described in the medical records, but in the conventional group the reasons were unknown. There was no significant difference in length of hospital stay, preventable complications during hospitalization, or 30-day readmission between the groups.

CONCLUSIONS

Hospitalist co-management of patients with vertebral compression fractures showed significantly higher rate of initiation of osteoporosis treatment than conventional orthopedic surgeon-led care.

Internal medicine consultation for high-risk surgical patients: reflection on hospital mortality and readmission rates in a low-income country

OBJECTIVE

The objective of this study was to assess the impact of internal medicine consultation on mortality, 30-day readmission, and length of stay in surgical patients.

METHODS

This is a retrospective descriptive study developed in a public Brazilian teaching hospital with 850 beds.

RESULTS

A total of 70,245 patients were admitted from 2010 to 2018 to the surgery departments. The main outcomes measured were patients' mortality, 30-day readmission, and length of stay. Mortality of high-risk patients was lower when followed by internal medicine consultation: patients with ASA≥3 (RR 0.89 [95% confidence interval (95%CI) 0.80-0.99], p=0.02), patients with ASA≥3 plus≥65 years (RR 0.88 [95%CI 0.78-0.99], p=0.04), patients with ASA≥3 plus high-risk surgery (RR 0.86 [95%CI 0.77-0.97], p=0.01), and patients with ASA≥4 plus age ≥65 years (RR 0.83 [95%CI 0.72-0.96], p=0.01). The 30-day readmission of high-risk patients was lower when followed by internal medicine consultation: patients with ≥65 years (RR 0.57 [95%CI 0.37-0.89], p=0.01) and patients with high-risk surgery (RR 0.63 [95%CI 0.46-0.57], p=0.005). The Poisson multivariate regression with adjustment in variances showed that all the variables (namely, age, ASA, morbidity index, surgery risk, and internal medicine consultation) were associated with higher mortality of patients; however, internal medicine consultation was associated with a reduction of mortality in high-risk patients (RR 0.72 [95%CI 0.65-0.84], p=0.02) and an increase of mortality in low-risk patients (RR 1.55 [95%CI 1.31-1.67], p=0.01).

CONCLUSION

High-risk surgical patients may benefit from perioperative internal medicine consultations, which probably decrease hospital mortality and 30-day hospital readmission.

The integrated structure of care: evidence for the efficacy of models of clinical governance in the prevention of fragility fractures after recent sentinel fracture after the age of 50 years

Randomized clinical trials and observational studies on the implementation of clinical governance models, in patients who had experienced a fragility fracture, were examined. Literature was systematically reviewed and summarized by a panel of experts who formulated recommendations for the Italian guideline.

PURPOSE

After experiencing a fracture, several strategies may be adopted to reduce the risk of recurrent fragility fractures and associated morbidity and mortality. Clinical governance models, such as the fracture liaison service (FLS), have been introduced for the identification, treatment, and monitoring of patients with secondary fragility fractures. A systematic review was conducted to evaluate the association between multidisciplinary care systems and several outcomes in patients with a fragility fracture in the context of the development of the Italian Guidelines.

METHODS

PubMed, Embase, and the Cochrane Library were investigated up to December 2020 to update the search of the Scottish Intercollegiate Guidelines Network. Randomized clinical trials (RCTs) and observational studies that analyzed clinical governance models in patients who had experienced a fragility fracture were eligible. Three authors independently extracted data and appraised the risk of bias in the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random-effects models. Primary outcomes were bone mineral density values, antiosteoporotic therapy initiation, adherence to antiosteoporotic medications, subsequent fracture, and mortality risk, while secondary outcomes were quality of life and physical performance.

RESULTS

Fifteen RCTs and 62 observational studies, ranging from very low to low quality for bone mineral density values, antiosteoporotic initiation, adherence to antiosteoporotic medications, subsequent fracture, mortality, met our inclusion criteria. The implementation of clinical governance models compared to their pre-implementation or standard care/non-attenders significantly improved BMD testing rate, and increased the number of patients who initiated antiosteoporotic therapy and enhanced their adherence to the medications. Moreover, the treatment by clinical governance model respect to standard care/non-attenders significantly reduced the risk of subsequent fracture and mortality. The integrated structure of care enhanced the quality of life and physical function among patients with fragility fractures.

CONCLUSIONS

Based on our findings, clinicians should promote the management of patients experiencing a fragility fracture through structured and integrated models of care. The task force has formulated appropriate recommendations on the implementation of multidisciplinary care systems in patients with, or at risk of, fragility fractures.

Managing Geriatric Patients with Falls and Fractures

Orthopedic fractures in adults 65 and older are common and can lead to functional decline and increased morbidity and mortality. Falls are often the precipitating event for fractures in this population, linked to common aging physiology with increasing comorbid conditions and advancing frailty. Managing falls and orthopedic fractures in the geriatric population is complex, requiring a systematic and collaborative approach spearheaded by a multidisciplinary team focused on improving patient outcomes.

The Pain Clinic for Older People

OBJECTIVE

Multidisciplinary pain clinics have an established role in the management of persistent pain, but there is little evidence to support this approach in an older population. This study describes the characteristics and pain outcomes of patients attending a pain clinic designed exclusively for older people.

METHODS

A retrospective audit was performed of outcomes of the Pain Clinic for Older People (PCOP) in 2015-2019. Response to treatment was determined by change in Brief Pain Inventory (BPI) scores at initial attendance and after a treatment program. Clinically meaningful improvement was defined by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus criteria of ≥30% improvement in average pain and one-point improvement in pain interference. Results were compared with the national benchmark collated by the electronic Persistent Pain Outcomes Collaboration (ePPOC), which reports the combined results from 67 participating Australian and New Zealand pain services.

RESULTS

Patients attending the PCOP had a mean age of 80.5 years and had high rates of frailty (84%), cognitive impairment (30%), and multimorbidity. Significant reductions in BPI average pain and BPI pain interference scores were achieved. Clinically meaningful improvement in BPI average pain was achieved in 63% of patients attending the PCOP who were 65-74 years of age and in 46% of patients who were ≥75 years of age, which met the national benchmark set by ePPOC of 40% for both age groups. Clinically meaningful improvement in BPI pain interference was achieved in 69% of those attending the PCOP who were 65-74 years of age and in 66% of those who were ≥75 years of age, comparable to the ePPOC benchmark of 71% and 65% for the respective age groups.

CONCLUSION

PCOP clients achieved significant and meaningful improvements in their pain outcomes that satisfied the national benchmark. Advanced age, cognitive impairment, frailty and multimorbidity should not be regarded as barriers to benefit from a pain clinic specifically designed for older people.

Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021

Background

Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field.

Purpose

This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline.

Methods

The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations.

Results

Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively.

Conclusions

The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.

Cephalomedullary nailing for reverse oblique intertrochanteric fractures 31A3 (AO/OTA)

INTRODUCTION

Reverse oblique intertrochanteric fractures are classified by the Orthopaedic Trauma Association [OTA]/[AO] as 31A3, and account for up to one-third of all hip fractures, and 2-23% of all trochanteric fractures. The treatment of choice of those fractures is intramedullary nailing as it decreases soft tissue damage and permits early weight bearing.

MATERIAL AND METHODS

A retrospective comparative study was conducted on patients surgically treated for 31A3 fractures from October 2018 to January 2022 in a high-volume regional referral centre. All the patients had been treated with intramedullary nailing.

RESULTS

The selected group included 11 males (16%) and 59 females (84%), with a mean age of 83.6 years (range 61 to 96 years). A Trigen Intertan Nail was the most frequent choice of intramedullary nailing in 33 patients (47%), an Elos Long nail was chosen in 19 cases (27%), while a ZNN nail was used in 18 patients (26%). The mean time between admission and surgery was 2.5 days, with a mean Hb value of 10.5 g/dl reported preoperatively.

CONCLUSION

Patients treated with an Intertan nail reported the lowest TAD, CALTAD, and TALCALTAD mean radiographic values, and the lowest rate of Hb loss and blood transfusions.

A Geriatrics-Focused Hospitalist Trauma Comanagement Program Improves Quality of Care for Older Adults

This study aimed to determine whether a geriatrics-focused hospitalist trauma comanagement program improves quality of care. A pre-/post-implementation study compared older adult trauma patients who were comanaged by a hospitalist with those prior to comanagement at a level 1 trauma center. One-to-one propensity score matching was performed based on age, gender, Injury Severity Score, comorbidity index, and critical illness on admission. Outcomes included orders for geriatrics-focused quality indicators, as well as hospital mortality and length of stay. Wilcoxon rank-sum test (continuous variables) and chi-square or Fisher exact test (categorical variables) were used to assess differences. Propensity score matching resulted in 290 matched pairs. The intervention group had decreased use of restraints (P = 0.04) and acetaminophen (P = 0.01), and earlier physical therapy (P = 0.01). Three patients died in the intervention group compared with 14 in the control (P = 0.0068). This study highlights that a geriatrics-focused hospitalist trauma comanagement program improves quality of care.

Complexities of care: Common components of models of care in geriatrics

As people age, they are more likely to have an increasing number of medical diagnoses and medications, as well as healthcare providers who care for those conditions. Health professionals caring for older adults understand that medical issues are not the sole factors in the phenomenon of this “care complexity.” Socioeconomic, cognitive, functional, and organizational factors play a significant role. Care complexity also affects family caregivers, providers, and healthcare systems and therefore society at large. The American Geriatrics Society (AGS) created a work group to review care to identify the most common components of existing healthcare models that address care complexity in older adults. This article, a product of that work group, defines care complexity in older adults, reviews healthcare models and those most common components within them and identifies potential gaps that require attention to reduce the burden of care complexity in older adults.

Improved outcomes and reduced medical costs through multidisciplinary co-management protocol for geriatric proximal femur fractures: a one-year retrospective study

BACKGROUND

To manage the rapidly growing incidence of, and related medical burden resulting from hip fractures in older adults in an aging society, studies involving orthogeriatric co-management treatment models have reported improved outcomes, including reduced medical costs. The treatment gap for osteoporosis was however seldom emphasized in the published treatment protocols. Aiming to improve the existing orthogeriatric protocol, we have established a patient-centered protocol for elderly patient hip fractures, which simultaneously focuses on fracture care and anti-osteoporosis agent prescription in regarding to healthcare quality and medical expense.

METHODS

This was a retrospective study comparing patients who enrolled in the multidisciplinary co-managed protocol for geriatric hip fractures and those who did not. The inclusion criteria for this study were: (a) single-sided hip fractures treated from 1 to 2018 to 30 June 2020, (b) patients who were 60-years or older (c) trauma treated within 3 days from time of injury, and (d) minimal follow-up period of 12 months after surgery.

RESULTS

From 1 to 2018 to 30 June 2020, 578 patients were included (267 patients in the protocol group vs. 331 patients in the conventional group). The protocol group was associated with significantly reduced lengths of hospital stay (p = 0.041), medical expenditures (p = 0.006), and mortality (p = 0.029) during their acute in-hospital admission period. Early osteoporosis diagnosis and anti-osteoporosis agent prescription were achieved in the protocol group, with a significantly wider coverage for BMD assessment (p < 0.001) and prescriptions for anti-osteoporosis medication (p < 0.001). Yet, there was no significant decline in the one-year refracture rate in the protocol group.

CONCLUSIONS

The implementation of a multidisciplinary co-managed care protocol for geriatric proximal femur fractures successfully improved patient outcomes with significantly reduced lengths of stay, medical expenditures, and mortality during the acute in-hospital admission period. The high prescription rate of anti-osteoporosis medication after hip fractures in the protocol group was not associated with a significantly lower re-fracture rate in the 12-month follow-up. However, the association between early anti-osteoporosis agent prescription and reduced long-term medical expenses in this group of patients has provided a direction for future research.

The older patient with cardiovascular disease: background and clinical implications of the comprehensive geriatric assessment (CGA)

Principles and processes of Comprehensive Geriatric Assessment (CGA) are increasingly being applied to subspecialties and subspecialty conditions, including cardiovascular patients (i.e. infective endocarditis; considerations of surgery or transcatheter aortic valve replacement, TAVR, for patients with aortic stenosis; vascular surgery) and postoperative mortality risk. In cardiovascular field CGA has mainly the aim to define ideal management according to the different typology of older adult patients (eg, robust versus intermediate versus physical and cognitively disabled versus end-stage or dying), allowing physicians to select different therapeutic goals according to life expectancy; Aspect to be valued are by CGA are global health status and patient's decision-making capacity: CGA allows the individualized treatment definition and optimize the preprocedure condition.

Effects of Delayed Hip Fracture Surgery on Severely Ill Patients: Defining the Time to Medical Optimization

BACKGROUND

Patients with multiple comorbidities often have delayed hip fracture surgery due to medical optimization. The goal of this study is to identify the allowable time for medical optimization in severely ill hip fracture patients.

METHODS

The 2016-2019 NSQIP database was used to identify patients over age 60 with ASA classification scores 3 and 4 for severe and life-threatening systemic diseases. Patients were divided into immediate (<24 hours), early (24-48 hours), or late (>48 hours) groups based on time to surgery (TTS). Risk-adjusted multivariable logistic regressions were conducted to compare relationships between 30-day postoperative outcomes and TTS.

RESULTS

43,071 hip fracture cases were analyzed for the purposes of this study. Compared to patients who underwent surgery immediately, patients who had surgeries between 24 and 48 hours were associated with higher rates of pneumonia (OR 1.357, CI 1.194-1.542), UTIs (OR 1.155, CI 1.000-1.224), readmission (OR 1.136, CI 1.041-1.240), postoperative LOS beyond 6 days (OR 1.249, CI 1.165-1.340), and mortality (OR 1.205, CI 1.084-1.338). Patients with surgeries delayed beyond 48 hours were associated with higher rates of CVA (OR 1.542, CI 1.048-2.269), pneumonia (OR 1.886, CI 1.611-2.209), UTIs (OR 1.546, CI 1.283-1.861), readmission (OR 1.212, CI 1.074-1.366), postoperative LOS beyond 6 days (OR 1.829, CI 1.670-2.003), and mortality (OR 1.475, CI 1.286-1.693) compared to patients with immediate surgery.

DISCUSSION

Severely ill patients with the hip fracture may have a 24-hour window for medical optimization. Hip fracture surgery performed beyond 48 hours is associated with higher complication rates and mortality among those who are severely ill. Further prospective studies are warranted to examine the effects of early surgical intervention among severely ill patients.

Unstable minimally displaced lateral compression type 1 (LC1) pelvic ring injuries have a similar hospital course as intertrochanteric femur fractures

INTRODUCTION

The purpose of this study was to evaluate how the hospital course of minimally displaced LC1 fractures, with and without occult instability, compares with that of intertrochanteric femur fractures.

PATIENTS AND METHODS

Retrospective comparative cohort analysis at an urban level one trauma center of 40 consecutive patients with an isolated LC1 pelvic ring injury and 40 age/sex matched patients with an isolated intertrochanteric femur fracture was performed. Medical records and radiographs were reviewed for patient and injury characteristics, including demographics, displacement, time to surgery, ambulation, physical therapy (PT) clearance, hospital length of stay (LOS), and inpatient morphine milligram equivalents (MME).

RESULTS

The LC1 pelvic ring injury group included 26 (65%) patients with ≥ 10 mm of displacement on lateral stress radiographs. The unstable LC1 group, compared to the stable LC1 group, had a greater LOS (median difference (MD): 2 days, 95% confidence interval (CI): 1 to 4, p = 0.0004), longer time to ambulate 15 feet (MD: 1 day, CI: 1 to 2, p = 0.0002), longer time to clear PT (MD: 2 days, CI: 1 to 3, p = 0.0003), and more inpatient MMEs (MD: 386 MME, CI: 225.8 to 546.7, p = 0.0002). The unstable LC1 and intertrochanteric fracture groups had no detectable differences in LOS (p = 0.24), days to ambulate 15 feet (p = 0.46), days to clear PT (p = 0.95), and inpatient MMEs (p = 0.06).

CONCLUSION

Patients with minimally displaced unstable LC1 injuries had worse hospital courses than stable LC1 injuries and similar hospital courses as intertrochanteric femur fractures. These findings emphasize the associated morbidity of unstable LC1 injuries.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

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

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

Comparison of pericapsular nerve group (PENG) block with fascia iliaca compartment block (FICB) for pain control in hip fractures: A double-blind prospective randomized controlled clinical trial

BACKGROUND

Fascia iliaca compartment block (FICB) is a common regional analgesic strategy in hip fracture surgery but, recently it has been suggested that FICB may not provide enough analgesia. Pericapsular nerve group block (PENG) is a novel method for hip analgesia which its efficacy is not well established yet. The aim of this study was to the effect of the PENG block in the control of the hip fracture pain as well as to compare the effectiveness of the PENG compared with FICB.

HYPOTHESIS

The hypothesis of this study was that the PENG block could be a good alternative to the FICB in hip fracture analgesia.

MATERIALS AND METHODS

This randomized controlled clinical trial was conducted in the Imam- Hossein Hospital, Tehran, Iran; between 2018 and 2019. Hip fracture patients were randomly divided into two groups; Group A (n=22) received FICB and Group B (n=30) received PENG block.

RESULTS

There was no significant difference between VAS score before blocks procedure between two groups (p=0.37). After 15minutes of blocks and after 12hours of post-surgery, VAS score significantly reduced in the PENG block group compared with the FICB group (p=0.031; p=0.021, respectively). The first time of the analgesic consumption after surgery was significantly longer in the PENG block compared with the FCIB (p=0.007). Compared with the FICB group, the total dose of morphine consumption during 24hours significantly reduced in the PENG block (p=0.008).

CONCLUSION

PENG block is a good method in hip fractures analgesia and provides better analgesia than FICB. However, further studies with larger sample sizes are required to validate the efficacy and superiority of the PENG blocks over conventional techniques.

LEVEL OF EVIDENCE

I.

Changes in Characteristics and Outcomes of Patients Undergoing Surgery for Hip Fractures Following the Initiation of Orthogeriatric Service: Temporal Trend Analysis

The Blue Book published by the British Orthopaedic Association and British Geriatrics Society, together with the introduction of National Hip Fracture Database Audit and Best Practice Tariff, have been influential in improving hip fracture care. We examined ten-year (2009-2019) changes in hip fracture outcomes after establishing an orthogeriatric service based on these initiatives, in 1081 men and 2891 women (mean age = 83.5 ± 9.1 years). Temporal trends in the annual percentage change (APC) of outcomes were identified using the Joinpoint Regression Program v4.7.0.0. The proportions of patients operated beyond 36 h of admission fell sharply during the first two years: APC =  - 53.7% (95% CI - 68.3, - 5.2, P = 0.003), followed by a small rise thereafter: APC = 5.8% (95% CI 0.5, 11.3, P = 0.036). Hip surgery increased progressively in patients > 90 years old: APC = 3.3 (95% CI 1.0, 5.8, P = 0.011) and those with American Society of Anaesthesiologists grade ≥ 3: APC = 12.4 (95% CI 8.8, 16.1, P < 0.001). There was a significant decline in pressure ulcers amongst patients < 90 years old: APC =  - 17.9 (95% CI - 32.7, 0.0, P = 0.050) and also a significant decline in mortality amongst those > 90 years old: APC =  - 7.1 (95% CI - 12.6, - 1.3, P = 0.024). Prolonged length of stay (> 23 days) declined from 2013: APC =  - 24.6% (95% CI - 31.2, - 17.4, P < 0.001). New discharge to nursing care declined moderately over 2009-2016 (APC =  - 10.6, 95% CI - 17.2, - 2.7, P = 0.017) and sharply thereafter (APC =  - 47.5%, 95%CI - 71.7, - 2.7, P = 0.043). The rate of patients returning home was decreasing (APC =  - 2.9, 95% CI - 5.1, - 0.7, P = 0.016), whilst new discharge to rehabilitation was increasing (APC = 8.4, 95% CI 4.0, 13.0; P = 0.002). In conclusion, the establishment of an orthogeriatric service was associated with a reduction of elapsed time to hip surgery, a progressive increase in surgery carried out on high-risk adults and a decline in adverse outcomes.

Short vs. long intramedullary nail systems in trochanteric fractures: A randomized prospective single center study

In unstable pertrochanteric fractures, there are still debates regarding the complications and long-term benefits after internal fixation using short or long cephalomedullary nails. Therefore, a study was developed regarding this idea. From May 2017 to April 2020, 61 patients with unstable (AO 31-A2) and intertrochanteric fractures (AO 31-A3) were surgically operated on. During follow-up, 8 patients were excluded (lost or deceased). A total of 26 patients received internal short nail system fixation and 27 received a long nail system. All cases followed the standard 6-week rehabilitation protocol. Follow-up was at 3, 6 weeks, 3, 6 and 12 months, and clinical and functional assessment were determined by a different surgeon using the Visual Analogue Scale (VAS), Harris Hip Score (HHS) and Functional Ambulation Categories (FAC). A total of 42 (79.2%) had a 31.A2 fracture (21 in the long nail group and 21 in the short nail group) and 11 (20.8%) had a 31.A3 fracture (6 in long nail group and 5 in the short nail group). Surgical time was significantly longer (P<0.05) in the long nail group (an average of 81.38±12.01 min), compared with the short nail group (53.11±8.36 min). Blood loss was significantly higher (P<0.05) in the long nail group (210±12.1 ml) compared to the short nail group (75.4±14.8 ml). No statistical differences were noted regarding tip-apex distance (TAD) and VAS score. At 6 months, HHS was better for the short nail group (84.76±3.68) (P<0.05). Regarding the FAC scale, no significant statistical differences were identified. Cut-out occurred in 2 cases in the short nail group and 1 case from the long nail group. Only 1 peri-implant fracture occurred in a patient with a long cephalomedullary nail. In conclusion, the long cephalomedullary nail requires a longer surgical time and is associated with an increase in intraoperative blood loss without improving the functional outcome after 12 months postoperatively. A larger sample of cases is required to thoroughly analyze the postoperative complications.

Readmissions after elective orthopedic surgery in a comprehensive co-management care system-a retrospective analysis

Background

No surgical intervention is without risk. Readmissions and reoperations after elective orthopedic surgery are common and are also stressful for the patient. It has been shown that a comprehensive ortho-medical co-management model decreases readmission rates in older patients suffering from hip fracture; but it is still unclear if this also applies to elective orthopedic surgery. The aim of the current study was to determine the proportion of unplanned readmissions or returns to operating room (for any reason) across a broad elective orthopedic population within 90 days after elective surgery. All cases took place in a tertiary care center using co-management care and were also assessed for risk factors leading to readmission or unplanned return to operating room (UROR).

Methods

In this observational study, 1295 patients undergoing elective orthopedic surgery between 2015 and 2017 at a tertiary care center in Switzerland were investigated. The proportion of reoperations and readmissions within 90 days was measured, and possible risk factors for reoperation or readmission were identified using logistic regression.

Results

In our cohort, 3.2% (42 of 1295 patients) had an UROR or readmission. Sixteen patients were readmitted without requiring further surgery—nine of which due to medical and seven to surgical reasons. Patient-related factors associated with UROR and readmission were older age (67 vs. 60 years; p = 0.014), and American Society of Anesthesiologists physical status (ASA PS) score ≥ 3 (43% vs. 18%; p < 0.001). Surgery-related factors were: implantation of foreign material (62% vs. 33%; p < 0.001), duration of operation (76 min. vs. 60 min; p < 0.001), and spine surgery (57% vs. 17%; p < 0.001). Notably, only spine surgery was also found to be independent risk factor.

Conclusion

Rates of UROR during initial hospitalization and readmission were lower in the current study than described in the literature. However, several comorbidities and surgery-related risk factors were found to be associated with these events. Although no surgery is without risk, known threats should be reduced and every effort undertaken to minimize complications in high-risk populations. Further prospective controlled research is needed to investigate the potential benefits of a co-management model in elective orthopedic surgery.

Analysis of the effects of a delay of surgery in patients with hip fractures: outcome and causes

This study analyzed characteristics of hip fracture patients who did not undergo surgery within 24 hours after hospitalization, as recommended by the Belgian quality standards. Reasons for delay were analyzed. Delay in surgery for hip fracture was related to the medical condition of the patients.

INTRODUCTION

To compare patients with optimal timing to patients with a delay in hip surgery, with respect to outcome (complications (postoperative) and mortality) and reasons for delay.

METHODS

A retrospective analysis of medical records compared patients operated on within 24h (Group A) to patients operated on more than 24h after admission (Group B). A follow-up period of 5 years after release or up to the time of data collection was used. Reasons for delay in relation with mortality were analyzed descriptively. Descriptive statistics were used for patient demographics and complications. Relationships causing a delayed surgery and mortality were analyzed using binary logistic regression. Additionally, a survival analysis was provided for overall mortality.

RESULTS

Respectively, 536 and 304 patients were included in Group A and B. The most prominent reason for delaying surgery was the patient not being medically fit (20.7%). Surgical delay was associated with more cardiovascular (p = 0.010), more pulmonary (p < 0.001), and less hematologic complications (p=0.037). Thirty-day mortality was higher with increasing age (p < 0.001), with hematologic (p < 0.001) or endocrine-metabolic complications (p = 0.001), and lower when no complications occurred (p = 0.004). Mortality at the end of data collection was higher for patients with delayed surgery (OR = 2.634, p < 0.001), an increased age (p = 0.006), male gender (p < 0.001), institutionalized patients (p = 0.009), pulmonary complication (p = 0.002), and having no endocrine-metabolic complications (p = 0.003). Survival analysis showed better survival for patients operated on within 24h (p < 0.001).

CONCLUSIONS

Delayed surgery for patients with hip fractures was associated with bad additional medical conditions. Survival was higher for patients operated on within 24h of admission.

Evaluation of the implementation of multidisciplinary fast-track program for acute geriatric hip fractures at a University Hospital in resource-limited settings

Background

Hip fractures are common among frail, older people and associated with multiple adverse outcomes, including death. Timely and appropriate care by a multidisciplinary team may improve outcomes. Implementing a team to jointly deliver the service in resource-limited settings is challenging, particularly on the effectiveness of patient outcomes.

Methods

A retrospective cohort study to compare outcomes of hip fracture patients aged 65 or older admitted at Siriraj hospital before and after implementation of the Fast-track program for Acute Geriatric Hip Fractures. The primary outcome was the incidence of medical complications. The secondary outcomes were time to surgery, factors related to the occurrence of various complications, in-hospital mortality, and mortality at month 3, month 6 and month 12 after the operation.

Results

Three hundred two patients were enrolled from the Siriraj hospital’s database from October 2016 to October 2018; 151 patients in each group with a mean age of 80 years were analyzed. Clinical parameters were similar between groups except the Fast-track group comprising more patients with dementia (37.1% VS 23.8%, p < 0.012). In the Fast-track group, there was a significantly higher proportion of patients underwent surgery within 72-h (80.3% VS 44.7%, p < 0.001) and the length of stay was significantly shorter (11 days (8–17) VS 13 days (9–18), p = 0.017). There was no significant difference in medical complications. Stratified analysis by dementia status showed a trend in delirium reduction in both patients with dementia and without dementia groups, and a pressure injury reduction among patients with dementia after the program was implemented but without statistical significance. There was no significant difference in mortality.

Conclusions

The implementation of a multidisciplinary team for hip fracture patients is feasible in resource-limited setting. In the Fast-track program, time to surgery was reduced and the length of stay was shortened. Other outcome benefits were not shown, which may be due to incomplete uptake of all involved disciplines.

Does operative treatment of geriatric pelvic ring injuries lead to a high risk of one-year mortality?

INTRODUCTION

Non-operative management of pelvic ring injuries in the elderly is associated with a high risk of one-year mortality. The majority of these injuries are the result of a low-energy mechanism, however, due to the multiple medical comorbidities in this patient population the injuries are associated with a high degree of morbidity. The purpose of this study was to determine the one-year mortality risk after operative treatment of pelvic ring injuries in a geriatric patient population and the effect of patient and injury characteristics on the risk of mortality.

PATIENTS AND METHODS

We performed a retrospective review of patients over the age of 70 who underwent operative fixation of a pelvic ring injury at two Level 1 trauma centers between January 2016 and June 2019. Medical records were reviewed for patient and injury characteristics including: Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) physical status score or Injury Severity Score (ISS), hospital and intensive care unit (ICU) length of stay (LOS). The primary outcome of interest was the one-year mortality risk following operative treatment. Secondary outcomes included the effect of patient and injury characteristics on the one-year mortality risk and the hospital LOS.

RESULTS

Ninety patients were included with an average age of 79.8  ±  6.5 years. The overall mortality was 8.9% (n = 8) and was significantly associated with the CCI. There was no significant effect related to the ASA physical status score or ISS. The average hospital LOS was 9.2 ± 7.3 days and was associated with the CCI, ASA physical status score, and ISS.

DISCUSSION

Non-operative management of pelvic ring injuries in geriatric patients is associated with a high risk of one-year mortality. Our findings suggest operative treatment of these fractures is associated with an acceptable risk of one-year mortality that falls below the commonly reported range for non-operatively managed injuries. Furthermore, the risk of mortality was significantly associated with the patient's pre-injury state as determined by the CCI.

Delirium in Frail Older Adults

Delirium and frailty are prevalent geriatric syndromes and important public health issues among older adults. The prevalence of delirium among hospitalized older adults ranges from 15% to 75%, while that of frailty ranges from 12% to 24%. The exact pathophysiology of these two conditions has not been clearly identified, although several hypotheses have been proposed. However, these conditions are considered to be multifactorial in etiology and are associated with inflammation related to aging, alterations in vascular systems, genetics, and nutritional deficiency. Furthermore, clinically, they are significantly associated with frailty, which increases the risk of delirium by almost two- to three-fold among hospitalized older adults. With their multifactorial etiology and unknown pathophysiology, current evidence supports more practical multicomponent patient-centered approaches to prevent and manage delirium with frailty among hospitalized older adults. These comprehensive and organized bundled approaches can identify high-risk patients with frailty and more effectively manage their delirium.

Care of Geriatric Patients with Lumbar Spine, Pelvic, and Acetabular Fractures before and after Certification as a Geriatric Trauma Center DGU®: A Retrospective Cohort Study

Background: More than 750,000 fragility fractures occur in Germany every year, with an expected increase in the following years. Interdisciplinary care pathways for geriatric patients are increasingly established to improve the treatment process and outcome, but there has been only limited evaluation of their use. Objectives: This study aimed to compare patient care before and after the implementation of a geriatric trauma center (GTC) in conformity with the German Society for Trauma Surgery (DGU^®). Patients and Methods: We performed a retrospective single-center cohort study, including 361 patients >70 years old with lumbar spine, pelvic, and acetabular fractures, admitted between January 2012 and September 2019. Patients were divided into a usual care cohort (UC, n = 137) before implementation and an ortho-geriatric care cohort (OGC, n = 224) after implementation of the GTC DGU^®. We recorded and compared demographic data, fracture type, geriatric assessment and management, therapy, complications, and various clinical parameters, e.g., length of stay, time to surgery, hours admitted to ICU, and change in walking ability. Results: The geriatric assessment revealed significant geriatric co-morbidities and a need for geriatric intervention in 75% of the patients. With orthogeriatric co-management, a significant increase in the detection of urological complications (UC: 25.5% vs. OGC: 37.5%; p = 0.021), earlier postoperative mobilization (UC: 57.1% vs. OGC: 86.3%; p < 0.001), an increased prescription of anti-osteoporotic treatment at discharge (UC: 13.1% vs. OGC: 46.8%; p < 0.001), and lower rates of revision surgery (UC: 5.8% vs. OGC: 3.1%; p = 0.012) could be seen. Conclusions: Our results emphasize the improvement in patient care and clinical outcome by implementing a GTC DGU^® and provide opportunities for future improvement in ortho-geriatric patient care.

A bibliometric analysis of orthogeriatric care: top 50 articles

Background

Population is ageing and orthogeriatric care is an emerging research topic.

Purpose

This bibliometric review aims to provide an overview, to investigate the status and trends in research in the field of orthogeriatric care of the most influential literature.

Methods

From the Core Collection databases in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to orthogeriatric care were identified in December 2020 using a multistep approach. A total of 50 articles were included and analysed in this bibliometric review.

Results

The 50 most cited articles were published between 1983 and 2017. The number of total citations per article ranged from 34 to 704 citations (mean citations per article: n = 93). Articles were published in 34 different journals between 1983 and 2017. In the majority of publications, geriatricians (62%) accounted for the first authorship, followed by others (20%) and (orthopaedic) surgeons (18%). Articles mostly originated from Europe (76%), followed by Asia–pacific (16%) and Northern America (8%). Key countries (UK, Sweden, and Spain) and key topic (hip fracture) are key drivers in the orthogeriatric research. The majority of articles reported about therapeutic studies (62%).

Conclusion

This bibliometric review acknowledges recent research. Orthogeriatric care is an emerging research topic in which surgeons have a potential to contribute and other topics such as intraoperative procedures, fractures other than hip fractures or elective surgery are related topics with the potential for widening the field to research.

Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study

OBJECTIVE

The aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes.

DESIGN

Cohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year.

SETTING

International (six countries, three continents) multicentre study.

PARTICIPANTS

281 patients aged ≥70 with operatively treated proximal femur fractures.

INTERVENTIONS

Treatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy.

OUTCOME MEASURES

Primary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life.

RESULTS

Patients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002).

CONCLUSIONS

Contrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02297581.

Ankle fractures in the elderly: Current concepts

Ankle fractures remain the third most common musculoskeletal injury in the elderly population. The presence of osteoporosis, significant multiple comorbidities and limited functional independence makes treatment of such injuries challenging. Early studies highlighted high rates of post-operative complications and poor outcomes after surgical intervention. With advances in surgical techniques and a greater understanding of multi-disciplinary team (MDT)-driven peri-operative care and rehabilitation, evidence now appears to suggest improved outcomes for operative management. Approaches must be adapted according to co-morbidities, baseline function and patient wishes. This review article aims to discuss contemporary treatment strategies and the complex challenges associated with the management of the elderly ankle fracture.

Association of orthogeriatric care models with evaluation and treatment of osteoporosis: a systematic review and meta-analysis

This systematic review and meta-analysis found low-quality evidence that orthogeriatric care is positively associated with diagnosis of osteoporosis, prescription of calcium and vitamin D supplements and bisphosphonates in older hip fracture patients. Evidence on fall and fracture prevention was scarce and inconclusive. Orthogeriatrics may reduce the treatment gap following hip fractures.

INTRODUCTION

Hip fracture patients are at imminent risk of additional fractures and falls. Orthogeriatric care might reduce the osteoporosis treatment gap and improve outcomes in these patients. However, the optimal orthogeriatric care model (geriatric liaison service, co-management, or geriatrician-led care) remains unclear.

PURPOSE

To summarize the association of different orthogeriatric care models for older hip fracture patients, compared to usual orthopaedic care, with fall prevention measures, diagnosis and treatment of osteoporosis and future falls and fractures.

METHODS

Two independent reviewers retrieved randomized controlled trials (RCTs) or controlled observational studies. Random effects meta-analysis was applied (PROSPERO ID: 165914).

RESULTS

One RCT and twelve controlled observational studies were included, encompassing 20,078 participants (68% women, median ages between 75 and 85 years). Orthogeriatric care was associated with higher odds of diagnosing osteoporosis (odds ratio [OR] 11.36; 95% confidence interval [CI] 7.26-17.77), initiation of calcium and vitamin D supplements (OR 41.44; 95% CI 7.07-242.91) and discharge on anti-osteoporosis medication (OR 7.06; 95% CI 2.87-17.34). However, there was substantial heterogeneity in these findings. Evidence on fall prevention and subsequent fractures was scarce and inconclusive. Almost all studies were at high risk of bias. Evidence was insufficient to compare different care models directly against each other.

CONCLUSIONS

Low-quality evidence suggests that orthogeriatric care is associated with higher rates of diagnosing osteoporosis, initiation of calcium and vitamin D supplements and anti-osteoporosis medication. Whether orthogeriatric care prevents subsequent falls and fractures in older hip fracture patients remains unclear.

A Nomogram for Predicting 30-day Mortality in Elderly Patients Undergoing Hemiarthroplasty for Femoral Neck Fractures

Introduction

Femoral neck fractures in the elderly are increasingly common as a result of a growing geriatric population with 1-year mortality rates approaching 35%. While preoperative medical optimization and early time to surgery have reduced morbidity and mortality, patients with numerous medical comorbidities remain high risk for death in the perioperative period. Identifying those with greatest risk with a scoring system or nomogram may assist multidisciplinary teams in reducing mortality following hemiarthroplasty.

Purpose

Identify predictors of 30-day mortality in elderly patients who underwent hemiarthroplasty for a femoral neck fracture to generate a predictive nomogram to determine the probability of post-operative mortality.

Methods

Retrospective evaluation using data from the ACS-NSQIP database from 2005 to 2014 with CPT code 27125 for hip hemiarthroplasty. Multiple factors including demographics and comorbidities were compared in patients who experienced 30-day mortality and those who did not. T-test and chi-square tests were used to analyze data and a multivariate model was generated using logistic regression.

Results

Advanced age (odds ratio (OR) 1.04), underweight BMI (OR 1.55), male sex (OR 1.80), reduced functional status (OR 2.04), heart failure within 30 days prior to surgery (OR 2.22), American Society of Anesthesiologists grade > 2 (OR > 2.50), disseminated cancer (OR 3.43) were all found to have statistically significant odds ratios for 30-day mortality following hemiarthroplasty.

Conclusion

A tool based on easily identifiable risk factors, demographics, and comorbidities was developed that can help predict elderly patients who will experience mortality within 30 days of following hemiarthroplasty. In addition to identifying high risk patients, the nomogram can serve as a counseling tool for physicians to use with patients and their families to assist with better understanding of perioperative mortality risk.

General medicine consultant of the week model shortens hospital length of stay and improves the patient journey

BACKGROUND AND AIMS

The consultant of the week (COW) model of inpatient care means the consultants' primary focus is to deliver ward-based care daily. At Sandwell and West Birmingham Hospitals NHS Trust, a COW model has been successfully used for cardiology and stroke services. This has improved continuity of care and developed a 7-day working week. Our aim was to extend this model to all general medical consultants who manage inpatients.

METHODS

We introduced the COW model to the unselected general medical take. Restructuring of consultant job plans allowed daily ward presence, 5 days per week. Outcome measures included length of stay (LOS) and accuracy of expected date of discharge (EDD).

RESULTS

LOS over a 12-month period improved from an average of 9.17 days to 6.61 days. The number of EDD changes reduced, from a previous average of 3.0 changes to 1.8 changes. Consultant feedback showed there was an improvement in collaboration between teams, improved training of junior doctors and higher job satisfaction.

CONCLUSIONS

Improved 5-day consultant presence is associated with reduced LOS. Learning points included the delay in implementation due to the complexity of consultant job planning. We plan to extend COW to 7-days for all general medical wards.

The Effect of Type of Femoral Component Fixation on Mortality and Morbidity after Hip Hemiarthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Hip hemiarthroplasty is a well-established treatment of displaced femoral neck fracture, although debate exists over whether cemented or uncemented fixation is superior. Uncemented prostheses have typically been used in younger, healthier patients and cemented prostheses in older patients with less-stable bone. Also, earlier research has suggested that bone cement has cytotoxic effects and may trigger cardiovascular and respiratory adverse events.

QUESTIONS/PURPOSES

The aim of this systematic review and meta-analysis was to compare morbidity and mortality rates after cemented and uncemented hemiarthroplasty for the treatment of displaced femoral neck fractures in elderly patients.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched seven medical databases for randomized clinical trials and observational studies. We compared cemented and uncemented hemiarthroplasty using the Harris Hip Score (HHS), as well as measures of postoperative pain, mortality, and complications. Data were extracted and pooled as risk ratios or standardized mean difference with their corresponding 95% confidence intervals in a meta-analysis model.

RESULTS

The meta-analysis included 34 studies (12 randomized trials and 22 observational studies), with a total of 42,411 patients. In the pooled estimate, cemented hemiarthroplasty was associated with less risk of postoperative pain than uncemented hemiarthroplasty. There were no significant differences between groups regarding HHS or rates of postoperative mortality, pulmonary embolism, cardiac arrest, myocardial infarction, acute cardiac arrhythmia, or deep venous thrombosis.

CONCLUSIONS

While we found that cemented hemiarthroplasty results in less postoperative pain than uncemented hemiarthroplasty in older patients with femoral neck fracture, the lack of significant differences in functional hip scores, mortality, and complications was surprising. Further high-level research is needed.

Mortality and the Risk Factors in Elderly Female Patients With Femoral Neck and Trochanteric Fractures

BACKGROUND

The main purpose of this study is to exhaustively explore risk factors, including age, gender, and several clinical indices, for mortality in elderly patients with femoral neck fracture and to evaluate some of them using survival analyses.

METHODS

This was a retrospective study tracking 1 year for vital prognosis. Data were collected at post-operation from medical records of the cases. Survival analysis was conducted to investigate the risk factors for death, including albumin, urinary retention, activity of daily living (ADL), and cognitive disorder.

RESULTS

We recruited 318 patients with a history of hip surgery carried out at Toyama Municipal Hospital, in which 39 patients died for 1 year after discharge. The results showed a significant decrease in survival rate in low albumin, positive urinary retention, and low ADL (P < 0.01, by log-rank test). The hazard ratios (95% confidence interval) of albumin, urinary retention, ADL, and cognitive disorder were 0.36 (0.19 - 0.69), 0.4 (0.2 - 0.8), 0.29 (0.15 - 0.58) and 0.65 (0.32 - 1.29), respectively.

CONCLUSIONS

This study demonstrated that albumin, urinary retention and ADL were the important risk factors for mortality, and suggested that the postoperative management of albumin, urinary retention and ADL is important, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.

What is the Role of Coordinators in the Secondary Fracture Prevention Program?

Background

The purpose of this study is to search for reports on the clinical effectiveness of FLS being implemented worldwide through the systematic review, analyze the roles of coordinators in each study, and provide basic data for the development of future coordinator education programs.

Methods

A systematic search of the literature using the Medline, PubMed, and EMBASE databases and the Cochrane Library was conducted for using the following keywords: ‘osteoporosis’ AND ‘fractures’ AND ’secondary prevention’. Finally, 65 studies are included in this study.

Results

At the coordinator-based fracture liaison service (FLS) center, the coordinator (often a nurse) acts as a central player in the establishing of patient connections, orthopedic surgeons, radiologists, and attending physicians. Coordinators help bridge the nursing gap by supporting identification, investigation, initiation of treatment, and patient follow-up. Medics has opened the way to effectively manage patients at high risk of developing another fracture. In addition, nurses are in a unique and important role as nurses responsible for enhancing their daily lives by building relationships with patients and families.

Conclusions

The coordinator in the FLS program plays an important role in the multidisciplinary management of vulnerable fractures, as well as in the diagnosis and treatment of osteoporosis and in maintaining continuity of treatment. In the future, the broader role of coordinators should be systematically organized and developed into accredited educational programs.

Electronic Rapid Fitness Assessment Identifies Factors Associated with Adverse Early Postoperative Outcomes following Radical Cystectomy

PURPOSE

Frailty is associated with adverse outcomes following radical cystectomy. Prospective tools to identify factors affecting outcomes are needed. We describe a novel electronic rapid fitness assessment to evaluate geriatric patients undergoing radical cystectomy.

MATERIALS AND METHODS

Before undergoing radical cystectomy between February 2015 and February 2018, 80 patients older than age 75 years completed the electronic rapid fitness assessment and were perioperatively comanaged by the Geriatrics Service. Physical function and cognitive function over 12 domains were evaluated and an accumulated geriatric deficit score was compiled. Hospital length of stay, discharge disposition, unplanned intensive care unit admissions, urgent care visits, readmissions, complications and deaths were assessed.

RESULTS

A total of 65 patients who underwent radical cystectomy for bladder cancer without concomitant procedures completed the assessment. Median age was 80 (77, 84) years and 52 (80%) were male. A higher proportion of patients with intensive care unit admission, urgent care visit and major complications had impairments identified within electronic rapid fitness assessment domains, including Timed Up and Go. Readmission rates were similar between patients with or without deficits identified. Higher accumulated geriatric deficit score was significantly associated with intensive care unit admission (p=0.035), death within 90 days (p=0.037) and discharge to other than home (p=0.0002).

CONCLUSIONS

We demonstrated the feasibility of assessing fitness in patients older than 75 years undergoing radical cystectomy using a novel electronic fitness tool. Physical limitations and overall impairment corresponded to higher intensive care unit admission rates and adverse postoperative outcomes. Larger studies in less resourced environments are required to validate these findings.

Primary total hip arthroplasty in elderly patients over 85 years old: risks, complications and medium-long term results

INTRODUCTION

The elderly population candidate for total hip arthroplasty (THA) is increasing exponentially in developed countries, due to the high prevalence of osteoarthritis (OA). The objective is to identify the overall survival in patients over 85 years with primary OA who underwent THA.

MATERIAL AND METHODS

Retrospective observational study in patients over 85 years with primary hip OA undergoing THA between 2012 and 2019. Demographic, clinical, comorbidity, complications, functionality and pain variables were collected. A descriptive analysis was performed, survival was estimated with the Kaplan-Meier method and the differences in pain and functionality before and after surgery with the McNemar-Bowker test.

RESULTS

We included 66 patients, 40 women and 26 men with a mean age of 87.22 years, of whom 15 had high comorbidity (Charlson>2). Only 14 patients presented complications in the postoperative period, the most frequent was confusional syndrome (5); and the most serious was a death (1), with a median hospital stay of 8 days. Two cases of dislocation were detected over a mean follow-up of 3.61 years, without requiring revision surgery. Improvement of pain was evident after surgery (p<.0001). The median overall survival is 6.77 years, with no difference in survival adjusted by the Charlson index (p=.75) or by ASA anaesthetic group (p=.23).

CONCLUSIONS

With good patient selection, THA is a good option for patients over 85 years of age with functional limitations or pain due to OA.

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.

Implementation of an in-patient hip fracture liaison services to improve initiation of osteoporosis medication use within 1-year of hip fracture: a population-based time series analysis using the RE-AIM framework

A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was effective for improving initiation of osteoporosis medication following hip fracture.

PURPOSE

To examine implementation of an in-patient hip fracture liaison service (H-FLS) to improve osteoporosis medication use after hip fracture using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance).

METHODS

Using population-based administrative data from 7 quarters before and up to 7 quarters after H-FLS implementation, we examined new starts, continued use, and overall use (new starts + continued use) of osteoporosis medication after hip fracture. A total of 1427 patients 50 years and older that underwent hip fracture surgery at 1 of 2 tertiary hospitals in a Canadian province and survived to 12 months post-fracture were included. We also compared treatment initiation rates by sex and hospital.

RESULTS

Of the 1427 patients, 1002 (70.2%) were female (mean age = 79.3 ± 11.9 years) and 425 (29.8%) were male (mean age = 73.8 ± 13.8 years). Based on pre-fracture residence within the health zone, 1101 (69%) were considered eligible (Reach). New starts of osteoporosis medication increased from 24.7% pre- to 43.9% post-implementation of the H-FLS (p < 0.001) (effectiveness). The proportion of patients prescribed osteoporosis medication prior to a hip fracture remained consistent (15.1% pre-; 14.7% post-implementation; p = 0.88) with a resultant improvement in overall medication use from 39.8% pre- to 58.6% post-implementation (p < 0.001). Both sites significantly improved medication initiation (site 1: 27.9% pre- to 40.3% post-implementation; site 2: 19.6% pre- to 50.0% post-implementation; p < 0.001 for both) (adoption). Medication initiation in females improved from 26.0% pre- to 43.4% post-implementation while initiation in males improved from 21.7% pre- to 45.1% post-implementation (p < 0.001[females]; p = 0.001[males]) (implementation). Post-implementation, elevated initiation rates were retained over the 7 quarters (p = 0.81) (maintenance).

CONCLUSIONS

An H-FLS based in two tertiary hospital sites significantly improved use of osteoporosis medications after hip fracture in both males and females.

[Post-acute geriatric rehabilitation outcomes in fracture patients treated in an orthogeriatric trauma center-A prospective investigation with historical control]

BACKGROUND

Despite the increasing amount of positive evidence with respect to mortality for the orthogeriatric co-management in a center for geriatric traumatology (CGT), effects on the course after the acute inpatient hospital treatment have been insufficiently investigated.

METHODS

Patients over 75 years old who needed rehabilitation following acute inpatient treatment before (retrospective, n = 90) and after (prospective, n = 99) the introduction of a certified CGT were investigated. The two groups were compared with respect to the frequency of discharge into an indication-specific (AHB) and geriatric rehabilitation, mobility performance including the five times sit-to-stand test, short physical performance battery (SPPB) and competence in activities of daily living with the Barthel index (BI).

RESULTS

After introduction of a CGT 17.2% (95 % confidence interval [95 % CI]: 10-25%; p < 0.027) of the patients were discharged to a specialized orthopedic inpatient rehabilitation (AHB) vs. 6.7% (95 % CI: 1-12%) before the introduction. Correspondingly less patients needed geriatric rehabilitation (before CGT 93.3 %, 95 % CI: 88.1-98.6 vs. CGT 82.8 %, 95 % CI: 75-90; p < 0.001). The overall outcome of post-acute geriatric inpatient rehabilitation improved in both groups but did not differ. Patients who needed two therapy sessions in the CGT were clearly poorer than those with one therapy session with respect to activities of daily living (BI: 34.1, 95 % CI: 30-37.2 vs. 41.2, 95 % CI: 30.9-51.4) and mobility performance (SPPB: 1.2, 95 % CI: 0.7-1.8 vs. 2.2, 95 % CI: 0.9-3.4; p = 0.048). The differences remained despite improvement of both groups during geriatric rehabilitation.

CONCLUSION

The establishment of a CGT enables more patients to be discharged into a less cost-intensive AHB. The more intensive treatment in the CGT offers more severely affected patients the chance for further functional improvement through post-acute inpatient geriatric rehabilitation. A predominantly closing treatment of patients in a CGT is not conceivable in the CGT model presented.

Hospital-based Hip fracture programs: Clinical need and effectiveness

Hospital-based hip fracture programs are essential for effective, efficient care of elderly patients who have sustained hip fractures. Many of the gains in outcomes and patient survival are a result of such integrated care models. We review the rationale, elements, and benefits of such programs across the spectrum of inpatient centers, including low-volume and high-volume community hospitals and trauma centers.

The Association Between Orthogeriatric Co-Management and Mortality Following Hip Fracture

BACKGROUND

To meet the special needs of older patients with fragility fractures, models for collaborative orthogeriatric care have been developed. The objective of our study was to analyze the association of orthogeriatric co-management with mortality following hip fracture in older patients in Germany.

METHODS

This observational study was based on health insurance claims data from 58 001 patients (79.4% women) aged ≥80 years admitted to the hospital with hip fracture between January 2014 and March 2016. They were treated in 828 German hospitals with or without orthogeriatric co-management. The outcome measure was cumulative mortality with adjustment of the regression analyses.

RESULTS

The crude 30-day mortality was 10.3% for patients from hospitals with orthogeriatric co-management and 13.4% for patients from hospitals without orthogeriatric co-management. The adjusted 30-day mortality was 22% lower for patients in hospitals with orthogeriatric co-management (rate ratio 0.78; 95% CI [0.74; 0.82]; adjusted absolute difference -2.48%; 95% CI [-2.98; -1.98]). The difference in 30-day mortality remained nearly unchanged over the first 6 months. The risk reduction with orthogeriatric co-management was consistently observed in both women and men, across age groups, and in patients with and without care needs. The mean length of the index stay was 19.8 days in hospitals with orthogeriatric co-management and 14.4 days in hospitals without orthogeriatric co-management.

CONCLUSION

A multidisciplinary orthogeriatric approach is associated with lower mortality and a longer index stay in hospital after hip fracture.