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Patterson JT, Parry JA. Lateral Compression Fragility Fractures of the Pelvis: Diagnosis, Classifications, and Modern Management. Curr Osteoporos Rep 2024:10.1007/s11914-024-00891-1. [PMID: 39313717 DOI: 10.1007/s11914-024-00891-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2024] [Indexed: 09/25/2024]
Abstract
PURPOSE OF REVIEW To describe the diagnosis, classification, and modern management of lateral compression fragility fractures of the pelvis. RECENT FINDINGS Practice patterns are shifting toward early operative treatment of fragility fractures of the pelvis among patients who are unable to mobilize or whose injuries demonstrate occult instability on stress imaging. Early internal fixation appears to decrease pain, facilitate mobilization, accelerate hospital discharge, and minimize morbidity in this population. Lateral compression pelvic ring injuries are the most common type of fragility fracture of the pelvis. Similar to fragility fractures of the hip, lateral compression fragility fractures of the pelvis are typically sustained in a ground level fall. These injuries are associated with long acute hospital and post-acute facility admissions, loss of physical function, loss of independence, mortality, anxiety, sleep disturbance, and caregiver burnout. Unlike hip fractures, for which urgent operative treatment and early mobilization reduce mortality, lateral compression fragility fractures of the pelvis are commonly treated without surgery. Recommendations for nonoperative management of these injuries in older adults may be inappropriately generalized from studies of younger patient populations with high-energy mechanisms of pelvis fracture. However, strong evidence to support early internal fixation of these injuries practice is lacking. High quality investigations of early surgical intervention for lateral compression fragility fractures of the pelvis are needed to guide care for these patients.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, 90033-5322, USA.
| | - Joshua A Parry
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
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Çağıran Z, Vahabi A, Özgül KK, Aljasim O, Karaman S, Özkayın N, Aktuğlu K, Sertöz N. Unilateral Spinal Anesthesia in Hip Fracture Surgery for Geriatric Patients With High Cardiovascular Risk due to Aortic Stenosis is Safe and Effective. Geriatr Orthop Surg Rehabil 2024; 15:21514593241280908. [PMID: 39220252 PMCID: PMC11366102 DOI: 10.1177/21514593241280908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 07/10/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024] Open
Abstract
Introduction Aortic stenosis is a cause of mortality or morbidity. It complicates the selection and management of anesthetic procedures. The aim of this study was to evaluate the efficacy, hemodynamic effects and postoperative outcome of unilateral spinal anesthesia in geriatric patients with hip fractures with moderate or severe aortic stenosis. Material and Method A retrospective observational study was conducted on geriatric high-risk patients with cardiac conditions who underwent surgery for hip fractures under unilateral spinal anesthesia with low-dose hyperbaric bupivacaine. The study period spanned from January 2018 to December 2021. The inclusion criteria were individuals with moderate to severe aortic stenosis, as defined by the American Heart Association Criteria. Data on demographic information, cardiac pathologies, hemodynamic data, data on motor and sensory block, perioperative complications, and mortality rates at 30th and 180th days were collected. Results Mortality rates at the 30th day and 180th day were 8.9% (n:4) and 24.4% (n:11), respectively. T6 level was predominantly obtained level of anesthesia (44.4%). Motor and sensory block formation times averaged 7.6 and 4.8 minutes, respectively. Surgical procedures were performed mostly within 1 hour (66.7%), and complications were rare (11.1% hypotension). Initial analgesic effect showed a rapid resolution, with 64.4% of patients requiring analgesic within the first hour postoperatively. Conclusion In elderly patients with moderate to severe aortic stenosis scheduled for hip fracture surgery, we posit that unilateral spinal anesthesia with ultra-low dose is safe and effective option.
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Affiliation(s)
- Zeynep Çağıran
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
| | - Arman Vahabi
- Department of Orthopaedics and Traumatology, Ege University School of Medicine, Izmir, Turkey
| | - Kazım Koray Özgül
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
| | - Omar Aljasim
- Department of Orthopedics and Traumatology, Medical Park Gebze Hospital, Kocaeli, Turkey
| | - Semra Karaman
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
| | - Nadir Özkayın
- Department of Orthopaedics and Traumatology, Ege University School of Medicine, Izmir, Turkey
| | - Kemal Aktuğlu
- Department of Orthopaedics and Traumatology, Ege University School of Medicine, Izmir, Turkey
| | - Nezih Sertöz
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
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Sermon A, Verhulst E, Aerden L, Hoekstra H. A retrospective chart analysis with 5-year follow-up of early care for geriatric hip fracture patients: why we should continue talking about hip fractures. Eur J Trauma Emerg Surg 2024; 50:1709-1718. [PMID: 38592463 DOI: 10.1007/s00068-024-02514-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/30/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Timing of surgery remains a topic of debate for hip fracture treatment in the geriatric patient population. The quality indicator "early surgery" was implemented in 2014 at the Department of Trauma Surgery of the University Hospitals Leuven to enhance timely operative treatment. In this follow-up study, we aim to evaluate the performance of this quality indicator, the clinical outcomes, and room for improvement. METHODS The charts of 1190 patients surgically treated for an acute hip fracture were reviewed between June 2017 and May 2022 at the University Hospitals Leuven. Primary endpoints were adherence to early surgery, defined as surgery within the next calendar day, and the evaluation of the reasons for deviating from this protocol. Secondary endpoints were length of stay (LOS); intensive care unit (ICU) admission and length of ICU stay; mortality after 30 days, 60 days, 90 days, and 6 months; and 90-day readmission rate. Pearson's Chi-square test and Mann-Whitney U test were used for data analysis. RESULTS One thousand eighty-four (91.1%) patients received early surgery versus 106 (8.9%) patients who received delayed surgery. The main reasons for surgical delay were the use of anticoagulants (33%), a general health condition not allowing safe surgery and/or existing comorbidities requiring workup prior to surgery (26.4%), and logistical reasons (17.9%). Patient delay and transfer from other hospitals were responsible for respectively 8.5% and 6.6% of delayed surgery. Early surgery resulted in a significantly shorter LOS and ICU stay (12 [8-25] vs. 18 [10-36] and 3 [2-6] vs. 7 [3-13] days, early vs. delayed surgery, respectively). No significant reduction was observed in ICU admission, mortality, and readmission rate. CONCLUSION We have been able to maintain the early surgery hip fracture protocol in approximately 90% of the patients. Comorbidities and anticoagulant use were responsible for delayed surgery in the majority of the patients. Correct implementation of the existing protocol on anticoagulant use could lead to a one-third decrease in the number of delayed surgeries. Subsequently, since the LOS and ICU stay in the delayed surgery group were significantly longer, a further increase of early surgery will lower the current economic burden.
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Affiliation(s)
- An Sermon
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
| | - Evelyne Verhulst
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Laurens Aerden
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.
- Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium.
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Rocha AC, Valente BG, Ramalho DW, Borri JB, de Mattos CA, Bittar CK. Cost and time of hospitalization for elderly people with bone fractures in a reference hospital. EINSTEIN-SAO PAULO 2024; 22:eGS0493. [PMID: 39082508 PMCID: PMC11239199 DOI: 10.31744/einstein_journal/2024gs0493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 12/18/2023] [Indexed: 08/03/2024] Open
Abstract
OBJECTIVE To describe and analyze the aspects regarding the cost and length of stay for elderly patients with bone fractures in a tertiary reference hospital. METHODS A cross-sectional retrospective study using data obtained from medical records between January and December 2020. For statistical analysis, exploratory analyses, Shapiro-Wilk test, χ2 test, and Spearman correlation were used. RESULTS During the study period, 156 elderly patients (62.2% women) with bone fractures were treated. The main trauma mechanism was a fall from a standing height (76.9%). The most common type of fracture in this sample was a transtrochanteric fracture of the femur, accounting for 40.4% of cases. The mean length of stay was 5.25 days. The total cost varied between R$2,006.53 and R$106,912.74 (average of R$15,695.76) (updated values). The mean daily cost of hospitalization was R$4,478.64. A positive correlation was found between the length of stay and total cost. No significant difference in cost was observed between the two main types of treated fractures. CONCLUSION Fractures in the elderly are frequent, resulting in significant costs. The longer the hospital stay for treatment, the higher the total cost. No correlation was found between total cost and number of comorbidities, number of medications used, and the comparison between the treatment of transtrochanteric and femoral neck fractures.
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Affiliation(s)
- Aline Cremasco Rocha
- Pontifícia Universidade Católica de CampinasCampinasSPBrazil Pontifícia Universidade Católica de Campinas, Campinas, SP, Brazil.
| | - Bruna Granig Valente
- Pontifícia Universidade Católica de CampinasCampinasSPBrazil Pontifícia Universidade Católica de Campinas, Campinas, SP, Brazil.
| | - Danilo Wingeter Ramalho
- Pontifícia Universidade Católica de CampinasCampinasSPBrazil Pontifícia Universidade Católica de Campinas, Campinas, SP, Brazil.
| | - Juliana Baleki Borri
- Pontifícia Universidade Católica de CampinasCampinasSPBrazil Pontifícia Universidade Católica de Campinas, Campinas, SP, Brazil.
| | - Carlos Augusto de Mattos
- Hospital PUC-Campinas Celso PierroCampinasSPBrazil Hospital PUC-Campinas Celso Pierro, Campinas, SP, Brazil.
| | - Cintia Kelly Bittar
- Pontifícia Universidade Católica de CampinasCampinasSPBrazil Pontifícia Universidade Católica de Campinas, Campinas, SP, Brazil.
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Rădulescu M, Necula BR, Mironescu SA, Roman MD, Schuh A, Necula RD. Is the Timing of Surgery a Sufficient Predictive Factor for Outcomes in Patients with Proximal Femur Fractures? A Systematic Review. J Pers Med 2024; 14:773. [PMID: 39064027 PMCID: PMC11277622 DOI: 10.3390/jpm14070773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 06/27/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
(1) Background: Hip fractures are currently recognized as major public health problems, raising many issues in terms of both patients' quality of life and the cost associated with caring for this type of fracture. Many authors debate whether to operate as soon as possible or to postpone surgery until the patient is stable. The purpose of this review was to review the literature and obtain additional information about the moment of surgery, the time to surgery, length of hospital stay, and how all of these factors influence patient mortality and complications. (2) Methods: The systematic search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and PICO guidelines, using the Google Scholar platform, for articles published between 2015 and 2023. Quality assessment was performed. (3) Results: After applying the inclusion criteria, 20 articles were included in the final list. Those who had surgery within 48 h had lower in-hospital and 30-day mortality rates than those who operated within 24 h. The American Society of Anesthesiologists (ASA) score is an important predictive factor for surgical delay, length of hospital stay (LOS), complications, and mortality. (4) Conclusions: Performing surgery in the first 48 h after admission is beneficial to patients after medical stabilization. Avoidance of delayed surgery will improve postoperative complications, LOS, and mortality.
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Affiliation(s)
- Mihai Rădulescu
- Faculty of Medicine, Transilvania University of Brașov, 500036 Brașov, Romania
| | - Bogdan-Radu Necula
- Faculty of Medicine, Transilvania University of Brașov, 500036 Brașov, Romania
| | | | - Mihai Dan Roman
- Faculty of Medicine, Lucian Blaga University of Sibiu, 550169 Sibiu, Romania
| | - Alexander Schuh
- Department of Musculoskeletal Research, Marktredwitz Hospital, 95615 Marktredwitz, Germany
| | - Radu-Dan Necula
- Faculty of Medicine, Transilvania University of Brașov, 500036 Brașov, Romania
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Zhong Y, Liu M, Cheng Z, Yao Y, Yu Y, Luo G, Zheng B, Yan M. "Multidisciplinary fast-track" care can significantly reduce risk of mortality among hip fracture patients at least 80 years old: a single-center retrospective study. BMC Geriatr 2024; 24:592. [PMID: 38987709 PMCID: PMC11238416 DOI: 10.1186/s12877-024-05183-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 06/27/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND "Multidisciplinary fast-track" (MFT) care can accelerate recovery and improve prognosis after surgery, but whether it is effective in older people after hip fracture surgery is unclear. METHODS We retrospectively compared one-year all-cause mortality between hip fracture patients at least 80 years old at our institution who underwent hip fracture surgery between January 2014 and December 2018 and who then received MFT or conventional care. Multivariable regression was used to assess the association between MFT care and mortality after adjustment for confounders. RESULTS The final analysis included 247 patients who received MFT care and 438 who received conventional orthopedic care. The MFT group showed significantly lower one-year mortality (8.9% vs. 14.4%, P = 0.037). Log-rank testing of Kaplan-Meier survival curves confirmed the survival advantage. However, the two groups did not differ significantly in rates of mortality during hospitalization or at 30 or 90 days after surgery. Regression analysis confirmed that MFT care was associated with lower risk of one-year mortality (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.281-0.788, P = 0.04), and the survival benefit was confirmed in subgroups of patients with anemia (HR 0.453, 95% CI 0.268-0.767, P = 0.003) and patients with American Society of Anesthesiologists grade III (HR 0.202, 95% CI 0.08-0.51, P = 0.001). CONCLUSIONS MFT care can reduce one-year mortality among hip fracture patients at least 80 years old. This finding should be verified and extended in multi-center randomized controlled trials.
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Affiliation(s)
- Yinbo Zhong
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Mingxia Liu
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang, China
- Department of Anesthesiology & Clinical Research Center for Anesthesia and Perioperative Medicine, Huzhou Central Hospital, The Affiliated Huzhou Hospital, Zhejiang University School of Medicine, The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University, Affiliated Central Hospital Huzhou University, Huzhou, Zhejiang, China
| | - Zhenzhen Cheng
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Yuanyuan Yao
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Yang Yu
- Department of Anesthesiology, The First People's Hospital of Weifang, Weifang, Shandong, China
| | - Ge Luo
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Bin Zheng
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Min Yan
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, Zhejiang, China.
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Krohn JN, Habboub B, Gosch M. [Fragility Fractures: Preoperative assessment and optimisation]. Z Gerontol Geriatr 2024; 57:235-243. [PMID: 38668778 DOI: 10.1007/s00391-024-02299-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/13/2024] [Indexed: 05/09/2024]
Abstract
Fragility fractures are associated with high morbidity and mortality. An interdisciplinary collaboration and an individualized, patient-centered approach are essential to ensure an optimized preoperative period and to improve perioperative safety. Preoperative responsibilities of trauma surgery include in the first step the identification of fragility fractures and the necessity for geriatric involvement. Orthogeriatric co-management (OCM) focuses on the identification of the medical, functional and social needs of the patient. In the preoperative period attention is focussed on acute diseases in need of treatment that have a negative impact on the course of further treatment and the prevention of delirium.
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Affiliation(s)
- Jan-Niklas Krohn
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Prof. Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland.
| | - Basel Habboub
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Prof. Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland
| | - Markus Gosch
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Prof. Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland
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Alito A, Fenga D, Portaro S, Leonardi G, Borzelli D, Sanzarello I, Calabrò RS, Milone D, Tisano A, Leonetti D. Early hip fracture surgery and rehabilitation. How to improve functional quality outcomes. A retrospective study. Folia Med (Plovdiv) 2023; 65:879-884. [PMID: 38351775 DOI: 10.3897/folmed.65.e99513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 01/27/2023] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Hip fractures are one of the major disability causes associated with a high morbidity and mortality rate. Early surgery and stable fixation could be associated with better pain control, possibly lower mortality rates, and early recovery of autonomy.
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Strage KE, Hadeed MM, Mauffrey C, Parry JA. Identifying Reasons for Nonmedical Delays in Fixation of Femur, Pelvis, and Acetabular Fractures at a Level 1 Trauma Center. J Orthop Trauma 2023; 37:553-556. [PMID: 37348037 DOI: 10.1097/bot.0000000000002656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE To identify reasons for nonmedical delays in femur, pelvis, and acetabular fracture fixation at an institution with a dedicated orthopaedic trauma room (DOTR) and an early appropriate care practice model. DESIGN Retrospective review of a prospective registry. SETTING Urban Level 1 trauma center. PATIENTS/PARTICIPANTS Two hundred ninety-four patients undergoing 313 procedures for 226 femur, 63 pelvis, and 42 acetabular fractures. INTERVENTION Definitive fixation. MAIN OUTCOME MEASUREMENTS Reasons for delays in fixation after hospital day 2. RESULTS Delays occurred in 12.5% of procedures (39/313), with 7.7% (24/313) having medical delays and 4.8% (15/313) having nonmedical delays. Nonmedical delays were most commonly due to the operating room being at-capacity (n = 6) and nonpelvic trauma specialists taking weekend call (n = 5). Procedures with nonmedical delays were associated with younger age (median difference -16.0 years, 95% confidence interval [CI], -28 to -5.0; P = 0.006), high-energy mechanisms (proportional difference [PD] 58.5%, 95% CI, 37.0-69.7; P < 0.0001), Thursday through Saturday hospital admission (PD 30.3%, 95% CI, 5.0-50.0; P < 0.0001), pelvis/acetabular fractures (PD 51.8%, 95% CI, 26.7-71.0%; P < 0.0001), and external fixation (PD 33.0%, 95% CI, 11.8-57.3; P < 0.0001). CONCLUSION Only 4.8% of procedures experienced nonmedical delays using an early appropriate care model and a DOTR. Nonmedical delays were most commonly due to 2 modifiable factors-the DOTR being at-capacity and nonpelvis trauma specialists taking weekend call. Patients with nonmedical delays were more likely to be younger, with pelvis/acetabular fractures, high-energy mechanisms, external fixation, and to be admitted between Thursday and Saturday. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Katya E Strage
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
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George J, Sharma V, Farooque K, Trikha V, Mittal S, Malhotra R. Excess mortality in elderly hip fracture patients: An Indian experience. Chin J Traumatol 2023; 26:363-368. [PMID: 37598017 PMCID: PMC10755790 DOI: 10.1016/j.cjtee.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/03/2023] [Accepted: 05/15/2023] [Indexed: 08/21/2023] Open
Abstract
PURPOSE Hip fractures in elderly have a high mortality. However, there is limited literature on the excess mortality seen in hip fractures compared to the normal population. The purpose of this study was to compare the mortality of hip fractures with that of age and gender matched Indian population. METHODS There are 283 patients with hip fractures aged above 50 years admitted at single centre prospectively enrolled in this study. Patients were followed up for 1 year and the follow-up record was available for 279 patients. Mortality was assessed during the follow-up from chart review and/or by telephonic interview. One-year mortality of Indian population was obtained from public databases. Standardized mortality ratio (SMR) (observed mortality divided by expected mortality) was calculated. Kaplan-Meir analysis was used. RESULTS The overall 1-year mortality was 19.0% (53/279). Mortality increased with age (p < 0.001) and the highest mortality was seen in those above 80 years (aged 50 - 59 years: 5.0%, aged 60 - 69 years: 19.7%, aged 70 - 79 years: 15.8%, and aged over 80 years: 33.3%). Expected mortality of Indian population of similar age and gender profile was 3.7%, giving a SMR of 5.5. SMR for different age quintiles were: 3.9 (aged 50 - 59 years), 6.6 (aged 60 - 69 years), 2.2 (aged 70 - 79 years); and 2.0 (aged over 80 years). SMR in males and females were 5.7 and 5.3, respectively. CONCLUSIONS Indian patients sustaining hip fractures were about 5 times more likely to die than the general population. Although mortality rates increased with age, the highest excess mortality was seen in relatively younger patients. Hip fracture mortality was even higher than that of myocardial infarction, breast cancer, and cervical cancer.
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Affiliation(s)
- Jaiben George
- Department of Orthopedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Vijay Sharma
- Department of Orthopedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Kamran Farooque
- Department of Orthopedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Trikha
- Department of Orthopedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Samarth Mittal
- Department of Orthopedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Adejuyigbe B, Kallini J, Chiou D, Kallini JR. Osteoporosis: Molecular Pathology, Diagnostics, and Therapeutics. Int J Mol Sci 2023; 24:14583. [PMID: 37834025 PMCID: PMC10572718 DOI: 10.3390/ijms241914583] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Osteoporosis is a major public health concern affecting millions of people worldwide and resulting in significant economic costs. The condition is characterized by changes in bone homeostasis, which lead to reduced bone mass, impaired bone quality, and an increased risk of fractures. The pathophysiology of osteoporosis is complex and multifactorial, involving imbalances in hormones, cytokines, and growth factors. Understanding the cellular and molecular mechanisms underlying osteoporosis is essential for appropriate diagnosis and management of the condition. This paper provides a comprehensive review of the normal cellular and molecular mechanisms of bone homeostasis, followed by an in-depth discussion of the proposed pathophysiology of osteoporosis through the osteoimmunological, gut microbiome, and cellular senescence models. Furthermore, the diagnostic tools used to assess osteoporosis, including bone mineral density measurements, biochemical markers of bone turnover, and diagnostic imaging modalities, are also discussed. Finally, both the current pharmacological and non-pharmacological treatment algorithms and management options for osteoporosis, including an exploration of the management of osteoporotic fragility fractures, are highlighted. This review reveals the need for further research to fully elucidate the molecular mechanisms underlying the condition and to develop more effective therapeutic strategies.
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Affiliation(s)
- Babapelumi Adejuyigbe
- David Geffen School of Medicine, The University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA;
| | - Julie Kallini
- Department of Computer Science, Stanford University, Stanford, CA 94305, USA;
| | - Daniel Chiou
- Department of Orthopedic Surgery, The University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA;
| | - Jennifer R. Kallini
- Department of Orthopedic Surgery, The University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA;
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George J, Sharma V, Farooque K, Mittal S, Trikha V, Malhotra R. The Impact of Surgical Timing of Hip Fracture on Mortality: Do the Cause and Duration of Delay Matter? Hip Pelvis 2023; 35:206-215. [PMID: 37727296 PMCID: PMC10505843 DOI: 10.5371/hp.2023.35.3.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 06/18/2023] [Accepted: 06/18/2023] [Indexed: 09/21/2023] Open
Abstract
Purpose Delay in performance of hip fracture surgery can be caused by medical and/or administrative reasons. Although early surgery is recommended, it is unclear what constitutes a delayed surgery and whether the impact of delayed surgery can differ depending on the reason for the delay. Materials and Methods A total of 269 consecutive hip fracture patients over 50 years of age who underwent surgery were prospectively enrolled. They were divided into two groups: early and delayed (time from reaching the hospital to surgery less than or more than 48 hours). Patients were also categorized as fit or unfit based on anesthetic fitness. One-year mortality was recorded, and regression analyses were performed to assess the impact of delay on mortality. Results A total of 153 patients (56.9%) had delayed surgery with a mean time to surgery of 87±70 hours. A total of 115 patients (42.8%) were considered medically fit to undergo surgery. No difference in one-year mortality was observed between patients with early surgery and those with delayed surgery (P=0.854). However, when assessment of the time to surgery was performed in a continuous manner, mortality increased with prolonged time to surgery, particularly in unfit patients, and higher mortality was observed when the delay exceeded six days (fit: P=0.117; unfit: P=0.035). Conclusion The effect of delay on mortality was predominantly observed in patients who were not considered medically fit, suggesting that surgical delays might have a greater impact on patients with medical reasons for delay.
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Affiliation(s)
- Jaiben George
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vijay Sharma
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Kamran Farooque
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Samarth Mittal
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vivek Trikha
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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13
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Chao TC, Lee HP, Wu JC, Hsu CJ. Analysis of Cardiac Events and the Subsequent Impact for Geriatric Patients Undergoing Hip Fracture Surgeries. J Clin Med 2023; 12:5276. [PMID: 37629317 PMCID: PMC10455102 DOI: 10.3390/jcm12165276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/02/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
Perioperative complications, particularly cardiac events, compromised surgical outcomes for geriatric patients. This retrospective study intended to investigate the occurrence and subsequent impact of cardiac events for geriatric patients undergoing hip fracture surgeries. We collected 607 patients undergoing hip fracture surgeries from January 2017 to December 2022 that received transthoracic echocardiography (TTE) pre-operatively to screen for cardiac abnormalities. Except for demographic characteristics, the researchers recorded fracture type, surgical method, American Society of Anesthesiologists (ASA) class, anesthesia type, perioperative cardiac events, and in-hospital mortality. Statistical analysis was performed using SPSS 22.0 statistics software. Throughout the whole course of the study, 16 postoperative cardiac events occurred. The cardiac events included ten arrhythmias, three acute myocardial infarctions, two heart failures, and one sudden death. Notably, 12 of 16 patients with cardiac events presented with abnormal findings on TTE, except 15 of them had a history of cardiac disease. This study disclosed 93.7% of cardiac events developed in patients with a history of cardiovascular disease. Among patients that experienced cardiac events, 75% of patients had abnormal echocardiographic findings. Pre-operative transthoracic echocardiography deserves a recommendation for geriatric patients with histories of cardiac diseases undergoing hip fracture surgeries to detect the risk of developing cardiac events earlier.
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Affiliation(s)
- Ting-Cheng Chao
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan;
- Department of Orthopaedic Surgery, Ping-Tung Christian Hospital, Pingtung 90059, Taiwan; (H.-P.L.); (J.-C.W.)
| | - Hsin-Pai Lee
- Department of Orthopaedic Surgery, Ping-Tung Christian Hospital, Pingtung 90059, Taiwan; (H.-P.L.); (J.-C.W.)
| | - Jung-Chou Wu
- Department of Orthopaedic Surgery, Ping-Tung Christian Hospital, Pingtung 90059, Taiwan; (H.-P.L.); (J.-C.W.)
| | - Chien-Jen Hsu
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan;
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14
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López-Hualda A, Arruti-Pérez E, Bebea-Zamorano FN, Sosa-Reina MD, Villafañe JH, Martínez-Martin J. Morbidity and Mortality Analysis in the Treatment of Intertrochanteric Hip Fracture with Two Fixation Systems: Dynamic Hip Screw (DHS) or Trochanteric Fixation Nail Advance (TFNA). Geriatrics (Basel) 2023; 8:66. [PMID: 37367098 DOI: 10.3390/geriatrics8030066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND The aim of this study was to compare the clinical outcomes, complications, and mortality of patients with intertrochanteric hip fracture treated with dynamic hip screw (DHS) vs. trochanteric fixation nail advance (TFNA). METHODS We evaluated 152 patients with intertrochanteric fractures concerning age, sex, comorbidity, Charlson Index, preoperative gait, OTA/AO classification, time from fracture to surgery, blood loss, amount of blood replacement, changes in gait, full weight-bearing at hospital discharge, complications, and mortality. The final indicators encompassed the adverse effects linked to implants, postoperative complications, clinical healing or bone healing duration, and functional score. RESULTS The study included a total of 152 patients, out of which 78 (51%) received DHS treatment and 74 (49%) received TFNA treatment. The results of this study show that the TFNA group demonstrated superiority (p < 0.001). However, it should be noted that the TFNA group had a higher frequency of the most unstable fractures (AO 31 A3, p < 0.005). Full weight-bearing at discharge also decreased in patients with more unstable fractures (p = 0.005) and severe dementia (p = 0.027). Mortality was higher in the DHS group; however, a longer time from diagnosis to surgery was also observed in this group (p < 0.005). CONCLUSIONS The TFNA group has shown a higher success rate in achieving full weight-bearing at hospital discharge when treating trochanteric hip fractures. This makes it the preferred choice for treating unstable fractures in this region of the hip. Additionally, it is important to note that a longer time to surgery is associated with increased mortality in patients with hip fractures.
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Affiliation(s)
- Alvaro López-Hualda
- Orthopedic Surgery and Traumatology Service, Hospital Universitario Fundación Alcorcon, 28922 Alcorcón, Spain
| | - Elsa Arruti-Pérez
- Orthopedic Surgery and Traumatology Service, Hospital Universitario Fundación Alcorcon, 28922 Alcorcón, Spain
| | - Fátima N Bebea-Zamorano
- Orthopedic Surgery and Traumatology Service, Hospital Universitario Fundación Alcorcon, 28922 Alcorcón, Spain
| | - María Dolores Sosa-Reina
- Department of Physiotherapy, Faculty of Sports Sciences, Universidad Europea de Madrid, Calle Tajo s/n, 28670 Villaviciosa de Odón, Spain
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
| | | | - Javier Martínez-Martin
- Orthopedic Surgery and Traumatology Service, Hospital Universitario Fundación Alcorcon, 28922 Alcorcón, Spain
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15
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Sun L, Wang C, Zhang M, Li X, Zhao B. The Surgical Timing and Prognoses of Elderly Patients with Hip Fractures: A Retrospective Analysis. Clin Interv Aging 2023; 18:891-899. [PMID: 37287528 PMCID: PMC10243344 DOI: 10.2147/cia.s408903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/17/2023] [Indexed: 06/09/2023] Open
Abstract
Background Guidelines exist for the surgical treatment of hip fractures, but the association between the surgical timing and the incidence of postoperative complications and other important outcomes in elderly patients with hip fracture remains controversial. Objective This study aims to explore the association between the surgical timing and the prognoses in elderly patients with hip fracture. Methods A total of 701 elderly patients (age ≥ 65 years) with hip fractures who were treated in our hospital from June 2020 to June 2021 were selected. Patients who underwent surgery within 2 d of admission were assigned to the early surgery group, and those who underwent surgery after 2 d of admission were assigned to the delayed surgery group. The prognosis indices of the patients in the two groups were recorded and compared. Results The length of postoperative hospitalisation in the early surgery group was significantly lower than that in the delayed surgery group (P < 0.001). The European quality of life questionnaire (EQ-5D) utility in the delayed surgery group was significantly lower than that in the early surgery group at 30 days and 6 months after operation (P<0.05). Compared with the delayed surgery group, the incidence of pulmonary infection, urinary tract infection (UTI) and deep vein thrombosis (DVT) in the early surgery group were significantly lower. There were no significant differences between the two groups in terms of mortality and excellent rates of the HHS at six months after the operation. In addition, the early surgery group had a lower readmission rate than the delayed surgery group [34 (9.5%) vs 56 (16.3%), P = 0.008]. Conclusion Earlier surgery can reduce the incidence of pulmonary infections, UTI, DVT and readmission rate among elderly patients with hip fractures, shorten postoperative hospitalisation.
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Affiliation(s)
- Lili Sun
- Department of Emergency, Beijing Jishuitan Hospital, Beijing, People’s Republic of China
| | - Cong Wang
- Department of Emergency, Beijing Jishuitan Hospital, Beijing, People’s Republic of China
| | - Mingqing Zhang
- Department of Emergency, Beijing Jishuitan Hospital, Beijing, People’s Republic of China
| | - Xiang Li
- Department of Emergency, Beijing Jishuitan Hospital, Beijing, People’s Republic of China
| | - Bin Zhao
- Department of Emergency, Beijing Jishuitan Hospital, Beijing, People’s Republic of China
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16
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Fenwick A, Pfann M, Antonovska I, Mayr J, Lisitano L, Nuber S, Förch S, Mayr E. Early surgery? In-house mortality after proximal femoral fractures does not increase for surgery up to 48 h after admission. Aging Clin Exp Res 2023; 35:1231-1239. [PMID: 37138145 PMCID: PMC10156577 DOI: 10.1007/s40520-023-02406-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/31/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE The economic cost linked to the increasing number of proximal femur fracture and their postoperative care is immense. Mortality rates are high. As early surgery is propagated to lower mortality and reduce complication rates, a 24-h target for surgery is requested. It was our aim to determine the cut-off for the time to surgery from admission and therefore establish a threshold at which the in-house mortality rate changes. METHODS A retrospective single-center cohort study was conducted including 1796 patients with an average age of 82.03 years treated operatively for a proximal femoral fracture between January 2016 and June 2020. A single treatment protocol was performed based on the type of anticoagulant, surgery, and renal function. Patient data, surgical procedure, time to surgery, complications, and mortality were assessed. RESULTS In-house mortality rate was 3.95%, and the overall complication rate was 22.7%. A prolonged length of hospital stay was linked to patient age and occurrence of complications. Mortality is influenced by age, number of comorbidities BMI, and postoperative complications of which the most relevant is pneumonia. The mean time to surgery for the entire cohort was 26.4 h. The investigation showed no significant difference in mortality rate among the two groups treated within 24 h and 24 to 48 h while comparing all patients treated within 48 h and after 48 h revealed a significant difference in mortality. CONCLUSIONS Age and number of comorbidities significantly influence mortality rates. Time to surgery is not the main factor influencing outcome after proximal femur fractures, and mortality rates do not differ for surgery up to 48 h after admission. Our data suggest that a 24-h target is not necessary, and the first 48 h may be used for optimizing preoperative patient status if necessary.
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Affiliation(s)
- Annabel Fenwick
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Michael Pfann
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Iana Antonovska
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Jakob Mayr
- Zentrum für Unfallchirurgie und Orthopädie, Klinikum Ingolstadt GmbH, Krumenauerstraße 25, 85049, Ingolstadt, Germany
| | - Leonhard Lisitano
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Stefan Nuber
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Stefan Förch
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Edgar Mayr
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
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Wilharm A, Wutschke I, Schenk P, Hofmann GO. Tranexamic Acid in Hip Hemiarthroplasty Surgery: A Retrospective Analysis of Perioperative Outcome. Geriatr Orthop Surg Rehabil 2023; 14:21514593221147817. [PMID: 36654888 PMCID: PMC9841876 DOI: 10.1177/21514593221147817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 09/24/2022] [Accepted: 11/21/2022] [Indexed: 01/15/2023] Open
Abstract
Introduction: Implantation of a dual-head hip prosthesis to treat medial femoral neck fractures is often associated with significant blood loss. In elective endoprosthetics procedures, it has already been demonstrated that administration of tranexamic acid (TXA) reduces blood loss and need for postoperative transfusions, as well as reducing the frequency of postoperative complications. The aim of this study is to show whether the administration of TXA also leads to a reduction in perioperative blood loss and haemorrhage-associated complications when applied as part of treatment of femoral neck fractures using a dual-head prosthesis. Methods: In a single-centre retrospective cohort study, 1 g TXA i.v. was administered preoperatively to 93 patients who had suffered from femoral neck fractures. This group was compared to a comparison group of 65 patients who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, frequency of transfusion, and frequency of specific complications occurring. Results: The transfusion rate in the TXA group was 6% lower, whereby the volume of blood transfused was 26.7% lower than in the nonTXA group. However, neither result was significant. The calculated perioperative blood loss remained the same. Similarly, the incidence of postoperative renal failure was not significantly lower in the TXA group, at 6.5%, as compared to the nonTXA group (7.7%). A higher rate of complications or deaths as a result of TXA administration was not observed. The tranexamic acid effect seems to be related to the dose. Conclusion: Preoperative administration of TXA during implantation of a dual-head prosthesis for treatment of a femoral neck fracture does not lead to an increased complication rate. The study revealed a trend towards fewer transfusions required, but a significant reduction in blood loss could not be demonstrated. There should be further investigation of other factors influencing blood loss, in particular the dosing regimen followed for perioperative administration of TXA. Level of Evidence: Level 4: retrospective case-control study.
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Affiliation(s)
- Arne Wilharm
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Jena, Germany,Arne Wilharm, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Am Klinikum 1, Jena 07747, Germany.
| | - Isabell Wutschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Jena, Germany
| | - Philipp Schenk
- Department of Research Executive, BG Klinikum Bergmannstrost Halle, Halle, Germany
| | - Gunther Olaf Hofmann
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Jena, Germany
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18
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Simonin M, Delsuc C, Meuret P, Caruso L, Deleat-Besson R, Lamblin A, Huriaux L, Abraham P, Bidon C, Giai J, Riche B, Rimmelé T. Hypobaric Unilateral Spinal Anesthesia Versus General Anesthesia for Hip Fracture Surgery in the Elderly: A Randomized Controlled Trial. Anesth Analg 2022; 135:1262-1270. [PMID: 36135347 DOI: 10.1213/ane.0000000000006208] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Hypotension during surgery is frequent in the elderly population and is associated with acute kidney and myocardial injury, which are, themselves, associated with increased 30-day mortality. The present study compared the hemodynamic effects of hypobaric unilateral spinal anesthesia (HUSA) to general anesthesia (GA) in patients ≥70 years of age undergoing hip fracture surgery. METHODS We conducted a single-center, prospective, randomized study. In the HUSA group, patients were positioned with the operated hip above, and the hypobaric anesthetic solution was composed of 9 mg ropivacaine, 5 µg sufentanil, and 1 mL of sterile water. Anesthesia was adjusted for the GA group. Mean arterial pressure (MAP) was measured with a noninvasive blood pressure upper arm cuff every 3 minutes. Hypotension was treated with a bolus of ephedrine and then a continuous intravenous of norepinephrine to obtain a MAP ≥65 mm Hg. Primary outcome was the occurrence of severe hypotension, defined as a MAP <65 mm Hg for >12 consecutive minutes. RESULTS A total of 154 patients were included. Severe hypotension was more frequent in the GA group compared to the HUSA group (odds ratio, 5.6; 95% confidence interval, 2.7-11.7; P < .001). There was no significant difference regarding the short-term outcomes between the HUSA and GA groups: acute kidney injury (respectively, 5.1% vs 11.3%; P = .22), myocardial injury (18.0% vs 14.0%; P = .63), and 30-day mortality (2.4% vs 4.7%; P = .65). CONCLUSIONS HUSA leads to fewer episodes of severe intraoperative hypotension compared to GA in an elderly population undergoing hip fracture surgery.
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Affiliation(s)
- Marine Simonin
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Claire Delsuc
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Pascal Meuret
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Liana Caruso
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Robert Deleat-Besson
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Antoine Lamblin
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Laetitia Huriaux
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Paul Abraham
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Cyril Bidon
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Joris Giai
- Université de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France
- Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Benjamin Riche
- Université de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France
- Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Thomas Rimmelé
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
- Hospices Civils de Lyon-Biomérieux-Université Claude Bernard Lyon 1, Hôpital Édouard Herriot, Lyon, France
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Den Haese JP, Delgadillo BE, Anderson BG, Storm SW. A Cautionary Tale of a Complex Peri-Trochanteric Fracture in a Very Important Person (VIP) Patient at a Community-Based Hospital: A Case Report. Cureus 2022; 14:e33150. [PMID: 36960330 PMCID: PMC10029698 DOI: 10.7759/cureus.33150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2022] [Indexed: 01/01/2023] Open
Abstract
Peri-trochanteric fractures with an extension into the femoral neck are relatively rare. Due to the lack of a defined treatment in the literature, these fractures pose a challenge to orthopedic surgeons. This case report highlights the value of timing to surgical intervention, choosing the appropriate operative course, not treating very important person (VIP) patients differently than standard patients, and decreasing unnecessary costs for the patient and the US healthcare system. An 85-year-old male VIP patient presented to the emergency department (ED) with a left peri-trochanteric fracture with an extension into the ipsilateral femoral neck. The initial plan was to perform arthroplasty with diaphyseal fixation. However, the community-based hospital would have to wait two to three days for the proper implants, and the patient insisted on being treated at this hospital. Due to concerns about increased mortality with delayed treatment, the patient underwent short cephalomedullary nail (CMN) fixation the next day. On postoperative day (POD) 49, a pop was heard and felt while ambulating, and radiographs revealed substantial lateral cutout of the CMN and subsidence of the femoral head. On POD 54, the patient underwent a successful left total hip arthroplasty using a modular diaphyseal press-fit femoral component, which resulted in an uneventful recovery. This case illustrates a cautionary tale in choosing the appropriate operative course for a VIP patient with a peri-trochanteric fracture extending into the femoral neck (a relatively rare fracture type that has no clearly defined treatment option). This is imperative to reduce pain and length of stay for the patient, postoperative complications, and cost. Based on the results from the second procedure and weighing the risk of prolonged treatment, the authors believe that this patient would likely have benefited from a primary arthroplasty procedure given his body habitus and complex fracture pattern.
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Affiliation(s)
- Jason P Den Haese
- Department of Orthopedic Surgery, Lake Erie College of Osteopathic Medicine (LECOM) Health, Millcreek Community Hospital, Erie, USA
| | - Blake E Delgadillo
- Department of Orthopedic Surgery, Lake Erie College of Osteopathic Medicine (LECOM), Bradenton, USA
| | - Bryan G Anderson
- Department of Spine Surgery, Swedish Neuroscience Institute, Seattle, USA
- Department of Orthopedic Surgery, Lake Erie College of Osteopathic Medicine (LECOM) Health, Millcreek Community Hospital, Erie, USA
| | - Shawn W Storm
- Department of Orthopedic Surgery, Lake Erie College of Osteopathic Medicine (LECOM) Health, Millcreek Community Hospital, Erie, USA
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20
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Early initiation of physical therapy after geriatric hip fracture surgery is associated with shorter hospital length of stay and decreased thirty-day mortality. Injury 2022; 53:4086-4089. [PMID: 36192201 DOI: 10.1016/j.injury.2022.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 09/02/2022] [Accepted: 09/23/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION While the importance of timely surgery and early mobilization are understood in geriatric fracture populations, the relationship between timing of initiation of physical therapy (PT) postoperatively on length of stay (LOS) and mortality has not been well delineated. The purpose of this investigation was to determine the effect of PT initiated on postoperative day zero (POD0) on LOS and mortality in geriatric hip fracture patients. MATERIALS AND METHODS Patients aged 60 and over who underwent hip fracture surgery, including arthroplasty or internal fixation, between January 2017 and December 2019 at three affiliated academic hospitals were identified. Retrospective chart review and review of hospital charges were used to determine patient demographics, Charlson Comorbidity Index (CCI), surgery performed, timing of postoperative PT visits, LOS, and mortality. RESULTS Of 1,551 patients identified that met inclusion criteria, 83 (5.3%) received PT on POD0. Most patients (76.3%) received PT on postoperative day 1 (POD1), and 18.4% received first PT on postoperative day 2 or later (POD2+). Time from admission to surgery, CCI, sex, and BMI did not differ significantly between groups. The age difference between patients in the POD0 and the POD1/POD2+ groups was statistically significant with the mean age in the POD1/2+ group being 2.3 years older than the POD0 group (p=0.045). There was no difference in postoperative length of stay (PLOS) based on type of fixation. The average PLOS was 3.4 days in the POD0 PT group compared to 5.2 days in the POD1 group (p<0.0001) and 8.2 days in the POD2+ group (p<0.0001). The POD0/1 group had significantly lower mortality than the POD2+ group [3.7% vs. 9.8%, OR 0.354 (95% CI 0.217-0.575), p<0.0001]. CONCLUSION Earlier initiation of PT postoperatively is associated with significantly shorter total and postoperative LOS and initiation of PT before POD2 is associated with decreased 30-day mortality. Each day that initiation of PT is delayed is associated with a two- to three-day increase in LOS.
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21
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Huff S, Henningsen J, Schneider A, Hijji F, Froehle A, Krishnamurthy A. Differences between intertrochanteric and femoral neck fractures in resuscitative status and mortality rates. Orthop Traumatol Surg Res 2022; 108:103231. [PMID: 35124249 DOI: 10.1016/j.otsr.2022.103231] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/17/2021] [Accepted: 09/02/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Hip fracture mortality remains a challenge for orthopedic surgeons. The purpose of this study was to compare resuscitative mean arterial pressures (MAPs), intravenous fluid (IVF) administration, and mortality rates between intertrochanteric (IT) and femoral neck (FN) fracture patients. HYPOTHESIS We hypothesized that IT fracture patients would receive less aggressive fluid resuscitation than FNF patients given the perceived less invasive nature of intra-medullary nails compared with hemiarthroplasty. MATERIALS AND METHODS An institutional database was queried to identify all hip fractures managed surgically over a 2-year period. Preoperative and intraoperative MAPs and IVF administration, as measures of resuscitation, were compared between IT fracture patients treated with open reduction internal fixation and FN fracture patients treated with hemiarthroplasty. RESULTS Six hundred and ninety-eight hip fractures, including 531 IT and 167 FN fractures, were analyzed. There were no differences between IT and FN fracture cohorts for age, sex distribution, or Charlson Comorbidity Index scores. IT fracture patients were found to have lower MAP upon admission (103.7±20.1 vs. 107.8±18.4mmHg; p=0.026), and lower average, minimum, and maximum MAP values preoperatively and intraoperatively. Despite lower MAPs, IT fracture patients received less total IVF (581.9±472.5 vs. 832.9±496.5cc; p<0.001) and lower IVF rates intraoperatively (306.5±256.8 vs. 409.8±251.0 cc/h; p<0.001). IT fracture patients experienced higher 30-day (7.9% vs. 3.6%; p=0.040) and 90-day (10.6% vs. 5.4%; p=0.035) mortality rates and trended towards higher inpatient mortality (3.0% vs. 0.6%; p=0.088). Multivariate regression demonstrated IT pattern to be independently predictive of 30-day mortality with 2.459 increased odds relative to FN fracture (p=0.039). DISCUSSION IT fracture patterns are associated with decreased perioperative MAP values, yet received lower perioperative IVF rates. IT fracture patients suffered higher 30- and 90-day mortality rates, despite similar age and comorbidities. LEVEL OF EVIDENCE III; retrospective cohort study.
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Affiliation(s)
- Scott Huff
- Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA.
| | - Joseph Henningsen
- Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA
| | - Andrew Schneider
- Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA
| | - Fady Hijji
- Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA
| | - Andrew Froehle
- Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA
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22
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Houserman DJ, Raszewski JA, Palmer B, Chavan B, Sferrella A, Campbell M, Santanello S. The Impact of the Fascia Iliaca Block Beyond Perioperative Pain Control in Hip Fractures: A Retrospective Review. Geriatr Orthop Surg Rehabil 2022; 13:21514593221099107. [PMID: 35794869 PMCID: PMC9251979 DOI: 10.1177/21514593221099107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Geriatric hip fractures are common injuries that are associated with high morbidity and mortality. Adequate pain control remains a challenge as the altered physiology in elderly patients makes use of traditional analgesics challenging. The use of regional anesthetics, specifically the fascia iliaca compartment block (FICB), in the perioperative period has been shown to decrease opioid use in this population. This study aimed to investigate the effect the FICB had on pain control, length of stay, readmissions, and complications in a 30-day postoperative period. Methods This was a retrospective cohort study comparing patients who sustained hip fractures; one cohort (110 patients) received a preoperative fascia iliaca block with continuous infusion (FICB), whereas the other cohort (110 patients) did not receive a block (NO-FICB). Both cohorts were from level II trauma centers. Data were collected between 2016 and 2019. Descriptive statistics was performed to describe and summarize the data. Bivariate analysis was performed using chi-square test, with 2 tailed P-values ≤ .05 were considered statistically significant. Results The FICB group had a lower length of stay (3.9 days vs 4.8 days; P < .001), and lower pain scores on post-operative days 2 and 3 (P = .019). There was no difference in time from admission to surgery (P = .112) or narcotic use between cohorts (P = .304). However, the FICB group was more likely to discharge to a skilled nursing facility (P=.002), and more likely to be readmitted within 30 days (P = .047). There were no differences in medical complications or mortality between the 2 groups. Conclusions The primary study endpoint, length of stay, was found to be significantly shorter in the patients who underwent the FICB vs the group who did not undergo the FICB. Pain scores on POD2 and POD3 were lower in patients who received a FICB. This study adds to the body of evidence that the FICB is an effective addition to a multimodal pain pathway. Level of Evidence Level III Evidence - Retrospective Cohort Study.
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Affiliation(s)
| | | | - Brandi Palmer
- Department of Trauma Surgery, Kettering Medical Center, Kettering Health Network, Dayton, OH, USA
| | | | - Abby Sferrella
- College of Osteopathic Medicine, Marian University, Indianapolis, IN, USA
| | - Melody Campbell
- Department of Trauma Surgery, Kettering Medical Center, Kettering Health Network, Dayton, OH, USA
| | - Steven Santanello
- Department of Trauma Surgery, Kettering Medical Center, Kettering Health Network, Dayton, OH, USA
- Parkview Health, Parkview Regional Medical Center, Fort Wayne, IN, USA
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23
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Queiroz RD, Borger RA, Heitzmann LG, Fingerhut DJP, Saito LH. Fraturas intracapsulares do colo femoral no idoso. Rev Bras Ortop 2022; 57:360-368. [PMID: 35785116 PMCID: PMC9246523 DOI: 10.1055/s-0041-1736473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/18/2021] [Indexed: 11/17/2022] Open
Abstract
Currently, intracapsular femoral neck fracture (IFNF) is still a great challenge for orthopedists. In spite of the progress that has been made, a high mortality rate persists in the first year, especially in Brazil, where there is no awareness that such fractures in elderly patients should be treated as a medical emergency. The present article seeks to provide an update on the preoperative, surgical, and postoperative approaches.
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Affiliation(s)
- Roberto Dantas Queiroz
- Serviço de Ortopedia e Traumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual (Iamspe), São Paulo, SP, Brasil
| | - Richard Armelin Borger
- Serviço de Ortopedia e Traumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual (Iamspe), São Paulo, SP, Brasil
| | - Lourenço Galizia Heitzmann
- Serviço de Ortopedia e Traumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual (Iamspe), São Paulo, SP, Brasil
| | - David Jeronimo Peres Fingerhut
- Serviço de Ortopedia e Traumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual (Iamspe), São Paulo, SP, Brasil
| | - Luiz Henrique Saito
- Serviço de Ortopedia e Traumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual (Iamspe), São Paulo, SP, Brasil
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24
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Murphy JR, Loh J, Smith NC, Stone NC. Association of length of hospital stay with delay to surgical fixation of hip fracture. Can J Surg 2022; 65:E188-E192. [PMID: 35292524 PMCID: PMC8929431 DOI: 10.1503/cjs.017520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Previous research has shown increases in length of stay (LOS), morbidity and mortality when the standard for surgical fixation of hip fracture of 48 hours is not met. However, few investigators have analyzed LOS as a primary outcome, and most used time of diagnosis as opposed to time of fracture as the reference point. We examined the effect of time to surgical fixation of hip fracture, measured from time of fracture, on length of hospital stay; the secondary outcome was average 1-year mortality. Methods: We conducted a retrospective cohort study of patients presenting to 1 of 2 tertiary care centres in St. John’s, Newfoundland and Labrador, Canada, with a hip fracture from Jan. 1, 2014, to Dec. 31, 2018. We analyzed 3 groups based on timing of surgical fixation after fracture: less than 24 hours (group 1), 24–48 hours (group 2) and more than 48 hours (group 3). We assessed statistical significance using 1-way analysis of variance. Results: Of the 692 patients included in the study, 212 (30.6%) were in group 1, 360 (52.0%) in group 2 and 120 (17.3%) in group 3. A delay to surgical fixation exceeding 48 hours was associated with a significantly longer LOS, by an average of 2.9 and 2.8 days compared to groups 1 and 2, respectively (p = 0.04); there was no significant difference in LOS between groups 1 and 2. A significant difference in average 1-year mortality was observed between groups 1 (11%) and 3 (26%) (p = 0.004), and groups 2 (13%) and 3 (p = 0.009). Conclusion: Surgical fixation beyond 48 hours after hip fracture resulted in significantly increased LOS and 1-year mortality. Further research should be conducted to evaluate reasons for delays to surgery and the effects of these delays on time to surgical fixation as measured from time of fracture.
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Affiliation(s)
- Justin R Murphy
- From the Discipline of Orthopaedic Surgery, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Nfld.
| | - Jeremy Loh
- From the Discipline of Orthopaedic Surgery, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Nfld
| | - Nicholas C Smith
- From the Discipline of Orthopaedic Surgery, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Nfld
| | - N Craig Stone
- From the Discipline of Orthopaedic Surgery, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Nfld
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25
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Fan J, Lv Y, Xu X, Zhou F, Zhang Z, Tian Y, Ji H, Guo Y, Yang Z, Hou G. The Efficacy of Multidisciplinary Team Co-Management Program for Elderly Patients With Intertrochanteric Fractures: A Retrospective Study. Front Surg 2022; 8:816763. [PMID: 35284470 PMCID: PMC8907576 DOI: 10.3389/fsurg.2021.816763] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundIntertrochanteric fractures increased quickly in past decades owing to the increasing number of aging population. Recently, geriatric co-management was rapidly emerging as a favored clinical care model for older patients with hip fractures. The purpose of this study was to assess the efficacy of a multidisciplinary team (MDT) co-management program in elderly patients with intertrochanteric fractures.MethodsIn this retrospective study, patients were divided into MDT group and traditional orthopedic care (TOC) group according to the healthcare model applied. 249 patients were included in the TOC group from January 2014 to December 2016 and 241 patients were included in the MDT group from January 2017 to December 2019. Baseline data, peri-operative data, and postoperative complications were collected and analyzed using SPSS 21.0.ResultsNo significant differences were observed between the two groups in terms of patient baseline characteristics. Patients in the MDT group had significantly lower time from admission to surgery and length-of-stay (LOS) compared with those in the TOC group. Furthermore, the proportion of patients receiving surgery within 24 h (61.4 vs. 34.9%, p < 0.001) and 48 h (80.9 vs. 63.5%, p < 0.001) after admission to the ward was significantly higher in the MDT group compared with those in the TOC group. In addition, patients in the MDT group had significantly lower proportion of postoperative complications (25.3 vs. 44.2%, p < 0.001), deep vein thrombosis (7.9 vs. 12.9%, p = 0.049), pneumonia (3.8 vs. 8.0%, p = 0.045) and delirium (4.1 vs. 9.2%, p = 0.025) compared with those in the TOC group. However, no significant changes were found for in-hospital and 30-day mortality.ConclusionThe MDT co-management could significantly shorten the time from admission to surgery, LOS, and reduce the postoperative complications for elderly patients with intertrochanteric fractures. Further research was needed to evaluate the impact of this model on patient health outcomes.
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Affiliation(s)
- Jixing Fan
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Yang Lv
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Xiangyu Xu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Fang Zhou
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- *Correspondence: Fang Zhou
| | - Zhishan Zhang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Yun Tian
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Hongquan Ji
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Yan Guo
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Zhongwei Yang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Guojin Hou
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
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26
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Owusu-Akyaw K. The Forward Movement: Amplifying Black Voices on Race and Orthopaedics-Disparity Studies Should Not Ignore America's Racial History. Clin Orthop Relat Res 2021; 479:2371-2372. [PMID: 34570729 PMCID: PMC8509960 DOI: 10.1097/corr.0000000000001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 01/31/2023]
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27
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Varady NH, Feroe AG, Fontana MA, Chen AF. Causal Language in Observational Orthopaedic Research. J Bone Joint Surg Am 2021; 103:e76. [PMID: 33886523 DOI: 10.2106/jbjs.20.01921] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
With the increasing availability of large clinical registries and administrative data sets, observational (i.e., nonexperimental) orthopaedic research is being performed with increased frequency. While this research substantially advances our field, there are fundamental limitations to what can be determined through a single observational study. Avoiding overstatements and misstatements is important for the sake of accuracy, particularly for ensuring that clinical care is not inadvertently swayed by how an observational study is written up and described. We have noticed that causal language is frequently misused in observational orthopaedic research-that is, language that says or implies that 1 variable definitively causes another, despite the fact that causation can generally only be determined with randomization. In this data-backed commentary, we examine the prevalence of causal language in a random sample of 400 observational orthopaedic studies; we found that causal language was misused in 60% of them. We discuss the implications of these results and how to report observational findings more accurately: the word "association" (and its derivatives) can almost always replace or reframe a causal phrase.
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Affiliation(s)
- Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aliya G Feroe
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark Alan Fontana
- Center for the Advancement of Value in Musculoskeletal Care, Hospital for Special Surgery, and Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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28
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Abstract
ABSTRACT Hip fractures are considered a significant public health issue, representing a substantial burden on our healthcare system and society. They are one of the leading causes of disability among older adults, especially women. Globally, an estimated 18% of women and 6% of men will be affected by hip fractures at some time in life. Hip fractures are a major cause of long-term disability among older adults and more significant than mortality, as only 60% of patients regain their preinjury level of mobility. This has detrimental effects on quality of life and activities of daily living, imposing a level of dependence that has personal, social, and systemic consequences.
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Affiliation(s)
- Meagan L Barry
- At the time this article was written, Meagan L. Barry was a student in the PA program at the University of Tennessee Health Science Center in Memphis. She now practices at Dallas (Tx.) Orthopaedic Joint Institute. Kristopher R. Maday is an associate professor and program director in the PA program at the University of Tennessee. The authors have disclosed no potential conflicts of interest, financial or otherwise
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29
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Keohane D, Downey C, Sheridan GA, O'Kelly P, Quinlan JF. Hip fracture surgery within 36 hours reduces both 30-day and 1-year mortality rates. Surgeon 2021; 20:262-267. [PMID: 34229977 DOI: 10.1016/j.surge.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/15/2021] [Accepted: 05/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Currently the Irish Hip Fracture Standards [IHFS] recommend a Time-to-Surgery [TTS] of within 48 h of admission. The aim of our research is to determine if there was a statistically significant relationship between TTS and 30-day or one-year mortality and to assess whether a 48 h window for surgery is still the most appropriate recommendation. METHODS USED This was a single-hospital retrospective review of all of the fragility hip fractures between 1st January 2013 and 31st December 2017. Patient demographics were described using descriptive statistics. Dependent variables of interest were 30-day mortality and one-year mortality. Independent predictor variables analysed included age, ASA grade, fracture type, surgery performed, anaesthesia administered, length of stay and TTS (hours as an interval variable), TTS in less than 36 h (binary variable) and TTS in less than 48 h (binary variable). When the significant predictor variables were identified, in order to control for confounder variables, a multivariate regression analysis was performed to identify which predictors were still significantly associated with the outcome variables even after controlling for all other known confounder variables. RESULTS In total, 806 patients were identified. TTS within 36 h was predictive of a significantly lower 30-day mortality when compared to those undergoing surgery after 36 h (p = 0.031). In contrast, TTS within 48 h did not demonstrate a significantly lower 30-day mortality when compared to those undergoing surgery after 48 h (p = 0.104). On multivariate regression analysis, TTS <36 h (p = 0.011) and age (p < 0.0001) were all independently predictive of 30-day mortality. On multivariate regression analysis, both age (p < 0.0001) and TTS < 36 h (p = 0.002) were significantly predictive of one-year mortality. CONCLUSION Performing hip fracture surgery within 36 h confers a significant reduction in both 30-day and one-year mortality rates when compared to patients undergoing surgery outside of this time frame. A 36-h window also appears to be superior to a 48-h window because performing surgery within 48 h has no significant impact on the reduction of 30-day mortality rates. We recommend that national guidelines reflect these important findings.
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Affiliation(s)
- David Keohane
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
| | - Colum Downey
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
| | - Gerard A Sheridan
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
| | - Patrick O'Kelly
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
| | - John F Quinlan
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
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30
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Welford P, Jones CS, Davies G, Kunutsor SK, Costa ML, Sayers A, Whitehouse MR. The association between surgical fixation of hip fractures within 24 hours and mortality : a systematic review and meta-analysis. Bone Joint J 2021; 103-B:1176-1186. [PMID: 34192937 DOI: 10.1302/0301-620x.103b7.bjj-2020-2582.r1] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
AIMS The aim of this study was to assess the effect of time to surgical intervention from admission on mortality and morbidity for patients with hip fractures. METHODS MEDLINE and Embase were searched from inception to June 2020. Reference lists were manually assessed to identify additional papers. Primary comparative research studies that recruited patients aged over 60 years, with non-pathological primary proximal femoral fractures that were treated surgically, were included. Studies that did not include a group operated on within 24 hours or which reported time to surgery in calendar days were excluded. Two investigators extracted data on study characteristics, methods, and outcomes. The pre-defined primary outcome was 30-day mortality. Secondary outcomes were complications and mortality at other time points. Relative risks (RRs) with 95% confidence intervals (CIs) were aggregated and were grouped by study-level characteristics. RESULTS This review included 46 studies (January 1991 to June 2020), comprising 521,857 hip fractures with 64,047 postoperative deaths. No randomized controlled trials were eligible for inclusion. In a pooled analysis of 15 studies, RR of mortality at 30 days comparing time to surgery < 24 hours with > 24 hours was 0.86 (95% CI 0.82 to 0.91; I 2 = 69%; 95% CI 50% to 81%; p-value for heterogeneity < 0.001). The association was stronger in observational studies that did not adjust for confounders than in those that adjusted for multiple covariates. In a pooled analysis of six studies, the RR of mortality at 30 days comparing time to surgery < 24 hours with 24 to 36 hours was 0.87 (95% CI 0.81 to 0.93; I 2 = 65%; 95% CI 16% to 85%; p-value for heterogeneity = 0.014). CONCLUSION This meta-analysis indicates reduced mortality for patients operated within 24 hours compared with those operated on beyond 24 hours or within 24 to 36 hours. Where resources allow and there is no specific reversible contraindication to early surgery, we recommend that hip fractures should be surgically treated within 24 hours. Cite this article: Bone Joint J 2021;103-B(7):1176-1186.
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Affiliation(s)
- Paul Welford
- North Bristol NHS Trust, Westbury on Trym, UK
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Conor S Jones
- North Bristol NHS Trust, Westbury on Trym, UK
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Gareth Davies
- North Bristol NHS Trust, Westbury on Trym, UK
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- Translational Health Sciences, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Matt L Costa
- Oxford Trauma, NDORMS, University of Oxford, Oxford, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- North Bristol NHS Trust, Westbury on Trym, UK
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
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31
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George J, Sharma V, Farooque K, Mittal S, Trikha V, Malhotra R. Injury Mechanisms of Hip Fractures in India. Hip Pelvis 2021; 33:62-70. [PMID: 34141692 PMCID: PMC8190498 DOI: 10.5371/hp.2021.33.2.62] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/04/2020] [Accepted: 12/16/2020] [Indexed: 01/16/2023] Open
Abstract
Purpose Hip fractures are a major cause of morbidity and mortality in the elderly; however, the current literature on the injury patterns of hip fractures in India is lacking. Understanding the injury profile of these patients is important to develop targeted interventions to prevent hip fractures. Materials and Methods This was a prospective study of all hip fracture patients aged 50 years or older admitted from February 2019 to December 2019. Details about the injury were recorded by an in-person interview. Multivariate logistic regression analysis was used to identify the factors associated with any particular injury mechanism. Results Two hundred and eighty-three hip fractures were included. The mechanism of injury for the majority of patients was a fall from a standing height (n=217, 76.7%) while 60 patients (21.2%) were injured as the result of a road traffic accident (RTA). Slipping on a wet floor (n=49, 22.6%) and change in posture (n=35, 16.1%) were the most commonly reported reasons for falling. Pedestrian injuries were the most common form of RTA (n=29, 48.3%). Increasing age (P<0.001) and female sex (P=0.001) were associated with fall as the mode of injury while sustaining another fracture in addition to hip fracture (P=0.032) was associated with RTA as the mode of injury. Conclusion A fall from standing height is the predominant mode of injury among elderly hip fractures especially among women. Environmental hazards and postural changes are responsible for the majority of falls while pedestrian accidents contribute to a majority of the RTAs.
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Affiliation(s)
- Jaiben George
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vijay Sharma
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Kamran Farooque
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Samarth Mittal
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vivek Trikha
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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32
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Shen CY, Hsiao CH, Tsai W, Chang WH, Chen TH. Associations between Hip Fracture Operation Waiting Time and Complications in Asian Geriatric Patients: A Taiwan Medical Center Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18062848. [PMID: 33799571 PMCID: PMC8000883 DOI: 10.3390/ijerph18062848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/28/2021] [Accepted: 03/08/2021] [Indexed: 01/09/2023]
Abstract
Early surgical intervention in hip fractures is associated with lower complications. This study aimed to determine the appropriate operation time among Asian geriatric patients. The data of 1118 elderly patients with hip fracture at Mackay Memorial Hospital from 1 January 2011, to 31 July 2019, were retrospectively examined. Association between operation waiting time and the occurrence of complications was calculated using a cubic spline model. Significantly increased incidence of pneumonia, myocardial infarction, and heart failure was observed in 30 and 90 days when the patient’s surgical waiting time exceeded 36 h. The incidence rates of pneumonia across the early and delayed groups within 30 and 90 days were 4.4% vs. 7.9%, and 6.2% vs. 10.7%, those of myocardial infarction were 3.0% vs. 7.2%, and 5.7% vs. 9.3%, and those of heart failure were 15.2% vs. 26.8%, and 16.2% vs. 28.5%. Deep vein thrombosis and pulmonary embolism were not associated with surgical delay. The overall 30-day mortality rate was 5.4%, and no significant difference was observed when the surgical waiting time exceeded 36 h. In summary, operation waiting time exceeding 36-h was associated with increased rates of pneumonia, myocardial infarction, and heart failure in Asian geriatric patients undergoing hip fracture surgery.
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Affiliation(s)
- Ching-Yi Shen
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei 104, Taiwan; (C.-Y.S.); (W.T.); (W.-H.C.)
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan
| | - Chien-Han Hsiao
- Department of Linguistics, Indiana University, Bloomington, IN 47405, USA;
| | - Weide Tsai
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei 104, Taiwan; (C.-Y.S.); (W.T.); (W.-H.C.)
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan
- MacKay Junior College of Medicine, Nursing, and Management, Taipei 112, Taiwan
| | - Wen-Han Chang
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei 104, Taiwan; (C.-Y.S.); (W.T.); (W.-H.C.)
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan
- MacKay Junior College of Medicine, Nursing, and Management, Taipei 112, Taiwan
- Institute of Mechatronic Engineering, National Taipei University of Technology, Taipei 106, Taiwan
| | - Tse-Hao Chen
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei 104, Taiwan; (C.-Y.S.); (W.T.); (W.-H.C.)
- Correspondence: ; Tel.: +886-2-2809-4661; Fax: +886-2-2809-4679
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Williams DGA, Ohnuma T, Haines KL, Krishnamoorthy V, Raghunathan K, Sulo S, Cassady BA, Hegazi R, Wischmeyer PE. Association between early postoperative nutritional supplement utilisation and length of stay in malnourished hip fracture patients. Br J Anaesth 2021; 126:730-737. [PMID: 33516455 DOI: 10.1016/j.bja.2020.12.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/05/2020] [Accepted: 12/12/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Malnutrition in older hip fracture patients is associated with increased complication rates and mortality. As postoperative nutrition delivery is essential to surgical recovery, postoperative nutritional supplements including oral nutritional supplements or tube feeding formulas can improve postoperative outcomes in malnourished hip/femur fracture patients. The association between early postoperative nutritional supplements utilisation and hospital length of stay was assessed in malnourished hip/femur fracture patients. METHODS This is a retrospective cohort study of malnourished hip/femur fracture patients undergoing surgery from 2008 to 2018. Patients were identified through International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes and nutritional supplement utilisation via hospital charge codes. The primary outcome was hospital length of stay. Secondary outcomes included infectious complications, hospital mortality, ICU admission, and costs. Propensity matching (1:1) and univariable analysis were performed. RESULTS Overall, 160 151 hip/femur fracture surgeries were identified with a coded-malnutrition prevalence of 8.7%. Early postoperative nutritional supplementation (by hospital day 1) occurred in 1.9% of all patients and only 4.9% of malnourished patients. Propensity score matching demonstrated early nutritional supplements were associated with significantly shorter length of stay (5.8 [6.6] days vs 7.6 [5.8] days; P<0.001) without increasing hospital costs. No association was observed between early nutritional supplementation and secondary outcomes. CONCLUSION Malnutrition is underdiagnosed in hip/femur fracture patients, and nutritional supplementation is underutilised. Early nutritional supplementation was associated with a significantly shorter hospital stay without an increase in costs. Nutritional supplementation in malnourished hip/femur fracture patients could serve as a key target for perioperative quality improvement.
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Affiliation(s)
- David G A Williams
- CAPER Unit, Department of Anesthesiology, USA; Duke Clinical Research Institute, Durham, NC, USA
| | | | - Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | | | | | | | | | - Paul E Wischmeyer
- CAPER Unit, Department of Anesthesiology, USA; Duke Clinical Research Institute, Durham, NC, USA.
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George J, Sharma V, Farooque K, Mittal S, Trikha V, Malhotra R. Factors associated with delayed surgery in elderly hip fractures in India. Arch Osteoporos 2021; 16:7. [PMID: 33409699 DOI: 10.1007/s11657-020-00858-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/13/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Early hip fracture surgery is recommended to decrease the morbidity and mortality. The extent to which such guidelines are being followed in developing countries like India is unknown. About 20% of the patients presented to hospital after 24 hours of injury, and only one-third had surgery within 48 hours of presentation. INTRODUCTION Early hip fracture surgery is recommended to decrease the morbidity and mortality following hip fractures. Understanding the factors responsible for delay in surgery is important to improve the quality of hip fracture care. This study was conducted to study the factors causing delay in elderly hip fracture surgery in India. METHODS In this prospective study, 272 consecutive hip fracture surgeries at a single hospital were included. Delayed surgery was defined as when the time to surgery (reaching hospital to start of incision) was more than 48 hours. Additionally, the total time to surgery (including time taken for patients to reach hospital after injury) was studied. Factors associated with delayed surgery were assessed using regression models. RESULTS Eighty-seven (32%) patients had a surgery within 48 hours of presentation. Majority of the patients had a delay (82%, N = 151/185) due to one or more medical reasons. Fifty-four (20%) patients presented to hospital after 24 hours of injury. The mean total time to surgery was 112 ± 90 hours with time after reaching hospital contributing to 78% of the total time. Multiple comorbidities (odds ratio, OR = 3.47 [1.42-8.45]), fall as mode of injury (OR = 3.54 [1.61-7.80]), requiring an additional investigation (OR = 10.4 [3.4-31.81]), and requiring arthroplasty (OR = 40.57 [7.01-234.97]) were independently associated with delayed surgery. CONCLUSION Only about one-third of the patients received surgery within 48 hours of reaching the hospital, and about 20% of the patients presented to hospital after 24 hours of injury. Delayed surgery was primarily due to medical comorbidities. Hospitals should establish protocols to ensure faster optimization of patients.
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Affiliation(s)
- Jaiben George
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vijay Sharma
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India. .,Department of Orthopaedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - Kamran Farooque
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India.,Department of Orthopaedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Samarth Mittal
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India.,Department of Orthopaedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vivek Trikha
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India.,Department of Orthopaedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Proximal femur fracture, analysis of epidemiology, complications, and mortality: A cohort with 380 patients. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.787253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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PAKSOY AE, ÖNER K, POLAT F, DURUSOY S. Is 48 h a critical cut-off point for mortality in geriatric hip fractures? Turk J Med Sci 2020; 50:1546-1551. [PMID: 32892536 PMCID: PMC7605087 DOI: 10.3906/sag-2003-194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 08/20/2020] [Indexed: 11/09/2022] Open
Abstract
Background/aim In this study, our objective was to evaluate the mortality in geriatric hip fracture patients who were operated within 48 h after admission or after the 48thh. Materials and methods A total of 194 patients who had undergone surgery for hip fracture between 2016 and 2018 were retrospectively evaluated. Patient information was obtained from the hospital’s database using the ICD codes 81.52, 82.00–82.09, and 82.10. Radiological examination reports were collected from the patient files. Information on mortality was obtained from the Death Notification System of the Turkish Ministry of Health. First-year mortality rates of patients operated within 48 h (Group 1) and those operated at 48–96 h (Group 2) were compared. Results The mean duration between admission to the hospital and surgical intervention was 33.90 ± 1.95 h (3–96 h). The mean total hospitalization time was 7.29 ± 1.53 days (2–36 days). Of the patients, 62 (32%) died within one year after the operation. The mean survival times for patients operated ≤48 h or >48 h were 8.47 ± 1.90 and 6.57 ± 2.59 months, respectively (Z = 1.074, P = 0.283). There was no significant correlation between survival time and the time delay before the operation (r = –0.103, P = 0.153). Additionally, the Cox regression analysis, including age (years), ASA (grade 3 vs. 2), time to operation (h), and days spent in the ICU, demonstrated no significant independent effect of the time to operation on survival (P = 0.200). Conclusion Although shortening the time to surgery may have some rationale, we did not find any difference in patients operated before 48 h compared to 48–96 h concerning mortality.
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Affiliation(s)
- Ahmet Emre PAKSOY
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Ataturk University, ErzurumTurkey
| | - Kerim ÖNER
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Bozok University YozgatTurkey
| | - Ferdi POLAT
- Department of Anesthesiology and Reanimation, Yozgat State Hospital, YozgatTurkey
| | - Serhat DURUSOY
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Bozok University YozgatTurkey
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37
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Kaidi AC, Held MB, Boddapati V, Trofa DP, Neuwirth AL. Timing and Tips for Total Hip Arthroplasty in a Critically Ill Patient With Coronavirus Disease 2019 and a Femoral Neck Fracture. Arthroplast Today 2020; 6:566-570. [PMID: 32802926 PMCID: PMC7359813 DOI: 10.1016/j.artd.2020.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 12/19/2022] Open
Abstract
Expedited time to surgery after hip fracture is associated with decreased morbidity and mortality in appropriately optimized patients. However, the optimal timing of surgery in patients with the novel coronavirus disease 2019 (COVID-19) infection remains unknown. This case report describes a patient with COVID-19 pneumonia complicated by multiorgan system failure requiring intubation who sustained a femoral neck fracture that required total hip arthroplasty. This patient had a significant, deliberate delay in time to surgical intervention because of his critical state. When deciding the optimal timing for total hip arthroplasty in patients with COVID-19, we recommend using inflammatory markers, such as procalcitonin and interleukin-6, as indicators of disease resolution and caution operative intervention when patients are nearing the 7-10th day of COVID-19 symptoms. Furthermore, implant cementation and spinal anesthesia in critically ill COVID-positive patients should be approached cautiously in the setting of pulmonary disease and multiorgan system failure. Close follow-up with medical doctors is recommended to minimize long-term sequelae and delay to baseline mobility.
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Affiliation(s)
- Austin C Kaidi
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Michael B Held
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - David P Trofa
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Alexander L Neuwirth
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
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Garlich JM, Pujari A, Moak Z, Debbi E, Yalamanchili R, Stephenson S, Stephan S, Polakof L, Little M, Moon C, Anand K, Lin CA. Pain Management with Early Regional Anesthesia in Geriatric Hip Fracture Patients. J Am Geriatr Soc 2020; 68:2043-2050. [PMID: 32442348 DOI: 10.1111/jgs.16547] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Geriatric hip fracture patients are susceptible to the adverse effects of opioid-induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs). DESIGN This is a prospective observational study. SETTING A level 1 trauma center in California. PARTICIPANTS From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control. INTERVENTION All prospectively enrolled patients were given FIBs. For a single-shot FIB, a 30- to 40-mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1. RESULTS A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0-44.5) versus 29.5 (interquartile range = 6.0-56.5) (P = .007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0-24.0) versus 29.0 (interquartile range = 12.0-59.0) (P < .001). CONCLUSION FIBs reduce preoperative opioid intake and have low rates of opioid-related adverse events in geriatric hip fracture patients. LEVEL OF EVIDENCE The level of evidence was II.
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Affiliation(s)
- John M Garlich
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Amit Pujari
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Zachary Moak
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Eytan Debbi
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Raj Yalamanchili
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sam Stephenson
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stephen Stephan
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Landon Polakof
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Milton Little
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Charles Moon
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Kapil Anand
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carol A Lin
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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39
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Mayor A, White SM. Direct oral anticoagulants and delays to hip fracture repair. Anaesthesia 2020; 75:1139-1141. [PMID: 32239509 DOI: 10.1111/anae.15008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2020] [Indexed: 02/01/2023]
Affiliation(s)
- A Mayor
- Department of Anaesthesia, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, Yorkshire, UK
| | - S M White
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, Sussex, UK
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40
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Abstract
While it is widely understood that management of hip fractures not only represents clinical decision making dilemmas for the individual orthopaedist, these increasingly common injuries present economic burdens to local and national systems as well. This supplement article looks at current clinical trends, as well as systems-based issues in the United States and Canada.
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Pablos-Hernández C, González-Ramírez A, da Casa C, Luis MM, García-Iglesias MA, Julián-Enriquez JM, Rodríguez-Sánchez E, Blanco JF. Time to Surgery Reduction in Hip Fracture Patients on an Integrated Orthogeriatric Unit: A Comparative Study of Three Healthcare Models. Orthop Surg 2020; 12:457-462. [PMID: 32167674 PMCID: PMC7189046 DOI: 10.1111/os.12633] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/10/2020] [Accepted: 01/21/2020] [Indexed: 12/17/2022] Open
Abstract
Objective To investigate the clinical efficacy of three different healthcare models (Traditional Model, Geriatric Consultant Model, and Orthogeriatric Unit Model) consecutively applied to a single academic center (University Hospital of Salamanca, Spain) for older hip fracture patients. Methods We performed a retrospective study, including 2741 hip fracture patients older than 64 years, admitted between 1 January 2003 and 31 December 2014 to the University Hospital of Salamanca. Patients were divided into three groups according to the healthcare model applied. There were 983 patients on the Traditional Model, 945 patients on the Geriatric Consultant Model, and 813 patients on the Orthogeriatric Unit Model. We recorded age and gender of patients, functional status at admission (Barthel Index, Katz Index, and Physical Red Cross Scale), type of fracture, and intervention, and we analyzed the length of stay, time to surgery, post‐surgical stay, and in‐hospital mortality according to the healthcare model applied. Results Hip fractures are much more frequent in women, and an increase in the average age of patients was observed along with the study (P < 0.001). The most common type of fracture in the three models studied was an extracapsular fracture, for which the most common surgical procedure used was osteosynthesis. On the functional status of patients, there were no differences on the ambulatory ability previous to fracture, measured by the Physical Red Cross Scale, and the percentage of patients with a slight dependence determined by the Barthel Index (>60) was similar in both groups, but considering the Katz Index, the percentage of patients with a high degree of independence (A‐B) was significantly higher for the group of patients treated on the Orthogeriatric Unit Model period (56%, P = 0.009). The Orthogeriatric Unit Model registered the greatest percentage of patients undergoing surgery (96.1%, P < 0.001) and the greatest number of early surgical procedures (<24 h) (24.8%, P < 0.001). The orthogeriatric unit model showed the shortest duration of stay (9 days median), decreasing by one day in respect of each of the other models studied (P < 0.001). Time to surgery was also significantly reduced with the Orthogeriatric Unit Model (median of 3 days, P < 0.001). With regard to in‐hospital follow‐up, there was a reduction in in‐hospital mortality during the study period. We observed differences among the three healthcare models, but without statistical significance. Conclusions The healthcare model based on an Orthogeriatric Unit seems to be the most efficient, because it reaches a reduction in time to surgery, with an increased number of patients surgically treated on in the first 24 h, and the greatest frequency of surgically‐treated patients.
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Affiliation(s)
- Carmen Pablos-Hernández
- Unidad de Ortogeriatría, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Alfonso González-Ramírez
- Unidad de Ortogeriatría, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Carmen da Casa
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Maria Margarida Luis
- Servicio de Medicina Interna, Centro Hospitalario de Vila Nova de Gaia, Espinho, Portugal
| | | | | | - Emiliano Rodríguez-Sánchez
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Unidad de Investigación en Atención Primaria, Salamanca, Spain
| | - Juan F Blanco
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Salamanca, Salamanca, Spain
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Krogue JD, Cheng KV, Hwang KM, Toogood P, Meinberg EG, Geiger EJ, Zaid M, McGill KC, Patel R, Sohn JH, Wright A, Darger BF, Padrez KA, Ozhinsky E, Majumdar S, Pedoia V. Automatic Hip Fracture Identification and Functional Subclassification with Deep Learning. Radiol Artif Intell 2020; 2:e190023. [PMID: 33937815 PMCID: PMC8017394 DOI: 10.1148/ryai.2020190023] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 11/06/2019] [Accepted: 12/19/2019] [Indexed: 05/01/2023]
Abstract
PURPOSE To investigate the feasibility of automatic identification and classification of hip fractures using deep learning, which may improve outcomes by reducing diagnostic errors and decreasing time to operation. MATERIALS AND METHODS Hip and pelvic radiographs from 1118 studies were reviewed, and 3026 hips were labeled via bounding boxes and classified as normal, displaced femoral neck fracture, nondisplaced femoral neck fracture, intertrochanteric fracture, previous open reduction and internal fixation, or previous arthroplasty. A deep learning-based object detection model was trained to automate the placement of the bounding boxes. A Densely Connected Convolutional Neural Network (or DenseNet) was trained on a subset of the bounding box images, and its performance was evaluated on a held-out test set and by comparison on a 100-image subset with two groups of human observers: fellowship-trained radiologists and orthopedists; senior residents in emergency medicine, radiology, and orthopedics. RESULTS The binary accuracy for detecting a fracture of this model was 93.7% (95% confidence interval [CI]: 90.8%, 96.5%), with a sensitivity of 93.2% (95% CI: 88.9%, 97.1%) and a specificity of 94.2% (95% CI: 89.7%, 98.4%). Multiclass classification accuracy was 90.8% (95% CI: 87.5%, 94.2%). When compared with the accuracy of human observers, the accuracy of the model achieved an expert-level classification, at the very least, under all conditions. Additionally, when the model was used as an aid, human performance improved, with aided resident performance approximating unaided fellowship-trained expert performance in the multiclass classification. CONCLUSION A deep learning model identified and classified hip fractures with expert-level performance, at the very least, and when used as an aid, improved human performance, with aided resident performance approximating that of unaided fellowship-trained attending physicians.Supplemental material is available for this article.© RSNA, 2020.
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Affiliation(s)
| | | | - Kevin M. Hwang
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Paul Toogood
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Eric G. Meinberg
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Erik J. Geiger
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Musa Zaid
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Kevin C. McGill
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Rina Patel
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Jae Ho Sohn
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Alexandra Wright
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Bryan F. Darger
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Kevin A. Padrez
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Eugene Ozhinsky
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Sharmila Majumdar
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
| | - Valentina Pedoia
- From the Departments of Orthopaedic Surgery (J.D.K., K.M.H., P.T., E.G.M., E.J.G., M.Z.), Emergency Medicine (B.F.D., K.A.P.), and Radiology and Biomedical Imaging (K.C.M., R.P., J.H.S., A.W., E.O., S.M., V.P.), University of California, San Francisco, 6945 Geary Blvd, San Francisco, CA 94121; and Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, Calif (K.V.C.)
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The impact of antithrombotic therapy on surgical delay and 2-year mortality in older patients with hip fracture: a prospective observational study. Eur Geriatr Med 2020; 11:555-561. [PMID: 32297256 DOI: 10.1007/s41999-020-00293-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 01/18/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To analyze the associations of oral anticoagulant and antiplatelet treatments in older patients requiring surgical treatment for hip fracture with mortality, length of stay, waiting time to surgery and postsurgical immediate complications. METHODS A prospective observational study, including surgically treated hip fracture patients aged 65 years and older. We analyzed admission status variables, and time to surgery, length of stay and immediate surgical and medical complications. We recorded a 2-year survival follow-up. RESULTS Of the 237 patients studied, 32.5% received antiplatelet treatment and 17.7% received oral anticoagulant treatment. The overall 2-year mortality was 29.1%. The 2-year mortality rate reached the 33.8% for antiplatelet-treated patients (n.s.) and 45.2% for oral anticoagulated patients (p = 0.011). The length of stay increased significantly associated with the oral anticoagulant or high-dose antiplatelet treatment (p < 0.001). The same happened for the time to surgery (p < 0.001), but no delay was observed for patients with low-dose antiplatelet treatment. Oral anticoagulated and antiplatelet-treated patients had a higher Charlson comorbidity index (p = 0.004, p = 0.019) and ASA score (p = 0.006, p = 0.011). Those treatments were also associated with a higher rate of some immediate postsurgical medical complications. We found a relationship between low hemoglobin at admission and high-dose antiplatelet treatment (p = 0.044). CONCLUSIONS Hip fracture patients following previous oral anticoagulant treatment have a higher 2-year mortality rate. The oral anticoagulant or high-dose antiplatelet treatments are significantly associated with an increase in the length of stay, related to time to surgery, but we could not demonstrate an effect on early mortality.
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Lu Y, Uppal HS. Hip Fractures: Relevant Anatomy, Classification, and Biomechanics of Fracture and Fixation. Geriatr Orthop Surg Rehabil 2019; 10:2151459319859139. [PMID: 31321116 PMCID: PMC6610445 DOI: 10.1177/2151459319859139] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction Hip fractures represent an important health-care dilemma, costing the US$ billions annually. Hip fractures can diminish quality of life and significantly increase morbidity and mortality if not properly treated. Recent research has brought forth new information regarding treatment as well as information on emerging complications seen within the fixation constructs themselves. Significance Understanding the pathoanatomy of hip fractures and the biomechanics of surgical fixation constructs is critical for successful treatment. In this article, we review the relevant anatomy and classification of femoral neck and intertrochanteric fractures. Furthermore, the biomechanics of hip fracture fixation strategies as well as implant-related complications are addressed. Results Even though laboratory testing demonstrated that intramedullary nails have greater biomechanical stability, the clinical results between fixation constructs have been similar when the chosen implant (ie, sliding hip screw vs cephalomedullary nail) has been correctly applied to the specific fracture pattern. Recently, data have shown that when using cephalomedullary nails, there is potential for increased failure with cutout when using the helical blade versus the lag screw, with majority being the atypical "medial cutout." Conclusion The goal of surgical treatment of hip fractures is surgical treatment that allows for early mobilization and weight bearing. A full understanding of the anatomy and fracture characteristics will allow the surgeon to correctly apply the right implant to allow for uneventful healing. Surgeons need to be aware, however, of complications that can arise when using specific implants. Further research is ongoing to further determine the treatments that will allow optimal cost-effective care for the geriatric patient with hip fracture.
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Affiliation(s)
- Young Lu
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, CA, USA
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Prevention of Osteoporosis in the Ovariectomized Rat by Oral Administration of a Nutraceutical Combination That Stimulates Nitric Oxide Production. J Osteoporos 2019; 2019:1592328. [PMID: 31275540 PMCID: PMC6582785 DOI: 10.1155/2019/1592328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/24/2019] [Accepted: 05/09/2019] [Indexed: 11/24/2022] Open
Abstract
Osteoporosis represents an imbalance between bone formation and bone resorption. As a result of low estrogen levels, it is markedly prevalent during menopause, thus making such patients susceptible to fractures. Both bone formation and resorption are modulated by nitric oxide (NO). Currently, there are no risk-free pharmaceutical prevention therapies for osteoporosis. COMB-4, a nutraceutical combination of Paullinia cupana, Muira puama, ginger, and L-citrulline, known to activate the NO-cGMP pathway, was reported to accelerate fracture healing in the rat. To determine whether COMB-4 could be effective in preventing menopausal osteoporosis, it was compared to estradiol (E2) in an ovariectomized (OVX) rat osteoporosis model. Nine-month-old female Sprague Dawley rats were divided into SHAM, OVX, OVX+E2, and OVX+COMB-4. After 100 days of treatment, bone mineral density (BMD) and bone mineral content (BMC) were measured by DXA scan. TRAP staining was performed in the femur and lumbar vertebrae. TRACP 5b and osteocalcin levels were assayed in the serum. MC3T3-E1 cells were differentiated into osteoblasts and treated with COMB-4 for one week in order to evaluate calcium deposition by Alizarin staining, cGMP production by ELISA, and upregulation of the nitric oxide synthase (NOS) enzymes by RT-PCR. OVX resulted in a decrease in BMD, BMC, and serum osteocalcin and an increase in serum TRACP 5b. Except for an increase in BMC with COMB-4, both E2 and COMB-4 reverted all bone and serum markers, as well as the number of osteoclasts in the vertebrae, to SHAM levels. Incubation of MC3T3-E1 cells with COMB-4 demonstrated an increase in the three NOS isoforms, cGMP, and calcium deposition. COMB-4 increased BMD in OVX rats by inhibiting bone resorption and increasing calcium deposition presumably via activation of the NO-cGMP pathway. It remains to be determined whether COMB-4 could be a potential nutraceutical therapy for the prevention of premenopausal bone loss.
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Borges FK, Bhandari M, Patel A, Avram V, Guerra-Farfán E, Sigamani A, Umer M, Tiboni M, Adili A, Neary J, Tandon V, Sancheti PK, Lawendy A, Jenkinson R, Ramokgopa M, Biccard BM, Szczeklik W, Wang CY, Landoni G, Forget P, Popova E, Wood G, Nabi Nur A, John B, Ślęczka P, Feibel RJ, Balaguer-Castro M, Deheshi B, Winemaker M, de Beer J, Kolesar R, Teixidor-Serra J, Tomas-Hernandez J, McGillion M, Shanthanna H, Moppett I, Vincent J, Pettit S, Harvey V, Gauthier L, Alvarado K, Devereaux PJ. Rationale and design of the HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) Trial: a protocol for an international randomised controlled trial evaluating early surgery for hip fracture patients. BMJ Open 2019; 9:e028537. [PMID: 31048449 PMCID: PMC6501985 DOI: 10.1136/bmjopen-2018-028537] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial-HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications. METHODS AND ANALYSIS HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients. ETHICS AND DISSEMINATION All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources. TRIAL REGISTRATION NUMBER NCT02027896; Pre-results.
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Affiliation(s)
- Flavia K Borges
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Ameen Patel
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Victoria Avram
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Ernesto Guerra-Farfán
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Alben Sigamani
- Department of Clinical Research, Narayana Health, Bangalore, India
| | - Masood Umer
- Department of Orthopaedic Surgery, Aga Khan University, Karachi, Pakistan
| | - Maria Tiboni
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anthony Adili
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - John Neary
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Parag K Sancheti
- Department of Orthopaedic Surgery, Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
| | - AbdelRahman Lawendy
- Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - Richard Jenkinson
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery and Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Mmampapatla Ramokgopa
- Department of Orthopaedic Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Chew Yin Wang
- Department of Anaesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milano, Italy
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrice Forget
- Department of Anesthesiology and Perioperative Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Ekaterine Popova
- Biomedical Research Institute (IIB - SANT PAU), Barcelona, Spain
| | - Gavin Wood
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | | | - Bobby John
- Department of Orthopaedic Surgery, Christian Medical College, Ludhiana, India
| | | | - Robert J Feibel
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Mariano Balaguer-Castro
- Department of Orthopaedic Surgery and Traumatology, Parc Taulí Hospital Universitari, Barcelona, Spain
| | - Benjamin Deheshi
- Department of Orthopaedics, Sharif Surgical Oncology, Fort Worth, Texas, USA
| | | | - Justin de Beer
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Richard Kolesar
- Department of Anaesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Jordi Teixidor-Serra
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jordi Tomas-Hernandez
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Harsha Shanthanna
- Department of Anaesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Iain Moppett
- Department of Anaesthesia & Critical Care, University of Nottingham, Nottingham, UK
| | - Jessica Vincent
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Shirley Pettit
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Valerie Harvey
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Kim Alvarado
- School of Nursing, McMaster University, Hamilton, Canada
| | - P J Devereaux
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
- Departments of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Canada
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Chandran M, Tay D, Huang XF, Hao Y. The burden of inpatient care for diabetic and non-diabetic patients with osteoporotic hip fractures-does it differ? An analysis of patients recruited into a fracture liaison service in Southeast Asia. Arch Osteoporos 2018; 13:27. [PMID: 29546650 DOI: 10.1007/s11657-018-0440-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/26/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED Hospital care and mortality of diabetic and non-diabetic osteoporotic Asian patients undergoing hip fracture surgery were explored with no difference in length of hospitalization, incidence of post-operative complications, or mortality between diabetics and non-diabetics seen. Time to operation correlated with post-operative complications occurrence and therefore surgery should be expeditiously done. INTRODUCTION Whether burden of inpatient care, problems after admission, and mortality rates differ between diabetics and non-diabetics undergoing surgery for osteoporotic hip fractures has not been explored in Asian populations. METHOD Three hundred eighty-nine multi-ethnic diabetic and non-diabetic patients recruited into a FLS at a large Asian hospital with new osteoporotic hip fractures requiring operative repair were analyzed. RESULTS 87.9% were Chinese, 6.4% Malay, and 3.6% Indians. BMI and age did not significantly differ between diabetics and non-diabetics. Median (IQR) length of hospitalization (LOHS) in days was 12 (9, 17) in diabetics and 11 (8, 14) in non-diabetics (p = 0.011). Median time from admission to operation (TTO) was 3 (2, 5) in diabetics versus 2 (1, 4.5) in the non-diabetics (p = 0.003). Occurrence of aggregate post-operative complications did not differ between diabetics and non-diabetics. No in-hospital mortalities occurred in either group. Thirty-day and 1-year mortality rates did not differ between the two groups. One-year mortality was 2.8% in the entire cohort. On multivariate regression analysis adjusted for age and race, only TTO (β; 1.8, 95% CI 1.5-2.0, p < 0.001) and occurrence of post-operative complications (β; 6.3, 95% CI 3.7-7.9, p < 0.001) correlated with LOHS. TTO and age-adjusted Charlson's Comorbidity Index (CCI) correlated significantly with the development of post-operative complications. CONCLUSIONS Diabetes was not independently associated with LOHS in patients undergoing hip fracture surgery. Aggregate post-operative complications did not differ between diabetics and non-diabetics. TTO and occurrence of post-operative complications significantly affected LOHS. TTO correlated with post-complications development. Surgery should be expeditiously done in both diabetics and non-diabetics to avoid the development of post-operative complications and to prevent prolonged hospital stay.
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Affiliation(s)
- M Chandran
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
| | - D Tay
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - X F Huang
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Y Hao
- Health Services Research Unit (HSRU), Division of Medicine, Singapore General Hospital, Singapore, Singapore
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Wong SHJ, Fang XC, Yee KHD, Wong TM, Pun CTT, Lau TW, Leung KLF. Hip fracture time-to-surgery and mortality revisited: mitigating comorbidity confounding by effect of holidays on surgical timing. INTERNATIONAL ORTHOPAEDICS 2018; 42:1789-1794. [PMID: 29299651 DOI: 10.1007/s00264-017-3737-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The association between delayed hip fracture surgery and mortality remains elusive because of strong confounding by comorbidity factors. We designed a study to investigate the effect of small delays in surgery due to holidays. METHODS Consecutive hip fractures operated in a high-income, publicly funded healthcare system between 2006 and 2013 were analysed. Age <65 years, pathological fractures, history of previous hip operation and time to surgery >seven days were excluded. Patients were grouped according to number of holidays following admission (HFA) as a surrogate for time to surgery, with difference in mean time to surgery tested for statistical significance and baseline characteristics including age, sex, Charlson comorbidity index (CCI) and fracture and operation types assessed. Survival up to two years was compared. RESULTS Thirty-one thousand five hundred and ninety-two patients were included. Patient groups with zero, one, two or three HFA had significantly different mean time to operation of 2.25, 2.47, 2.67 and 2.84 days, respectively (Kruskal-Wallis test p < 0.0001), but baseline characteristics were similar. There was no difference in mortality at six months (p = 0.431) and two years (p = 0.785). Cox's regression analysis identified age, gender and CCI as independent predictors of mortality but not HFA, and the adjusted hazards ratio for each HFA increment was 1.026 [95% confidence interval (CI) 0.999-1.025; p = 0.056] which was not statistically significant. CONCLUSIONS We observed no increase in mortality rate in patients having small delays in surgery because of holidays.
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Affiliation(s)
- Siu Him Janus Wong
- Department of Orthopaedics & Traumatology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
| | - Xinshuo Christian Fang
- Department of Orthopaedics & Traumatology, University of Hong Kong, 102 Pokfulam Road, Hong Kong, China. .,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
| | - King Hang Dennis Yee
- Department of Orthopaedics & Traumatology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
| | - Tak Man Wong
- Department of Orthopaedics & Traumatology, University of Hong Kong, 102 Pokfulam Road, Hong Kong, China.,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Cheuk Ting Terence Pun
- Department of Orthopaedics & Traumatology, University of Hong Kong, 102 Pokfulam Road, Hong Kong, China
| | - Tak Wing Lau
- Department of Orthopaedics & Traumatology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
| | - Ka Li Frankie Leung
- Department of Orthopaedics & Traumatology, University of Hong Kong, 102 Pokfulam Road, Hong Kong, China.,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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