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Ganta A, Merrell LA, Esper GW, Gibbons K, Egol KA, Konda SR. Under pressure: symptomatic pulmonary hypertension is a predictor of poor outcome following hip fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:3145-3154. [PMID: 38987403 DOI: 10.1007/s00590-024-04028-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 06/09/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Pulmonary hypertension (PHTN) is associated with increased morbidity and mortality in noncardiac surgery and elective surgery. This population of patients has a low physiological reserve and is prone to cardiac arrest as a result. This study aims to identify the impact that PHTN has on outcomes among geriatric hip fracture patients. METHODS A 3:1 propensity-score-matched retrospective case (PHTN)-control (no PHTN [N]) study of hip fracture patients from 2014 to 2022 was performed. Patients were matched utilizing propensity score matching of a validated geriatric trauma risk assessment tool (STTGMA). All patients were reviewed for hospital quality measures and outcomes. Comparative univariable and multivariable analyses were conducted between the two matched cohorts. A sub-analysis compared patients across PHTN severity levels (mild, moderate, severe) based on pulmonary artery systolic pressures (PASP) as measured by transthoracic echocardiogram. RESULTS PHTN patients (n = 67) experienced a higher rate of inpatient, 30-day, and 1-year mortality, major complications, and 90-day readmissions as compared to the N cohort (n = 201). PHTN patients with a PASP > 60 experienced a significantly higher rate of major complications, need for ICU, longer admission length, and worse 1-year functional outcomes. Pulmonary hypertension was found to be independently associated with a 3.5 × higher rate of 30-day mortality (p = 0.016), 2.7 × higher rate of 1-year mortality (p = 0.008), 2.5 × higher rate of a major inpatient complication (p = 0.028), and 1.2 × higher rate of 90-day readmission (p = 0.044). CONCLUSION Patients who had a prior diagnosis of pulmonary hypertension before sustaining their hip fracture experienced significantly worse inpatient and post-discharge outcomes. Those with a PASP > 60 mmHg had worse outcomes within the PHTN cohort. Providers must recognize these at-risk patients at the time of arrival to adjust care planning accordingly. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Abhishek Ganta
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA
- Department of Orthopedic Surgery, Medisys Health Network, Jamaica Hospital Medical Center, Richmond Hill, NY, USA
- NYU Grossman School of Medicine, New York, USA
| | - Lauren A Merrell
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA
| | - Garrett W Esper
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA
| | - Kester Gibbons
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA
| | - Kenneth A Egol
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA
- Department of Orthopedic Surgery, Medisys Health Network, Jamaica Hospital Medical Center, Richmond Hill, NY, USA
- NYU Grossman School of Medicine, New York, USA
| | - Sanjit R Konda
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA.
- Department of Orthopedic Surgery, Medisys Health Network, Jamaica Hospital Medical Center, Richmond Hill, NY, USA.
- NYU Grossman School of Medicine, New York, USA.
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Sagona A, Ortega CA, Wang L, Brameier DT, Selzer F, Zhou L, von Keudell A. Frailty Is More Predictive of Mortality than Age in Patients With Hip Fractures. J Orthop Trauma 2024; 38:e278-e287. [PMID: 39007664 DOI: 10.1097/bot.0000000000002844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVES To investigate the association between the Comprehensive Geriatric Assessment-based Frailty Index and adverse outcomes in older adult patients undergoing hip fracture surgery. METHODS DESIGN Retrospective cohort study. SETTING Academic Level 1 Trauma Center. PATIENTS All patients aged 65 or older who underwent surgical repair of a hip fracture between May 2018 and August 2020 were identified through institutional database review. OUTCOME MEASURES AND COMPARISONS Data including demographics, FI, injury presentation, and hospital course were collected. Patients were grouped by FI as nonfrail (FI < 0.21), frail (0.21 ≤ FI < 0.45), and severely frail (FI > 0.45). Adverse outcomes of these groups were compared using Kaplan Meier survival analysis. Risk factors for 1-year rehospitalization and 2-year mortality were evaluated using Cox hazard regression. RESULTS Three hundred sixteen patients were included, with 62 nonfrail, 185 frail, and 69 severely frail patients. The total population was on average 83.8 years old, predominantly white (88.0%), and majority female (69.9%) with an average FI of 0.33 (SD: 0.14). The nonfrail cohort was on average 78.8 years old, 93.6% white, and 80.7% female; the frail cohort was on average 84.5 years old, 92.4% white, and 71.9% female; and the severely frail cohort was on average 86.4 years old, 71.0% white, and 55.1% female. Rate of 1-year readmission increased with frailty level, with a rate of 38% in nonfrail patients, 55.6% in frail patients, and 74.2% in severely frail patients (P = 0.001). The same pattern was seen in 2-year mortality rates, with a rate of 2.8% in nonfrail patients, 36.7% in frail patients, and 77.5% in severely frail patients (P < 0.0001). Being classified as frail or severely frail exhibited greater association with mortality within 2 years than age, with hazard ratio of 17.81 for frail patients and 56.81 for severely frail patients compared with 1.19 per 5 years of age. CONCLUSIONS Increased frailty as measured by the Frailty Index is significantly associated with increased 2-year mortality and 1-year hospital readmission rates after hip fracture surgery. Degree of frailty predicts mortality more strongly than age alone. Assessing frailty with the Frailty Index can identify higher-risk surgical candidates, facilitate clinical decision making, and guide discussions about goals of care with family members, surgeons, and geriatricians. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Abigail Sagona
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Carlos A Ortega
- Vanderbilt University School of Medicine, Nashville, TN
- Division of Internal and General Medicine, Brigham and Women's Hospital, Boston, MA
| | - Liqin Wang
- Division of Internal and General Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA; and
| | - Devon T Brameier
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Faith Selzer
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA; and
| | - Li Zhou
- Division of Internal and General Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA; and
| | - Arvind von Keudell
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA; and
- Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Shim EH, Ghodasara SK, Roskam JS, Gaccione AG, DiFazio LT, Lombardo G, Nemeth ZH. Effects of COVID-19 Status on Hip Fracture Surgical Outcomes: An ACS NSQIP Study. J Trauma Nurs 2024; 31:123-128. [PMID: 38742718 DOI: 10.1097/jtn.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND Studies have indicated that patients infected with the SARS-CoV-2 virus fare worse clinically after a traumatic injury, especially those who are older and have other comorbidities. OBJECTIVE This study aims to understand the effects of Corona Virus Disease 19 (COVID-19) diagnosis on patients undergoing surgery for hip fractures. METHODS This is a retrospective review of the 2021 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Targeted Hip Fracture database for patients who underwent surgery. Two cohorts were formed based on patients' preoperative COVID-19 status, as tested within 14 days prior to the operation. Several clinical factors were compared. RESULTS The COVID-positive cohort consisted of 184 patients, all of whom had a laboratory-confirmed or clinically suspected SARS-CoV-2 infection, while the COVID-negative cohort consisted of 12,211 patients with no infection. A lower proportion of COVID-positive patients had an emergent operation compared to the COVID-negative cohort (58.70% vs. 73.09%, p < .001). Preoperatively, the COVID-positive cohort showed higher rates of coagulopathy/bleeding disorders (22.83% vs. 14.12%), congestive heart failure (16.30% vs. 9.84%), diabetes mellitus (28.26% vs. 19.24%), and dementia (42.39% vs. 28.07%), with p ≤ .005 for all. Postoperatively, a higher proportion of COVID-positive patients died (9.78% vs. 5.40%) or had pneumonia (8.70% vs. 3.65%), hospital readmission within 30 days (10.87% vs. 6.76%), and pressure sores (8.15% vs. 4.55%), with p ≤ .033 for all. CONCLUSION The diagnosis of COVID-19 in hip fracture patients was associated with higher rates of postoperative complications, including mortality, when compared to COVID-negative patients, indicating the severity of the viral infection.
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Affiliation(s)
- Esther H Shim
- Author Affiliations: Department of Surgery, Morristown Medical Center, Morristown, New Jersey
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Esper GW, Meltzer-Bruhn AT, Ganta A, Egol KA, Konda SR. Can we predict 1-year functional outcomes and mortality following hip fracture in middle-aged and geriatric patients at time of admission? Musculoskelet Surg 2024; 108:99-106. [PMID: 38218747 DOI: 10.1007/s12306-023-00804-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: 11/01/2022] [Accepted: 11/20/2023] [Indexed: 01/15/2024]
Abstract
This study's purpose is to determine if patients treated for hip fracture at highest risk for poor functional outcomes, shorter time to death, and death within 1-year can be predicted at the time of admission. We hypothesized that the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool can be used to predict risk of these variables. Between February 2019-July 2020, 544 patients ≥ 55-years-old were treated for hip fracture [AO/OTA 31A/B, 32A/C]. Each patient's demographics, functional status, and injury details were used to calculate their respective risk (STTGMA) score at time of admission. Patients were divided into risk quartiles by STTGMA score. Patients were contacted by phone to complete EuroQol-5 Dimension (EQ5D-3L) questionnaires on functional status. Comparative analyses were conducted on outcomes and EQ5D-3L questionnaire results. 439 patients (80.7%) had at least 1-year follow-up. 82 patients (18.7%) died within 1-year after hospitalization. Mean STTGMA score was 1.67% ± 4.49%. The highest-risk cohort experienced a 42x (p < 0.01) and 2.5x (p = 0.01) increased rate of 1-year mortality compared to the minimal- and low-risk groups respectively. The highest-risk cohort had the shortest time to death (p = 0.015). The highest-risk cohort had the lowest EQ5D index (p < 0.01) and VAS scores (p < 0.01) along with the highest rate of 30 day readmission (p < 0.01) and the longest length of stay (p < 0.01). The STTGMA tool provides important prognostic information for middle-aged and geriatric hip fracture patients that can help modulate care levels. This information is useful when counseling patients, their families, and caregivers on expected outcomes.
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Affiliation(s)
- G W Esper
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA
| | - A T Meltzer-Bruhn
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA
| | - A Ganta
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Richmond Hill, NY, USA
| | - K A Egol
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Richmond Hill, NY, USA
| | - S R Konda
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, 14th Floor, New York, NY, 10003, USA.
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Richmond Hill, NY, USA.
- NYU Grossman School of Medicine, New York, NY, USA.
- Medisys Health Network, Richmond Hill, NY, USA.
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Fisher ND, Parola R, Anil U, Herbosa C, Boadi B, Ganta A, Tejwani N, Konda SR, Egol KA. A Good Tip-Apex Distance Does Not Make Up For a Poor Reduction in Intertrochanteric Hip Fractures Treated with an Cephalomedullary Nail: The Utility of the Neck-Shaft Angle in Preventing Fixation Failure. J Am Acad Orthop Surg 2024; 32:83-91. [PMID: 37748038 DOI: 10.5435/jaaos-d-22-00972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 07/25/2023] [Indexed: 09/27/2023] Open
Abstract
PURPOSE Determine if any fracture characteristics or radiographic parameters were predictive of fixation failure [FF] within 1 year following cephalomedullary nailing for intertrochanteric fractures. METHODS A consecutive series of intertrochanteric hip fracture patients (AO/OTA 31A) treated with a cephalomedullary nail were reviewed. Pre-fixation (neck-shaft angle [NSA], distance from ischial tuberosities to greater and lesser trochanters, integrity of lesser trochanter, and fracture angulation) and post-fixation (post-fixation NSA, posteromedial cortex continuity, lag screw position, tip to apex distance [TAD], and post-fixation angulation and translation) radiographic parameters were measured by blinded independent reviewers. The FF and non-FF groups were statistically compared. Logistic regression was performed to determine radiographic parameter correlates of FF. RESULTS Of 1249 patients, 23 (1.8%) developed FF within 1 year. The FF patients were younger than their non-FF counterparts (77.2 years vs 81.0 years, p=0.048), however there were no other demographic differences. The FF cohort did not differ in frequency of TAD over 25 mm (4.3% vs 9.6%, p=0.624) and had decreased mean TAD (13.6mm vs 16.3mm, p=0.021) relative to the non-FF cohort. The FF cohort had a higher rate of a post-fixation coronal plane NSA more than 10° different from the contralateral side (delta NSA>10°, 34.8% vs 13.7%, p=0.011) with the majority fixed in relative varus. For every 1° increase in varus compared to the contralateral side the odds of FF increased 7% (OR=1.065, 95%CI[1.005-1.130], p=0.034) on univariate analysis. On univariate logistic regression, patients with an absolute post-fixation NSA of 10° or more of varus compared to contralateral were significantly more likely to have a FF (OR=3.139, 95%CI[1.067-8.332], p=0.026). CONCLUSION Despite an acceptable TAD, post-fixation NSA in relative varus as compared to the contralateral side was significantly associated with failure in intertrochanteric hip fractures fixed with a cephalomedullary nail. LEVEL OF EVIDENCE Prognostic Level III.
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Affiliation(s)
- Nina D Fisher
- From the NYU Langone Orthopedic Hospital, New York, NY (Fisher, Parola, Anil, Herbosa, Boadi, Ganta, Tejwani, Konda, and Egol), and the Jamaica Hospital Medical Center, Richmond Hill, NY (Ganta, Tejwani, Konda, and Egol)
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van Oppen JD, Conroy SP, Coats TJ, Mackintosh NJ, Valderas JM. Measuring health-related quality of life of older people with frailty receiving acute care: feasibility and psychometric performance of the EuroQol EQ-5D. BMC Emerg Med 2023; 23:137. [PMID: 37981703 PMCID: PMC10659073 DOI: 10.1186/s12873-023-00909-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/11/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Although outcome goals for acute healthcare among older people living with frailty often include Health-Related Quality of Life (HRQoL) and other patient-reported outcome measures (PROMs), current quality metrics usually focus on waiting times and survival. Lay and patient review have identified the EuroQol EQ-5D as a candidate measure for this setting. This research appraised the EQ-5D for feasibility, psychometric performance, and respondents' outcomes in the acute frailty setting. METHODS People aged 65 + with Clinical Frailty Scale (CFS) 5-8 were recruited from eight UK hospitals' emergency care and acute admissions settings. They completed the five-level EQ-5D and the EQ-VAS. Feasibility was assessed with completion times and completeness. For reliability, response distributions and internal consistency were analysed. Finally, EQ-Index values were compared with demographic characteristics and service outcomes for construct validity. RESULTS The 232 participants were aged 65-102. 38% responded in emergency departments and 62% in admissions wards. Median completion time was 12 (IQR, 11) minutes. 98% responses were complete. EQ-5D had acceptable response distribution (SD 1.1-1.3) and internal consistency (Cronbach's alpha 0.69). EQ-VAS demonstrated a midpoint response pattern. Median EQ-Index was 0.574 (IQR, 0.410) and was related positively with increasing age (p = 0.010) and negatively with CFS (p < 0.001). Participants with higher CFS had more frequent problems with mobility, self-care, and usual activities. CONCLUSIONS Administration of the EQ-5D was feasible in these emergency and acute frailty care settings. EQ-5D had acceptable properties, while EQ-VAS appeared problematic. Participants with more severe frailty had also poorer HRQoL.
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Affiliation(s)
- James D van Oppen
- College of Life Sciences, George Davies Centre, University of Leicester, Leicester, UK.
- Emergency and Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Simon P Conroy
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Timothy J Coats
- College of Life Sciences, George Davies Centre, University of Leicester, Leicester, UK
- Emergency and Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nicola J Mackintosh
- College of Life Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - Jose M Valderas
- Department of Family Medicine, National University Health System, Singapore, Singapore
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Fiorentino M, Hwang F, Pentakota SR, Glass NE, Livingston DH, Mosenthal AC. The Geriatric Patient One Year After Trauma: Palliative Performance Scale Predicts Functional Outcomes. Injury 2023; 54:110957. [PMID: 37532666 DOI: 10.1016/j.injury.2023.110957] [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: 01/07/2023] [Revised: 06/26/2023] [Accepted: 07/19/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Frailty in trauma has been found to predict poor outcomes after injury including additional in-hospital complications, mortality, and discharge to dependent care. These gross outcome measures are insufficient when discussing long-term recovery as they do not address what is important to patients including functional status and quality of life. The purpose of this study is to determine if the Palliative Performance Scale (PPS) predicts mortality and functional status one year after trauma in geriatric patients. MATERIAL AND METHODS Prospective observational study of trauma survivors, age ≥55 years. Patients were stratified by pre-injury PPS high (>70) or low (≤70). Outcomes were functional status at 1 year measured by Glasgow Outcome Scale Extended (GOSE), Euroqol-5D and SF-36. Adjusted relative risks (aRR) were obtained using modified Poisson regression. RESULTS Follow-up was achieved on 215/301 patients. Mortality was 30% in low PPS group vs 8% in the high PPS group (P<0.001). A greater percentage of patients in the high group had a good functional outcome at one year compared to patients in the low group (78% vs 30% p<0.001). The high PPS patients were more likely to have improvement of GOSE at 1 year from discharge compared to low group (66% vs 27% P<0.001). Low PPS independently predicted poor functional outcome (aRR, 2.64; 95% confidence interval, 1.79-3.89) and death at 1 year (aRR, 3.64; 95% confidence interval 1.68-7.92). An increased percentage of low PPS patients reported difficulty with mobility (91% vs 46% p<0.0001) and usual activities (82% vs 56% p=0.002). Both groups reported pain (65%) and anxiety/depression (47%). CONCLUSION Low pre-Injury PPS predicts mortality and poor functional outcomes one year after trauma. Low PPS patients were more likely to decline, rather than improve. Regardless of PPS, most patients have persistent pain, anxiety, and limitations in performing daily activities.
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Affiliation(s)
- Michele Fiorentino
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Medical Science Building, Room G 594, Newark, NJ 07101.
| | - Franchesca Hwang
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Medical Science Building, Room G 594, Newark, NJ 07101
| | - Sri Ram Pentakota
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Medical Science Building, Room G 594, Newark, NJ 07101
| | - Nina E Glass
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Medical Science Building, Room G 594, Newark, NJ 07101
| | - David H Livingston
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Medical Science Building, Room G 594, Newark, NJ 07101
| | - Anne C Mosenthal
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Medical Science Building, Room G 594, Newark, NJ 07101
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Adeyemi OJ, Meltzer-Bruhn A, Esper G, DiMaggio C, Grudzen C, Chodosh J, Konda S. Crosswalk between Charlson Comorbidity Index and the American Society of Anesthesiologists Physical Status Score for Geriatric Trauma Assessment. Healthcare (Basel) 2023; 11:1137. [PMID: 37107971 PMCID: PMC10137761 DOI: 10.3390/healthcare11081137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
The American Society of Anesthesiologists Physical Status (ASA-PS) grade better risk stratifies geriatric trauma patients, but it is only reported in patients scheduled for surgery. The Charlson Comorbidity Index (CCI), however, is available for all patients. This study aims to create a crosswalk from the CCI to ASA-PS. Geriatric trauma cases, aged 55 years and older with both ASA-PS and CCI values (N = 4223), were used for the analysis. We assessed the relationship between CCI and ASA-PS, adjusting for age, sex, marital status, and body mass index. We reported the predicted probabilities and the receiver operating characteristics. A CCI of zero was highly predictive of ASA-PS grade 1 or 2, and a CCI of 1 or higher was highly predictive of ASA-PS grade 3 or 4. Additionally, while a CCI of 3 predicted ASA-PS grade 4, a CCI of 4 and higher exhibited greater accuracy in predicting ASA-PS grade 4. We created a formula that may accurately situate a geriatric trauma patient in the appropriate ASA-PS grade after adjusting for age, sex, marital status, and body mass index. In conclusion, ASA-PS grades can be predicted from CCI, and this may aid in generating more predictive trauma models.
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Affiliation(s)
- Oluwaseun John Adeyemi
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Ariana Meltzer-Bruhn
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA; (A.M.-B.); (G.E.); (S.K.)
| | - Garrett Esper
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA; (A.M.-B.); (G.E.); (S.K.)
| | - Charles DiMaggio
- Department of Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA;
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA;
| | - Corita Grudzen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, West Harrison, NY 10604, USA;
| | - Joshua Chodosh
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA;
- Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Sanjit Konda
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA; (A.M.-B.); (G.E.); (S.K.)
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The Lateral Femoral Cutaneous and Over the Hip (LOH) Block for the Surgical Management of Hip Fractures: A Safe and Effective Anesthetic Strategy. J Orthop Trauma 2023; 37:135-141. [PMID: 36253914 DOI: 10.1097/bot.0000000000002508] [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: 10/10/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip (LOH) block. DESIGN Retrospective. SETTING Orthopedic specialty hospital. PATIENTS/PARTICIPANTS 40 patients who presented between November 2021 and February 2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used. INTERVENTION Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve, and accessory obturator nerve. MAIN OUTCOME MEASUREMENTS Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates. RESULTS A total of 120 patients (40 each: general, spinal, and LOH block) were compared. The cohorts were similar in age, race, body mass index, sex, Charlson comorbidity index, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block cohort ( P < 0.05). Total OR time and anesthesia time were the shortest for the LOH block cohort ( P < 0.05). Patients in the LOH block cohort also had lower postoperative pain scores ( P < 0.05). Length of hospital stay was the shortest for patients in the LOH block cohort ( P < 0.05), and during discharge, patients in the LOH block cohort ambulated the furthest ( P < 0.05). No differences were found for anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates. CONCLUSIONS The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly patients requiring surgery. In addition, this block may decrease postoperative pain and length of hospital stay, and allow for greater ambulation in the early postoperative period for patients with hip fracture. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fisher ND, Parola R, Bi AS, Konda SR, Egol KA. Ambulation on hip fracture postoperative day 1: a marker for better outcomes following hip fracture surgery in patients 55 years or older. Hip Int 2022:11207000221107853. [PMID: 35773620 DOI: 10.1177/11207000221107853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to investigate if early postoperative ambulation metrics affect hospital quality measures and 1-year outcomes in operative hip fracture patients. METHODS A consecutive series of hip fracture patients [OTA/AO 31A, 31B, 32A-C] who underwent operative treatment were reviewed for demographic and clinical data. Chart review was performed to determine participation with physical therapy [PT] and ambulation distance on postoperative day (POD) 1, 3, and 5. POD1 ambulators and non-ambulators were statistically compared. Outcome correlates of postoperative ambulation distance were investigated by univariate and multivariate linear and logistic regression. RESULTS 1044 patients were identified with 546 (52.3%) able to ambulate on POD1. Those able to ambulate on POD1 were significantly younger (78.4 ± 10.9 vs. 82.1 ± 10.4, p < 0.001), had fewer co-morbidities (CCI 1.22 ± 1.60 vs. 1.73 ± 1.82, p < 0.001), and were more likely to be preoperative community ambulators (82.2% vs. 68.3%, p < 0.001). Patients unable to ambulate on POD1 had significantly higher rate of inpatient mortality (2.8% vs. 0.5%, p = 0.004), 1-year mortality (14.6% vs. 6.9%, p < 0.001), and a longer length of stay (7.94 ± 4.73 vs. 6.43 ± 4.02 days, p < 0.001). Non-ambulators more often required the intensive care unit postoperatively (18.7% vs. 7.1%, p < 0.001), and had increased rates of major complications (15.5% vs. 5.7%, p < 0.001). Patients with OTA 31B or 32A fractures were 1.63 times more likely to ambulate on POD1 while patients with an assistive device at baseline were 0.51 times less likely to ambulate on POD1. Increasing postoperative ambulation distance correlated with shorter length of stay (p < 0.001 for POD1, 3, and 5) and every foot walked was associated with 0.57% decreased odds of a hospital complication (p = 0.0353). CONCLUSIONS Failure to ambulate on POD1 following hip fracture surgery in >55 years is associated with an increased risk of in-hospital complications and mortality. Every effort should be made address this modifiable risk factor and mobilise patients on POD1 to improve patient outcomes.
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Affiliation(s)
| | - Rown Parola
- NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Andrew S Bi
- NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Sanjit R Konda
- NYU Langone Orthopedic Hospital, New York, NY, USA
- Jamaica Hospital Medical Center, Queens, NY, USA
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, New York, NY, USA
- Jamaica Hospital Medical Center, Queens, NY, USA
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Parola R, Ganta A, Egol KA, Konda SR. Trauma Risk Score Matching for Observational Studies in Orthopedic Trauma. Injury 2022; 53:440-444. [PMID: 34916032 DOI: 10.1016/j.injury.2021.12.009] [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: 08/21/2021] [Revised: 11/27/2021] [Accepted: 12/01/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine if matching by trauma risk score is non-inferior to matching by chronic comorbidities and/or a combination of demographic and patient characteristics in observational studies of acute trauma in a hip fracture model. DESIGN Retrospective cohort study SETTING: Level-1 Trauma Center PATIENTS: 1,590 hip fracture [AO/OTA 31A and 31B] patients age 55 and over treated between October 2014 and February 2020 at 4 hospitals within a single academic medical center. INTERVENTION Repeatedly matching randomized subsets of patients by (1) Score for Trauma Triage in Geriatric and Middle-Aged (STTGMA), (2) Charlson Comorbidity Index (CCI), or (3) a combination of sex, age, CCI and body mass index (BMI). MAIN OUTCOME MEASUREMENTS "Matching failures" where rate of significant differences in variables of matched cohorts exceeds the 5% expected by chance. RESULTS STTGMA and combination matching resulted in no "matching failures". Matching by CCI alone resulted in "matching failures" of BMI, ASA class, STTGMA, major complications, sepsis, pneumonia, acute respiratory failure, and 90-day readmission. CONCLUSIONS STTGMA matching in observational cohort studies is less likely to yield significant differences of demographics and outcomes than CCI matching. STTGMA matching is noninferior to matching a combination of demographic variables optimized for each treatment cohort. STTGMA matching is apt to reflect equipoise of health at admission and outcome likelihood in observational cohort studies of orthopedic trauma, while maintaining consistent weighting of demographic and injury characteristic variables that may expand the generalizability of these studies. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rown Parola
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Abhishek Ganta
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY
| | - Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY.
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12
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Trauma risk score matching for observational studies in orthopedic trauma dataset and code. Data Brief 2022; 40:107794. [PMID: 35036491 PMCID: PMC8749164 DOI: 10.1016/j.dib.2022.107794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 12/29/2021] [Accepted: 01/03/2022] [Indexed: 12/02/2022] Open
Abstract
The dataset presented was collected via retrospective review from an orthopedic trauma database approved by the institutional review board at the author's institution from patients treated at any of the four hospitals serviced by the academic orthopedic surgery department. Femoral neck and intertrochanteric hip fracture patients from low energy mechanisms admitted between October 2014 and February 2020, were selected if they were age 55 or older and had recorded sex, body mass index (BMI), Charlson Comorbidity Index (CCI), American Society of Anaesthesiologists (ASA) physical status classification, Glasgow Coma Score, Abbreviated Injury Severity score for the chest, head and neck, and extremities, and ambulation status prior to injury. The resultant 1,590 subject dataset may be analysed via the supplied R statistical code to determine the frequency of equipoise in baseline and outcome variables from propensity matching via three matching schemes. The code implements three matching schemes including matching by (1) The Score for Trauma Triage in Geriatric and Middle-Aged (STTGMA) (2) CCI alone, or (3) a combination of sex, age, CCI and BMI. The code selects a subset of ten percent of hip fracture patients by a pseudorandom number generator (PRNG). The code matches the remaining patients 1:1 to the selected patients by propensity score generated by logistic regression of STTGMA, CCI, or a combination of sex, age, CCI and BMI using greedy nearest neighbor matching without replacement by the MatchIt package for R software. The code then compares matched cohorts by Chi-square, Fisher, or Mann-Whitney U test with significance level of 0.05 representing a 5% chance of significant differences due to random sampling of subjects. The supplied code repeats the random selection, matching and testing process 100,000 times for each matching method. The resultant code output is the frequency of significantly different demographic or outcome parameters among matched cohorts by matching method. This data and statistical code have reuse potential to explore alternative matching schemes. The supplied baseline variables should be robust enough to derive alternative risk scores for each patient which may be included as a matching variable for comparison. The authors also look forward to unexpected ways that this data may be used by readers.
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Risk Stratification of Operatively Treated Intertrochanteric Hip Fractures Reveals Differences in Short-Term Outcomes and Procedure Costs Between Sliding Hip Screw Versus Short Cephalomedullary Nail. J Am Acad Orthop Surg Glob Res Rev 2021. [PMCID: PMC8654425 DOI: 10.5435/jaaosglobal-d-21-00242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study sought to retrospectively compare short-term outcomes between sliding hip screw (SHS) fixation versus short cephalomedullary nailing (CMN) in a risk-stratified cohort of geriatric intertrochanteric hip fracture patients. Data of 458 patients, aged 55 years and older, who sustained intertrochanteric fractures (OTA 31A1-3) and were treated with either SHS or short CMN from October 2014 to March 2019 were collected. Patient demographics, injury severity, and functional status were used to calculate a score using the Score for Trauma Triage in the Geriatric and Middle-Aged system. Based on the Score for Trauma Triage in the Geriatric and Middle-Aged tool, 229 patients (50%) were placed into a low-risk cohort, whereas 229 patients (50%) were placed into a high-risk cohort.
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14
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Monitored Anesthesia Care and Soft-Tissue Infiltration With Local Anesthesia: An Anesthetic Option for High-Risk Patients With Hip Fractures. J Orthop Trauma 2021; 35:542-549. [PMID: 33967226 DOI: 10.1097/bot.0000000000002062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the feasibility of a novel anesthetic option for hip fracture fixation with short cephalomedullary nails. DESIGN Retrospective cohort study. SETTING The study setting involved an urban, academic Level 1 trauma center, a tertiary care academic medical center, and an orthopaedic specialty hospital. PATIENTS/PARTICIPANTS Twenty recent and 40 risk-matched (1:1:1 by anesthesia type) historical hip fracture patients were included in the study. INTERVENTION All patients with an OTA/AO 31.A1-3 intertrochanteric hip fracture presenting from October 1, 2019 to March 31, 2020 treated with a short cephalomedullary nail underwent a new intraoperative anesthesia protocol using monitored anesthesia care (MAC) and soft-tissue infiltration with local anesthesia (STILA). MAIN OUTCOME MEASUREMENTS Intraoperative measures, postoperative pain scores, narcotic and acetaminophen use, hospital quality measures, and inpatient cost. RESULTS A total of 60 patients (20 each: MAC, general, and spinal) were identified. There were differences among the groups regarding mean minimum and maximum intraoperative heart rate with MAC-STILA protocol demonstrating the best maintenance of normal heart rate parameters (60-100 beats per minute). For the first 3 hours postoperatively, MAC-STILA patients reported consistently lower pain scores (visual analog scale <1) than spinal or general patients (visual analog scale > 1). Through 48 hours postoperatively, MAC-STILA narcotic usage was similar to that of the spinal cohort and approximately 5 times less than the general cohort. There were no differences in procedural time, length of stay, minor or major complications, inpatient and 30-day mortality, or 30-day readmissions, or postoperative ambulatory distance. There was no difference in inpatient cost among cohorts. CONCLUSIONS This feasibility study demonstrates safety for the MAC-STILA protocol with comparison to spinal and general anesthesia. The MAC-STILA protocol is a viable option for treatment of OTA/AO 13.A1-3 intertrochanteric fractures with a short cephalomedullary nail and may be the preferred method for patients with severe medical comorbidities or relative contraindications to general and/or spinal anesthesia. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
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15
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Reider L, Pollak A, Wolff JL, Magaziner J, Levy JF. National trends in extremity fracture hospitalizations among older adults between 2003 and 2017. J Am Geriatr Soc 2021; 69:2556-2565. [PMID: 34062611 DOI: 10.1111/jgs.17281] [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: 03/18/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Fractures in late life are highly consequential for health, services use, and spending. Little is known about trends in extremity fracture hospitalizations among older adults in the United States. DESIGN Retrospective longitudinal cohort study. SETTING The 2003-2017 National Inpatient Sample (NIS), a representative sample of U.S. community hospitals. PARTICIPANTS Hospitalized adults aged 65 and older with a diagnosis of upper or lower extremity fracture. MEASUREMENTS Incidence of extremity fracture hospitalization and mortality, using NIS discharge and trend weights, and population denominators derived from the U.S. Census Bureau. Incidence was reported separately for men and women by age, fracture diagnosis, and injury mechanism. Weighted linear regression was used to test for significant trends over time. RESULTS Incidence of extremity fracture hospitalizations declined in both women (15.7%, p trend < 0.001) and men (3.2%, p trend < 0.001) between 2003 and 2017. This trend was primarily attributed to a decline in low energy femur fractures which accounted for 65% of all fracture hospitalizations. Among older adults with an extremity fracture hospitalization, mortality declined from 5.1% in 2003 to 3.3% in 2017 in men, and from 2.6% to 1.9% in women (p trend < 0.001). High energy fractures were due to falls (53%), motor vehicle accidents (34%), and other high impact injuries (13%). Overall, 12% of extremity fracture hospitalizations were attributed to high-energy injuries: increases were observed among men ages 65-74 (20%; p trend < 0.001) and 75-84 (10%; p trend = 0.013), but not among women of any age. CONCLUSION Observed declines in the incidence of extremity fracture hospitalizations and related mortality are encouraging. However, increasing incidence of fracture hospitalization from high energy injuries among men suggests that older adults with complex injuries will be seen with more prevalence in the future.
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Affiliation(s)
- Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrew Pollak
- School of Medicine, Department of Orthopaedics, University of Maryland, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jay Magaziner
- School of Medicine, Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland, USA
| | - Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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16
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Using the STTGMA Risk Stratification Tool to Predict Complications, Additional Operations, and Functional Outcomes After Ankle Fracture. J Orthop Trauma 2021; 35:e134-e141. [PMID: 32890072 DOI: 10.1097/bot.0000000000001955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the usefulness of a validated trauma triage score to stratify postdischarge complications, secondary procedures, and functional outcomes after ankle fracture. DESIGN Retrospective cohort. SETTING Level 1 trauma center. PATIENTS Four hundred fifteen patients 55 years of age and older with 431 ankle fractures. INTERVENTION Closed or open reduction. MAIN OUTCOME MEASUREMENTS Score for Trauma Triage in Geriatric and Middle-Aged Patients (STTGMA), postdischarge complications, secondary operations, Foot Function Index (FFI, n = 167), and Short Musculoskeletal Function Assessment (SMFA, n = 165). RESULTS Mean age was 66 years, 38% were men, and 68% of fractures were secondary to ground-level falls. Forty patients (9.6%) required an additional procedure, with implant removal most common (n = 21, 5.1%), and 102 (25%) experienced a postdischarge complication. On multiple linear regression, STTGMA was not a significant independent predictor of complications or secondary procedures. Patients completed FFI and SMFA surveys a median of 62 months (5.2 years) after injury. On the FFI, low-risk STTGMA stratification was an independent predictor of worse functional outcomes. Similarly, low-risk stratification was a predictor of worse scores on the SMFA dysfunction and daily activity subcategories (both B > 10, P < 0.05). CONCLUSIONS Low-risk STTGMA stratification predicted worse long-term function. The STTGMA tool was not able to meaningfully stratify risk of postdischarge complications and secondary procedures after ankle fracture. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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17
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Konda SR, Dedhia N, Ranson RA, Tong Y, Ganta A, Egol KA. Loss of Ambulatory Level and Activities of Daily Living at 1 Year Following Hip Fracture: Can We Identify Patients at Risk? Geriatr Orthop Surg Rehabil 2021; 12:21514593211002158. [PMID: 33868763 PMCID: PMC8020397 DOI: 10.1177/21514593211002158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Operative hip fractures are known to cause a loss in functional status in the elderly. While several studies exist demonstrating the association between age, pre-injury functioning, and comorbidities related to this loss of function, no studies have predicted this using a validated risk stratification tool. We attempt to use the Score for Trauma Triage for Geriatric and Middle-Aged (STTGMA) tool to predict loss of ambulatory function and need for assistive device use. Materials and Methods Five hundred and fifty-six patients ≥55 years of age who underwent operative hip fracture fixation were enrolled in a trauma registry. Demographics, functional status, injury severity, and hospital course were used to determine a STTGMA score and patients were stratified into risk quartiles. At least 1 year after hospitalization, patients completed the EQ-5D questionnaire for functional outcomes. Results Two hundred and sixty-eight (48.2%) patients or their family members responded to the questionnaire. Of the 184 patients alive, 65 (35.3%) reported a return to baseline function. Eighty-nine (48.4%) patients reported a loss in ambulatory status. Patients with higher STTGMA scores were older, had more comorbidities, reported greater need for help with daily activities, increased difficulty with self-care, and a reduction in return to activities of daily living (all p ≤ 0.001). Patients with lower STTGMA scores were more likely to never require an assistive device while those with higher scores were more likely to continue needing one (p = 0.004 and p < 0.001). Patients in the highest STTGMA risk groups were 1.5x more likely to have an impairment in ambulatory status (need for ambulatory assistive device or decreased ambulatory capacity) (p = 0.004). Discussion Patients in higher STTGMA risk quartiles were more likely to experience impairment after hip fracture surgery. The STTGMA tool can predict loss of ambulatory independence following hip fracture. At-risk populations can be targeted for enhanced physiotherapy and rehabilitation services for optimal return to prior functioning.
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Affiliation(s)
- Sanjit R Konda
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Nicket Dedhia
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Rachel A Ranson
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Yixuan Tong
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Abhishek Ganta
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Kenneth A Egol
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
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18
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Adenikinju A, Ranson R, Rettig SA, Egol KA, Konda SR. Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Distal Radius Fractures. Geriatr Orthop Surg Rehabil 2021; 12:2151459321999634. [PMID: 33786205 PMCID: PMC7961699 DOI: 10.1177/2151459321999634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/17/2021] [Accepted: 02/09/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Distal radius fractures are the second most common fracture in the elderly population. The incidence of these fractures has increased over time, and is projected to continue to do so. The aim of this study is to utilize a validated trauma risk prediction tool to stratify middle-aged and geriatric patients with operative distal radius fractures as well as compare hospital quality metrics and inpatient hospitalization costs among the risk groups. Materials and Methods: Patients were prospectively enrolled in an orthopedic trauma registry. The Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) was calculated using patient demographics, injury severity, and functional status. Patients were then stratified into minimal-risk, moderate-risk, and high-risk cohorts based on their scores. Length of stay, need for escalation of care, complications, mortality, discharge location, 1-year patient reported outcomes, and index admission costs were evaluated. Results: Ninety-two patients met inclusion criteria. Sixty-three (68.5%) patients were managed with outpatient surgery. The mean inpatient length of stay for the high-risk cohort was 2.9x and 2.2x higher than the minimal and moderate-risk cohorts, respectively (2.0 + 2.9 days vs. 0.7 + 0.9 and 0.9 + 1.1 days, P = .019). There were no complications or mortality in any of the risk groups. No patients required intensive care and all patients were discharged home. There was no difference in readmission rates, inpatient cost, or 1-year patient reported outcomes among the risk cohorts. Discussion/Conclusions: The Score for Trauma Triage in Geriatric and Middle-Aged is able to risk-stratify patients that undergo operative intervention of distal radius fractures. Middle aged and elderly patients with isolated closed distal radius fractures can be safely managed on an outpatient basis regardless of risk. Standardized pathways can be created in the management of these injuries, thereby optimizing value-based care. Level of evidence: Prognostic Level III
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Affiliation(s)
- Abidemi Adenikinju
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Rachel Ranson
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Samantha A Rettig
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Kenneth A Egol
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA.,Department of Orthopedics, Jamaica Hospital Medical Center, Medisys Health Network, Queens, NY, USA
| | - Sanjit R Konda
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA.,Department of Orthopedics, Jamaica Hospital Medical Center, Medisys Health Network, Queens, NY, USA
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19
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Konda SR, Johnson JR, Dedhia N, Kelly EA, Egol KA. Can We Stratify Quality and Cost for Older Patients With Proximal and Midshaft Humerus Fractures? Geriatr Orthop Surg Rehabil 2021; 12:2151459321992742. [PMID: 33680532 PMCID: PMC7900848 DOI: 10.1177/2151459321992742] [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: 10/17/2020] [Revised: 01/03/2021] [Accepted: 01/16/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction: This study sought to investigate whether a validated trauma triage tool can
stratify hospital quality measures and inpatient cost for middle-aged and
geriatric trauma patients with isolated proximal and midshaft humerus
fractures. Materials and Methods: Patients aged 55 and older who sustained a proximal or midshaft humerus
fracture and required inpatient treatment were included. Patient
demographic, comorbidity, and injury severity information was used to
calculate each patient’s Score for Trauma Triage in the Geriatric and
Middle-Aged (STTGMA). Based on scores, patients were stratified to create
minimal, low, moderate, and high risk groups. Outcomes included length of
stay, complications, operative management, ICU/SDU-level care, discharge
disposition, unplanned readmission, and index admission costs. Results: Seventy-four patients with 74 humerus fractures met final inclusion criteria.
Fifty-eight (78.4%) patients presented with proximal humerus and 16 (21.6%)
with midshaft humerus fractures. Mean length of stay was 5.5 ± 3.4 days with
a significant difference among risk groups (P = 0.029). Lower risk patients
were more likely to undergo surgical management (P = 0.015) while higher
risk patients required more ICU/SDU-level care (P < 0.001). Twenty-six
(70.3%) minimal risk patients were discharged home compared to zero high
risk patients (P = 0.001). Higher risk patients experienced higher total
inpatient costs across operative and nonoperative treatment groups. Conclusion: The STTGMA tool is able to reliably predict hospital quality measures and
cost outcomes that may allow hospitals and providers to improve value-based
care and clinical decision-making for patients presenting with proximal and
midshaft humerus fractures. Level of Evidence: Prognostic Level III.
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Affiliation(s)
- Sanjit R Konda
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY, USA.,Jamaica Hospital Medical Center, Queens, NY, USA
| | - Joseph R Johnson
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY, USA
| | - Nicket Dedhia
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY, USA
| | - Erin A Kelly
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY, USA
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY, USA.,Jamaica Hospital Medical Center, Queens, NY, USA
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20
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Haskel JD, Lin CC, Kaplan DJ, Dankert JF, Merkow D, Crespo A, Behery O, Ganta A, Konda SR. Hip Fracture Volume Does Not Change at a New York City Level 1 Trauma Center During a Period of Social Distancing. Geriatr Orthop Surg Rehabil 2020; 11:2151459320972674. [PMID: 33240558 PMCID: PMC7672735 DOI: 10.1177/2151459320972674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/12/2020] [Accepted: 10/20/2020] [Indexed: 11/16/2022] Open
Abstract
Purpose: To characterize the volume and variation in orthopedic consults and surgeries that took place during a period of social distancing and pandemic. Methods: All orthopedic consults and surgeries at an urban level 1 trauma center from 3/22/20-4/30/2020 were retrospectively reviewed (the social distancing period). Data from the same dates in 2019 were reviewed for comparison. Age, gender, Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) score and injury type were queried. Operating room data collected included: type of surgery performed, inpatient or outpatient status, and if the cases were categorized as elective, trauma or infectious cases. Results: Compared to 2019, there was a 48.3% decrease in consult volume in 2020. The 2020 population was significantly older (44.0 vs 52.6 years-old, p = 0.001) and more male (65% vs 35%, p = 0.021). There were 23 COVID positive patients, 10 of which died within the collection period. Consult distribution dramatically changed, with decreases in ankle fractures, distal radius fractures and proximal humerus fractures of 76.5%, 77.4% and 55.0%, respectively. However, there was no significant difference in volume of hip, tibial shaft and femoral shaft fractures (p > 0.05). In 2020, there was a 41.4% decrease in operating room volume, no elective cases were performed, and cases were primarily trauma related. Conclusions: During a period of pandemic and social distancing, the overall volume of orthopedic consults and surgeries significantly declined. However, hip fracture volume remained unchanged. Patients presenting with orthopedic injuries were older, and at higher risk for inpatient mortality.
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Affiliation(s)
- Jonathan D Haskel
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Charles C Lin
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Daniel J Kaplan
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - John F Dankert
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - David Merkow
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Alexander Crespo
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Omar Behery
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Abhishek Ganta
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA.,Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
| | - Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA.,Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
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Pull the Foley: Improved Quality for Middle-Aged and Geriatric Trauma Patients Without Indwelling Catheters. J Healthc Qual 2020; 42:341-351. [PMID: 33149051 DOI: 10.1097/jhq.0000000000000241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Urinary tract infection (UTI) complications are often attributed to the inappropriate use of urinary catheters. PURPOSE We sought to examine the effectiveness of a hospital-wide policy aimed at reducing the use of indwelling Foley catheters. METHODS We completed a retrospective review of prospectively collected data on 577 hip and femur fracture patients aged 55 years and older who were operatively treated at a Level 1 trauma center between October 2014 and March 2019. New standard-of-care guidelines restricting the use of indwelling Foley catheters were implemented starting January 2018, and we compared perioperative outcomes between cohorts. RESULTS Over a 50% absolute reduction in indwelling Foley catheter use and a near 30% relative reduction in hospital-acquired UTI were achieved. Postpolicy cohort patients without indwelling Foley catheters experienced lower odds of hospital-acquired UTI, higher odds of home discharge, as well as decreased time to surgery, shorter length of stay, and lower total inpatient cost compared with those with indwelling Foley catheters. CONCLUSIONS The policy of restricting indwelling Foley catheter placement was safe and effective. A decrease in indwelling Foley catheter use led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes.
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Predicting Length of Stay and Readmissions After an Ankle Fracture Using a Risk Stratification Tool (STTGMA). J Orthop Trauma 2020; 34:e407-e413. [PMID: 33065665 DOI: 10.1097/bot.0000000000001788] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the usefulness of a validated trauma triage score to stratify short-term outcomes including hospital length of stay (LOS), in-hospital complications, discharge location, and rate of readmission after an ankle fracture. DESIGN Retrospective cohort. SETTING Level 1 trauma center. PATIENTS Four hundred fifteen patients, age ≥55 with 431 ankle fractures. INTERVENTION Closed or open reduction. MAIN OUTCOME MEASUREMENTS Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA). RESULTS Of the 415 patients, 38% were male, 72% were white, and the mean age was 66 years. The mean LOS was 4.4 days, and this increased from 2.6 days in the minimal-risk group to 11.8 days in the high-risk group (P < 0.001). Similarly, 74% of minimal-risk patients were discharged home versus 13% of high-risk patients (P < 0.001). There were 19 readmissions (4.6%) within 30 days, ranging from 1.5% to 10% depending on the risk cohort (P = 0.006). Seventy-three patients (18%) experienced an in-hospital complication. On multiple linear regression, moderate- and high-risk STTGMA stratification was predictive of a longer hospital LOS, and moderate-risk STTGMA stratification was predictive of subsequent readmission after injury. CONCLUSIONS Calculation of the STTGMA score is helpful for stratifying patients according to hospital LOS and readmission rates, which have substantial bearing on resource utilization and cost of care. The STTGMA tool may allow for effective identification of patients to potentially ameliorate these common issues and to inform payers and policymakers regarding patients at risk for greater costs of care. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Tibial Shaft and Plateau Fractures. J Orthop Trauma 2020; 34:539-544. [PMID: 32349026 DOI: 10.1097/bot.0000000000001791] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether a validated trauma triage tool can identify the middle-aged and geriatric trauma patients with tibial shaft and plateau fractures who are at the risk for costly admissions and poorer hospital quality measures. DESIGN Prospective cohort study. SETTING Level-1 trauma center. PATIENTS/PARTICIPANTS Sixty-four patients older than 55 years hospitalized with isolated tibial shaft or plateau fractures. INTERVENTION Patients with either isolated tibial plateau fractures or tibial shaft fractures over a 3-year period were prospectively enrolled in an orthopedic trauma registry. Demographic information, injury severity, and comorbidities were assessed and incorporated into the Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) score, a validated trauma triage score that calculates inpatient mortality risk upon admission. Patients were then grouped into tertiles based on their STTGMA score. MAIN OUTCOME MEASURES Length of stay, complications, discharge location, and direct variable costs. RESULTS Sixty-four patients met inclusion criteria. Thirty-three patients (51.6%) presented with tibial plateau fractures and 31 (48.4%) with tibial shaft fractures. The mean age was 66.7 ± 10.2 years. Mean length of stay was significantly different between risk groups with a mean of 6.8 ± 4 days (P < 0.001). Although 19 (90.5%) of the minimal risk patients were discharged home, only 7 (33.3%) and 5 (22.7%) of moderate- and high-risk patients were discharged home, respectively (P < 0.001). Higher-risk patients experienced a significantly greater number of complications during hospitalization but had no differences in the need for intensive care unit-level care (P = 0.027 and P = 0.344, respectively). The total cost difference between the lowest- and highest-risk group was nearly 50% ($14,070 ± 8056 vs. $25,147 ± 14,471; mean difference, $11,077; P = 0.022). CONCLUSION Application of the STTGMA triage tool allows for the prediction of key hospital quality measures and cost of hospitalization that can improve clinical decision-making. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Konda SR, Ranson RA, Solasz SJ, Dedhia N, Lott A, Bird ML, Landes EK, Aggarwal VK, Bosco JA, Furgiuele DL, Gould J, Lyon TR, McLaurin TM, Tejwani NC, Zuckerman JD, Leucht P, Ganta A, Egol KA. Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World. J Orthop Trauma 2020; 34:e317-e324. [PMID: 32815845 PMCID: PMC7446996 DOI: 10.1097/bot.0000000000001895] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES (1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS Inpatient and 30-day mortality, major, and minor complications. RESULTS Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
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Affiliation(s)
- Sanjit R. Konda
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Rachel A. Ranson
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Sara J. Solasz
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Nicket Dedhia
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Ariana Lott
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Mackenzie L. Bird
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Emma K. Landes
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Vinay K. Aggarwal
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Bellevue Hospital, New York, NY
| | - Joseph A. Bosco
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - David L. Furgiuele
- Department of Orthopaedic Surgery, NYU Winthrop Hospital, Mineola, NY; and
| | - Jason Gould
- Department of Orthopaedic Surgery, NYU Winthrop Hospital, Mineola, NY; and
| | - Thomas R. Lyon
- Department of Orthopaedic Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY
| | - Toni M. McLaurin
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Bellevue Hospital, New York, NY
| | - Nirmal C. Tejwani
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Bellevue Hospital, New York, NY
| | - Joseph D. Zuckerman
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Philipp Leucht
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Bellevue Hospital, New York, NY
| | - Abhishek Ganta
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Kenneth A. Egol
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY
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Konda SR, Johnson JR, Kelly EA, Chan J, Lyon T, Egol KA. Can We Accurately Predict Which Geriatric and Middle-Aged Hip Fracture Patients Will Experience a Delay to Surgery? Geriatr Orthop Surg Rehabil 2020; 11:2151459320946021. [PMID: 32821470 PMCID: PMC7412893 DOI: 10.1177/2151459320946021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/04/2020] [Accepted: 07/07/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction This study sought to investigate whether a validated trauma triage risk assessment tool can predict time to surgery and delay to surgery. Materials and Methods Patients aged 55 and older who were admitted for operative repair or arthroplasty of a hip fracture over a 3-year period at a single academic institution were included. Risk quartiles were constructed using Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) calculations. Negative binomial and multivariable logistic regression were used to evaluate time to surgery and delay to surgery, respectively. Pairwise comparisons were performed to evaluate 30-day mortality rates and demonstrate the effectiveness of the STTGMA tool in triaging mortality risk. Results Six hundred eleven patients met inclusion criteria with mean age 81.1 ± 10.5 years. Injuries occurred mainly secondary to low-energy mechanisms (97.9%). Median time to surgery (31.9 hours overall) was significantly associated with STTGMA stratification (P = .002). Moderate-risk patients had 33% longer (P = .019) and high-risk patients had 28% longer time to surgery (P = .041) compared to minimal risk patients. Delay to surgery (26.4% overall) was significantly associated with STTGMA stratification (P = .015). Low-risk patients had 2.14× higher odds (P = .009), moderate-risk patients had 2.70× higher odds (P = .001), and high-risk patients had 2.18× higher odds of delay to surgery (P = .009) compared to minimal risk patients. High-risk patients experienced higher 30-day mortality compared to minimal (P < .001), low (P = .046), and moderate-risk patients (P = .046). Discussion Patients in higher STTGMA quartiles encountered longer time to surgery, greater operative delays, and higher 30-day mortality. Conclusion Score for Trauma Triage in the Geriatric and Middle-Aged can quickly identify hip fracture patients at risk for a delay to surgery and may allow treatment teams to optimize surgical timing by proactively targeting these patients. Level of Evidence Prognostic Level III.
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Affiliation(s)
- Sanjit R Konda
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, NY, USA.,Jamaica Hospital Medical Center, Queens, NY, USA
| | - Joseph R Johnson
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, NY, USA
| | - Erin A Kelly
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, NY, USA
| | - Jeffrey Chan
- Jamaica Hospital Medical Center, Queens, NY, USA
| | | | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, NY, USA.,Jamaica Hospital Medical Center, Queens, NY, USA
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Konda SR, Gonzalez LJ, Johnson JR, Friedlander S, Egol KA. Marriage Status Predicts Hospital Outcomes Following Orthopedic Trauma. Geriatr Orthop Surg Rehabil 2020; 11:2151459319898648. [PMID: 32030312 PMCID: PMC6977201 DOI: 10.1177/2151459319898648] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/20/2019] [Accepted: 12/08/2019] [Indexed: 11/24/2022] Open
Abstract
Introduction: Rising costs of post-acute care facilities for both the patient and payers make discharge home after hospital stay, with or without home help, a favorable alternative for all parties. Our objectives were to assess the effect of marital status, a large source of social support for many, on disposition following hospital stay. Methods: Patients were prospectively entered into an institutional review board-approved, trauma database at a large, academic medical center. Patients aged 55 years or older with any fracture injury between 2014 and 2017 were included. Retrospectively, their relationship status was recorded through review of patient records. A status of “married” was separated from those with a status self-reported as “single,” “divorced,” or “widowed.” Multinomial logistic regression was used to assess whether discharge location differs by marital status while controlling for demographics and injury characteristics. Results: Of 1931 patients, 8.3% were divorced, 29.9% were single, 20.0% were widowed, and 41.8% were married. There was a significant correlation between discharge disposition and marital status. Single patients had 1.71 times, and widowed patients had 1.80 times, the odds of being discharged to a nursing home, long-term care facility, or skilled nursing facility compared to married patients after controlling for age, gender, Score for Trauma Triage in the Geriatric and Middle-Aged score, and insurance type. Additionally, single and widowed patients experienced 1.36 and 1.30 times longer length of hospital stay than their married counterparts, respectively. Discussion: Patients who are identified as “single” or “widowed” should have early social work intervention to establish clear discharge expectations. Early intervention in this way would allow time for contact with close, living relatives or friends who may be able to provide sufficient support so that patients can return home. Increasing home discharge rates for these patients would reduce lengths of hospital stay and reduce post-acute care costs for both patient and payers without materially altering unplanned readmission rates.
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Affiliation(s)
- Sanjit R Konda
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA.,Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
| | - Leah J Gonzalez
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Joseph R Johnson
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Scott Friedlander
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
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Cubitt M, Downie E, Shakerian R, Lange PW, Cole E. Timing and methods of frailty assessments in geriatric trauma patients: A systematic review. Injury 2019; 50:1795-1808. [PMID: 31376920 DOI: 10.1016/j.injury.2019.07.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The trauma population is aging and better prognostic measures for geriatric trauma patients are required. Frailty rather than age appears to be associated with poor outcomes. This systematic review aimed to identify the optimum frailty assessment instrument and timing of assessment in patients aged over 65 years admitted to hospital after traumatic injury. The secondary aim was to evaluate outcomes associated with frailty in elderly trauma populations. METHODS This systematic review was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42018090620). A MEDLINE and EMBASE literature search was conducted from inception to June 2019 combining the concepts of injury, geriatric, frailty, assessment and prognosis. Included studies were in patients 65 years or older hospitalised after injury and exposed to an instrument meeting consensus definition for frailty assessment. Study quality was assessed using criteria for review of prognostic studies combined with a GRADE approach. RESULTS Twenty-eight papers met inclusion criteria. Twenty-eight frailty or component instruments were reported, and assessments of pre-injury frailty were made up to 1-year post injury. Pre-injury frailty prevalence varied from 13% (13/100) to 94% (17/18), with in-hospital mortality rates from 2% (5/250) to 33% (6/18). Eleven studies found an association between frailty and mortality. Eleven studies reported an association between frailty and a composite outcome of mortality and adverse discharge destination. Generalisability and assessment of strength of associations was limited by single centre studies with inconsistent findings and overlapping cohorts. CONCLUSIONS Associations between frailty and adverse outcomes including mortality in geriatric trauma patients were demonstrated despite a range of frailty instruments, administering clinicians, time of assessment and data sources. Although evidence gaps remain, incorporating frailty assessment into trauma systems is likely to identify geriatric patients at risk of adverse outcomes. Consistency in frailty instruments and long-term geriatric specific outcome measures will improve research relevance. LEVEL OF EVIDENCE Level III prognostic.
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Affiliation(s)
- Mya Cubitt
- Department of Emergency Medicine, The Royal Melbourne Hospital, VIC, Australia.
| | - Emma Downie
- Trauma Service, The Royal Melbourne Hospital, VIC, Australia
| | - Rose Shakerian
- Trauma Service, The Royal Melbourne Hospital, VIC, Australia
| | - Peter W Lange
- Department of Medicine and Aged Care, The Royal Melbourne Hospital, VIC, Australia
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, England
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Kugelman DN, Fisher N, Konda SR, Egol KA. Loss of Ambulatory Independence Following Low-Energy Pelvic Ring Fractures. Geriatr Orthop Surg Rehabil 2019; 10:2151459319878101. [PMID: 31598390 PMCID: PMC6764068 DOI: 10.1177/2151459319878101] [Citation(s) in RCA: 4] [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: 05/22/2019] [Revised: 08/11/2019] [Accepted: 08/15/2019] [Indexed: 12/01/2022] Open
Abstract
Introduction: Lateral compression type 1 (LC1) pelvic ring fractures make up 63% of all pelvic ring
injuries. This fracture pattern is typically seen in older patients. The purpose of this
study is to assess the ambulatory status of individuals sustaining LC1 fractures at
long-term follow-up and what specific characteristics, if any, effect this status or
functional outcomes. Methods: Over a 2-year period, all pelvic ring injury at 2 hospitals within one academic
institution was queried. One hundred sixty-one low-energy LC1 pelvic fractures were
identified. Results: Fifty patients were available for long-term outcomes (mean: 36 months). Long-term
functional outcomes (mean follow-up: 36 months) as measured by SMFA subgroup scores were
demonstrated to be 3 times higher in patients currently using assistive devices for
walking (P = .012). Increased age (P = .050) was
associated with the continued use of assistive walking devices. Of the patients who did
not use an ambulatory device prior to LC1 injury, 5 (11.6%) sustained a fall or medical
complication within 30 days of the index pelvic fracture; this was associated with the
current use of an assistive ambulatory device (P = .010). Forty-three
(86%) patients didn’t use an assistive ambulatory device prior to sustaining the LC1
fracture. Seven (14%) patients utilized assistive devices both before and after the LC1
injury. Thirteen (26%) patients, who did not utilize assistive ambulatory devices prior
to their injury, necessitated them at long-term follow-up. Discussion: Surgeons should be aware of these associations, as they can implement early
interventions aimed at patients at risk, for assistive device use, following LC1 pelvic
fractures. Conclusion: More than a quarter of the patients sustaining an LC1 pelvic fracture continue to use
an aid for ambulation at long-term follow-up. Older age, complications, and falls within
30 days of this injury are associated with the utilization of an assistive ambulatory
device.
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Affiliation(s)
| | - Nina Fisher
- NYULMC Hospital for Joint Diseases, New York, NY, USA
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