Hip Fracture: Can We Do Better?

Pre-Fracture Functional Status and Early Functional Recovery are Significant Predictors of Instrumental Activities of Daily Living After Hip Fracture: A Prospective Cohort Study

Introduction

Although the overall quality of medicine has improved in recent decades, the functional capacity in many hip fracture patients remains insufficient. The goal of the present study was to identify significant predictors of Instrumental Activities of Daily Living (IADL) measured by the Lawton-Brody scale at 3- and 6-month follow-up in patients with hip fractures admitted to a hospital.

Methods

This observational cohort study included 191 patients with acute hip fractures. IADL was measured at baseline and after 3 and 6 months using the Lawton-Brody scale. Multivariable logistic regression analysis was carried out using pre-fracture functional status, sociodemographic variables, hand grip strength (HGS), surgical procedure, complications, and length of hospital stay, Short Physical Performance Battery, and Barthel Index (BI) on the fifth postoperative day as potential predictors for IADL after a hip fracture surgery.

Results

The mean age of the participants was 80.3 ± 6.8 years, and 77.0% of our cohort were women. Multivariate regression analysis revealed that pre-fracture functional status and early functional recovery were independent predictors of IADL after hip fracture surgery.

Conclusions

Clinicians should take steps to improve functional outcomes by changing how patients are rehabilitated in the first days after hip fracture surgery, especially for the group of patients with a lower functional status before the fracture.

The functional effect of lesser trochanter involvement in hip fractures: A prospective cohort study

INTRODUCTION

Hip fractures are the most common fractures amongst frail older patients. Earlier studies have indicated an impaired hip flexion strength in patients with fractures that include detachment of the lesser trochanter. These patients may experience protracted functional impairment and longer recovery time, causing prolonged rehabilitation journeys. This study aimed to evaluate the effects of a detached lesser trochanter in trochanteric fractures on the recovery of hip function.

METHOD

A prospective observational cohort study was performed between 2016 and 2019. Community dwelling patients aged 70 years or older with AO 31A1-A3 trochanteric fractures were included. Patients followed routine care and were treated with a DHS or PFNA. The groups with and without involvement of the lesser trochanter were analysed. The primary outcome was hip function assessed at 6 weeks, 3 months and 1 year after surgery with the Harris Hip Score. Secondary outcomes included the Ludloff's test, complications, rehabilitation time, and pain-, independence-, and quality of life scores. A propensity score was used to adjust for any baseline differences between the two groups.

RESULTS

A total of 114 patients were included, 51 (44.7%) with involvement of the lesser trochanter and 63 (55.3%) without. Minor differences were observed in the baseline characteristics. No significant difference was observed for the Harris Hip Score (coefficient estimate: 3.31; 95% CI, -5.09-11.72; P = 0.43). The flexion function of the iliopsoas muscle was more often normal with the Ludloff's test in patients without involvement of the lesser trochanter (OR, 2.33; 95% CI, 1.241-4.387; P = 0.009). However, no differences were observed for any of the other secondary outcomes.

CONCLUSION

Although no differences in overall hip function were found, more hip fracture patients with involvement of the lesser trochanter showed prolonged impaired flexion of the hip. The absence of long-term, clinically relevant disadvantages however, proves fixing the lesser trochanter to be redundant.

Independent factors associated with long-term functional outcomes in patients with a proximal femoral fracture: A systematic review

INTRODUCTION

The current understanding of prognostic factors of functional recovery after a proximal femoral fracture is limited, and enhancements could improve the prognostic accuracy and target subgroups for additional care strategies. This systematic review aims to identify all studied factors with an independent prognostic value for the long-term functional recovery of patients with a proximal femoral fracture.

MATERIALS AND METHODS

Observational studies with multivariate analyses on prognostic factors of long-term functional outcome after proximal femoral fractures were obtained through an electronic search performed on November 9, 2018.

RESULTS

In the 31 included articles, thirteen prognostic factors were studied by at least two independent studies and an additional ten by only one study. Age, comorbidity, functionality and cognition were factors for which the majority of studies indicated a significant effect. The majority of studies which included sex as a factor found no significant effect. The level of evidence for the remaining factors was deemed too low to be conclusive on their relevance for long-term functional outcome.

CONCLUSION

The identified factors showed overlap with prognostic factors of short-term functional outcomes and mortality. The validity and applicability of prognostic models based on these factors may be of interest for future research.

Mobile Outreach: An Innovative Program for Older Orthopedic Patients in Care Facilities

Introduction:

The worldwide incidence of fragility fractures is increasing and the greatest burden is borne by the oldest population. Mobile Outreach, an innovative orthopedic-based program providing on-site musculoskeletal care for individuals in nursing care facilities, was implemented as part of our Geriatric Orthopaedic Trauma Program. The objectives of this report are to describe characteristics of patients cared for through Mobile Outreach and to report specific services provided.

Program Description:

Based from a nonprofit, private hospital that serves as the community’s level 1 trauma center and teaching hospital, the Mobile Outreach Program is directed by an orthopedic surgeon with geriatric subspecialization and staffed by a full-time geriatric nurse practitioner. Patients receive care for musculoskeletal concerns and fracture assessments at their nursing care facilities by a Mobile Outreach care provider. Referral for care is from nursing care facilities or as scheduled postoperative follow-up.

Results:

In 2016, the program treated 458 patients (76% female) in the patients’ care settings for a total of 689 visits. The mean age was 81 years (standard deviation = 14; range 25-107). Care of patients included nonoperative fracture care in 100 (22%), postoperative fracture follow-up in 149 (33%), injections for pain management in 184 (40%), and other orthopedic care in 25 (5%). Visits occurred at 88 facilities, mean 7 visits per site (range 1-57).

Conclusions:

Mobile Outreach was implemented to improve postoperative fracture care in the elderly patients. The program also provides on-site nonoperative fracture care and care of frail elderly individuals with chronic musculoskeletal conditions. This report aims to establish the feasibility of a program focused on the provision of appropriate, coordinated care for older fracture patients in their care facility. Level of Evidence: Level V.

Residual Disability, Mortality, and Nursing Home Placement After Hip Fracture Over 2 Decades

OBJECTIVE

To examine trends in 12-month postfracture residual disability, nursing home placement, and mortality among patients with a hip fracture between 1990 and 2011.

DESIGN

Secondary analysis of 12-month outcomes from 3 cohort studies and control arms of 2 randomized controlled trials.

SETTING

Original studies were conducted as part of the Baltimore Hip Studies (BHS).

PARTICIPANTS

Community-dwelling patients ≥65 years of age hospitalized for surgical repair of a nonpathologic hip fracture (N=988).

MAIN OUTCOME MEASURES

Twelve-month residual disability, mortality, and nursing home residency were examined in case-mix adjusted models by sex and study. Residual disability was calculated by subtracting prefracture scores of Lower Extremity Physical Activities of Daily Living from scores at 12 months postfracture. We also examined the proportion of individuals with a 12-month score higher than their prefracture score (residual disability>0).

RESULTS

Only small improvements were seen in residual disability between 1990 and 2011. No significant differences were seen for men between BHS2 (enrollment 1990-1991; mean residual disability=3.1 activities; 95% confidence interval [CI], 2.16-4.10) and BHS7 (enrollment 2006-2011; mean=3.1 activities; 95% CI, 2.41-3.82). In women, residual disability significantly improved from BHS2 (mean=3.5 activities; 95% CI, 2.95-3.99) to BHS3 (enrollment 1992-1995; mean=2.7 activities; 95% CI, 2.01-3.30) with no significant improvements in later studies. After adjustment, a substantial proportion (91% of men and 79% of women) had a negative outcome (residual disability, died, or nursing home residence at 12 months) in the most recently completed study (BHS7).

CONCLUSIONS

Over 2 decades, patients undergoing usual care post-hip fracture still had substantial residual disability. Additional clinical and research efforts are needed to determine how to improve hip fracture treatment, rehabilitation, and subsequent outcomes.