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Fenwick A, Pfann M, Antonovska I, Mayr J, Lisitano L, Nuber S, Förch S, Mayr E. Early surgery? In-house mortality after proximal femoral fractures does not increase for surgery up to 48 h after admission. Aging Clin Exp Res 2023; 35:1231-1239. [PMID: 37138145 PMCID: PMC10156577 DOI: 10.1007/s40520-023-02406-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/31/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE The economic cost linked to the increasing number of proximal femur fracture and their postoperative care is immense. Mortality rates are high. As early surgery is propagated to lower mortality and reduce complication rates, a 24-h target for surgery is requested. It was our aim to determine the cut-off for the time to surgery from admission and therefore establish a threshold at which the in-house mortality rate changes. METHODS A retrospective single-center cohort study was conducted including 1796 patients with an average age of 82.03 years treated operatively for a proximal femoral fracture between January 2016 and June 2020. A single treatment protocol was performed based on the type of anticoagulant, surgery, and renal function. Patient data, surgical procedure, time to surgery, complications, and mortality were assessed. RESULTS In-house mortality rate was 3.95%, and the overall complication rate was 22.7%. A prolonged length of hospital stay was linked to patient age and occurrence of complications. Mortality is influenced by age, number of comorbidities BMI, and postoperative complications of which the most relevant is pneumonia. The mean time to surgery for the entire cohort was 26.4 h. The investigation showed no significant difference in mortality rate among the two groups treated within 24 h and 24 to 48 h while comparing all patients treated within 48 h and after 48 h revealed a significant difference in mortality. CONCLUSIONS Age and number of comorbidities significantly influence mortality rates. Time to surgery is not the main factor influencing outcome after proximal femur fractures, and mortality rates do not differ for surgery up to 48 h after admission. Our data suggest that a 24-h target is not necessary, and the first 48 h may be used for optimizing preoperative patient status if necessary.
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Affiliation(s)
- Annabel Fenwick
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Michael Pfann
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Iana Antonovska
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Jakob Mayr
- Zentrum für Unfallchirurgie und Orthopädie, Klinikum Ingolstadt GmbH, Krumenauerstraße 25, 85049, Ingolstadt, Germany
| | - Leonhard Lisitano
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Stefan Nuber
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Stefan Förch
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Edgar Mayr
- Department of Trauma, Orthopedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
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Oyekan AA, Lee JY, Hodges JC, Chen SR, Wilson AE, Fourman MS, Clayton EO, Njoku-Austin C, Crasto JA, Wisniewski MK, Bilderback A, Gunn SR, Levin WI, Arnold RM, Hinrichsen KL, Mensah C, Hogan MV, Hall DE. Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates: One-Year Results of the Surgical Pause Program. JB JS Open Access 2023; 8:JBJSOA-D-22-00107. [PMID: 37101601 PMCID: PMC10125643 DOI: 10.2106/jbjs.oa.22.00107] [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] [Indexed: 04/28/2023] Open
Abstract
Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a "surgical pause" (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Anthony A. Oyekan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Email for corresponding author:
| | - Joon Y. Lee
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob C. Hodges
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen R. Chen
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan E. Wilson
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mitchell S. Fourman
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Elizabeth O. Clayton
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Jared A. Crasto
- Department of Orthopaedic Surgery, The Spine Institute of Arizona, Scottsdale, Arizona
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Bilderback
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Scott R. Gunn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William I. Levin
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie L. Hinrichsen
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Mensah
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - MaCalus V. Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Early surgery for thoracolumbar extension-type fractures in geriatric patients with ankylosing disorders reduces patient complications and mortality. Spine J 2023; 23:157-162. [PMID: 36049703 DOI: 10.1016/j.spinee.2022.08.016] [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: 04/25/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT The management of trauma patients with ankylosing spinal disorders has become an issue of increasing interest. Geriatric patients frequently sustain unstable extension type vertebral fractures with ankylosed spines. In this population, studies have shown that early surgery for other injuries such as hip fractures may reduce patient complications and mortality. These studies have changed patient care protocols in many medical centers worldwide. PURPOSE We aim to assess the relationship between the timing of surgery for unstable vertebral fractures in ankylosed spines in the geriatric population and patient outcomes. STUDY DESIGN/SETTING Retrospective clinical study conducted in a tertiary hospital. PATIENT SAMPLE Patients included were those diagnosed with isolated thoracolumbar extension type fractures and a spinal ankylosing disorder over 65 years old following minor trauma and with no additional injuries or neurological deficit. OUTCOME MEASURES Primary outcome measures included postoperative medical complications and mortality at 1 and 6 months. Secondary outcome measures included rehospitalization rates, length of stay, and surgical site infections. METHODS We searched our department's database for all that met our inclusion criteria who underwent surgery. The difference in patient outcomes that underwent early surgery defined as less than 72 hours from diagnosis as opposed to those that underwent later surgery was assessed. RESULTS A total of 82 patients underwent surgery following a diagnosis of an extension type thoracolumbar fracture at our institution between 2015 and 2021. Of these, 50 met inclusion criteria. Nineteen patients underwent surgery less than 72 hours from diagnosis and 31 more than 72 hours from diagnosis. No difference was found in age, functional status, and Elixhauser comorbidity scores between the groups. A statistically significant difference in perioperative patient complications between the early and the late groups (p=.005) was found. Mortality at six-months was significantly different between the groups as well (p=.035). There was no statistically significant difference between the groups when comparing surgical site infections, length of hospital stay, rehospitalization within a month, and perioperative mortality. CONCLUSIONS Time to surgery affects complication rates and six-month mortality in geriatric patients with spinal ankylosing disorders presenting with an isolated unstable hyperextension type thoracolumbar fracture. Early surgery of less than 72 hours from presentation in this patient population is recommended.
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Resultados en salud tras la implantación de una guía multidisciplinar para la atención a la fractura de cadera. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Allahabadi S, Roostan M, Roddy E, Ward DT, Rogers S, Kim C. Operative Management of Hip Fractures Within 24 Hours in the Elderly is Achievable and Associated With Reduced Opiate Use. Geriatr Orthop Surg Rehabil 2022; 13:21514593221116331. [PMID: 37101932 PMCID: PMC10123378 DOI: 10.1177/21514593221116331] [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] [Received: 04/22/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Morbidity and mortality benefits have been associated with prompt surgical treatment of geriatric hip fractures. The purpose of this study was to evaluate the impact of early (≤24 hr) vs delayed (>24 hr) time to operating room (TTOR) on 1) hospital length of stay and 2) total and post-operative opiate use in geriatric hip fractures. Materials and Methods This study was a retrospective review of patients ≥65 years-old at the time of admission for surgery for hip fracture at a Level II academic trauma center. Outcome measures were length of stay (LOS), oral morphine equivalents (OME) throughout hospitalization. Patients were stratified into early and delayed TTOR groups and comparisons were made between groups. Results Between the early (n = 75, 80.6%) and late (n = 18, 19.4%) groups, there were no differences in age, fracture pattern, type of treatment, preoperative opiate use, and perioperative non-oral pain management. The early group trended toward shorter total LOS (108.0 ± 67.2 hours vs 144.8 ± 103.7 hours, P = .066), but not post-operative LOS. Total OME usage was less in the early intervention group (92.5 ± 188.0 vs 230.2 ± 296.7, P = .015), in addition to reduced post-operative OME (81.3 ± 174.9 vs 213.3 ± 271.3, P = .012). There were no differences in evaluated potential delay sources such as primary language, use of surrogate decision makers, or need for advanced imaging. Discussion Surgical treatment of geriatric hip/femur fractures in ≤24 hours from presentation is achievable and may be associated with reduced total inpatient opiate use, although daily use did not differ. Conclusion Establishing institutional TTOR goals as part of an interdisciplinary hip fracture co-management clinical pathway can facilitate prompt care and contribute to recovery and less opiate use in these patients with highly morbid injuries.
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Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Mohammad Roostan
- Department of Internal Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Erika Roddy
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Derek T. Ward
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Stephanie Rogers
- Department of Internal Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Candace Kim
- Department of Internal Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
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Health outcomes after the implementation of multidisciplinary clinical guidelines for the care of hip fractures. Rev Clin Esp 2021; 222:73-81. [PMID: 34548255 DOI: 10.1016/j.rceng.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 04/15/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES This study aims to evaluate the impact of implementing multidisciplinary clinical guidelines in the process of caring for patients with hip fractures. MATERIALS AND METHODS This work is a pre- and post-intervention prospective study in the Orthogeriatrics Unit of a second-level hospital after implementing multidisciplinary clinical guidelines for hip fracture care. We analyzed patients' baseline characteristics and the variations observed in care provided and in outcome variables in the two periods studied (June 2015-May 2016 and June 2016-May 2017). RESULTS The baseline characteristics of the population were similar in the pre-intervention period (n = 455) compared to the post-intervention period (n = 456). Patients' mean age was 84.8 ± 6.8 years and 70.8% were women. The implementation of the multidisciplinary clinical guidelines led to a reduction in the mean length of hospital stay (16.9 days vs. 15.6 days, p= .014); improved osteoporosis treatment prescribing (51.6% vs. 88%, p< .001); and reduced episodes of delirium (44% vs. 31.2%, p < .001), bronchospasm (18.3% vs. 12%, p = .019), heart failure (20% vs. 11.5%, p < .001), and COPD exacerbation (7.9% vs. 3.8%, P = .017). We observed an increase in pressure ulcers at discharge (2.9 vs. 9%, P < .001). There were no differences in the percentage of operations in less than 48 h (56% vs. 61.2% p = .64), hospital readmissions (6.9% vs. 5.9%, p = .51), or mortality (5.0% vs. 7.2%, p = .17). CONCLUSIONS The implementation of multidisciplinary clinical guidelines improved aspects of the care process for patients with hip fracture.
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Welford P, Jones CS, Davies G, Kunutsor SK, Costa ML, Sayers A, Whitehouse MR. The association between surgical fixation of hip fractures within 24 hours and mortality : a systematic review and meta-analysis. Bone Joint J 2021; 103-B:1176-1186. [PMID: 34192937 DOI: 10.1302/0301-620x.103b7.bjj-2020-2582.r1] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
AIMS The aim of this study was to assess the effect of time to surgical intervention from admission on mortality and morbidity for patients with hip fractures. METHODS MEDLINE and Embase were searched from inception to June 2020. Reference lists were manually assessed to identify additional papers. Primary comparative research studies that recruited patients aged over 60 years, with non-pathological primary proximal femoral fractures that were treated surgically, were included. Studies that did not include a group operated on within 24 hours or which reported time to surgery in calendar days were excluded. Two investigators extracted data on study characteristics, methods, and outcomes. The pre-defined primary outcome was 30-day mortality. Secondary outcomes were complications and mortality at other time points. Relative risks (RRs) with 95% confidence intervals (CIs) were aggregated and were grouped by study-level characteristics. RESULTS This review included 46 studies (January 1991 to June 2020), comprising 521,857 hip fractures with 64,047 postoperative deaths. No randomized controlled trials were eligible for inclusion. In a pooled analysis of 15 studies, RR of mortality at 30 days comparing time to surgery < 24 hours with > 24 hours was 0.86 (95% CI 0.82 to 0.91; I 2 = 69%; 95% CI 50% to 81%; p-value for heterogeneity < 0.001). The association was stronger in observational studies that did not adjust for confounders than in those that adjusted for multiple covariates. In a pooled analysis of six studies, the RR of mortality at 30 days comparing time to surgery < 24 hours with 24 to 36 hours was 0.87 (95% CI 0.81 to 0.93; I 2 = 65%; 95% CI 16% to 85%; p-value for heterogeneity = 0.014). CONCLUSION This meta-analysis indicates reduced mortality for patients operated within 24 hours compared with those operated on beyond 24 hours or within 24 to 36 hours. Where resources allow and there is no specific reversible contraindication to early surgery, we recommend that hip fractures should be surgically treated within 24 hours. Cite this article: Bone Joint J 2021;103-B(7):1176-1186.
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Affiliation(s)
- Paul Welford
- North Bristol NHS Trust, Westbury on Trym, UK
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Conor S Jones
- North Bristol NHS Trust, Westbury on Trym, UK
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Gareth Davies
- North Bristol NHS Trust, Westbury on Trym, UK
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- Translational Health Sciences, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Matt L Costa
- Oxford Trauma, NDORMS, University of Oxford, Oxford, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- North Bristol NHS Trust, Westbury on Trym, UK
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
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Minimizing Nonessential Follow-up for Hip Fracture Patients. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202106000-00002. [PMID: 34077401 PMCID: PMC8174547 DOI: 10.5435/jaaosglobal-d-21-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/30/2021] [Indexed: 11/23/2022]
Abstract
Hip fractures pose a significant burden to patients and care providers. The
optimal protocol for postoperative care across all surgically treated hip
fracture patients is unknown. The purpose of this study was to investigate the
effect that routine follow-up had on changing the clinical course.
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Early Surgery Does Not Improve Outcomes for Patients with Periprosthetic Femoral Fractures-Results from the Registry for Geriatric Trauma of the German Trauma Society. ACTA ACUST UNITED AC 2021; 57:medicina57060517. [PMID: 34064211 PMCID: PMC8224313 DOI: 10.3390/medicina57060517] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/12/2021] [Accepted: 05/19/2021] [Indexed: 01/28/2023]
Abstract
Background and Objectives: Appropriate timing of surgery for periprosthetic femoral fractures (PFFs) in geriatric patients remains unclear. Data from a large international geriatric trauma register were analyzed to examine the outcome of patients with PFF with respect to the timing of surgical stabilization. Materials and Methods: The Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) was analyzed. Patients treated surgically for PFF were included in this analysis. As outcome parameters, in-house mortality rate and mortality at the 120-day follow-up as well as mobility, the EQ5D index score and reoperation rate were analyzed in relation to early (<48 h) or delayed (≥48 h) surgical stabilization. Results: A total of 1178 datasets met the inclusion criteria; 665 fractures were treated with osteosynthesis (56.4%), and 513 fractures were treated by implant change (43.5%). In contrast to the osteosynthesis group, the group with implant changes underwent delayed surgical treatment more often. Multivariate logistic regression analysis of mortality rate (p = 0.310), walking ability (p = 0.239) and EQ5D index after seven days (p = 0.812) revealed no significant differences between early (<48 h) and delayed (≥48 h) surgical stabilization. These items remained insignificant at the follow-up as well. However, the odds of requiring a reoperation within 120 days were significantly higher for delayed surgical treatment (OR: 1.86; p = 0.003). Conclusions: Early surgical treatment did not lead to decreased mortality rates in the acute phase or in the midterm. Except for the rate of reoperation, all other outcome parameters remained unaffected. Nevertheless, for most patients, early surgical treatment should be the goal, so as to achieve early mobilization and avoid secondary nonsurgical complications. If early stabilization is not possible, it can be assumed that orthogeriatric co-management will help protect these patients from further harm.
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Gupta P, Kang KK, Pasternack JB, Klein E, Feierman DE. Perioperative Transfusion Associated With Increased Morbidity and Mortality in Geriatric Patients Undergoing Hip Fracture Surgery. Geriatr Orthop Surg Rehabil 2021; 12:21514593211015118. [PMID: 34035979 PMCID: PMC8132085 DOI: 10.1177/21514593211015118] [Citation(s) in RCA: 6] [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: 03/11/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction: Both conservative and liberal transfusion thresholds, in regard to hematocrit and hemoglobin levels, have been widely studied with varying outcomes. The aim of this study was to evaluate if transfusion administered peri- (anytime during the admission), pre-, intra-, or postoperatively an its association with morbidity and mortality in the geriatric population undergoing hip surgery. Methods: This study was an institutional review board approved retrospective analysis of data collected from 841 patients at a single urban institution who underwent surgical repairs for hip fractures from 2008 to 2010. Results: Our analysis included data from 841 surgical patients. Mean patient age was 83, 74% were female, 48% received spinal anesthesia while 52% underwent general anesthesia. Out of 841 patients, 425 were transfused during the perioperative period. Most transfusions occurred postoperatively. Perioperative, intraoperative and postoperative transfusion was associated with an increase in post-operative AKI. Intraoperative blood transfusion was associated with an increase in morbidity (11.6% increased to 22.2%) by 1.9 fold, AKI (3.9% increased to 11.1%) by 2.8 fold, as well as an increase in mortality (5.2 increased to 15.6%) within 60 days by 3 fold. Conclusions: This may suggest that patients transfused prior to surgery, despite having met a specific trigger hemoglobin level earlier, may have been treated before deteriorating to a point that would cause future systemic implications.
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Affiliation(s)
- Piyush Gupta
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Kevin K Kang
- Department of Orthopedics, Maimonides Medical Center, Brooklyn, NY, USA
| | | | - Elliot Klein
- Department of Anesthesiology, Donald and Barbara Zucker School of Medicine at Hofstra, Queens NY, USA
| | - Dennis E Feierman
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA
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The Impact of the Aging Population on Surgical Diseases. CURRENT GERIATRICS REPORTS 2021. [DOI: 10.1007/s13670-020-00352-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ranti D, Warburton AJ, Hanss K, Katz D, Poeran J, Moucha C. K-Means Clustering to Elucidate Vulnerable Subpopulations Among Medicare Patients Undergoing Total Joint Arthroplasty. J Arthroplasty 2020; 35:3488-3497. [PMID: 32739081 DOI: 10.1016/j.arth.2020.06.063] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/14/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The role of preoperative laboratory values for risk stratification following joint arthroplasty is currently ambiguous. In order to improve upon existing risk stratification within joint arthroplasty, this study sought to define novel phenotypes of total hip or total knee arthroplasty patients based entirely on preoperative laboratory measures. These phenotypes ("clusters") were compared to elucidate statistically and clinically significant differences in outcomes. METHODS A total of 134,252 patients were gathered from the National Surgical Quality Improvement Program database between 2005 and 2015. "K-means" with 3 clusters was applied using 9 preoperative laboratory values: sodium, blood urea nitrogen (BUN), creatinine, albumin, bilirubin, white blood cell count, hematocrit, platelet count, and international normalized ratio of prothrombin values (INR). Outcome measures included 30-day readmissions, severe adverse events, and discharge to nonhome. RESULTS Cluster 2 was characterized by elevated preoperative BUN, creatinine, and INR and demonstrated almost twice the rate of adverse events (3.52% vs 2.20% and 2.22%), 30-day readmissions (6.39% vs 3.31% and 3.71%), and discharge to nonhome (47.97% vs 30.50% and 35.85%). Cluster 3 was characterized by a slightly higher risk of discharge to nonhome than cluster 1 and was overwhelmingly female (79.5% female, 35.8% discharge to nonhome). Cluster 1 represents the lowest-risk subgroup, experiencing the lowest rates of readmissions, adverse events, and discharge to nonhome. CONCLUSION Preoperative laboratory values, namely BUN, creatinine, and INR, are useful in identifying patients at risk of adverse outcomes. This analysis supports the existing surgical literature pushing for preoperative hydration as a targeted intervention to expedite recovery.
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Affiliation(s)
- Daniel Ranti
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew J Warburton
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kaitlin Hanss
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniel Katz
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jashvant Poeran
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Calin Moucha
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Plaza-Carmona M, Requena-Hernández C, Jiménez-Mola S. Good practices in the recovery of ambulation in octogenarian women with hip fractures. Rev Assoc Med Bras (1992) 2020; 66:1417-1422. [PMID: 33174937 DOI: 10.1590/1806-9282.66.10.1417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 04/21/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Determine good recovery practices for ambulation of octogenarian women after hospital discharge after being operated on for hip fracture. METHODS Prospective study during the second half of 2019, with 192 women (85.95 ± 5.1 years) with hip fracture. A medical history, fracture types, complications, surgical treatment, and assessment of the level of ambulation were recorded before and after six months of hospital discharge. RESULTS 100 patients lived in the family home and 92 in an institutional center, 68.2% provided pertrochanteric fracture and a total of 3.7 comorbidities, all of them received spinal anesthesia and were admitted an average of 11.4 days. After six months, the patients showed a significant loss of functional independence with respect to the situation prior to the fracture, both for the ability to wander and for activities of daily living. It is noteworthy that the worst prognosis in the recovery of ambulation has to do with intermediate levels of ambulation and that the functional level of departure influences to a lesser extent than the place where they perform the recovery. CONCLUSIONS Age is a factor that influences the recovery of hip fracture, but there are other influential factors since patients who remain in the family home have a better functional prognosis than those who recover in institutionalized centers, after six months of hospital discharge.
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Affiliation(s)
| | | | - Sonia Jiménez-Mola
- Orthogeriatrics Unit, University Assistance Complex of León, León, Spain
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Lepkowsky E, Simcox T, Rogoff H, Barzideh O, Islam S. Is There a Role for CT Pan-Scans in the Initial Workup of Fragility Fracture Patients? Geriatr Orthop Surg Rehabil 2020; 11:2151459320916937. [PMID: 32313714 PMCID: PMC7153176 DOI: 10.1177/2151459320916937] [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: 12/13/2019] [Accepted: 03/09/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction: Computed tomography (CT) pan-scans have become increasingly commonplace as part of the initial diagnostic workup for patients sustaining traumatic injuries. They have proven effective in improving diagnostic accuracy in those with high-energy mechanisms of injury. However, the utility of pan-scans in the geriatric population sustaining low-energy traumatic injuries remains unproven. Methods: A retrospective review was conducted of patients who sustained a fragility fracture at a level-1 trauma center over a 15-month period. Radiologist interpretations of any CT pan-scans were reviewed for acute findings, and charts were reviewed for resulting changes in orthopedic and nonorthopedic management. Additionally, mechanism of injury, definitive management, time to surgery, length of stay, level of care at discharge, and demographic data were compared against similar patients who did not receive a pan-scan. Results: Of the 109 patients who underwent a CT pan-scan, 1 (0.92%) had a change in orthopedic treatment. Twelve (11.01%) patients had changes to their nonorthopedic management. In addition, 14 other patients had one or more consultations obtained based on pan-scan results that did not result in any change in management. Discussion: This study found that only 1 of the included patients had a change in orthopedic management and 12 had a change in nonorthopedic management, despite over half of the study population being found to have additional findings. Furthermore, patients who underwent a pan-scan did not have expedited surgical intervention or earlier discharges compared to those who were not pan-scanned. Conclusion: This study demonstrates whole-body CT imaging provides little benefit in geriatric patients who sustain fragility fractures and should be utilized judiciously and in a targeted fashion instead of as a routine part of trauma surgery or emergency department protocol in this patient population. Level of Evidence: Level III Retrospective Study.
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Affiliation(s)
- Eric Lepkowsky
- Department of Orthopedic Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Trevor Simcox
- Department of Orthopedic Surgery, NYU Winthrop Hospital, Mineola, NY, USA
| | - Hunter Rogoff
- Department of Orthopedic Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Omid Barzideh
- Department of Orthopedic Surgery, NYU Winthrop Hospital, Mineola, NY, USA
| | - Shahidul Islam
- Department of Orthopedic Surgery, NYU Winthrop Hospital, Mineola, NY, USA
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