Enhanced recovery after surgery for hip fractures: a systematic review and meta-analysis

An Economic Cost Analysis of Implementing a Frailty Care Bundle to Reduce Risk of Hospital Associated Decline Among Older Patients

Objective

To conduct an economic cost analysis and budget impact assessment (BIA) of implementing the Frailty Care Bundle (FCB) intervention nationally over five-years for hip fracture patients. The FCB was designed to reduce hospital associated decline in older hospitalised patients.

Methods

The FCB was delivered in two Irish hospitals on two wards per hospital. A micro level cost analysis, from the Irish health service perspective was undertaken. Direct costs of the FCB were considered (personnel, training, resources), expressed in Euros (2020). For the BIA national population estimates for hip fracture and costs avoided were based on 18% difference in patients returning to their baseline capability in the post compared to pre-intervention group, valued using cost estimates of functional decline.

Results

We estimated total intervention costs at €53,619 (89% for personnel) and the average cost per patient was €156.03. The expected costs of implementing the FCB nationally over 12-months was €57,274 per hospital (€72.92 per patient). The BIA for an expected targeted population (16,000 over 5 years), estimated that the cost of implementing the FCB (€1.2m) was less than the expected value of functional decline avoided owing to the intervention (€3.6m), suggesting a positive net effect (€2.4m).

Conclusion

Investment in the FCB can be offset with more rapid patient return to baseline functional capability, reducing health care costs. Trial and Protocol Registration (retrospective): BMC ISRCTN 15145850, (https://doi.org/10.1186/ISRCTN15145850).

Perioperative Administration of Tranexamic Acid and Low Molecular Weight Heparin for Enhanced Blood Management in Intertrochanteric Fractures: A Randomized Controlled Study

BACKGROUND This prospective study from a single center aimed to compare the perioperative blood loss (PBL) in 79 patients with intertrochanteric fractures (IF) treated with intramedullary nailing (IMN) using 3 regimens of combined tranexamic acid (TXA) and low molecular weight heparin (LMWH), proposing a novel therapy of 4-dose TXA. MATERIAL AND METHODS We recruited 79 patients and randomly divided them into 3 groups. The 4-dose TXA group (22 patients) received 1.0 g intravenous TXA 30 min before surgery and 1.0 g at intervals of 3, 6, and 9 h before surgery. The 1-dose TXA group (25 patients) received 1.0 g intravenous TXA 30 min before surgery, while the control group (32 patients) did not receive TXA. LMWH was applied 12 h after surgery in each group. The primary metrics evaluated included hidden blood loss (HBL), total blood loss (TBL), and the number and incidence rate of deep vein thrombosis (DVT). RESULTS Analysis of the HBL revealed that the 4-dose TXA group had the lowest average (583.13±318.08 ml), followed by the 1-dose TXA group (902.94±509.99 ml), and the control group showed the highest (1154.39±452.06 ml) (P<0.05). A similar result was observed for TBL (4-dose group: 640.86±337.22 ml, 1-dose group: 971.74±511.14 ml, control group: 1226.27±458.22 ml, P<0.05). Regarding DVT, the 4-dose TXA group had 5 cases (incidence rate 22.73%), the 1-dose TXA group had 6 cases (incidence rate 24.00%), and the control group had 8 cases (incidence rate 25.00%), with no significant difference among groups (P>0.05). CONCLUSIONS Treatment using 4-dose TXA and LMWH can effectively reduce PBL without increasing the DVT risk in IF patients with IMN.

Nationwide study on open tibial fractures in the Netherlands: Incidence, demographics and level of hospital care

OBJECTIVES

Open tibial fractures are relatively common injuries following traffic accidents. The vulnerability of the soft tissues surrounding the tibia increases the susceptibility to complications, including infection and nonunion. To minimize complications, a multidisciplinary, timely approach is crucial. To date, the Dutch incidence and level of hospital treatment remain unknown due to a lack of condition-specific nationwide registries. This study aimed to estimate the incidence and management of open tibial fractures in the Netherlands, providing essential information for public health policymaking and guideline development.

METHODS

The 2018 and 2019 Dutch National Hospital Care Basic Registration data, provided by the Dutch Hospital Data Foundation, were utilized to identify all patients admitted to Dutch hospitals with tibial fractures. Incidence rates, patient demographics, primary diagnoses, fracture classification, level of hospital, and length of hospital stays were analyzed using descriptive statistics.

RESULTS

1,079 ICD-10 codes for closed and open tibial fractures were identified in patients that were admitted to a Dutch hospital. Thirty-four percent were classified as open tibial fractures, accounting for an estimated incidence rate of 1.1 per 100,000 person-years (95 % CI 0.97-1.12). When categorized by age, the calculated incidence rate was higher in males for all age categories up until the age of 70. Notably, the overall highest incidence rate was found for females aged 90 and above (6.6 per 100,000 person-years). Open tibial fractures were predominantly treated in general or top clinical hospitals (comprising 69 % of open all tibia fractures). Notably, the minority (31 %) presented at university medical centers, all Level-1 trauma centers, equipped with orthoplastic teams.

CONCLUSION

This is the first study to report the nationwide incidence rate of open tibial fractures in the Netherlands; 34 % of tibial fractures were registered as open. Notably, a limited proportion of open tibial fractures underwent treatment within Level-1 trauma centers. Consequently, in the majority of cases, the implementation of an orthoplastic team approach was unattainable. This study underscores the need for more comprehensive data collection to assess and improve the current treatment landscape.

The effect of a post-anaesthesia high-care unit (PAHCU) admission on mobilization, length of stay and in-hospital mortality post-surgery in low energy neck of femur fracture patients

PURPOSE/AIM

With an ageing population and an increase in fragility fractures of the hip (FFH), the role of an anaesthetist is evolving to include more peri-operative care. A post-anaesthesia high-care unit (PAHCU) should enhance care in post-operative patients. To our knowledge, there are no studies that have investigated the effect of a PAHCU admission on post-operative outcomes after FFH. This study aimed to compare post-operative outcomes of FFH patients admitted to PAHCU versus a standard post-operative orthopaedic ward (POOW).

METHODOLOGY

A retrospective cohort study was conducted on adult patients with FFH who underwent surgery between January 2019 and December 2020 at our institution. Data were sourced from electronic medical records. SPSS version 28 was used to analyse data.

RESULTS

A total of 231 patients were included. The PAHCU group (n = 35) displayed a higher burden of chronic illness and higher peri-operative risk scores as compared to the POOW group (n = 196). Median time to mobilize (TTM) in PAHCU was 84 h vs. 45 h in POOW group (p = 0.013). Median length of stay (LOS) in PAHCU was 133 h vs. 94 h in POOW (p = 0.001). The in-hospital mortality was 2.9% (n = 1) for PAHCU and 3.6% (n = 7) for POOW (p = 1). The 30-day mortality was 11.8% (n = 4) for PAHCU and 10.1% (n = 19) in POOW.

CONCLUSION

PAHCU admission resulted in delayed time to surgery and TTM, together with prolonged LOS, compared to those managed in POOW. However, these mortality rates remained comparable in both groups. This study contributes valuable insights into post-operative care of FFH patients in a resource-poor setting.

Implementation of a Frailty Care Bundle (FCB) Targeting Mobilisation, Nutrition and Cognitive Engagement to Reduce Hospital Associated Decline in Older Orthopaedic Trauma Patients: Pretest-Posttest Intervention Study

Objective

To implement and evaluate a Frailty Care Bundle (FCB) targeting mobilisation, nutrition, and cognition in older trauma patients to reduce hospital associated decline.

Methods

We used a two group, pretest-posttest design. The FCB intervention was delivered on two orthopaedic wards and two rehabilitation wards, guided by behaviour change theory (COM-B) to implement changes in ward routines (patient mobility goals, nurse assisted mobilisation, mealtimes, communication). Primary outcomes were patient participants' return to pre-trauma functional capability (modified Barthel Index - mBI) at 6-8 weeks post-hospital discharge and average hospital daily step-count. Statistical analysis compared pre versus post FCB group differences using ordinal regression and log-linear models.

Results

We recruited 120 patients (pre n=60 and post n=60), and 74 (pre n=43, post n=36) were retained at follow-up. Median age was 78 years and 83% were female. There was a non-significant trend for higher mBI scores (improved function) in the post compared to pre FCB group (OR 2.29, 95% CI 0.98-5.36), associated with an average 11% increase in step-count.

Conclusion

It was feasible, during the Covid-19 pandemic, for multidisciplinary teams to implement elements of the FCB. Clinical facilitation supported teams to prioritise fundamental care above competing demands, but sustainability requires ongoing attention. ISRCTN registry: ISRCTN15145850 (https://doi.org/10.1186/ISRCTN15145850).

A systematic review and meta-analysis of short-stay programmes for total hip and knee replacement, focusing on safety and optimal patient selection

BACKGROUND

Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically review evidence on the safety of short-stay programmes versus usual care for total hip (THR) and knee replacement (KR), and optimal patient selection.

METHODS

A systematic review and meta-analysis. Randomised controlled trials (RCTs) and quasi-experimental studies including a comparator group reporting on 14 safety outcomes (hospital readmissions, reoperations, blood loss, emergency department visits, infection, mortality, neurovascular injury, other complications, periprosthetic fractures, postoperative falls, venous thromboembolism, wound complications, dislocation, stiffness) within 90 days postoperatively in adults ≥ 18 years undergoing primary THR or KR were included. Secondary outcomes were associations between patient demographics or clinical characteristics and patient outcomes. Four databases were searched between January 2000 and May 2023. Risk of bias and certainty of the evidence were assessed.

RESULTS

Forty-nine studies were included. Based upon low certainty RCT evidence, short-stay programmes may not reduce readmission (OR 0.95, 95% CI 0.12-7.43); blood transfusion requirements (OR 1.75, 95% CI 0.27-11.36); neurovascular injury (OR 0.31, 95% CI 0.01-7.92); other complications (OR 0.63, 95% CI 0.26-1.53); or stiffness (OR 1.04, 95% CI 0.53-2.05). For registry studies, there was no difference in readmission, infection, neurovascular injury, other complications, venous thromboembolism, or wound complications but there were reductions in mortality and dislocations. For interrupted time series studies, there was no difference in readmissions, reoperations, blood loss volume, emergency department visits, infection, mortality, or neurovascular injury; reduced odds of blood transfusion and other complications, but increased odds of periprosthetic fracture. For other observational studies, there was an increased risk of readmission, no difference in blood loss volume, infection, other complications, or wound complications, reduced odds of requiring blood transfusion, reduced mortality, and reduced venous thromboembolism. One study examined an outcome relevant to optimal patient selection; it reported comparable blood loss for short-stay male and female participants (p = 0.814).

CONCLUSIONS

There is low certainty evidence that short-stay programmes for THR and KR may have non-inferior 90-day safety outcomes. There is little evidence on factors informing optimal patient selection; this remains an important knowledge gap.

Prognostic Value of Systemic Inflammation Score for Esophageal Cancer Patients Undergoing Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The link between inflammation and cancer survival has been the subject of substantial research. The goal of this review is to summarize the evidence on the prognostic value of systemic inflammation score (SIS) in esophageal cancer patients undergoing surgical intervention.

METHODS

PubMed, Scopus, Embase, and Web of Science were searched for relevant articles published until 30^th June 2022. We pooled adjusted data on overall survival (OS) and disease-free survival (DFS) using a random-effects meta-analysis model. The review was pre-registered on PROSPER (No. CRD42022340717).

RESULTS

Eight studies were included. All studies were conducted either in China or Japan. Six studies showed that patients with SIS of 1-2 had poor OS as compared to those with scores of 0 (HR:1.42 95% CI: 1.24, 1.62 I²=25%). SIS of 1 (HR:1.45 95% CI: 1.18, 1.78 I²=0%) and 2 (HR:1.94 95% CI: 1.49, 2.53 I²=0%) were also associated with poor OS. Two studies compared the SIS score of 2 vs 0-1. Meta-analysis indicated that poor OS was associated with SIS of 2 (HR:1.80 95% CI: 1.25, 2.58). Data from three studies showed that the SIS score did not predict DFS (HR:1.40 95% CI: 0.82, 2.39 I²=91%).

CONCLUSION

SIS can be a novel prognostic indicator for esophageal cancer patients undergoing surgical intervention. Higher SIS is associated with a poor OS, but it does not predict DFS. Future studies are needed to strengthen the current evidence.

The safety and effectiveness of enhanced recovery after surgery (ERAS) in older patients undergoing orthopedic surgery: a systematic review and meta-analysis

INTRODUCTION

To systematically review and analyze the safety and effectiveness of ERAS in older patients undergoing orthopedic surgeries.

MATERIALS AND METHODS

We searched PubMed, EMBASE, CINAHL, MEDLINE (Ovid), Web of Science, the Cochrane Library, and other databases to identify all randomized controlled studies and cohorts. We used the Cochrane Risk of Bias Assessment Tool and the Newcastle‒Ottawa Scale to assess the study quality. A meta-analysis was performed using the inverse variance weighting method.

RESULTS

This study included 15 studies involving a total of 2591 older patients undergoing orthopedic surgeries with 1480 in the ERAS group. The ERAS group had a lower incidence of postoperative complications than the control group (RR 0.52; 95% CI 0.42-0.65). Length of stay was 3.37 days lower in the ERAS group than in the control group (P < 0.01). And the ERAS protocol reduced the patient's postoperative VAS score (P < 0.01). Meanwhile, there was a lack of evidence of significant differences between the ERAS group and the control group in total bleeding and 30-day readmission rate.

CONCLUSIONS

The implementation of the ERAS program in older patients undergoing orthopedic surgeries is safe and effective. However, there is still a lack of standardization of protocols across institutions and centers for orthopedic surgery for older patients. Identifying ERAS components that are beneficial to older patients and developing ERAS protocols that are appropriate for older adults may further improve outcomes.

Comparison of the clinical efficacy of three cannulated screws with parallel distribution and inverted triangular distribution in the treatment of femoral neck fractures in the elderly

The aim of the present study was to investigate the clinical efficacy of three cannulated screws with parallel distribution in comparison with the 'gold standard' of inverting three cannulated screws with triangular distribution, in the treatment of femoral neck fractures in the elderly. A total of 106 elderly patients with femoral neck fractures treated at the Department of Orthopedics of the First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial Hospital) from October 2018 to March 2020 were retrospectively analyzed and divided into groups A and B. Group A consisted of 51 patients with a mean age of 73.3±6.8 years; and group B consisted of 55 patients with a mean age of 74.5±7.3 years. Group A was treated with closed reduction + inverted triangular distribution of three cannulated screws, while group B was treated with closed reduction + parallel distribution of three cannulated screws, and the general surgical conditions, including fracture reduction quality, fracture healing, incidence of avascular necrosis of the femoral head, and functional recovery scale (FRS) score of hip joint function were assessed in both groups. All patients were followed up for an average of 14.8 months. Compared with group A, group B had significant advantages in operation time, number of times intraoperative fluoroscopy was performed, number of intraoperative guide wire adjustments, and proportion of postoperative referrals to the intensive care unit (P<0.05). There were no significant differences in fracture reduction quality, fracture healing, incidence of avascular necrosis of the femoral head, and FRS score of hip joint function between groups A and B (P>0.05). For elderly patients with femoral neck fractures, distributing three cannulated screws in parallel after closed reduction achieved similar clinical efficacy to 'gold standard' inverted triangular distribution, and had obvious advantages in operation time, with significantly reduced surgical difficulty. This procedure is therefore deemed worthy of promotion and clinical application in the primary hospitals of China.

Effect of Enhanced Recovery After Surgery on the Prognosis of Patients With Hip Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Hip fractures, predominantly occurring in the elderly, are a significant public health concern due to associated morbidity, disability, and mortality. Prolonged bed rest following the fracture often leads to complications, further threatening patient health. Enhanced recovery after surgery, a modern approach to postoperative care, is being explored for its potential to improve outcomes and quality of life in hip fracture patients.

OBJECTIVE

This study investigates the impact of enhanced recovery after surgery on hip fracture patients.

METHODS

In this systematic review, we addressed the PICO question: Does the enhanced recovery after surgery program reduce 1-year mortality, readmissions, and postoperative pain and improve Harris Hip Score compared with traditional care in elderly hip fracture patients? We searched key databases and gray literature and analyzed outcomes through a meta-analysis using RevMan, Stata, and the Newcastle-Ottawa Scale for quality assessment.

RESULTS

Nine studies involving 10,359 patients were included. Compared with the control group, the enhanced recovery after surgery group showed significant reduction in length of stay (mean difference [MD] = -2.00; 95% confidence interval [CI] [-2.87, -1.14]; p < .0001) and overall complication rate (risk ratio [RR] = 0.76; 95% CI [0.67, 0.85]; p < .0001), with a lower delirium rate (RR = 0.42; 95% CI [0.26, 0.68]; p = .004). No significant differences were observed in Harris Hip Score, pain score, 1-year mortality, readmission rate, or incidences of urinary tract infection, respiratory tract infection, and deep vein thrombosis.

CONCLUSION

Enhanced recovery after surgery is associated with reduced length of stay, complication rate, and delirium rate in hip fracture patients.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Enhanced Recovery After Surgery (ERAS) Protocol in Geriatric Hip Fractures: An Observational Study

INTRODUCTION

Geriatric hip fractures are the new global pandemic. It is predicted to reach 7.3-21.3 million cases worldwide by 2050. Even with optimal care, geriatric patients suffer a higher morbidity and mortality rate when compared with the general population and often demand expensive hospital aftercare. This study aims to assess the implications of the successful adoption of the enhanced recovery after surgery (ERAS) protocol in the management of geriatric hip fractures in an Indian facility.

METHODS

This is a retrospective study conducted in a tertiary care hospital in India and reported following REporting of studies Conducted using the Observational Routinely collected health Data (RECORD) guidelines. We included all geriatric patients over 60 years of age who were admitted with hip fractures for surgical management between January 2021 and January 2023. The individual perioperative components of the ERAS protocol focus on key areas such as preoperative nutritional support, effective multimodal analgesia with optimal pain control, fluid management, and early postoperative mobilization.

RESULTS

Thirty-eight geriatric patients with a mean age of 77.5 (± 9.6) years were included for analysis. Twenty-three patients sustained intertrochanteric fractures and underwent fixation with proximal femur nailing and the remaining had 15 sustained neck or femur fractures of which 11 underwent hemiarthroplasty surgery and the remaining four underwent a total hip replacement. The mean time to surgery was 2 (± 0.2) days. Eighty-two percent (n=31) of the patients were mobilized with a walking frame within a day after surgery and were followed up after discharge with home physiotherapy. The mean time to ambulation was 2 (± 0.62) days. The mean length of stay was 4 (± 1.6) days. We had a 30-day readmission rate of 5.2% (n=2) and a 30-day mortality rate of 5.2% (n=2). The one-year mortality rate was 13% (n=5).

CONCLUSION

Management of geriatric hip fractures requires exceptional interdisciplinary coordination and carefully planned strategies to optimize patient care. With the implementation of the ERAS protocol, we could perceive clinical benefits in terms of early recovery and short length of hospital stay in patients with hip fractures. Further comparative studies are required, which can determine the relative importance of individual measures in the ERAS protocol and understand their longer-term outcomes in hip fracture surgeries.

Outcomes of Geriatric Hip Fractures in a Tertiary Referral Center in Malaysia During the COVID-19 Pandemic

Introduction With the advancing age of the population, there are an increasing number of patients with geriatric hip fractures. Despite the advancement of surgical knowledge and improvement of implant designs to treat geriatric hip fractures, mortality and morbidity remain high among these frail patients. In conjunction with the COVID-19 pandemic, the collateral damage dealt to these patients remains unknown as scarce resources are funneled to deal with the pandemic. This study is geared to investigate the surgical outcomes of patients with geriatric hip fractures who were admitted during the initial phase of the COVID-19 pandemic. Methods This retrospective study was carried out at Hospital Kuala Lumpur, the largest public hospital in the capital of Malaysia, from March 1, 2020, to March 1, 2021. All patients of age 60 years and above were screened for suitability. Only patients who had undergone surgical intervention during the study period were included in this study. Patients' demographic data, mechanism of injury, waiting time for surgery, type of surgery, complications and ambulatory status were obtained from the medical records. Univariate analysis was performed to determine the factors associated with complications as well as the post-operative ambulatory status of the patients. Results A total of 52 patients were included in this study, with a median age of 72 years. The majority of the patients were Chinese (n=21, 40.4%). This was followed by Malay and Indian (n=14, 26.9% each) and other ethnicity (n=3, 5.8%). More than three-quarters of the patients had a trivial injury such as a fall due to a miss-step (n=16, 30.8%) and slip (n=16, 30.8%) and a fall due to dizziness (n=8, 15.4%). Only 12 patients (23.1%) sustained hip fractures due to trauma. The median time to surgery for these patients was 5 days (interquartile range: 4 days). Most of these patients underwent total hip replacement (n=30, 57.7%). This was followed by unipolar hemiarthroplasty (n=11, 21.2%), bipolar hemiarthroplasty (n=10, 19.2%) and internal fixation (n=1, 1.9%). Among these patients, six of them had documented complications. There were periprosthetic joint infection (n=2, 3.8%), dislocation (n=2, 3.8%), hematoma formation (n=1, 1.9%) and seroma (n=1, 1.9%). Six months after the surgery, most of the patients were able to ambulate, albeit some patients required walking aid such as walking stick and walking frame. Univariate analysis showed that all the factors were not associated with the complications and the post-operative ambulatory status of the patients. Conclusion  The incidence of geriatric hip fractures remains high during the COVID-19 pandemic despite the movement control order (MCO) being enforced in Malaysia. With prompt surgical intervention, most of the patients can regain ambulatory status, albeit with a walking aid.

Short-Term Outcomes of Enhanced Recovery after Surgery (ERAS) for Ankle Fracture Patients: A Single-Center Retrospective Cohort Study

OBJECTIVE

Enhanced recovery after surgery (ERAS) has been successfully adopted for the improvement of medical quality and efficacy in many diseases, but the effect thereof for ankle fracture patients can vary. The aim of the present study was to explore the short-term postoperative outcomes of ERAS among ankle fracture patients.

METHODS

The present study was a retrospective cohort study conducted between January 2019 and May 2019. One hundred and sixty ankle fracture participations (58 males and 102 females, aged 41.71 ± 14.51 years) were included. The participants treated with open reduction and internal fixation were divided into two groups (non-ERAS vs. ERAS) depending on whether ERAS was applied. Postoperative outcomes included American Orthopedic Foot and Ankle Society (AOFAS) score, length of stay (LOS), hospital cost, complications, and consumption of opioids. To assess the association between the groups and outcomes, generalized estimating equation (GEE) modeling and multivariable linear regression analysis were performed.

RESULTS

The average follow-up periods of the participations were 24 months postoperatively. No significant differences were detected between the non-ERAS group and ERAS group with respect to the demographic of patients in terms of gender, age, Danis-Weber classification of fracture, dislocation of ankle joint, and comorbidity (P > 0.05). Significant differences in terms of a higher AOFAS score were found in the ERAS group compared with the non-ERAS group (6.73, 95% CI, 5.10-8.37, p < 0.001) at 3 months postoperatively (PO3M) and (4.73, 95% CI, 3.02-6.45, p < 0.001) at 6 months postoperatively (PO6M). However, similar AOFAS scores were found at 12 months postoperatively (PO12M) (0.28, 95% CI, -0.32 to 0.89, P > 0.05) and at 24 months postoperatively (PO24M) (0.56, 95% CI, -0.07 to 1.19, P > 0.05). Additionally, the GEE analysis and group-by-time interaction of AOFAS score revealed that the ERAS protocol could facilitate faster recovery for ankle fracture patients, with higher PO3M and PO6M (both P < 0.05). At the same time, significant differences in terms of a shorter length of stay (-3.19, 95% CI, -4.33 to -2.04, P < 0.01) and less hospital cost (-6501.81, 95% CI, -10955.21 to -2048.42, P < 0.01) were found in the ERAS group compared with the non-ERAS group.

CONCLUSION

By reducing LOS and hospital cost, the ERAS protocol might improve the medical quality and efficacy. The present study can provide a realistic evaluation and comparison of the ERAS protocol among ankle fracture patients, and ultimately guide clinical decision making.

Patient characteristics and procedural variables are associated with length of stay and hospital cost among unilateral primary total hip arthroplasty patients: a single-center retrospective cohort study

BACKGROUND

Total hip arthroplasty (THA) is a successful treatment for many hip diseases. Length of stay (LOS) and hospital cost are crucial parameters to quantify the medical efficacy and quality of unilateral primary THA patients. Clinical variables associated with LOS and hospital costs haven't been investigated thoroughly.

METHODS

The present study retrospectively explored the contributors of LOS and hospital costs among a total of 452 unilateral primary THA patients from January 2019 to January 2020. All patients received conventional in-house rehabilitation services within our institute prior to discharge. Outcome parameters included LOS and hospital cost while clinical variables included patient characteristics and procedural variables. Multivariable linear regression analysis was performed to assess the association between outcome parameters and clinical variables by controlling confounding factors. Moreover, we analyzed patients in two groups according to their diagnosis with femur neck fracture (FNF) (confine THA) or non-FNF (elective THA) separately.

RESULTS

Among all 452 eligible participants (266 females and 186 males; age 57.05 ± 15.99 year-old), 145 (32.08%) patients diagnosed with FNF and 307 (67.92%) diagnosed with non-FNF were analyzed separately. Multivariable linear regression analysis revealed that clinical variables including surgery duration, transfusion, and comorbidity (stroke) among the elective THA patients while the approach and comorbidities (stoke, diabetes mellitus, coronary heart disease) among the confine THA patients were associated with a prolonged LOS (P < 0.05). Variables including the American Society of Anesthesiologists classification (ASA), duration, blood loss, and transfusion among the elective THA while the approach, duration, blood loss, transfusion, catheter, and comorbidities (stoke and coronary heart disease) among the confine THA were associated with higher hospital cost (P < 0.05). The results revealed that variables were associated with LOS and hospital cost at different degrees among both elective and confine THA.

CONCLUSIONS

Specific clinical variables of the patient characteristics and procedural variables are associated the LOS and hospital cost, which may be different between the elective and confine THA patients. The findings may indicate that evaluation and identification of detailed perioperative factors are beneficial in managing perioperative preparation, adjusting patients' anticipation, decreasing LOS, and reducing hospital cost.

Accelerated rehabilitation in treating neer type V distal clavicle fractures using anatomical locking plates with coracoclavicular ligament augmentation

Background

There is still no gold standard treatment for Neer type V distal clavicle fractures. This study was designed to evaluate the therapeutic effects of accelerated rehabilitation in treating Neer type V fractures using anatomical locking plate (ALP) fixation with additional coracoclavicular (CC) ligament augmentation.

Methods

In this retrospective study, patients who underwent ALP fixation with additional suture anchor fixation of acute Neer type V distal clavicle fracture from January 2016 to January 2021 were reviewed. Injury radiography and computed tomography (CT) were performed to determine the Neer classification. All patients performed standardized early rehabilitation exercises after surgery and were followed up for more than 12 months. The Constant-Murley score (CMS); the disabilities of the arm, shoulder, and hand (DASH) questionnaire; visual analog scale (VAS); and the percentage of modified CC distance (MCCD%) were evaluated at the last follow-up.

Results

Thirty-two patients were included in this study. The mean follow-up time was 31.1 ± 10.4 months. All patients achieved bone union 6-8 weeks (7.2 ± 0.7 weeks) after surgery and were allowed to return to normal daily life. No surgery-related complications occurred in any case. The MCCD% value at the last follow-up (104.7% ± 8.5%) significantly decreased compared with preoperative MCCD% value (162.8% ± 7.2%) (p < 0.001), indicating that all patients achieved ideal fracture reduction. And all patients obtained satisfactory shoulder joint function with a mean CMS of 97.1 ± 2.6, a mean DASH score of 1.6 ± 1.3, and a mean VAS score of 0.4 ± 0.6.

Conclusion

This study has demonstrated that ALP fixation with additional suture anchor fixation is a promising strategy for accelerated rehabilitation in treating patients with Neer type V fracture.

Can the systemic inflammation score be used to predict prognosis in gastric cancer patients undergoing surgery? A systematic review and meta-analysis

Background

Inflammatory markers are being increasingly used to predict the prognosis of cancer patients. We hereby conducted the first meta-analysis assessing the association between systemic inflammation score (SIS) and prognosis of gastric cancer patients undergoing surgical intervention.

Methods

A literature search was carried out on PubMed, CENTRAL, Scopus, and Embase up to 3rd June 2022 for relevant studies. Adjusted data reported as hazard ratios (HR) was combined in a random-effects model.

Results

A total of seven studies with 5,338 patients could be included. All studies were from either China or Japan and published in the last four years. Meta-analysis showed that higher SIS scores (1 or 2) were significant predictors of poor overall survival (OS) in gastric cancer patients (HR: 1.25 95% CI: 1.05, 1.49, I²= 11%). Similarly, the meta-analysis demonstrated that an SIS score of 2 was associated with poor OS as compared to scores of 0/1 (HR: 2.53 95% CI: 1.30, 4.89, I²= 45%). Data on disease-free survival (DFS) was scarce to draw conclusions.

Conclusion

The SIS score can be a simple and useful tool to predict OS in gastric cancer patients undergoing surgery. Data on DFS is scarce and conflicting. Future studies should report using standard reference groups and provide data on DFS to enhance current evidence.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/#searchadvanced, identifier: CRD42022335548.

COVID-19 Elderly Patients Treated for Proximal Femoral Fractures during the Second Wave of Pandemic in Italy and Iran: A Comparison between Two Countries

Background and objevtive: The worldwide spread of SARS-CoV-2 has affected the various regions of the world differently. Italy and Iran have experienced a different adaptation to coexistence with the pandemic. Above all, fractures of the femur represent a large part of the necessary care for elderly patients. The aim of this study was to compare the treatment in Italy and Iran of COVID-19-positive patients suffering from proximal femur fractures in terms of characteristics, comorbidities, outcomes and complications. Materials and Methods: Medical records of COVID-19-positive patients with proximal femoral fractures treated at IRCCS Istituto Ortopedico Galeazzi in Milan (Italy) and at Salamat Farda and Parsa hospitals in the province of Tehran (Iran), in the time frame from 1 October 2020 to 16 January 2021, were analyzed and compared. Results: Records from 37 Italian patients and 33 Iranian patients were analyzed. The Italian group (mean age: 83.89 ± 1.60 years) was statistically older than the Iranian group (mean age: 75.18 ± 1.62 years) (p value = 0.0003). The mean number of transfusions for each patient in Italy was higher than the Iranian mean number (p value = 0.0062). The length of hospital stay in Italy was longer than in Iran (p value < 0.0001). Furthermore, laboratory values were different in the post-operative value of WBC and admission and post-operative values of CRP. Conclusions: The present study shows that differences were found between COVID-19-positive patients with proximal femoral fractures in these two countries. Further studies are required to validate these results and to better explain the reasons behind these differences.

Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment

Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.

Effect of WeChat-Based Health Preaching Combined with an Enhanced Recovery after Surgery Model on Perioperative Limb Motor Function and Complications in Orthopaedic Patients

Objective

To evaluate the effect of WeChat-based health preaching combined with an enhanced recovery after surgery (ERAS) model on perioperative limb motor function and complications in orthopaedic patients.

Methods

By means of retrospective analysis, the medical data of 68 orthopaedic patients who received surgical treatment in our hospital (from 01, 2020–12, 2021) were collected, and the patients were equally divided into the study group (SG) and control group (CG) according to their admission order, with 34 cases each. From 7 d before surgery to the time of hospital discharge, WeChat-based health preaching combined with ERAS perioperative nursing was performed to patients in the SG, and routine orthopaedic perioperative nursing was performed to those in the CG. Before and after nursing, patients' Visual Analog Scale for Fatigue (VAS-F) scores, Houston Pain Outcome Instrument (HPOI) scores, and brief Fu-gI-Meyer (FMA) motor scores were investigated and the incidence rates of postoperative complications and nursing satisfaction of patients in the two groups were recorded.

Results

After nursing, SG obtained a significantly better VAS-F score and HPOI score (P < 0.001), significantly higher postoperative 7 d and predischarge lower limb FMA scores (20.06 ± 2.13 vs 18.38 ± 2.36, 27.50 ± 1.90 vs 24.09 ± 2.25, P < 0.05), and significantly lower annual incidence rate of complications compared with those of the CG (P < 0.05); and the nursing satisfaction scores of the SG and CG were 9.18 ± 0.82 points and 6.76 ± 0.91 points, respectively, indicating significantly higher nursing satisfaction in the SG than in the CG (P < 0.001).

Conclusion

The nursing model of WeChat-based health preaching combined with ERAS can effectively improve the knowledge level of orthopaedic patients, thereby improving their abilities of pain management and self-management, accelerating the recovery of their limb function, and reducing the incidence rate of postoperative complications. The patients are more satisfied with such nursing model, indicating its better promotion value.

Enhanced recovery after surgery for major orthopedic surgery: a narrative review

Background

With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully.

Main body

Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary.

Conclusion

The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.

Effect of Different Anesthesia and Puncture Methods of Percutaneous Kyphoplasty on More Than 90-Year-Old Osteoporotic Vertebral Fracture: Advantages of the ERAS Concept

BACKGROUND

Percutaneous kyphoplasty (PKP) is an effective minimally invasive technique for the treatment of osteoporotic vertebral fracture (OVF) in recent years. This study focuses on the analysis of PKP surgery and anesthesia in osteoporotic vertebral facture patients over 90 years old with the concept of "enhanced recovery after surgery."

METHODS

This study reviewed 239 patients who were diagnosed with OVF retrospectively between October 2015 and June 2019. According to the method of anesthesia, these patients were divided into Group A (n = 125) and Group B (n = 114). According to the pedicle puncture approach, these patients were divided into Group C (n = 102) and Group D (n = 137). The anterior vertebral height (AVH) and local kyphosis angle (LKA) were used to evaluate the degree of vertebral damage and restoration. The visual analogue scale (VAS) and the Oswestry Disability Index (ODI) scores were used for assessing functional outcomes. Some parameters were used to assess the perioperative conditions such as operation time, amount of bone cement perfusion, intraoperative fluoroscopy times, anesthesia recovery time, time out of the bed, hospital stay, hospitalization cost, and complications.

RESULTS

The visual analogue scale (VAS), Oswestry Disability Index (ODI), anterior vertebral height (AVH), and local kyphosis angle (LKA) 1 day, 1 year after surgery, and at the last follow-up all showed significant improvement (P < 0.05) in comparison with those before surgery both in Groups A and B and Groups C and D. The ODI 1 day after surgery was significantly better in Group B than Group A (P < 0.05). Compared with Group B, Group A required longer time of anesthesia, operation time, anesthesia recovery time, time to get out of bed, and length of hospital stay and more hospitalization costs (P < 0.05). Group D required longer operation time, longer time to get out of bed, more bone cement volume, fluoroscopy time, and more operation hospitalization costs compared with Group C (P < 0.05).

CONCLUSION

We recommend unilateral puncture under local anesthesia for OVF in the patients aged over 90 from the perspective of rapid recovery.

Association between General Anesthesia and the Occurrence of Cerebrovascular Accidents in Hip Fracture Patients

Background

General anesthesia is an important factor leading to postoperative complications, and cerebrovascular accidents take the first place in the causes of postoperative death. Therefore, it is extremely important to explore the correlation between general anesthesia and the occurrence of cerebrovascular accidents in hip fracture patients.

Objective

To explore the association between general anesthesia and the occurrence of cerebrovascular accidents in hip fracture patients.

Methods

The data of 240 hip fracture patients treated in our hospital from February 2017 to February 2021 were retrospectively analyzed, and the patients were divided into the general anesthesia group (n = 120) and nongeneral anesthesia group (n = 120) according to whether or not they received general anesthesia, so as to compare their incidence rate of cerebrovascular accidents between the two groups, record their hemodynamic changes, and analyze the association between various risk factors under general anesthesia and the occurrence of cerebrovascular accidents.

Results

No statistical differences in patients' general information such as age and gender between the two groups were observed (P > 0.05); compared with the nongeneral anesthesia group, the incidence rate of cerebrovascular accidents was significantly higher in the general anesthesia group (P < 0.001); between the two groups, the heart rates and mean arterial pressure (MAP) at 15 min after anesthesia, at the time of skin incision, and 15 min before the end of surgery were significantly different (P < 0.05); according to the multiple logistic regression analysis, general anesthesia was a risk factor affecting the occurrence of cerebrovascular accidents in hip fracture patients, and under general anesthesia, age ≥80 years, BMI ≥23 kg/m², types of anesthetic drugs ≥4, intraoperative blood pressure ≥140 mmHg, and intraoperative heart rate ≥80 bpm were also regarded as the risk factors.

Conclusion

General anesthesia is a risk factor affecting the occurrence of cerebrovascular accidents in hip fracture patients, and under general anesthesia, age ≥80 years, BMI ≥23 kg/m², types of anesthetic drugs ≥4, intraoperative blood pressure ≥140 mmHg, and intraoperative heart rate ≥80 bpm will further increase the possibility of cerebrovascular accidents.