Outcome assessment after hip fracture: is EQ-5D the answer?

Trochleoplasty Provides Good Outcomes for Recurrent Patellofemoral Dislocations with No Clear Superiority across Different Techniques

Background: Literature is sparse on outcome comparisons between different trochleoplasty techniques in the treatment of patella instability. To date, it is unclear whether there is a technique that offers superior outcomes. This systematic review and meta-analysis aims to compare and evaluate the outcomes of trochleoplasty techniques in the treatment of patellofemoral instability in trochlea dysplasia to establish whether there is an ideal choice of trochleoplasty technique for superior outcomes. Methods: 21 studies involving 880 knees were included. The mean age of the patients was 21.7 years (range 8-49 years). Mean follow-up timeframe of 43.5 months (range 8.8-100 months). Clinical outcomes assessed included rates of recurrence of patellofemoral dislocation, patient satisfaction, Kujala score, International Knee Documentation Committee (IKDC) score, Tegner score, and Lysholm score. Egger's test showed no publication bias across all outcomes assessed. Results: Favourable results were seen across all outcomes assessed and patient satisfaction. Improvements were seen with Kujala, IKDC, and Lysholm scores. Tegner scores showed good return to function. Post-operative dislocation and complication rates were low across the different techniques. Meta-regression for Kujala and IKDC scores showed good outcomes regardless of trochleoplasty technique used (Kujala, p = 0.549, relative risk 492.06; IKDC, p = 0.193, RR 0.001). The exact risk that trochleoplasty poses to the cartilage remains uncertain, as no study had a conservatively managed arm for comparison. Conclusions: Trochleoplasty yielded good outcomes irrespective of technique used with no clear superiority demonstrated in any technique in terms of outcome scores, satisfaction, post-operative dislocation rates or complications.

Acetabular Fractures in older patients Intervention Trial (AceFIT): a feasibility triple-arm randomized controlled study

Aims

To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment.

Methods

Patients were recruited from seven UK NHS centres and randomized to a three-arm pilot trial if aged older than 60 years and had a displaced acetabular fracture. Feasibility outcomes included patients' willingness to participate, clinicians' capability to recruit, and dropout rates. The primary clinical outcome measure was the EuroQol five-dimension questionnaire (EQ-5D) at six months. Secondary outcomes were Oxford Hip Score, Disability Rating Index, blood loss, and radiological and mobility assessments.

Results

Between December 2017 and December 2019, 60 patients were recruited (median age 77.4 years, range 63.3 to 88.5) (39/21 M/F ratio). At final nine-month follow-up, 4/60 (7%) had withdrawn, 4/60 (7%) had died, and one had been lost to follow-up; a 98% response rate (50/51) was achieved for the EQ-5D questionnaire. Four deaths were recorded during the three-year trial period: three in the non-surgical treatment group and one in the fix-and-replace group.

Conclusion

This study has shown a full-scale RCT to be feasible, but will need international recruitment. The Acetabular Fractures in older patients Intervention Trial (AceFIT) has informed the design of a multinational RCT sample size of 1,474 or 1,974 patients for a minimal clinically important difference of 0.06 on EQ-5D, with a power of 0.8 or 0.9, and loss to follow-up of 20%. This observed patient cohort comprises a medically complex group requiring multidisciplinary care; surgeon, anaesthetist, and ortho-geriatrician input is needed to optimize recovery and rehabilitation.

Pinloc or Hansson pins: a multicenter, randomized controlled study of 439 patients treated for femoral neck fractures

Objectives

To compare the recently developed Hansson Pinloc system, which features 3 cylindrical parallel pins with hooks connected through a fixed-angle interlocking plate, with the Hansson Pin System (2 hook pins) for the treatment of femoral neck fractures.

Design

One hundred fourteen patients with displaced femoral neck fractures and 325 patients with nondisplaced fractures from 9 orthopaedic centers were randomized to either Hansson Pinloc system or Hansson Pin System and followed for 2 years or until death. Age at inclusion was 50 years or older.

Main Outcome Measurements

The primary outcome was failure (defined as early displacement, nonunion, symptomatic avascular necrosis, or deep infection). Secondary outcomes included revision surgery, Timed Up and Go (TUG) test and patient-reported outcome measures (PROMs: EQ-5D and WOMAC).

Results

For nondisplaced fractures, the incidence of failure was 14% (23/169) in the Pinloc group and 16% (25/156) in the Hansson group. For displaced fractures, the analysis was stratified by age. Patients aged 50-69 years with displaced fractures showed a 2-year failure rate of 44% (17/39) in the Pinloc group versus 44% (16/36) in the Hansson group. For patients 70 years or older with displaced fractures, 33% (7/21) in the Pinloc group versus 22% (4/18) in the Hansson group failed. At 3 and 12 months, no clinically significant differences between treatment groups were found for EQ-5D-3L, WOMAC, or for the TUG in any fracture type or age group.

Conclusions

There were no advantages for Pinloc in any of the studies aspects.

Level of evidence

1.

SF-36 physical function and general health domains are independent predictors of acute hospital length of stay after hip fracture surgery

OBJECTIVE

The demographics and co-morbidities of individuals may impact healthcare consumption, but it is less understood how premorbid physical and mental function may influence these effects. The aim of this study is to determine patient's pre-fracture quality of life and mobility affect acute hospital burden in the management of hip fracture, using length of stay (LOS) as a proxy for healthcare resource.

MATERIALS AND METHODS

This is a retrospective study which investigated hip fracture patients who underwent surgery over the period of 2017-2020. Variables collected include LOS, age, gender, race, marital status, payer type, ASA score, time to surgery (TTS), type of surgery, fracture type, POD1 mobilization, discharge disposition, pre-fracture SF-36, EQ-5D and Parker mobility score (PMS) based on patient's recollection on admission. These variables were correlated with LOS using binary logistic regression on SAS.

RESULTS

There were 1045 patients, and mean age was 79.5 + 8.57 (range 60-105) years with an average LOS 13.64 + 10.0 days (range 2-114). On univariate analysis, PMS, EQ-5D and all domains of SF-36 except bodily pain (BP), emotional role and mental health were associated significantly with LOS. Amongst the QOL and PMS scores, only the domains of SF-36 Physical Function (PF) (OR = 0.993, p = 0.0068) and General Health perception (GH) (OR 0.992, p = 0.0230) remained significant on the multivariate model.

CONCLUSION

Our study showed that poor premorbid scores of SF36 PF and GH are independent factors associated with longer LOS in hip fracture patients after surgery, regardless of fracture type, age and ASA status. Hence, premorbid SF36 PF and GH can be used to identify patients that are at risk of prolonged hospital stay and employ targeted strategies to facilitate rehabilitation and discharge planning.

High-dose dual-antibiotic loaded cement for hip hemiarthroplasty in the UK (WHiTE 8): a randomised controlled trial

BACKGROUND

Hip fracture is the most common injury requiring treatment in hospital. Controversy exists regarding the use of antibiotic loaded bone cement in hip fractures treated with hemiarthroplasty. We aimed to compare the rate of deep surgical site infection in patients receiving high-dose dual-antibiotic loaded cement versus standard care single-antibiotic loaded cement.

METHODS

We included people aged 60 years and older with a hip fracture attending 26 UK hospitals in this randomised superiority trial. Participants undergoing cemented hemiarthroplasty were randomly allocated in a 1:1 ratio to either a standard care single-antibiotic loaded cement or high-dose dual-antibiotic loaded cement. Participants and outcome assessors were masked to the treatment allocation. The primary outcome was deep surgical site infection at 90 days post-randomisation as defined by the US Centers for Disease Control and Prevention in an as-randomised population of consenting participants with available data at 120 days. Secondary outcomes were quality of life, mortality, antibiotic use, mobility, and residential status at day 120. The trial is registered with ISRCTN15606075.

FINDINGS

Between Aug 17, 2018, and Aug 5, 2021, 4936 participants were randomly assigned to either standard care single-antibiotic loaded cement (2453 participants) or high-dose dual-antibiotic loaded cement (2483 participants). 38 (1·7%) of 2183 participants with follow-up data in the single-antibiotic loaded cement group had a deep surgical site infection by 90 days post-randomisation, as did 27 (1·2%) of 2214 participants in the high-dose dual-antibiotic loaded cement group (adjusted odds ratio 1·43; 95% CI 0·87-2·35; p=0·16).

INTERPRETATION

In this trial, the use of high-dose dual-antibiotic loaded cement did not reduce the rate of deep surgical site deep infection among people aged 60 years or older receiving a hemiarthroplasty for intracapsular fracture of the hip.

FUNDING

Heraeus Medical. Supported by the UK National Institute for Health and Care Research Oxford Biomedical Research Centre.

Socio-demographic disparities in health-related quality of life after hip fracture in China: evidence from the China Health and Retirement Longitudinal Study

This study analyzed the impact of hip fractures on people's health-related quality of life and its socio-demographic disparities in China.

PURPOSE

Hip fractures cause high mortality and worsened health-related quality of life (HRQoL). This study aimed to investigate whether socio-demographic-related inequities in post-hip fracture participants' HRQoL exist in China.

METHODS

Data from the China Health and Retirement Longitudinal Study (waves 2013, 2015, and 2018) were used. The measurement of HRQoL in this study focused on 5 health dimensions: depression, body pain, mobility, basic activities of daily living, and instrumental activities of daily living. A difference-in-differences (DID) analysis with multiple time periods was performed to gauge the impact of hip fracture on HRQoL. A multivariate regression approach was used to explore socio-demographic-related factors associated with inequities of HRQoL.

RESULTS

A total of 23,622 individuals were included, and 341 participants reported hip fracture events during the survey period. In participants with hip fracture, the presentation rate of body pain increased by 14% (p < 0.01) and the HRQoL of other health dimensions worsened (p ≤ 0.01) after hip fracture. The DID analysis showed that hip fracture had a negative impact on all HRQoL dimensions (p < 0.01). Socioeconomic-related factors of HRQoL inequities included school education level and location of residence. Study participants with hip fracture with greater educational attainment or living in urban areas had higher (p < 0.05) levels of HRQoL. In addition, comorbidities also correlated with a worse HRQoL (p < 0.05).

CONCLUSION

Hip fracture significantly affects people's HRQoL in China, and the impact is more profound for those with lower educational attainment or living in rural areas. Targeted interventions should be designed to narrow this inequity.

Developing a Modeling Framework for Quantifying the Health and Cost Implications of Antibiotic Resistance for Surgical Procedures

Background. Antimicrobial resistance (AMR) is a global public health threat. The wider implications of AMR, such as the impact of antibiotic resistance (ABR) on surgical procedures, are yet to be quantified. The objective of this study was to produce a conceptual modeling framework to provide a basis for estimating the current and potential future consequences of ABR for surgical procedures in England. Design. A framework was developed using literature-based evidence and structured expert elicitation. This was applied to populations undergoing emergency repair of the neck of the femur and elective colorectal resection surgery. Results. The framework captures the implications of increasing ABR by allowing for higher rates of surgical site infection (SSI) as the effectiveness of antibiotic prophylaxis wanes and worsened outcomes following SSIs to reflect reduced antibiotic treatment effectiveness. The expert elicitation highlights the uncertainty in quantifying the impact of ABR, reflected in the results. A hypothetical SSI rate increase of 14% in a person undergoing emergency repair of the femur could increase costs by 39% (-2% to 108% credible interval [CI]) and decrease quality-adjusted life-years by 11% (0.4% to 62% CI) over 15 y. Conclusions. The modeling framework is a starting point for addressing the implication of ABR on the outcomes and costs of surgeries. Due to clinical uncertainty highlighted in the expert elicitation process, the numerical outputs of the case studies should not be focused on but rather the framework itself, illustration of the evidence gaps, the benefit of expert elicitation in quantifying parameters with limited data, and the potential magnitude of the impact of ABR on surgical procedures. Implications. The framework can be used to support research surrounding the health and cost burden of ABR in England.

Highlights

The modeling framework is a starting point for assessing the health and cost impacts of antibiotic resistance on surgeries in England.Formulating a framework and synthesizing evidence to parameterize data gaps provides targets for future research.Once data gaps are addressed, this modeling framework can be used to feed into overall estimates of the health and cost burden of antibiotic resistance and evaluate control policies.

Lateral compression type 1 fracture fixation in the elderly (L1FE): study protocol for a randomised controlled trial (with internal pilot) comparing the effects of INFIX surgery and non-surgical management for treating patients with lateral compression type 1 (LC-1) fragility fractures

BACKGROUND

Lateral compression type1 (LC-1) fragility fractures are a common, painful injury in older adults resulting in reduced mobility. The incidence of these fractures is increasing with the growing older adult population. The current standard of care is non-surgical management; however, patients with this injury are at risk of long-term immobility and related complications. INFIX is a pelvic fixation device used in younger patients with high-energy fractures. The device is fitted via a percutaneous technique with no external pin sites and has good purchase even in osteoporotic bone. It therefore has the potential to be well tolerated in patients with LC-1 fragility fractures. INFIX could improve patients' ability to mobilise and reduce the risk of immobility-related complications. However, there is a risk of complications related to surgery, and robust evidence is required on patient outcomes. This study will investigate the clinical and cost-effectiveness of surgical fixation with INFIX compared to non-surgical management of LC-1 fragility fractures in older adults.

METHODS

A multi-centre randomised controlled trial of 600 patients allocated 1:1 to non-surgical management or INFIX surgery. The study will have a 12-month internal pilot to assess recruitment and trial feasibility. The primary outcome will be the patient quality of life over 6 months, measured by the patient-reported EQ-5D-5L. The secondary outcomes will include physical function, mental health, pain, delirium, imaging assessment, resource use, and complications.

DISCUSSION

The L1FE study aims to compare the clinical and cost-effectiveness of surgical and non-surgical management of people aged 60 years and older with LC-1 fragility fractures. The trial is sufficiently powered and rigorously designed to inform future clinical and patient decision-making and allocation of NHS resources.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number Registry ISRCTN16478561. Registered on 8 April 2019.

Health-related quality of life and associated factors after hip fracture. Results from a six-month prospective cohort study

Background

Hip fractures are a major public health problem with increasing relevance in aging societies. They are associated with high mortality rates, morbidity, and loss of independence. The aim of the EMAAge study was to determine the impact of hip fractures on patient-reported health-related quality of life (HRQOL), and to identify potential risk factors for worse outcomes.

Methods

EMAAge is a multicenter, prospective cohort study of patients who suffered a hip fracture. Patients or, if necessary, proxies were interviewed after initial treatment and after six months using standardized questionnaires including the EQ-5D-5L instrument, the Oxford Hip Score, the PHQ-4, the Short Nutritional Assessment Questionnaire, and items on patients living situation. Medical data on diagnoses, comorbidities, medications, and hospital care were derived from hospital information systems.

Results

A total of 326 patients were included. EQ-5D index values decreased from a mean of 0.70 at baseline to 0.63 at six months. The mean self-rated health on the EQ-VAS decreased from 69.9 to 59.4. Multivariable linear regression models revealed three relevant associated factors with the six-months EQ-5D index: symptoms of depression and anxiety, pre-fracture limitations in activities of daily living, and no referral to a rehabilitation facility had a negative impact. In addition, the six-months EQ-VAS was negatively associated with polypharmacy, living in a facility, and migration background.

Conclusions

Hip fractures have a substantial negative impact on patients HRQOL. Our results suggest that there are modifying factors that need further investigation including polypharmacy and migration background. Structured and timely rehabilitation seems to be a protective factor.

Measurement properties of the EQ-5D in populations with a mean age of ≥ 75 years: a systematic review

PURPOSE

Healthcare interventions for middle-old and oldest-old individuals are often (economically) evaluated using the EQ-5D to measure health-related quality of life (HrQoL). This requires sufficient measurement properties of the EQ-5D. Therefore, the current study aimed to systematically review studies assessing the measurement properties of the EQ-5D in this population.

METHODS

The databases PubMed, Cochrane library, Web of Science, Embase, and EconLit were searched for studies providing empirical evidence of reliability, validity, and/or responsiveness of the EQ-5D-3L and EQ-5D-5L in samples with a mean age ≥ 75 years. Studies were selected by two independent reviewers, and the methodological quality was assessed using the COSMIN Risk of Bias checklist. Results were rated against updated criteria for good measurement properties (sufficient, insufficient, inconsistent, indeterminate). The evidence was summarized, and the quality of evidence was graded using a modified GRADE approach.

RESULTS

For both EQ-5D versions, high-quality evidence for sufficient convergent validity was found. Known-groups validity was sufficient for the EQ-5D-5L (high-quality evidence), whereas the results were inconsistent for the EQ-5D-3L. Results regarding the reliability were inconsistent (EQ-5D-3L) or entirely lacking (EQ-5D-5L). Responsiveness based on correlations of change scores with instruments measuring related/similar constructs was insufficient for the EQ-5D-3L (high-quality evidence). For the EQ-5D-5L, the available evidence on responsiveness to change in (Hr)QoL instruments was limited.

CONCLUSION

Since the responsiveness of the EQ-5D in a population of middle-old and oldest-old individuals was questionable, either using additional instruments or considering the use of an alternative, more comprehensive instrument of (Hr)QoL might be advisable, especially for economic evaluations.

The health-related quality of life for hemiarthroplasty and total hip arthroplasty in the elderly: A meta-analysis

Purpose

What constitutes the optimal surgical plan for femoral neck fractures (FNFs) in elderly patients is controversial. The European quality of life 5-Dimension Questionnaire (EU-5Q) is an international scale used to measure the health-related quality of life (HRQoL) after surgery. We aim to verify the hip arthroplasty effect in elderly patients by analyzing HRQoL scores in the EU-5Q scale.

Methods

We searched the EBSCO, Embase, PubMed, Ovid, Cochrane Library, and Web of Science databases using strict searching from established to 30 November 2022; used the Cochrane Library's Risk of Bias Assessment Tool and the Newcastle-Ottawa Scale to evaluate the literature; and used RevMan5.4.1 software to perform a meta-analysis. All the included studies used the EU-5Q scale to validate the overall outcomes for elderly hip arthroplasty.

Results

The final included literature is composed of four RCTs, two cohort studies, three case-control trials, and three cross-sectional surveys. This study compared HRQoL scores measured by the EU-5Q scale, including 328 elderly patients with total hip arthroplasty (THA) and 323 elderly patients with hemiarthroplasty, which is statistically significant (OR = 0.05; 95% CI, 0.02~0.08; P = 0.002). The subgroups were as follows: unipolar vs. bipolar and cemented vs. uncemented hemiarthroplasty (OR = 0.06; 95% CI, 0.03~0.08; P < 0.001), follow-up time and age arthroplasty (OR = 0.16; 95% CI, 0.11~0.22; P < 0.001), molecular exercise and enhanced recovery after surgery (ERAS) (OR = 0.02; 95% CI,-0.03~0.07; P = 0.38), and analysis of hemiarthroplasty with cognitive dysfunction vs. the normal group (OR = 0.17; 95% CI, 0.08~0.26; P < 0.001). The outcome analysis was consistent with the included studies, and HRQoL of the EU-5Q scale is sensitive to surgical outcomes between THA and hemiarthroplasty.

Conclusion

Surgeons still need to further evaluate and verify whether the hip arthroplasty surgical program or effect in elderly patients is optimal. Hemiarthroplasty operations in elderly patients have pointed toward a new direction for clinical treatment, and HRQoL scores measured by the EU-5Q can sensitively reflect the rehabilitation status after hip arthroplasty surgery. Moreover, the extensive correlation between surgical outcomes and perioperative neurocognitive function should be further investigated.

Preoperative health-related quality of life is independently associated with postoperative mortality risk following total hip or knee arthroplasty : seven to eight years' follow-up

AIMS

The primary aim was to assess whether preoperative health-related quality of life (HRQoL) was associated with postoperative mortality following total hip arthroplasty (THA) and knee arthroplasty (KA). Secondary aims were to assess whether patient demographics/comorbidities and/or joint-specific function were associated with postoperative mortality.

METHODS

Patients undergoing THA (n = 717) and KA (n = 742) during a one-year period were identified retrospectively from an arthroplasty register. Patient demographics, comorbidities, Oxford score, and EuroQol five-dimension (EQ-5D) were recorded preoperatively. Patients were followed up for a minimum of seven years and their mortality status was obtained. Cox regression analysis was used to adjust for confounding.

RESULTS

During the study period, 111 patients (15.5%) undergoing THA and 135 patients (18.2%) undergoing KA had died at a mean follow-up of 7.5 years (7 to 8). When adjusting for confounding, the preoperative EQ-5D was associated with postoperative mortality, and for each 0.1 difference in the utility there was an associated change in mortality risk of 6.7% (p = 0.048) after THA, and 6.8% (p = 0.047) after KA. Comorbidities of connective tissue disease (p ≤ 0.026) and diabetes (p ≤ 0.028) were associated with mortality after THA, whereas MI (p ≤ 0.041), diabetes (p ≤ 0.009), and pain in other joints (p ≤ 0.050) were associated with mortality following KA. The preoperative Oxford score was associated with mortality, and for each one-point change in the score there was an associated change in mortality risk of 2.7% (p = 0.025) after THA and 4.3% (p = 0.003) after KA.

CONCLUSION

Worse preoperative HRQoL and joint specific function were associated with an increased risk of postoperative mortality. Both HRQoL and joint-specific function decline with longer waiting times to surgery for THA and KA and therefore may result in an increased postoperative mortality risk than would have been expected if surgery had been undertaken earlier.Cite this article: Bone Jt Open 2022;3(12):933-940.

Clinical effectiveness and safety of spinal anaesthesia compared with general anaesthesia in patients undergoing hip fracture surgery using a consensus-based core outcome set and patient-and public-informed outcomes: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

We conducted a systematic review and meta-analysis of contemporary RCTs to determine the clinical effectiveness of spinal vs general anaesthesia (SA vs GA) in patients undergoing hip fracture surgery using a consensus-based core outcome set, and outcomes defined as important by patient and public involvement (PPI) initiatives.

METHODS

RCTs comparing any of the core outcomes (mortality, time from injury to surgery, acute coronary syndrome, hypotension, acute kidney injury, delirium, pneumonia, orthogeriatric input, being out of bed at day 1 postoperatively, and pain) or PPI-defined outcomes (return to preoperative residence, quality of life, and mobility status) between SA and GA were identified from MEDLINE, Embase, Cochrane Library, and Web of Science (2000 to February 2022). Pooled relative risks (RRs) and mean differences (95% confidence intervals [CIs]) were estimated.

RESULTS

There was no significant difference in the risk of delirium comparing SA vs GA (RR=1.07; 95% CI, 0.90-1.29). Comparing SA vs GA, the RR for mortality was 0.56 (95% CI, 0.22-1.44) in-hospital, 1.07 (95% CI, 0.52-2.23) at 30 days, and 1.08 (95% CI, 0.55-2.12) at 90 days. Spinal anaesthesia reduced the risk of acute kidney injury compared with GA: RR=0.59 (95% CI, 0.39-0.89). There were no significant differences in the risk of other outcomes. Few studies reported PPI-defined outcomes, with most studies reporting on one to three core outcomes.

CONCLUSIONS

Except for acute kidney injury, there were no differences between SA and GA in hip fracture surgery when using a consensus-based core outcome set and patient and public involvement-defined outcomes. Most studies reported limited outcomes from the core outcome set, and few reported outcomes important to patients, which should be considered when designing future RCTs.

PROSPERO REGISTRATION

CRD42021275206.

The effect of preexisting radiographic hip osteoarthritis on the functional recovery after surgical treatment of intertrochanteric fractures in elderly patients

OBJECTIVE

The aim of this study was to evaluate the effect of the grade of preexisting radiographic hip osteoarthritis on the functional outcome of elderly patients with intertrochanteric fractures treated by intramedullary fixation.

METHODS

We retrospectively examined the impact of the grade of preexisting osteoarthritis on the functional outcome of 88 patients older than 60 years with intertrochanteric fractures treated by intramedullary fixation. The patients were divided into 2 groups accord ing to the grade of osteoarthritis: group 1, including 52 patients (32 females and 20 males) with Kellgren-Lawrence grades 1 and 2, and group 2, including 36 patients (24 females and 12 males) with Kellgren-Lawrence grades 3 and 4. Functional outcomes were evaluated using the Harris hip score, visual analog scale, EuroQoL general health questionnaire, and the Barthel index.

RESULTS

The mean age was 74.8 ± 5.5 (range=63-87) years in group 1 and 75.06 ± 5.3 (range=64-87) years in group 2. At the last follow-up, the mean Harris hip score was significantly higher in group 1 (71.3 ± 4.3) than that of group 2 (69.5 ± 3.5) (P=.047). There was no signifi cant difference between the groups in terms of the visual analog scale (P=.102), EuroQoL general health questionnaire (P=.144), and the Barthel index (P=.261) scores. The EuroQoL general health questionnaire and Barthel index scores were worse with increasing age.

CONCLUSION

As the grade of hip osteoarthritis increases, it may adversely affect the specific hip score, but this parameter alone may not be a poor prognostic factor that affects the quality of life and daily activity level.

LEVEL OF EVIDENCE

Level III, Prognostic Study.

The geriatric distal femur fracture: nail, plate or both?

Surgical fixation of distal femur fractures in geriatric patients is an evolving topic. Unlike hip fractures, treatment strategies for distal femur fractures are ill-defined and lack substantive high-quality evidence. With an increasing incidence and an association with significant morbidity and mortality, it is essential to understand existing treatment options and their supporting evidence. Current fixation methods include the use of either retrograde intramedullary nails, or plate and screw constructs. Due to the variability in fracture patterns, the unique anatomy of the distal femur, and the presence or absence or pre-existing implants, decision-making as to which method to use can be challenging. Recent literature has sought to describe the advantages and disadvantages of each, however, there is currently no consensus on a standard of care, and little randomized evidence is available that directly compares intramedullary nails with plating. Future randomized studies comparing intramedullary nails with plating constructs are necessary in order to develop a standard of care based on injury characteristics.

Randomised controlled trial comparing intraoperative cell salvage and autotransfusion with standard care in the treatment of hip fractures: a protocol for the WHITE 9 study

INTRODUCTION

People who sustain a hip fracture are typically elderly, frail and require urgent surgery. Hip fracture and the urgent surgery is associated with acute blood loss, compounding patients' pre-existing comorbidities including anaemia. Approximately 30% of patients require a donor blood transfusion in the perioperative period. Donor blood transfusions are associated with increased rates of infections, allergic reactions and longer lengths of stay. Furthermore, there is a substantial cost associated with the use of donor blood. Cell salvage and autotransfusion is a technique that recovers, washes and transfuses blood lost during surgery back to the patient. The objective of this study is to determine the clinical and cost effectiveness of intraoperative cell salvage, compared with standard care, in improving health related quality-of-life of patients undergoing hip fracture surgery.

METHODS AND ANALYSIS

Multicentre, parallel group, two-arm, randomised controlled trial. Patients aged 60 years and older with a hip fracture treated with surgery are eligible. Participants will be randomly allocated on a 1:1 basis to either undergo cell salvage and autotransfusion or they will follow the standard care pathway. Otherwise, all care will be in accordance with the National Institute for Health and Care Excellence guidance. A minimum of 1128 patients will be recruited to obtain 90% power to detect a 0.075-point difference in the primary endpoint: EuroQol-5D-5L HRQoL at 4 months post injury. Secondary outcomes will include complications, postoperative delirium, residential status, mobility, allogenic blood use, mortality and resource use.

ETHICS AND DISSEMINATION

NHS ethical approval was provided on 14 August 2019 (19/WA/0197) and the trial registered (ISRCTN15945622). After the conclusion of this trial, a manuscript will be prepared for peer-review publication. Results will be disseminated in lay form to participants and the public.

TRIAL REGISTRATION NUMBER

ISRCTN15945622.

The impact of hallux valgus on function and quality of life in females

BACKGROUND

The effect of hallux valgus (HV) on health-related quality of life (HRQOL) and the relationship between radiographic severity of deformity and patient reported outcome measures (PROMs) is poorly understood. The aim of this study was to compare the HRQOL of female patients with HV to the UK population. The secondary aim was to assess the correlation between PROMs, including HRQOL, with radiographic severity of deformity.

METHODS

Weight bearing radiographic data (hallux valgus (HVA) angle; intermetatarsal (IM) angle) were measured in consecutive female patients presenting with HV. Each patient prospectively completed the Euroqol EQ-5D-5L questionnaire (EQ-5D), Visual Analogue Scale for Pain (VAS-Pain) and Manchester Oxford Foot Questionnaire (MOXFQ). Data were stratified into age ranges and compared with an EQ-5D United Kingdom general population reference dataset. Pearson R correlation values were calculated for the PROMs and radiographic deformity.

RESULTS

Between July 2015 and March 2020, 425 consecutive female patients presented with HV for consideration for surgery. EQ-5D-5L data were prospectively collected for 396 of these patients (93.2%). Females less than 65 years with HV had a statistically significantly worse quality of life compared with females of the same age group in the general population. Above the age of 65, there was no statistically significant difference in EQ-5D-5L Index score between the two groups. Younger females reported higher VAS-Pain scores compared to older patients with 91% of patients reporting some degree of pain symptoms. There was a moderate correlation with MOXFQ Index score and EQ-5D-5L Index (R = -0.51, p < 0.001) and VAS-Pain scores (R = 0.54, p < 0.001). There was no correlation between radiographic HV deformity and HRQOL measures or MOXFQ scores although it was noted that there was a trend of increasing HVA/IMA with age.

CONCLUSION

Female patients presenting with HV deformity have a significantly reduced quality of life compared with the UK general population. The radiographic severity of deformity did not correlate with HRQOL measures or foot and ankle specific PROMs. Foot and ankle specific clinical PROMsmoderately correlate with HRQOL and may be a better marker of the negative effect of symptomatic hallux valgus deformity on quality of life.

LEVEL OF EVIDENCE

III.

Functional Symmetry after Surgical Treatment of Pertrochanteric Fractures in the Elderly

Pertrochanteric fractures (PFs) in the elderly and their consequences are among the leading causes of disability; they significantly reduce the quality of life and lead to loss of independence. This article aims to determine the functional and radiological outcomes in a group of patients with PFs treated with either the Dynamic hip screw (DHS) or intramedullary Gamma nail fixation. A total of 618 patients, admitted to hospital for pertrochanteric fractures between 2015 and 2019, at a mean age of 82.40 (range 29–104) were screened. Finally, 78 patients were enrolled. Parameters related to hospital stay and surgery (length of hospital stay, surgery duration) were compared in both groups. Functional outcomes were assessed by the Harris hip score, subjective pain was measured with a visual analogue scale (VAS), and quality of life was evaluated using the EQ-5D-5L questionnaire. The obtained results were evaluated at 3- and 6-month follow-up. Radiographic parameters were measured based on the preoperative and postoperative standing anterior–posterior pelvic radiographs and axial projection of the hip at 6-month follow-up. The results showed no significant difference between groups treated either with DHS or intramedullary Gamma nail fixation within the scope of the variables under study. In conclusion, both analysed methods support the functional symmetry of the musculoskeletal system.

Cemented or Uncemented Hemiarthroplasty for Intracapsular Hip Fracture

BACKGROUND

Controversy exists over the use of bone cement in hip fractures treated with hemiarthroplasty. Only limited data on quality of life after cemented as compared with modern uncemented hemiarthroplasties are available.

METHODS

We conducted a multicenter, randomized, controlled trial comparing cemented with uncemented hemiarthroplasty in patients 60 years of age or older with an intracapsular hip fracture. The primary outcome was health-related quality of life measured with the use of utility scores on the EuroQol Group 5-Dimension (EQ-5D) questionnaire at 4 months after randomization (range of scores, -0.594 to 1, with higher scores indicating better quality of life; range for minimal clinically important difference, 0.050 to 0.075).

RESULTS

A total of 610 patients were assigned to undergo cemented hemiarthroplasty and 615 to undergo modern uncemented hemiarthroplasty; follow-up data were available for 71.6% of the patients at 4 months. The mean EQ-5D utility score was 0.371 in patients assigned to the cemented group and 0.315 in those assigned to the uncemented group (adjusted difference, 0.055; 95% confidence interval [CI], 0.009 to 0.101; P = 0.02). The between-group difference at 1 month was similar to that at 4 months, but the difference at 12 months was smaller than that at 4 months. Mortality at 12 months was 23.9% in the cemented group and 27.8% in the uncemented group (odds ratio for death, 0.80; 95% CI, 0.62 to 1.05). Periprosthetic fractures occurred in 0.5% and 2.1% of the patients in the respective groups (odds ratio [uncemented vs. cemented], 4.37; 95% CI, 1.19 to 24.00). The incidences of other complications were similar in the two groups.

CONCLUSIONS

Among patients 60 years of age or older with an intracapsular hip fracture, cemented hemiarthroplasty resulted in a modestly but significantly better quality of life and a lower risk of periprosthetic fracture than uncemented hemiarthroplasty. (Funded by the National Institute for Health Research; WHiTE 5 ISRCTN number, ISRCTN18393176.).

Intramedullary nail versus sliding hip screw for stable and unstable trochanteric and subtrochanteric fractures : 17,341 patients from the Norwegian Hip Fracture Register

AIMS

The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability.

METHODS

We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score.

RESULTS

Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014).

CONCLUSION

This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN. Cite this article: Bone Joint J 2022;104-B(2):274-282.

Association Between Frailty and Clinical Outcomes and Quality of Life in Older Adults Following Hip Fracture Surgery: A Retrospective Cohort Study

BACKGROUND

Hip fracture is a serious event in the older population and is associated with morbidity, mortality, and disability among those who survive. Emerging evidence suggests that frailty is pertinent to the clinical outcomes of older patients with hip fracture.

METHODS

We conducted a retrospective cohort study on older patients (aged ≥65 years) who underwent orthopedic repair with hip fracture under spinal or general anesthesia between June 1, 2019 and May 31, 2020. Demographic, surgical, and anesthetic features; chart-derived frailty index (CFI); occurrence of complications; and length of stay were retrospectively collected by reviewing patients' anesthesia records and medical charts. Patients were divided into 2 groups according to their CFI: high CFI group (CFI, 3-5) and low CFI group (CFI, 0-2). The CFI was calculated as the addition of the patient's conditions, including age >70 years, preoperative body mass index <18.5 kg/m2, hematocrit <35%, albumin <34 g/L, and serum creatinine >176.8 mol/L (2.0 mg/dL). The EuroQol 5-dimensional questionnaire (EQ-5D) was obtained through telephone interviews 12 months after surgery to assess mortality and long-term quality of life.

RESULTS

During the study period, 381 patients met the inclusion criteria. Patients in the high CFI group had an increased incidence of delirium by 13.80% (95% confidence interval [CI], 6.31-21.29) (17 [16.6%] vs 8 [2.8%]; P < .001) compared to patients in the low CFI group. More patients in the high CFI group had pneumonia with an increased incidence of 17.71% (95% CI, 7.08-23.34) (40 [39.2%] vs 60 [21.5%]; P < .001) than patients in the low CFI group. Postoperative hospital stay was significantly longer in the high CFI group (8 [6-12] vs 7 [5-10] days; P = .0222) than in the low CFI group. More patients died in the high CFI group 1 year after surgery with an increased mortality of 19.33% (95% CI, 9.47-29.18) (26.4% [23/87] vs 7.1% [16/225]; P < .001) than patients in the low CFI group. A total of 64 patients in the high CFI group and 209 patients in the low CFI group completed the EQ-5D survey 1 year after surgery. The EQ-5D score in the high CFI group was significantly lower than that in the low CFI group (0.63 ± 0.22 vs 0.72 ± 0.22; P = .002).

CONCLUSIONS

Frailty status is associated with adverse postoperative outcomes, mortality, and low quality of life 12 months after hip fracture surgery in older patients.

High variability in patient reported outcome utilization following hip fracture: a potential barrier to value-based care

For patients with hip fractures, outcomes can be measured by giving surveys measuring "patient rated outcome measures" (PROMs), performance based measures (PBMS), and objective medical outcomes (e.g., mortality, living situation, resource utilization). This study reviewed articles on hip fracture published in top academic journals, and found that most studies are not reliably using a single set of outcome measures including PROMs, and no single PROM or outcome battery is being used commonly.

PURPOSE/INTRODUCTION

Osteoporotic hip fractures are associated with high levels of morbidity, mortality, and cost, while gains in mortality over the past 30 years have been modest. To improve care beyond simple mortality metrics requires identifying and then consistently measuring outcomes that are meaningful to patients and families. The purpose of this study was to review the top-tier hip fracture literature published in the past 30 years to determine if there are consensus outcome measures being routinely used and if the rate of reporting clinically meaningful patient-rated outcome measures is improving over time.

METHODS

This was a systematic review and meta-analysis on outcome measures reported in osteoporotic hip fractures. Articles were included if they had been published over the last 30 years and were from high impact factor journals. Inclusion criteria were elderly hip fractures, therapeutic or prognostic study, unique and identifiable patients, and included follow-up beyond initial hospitalization. We analyzed study type, inclusion criteria, outcomes reported, and journal specialty orientation.

RESULTS

Three hundred eighty-four articles were included in the final analysis. Sixty-seven percent of the articles were therapeutic studies; 33% were prognostic studies. The average number of patients in each study was 435; the average age was 78 years. The most commonly reported outcome was mortality, and was present in 79% of studies. There was a high degree of heterogeneity in patient-reported outcome measures, with the most popular score (Harris Hip Score) reported only 14% of the time. Only 6% of articles had all components of essential core outcome sets previously defined in the literature.

CONCLUSIONS

Despite the apparent advances that have been made in our ability to care for hip fractures, the overall rate of reporting outcomes beyond mortality rate remains low. This lack of consensus represents a major barrier to implementation of value-based care in this patient population.

Musculoskeletal health and capability wellbeing: Associations between the HAQ-DI, ICECAP-A and ICECAP-O measures in a population survey

BACKGROUND

The capability approach has received increasing attention in wellbeing measurement in the past years, but it has still remained an underexplored area in musculoskeletal (MSK) health.

OBJECTIVE

We aimed to explore the capability wellbeing in relation to MSK health, by measuring the associations between the Health Assessment Questionnaire Disability Index (HAQ-DI) physical functioning and the ICECAP-A and ICECAP-O capability wellbeing measures.

DESIGN

A cross-sectional survey was performed in 2019 on a representative sample of the Hungarian general adult population.

METHOD

Capability wellbeing was measured by the ICECAP-A (age-group 18-64) and ICECAP-O (age group 65+) questionnaires. MSK health was defined by the HAQ-DI, the mobility domain of the EQ-5D-3L/-5L health status measures, self-reported walking problems and MSK diagnosis (neck/back/low back defects, hip/knee arthrosis, osteoporosis).

RESULTS

Altogether 2021 individuals (female: 50.1%) participated in the survey with mean (SD) age of 48.7 (17.9) years and HAQ-DI of 0.138 (0.390). ICECAP-A (N = 1568, 77.6%) and ICECAP-O (N = 453, 22.4%) scores were on average (SD) 0.894 (0.126) and 0.828 (0.150), respectively. Spearman correlations between the HAQ-DI and ICECAP-A/-O index scores were moderate (r = -0.303 and -0.496; p < 0.05). Both the ICECAP-A/-O index scores differed significantly (ANOVA test, p < 0.05) across all MSK subgroups. In the ordinary least square regressions, marginal effects of ICECAP-A/-O scores on HAQ-DI were significant (-0.149 and -0.123) when controlling for socio-demographic characteristics.

CONCLUSIONS

MSK health problems are associated with lower capability wellbeing. ICECAP-A/-O might capture effects of MSK conditions not measured by the HAQ-DI or the EQ-5D-5L. Further studies should test these associations in disease-specific samples.

Long-term outcomes after hip fracture in Ireland: a protocol for a systematic review of traditional and grey literature

Background: Hip fracture is experienced by almost 3,500 older people in Ireland annually. The Irish Hip Fracture Database (IHFD), which drives clinical improvements in acute hospitals, aims to allow recording of longer-term outcomes. Feasible and robust methods of data collection need to be identified to inform this activity. The aim of this systematic review is to identify, describe and appraise studies that have collected long-term outcomes after hip fracture in Ireland in the last 15 years and to generate pooled estimates of outcomes if appropriate. Methods: A search of electronic databases (MEDLINE, Embase, Scopus, Web of Science and CINAHL) and grey literature sources will be conducted for journal articles, conference abstracts, academic theses, and reports. Search terms related to hip fracture and Ireland will be included for most sources. The search will be supplemented by email contact with relevant professionals. Observational and interventional studies published between 2005 and 2021 will be included if outcome data were collected in the Republic of Ireland in patients with hip fracture. Outcomes of interest will include data collected after discharge from an inpatient setting or at a fixed time-point greater than 30 days after fracture, hospital admission or surgery. Information relating to study characteristics, description of researchers, data collection methods, patient characteristics and long-term outcomes will be extracted from each study and summarised in tables. Studies will be assessed for risk of bias by two review authors. Where outcomes are sufficiently homogeneous, meta-analyses of estimates will be conducted. Conclusion: Results from this study will inform the planning of further qualitative research to explore barriers and facilitators of long-term outcome collection in Ireland. It will form the basis of education and training for future data collectors in this setting.

A comprehensive multidisciplinary care pathway for hip fractures better outcome than usual care?

INTRODUCTION

Hip fracture surgery is among the most performed surgical procedures in elderly patients. Mortality rates are high, however, and patients often fail to live independently following a hip fracture. To improve outcome, multidisciplinary care pathways have been initiated, but longer-term results are lacking. Aim of this study was to compare functional outcome and living situation six months after hip fracture treatment with and without a care pathway.

PATIENTS AND METHODS

A multicentre prospective controlled trial was conducted with three hospitals: in one hospital patients were treated with a care pathway, in the other hospitals patients received usual care. All patients aged ≥ 60 years with a hip fracture were asked to participate. Besides basic characteristics, health-related quality of life (EQ-5D) and performance scores of activities of daily living (Katz Index and Lawton IADL) were assessed. Differences in scores were analysed using linear regression. Propensity score adjustment was used to correct for differences between the care pathway and the usual care group. Missing data were imputed.

RESULTS

No differences in rate of return to prefracture ADL level were found between patients in the care pathway group and the usual care group. The percentage of participants in the same situation as before the fracture was the same in both treatment groups (81%). There were no significant differences in quality of life, activities of daily living or mortality (15% vs 10%, p = 0.17), but hospital stay in the care pathway group was significantly shorter (median 7 vs 10 days).

DISCUSSION

Treatment of elderly patients with a hip fracture is commonly organised in care pathways. Although short-term advantages are reported, positive effects on longer-term functional results could not be proven in our study. This study confirmed a shorter hospital stay in the care pathway group, which potentially may lead to a reduction in costs.

CONCLUSIONS

Functional outcome and living situation six months after a hip fracture is the same for patients treated with or without a care pathway.

Patient-reported outcome measures after hip fracture in patients with chronic cognitive impairment : results from 34,675 patients in the Norwegian Hip Fracture Register

Aims

Hip fracture patients have high morbidity and mortality. Patient-reported outcome measures (PROMs) assess the quality of care of patients with hip fracture, including those with chronic cognitive impairment (CCI). Our aim was to compare PROMs from hip fracture patients with and without CCI, using the Norwegian Hip Fracture Register (NHFR).

Methods

PROM questionnaires at four months (n = 34,675) and 12 months (n = 24,510) after a hip fracture reported from 2005 to 2018 were analyzed. Pre-injury score was reported in the four-month questionnaire. The questionnaires included the EuroQol five-dimension three-level (EQ-5D-3L) questionnaire, and information about who completed the questionnaire.

Results

Of the 34,675 included patients, 5,643 (16%) had CCI. Patients with CCI were older (85 years vs 81 years) (p < 0.001), and had a higher American Society of Anesthesiologists (ASA) classification compared to patients without CCI. CCI was unrelated to fracture type and treatment method. EQ-5D index scores were lower in patients with CCI after four months (0.37 vs 0.60; p < 0.001) and 12 months (0.39 vs 0.64; p < 0.001). Patients with CCI had lower scores for all dimensions of the EQ-5D-3L pre-fracture and at four and 12 months.

Conclusion

Patients with CCI reported lower health-related quality of life pre-fracture, at four and 12 months after the hip fracture. PROM data from hip fracture patients with CCI are valuable in the assessment of treatment. Patients with CCI should be included in future studies.

Cite this article: Bone Jt Open 2021;2(7):454–465.

Plaster cast versus functional bracing for Achilles tendon rupture: the UKSTAR RCT

BACKGROUND

Achilles tendon rupture affects > 11,000 people each year in the UK, leading to prolonged periods away from work, sports and social activities. Traditionally, the ruptured tendon is held still in a plaster cast for ≥ 8 weeks. Functional bracing is an alternative treatment that allows patients to mobilise earlier, but there is little evidence about how bracing affects patients' recovery.

OBJECTIVES

To measure the Achilles Tendon Rupture Score, quality of life, complications and resource use of patients receiving non-operative treatment for an Achilles tendon rupture treated with plaster cast compared with those treated with functional bracing.

DESIGN

This was a multicentre, randomised, pragmatic, two-group superiority trial.

SETTING

The setting was 39 NHS hospitals.

PARTICIPANTS

A total of 540 adult patients treated non-operatively for Achilles tendon rupture were randomised from July 2016 to May 2018. Exclusion criteria included presenting after 14 days, having had previous rupture and being unable to complete questionnaires.

INTERVENTIONS

A total of 266 participants had a plaster cast applied, with their toes initially pointing to the floor. The cast was changed over 8 weeks to bring the foot into a walking position. A total of 274 patients had a functional brace that facilitated immediate weight-bearing. The foot position was adjusted within the brace over the same 8-week period.

MAIN OUTCOME MEASURES

Achilles Tendon Rupture Score is patient reported and assesses symptoms and physical activity related to the Achilles tendon (score 0-100, with 100 being the best possible outcome). The secondary outcomes were quality of life, complications and resource use at 8 weeks and at 3, 6 and 9 months.

RESULTS

Participants had a mean age of 48.7 years, were predominantly male (79%) and had ruptured their tendon during sports (70%). Over 93% of participants completed follow-up. There was no statistically significant difference in Achilles Tendon Rupture Score at 9 months post injury (-1.38, 95% confidence interval -4.9 to 2.1). There was a statistically significant difference in Achilles Tendon Rupture Score at 8 weeks post injury in favour of the functional brace group (5.53, 95% confidence interval 2.0 to 9.1), but not at 3 or 6 months post injury. Quality of life showed the same pattern, with a statistically significant difference at 8 weeks post injury but not at later time points. Complication profiles were similar in both groups. Re-rupture of the tendon occurred 17 times in the plaster cast group and 13 times in the functional brace group. There was no difference in resource use.

CONCLUSIONS

This trial provides strong evidence that early weight-bearing in a functional brace provides similar outcomes to traditional plaster casting and is safe for patients receiving non-operative treatment of Achilles tendon rupture. The probability that functional bracing is cost-effective exceeds 95% for the base-case imputed analysis, assuming a cost-effectiveness threshold of £20,000 per quality-adjusted life-year. On average, functional brace is associated with lower costs (-£103, 95% confidence interval -£290 to £84) and more quality-adjusted life-years (0.015, 95% confidence interval -0.0013 to 0.030) than plaster cast.

LIMITATIONS

Some patients declined to participate in the trial, but only a small proportion of these declined because they had a preference for one treatment or another. Overall, 58% of eligible patients agreed to participate, so the participants are broadly representative of the population under investigation.

FUTURE WORK

Although the UK Study of Tendo Achilles Rehabilitation provides guidance with regard to early management, rehabilitation following Achilles tendon rupture is prolonged and further research is required to define the optimal mode of rehabilitation after the initial cast/brace has been removed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN62639639.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 8. See the NIHR Journals Library website for further project information.

Does performance-based remuneration improve outcomes in the treatment of hip fracture?

Aims

The aim of this study was to determine whether national standards of best practice are associated with improved health-related quality of life (HRQoL) outcomes in hip fracture patients.

Methods

This was a multicentre cohort study conducted in 20 acute UK NHS hospitals treating hip fracture patients. Patients aged ≥ 60 years treated operatively for a hip fracture were eligible for inclusion. Regression models were fitted to each of the “Best Practice Tariff” indicators and overall attainment. The impact of attainment on HRQoL was assessed by quantifying improvement in EuroQol five-dimension five-level questionnaire (EQ-5D-5L) from estimated regression model coefficients.

Results

A total of 6,532 patients provided both baseline and four-month EQ-5D-5L, of whom 1,060 participants had died at follow-up. Best practice was achieved in the care of 57% of participants; there was no difference in age, cognitive ability, and mobility at baseline for the overall attainment and non-attainment groups. Attaining at least ‘joint care by surgeon and orthogeriatrician’, ‘delirium assessment’, and ‘falls assessment’ was associated with a large, clinically relevant increase in four months EQ-5D-5L of 0.094 (bootstrapped 95% confidence interval (CI) 0.046 to 0.146).

Conclusion

National standards with enhanced remuneration in hip fracture care results in improvement in individual patients’ HRQoL.

Cite this article: Bone Joint J 2021;103-B(5):881–887.

Primary hemiarthroplasty for the elderly patient with cognitive dysfunction and a displaced femoral neck fracture: a prospective, observational cohort study

BACKGROUND

At least one-third of hip fracture patients have some degree of impaired cognitive status, which may complicate their postoperative rehabilitation.

AIM

We aimed to describe the outcome for elderly patients with cognitive dysfunction operated with hemiarthroplasty (HA) for a femoral neck fracture and to study the impact postoperative geriatric rehabilitation has on functional outcome up to 1 year after surgery.

METHODS

98 patients with a displaced femoral neck fracture with a mean age of 86 years were included and followed up to 1 year. The outcomes were hip-related complications and reoperations, the capacity to return to previous walking ability, health-related quality of life, hip function and mortality.

RESULTS

The prevalence of hip complications leading to a major reoperation was 6% and the 1-year mortality rate was 31%. The lack of geriatric rehabilitation was correlated with poorer outcomes overall and those who receive geriatric rehabilitation were less likely to be confined to a wheelchair or bedridden at the 1-year follow-up.

CONCLUSIONS

Hemiarthroplasty is an acceptable option for elderly patients with a displaced femoral neck fracture and cognitive dysfunction. A lack of structured rehabilitation is associated with a significant deterioration in walking ability despite a well-functioning hip. However, the causality of this could be due to selection bias of healthier patients being sent to geriatric rehabilitation.

Physical Therapy Management of Older Adults With Hip Fracture

Hip fracture is a leading cause of profound morbidity in individuals aged 65 years and older, ranking in the top 10 causes of loss of disability-adjusted life-years for older adults. Worldwide, the number of people with hip fracture is expected to rise significantly due to the aging population and other factors. Physical therapist management is recommended within medical, surgical, and multidisciplinary clinical practice guideline (CPGs) and is considered to be the standard of care in rehabilitation for people with hip fracture. The goal of this CPG was to review the evidence relevant to physical therapist management and to provide evidence-based recommendations for physical therapy diagnosis, prognosis, intervention, and assessment of outcome in adults with hip fracture. J Orthop Sports Phys Ther 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301.

Changes in Health-Related Quality of Life for Older Persons With Cognitive Impairment After Hip Fracture Surgery: A Systematic Review

BACKGROUND

Hip fractures in persons with cognitive impairments represent a major public health issue in older populations that often results in poor health-related quality of life (HRQoL).

PURPOSE

The aim of this systemic review was to examine the changes in HRQoL in older, cognitively impaired patients with hip fracture who had received surgical treatment.

METHODS

A literature search of PubMed, Scopus, MEDLINE, PsycINFO, and CINAHL (EBSCO) databases was conducted for studies published up to July 2018 that addressed the issue of HRQoL in cognitively impaired patients with hip fracture after surgery. Studies that met the following criteria were included: Patients with hip fracture were over 60 years old and had cognitive impairment or dementia, patients had undergone hip fracture repair surgery, HRQoL was determined using standardized questionnaires, a descriptive or interventional methodology was used, and the full-text article was available in English.

RESULTS

A primary search of databases yielded 1,528 studies, 621 duplicates were removed, and the remaining 907 abstracts were screened. Thirty-four full-text articles were deemed relevant for full review; of these, 10 articles met the criteria for inclusion in the review. Cognitive impairment was found to impact negatively on the patients' HRQoL after hip fracture surgery (n = 809). Severity of cognitive impairment was correlated with deterioration in HRQoL after hospital discharge. When compared with prefracture measures of HRQoL, the greatest deterioration in HRQoL postsurgery occurred during the first 4 months after discharge. Impacts on HRQoL for patients with cognitive impairment at later time points differed depending on type of hip fracture and type of surgical treatment. However, for most of the patients, HRQoL remained relatively unchanged at 6, 12, and 24 months postdischarge.

CONCLUSIONS

We recommend nursing care interventions for older persons with cognitive impairment be initiated immediately after surgery for hip fracture to prevent a significant decline in HRQoL. Further examination of interventions that are effective in maintaining HRQoL for these patients such as interdisciplinary care is necessary. In addition, the influences of hip fracture type and surgical approach on changes in HRQoL suggest a need for further investigations to determine what contributed to the observed inconsistencies in the outcomes.

Effect on health-related quality of life of the X-Bolt dynamic plating system versus the sliding hip screw for the fixation of trochanteric fractures of the hip in adults: the WHiTE Four randomized clinical trial

Aims

Surgical treatment of hip fracture is challenging; the bone is porotic and fixation failure can be catastrophic. Novel implants are available which may yield superior clinical outcomes. This study compared the clinical effectiveness of the novel X-Bolt Hip System (XHS) with the sliding hip screw (SHS) for the treatment of fragility hip fractures.

Methods

We conducted a multicentre, superiority, randomized controlled trial. Patients aged 60 years and older with a trochanteric hip fracture were recruited in ten acute UK NHS hospitals. Participants were randomly allocated to fixation of their fracture with XHS or SHS. A total of 1,128 participants were randomized with 564 participants allocated to each group. Participants and outcome assessors were blind to treatment allocation. The primary outcome was the EuroQol five-dimension five-level health status (EQ-5D-5L) utility at four months. The minimum clinically important difference in utility was pre-specified at 0.075. Secondary outcomes were EQ-5D-5L utility at 12 months, mortality, residential status, mobility, revision surgery, and radiological measures.

Results

Overall, 437 and 443 participants were analyzed in the primary intention-to-treat analysis in XHS and SHS treatment groups respectively. There was a mean difference of 0.029 in adjusted utility index in favour of XHS with no evidence of a difference between treatment groups (95% confidence interval -0.013 to 0.070; p = 0.175). There was no evidence of any differences between treatment groups in any of the secondary outcomes. The pattern and overall risk of adverse events associated with both treatments was similar.

Conclusion

Any difference in four-month health-related quality of life between the XHS and SHS is small and not clinically important. There was no evidence of a difference in the safety profile of the two treatments; both were associated with lower risks of revision surgery than previously reported.

Cite this article: Bone Joint J 2021;103-B(2):256–263.

Measuring daily functioning in older persons using a frailty index: a cohort study based on routine primary care data

BACKGROUND

Electronic health records (EHRs) are increasingly used for research; however, multicomponent outcome measures such as daily functioning cannot yet be readily extracted.

AIM

To evaluate whether an electronic frailty index based on routine primary care data can be used as a measure for daily functioning in research with community-dwelling older persons (aged ≥75 years).

DESIGN AND SETTING

Cohort study among participants of the Integrated Systemic Care for Older People (ISCOPE) trial (11 476 eligible; 7285 in observational cohort; 3141 in trial; over-representation of frail people).

METHOD

At baseline (T0) and after 12 months (T12), daily functioning was measured with the Groningen Activities Restriction Scale (GARS, range 18-72). Electronic frailty index scores (range 0-1) at T0 and T12 were computed from the EHRs. The electronic frailty index (electronic Frailty Index - Utrecht) was tested for responsiveness and compared with the GARS as a gold standard for daily functioning.

RESULTS

In total, 1390 participants with complete EHR and follow-up data were selected (31.4% male; median age = 81 years, interquartile range = 78-85). The electronic frailty index increased with age, was higher for females, and lower for participants living with a partner. It was responsive after an acute major medical event; however, the correlation between the electronic frailty index and GARS at T0 and over time was limited.

CONCLUSION

Because the electronic frailty index does not reflect daily functioning, further research on new methods to measure daily functioning with routine care data (for example, other proxies) is needed before EHRs can be a useful data source for research with older persons.

The prevalence and prognostic factors of psychological distress in older patients with a hip fracture: A longitudinal cohort study

INTRODUCTION

A hip fracture can be experienced as a traumatic event that can induce psychological distress. The aim of this study is to give more insight into the prevalence of symptoms of psychological distress in older patients following the first year after a hip fracture. In addition, prognostic factors were determined for psychological distress after hip fracture.

MATERIALS AND METHODS

This hip fracture cohort data was derived from the Brabant Injury Outcome Surveillance, a multicenter longitudinal prospective cohort study. Hip fracture patients (≥65years) admitted to a hospital between August 2015 and November 2016 were asked to complete a questionnaire at 1 week, and 1, 3, 6 and 12 months. The Hospital Anxiety and Depression Scale (HADS) was used to assess symptoms of anxiety and depression and the Impact of Event Scale (IES) was used to assess symptoms of posttraumatic stress (PTS). Prognostic factors were assessed with multivariable logistic mixed models.

RESULTS

In total 570 patients (inclusion rate: 69.7%) were included. The prevalence of psychological distress ranged from 36% at 1 week to 31% at 1 year after hip fracture. Frailty at onset of hip fracture was the most important prognostic factor of symptoms of depression (Odds ratio (OR), 2.74; 95% Confidence interval (CI) 1.41 to 5.34) and anxiety (OR, 2.60; 95% CI 1.15 to 5.85) on average in the year following hip fracture. Frailty was not a prognostic factor of symptoms of PTS (OR, 1.97; 95% CI 0.42 to 9.23).

CONCLUSIONS

The prevalence of psychological distress is high in the first year after a hip fracture. Frailty at onset of a hip fracture is the most important prognostic factor of symptoms of depression and anxiety. These findings have important implications for strategies with early identification of frail patients with a hip fracture at high risk of psychological distress.

Is Total Hip Arthroplasty a Cost-Effective Option for Management of Displaced Femoral Neck Fractures? A Trial-Based Analysis of the HEALTH Study

BACKGROUND

Displaced femoral neck fractures are a significant source of morbidity and mortality and can be treated with either hemiarthroplasty (HA) or total hip arthroplasty (THA). Proponents of THA have argued THA offers lower risk of revision, with improved functional outcomes when compared to HA. To evaluate cost effectiveness of THA compared with HA, a trial-based economic analysis of the HEALTH study was undertaken.

METHODS

Health care resource utilization (HRU) and health-related quality of life (HRQoL) data were collected postoperatively and costed using publicly available databases. Using EuroQol-5 Dimensions (EQ-5D) scores, we derived quality adjusted life years (QALYs). A 1.5% discount rate to both costs and QALYs was applied. Age analyses per age group were conducted. All costs are reported in 2019 Canadian dollars.

RESULTS

When compared with HA, THA was not cost-effective for all patients with displaced femoral neck fractures ($150,000/QALY gained). If decision makers were willing to spend $50,000 or $100,000 to gain one QALY, the probability of THA being cost-effective was 12.8% and 32.8%, respectively. In a subgroup of patients younger than 73 (first quartile), THA was both more effective and less costly. Otherwise, THA was more expensive and yielded marginal HRQoL gains.

CONCLUSIONS

Our results suggest that for most patients, THA is not a cost-effective treatment for displaced femoral neck fracture management versus HA. However, THA may be cost effective for younger patients. These patients experience more meaningful improvements in quality of life with less associated cost because of shorter hospital stay and fewer postoperative complications.

LEVEL OF EVIDENCE

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Retrograde intramedullary nail fixation compared with fixed-angle plate fixation for fracture of the distal femur: the TrAFFix feasibility RCT

BACKGROUND

Fractures of the distal femur are an increasingly common injury; the optimal management of these injuries remains controversial. The two interventions used in UK practice are intramedullary fixation, with a locked retrograde nail, and extramedullary fixation, with a fixed angle plate.

OBJECTIVES

This study assessed the feasibility of a definitive trial and included a process evaluation to understand the generalisability and likely success of a future trial.

DESIGN

A multicentre, parallel, two-arm, randomised controlled feasibility trial with an embedded process evaluation. Treatment with a plate or nail was allocated in a 1 : 1 ratio, stratified by centre and chronic cognitive impairment. Surgeons were not blinded, but participants were not told their allocation.

SETTING

Seven NHS hospitals.

PARTICIPANTS

Patients aged ≥ 18 years with a fracture of the distal femur who the attending surgeon believed would benefit from internal fixation were potentially eligible. Patients were excluded if they had a loose arthroplasty requiring revision or a femoral deformity or arthroplasty that precluded nail fixation. The sample was recruited between 29 September 2016 and 31 August 2017. Consent was obtained from the patient or appropriate consultee before enrolment.

INTERVENTIONS

Patients were randomised to receive fixation of their distal femur fracture with either a proximally and distally locked retrograde nail that spanned the diaphysis of the femur or an anatomical distal femoral locking plate with at least one locked screw distal to the fracture. Reduction and supplemental fixation were at the surgeon's discretion.

OUTCOMES

The primary outcome measures for this study were the recruitment rate and the completion rate of the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), at 6 weeks and 4 months. Additional measurements included baseline characteristics, measures of social support and self-efficacy, disability rating index, dementia quality-of-life measures and a radiographical assessment of any malunion. Participants' and staff views were obtained, at interview, for the process evaluation.

RESULTS

The process evaluation showed that surgeon-related factors, principally confidence with both technologies and a lack of individual equipoise, were key barriers to recruitment. A total of 23 participants were randomised and analysed (nail, n = 11; plate, n = 12). The recruitment rate was estimated as 0.42 [95% confidence interval (CI) 0.27 to 0.62] participants per centre per month, lower than the prespecified feasibility threshold of 1.0 participants per centre per month. Data completeness of the EQ-5D-5L was estimated at 65% (95% CI 43% to 83%).

CONCLUSIONS

This feasibility study has challenged many of the assumptions that underpinned the development of proposed definitive trial protocol. A modified protocol is proposed that would be feasible given the recruitment rate observed here, which is equal to that reported in the similar FixDT trial [Health Technology Assessment (HTA) 11/136/04: Costa ML, Achten J, Hennings S, Boota N, Griffin J, Petrou S, et al. Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT. Health Technol Assess 2018;22(25)], which delivered to target and budget.

FUTURE WORK

A definitive trial with a modified design is recommended, including an internal pilot to confirm initial recruitment rate assumptions.

REGISTRATION

Current Controlled Trials ISRCTN92089567.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 51. See the NIHR Journals Library website for further project information. Funding was also supported by the NIHR Oxford Biomedical Research Centre.

Development of a Questionnaire to Assess Patient Priorities in Hip Fracture Care

Background:

Patient reported outcome measures (PROMs) are becoming well recognized as an important component of health care outcomes and determinants of value in patient-centered care. Yet, there is emerging recognition that guidance is lacking in the utilization of PROMs in hip fracture patients. The aim of this study was to collect input from hip fracture patients and their health care advocates as proxies to identify outcomes that are important and to gain insight into which ones are of greatest importance.

Methods:

A cross-section of patients aged 65 and older treated for hip fractures at a single level 1 trauma center within the previous 3 to 9 months was identified. Semistructured telephone interviews of patients and/or health care proxies were performed in 2 phases: (1) concept identification and conceptual framework development and (2) item generation and assessment of relative importance of health care outcomes. Each phase was completed by separate patient cohorts.

Results:

Sixty-four interviews were completed. Eighteen interviews with 13 patients and 5 proxies were completed for framework development. Forty-six interviews with 33 patients and 13 proxies were completed for the assessment of relative importance. Care team and communication were reported as important in hip fracture patients. Physical outcomes were ranked as most important by only 9% of respondents. “Having confidence that I/my loved one received the best care possible” was perceived as very important by 98% of respondents and “Having access to the surgeon” was perceived as very important by 76% of the respondents.

Conclusions:

In our study, communication between patients and care providers as well as collaboration among patients’ care providers ranked as the most important postoperative preferences in our cohort. Notably, physical outcomes were ranked as most important by only 9% of respondents.

Short or long intramedullary devices for hip fracture? A systematic review of the evidence

Trochanteric hip fractures may be fixed with either sliding hip screws or intramedullary devices. Current UK guidance is that intramedullary fixation should be used for AO/OTA 31A3 fractures but does not stipulate length of nail. We present a systematic review comparing short and long nails for these injuries in older patients. Three studies were randomized, all with methodological concerns. None demonstrated a clinically significant difference in outcome. There is no good evidence to support long over short intramedullary devices in this scenario. Evidence is required to demonstrate whether the potentially increased surgical risk confers any benefits in this group.

Baseline quality of life in people with hip fracture: results from the multicentre WHiTE cohort study

Aims

To assess the variation in pre-fracture quality of life (QoL) within the UK hip fracture population, and quantify the nature and strength of associations between QoL and other routinely collected patient characteristics and treatment choices.

Methods

The World Hip Trauma Evaluation (WHiTE) study, an observational cohort study of UK hip fracture patients, collects a range of routine data and a health-related QoL score (EuroQol five-dimension questionnaire (EQ-5D)). Pre-fracture QoL data are summarized and statistical models fitted to understand associations between QoL, patient characteristics, fracture types, and operations.

Results

Fitting a multiple linear regression model indicated that 36.5% of the variance in pre-fracture EQ-5D scores was explained by routinely collected patient characteristics: sex (0.14%), age (0.17%), American Society of Anesthesiologists (ASA) score (0.73%), Abbreviated Mental Test Score (AMTS; 1.3%), pre-fracture mobility (11.2%), and EQ-5D respondent (participant, relative, or carer; 23.0%). There was considerable variation in pre-fracture EQ-5D scores between operations within fracture types. Participants with trochanteric fractures reported statistically significant but not clinically relevant lower pre-fracture QoL than those with intracapsular fractures. Participants with intracapsular fractures treated with internal fixation or total hip arthroplasty (THA) reported better QoL than those treated with hemiarthroplasty with the overall fittest group receiving THA.

Conclusion

Pre-fracture QoL varies considerably between hip fracture patients; it is generally higher in younger than older patients, patients with better mobility, and those patients who live more independently. Pre-fracture QoL is significantly associated with a range of patient characteristics (e.g. age, mobility, residency). These data explain ~35% of the variation in QoL.

Cite this article: Bone Joint Res 2020;9(8):468–476.

Capability instruments in economic evaluations of health-related interventions: a comparative review of the literature

PURPOSE

Given increasing interest in using the capability approach for health economic evaluations and a growing literature, this paper aims to synthesise current information about the characteristics of capability instruments and their application in health economic evaluations.

METHODS

A systematic literature review was conducted to assess studies that contained information on the development, psychometric properties and valuation of capability instruments, or their application in economic evaluations.

RESULTS

The review identified 98 studies and 14 instruments for inclusion. There is some evidence on the psychometric properties of most instruments. Most papers found moderate-to-high correlation between health and capability measures, ranging between 0.41 and 0.64. ASCOT, ICECAP-A, -O and -SCM instruments have published valuation sets, most frequently developed using best-worst scaling. Thirteen instruments were originally developed in English and one in Portuguese; however, some translations to other languages are available. Ten economic evaluations using capability instruments were identified. The presentation of results show a lack of consensus regarding the most appropriate way to use capability instruments in economic evaluations with discussion about capability-adjusted life years (CALYs), years of capability equivalence and the trade-off between maximisation of capability versus sufficient capability.

CONCLUSION

There has been increasing interest in applying the capability-based approach in health economic evaluations, but methodological and conceptual issues remain. There is still a need for direct comparison of the different capability instruments and for clear guidance on when and how they should be used in economic evaluations.

Is PROMIS the new standard for patient-reported outcomes measures in orthopaedic trauma research?

This review describes some of the benefits of the Patient-Reported Outcomes Measurement Information System (PROMIS) architecture, determined how frequently PROMIS measures were used in the current orthopaedic trauma literature, and compared the features of PROMIS instruments with other frequently used patient-reported outcomes measures (PROMs). PROMIS instruments have several unique elements to their architecture, such as item response theory, computerized adaptive testing options, and scaling using T-scores, that differentiate the instruments from many other PROMs. Over the past five years, 108 different PROMs were reported in 319 studies published in high-impact orthopaedic journals. PROMIS measures, including PROMIS Physical Function, Pain Interference, and Upper Extremity Function, were only used in seven studies (2%). PROMIS measures were found to be comparable to other more common PROMs with respect to respondent burden, administration options, and psychometric assessments specific to fracture patients. Likely, the limited familiarity and interpretability of PROMIS measures in the fracture population remain the most substantial barriers to broader adoption in orthopaedic trauma research.

Coned hemipelvis reconstruction for osteoporotic acetabular fractures in frail elderly patients

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

Methods

We have prospectively monitored a series of 22 cases (21 patients) with a mean follow-up of 32 months (13 to 59).

Results

The mean patient age was 79 years (67 to 87), and the mean ASA score was 3.3 (3 to 5). Three patients had high-energy injuries and 18 had low-energy injuries. All cases were associated fractures (Letournel classification: anterior column posterior hemitransverse, n = 13; associated both column, n = 6; transverse posterior wall, n = 3) with medialization of the femoral head. Mean operative time was 93 minutes (61 to 135). There have been no revisions to date. Of the 21 patients, 20 were full weight-bearing on day 1 postoperatively. Mean length of hospital stay was 12 days (5 to 27). Preoperative mobility status was maintained in 13 patients. At one year, mean Merle d’Aubigné score was 13.1 (10 to 18), mean Oxford Hip Score was 38.5 (24 to 44), mean EuroQol five-dimension five-level (EQ-5D-5L) health score was 68 (30 to 92), and mean EQ-5D-5L index score was 0.68 (0.335 to 0.837); data from 14 patients. Mortality was 9.5% (2/21) at one year. There have been no thromboembolic events, deep infections, or revisions.

Conclusion

The coned hemipelvis reconstruction bypasses the fracture, creating an immediately stable construct that allows immediate full weight-bearing. The posterior approach minimizes the operative time and physiological insult in this vulnerable patient population. Early results suggest this to be a safe addition to current surgical options, targeted at the most medically frail elderly patient with a complex displaced acetabular fracture. Cite this article: Bone Joint J 2020;102-B(2):155–161.

Preliminary effect and feasibility of physiotherapy with strength training and protein-rich nutritional supplement in combination with anabolic steroids in cross-continuum rehabilitation of patients with hip fracture: protocol for a blinded randomized controlled pilot trial (HIP-SAP1 trial)

BACKGROUND

A 2014 Cochrane review evaluating the effect of anabolic steroids after hip fracture concluded that the quality of the studies was insufficient to draw conclusions on the effects and recommended further high-quality trials in the field. Therefore, the aim of this pilot trial is to determine the preliminary effect and feasibility of a 12-week multimodal intervention consisting of physiotherapy (with strength training), protein-rich nutritional supplement and anabolic steroid on knee-extension muscle strength and function 14 weeks after hip fracture surgery.

METHODS

We plan to conduct a randomized, placebo-controlled pilot trial with 48 patients operated for acute hip fracture. The patients are randomized (1:1) to either (1) physiotherapy with protein-rich nutritional supplement plus anabolic steroid or (2) physiotherapy with protein-rich nutritional supplement plus placebo. Outcome assessments will be carried out blinded at baseline (3-10 days after surgery) and at 14 weeks after entering the trial. Primary outcome is the change from baseline to follow-up in maximal isometric knee-extension muscle strength in the fractured limb. Secondary outcomes are physical performance test, patient-reported outcomes, and measures of body composition.

DISCUSSION

If the trial is found feasible and the results show an indication of anabolic steroid being a relevant addition to further enhance the recovery of muscle strength and function in an enhanced recovery after surgery program, this trial will constitute the basis of a larger confirmatory trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03545347. Preregistered on 4 June 2018.

Randomised controlled trial comparing hydroxyapatite coated uncemented hemiarthroplasty with cemented hemiarthroplasty for the treatment of displaced intracapsular hip fractures: a protocol for the WHITE 5 study

INTRODUCTION

Hip fracture is a serious injury in adults, especially those aged over 60 years. The most common type of hip fracture (displaced intracapsular) is treated for the majority of patients with a partial hip replacement (hemiarthroplasty). The hemiarthroplasty implant can be fixed to the bone with or without bone cement. Cement is the current recommended technique but recently some risks have been identified, which could potentially be avoided by using uncemented implants. Controversy, therefore, remains about which type of hemiarthroplasty offers patients the best outcomes.This is the protocol for a multicentre randomised controlled trial comparing cemented hemiarthroplasty versus uncemented hemiarthroplasty for patients 60 years and over with a displaced intracapsular hip fracture.

METHODS AND ANALYSIS

Multicentre (a minimum of seven UK hospitals), multisurgeon, parallel group, two-arm, superiority, randomised controlled trial. Patients aged 60 years and older with a displaced intracapsular hip fracture treated with hemiarthroplasty surgery are eligible. Participants will be randomly allocated on a 1:1 basis to either a cemented hemiarthroplasty or a modern hydroxyapatite coated uncemented hemiarthroplasty. Otherwise all care will be in accordance with the National Institute for Health and Care Excellence guidance. A minimum of 1128 patients will be recruited to obtain 90% power to detect a 0.075-point difference in the primary endpoint: health-related quality of life (EuroQol 5 dimensions 5 levels) at 4 months postinjury. The treatment effect will be estimated using a two-sided t-test adjusted for age, gender and cognitive impairment based on an intention-to-treat analysis. Secondary outcomes include mortality, complications including revision surgery and cause, mobility status, residential status, health-related quality of life at 1 and 12 months and health resource use. A within-trial economic analysis will be conducted.

ETHICS, DISSEMINATION AND FUNDING

Wales Research Ethics Committee 5 approved the feasibility phase on 2 December 2016 (16/WA/0351) and the definitive trial on 22 November 2017 (17/WA/0383). This study is sponsored by the University of Oxford and funded by the National Institute for Health Research, Research for Patient Benefit (PB-PG-0215-36043 and PB-PG-1216-20021). A manuscript for a peer-reviewed journal will be prepared and the results shared with patients via local mechanisms at participating centres.

TRIAL REGISTRATION NUMBER

ISRCTN18393176.

The value of nonoperative versus operative treatment of frail institutionalized elderly patients with a proximal femoral fracture in the shade of life (FRAIL-HIP); protocol for a multicenter observational cohort study

Background

Proximal femoral fractures are strongly associated with morbidity and mortality in elderly patients. Mortality is highest among frail institutionalized elderly with both physical and cognitive comorbidities who consequently have a limited life expectancy. Evidence based guidelines on whether or not to operate on these patients in the case of a proximal femoral fracture are lacking. Practice variation occurs, and it remains unknown if nonoperative treatment would result in at least the same quality of life as operative treatment. This study aims to determine the effect of nonoperative management versus operative management of proximal femoral fractures in a selected group of frail institutionalized elderly on the quality of life, level of pain, rate of complications, time to death, satisfaction of the patient (or proxy) and the caregiver with the management strategy, and health care consumption.

Methods

This is a multicenter, observational cohort study. Frail institutionalized elderly (70 years or older with a body mass index < 18.5, a Functional Ambulation Category of 2 or lower pre-trauma, or an American Society of Anesthesiologists score of 4 or 5), who sustained a proximal femoral fracture are eligible to participate. Patients with a pathological or periprosthetic fractures and known metastatic oncological disease will be excluded. Treatment decision will be reached following a structured shared decision process. The primary outcome is quality of life (Euro-QoL; EQ-5D-5 L). Secondary outcome measures are quality of life measured with the QUALIDEM, pain level (PACSLAC), pain medication use, treatment satisfaction of patient (or proxy) and caregivers, quality of dying (QODD), time to death, and direct medical costs. A cost-utility and cost-effectiveness analysis will be done, using the EQ-5D utility score and QUALIDEM score, respectively. Non-inferiority of nonoperative treatment is assumed with a limit of 0.15 on the EQ-5D score. Data will be acquired at 7, 14, and 30 days and at 3 and 6 months after trauma.

Discussion

The results of this study will provide insight into the true value of nonoperative treatment of proximal femoral fractures in frail elderly with a limited life expectancy. The results may be used for updating (inter)national treatment guidelines.

Trial registration

The study is registered at the Netherlands Trial Register (NTR7245; date 10-06-2018).

What are the influencing factors in self-rated health status after hip fracture? A prospective study on 402 patients

Health status (HS) and influencing factors in HS were evaluated six and 12 months after hip fracture. One-third of the patients did not reach their pre-fracture HS within 1 year. HS before fracture and fall risk could, inter alia, be identified as influencing factors.

PURPOSE

From a patient's perspective, regaining pre-fracture health status (HS) is one of the most important factors concerning the outcome after hip fracture. The aim of this study was to evaluate the HS and particularly to identify influencing factors in HS 6 and 12 months after hip fracture.

METHODS

A total of 402 patients with hip fractures aged 60 years and older were included. HS was evaluated using the EQ-5D questionnaire pre-fracture and at 6 and 12 months after surgery. Multivariate regression analysis was performed to identify influencing factors in HS at 6 and 12 months. Afterwards, the results in the EQ-5D index were dichotomized into worse and equal/better results than before fracture, and a multivariate logistic regression analysis was performed for the dichotomized variables at 6 and 12 months.

RESULTS

The EQ-5D index decreased from 0.71 before the fracture to 0.60 at 6 months (p < 0.001) and increased slightly to 0.63 at 12 months (p = 0.328). A high pre-fracture EQ-5D index was associated with not reaching the pre-fracture EQ-5D index, and a high Tinetti score at hospital discharge was associated with reaching the pre-fracture EQ-5D index at 6 and 12 months. A high ASA score was an influencing factor behind a lower EQ-5D index than before the fracture at 6 months.

CONCLUSIONS

Hip fractures constitute a deep and long-lasting drop in the patients' HS. Early and intensive physiotherapy and individualized rehabilitation programmes regarding a patient's living situation before the fracture seem to be essential to improve HS.

Effect of frailty on quality of life in elderly patients after hip fracture: a longitudinal study

OBJECTIVES

The aims of this study were to examine the pattern of changes over time in health status (HS) and quality of life (QoL) in the first year after hip fracture and to quantify the association between frailty at the onset of hip fracture and the change in HS and QoL 1 year later. The major hypothesis was that frailty, a clinical state of increased vulnerability, is a good predictor of QoL in patients recovering from hip fracture.

DESIGN

Prospective, observational, follow-up cohort study.

SETTING

Secondary care. Ten participating centres in Brabant, the Netherlands.

PARTICIPANTS

1091 patients entered the study and 696 patients completed the study. Patients with a hip fracture aged 65 years and older or proxy respondents for patients with cognitive impairment were included in this study.

MAIN OUTCOME MEASURES

The primary outcomes were HS (EuroQol-5 Dimensions questionnaire) and capability well-being (ICEpop CAPability measure for Older people). Prefracture frailty was defined with the Groningen Frailty Indicator (GFI), with GFI ≥4 indicating frailty. Participants were followed up at 1 month, 3 months, 6 months and 1 year after hospital admission.

RESULTS

In total, 371 patients (53.3%) were considered frail. Frailty was negatively associated with HS (β -0.333; 95% CI -0.366 to -0.299), self-rated health (β -21.9; 95% CI -24.2 to -19.6) and capability well-being (β -0.296; 95% CI -0.322 to -0.270) in elderly patients 1 year after hip fracture. After adjusting for confounders, including death, prefracture HS, age, prefracture residential status, prefracture mobility, American Society of Anesthesiologists grading and dementia, associations were weakened but remained significant.

CONCLUSIONS

We revealed that frailty is negatively associated with QoL 1 year after hip fracture, even after adjusting for confounders. This finding suggests that early identification of prefracture frailty in patients with a hip fracture is important for prognostic counselling, care planning and the tailoring of treatment.

TRIAL REGISTRATION NUMBER

NCT02508675.

ICECAP-O, the current state of play: a systematic review of studies reporting the psychometric properties and use of the instrument over the decade since its publication

PURPOSE

A paper reporting the development of the ICECAP-O was published in 2006. Since then, there has been increasing interest in the use of capability-based measures within health economics and the ICECAP-O has been suggested for use in economic evaluation by decision-making bodies in the Netherlands and UK.

METHODS

A systematic review of studies published between January 2006 and October 2018 which have assessed the psychometric properties of ICECAP-O or utilised the measure within economic evaluation.

RESULTS

Twenty-four studies explored the psychometric properties of ICECAP-O and 21 have utilised the measure within economic evaluation; one study reported psychometric properties as well as utilising the measure within economic evaluation. The ICECAP-O has good construct validity and responsiveness, but there is evidence of some issues relating to content validity. In the context of economic evaluation, the ICECAP-O has, to date, mainly been included as a secondary economic measure and the reporting of results is brief with minimal detail and often no discussion. Five of the economic evaluation studies combined scores from ICECAP-O with time, but each used different terminology to describe this result.

CONCLUSION

Focus, in terms of publications, appears to have shifted now from assessment of psychometric properties to the utilisation of the ICECAP-O within economic evaluation. Further research is needed with respect to a decision-rule for the ICECAP measures. This additional research should also guide users in terms of appropriate analysis, terminology and presentation of results, which are in-keeping with the conceptual framework underpinning the ICECAP-O.

Impact of surgically operated hip fracture on the quality of life, functional status and mood of the elderly

OBJECTIVES

To determine the quality of life related to health, functional capacity and mood to hip fracture and one month after surgery.

METHOD

Prospective and descriptive study developed from January 2015 to January 2016 in Campo Arañuelo Hospital (Navalmoral de la Mata, Cáceres, Spain). Sociodemographic variables, functional capacity (Barthel Index), dependence (Lawton and Brody Scale), quality of life related to health (Questionnaire Euroqol-5D) and on mood (Yesavage geriatric depression scale GDS15) were collected, prior to the hip fracture and one month after the intervention.

RESULTS

Significant decrease in functional capacity (Barthel), the mean score was 86.66 before the fracture, compared to 58.72 at the month after surgery (P<.001). Regarding the Lawton and Brody Scale, the mean was 4.95 and at 2.24months (P<.001). The mean scores on health related quality of life, baseline and post-intervention in the analog visual scale of the EQ-5D questionnaire were 72.95 vs 59.45 respectively (P=.004). Although before the fracture, 94.10% had no alteration in mood, one month after the intervention there was a possible depression of 20.50% and an established depression of 11%.

CONCLUSIONS

The fracture of the head affects the functionality of the elderly, causing dependence for the basic and instrumental activities of daily life. It also affects the quality of life related to health and this decreases significantly in the month after surgery. Depressive mood is inversely related to perceived perceived quality of life.