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Rădulescu M, Necula BR, Mironescu SA, Roman MD, Schuh A, Necula RD. Is the Timing of Surgery a Sufficient Predictive Factor for Outcomes in Patients with Proximal Femur Fractures? A Systematic Review. J Pers Med 2024; 14:773. [PMID: 39064027 PMCID: PMC11277622 DOI: 10.3390/jpm14070773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 06/27/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
(1) Background: Hip fractures are currently recognized as major public health problems, raising many issues in terms of both patients' quality of life and the cost associated with caring for this type of fracture. Many authors debate whether to operate as soon as possible or to postpone surgery until the patient is stable. The purpose of this review was to review the literature and obtain additional information about the moment of surgery, the time to surgery, length of hospital stay, and how all of these factors influence patient mortality and complications. (2) Methods: The systematic search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and PICO guidelines, using the Google Scholar platform, for articles published between 2015 and 2023. Quality assessment was performed. (3) Results: After applying the inclusion criteria, 20 articles were included in the final list. Those who had surgery within 48 h had lower in-hospital and 30-day mortality rates than those who operated within 24 h. The American Society of Anesthesiologists (ASA) score is an important predictive factor for surgical delay, length of hospital stay (LOS), complications, and mortality. (4) Conclusions: Performing surgery in the first 48 h after admission is beneficial to patients after medical stabilization. Avoidance of delayed surgery will improve postoperative complications, LOS, and mortality.
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Affiliation(s)
- Mihai Rădulescu
- Faculty of Medicine, Transilvania University of Brașov, 500036 Brașov, Romania
| | - Bogdan-Radu Necula
- Faculty of Medicine, Transilvania University of Brașov, 500036 Brașov, Romania
| | | | - Mihai Dan Roman
- Faculty of Medicine, Lucian Blaga University of Sibiu, 550169 Sibiu, Romania
| | - Alexander Schuh
- Department of Musculoskeletal Research, Marktredwitz Hospital, 95615 Marktredwitz, Germany
| | - Radu-Dan Necula
- Faculty of Medicine, Transilvania University of Brașov, 500036 Brașov, Romania
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Lu X, Gou W, Wu S, Wang Y, Wang Z, Xiong Y. Complication Rates and Survival of Nonagenarians after Hip Hemiarthroplasty versus Proximal Femoral Nail Antirotation for Intertrochanteric Fractures: A 15-Year Retrospective Cohort Study of 113 Cases. Orthop Surg 2023; 15:3231-3242. [PMID: 37880497 PMCID: PMC10694023 DOI: 10.1111/os.13913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVE Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti-rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population. METHODS A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90-101 years) at the time of operation. The average duration of follow-up was 29.7 months (range 1-120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan-Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow-up period into 1-12 months (short-term), 13-42 months (medium-term) and 43-120 months (long-term) according to the configurations of Kaplan-Meier survival curves. RESULTS Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p < 0.05). The complications rates, 1- to 60-month cumulative all-cause mortality, postoperative optimal Harris hip score (HHS), and Barthel index (BI) presented no significant difference between the two groups (all p > 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium-term (p = 0.01), while similar survival rates were observed in the short- and long-term post-operation periods (both p > 0.05). Cox regression with survival-time-dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium-term (p = 0.039). CONCLUSION Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium-term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population.
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Affiliation(s)
- Xingchen Lu
- Department of Orthopaedics, Daping HospitalArmy Medical University (Third Military Medical University)ChongqingChina
| | - Wenlong Gou
- Department of Orthopaedics, Daping HospitalArmy Medical University (Third Military Medical University)ChongqingChina
| | - Siyu Wu
- Department of Orthopaedics, Daping HospitalArmy Medical University (Third Military Medical University)ChongqingChina
| | - Yu Wang
- Department of Orthopaedics, Daping HospitalArmy Medical University (Third Military Medical University)ChongqingChina
| | - Ziming Wang
- Department of Orthopaedics, Daping HospitalArmy Medical University (Third Military Medical University)ChongqingChina
| | - Yan Xiong
- Department of Orthopaedics, Daping HospitalArmy Medical University (Third Military Medical University)ChongqingChina
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Sinkler MA, Pennacchio CA, Kotchman HM, Vallier HA. Association of Chronic Kidney Disease and Complications Following Acute Torsional Ankle Fracture. Foot Ankle Int 2022; 43:1569-1576. [PMID: 36254721 DOI: 10.1177/10711007221127026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although chronic kidney disease (CKD) has been associated with poor outcomes following traumatic fractures, there is a scarcity of literature describing the effect on outcomes of ankle fractures. We will examine the impact of CKD on clinical outcomes following torsional ankle fracture, including complications and unplanned surgical procedures. METHODS A retrospective review of 1981 adult patients with torsional ankle fractures treated at a level 1 trauma center was performed to identify patients with CKD based on glomerular filtration rate. Demographic, injury, and treatment-related characteristics were collected. Outcomes included any unplanned procedure: implant removal, debridement, revision, arthrodesis, and amputation; in addition to complications of superficial infection, deep infection, and implant irritation. Patients with CKD were matched with patients without CKD by propensity score matching. Univariate comparisons between groups were conducted using chi-square and Mann-Whitney U tests. RESULTS 136 patients (68 with CKD and 68 without CKD) were analyzed. Of the 68 patients with CKD, the mean stage of disease was 3.7 with 24% on dialysis for a mean length of 4.1 years. Patients without CKD were more likely to undergo primary ORIF (100% vs 54%, P < .001). Thirty-five percent of patients with CKD had surgical complications vs 19% in the cohort without (P = .07). Patients with open fractures, dislocation, and chronic kidney disease were, respectively, 5.19, 3.77, and 3.91 times more likely to have any complication (P = .02, P = .05, P = .05). Patients with CKD were more likely to undergo unplanned arthrodesis (P = .01). Only dislocation was an independent predictor for unplanned procedure (odds ratio = 5.08, P = .026). CONCLUSION Following torsional ankle fracture, CKD is associated with increased likelihood of having a complication or an unplanned arthrodesis. Open fractures and dislocation at time of injury are also associated with complications. Our findings encourage caution about surgical treatment of ankle fractures in patients with CKD. LEVEL OF EVIDENCE Level III, retrospective, comparative, prognostic.
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Affiliation(s)
- Margaret A Sinkler
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Halle M Kotchman
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Heather A Vallier
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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National study: Most elderly patients benefit from earlier hip fracture surgery despite co-morbidity. Injury 2021; 52:905-909. [PMID: 33082028 DOI: 10.1016/j.injury.2020.10.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/24/2020] [Accepted: 10/13/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To estimate the potential influence of pre-operative patient condition on the benefit of earlier hip fracture surgery for elderly patients. BACKGROUND Many studies emphasize the benefit of earlier hip fracture surgery for patient survival. However less is known regarding how this relationship is influenced by clinical factors which could serve as potential contra-indicators for earlier surgery. Rushed surgery of patients with contra-indications may even compromise their survival. METHODS A retrospective study of patients aged 65 and above with an isolated hip fracture following trauma, based on data from 19 hospitals of the national trauma registry available for the years 2015-2016. Registry data was crossed with data on co-morbidities and medication intake from the biggest health insurance agency in the country, serving more than 50% of the country's population. Mediation analysis was performed on a wide list of co-morbidities, medications and clinical test results in order to establish the mediation of their relationship with inhospital mortality by earlier hip fracture surgery. Factors found significant in the mediation analysis were utilized to adjust a logistic regression for predicting inhospital mortality by function of waiting time to surgery and patient's sex and age. RESULTS Anti-coagulant and anti-platelet intake; test results pointing to decreased kidney function and being diagnosed with diabetes or Ischemic Heart Disease were found to be significantly mediated in their influence on inhospital mortality by hip fracture surgery. Despite anti-platelet intake and kidney function having a significant impact on mortality in the multi-variate analysis, the positive effect of earlier hip surgery on survival remained unchanged after adjustment. CONCLUSIONS Earlier hip fracture surgery was found to be beneficial for elderly patients even when their co-morbidities and medication intake are taken into account.
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Scala A, Ponsiglione AM, Loperto I, Della Vecchia A, Borrelli A, Russo G, Triassi M, Improta G. Lean Six Sigma Approach for Reducing Length of Hospital Stay for Patients with Femur Fracture in a University Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18062843. [PMID: 33799518 PMCID: PMC8000325 DOI: 10.3390/ijerph18062843] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 11/30/2022]
Abstract
Surgical intervention within 48 h of hospital admission is the gold standard procedure for the management of elderly patients with femur fractures, since the increase in preoperative waiting time is correlated with the onset of complications and longer overall length of stay (LOS) in the hospital. However, national evidence demonstrates that there is still the need to provide timely intervention for this type of patient, especially in some regions of central southern Italy. Here we discuss the introduction of a diagnostic–therapeutic assistance pathway (DTAP) to reduce the preoperative LOS for patients undergoing femur fracture surgery in a university hospital. A Lean Six Sigma methodology, based on the DMAIC cycle (Define, Measure, Analyze, Improve, Control), is implemented to evaluate the effectiveness of the DTAP. Data were retrospectively collected and analyzed from two groups of patients before and after the implementation of DTAP over a period of 10 years. The statistics of the process measured before the DTAP showed an average preoperative LOS of 5.6 days (standard deviation of 3.2), thus confirming the need for corrective actions to reduce the LOS in compliance with the national guidelines. The influence of demographic and anamnestic variables on the LOS was evaluated, and the impact of the DTAP was measured and discussed, demonstrating the effectiveness of the improvement actions implemented over the years and leading to a significant reduction in the preoperative LOS, which decreased to an average of 3.5 days (standard deviation of 3.60). The obtained reduction of 39% in the average LOS proved to be in good agreement with previously developed DTAPs for femur fracture available in the literature.
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Affiliation(s)
- Arianna Scala
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (I.L.); (M.T.); (G.I.)
| | - Alfonso Maria Ponsiglione
- Department of Electrical Engineering and Information Technology, University of Naples “Federico II”, 80125 Naples, Italy
- Correspondence:
| | - Ilaria Loperto
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (I.L.); (M.T.); (G.I.)
| | - Antonio Della Vecchia
- Hospital Directorate, “San Giovanni di Dio e Ruggi d’Aragona” University Hospital of Salerno, 84125 Salerno, Italy; (A.D.V.); (A.B.)
| | - Anna Borrelli
- Hospital Directorate, “San Giovanni di Dio e Ruggi d’Aragona” University Hospital of Salerno, 84125 Salerno, Italy; (A.D.V.); (A.B.)
| | - Giuseppe Russo
- Hospital Directorate, National Hospital A.O.R.N. “Antonio Cardarelli” of Naples, 80131 Naples, Italy;
| | - Maria Triassi
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (I.L.); (M.T.); (G.I.)
- Interdepartmental Center for Research in Healthcare Management and Innovation in Healthcare (CIRMIS), University of Naples “Federico II”, 80131 Naples, Italy
| | - Giovanni Improta
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (I.L.); (M.T.); (G.I.)
- Interdepartmental Center for Research in Healthcare Management and Innovation in Healthcare (CIRMIS), University of Naples “Federico II”, 80131 Naples, Italy
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Zhu Y, Hu J, Han W, Lu J, Zeng Y. Simultaneous bilateral femoral neck fractures in a dialysis-dependent patient: case report and literature review. BMC Musculoskelet Disord 2020; 21:242. [PMID: 32293406 PMCID: PMC7158116 DOI: 10.1186/s12891-020-03281-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/13/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Simultaneous bilateral femoral neck fractures are extremely rare without obvious injury. Herein, we report the case of a patient on dialysis presenting with bilateral femoral neck fractures, which is a condition with high complication and mortality rates according to a review of the pertinent literature. CASE PRESENTATION We report the case a 47-year-old female with a history of 8 years of haemodialysis due to polycystic kidney disease who presented with bilateral hip pain during walking. The clinical history and results of physical and radiographic examinations of this patient are shown. Single-stage bilateral hemiarthroplasty was performed after a multidisciplinary team consultation. Three days after the operation, she could ambulate with a walker. The woman gradually regained her previous ability to walk over 6 months after surgery. CONCLUSIONS A multidisciplinary team consultation for perioperative management is necessary and effective in patients on dialysis. Early diagnosis with prompt surgical treatment could lead to favourable recovery.
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Affiliation(s)
- Yunyun Zhu
- Department of Nephrology, Tongde Hospital of Zhejiang Province, HangZhou, Zhejiang Province, China
| | - Jingtao Hu
- Zhejiang Chinese Medical University, HangZhou, Zhejiang Province, China
| | - Wenlun Han
- Department of Nephrology, Tongde Hospital of Zhejiang Province, HangZhou, Zhejiang Province, China
| | - Jianwei Lu
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234 GuCui Road, HangZhou, 310012, Zhejiang Province, China
| | - Yuqing Zeng
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234 GuCui Road, HangZhou, 310012, Zhejiang Province, China.
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Abstract
OBJECTIVE To compare the outcomes of patients with predialysis chronic kidney disease (CKD) or end-stage renal disease (ESRD) with the outcomes of patients with no kidney disease after hemiarthroplasty (HA) for femoral neck fractures (FNF). DESIGN Retrospective review utilizing the Nationwide Readmissions Database. SETTING National database incorporating inpatient data from 22 states. PATIENTS Using the Nationwide Readmissions Database, 214,399 patients who underwent HA after FNF between 2010 and 2014 were identified and divided into 3 groups using ICD-9 diagnosis codes: no kidney disease (n = 176,300, 82%), predialysis CKD (n = 34,400, 16%), and ESRD (n = 3,698, 2%). INTERVENTION HA for FNF. MAIN OUTCOME MEASUREMENT Mortality, blood transfusion, and postoperative complications during index hospitalization. Hospital readmission, postoperative dislocation, periprosthetic fracture, and revision surgery within 90 days of surgery. RESULTS Compared to patients with no kidney disease, ESRD patients had an increased risk of mortality [odds ratio (OR) = 3.76, 95% confidence interval (CI), 2.95-4.78], blood transfusion (OR = 2.35, 95% CI, 2.08-2.64), and postoperative complications (OR = 1.64, 95% CI, 1.45-1.86) during the index hospitalization as well as an increased risk of 90-day hospital readmission (OR = 3.09, 95% CI, 2.72-3.50). Interestingly, even patients with predialysis CKD had an increased risk of mortality (OR = 1.80, 95% CI, 1.59-2.05), blood transfusion (OR = 1.66, 95% CI, 1.59-1.75), and postoperative complications (OR = 2.37, 95% CI, 2.25-2.50) during the index hospitalization as well as an increased risk of 90-day hospital readmission (OR = 1.43, 95% CI, 1.37-1.51). CONCLUSIONS This retrospective cohort study demonstrates that both ESRD and CKD patients have worse outcomes compared to patients with no kidney disease after HA for FNF. LEVEL OF EVIDENCE Prognostic Level III. See instructions for authors for a complete description of levels of evidence.
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Liu Z, Zhang J, He K, Zhang Y, Zhang Y. Optimized clinical practice for superaged patients with hip fracture: significance of damage control and enhanced recovery program. BURNS & TRAUMA 2019; 7:21. [PMID: 31410362 PMCID: PMC6686476 DOI: 10.1186/s41038-019-0159-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 05/06/2019] [Indexed: 11/24/2022]
Abstract
With the advent of global aging, the incidence, mortality, and medical costs of hip fracture among aged patients are increasing annually. The number of controlled clinical studies and health economics analyses that conform to evidence-based medicine principles is growing day by day. However, unfortunately, no specific recommendations regarding the procedures for the treatment of hip fracture are available. Meanwhile, the existence of both traditional treatment systems and new treatment theories means that most doctors confront difficult choices in their daily practice. These factors make the therapeutic approach for aged patients, especially among superaged patients with hip fracture, extremely challenging. This study focuses on superaged patients (> 80 years as defined by the World Health Organization) with hip fracture and includes their preoperative pathological condition; therapeutic decision-making in terms of the benefit and risk ratio, damage control theory, and enhanced recovery after surgery were also investigated. These patients were discussed specifically by combining the current treatment strategies from several experts and the results of a meta-analysis published recently. The study presents some new ideas and approaches currently recognized in the field, such as preoperative assessment, surgical planning, safety consideration, complication intervention, and enhanced recovery implementation, and further presents some clear interpretations regarding misunderstandings in clinical practice. Finally, optimized treatment according to damage control principles and enhanced recovery after surgery during the perioperative period among superaged hip fracture patients is defined.
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Affiliation(s)
- Zaiyang Liu
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, 400037 China
| | - Jun Zhang
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, 400037 China
| | - Kaiqi He
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, 400037 China
| | - Yumei Zhang
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, 400037 China
| | - Yuan Zhang
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, 400037 China
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Yoon BH, Koo KH. Hip Fracture in Chronic Kidney Disease Patients: Necessity of Multidisciplinary Approach. J Korean Med Sci 2017; 32:1906-1907. [PMID: 29115068 PMCID: PMC5680485 DOI: 10.3346/jkms.2017.32.12.1906] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 10/23/2017] [Indexed: 11/20/2022] Open
Affiliation(s)
- Byung Ho Yoon
- Department of Orthopaedic Surgery, Inje University College of Medicine, Seoul Paik Hospital, Seoul, Korea.
| | - Kyung Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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