Geriatric Orthopaedic Surgery & Rehabilitation最新文献

Aim: Hip fractures in older adults often result in decreased mobility and independence. This study aimed to identify critical balance skills that distinguish different activity levels following fracture, using sub-items of the Berg Balance Scale (BBS).

Methods: This retrospective cross-sectional study analyzed the medical records of 252 older adults (mean age 79.8 ± 8.8 years) with hip fractures. Participants were classified into Independent (n = 90), House-bound (n = 92), and Chair-bound (n = 70) groups based on the Japanese Bedriddenness Rank (BR). Decision tree analysis was performed using BBS sub-items as predictors of activity level.

Results: Key discriminators between activity levels were identified: "360° Turning" and "Sit to Stand" differentiated the Independent from the House-bound groups, while "Reaching Forward While Standing" and "Standing Unsupported" distinguished the House-bound from Chair-bound groups. Model accuracy was 81.9% (AUC 0.894) for Independent vs House-bound and 83.3% (AUC 0.910) for House-bound vs Chair-bound groups.

Discussion: Our results offer a novel, evidence-based approach to tailoring rehabilitation strategies for hip fracture patients. By focusing on these critical balance skills, patient functional outcomes may improve, ultimately enhancing quality of life in older adults following hip fracture.

Introduction: Prophylactic surgery for symptomatic incomplete atypical femoral fractures (SIAFFs) has demonstrated favorable outcomes. However, concerns remain regarding surgical intervention for a fracture that has not yet completed. This retrospective study aimed to evaluate the efficacy of conservative treatment using teriparatide (TPTD) as a conservative treatment for SIAFF.

Methods: This retrospective study reviewed 30 cases with SIAFF who underwent conservative treatment between November 2012 and September 2019. The diagnosis of SIAFF was based on the criteria established by the Task Force of the American Society for Bone and Mineral Research(ASBMR). The treatment protocol included (1) discontinuation of bisphosphonates, (2) use of 2 crutches or a four-point walker, (3) daily subcutaneous TPTD injection until pain subsided, and (4) monthly radiographic follow-up. Radiographs and bone scans were used to assess bone union, and follow-up continued for up to 2 years from protocol initiation. Comparisons between the successful and failed treatment groups were performed using the Student's t-test for continuous variables and Fisher's exact test for categorical variables.

Results: The mean age was 72.6 years (range, 55-87) and all patients were female. 13 cases involved the diaphyseal region and 17 involved the subtrochanteric region. The average duration of TPTD treatment was 6.5 months (range, 3-12), and the average follow-up was 45.5 months (range, 19-84) after the final injection. The mean SIAFF severity score was 9.5 (range, 7-11). Symptom-free bone union was achieved in 23 of 30 cases (76.7%). Five cases (4 with worsening pain, 1 with radiographic progression) underwent prophylactic intramedullary nailing, and 2 cases progressed to complete fracture and were treated with intramedullary nailing.

Conclusion: The result of this study suggests that the conservative treatment with teriparatide injection may be a potentially effective option for patients with SIAFF.

Purpose: Post-acute care (PAC) plays a key role in recovery following hip fractures. The aim of the study is to examine the factors affecting the achievement of the minimal important change (MIC) in older patients with hip fractures.

Methods: This retrospective cohort study included 228 patients who underwent surgical interventions for hip fractures and received subsequent PAC between 2020 and 2021. Data on demographics, medical history, and lifestyle habits were collected. Outcomes were measured using the Barthel Index, Numeric Rating Scale (NRS), and Harris Hip Score (HHS). Univariate and multivariate regression analyses were conducted to identify predictors of achieving the MIC.

Results: After treatment, significant improvements were observed in the Barthel Index (from 41.45 to 65.15, P < 0.001), NRS (from 5.03 to 2.52, P < 0.001), and HHS (from 29.35 to 63.68, P < 0.005). The MIC for the Barthel Index, NRS, and HHS were determined to be 6.20, 0.92, and 6.69, respectively. Dementia (odds ratio [OR] = 3.77, 95% confidence interval [CI] = 1.51-9.44, P = 0.005), age above 80 years (OR = 2.80, 95% CI = 1.15-6.84, P = 0.024), and heart failure (OR = 4.21, 95% CI = 1.34-13.23, P = 0.014) served as significant predictors of failure to achieve the MIC with the Barthel Index. For HHS, Diabetes mellitus was the only significant predictor of failure to achieve the MIC (OR = 4.32, 95% CI = 1.00-18.62, P = 0.050).

Conclusions: This study highlights major improvements in the Barthel Index, NRS, and HHS among older patients receiving PAC after hip fractures, along with a quantifiable MIC. Dementia is a robust predictor of failure to achieve the MIC with the Barthel Index, and advanced age, heart failure, and diabetes mellitus are key factors for optimizing recovery.

Background: To evaluate the clinical efficacy of PFNA in treating intertrochanteric fractures in super-elderly patients.

Methods: This study included patients aged over 90 years admitted to the orthopedic department of our hospital with intertrochanteric fractures between January 2021 and December 2023. The patients were categorized into two groups: the surgical group, which received treatment with PFNA, and the conservative group, which underwent tibial tubercle skeletal traction. PSM was additionally applied to control for confounding biases. Comparisons were conducted between the two groups concerning VAS scores at 1 week and 3 months post-admission, fracture healing time, complication rates, HHS, and SF-36 at the final follow-up, as well as 1-year survival rates.

Results: A total of 112 patients were enrolled, including 36 in the surgical group and 76 in the conservative group. After performing 1:1 PSM on baseline characteristics such as gender, age, BMI, bone density, Evans-Jensen classification, ASA grade, and CCI, 32 pairs of data were obtained, with 32 patients in the surgical group and 32 in the conservative group. Follow-up results indicated that the surgical group experienced faster pain relief, shorter fracture healing times, and lower incidence rates of most complications. Additionally, the HHS and SF-36 scores at the final follow-up were higher in the surgical group, and the one-year survival rate was also greater than that of the conservative group (P < 0.05).

Conclusion: For super-elderly patients with relatively good physical conditions who suffer from intertrochanteric fractures, the use of PFNA fixation, compared to conservative treatment, can achieve better limb function, a lower incidence of complications, and a higher survival rate.

Background: To evaluate the incidence rate of urinary tract infection (UTI) and postoperative urinary retention (POUR) in the initial indwelling urinary catheter (IIC) and intraoperative indwelling urinary catheter (IOC) groups of hip fracture patients who had undergone either fracture fixation or hemiarthroplasty operation within 48 hours.

Methods: Between June 2023 and October 2024, 110 patients who met the eligible criteria were enrolled in this study. We prospectively randomized all patients into the IOC (n = 55) and IIC (n = 55) groups. The postoperative incidence of UTI and POUR was compared between the two groups and evaluated 24 h postoperatively.

Results: The incidence of UTI was significantly higher in the IIC group (23.6%) than in the IOC group (9.1%) (P = .039). However, the incidence of POUR was not significantly different between the groups (16.4% vs 9.1%; P = .252).

Conclusion: For hip fracture patients undergoing early surgery within 48 h, intraoperative urinary catheterization significantly reduced the incidence of POUR, while the incidence of UTI did not differ significantly between the groups.

Objectives: To explore the impact of race, language, and socioeconomic status on vitamin D screening and osteoporosis treatment after operative management of proximal femur fractures.

Methods: Design: Retrospective cohort. Setting: Level I, II, and III Trauma Centers within an overarching institutional organization. Patient Selection Criteria: Patients greater than 65 years of age who underwent operative treatment for a proximal femur fracture between January 2020 and June 2023. Outcome Measures and Comparisons: Primary outcomes were rates of vitamin D screening and osteoporosis treatment. Secondary outcomes were rates of geriatric and endocrinology consultation during admission. Primary and secondary outcomes were compared by race, language, and socioeconomic status (Area of Deprivation Index [ADI]). ADI was recorded at the state level (0 to 10) using the ADI mapping tool with higher ADI indicating more socioeconomic disadvantage.

Results: In total, 1149 patients were included (primary English-speaking: 89.2%, White: 90.3%, with intertrochanteric hip fractures: 76.6%). There were no differences in vitamin D screening or osteoporosis treatment observed between racial, language, or socioeconomic groups (P > 0.05). While non-English speakers were more likely to get an endocrine consult (OR 1.98, 95% CI 1.29-3.04, P = 0.002), Black patients or those with a higher ADI were less likely to receive endocrine consults (OR 0.30, 95% CI 0.11-0.81, P = 0.018 and OR 0.69, 95% CI 0.50-0.90, P = 0.008, respectively).

Conclusions: Black patients or those from higher area of deprivation neighborhoods were less likely to receive endocrine consults. Geriatric and endocrine consults increased the odds of obtaining vitamin D screening and osteoporosis treatment. Despite this finding, race, language, and socioeconomic status did not impact vitamin D screening or osteoporosis treatment after proximal femur fracture. The discrepancies in consultation based on non-clinical factors emphasize the importance of interdepartmental collaboration to optimize standardized osteoporosis treatment after proximal femur fracture and highlight disparities in osteoporosis care.

Level of evidence: Therapeutic Level III.

Introduction: Hip fractures are common among older adults; and while urgent fracture fixation is recommended, it is often weighed against preoperative optimization needs. Previous studies have reported conflicting findings on the association between time to surgery and mortality risk. In this study, we investigated the association between surgical timing and mortality. We also explored the relationship between time to surgery and secondary outcomes, including length of stay and hospital readmission.

Methods: We conducted a retrospective cross-sectional study of 967 adults aged $\ge$ 65 who underwent hip fracture repair between 2018 and 2023. Time to surgery (in days) was the primary exposure. Multivariable Cox proportional hazards models were used to assess associations with 30-day, 90-day, and 365-day mortality. Firth penalized logistic regression was used to examine associations with secondary outcomes, including length of stay >7 days and 30-day readmission.

Results: For 30-day, 90-day, and 365-day mortality, each additional day of delay in surgery was associated with an increased risk of mortality, with adjusted hazard ratios (HR) of 1.15 (95% CI [1.02, 1.30], P = .02), 1.13 (95% CI [1.02, 1.26], P = .02), and 1.09 (95% CI [1.01, 1.19], P = .03), respectively. Similarly, each additional day of delay was associated with an increased risk of a length of stay >7 days and readmission within 30 days of discharge, with adjusted odds ratios (OR) of 2.26 (95% CI [1.89, 2.74]) and 1.16 (95% CI [1.05, 1.29]), respectively.

Conclusion: Delaying surgery in older adults increases the risk of mortality, along with a potential elevated risk of prolonged hospital stays and readmission. We recommend that, when safe, surgery should be performed promptly for these patients.

Background: Frailty is an established risk factor for adverse outcomes following total joint arthroplasty, including higher rates of prosthetic joint infection (PJI), reoperation rates, and readmission, which may be greater in the setting of revision. The purpose of this study is to compare the association of frailty indices with mortality and complications following septic revision arthroplasty.

Methods: A query from The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was performed for adult patients undergoing revision total knee or hip arthroplasty between 2015 and 2020, which records perioperative data (30 days postoperatively) for over 700 centers nationwide. PJI cases without revision arthroplasty were excluded. The RAI-rev and mFI-5 frailty scores were calculated for each patient. Outcomes included major complications, mortality, non-home discharge (NHD), DVT, readmission within 30 days, wound complications, pulmonary complications, cardiac complications, and postoperative infection. T-test and binary logistic regression assessed associations with frailty scores and outcomes. Predictability was evaluated through multivariate regression analysis, and its discriminative accuracy was measured using receiver operating curve (ROC) analysis and C-statistics.

Results: A total of 4395 patients were included (median age: 66 [IQR 59-73]). Within the cohort, 46.44% were female and 38.02% exhibited NHD. RAI-rev demonstrated increased association compared to mFI-5 with mortality (OR: 1.20 vs 1.10, CI: 95%) and NHD (OR: 1.15 vs 1.05, CI: 95%). RAI-Rev demonstrated significantly superior discriminatory accuracy when compared to mFI-5 for NHD (Cs: 0.670 vs 0.602, P < 0.001) and mortality (Cs: 0.795 vs 0.574, P < 0.001).

Conclusions: Frailty may have a distinct association with mortality and NHD following septic rTJA, especially when assessed by the revised Risk Analysis Index. This understanding is important to educate the patient and their family and provide insight into the necessary resources and surveillance needed to manage frail patients undergoing septic revision total joint arthroplasty.

Purpose: To examine five-year trends in 30-day readmission and length of stay (LOS) among the geriatric population after surgical fixation for hip fracture in a large database model.

Methods: Patients ≥ 65 years of age in the American College of Surgeons National Surgical Quality Improvement Program Targeted Hip Fracture (ACS-NSQIP THF) were identified using Current Procedural Terminology (CPT®) codes 27 236, 27 244, 27 245 for intramedullary nailing or Open Reduction and Internal Fixation (ORIF) of fractures involving the femoral head, neck, peritrochanteric, intertrochanteric, and subtrochanteric regions. The primary outcome was incidence of ≥1 30-day hospital readmission and secondary outcome was total hospital length of stay in trend analysis.

Results: Overall, there were 64 794 patients who met inclusion criteria, of which 7.85% (95% CI: 7.64% to 8.05%) were readmitted within 30 days of hip fracture surgical fixation. The proportion of patients with ≥1 30-day readmission were presented over time and Cochran-Armitage Trend Testing indicated a statistically significant decreasing trend in the 30-day readmission incidence from 2016-2021 (P < 0.0001). The mean absolute change in incidence from year-to-year was -0.24% (mean relative change, 0.97) and the total absolute difference in incidence from 2016 to 2021 was -1.20% (relative difference, 0.85). LOS data were missing for 1048 cases (1.62%). Mean and median length of stay data was similar across all years.

Conclusion: The probability of having ≥1 30-day readmission decreased 0.85-times from 2016 to 2021, with a statistically significant downward trend over time. There were no meaningful changes in length of stay. Healthcare providers, policymakers, and stakeholders can utilize these findings to implement initiatives that enhance value-based care in hip fracture management and benchmark institutional metrics, ultimately improving patient outcomes and optimizing healthcare resources.