Geriatric Orthopaedic Surgery & Rehabilitation最新文献

Introduction: Hip fractures in individuals aged 65 and older present a significant burden to patients, families, and health care systems. These fractures lead to increased morbidity, loss of autonomy in Activities of Daily Living (ADLs), prolonged hospitalization, and heightened mortality rates. Despite existing knowledge, there is a need for high-quality studies to understand mid- to long-term outcomes and the impact of postoperative variables on mortality.

Methods: This retrospective matched case-control study analyzed patients who underwent operative management for hip fractures between August 1, 2021, and August 1, 2023, at a single Level II trauma center. Cases were defined as patients who expired between postoperative day 1 and ninety, while controls were patients alive at postoperative day 90. Cases and controls were matched by sex and age at the time of surgery. Patients over age 60, who underwent surgical treatment of a femoral neck or intertrochanteric fracture after receiving a preoperative block and were able to ambulate prior to their injury included. Cases and controls were matched based upon patient demographics including comorbidities. Major matched comorbidities were diabetes mellitus, hypertension, Chronic Obstructive Pulmonary Disease, and Coronary Artery Disease. A logistic regression was used to measure the association between in-hospital mobility and 90-day mortality.

Results: The 90-day mortality rate was 9.5% (16/169). The mean age of participants was 85.7 years, with 62.5% female. No significant differences were found in hospital length of stay or operative time. However, 37.5% of cases were discharged on hospice compared to 3.1% of controls. Only 6.3% of cases ambulated in the hospital compared to 53.1% of controls (P-value <.001). Logistic regression indicated that the odds of death were 17 times higher in patients who did not walk during their hospital stay (OR: 17.0, 95% CI: 2.91-326.0, P-value: 0.01).

Conclusions: This study highlights the critical importance of early postoperative mobilization in reducing 90-day mortality in hip fracture patients. The findings reveal that patients who ambulated during hospital admission had significantly lower mortality rates. These results suggest that early mobilization could serve as a strong protective factor against early postoperative mortality.

Purpose: To determine the relationship between trunk muscle cross-sectional area (CSA) measured using trunk computed tomography at the time of injury and gait ability at discharge.

Methods: This multicenter retrospective cohort study was performed in comprehensive rehabilitation units of four hospitals in Japan. The study included 442 patients with hip fractures who underwent surgery (bipolar hip arthroplasty or open reduction and internal fixation) and were hospitalized for treatment between January 2020 and January 2023. The main outcome measure was bilateral trunk muscle CSA (multifidus, erector spinae, psoas major, lateral abdominal muscles, and rectus abdominis). Participants who met the eligibility criteria were classified into two groups based on gait ability at the time of hospital discharge: those who maintained their gait ability (the maintenance group) and those who declined (the decline group).

Results: The CSA of the multifidus muscle was 0.015 ± 0.005 (CSA/Weight/fourth lumbar vertebrae) and 0.013 ± 0.004 (CSA/Weight/fourth lumbar vertebrae) in the maintenance and decline groups, respectively, being significantly lower in the decline group (P = 0.028, effect size = 0.457). The CSA of the psoas major was 15.3 [13.1⁠-⁠18.0] (CSA/Weight/fourth lumbar vertebrae) and 13.4 [11.9⁠-⁠16.0] (CSA/Weight/fourth lumbar vertebrae) in the maintenance and decline groups, respectively, being significantly lower in the decline group (P = 0.020, effect size = 0.335).

Conclusion: Smaller CSAs of the multifidus and psoas major muscles before injury were associated with decreased gait ability after hip fractures.

Introduction: The optimal management of patients taking DOAC medications in the perioperative trauma setting is based on limited evidence. Current guidelines recommend withholding DOAC medications 48-72 hours pre-operatively. The objective of this trial was to determine the utility of measuring DOAC levels prior to surgery, evaluate the safety of a cut-off level of <50 ng/mL and to compare the outcomes with time parameters.

Materials and methods: We performed a cohort study of patients aged 50 years and older admitted with a hip fracture who underwent surgery between January 12 017 and December 31 2019. Primary outcome was time to surgery (TTS) in hours. Secondary outcomes include inpatient transfusion and thromboembolism rates and 30-day mortality.

Results: 1579 patients underwent operative management of their hip fracture. The mean TTS in the DOAC group was 33.0 hours. This was significantly longer when compared to patients not on anticoagulation whose mean TTS was 24.4hours (95% CI -13.78: -8.71, P value <.05). It was also significantly higher than patients on warfarin whose mean TTS was 26.4hours (95% CI -12.41: -4.18, P value <.05). There was no significant difference in the transfusion rate and 30-day mortality between the groups (X² = 2.086, df = 2, P value = .352)]. There was no significant difference in transfusion rates and 30-day mortality between the patients with a DOAC level <50 ng/mL compared with the patients not on any anticoagulation. There was no significant difference in 30-day mortality or transfusion rates between those patients on a DOAC operated within 48 hours compared with those operated after 48 hours (P value = .67).

Discussion and conclusion: DOAC therapy delays surgery for patients with a hip fracture. Using a DOAC level <50 ng/mL is a safe level to proceed with surgery and reduces the TTS compared to following current guidelines. If DOAC levels are not available the data still supports operation at 48 hours.

Background: There is ongoing debate regarding the optimal management of older adult ankle fractures. The purpose of this study was to describe baseline characteristics and functional outcomes including complications in older adult patients receiving nonoperative treatment for low-energy ankle fracture and compare the outcomes of those with unstable vs stable fracture patterns.

Methods: Patients aged ≥65 from January 2012 to March 2019 that sustained an ankle fracture were identified. Those who had surgical treatment, age <65, high-energy trauma, bilateral ankle fractures, and patients without adequate follow-up (minimum 12 weeks) were excluded. Baseline demographics, injury characteristics, Charlson Comorbidity Index (CCI) score, and functioning regarding ambulatory status, living environment, and assistance personnel in the household were collected for all patients. The primary outcome of interest was retention of baseline ambulation, living environment, and assistance requirements at follow-up (>12 weeks). Pain improvement, radiographic changes, and adverse clinical events were also assessed.

Results: A total of 158 patients were included with an average follow-up timeframe of 41.6 weeks. Eighty-six percent of patients (n = 136) retained their ambulatory status at long-term follow up. Most patients retained the same living environment (n = 145, 91.8%). Thirty-five patients (22.2%) required additional assistance long-term. Approximately 67.1% of the entire cohort retained all three functional metrics. Patients who experienced functional decline were older (77.8 vs 71.6, P < 0.001), had higher CCI (3.2 vs 1.6, P < 0.001), had a diagnosis of dementia or cognitive impairment (36.5% vs 3.8%, P < 0.001), had lower baseline functional status (ambulation, living environment, and assistance required; all P < 0.001), and had an unstable fracture pattern (P = 0.003).

Conclusions: Understanding the functional outcomes of non-operative treatment in geriatric ankle fracture cases can contribute to a shared decision-making among healthcare providers, patients, and families.

Introduction: Postoperative rehabilitation for distal femur fracture generally requires gait exercises with weight-bearing restrictions. We aimed to determine whether full weight-bearing gait exercises immediately postoperatively effectively maintain walking ability in older adult patients with distal femur fractures.

Methods: Patients diagnosed with distal femur fractures between April 2017 and March 2024 were retrospectively evaluated. Patients aged ≥75 years who had undergone surgical treatment were classified into full weight-bearing (FWB) and non-weight-bearing (NWB) groups, with FWB and NWB gait exercises starting immediately postoperatively. Patient background was evaluated in terms of age at time of surgery, sex, weight, cognitive function, and fracture type (AO classification). Postoperative outcomes were operative time, intraoperative blood loss, gait function, and postoperative complications. Two osteosynthesis conditions that allowed postoperative FWB were achievement of bony support through anatomical reduction of the medial femur and the use of adequate supplemental fixation to maintain reduction.

Results: The study comprised 21 patients (1 man, 20 women; mean age, 87.2 [79-99] years). Extra- and intra-articular fractures were identified in 16 and 5 patients, respectively. The surgical procedures were lateral plating, double plating, and one-stage total knee arthroplasty in 16, 3, and 2 patients, respectively. There were 9 and 12 patients in the FWB and NWB groups, respectively, with no significant differences in patient background. The mean decrease in the Parker mobility score was 0.11 points (range, -3-2 points) in the FWB group vs 1.92 points (range, 0-3 points) in the NWB group, indicating that gait function was maintained in the FWB group (P = 0.0063). Two and 9 patients in the FWB and NWB groups, respectively, experienced complications (P = 0.017).

Conclusion: Consideration should be given to treatment involving orthogeriatric care for older adults with distal femur fractures. Rehabilitation with FWB can preserve gait function and reduce postoperative complications.

Background: Osteoporotic pelvic fractures in the elderly lead to pain and immobility resulting in decreased quality of life and worsening frailty. Teriparatide has been shown to shorten time to fracture union, diminish pain, and improve mobilization. At our hospital, this medication is prescribed by an outpatient endocrinologist or geriatrician. We hypothesize that elderly female patients sustaining low energy lateral compression (LC) pelvic fractures are not given Teriparatide. This study reports rates of successful Teriparatide initiation and looks for areas of improvement.

Materials and methods: A retrospective chart review of stable LC pelvic fractures admitted to a single urban academic level 1 trauma center from January 2012 to February 2021 was conducted. Females over 60 years old with stable LC pelvic fractures were included. Males and those aged less than 60 were excluded.

Results: 118 females with mean age of 79.1 ± 10.5 were included. Fourteen patients were not eligible for Teriparatide due to medical history, leaving 104 eligible patients. Twenty-eight patients (23.7%) had previous dual energy X-ray absorptiometry (DEXA) scans with mean T-scores of -3.14 ± 1.1 and 61% had Medicare insurance. Orthopaedic services recommended Teriparatide in 100% of cases. Geriatricians or endocrinologists documented evaluations for Teriparatide in 18 (17%), prescribed in 10 (9.6%), and initiated in 7 (6.7%) patients. Insurance type did not significantly differ among those that initiated Teriparatide and those that did not (p-0.10). Insurance did not approve the medication in 2 instances and in 1 instance it was discontinued at follow-up.

Conclusion: Despite level 1 evidence of Teriparatide's benefit for elderly osteoporotic women with low energy LC pelvic fractures, we failed to initiate treatment in 93% of eligible patients. Barriers to initiation included low rates of medical evaluation for its use and failure of insurance coverage. There are opportunities for multidisciplinary collaboration to increase evaluation for and initiation of Teriparatide.

Level of evidence: Cohort Retrospective (level III evidence).

Introduction: 1 mm cerclage cables have been introduced that can be placed under plates and hold reduction of periprosthetic femur fractures (PPFFx) around total hip arthroplasty (THA). Their utilization remains controversial due to the risk of nonunion secondary to periosteal stripping associated for their application. We compared surgical outcomes in patients with THA PPFFx treated with open reduction internal fixation (ORIF) and cables vs patients with PPFFx treated with ORIF without cables. We hypothesized that cable use would decrease hardware failure and nonunion rates.

Materials & methods: We retrospectively reviewed 42 cases of PPFFx around THA performed from 2015 to 2021. Twenty-three PPFFx were treated with plate and 1 mm cerclage cables, and 19 PPFFx were treated with plate without cables. Primary surgical outcomes included hardware failure, nonunion, reoperation, and time to radiographic union.

Results: There was no significant difference in nonunion rates: 9% in the cerclage cable group vs 16% in the plate-only group (P = .64). The average time to union was 6.0 months among 17 observed unions in the cerclage cable group, vs 8.0 months among 15 observed unions in the plate-only group, but this failed to reach significance (P = .12). There was no statistical difference in overall complication rates (13% cerclage vs 16% plate) requiring reoperation (P = 1.0).

Discussion & conclusion: The utilization of 1 mm cerclage cables to hold reduction of PPFFx provides an easy method to hold fixation with a low overall complication rate and no significant differences in nonunion rate or time to union when compared to cases performed without cables.

Introduction: Femoral neck fractures (FNF) represent a significant challenge in orthopedic practice, demanding prompt intervention to restore function and mobility in affected individuals. Numerous surgical interventions have been developed to address these fractures, including internal fixation with devices such as the Femoral Neck System (FNS, DePuy Synthes, Inc., West Chester, PA, USA). However, the optimal fixation system remains unclear. Understanding the postoperative outcomes associated with these interventions is crucial for optimizing patient care and informing treatment decisions.

Significance: This PRISMA-compliant systematic literature review evaluates the efficacy and safety of the Femoral Neck System relative to other operative treatment options. Clinical and safety outcomes included mortality, perioperative complications, postoperative complications at 1 year, and reoperation.

Results: A total of 117 studies with 68,567 patients with FNF treated with internal fixation were identified. Of these, thirteen included FNS as a treatment arm (1078 patients). Due to heterogeneity in study designs and populations, only the eleven studies that directly compared FNS to other operative treatments, and 2 non-comparative studies that treated with FNS were included in the systematic review. Seven of the eleven included studies had high risk of bias, 2 had moderate risk of bias, and 2 had low risk of bias. FNS groups had similar or significantly lower incidences of postoperative complications, reoperations, and mortality compared to cannulated screw, cancellous screw, or dynamic or sliding hip screw groups in all studies.

Conclusion: FNS can be a safe and effective operative treatment option for FNF. Safety outcomes and reoperation rates are comparable between patients treated with FNS and patients treated with cannulated screws, cancellous screws, and dynamic or sliding hips screws. Future prospective, controlled studies are needed to confirm the safety and efficacy of FNS relative to other operative treatment options.

Introduction: Hip fracture is particularly seen in elderly patients with frailty and osteoporosis and leads to diminished functional independence and quality of life. Despite the susceptibility of these patients to a second hip fracture (SHF), the literature insufficiently discussed its impact leading to poor outcomes. This study aims to directly assess the outcomes of elderly patients with initial hip fractures (IHF) vs those experiencing an SHF within a well-matched group with similar characteristics.

Materials and methods: This case-control study gathered data from the clinical hip fracture registry at a medical center from 2019 to 2022. Patients with SHF were matched with those with IHF in a 1:2 ratio according to the similarity of age, sex, and Charlson Comorbidity Index classification. Demographics at admission, baseline characteristics, and 1-year postoperative outcome were compared between the SHF and IHF groups.

Results: Thirty-two SHF patients were matched with 64 IHF patients (81.25% of women, median age of 86 years). Anthropometric measurements and socioeconomic factors were not significantly different between the two groups. No differences in baseline characteristics were observed, except IHF patients had a significantly lower T-score than SHF patients (-3.98 vs. -3.31, P = 0.016). At one-year follow-up, despite a notable decrease in Barthel Index scores and an uptick in EQ-5D measures among the patients, the IHF and SHF groups demonstrated similar quality of life and a high level of activities of daily living.

Discussions: In this case-control study, after matching for age, sex, and comorbidities, an SHF did not indicate poorer outcomes than an IHF, providing a more optimistic outlook for the patients and healthcare providers.

Conclusion: Despite the significant challenges presented by hip fracture, the one-year postoperative outcomes did not differ between IHF and SHF patients, suggesting that SHF is not an independent predictor of poor outcomes following hip fracture in the elderly population.

Introduction: The purpose of this study was to describe how hip fractures differentially affect male and female patients regarding fracture pattern, hospital course, and postoperative course.

Materials and methods: This retrospective case series was performed in a metropolitan healthcare system involving 2996 hip fracture patients >59 years old who underwent surgical management (eg, intramedullary nail, hemiarthroplasty, percutaneous pinning, etc.). Male patients were matched to female patients using 1:2 nearest neighbor matching on the basis of age and Charlson Comorbidity Index. Outcomes of interest included AO/OTA fracture classification, 30- and 90-day readmission, and 30-day and 1-year mortality rates.

Results: The cohort was predominantly female (64.5%). Female patients were more likely to sustain a type 31A fracture compared to males (P = .016). The average CCI was higher for males vs females (3.0 ± 2.5 vs 2.6 ± 2.3, P < .001). Males were more likely to be readmitted at 30 (P < .001) and 90 (P = .015) days after discharge. The 30-day mortality was higher for males vs females (6.6% vs 4.5%, P = .015). Approximately 19.9% of male patients vs 15.1% of females died within a year of surgery (P < .001). The average time to surgery was longer for males vs females (23.8 ± 18.8 vs 22.5 ± 21.9 h, P = .048). Males were more likely to die within a year if they underwent surgery >24 h after admission (P = .029).

Discussion: Hip fractures have different implications for male and female patients. With age, the incidence of IT fractures increased in females, while it decreased in males. On average, males with hip fractures are sicker than females, which likely contributes to the longer time to surgery as well as increased readmission and mortality rates seen in males.

Conclusions: Male and female hip fracture patients are not similar in baseline health status, fracture pattern, or postoperative morbidity and mortality. Orthogeriatricians and other providers that care for this patient population should be aware of these differences when implementing treatment strategies to optimize the recovery of their patients, and while educating patients and their families about postoperative expectations.