Geriatric Orthopaedic Surgery & Rehabilitation最新文献

Introduction: Up to one-third of patients with fragility hip fractures are totally dependent in the year following the injury which leads to later morbidity and mortality. Understanding the related factors that affect patients' ambulation helps health care providers prepare for the treatment plans to improve their functional outcomes. This study aimed to evaluate the factors associated with independent walking disability in the early postoperative period after fragility hip fractures.

Material and methods: This retrospective cohort study involved 394 patients with fragility hip fractures with either intertrochanteric, subtrochanteric, or femoral neck fractures from January 2018 to June 2023. The related factors including preoperative demographics, perioperative, and postoperative factors, were collected and analyzed. The endpoint was the independent walking disability of patients at 6 weeks after surgery.

Results: 110 patients (27.9%) were disabled, whereas 284 patients (72.1%) could walk independently at postoperative 6 weeks. The multivariable risk ratio regression analysis showed that patients with age ≥80 years (RR 1.65; 95% CI 1.21-2.25; P = 0.001), pre-fracture walking with the gait aid (RR 2.03; 95% CI 1.53-2.69; P < 0.001), having ≥2 underlying comorbidities (RR 1.63; 95% CI 1.19-2.23; P = 0.002), preoperative hypoalbuminemia (RR 1.74; 95% CI 1.32-2.29; P < 0.001), and presence of the postoperative medical complication (RR 2.04; 95% CI 1.37-3.02; P < 0.001) were significantly associated with independent walking disability at the early postoperative period of 6 weeks.

Conclusions: Post-hip fracture surgery patients with the presence of postoperative medical complication have the highest risk of independent walking disability. Health care providers should concentrate on high-risk patients, correct the modifiable factors, and minimize any postoperative complications to improve functional recovery and decrease morbidity related to non-ambulation after fragility hip fractures.

Introduction: Geriatric fracture is a pressing global health issue, marked by elevated mortality and morbidity rates and escalating health care costs. The evolving health care system from fee-for-service to quality-based reimbursement has led to externally driven reward and reimbursement systems that may not account for the complexity of caring for older adults with fracture.

Significance: The aim of this review is to highlight the need for a shift towards meaningful metrics that impact geriatric fracture care and to issue a call to action for all medical societies to advocate for national reimbursement and ranking systems that focus on metrics that truly matter.

Results: Traditional metrics, while easier to capture, may not necessarily represent high quality care and may even have unintentional adverse consequences. For example, the focus on reducing length of stay may lead to older patients being discharged too early, without adequately addressing pain, constipation, or delirium. In addition, a focus on mortality may miss the opportunity to deliver compassionate end-of-life care. Existing geriatric fracture care metrics have expanded beyond traditional metrics to include assessment by geriatricians, fracture prevention, and delirium assessments. However, there is a need to further consider and develop patient-focused metrics. The Age-Friendly Health Initiative (4 Ms), which includes Mobility, Medication, Mentation, and what Matters is an evidence-based framework for assessing and acting on critical issues in the care of older adults. Additional metrics that should be considered include an assessment of nutrition and secondary fracture prevention.

Conclusion: In the realm of geriatric fracture care, the metrics currently employed often revolve around adherence to established guidelines and are heavily influenced by financial considerations. It is crucial to shift the paradigm towards metrics that truly matter for geriatric fracture patients, recognizing the multifaceted nature of their care and the profound impact these fractures have on their lives.

Introduction: The surgical approach of hemiarthroplasty for displaced femoral neck fractures remains debated. The study objective was to compare in-hospital outcomes for geriatric displaced femoral neck fractures treated with hemiarthroplasty based on surgical approach (direct lateral vs. posterior approach).

Materials and methods: This retrospective cohort study included geriatric patients (≥60 y/o) admitted 7/1/2016-3/31/2020 treated with hemiarthroplasty. Outcomes included: operative time (incision to closure), length of stay (HLOS), and blood loss volume (mL). The Harding direct lateral approach was compared to the posterior approach; P < .05.

Results: There were 164 patients (59% direct lateral, 41% posterior). Patients treated with the direct lateral approach had an advanced directive (P = .03), dementia, (P = .03), or were functionally dependent (P = .03) more often than patients treated with the posterior approach. Time to surgery was comparable between groups (P = .52). The direct lateral approach was associated with a shorter operative time (2.3 vs. 2.8 h, P = .03), a longer HLOS (5.0 vs. 4.0 days, P < .01), and a lower median volume of blood loss (50 vs. 100 mL, P = .01), than the posterior approach, respectively. In a stratified analysis, for those who were not functionally dependent, did not have dementia or an advanced directive, the direct lateral approach led to a longer HLOS (P = .03) and shorter operative time (P = .04) than the posterior approach. Whereas among those who were functionally dependent, had dementia or had an advanced directive, the direct lateral approach led to less blood loss (P = .02) than the posterior approach.

Discussion: While those treated with the direct lateral approach lost significantly less blood, they had a significantly longer HLOS than those treated with the posterior approach. Comorbidities significantly modified outcomes, which may suggest their presence could assist with treatment decisions.

Conclusions: This study found neither approach, the direct lateral nor posterior, to be superior. Surgical approach could remain physician preference.

Introduction: Adherence to best practices for care of hip fracture patients is fundamental to decreasing morbidity and mortality in older adults. This includes timely transfer from the hospital to rehabilitation soon after their surgical care. Hospitals experience challenges in implementing several best practices. We examined the potential barriers associated with timely discharge for patients who underwent a hip fracture surgery in an academic hospital in Ontario, Canada.

Methods: We conducted a retrospective cross-sectional review of a local database. We used descriptive statistics to characterize individuals according to the time of discharge after surgery. Multivariable binary logistic regression was used to evaluate factors associated with delayed discharge (>6 days post-surgery).

Results: A total of 492 patients who underwent hip fracture surgery between September 2019 and August 2020 were included in the study. The odds of having a delayed discharge occurred when patients had a higher frailty score (odds ratios [OR] 1.19, 95% confidence interval [CI] 1.02;1.38), experienced an episode of delirium (OR 2.54, 95% CI 1.35;4.79), or were non-weightbearing (OR 3.00, 95% CI 1.07;8.43). Patients were less likely to have a delayed discharge when the surgery was on a weekend (OR .50, 95% CI .32;.79) compared to a weekday, patients had a total hip replacement (OR .28, 95% CI .10;.80) or dynamic hip screw fixation (OR .49, 95% CI .25;.98) compared to intramedullary nails, or patients who were discharged to long-term care (OR .05, 95% CI .02;.13), home (OR .26, 95% CI .15;.46), or transferred to another specialty in the hospital (OR .49, 95% CI .29;.84) compared to inpatient rehabilitation.

Conclusions: Clinical and organizational factors can operate as potential barriers to timely discharge after hip fracture surgery. Further research is needed to understand how to overcome these barriers and implement strategies to improve best practice for post-surgery hip fracture care.

Introduction: Elder abuse is a prevalent, though often overlooked and underreported, cause of musculoskeletal injury in the elderly population. The purpose of this review is to provide an updated overview of the prevalence of elder abuse, its association with musculoskeletal injuries, and the available resources to aid orthopaedic surgeons in early detection and intervention.

Significance: Improved training on this topic is needed throughout the medical education of orthopaedic surgeons to effectively recognize and address elder abuse. Our findings reveal an urgent need for increased awareness, education, and collaboration among healthcare professionals to address this significant public health concern. As the aging population continues to grow, understanding the connection between elder abuse and musculoskeletal injuries is essential for providing comprehensive care to older adults.

Results: This review offers practical recommendations for identifying individuals at risk of elder abuse and outlines strategies for intervention. Indicators of abuse range from obvious signs like dirty clothes, neglect, and unattended injuries from falls, to more subtle cues requiring careful observation and questioning, such as mental health symptoms and family histories of abuse.

Conclusion: By shedding light on this often-overlooked issue, this review advocates for a proactive approach to identifying and addressing elder abuse to safeguard the well-being and quality of life of older individuals.

Background: Patients with frailty are more prone to have perioperative adverse events, and enhanced recovery after surgery (ERAS) has been widely adopted to improve perioperative outcomes. The purpose of this study was to assess the impact of improved compliance with ERAS on perioperative outcomes in frail patients.

Methods: Geriatric patients (over 65 years) who underwent multi-level lumbar fusion surgery between June 2017 and June 2022 were included. The patients were divided into two groups according to their degree of compliance with the ERAS. Stepwise nearest-neighbor propensity score matching 1:1 cohorts for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classfication and Charlson Comorbidity Index (CCI) was performed between groups, namely frail-compliant (FC), frail-noncompliant (FN). Further length of stay (LOS), complications and clinical efficacy were compared between groups.

Results: There were 83 pairs of well-balanced patients with comparable clinical baseline data. It was worth noting that patients in FC group has significant lower overall complications (20.5% in the FC group vs 39.8% in the FN group, P = 0.007), major complications (7.2% in the FC group vs 19.3% in the FN group, P = 0.022) and shorter LOS (11.18 ± 5.32 in the FC group vs 14.45 ± 4.68 in the FN group, P < 0.001) than patients in FN group. In addition, the initial occurrence of ambulation (2.14 ± 1.21 in FC group vs 3.18 ± 1.73 in FN group, P = 0.012) and bowel movement (3.68 ± 1.24 in FC group vs 4.17 ± 1.32 in FN group, P = 0.031) were earlier for patients in FC group than patients in FN group. With regard to clinical efficacy, there were no significant difference between FC and FN group in terms of patients who meet minimal clinical important difference (MCID) for Oswestry Disability Index (ODI) at postoperative day (POD) 30, Visual Analog Scale (VAS) for back at POD 30-90 and VAS for legs at POD 30, 90, and 180 follow-up intervals. However, there were significant more patients meeting MCID for ODI at POD 90 and180, and VAS for back at POD 180 between FC and FN group.

Conclusions: In this retrospective cohort study, we found that frail patients with higher ERAS adherence group had a lower incidence of overall complication, mjor complications, and a shorter LOS than their lower ERAS adherence counterparts. In addition, frail patients with higher ERAS adherence had earlier ambulatioin and bowel movement. More importantly, we found there were significant more patients meeting MCID for ODI at POD 90 and180, and VAS for back at POD 180 in higher ERAS adherence than their lower counterparts.

Introduction: Limited evidence exists on health system characteristics associated with initial and long-term prescribing of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) following total hip and knee arthroplasty (THA/TKA), and if these characteristics differ among individuals based on preoperative NSAID exposure. We identified orthopedic surgeon opioid prescribing practices, hospital characteristics, and regional factors associated with initial and long-term prescribing of opioids and NSAIDs among older adults receiving THA/TKA.

Materials and methods: This observational study included opioid-naïve Medicare beneficiaries aged ≥65 years receiving elective THA/TKA between January 1, 2014 and July 4, 2017. We examined initial (days 1-30 following THA/TKA) and long-term (days 90-180) opioid or NSAID prescribing, stratified by preoperative NSAID exposure. Risk ratios (RRs) for the associations between 10 health system characteristics and case-mix adjusted outcomes were estimated using multivariable Poisson regression models.

Results: The study population included 23,351 NSAID-naïve and 10,127 NSAID-prevalent individuals. Increases in standardized measures of orthopedic surgeon opioid prescribing generally decreased the risk of initial NSAID prescribing but increased the risk of long-term opioid prescribing. For example, among NSAID-naïve individuals, the RRs (95% confidence intervals [CIs]) for initial NSAID prescribing were 0.95 (0.93-0.97) for 1-2 orthopedic surgeon opioid prescriptions per THA/TKA procedure, 0.94 (0.92-0.97) for 3-4 prescriptions per procedure, and 0.91 (0.89-0.93) for 5+ opioid prescriptions per procedure (reference: <1 opioid prescription per procedure), while the RRs (95% CIs) for long-term opioid prescribing were 1.06 (1.04-1.08), 1.08 (1.06-1.11), and 1.13 (1.11-1.16), respectively. Variation in postoperative analgesic prescribing was observed across U.S. regions. For example, among NSAID-naïve individuals, the RR (95% CIs) for initial opioid prescribing were 0.98 (0.96-1.00) for Region 2 (New York), 1.09 (1.07-1.11) for Region 3 (Philadelphia), 1.07 (1.05-1.10) for Region 4 (Atlanta), 1.03 (1.01-1.05) for Region 5 (Chicago), 1.16 (1.13-1.18) for Region 6 (Dallas), 1.10 (1.08-1.12) for Region 7 (Kansas City), 1.09 (1.06-1.12) for Region 8 (Denver), 1.09 (1.07-1.12) for Region 9 (San Francisco), and 1.11 (1.08-1.13) for Region 10 (Seattle) (reference: Region 1 [Boston]). Hospital characteristics were not meaningfully associated with postoperative analgesic prescribing. The relationships between health system characteristics and postoperative analgesic prescribing were similar for NSAID-naïve and NSAID-prevalent participants.

Discussion: Future efforts aiming to improve the use of multimodal analgesia through increased NSAID prescribing and reduced long-term opioid prescribing following THA/TKA could consider targeting orthopedic

Introduction: A minority of geriatric hip fracture patients pursue non-operative treatment. Compared with surgical patients, non-operative patients have higher mortality rates. However, patient satisfaction following non-operative vs operative treatment has not been investigated extensively. The purpose of this study was to compare satisfaction among non-operatively vs operatively treated hip fracture patients.

Methods: We identified patients aged 60+ years with proximal femur fractures treated over a 10-year period. Excluded were patients with isolated greater/lesser trochanteric fractures. Patients or relatives were asked to complete a 6-question survey about their treatment satisfaction.

Results: Survey responses from 56 operative and 28 non-operative patients were recorded. Overall, 91.1% of operative and 82.1% of non-operative patients were satisfied with their treatment course (P = 0.260). However, only 71.4% of non-operative patients were satisfied with treatment option explanations vs 83.9% of operative patients (P = 0.014). While only 64.3% of non-operative respondents were satisfied with the ultimate treatment outcome (vs 85.7% of operative patients, P = 0.025), 89.3% of patients in each cohort would choose the same treatment plan again.

Discussion: Our findings highlight the complexity of defining patient satisfaction, particularly in a geriatric hip fracture population. Unlike previous studies, we chose a direct approach to quantifying patient satisfaction by asking participants specifically about satisfaction with treatment outcome and the overall treatment course. Additional survey questions were then included to assess factors considered important in treatment satisfaction, such as health care provider treatment explanations, post-treatment mobility, and palliative care service involvement.

Conclusions: We identified significant differences between non-operatively and operatively treated geriatric hip fracture patients regarding satisfaction with the explanation of treatment options, and ultimate treatment outcomes. There was no significant difference in overall satisfaction with the treatment course or likelihood of choosing the same treatment again. Further research investigating patient satisfaction following geriatric hip fracture treatment is warranted.

Introduction: The COVID-19 pandemic has profoundly impacted global healthcare systems, necessitating substantial shifts in patient care strategies. The pandemic's onset led to drastic operational changes in hospitals, including reduced bed capacity and staffing levels, which could have further influenced the mortality outcomes for geriatric patients. The study aimed to assess the impact of the COVID-19 pandemic on 1-year mortality rates of surgically treated geriatric hip fractures.

Methods: This retrospective, single-center cohort study included 346 participants aged 65 and above who underwent surgical treatment for hip fractures. We compared mortality rates between the pre-COVID and COVID eras. Data included demographics, treatment, complications, and COVID-19 status. The independent samples t test and Chi-square tests (or Fisher's exact test) were used for comparisons for era cohorts. Survival probabilities were assessed using Kaplan-Meier, while multivariate analysis identified mortality predictors.

Results: 175 patients were included in the pre-COVID era, and 171 patients were included in the COVID era. During the COVID era, the 30-day mortality rate was 11.7% (compared to 13.7% in the pre-COVID era, p = 0.573), and the 1-year mortality rate was 43.9% (compared to 49.1% in the pre-COVID era, p = 0.325). The overall 1-year mortality rate was 46.5%. Patients who underwent surgery within 48 hours had a higher 1-year survival rate (60.5%) compared to those with delayed surgery (51.2%), p = 0.031. Additionally, patients not admitted to the ICU had a higher 1-year survival rate (74.7%) than those who were admitted (44.9%), p < 0.001. 70.1% of the total deaths occurred within the first 90 days.

Conclusion: Elderly patients with hip fractures experienced high mortality rates before and during the pandemic. This study demonstrates that the 1-year mortality rates of geriatric hip fractures were not significantly affected by the pandemic. The findings emphasize the importance of pandemic preparedness and prompt surgeries and attentive ICU care in reducing mortality rates.

Introduction: Increasing incidence of fragility fractures has spurred development of protocols, largely focused on peri-operative care, with numerous proven benefits. The purpose of this investigation was to evaluate outcomes of our hip fracture treatment program regarding successful protocol implementation, compliance, effect on subsequent fracture rates, and mortality during the first decade of adoption.

Methods: A retrospective review identified patients >65 years old with fragility hip fractures between 2010 and 2022. The HiROC (+) cohort consisted of patients who received a "High-Risk Osteoporosis Clinic" (HiROC) referral for bone health evaluation and bisphosphonate initiation as indicated. Additional fracture rates and mortality at 3 years were calculated. Protocol implementation and compliance over the first 10 years was analyzed in the four identified cohorts.

Results: A total of 1671 fragility hip fractures were identified, with 386 excluded due to insufficient follow-up, with an average age of 81.6 years and a median follow-up of 36.4 months. Of the 1280 included cases, 56% (n = 717) had a HiROC referral placed. HiROC(+) groups had lower subsequent fracture rates at two years, compared to those without referral (28% vs 13%, P < 0.0001) and those completing more steps of the protocol had lower subsequent fracture rates (28% vs 15% vs 13% vs 5%, P < 0.0001). No statistically significant difference was observed between the cohorts for anatomic site of subsequent fractures.

Discussion: Greater than half of all eligible patients were successfully captured by the protocol. Patients completing more steps of the protocol had lower subsequent fracture rates. Captured patients demonstrated reduced mortality rates when compared to current literature.

Conclusion: Successful implementation of this geriatric hip fracture protocol was associated with reduced additional fractures and mortality rates. Identifying steps of process failures in the protocol can provide opportunities for increased compliance and reduction in future fracture occurrences.