Geriatric Orthopaedic Surgery & Rehabilitation最新文献

Introduction: Surgical fixation of hip fractures in older adults is associated with significant morbidity and mortality. We investigated whether regional anesthesia, which excluded epidural, spinal, or combined epidural-spinal, was associated with lower postoperative complication rates compared to general or spinal anesthesia in patients aged 50 years and older undergoing hip fracture surgery.

Methods: A retrospective analysis was conducted using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Targeted Hip Fracture dataset from January 1, 2016, to December 31, 2022. Propensity score matching was used to compare regional anesthesia with general and spinal anesthesia. Given the NSQIP database excludes epidural, spinal, and combined epidural-spinal anesthesia from the regional classification, it was presumed that the remaining regional anesthesia patients received a peripheral nerve block. The primary outcome measure was a 30-day composite of death, myocardial infarction, or stroke.

Results: The study analyzed 54,623 patients, from which 323 received regional anesthesia. These were separately matched with 323 cases of general anesthesia and 323 cases of spinal anesthesia. Regional anesthesia was associated with a lower incidence of the primary composite outcome compared to both general anesthesia (3% vs 7%, risk ratio 0.3, 95% CI: 0.2 to 0.6, P < 0.001) and spinal anesthesia (3% vs 7%, risk ratio 0.5, 95% CI: 0.3 to 0.9, P = 0.01). A subgroup effect was detected, with high-risk patients (ASA IV-V) experiencing the greatest protective benefit from regional anesthesia.

Conclusions: Regional anesthesia techniques, excluding epidural, spinal, or combined epidural-spinal techniques, were associated with lower rates of major postoperative complications in older adults undergoing hip fracture surgery compared to general or spinal anesthesia. This benefit was more pronounced in high-risk patients. Our findings suggest that regional anesthesia, most likely administered via a peripheral nerve block, may offer benefits beyond pain control in this population, potentially improving postoperative outcomes.

Purpose: Distal radius fractures (DRF) often serve as the initial indication of bone mineral disease. This study aims to determine the extent to which the risk of subsequent fragility fractures can be reduced by initiating anti-osteoporotic therapy after initial presentation of a DRF.

Methods: This study utilized TriNetX, an online database with de-identified patient data from 79 US healthcare organizations. Females above the age of 50 were categorized based on receiving initial anti-osteoporotic treatment within a year of the DRF. Group characteristics, antiosteoporosis medications, and bone density evaluations were analyzed. After propensity matching, the risk of subsequent DRF, hip and vertebral fractures, as well as incidence of additional DEXA scans from 2004 to 2024 was explored.

Results: The Medication (M) group (n = 6709) had a mean age of 69, the No Medication (NM) group (n = 181,065) had a mean age of 65 at the index incidence. Baseline differences included higher rates of bone density disorders, inflammatory polyarthropathies, spondylopathies, metabolic disorders, obesity, malnutrition, and neoplasm in the M group. Notably, 43% of the M group had a prior DEXA scan compared to 8.7% of the NM group. The most prescribed anti-osteoporotic medication in the M group was Alendronate (49%). After propensity matching (n = 6627), the M group had 32% more DEXA scans and were 25% less likely to have a subsequent DRF fracture compared to the NM group. There was no difference between groups in combined intertrochanteric and femoral neck fractures. Vertebral compression fractures demonstrated a small but statistically significant increase in the M group, with an absolute risk difference of 0.8% (number needed to treat = 125) and an effect size (Cohen's h = 0.079), suggesting limited clinical relevance.

Conclusions: Timely assessment and medical intervention can prevent future DRF. However, post-DRF bone density evaluations remain infrequent. This study highlights the hand surgeon's role in identifying osteoporosis. Level of Evidence: Level III Cohort Study.

Introduction: In Sweden approximately 9% of hip-arthroplasty require a revision. All-cause 30-day mortality following hip revisions in Sweden is unknown.

Aim: To assess all-cause 30-days mortality among hip-revision in Sweden and whether mortality has changed 2017-2022 based on data from the Swedish perioperative register (SPOR) adjusted for sex, age, ASA-class, indication and fixation technique.

Method: This observational cohort study includes all hip revisions registered in SPOR between 2017 - June 2022 analysing 30-day postoperative mortality rates. Inclusion criteria: age >18 having had a hip arthroplasty revision ICD-10-SE codes NFC. Binary-logistic-regressions estimated odds-ratio (OR) for 30-days mortality over the study period, adjusted for sex, age, ASA-class, indication and fixation technique.

Result: 6937 patients were included in the analysis, 3333 females and 3063 males mean-age 73 years with an overall 30-day mortality rate of 1.3%. No significant differences in 30-day mortality were found over the study-period. There was no death within 30-days among patients below 65 years and within ASA-class I. Males had a mortality rate of 1.4% vs females 1.1% (ns.). Adjusted OR was significantly higher for patients with age >80 years OR 9.1 (P < 0.001), AS-classes III OR 3.9 and IV 14.9 (P < 0.001) infection 3.4 and fracture 9.1 (P < 0.001) but fixation technique had not.

Conclusion: The all-cause 30-day mortality in Sweden was 1.3% with minor differences over the study period and between sexes, while high age especially above 80 and ASA-classes III and IV significantly increased the adjusted OR for 30-day mortality. Efforts to further optimize the perioperative care of this patient group are of importance.

Objective: As the global population ages, hip fracture importance will increase. The high postoperative mortality and morbidity necessitate tools for accurate risk assessment to aid surgical decisions and inform patients and families. This study aimed to compare and validate ACS NSQIP, Nottingham hip fracture risk calculators, and C reactive protein/albumin ratio in predicting complications and 30 day mortality. Methods: 583 patients over the 65 years old who sustained hip fracture from simple fall and underwent surgical treatment for hip fracture were included in prospective study. Each patient was evaluated by ACS NSQIP and Nottingham hip fracture risk calculators and C reactive protein/albumin ratio was calculated from preoperative values. Patients were followed up for 30 days and all the complications were recorded. Results: ACS NSQIP and Nottingham hip fracture score showed AUC of .724 and .731 respectively. C reactive protein/albumin ratio performed less and showed AUC of .623 that is defined as poor predictor for 30 day mortality. Furthermore, in terms of predicting any complication, ACS NSQIP showed AUC of .645, Nottingham hip fracture score of .611 and C reactive protein/albumin ratio of .594. Nottingham hip fracture score than compared to ACS NSQIP yielded lower average of mortality rates (5.4% compared to 7.9%) in contrast of study findings of 8.1%. None of the ACS NSQIP scale predictive complication showed acceptable performance. When adjusted for fracture type, Nottingham hip fracture score showed .858 AUC in predicting 30 day mortality in femoral neck fractures. Conclusions: We recommend Nottingham fracture risk calculator use for 30 day mortality risk assessment in femoral neck fractures. In hip fractures combined-none of models showed strong discrimination. In our cohort C reactive protein/albumin ratio showed poor prognostic values in terms of mortality and complications.

Background: Elderly patients have an impaired functional state and multiple comorbidities, resulting in poor postoperative rehabilitation ability and high rates of disability and mortality. However, little evidence exists on mortality predictors for geriatric hip fractures within the context of the multidisciplinary team co-management model. This study aimed to investigate the incidence and explore preoperative indicators of 1-year mortality following hip fractures in the elderly under this model.

Methods: A total of 439 elderly patients (130 men and 309 women) surgically treated for hip fractures under the multidisciplinary team co-management model between January 2018 and June 2021were included. Data regarding demographics, health state-related variables, injury- and admission-related variables, and preoperative laboratory test results were collected from medical records. Univariate and multivariate logistic regression analyses were used to identify preoperative indicators for 1-year mortality.

Results: A total of 49 patients died within 1 year of hip fracture surgery between January 2018 and June 2021, with an accumulated mortality rate of 11.16%. In univariate analysis, 14 items were found to be significant. In the multivariable logistic regression model, age >85 years, body mass index <21.0 kg/m², time from injury to admission >9.5 h, preoperative haemoglobin <117 g/L, serum albumin <33.9 g/L, lactate dehydrogenase >292 U/L, and blood urea nitrogen >8.5 mmol/L were the independent preoperative indicators for 1-year mortality after surgery in elderly patients with hip fracture under the multidisciplinary team co-management model.

Conclusions: This study establishes a novel set of preoperative predictors for 1-year mortality in geriatric hip fracture patients managed under an MDT model, distinct from previous investigations focusing on postoperative interventions. The identified indicators enable early risk stratification, facilitating timely preoperative optimization. These findings underscore the prognostic value of integrating clinical and biochemical markers before surgery, warranting validation in multicenter prospective studies. Further prospective studies should be conducted to elucidate these associations and assess the effectiveness of targeted measures.

Background: Owing to the increasing number of arthroplasty cases performed annually and an aging population with longer life expectancy, periprosthetic fractures have become more common. Very low distal femur periprosthetic fractures (PPDFF) are rare and still underreported. Due to the osteopenia bone quality at metaphysis and complex fracture pattern, fixation stability could decline over time especially with single-plate fixation, even with weight-bearing restriction. Dual construct, a newer fixation strategy, not only ensures the most stable fixation but also allows immediate weight bearing in this frail geriatric group. This study aims to demonstrate any change in fracture alignment 1 year after immediate weight-bearing practice post-surgery and to report the fracture union and functional outcomes with the newer dual construct technique.

Method: All Type III Su Classification very low PPDFFs with surgery performed from 2020 to 2023 were reviewed. All surgeries were performed using an extensile medial parapatellar single-incision approach. Either dual plate (DPC) or nail-plate construct (NPC) was performed. Immediate weight bearing was allowed from Day 1 post-surgery. Radiographs were assessed for malunion or non-union. Patients were evaluated for pain, stiffness, functional activity in the WOMAC score, range of knee motion and complications.

Results: Six were performed with DPC and another two with NPC. All patients had union at 8.0 weeks and consolidation at 35 weeks. The differences in LDFA and PDFA were only 1.4° and 1.2°. Post-surgery knee flexion was at a mean of 100°, with a mean WOMAC score of 32 points and Parker Mobility Score of 8. There was no change in ambulatory status and no postoperative complication despite the longer operative time, a mean of 172 min.

Conclusion: A dual construct by dual-plating or nail-plate combination in very low PPDFF ensures fracture fixation stability with early union and allows safe, immediate postoperative weight-bearing as tolerated in older adults.

Introduction: Fragility fractures of the pelvis (FFP) are associated with loss of mobility and significant mortality in elderly patients. The purpose of this study was to assess the 60-day readmission rates following FFP and to identify what factors may predict readmission.

Methods: Six hundred thirty-one patients over 65 years of age presenting for FFP to a level 1 trauma center between 2010 and 2022 were reviewed. The chi-square test of independence and logistic regression were performed to identify factors associated with readmission.

Results: One hundred and thirty-six patients met inclusion criteria. Of these, 31 (23%) returned to the Emergency Department (ED) within 60 days of discharge and 16 (12%) were readmitted. Chronic obstructive pulmonary disease (COPD) (OR = 3.30, P = .01), discharge home instead of to a skilled nursing facility (SNF) (OR = 2.75, P = .01), discharge home from the ED instead of admission to the hospital (OR = 2.95, P = .009), and an American Society of Anesthesiologists (ASA) score ≥4 (OR = 5.14, P = .03) were all associated with return to the ED. Patients who were able to ambulate in the ED were less likely to be admitted to the hospital (OR = 0.05, P < .001) and more likely to return to the ED within 60 days (OR = 4.52, P = .03).

Conclusion: Return to the ED and readmission following FFP is common, with an incidence of 23% and 12% in our cohort. Patients who were not admitted as an inpatient after their initial presentation, and patients who were discharged home instead of to a SNF, both had a higher risk of repeat presentation within 60 days of discharge. Additionally, ambulation by patients in the ED may provide false reassurance, as these patients were less likely to be admitted as an inpatient, but more likely to subsequently return within 60 days.

Objective: We conducted a systematic review and meta-analysis to compare post-operative rehabilitation outcomes between two common treatments in patients who have suffered an intertrochanteric hip fracture: intramedullary nails vs dynamic hip screws.

Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science up to August 10, 2022. The inclusion criteria were defined as Population: adults (>18 years old); Interventions/Comparators: intramedullary nails and dynamic hip screws; Outcomes: function, quality of life and survival; and Study type: randomized controlled trials and non-randomized studies. A meta-analysis was performed, and the fixed-effect model was selected to pool the data for homogeneous studies (I² < 50%) and the random effect model was selected for heterogeneity I²>50%. The P-value of less than 0.05 was considered statistically significant. A narrative synthesis was conducted on the remaining outcomes with insufficient data (ie, missing means, or standard deviations).

Results: 108 studies were included in the review. 42 studies had outcomes that were included in the meta-analysis. There were modest differences after sensitivity analysis for the Parker mobility score mean difference (MD) = 0.70, 95% CI [0.12, 1.28], T = 3.11, df = 5, P = 0.03, and Harris hip score (MD = 0.94, 95% CI [0.34, 1.54], T = 3.54, df = 9, P = 0.006) favoring the nails. There were no statistically significant differences in the Functional Independence Measure (FIM) (MD = -2.50, 95% CI [-6.46, 1.45], Z = 1.24, P = 0.22), the Barthel Index (MD = 2.66, 95% CI [-7.60, 12.92], T = 1,12, df = 2, P = 0.38), the generic quality of life (MD = 0.04, 95% CI [-0.08, 0.17], Z = 0.70, P = 0.49), the health-related quality of life (MD = -0.14, 95% CI [-3.57, 3.28], Z = 0.08, P = 0.93) or mortality (1.00, 95% CI [0.96, 1.03], Z = 0.16, P = 0.87) outcomes.

Conclusion: This review showed some differences in functional outcomes in the treatment of intertrochanteric fractures favoring intramedullary nails over dynamic hip screws. There were no differences between the groups for quality of life and mortality outcomes. The narrative synthesis showed additional outcomes that warrant further investigations.

Background: With the increasing elderly population and prevalence of osteoporosis, geriatric intertrochanteric fragility fractures pose a major challenge to orthopedic practice. These fractures have a significant impact on patient outcomes, with a reported mortality rate of 13.3% within 30 days and 24.5% within one year.

Case presentation: This report presents a rare case of delayed iatrogenic deep femoral artery (DFA) injury due to progressive displacement of the lesser trochanter following intertrochanteric fracture fixation. An 87-year-old female patient developed significant thigh swelling and pain 33 days postoperatively. Imaging confirmed migration of the lesser trochanter fragment, leading to DFA injury and active bleeding.

Discussion: Through a comprehensive literature review, we explore the incidence, diagnostic modalities, and management of vascular injuries associated with pertrochanteric fracture fixation. We emphasize the importance of identifying significantly displaced lesser trochanter fragments (>1 cm) preoperatively, as they markedly increase the risk of DFA injury. While debate continues over routine fragment fixation, our case suggests that surgical fixation may be beneficial in selected patients with large displacements to prevent vascular complications. Early CT angiography is highlighted as a crucial non-invasive diagnostic tool for timely detection and intervention in these high-risk cases.

Conclusion: This case underscores the need for careful postoperative monitoring and early intervention to optimize patient outcomes. As PFFs become more prevalent, further research is essential to improve geriatric orthopedic care.

Introduction: Distal femur fractures are the second most common femoral fragility fractures in older adults, with postoperative mortality rates similar to or exceeding those of hip fractures. While early surgery has been shown to improve outcomes in hip fracture patients, its impact on distal femur fractures remains unclear. This study examines the relationship between surgical timing and postoperative outcomes in distal femur fracture patients.

Methods: This retrospective cohort study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients aged 65 and older who underwent surgery for distal femur fractures between 2015 and 2022. Patients were categorized into early (within 1 day), intermediate (between 1-2 days), and delayed (>2 days) surgery groups. The primary outcome was 30-day mortality. Secondary outcomes included postoperative complications, length of hospital stay (LOS), and hospital readmission rates. Multivariate logistic regression was performed to adjust for potential confounders.

Results: A total of 4500 cases met the inclusion criteria, with 67% undergoing surgery within one day, 20% within 1-2 days, and 13% after more than two days. After adjustment for baseline characteristics, early surgery was not associated with a significant reduction in 30-day mortality (OR: 1.00, 95% CI: 0.57-1.83, P = 0.99). However, the risk of urinary tract infections (UTIs) was significantly lower in the early surgery group (adjusted OR: 0.61, 95% CI: 0.43-0.88, P = 0.01). No significant differences were observed for other major complications.

Conclusions: Unlike in hip fractures, early surgery did not significantly impact mortality or most postoperative complications in distal femur fracture patients. However, it was associated with a reduced risk of UTIs. These findings suggest that surgical timing may be less critical than preoperative optimization and comprehensive perioperative care in improving outcomes for this population.