Geriatric Orthopaedic Surgery & Rehabilitation最新文献

Introduction: In surgeries for unstable AO/OTA 31A3.3 fractures, surgeons use various lengths of intramedullary nails (IMNs). However, there is insufficient evidence regarding the appropriate nail length for these fractures. This study compared the biomechanical properties of IMNs of different lengths for AO/OTA 31A3.3 fractures.

Methods: 30 synthetic femora of AO/OTA 31A3.3 fracture model were randomly assigned to the following three groups: short- (170 mm), mid- (235 mm), and long-length (300 mm) nail groups, and were performed fixation surgery. The translation patterns of the constructs were examined by cyclic testing and compared among three groups. Additionally, changes in the neck-shaft and shaft-nail angles after cyclic testing were evaluated using radiological images.

Results: The translation patterns during cyclic loading did not differ among the groups. Conversely, one-way analysis of variance (ANOVA) revealed a significant difference in the neck-shaft angle change (5.8° ± 1.8°, 2.8° ± 1.3°, and 1.9° ± .9° in the short-, mid-, and long-length groups, respectively; P < .001), and post-hoc analysis revealed that the change was greater in the short-length group than in the mid- and long-length groups (P < .001 and P < .001, respectively). Furthermore, one-way ANOVA revealed a significant difference in the shaft-nail angle change (3.1° ± 2.1°, 1.4° ± 1.4°, and .1° ± .6° in the short-, mid-, and long-length groups, respectively; P < .001), and post-hoc analysis revealed that the change was greater in the short-length group than in the mid- and long-length groups (P = .044 and P < .001, respectively).

Conclusions: Short-length nails were associated with relevant changes in the neck-shaft and shaft-nail angles in our AO/OTA 31A3.3 fracture model. Thus, the selection of mid- or long-length nails instead of short-length nails might be better in IMN surgery for these fractures to prevent postoperative varus deformity.

Introduction: With a rapidly ageing population, the number of distal radius fractures (DRFs) in the elderly will increase dramatically. The aim of this retrospective register study was to examine the 1- and 5-year mortality in DRF patients aged 80 years or more and correlate the overall survival to factors not related to the fracture itself.

Material and methods: Patients aged ≥80 diagnosed with DRFs in Lund University Hospital in Sweden in the period 2010-2012 were extracted from the prospective Lund Distal Radius Fracture register. One- and 5-year standardised mortality rates (SMRs) were calculated using the Swedish standard population as a reference. Medical records were searched for non-fracture-related factors including comorbidity, medications, cognitive impairment and type of living. Cox proportional hazard regression models were used to identify prognostic factors for all-cause mortality.

Results: The study cohort included 240 patients, with a mean age of 86. The overall 1-year mortality was 5% (n = 11/240) and the 5-year mortality was 44% (n = 105/240). The 1-year SMR was .44 (CI .18-.69, P < .01) when indirectly adjusted for age and gender and compared to the Swedish standard population. The 5-year SMR was .96 (CI .78-1.14). The patients' ability to live independently in their own home had the highest impact on survival.

Discussion: The 1-year mortality rate among the super-elderly DRF patients was only 44% of that expected. Possibly, a DRF at this age could be a sign of a healthier and more active patient.

Conclusions: The DRF patients aged 80 or more had a substantially lower mortality rate 1 year after fracture compared to the age- and gender-matched standard population. Patients living independently in their own homes had the longest life expectancy. Treatment should not be limited solely because of old age, but individualised according to the patient's ability and activity level.

Objective: Preoperative frailty and surgical waiting times are associated with the occurrence of adverse outcomes in patients with hip fractures. Specifically, we aimed to investigate the influence of frailty status and surgical timing on the risk of serious adverse events during hospitalization.

Methods: This study utilized an observational single cohort design and included patients aged ≥60 years with a primary diagnosis of hip fracture. Frailty was assessed using the chart-derived frailty index (CFI), which was calculated based on demographic and routine laboratory variables. The primary outcome of interest was the occurrence of in-hospital serious adverse events. A multivariate logistic regression model was utilized to examine the risk factors influencing outcomes.

Results: The study included 427 participants, with a mean age of 80.28 ± 8.13 years and 64.2% of whom were female. Patients with high CFI have more comorbidities (P < .001), lower surgical rates (P = .002), and delayed surgical times (P = .033). A total of 239 patients (56.0%) experienced serious adverse events. The high CFI group had a significantly higher occurrence of serious adverse events compared to the low CFI group (73.4% vs 48.5%, P < .001). After adjusting for surgical timing and covariates, the multivariate logistic regression analysis revealed that high frailty significantly increased the risk for serious adverse events (OR = 2.47, 95% CI 1.398-4.412), infection (OR = 1.99, 95% CI 1.146-3.446), acute heart failure (OR = 3.37, 95% CI 1.607-7.045). However, the timing of surgery did not demonstrate any association with these outcomes. In addition, after adjusting for surgical factors, high CFI remains an independent risk factor for these complications.

Conclusions: Frailty serves as a reliable predictor of the probability of encountering severe adverse events while hospitalized for elderly individuals with hip fractures. This method has the potential to pinpoint particular modifiable factors that necessitate intervention, whereas the impact of surgical timing remains uncertain and necessitates additional research.

Background: There are multiple recommended protocols for Vitamin D (VitD) supplementation in elderly; however, only a few studies achieved to examine the role of VitD supplements before intertrochanteric fracture surgery on mortality and complications after surgery.

Methods: This single-center block-randomized double-blinded trial was conducted on 80 patients with intertrochanteric fractures and a sufficient level of 25 (OH) VitD. The intervention group received an intramuscular 300,000 IU VitD ampule before surgery. The primary outcome was a 6-month mortality rate, and the secondary outcomes were 1- and 2-year mortality rates and Harris Hip Score (HHS) in 6, 12, and 24 months after surgery. Chi-square, t-test, repeated measure ANOVA, and Cox regression survival model was used for statistical analysis.

Results: 40 patients were allocated to each group. Demographic, clinical characteristics, and preoperative evaluations were not significantly different between the groups. Mortality rate 6-month after the surgery was 7.5% and 10% for the intervention and placebo groups respectively (P value = .71), 15% and 12.5% at 1-year (P value = .83), and 25% and 27.5% at 2-year (P value = .98). Based on the Cox regression model, only age was significantly associated with mortality (HR = 1.229, P value <.001). Significant HHS changes from baseline through 24 months after surgery were observed within both groups; however, mean differences were not significantly different between groups.

Conclusions: A single preoperative 300,000 IU VitD did not significantly impact 2-year survival and HHS in patients with intertrochanteric fractures and sufficient serum VitD level.

Introduction: Fractures are often caused by falls in older people. Among various causes of falls, polypharmacy is known to be a risk of falls. Furthermore, potentially inappropriate medicines (PIMs), which interact with polypharmacy, include the drugs involved in falls. Here, we primarily aimed to investigate the prescribed drugs in older surgical patients with extremity fractures to determine the frequency of polypharmacy and identify PIMs. The second aim was to clarify the characterization of prescribed drugs of older patients with hip fracture.

Materials and methods: We retrospectively collected the following clinical data of consecutive patients aged ≥65 years who underwent surgery for extremity fractures at our hospital between April 2019 and March 2021. A total of 19 categories were considered as PIMs. The Poisson regression models were used to examine the association between the number of prescribed drugs and hip fracture prevalence.

Results: A total of 590 patients were reviewed. Our data showed that 55% of older patients with extremity fractures took ≥6 prescription drugs. The frequency of prescription of hypnotics, antithrombotic drugs, diuretics, and non-steroidal anti-inflammatory drugs was comparatively high among the 19 categories of PIMs. Multivariable analysis revealed that polypharmacy was significantly associated with hip fractures. Among PIMs, antithrombotic drugs and diuretics were significantly associated with the prevalence of hip fractures. Finally, we found a significant positive association between the prevalence of hip fracture and the number of drug categories of PIMs among older patients with extremity fractures.

Conclusions: The present study clarified the characterization of the prescribed drugs in older surgical patients with extremity fractures. Special attention should be paid to hip fractures of older patients with polypharmacy or prescribed with many drugs categories of PIMs, particularly antithrombotic drugs and diuretics.

Introduction: When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture.

Materials and methods: We administered a discrete choice experiment survey to 150 patients who were at least 60 years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24 months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling.

Results: The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6 months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively).

Discussion: After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes.

Conclusions: Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.

Introduction: Femoral neck fractures (FNF) in the geriatric population are commonly treated with hip replacement procedures, such as total hip arthroplasty, unipolar hip hemiarthroplasty (UHA), and bipolar hip hemiarthroplasty (BHA). The optimal treatment remains controversial, considering outcomes and cost-effectiveness, with UHA often being cheaper. This prospective observational study aims to evaluate UHA's clinical and radiological outcomes, safety, and survivorship compared to existing literature.

Methods: We followed 90 elderly patients who underwent UHA following FNF. We assessed patients using the Parker score before and after surgery, as well as Harris Hip Score (HHS), and Postel-Merle d'Aubigné (PMA) scores postoperatively. All complications, acetabular erosions and heterotopic ossifications (HO), were documented.

Results: One year post-surgery, 26.7% of patients had passed away, mostly due to declining general health status. Systemic complications occurred in 14.4% of cases, with a 1.1% rate of deep surgical site infections. A single dislocation resulted from excessive stem anteversion. UHA implant survival rate was 97.8% after 4 years. The Parker score remained stable, and HHS at 6 and 12 months was 71.5 ± 12.9 and 70.9 ± 11.8, respectively, while PMA score was 14.3 ± 2.4 and 14.5 ± 2.1, respectively. Five hips showed Baker I acetabular wear. HO were noted as Brooker I in 12 patients, II in 4 patients, and IV in 1 patient.

Discussion: UHA exhibited comparable systemic complication rates, implant survivorship, and dislocation rates to those in the literature for both UHA and BHA. The deep surgical site infection rate was lower than reported for BHA. Patients' functional and mental abilities did not decline based on clinical scores. Acetabular wear in UHA was similar to its bipolar counterpart, while HO were only minor findings with no clinical implications.

Conclusion: In elderly patients, UHA demonstrated clinical and radiological outcomes similar to BHA in existing literature. UHA may represent a cost-effective alternative for patients with limited life expectancy.

Introduction: The complication of delirium for hip fracture patients is a predictor of mortality. Use of opioid medication increases the incidence of delirium in the pre- and postoperative periods. Regional nerve blocks are effective in managing acute pain for acute hip fractures. This study aims to evaluate the utilization of ED physicians to perform fascia iliaca nerve blocks on hip fracture patients to decrease the incidence of delirium by decreasing usage of opioid medication.

Methods: A quality improvement project for performing regional nerve blocks on patients with femoral neck fractures was implemented during fiscal year 2019. Data was collected retrospectively for frequency of ED nerve block procedures, amount of opioid medication use, and incidence of delirium in patients diagnosed with hip fracture. This data was compared to baseline data to determine success of the intervention.

Results: Utilization of regional nerve blocks in the ED increased from 2% in 2018 to 96% in 2021 and 89% in 2022. Preoperative opioid usage decreased from 38 MMEs to 16.9 and 18 MMEs respectively. Daily average MMEs decreased from 34 to 12.1 and 14 respectively. Postoperative delirium decreased from 6% in 2018 to 0% from 2020 to 2022.

Discussion: ED provider administration of fascia iliaca blocks and follow-up is a novel practice in our region to decrease the adverse effects of opiate use and decrease delirium rates. There was a reduction in length of stay and increased discharge home rate despite the Covid-19 pandemic.

Conclusion: Administration of regional nerve blocks by ED physicians to hip fracture patients presenting to the ED results in a decrease in opioid medication usage. This also results in a decreased delirium rates in the hip fracture patient population.

Background: Understanding the impact of situational variables on surgical recovery can improve outcomes in total hip arthroplasty (THA). Literature examining hospital outcomes by season remains inconclusive, with limited focus on patient experience. The aim of this study is to investigate if there are differences in hospital and patient-reported outcomes measures (PROMS) after THA depending on the season of the index procedure to improve surgeon preoperative counseling.

Methods: A retrospective chart review was performed on patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographic, operative, hospital, and PROMs were gathered from the institutional electronic medical record and our institutional joint replacement outcomes database.

Results: 6418 patients underwent primary THA and met inclusion criteria. Of this patient population, 1636 underwent surgery in winter, 1543 in spring, 1811 in summer, and 1428 in fall. PROMs were equivalent across seasons at nearly time points. The average age of patients was 65 (+/- 10) years, with an average BMI of 29.3 (+/- 6). Rates of complications including ED visits within 30 days, readmission within 90 days, unplanned readmission, dislocation, fracture, or wound infection were not significantly different by season (P > .05).

Conclusion: Our findings indicate no differences in complications and PROMs at 1 year in patients undergoing THA during 4 distinct seasons. Notably, patients had functional differences at the second follow-up visit, suggesting variation in short-term recovery. Patients could be counseled that they have similar rates of complications and postoperative recovery regardless of season.

Introduction: A care conundrum for low-energy pelvic ring fracture patients in which they face financial burden after not qualifying for an inpatient stay of 3 days or more has been noted in the literature. The purpose of this study was to identify factors that lead to inpatient length of stay (IP LOS) ≥3 days in older adults with nonoperative pelvic ring fragility fractures and to highlight the challenging financial decision-making of those with IP LOS <3 days in the context of the Medicare 3-day rule.

Methods: This was a retrospective review of 322 patients aged ≥65 presenting from March 2016 and February 2019 to either of 2 emergency departments (EDs) after a ground-level fall resulting in a pelvic ring fracture. Patient demographic, IP LOS, and mortality data were extracted. Case management notes were analyzed to summarize financial decision-making for patients with IP LOS <3 days. Multivariate logistic regression analysis was conducted to identify factors that predicted IP LOS ≥3 days and mortality.

Results: IP LOS ≥3 days was associated with presentation to level I hospital (OR .30 [.19, 0.50]) and being single (OR 2.50 [1.10, 5.68]). 70.3% required a post-acute skilled nursing facility (SNF) stay. Of patients with LOS <3 days, 25.0% were financially responsible for their SNF stay, while 7.9% elected home care due to financial reasons. Overall 30-day, 90-day, and 1-year mortality were 2.5%, 8.1%, and 20.8%, respectively. For patients with LOS <3 days, returning to assisted living compared to discharging to a SNF increased 90-day mortality risk (HR 8.529, P = .0451). Having Medicare trended towards increased 90-day mortality risk compared to commercial insurance (HR 4.556, P = .0544).

Conclusion: The current system is failing older adult patients who sustain nonoperative low-energy pelvic ring fractures in terms of financial coverage of necessary post-acute treatment. This care conundrum has yet to be solved.