Geriatric Orthopaedic Surgery & Rehabilitation最新文献

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.

Introduction: The management of low-energy pelvic fractures poses a multifaceted challenge in orthopedic and geriatric care. With an increasing prevalence of patients taking new oral anticoagulant medications, it is unclear, which patients with pelvis fractures will have a significant life threatening bleed. The aim of this study was to assess the main risk factors leading to blood transfusion and longer hospital stay in patients with low-energy pelvic fractures.

Materials and methods: This single center retrospective observational study was performed with reference to STROBE guidelines. Demographic data, bleeding risk factors as well as blood transfusion rates were recorded. Initially, a univariate regression analysis was performed to analyze factors associated with blood transfusion. Significant variables were selected and a multidimensional predictive model was built based on variables that showed a significant relationship with the transfusion occurrence.

Results: In total 167 patients were included in the study, there were 24 male and 143 female patients. The number of patients requiring blood transfusion was 20 (12%). Following univariate analysis, in final multivariate regression model, the only variable factors predicting the need for blood transfusion were low hemoglobin level on first hospital assessment (9.85 g/dl in transfused group vs 12 g/dl in non-transfused group, OR: 0.364, P < 0.005). First control hemoglobin check after 24 hours was also a significant predictor of transfusion (8.45 g/dl in transfused group vs 11.20 in non-transfused group, OR: 0.347, P < 0.005). The area under curve analysis for ROC showed good predictive accuracy for blood transfusion in patients with low haemoglobin level on first assessment (AUC = 0.9) and for first control haemoglobin (AUC = 0.88).

Conclusions: We suggest that all patients following low energy pelvic fractures have a haemoglobin level assessment in the emergency department. Patients with initial haemoglobin <10 g/dl should be considered for hospital admission and repeat blood tests within the first 24 hours.

Introduction: Geriatric femur fractures occur in complex hosts that pose significant challenges in perioperative management, with venous thromboembolism (VTE) as a well described complication. Hyperglycemia, prevalent in the perioperative period, has been implicated in increasing thrombotic risk. However, data on its impact on outcomes following femur fracture fixation in the elderly population remains limited.

Methods: A retrospective cohort analysis was conducted on adults >60 years old undergoing operative fixation for femur fractures between January 2017 and December 2019. Demographic information, comorbidities, and outcomes were collected from electronic medical records.

Results: Six hundred and fourteen patients met inclusion criteria. The average age was 78.7 years (30.3% male; 25.0% with diabetes mellitus (DM) diagnosis). Patients with postoperative glucose ≥180 mg/dL had significantly higher rates of pulmonary embolism (PE) and VTE within 90 days, and glucose ≥180 mg/dL was an independent predictor for these events. Those with a DM diagnosis had higher rates of sepsis but not PE, VTE, or other complications compared to those without DM.

Conclusion: Acute perioperative hyperglycemia, regardless of DM diagnosis, is an independent risk factor for VTE and PE following geriatric femur fracture fixation. Strict glucose control in the postoperative period may improve outcomes in this patient population.

Introduction: Hip fractures, which result in a high rate of complications and mortality, are a major public health concern in aging societies. Physical restraint for older patients with hip fractures may be employed to ensure safety, continue medical treatment, and minimize the risk of harm to oneself or others. This study aimed to investigate the current practices of physical restraint use among hip fracture patients across 2 acute-care hospitals, as well as uncover factors associated with physical restraint in patients with hip fracture.

Methods: We retrospectively reviewed all patients aged ≥65 years who underwent surgery for hip fractures at two institutions. Physical restraint was applied in accordance with institutional guidelines, following thorough assessments by physicians and nurses and obtaining informed consent from the patient or their family. When we examined the independent associations of physical restraint during hospitalization, the Poisson regression models were used to estimate the relative risks (RRs) and 95% confidence intervals (CIs).

Results: In total, 463 older patients with hip fractures were assessed. Among the included patients, 118 (25.5%) were subjected to physical restraint. Multivariable analysis revealed that 85 years or older (RR, 1.8; CI: 1.1-3.0), a BMI below 18.5 (RR, 1.8; CI: 1.4-2.5), dementia (RR, 2.3; CI: 1.7-3.1), stroke (RR, 1.5; CI: 1.1-2.0), impairment in physical function (RR, 3.1; CI: 1.2-8.3), and administration of antipsychotics (RR, 1.6; CI: 1.0-2.4) were significantly associated with the implementation of physical restraint.

Conclusions: This retrospective study provided real-world data regarding the use of physical restraint in older patients with hip fractures. Patients with older age, low BMI, dementia, stroke, impaired physical function, and administration of antipsychotics may be at high risk for the use of physical restraints. To minimize the use of physical restraints, future research for further data collection will be essential.

Objective: To evaluate and compare the 1-year mortality outcomes of elderly patients with hip fractures treated with either hemiarthroplasty (HA) or proximal femoral nailing (PFN), focusing on both intracapsular and extracapsular fractures.

Methods: This retrospective cohort study included 210 patients aged 60 years or older who underwent hip fracture surgery between January 2020 and December 2021. Patients were categorized into three groups: Group 1 (PFN for extracapsular fractures), Group 2 (HA for intracapsular fractures), and Group 3 (HA for extracapsular fractures). Demographic variables, surgical details, and 1-year mortality were analyzed.

Results: The overall 1-year mortality rate was 37.6%. Mortality was lowest in patients treated with PFN for extracapsular fractures and highest in those treated with HA for extracapsular fractures. Older age and male gender were associated with increased mortality, while female gender had a protective effect.

Conclusion: PFN should be considered the preferred surgical approach for elderly patients with extracapsular hip fractures due to its lower mortality and complication rates. HA, while effective for intracapsular fractures, presents higher risks in extracapsular cases. Tailoring surgical strategies to fracture type is essential to optimize patient outcomes.

Objective: As walking ability and balance deteriorate with age for bipedal humans, ambulating independently becomes cumbersome without using walking aids. However, age-related risk factors for loss of independent walking ability are not well characterized. We aimed to analyze the clinically relevant factors for ambulatory device aid from the perspectives of nutrition, body composition, and postural abnormalities between independent and assisted walkers based on their ambulatory status.

Methods: Among the 3640 patients aged ≥65 years initially enrolled in the study, 1557 patients with a history of fragility fractures were excluded. Patients were categorized into those who could walk independently and those who required assistance. Body composition, including skeletal muscle mass index, whole-spine sagittal alignment, and blood biochemical findings, were compared.

Results: Among the 2083 participants, 1323 and 760 were included in the independent and assisted groups, respectively. The logistic regression analysis identified five significant factors (P < 0.01): age, body mass index, red blood cell distribution width, skeletal muscle mass index, and sagittal vertical axis. The receiver operating characteristic analysis determined the threshold for assisted walking to be age 81.0 years, red blood cell distribution width of 14.0%, skeletal muscle mass index of 5.96 kg/m², and a sagittal vertical axis of 54.64 mm with areas under the curve of 0.727, 0.677, 0.645, and 0.708, respectively. Combining these four factors as propensity scores revealed an area under the curve of 0.768.

Conclusion: The comparison of independent and assisted walkers among older adults revealed the importance of age, red blood cell distribution width, skeletal muscle mass, and spinal sagittal balance as clinical factors of assisted walkers.

Background: Hemiarthroplasty is the primary treatment for displaced intracapsular hip fractures in frail patients. Implant selection is crucial to reduce reoperations, which carry a high complication risk. This study reports on reoperations, mortality, revisions, and patient-reported outcome measures (PROMs) following the use of the JRI (Joint Replacement Instrumentation Limited) Furlong Cemented Hemiarthroplasty prosthesis.

Methods: We undertook a retrospective cohort study at a major trauma centre in the United Kingdom. All intracapsular neck of femur patients aged over 60 who underwent cemented hip hemiarthroplasty with the JRI Furlong femoral stem over a 5 year period from January 2018 to December 2022 were included. The primary outcome measure was reoperation, including closed reduction of dislocation. Secondary outcome measures were dislocation specifically, revision, mortality and PROMs.

Results: 1183 patients in the study period (793 female, 390 male) with an average age of 84.3 were followed up to 6 years. For a subset of patients, PROMs were recorded at 4 months (n = 237) and 3 years (n = 215). The reoperation rate at 1 year was 1.13% (95% CI 0.64% to 1.99%), increasing to 1.62% (95% CI 0.95% to 2.75%) at 5 years. The 5-year revision rate was 0.68% (95% CI 0.39% to 1.55%); 5-year dislocation rate was 0.87% (95% CI 0.45% to 1.67%). Mean EQ5D utility score was 0.621 at 4 months and 0.603 at 3 years for those alive.

Conclusions: Our cohort shows low re-operation, revision and dislocation rates in the mid-term. We describe acceptable PROMS in the context of a frail population.