Geriatric Orthopaedic Surgery & Rehabilitation最新文献

Background: Poor pain control and opioid use are risk factors for perioperative neurocognitive disorders (PND). The peripheral nerve block (PNB) can reduce pain and opioid consumption. This systematic review aimed to investigate the effects of PNB on PND in older patients with hip fractures.

Methods: The PubMed, Cochrane Central Registers of Controlled Trial, Embase and ClinicalTrials.gov databases were searched from inception until November 19, 2021 for all randomized controlled trials (RCTs) comparing PNB with analgesics. The quality of the selected studies was assessed according to Version 2 of the Cochrane tool for assessing the risk of bias in RCTs. The primary outcome was the incidence of PND. Secondary outcomes included pain intensity and the incidence of postoperative nausea and vomiting. Subgroup analyses were based on population characteristics, type and infusion method of local anesthetics, and type of PNB.

Results: Eight RCTs comprising 1015 older patients with hip fractures were included. Compared with analgesics, PNB did not reduce the incidence of PND in the elderly hip fracture population comprising patients with intact cognition and those with pre-existing dementia or cognitive impairment (risk ratio [RR] = .67; 95% confidence interval [CI] = .42 to 1.08; P = .10; I² = 64%). However, PNB reduced the incidence of PND in older patients with intact cognition (RR = .61; 95% CI = .41 to .91; P = .02; I² = 0%). Fascia iliaca compartment block, bupivacaine, and continuous infusion of local anesthetics were found to reduce the incidence of PND.

Conclusions: PNB effectively reduced PND in older patients with hip fractures and intact cognition. When the study population included patients with intact cognition and those with pre-existing dementia or cognitive impairment, PNB showed no reduction in the incidence of PND. These conclusions should be confirmed with larger, higher-quality RCTs.

Introduction: A negative correlation exists between functional outcomes and leg length discrepancy (LLD) following hip fracture repair. We have assessed the effects of LLD following hip fracture repair in elderly patients on 3-meter walking time, standing time, activities of daily living (ADL), and instrumental activities of daily living (IADL).

Methods: One hundred sixty-nine patients enrolled in the STRIDE trial were identified with femoral neck, intertrochanteric, and subtrochanteric fractures that were treated with partial hip replacement, total hip replacement, cannulated screws, or intramedullary nail. Baseline patient characteristics recorded included age, sex, body mass index Charlson comorbidity index (CCI) score. ADL, IADL, grip strength, sit-to-stand time, 3-meter walking time and return to ambulation status were measured at 1 year after surgery. LLD was measured on final follow-up radiographs by either the sliding screw telescoping distance or the difference from a trans-ischial line to the lesser trochanters, and was analyzed as a continuous variable using regression analysis.

Results: Eighty eight patients (52%) had LLD <5 mm, 55 (33%) between 5-10 mm and 26 subjects (15%) >10 mm. Age, sex, BMI, Charlson score, and ambulation status had no significant impact on LLD occurrence. Type of procedure and fracture type did not correlate with severity of LLD. Having a larger LLD was not found to have a significant impact on post-operative ADL (P = .60), IADL (P = .08), sit-to-stand time (P = .90), grip strength (P = .14) and return to former ambulation status (P = .60), but did have a statistically significant impact on 3-meter walking time (P = .006).

Discussion: LLD after hip fracture was associated with reduced gait speed but did not affect many parameters associated with recovery. Continued efforts to restore leg length after hip fracture repair are likely to be beneficial.

Introduction: Vertebral compression fractures (VCF) are the most common low-energy fractures in older people and are associated with increased mortality. To assess mortality risk in patients suffering from VCF, we conducted a retrospective observational long-term cohort study.

Patients and methods: The study included 270 patients. 221 patients were treated conservatively, and 49 were treated with vertebroplasty. The study group was compared to a control group of 1641 random individuals age and sex-matched. Electronic healthcare data extracted included monthly chronic medications taken regularly 3 months before hospitalisation, analgesics excluded, and date of death.

Results: Patients who suffer from VCF tend to consume more chronic medications. The mean count of chronic medication prescriptions in the 3 months before hospitalisation was 16.41 (±9.11) in the VCF group and 11.52 (± 7.17) in the control cohort (P < .0001). In univariate analysis, patients with VCF showed decreased long-term survival (P < .00). However, when controlled for age, sex, and chronic medications uptake, no significant difference was observed between the groups in a multivariate model (P = .12).

Conclusions: The study demonstrates that VCF as an independent variable has a marginal effect on mortality. The higher mortality prevalent in these patients is due to the deteriorated health status of the patients before fracture.

Background: Preoperative anemia has been associated with perioperative morbidity and mortality in patients undergoing cardiac and non-cardiac surgery. Preoperative anemia is common in elderly hip fracture patients. The primary objective of the study was to explore the relationship between preoperative hemoglobin levels and postoperative major adverse cardiovascular events (MACEs) in hip fracture patients over 80 years.

Methods: The retrospective study enrolled hip fracture patients over 80 years from January 2015 to December 2021 in our center. The data were collected from the hospital's electronic database after approval by the ethics committee. The primary objective of the study was to investigate MACEs, and the secondary objectives included in-hospital mortality, delirium, acute renal failure, ICU admission rate, and transfusion (>2 U).

Results: 912 patients were entered for final analysis. Based on the restricted cubic spline, the risk of preoperative hemoglobin (<10 g/DL) was associated with an increased risk of postoperative complications. With univariable logistic analysis, a hemoglobin level <10 g/DL was associated with increased MACEs [OR 1.769, 95% CI (1.074, 2.914), P = .025], in-hospital mortality [OR 2.709, 95% CI (1.215, 6.039), P = .015] and transfusion >2 U risk [OR 2.049, 95% CI (1.56, 2.69), P < .001]. Even after adjustment for confounding factors, MACEs [OR 1.790, 95% CI (1.073, 2.985), P = .026], in-hospital mortality [OR 2.81, 95% CI (1.214, 6.514), P = .016] and transfusion >2 U rate [OR 2.002, 95% CI (1.516, 2.65), P < .001] were still higher in the lower hemoglobin level cohort. Moreover, a log-rank test showed increased in-hospital mortality in the cohort with a preoperative hemoglobin level of <10 g/DL. However, there was no difference in delirium, acute renal failure, and ICU admission rates.

Conclusions: In conclusion, for hip fracture patients over 80 years, preoperative hemoglobin levels <10 g/DL might be associated with increased postoperative MACEs, in-hospital mortality, and transfusion >2 U.

Introduction: Hip fractures are common among the elderly, and delays in time to surgery (TTS) and length of stay (LOS) are known to increase mortality risk in these patients. Preoperative multidisciplinary protocols for hip fracture management are effective at larger trauma hospitals. The purpose of this study is to evaluate the effect of a similar multidisciplinary preoperative protocol for geriatric hip fracture patients at our Level III trauma center.

Materials and methods: In this single-center retrospective study, patients aged 65 and older who were admitted from March 2016 to December 2018 (pre-protocol group, Cohort #1, n = 247) and from August 2021 to September 2022 (post-protocol group, Cohort #2, n = 169) were included. Demographic information, TTS, and LOS were obtained and compared using Student's t-test and Chi-square testing.

Results: There was a significant decrease in TTS in Cohort #2 compared to Cohort #1 (P < .001). There was a significant increase in LOS in Cohort #2 compared to Cohort #1 (P < .05), but when comparing a subset of Cohort #2 (Subgroup 2B, patients admitted from May to September 2022 when the effects of COVID-19 were likely dissipated) to Cohort #1, there was no significant difference in LOS (P = .13). For patients admitted to skilled nursing facilities (SNF), LOS in Cohort #2 was significantly longer than in Cohort #1 (P = .001).

Discussion: In general, Level III hospitals have fewer perioperative resources compared to larger Level I hospitals. Despite this fact, this multidisciplinary preoperative protocol effectively reduced TTS which improves mortality risk in elderly patients. LOS is a multifactorial variable, and we believe the COVID-19 pandemic was a significant confounder that reduced available SNF beds in our area which prolonged the average LOS in Cohort #2.

Conclusion: A multidisciplinary preoperative protocol for geriatric hip fracture management can improve efficiency of getting patients to surgery at Level III trauma centers.

Introduction: The role of patient-reported outcomes in preoperative assessment is not well studied. There is recent interest in studying whether Patient-reported outcomes scores can be used either independently, or in conjunction with clinical findings, in the assessment of patients for surgery.

Aims: To investigate if improvement in clinically significant scores correlate with post-operative patient satisfaction in 1-2 level transforaminal lumbar interbody fusion (TLIF) surgery. We also aim to define a threshold Oswestry Disability Index (ODI) which correlate with achieving post-operative MCID and patient satisfaction.

Methods: 1001 patients who underwent single or double level TLIF (Minimally invasive and Open) in our institution with at least 2 years follow up were included in this study. We studied self-reported measures including patient satisfaction and ODI score.

Results: At 2-year follow-up, the overall mean ODI score improved from 49.7 ± 18.3 to 13.9 ± 15.2 (P < 0.001) with 74.6% of patients meeting the MCID. Patient satisfaction was achieved in 95.3% of all patients. In the MIS group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.72 (95% CI 0.65-0.86). In the open group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.70 (95% CI 0.62-0.77). Using the preoperative cut-offs found, there was no significant difference in patient satisfaction in both MIS and open groups.

Conclusions: Overall, our patients undergoing TLIF had good 2-year ODI score improvement and patient satisfaction after surgery. While meeting the MCID for ODI score correlates with patients' satisfaction postoperatively, 75% of patients not meeting the MCID for ODI score remained satisfied with the surgery. We are unable to define a threshold pre-operative ODI which correlates with achieving post-operative MCID and patient satisfaction.

Introduction: Implantation of a dual-head hip prosthesis to treat medial femoral neck fractures is often associated with significant blood loss. In elective endoprosthetics procedures, it has already been demonstrated that administration of tranexamic acid (TXA) reduces blood loss and need for postoperative transfusions, as well as reducing the frequency of postoperative complications. The aim of this study is to show whether the administration of TXA also leads to a reduction in perioperative blood loss and haemorrhage-associated complications when applied as part of treatment of femoral neck fractures using a dual-head prosthesis. Methods: In a single-centre retrospective cohort study, 1 g TXA i.v. was administered preoperatively to 93 patients who had suffered from femoral neck fractures. This group was compared to a comparison group of 65 patients who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, frequency of transfusion, and frequency of specific complications occurring. Results: The transfusion rate in the TXA group was 6% lower, whereby the volume of blood transfused was 26.7% lower than in the nonTXA group. However, neither result was significant. The calculated perioperative blood loss remained the same. Similarly, the incidence of postoperative renal failure was not significantly lower in the TXA group, at 6.5%, as compared to the nonTXA group (7.7%). A higher rate of complications or deaths as a result of TXA administration was not observed. The tranexamic acid effect seems to be related to the dose. Conclusion: Preoperative administration of TXA during implantation of a dual-head prosthesis for treatment of a femoral neck fracture does not lead to an increased complication rate. The study revealed a trend towards fewer transfusions required, but a significant reduction in blood loss could not be demonstrated. There should be further investigation of other factors influencing blood loss, in particular the dosing regimen followed for perioperative administration of TXA. Level of Evidence: Level 4: retrospective case-control study.

Introduction: The effects of postoperative early weight-bearing (WB) on walking ability, muscle mass, and sarcopenia have been investigated. Postoperative WB restriction is also reportedly associated with pneumonia and prolonged hospitalization; however, its effect on surgical failures has not been studied. This study aimed to assess whether WB restriction after surgery for trochanteric fracture of the femur (TFF) is useful in preventing surgical failure, considering the unstable fracture type, quality of intraoperative reduction, and tip-apex distance.

Patients and methods: This retrospective analysis included 301 patients admitted to a single institution between January 2010 and December 2021, diagnosed with TFF, and who underwent femoral nail surgery. Eight patients were excluded, and finally 293 patients were included in the study. Propensity score (PS) matching yielded 123 cases; 41 patients in the non-WB (NWB) group and 82 patients in the WB group were included in the final analysis. The primary outcome was surgical failure (cutout, nonunion, osteonecrosis, and implant failure). The secondary outcomes were medical complications (pneumonia, urinary tract infection, stroke, and heart failure), change in walking ability, period of hospitalization, and sliding distance of the lag screw.

Results: Five surgical complications occurred in the NWB group and two in the WB group, with significantly more surgical complications in the NWB group (P = .041). Cutout occurred in two cases, each in the NWB and WB groups. Two cases of nonunion and one case of implant failure occurred in the NWB group, but not in the WB group. Osteonecrosis did not occur in both groups. The secondary outcomes were not significantly different between the two groups.

Conclusions: The results of this retrospective cohort study using a PS matching approach showed that WB restriction after TFF surgery could not decrease the incidence of surgical failures.

Background: In-hospital mortality and discharge disposition following traumatic hip fractures previously reported in the literature, has mainly focused on a nationwide scale, which may not be reflective of unique populations.

Objective: Our aim was to characterize demographics, hospital disposition, and associated outcomes for patients with the most common hip fractures.

Methods: A retrospective study utilizing the Trauma Registry from the Texas Department of State Health Services. Patient demographics, injury characteristics, and outcomes, such as in-hospital mortality, and discharge dispositions, were collected. The data were analyzed via univariate analysis and multivariate regressions.

Results: There were 17,104 included patients, composed of 45% femoral neck fractures (FN) and 55% intertrochanteric fractures (IT). There were no differences in injury severity score (ISS) (9 ± 1.8) or age (77.4 ± 8 years old) between fracture types. In-hospital mortality risk was low but different among fracture types (intertrochanteric, 1.9% vs femoral neck, 1.3%, P = .004). However, when controlling for age, and ISS, intertrochanteric fractures and Hispanic patients were associated with higher mortality (P < .001, OR 1.5, 95% CI 1.1-2.0). Uninsured, and Black/African American (P = .05, OR 1.2, 95% CI 1.1-1.3) and Hispanic (P < .001, OR 1.2, 95% CI 1.1-1.3) patients were more likely to be discharged home after adjusting for age, ISS, and payment method.

Conclusion: Regardless of age, severity of the injury or admission hemodynamics, intertrochanteric fractures and Hispanic/Latino patients had an increased risk of in-hospital mortality. Patients who were uninsured, Hispanic, or Black were discharged home rather than to rehabilitation, regardless of age, ISS, or payment method.