Geriatric Orthopaedic Surgery & Rehabilitation最新文献

Purpose: With the aging population and rising life expectancy the incidence of trauma-related injuries, particularly proximal femur fractures, is expected to increase. Complications such as fracture-related infections (FRI) significantly impede the healing process and pose substantial risks to patients. Despite advancements in understanding, diagnosing, and treating FRI, challenges persist in achieving optimal outcomes. This review addresses the significance of FRI following proximal femur fractures, emphasizing diagnostic methodologies and therapeutic modalities to enhance clinical care.

Findings: Notably, a consensus definition for FRI has been established, providing clarity for accurate diagnosis. Diagnostic criteria encompass confirmatory and suggestive elements, facilitating precise identification of FRI. Therapeutic strategies for FRI in proximal femur fractures include a spectrum of surgical and antimicrobial approaches. Surgical interventions, ranging from debridement with implant retention over implant removal/exchange to staged conversions to arthroplasty, are tailored based on fracture stability, individual patient factors, and infection characteristics. The intricate decision-making process is elucidated, highlighting the importance of individualized treatment plans and multidisciplinary collaboration. Antimicrobial therapy plays a pivotal role in FRI management, with empirical regiments targeting common pathogens and local delivery systems offering sustained antibiotic release. Microbiological analysis and collaboration with infectious disease specialists should guide antimicrobial treatment and ensure optimal therapy efficacy.

Conclusion: Managing FRI following proximal femur fractures requires a tailored, multidisciplinary approach. Treatment strategies should be guided by diagnostic precision, patient-specific considerations, and collaboration among surgical, infectious disease, and clinical teams. Implementing comprehensive therapeutic approaches is essential for mitigating the impact of FRI and improving patient outcomes.

Background: Fragility hip fractures are a common and often devastating event, and a shared care approach between orthopaedics and geriatrics can improve patient, health service and quality of care outcomes. The aim of this cross-sectional survey, administered to all hospitals caring for patients with acute hip fracture, in New South Wales (NSW), Australia, was to establish current models of care (e.g. shared care or other), and barriers and facilitators of best care.

Methods: A combination of quantitative and free-text data was collected. In total, 30/36 (83%) hospitals responded, with representation from all 15 state local health districts.

Results: Overall, 21/30 had a formal orthopedic surgery/geriatric medicine shared care model; orthopaedic surgery admission with routine (ortho)geriatrician input was commonest (13/21). Multiple barriers to optimal hip fracture care were identified along the various stages of the national guideline-recommended care pathway. Common barriers reported included staffing deficits (for pain assessment, fascia iliaca block administration) and gaps in service structure (lack of specialist services for refracture prevention). Multidisciplinary meetings were in place to enable best care and to promote team communication, but were impeded by absence of relevant team members (8/16). Free-text themes of enablers of good practice included clear escalation and hand-over processes, multidisciplinary communication strategies, and guideline-aligned clinical pathways.

Conclusion: Moving forward, addressing common barriers such as staffing and knowledge deficits, and harnessing enablers of good practice such as multidisciplinary communication and support, combined with effective implementation strategies, are likely to optimize care for patients with hip fracture.

Objective: This study aims to explore the effects of attribution training on postoperative negative emotions, attributional styles, and knee joint function in elderly patients who have undergone total knee arthroplasty (TKA).

Methods: A total of 76 elderly patients who underwent TKA were selected and randomly divided into an intervention group and a control group in this prospective randomized controlled study. All patients received routine postoperative care, while the intervention group also underwent eight sessions of attribution training intervention, each lasting 60 minutes. The Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD), Attributional Style Questionnaire (ASQ) scores and Hospital for Special Surgery (HSS) knee joint function scores between the two groups before and after the intervention were compared.

Results: The study revealed that after the intervention, the intervention group exhibited lower scores on the HAMA and the HAMD compared to the control group, a difference that was statistically significant (P < 0.05). Additionally, the intervention group scored significantly higher on the ASQ for positive events and demonstrated better knee joint function compared to the control group (P < 0.05).

Conclusion: The results of the study indicate that attribution training can effectively enhance psychological resilience and rehabilitation adherence in elderly patients post-TKA, thereby promoting functional recovery of the knee joint. This suggests that attribution training can play a crucial role in optimizing postoperative care.

Introduction: While epidemiology and treatment strategies of proximal humerus fractures have been well studied, post-hospital care is poorly analysed. Corresponding data is available in the context of hip fractures, but the evidence regarding proximal humerus fractures is weak. Aim of this study is to identify risk factors for institutionalisation required after discharge into inpatient aftercare for elderly patients treated for proximal humerus fractures.

Materials and methods: For this retrospective single-centre investigation, n = 295 patients (age 70 (58,79) years, 63.7% female) admitted to hospital from home due to proximal humerus fractures were included and divided into two study groups: Patients being discharged home ('Home') vs being discharged into aftercare ('Aftercare'). Differences regarding demographic and clinical data were analysed. Odds ratios (OR) of influencing factors (adjusted for age) were calculated by logistic regression analysis.

Results: Increased age notably increased the likelihood for discharge of patients into 'Aftercare' (OR 1.09 [1.06;1.12] per year of life). Age-independent indicators for 'Aftercare' were higher ASA score (OR 2.16 per ASA point [1.37;3.49]; P < .001), anterior surgical approach (OR 6.05 [1.93,27.1]; P < .006), duration of surgery (OR 1.01 per min [1.00,1.02]; P < .012), non-surgical complications (OR 3.82 [1.60,9.49]; P < .003), length of stay (OR 1.12 per day [1.04,1.22]; P < .005), ICU stay (OR 3.15 [1.71,6.00]; P < .001) and reversely surgery (OR 0.39 [0.19,0.80]; P < .010).

Conclusion: Increased Age and higher ASA score notably increase the likelihood for post-hospital discharge to an inpatient aftercare facility. Available literature in the context of hip fractures is confirmed. The results of this study may assist in identifying patients at risk and may serve as a stepstone in establishing a scoring system for elderly patients with proximal humerus fractures.

Background: Hip fractures are a major public health concern with a high mortality rate. Numerous risk factors for hip fracture have been identified, and efforts made to reduce complications and improve outcomes. This study aimed to assess recent trends in postoperative complications amongst early-career orthopaedic surgeons.

Methods: This retrospective study analyzed surgical cases submitted to the American Board of Orthopaedic Surgery (ABOS) for the Part II Oral Examination from 2013 to 2022. The database includes patient demographics and medical and surgical complications. Current Procedural Terminology codes reflecting operative fixation for hip fracture were selected. Data was split into two cohorts: 2013-2016 and 2017-2020. Univariate and multivariable logistic regression analyses were used to identify significant differences between cohorts.

Results: 49,418 cases were analyzed. Compared to 2013-2016, 2017-2020 had a reduction in the overall medical complication rate (-1.49%, P = 0.0005), saw slight increases in congestive heart failure (+0.18%, P = 0.049), renal failure (+0.37%, P = 0.004), hypotension (+0.41%, P = 0.0007), and hypoxia (+0.41%, P = 0.0016). Minor decreases in myocardial infarction (-0.18%, P = 0.047) and pneumonia (-0.34%, P = 0.021) were noted. No differences occurred in confusion/delirium, deep vein thrombosis/pulmonary embolism, and mortality. There were no significant differences in overall surgical complications. The 90-day readmission rate increased with time (+1.17%, P < 0.0001). Multivariable logistic regression identified a decrease in the likelihood of overall medical complications (Odds Ratio (OR): 0.92 [0.89, 0.96]; P < 0.0001). Decreases were noted for the likelihood of myocardial infarction (OR: 0.81 [0.68, 0.98]; P = 0.031), pneumonia (OR: 0.87 [0.78, 0.97]; P = 0.013), fracture (OR: 0.80 [0.69, 0.92]; P = 0.002), and recurrent/persistent/uncontrolled pain (OR: 0.72 [0.56, 0.92]; P = 0.008). The likelihood of renal failure (OR: 1.18 [1.04, 1.34]; P = 0.009) and readmission increased (OR: 1.14 [1.07, 1.20]; P < 0.0001).

Conclusion: This study found little change in postoperative complication patterns over the past decade. These findings suggest that more efforts are needed to improve hip fracture care and outcomes.

Introduction: The retrospective study evaluated the clinical and radiological outcomes of conservative treatment for type II odontoid C2 fractures in octogenerians. The study aimed to assess the clinical outcomes and quality of survival of patients treated using conservative methods. Additionally, the study sought to define radiological outcomes, fracture healing success and the development of complications in correlation with clinical outcomes.

Materials and methods: Patients aged ≥80 with dens C2 fracture were fixed with a hard cervical collar for 6 weeks, followed by early mobilization. Patients showing delayed fracture healing on computed tomography (CT) scan were subsequently immobilized in a soft neck collar for additional 6 weeks. The follow-up CT scan was then performed with consequential rehabilitation. Patients with nonunion of the C2 on the follow-up CT scan and clinical symptoms were contraindicated for physical rehabilitation for cervical spine till next CT scan after another 12 weeks. Clinical and radiographic evaluations were performed during follow-up visits, with a median follow-up was 109 days, with the range extending from 1 day to 1 year.

Results: In total, 33 patients were included in the study and were followed for 1 year. The 30-day mortality rate was 21.2%, and between 30 days and one year post-treatment, it was 18.2%. Mortality was higher during the study period in displaced fractures (>2 mm; 9 out of 16 patients died) compared to non-displaced fractures (≤2 mm; 4 out of 17 patients died). The Japanese Orthopaedic Association (JOA) score remained unchanged between admission (mean 16.9; SD ± 0.5) and the end of follow-up (mean 16.9; SD ± 0.5; P > 0.05), the Visual Analogue Scale (VAS) score showed improvement from values measured upon admission to the hospital (mean 7.97; SD ± 1.33) to values measured at the end of follow-up (mean 1.58; SD ± 1.62; P < 0.001) and the Neck Disability Index (NDI) showed a statistically significant difference between admission (mean 41.3; SD ± 14.92) and the end of follow-up (mean 14.29; SD ± 4.65; P < 0.001). The standard measurement of Posterior Atlantodental Interval (PADI) had an average value of 18.6 (range 16-22 mm) and primary bony union of odontoid fractures occurred in eleven cases (33.3%), while six patients (18.2%) had fibrous union with minimal clinical difficulties.

Conclusion: This study demonstrates the safety and efficacy of conservative treatment for odontoid fractures in octogenerians and underscores the critical role of conservative management in a polymorbid elderly population.

Introduction: Hip fractures in individuals aged 65 and older present a significant burden to patients, families, and health care systems. These fractures lead to increased morbidity, loss of autonomy in Activities of Daily Living (ADLs), prolonged hospitalization, and heightened mortality rates. Despite existing knowledge, there is a need for high-quality studies to understand mid- to long-term outcomes and the impact of postoperative variables on mortality.

Methods: This retrospective matched case-control study analyzed patients who underwent operative management for hip fractures between August 1, 2021, and August 1, 2023, at a single Level II trauma center. Cases were defined as patients who expired between postoperative day 1 and ninety, while controls were patients alive at postoperative day 90. Cases and controls were matched by sex and age at the time of surgery. Patients over age 60, who underwent surgical treatment of a femoral neck or intertrochanteric fracture after receiving a preoperative block and were able to ambulate prior to their injury included. Cases and controls were matched based upon patient demographics including comorbidities. Major matched comorbidities were diabetes mellitus, hypertension, Chronic Obstructive Pulmonary Disease, and Coronary Artery Disease. A logistic regression was used to measure the association between in-hospital mobility and 90-day mortality.

Results: The 90-day mortality rate was 9.5% (16/169). The mean age of participants was 85.7 years, with 62.5% female. No significant differences were found in hospital length of stay or operative time. However, 37.5% of cases were discharged on hospice compared to 3.1% of controls. Only 6.3% of cases ambulated in the hospital compared to 53.1% of controls (P-value <.001). Logistic regression indicated that the odds of death were 17 times higher in patients who did not walk during their hospital stay (OR: 17.0, 95% CI: 2.91-326.0, P-value: 0.01).

Conclusions: This study highlights the critical importance of early postoperative mobilization in reducing 90-day mortality in hip fracture patients. The findings reveal that patients who ambulated during hospital admission had significantly lower mortality rates. These results suggest that early mobilization could serve as a strong protective factor against early postoperative mortality.

Purpose: To determine the relationship between trunk muscle cross-sectional area (CSA) measured using trunk computed tomography at the time of injury and gait ability at discharge.

Methods: This multicenter retrospective cohort study was performed in comprehensive rehabilitation units of four hospitals in Japan. The study included 442 patients with hip fractures who underwent surgery (bipolar hip arthroplasty or open reduction and internal fixation) and were hospitalized for treatment between January 2020 and January 2023. The main outcome measure was bilateral trunk muscle CSA (multifidus, erector spinae, psoas major, lateral abdominal muscles, and rectus abdominis). Participants who met the eligibility criteria were classified into two groups based on gait ability at the time of hospital discharge: those who maintained their gait ability (the maintenance group) and those who declined (the decline group).

Results: The CSA of the multifidus muscle was 0.015 ± 0.005 (CSA/Weight/fourth lumbar vertebrae) and 0.013 ± 0.004 (CSA/Weight/fourth lumbar vertebrae) in the maintenance and decline groups, respectively, being significantly lower in the decline group (P = 0.028, effect size = 0.457). The CSA of the psoas major was 15.3 [13.1⁠-⁠18.0] (CSA/Weight/fourth lumbar vertebrae) and 13.4 [11.9⁠-⁠16.0] (CSA/Weight/fourth lumbar vertebrae) in the maintenance and decline groups, respectively, being significantly lower in the decline group (P = 0.020, effect size = 0.335).

Conclusion: Smaller CSAs of the multifidus and psoas major muscles before injury were associated with decreased gait ability after hip fractures.

Introduction: The optimal management of patients taking DOAC medications in the perioperative trauma setting is based on limited evidence. Current guidelines recommend withholding DOAC medications 48-72 hours pre-operatively. The objective of this trial was to determine the utility of measuring DOAC levels prior to surgery, evaluate the safety of a cut-off level of <50 ng/mL and to compare the outcomes with time parameters.

Materials and methods: We performed a cohort study of patients aged 50 years and older admitted with a hip fracture who underwent surgery between January 12 017 and December 31 2019. Primary outcome was time to surgery (TTS) in hours. Secondary outcomes include inpatient transfusion and thromboembolism rates and 30-day mortality.

Results: 1579 patients underwent operative management of their hip fracture. The mean TTS in the DOAC group was 33.0 hours. This was significantly longer when compared to patients not on anticoagulation whose mean TTS was 24.4hours (95% CI -13.78: -8.71, P value <.05). It was also significantly higher than patients on warfarin whose mean TTS was 26.4hours (95% CI -12.41: -4.18, P value <.05). There was no significant difference in the transfusion rate and 30-day mortality between the groups (X² = 2.086, df = 2, P value = .352)]. There was no significant difference in transfusion rates and 30-day mortality between the patients with a DOAC level <50 ng/mL compared with the patients not on any anticoagulation. There was no significant difference in 30-day mortality or transfusion rates between those patients on a DOAC operated within 48 hours compared with those operated after 48 hours (P value = .67).

Discussion and conclusion: DOAC therapy delays surgery for patients with a hip fracture. Using a DOAC level <50 ng/mL is a safe level to proceed with surgery and reduces the TTS compared to following current guidelines. If DOAC levels are not available the data still supports operation at 48 hours.

Background: There is ongoing debate regarding the optimal management of older adult ankle fractures. The purpose of this study was to describe baseline characteristics and functional outcomes including complications in older adult patients receiving nonoperative treatment for low-energy ankle fracture and compare the outcomes of those with unstable vs stable fracture patterns.

Methods: Patients aged ≥65 from January 2012 to March 2019 that sustained an ankle fracture were identified. Those who had surgical treatment, age <65, high-energy trauma, bilateral ankle fractures, and patients without adequate follow-up (minimum 12 weeks) were excluded. Baseline demographics, injury characteristics, Charlson Comorbidity Index (CCI) score, and functioning regarding ambulatory status, living environment, and assistance personnel in the household were collected for all patients. The primary outcome of interest was retention of baseline ambulation, living environment, and assistance requirements at follow-up (>12 weeks). Pain improvement, radiographic changes, and adverse clinical events were also assessed.

Results: A total of 158 patients were included with an average follow-up timeframe of 41.6 weeks. Eighty-six percent of patients (n = 136) retained their ambulatory status at long-term follow up. Most patients retained the same living environment (n = 145, 91.8%). Thirty-five patients (22.2%) required additional assistance long-term. Approximately 67.1% of the entire cohort retained all three functional metrics. Patients who experienced functional decline were older (77.8 vs 71.6, P < 0.001), had higher CCI (3.2 vs 1.6, P < 0.001), had a diagnosis of dementia or cognitive impairment (36.5% vs 3.8%, P < 0.001), had lower baseline functional status (ambulation, living environment, and assistance required; all P < 0.001), and had an unstable fracture pattern (P = 0.003).

Conclusions: Understanding the functional outcomes of non-operative treatment in geriatric ankle fracture cases can contribute to a shared decision-making among healthcare providers, patients, and families.