Acute Hip Fracture Research Articles

Influence of IGF-I serum concentration on muscular regeneration capacity in patients with sarcopenia

BackgroundPrevious research has described a neuroprotective effect of IGF-I, supporting neuronal survival, axon growth and proliferation of muscle cells. Therefore, the association between IGF-I concentration, muscle histology and electrophysiological markers in a cohort of patients with sarcopenia dares investigation.MethodsMeasurement of serum concentrations of IGF-I and binding partners, electromyographic measurements with the MUNIX (Motor Unit Number Index) method and muscle biopsies were performed in 31 patients with acute hip fracture older age 60 years. Molecular markers for denervation (neural cell adhesion molecule NCAM) and proliferation markers (Ki67) were assessed by immunofluorescence staining of muscle biopsy tissue. Skeletal muscle mass by bioelectrical impedance analysis and hand-grip strength were measured to assess sarcopenia status according to EWGSOP2 criteria.ResultsThirty-one patients (20 women) with a mean age of 80.6 ± 7.4 years were included. Concentrations of IGF-I and its binding partners were significantly associated with sarcopenia (ß = − 0.360; p = 0.047) and MUNIX (ß = 0.512; p = 0.005). Further, expression of NCAM (ß = 0.380; p = 0.039) and Ki67 (ß = 0.424; p = 0.022) showed significant associations to IGF-I concentrations.ConclusionsThe findings suggest a pathogenetic role of IGF-I in sarcopenia based on muscle denervation.

Reviewing acute hip fractures in adults.

Hip fractures are considered a significant public health issue, representing a substantial burden on our healthcare system and society. They are one of the leading causes of disability among older adults, especially women. Globally, an estimated 18% of women and 6% of men will be affected by hip fractures at some time in life. Hip fractures are a major cause of long-term disability among older adults and more significant than mortality, as only 60% of patients regain their preinjury level of mobility. This has detrimental effects on quality of life and activities of daily living, imposing a level of dependence that has personal, social, and systemic consequences.

Safety of early surgery for geriatric hip fracture patients taking clopidogrel: a retrospective case-control study of 120 patients in China.

Background:Geriatric hip fracture patients receiving clopidogrel are a surgical challenge. In China, most of these patients undergo delayed surgical treatment after clopidogrel withdrawal for at least 5 to 7 days. However, delayed surgery is associated with increased complications and mortality in the older adults. This retrospective paralleled comparison study investigated the safety of early surgery for geriatric hip fracture patients within 5 days of clopidogrel withdrawal.Methods:Acute hip fracture patients (≥65 years) who were hospitalized in the orthogeriatric co-management ward of Beijing Jishuitan Hospital between November 2016 and April 2018 were retrospectively reviewed. Sixty patients taking clopidogrel before injury and discontinued <5 days before surgery constituted the clopidogrel group. The control group constituted 60 patients not taking antiplatelet or anticoagulant drugs and matched 1:1 with the clopidogrel group for sex, fracture type, operative procedure, and time from injury to operation (±10 h). The primary outcome was perioperative blood loss and the secondary outcomes were transfusion requirement, complications, and mortality. The Student's t test or Wilcoxon signed rank sum test was used for continuous variables and the Chi-square test was used for categorical variables.Results:Age, body mass index, American Society of Anesthesiologists score, and percentage undergoing general anesthesia were comparable between the groups (P > 0.050). The percentages of patients with coronary heart disease (61.7% vs. 18.3%; P < 0.001) and cerebrovascular disease (45.0% vs. 15.0%; P < 0.010) were significantly higher in the clopidogrel vs. control groups, respectively. The median clopidogrel discontinuation time before operation was 73.0 (range: 3.0–120.0) h. There was no significant difference in the estimated perioperative blood loss between the clopidogrel group (median: 745 mL) and control group (median: 772 mL) (P = 0.866). The intra-operative transfusion rate was higher in the clopidogrel group (22/60, 36.7%) than that in the control group (12/60, 20.0%) (P < 0.050). However, there was no significant difference in the blood transfusion rate during the entire perioperative period (26/60, 43.3% vs. 20/60, 33.3%; clopidogrel group vs. control group, respectively; P > 0.050). There was no significant difference in perioperative complications, and 30-day and 1-year mortality rates between the groups.Conclusions:Early hip fracture surgery is safe for elderly patients within 5 days of clopidogrel withdrawal, without increased perioperative blood loss, transfusion requirement, complications, and mortality compared with patients not taking antiplatelet drugs.

Effect of Hip Fracture on Prognosis of Acute Cerebral Infarction

&lt;p&gt;&lt;strong&gt;Background and Objective:&lt;/strong&gt; The guidelines on the factors to determine whether a patient with concomitant stroke and hip fracture is a good candidate for surgical hip repair are still debatable. This study was carried out to investigate the relationship between the management of acute hip fracture and the recovery of neurological function and prognosis in patients with concomitant acute cerebral infarction.&lt;/p&gt;&#x0D; &lt;p&gt;&lt;strong&gt; Methods:&lt;/strong&gt; Thirty patients with acute cerebral infarction combined with acute hip fracture, who were hospitalized and did not accept surgical treatment, and matched 60 cases as control group having acute cerebral infarction without hip fracture admitted in the same period were selected. The neurological function recovery, hospitalization period, 6 months recovery rate, frequency of complications, and 1 year mortality rate between the groups were compared.&lt;/p&gt;&#x0D; &lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Compared with common acute cerebral infarction patients, the NIH Stroke Scale/Score of acute cerebral infarction group with hip fracture was higher (7.2 &amp;plusmn; 5.4 vs. 5.6 &amp;plusmn; 4.3, p = 0.034). The hospitalization period was prolonged (16.1 &amp;plusmn; 8.9 vs. 12.2 &amp;plusmn; 5.3, p = 0.041), and 6 months recovery rate was lower (26.7% vs. 53.3%, p = 0.016), the frequency of pulmonary infection and lower extremity deep vein thrombosis was higher (30% vs. 11.7%, p = 0.03; 6.7% vs. 0, p = 0.043). The 1-year mortality rate in patients with combined hip fracture was higher than in patients with cerebral infarction only.&lt;/p&gt;&#x0D; &lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; Acute cerebral infarction combined with hip fracture lead to worse neurological recovery, prolonged hospitalization period, increased complications, decreased patient prognosis, and increased 1 year mortality. Surgical treatment of hip fracture with concomitant acute cerebral infarction may improve the prognosis of patients. According to the statistics of neurological function and mortality after 1 year of follow-up, the prognosis of patients with Modified Rankin Scale below 3 was considered good.&lt;/p&gt;

Does Adopting a Multidisciplinary Approach in the Management of Acute Hip Fractures in Orthopedic Geriatric Patients Lead to Better Outcomes? A Preliminary Report of the University of the Philippines - Philippine General Hospital (UP-PGH) Orthogeriat

Objectives. This study is a retrospective cohort that aims to describe the profile of orthopedic geriatric patients aged 60 years old and above with acute hip fractures occurring within one month of admission in the Philippine General Hospital managed by a multidisciplinary team approach.&#x0D; Methods. Data collection from the database was done to gather information regarding the patient profile, time to surgery, causes for delay in consultation, length of hospital stay, and follow-up rate, since this model was implemented.&#x0D; Results. Overall, we saw a decrease in the time from admission to surgery and a decrease in the length of hospital stay, when compared to previous data. Follow-up rates and compliance to maintenance medication are at 96% and 72% respectively.&#x0D; Conclusion. The implementation of a multidisciplinary approach and fracture liaison service presents us with favorable results in addressing hip fractures and osteoporosis.

Economic burden and the effects of early versus delayed hospitalization on the treatment cost of patients with acute fragility hip fractures under the UPM-PGH Orthogeriatric Multidisciplinary Fracture Management Model and Fracture Liaison Service

ObjectivesFragility hip fractures present not only as a significant cause of morbidity and mortality to the elderly population but also as an important source of financial burden due to staggering costs for treatment. This study is designed to determine the effects of timing of hospitalization to the treatment costs of patients with acute fragility hip fractures. MethodsIn this retrospective cohort study, the patient database of the University of the Philippines Manila-Philippine General Hospital Orthogeriatric Multidisciplinary Fracture Management Model and Fracture Liaison Service was reviewed to investigate the effects of timing of hospitalization to the treatment cost of patients with acute fragility hip fractures admitted in a tertiary government hospital. The economic burden of this group of patients was also computed. ResultsA total of 118 patients were enrolled in the study with 54 patients in the early hospitalization (EH) group (≤ 3 days from injury) and 64 in the delayed hospitalization (DH) group (4–28 days). Median treatment cost is less among the EH group than those who were in the DH group (P = 0.0362). The computed economic burden of patients with acute fragility hip fractures is PhP 1,094,048,363.00 (USD 22,595,007.79) per year in the Philippines. ConclusionsFragility hip fractures impose significant financial impact; and therefore, recommend early hospitalization to lessen treatment cost. Future studies should also be undertaken to investigate other interventions that may help alleviate this burden.

Emergency department visits for emergent conditions among older adults during the COVID-19 pandemic.

Background/objectiveEmergency department (ED) visits have declined while excess mortality, not attributable to COVID‐19, has grown. It is not known whether older adults are accessing emergency care differently from their younger counterparts. Our objective was to determine patterns of ED visit counts for emergent conditions during the COVID‐19 pandemic for older adults.DesignRetrospective, observational study.SettingObservational analysis of ED sites enrolled in a national clinical quality registry.ParticipantsOne hundred and sixty‐four ED sites in 33 states from January 1, 2019 to November 15, 2020.Main outcome and measuresWe measured daily ED visit counts for acute myocardial infarction (AMI), stroke, sepsis, fall, and hip fracture, as well as deaths in the ED, by age categories. We estimated Poisson regression models comparing early and post‐early pandemic periods (defined by the Centers for Disease Control and Prevention) to the pre‐pandemic period. We report incident rate ratios to summarize changes in visit incidence.ResultsFor AMI, stroke, and sepsis, the older (75–84) and oldest old (85+ years) had the greatest decline in visit counts initially and the smallest recovery in the post‐early pandemic periods. For falls, visits declined early and partially recovered uniformly across age categories. In contrast, hip fractures exhibited less change in visit rates across time periods. Deaths in the ED increased during the early pandemic period, but then fell and were persistently lower than baseline, especially for the older (75–84) and oldest old (85+ years).ConclusionsThe decline in ED visits for emergent conditions among older adults has been more pronounced and persistent than for younger patients, with fewer deaths in the ED. This is concerning given the greater prevalence and risk of poor outcomes for emergent conditions in this age group that are amenable to time‐sensitive ED diagnosis and treatment, and may in part explain excess mortality during the COVID‐19 era among older adults.

896 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Hip Fracture Patients

Abstract Background Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of &amp;gt; 62.5mL/Hr for hip fracture patients. Method Three prospective audits, each including 100 consecutive acute hip fracture patients, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included implementation of admission/post-take checklist tools and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively. Results In cycle one and two, many patients received inadequate fluids (46/100 and 56/100 respectively). There was no significant difference in the incidence of AKI between patients receiving adequate or inadequate fluid in either cycle (p &amp;lt; 0.05). In cycle three, more patients received adequate fluids (79/100, p &amp;lt; 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI (2/79, 2.5% vs 3/21, 14.3%; p &amp;lt; 0.05). Discussion This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

Integrated hip fracture care pathway (IHFCP): reducing complications and improving outcomes.

Introduction:Hip fractures in elderly people are increasing. A five-year Integrated Hip Fracture Care Pathway (IHFCP) was implemented at our hospital for seamlessly integrating care for these patients from admission to post discharge. We aimed to evaluate how IHFCP improved process and outcome measures in these patients.Methods:A study was conducted over a five-year period on patients with acute fragility hip fracture who were managed on IHFCP. The evaluation utilised a descriptive design, with outcomes analysed separately for each of the five years of the programme. First-year results were treated as baseline.Results:The main improvements in process and outcome measures over five years, when compared to baseline, were: (a) increase in surgeries performed within 48 hours of admission from 32.5% to 80.1%; (b) reduced non-operated patients from 19.6% to 11.9%; (c) reduced average length of stay at acute hospital among surgically (from 14.0 ± 12.3 days to 9.9 ± 1.0 days) and conservatively managed patients (from 19.1 ± 22.9 to 11.0 ± 2.5 days); (d) reduced 30-day readmission rate from 3.2% to 1.6%; and (e) improved Modified Functional Assessment Classification of VI to VII at six months from 48.0% to 78.2%.Conclusion:The IHFCP is a standardised care path that can reduce time to surgery, average length of stay and readmission rates. It is distinct from other orthogeriatric care models, with its ability to provide optimal care coordination, early transfer to community hospitals and post-discharge day rehabilitation services. Consequently, it helped to optimise patients’ functional status and improved their overall outcome.

Update on medical management of acute hip fracture.

Morbidity and mortality rates associated with acute hip fracture remain high. Over the past decade, the management of hip fracture has shifted to emphasize prompt surgical treatment, multimodal analgesia to reduce opioid use, and incorporation of enhanced recovery pathways. Preoperative evaluation focuses on acutely correctable problems, with the understanding that delaying surgery may worsen the outcome. Prophylaxis of venous thromboembolism, treatment of preoperative anemia and acute kidney injury, and cardiac stabilization are important measures to reduce morbidity. Multimodal analgesia incorporating regional anesthesia techniques may help prevent delirium and facilitate early participation in physical therapy to reduce complications.

113 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Elderly Hip Fracture Patients

Abstract Background Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of &amp;gt;62.5 mL/Hr for hip fracture patients. However, audits have shown that many patients still receive inadequate IV fluids. Methods Three prospective audits, each including 100 consecutive acute hip fracture patients aged &amp;gt;55, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included a revised checklist for admissions with a structured ward round tool for post-take ward round and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively. Results Cycle 1: 64/100 (64%) patients received adequate fluids. No significant difference in developing AKI post operatively was seen in patients given adequate fluids (2/64, 3.1%) compared to inadequate fluids (4/36, 11.1%; p = 0.107). More patients with pre-operative AKI demonstrated resolution of AKI with appropriate fluid prescription (5/6, 83.3%, vs 0/4, 0%, p &amp;lt; 0.05) Cycle 2: Fewer patients were prescribed adequate fluids (54/100, 54%). There was no significant difference in terms of developing AKI post operatively between patients with adequate fluids (4/54, 7.4%) or inadequate fluids (2/46, 4.3%; p = 0.52). Resolution of pre-operative AKI was similar in patients with adequate or inadequate fluid administration (4/6, 67% vs 2/2, 100%). Cycle 3: More patients received adequate fluids (79/100, 79%, p &amp;lt; 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI than those receiving inadequate fluids (2/79, 2.5% vs 3/21, 14.3%; p &amp;lt; 0.05). Discussion This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

Preoperative Cerebrospinal Fluid Cortisol and the Risk of Postoperative Delirium: A Prospective Study of Older Hip Fracture Patients

Background: Ageing, depression, and neurodegenerative disease are common risk factors for delirium in the elderly. These risk factors are associated with dysregulation of the hypothalamic-pituitary-adrenal axis, resulting in higher levels of cortisol under normal and stressed conditions and a slower return to baseline. Objectives: We investigated whether elevated preoperative cerebrospinal fluid (CSF) cortisol levels are associated with the onset of postoperative delirium. Methods: In a prospective cohort study CSF samples were collected after cannulation for the introduction of spinal anesthesia of 75 patients aged 75 years and older admitted for surgical repair of acute hip fracture. Delirium was assessed with the confusion assessment method (CAM) and the Delirium Rating Scale-Revised-98 (DRS-R98). Because the CAM and DRS-R98 were available for time of admission and 5 postoperative days, we used generalized estimating equations and linear mixed modeling to examine the association between preoperative CSF cortisol levels and the onset of postoperative delirium. Results: Mean age was 83.5 (SD 5.06) years, and prefracture cognitive decline was present in one-third of the patients (24 [33%]). Postoperative delirium developed in 27 (36%) patients. We found no association between preoperative CSF cortisol levels and onset or severity of postoperative delirium. Conclusions: These findings do not support the hypothesis that higher preoperative CSF cortisol levels are associated with the onset of postoperative delirium in elderly hip fracture patients.

CCD angle & hip fractures – Predictor of fracture symmetry?

BackgroundHip fracture caused by fall is a common injury of the elderly. The risk of sustaining a contralateral hip fracture has been reported to be 5–10%. Aging society heightens the need of efficient prevention tools. To be able to cope with this demand, understanding of biomechanics of hip fractures are mandatory. Previous studies suggest that geometry of the proximal femur could play an important role for fracture probability and fracture type. Thus, analysis of hip geometry could play an important role in the prediction and prevention of bilateral hip fractures. Aim of this study was to elucidate the influence of caput collum diaphyseal angle on the fracture type of proximal femur. Material and methodsIn a retrospective analysis, data of patients with an acute hip fracture who underwent surgical treatment within five years were included. Data was separated into two groups: (I) intra capsular femur fracture (femoral neck fractures) and (II) extra capsular femur fracture (inter- and subtrochanteric femur fractures). Occurrence of a bilateral fracture, age, gender, weight, height and caput collum diaphyseal angle (standardized measurement of the opposite joint on preoperative digital x-rays) of each group were further analyzed. ResultsData of 448 patients were included ((I): 250 vs. (II): 198 patients). Group (I) showed a significant higher mean caput collum diaphyseal angle of 133.9 ± 7.0° (mean ± standard deviation) compared to group (II) with 127.6 ± 6.1° (F (1, 451) = 106.5, p = 0.00). In group (I) 0 patients had a caput collum diaphyseal angle <120° (varus), 214 patients (86%) 120°–140° and 35 patients (14%) angle>140° (valgus). In contrast, in group (II) 21 patients (10%) had a caput collum diaphyseal angle <120° (varus), 175 patients (86%) 120°–140° and 7 patients (4%) >140° (valgus). 52 patients had a bilateral hip fracture. 36 patients (69%) sustained a bilateral hip fracture of the same fracture type. ConclusionPatients with an intra capsular proximal femur fracture showed a significantly higher caput collum diaphyseal angle compared to patients with an extra capsular proximal femur fracture. Moreover, intra capsular femur fractures are correlated with an indifferent (120–140°) or valgus (>140°) femoral neck configuration. Extra capsular femur fractures correlate with an indifferent (120–140°) or varian femoral neck configuration (<120°). The results support the assumption that the caput collum diaphyseal angle has an influence on fracture type of the proximal femur. This could possibly be a predictor for the fracture type of the contralateral hip (second fracture). Based on this, present data may benefit prosthetists in developing new and more efficient hip protectors. Level of evidenceLevel III. Retrospective comparative study.

The efficacy of intravenous tranexamic acid administration at induction in definitive hip fracture surgery: Is there a role?

Tranexamic acid (TXA) is a cheap and powerful drug that has several uses in surgery and is well established in elective orthopaedic surgery. At present, limited small studies have looked into its role in the acute hip fracture. Transfusion in the geriatric population presents risks and increased costs to healthcare systems around the world. Our retrospective study looks at the role of TXA administration at induction for both intracapsular fracture requiring hemiarthroplasty and our preferred method of fixation of extracapsular fracture by intramedullary nail (IM nail). We show a statistically significant reduction in the number of patients requiring transfusion as well as mean haemoglobin (Hb) drop in those undergoing hemiarthroplasty. This was not replicated in those undergoing IM nail fixation. Both groups showed no increase in 1-year mortality or thromboembolic events following TXA administration. These results support the use of TXA for hemiarthroplasty for intracapsular hip fractures over the age of 60.OBJECTIVES: The aim of this pre and post interventional study looks at the effects of intravenous administration of tranexamic acid on induction for elderly patients undergoing hemiarthroplasty or intramedullary nail fixation for hip fractures.DESIGN: Pre and post interventional, randomised observational studySETTING: Large hip fracture unit, Level 2 Trauma Centre, single centrePATIENTS: Two arms of the study looking at those aged above the age of 60 undergoing hemiarthroplasty and intramedullary nail fixation without and with tranexamic acid on induction.RESULTS: 12.1% of hemiarthroplasties required post-operative transfusion without tranexamic acid compared to 2.6% of those with tranexamic acid (n=15 vs n=3 respectively, p=0.006). Equally, the mean Hb drop in g/L is reduced in those with tranexamic acid compared to those without (mean Hb = 14.6 vs 17.7 respectively, p=0.034). This was not replicated in the IM nail group between those without and those with tranexamic acid (n=31 vs n=20 respectively, p= 0.16). The mean Hb drop in g/L was not statistically significant in the tranexamic acid arm compared to without (mean Hb = 19.2 vs mean Hb = 21.9, p=0.11). Gross reporting of thromboembolic events did not demonstrate an increase in the number of those with DVT, PE, MI or stroke. 1-year mortality was not statistically significant in either hemiarthroplasty or IM nail fixation following tranexamic acid administration.CONCLUSIONS: Tranexamic acid both statistically significantly reduces the number of patients requiring transfusion post hemiarthroplasty and also the value of mean Hb drop without appearing to increase in thromboembolic events or 1 year mortality rates. This does not appear to be emulated in the IM nail fixation although both thrombotic events and 1-year mortality rates are also not affected by administration of TXA. We propose that TXA has a role in hemiarthroplasty surgery in reducing post-operative transfusions.LEVEL OF EVIDENCE: Level 3 – retrospective cohort study.

High volumes of recent surgical admissions, time to surgery, and 60-day mortality.

AimsFew studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients.MethodsThis study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions.ResultsAmong 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75th percentile) proportion of recent surgical admission compared to a low (25th percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4).ConclusionA high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality.Cite this article: Bone Joint J 2021;103-B(2):264–270.

Qualitative Evaluation of a Novel Educational Tool to Communicate Individualized Hip Fracture Prognostic Information to Patients and Surrogates: My Hip Fracture (My-HF).

IntroductionMortality and morbidity are high for older adults after hip fracture (HF), but patients and surrogate decision makers (SDMs) are typically unaware of the poor prognosis. We developed a novel educational tool, My Hip Fracture (My-HF), to provide patients and SDMs of patients hospitalized with acute HF individualized estimates of their post-HF prognosis. We conducted initial usability testing of My-HF in a sample of patients with HF and SDMs.Materials and MethodsMy-HF provides information about: 1) anatomy and risk factors for HF; 2) Hip fracture treatment received; 3) individualized predicted risk of adverse events and 4) anticipated discharge trajectory. We conducted a qualitative usability study using a convenience sample of hospitalized, post-operative patients with acute HF or SDMs of patients who lacked decision-making capacity. We used semi-structured interviews to obtain feedback. Thematic analysis was used to identify themes and concepts.ResultsWe conducted interviews with 8 patients and 9 SDMs (mean age of interviewees 70.1 years, 41% female). My-HF was generally well received. Thematic analysis identified legibility and visual appeal, comprehension, numeracy, utility and reflection as prominent themes. Most respondents found My-HF to be useful in improving their understanding of HF and as a potential mechanism for sharing information with other care team members (including family and professionals). Suggestions for improvement of legibility, presentation of the individualized prognosis information and content were identified.DiscussionPatients and SDMs are generally accepting of My-HF and found it useful for communicating individualized prognostic information. Feedback identified areas for improvement for future iterations of the tool.ConclusionMy-HF presents a means of addressing the gap in understanding of prognosis post-HF as a part of patient-centered care. Further evaluation will be needed to assess the impact of My-HF on patient and SDM reported outcomes as we transition from a paper to smart-phone enabled web application.

Antithrombotics in Patients With a Femoral Neck Fracture: Evaluating Daily Practice in an Observational Cohort Study.

IntroductionGeriatric hip fracture patients are characterized by frailty due to multiple comorbidities, such as cardiovascular disease, in which the use of antithrombotics is frequent. The aim of this study is to assess the effect of antithrombotics on perioperative care and patient outcomes after hip hemiarthroplasty following current guidelines.Materials and MethodsThis observational cohort study included all consecutively admitted patients with a femoral neck fracture requiring hip hemiarthroplasty between January 1st 2010, and May 16th 2016, in two level II trauma teaching hospitals. Patients with multiple trauma injuries were excluded.ResultsIn total, n = 907 patients (68% female (n = 615), median age 84 years) were included of which n = 142 used a vitamin K antagonist (VKA) and n = 213 used antiplatelet (AP) therapy. Both were associated with more packed cell supplementation (.4 ± 1.1 units and .3 ± .8 units vs .2 ± .6 units, P < .001 and P = .03, respectively). VKA was associated with more hematomas compared no antithrombotics (23% vs 11%, P = .001). VKA had a longer time to surgery compared to no antithrombotics and AP (24 hours vs 19 and 20 hours, P < .001 and P < .001, respectively) and longer admission duration (9 days vs 7 days P < .001. There were no differences in 30 day mortality nor in 1-year mortality rates.DiscussionAll modifiable causes for deep SSI, such as hematomas, should be prevented in acute hip fracture surgery. Since antithrombotics are associated with hematomas, an optimal handling in perioperative setting is necessary.ConclusionVKA was associated with longer time to surgery, more hematomas, and longer admission duration. VKA and AP were associated with more packed cell supplementation.

Hip fracture patients admitted to hospital on weekends are not at increased risk of 30-day mortality as compared with weekdays

BackgroundHip fractures remain a major health concern owing to the increasing elderly population and their association with significant morbidity and mortality. The effects of weekend admission on mortality have been studied since the late 1970s. Despite most studies showing that mortality rates are higher for patients admitted on a weekend, the characteristics of the admitted patients have remained unclear. We aim to investigate this ‘weekend effect’ at our hospital in patients presenting with a hip fracture.MethodsPatients undergoing acute hip fracture surgery were identified from the local National Hip Fracture Database. Patient demographics, fracture type, co-morbidities and admission blood parameters were examined. The outcome analysed was 30-day mortality. The data were analysed with regard to day of admission, i.e. weekday (Monday to Friday) or weekend (Saturday and Sunday).ResultsA total of 894 patients were included. Results demonstrated that 30-day mortality was similar on the weekend compared with the weekday (6.96% versus 10.39%, OR 0.65, 95% CI 0.36–1.14, p = 0.128) for patients who sustained an acute hip fracture. The total number of deaths within 30 days was 85 (69 weekday versus 16 weekend). This remained non-significant after adjusting for several variables: age and sex only (OR = 0.65, 95% CI 0.37–1.16, p = 0.146), age, sex, and care variables (OR = 0.59, 95% CI 0.33–1.06, p = 0.080), age, sex, and blood test results (OR = 0.62, 95% CI 0.35–1.12, p = 0.111), and all covariates (OR = 0.69, 95% CI 0.29–1.62, p = 0.392). In the fully adjusted model, the following variables were independent predictors of mortality: sex (male) (OR = 1.93, 95% CI 1.11–3.35, p = 0.019) and ASA > 2 (OR = 2.6, 95% CI 1.11–6.11, p = 0.028) and age (1.08, 95% CI 1.04–1.13, p < 0.001).ConclusionThe evidence for a ‘weekend effect’ in patients with a hip fracture is absent in this study. However, we have shown other factors that are associated with increased mortality such as increased age, male sex and higher ASA grade.Level of evidenceLevel 3.

Low revision rate of dual mobility cups after arthroplasty for acute hip fractures: report of 11,857 hip fractures in the Dutch Arthroplasty Register (2007–2019)

Background and purpose — Dislocation is one of the most frequent reasons for cup revision after total hip arthroplasty (THA) for an acute fracture. A dual mobility cup (DMC) might reduce this risk. We determined the cup revision rate after THA for an acute fracture according to type of cup. Patients and methods — All THAs for an acute fracture registered in the Dutch Arthroplasty Register (LROI) during 2007–2019 were included (n = 11,857). Type of cup was divided into DMC and unipolar cup (UC). Competing risk analyses were performed with cup revision for any reason as endpoint. Multivariable Cox regression analyses with outcome cup revision were performed adjusted for sex, age, ASA class, and surgical approach, stratified for UC THA with femoral head size of 32 mm and 22–28 mm. Results — A DMC was used in 1,122 (9%) hips. The overall 5-year cup revision rate for any reason after THA for acute fracture was 1.9% (95% CI 1.6–2.2). Cup revision for dislocation within 5 years was performed in 1 of 6 DMC THAs versus 108 of 185 (58%) UC THAs. Univariable Cox regression analyses showed no statistically significant difference in cup revision rate between DMC and UC (HR = 0.8; CI 0.4–1.5). Multivariable Cox regression analyses showed lower risk of cup revision in DMC THA (n = 1,122) compared with UC THA with 22–28 mm femoral head size (n = 2,727) (HR = 0.4; CI 0.2–0.8). Interpretation — The 5-year cup cumulative incidence of revision after THA for acute fracture was comparable for DMC and UC THA. However, DMC THA had a lower risk of cup revision than UC THA with 22–28 mm femoral head.

Implementation of a fracture liaison service for patients with hip fracture cared for on a hospital medicine service

ABSTRACT Objective Hip fracture is a common and morbid condition. Prior studies have shown that the majority of patients with fragility fracture are not treated for underlying osteoporosis. Our hospitalist-led co-management service for patients with acute hip fracture had no system for evaluating and treating osteoporosis in this cohort. Our objective was to implement a fracture liaison service (FLS) to assist patients with acute hip fracture and assess subsequent impact on diagnosis and treatment of osteoporosis. Methods We conducted a pre-post study design at our tertiary academic center, including patients >50 years old hospitalized with acute hip fracture. We implemented a FLS, whereby all patients received endocrinology consultation. Outcome measures included the proportion of patients evaluated for osteoporosis by time of hospital discharge, comparing pre-implementation (12 months) and post-implementation (9 months) cohorts. We also measured the proportions of patients evaluated for and offered treatment for osteoporosis within 3 months of discharge for patients with post-discharge encounters visible in the medical record. Results We identified 167 patients before and 124 after FLS implementation. In univariate analysis, the proportion of patients evaluated for osteoporosis before discharge increased from 0.6% to 72.6% (p < 0.001) pre- vs. post-implementation. The proportion of patients offered osteoporosis treatment within 3 months after discharge increased from 25.3% to 46.3% (p = 0.01). In multivariate analysis, post-implementation patients had higher odds of osteoporosis evaluation while hospitalized (OR = 470.4, p < 0.001) and higher odds of being offered osteoporosis treatment within 3 months (OR = 2.8, p = 0.008). Conclusions Establishment of an FLS partnered with a hospitalist-led co-management service for patients with hip fracture was associated with significant improvements in the proportions of patients evaluated and offered treatment for osteoporosis. Wider adoption of this model has the potential to improve care for patients with hip fracture by narrowing the osteoporosis treatment gap.