Hip Fracture Research Articles

Refining, implementing, and evaluating an anesthesia choice conversation aid for older adults with hip fracture: protocol for a stepped wedge cluster randomized trial

BackgroundHip fracture surgery under general or spinal anesthesia is a common procedure for older adults in the United States (US). Although spinal or general anesthesia can be appropriate for many patients, and the choice between anesthesia types is preference-sensitive, shared decision-making is not consistently used by anesthesiologists counseling patients on anesthesia for this procedure. We designed an Option Grid™-style conversation aid, My Anesthesia Choice─Hip Fracture, to promote shared decision making in this interaction. This study will refine the aid and evaluate its implementation and effectiveness in clinical practice.MethodsThe study will be conducted over 2 phases: qualitative interviews with relevant clinicians and patients to refine the aid, followed by a stepped wedge cluster randomized trial of the intervention at 6 settings in the US. Primary outcomes will include the percentage of eligible patients who receive the intervention (intervention reach) and the change in quality of patient/clinician communication (intervention effectiveness). Secondary outcomes addressing other RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) domains will also be collected. Outcomes will be compared between baseline data and an active implementation period and then compared between the active implementation period and a sustainment period. Implementation strategies are guided by three constructs from the Practical, Robust Implementation and Sustainability Model (PRISM): intervention, recipients, and implementation and sustainability infrastructure.DiscussionThis is a novel, large-scale trial evaluating and implementing a shared decision-making conversation aid for anesthesia choices. Strong buy-in from site leads and expert advisors will support both the success of implementation and the future dissemination of results and the intervention. Results from this study will inform the broader implementation of this aid for patients with hip fractures and can lead to the development and implementation of similar conversation aids for other anesthesia choices.Trial registrationClinicalTrials.gov, NCT06438640

Tenofovir-Induced Fanconi Syndrome Associated with a Fragility Fracture of the Right Femoral Neck

Tenofovir-Induced Fanconi Syndrome Associated with a Fragility Fracture of the Right Femoral Neck

Differences in opioid prescriptions by race among U.S. older adults with a hip fracture transitioning to community care.

Appropriate pain management can facilitate rehabilitation after a hip fracture as patients transition back to the community setting. Differences in opioid prescribing by race may exist during this critical transition period. We conducted a retrospective cohort study of older adult U.S. Medicare beneficiaries with a hip fracture to examine whether the receipt and dose of opioids differs between Black and White patients as they transitioned back to the community setting. We stratified beneficiaries by whether they received institutional post-acute care (PAC). Outcomes were (1) receipt of an opioid and (2) opioid doses in the first 90 days in the community in milligram morphine equivalents (MMEs; also presented in mg oxycodone). We estimated relative rates and risk differences of opioid receipt and dose differences using Poisson and linear regression models, respectively, using the parametric g-formula to standardize for age and sex. We identified 164,170 older adults with hip fracture (mean age = 82.7 years; 75% female; 72% with PAC; 46% with opioid use after fracture). Overall use of opioids in the community was similar between Black and white beneficiaries. Black beneficiaries had lower average doses in their first 90 days in both total cumulative doses (PAC group: 165 [95% CI -264 to -69] fewer MMEs [-248 mg oxycodone]; no PAC: 167 [95% CI -274 to -62] fewer MMEs [-251 mg oxycodone]) and average MME per days' supply of medication (PAC: -3.0 [-4.6 to -1.4] fewer MMEs per day [-4.5 mg oxycodone]; no PAC: -4.7 [-4.6 to -1.4] fewer MMEs per day [-7.1 mg oxycodone]). In secondary analyses, Asian beneficiaries experienced the greatest differences (e.g., 617-653 fewer cumulative mg oxycodone). Racial differences exist in pain management for Medicare beneficiaries after a hip fracture. Future work should examine whether these differences result in disparities in short- and long-term health outcomes.

Comparative analysis of the quality of the cement mantle in hip hemiarthroplasty after femoral neck fracture between three different surgical approaches: a single-center retrospective observational study.

Achieving the initial stability of implants is necessary for hip hemiarthroplasty (HHA), especially in elderly patients, and this can be achieved with a cement mantle of quality. The direct anterior approach (DAA) for HHA lately has shown positive results. However, evidence is lacking of HHA in elderly patients with osteoporosis after femoral neck fracture (FNF). This study compares differences in cement mantle quality after HHA, its complications, radiological outcomes and functional status in elderly patients with FNF intervened through different approaches. A non-interventional, retrospective case-control study was conducted. 150 cases were selected based on the surgical approach (DAA, DLA and PLA) in a 1:1:1 proportion between 2018 and 2019. Under 75years old suspicion or confirmation of a pathological fracture were excluded. Antibiotic-loaded cement was utilized. Cement preparation involved vacuum centrifugation and standard instructions for preparation canal and filling, and prosthesis placement were followed. No statistically significant differences in cement mantle quality, radiological outcomes, and the majority of the postoperative complications and functional status considering the surgical approach (p > 0.05). However, the DAA was associated significantly with shorter hospital stays (8.3days vs 11.3 and 13days for DLA and PLA) a decrease in postoperative blood transfusion (22% vs 34% and 53%), and lower rate of loss of walking (8% vs 20% and 28.6%). The DAA for HHA in patients with FNF provides a high-quality cement mantle, similar to other approaches. Also, the DAA shows advantages like shorter hospital stays and lower transfusion rates in elderly patients.

Characteristics and outcomes of reversible platypnoea-orthodeoxia syndrome in COVID-19 pneumonia.

Platypnoea-orthodeoxia syndrome (POS) is an uncommon clinical entity characterised by dyspnoea and platypnoea (oxygen desaturation that follows the assumption of an upright position from recumbency). Since the coronavirus disease 2019 (COVID-19) outbreak, increasing reports of COVID-19-related POS and its associated morbidity have been reported around the world. We aimed to study the characteristics of COVID-19-related POS and orthodeoxia (including associations leading to a more prolonged orthodeoxia), and the postdischarge functional outcomes of patients with COVID-19-related POS. An observational cohort study was conducted in a tertiary hospital that managed post-COVID-19 patients. Twenty-four participants with severe-to-critical COVID-19 disease/pneumonia and POS, who received inpatient pulmonary rehabilitation, were enrolled. Descriptive analysis of the data was performed to describe POS/orthodeoxia characteristics and functional outcomes in these participants. Correlation analyses were carried out to identify significant factors associated with a prolonged orthodeoxia. The mean duration of POS and orthodeoxia was 12.9 ± 8.3 days and 28.5 ± 14.6 days, respectively. All participants demonstrated resolution of POS and orthodeoxia by hospital discharge. On multivariable analysis, intensive care unit admission and maximal level of respiratory support were significantly associated with a prolonged duration of orthodeoxia. One participant was lost to follow-up. The remaining 23 participants achieved independence in self-care. With the exception of one patient, who was recovering from a hip fracture, the rest achieved independence in ambulation and independent community access. Resolution of orthodeoxia was observed in all our participants with COVID-19-related POS. Good functional outcome can be attained with timely and effective rehabilitation interventions.

A Comparative Study of the Effect of Pericapsular Nerve Block (PENG) and Ultrasound-guided Fascia Iliaca Blocks on Postoperative Pain of Intertrochanteric Fractures

Background: Previous anesthesia blocks often failed to provide complete pain relief and were associated with weakness in the lower limbs, which hindered the essential mobility of patients undergoing hip surgery. Recently, the pericapsular nerve group block (PENG) has emerged as a promising alternative for managing postoperative pain following hip fracture surgery. Objectives: This study aimed to compare pain reduction between the pericapsular nerve group block (PENG) and the fascia iliaca compartment block (FICB) in patients who underwent intertrochanteric hip surgery. Methods: This randomized, double-blind clinical trial included 41 patients who were randomly assigned to either the pericapsular block group (PENG) or the ultrasound-guided (FICB). The primary outcome was pain relief, assessed using the postoperative Visual Analog Scale (VAS) score. Secondary outcomes included the dose of morphine consumed, the time of first morphine request, patient satisfaction with analgesia, and complications. Results: There was no significant difference between the PENG and FICB groups in terms of pain scores at any of the studied intervals (P-value > 0.05). The dose of morphine consumed and the time to the first morphine request were similar for both methods, with no significant difference (P-value > 0.05). The complication rates were 15% for the PENG group and 8.3% for the FICB group, with no significant difference observed (P-value > 0.05). Conclusions: Both pericapsular and fascia iliaca blocks effectively reduced postoperative pain in patients undergoing intertrochanteric fracture surgery. Additionally, both methods were well tolerated by patients with no significant complications. However, there was no evidence to suggest that PENG is superior to FICB in terms of pain reduction.

A personalized clinical assessment: multi-sensor approach for understanding musculoskeletal health in the frail population

BackgroundSarcopenia is a muscle disorder causing a progressive reduction of muscle mass and strength, but the mechanism of its manifestation is still partially unknown. The three main parameters to assess are: muscle strength, muscle volume or quality and low physical performance. There is not a definitive approach to assess the musculoskeletal condition of frail population and often the available tests to be performed in those clinical bedridden patients is reduced because of physical impairments. In this paper, we propose a novel instrumental multi-domain and non-invasive approach during a well-defined protocol of measurements for overcoming these limitations. A group of 28 bedridden elder people, subjected to surgery after hip fracture, was asked to perform voluntary isometric contractions at the 80% of their maximum voluntary contraction with the non-injured leg. The sensor employed before and/or during the exercise were: ultrasound to determine the muscle architecture (vastus lateralis); force acquisition with a load cell placed on the chair, giving an indication of the muscle strength; surface electromyography (EMG) for monitoring muscular electrical activity; time-domain (TD) near-infrared spectroscopy (NIRS) for evaluating muscle oxidative metabolism.ResultsA personalized “report card” for each subject was created. It includes: the force diagram (both instantaneous and cumulative, expected and measured); the EMG–force diagram for a comparison between EMG derived median frequency and measured force; two graphs related to the hemodynamic parameters for muscle oxidative metabolism evaluation, i.e., oxy-, deoxy-, total-hemoglobin and tissue oxygen saturation for the whole exercise period. A table with the absolute values of the previous hemodynamic parameters during the rest and the ultrasound related parameters are also included.ConclusionsIn this work, we present the union of protocols, multi-domain sensors and parameters for the evaluation of the musculoskeletal condition. The novelties are the use of sensors of different nature, i.e., force, electrical and optical, together with a new way to visualize and combine the results, by means of a concise, exhaustive and personalized medical report card for each patient. This assessment, totally non-invasive, is focused on a bedridden population, but can be extended to the monitoring of rehabilitation progresses or of the training of athletes.

ThP7.11 - Does Hypoalbuminaemia Increase the Risk of Surgical Site Infection in Neck of Femur Fracture Patients? A Systematic Review and Meta-analysis

Abstract Aim Serum albumin plays an important role in physiological and inflammatory haemostasis; low serum levels are linked with an increased incidence of surgical site infections (SSI). Although this has been demonstrated in spinal and elective arthroplasty surgeries, there is a paucity of evidence with regard to the effect of low preoperative serum albumin on rates of SSI following surgery for adult patients suffering from traumatic, acute hip fractures. Method A systematic review was conducted using the PRISMA guidelines. Four databases were searched for randomised controlled trials, cohort and case-controlled studies. The risk of bias was assessed using the Newcastle-Ottawa Score (NOS). Data was collected and pooled using RevMan Web Software. Results were reported as Odds Ratio (OR) with 95% Confidence Intervals (CI) and statistical significance of p <0.05. An Inverse-Variance model was used in meta-analysis. Results Six retrospective studies (five cohorts, one case-control) with a total of 43,059 patients were included. 45.3% (n=19,496) had low serum albumin (<3.5 g/dL). Hypoalbuminemia was associated with a significantly higher risk of any form of SSI (OR 1.25, p=0.008) and deep SSI (OR 1.76, p=0.05). There was no statistical significance between hypoalbuminemia and the incidence of superficial SSI (OR 1.06, p=0.77). Organ-space SSI was associated with hypoalbuminemia, albeit only one study reported this with poor statistical significance (OR 8.74, p<0.054). Conclusion Hypoalbuminemia increases the risks of most forms of surgical site infections; superficial and deep infections. There is a weak conclusion to draw between incidence of deep-space organ infections and low serum albumin.

Admission Hemoglobin Associated with Increased Mortality in Hip Fracture Surgical Patients: An Observational Study.

In hip fracture patients, who are mostly elderly, preexisting anemia can be worsened when combined with trauma and surgery. To this date, there is no unequivocal approach about transfusion thresholds. We analyzed hemoglobin (Hb) and hematocrit (Hct) levels at three time points in surgical patients with proximal femoral fractures (PFF) to see which levels were triggers for transfusions and whether transfusions were related to mortality after hospital discharge. A total of 956 patients were operated on from 1 January 2021 to 31 December 2022 at the University Hospital of Split and included in the study. There were more women (74%); 47% patients had admission Hb < 120 g/L. Transfusion was given preoperatively to 88, intraoperatively to 74 and postoperatively to 309 patients. Transfusion thresholds were as follows: Hb 84 g/L preoperatively, 99 intraoperatively and 83 postoperatively. After hospital discharge, 10.79% of patients died within the 1st month and 23% within 6 months. In the group of non-survivors, 60% of patients had admission Hb ≤ 117 g/L and the proportion of patients transfused preoperatively was two times higher. Preoperative transfusion thresholds could be set to higher levels for patients with surgically treated PFF. However, that could increase mortality even more. Further investigation is necessary.

Nine-year survival after intertrochanteric fracture in elderly with chronic kidney disease

The outcome of this study was to identify 9-year survivors of intertrochanteric fracture at each stage of chronic kidney disease (CKD) and to investigate the risk factors associated with mortality following surgery with proximal femoral nail anti-rotation (PFNA). 443 elderly intertrochanteric fractures underwent PFNA fixation were recruited. Mortality rate was identified until 9 years. We compared the survival time of hip fracture in each stage of CKD. A regression analysis was used to determine the association between risk factors and one-year mortality. The overall median survival time was 7.1 years. The Kaplan–Meier curve was significantly different in each CKD stage especially in CKD5. In addition, the incidence rate of mortality was highest in CKD 5 (17.4%) and the median survival time in CKD 5 was 3.3 years. The multivariate analysis demonstrated that heart disease, operative time > 60 min, presence of pulmonary embolism, and poor to fair Harris hip score were significantly increased mortality. CKD stage 5 is associated with the highest mortality rate and the shortest median time of survival during the 9-year follow up. Patients who have high risk should focus on long-term care planning, including the counseling for their healthcare providers and families.

Short-term primary and revision modular dual-mobility cup total hip arthroplasty outcomes in high-risk dislocation patients: a retrospective study

PurposeModular dual-mobility cups (MDMCs) have a lower risk for dislocation after total hip arthroplasty (THA). The primary aims of our study were to analyze implant survivorship and to determine complications, especially dislocation, and revision rates of primary THAs used for hip fracture patients and for revision THAs. Secondary aims were to evaluate mortality after MDMC surgery and to find out if introduction of MDMC at our institution (Kuopio University Hospital, Finland) have decreased dislocation rate.MethodsThis retrospective cohort study consisted of 101 MDMC patients who were consecutively operated at our institution between April 1, 2018 and June 30, 2020. The implant survival rate, complications and mortality were evaluated with minimum of 2-year follow-up. Finnish Hospital Discharge Register was used to find out yearly dislocation rates following THA at our institution.ResultsThe cumulative estimate implant survival after MDMC in the primary THA group was 97% at 2 years, and in the revision THA group, it was 90% at 2 years. Dislocation was a rare complication in the primary THA group (1.4%), while it was common in revision THA group (12.9%). The cumulative estimate for mortality after MDMC in the primary THA group was 13% at 2 years, and in the revision group, it was also 13% at 2 years. The yearly number of patients who had re-hospitalization period due to THA dislocation decreased 46% after implementation of MDMC.ConclusionShort-term survival and complication rates after MDMC were excellent after primary THA and moderate after revision THA. Implementation of MDMC THA for hip fracture patients seems to have effectively decrease dislocation rate during a short follow-up.

Hip fracture projections up to the year 2060: an analysis based on data from the National Hip Fracture Database (NHFD) for England, Wales, and Northern Ireland

IntroductionHip fractures are common and cause a huge socioeconomic burden to patients, their carers, and healthcare services worldwide. Our aim was to examine how much hip fracture numbers would be expected to rise over coming decades, simply as a consequence of the ageing of the population. MethodsWe used data from the National Hip Fracture Database on the volume of hip fractures occurring in England, Wales and Northern Ireland in the year 2019 (n = 67,210). We projected future numbers of hip fractures by applying this number, assuming stable rates, to population growth forecast data provided by the Office for National Statistics up to the year 2060. ResultsBy 2060, the number of hip fractures occurring in England, Wales and Northern Ireland are projected to increase by 107 % (n = 139,105). In males, there was an estimated increase of 130 % compared with 97 % in females. There was an estimated increase across all age ranges, however the oldest age groups demonstrated the largest relative increases. The estimated increase for those aged 90 years or over was as high as 348 % and 198 % for males and females, respectively. ConclusionAs a consequence of future ageing of the population, the demand on the health service posed by people with hip fracture is projected to more than double by the year 2060. Policymakers should be striving to mitigate against the huge public health impact of these projections by maximising fracture prevention strategies as far as possible and by improving the quality of hip fracture care.

Functional Outcomes of a Dynamic Condylar Screw for Unstable Femoral Intertrochanteric Fractures in Patients Above 50.

Hip fractures areamong the most common fractures encountered in the emergency departments by orthopedic trauma teams. The optimal treatment method and implant choice for unstable intertrochanteric fractures are subject to debate, with various options available, including intramedullary and extramedullary implants. In this descriptive cross-sectional study, the researchers examined patients with unstable intertrochanteric fractures (classified as 31A2 according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification) who had undergone open reduction and internal fixation with a 95° dynamic condylar screw (DCS). The study was conducted at the Gezira Centre for Orthopedic Surgery and Traumatology (GCOST) during the latter half of 2022. Functional outcomes were assessed using the modified Harris Hip Score (mHHS). A total of 30 patients were enrolled in this study, with a mean age of 73 ± 12.27 years. Of these, 11 (36.7%) were male, and 19 (63.3%) were female. The mHHS was 73.6 ± 14.654. Among the surveyed patients, seven (23.3%) reported poor outcomes, 13 (43.3%) reported fair outcomes, six (20%) reported good outcomes, and four (13.3%) reported excellent outcomes. The Kruskal-Wallis test revealed statistically differences in mean mHHS scores between gender groups (p = 0.024) and between age groups (p = 0.04). However, no significant differences were found across different modes of trauma groups (p = 0.73), affected hip groups (p = 0.35), comorbidity groups (p = 0.84), or postoperative complication groups (p = 0.06). Our study found that DCS treatment for unstable intertrochanteric fractures yielded acceptable functional outcomes, making it a viable and effective treatment option.

Comparison of outcomes after total hip arthroplasty in hip fracture versus elective cases in patients over 60 years of age

BackgroundTotal hip arthroplasty (THA) allows for the replacement of impaired parts of the hip joint with artificial ones. This study aimed to compare the differences in preoperative patient profiles, postoperative complications, and clinical outcomes of two patient groups: those who underwent THA for fractures and those who underwent THA electively for diseases such as osteoarthritis (OA) and avascular necrosis (AVN). MethodsWe retrospectively analyzed the data of patients who underwent THA between March 2012 and December 2021. Of 232 patients, 173 patients who met the exclusion and inclusion criteria were included. Patients were divided into two groups (Group 1: 113 patients diagnosed with OA or AVN; Group 2: 60 patients diagnosed with hip fracture). Pre- and postoperative Visual Analogue Scale (VAS), Koval scores, and postoperative modified Harris Hip Score (mHHS) were used to assess clinical outcomes. Demographic data and postoperative complications of the two groups were compared. After surgery, a rehabilitation protocol was initiated. ResultsPatients in Group 2 (fracture) had more preoperative comorbidities than those in Group 1 (elective). Follow-up months are 26.22 ± 19.78 (Group 1), and 27.42 ± 17.02 (Group 2) respectively (P > 0.05). There were no statistical differences in the prevalence of postoperative complications between two groups (P > 0.05). Compared with Group 1(elective), Group 2(fracture) showed lower VAS (P < 0.01) at last follow-up, and no difference in Koval score (P = 0.77) and mHHS (P = 0.96) at last follow-up. ConclusionConsidering the characteristics of the two groups and their perioperative multidisciplinary care, THA for hip fractures can provide good clinical results compared to those with elective THA.

Long-term outcome of robotic-guided closed reduction internal fixation for Delbet II femoral neck fractures in children

ObjectiveTo retrospectively analyze and assess the long-term effectiveness of robotic navigation and traditional closed reduction internal fixation in the treatment of Delbet type II femoral neck fracture in children.MethodsA total of fifty-five patients diagnosed with pediatric Delbet type II femoral neck fracture, who were admitted to Foshan Hospital of Traditional Chinese Medicine between January 2018 and June 2022, were included in this study. Among them, 22 cases of nailing under robotic navigation were set as the observation group, and 33 cases of nailing under fluoroscopy of the C-arm machine were set as the control group. All patients had their femoral neck fractures closed and repositioned first. After confirming the satisfactory fracture repositioning under the fluoroscopic view of the C-arm machine, internal fixation was performed by inserting hollow compression screws in the corresponding surgical way.A comparative analysis was conducted between the two groups to assess the disparity in the amount of X-ray exposure during surgery, the number of guide pins inserted, and the duration of the surgical procedure. The quality of comparative fracture reduction was assessed according to the Haidukewych criteria on the first postoperative hip X-ray, and the parallelism and distribution of the comparative screws were measured. The incidence of hip function and postoperative complications according to the Ratliff criteria were evaluated between each of the subgroups at the final follow-up.ResultsComparison of general information, operation duration, and quality of fracture reduction between the two groups failed to reveal statistically significant results (P > 0.05). The observation group had a lower number of X-ray exposures and guide pin placements compared to the control group, and this difference was statistically significant (P < 0.05).At the last follow-up, the observation group exhibited superior screw parallelism and distribution, as well as hip joint function, compared to the control group, and this difference was statistically significant (P < 0.05). The incidence of complications in the observation group was lower than that in the control group; however, the difference was not statistically significant (P > 0.05).ConclusionClosed reduction and internal fixation under orthopedic robot navigation can achieve better long-term efficacy in treating Delbet type II femoral neck fracture in children.

"Dr. AI Will See You Now": How Do ChatGPT-4 Treatment Recommendations Align With Orthopaedic Clinical Practice Guidelines?

Artificial intelligence (AI) is engineered to emulate tasks that have historically required human interaction and intellect, including learning, pattern recognition, decision-making, and problem-solving. Although AI models like ChatGPT-4 have demonstrated satisfactory performance on medical licensing exams, suggesting a potential for supporting medical diagnostics and decision-making, no study of which we are aware has evaluated the ability of these tools to make treatment recommendations when given clinical vignettes and representative medical imaging of common orthopaedic conditions. As AI continues to advance, a thorough understanding of its strengths and limitations is necessary to inform safe and helpful integration into medical practice. (1) What is the concordance between ChatGPT-4-generated treatment recommendations for common orthopaedic conditions with both the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines (CPGs) and an orthopaedic attending physician's treatment plan? (2) In what specific areas do the ChatGPT-4-generated treatment recommendations diverge from the AAOS CPGs? Ten common orthopaedic conditions with associated AAOS CPGs were identified: carpal tunnel syndrome, distal radius fracture, glenohumeral joint osteoarthritis, rotator cuff injury, clavicle fracture, hip fracture, hip osteoarthritis, knee osteoarthritis, ACL injury, and acute Achilles rupture. For each condition, the medical records of 10 deidentified patients managed at our facility were used to construct clinical vignettes that each had an isolated, single diagnosis with adequate clarity. The vignettes also encompassed a range of diagnostic severity to evaluate more thoroughly adherence to the treatment guidelines outlined by the AAOS. These clinical vignettes were presented alongside representative radiographic imaging. The model was prompted to provide a single treatment plan recommendation. Each treatment plan was compared with established AAOS CPGs and to the treatment plan documented by the attending orthopaedic surgeon treating the specific patient. Vignettes where ChatGPT-4 recommendations diverged from CPGs were reviewed to identify patterns of error and summarized. ChatGPT-4 provided treatment recommendations in accordance with the AAOS CPGs in 90% (90 of 100) of clinical vignettes. Concordance between ChatGPT-generated plans and the plan recommended by the treating orthopaedic attending physician was 78% (78 of 100). One hundred percent (30 of 30) of ChatGPT-4 recommendations for fracture vignettes and hip and knee arthritis vignettes matched with CPG recommendations, whereas the model struggled most with recommendations for carpal tunnel syndrome (3 of 10 instances demonstrated discordance). ChatGPT-4 recommendations diverged from AAOS CPGs for three carpal tunnel syndrome vignettes; two ACL injury, rotator cuff injury, and glenohumeral joint osteoarthritis vignettes; as well as one acute Achilles rupture vignette. In these situations, ChatGPT-4 most often struggled to correctly interpret injury severity and progression, incorporate patient factors (such as lifestyle or comorbidities) into decision-making, and recognize a contraindication to surgery. ChatGPT-4 can generate accurate treatment plans aligned with CPGs but can also make mistakes when it is required to integrate multiple patient factors into decision-making and understand disease severity and progression. Physicians must critically assess the full clinical picture when using AI tools to support their decision-making. ChatGPT-4 may be used as an on-demand diagnostic companion, but patient-centered decision-making should continue to remain in the hands of the physician.

Postoperative ileus in obstetric and gynecological practice: a prospective solution to the problem

Proton pump inhibitors (PPIs) are the undisputed leaders in the treatment of acid-related diseases. In actual clinical practice, the use of PPIs has been growing exponentially in recent decades. For a long time, PPIs were considered completely safe drugs for both short-term and long-term use. However, modern clinical guidelines and reviews and meta-analyses of the current decade on the safety of PPI use note that when prescribing PPIs in large doses for a long period, the possibility of developing numerous side effects should be taken into account. We searched the PubMed and Scopus information databases for publications on the safety of PPI use, including sources up to 12/01/2023. The review addresses issues of drug interactions between PPIs and chemotherapeutic drugs, which should certainly be taken into account in real clinical practice. In addition, recent reviews and meta-analyses have examined side effects of long-term PPI use, such as increased risk of infection (Clostridium difficile infection, community-acquired pneumonia), electrolyte disturbances, kidney damage, increased risk of hip, wrist and spine fractures; increased cardiovascular risk and a number of others, which can also have an adverse effect on the prognosis of cancer patients. The risk of developing gastric cancer with long-term PPI therapy can be considered as a likely side effect, since their association with PPI use is not denied or questioned in recent reviews and meta-analyses. There is still uncertainty regarding the increased risk of other cancers, since there are publications that do not confirm their association with PPI use. However, the presented review, despite a number of contradictions, allows us to conclude that the increased cancer risk with long-term use of PPIs is real and must be taken into account when prescribing PPIs for a long term.

Comparison of the surgical efficacy of robot-assisted and freehand nail placement in the treatment of sarcopenia combined with femoral neck fractures younger than 65 years

ObjectiveThere is limited research on the effectiveness of orthopedic robot-assisted treatment for sarcopenia combined with femoral neck fractures (FNF) in clinical settings. This study aimed to compare the clinical outcomes of orthopedic robot-assisted screw placement with traditional manual screw placement for treating sarcopenia combined with FNF. MethodsThe retrospective study included patients with FNF under the age of 65 who were admitted to the Department of Orthopedics at XX Hospital Affiliated to XX University between January 2019 and March 2022 and underwent internal fixation with cannulated screws. Grip strength of the dominant hand was measured, and the skeletal muscle index (SMI) was calculated based on the muscle tissue area at the level of the 12th thoracic vertebrae on chest CT divided by height squared. Sarcopenia was diagnosed when SMI was below 42.6 cm2/m2 for men or 30.6 cm2/m2 for women. Patients were then grouped based on whether they underwent orthopedic robot-assisted surgery, as the robot-assisted (RA) group or the freehand (FH) group. Follow-up evaluations over 24–36 months included various parameters such as operation time, blood loss, X-ray shots, number of needle drilling, cannulated nail parallelism, C-reactive protein (CRP) levels, time to weight-bearing, perioperative infection, VAS (visual analogue scale) scores at 1 and 6 months post-surgery, Harris hip score at 6 months post-surgery, and incidence of nonunions and femoral head necrosis within 24 months post-surgery. ResultsA total of 127 participants were enrolled in this study, with 46 individuals in the RG group and 81 in the FG group. Across both groups, factors such as gender, age, SMI, injury sides, Garden classifications, intraoperative blood loss, preoperative CRP, and VAS scores at 6 months post-surgery did not show statistically significant differences (p > 0.05). The RA group exhibited shorter operation time, fewer intraoperative X-ray shots, less needle drilling, and lower postoperative CRP levels compared to the FH group. The VAS score of the RA group was lower one month after surgery, whereas the Harris score was higher six months post-surgery (p < 0.05). The parallel angle of the hollow screws in the RA group was superior to that in the FH screw placement group, with an earlier time to bear weight on the ground post-surgery (p < 0.05). There were no statistically significant differences in incision infection, femoral neck nonunion (within 9 months after surgery), and patient satisfaction between the two groups (p > 0.05). Furthermore, the rate of femoral head necrosis after fracture within 2 years in the RA group was lower compared to the FH screw placement group, with statistically significant differences (p < 0.05).

Closed reduction followed by percutaneous fixation of acute femoral neck fractures in young adults: a retrospective cohort study

OBJECTIVES: To evaluate the surgical outcomes of femoral neck fractures (FNF) in young adults treated with a closed reduction technique as it pertains to reduction quality, rates of union and risk factors for complication. METHODS: Design: Retrospective cohort study with radiograph and electronic medical record review. Setting: Level 1 Swiss Trauma center. Patient Selection Criteria: Between 2012 and 2021, young adults with isolated FNF (AO/OTA 31-B1) treated with percutaneous screw fixation were selected. Exclusion criteria were open reduction technique, age over 65 or under 16, pathologic fractures, associated femoral head or shaft fractures. Outcome Measures and Comparisons: Primary outcome was quality of reduction, as assessed by three experienced trauma surgeons’ evaluation of, intraoperative and/or first postoperative radiographs using the overall impression, the Garden’s alignment index, and Lowell`s criteria. Additionally, clinical outcomes, conversion to arthroplasty and complications following closed reduction and fixation of femoral neck fractures was reviewed. RESULTS: A total of 54 patients with a median (IQR) age of 57.5 (48-60) years were included. Among them, 22 (41%) were female and 32 (59%) were male. The closed reduction technique demonstrated satisfactory reduction results in up to 87% of cases. Major complications occurred in 19%, with 17% requiring conversion to total hip arthroplasty. Unacceptable or borderline acceptable reduction quality correlated significantly with the need for later conversion (p=0.03). CONCLUSIONS: The study supported the use of the closed reduction technique for acute FNF in patients under 65, achieving satisfactory reduction results in up to 87% of cases with comparable complication rates to treatment of young femoral neck fractures with open reduction. Furthermore, it underscored the significance of the surgeon's overall impression of reduction quality, alongside the established reduction criteria, the Garden alignment index and Lowell’s criteria, in evaluating the quality of the reduction. Additionally, risk of conversion to total hip arthroplasty was associated with worse closed reduction quality. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Perioperative pain management intervention in older patients with hip fracture in an orthogeriatric unit. A controlled before/after study assessing an audit and feedback intervention (PAIN-AGE)

BackgroundPostoperative pain delays ambulation, extends hospital stay, reduces the probability of recovery, and increases risk of long-term functional impairment. Pain management in hip fractured patients poses a challenge to the healthcare teams. Older adults are more vulnerable to opioid-associated side effect and it is primordial to minimize their exposure to opioids. Acetaminophen is associated with reduced opioid use so we need to focus on acetaminophen use in first-line analgesia.MethodsWe conducted a controlled before/after study to assess the ability of an audit and feedback (A&F) intervention built with nurses to improve the quality of perioperative pain management in older patients hospitalized for hip fracture in an orthogeriatric unit (experimental group) versus a conventional orthopedic unit (no A&F intervention). The primary endpoint was the percentage of patients who received 3 g/day of acetaminophen during the three postoperative days, before and after the A&F intervention. Secondary endpoints included nurses’ adherence to medical prescriptions, clinical data associated with patients and finally factors associated with intervention. The significative level was set at 0.05 for statistical analysis.ResultsWe studied data from 397 patients (mean age 89 years, 75% female). During the postoperative period, 16% of patients from the experimental group received 3 g/day of acetaminophen before the A&F intervention; the percentage reached 60% after the intervention. The likelihood of receiving 3 g/day of acetaminophen during the postoperative period and adhering to the medical prescription of acetaminophen were significantly increased in the experimental group as compared with the control group. The patient’s functional status at discharge (assessed by Activities of Daily Living scores) was significantly better and the length of hospital stay significantly reduced after the A&F intervention.ConclusionOur controlled before/after study showed that an A&F intervention significantly improved perioperative pain management in older adults hospitalized for hip fracture. Involving teams in continuous education programs appears crucial to improve the quality of pain management and ensure nurses’ adherence to medical prescriptions.