Management Of Hip Fracture Patients Research Articles

‘NOF Said’: enhancing perioperative management of hip fracture patients in Royal Victoria Hospital Belfast

‘NOF Said’: enhancing perioperative management of hip fracture patients in Royal Victoria Hospital Belfast

Calcifediol in patients with hip fractures

Vitamin D deficiency has a high prevalence in the elderly population. This condition can cause sarcopenia and osteoporomalacia, which are associated with an increased risk of falls and fractures, especially of the proximal femur. These fractures have devastating consequences in terms of mortality, disability, and healthcare and social costs. Considering that 60% of hip fracture patients have hypovitaminosis D, and a serum 25(OH)D₃ increase of 10 ng/ml reduces the risk of hip fracture by 20%, correction of vitamin D status is clearly essential. Among the available preparations of vitamin D, calcifediol is preferred in cases with liver disease, malabsorption, obesity, and concomitant use of corticosteroids. Calcifediol administration corrects vitamin D deficiency and suppresses parathyroid hormone within 1 week, reaching the serum 25(OH)D₃ threshold of 30 ng/ml in 2 weeks. Correction of hypovitaminosis D with calcifediol also improves muscle strength and physical performance, reducing the risk of falls. Evidence about the role of calcifediol in the management of hip fracture patients is still scarce. Compared with placebo, administration of calcifediol in combination with strengthening exercise led to increased overall survival in patients with hip fracture. The efficacy of calcifediol in rapidly normalizing vitamin D status might be particularly useful in patients at imminent risk of fracture, such as those with hip fracture who need to receive immediate treatment with anti-osteoporotic drugs. KEY WORDS: Hip fractures, vitamin D deficiency, calcifediol, osteoporosis.

Review of perioperative outcomes and management of hip fracture patients on direct oral anticoagulants.

Anticoagulation use is common in elderly patients presenting with hip fractures and has been shown to delay time to surgery (TTS). Delays in operative treatment have been associated with worse outcomes in hip fracture patients. Direct oral anticoagulants (DOACs) comprise a steadily increasing proportion of all oral anticoagulation. Currently, no clear guidelines exist for perioperative management of hip fracture patients taking DOACs. DOAC use is associated with increased TTS, with delays frequently greater than 48 h from hospital presentation. Increased mortality has not been widely demonstrated in DOAC patients, despite increased TTS. Timing of surgery was not found to be associated with increased risk of transfusion or bleeding. Early surgery appears to be safe in patients taking DOACs presenting with a hip fracture, but is not currently widely accepted due to factors such as site-specific anesthesiologic protocols that periodically delay surgery. Direct oral anticoagulant use should not routinely delay surgical treatment in hip fracture patients. Surgical strategies to limit blood loss should be considered and include efficient surgical fixation, topical application of hemostatic agents, and the use of intra-operative cell salvage. Anesthesiologic strategies have utility in minimizing risk and a collaborative effort to minimize blood loss should be undertaken by the surgeon and anesthesiologist. Anesthesia team interventions include considerations regarding positioning, regional anesthesia, permissive hypotension, avoidance of hypothermia, judicious administration of blood products, and the use of systemic hemostatic agents.

Experience in the perioperative management of patients with hip fracture in southwestern Colombia. Retrospective cohort study

Introduction: Hip fracture is one of the main causes of morbidity and mortality among the elderly population. In Colombia there is a shortage of scientific literature on the perioperative management of this population of patients.
 Objective: To describe the perioperative management of hip fracture patients at a tertiary university hospital in Cali, Colombia.
 Methods: An observational study was conducted with relational scope of a historical cohort of patients with hip fracture who underwent surgical management between January 2018 and June 2022. A non-probability sampling method was used and contingency tables were designed aimed at describing the relationship between the patients’ characteristics and the postoperative outcomes.
 Results: 235 patients were included, of which 57 % were males. The mean age was 79 years and 49.8 % were classified as ASA III or higher. Spinal anesthesia was the most commonly used technique in 63.4 % of the cases. The most frequent outcomes were delirium in 17.9 %, and acute kidney failure in 6.8 %. 83.4 % of the patients underwent surgery within 48 hours of admission to the emergency department and intra-hospital mortality was 2.6 %.
 Conclusion: The results of this study provide relevant information to identify opportunities for improvement and their implementation, such as the reduction in the time elapsed until surgical management and the development of care protocols in the region.

Construction and validation of a risk prediction model for delayed discharge in elderly patients with hip fracture

BackgroundBecause of their poor physical state, elderly hip fracture patients commonly require prolonged hospitalization, resulting in a drop in bed circulation rate and an increased financial burden. There are currently few predictive models for delayed hospital discharge for hip fractures. This research aimed to develop the optimal model for delayed hospital discharge for hip fractures in order to support clinical decision-making.MethodsThis case-control research consisted of 1259 patients who were continuously hospitalized in the orthopedic unit of an acute hospital in Tianjin due to a fragility hip fracture between January and December 2021. Delayed discharge was defined as a hospital stay of more than 11 days. The prediction model was constructed through the use of a Cox proportional hazards regression model. Furthermore, the constructed prediction model was transformed into a nomogram. The model’s performance was assessed using the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA). the STROBE checklist was used as the reporting guideline.ResultsThe risk prediction model developed contained the Charlson Comorbidity Index (CCI), preoperative waiting time, anemia, hypoalbuminemia, and lower limbs arteriosclerosis. The AUC for the risk of delayed discharge was in the training set was 0.820 (95% CI,0.79 ~ 0.85) and 0.817 in the testing sets. The calibration revealed that the forecasted cumulative risk and observed probability of delayed discharge were quite similar. Using the risk prediction model, a higher net benefit was observed than when considered all patients were at high risk, demonstrating good clinical usefulness.ConclusionOur prediction models could support policymakers in developing strategies for the optimal management of hip fracture patients, with a particular emphasis on individuals at high risk of prolonged LOS.

Hypoalbuminemia is associated with 30-day mortality in hip fracture patients independently of Body Mass Index

The aim of this study was to assess the possible association between P-Albumin and 30-day mortality in hip fracture patients. The study is based on information from a database of hip fracture patients, established and collected at Bispebjerg University Hospital (Copenhagen, Denmark). This database includes all femoral neck (DS720), pertrochanteric (DS721) and subtrochanteric fractures (DS722) admitted to Bispebjerg Hospital between 1996 and 2012. We further identified all surgically treated hip fracture patients aged >60 years with an available P-Albumin at admission. 1856 patients were eligible for inclusion in this study (73.7% female, 26.3% male). 11.8% of these had died within 30 days. Differences between continuous variables were tested using unpaired t-tests while differences in the distribution of categorical variables were tested using chi square tests. After adjusting for co-variates in a logistic regression model, the association between P-Albumin and 30-day mortality remained increased, (OR 1.09, 95% CI 1.05;1.11 (p < 0.0001)). This study shows an increased 30-day mortality risk among surgically treated hip fracture patients with decreasing levels of P-Albumin even after adjusting for age, sex, BMI, CCI and fracture type. Routine screening of patients for hypoalbuminemia at hospital admission may be beneficial in the management of hip fracture patients.

Management of hip fracture in COVID-19 infected patients.

Given that the global population of elderly individuals is expanding and the difficulty of recovery, hip fractures will be a huge challenge and a critical health issue for all of humanity. Although people have spent more time at home during the coronavirus disease 2019 (COVID-19) pandemic, hip fractures show no sign of abating. Extensive studies have shown that patients with hip fracture and COVID-19 have a multifold increase in mortality compared to those uninfected and a more complex clinical condition. At present, no detailed research has systematically analyzed the relationship between these two conditions and proposed a comprehensive solution. This article aims to systematically review the impact of COVID-19 on hip fracture and provide practical suggestions. We found that hip fracture patients with COVID-19 have higher mortality rates and more complicated clinical outcomes. Indirectly, COVID-19 prevents hip fracture patients from receiving regular medical treatment. With regard to the problems we encounter, we provide clinical recommendations based on existing research evidence and a clinical flowchart for the management of hip fracture patients who are COVID-19 positive. Our study will help clinicians adequately prepare in advance when dealing with such patients and optimize treatment decisions.

Interventional therapies for management of hip fracture pain peri-operatively: A review article

Background Hip fracture is a common reason for elderly admission to hospital and majority of patients will require a hip fixation surgery. Pain originating from a hip fracture is usually severe and the need to improve comfort is paramount, especially before the hip fixation surgery because severe pain results in unnecessary stress response such as catecholamines release, tachycardia and hypertension. This worsens outcomes, increases risk of complications such as myocardial ischaemia, strokes, pulmonary embolus or deep vein thrombosis. Multimodal systemic analgesia has been shown to be effective in reducing pain in hip fractures but the associated side effects and contraindications have accelerated the adoption of nerve blocks in the peri-operative management of hip fracture patients. 1 As a result, this has been increasingly recognised as a important component of the hip fracture pathway (as part of a multimodal approach for analgesia) and many hospitals have protocols to perform various interventional therapies (various nerve blocks) for newly admitted patients with hip fracture to alleviate pain immediately and potentially provide intra and post-operative analgesia. Objective The aim of this review is to elucidate the various interventional therapies currently available (including pericapsular nerve group (PENG) block which was first described in 2018), their evidence and the pros and cons. Methods We reviewed the latest evidence for femoral nerve block (FNB), 3-in-1 block, lumbar plexus block (LPB), fascia iliaca block (FIB), erector spinae plane block (ESPB) and pericapsular nerve group (PENG) block. Results and conclusion Each block has its pros and cons, as discussed in this review article. The procedurist should deliberate these considerations before deciding which block is most appropriate.

Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®.

Background and Objectives: The increased use of direct oral anticoagulants (DOACs) results in an increased prevalence of DOAC treatment in hip fractures patients. However, the impact of DOAC treatment on perioperative management of hip fracture patients is limited. In this study, we describe the prevalence of DOAC treatment in a population of hip fracture patients and compare these patients with patients taking vitamin K antagonists (VKA) and patients not taking anticoagulants. Materials and Methods: This study is a retrospective analysis from the Registry for Geriatric Trauma (ATR-DGU). The data were collected prospectively from patients with proximal femur fractures treated between January 2016 and December 2018. Among other factors, anticoagulation was surveyed. The primary outcome parameter was time-to-surgery. Further parameters were: type of anesthesia, surgical complications, soft tissue complications, length of stay and mortality. Results: In total, 11% (n = 1595) of patients took DOACs at the time of fracture, whereas 9.2% (n = 1325) were on VKA therapy. During the study period, there was a shift from VKA to DOACs. The time-to-surgery of patients on DOACs and of patients on VKA was longer compared to patients who did not take any anticoagulation. No significant differences with regard to complications, type of anesthesia and mortality were found between patients on DOACs compared to VKA treatment. Conclusion: An increased time-to-surgery in patients taking DOACs and taking VKA compared to non-anticoagulated patients was found. This underlines the need for standardized multi-disciplinary orthopedic, hematologic and ortho-geriatric algorithms for the management of hip fracture patients under DOAC treatment. In addition, no significant differences regarding complications and mortality were found between DOAC and VKA users. This demonstrates that even in the absence of widely available antidotes, the safe management of geriatric patients under DOACs with proximal femur fractures is possible.

Abstract No.: ABS0455: Perioperative management of hip fracture patients- are we following the guidelines? a retrospective observational study

Background and Aims:No study have explored guidelines on management of hip fracture patients practice in our country.Methods:This retrospective study included all patients above 65 years of age , scheduled for orthopaedic surgery following hip fracture from January 2020 - 21. The hospital information system was used to obtain the clinical details. The details of care pathway received by patient from the time of admission until discharge were collected. For perioperative outcome, patients were followed up to 30 days after hospital admission. . The perioperative management was compared with the Association of Anaesthetists of Great Britain and Ireland (AAGBI), guidelines for management of hip fractures and any deviations from compliance was recorded. Our primary objective was to assess the adherence to these guidelines at our hospital. Secondary objectives were to explore the deviations in practice.Results:A total of 126 patients were included in the tsudy.The adherence to the major recommendations are shown in Figure 1.Use of antiplatelet drugs was the reason most commonly cited for delay in surgery. Anaesthesia was administered in 75% of the patients by senior anaesthesiologist. Majority (71.1%) were operated under subarachnoid block [Figure 1]. A total of 32% patients developed intraoperative hypotension and 16% patients developed postoperative complications, the most common was aspiration pneumonia. Out of all patients, 10 patients expired in the postoperative period.Figure 1Adherence to the major recommendation in the guidelinesConclusion:We found that the adherence to the AAGBI recommendations was good in several areas but lacked in. preoperative cognitive assessment and involvement of geriatrician. Aged; hip fractures;medical audit; total quality management..

Development and initial validation of MedHipPro-Q: a questionnaire assessing medication management of hip fracture patients in different care settings

BackgroundA validated questionnaire to assess medication management of hip fracture patients within and outside the hospital setting was lacking. The study aims were to describe the hip fracture patient pathway, and develop a valid and feasible questionnaire to assess clinicians’ experience with medication management of hip fracture patients in different care settings throughout the patient pathway.MethodsThis qualitative, descriptive methodological study used strategic and snowball sampling. The questionnaire was developed, and face and content validity explored through interviews with stakeholders. Phase I described the hip fracture patient pathway, and identified questionnaire dimensions in semi-structured interviews with management and clinicians (n = 37). The patient pathway was also discussed in six meetings (n = 70). Phase II refined a first draft of the questionnaire through cognitive interviews with future respondents (n = 23). The draft was modified after each interview. Post hoc, cognitive interview data were analysed using matrix analysis to condense problems and solutions into themes and subthemes. Phase III, converted the final version to a digital format, and tested its feasibility with a subset of the cognitive interview participants (n = 21) who completed the questionnaire and provided feedback.ResultsPhase I: Hip fracture patients were cared for in at least three different care settings, and went through at least four handovers between and within primary and secondary care. Three questionnaire dimensions were identified: 1) Medication reconciliation and review, 2) Communication of key information, and 3) Profession and setting. Phase II: The MedHipPro-Q was representative of how the different professions experienced medication management in all settings, and hence showed face and content validity. Post hoc analysis: Problem themes (with sub-themes) were Representativeness (-of patient pathway and -of respondent reality) and Presentation (Language and Appearance). Solution themes (with sub-themes) were: Content (added or deleted) and Presentation (modified appearance or corrected language). Phase III: Participants did not identify technical, linguistic or content flaws in the questionnaire, and the digital version was considered feasible for use.ConclusionThe novel MedHipPro-Q showed good face and content validity, and was feasible for use throughout the hip fracture patient pathway. The rigorous development process supports its construct validity and reliability.

Association Between COVID-19 and Mortality in Hip Fracture Surgery in the National COVID Cohort Collaborative (N3C): A Retrospective Cohort Study.

Background:This study investigated the outcomes of coronavirus disease (COVID-19)-positive patients undergoing hip fracture surgery using a national database.Methods:This is a retrospective cohort study comparing hip fracture surgery outcomes between COVID-19 positive and negative matched cohorts from 46 sites in the United States. Patients aged 65 and older with hip fracture surgery between March 15 and December 31, 2020, were included. The main outcomes were 30-day all-cause mortality and all-cause mortality.Results:In this national study that included 3303 adults with hip fracture surgery, the 30-day mortality was 14.6% with COVID-19-positive versus 3.8% in COVID-19-negative, a notable difference. The all-cause mortality for hip fracture surgery was 27.0% in the COVID-19-positive group during the study period.Dicussion:We found higher incidence of all-cause mortality in patients with versus without diagnosis of COVID-19 after undergoing hip fracture surgery. The mortality in hip fracture surgery in this national analysis was lower than other local and regional reports. The medical community can use this information to guide the management of hip fracture patients with a diagnosis of COVID-19.

Impact of COVID-19 on Key Performance Indicators of the National Hip Fracture Database and the Management of Hip Fracture Patients.

Background: A hospital's performance regarding the management of hip fractures is based on six key performance indicators (KPIs) which are recorded onto the National Hip Fracture Database (NHFD). The aim of this study was to assess the overall impact of coronavirus disease 2019 (COVID-19) on the management and outcomes of hip fracture patients against a similar period in 2019 by utilizing the KPIs.Method: Retrospective data collection of hip fracture patients during a six-week (pre-COVID) period in 2019 and a six-week (COVID-19) period in a single orthopedic unit. The following parameters were compared; patient age, time to theater, surgeon operating time, total time in the operating room, time from ward to recovery, time from hospital presentation to theater, and total time from presentation to hospital discharge.Results: Some 38 patients in the pre-COVID-19 period vs. 27 patients with hip fractures in the COVID-19 period were included in the study. Time from diagnosis to theater and surgeon operating time were similar in both groups. The mean length of stay was 9.3 days vs. a mean of 31.34 days (p = 0.0004) in the COVID-19 and pre-COVID-19 groups respectively. A 30-day mortality was 22.2% (n = 6) in the COVID-19 group vs. 5.3% (n = 2) in the pre-COVID-19 group.Conclusion: Our study demonstrates that the combination of surgical stress and COVID-19 leads to higher mortality rates. Our hospital’s structural reorganization during the pandemic has shown progress in achieving important KPIs and improved short-term outcomes for hip fracture and trauma patients.

Shorter acute hospital length of stay in hip fracture patients after surgery predicted by early surgery and mobilization.

As hip fracture incidence rises with our ageing global population, there will be an increase in consumption of healthcare resources. We hypothesized that hospital management and patient factors can affect healthcare burden load. Using length of stay (LOS) as a surrogate for consumption, the aim of this study is to elucidate the effect of hospital management and patient-related factors on length of stay (LOS) for patients after hip fracture surgery. We studied modifiable and non-modifiable factors influencing LOS, and identification of these modifiable factors accords opportunities for mitigating these factors. This retrospective study examines hip fracture data from a large tertiary hospital in Singapore over the period of 2017 to 2020. Data collected on the electronic medical record included age, gender, race, marital status, payer type, ASA score, TTS, type of surgery, fracture type, POD1 mobilization, discharge position, and presence of pressure sores, and they were correlated with LOS using binary logistic regression on SAS. A total of 1045 patients were included in this study with 704 females and 341 males. The mean age was 79.5 ± 8.57years (range 60-105) with an average LOS 13.64 ± 10.0days (range 2-114). On binary logistic regression, ASA and trochanteric fracture remains a significant non-modifiable factor for LOS with OR = 1.486 (95% CI 1.106, 1.996, p = 0.0086) and OR 1.522 (95% CI 1.149, 2.015, p = 0.0034) respectively. Significant modifiable factors were TTS > 48h (OR = 1.819, 95% CI 1.205, 2.746, p = 0.0044) and POD1 mobilization (OR = 0.441, 95% CI 0.257, 0.756, p = 0.0029). Our analysis showed TTS and POD1 are significant modifiable factors for LOS, and resources can be diverted towards them for the management of hip fracture patients and pre-empting the increasing load on our healthcare system.

Characteristics and clinical outcomes of hip fracture patients during the first lockdown of COVID-19, lessons learnt: A retrospective cohort analysis.

The management of hip fracture patients has been challenging across the UK in the wake of emergency coronavirus disease 2019 guidelines. This retrospective, observational cohort study analyses the impact of the first lockdown during the early part of the coronavirus disease 2019 pandemic on the management of hip fracture patients at a district general hospital in the UK. Comparative analysis to assess hip fracture patients treated at this Trust between 1 April to 31 May 2019 and 1 April to 31 May 2020 was undertaken. The primary outcome measures appraised were 30 and 60-day mortality and the secondary outcome measure included time to surgery. There was a higher 30 and 60-day mortality rate in the first lockdown period at 8.1% and 13.5%, respectively, compared to 1.96% and 5.88% in 2019. A significantly lower proportion of hip fracture patients at 59.46% were operated within the 36h target time frame during the first lockdown. In our Trust, hip fractures were treated as obligatory injuries. However, the mortality was higher in the 2020 cohort with a significant reduction in patients achieving the recommended '36 hours' time to surgery target and accruement of Best Practice Tariff. Enhanced infection control strategies have prepared us for the future.

The Application of Fascia Iliaca Compartment Block for Acute Pain Control of Hip Fracture and Surgery.

Over 300,000 patients are hospitalized annually following hip fractures in the USA. Many patients experienced inadequate analgesia. We will review the perioperative effects of the fascia iliaca compartment block (FICB) in hip fracture patients. FICB by injecting local anesthetics beneath the fascia iliaca results in significant pain relief in hip fractures. Neuropathies and vascular injuries are almost unlikely. Single-shot FICB is faster to place, yet providing about 8 h of analgesia when bupivacaine is used. Continuous FICB provides prolonged titratable analgesia, improved patient satisfaction, and leads to faster hospital discharge. FICB reduces opioid consumption, decreases morbidity and mortality, reduces hospital stay, reduces delirium, and improves satisfaction. FICB should form part of a multimodal analgesic regime, in the context of a multidisciplinary approach to the management of hip fracture patients. More clinical investigations are needed to validate the long-term outcome benefits of FICB in hip fracture patients.

The impact of COVID-19 on the management and outcomes of patients with proximal femoral fractures: a multi-centre study of 580 patients

BackgroundOn the 11th March 2020, the World Health Organization declared the COVID-19 outbreak a pandemic. Multiple new guidelines were proposed and existing models of social, domestic and hospital care altered. Most healthcare systems were largely unprepared for this, and the pandemic has tested their adaptability. This study aimed to assess the impact of COVID-19 on the demographics, presentation, clinical management and outcomes of patients with proximal femoral (hip) fractures comparing them to a similar cohort of patients admitted a year earlier.MethodsThis retrospective multi-centre cohort study compared all patients admitted with hip fractures between 1st March and 30th May 2019 (group PC: pre-COVID-19) with hip fracture patients admitted over the same time period during the pandemic in 2020 (group C: COVID-19). The data was obtained from the hospitals’ local and National Hip Fracture Databases. Mortality data was checked with the Office for National Statistics (ONS). Primary outcomes were time to theatre, in-patient length of stay and 30-day mortality.ResultsA total of 580 patients were included (304 group PC, 276 group C). Patient demographics including Charlson Comorbidity Index and Nottingham Hip Fracture Scores were broadly similar across the two cohorts. There was a significant reduction in the percentage of total hip replacements (11 to 5%, p = 0.006) in group C. There was an increase in conservative management (1 to 5%, p = 0.002) in group C. Time to theatre was significantly delayed in group C (43.7 h) vs group PC (34.6 h) (p ≤ 0.001). The overall length of hospital stay was significantly longer in group PC (16.6 days) vs group C (15 days) (p = 0.025). The 30-day mortality rate in group C was 9.8% compared to 8.2% in group PC (p = 0.746), but for COVID-19 (+) patients, it was significantly higher at 38.2% vs 5.8% in COVID-19 (−) patients (p < 0.001).ConclusionThis is one of the largest multi-centre comparative cohort study in the literature to date examining the impact of the COVID-19 pandemic on the management of hip fracture patients. Whilst mortality rates were similar in both groups, COVID-19-positive patients were almost seven times more likely to die, reflecting the seriousness of the COVID-19 infection and its sequelae in such elderly, vulnerable patients.

Fifteen years change in acute management of hip fracture patients: 1-year mortality calls for improvements

IntroductionOver the past two decades, the average age of hip fractured patients has increased, patients are increasingly fragile and their management is more complex. Most of the literature suggest that care improvement lowered short-term mortality but there is no clear evidence whether mid- and long-term mortality rates are improving. The aim of this study was to evaluate the variations in comorbidities in hip fractured patients over 15 years, the changes in mortality and identify the predictive factors for mortality for identifying the patients at higher risk. Materials and MethodsHip fractured patients admitted in hospital in 2000-2001 (192 patients) and 2015-2016 (323 patients) were retrospectively reviewed. Demographic, clinical and management data from the two cohorts were compared. Thirty-day and 1-year mortality were calculated and compare between the two cohorts. A multivariate logistic regression model were performed to identify the most significant predictors of mortality. ResultsAfter fifteen years, mean age of hip fracture patients increased by 2.6 years with a 31% increase in comorbidity. The most prevalent comorbidities were hypertension, COPD, diabetes, arrhythmia, renal impairment and dementia. In the 2015-2016 cohort, the age-adjusted mortality at 30 days significantly declined compared to the 2000-2001 cohort (respectively 6.9% vs. 12.5%) but the age-adjusted mortality at 1-year was equivalent. Older age, reduced mobility, higher comorbidity, lateral fractures and male sex were significant risk factors for reduced survival time ConclusionsAfter 15 years, there was a significant improvement in 30-days mortality in hip fractured patients despite their increase in comorbidities but this advantage was not observed in 1-year mortality. This suggests the need to implement targeted and longer-term care support for males, older patients and those with greater comorbidities which are at higher risk.

Patients Undergoing Surgery for Hip Fractures Suffer from Severe Oxidative Stress as Compared to Patients with Hip Osteoarthritis Undergoing Total Hip Arthroplasty.

Hip fractures are associated with the highest degree of morbidity and mortality of all fractures in elderly patients and pose a major risk for subsequent fractures. Patients with hip fractures also present accelerated bone turnover despite early stable fracture fixation and early mobilization. We aimed to evaluate oxidative stress in two groups of patients (25 patients each, matched for age, side, and BMI) who underwent internal fixation of hip fractures and total hip arthroplasty for hip osteoarthritis. Blood samples were taken from all patients during admission, the day of surgery, the 4th postoperative day, and the 15th postoperative day. Reduced (GSH) and oxidized (GSSG) glutathione, GSH/GSSG, catalase (CAT), thiobarbituric acid reactive substances (TBARS), protein carbonyls (PC), and total antioxidant capacity (TAC) as a widely used battery of redox biomarkers were recorded from blood samples. Patients with hip fractures who undergo fixation surgery, compared to those with hip osteoarthritis, suffer significant oxidative stress with an active but insufficient first line of oxidative defense, an intensive first line reaction, a very active second line of oxidative defense, and a low plasma antioxidant capacity. Surgery worsened already present lipid- and protein-related tissue damage. The severe oxidative stress observed may explain high morbidity and mortality rates and high bone turnover status, as well as the high incidence of refractures. Furthermore, the question of whether antioxidant therapy measures should be introduced in the management of hip fracture patients is raised.

Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis.

Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients. Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence. We included five trials (n= 254), where participants received FNB 30minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty. The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.