Surgical Fixation Of Hip Fractures Research Articles

Effect of operative time in outcomes following surgical fixation of hip fractures: a multivariable regression analysis of 35,710 patients.

Prolonged operative time is a risk factor for increased morbidity and mortality after open reduction and internal fixation (ORIF) of hip fractures. However, the quantitative nature of such association, including graduated risk levels, has yet to be described. This study outlines the graduated associations between operative time and (1) healthcare utilisation, and (2) 30-day complications after ORIF of hip fractures. The National Surgical Quality Improvement Program (NSQIP) database was queried (January 2016-December 2019) for all patients who underwent ORIF of hip fractures (n = 35,710). Demographics, operative time, fracture type, and comorbidities were recorded. Outcomes included healthcare utilisation (e.g., prolonged length of stay [LOS>2 days], discharge disposition, 30-day readmission, and reoperation), inability to weight-bear (ITWB) on postoperative day-1 (POD-1), and any 30-day complication. Adjusted multivariate regression models evaluated associations between operative time and measured outcomes. Operative time <40 minutes was associated with lower odds of prolonged LOS (odds ratio [OR] 0.77), non-home discharge (OR 0.85), 30-day readmission (OR 0.85), and reoperation (OR 0.72). Operative time ⩾80 minutes was associated with higher odds of ITWB on POD-1 (OR 1.17). Operative time ⩾200 minutes was associated with higher odds of deep infection (OR 7.5) and wound complications (OR 3.2). The odds of blood transfusions were higher in cases ⩾60 minutes (OR1.3) and 5-fold in cases ⩾200 minutes (OR 5.4). The odds of venous thromboembolic complications were highest in the ⩾200-minute operative time category (OR 2.5). Operative time was not associated with mechanical ventilation, pneumonia, delirium, sepsis, urinary tract infection, or 30-day mortality. Increasing operative time is associated with a progressive increase in the odds of adverse outcomes following hip fracture ORIF. While a direct cause-effect relationship cannot be established, an operative time of <60 minutes could be protective. Perioperative interventions that shorten operative time without compromising fracture reduction or fixation should be considered.

Trauma

The August 2023 Trauma Roundup360 looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

Association of length of hospital stay with delay to surgical fixation of hip fracture

Background:Previous research has shown increases in length of stay (LOS), morbidity and mortality when the standard for surgical fixation of hip fracture of 48 hours is not met. However, few investigators have analyzed LOS as a primary outcome, and most used time of diagnosis as opposed to time of fracture as the reference point. We examined the effect of time to surgical fixation of hip fracture, measured from time of fracture, on length of hospital stay; the secondary outcome was average 1-year mortality.Methods:We conducted a retrospective cohort study of patients presenting to 1 of 2 tertiary care centres in St. John’s, Newfoundland and Labrador, Canada, with a hip fracture from Jan. 1, 2014, to Dec. 31, 2018. We analyzed 3 groups based on timing of surgical fixation after fracture: less than 24 hours (group 1), 24–48 hours (group 2) and more than 48 hours (group 3). We assessed statistical significance using 1-way analysis of variance.Results:Of the 692 patients included in the study, 212 (30.6%) were in group 1, 360 (52.0%) in group 2 and 120 (17.3%) in group 3. A delay to surgical fixation exceeding 48 hours was associated with a significantly longer LOS, by an average of 2.9 and 2.8 days compared to groups 1 and 2, respectively (p = 0.04); there was no significant difference in LOS between groups 1 and 2. A significant difference in average 1-year mortality was observed between groups 1 (11%) and 3 (26%) (p = 0.004), and groups 2 (13%) and 3 (p = 0.009).Conclusion:Surgical fixation beyond 48 hours after hip fracture resulted in significantly increased LOS and 1-year mortality. Further research should be conducted to evaluate reasons for delays to surgery and the effects of these delays on time to surgical fixation as measured from time of fracture.

Does a patient's anaesthetic grading bear any correlation to the achievement of early mobilisation following surgical fixation of hip fracture?

Purpose: American Society of Anaesthesiologists (ASA) grading is routinely utilised in orthopaedic surgery to rate a patient's medical and physical fitness for the procedure; whereby a higher grade score indicates a lower level of pre-operative health status.

Intraoperative Fluoroscopic Radiation Exposure During Hip Fracture Fixation: A Study Combining Surgical Experience and Fracture Complexity.

AimHip fracture fixation surgeries are one of the most common surgeries that every trauma unit does regularly. Surgical training and expertise to fix these fractures properly are quite crucial for every orthopaedic surgeon. Therefore, orthopaedic training programmes all over the world consider significant focus on this and teach trainee surgeons expectantly to manage these fractures independently. Surgical fixation of hip fractures often requires fluoroscopy assistance in the operating theatre with associated hazards from ionising radiation. Moreover, hip fractures can be sometimes quite complex and may require relatively more fluoroscopy usage even with the higher grade of the operating surgeons. Therefore, training need for hip fracture fixation surgery is imperative and there is also a need for intraoperative radiation safety. This study has tried to find a balance between intraoperative fluoroscopic radiation exposure, surgical training requirement, and hip fracture complexity.MethodologyThis single centre study has collected retrospective peri-operative data over a period of two years including hip fractures that required fluoroscopy-guided surgical fixation. Femoral head fractures, subtrochanteric fractures, diaphyseal fractures, and trochanteric fractures with associated pelvic fractures were excluded from the study. We collected data on demographic parameters, fracture complexity and grading (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA] Classification), intraoperative ionising radiation exposure (centi-Gray/cm2), and grade of the operating surgeon in order to find any relation between these factors.ResultsTotal 268 patients were included in the study with a mean age of 81.8 years (SD 9.3) comprising of 83 (31%) male patients and 185 (69%) female patients. The study population was further stratified into three groups depending upon the operating grade of the surgeon: ‘Junior Trainee’ (<five years of experience; 77 cases [29%]); ‘Senior Trainee’ (>five years of experience; 148 cases [55%]); and ‘Consultant’ (fully trained to practice independently; 43 cases [16%]). There was no statistically significant difference among these three sub-groups with regards to the age (p = 0.79), gender (p = 0.73), body mass index (p = 0.46), and fracture pattern (p = 0.96) of the patients. However, consultants tend to operate more on the higher American Society of Anesthesiologists (ASA) grade patients (p = 0.049) with more comorbidities. There was statistically significant higher fluoroscopic radiation exposure while junior trainee surgeons (p = 0.005) were operating and during the higher complex grade of hip fracture (p = <0.001) fixation.ConclusionIn conclusion, the quantity of intra-operative radiation dose utilised in the surgical fixation of hip fractures is significantly associated with the grade and level of training of the operating surgeon and fracture complexity type. The results of this study emphasise and support the importance of comprehensive, supervised, and structured orthopaedic training for in-theatre radiation safety. It is recommended to have a safe balance between teaching, learning, and prevention of ionising radiation hazards in order to optimally achieve trainee’s professional development with successful patient outcomes.

Intertrochanteric fracture fixation in solid organ transplant patients: outcomes and survivorship.

Solid organ transplantation (SOT) recipients have complex medical and surgical risk factors; however, the outcomes of these patients undergoing surgical fixation of hip fractures are unknown. This study sought to evaluate SOT patients' outcomes and survivorship after intertrochanteric (IT) fracture fixation. A retrospective review identified 12 SOT patients who underwent cephalomedullary (CMN) nail fixation for IT fractures and were matched (1:2) to a cohort of 24 non-SOT IT fracture patients. Perioperative results and complications, mortality/patient survivorship, and clinical outcomes were compared between the cohorts. The time from presentation to surgical fixation was within 48h of presentation for the non-SOT patients, while only 75% of SOT patients underwent surgery within 48h of presentation (p = 0.034). The 90-day readmission rate for SOT patients was 25% versus 13% in the non-SOT group (p = 0.38). Similarly, the SOT cohort experienced a higher rate of major medical complication (25% vs. 13%, p = 0.38). There were two (16%) reoperations in the SOT group and three (13%) in the non-SOT matched group (p = 0.99). Respectively, the 90-day and 1-year estimated patient survivorship was similar between the two cohorts: SOT patients with 92% (95% CI 54-99%) and 73% (95% CI 24-93%) versus 86% (95% CI 62-95%) and 72% (95% CI 47-86%, HR 0.92, 95% CI 0.18-4.62, p = 0.92) in non-SOT patients. SOT patients who underwent CMN fixation for IT fractures required more time from hospital presentation to surgical management than non-SOT patients. Although not statistically significant, SOT patients demonstrated more acute complications and readmissions, but similar mortality compared to those without transplant.

The association between surgical fixation of hip fractures within 24 hours and mortality : a systematic review and meta-analysis.

The aim of this study was to assess the effect of time to surgical intervention from admission on mortality and morbidity for patients with hip fractures. MEDLINE and Embase were searched from inception to June 2020. Reference lists were manually assessed to identify additional papers. Primary comparative research studies that recruited patients aged over 60 years, with non-pathological primary proximal femoral fractures that were treated surgically, were included. Studies that did not include a group operated on within 24 hours or which reported time to surgery in calendar days were excluded. Two investigators extracted data on study characteristics, methods, and outcomes. The pre-defined primary outcome was 30-day mortality. Secondary outcomes were complications and mortality at other time points. Relative risks (RRs) with 95% confidence intervals (CIs) were aggregated and were grouped by study-level characteristics. This review included 46 studies (January 1991 to June 2020), comprising 521,857 hip fractures with 64,047 postoperative deaths. No randomized controlled trials were eligible for inclusion. In a pooled analysis of 15 studies, RR of mortality at 30 days comparing time to surgery < 24 hours with > 24 hours was 0.86 (95% CI 0.82 to 0.91; I 2 = 69%; 95% CI 50% to 81%; p-value for heterogeneity < 0.001). The association was stronger in observational studies that did not adjust for confounders than in those that adjusted for multiple covariates. In a pooled analysis of six studies, the RR of mortality at 30 days comparing time to surgery < 24 hours with 24 to 36 hours was 0.87 (95% CI 0.81 to 0.93; I 2 = 65%; 95% CI 16% to 85%; p-value for heterogeneity = 0.014). This meta-analysis indicates reduced mortality for patients operated within 24 hours compared with those operated on beyond 24 hours or within 24 to 36 hours. Where resources allow and there is no specific reversible contraindication to early surgery, we recommend that hip fractures should be surgically treated within 24 hours. Cite this article: Bone Joint J2021;103-B(7):1176-1186.

Increased Reimbursement for Surgical Fixation of Hip Fractures: The Difference Between the Hospital and the Surgeon.

To evaluate trends and variations in hospital charges and payments relative to surgeon charges and payments for surgical treatment of hip fractures in the US Medicare population. Hospital and surgeon charges and payments after treatment of hip fractures by closed reduction and percutaneous pinning (CRPP), open reduction internal fixation (ORIF), or intramedullary nail (IMN), along with corresponding patient demographics, 90-day and 1-year mortality, Charlson Comorbidity Index (CCI), and length of stay (LOS) from 2005 to 2014 were captured from the 5% Medicare Standard Analytic Files. The ratio of hospital to surgeon charges (CM: Charge Multiplier) and the ratio of hospital to surgeon payments (PM: Payment Multiplier) were calculated for each year and region of the United States and trended over time. Correlations between the CM and PM and LOS were evaluated using a Pearson correlation coefficient (r). Three thousand twenty-eight patients who underwent CRPP and 25,341 patients who underwent ORIF/IMN were included. The CM for CRPP increased from 10.1 to 15.6, P < 0.0001. The CM for ORIF/IMN increased from 11.9 to 17.2, P < 0.0001. The PM for CRPP increased from 15.1 to 19.2, P < 0.0001. The PM for ORIF/IMN increased from 11.5 to 17.4, P < 0.0001. Hospital charges and payments have continually increased relative to surgeon charges and payments for treatment of hip fractures despite decreasing LOS.

Temporal Trends in Hip Fractures: How Has Time-to-Surgery Changed?

Surgical fixation of hip fractures within 24-48 hours of hospital presentation is associated with decreased rates of postoperative morbidity and death, and recently, hospitals nationwide have implemented strategies to expedite surgery. Our aim was to describe how time-to-surgery and short-term complication rates have changed using the National Surgical Quality Improvement Program database from 2011 to 2017. We identified more than 73,000 patients aged ≥65 years who underwent surgical fixation. Poisson regression adjusting for comorbidities, surgery type, type of anesthesia, patient sex, and patient age was performed to quantify annual changes in time-to-surgery. Annual changes in 30-day postoperative complications were analyzed using a generalized linear model with binomial distribution. A significant decrease in time-to-surgery was observed during the study period (mean 30 hours in 2011 versus 26 hours in 2017; P<0.001). Time-to-surgery decreased by 2% annually during the 7-year period (0.5 hour/year, 95% CI: -35, -23; P<0.001). The all-cause 30-day complication rate also decreased annually (annual risk difference: -0.35%, 95% CI: -0.50%, -0.20%; P<0.001). For individual complications, we found significant decreases in deep infection (-0.2%, P=0.002), reintubation (-0.3%, P=0.001), urinary tract infection (-2.5%, P<0.001), and death (-1.3%, P=0.03). We found significant but small increases of pulmonary embolism (0.3%, P=0.03) and myocardial infarction (0.1%, P=0.02). Higher rates of complications were associated with increased time-to-surgery (P<0.001). From 2011 to 2017, time-to-surgery for hip fracture decreased significantly, as did short-term postoperative rates of all-cause complications and death. Longer time-to-surgery was associated with increased number of complications.

Comparison of the Analgesic Effects of Ultrasound Guided Supra-Inguinal Fascia Iliaca Block with Femoral Nerve Block for Surgical Fixation of Hip Fractures

Introduction: Regional anaesthesia techniques have been used for perioperative analgesia for hip fractures. The supra-inguinal approach to fascia iliaca block (FIB) can potentially provide superior analgesia compared to femoral nerve block (FNB) by blocking the obturator and lateral femoral cutaneous nerves. We aimed to evaluate the analgesic effect of single shot FIB and FNB for surgical fixation of hip fractures. Methods: After obtaining ethics approval and written, informed consent, 30 patients undergoing surgical fixation of hip fractures were recruited and randomized into 2 groups. Patients received either a single shot FIB or FNB with 0.5% Ropivacaine 30 mls, and a subarachnoid block. Pain scores were assessed pre-operatively, post-block, in recovery and at 24 hours post-operatively. Time to first analgesic, oxynorm consumption, opioid related side effects and block related complications were assessed at 24 hours. Results: There were no statistically significant difference in post-block pain scores, median (IQR) of 0 (0 - 0) versus 0 (0 - 0) at rest and 3 (2 - 6) versus 5 (2 - 6) on positioning for spinal; and 24 hour pain scores were 0 (0 - 0) versus 0 (0 - 0) at rest and 4 (2 - 5) versus 5 (2 - 6) on movement for FIB and FNB groups respectively. 5 patients from each group required post-operative opioids, post-operative opioids requirement were similar. Conclusions: Though ultrasound guided supra-inguinal FIB was more consistent in blocking the lateral femoral cutaneous nerve then a femoral nerve block, this did not translate to any difference in terms of pain scores, opioid consumption and side effects.

Does Resident Participation in the Surgical Fixation of Hip Fractures Increase Operative Time or Affect Outcomes?

Surgical fixation of hip fractures is a common procedure at teaching hospitals with resident support and in community hospitals. We evaluated to what extent participation by residents in hip fracture fixation affects operative times or outcomes. Operations were performed by three surgeons who operate at a teaching hospital with resident support, and at a community hospital without residents in the same metropolitan area. We performed a retrospective analysis of operative time and early post-operative outcomes on a series of 314 patients with hip fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association A1-3, B1-3) treated with surgical fixation between April 2012 and March 2015; 177 patients at the community hospital, and 137 at the teaching hospital. Multivariate regression assessed the effect of hospital type, adjusting for age, gender, American Society of Anesthesiologist classification, and Charlson comorbidity index. We found lower median operative time at the community hospital than the teaching hospital (46 minutes, 95% confidence interval [CI] = [43, 52] versus 75 minutes, 95% CI = [70, 81]) and lower estimated blood loss (177.3 mL, 95% CI=[158.6, 195.1] versus 234.8 mL, 95% CI = [196.4, 273.6]), but no differences in transfusion requirement, length of stay, or discharge to skilled nursing facility. Adjusted odds ratio for thirty-day mortality at the teaching hospital was 5.44 (95% CI = [1.22, 24.1]). We found longer operative times and elevated estimated blood loss with resident involvement in surgical fixation of hip fractures. There was a difference in 30-day mortality between the groups, although this cannot simply be attributed to resident involvement as there are many other factors related to mortality.

The Impact of Mental Health and Substance Use on Opioid Demand After Hip Fracture Surgery.

Mental health and substance use and abuse disorders have been associated with poor patient-reported outcomes. Despite the prevalence of hip fractures in the United States, the relationship between opioid demand and these factors in hip fracture surgery is not well understood. The purpose of this study is to describe opioid filling volume and rates after hip fracture surgery and to identify mental health risk factors for increased demand. The study hypothesis is that psychiatric comorbidities such as depression and psychoses as well as substance use and abuse indicators such as pre-op opioid dependence, drug, alcohol, and tobacco abuse would be associated with increased perioperative opioid demand. This is a retrospective cohort study of 40,514 patients undergoing surgical fixation of hip fractures using a commercially available insurance database. The primary patient-level outcome was filled opioid prescription volume in oral morphine milliequivalents converted to oxycodone 5-mg equivalents up to 1-year post-op. Adjusted measures of overall quantities filled and refill rates were assessed with multivariable main effects linear and logistic regression models. Twenty four thousand four hundred forty-one of 40,514 patients (60.3%) filled opioid prescriptions within 7 days pre-op to 1-year post-op. Patients filling prescriptions filled a mean of 187.7 oxycodone 5-mg equivalents. Sixteen thousand five hundred seventy-seven patients (41.1%) filled two or more opioid prescriptions within 7 days pre-op to 1-year post-op. Fifteen thousand two hundred seventy-nine patients (37.7%) filled an opioid prescription between 3 months post-op and 1-year post-op, and 8,502 patients (21%) filled an opioid prescription between 9 months post-op and 1-year post-op. In multivariable models, age, pre-op opioid filling, depression, tobacco abuse, and drug abuse were risk factors significantly associated with increased perioperative opioid filling. Psychoses had a mixed effect on outcomes with decreased early perioperative filling and increased late perioperative filling. Pre-op opioid filling had the largest impact on perioperative opioid demand. Pre-op opioid filling and drug abuse were the main mental health-related drivers of increased perioperative opioid prescription filling. Depression, psychoses, alcohol abuse, and tobacco abuse had small effects on prescription filling. These results can help identify patients at risk for increased opioid demand who may benefit from additional counseling, maximizing alternative pain management strategies, and possible referral to pain management specialists. Level III, retrospective, prognostic cohort study.

AN UNUSUAL PRESENTATION OF ENDOBRONCHIAL ASPERGILLOMA

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Endobronchial aspergilloma (EBA) is a rare manifestation of pulmonary Aspergillosis characterized by growth of an Aspergillus species as a space-occupying lesion into the bronchial lumen. This can be an isolated manifestation of aspergillus, or occurs in association with parenchymal aspergilloma, allergic broncho-pulmonary aspergillosis, or necrotizing forms of pulmonary aspergillus.1 The clinical presentation of EBA is quite diverse, ranging from an asymptomatic state to dyspnea, cough, hemoptysis and weight loss. In most cases, EBA is found incidentally when patients undergo bronchoscopy for evaluation of other pulmonary symptoms. EBA can mimic endobronchial cancer or carcinoid due to similar clinical and radiographic presentation.1 CASE PRESENTATION: A 46-years-old female was admitted to hospital for surgical fixation of hip fracture after a fall. She also had exertional dyspnea with non-productive cough for past six months. She denied hemoptysis, chest pain, fever, chills and night sweats. Her past medical history included recurrent pneumonia, type I diabetes, end stage renal disease on hemodialysis, and right heart failure. Laboratory evaluations were unremarkable. Chest x-ray showed right upper lobe opacity superior to minor fissure. Computerized tomography (CT) scan of the chest (Figure 1) revealed right upper lobe consolidation with partial occlusion of the right upper lobe bronchus. A diagnostic bronchoscopy was performed to confirm the etiology. It demonstrated complete endobronchial obstruction of the anterior segment of the right upper lobe with cobblestone appearing white material. A biopsy demonstrated pseudohyphae (Figure 2). Polymerase chain reaction (PCR) of material was diagnostic of Aspergillus species. A final diagnosis of EBA was made and the patient was treated with antifungal (Voriconazole) therapy for 6 weeks with subsequent resolution of her symptoms. DISCUSSION: Aspergillus spp. have been associated with a wide spectrum of lung disorders, especially in immunosuppressed patients. Our patient had multiple comorbidities, but did not have typical risk factors for opportunistic infection, resulting in a low index of suspicion for invasive fungal disease. The diagnosis of EBA is challenging on cross-sectional imaging. Bronchoscopy with biopsy is mandatory to confirm the diagnosis of EBA.2 The morphology of fungal form found in our case was atypical for aspergillus, which required further confirmation with PCR testing. Medical management with antifungal therapy may be effective, however, a surgical approach is recommended in patients with massive hemoptysis and adequate lung reserve.3 CONCLUSIONS: A high index of suspicion is required for diagnosing EBA. Bronchoscopic evaluation of endobronchial masses, followed by histologic examination is critical in establishing a diagnosis of EBA. Early medical management with antifungal therapy may hasten resolution of infection. Reference #1: Huang D, Li B, Chu H, et al. Endobronchial aspergilloma: A case report and literature review. Exp Ther Med 2017;14(1):547-54. doi: 10.3892/etm.2017.4540 [published Online First: 2017/06/01] Reference #2: Ma JE, Yun EY, Kim YE, et al. Endobronchial aspergilloma: report of 10 cases and literature review. Yonsei Med J 2011;52(5):787-92. doi: 10.3349/ymj.2011.52.5.787 [published Online First: 2011/07/26] Reference #3: Pohl C, Jugheli L, Haraka F, et al. Pulmonary aspergilloma: a treatment challenge in sub-Saharan Africa. PLoS Negl Trop Dis 2013;7(10):e2352. doi: 10.1371/journal.pntd.0002352 [published Online First: 2013/11/10] DISCLOSURES: No relevant relationships by Yumna Gulzar, source=Web Response No relevant relationships by Richa Purohit, source=Web Response No relevant relationships by stephen Selinger, source=Web Response No relevant relationships by Muhammad Yousaf, source=Web Response

Undertreatment of osteoporosis following hip fracture: a retrospective, observational study in Singapore.

The aim of this study was to identify factors that contributed to the initiation of osteoporosis medications following hip fracture as well as the compliance and persistence to osteoporosis medications. Clinical data of 532 patients older than 50 years old admitted for surgical fixation of hip fractures were reviewed. Three hundred forty-seven had sufficient data for analysis after excluding patients with non-fragility fractures. Prescription for any osteoporosis medication in the year following hip fracture as well as compliance to treatment was evaluated. Only 40.3% of patients were prescribed with osteoporosis medication within 1 year post-hip fracture. Females (p = 0.020) performing dual-energy x-ray absorptiometry scan (p < 0.001) and 25 hydroxyvitamin D levels testing post-hip fracture (p < 0.027) were independent determinants of increased likelihood of being prescribed with osteoporosis medication. Patients with proportion of days covered (PDC) ≥ 0.8 (or 80% of days covered in a year) were defined as compliant. Overall, only 49.7% of the patients were compliant with osteoporosis medications. Elderly patients aged 70-79 years (p = 0.002) and males (p = 0.017) were less persistent with osteoporosis treatment when compared with patients aged < 69 years and females. The compliance was poorer in patients aged 70-79 years (p = 0.026) as compared with those under 69 years of age. Statistically significant difference (p = 0.032) was observed between mean PDC of oral bisphosphonates (0.66) and denosumab (0.83). Only 39.3% of patients were persistent with treatment at 1 year. Our findings demonstrate the urgent need to increase awareness through a structured protocol of osteoporosis treatment. A multi-disciplinary Fracture Liaison Service should be set up to ensure compliance to osteoporosis medication post-hip fracture.

Severe aortic stenosis is associated with perioperative mortality in proximal femur fracture patients.

Objectives:Evaluate the correlation between aortic stenosis and perioperative mortality in patients following surgical fixation of proximal femur fractures.Design:Retrospectively reviewed case series.Setting:Two Academic, Level 1 Trauma Centers.Patients/Participants:One hundred fifty-eight patients, definitively diagnosed with aortic stenosis by means of echocardiogram, who underwent surgical fixation for an isolated proximal femur fracture (OTA/AO 31-A, 31-B, 32-A, 32-B, and 32-C fractures) between January 2000 and June 2015. The severity of the aortic stenosis was based upon accepted echocardiographic hemodynamic parameters designated by the 2014 American Heart Association guidelines.Main Outcome Measures:Post Injury mortality, 30-day mortality, and 1-year mortality.Secondary Outcome Measures:Postoperative mortality stratified by severity of aortic stenosis based on aortic valve area (AVA) and ejection fracture (EF) as determined by preoperative echocardiography.Results:One hundred fifty-eight patients were available for final analysis. Kaplan–Meier survival analysis revealed a significantly longer time to mortality among Non-severe aortic stenosis patients compared to Severe aortic stenosis patients, P value .006. Twenty-three percent of patients with Severe aortic stenosis and 10% of patients with Non-severe aortic stenosis died within 30 days of surgery. No significant difference was observed in mean survival among AS patients who underwent surgery within 48 hours of injury (34.5 months) and those delayed more than 48 hours after injury (25.0 months), P value .116. Among the commonly measured hemodynamic parameters of aortic stenosis, only AVA and EF were significantly associated with mortality, P value .015, and P value < .001, respectively. There were no significant effects for Aortic Vmax, Peak ΔP, and Mean ΔP. An AVA of 0.8 cm2 or less is associated with a significantly shorter (22 months) postinjury mortality than patients with an AVA > 0.8 cm2. (37 months), P value .009.Conclusions:Severe aortic stenosis is associated with a shorter postoperative time to mortality after surgical fixation of hip fractures compared to patients with Non-severe stenosis. Aortic valve area and Ejection Fraction are the only hemodynamic parameters significantly associated with postoperative mortality.Level of Evidence: Prognostic Level III

Postoperative Dietary Quality is Poor after Major Musculoskeletal Trauma

Abstract Objectives Musculoskeletal trauma often leads to prolonged functional deficits. Adequate dietary intake and supplementation improves clinical outcomes after surgical fixation of hip fracture in older adults. The role of post-operative nutrition after acute fracture has not been elucidated. Our objective was to describe dietary deficiencies after operative fixation of acute fracture in young adults. Methods An observational, cohort study identified patients aged 18–55 years presenting to a Level 1 trauma center with pelvic or extremity fracture indicated for operative fixation. Dietary intake was measured using Automated Self- Administered 24-hour dietary recall (ASA24®) in weeks 1, 2, and 4 postoperatively. Individual macro- and micro-nutrients for each subject were summarized using arithmetic means. Inadequate nutritional intake was determined using Dietary Reference Intake (DRI) values reported by the Institute of Medicine. The Healthy Eating Index 2015 (HEI-2015) score was calculated based on ASA24® data as described by the USDA. Results Most subjects were healthy preoperatively, 98% had ≤1 comorbidity. Eighty-four % of injures were to the lower extremities, and 59% were isolated. The majority of subjects (78%) discharged home. An average of 3.9 surveys were filled out per subject. Dietary intake overall was inadequate; 72% did not meet calorie needs. Protein intake was inadequate in 66%. All subjects did not meet DRIs for fiber, vitamin E, or potassium. More than 50% did not meet DRI for calcium, iron, magnesium, folate, vitamins C, A, or K. Added sugar and saturated fat intake exceeded recommendations in 38% and 41% of subjects respectively. Intake of beneficial foods such as whole grains and vegetables were inadequate in 100% of subjects; fruit intake was inadequate in 88%. The mean HEI-2015 score was 44.7 (±11.4 SD) across all time points. Conclusions In a population of previously healthy, young adults with major musculoskeletal trauma, dietary quality was poor compared to the average for the US population, 44.7 vs 59 HEI-2015. Diet analysis revealed a concerning lack of vegetables, whole grains, multiple micronutrients, and total calories. This data provides goals for adequate nutritional supplementation after musculoskeletal trauma. Funding Sources No payments were received to conduct this research study.

A Reimbursement System Based on a 48-Hour Target Time for Surgery Shortens the Waiting Time for Hip Fracture Fixation in Elderly Patients.

To evaluate whether a pay-for-performance reimbursement system, aimed at expediting surgical fixation of hip fractures in elderly patients, has, in fact, succeeded in shortening the waiting time for surgery. Retrospective analysis of prospectively collected data. Academic Level II trauma center. One hundred fifty patients older than 70 years with femoral neck fractures (OTA/AO 31 A1-A3). Implementation of a reimbursement system which incentivizes meeting a 48-hour target time for surgical fixation of hip fractures in elderly patients. Medical records of 75 consecutive patients operated on 1 year before the implementation of the reimbursement system were compared with records of 75 consecutive patients operated on 1 year after the implementation of the reimbursement system. The collected data included age, sex, American Society of Anesthesiologist score, time from injury to hospital admission, time from admission to surgery, reason for surgical delay beyond 48 hours, perioperative complication rate, and length of postoperative hospitalization. Patients' mean age, sex distribution, American Society of Anesthesiologist score, and time from injury to hospital admission were similar in both groups. The average waiting time for surgery shortened from a mean of 77 hours before implementing the reimbursement system to 28 hours after the implementation (P < 0.001). Before the reimbursement system implementation, 41% of the surgeries were delayed beyond 48 hours due to medical causes, compared with 20% only after the implementation (P < 0.001). Fewer patients developed perioperative complications in the postimplementation group in comparison with the preimplementation group (9% vs. 13%, respectively); however, because the study was not powered to examine differences in complication rate, the significance of this difference remains unclear. A reimbursement system which incentivizes meeting a 48-hour target time for surgery has led to a substantial shortening in the waiting time for surgical fixation of hip fractures in elderly patients in our institution.

Sub-optimal serum 25-hydroxyvitamin D level affects 2-year survival after hip fracture surgery.

Hypovitaminosis D is a common condition seen in patients with acute hip fracture. We hypothesize that in addition to the other prognosticating factors, hypovitaminosis D may affect survival in patients treated for hip fractures. The objective of this study is to evaluate the impact of serum level of25-hydroxyvitamin D (25(OH)D) on the survivability after surgical fixation of hip fractures. We retrospectively studied data collected from January 2013 through December 2015 at a large tertiary hospital in Singapore. Patient's age, gender, Charlson Comorbidity Index (CCI), delay of surgery, fracture patterns, ASA score, as well as their pre-operative serum levels of 25(OH)D, albumin and calcium were examined. Univariate and multivariate logistic regression were used to analyse post-operative outcomes including short (inpatient, 30 and 90days) and long-term mortality (2years). Data from 1004 patients were used. Information on the serum level of 25(OH)D was available in 80% of them (n = 801) and more than 90% (n = 735) of the patients had a baseline serum level of less than 30ng/ml. Mortality rate within this group were 1.1% (n = 9) at 30days, 1.9% (n = 15) at 90days and 11.0% (n = 88) at 2years follow up. Hypovitaminosis D was not a significant risk predictor for short-term mortality, but found to be a significant predictor at 2years. In this study, we showed a high prevalence of hypovitaminosis D among the osteoporotic hip fracture population and its impact on 2-year survivorship after hip fracture surgery.

Surgical Fixation of a Comminuted Inter-Trochanteric Fracture in a Patient with Bilateral Below Knee Amputation.

Surgical fixation of hip fractures in patients with below knee amputation is challenging due to the difficulty in obtaining optimal traction for reduction of the fracture. Surgeons may face difficulty in positioning such patients on the traction table due to the absence of the foot and distal lower limb. There are several techniques described to overcome this technical difficulty. In this case report, we present a case of a 64-year old gentleman with bilateral below knee amputation presenting with a comminuted right intertrochanteric fracture. We highlight a simple and effective method of applying skin traction to obtain adequate reduction for hip fracture fixation.

Intraoperative Hypothermia During Surgical Fixation of Hip Fractures.

Hip fractures are common orthopedic injuries and are associated with significant morbidity/mortality. Intraoperative normothermia is recommended by national guidelines to minimize additional morbidity/mortality, but limited evidence exists regarding hypothermia's effect on orthopedic patients. The purpose of this study was to determine the incidence of intraoperative hypothermia in patients with operatively treated hip fractures and evaluate its effect on complications and outcomes. Retrospective chart review was performed on clinical records from 1541 consecutive patients who sustained a hip fracture and underwent operative fixation at the authors' institution between January 2005 and October 2013. A total of 1525 patients were included for analysis, excluding those with injuries requiring additional surgical intervention. Patient demographic data, surgery-specific data, postoperative complications, length of stay, and 30-day readmission were recorded. Patients with a mean intraoperative temperature less than 36°C were identified as hypothermic. Statistical analysis with univariate and multivariate logistic regression modeling evaluated associations with hypothermia and effect on complications/outcomes. The incidence of intraoperative hypothermia in operatively treated hip fractures was 17.0%. Hypothermia was associated with an increase in the rate of deep surgical-site infection (odds ratio, 3.30; 95% confidence interval, 1.19-9.14; P=.022). Lower body mass index and increasing age demonstrated increased association with hypothermia (P=.004 and P=.005, respectively). To the authors' knowledge, this is the first and largest study analyzing the effect of intraoperative hypothermia in orthopedic patients. In patients with hip fractures, the study's findings confirm evidence found in other surgical specialties that hypothermia may be associated with an increased risk of deep surgical-site infection and that lower body mass index and increasing age are risk factors for intraoperative hypothermia. [Orthopedics. 2016; 39(6):e1170-e1177.].