Surgical Repair Of Hip Fracture Research Articles

Minimum Detectable Change in Gait Velocity during Acute Rehabilitation following Hip Fracture

Early ambulation and rehabilitation are recommended for patients undergoing surgical fixation of hip fracture. Gait velocity may be used as an outcome measure for these patients during acute rehabilitation. As an outcome measure, an estimate of meaningful change (responsiveness) in gait velocity for these patients, however, has not been described. The minimum detectable change (MDC) is a value that represents true change in a measure beyond that accounted for by measurement error. The purpose of this study was to quantify MDC in gait velocity as an index of responsiveness for persons in the acute stage of rehabilitation following hip fracture. The study design was a descriptive cohort study with one repeated measure. A volunteer sample of 16 subjects over the age of 65, at a mean of 4.7 days postsurgical fixation of unilateral hip fracture, participated in the study. The study was conducted in an acute care rehabilitation practice in a large, tertiary care hospital. We measured gait velocity with the 10-meter walk test, estimated test-retest reliability with an intraclass correlation coefficient and quantified responsiveness of gait velocity as the MDC at a 95% level of confidence. Mean gait velocity was 15 cm/s and the test-retest reliability coefficient was equal to 0.823. The MDC in gait velocity during acute rehabilitation following surgical repair for hip fracture was 8.2 cm/s. Self-selected gait velocity in patients during acute rehabilitation following surgical fixation for hip fracture must improve by 8.2 cm/s or more to designate the change as being real change beyond the bounds of measurement error.

Predictive value of six risk scores for outcome after surgical repair of hip fracture in elderly patients

Hip fracture surgery is associated with high post-operative mortality and poor functional results: the excess mortality is 20% in the first year; of those patients who survive, only 50% recover their previous ability to walk. The purpose of this study was to assess the predictive value of six functional status and/or surgical risk scoring systems with regard to serious complications after hip fracture surgery in the elderly. We performed a prospective study of a consecutive series of 232 patients (aged 65 years or older) undergoing hip fracture surgery. We pre-operatively applied: The American Society of Anesthesiologists classification, the Barthel index, the Goldman index, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system, the Charlson index and the Visual Analogue Scale for Risk (RISK-VAS) scale. These scales were evaluated with respect to three variables: incidence of serious complications, the ability to walk after a 3-month period and 90-day survival. The predictive value of the different scales was assessed by the calculated area under a receiver operating characteristic curve. The RISK-VAS scale, the POSSUM scoring system and the Charlson index reached a sufficient predictive value with regard to serious post-operative complications. The Barthel index and the RISK-VAS scale were those most useful for predicting ambulation at 3 months. None of the scales proved to be capable of predicting 90-day mortality. A simple index such as the RISK-VAS scale was the best predictor of serious post-operative complications. The functional level before the fracture, measured with the Barthel index, had a major influence on the ambulation recovery.

Morbidity and Mortality Among Patients With Hip Fractures Surgically Repaired Within and After 48 Hours

The objectives were (1) to compare the morbidity and mortality of patients with hip fractures surgically repaired within and after 48 hours of the occurrence of fracture and (2) to establish whether timing of repair alone had a major role in determining how the patients fared after the surgical repair or whether comorbidities also affected outcomes. The study involved the medical records of 49 patients (aged 51 to 99 years) admitted to Coney Island Hospital between January 2003 and January 2004 with a primary diagnosis of hip fracture who underwent surgical repair. Analysis of data was done by retrospective chart review of patients admitted with the diagnosis of hip fracture to an acute care hospital setting. Follow-up continued until the patients were transferred to a rehabilitation facility for physical or occupational therapy after surgery. The preoperative health status of each patient was assessed by cardiopulmonary risk index score, based on comorbid conditions, and postoperative outcome was determined by complications (such as bed sores, pneumonia, urinary tract infection, deep vein thrombosis, or pulmonary embolism) or death. Patients who underwent early surgical repair (within 48 hours) had fewer postoperative complications (14.7%, as compared with 33.3% in the group undergoing surgery >48 hours after fracture). CPRI scores in the early and delayed surgery groups were also compared with regard to postoperative mortality and morbidity. It appeared that there was a higher statistical correlation between CPRI scores and complications among patients in the early surgery group (P=0.39) and an insignificant correlation among patients in the delayed surgery group (P=0.07). Surgical repair of hip fractures within the first 48 hours was associated with better health outcomes in a nationally representative sample, as observed in an acute care facility, irrespective of comorbid conditions.

Spinal Anesthesia Using Single Injection Small-Dose Bupivacaine Versus Continuous Catheter Injection Techniques for Surgical Repair of Hip Fracture in Elderly Patients

Survey of Anesthesiology: June 2007 - Volume 51 - Issue 3 - p 135 doi: 10.1097/sa.0b013e3180597205

The effect of co-morbidity on the rehabilitation process in elderly patients after hip fracture

We conducted a prospective observational study involving patients older than 65 years admitted for rehabilitation to the Geriatric Department of a university hospital after surgical treatment of hip fracture. We assessed functional status before, during and at the end of rehabilitation and as a measure of success of rehabilitation we calculated the Montebello Rating Factor Score (MRFS). In an attempt to make this index more reflective of changes in rehabilitative status we revised it accordingly. We measured demographic characteristics, cognitive function, affective status and co-morbidity. Data were collected from 102 patients with average age 79.0 ± 6.5 years over a period of 12 months. In the uinvariant analysis, cognitive status, length of stay in Geriatric Department and co-morbidity were found as significant predictors of rehabilitation success. In the linear regression only Severity Index (SI) of Cumulative Illness Rating Scale for Geriatrics (CIRS-G) was found as a statistically significant predictor of rehabilitation outcome. In our context, we found that only co-morbidity (as measured by CIRS) is the best predictor of rehabilitation outcome of elderly patients after surgical repair of hip fracture.

Rehabilitation outcome following hip fracture surgery in elderly diabetics: A prospective cohort study of 224 patients

Purpose. To characterize the course and outcome of rehabilitation following hip fracture (HF) in elderly diabetic patients.Method. A non-interventional prospective cohort study of 224 elderly diabetic patients who were hospitalized for rehabilitation, compared to 738 non-diabetic patients. Stepwise multiple regression was used to assess the relative contribution of the variables to the variance of the rehabilitation outcome.Results. The absolute efficacy of rehabilitation was lower in diabetics vs. non-diabetics (28.8 ± 20.0 vs. 31.8 ± 18.4, respectively, p = 0.04). This difference was caused by a significantly lower pre-event Functional Independence Measure (FIM™) (112 ± 17 vs. 115 ± 14, p = 0.002) and a significantly higher rate of prior stroke with motor impairment (16% vs. 7%, p < 0.0001). No significant difference was found between the study groups for various rehabilitation-related complications, including mortality. None of the 12 specific variables associated with diabetes or its complications was significantly and independently associated with the outcome of rehabilitation among diabetics.Conclusions. The outcome of rehabilitation in elderly diabetic patients following HF is significantly worse than in non-diabetics. This result stems from the poor pre-event functional state of these patients. The results of this study can help to predict the outcome of rehabilitation in elderly diabetic patients who are candidates for rehabilitation following surgical repair of HF.

Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair (FOCUS)

Summary of current knowledge The TRICC trial found that a 7 g per dL threshold was assafe as a 10 g per dL threshold in intensive care unitpatients. Except for the pilot study for FOCUS, 14 there areno published studies evaluating the safety of withholdingblood until patients become symptomatic even thoughthis transfusion strategy is now advocated by many trans-fusion medicine experts. 28-30 Also, there are no publishedstudies evaluating whether symptomatic transfusion issafe in patients with cardiovascular disease or cardio-vascular risk factors. There are no published clinical trialsthat have rigorously evaluated the relationship betweenanemia, transfusion, and functional recovery. Two trialsevaluating transfusion thresholds are registered on theClinicalTrials.gov website. 31,32 During the past decadeblood screening and testing procedures have continuallyimproved; in the United States and Canada, the risk ofserious transfusion-associated infections is so small thatit is difficult to measure.

The Role of Pain in the Recovery of Instrumental and Social Functioning After Hip Fracture

It is critical to identify modifiable factors associated with functional recovery from hip fracture. The authors examined the association between pain intensity and two functional endpoints-instrumental activities of daily living and social activity participation-after hip fracture. A total of 270 cognitively intact, community-dwelling persons older than 65 who underwent surgical hip fracture repair in New Haven, Connecticut, were followed for 12 months. Pain intensity was strongly negatively associated with both instrumental and social functioning (p values < .001). Increases in pain intensity between 6 and 12 months were also associated with concurrent decreases in function (p values < .001). These relationships were partly explained by depressive symptoms and a marker of physical ability-gait speed. Interventions to control pain may enhance functional status after hip fracture; however, pain relief must be maintained to sustain recovery. Attention to the complex relationships among pain, depressive symptoms, and physical impairments should inform intervention development.

Spinal Anesthesia Using Single Injection Small-Dose Bupivacaine Versus Continuous Catheter Injection Techniques for Surgical Repair of Hip Fracture in Elderly Patients

Aging and disease may make elderly patients particularly susceptible to hypotension during spinal anesthesia. We compared the hemodynamic effect of continuous spinal anesthesia (CSA) and small dose single injection spinal anesthesia (SA) regarding the incidence of hypotension. Seventy-four patients aged >75 yr undergoing surgical repair of hip fracture were randomized into 2 groups of 37 patients each. Group CSA received a continuous spinal anesthetic with a titration of 2.5 mg boluses every 15 min of isobaric bupivacaine, while group SA received a single injection spinal anesthetic with 7.5 mg of isobaric bupivacaine. The overall variations in noninvasive automated arterial blood pressure were not statistically significantly different in the 2 groups at baseline and after CSA or SA (not significant). In the SA group, 68% of patients experienced at least one episode of hypotension (decrease in systolic arterial blood pressure greater than 20% of baseline value) versus 31% of patients in the CSA group (P = 0.005). In the SA group, 51% of patients experienced at least one episode of severe hypotension (decrease in systolic arterial blood pressure more than 30% of baseline value) versus 8% of patients in the CSA group (P < 0.0001). In the CSA group, 4.5 +/- 2 mg of ephedrine was injected versus 11 +/- 2 mg in the SA group (P = 0.005). In the CSA group, 5 mg (2.5-10) of anesthetic solution was required versus 7.5 mg in the SA group (P < 0.0001). We conclude that, in elderly patients undergoing hip fracture repair, CSA provides fewer episodes of hypotension and severe hypotension compared with a single intrathecal injection of 7.5 mg bupivacaine.

Inpatient Rehabilitation Outcome After Hip Fracture Surgery in Elderly Patients: A Prospective Cohort Study of 946 Patients

Lieberman D, Friger M, Lieberman D. Inpatient rehabilitation outcome after hip fracture surgery in elderly patients: a prospective cohort study of 946 patients. Objective To identify the factors associated with inpatient rehabilitation outcome after surgical repair of hip fracture in elderly patients. Design A noninterventional prospective cohort study. Setting Geriatric inpatient rehabilitation center in a tertiary university medical center in southern Israel. Participants Patients (N=946) aged 65 years of age or older who were hospitalized for rehabilitation after surgery for hip fracture. Interventions Not applicable. Main Outcome Measures Functional studies by the FIM instrument and a broad spectrum of clinical, demographic, and social variables. Stepwise multiple regression was used to assess the relative contribution of the variables to the variance of the percentage change in the FIM score during the course of rehabilitation in relation to the severity of the functional impairment at its inception. Results Eight variables were significantly and independently associated with rehabilitation outcome. Prefracture FIM scale (standardized regression coefficient in multiple regression [β]=.261, P<.001), serum albumin at discharge (β=.222, P<.001), Folstein Mini-Mental State Examination (β=.174, P<.001), visual impairment (β=−.089, P=.002), dyspnea at mild exertion (New York Heart Association class III) (β=−.080, P=.005), age (β=−.080, P=.007), poststroke motor impairment (β=−.072, P=.011), and decreased serum folic acid (β=−.055, P=.047). The total percentage of the explained variance of the primary rehabilitation outcome measure accounted for by these 8 variables (adjusted R 2) was 31.9%. Conclusions The outcome of rehabilitation of elderly patients after surgical repair of hip fracture is associated with 4 clinical and nutritional correctable parameters. The other 4 variables that are associated with the process cannot be corrected but may help predict outcomes and adjust expectations.

Delayed surgical fixation of fractured hips in older people: impact on mortality

The aim of this project was to ascertain whether increasing delays from admission to surgical repair of hip fractures showed a direct relationship to mortality within the first postoperative year. It has been recommended that surgical repair of hip fractures should be performed within 24 hours of admission in an effort to reduce postoperative mortality. A literature review of articles relevant to this directive revealed that previous research is conflicting in its findings, and fails to provide conclusive evidence on which to base this recommendation. Using a retrospective correlational design, Cox Multivariate Regression was used to analyse data from a sample of 381 patients admitted with hip fractures between September 2000 and March 2002. Exclusions from the total accessible population were made in an effort to control bias because of other factors that could contribute to mortality, resulting in 381 patients (64% of total population) being included in the study. All patients in the sample had an American Society of Anaesthesiologists score of 2 or less, were fit for immediate surgery, had an intracapsular or trochanteric fracture, had not had contralateral hip fracture in the previous 2 years, and had presented exclusively with a hip fracture. There was no relationship between delayed surgery and postoperative mortality (P>0.05) when all other independent variables were controlled. Cognitive dysfunction and reduced prefracture mobility were both good prognostic indicators of increased mortality within the first operative year. It is important that patients are adequately prepared and resuscitated before surgery is carried out. The nursing contribution to this is paramount. The findings also identify useful information for preparing patient's relatives in relation to prognosis.

Effects of a Hospitalist Model on Elderly Patients With Hip Fracture

Hospitalists' increased role in perioperative medicine allows for examination of their effects on surgical patients. This study examined the effects of a hospitalist service created to medically manage elderly patients with hip fracture. During a 2-year historical cohort study of 466 patients 65 years or older admitted for surgical repair of hip fracture, we examined outcomes 1 year prior to and subsequent to the change from the standard to the hospitalist model. The mean (SD) time to surgery (38 [47] vs 25 [53] hours; P<.001), time from surgery to dismissal (9 [8] vs 7 [5] days; P = .04), and length of stay (10.6 [9] vs 8.4 [6] days; P<.001) were shorter in the hospitalist group. Predictors of shorter time to surgery were care by the hospitalist group (P = .002), older age (P = .01), and fall as the mechanism of fracture (P<.001), while American Society of Anesthesia scores of 3 and 4 were associated with increased time to surgery (P<.001). Receiving care by the hospitalist group (P<.001) and diagnosis of delirium (P<.001) were associated with increased chance of earlier dismissal, while admission to the intensive care unit decreased this chance (P<.001). Diagnosis of delirium was more frequent in the hospitalist group (74 [32.2%] of 230 vs 42 [17.8%] of 236; P<.001). There were no differences in inpatient deaths or 30-day readmission rates. In elderly patients with hip fracture, a hospitalist model decreased time to surgery, time from surgery to dismissal, and length of stay without adversely affecting inpatient deaths or 30-day readmission rates.

Progressive resistance training reduces disability and improves physical performance in elderly people after surgical repair of hip fracture

QuestionDoes progressive resistance training improve physical performance of frail elderly people who have had surgery for hip fracture?Study designDouble blinded randomised controlled trial.Main resultsAt 6 months, physical therapy plus progressive resistance training improved physical performance and reduced physical disability after surgery for hip fracture in elderly people compared with low intensity home exercise (see Results Table 1). Physical therapy significantly increased physical performance and functional questionnaire scores between baseline and 6 months compared with low intensity home exercise (see Results Table 2). People who had physical therapy and used a walking aid were less likely to need one after 6 months (p=0.03). Physical therapy also improved muscle strength, walking speed, balance and improved quality of life (data not shown).Authors’ conclusionsSupervised physical therapy and exercise training that includes progressive resistance training significantly improves physical function and mobility in elderly people after surgery for hip fracture. This reduces disability and improves their quality of life.

Does early surgical repair of hip fractures improve patient outcomes?

Orosz GM, Magaziner J, Hannan EL, Morrison RS, Koval K, Gilbert M, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA 2004;291:1738-43. Background: Over 220 000 hip fractures occur every year in the United States, representing an annual $9 billion cost to the health

Intrathecal fentanyl and sufentanil added to bupivacaine augments analgesia after surgical repair of hip fracture

The aim of our study was to assess efficacy and safety of intrathecal fentanyl and sufentanil added to bupivacaine for surgical repair of fractured hip in patients over 60 years. After standard premedication group C was administered bupivacaine 0.5% 3ml+saline 1 ml, group F bupivacaine 0.5% 3ml+fentanyl 50 μg/1 ml and group S bupivacaine 0.5% 3ml+sufentanil 5 μg/l ml. Time to request for analgesia and side-effects were recorded. Duration of analgesia was longer in both opioid groups compared to control (5.4 h, P<0.001), and longer in S (9.5 h) than in F (8.1 h, P<0.05). There were no differences in bradycardia, hypotension, peripheral oxygen saturation below 90% and pruritus among groups. Postoperative nausea and vomiting were higher in F compared to C and S (P<0.05). Intrathecal fentanyl and sufentanil in our study significantly prolonged time to first request for analgesia and were safe to use even in old patients. Sufentanil appears to be more convenient because of longer analgesia and less postoperative nausea and vomiting.

Association of timing of surgery for hip fracture and patient outcomes.

Previous studies of surgical timing in patients with hip fracture have yielded conflicting findings on mortality and have not focused on functional outcomes. To examine the association of timing of surgical repair of hip fracture with function and other outcomes. Prospective cohort study including analyses matching cases of early (< or =24 hours) and late (>24 hours) surgery with propensity scores and excluding patients who might not be candidates for early surgery. Four hospitals in the New York City metropolitan area. A total of 1206 patients aged 50 years or older admitted with hip fracture over 29 months, ending December 1999. Function (using the Functional Independence Measure), survival, pain, and length of stay (LOS). Of the patients treated with surgery (n = 1178), 33.8% had surgery within 24 hours. Earlier surgery was not associated with improved mortality (hazard ratio, 0.75; 95% confidence interval [CI], 0.52-1.08) or improved locomotion (difference of -0.04 points; 95% CI, -0.49 to 0.39). Earlier surgery was associated with fewer days of severe and very severe pain (difference of -0.22 days; 95% CI, -0.41 to -0.03) and shorter LOS by 1.94 days (P<.001), but postoperative pain and LOS after surgery did not differ. Analyses with propensity scores yielded similar results. When the cohort included only patients who were medically stable at admission and therefore eligible for early surgery, the results were unchanged except that early surgery was associated with fewer major complications (odds ratio, 0.26; 95% CI, 0.07-0.95). Early surgery was not associated with improved function or mortality, but it was associated with reduced pain and LOS and probably major complications among patients medically stable at admission. Additional research is needed on whether functional outcomes may be improved. In the meantime, patients with hip fracture who are medically stable should receive early surgery when possible.

Rehabilitation following hip fracture surgery: a comparative study of females and males

Purpose: To compare patient, fracture and rehabilitation variables between male and female patients during the rehabilitation period immediately following surgical repair of hip fracture (HF).Methods: A prospective cohort study was conducted in a rehabilitation geriatric ward in a tertiary university hospital in southern Israel. The study group consisted of 808 elderly patients, 65 years of age or older, selected for hospitalized rehabilitation following surgery for HF. The measurements included functional studies by the Functional Independence Measure (FIM™) scale, mental status by Folstein Minimental Test and Clock Drawing Test, Geriatric Depression Screening Scale (GDS), demographic and social parameters, laboratory tests, length of rehabilitation, complications and mortality during rehabilitation.Results: Six hundred and fourteen patients (76%) were women and 194 (24%) were men. The mean age ( ± SD) of the women was 78.4 ± 7.1 years and of the men was 77.8 ± 7.5 (NS). There were no significant differences between women and men in terms of the anatomic site of the fracture or the type of surgery, the complication rate or mortality during rehabilitation, the length of time needed for rehabilitation, the framework to which the patient was discharged, FIM values before the HF, on admission and at the end of rehabilitation, or the difference between FIM scores at these last two points in time.Conclusions: In selected elderly patients with HF gender does not affect variables associated with hip fracture, the rehabilitation process immediately following the fracture, or the results of rehabilitation.

Prophylactic IM Small-Dose Phenylephrine Blunts Spinal Anesthesia-Induced Hypotensive Response During Surgical Repair of Hip Fracture in the Elderly

Prophylactic IM Small-Dose Phenylephrine Blunts Spinal Anesthesia-Induced Hypotensive Response During Surgical Repair of Hip Fracture in the Elderly

Prophylactic IM Small-Dose Phenylephrine Blunts Spinal Anesthesia-Induced Hypotensive Response During Surgical Repair of Hip Fracture in the Elderly

Prophylactic IM Small-Dose Phenylephrine Blunts Spinal Anesthesia-Induced Hypotensive Response During Surgical Repair of Hip Fracture in the Elderly

Hip fracture in the older patient: reasons for delay in hospitalization and timing of surgical repair.

To quantify the interval between injury and hospitalization in older hip fracture patients, to quantify the time from hospital arrival to surgical repair of hip fracture, and to describe factors contributing to extended intervals between injury, hospitalization, and surgical repair of hip fracture. Prospective cohort study. Four hospitals in the New York City metropolitan area. Consecutive patients aged 50 and older admitted with diagnosis of hip fracture to these four hospitals between August 1997 and August 1998. Time of injury, time of arrival to the emergency room, and time of surgery were recorded and used to calculate intervals between injury and hospital arrival and between hospital arrival and surgical repair. Of the 571 patients enrolled, 99 (17%) arrived at the hospital more than 24 hours after injury. After hospital arrival, 17 (3%) patients did not have surgery, 166 (29%) had surgery within 24 hours of arrival, and 388 (68.0%) had surgery more than 24 hours after arrival (median 41 hours, range 25-584). For those patients who had surgery after 24 hours, 163 (29.4%) had surgery 25 to 36 hours after hospital arrival, 102 (18.4%) had surgery 37 to 48 hours after arrival, and 123 (22.2%) had surgery more than 48 hours after arrival. The primary reasons for delaying surgery more than 24 hours after hospital arrival were waiting for routine medical clearance (52%) and unavailability of the operating suite or surgeon (29%). Stabilization of associated medical conditions resulted in the lengthiest periods of delay. A wait time of more than 24 hours from hospitalization to surgical repair of hip fracture in older patients is common. Some of this delay time is patient related and some occurs because of systems factors and may be avoidable. The extent to which surgical timing affects survival and functional recovery needs more detailed examination.