Evaluation of the Surgical Treatment of Patients over 90 Years Old with Hip Fractures and Their Morbidity and Mortality / Avaliação do tratamento cirúrgico de pacientes acima de 90 anos com fraturas de quadril e sua morbimortalidade

Abstract Objective: Hip fractures in older adults have the highest impact on the patient's health. These injuries result in many complications, reducing functional capability, quality of life, and life expectancy. This study aimed to provide more epidemiological data on the outcomes of these fractures in nonagenarians from a large city treated at a tertiary hospital. Methods: This study consisted of medical record reviews and interviews. Results: In this study, 76 patients underwent 82 surgeries. The mean age of the patients was 92.5 years. Ninety percent of the subjects were female. The patients spent 10.4 days in hospital. Surgery occurred on average 2.3 days after hospitalization. Regarding fractures, 46 were trochanteric (56%), and 34 affected the femoral neck (41.5%). Forty-one surgeries used the short proximal femoral nail (50%), and 18 were partial hip replacements (22%). During hospitalization, 46 patients (55%) had no complications, excluding episodes of delirium, and seven patients (9%) died. Forty-two subjects completed the one-year postoperative follow-up period, with 56% alive and 44% dead. Conclusions: Treating hip fractures in older patients is challenging. Our goal must focus on helping these subjects receive the quickest and least aggressive treatment possible and start mobilization early. We hope the data presented in this study can lead to a better understanding of the characteristics of our nonagenarian population with hip fractures and seek the best possible treatment for them.

Resumo Objetivo: As fraturas de quadril em idosos são as que mais impactam na saúde do paciente e estão associadas a muitas complicações, levando a redução da capacidade funcional, da qualidade de vida e da expectativa de vida. O nosso trabalho visa trazer mais dados epidemiológicos sobre os desfechos dessas fraturas em nonagenários em uma grande cidade atendidos em um hospital terciário. Métodos: O trabalho foi realizado através de revisão de prontuários e entrevistas. Resultados: Foram realizadas 82 cirurgias em 76 pacientes nesse período. A média de idade foi de 92,5 anos, 90% eram mulheres e ficaram 10,4 dias internados. A cirurgia foi realizada em média 2,3 dias após a internação. Do total, 46 fraturas foram trocantéricas (56%) e 34 do colo do fêmur (41,5%). Foram realizadas 41 cirurgias com a técnica da haste cefalomedular curta (50%) e 18 artroplastias parcial de quadril (22%). Durante a internação, 46 pacientes (55%) não apresentaram complicações, excluindo episódios de delirium, e 7 pacientes (9% dos casos) evoluíram para óbito. 42 pacientes já fecharam 1 ano após cirurgia: 56% estão vivos e 44% evoluíram para óbito. Conclusões: O tratamento de fraturas de quadril em pacientes idosos é desafiador. O nosso objetivo deve estar focado em ajudar esses idosos a receber um tratamento rápido e menos agressivo possível e a mobilizar precocemente. Esperamos que, com os dados apresentados nesse trabalho, possamos entender melhor acerca das características da nossa população nonagenária vítimas de fratura de quadril e buscar o melhor tratamento possível para esses pacientes.

Risk factors for osteoporotic hip fracture among community-dwelling older adults: a real-world evidence study

Abstract Background Hip fractures in the older adults lead to increased morbidity and mortality. Although a low bone mineral density is considered the leading risk factor, it is essential to recognize other factors that could affect the risk of hip fractures. This study aims to evaluate the contribution of clinical characteristics, patient-reported outcomes, and muscle and aerobic capacity for hip fractures in community-dwelling older adults. Methods This is a retrospective cohort study with real world-data from subjects ≥ 60 years old attending an outpatient clinic in Minas Gerais, Brazil, from May 1, 2019, to August 22, 2022. Data about clinical characteristics (multimorbidity, medications of long-term use, sedative and or tricyclic medications, number of falls), patient-reported outcomes (self-perception of health, self-report of difficulty walking, self-report of vision problems, and self-report of falls) and muscle and aerobic capacity (calf circumference, body mass index, and gait speed) were retrieved from an electronic health record. The association of each potential risk factor and hip fracture was investigated by a multivariable logistic regression analysis adjusted for age and sex. Results A total of 7,836 older adults were included with a median age of 80 years (IQR 72-86) and 5,702 (72.7%) were female. Hip fractures occurred in 121 (1.54%) patients. Multimorbidity was associated with an increased risk of hip fracture (OR = 1.12, 95%CI 1.06-1.18) and each episode of fall increased the chance of hip fracture by 1.7-fold (OR = 1.69, 95%CI 1.52-1.80). Patient-reported outcomes associated with increased fracture risk were regular or poor self-perception of health (OR = 1.59, 95%CI 1.06-2.37), self-report of walking difficulty (OR = 3.06, 95%CI 1.93-4.84), and self-report of falls (OR = 2.23, 95%CI 1.47-3.40). Body mass index and calf circumference were inversely associated with hip fractures (OR = 0.91, 95%CI 0.87-0.96 and OR = 0.93, 95%CI 0.88-0.97, respectively), while slow gait speed increased the chance of hip fractures by almost two-fold (OR = 1.80, 95%CI 1.22-2.66). Conclusion Our study reinforces the importance of identified risk factors for hip fracture in community-dwelling older adults beyond bone mineral density and available fracture risk assessment tools. Data obtained in primary care can help physicians, other health professionals, and public health policies to identify patients at increased risk of hip fractures.

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 %. Conclusions 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.

Introducción: La fractura de cadera es una de las principales causas de morbimortalidad en la población adulta mayor. En Colombia hay un déficit en la literatura científica acerca del manejo perioperatorio de esta población de pacientes. Objetivo: Describir el manejo perioperatorio de pacientes con fractura de cadera en un hospital universitario de alto nivel de complejidad de Cali, Colombia. Métodos: Se realizó un estudio observacional con alcance relacional de una cohorte histórica de pacientes con fractura de cadera, que recibieron manejo quirúrgico entre enero de 2018 y junio de 2022. Se hizo un muestreo no probabilístico y se diseñaron tablas de contingencia con el propósito de describir relaciones entre las características y los desenlaces posoperatorios. Resultados: Se incluyeron 235 pacientes de los cuales el 57 % fueron hombres. La mediana de edad fue de 79 años y el 49,8 % tenían una clasificación ASA III o mayor. La anestesia espinal fue la técnica más utilizada en el 63,4 %. Los desenlaces más frecuentes fueron el delirio en el 17,9 %, y la falla renal aguda en el 6,8 %. El 83,4 % de los pacientes fueron intervenidos quirúrgicamente antes de las 48 horas desde el ingreso a urgencias y la mortalidad intrahospitalaria fue del 2,6 %. Conclusiones: Los resultados de este estudio brindan información relevante que permite la implementación de oportunidades de mejora como disminución en los tiempos hasta el manejo quirúrgico y el desarrollo de protocolos de atención en la región.

Factores asociados al desarrollo de delírium en pacientes ancianos en el postoperatorio de cirugía por fractura de cadera / Factors Related to the Development of Delirium in Elderly Patients in the Postoperative Period of Hip Fracture Surgery / Fatores associados ao desenvolvimento de Delirium em pacientes idosos no pós-operatório de cirurgia de fratura de quadril

Introducción: durante el postoperatorio por cirugía de cadera, el delírium es la complicación más frecuente en los pacientes ancianos, con una alta incidencia y prevalencia, la cual lleva a una alta morbimortalidad en ellos. Objetivo: identificar los factores asociados con delírium en pacientes ancianos durante su posto-peratorio de cirugía por fractura de cadera. Materiales y métodos: se realizó un estudio observacional analítico de corte retrospectivo con pacientes hospitalizados por el grupo de Ortogeriatría en el Hospital Universitario San Ignacio en Bogotá (Colombia), entre enero de 2017 y septiembre de 2020. Resultados: se incluyeron 210 personas, en quienes se documentó una incidencia de delírium del 28.57 %. En el análisis bivariado, las variables con asociación estadísticamente significativa fueron edad, dependencia, demencia previa, malnutrición, polifarmacia y tipo de anestesia. Sin embargo, en el análisis multivariado, las dos variables con asociación estadísticamente significativa fueron edad (OR: 1.05; IC95 %: 1.01-1.10; p = 0.014) y demencia (OR: 2.83; IC95 %: 1.28-6.27; p = 0.010). Conclusión: las variables asociadas con delírium reportadas en el estudio concuerdan con la literatura ya publicada. Esto abre las puertas a futuras investigaciones no solo para identificar nuevos o más factores asociados, sino también para adoptar medidas en conjunto con los programas de ortogeriatría, a fin de intervenir estos factores y, de esta manera, poder disminuir la incidencia y prevalencia del delírium y, por ende, su morbimortalidad.

Introduction: Post-operative delirium after hip surgery is the most common complication among the elderly, with a high incidence and prevalence, which leads to high morbidity and mortality rates among them. Objective: To identify the main factors associated with post-operative delirium after hip surgery among older adults. Materials and methods: a retrospective analytical observational study was conducted using data from patients hospitalized by the Orthogeriatric group at the San Ignacio University Hospital in Bogotá, Colombia, between January 2017 and September 2020. Results: 210 people were included in the study, with a documented incidence of delirium of 28.57% was documented. In the bivariate analysis, the variables with a statistically significant association with delirium were age, dependency, previous dementia, malnutrition, polypharmacy, and type of anesthesia used in the procedure. Nonetheless, in a multivariate analysis, the two variables with a statistically significant association were age (OR: 1.05; 95%CI: 1.01-1.10; p = 0.014) and dementia (OR: 2.83; 95% CI: 1.28-6.27; p = 0.010). Conclusion: the variables associated with postoperative delirium reported in our study align with the existing literature. This opens doors to future research not only to identify new or more risk factors, but also to adopt measures, jointly with the Orthogeriatric programs, to intervene such factors so that the incidence and prevalence of delirium can be reduced, and therefore, reduce the morbidity and mortality among the elderly.

Introdução: o delirium no pós-operatório de cirurgia de quadril é a complicação mais frequente em pacientes idosos, com alta incidência e prevalência, o que leva a alta morbimortalidade nos mesmos e, assim, o objetivo deste estudo foi identificar os fatores associados ao delirium em pacientes idosos no pós-operatório de cirurgia de fratura de quadril. Materiais e métodos: foi realizado um estudo observacional analítico retrospectivo com pacientes internados pelo grupo de Ortogeriatria do Hospital Universitário San Ignacio, em Bogotá, Colômbia, entre janeiro de 2017 e setembro de 2020. Resultados: foram incluídas 210 pessoas, nas quais foi documentado incidência de delirium de 28,57%. Na análise bivariada, as variáveis com associação estatisticamente significativa foram idade, dependência, demência prévia, desnutrição, polifarmácia e tipo de anestesia. Porém, na análise multivariada, as duas variáveis com associação estatisticamente significativa foram idade (or: 1,05; Ic 95% 1,01-1,10; p: 0,014) e demência (or: 2,83; Ic 95% 1,28-6,27, p: 0,010). Conclusão: as variáveis associadas ao delirium relatadas em nosso estudo concordam com a literatura publicada anteriormente. Isso abre as portas para pesquisas futuras não só para identificar novos ou mais fatores associados, mas também para adotar medidas em conjunto com programas de ortogeriatria para poder intervir nesses fatores e, assim, reduzir a incidência e prevalência de delirium e, portanto, a morbimortalidade

Modificación de instrumento del sistema de clavos dinamic hip screw para fracturas de cadera

Introducción: El aumento de la fractura de cadera durante los últimos años se ha convertido en un problema socioeconómico y sanitario a nivel mundial. Objetivo: Modificar cuatro instrumentos del sistema de clavos dinamic hip screw para su uso en la instalación hospitalaria. Métodos: Se trabajó junto con electromedicina provincial para efectuar la innovación tecnológica. Se modificaron cuatro instrumentos del sistema de clavos dinamic hip screw para operar pacientes adultos con diagnóstico de fracturas de cadera en enero 2020. Resultados: Se elaboraron los siguientes instrumentos: soporta clavo tipo a, soporta clavo tipo b, "macho" para hacer rosca y atornillador para ajustar el medidor del fresador del cuello. Conclusiones: Las modificaciones a los cuatro instrumentos del sistema de clavos dinamic hip screw significaron un importante ahorro de recursos para la institución hospitalaria.

Introduction: The increase in hip fracture in recent years makes it a worldwide socio-economic and health problem. Objective: To modify four instruments of the dynamic hip screw nail system for its use in a hospital facility. Methods: The work was implemented together with the provincial electromedicine unit in order to carry out technological innovations. Four instruments of the dynamic hip screw nail system were modified to operate adult patients with a diagnosis of hip fractures. Results: The following instruments were developed: supports nail type a, supports nail type b, "male" to make screw thread and screwdriver to adjust the milling maching meter of the neck. Conclusions: The modifications to the four instruments of the dynamic hip screw nail system meant a significant saving of resources for the hospital.

Evaluación geriátrica integral en pacientes con fractura de cadera

Introducción. Las fracturas de cadera son un conjunto de patologías frecuentes en los adultos mayores frágiles, con impacto negativo sobre la funcionalidad. Objetivo. Determinar las características clínicas, funcionales, mentales y sociales basados en la evaluación geriátrica integral. Métodos. Se evaluó a 445 pacientes, la comorbilidad se midió con el índice de Charlson, el estado funcional basal con el índice de Barthel y la escala de Lawton y Brody, el estado mental con el cuestionario de Pfeiffer, el delirio mediante el Confusion Assessment Method y la evaluación social con la Escala Sociofamiliar de Gijón. Las variables categóricas se presentaron como valor absoluto y porcentaje, y las continuas como media y desviación estándar. Resultados. El sexo femenino representó el 71,5%, el promedio de edad en mujeres fue de 81,58 años y en varones de 82,58 años. El deterioro visual fue 48,8% y el auditivo fue 46,1%. El 46,0% tuvieron más de una comorbilidad. 30,3% era independiente para actividades básicas, así como 90,3% de mujeres y 64,3% de hombres fueron dependientes para actividades instrumentales. El deterioro cognitivo estuvo presente en el 53,5% de los pacientes y delirio el 20,4%. En la segunda semana fueron operados 30,5% y en la tercera 21,6%. La mortalidad fue de 2,7% durante la hospitalización. Conclusión. Las características más frecuentes fueron de una octogenaria, con deterioro visual/auditivo, sin comorbilidad, pero pluripatológica, con dependencia leve para actividades básicas de vida diaria y deterioro cognitivo en entorno social de riesgo.

Introduction. Hip fractures are a group of frequent pathologies in frail older adults, with a negative impact on functionality. Objective. To determine the clinical, functional, mental, and social characteristics based on the comprehensive geriatric assessment. Methods. 445 patients were evaluated, comorbidity was measured with the Charlson index, baseline functional state with the Barthel index and the Lawton and Brody scale, mental state with the Pfeiffer questionnaire, delirium using the Confusion Assessment Method and social assessment with the Gijón Socio-Family Scale. Categorical variables were presented as absolute value and percentage and continuous variables as mean and standard deviation. Results. The female sex represented 71.5%, the average age in women was 81.58 years and in men 82.58 years. Visual impairment was 48.8% and hearing impairment 46.1%. 46% had more than one comorbidity. 30.3% were independent for basic activities, as well as 90.3% of women and 64.3% of men were dependent for instrumental activities. Cognitive impairment was present in 53.5% and delirium developed in 20.4%. In the second week, 30.5% were operated and in the third, 21.6%. Mortality was 2.7% during hospitalization. Conclusion. the most frequent characteristics were of an octogenarian, with visual / auditory deterioration, without comorbidity, but multipathological, with slight dependence for basic activities of daily living and cognitive deterioration in a risky social environment.

Pipkin Type-II Femoral Head Fracture: A Biomechanical Evaluation by the Finite-Element Method / Fratura da cabeça femoral de tipo II de Pipkin: Avaliação biomecánica pelo método de elementos finitos

Abstract Objective To evaluate the biomechanical capacity of two forms of fixation for Pipkin type-II fractures, describing the vertical fracture deviation, the maximum and minimum principal stresses, and the Von Mises equivalent stress in the syntheses used. Materials and Methods Two internal fasteners were developed to treat Pipkin type-II fractures through finite elements: a 3.5-mm cortical screw and a Herbert screw. Under the same conditions, the vertical fracture deviation, the maximum and minimum principal stresses, and the Von Mises equivalent stress in the syntheses used were evaluated. Results The vertical displacements evaluated were of 1.5mm and 0.5mm. The maximum principal stress values obtained in the upper region of the femoral neck were of 9.7 KPa and 1.3 Kpa, and the minimum principal stress values obtained in the lower region of the femoral neck were of-8.7 KPa and -9.3 KPa. Finally, the peak values for Von Mises stress were of 7.2 GPa and 2.0 GPa for the fixation models with the use of the 3.5-mm cortical screw and the Herbert screw respectively. Conclusion The fixation system with the Herbert screw generated the best results in terms of reduction of vertical displacement, distribution of the maximum principal stress, and the peak Von Mises equivalent stress, demonstrating mechanical superiority compared to that of the 3.5-mm cortical screw in the treatment of Pipkin type-II fractures.

Resumo Objetivo Avaliar a capacidade biomecánica de duas formas de fixação de fraturas tipo II de Pipkin descrevendo o desvio da fratura no sentido vertical, as tensões máxima e mínima principais, e a tensão equivalente de Von Mises nas sínteses utilizadas. Materiais e Métodos Dois fixadores internos foram desenvolvidos para tratar a fratura tipo II de Pipkin por meio de elementos finitos: parafuso cortical de 3,5 mm e parafuso de Herbert. Sob as mesmas condições, foram avaliados o desvio da fratura no sentido vertical, as tensões máxima e mínima principais, e a tensão equivalente de Von Mises nas sínteses utilizadas. Resultados Os deslocamentos verticais avaliados foram de 1,5 mm e 0,5 mm. Os valores de tensão máxima obtidos na região superior do colo femoral foram de 9,7 KPa e 1,3 KPa, e os valores de tensão mínima obtidos na região inferior do colo femoral foram de -8,7KPa e -9,3 KPa. Por fim, os valores de pico da tensão equivalente de Von Misesforam de 7,2 GPa e2,0 GPa paraosmodelos de fixação com o uso do parafuso cortical de 3,5 mm e do parafuso de Herbert, respectivamente. Conclusão Osistema de fixação com parafuso de Herbert gerou os melhores resultados em termos de redução do deslocamento vertical, distribuição da tensão máxima e do pico da tensão equivalente de Von Mises, o que demonstra sua superioridade mecânica comparada à do parafuso cortical de 3,5 mm no tratamento da fratura tipo II de Pipkin.

Proceso de atención en enfermería basado en mapa de cuidados en persona mayor reintervenida quirúrgicamente por reemplazo de cadera. Reporte de un caso

El proceso de atención en enfermería (PAE) es un método sistemático y organizado que requiere de un entrenamiento específico, tener conocimientos y habilidades prácticas que proporcionan las herramientas para brindar cuidado abordando las dimensiones de forma holística a partir de una interacción directa con el paciente, la familia y el entorno social. Se presenta el PAE de una persona mayor, femenina, de 65 años de edad, con pluripatologías: síndrome purpúrico, monoparesia de miembro inferior derecho y síndrome convulsivo, reintervenida quirúrgicamente de un reemplazo de cadera derecha. Se plantea el PAE y sus cinco etapas: valoración, diagnóstico, planeación, ejecución y evaluación; siguiendo la valoración por dominios. El plan de cuidados se realiza con el enfoque de mapa de cuidados en la situación quirúrgica, diagnóstico NANDA International, lnc. La evaluación de intervenciones NIC (Nursing Interventions Classification) y resultados NOC (Nursing Outcomes Classification).

The Nursing Care Process (NCP) is a systematic and organized method that requires specific training, knowledge and practical skills that provide the tools needed to provide care by addressing the dimensions holistically from direct interaction with the patient, the family and social environment. Te NCP of a 65-year-old female elderly person with multiple pathologies; purpuric syndrome, right lower limb monoparesis and convulsive syndrome, who underwent surgery for a right hip replacement is presented. The Nursing Care Process (NCP) and its five stages are proposed: assessment, diagnosis, Outcomes/ Planning, Implementation and evaluation; following the valuation by domains. The care plan was carried out with the care map approach, NANDA Internacional Inc. Te evaluation of NIC (Nursing Interventions Classification) interventions and NOC (Nursing Outcomes Classification) results.

Desfechos clínicos e físico-funcionais na fase intra-hospitalar de idosos com fratura de fêmur / Clinical and physical-functional outcomes in the in-hospital phase of elderly people with femur fracture

As quedas em idosos representam um importante problema de saúde pública devido à associação com a morbimortalidade. Objetivos: Descrever o perfil epidemiológico de idosos com fratura de fêmur proximal, bem como associar o tempo de espera para a cirurgia e os desfechos clínicos com as variáveis físico-funcionais. Métodos: Estudo transversal analítico, de idosos com fratura de fêmur proximal de origem traumática. Os aspectos físico-funcionais foram avaliados pelo Índice de Barthel, Escala de Lawton, Medical Research Council e Dinamometria de Força de Preensão Palmar em dois momentos distintos, admissão e alta hospitalar. Foi realizado análise estatística descritiva e inferencial adotando-se p<0,05. Resultados: A amostra foi composta por 64 indivíduos, sendo 48 (75%) do sexo feminino, com média de idade de 77,8 anos (±8,73). Os pacientes com maior dependência funcional no Índice de Barthel na admissão (U= 282,000; p<0,05) e na alta hospitalar (U= 248,000; p<0,05) aguardaram mais tempo para o procedimento cirúrgico. O principal desfecho foi a alta, de 55 pacientes (85,9%), no entanto aqueles que evoluíram a óbito apresentaram piores pontuações na Escala de Lawton (t(62)= -2,060; p<0,05) e no Índice de Barthel (U= 145,500; p<0,05) no momento da admissão. Conclusão: O perfil de idosos com fratura de fêmur proximal são mulheres, na transição para a oitava década de vida, vítimas de queda da própria altura. Idosos com maior dependência funcional aguardaram mais tempo para a cirurgia e apresentaram piores desfechos

Falls in the elderly represent an important public health problem due to the association with morbidity and mortality. Objectives: To describe the epidemiological profile of elderly people with proximal femur fractures, as well as to associate the waiting time for surgery and clinical outcomes with physical-functional variables. Methods: Analytical cross-sectional study of elderly patients with fractures of the proximal femur of traumatic origin. Sociodemographic, trauma and clinical information were obtained via electronic medical records. The physical-functional aspects were assessed using the Barthel Index, Lawton Scale, Medical Research Council and Hand Grip Strength at two different times, admission and hospital discharge. Descriptive and inferential statistical analysis was performed, adopting p<0.05. Results: The sample consisted of 64 individuals, 48 (75.0%) of which were female, with a mean age of 77.8 years (±8.73). The median waiting time for surgery was 12 (8-15) days. Patients with greater functional dependence on the Barthel Index at admission (U= 282.000; p<0.05) and at hospital discharge (U= 248.000; p<0.05) waited longer for the surgical procedure. The main outcome was discharge 55 (85.9%), however, patients who evolved to death had worse scores on the Lawton Scale (t(62)= -2.060; p<0.05) and on the Barthel Index (U = 145.500; p<0.05) at admission. Conclusion: The profile of elderly people with proximal femur fractures are women, in the transition to the eighth decade of life, victims of a fall from their own height. Elderly people with greater functional dependence waited longer for surgery and had worse outcomes

A comparative analysis of distal locked and unlocked long proximal femoral nail antirotation (PFNA-II) in the fixation of stable intertrochanteric fractures / 中华创伤杂志(英文版)

PURPOSE@#Long proximal femoral nail anti-rotation (PFNA-II) is a preferred implant in recent years for fixation of pertrochanteric fractures, especially in osteoporotic patients. The purpose of this study is to prospectively investigate the effect of distal locking in long PFNA-II fixation of stable intertrochanteric fractures.@*METHODS@#A total of 58 patients with isolated stable intertrochanteric fractures and treated in our hospital during the study period of 2017-2019 by distal locked or unlocked long PFNA-II fixation were included in this study. Patients who had multiple injuries or open fractures were excluded. There were 40 female and 18 male patients, with 33 affecting the left side and 25 the right side. Of them, 31 belonged to the distal locked group (group A) and 27 to the unlocked group (group B). Surgical procedures and implants used in both groups were similar except for the distal locking of the nails. General data (age, gender, fracture side, etc.) showed no significant difference between two groups (all p > 0.05). The intraoperative parameters like operative time, radiation exposure and follow-up parameters like functional and radiological outcomes were recorded and compared. Statistical tests like the independent samples t-test Fischer's exact and Chi-square test were used to analyze association.@*RESULTS@#The distribution of the fractures according to AO/OTA classification and 31A1.2 type of intertrochanteric fractures were most common in our study. All the included fractures united and the average functional outcome in both groups were good and comparable at the end of one year. The operative time (mL, 107.1 ± 12.6 vs. 77.0 ± 12.0, p < 0.001) and radiation exposure (s, 78.6 ± 11.0 vs. 40.3 ± 9.3, p < 0.001) were significantly less among the patients in group B. Fracture consolidation, three months after the operative procedures, was seen in a significantly greater proportion of patients in group B (92.6% vs. 67.7%, p = 0.025). Hardware irritation because of distal locking bolt was exclusively seen in group A, however this was not statistically significant (p = 0.241).@*CONCLUSION@#We conclude that, in fixation of stable intertrochanteric fractures by long PFNA-II nail, distal locking not only increases the operative time and radiation exposure but also delays the fracture consolidation and increases the chances of hardware irritation, and hence is not required.

Interpretations of Management of Hip Fractures in Older Adults:Evidence-Based Clinical Practice Guideline dopted by AAOS 2021 / 中国骨伤

American Academy of Orthopaedic Surgeons (AAOS) just released the up-to-date <Management of Hip Fractures in Older Adults:Evidence-Based Clinical Practice Guideline>, which has become the principles to care hip fractures in the elderly. In comparison to the Guideline 2014, considerable changes are made in terms of guideline composition and focused items. The interval of 7 years yielded dramatic progress in the care of geriatric hip fractures, including the recommendation of cemented femoral stems in hip arthroplasty due to displaced femoral neck fractures, cephalomedullary device for unstable intertrochanteric fractures and tranexamic acid to reduce blood loss and blood transfusion. Additionally, the individualized properties of the elderly with hip fractures should be noted to balance an early operation within 24 and 48 hours and patient safety. The interpretation of <Management of Hip Fractures in Older Adults:Evidence-Based Clinical Practice Guideline> is helpful to comprehensively understand the progress of the care of geriatric hip fractures, thus to make orthopaedic surgeons master the key points of clinical practice, and to improve the quality of operations and decrease perioperative complications.

Early mobilisation following fragility hip fracture surgery: current trends and association with discharge outcomes in a local tertiary hospital

INTRODUCTION@#Postoperative day 1 (POD 1) mobilisation is a key clinical indicator for the fragility hip fracture surgery population. This study aimed to evaluate the current trends of POD 1 mobilisation at our institution and to review the relationships between early mobilisation and outcomes of early functional recovery, length of stay (LOS) and discharge destination.@*METHODS@#In this preliminary observational study, data pertaining to demographics, premorbid function, health status, injury and surgical factors, POD 1 mobilisation status and clinical outcomes of interest were retrieved from eligible patients. Patients who attained POD 1 ambulation formed the early ambulation (EA) group, while the remaining patients formed the delayed ambulation (DA) group. Data were analysed for any significant difference between the groups.@*RESULTS@#One hundred and fifteen patients were included in the analysis. The rate of patients achieving at least sitting out of bed on POD 1 was 80.0% (n=92), which was comparable to the data available from international hip fracture audit databases. There were 55 (47.8%) patients in the EA group and 60 (52.5%) patients in the DA group. The EA group was approximately nine times more likely to achieve independence in ambulation at discharge compared to the DA group (adjusted odds ratio 9.20, 95% confidence interval 1.50-56.45; P = 0.016). There were observed trends of shorter LOS and more proportion of home discharge in the EA group compared to the DA group (P > 0.05).@*CONCLUSION@#This is the first local study to offer benchmark of the POD 1 mobilisation status for this population. Patients who attained POD 1 ambulation had better early functional recovery.

A medium term analysis on of therapeutic effects of bio-lengthend stem hemiarthroplasty in the treatment of unstable osteoporotic intertrochanteric fractures in elderly patients / 中国骨伤

OBJECTIVE@#To retrospectively study medium term follow up outcomes effects of effect of bio-lengthend stem hemiarthroplasty in the treatment of unstable osteoporotic intertrochanteric fractures in elderly patients.@*METHODS@#Total of 32 elderly patients with the osteoporotic intertrochanteric fractures were treated with bio-lengthend stem hemiarthroplasty from Jan. 2016 to Jan. 2019 including 14 males and 22 females, aged from 85 to 95 years old with an average of (89.5±4.5) years old. According to classification of Evans, there were 12 cases with type Ⅲ, 11 with type Ⅳ and 9 with type Ⅳ. The time from injury to operation ranged from 0.5 to 9 days with an average of (4.5±3.9) days. The operation time, blood loss and postoperative complications were analyzed. Functional outcome was assessed by Parker Palmer mobility score(PPMS) and Harris hip score.@*RESULTS@#Four patients died within one year after operation, and the mortality was 12.5%. The follow up time for the rest 28 patients ranged from 24 to 60 months with an average of (28.5±4.5) months. The mean operative time was (54.2±22.5) min;the mean blood loss (hidden blood loss+obvious blood loss) was (450±140) ml;the first weight bearing was (3.35±1.35) days. No perioperative death occurred. PPMS were(6.63±1.25), (6.94±1.18), (7.11±0.83), (7.32±1.11) and Harris scores were(67.85±6.19), (71.42±5.57), (73.41±5.62), (77.32±5.24) respectively at 1, 3, 6 months and the final follow-up after operation. There were no significant difference in PPMS and Harris score at 1, 3, 6 months after operation and the final follow-up(P>0.05). There were no complications such as joint dislocation and prosthesis loosening occure at the final follow-up.@*CONCLUSION@#On the premise of strictly mastering the case selection criteria, the bio-lengthend stem hemiarthroplasty in the treatment of unstable osteoporotic intertrochanteric fractures in elderly patients has a satisfied medium term follow-up outcomes. It can restore hip function in the early stage and improve the quality of life of patients.

Telecarers improve osteoporosis treatment and compliance rates in secondary osteoporosis prevention for elderly hip fracture patients

INTRODUCTION@#A significant treatment gap has been observed in patients with osteoporosis. Our previous audit found a 31.5% rate of anti-osteoporosis medication initiation after fragility fractures at one year. We piloted the use of telecarers to monitor osteoporosis treatment and compliance.@*METHODS@#From January 2017 to January 2018, all hip fracture patients at Changi General Hospital, Singapore, were automatically enrolled into the Health Management Unit valued care hip fracture programme. Telecarer calls were scheduled at discharge, 3, 6 and 12 months. We assessed the acceptability, completion and treatment rates of patients enrolled in this programme.@*RESULTS@#A total of 537 patients with a hip fracture were enrolled in the telecarer programme over one year. Their average age was 79.8 ± 8.23 years, and 63.1% of them were female. A total of 341 patients completed 12 months of follow-up, of which 251 (73.6%) patients were on treatment at 12 months. The most common cause of lack of initiation of secondary osteoporosis treatment was patient or family rejection (34.4%), followed by physician failure to prescribe (24.4%) and renal impairment (24.4%). 16.7% of patients were deemed to have advanced dementia with a life-limiting illness and were, thus, deemed unsuitable for treatment.@*CONCLUSION@#Telecarers may be a useful adjunct in the monitoring of osteoporosis treatment after hip fractures in an elderly population. The main limitations are patient or family rejection and physician inertia. Further studies should focus on a combination of interventions for both patients and physicians to increase awareness of secondary fracture prevention.

Risk factors and prognosis of acute stroke within 1 year after hip fracture surgery in elderly patients / 中华老年医学杂志

Objective:To study the risk factors of acute stroke within 1 year after hip fracture in the elderly and its effect on prognosis.Methods:From January 2018 to December 2020, 278 elderly hip fracture patients undergoing surgery were retrospectively analyzed, including 101 males and 177 females, aged from 60 to 99 years with an average of(78.9±8.7)years.According to whether acute stroke occurred within 1 year after operation, the patients were divided into stroke group and non-stroke group.A multivariate Logistic regression was used to evaluate the risk factors for acute stroke within 1 year after hip fracture, and the prognosis was analyzed.Results:Acute stroke occurred in 28 patients(10.1%)within 1 year after operation, and the peak of stroke onset occurred in the third months after operation.Patients in the stroke group were older, and had a higher proportion of hypertension, arrhythmia, previous stroke history, and use of anticoagulant or antiplatelet drugs before fracture( P<0.05 for all). Multivariate Logistic regression analysis showed that advanced age( OR=1.078, 95% CI=1.007-1.153, P=0.030), male( OR=2.643, 95% CI=1.060-6.742, P=0.037)and previous stroke history( OR=12.202, 95% CI=4.662-31.940, P<0.001)were independent risk factors for stroke in elderly patients with hip fracture within 1 year after operation.The 1-year mortality, complication rate and readmission rate in the stroke group were significantly higher than those in the non-stroke group( P<0.05 for all). Conclusions:The incidence of stroke is high in elderly patients with hip fracture within 1 year after operation.Older age, male, and previous stroke history were independent risk factors for acute stroke.The prognosis of stroke was poor in elderly patients with hip fracture, and the 1-year mortality, complication and readmission rates were high.

Relationship between red blood cell distribution width and short-term mortality of hip fractures in the elderly / 中华老年医学杂志

Objective:To study the relationship between red blood cell distribution width(RDW)and short-term mortality in elderly patients with hip fragility fractures.Methods:The clinical data and blood routine test at admission of 205 elderly patients with brittle hip fractures who were admitted to our hospital from 2020 to 2021 and were followed up for one year were retrospectively analyzed.The comorbid conditions, RDW and cumulative mortality at 6 months and 1 year after fractures were counted, and the relationship between RDW and short-term mortality were analyzed.Results:The 6-month(6.7% and 20.8%, χ2=8.591, P=0.003)and 1-year(6.7% and 26.7%, χ2=14.818, P<0.001)mortality of patients with ≤1 comorbidity were significantly lower than those of patients with ≥2 comorbidities.Moreover, the 6-month and 1-year mortality in patients with RDW>13.5% were significantly higher than those of patients with RDW ≤ 13.5%.The proportion of RDW>13.5 % in patients with at least two comorbidities was significantly higher than that in patients with ≤1 comorbidity.Taking RDW=13.6% as the cut-off value of 6-month and 1-year mortality, the sensitivity and specificity for predicting 6-month mortality were 71.4 % and 59.9 %, respectively, and the sensitivity and specificity for predicting 1-year mortality were 64.7 % and 59.6 %, respectively. Conclusions:Red cell distribution width is associated with short-term mortality, and higher RDW is associated with a higher risk of mortality among elderly patients with brittle hip fractures.

Risk factors analysis and prediction nomogram establishment of acute kidney injury in hip fracture patients with severe underlying diseases / 中华骨科杂志

Objective:To analyze the risk factors of acute kidney injury (AKI) in hip fracture patients with serious underlying diseases and establish a prediction nomogram.Methods:Clinical information of hip fracture patients admitted to the intensive care unit (ICU) of Beth Israel Deaconess Medical Center (BIDMC) was analyzed using the Medical Information Mart for Intensive Care (MIMIC)-IV. Patient comorbidities, disease scores, vital signs and laboratory tests, surgical modalities, invasive procedures, and drug use were recorded. According to the diagnostic criteria of AKI in the Kidney Disease Improving Global Outcome (KDIGO) guideline, the enrolled patients were randomly divided into training set and validation set. Based on logistic regression analysis, least absolute shrinkage and selection operator (LASSO) logistic regression algorithm was used to analyze the risk factors of AKI after admission, and the corresponding prediction model was calculated.Results:A total of 474 patients were enrolled, including 331 in the training set and 143 in the validation set. According to the diagnostic criteria of AKI of KDIGO guidelines, the patients were divided into AKI group (159 cases) and non-AKI group (172 cases). Univariate analysis showed that age ( t=2.61, P=0.009), coronary heart disease (χ 2=2.08, P=0.038), heart failure (χ 2=2.60, P=0.009), hemoglobin ( t=1.89, P=0.059), platelets ( t=1.81, P=0.070), urea nitrogen ( t=2.83, P=0.005), blood creatinine ( t=3.65, P<0.001), blood sodium ( t=2.55, P=0.011), blood glucose ( t=2.52, P=0.012), anion gap ( t=3.44, P=0.001), diastolic blood pressure ( t=2.72, P=0.007), mean arterial pressure ( t=2.16, P=0.031), SOFA score ( t=3.69, P<0.001), simplified acute physiological function score II (SAPSII) score ( t=2.95, P=0.003), as well as furosemide (χ 2=2.03, P=0.042), vancomycin (χ 2=1.70, P=0.089), vasoactive medications (χ 2=3.74, P<0.001) and use of invasive mechanical ventilation (χ 2=4.81, P<0.001) were risk factors associated with the development of AKI in hip fracture patients. Multivariate logistic regression analysis showed that age ( OR=1.03, P<0.001), coronary heart disease ( OR=2.05, P=0.069), hemoglobin ( OR=0.88, P=0.050), blood creatinine ( OR=1.37, P=0.009), blood sodium ( OR=1.07, P=0.026), anion gap ( OR=1.09, P=0.028) and vasoactive medications ( OR=3.83, P=0.018) and the use of invasive mechanical ventilation ( OR=6.56, P<0.001) were independent predictors of the development of AKI in hip fracture patients with serious underlying diseases. The area under the curve of the nomogram prediction model constructed by the above 8 predictors was 0.789, and the calibration curve of the nomogram was close to the ideal diagonal. Decision curve analysis showed that the net benefit of the model was significant. Conclusion:The incidence of AKI is high in hip fracture patients with serious underlying diseases. Age, coronary heart disease, hemoglobin, serum creatinine, serum sodium, anion gap, vasoactive drugs, and invasive mechanical ventilation can predict the occurrence of AKI to a certain extent. Combined with the risk factors, the construction of the corresponding prediction model can predict and manage the diagnosis and treatment of AKI in patients with hip fracture complicated with severe underlying diseases.

The predictive function and application value of hip fracture scoring system in the elderly / 中华骨科杂志

Objective:To establish a risk assessment system focusing on surgical and anesthesian-related indicators for the incidence of complications and mortality of hip fracture surgery in senile patients, and to evaluate its prediction accuracy, sensitivity and specificity.Methods:From January 2020 to February 2021, a total of 1 086 elderly patients (493 males and 593 females) aged 76±5 years (ranging from 60 to 94 years) underwent hip fracture surgery in Tianjin Hospital were collected. A total of 543 patients were randomly selected for the establishment of the hip fracture scoring system in senile patients, including 253 males and 290 females, aged 75±6 years (ranging from 60 to 92 years). With the preoperative physiological factor score and surgical risk factor score as independent variables and the occurrence of complications and death as dependent variables, binary logistic regression analysis was performed to establish a surgical risk scoring system for hip fracture in senile patients. The remaining 543 patients, including 240 males and 303 females, aged 74±7 years (range 60-94 years), their data were used to compare AUC, sensitivity, specificity, and compliance of the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM), Daping orthopedics operative risk scoring system for senile patient (DORSSSP), and our surgical risk scoring system for hip fracture in senile patients through receiver operating characteristic (ROC) curves, and to compare the predictive value of these systems for complication incidence and mortality.Results:The predictive model equation of the elderly hip fracture scoring system is: ln R1/ (1- R1) =-7.13+0.112× PS+0.148× OS; ln R2/ (1- R2) =-6.14+0.124× PS+0.136× OS; [ R1 is the incidence of complications, R2 is the mortality, PS (physiology score) is the score of preoperative physiological factors, and OS (operation score) is the score of surgical risk factors]. Among the 543 patients whose data were used to compared with the hip fracture scoring system, POSSUM and DORSSSP, 72 actually developed complications and 36 died. The complication rate predicted by surgical risk scoring system for hip fracture in senile patients was 12.05%±6.34% (range 6.18%-61.29%), and 64 cases were predicted to have complications. The predicted mortality was 6.05%±3.26% (range 2.45%-58.36%), and 29 cases were predicted to die. The complication rate predicted by POSSUM was 25.36%±13.95% (range 9.16%-76.34%), and 126 cases were predicted to have complications. The predicted mortality rate was 10.46%±5.31% (range 6.23%-59.34%), and 54 deaths were predicted. The predicted complication rate of DORSSSP was 19.34%±9.67% (range 8.36%-70.85%), and 99 cases were predicted to have complications. The predicted mortality was 10.12%±5.16% (range 7.35%-57.54%), and 52 deaths were predicted. In predicting the incidence of complications, the AUC of surgical risk scoring system for hip fracture in senile patients, POSSUM and DORSSSP were 0.95, 0.82 and 0.75, the sensitivity was 0.89, 0.83 and 0.85, the specificity was 0.80, 0.86 and 0.92, and the compliance rate was 0.94, 0.93 and 0.94, respectively. In the prediction of mortality, the AUC of surgical risk scoring system for hip fracture in senile patients, POSSUM and DORSSSP were 0.87, 0.67 and 0.71, the sensitivity was 0.85, 0.69 and 0.75, the specificity was 0.73, 0.94, 0.95, and the compliance rate was 0.94, 0.93 and 0.94, respectively. Conclusion:Compared with POSSUM and DORSSSP, hip fracture scoring system in elderly patients has improved its ability to predict surgical risk, and can accurately predict the incidence of complications and mortality in elderly patients undergoing hip surgery.

Proximal femoral bionic nail versus proximal femoral nail antirotation in treatment of femoral intertrochanteric fracture: a comparison of short-term efficacy / 中华创伤骨科杂志

Objective:To compare the short-term effects of proximal femoral bionic nail (PFBN) and proximal femoral nail antirotation (PFNA) in the treatment of intertrochanteric fracture.Methods:Retrospectively analyzed were the data of 56 patients with intertrochanteric fracture of the femur who had been admitted to Department of Orthopedic Trauma, The People's Hospital of Juye County and Trauma Center, Central Hospital Affiliated to The First Medical University of Shandong from August 2020 to April 2022. The patients were divided into 2 even groups according to their internal fixation methods ( n=28). In the PFBN fixation group, there were 12 males and 16 females with an age of (70.4±7.8) years; by AO classification, there were 4 cases of type 31-A1, 16 cases of type 31-A2, and 8 cases of type 31-A3. In the PFNA fixation group, there were 10 males and 18 females with an age of (73.0±8.9) years; by AO classification, there were 2 cases of type 31-A1, 16 cases of type 31-A2, and 10 cases of type 31-A3. The operation time, intraoperative blood loss, fracture reduction, fracture healing time, Harris hip score, and complications were compared between the 2 groups. Results:There was no statistically significant difference between the 2 groups in the preoperative general data, showing comparability ( P>0.05). The follow-up time was (7.3±0.9) months for the PFBN group and (7.4±1.1) months for the PFNA group, showing no significant difference ( P>0.05). There was no significant difference either between the 2 groups in operation time, intraoperative blood loss or quality of fracture reduction ( P>0.05). The PFNA group had significantly shorter fracture healing time [(3.9±0.9) months] than the PFNA group [(4.7±1.1) months], and a significantly higher Harris hip score at the last follow-up [(83.9±4.3) points] than the PFNA group [(81.0±3.4) points] (both P<0.05). Fixation failed in one patient in the PFNA group due to cut-out of the head and neck screws while no complications were observed in the PFBN group. Conclusion:In the treatment of intertrochanteric fracture of the femur, PFBN fixation may result in stronger fixation to effectively avoid cut-out of the head and neck screws, and faster fracture healing and functional recovery of the hip than PFNA fixation.

Progress in research into the wedge effect during cephalomedullary nailing for intertrochanteric fractures / 中华创伤骨科杂志

Surgical intervention is the first choice treatment for intertrochanteric fractures that are common in clinical practice. Cephalomedullary nailing with two parts inserted respectively into the femoral medullary cavity and femoral head has been the mainstream protocols for the elderly patients with intertrochanteric fracture, but insertion of the cephalomedullary nail may likely lead to the outward displacement of the femoral shaft and the inversion and rotation of the head and neck bone mass, namely the so-called wedge effect. However, few reports have dealt with how to prevent the wedge effect and reduce the complications it may cause such as coxa vara deformity. The present review expounds and analyzes the concept, biomechanical mechanism, influencing factors, measurements, and prevention methods of the wedge effect, hoping to help the surgeons who try to avoid the wedge effect in surgical treatment.