Modifiable and non-modifiable risk factors affecting walking recovery after hip fracture.

UNLABELLED: Modifiable and non-modifiable predictors of mobility recovery were analyzed on a sample of 774 hip fracture patients according to pre-fracture abilities. Overall predictors were mostly non-modifiable factors related to frailty of patients with the exception of 25-hydroxyvitamin D concentration which significantly affected walking recovery, especially in patients with higher pre-fracture performance. INTRODUCTION: This study aims to investigate mobility changes after hip fracture with the aim of identifying modifiable and non-modifiable predictors of mobility recovery according to different pre-fracture abilities. METHODS: This is a prospective inception cohort study of consecutive older patients, admitted with a fragility hip fracture in three Hospitals of Emilia Romagna (Italy). A sample of 774 patients alive at the sixth month was divided into three groups according to pre-fracture ambulation ability (group 1: mobile outdoors; group 2: mobile indoors; and group 3: mobile with help). The relationship between baseline characteristics of patients and the odds of walking recovery was analyzed using multivariate regression analysis. RESULTS: Mortality differed significantly among the three groups and was the highest in patients needing help to walk. Among the survivors, only 50.3 % of patients recovered walking ability. In a multivariate analysis, independent risk factors were different among the three groups. In group 1, older age, comorbidities, the use of walking devices before fracture, and low albumin level acted as negative factors while male gender, a pre-fracture high functional status, and higher 25-hydroxyvitamin D levels increased the probability of full recovery. In group 2, only pre-fracture functional status and 25-hydroxyvitamin D concentration were related to the recovery of walking ability. Pre-fracture functional status was also the only significant predictor for patients in group 3. CONCLUSIONS: Several baseline characteristics of patients are related to the likelihood of recovering walking ability after hip fracture. The 25-hydroxyvitamin D level seems to be the only relevant modifiable factor even if the effectiveness of its supplementation has yet to be demonstrated.

Comprehensive care.

Comprehensive care (CC) represents the basic approach of orthogeriatric comanaged care with the overall objectives of improving results regarding physical and psychological functions and reducing hospitalization, long-term care placement and mortality. It is a two-stage process that includes the Comprehensive Geriatric Assessment (CGA) and the development and implementation of an interdisciplinary treatment plan based on priority interventions and unmet needs. In older hip fracture patients CC has to face crucial issues such as treatment choice and surgical options, clinical stabilization of patients before surgery and the prevention and treatment of complication in the postoperative phase. The main aim are to avoid inappropriate surgical delays and reduce the overall number of days of immobility endorsing an early ambulation with full weight bearing as tolerated. Multiprofessional CC must also ensure uninterrupted care for transition between the different care levels that patients need after fracture before returning home. Therefore another important issue is a structured discharge plan tailored to the individual patient identifying subjects that could benefit from a skilled or more intensive rehabilitation, identifying patients and family that will probably need a higher level of care even after rehabilitation, determining timing of discharge, defining the continuing care that needs to be provided and finally ensuring the patient has access to available services and resources. However, the implementation of a comprehensive and multidisciplinary co-care model in an orthopedic unit is a difficult task because it is necessary a great effort to change cultural attitudes related to traditional model of care.

The locked intramedullary Grosse Kempf nail in the treatment of proximal diaphyseal fractures of the femur.

The authors studied the effectiveness of locked intramedullary nailing (Grosse-Kempf) in the treatment of proximal shaft femoral fractures. They reviewed 24 cases with an average two-year follow-up and which had obtained positive clinical radiographic results in 80% of cases as compared to 88% in a previous revision of femoral shaft fractures. The difference is due to the greater difficulty encountered in intraoperative reduction of fractures from which defects in axial (varus) and rotatory (extra) alignment arise. They discuss indications as regards locking type, weight-bearing, as well as surgical techniques, which may prevent some of the most frequent problems observed.

Retention of the posterior cruciate ligament in total knee arthroplasty.

The importance of the preservation of the posterior cruciate ligament in total knee arthroplasty is analyzed from a biomechanical, clinical, and functional standpoint. Using clinical and radiographic criteria, the authors assess posterior cruciate ligament validity in a selected group of 31 of 45 total knee arthroplasties (PCA prosthesis) reviewed at least 18 months after the operation. Sixty-eight percent of the replaced knees, which were divided into two groups on the basis of preoperative deformity, had a functional posterior cruciate ligament. In view of these results the authors are satisfied with the prosthetic model they adopted, which was designed not only to preserve the posterior cruciate ligament, but also, by virtue of its special shape, to compensate in the event of ligament insufficiency.

The locked Grosse-Kempf intramedullary nail in the treatment of diaphyseal and metaphyseal fractures of the femur and tibia.

The Gross-Kempf locked intramedullary nail widens the indications for the traditional Küntscher nail in the treatment of diaphyseal and metaphyseal fractures of the lower limbs. The study includes 87 patients with a total of 93 closed fractures treated between 1981 and 1987. Osteosynthesis was carried out in 85 closed fractures and in 8 Grade 1 or 2 open fractures. Possible assemblies in relation to the level and type of fracture and the protocol for weightbearing are illustrated, with emphasis on the fact that dynamization of static assemblies is not always essential. The high percentage of positive results (86%) and the relatively small incidence of complications confirm the validity of this method. The only drawback is the fairly high dose of radiation absorbed by the surgeon during the operation.

Total P.C.A. knee arthroprosthesis.

Between 1983 and 1986 the authors implanted 36 porous-coated P.C.A. total knee prostheses in 34 patients. Complications included two fatal cases of pulmonary embolism and one deep infection which healed within five months following removal of the prosthesis and arthrodesis. The results obtained in 23 patients after an average follow-up of 18 months were excellent in 87% and fair in 13% (according to the Hungerford evaluation system). Radiographic evaluation showed excellent prosthetic positioning in 70% of the cases, the presence of radiolucent lines in areas 5-6-7-8-11-15-19 (according to Hungerford) in 21% of the cases, and zonal bone resorption in areas 1-2-3-4 in 43% of the cases. The authors report their conclusions with reference to complications, the preservation of the posterior cruciate ligament, and problems related to positioning the prosthesis.