Anticoagulant Medication in Endoprosthetically Treated Proximal Femur Fracture - Complications and Mortality Considering the Time of Treatment as a Quality Criterion. / Gerinnungsaktive Medikation bei endoprothetisch versorgter proximaler Femurfraktur - Komplikationen und Mortalität unter Berücksichtigung des Versogungszeitpunktes als Qualitätskriterium.

There is an international debate on the optimal time to surgery following hip fracture in older patients. Pre-existing anticoagulation seems to be a major concern when it comes to a delay in operative fracture treatment. The aim of this study was to examine complication and mortality rates for elderly anticoagulated hip fracture patients considering early (< 24 h) vs. delayed (> 24 h) surgery.Our Analysis is based on data of the external inpatient quality assurance of North Rhine Westphalia as the most populous German federal state. We identified 13,201 hip fracture patients with antithrombotic medication and a minimum age of 65 years treated from January 2015 to December 2017.Delayed surgery was associated with significantly higher rates of general and surgical complications as well as mortality. Except for pre-existing heart failure, we were not able to identify certain comorbidities that could clearly indicate, why there might have been a delay.In most cases, patients with antithrombotic medication have a poor outcome to be expected due to serious comorbidity. If there was a delay in surgery for those patients, treatment results were even worse. Thus, surgery with a delay of > 24 h must be avoided to reduce the risk of complications.

[Long-term anticoagulation treatment in proximal femoral fractures as obstacle to surgery in the 24h time window? : Results of an analysis of Quality Assurance data on 32,252 treatment courses with osteosynthesis]. / Antikoagulative Dauertherapie bei proximaler Femurfraktur als Operationshindernis im 24-h-Zeitfenster? : Ergebnisse einer Analyse aus Qualitätssicherungsdaten über 32.252 Behandlungsverläufe mit osteosynthetischer Versorgung.

BACKGROUND: Both in Germany and internationally there is a vehement controversy about the appropriate time for care of proximal femoral fractures in older patients. The effort to achieve high quality and uniform standards of care culminated in the German healthcare system in the strict requirement of delay-free surgery within 24 h. Until now, in view of their high vulnerability patients who were severely injured were too often operated on late with the reference to a general medical condition that could be improved preoperatively. In particular, the fear of complications due to a pre-existing long-term anticoagulation treatment was repeatedly emphasized. OBJECTIVE: The present study is dedicated to the question of whether a delay in surgery of anticoagulated patients with proximal femoral fractures already during the inpatient course has a detrimental effect on the complication statistics and the mortality of the patients. The extent to which external quality assurance data are suitable for rebutting any objections to an operation as soon as possible are examined. MATERIAL AND METHODS: The study is based on treatment data from the external inpatient quality assurance procedure of the federal state of North Rhine-Westphalia from the years 2018-2020. Patients with a proximal femoral fracture were considered. This includes femoral neck fractures and fractures in the area of the pertrochanteric to subtrochanteric region. Only cases with joint-preserving fracture care were selected. The data sets were analyzed using suitable statistical software. RESULTS: More general complications and deaths have been observed in anticoagulated patients. The trend of delayed fracture treatment under anticoagulant medication continues to be clearly visible. A positive association between longer preoperative waiting time and undesirable courses can be confirmed. CONCLUSION: With respect to fracture care when taking anticoagulants, it must be critically examined to what extent a rapid normalization of the coagulation situation is necessary and this actually improves the chances of low complication courses. Should the elimination of the anticoagulant effect by substitution or antidote appear necessary, this should not prevent early care.

[Hip Fractures in Adults - Contemporary Clinical Management Based on International Standards]. / Zur hüftgelenknahen Femurfraktur des erwachsenen Menschen ­ Zeitgemäßes klinisches Management auf der Basis internationaler Standards.

BACKGROUND: Patients with hip fractures, often of advanced age and with multimorbidity-trauma, require early surgery and interdisciplinary treatment in order to avoid complications and reduce morbidity and mortality. "Time to surgery" is a sensitive quality indicator (QI) for the treatment process, reflecting multiple factors. Due to persistently noticeable problems in relation to this QI in external inpatient quality assurance in Germany, a special need for action was identified by the Federal Joint Committee (Gemeinsamer Bundesausschuss - G-BA). OBJECTIVES: Identification of methodologically particular reliable recommendations to establish structural and procedural standards to ensure adequate clinical care. METHODS: Systematic international web-based research and analysis of relevant guidelines for domain 3 of the AGREE II instrument; extraction of distinct, methodologically well-founded recommendations; supplementing the guideline analysis with an assessment of regulations with structure and process requirements or criteria for quality and care standards. RESULTS: Out of 66 identified, context-relevant guidelines, 15 were of "high methodological quality". Out of these 15, particular reliable recommendations could be extracted-among others - regarding surgical technique, combined orthogeriatric treatment, antibiotics, pressure ulcers and thromboembolic prophylaxis, time to surgery, anesthetics, physiotherapy, postoperative management and delirium. Further structural and procedural specifications could be extracted from nine other sets of rules. CONCLUSIONS: Surgery as early as possible and adequate care can be assured through a consistent, multifactorial, interdisciplinary and coordinated team approach in well structured and adequately staffed facilities of appropriate quality.

The Interdisciplinary Management of Foot Drop.

BACKGROUND: Foot drop can be caused by a variety of diseases and injuries. Although it is a common condition, its overall incidence has not been reported to date. Foot drop markedly restricts the everyday activities of persons suffering from it. There is, therefore, a need for an optimized strategy for its diagnosis and treatment that would be standardized across the medical specialties encountering patients with this problem. METHODS: This article consists of a review on the basis of pertinent publications re- trieved by a search in the Pubmed/MEDLINE and Cochrane databases, as well as a description of the authors' proposed strategy for the diagnosis and treatment of foot drop. RESULTS: Foot drop can be due to a disturbance at any central or peripheral location along the motor neural pathway that terminates in the dorsiflexor muscles of the foot, or at multiple locations in series. Optimal localization of the lesion(s) is a pre- requisite for appropriate treatment and a successful outcome. The most common causes are L5 radiculopathy and peroneal nerve injury. An operation by a neuro- surgeon or spinal surgeon is a reasonable option whenever there is a realistic chance that the nerve will recover. In our opinion, any patient with a subjectively disturbing foot drop and a clinically suspected compressive neuropathy of the peroneal nerve should be informed about the option of surgical decompression of the nerve at the fibular head, which can be performed with little risk. In case of a permanent foot drop, some patients can benefit from muscle-transfer surgery. For spastic foot drop, the option of botulinum toxin injections should be evaluated. CONCLUSION: The care of patients with foot drop could be optimized by interdisciplin- ary foot-drop clinics involving all of the relevant specialists. The goals of treatment should always be improved mobility in everyday life and the prevention of falls, pain, and abnormal postures.

Spinal anesthesia protects against perioperative hyperglycemia in patients undergoing hip arthroplasty.

STUDY OBJECTIVE: To determine whether spinal anesthesia blunts surgical stress reactions and results in less perioperative hyperglycemia. DESIGN: Prospective, randomized controlled study. SETTING: Operating room of a university hospital. PATIENTS: 68 adult, nondiabetic (n = 40) and diabetic (n = 28), ASA physical status 1, 2, and 3 patients patients undergoing elective total hip replacement. INTERVENTIONS: General or spinal anesthesia was administered. MEASUREMENTS: Blood HbA1C was measured preoperatively to identify patients with undiagnosed diabetes. Glucose levels were checked preoperatively, then immediately after, and one hour after surgery. A conventional glucose control protocol was used, where insulin was given when blood glucose concentrations exceeded 250 mg/dL. MAIN RESULTS: Preoperative glucose levels in general and spinal anesthesia patients were comparable and not significantly different in nondiabetic and diabetic patients. At the end of surgery and one hour after surgery, glucose levels were significantly higher in patients undergoing general anesthesia compared with baseline values in both diabetic and nondiabetic patients (P < 0.05). In nondiabetic and diabetic patients, a significant increase in glucose level was found in patients undergoing general anesthesia versus spinal anesthesia (P < 0.05). In patients receiving spinal anesthesia, glucose levels remained stable. Two diabetic patients undergoing general anesthesia received insulin. CONCLUSION: Spinal anesthesia attenuates the hyperglycemic response to surgical stimuli in diabetics and nondiabetic patients.

The effect of time-to-surgery on outcome in elderly patients with proximal femoral fractures.

BACKGROUND: Whether reducing time-to-surgery for elderly patients suffering from hip fracture results in better outcomes remains subject to controversial debates. METHODS: As part of a prospective observational study conducted between January 2002 and September 2003 on hip-fracture patients from 268 acute-care hospitals all over Germany, we investigated the relationship of time-to-surgery with frequency of post-operative complications and one-year mortality in elderly patients (age > or =65) with isolated proximal femoral fracture (femoral neck fracture or pertrochanteric femoral fracture). Patients with short (< or =12 h), medium (> 12 h to < or =36 h) and long (> 36 h) times-to-surgery, counting from the time of the fracture event, were compared for patient characteristics, operative procedures, post-operative complications and one-year mortality. RESULTS: Hospital data were available for 2916 hip-fracture patients (mean age (SD) in years: 82.1 (7.4), median age: 82; 79.7% women). Comparison of groups with short (n = 802), medium (n = 1191) and long (n = 923) time-to-surgery revealed statistically significant differences in a few patient characteristics (age, American Society of Anesthesiologists ratings classification and type of admission) and in operative procedures (total hip endoprosthesis, hemi-endoprosthetic implants, other osteosynthetic procedures). However, comparison of these same groups for frequency of postoperative complications revealed only some non-significant associations with certain complications such as post-operative bleeding requiring treatment (early surgery patients) and urinary tract infections (delayed surgery patients). Both unadjusted rates of one-year all-cause mortality (between 18.1% and 20.5%), and the multivariate-adjusted hazard ratios (HR for time-to-surgery: 1.04; p = 0.55) showed no association between mortality and time-to-surgery. CONCLUSION: Although this study found a trend toward more frequent post-operative complications in the longest time-to-surgery group, there was no effect of time-to-surgery on mortality. Shorter time-to-surgery may be associated with somewhat lower rates of post-operative complications such as decubitus ulcers, urinary tract infections, thromboses, pneumonia and cardiovascular events, and with somewhat higher rates of others such as post-operative bleeding or implant complications.

Guidelines or state civil codes in the management of femoral neck fracture? An analysis of the reality of care provision in North Rhine-Westphalia.

INTRODUCTION: This study analyzes healthcare management patterns in the German Federal State of North Rhine-Westphalia, with regard to time-to-surgery and operative technique in the management of femoral neck fracture. METHODS: Analysis of external quality assurance data relating to inpatient episodes of femoral neck fracture for North Rhine-Westphalia in the years 2004 and 2005. The study included data on 19 767 patients. RESULTS: More than half of patients receive surgery within 24 hours of hospital admission. Large regional differences exist in relation to the type and timing of surgery. Day of the week is a key determinant of the timing of surgery. Even younger patients, in whom the hip joint should be preserved, receive delayed surgery in some regions. DISCUSSION: Structured dialog with individual hospitals revealed the following causes for the differences in care provision: guideline recommendations and the recommendations of the Federal Office for Quality Assurance ltd. (Bundesgeschäftsstelle Qualitätssicherung, BQS GmbH), are not accepted as the basis for practice in all quarters; in some areas the necessary staff to ensure timely surgery are lacking. This situation cannot be defended to a wider public, given the clear indications from international literature that a short time to surgery reduces postoperative mortality as well as the incidence of key complications, such as pressure sores, thromboembolisms and pneumonia.

Fracture-related hip pain in elderly patients with proximal femoral fracture after discharge from stationary treatment.

BACKGROUND: Proximal femoral fracture is a common condition in the elderly but very little is known about fracture-related hip pain in these patients after discharge from stationary treatment. AIMS: To identify risk factors associated with persistent hip pain in elderly hip-fracture patients. METHODS: We analysed data from a large observational study, evaluating the health care situation of hip-fracture patients between January 2002 and September 2003 in Germany. For this analysis, we focused on a sub-sample of patients who were 65 years or older, had sustained an isolated proximal femoral fracture and had undergone surgical intervention. A telephone interview was conducted 6-12 months after discharge. Pain intensity, pain-related disability and severity of chronic pain were measured using the Graded Chronic Pain Scale (GCPS). Multivariate linear regression methods were applied to test hospital patient data for their value in predicting post-hospitalisation presence of fracture-related pain. RESULTS: In total, 1541 patients (mean age 78.4, 76.1% female) were enrolled in this analysis. The prevalence of fracture-related hip pain was 13.4% (206/1541). Among these 206 patients, 57.3% had pain intensity scores 50, 65.0% had pain disability scores 50, and the severity of chronic pain (Grades 1-4) was assessed as follows: (1) 34.0%, (2) 19.4%, (3) 31.5%, (4) 15.1%. The clinical variables age, weight and operative procedure were found to be predictive of post-hospitalisation fracture-related pain. CONCLUSIONS: This analysis shows that a substantial percentage of elderly patients with proximal femoral fracture suffer intense fracture-related hip pain after stationary treatment.

Diagnosis and treatment of osteoporosis in postmenopausal women with distal radius fracture in Germany.

OBJECTIVE: The aim of this study was to evaluate osteoporosis diagnosis and treatment on the basis of medical history, at hospital discharge, and 6-12 months after discharge, as well as to assess the frequency of subsequent fractures in postmenopausal women with distal radius fracture. RESEARCH DESIGN AND METHODS: A prospective, observational study of hospitalized women aged 55 years and older with an isolated distal radius fracture from minimal trauma. Subjects were recruited in 242 acute care hospitals in Germany. OUTCOME MEASURES: Potential risk factors for osteoporosis, frequency of osteoporosis assessment, frequency of medication treatment and subsequent fractures 6-12 months after discharge. RESULTS: Among 2031 patients we identified 652 appropriate postmenopausal women. Less than one-third of patient histories contained any bone density parameters, and only a minority of subjects (33%, 217) underwent bone density assessment while in hospital. Of these, 55% (119) were diagnosed with low bone density, yet only 30% of those were prescribed supplements (calcium/vitamin D) and/or specific osteoporosis medication (mostly bisphosphonates) at discharge. Six to twelve months after hospital discharge, the low rate of treatment had not changed substantially. In the interval, 4.3% had sustained a subsequent fracture from minimal trauma: 1.4% a distal radius fracture (0.3% a refracture) and 2.9% a hip joint or other fracture (not specified). A significant age difference between those with and without subsequent distal radius fractures was found (p = 0.01) but not a significant difference between patients with or without osteoporosis medication (p = 0.79), primarily because the case numbers were too small. CONCLUSIONS: A substantial proportion of postmenopausal women hospitalized with distal radius fracture were not sufficiently evaluated or treated for their potential risk of osteoporosis.

[Osteoporosis and falls in Germany: health care for the elderly with an increased risk for fractures]. / Osteoporose und Sturz: medizinische Versorgung alterer Menschen mit einem erhöhten Frakturrisiko in Deutschland.

Fractures are a considerable risk, especially in older patients. The fracture of the proximal femur is of particular relevance. Functional deficiency, an increased need for care and assistance and a limitation of the quality of life after a fracture lead to an increase in morbidity and mortality among patients who lived independently prior to the event in most cases. The risk of suffering a femoral fracture mainly depends on two risk factors: osteoporosis and falls. Both can be influenced and are therefore suitable for interventions. National and international guidelines for diagnosis and treatment have so far separately addressed deficiencies in bone stability and neuromuscular function. The current German DVO guideline is the first to consider both aspects simultaneously and develop an individual concept for diagnosis and therapy depending on a risk prediction of a fracture within the following 10 years. The evaluation of the current quality of health care in the field of osteoporosis and falls both nationally and internationally seems to be hardly possible. Merely the delivery of DXA measurements and medication for osteoporosis are assessable. In these sectors a deficiency in the delivery of care is apparent. Standardized evaluations of the implementation of guidelines are needed to assess deficiencies and reveal options for improving quality of care in the future.

Patients with femoral or distal forearm fracture in Germany: a prospective observational study on health care situation and outcome.

BACKGROUND: Distal radius and proximal femoral fractures are typical injuries in later life, predominantly due to simple falls, but modulated by other relevant factors such as osteoporosis. Fracture incidence rates rise with age. Because of the growing proportion of elderly people in Western industrialized societies, the number of these fractures can be expected to increase further in the coming years, and with it the burden on healthcare resources. Our study therefore assessed the effects of these injuries on the health status of older people over time. The purpose of this paper is to describe the study method, clinical parameters of fracture patients during hospitalization, mortality up to one and a half years after discharge in relation to various factors such as type of fracture, and to describe changes in mobility and living situation. METHODS: Data were collected from all consecutive patients (no age limit) admitted to 423 hospitals throughout Germany with distal radius or femoral fractures (57% acute-care, femoral and forearm fractures; 43% rehabilitation, femoral fractures only) between January 2002 and September 2003. Polytrauma and coma patients were excluded. Demographic characteristics, exact fracture location, mobility and living situation, clinical and laboratory parameters were examined. Current health status was assessed in telephone interviews conducted on average 6-7 months after discharge. Where telephone contact could not be established, at least survival status (living/deceased/date of death) was determined. RESULTS: The study population consisted of 12,520 femoral fracture patients (86.8% hip fractures), average age 77.5 years, 76.5% female, and 2,031 forearm fracture patients, average age 67.6 years, 81.6% female. Women's average age was 6.6 (femoral fracture) to 10 years (forearm fracture) older than men's (p < 0.0001). Only 4.6% of femoral fracture patients experienced changes in their living situation post-discharge (53% because of the fracture event), although less than half of subjects who were able to walk without assistive devices prior to the fracture event (76.7%) could still do so at time of interview (34.9%). At time of interview, 1.5% of subjects were bed-ridden (0.2% before fracture). Forearm fracture patients reported no change in living situation at all. Of the femoral fracture patients 119 (0.95%), and of the forearm fracture patients 3 (0.15%) died during hospital stay. Post-discharge (follow-up one and a half years) 1,463 femoral fracture patients died (19.2% acute-care patients, 8.5% rehabilitation patients), but only 60 forearm fracture patients (3.0%). Ninety percent of femoral fracture deaths happened within the first year, approximately 66% within the first 6 months. More acute-care patients with a pertrochanteric fracture died within one year post-discharge (20.6%) than patients with a cervical fracture (16.1%). CONCLUSION: Mortality after proximal femoral fracture is still alarmingly high and highest after pertrochanteric fracture. Although at time of interview more than half of femoral fracture patients reported reduced mobility, most patients (96%) attempt to live at home. Since forearm fracture patients were on average 10 years younger than femoral fracture patients, forearm fractures may be a means of diagnosing an increased risk of later hip fractures.

[Trochanteric femur fractures--analysis of external quality assurance within a comprehensive survey]. / Pertrochantäre Femur-frakturen--Analyse der Daten externer Qualitäts- sicherung im Rahmen einer flächendeckenden Erfassung.

INTRODUCTION: Trochanteric femur fractures are a typical injury of elderly people and are of significant relevance for their quality of life. MATERIAL AND METHOD: Data on 7252 proximal femur fractures from the department of external quality assurance of the chamber of physicians of Westphalia-Lippe/Germany were analysed. Topics of interest were: patient profile, type of femur fracture, method of treatment, intra- and postoperative complications, mobility before and after fracture. RESULTS: 2883 of 7252 proximal femur fractures were trochanteric fractures, 89.9% of which were instable. Trochanteric fractures were either stabilised by extra-medullary implants, e.g. dynamic hip screw (DHS; 57.5%), or by intra-medullary implants, e.g. proximal femur nail (PFN; 38.3%). The following intra-operative complications were reported: bone injury, vessel injury, nerve injury, others. Intra-medullary implants caused nearly twice as many complications as DHS (1.8% vs. 1.1%; chi-square test, p < 0.01). Specialised orthopaedic trauma departments (1.7%) had fewer complications than non-specialised units (2.2%) (chi-square test, p < 0.001). Mobility after intra- and extra-medullary fixation was comparable. At the time of discharge, 58% of patients were able to walk with crutches. High-volume hospitals (151 - 175 patients) performed significantly better than low-volume hospitals (1 - 25 patients) concerning mortality and intra- and postoperative complications. However, it is not possible to infer good quality from high volume alone, because some low-volume hospitals showed excellent results. CONCLUSION: Treatment of trochanteric femur fractures is relatively safe. Extra-medullary implants can be used for instable trochanteric fractures with good results.

[A new model of comprehensive data linkage--evaluation of its application in femoral neck fracture]. / Ein neues Modell der sektorübergreifenden Datenzusammenführung und Evaluation am Beispiel der Schenkelhalsfraktur.

Aim of the project was a comprehensive assessment of short- and middle-term outcome of femoral neck fracture by linkage and analysis of available data from routine care. For this purpose, a generic model of data linkage was developed, agreed with the data security officer, and practically applied. Included were all patients of the AOK Westphalia-Lippe, who were treated in a general or trauma surgery hospital in 1995/1999 for a femoral neck fracture (ICD-9: 820). For these patients, the linkage was based on the following sources: the data regarding the initial hospital stay were provided by the office of quality assurance of the chamber of physicians of Westphalia-Lippe; the administrative data were provided by the AOKWestphalia-Lippe; and the data evaluating the nursing needs were obtained from the Medical Services of the Health Insurance of Westphalia-Lippe (MDK). This paper presents the model of data linkage and describes its practical implementation; it also presents medical data demonstrating that femoral neck fractures are associated with high mortality and increase of nursing needs in the course of disease. The benefit of the new model is manifold and can be easily extended to other clinical questions.