What determines health-related quality of life in hip fracture patients at the end of acute care?--a prospective observational study.

UNLABELLED: Hip fractures are associated with reduced health-related quality of life (HrQoL). We found pre-existing need of care or limited function, cognitive impairment, and depression to be independent factors associated with lower HrQoL during the postsurgical period. In contrast, joint replacement was associated with better HrQoL compared to internal fixation. Patients' treatment should be focused on functional recovery and treatment of depression. INTRODUCTION: The aim of the study was to identify independent factors that were correlated with health-related quality of life (HrQoL) after hip fracture. METHODS: A total of 402 patients with a mean age of 81 years suffering from a hip fracture were included in this prospective, observational cohort study. HrQoL (determined by the EuroQol instrument) was measured at admission and at discharge from an acute care hospital. Independent factors correlated with HrQoL at discharge and changes from pre-fracture to discharge were determined using multivariate analyses. The influence of antidepressants was evaluated by an ANOVA with repeated measurements. RESULTS: Need of care prior to fracture was the most important determinant of EQ-5D index at discharge (ß = -0.359, p = 0.003). Additionally, low Mini Mental Status Examination (MMSE) was associated with a lower EQ-5D index at discharge (MMSE 0-9: ß = -0.238, p <0.001; MMSE 10-19: ß = -0.294, p <0.001) and a greater decrease in EQ-5D during hospitalisation (MMSE 10-19: ß = 0.281, p <0.001), while joint replacement (compared to internal fixation) was associated with a higher EQ-5D index (ß = 0.188, p = 0.002) and a lower decrease in the index (ß = -0.216, p = 0.003). EQ VAS values at discharge were correlated with pre-fracture Barthel Index (ß = 0.253, p <0.001) and Geriatric Depression Scale scores (ß = -0.135, p = 0.026). Depressive patients on antidepressants demonstrated less of a decrease in the EQ-5D index compared to patients not receiving medication (F = 2.907, p = 0.090). CONCLUSIONS: Acute care of hip fracture patients should be focused on functional recovery and treatment of depression. When the preferred surgical strategy is unclear, joint replacement should be considered.

[Surgical treatment of proximal femoral fractures--a training intervention?]. / Die operative Versorgung proximaler Femurfrakturen--ein Weiterbildungseingriff?

BACKGROUND: Proximal femoral fractures are common in the elderly. Surgical and postoperative complications are of major importance in this population. Numerous factors affecting the treatment results could be identified so far. The effect of surgeons' experience in terms of educational status is not entirely clarified yet. The aim of the present study was to analyse the effect of surgeons' educational status on the outcome in proximal femoral fractures. Therefore treatment results were compared in terms of individual surgeons' experience. Furthermore, the surgical education concept of our department was evaluated. MATERIAL AND METHODS: At a national trauma centre, patients of at least 60 years of age with proximal femoral fractures were prospectively screened. Patient-specific parameters like Barthel index, ASA score, Charlson score, patients' age and type of fracture were collected at the time of hospital admission. During the in-hospital stay type of fracture treatment, surgery time, number of blood transfusions, perioperative complications, duration of in-hospital stay as well as in-hospital mortality were recorded. Results were analysed for osteosynthesis and prosthesis depending on the surgeons' educational status. Four different groups of surgeons were distinguished (inexperienced senior house officer; experienced senior house officer; specialist in orthopaedics and accident surgery; specialist in orthopaedics and accident surgery with an additional qualification for special accident surgery). RESULTS: 402 patients with coxal femoral fractures could be included into the study. 160 patients (40 %) sustained complications of different severity. In-hospital mortality was shown to be 6.2 %. Separate consideration of osteosynthesis and prosthesis revealed no difference between the four groups of surgeons regarding mortality rate, number of blood transfusions and in-hospital stay. In terms of cutting/suture time consultants with a further specialisation in trauma surgery were significantly faster. CONCLUSION: Apart from cutting/suture time, surgeons' educational status had no statistically significant impact on the rate of complications, rate of blood transfusions, hospital mortality and in-hospital stay. It can be presumed that surgical education according to our educational concept has no negative effects on treatment quality of patients with proximal femoral fractures. Differences in cutting/suture time give a hint for the additional expense that is connected with surgical education.

[Semilunar bone necrosis (Kienböck's disease) - first clinical results after free microvascularised bone graft from the distal femur]. / Die idiopathische Mondbeinnekrose (M. Kienböck) - Erste Ergebnisse nach operativer Therapie mit einem freien mikrovaskulären Femurtransplantat.

BACKGROUND: Idiopathic aseptic osseous necrosis of the semilunar bone is also called Kienböck's disease after Robert Kienböck who firstly described this disease. The clinical picture is characterised by a stage-like course. Internationally the classification according to Lichtman and Ross has achieved the most acceptance. The actual therapy is dependent on the present disease stage. Basically, various pressure-relieving operative procedures are possible, on the other hand operative interventions via revascularisation represent a therapeutic option. In the case of advanced disease only, "salvage procedures" like partial or total arthrodesis of the wrist are available. However, such operations are associated with marked restrictions in the range of motion and unsatisfactory clinical results. The present study reports on our clinical experiences after operative therapy for aseptic lunar bone necrosis via free microvascularised bone grafting from the distal femur. PATIENTS AND METHODS: Between 01/2005 and 12/2010 nineteen patients with idiopathic semilunar bone necrosis underwent operative care via a free microvascularised bone graft from the distal femur at our institution. 16 patients could be re-evaluated retrospectively on follow-up examination at 26.5 months (range 16-42) on average after primary care. Mean age was 43.8 years (range 24-66). Clinical assessment was performed according to the Mayo wrist score (MWS) and the disabilities of the arm, shoulder and hand (DASH) score. Radiological assessment was performed according to the classification of Lichtman and Ross. RESULTS: On operative treatment 14 patients were graded II at least according to the Lichtman classification. An additional 2 patients showed a stage III B disease. The median operative time amounted to 254 min (range 233-362). The postoperative course did not reveal any complications, in particular concerning wound healing. Only one patient (6 %) showed no trabecular integration between the inserted graft and the lunar bone. Clinical evaluation according to the MWS with a median of 82.5 points (65-100), and the DASH score with a median of 29.5 points (24.2-102.2) documented good to excellent clinical results. CONCLUSION: Operative treatment for idiopathic semilunar bone necrosis via a free microvascularised bone graft from distal femur achieves good clinical results without an increase of postoperative complications even with advanced stages of the disease. However, long-term results and larger patient samples are required to prove the final success of this operative technique.