Resultado de la actualización de la vía clínica de la fractura de cadera del anciano en un hospital universitario de Madrid / Result of the update of the clinical pathway for hip fracture in the older adult at a university hospital in Madrid

Antecedentes y objetivos: El manejo ortogeriátrico con vías clínicas (VC) en la fractura de cadera (FC) se muestra superior a otros modelos. Estudiamos si actualizar la VC, mediante la priorización organizativa del ingreso y la cirugía, mejora en la prevención y tratamiento del delirium, el manejo de anticoagulantes y antiagregantes y el uso del bloqueo periférico nervioso perioperatorio, modifica la demora quirúrgica, estancia, reingresos, mortalidad, delirium y estado funcional al alta. Material y método: Estudio observacional retrospectivo de cohortes unicéntrico de 468 pacientes con FC, 220 del año 2016 (VC antigua) y 248 del año 2019 (VC nueva). Las variables son: intervención en 48h, demora quirúrgica (horas), estancia (días), estancia menor de 15 días, delirium, pérdida funcional al alta (escala Barthel prefractura menos escala Barthel al alta), reingreso al mes, y mortalidad en el ingreso, al mes y al año. Resultados: Mediana de edad de 87,0 [rango intercuartílico 8,0], mujeres 76,7%. Significativamente con la nueva VC se observa un mayor número de pacientes intervenidos en 48h (27,7% vs. 36,8%; p=0,036), menor demora quirúrgica (72,5 [47,5-110,5] vs. 64,0 [42,0-88,0]; p=0,001), menor estancia (10,0 [7,0-13,0] vs. 8,0 [6,0-11,0]; p<0,001), mayor número de altas en 15 días (78,2% vs. 91,5%; p<0,001), menor delirium (54,1% vs. 43,5%; p=0,023). No se detectan cambios significativos en reingresos, pérdida funcional, mortalidad en el ingreso, a los 3 meses o al año. Conclusiones: Actualizar la VC aporta beneficios al paciente (menor demora quirúrgica, igual estado funcional al alta con menos días de ingreso) y beneficios en la gestión (menor ingreso) sin modificar la mortalidad. (AU)

Background and objectives: Orthogeriatric management with clinical pathways (CP) in hip fracture (HF) has been shown to be superior to other models. We studied whether updating the CP, through prioritization of admission and surgery, improvement in the prevention and treatment of delirium, management of anticoagulants and antiplatelet agents and the use of perioperative peripheral nerve block, modifies surgical delay, stay, readmissions, mortality, suffering delirium and functional status at discharge. Material and method: A retrospective observational study of unicenter cohorts of 468 patients with HF, 220 from 2016 (old VC) and 248 from 2019 (new VC). The variables are: intervention in the first 48hours, surgical delay (hours), stay (days), stay less than 15 days, delirium, functional loss at discharge (Barthel prefracture scale less Barthel scale at discharge), readmission at one month, and mortality at admission, month and year. Results: Median age: 87.0 [interquartile range 8.0], mostly women (76.7%). Significantly, with the new VC, there was a greater number of patients operated on in the first 48hours (27,7% vs 36,8% p=0.036), less surgical delay (72.5 [47,5-110,5] vs 64.0 [42,0-88,0] p<0.001), shorter stay (10,0 [7,0-13,0] vs 8,0 [6,0-11,0] p<0.001), greater number of discharges in 15 days (78,2% vs 91,5% p<0.001), lower delirium (54,1% vs 43,5% p=0.023). No significant changes in readmissions, functional loss at discharge, mortality at admission, 3 months or year.Conclusions: Updating the VC brings benefits to the patient (less surgical delay, equal functional status at discharge with fewer days of admission) and benefits in management (lower admission) without modifying mortality. (AU)

[Result of the update of the clinical pathway for hip fracture in the older adult at a university hospital in Madrid]. / Resultado de la actualización de la vía clínica de la fractura de cadera del anciano en un hospital universitario de Madrid.

BACKGROUND AND OBJECTIVES: Orthogeriatric management with clinical pathways (CP) in hip fracture (HF) has been shown to be superior to other models. We studied whether updating the CP, through prioritization of admission and surgery, improvement in the prevention and treatment of delirium, management of anticoagulants and antiplatelet agents and the use of perioperative peripheral nerve block, modifies surgical delay, stay, readmissions, mortality, suffering delirium and functional status at discharge. MATERIAL AND METHOD: A retrospective observational study of unicenter cohorts of 468 patients with HF, 220 from 2016 (old VC) and 248 from 2019 (new VC). The variables are: intervention in the first 48hours, surgical delay (hours), stay (days), stay less than 15 days, delirium, functional loss at discharge (Barthel prefracture scale less Barthel scale at discharge), readmission at one month, and mortality at admission, month and year. RESULTS: Median age: 87.0 [interquartile range 8.0], mostly women (76.7%). Significantly, with the new VC, there was a greater number of patients operated on in the first 48hours (27,7% vs 36,8% p=0.036), less surgical delay (72.5 [47,5-110,5] vs 64.0 [42,0-88,0] p<0.001), shorter stay (10,0 [7,0-13,0] vs 8,0 [6,0-11,0] p<0.001), greater number of discharges in 15 days (78,2% vs 91,5% p<0.001), lower delirium (54,1% vs 43,5% p=0.023). No significant changes in readmissions, functional loss at discharge, mortality at admission, 3 months or year. CONCLUSIONS: Updating the VC brings benefits to the patient (less surgical delay, equal functional status at discharge with fewer days of admission) and benefits in management (lower admission) without modifying mortality.

Hierro intravenoso, recuperación funcional y delirium en pacientes con fractura de cadera. Estudio FEDEREF. Ensayo clínico unicéntrico aleatorizado, controlado con placebo, doble ciego. Número EudraCT: 2014-001923-53 / Intravenous iron, functional recovery and delirium in patients with hip fracture. FEDEREF study. Single-centre randomised, placebo-controlled, and double-blind clinical trial. 2014-001923-53: EudraCT number

Introducción. No existen estudios previos que evalúen el efecto de la ferroterapia intravenosa sobre la situación funcional y cognitiva de pacientes con fractura de cadera (FC). Material y métodos. Ensayo clínico unicéntrico aleatorizado, controlado con placebo, doble ciego en grupos paralelos, para comparar la eficacia del tratamiento con hierro intravenoso perioperatorio en pacientes ancianos intervenidos de FC. Se asegura el enmascaramiento del tratamiento, envolviendo el fármaco y el sistema de infusión. El grupo intervención recibirá, los días 1, 3 y 5 de ingreso, 200mg de Venofer (R ) (hierro sacarosa), diluidos en 100ml de suero salino y el control, 100ml de suero salino los días 1, 3 y 5 de ingreso. Los pacientes reciben la asistencia convencional en la Unidad de Ortogeriatría del Hospital Universitario Infanta Sofía. Para valorar el impacto del tratamiento, se recogen variables funcionales (actividades de la vida diaria y capacidad de deambulación), cognitivas (situación cognitiva previa y delirium), quirúrgicas, demográficas y clínicas durante el ingreso y se realiza un análisis de seguridad del tratamiento. Los pacientes reciben seguimiento a los 3, 6 y 12 meses. Resultados. El estudio reportará evidencia acerca del impacto de la administración de hierro intravenoso sobre la recuperación funcional a corto y medio plazo. Permitirá evaluar si la administración de ferroterapia intravenosa tiene algún efecto negativo sobre la incidencia de delirium postoperatorio. Aportará información acerca de la seguridad de la administración de ferroterapia intravenosa en pacientes ancianos con FC y su repercusión sobre el ahorro transfusional. Conclusiones. La inclusión de los pacientes ancianos con FC ingresados en una unidad de ortogeriatría en el ensayo clínico permitirá la evaluación del impacto del fármaco en un escenario habitual, y aportará datos valiosos para la protocolización de su uso en otras unidades (AU)

Introduction. There are no previous studies evaluating the effect of intravenous iron therapy on functional and cognitive status of patients with hip fracture (HF). Material and methods. A single-centre randomised, placebo-controlled, double-blind and parallel treatment, clinical trial has been designed to assess the efficacy of intravenous iron therapy during the peri-operative period in elderly patients suffering from a HF. Blinding will be ensured by the packaging of the drug infusion system. On days 1, 3, and 5 from admission, the intervention group will receive 200mg Venofer (R ) (iron sucrose) diluted in 100ml saline, and the control group 100ml saline, also on days 1, 3 and 5. Patients will received conventional treatment in ortho-geriatric unit of the Hospital Infanta Sofia. Functional variables (activities of daily living and walking), cognitive (cognitive status and delirium), surgical, demographic and clinical characteristics will be collected during admission in order to assess the impact of treatment. A safety analysis of the treatment will also performed. Patients will be followed-up at 3, 6, and 12 months. Results. The study will attempt to provide evidence on the impact of the intravenous iron administration on functional recovery. It will be determined whether iron therapy negatively affects the incidence of post-operative delirium. Finally, report will be presented on the safety data of intravenous iron in elderly HF patients, as well as the impact on allogenic blood transfusion savings. Conclusions. The inclusion of elderly HF patients admitted to an ortho-geriatric unit, in a clinical trial, will help to improve the knowledge of the treatment impact on a usual scenario, and provide useful data for use in other units (AU)

[Intravenous iron, functional recovery and delirium in patients with hip fracture. FEDEREF study. Single-centre randomised, placebo-controlled, and double-blind clinical trial. 2014-001923-53: EudraCT number]. / Hierro intravenoso, recuperación funcional y delirium en pacientes con fractura de cadera. Estudio FEDEREF. Ensayo clínico unicéntrico aleatorizado, controlado con placebo, doble ciego. Número EudraCT: 2014-001923-53.

INTRODUCTION: There are no previous studies evaluating the effect of intravenous iron therapy on functional and cognitive status of patients with hip fracture (HF). MATERIAL AND METHODS: A single-centre randomised, placebo-controlled, double-blind and parallel treatment, clinical trial has been designed to assess the efficacy of intravenous iron therapy during the peri-operative period in elderly patients suffering from a HF. Blinding will be ensured by the packaging of the drug infusion system. On days 1, 3, and 5 from admission, the intervention group will receive 200mg Venofer® (iron sucrose) diluted in 100ml saline, and the control group 100ml saline, also on days 1, 3 and 5. Patients will received conventional treatment in ortho-geriatric unit of the Hospital Infanta Sofia. Functional variables (activities of daily living and walking), cognitive (cognitive status and delirium), surgical, demographic and clinical characteristics will be collected during admission in order to assess the impact of treatment. A safety analysis of the treatment will also performed. Patients will be followed-up at 3, 6, and 12 months. RESULTS: The study will attempt to provide evidence on the impact of the intravenous iron administration on functional recovery. It will be determined whether iron therapy negatively affects the incidence of post-operative delirium. Finally, report will be presented on the safety data of intravenous iron in elderly HF patients, as well as the impact on allogenic blood transfusion savings. CONCLUSIONS: The inclusion of elderly HF patients admitted to an ortho-geriatric unit, in a clinical trial, will help to improve the knowledge of the treatment impact on a usual scenario, and provide useful data for use in other units.

Vía clínica de fractura de cadera de la Unidad de Ortogeriatría del Hospital Universitario Infanta Sofía / Clinical pathway for hip fracture in the Orthogeriatric Unit of the Hospital Infanta Sofia

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Proximal Gastrocnemius Release in the Treatment of Mechanical Metatarsalgia.

BACKGROUND: Gastrocnemius shortening causes an equinus deformity that may clinically manifest in foot disorders, including metatarsalgia. We use this term to describe pain localized to the metatarsal heads. The purposes of this prospective study were to review the effect of medial gastrocnemius proximal release on ankle dorsiflexion and assess the outcome of this technique on pain and functional limitations in patients who have mechanical metatarsalgia and isolated gastrocnemius shortening. METHODS: We prospectively followed a consecutive series of 78 feet in 52 patients with metatarsalgia who had an isolated gastrocnemius contracture assessed with the Silfverskiöld test. Surgical release was evaluated with visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scales. Ankle dorsiflexion was measured at 1, 3, and 6 months postoperatively. RESULTS: Preoperative values of VAS and AOFAS were 7.4 and 46.8, respectively. After 3 months postoperatively, the values were 3.0 and 81.7, and 6 months after surgery these values were 3.5 and 83.6. No patient worsened clinically. There were no major complications. Thirty-six patients (69.2%) were completely satisfied with the results of the surgery. Preoperatively, ankle dorsiflexion with the knee straight was -17.5 degrees, which improved to 2.5 degrees at 6 months postoperatively. CONCLUSION: We believe proximal medial gastrocnemius recession is an alternate procedure to treat selected patients with mechanical metatarsalgia and gastrocnemius shortening. It had acceptable morbidity and cosmetic results. LEVEL OF EVIDENCE: Level IV, case series.

Implantación de una Unidad de Ortogeriatría de Agudos en un hospital de segundo nivel / Opening of an Acute Orthogeriatric Unit in a general hospital

Introducción. Los pacientes con fractura de cadera (FC), precisan por sus características una asistencia específica. Una de las que más beneficios han demostrado es la Unidad Ortogeriátrica de Agudos (UOG). Objetivos. Evaluar las principales variables, de los pacientes con FC atendidos en una UOG de nueva creación y compararlas con el modelo interconsultor previo (IC). Material y métodos. Estudio prospectivo observacional con control retrospectivo. Se distribuyen en 2 grupos, 169 pacientes. En el grupo IC, los pacientes ingresan en planta convencional de Traumatología y en el grupo UOG, se realiza una valoración geriátrica precoz, son atendidos a diario por el traumatólogo, la enfermera y el geriatra simultáneamente, y semanalmente en una reunión con el resto de profesionales se planifican los tiempos de cirugía, de carga, de alta y el destino. Resultados. Se incluyen 71 pacientes en el grupo de IC y 96 en el grupo de UOG. Las características previas son homogéneas, salvo una comorbilidad discretamente superior en el grupo de UOG. Los pacientes de UOG se intervinieron antes (3,82±2,08 vs 4,61±2,5 días; p<0,32) y la estancia hospitalaria global se redujo un 28% (11,84±4,04 vs 16,46±8,4 días; p<0,001). La eficiencia funcional (índice de Barthel al alta-índice de Barthel al ingreso/estancia global-estancia precirugía) fue superior en el grupo de UOG (1,56±0,7 vs 2,61±1,1; p<0,05). No hubo diferencias en la situación funcional, la mortalidad o la ubicación al alta. Conclusiones. La UOG es un nivel asistencial que aporta una atención más eficaz de los pacientes con FC en hospitales de segundo nivel(AU)

Background. Patients with hip fracture (HF), due to their characteristics, require a specific support. The Acute Orthogeriatric Unit (OGU) has been shown to be one of the most beneficial. Objective. To evaluate the main variables of HF patients treated at an OGU and compare them with the previous referral model (RC). Material and methods. A prospective observational study with retrospective control was conducted on 169 patients, split into two groups. In the RC group, patients were admitted to conventional trauma ward. In the OGU group, an early geriatric assessment was performed, and patients were simultaneously attended daily by the orthopaedic surgeon, nurse and geriatrician, and the surgery times, work load, discharge and destination, were planned in a weekly meeting with the rest of professionals. Results. A total of 71 patients were included in the RC group and 96 in the OGU group. The preoperative characteristics were similar, except for a slightly higher comorbidity in the OGU group. The OGU patients were operated on earlier (3.82±2.08 vs 4.61±2.5 days; P<.32), and overall hospital stay was reduced by 28% (11.84±4.04 vs 16.46±8.4 days; P<.001). The functional efficiency (Barthel Index at discharge-Barthel Index at admission/overall stay - stay before surgery) was higher in the OGU group (1.56±0.7 vs 2.61±1.1; P<.05). There were no differences in functional status, mortality or discharge location. Conclusions. The OGU is a level of care that provides effective medical care in HF patients in general hospitals(AU)

[Opening of an Acute Orthogeriatric Unit in a general hospital]. / Implantación de una Unidad de Ortogeriatría de Agudos en un hospital de segundo nivel.

BACKGROUND: Patients with hip fracture (HF), due to their characteristics, require a specific support. The Acute Orthogeriatric Unit (OGU) has been shown to be one of the most beneficial. OBJECTIVE: To evaluate the main variables of HF patients treated at an OGU and compare them with the previous referral model (RC). MATERIAL AND METHODS: A prospective observational study with retrospective control was conducted on 169 patients, split into two groups. In the RC group, patients were admitted to conventional trauma ward. In the OGU group, an early geriatric assessment was performed, and patients were simultaneously attended daily by the orthopaedic surgeon, nurse and geriatrician, and the surgery times, work load, discharge and destination, were planned in a weekly meeting with the rest of professionals. RESULTS: A total of 71 patients were included in the RC group and 96 in the OGU group. The preoperative characteristics were similar, except for a slightly higher comorbidity in the OGU group. The OGU patients were operated on earlier (3.82±2.08 vs 4.61±2.5 days; P<.32), and overall hospital stay was reduced by 28% (11.84±4.04 vs 16.46±8.4 days; P<.001). The functional efficiency (Barthel Index at discharge-Barthel Index at admission/overall stay - stay before surgery) was higher in the OGU group (1.56±0.7 vs 2.61±1.1; P<.05). There were no differences in functional status, mortality or discharge location. CONCLUSIONS: The OGU is a level of care that provides effective medical care in HF patients in general hospitals.