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.

Percutaneous fixation of displaced proximal humeral fractures: indications based on the correlation between clinical and radiographic results.

We evaluated 74 patients with displaced proximal humeral fractures (mean age, 70.9 years) treated with closed reduction and percutaneous pinning. Fractures were classified radiographically following Neer's system, and the quality of reduction was assessed according to Kristiansen and Kofoed. Patients were also evaluated clinically with the Constant scale. Overall, the reduction was good in 72% of fractures, but the probability of obtaining a satisfactory reduction of displaced tuberosities was significantly lower in comparison to the humeral head. Four-part fractures obtained the worst radiographic results. The mean Constant scores were 65.8 +/- 18 points for the injured shoulder and 79.5 +/- 9.1 points for the opposite shoulder. Clinical results correlated with the quality of reduction. Closed reduction and percutaneous pinning should be reserved for 2-part fractures, but the technique can also be used in 3-part fractures in elderly patients, in whom an incomplete reduction can yield satisfactory clinical results.

Rotator cuff impingement due to enchondroma of the acromion.

We report the case of a patient with a long standing clinical history of subacromial impingement, in which plain radiographs and CT-scan revealed a well-circumscribed lucent lesion expanding the undersurface of the acromion. MRI showed the subacromial fat to be completely obliterated and the infraspinatus tendon deformed due to compression by a mass localised at the acromion. The acromial lesion was curetted, and histopathologic analysis was consistent with the diagnosis of enchondroma. Tumours located in the coracoacromial arch have been very rarely reported as a cause of subacromial impingement. To the best of our knowledge, this is the first description of subacromial impingement secondary to acromial enchondroma.