Reduced morbidity for elderly patients with a hip fracture after implementation of a perioperative evidence-based clinical pathway.

BACKGROUND: Hip fractures, common in the elderly population, result in significant morbidity and mortality. A study was undertaken to determine how an evidence based clinical pathway (CP) for treatment of elderly patients with hip fracture affected morbidity, in-hospital mortality, and health service utilization. METHODS: A pre-post study design using two population based inception cohorts of hip fracture patients aged > or =65 years was used. The control group (n = 678) was enrolled between July 1996 and September 1997 before implementation of the pathway and the CP group (n = 663) was enrolled between July 1999 and September 2000 following pathway implementation. Chart reviews were completed during study time frames to determine complications, mortality, and health service utilization. RESULTS: Only nine patients (1%) in the CP group experienced postoperative congestive heart failure compared with 37 (5%) control patients (p<0.001). Postoperative cardiac arrythmias were significantly lower in the CP group than in the control group (8 (1%) v 36 (5%); p<0.001). Postoperative delirium occurred in 22% of the CP group and 51% of the control group (p<0.001). There was no difference in risk adjusted in-hospital mortality between the two groups. Overall length of stay (LOS) and costs were unchanged between the groups; however, hospital LOS increased while rehabilitation LOS decreased in the CP group. CONCLUSION: Implementation of an evidence based clinical pathway reduced postoperative morbidity and did not affect in-hospital mortality or overall costs of inpatient care. The effect of changing trends in medical care cannot be ruled out, but the reduction in complications in several clinical areas lends support to the positive impact of the clinical pathway. Perioperative CP is one successful management approach for this fragile patient population as patient morbidity was reduced without negatively affecting resource utilization.

Quantitative assessment of growth factors in reaming aspirate, iliac crest, and platelet preparation.

Large bony defects and non-unions are still a complication in trauma and orthopedic surgery. Treatment strategies include the use of autogenous materials (iliac crest), allogenic bone, bone substitutes, and currently stimulation with growth factors such as BMP-2, BMP-7 or the growth factors containing platelet-rich plasma (PRP). Another source of bone graft material might be the cuttings produced during intramedullary reaming. The aim of this study was to compare the quantity of various growth factors found within iliac crest, bony reaming debris, reaming irrigation fluid, and platelet-rich plasma. Iliac crest and reaming debris and irrigation samples were harvested during surgery. PRP was prepared from blood. The growth factors in the bony materials (iliac crest or reaming debris) and of the liquid materials (platelet-poor plasma (PPP), platelet-rich plasma (PRP) or reaming irrigation) were compared. Elevated levels of FGFa, PDGF, IGF-I, TGF-beta1 and BMP-2 were measured in the reaming debris as compared to iliac crest curettings. However, VEGF and FGFb were significantly lower in the reaming debris than from iliac crest samples. In comparing PRP and PPP all detectable growth factors, except IGF-I, were enhanced in the platelet-rich plasma. In the reaming irrigation FGFa (no measurable value in the PRP) and FGFb were higher, but VEGF, PDGF, IGF-I, TGF-beta1 and BMP-2 were lower compared to PRP. BMP-4 was not measurable in any sample. The bony reaming debris is a rich source of growth factors with a content comparable to that from iliac crest. The irrigation fluid from the reaming also contains growth factors.