Impact of the nail insertion angle on the wedge effect in intramedullary nail fixation of intertrochanteric hip fractures.

BACKGROUND: The wedge effect is known to be influenced by the insertion of the proximal femoral intramedullary nail through the fracture line and the large proximal diameter of the nail. However, the impact of the nail insertion angle (NIA) on the wedge effect remains unclear. This study aimed to investigate: (1) how to evaluate the NIA intraoperatively, (2) whether the NIA is associated with the wedge effect, (3) whether the NIA can serve as a reliable predictor of the wedge effect, (4) which factors affect the NIA, and (5) which surgical techniques can prevent the occurrence of the wedge effect associated with the NIA. HYPOTHESIS: We hypothesized that an excessive NIA is related to the wedge effect and that lateral deviation of the entry point is associated with an excessive NIA. PATIENTS AND METHODS: Intraoperative fluoroscopy images of patients who underwent intramedullary nail fixation for intertrochanteric hip fractures between 2013 and 2023 were analyzed. NIA and insertion point distance (IPD) were measured on hip anteroposterior radiographs with the guidewire inserted. Femoral shaft lateralization (FSL) and neck-shaft angle (NSA) were measured on hip anteroposterior radiographs before and after nail insertion; differences in FSL and NSA were calculated. A negative difference in FSL combined with a positive difference in NSA indicated the occurrence of the wedge effect. Pearson's correlation test was used to determine relationships between continuous variables (NIA, FSL, NSA, and IPD). Binary logistic regression analyzed the association between NIA and the wedge effect. Receiver operating characteristic (ROC) curve analysis was used to determine the threshold value of NIA, with predictive performance assessed using the area under the ROC curve (AUC). Other potential factors influencing the wedge effect were also examined. RESULTS: A total of 408 patients were included. The mean NIA was 15.61 ± 4.49 °. Post-nail insertion, the average increase in FSL was 3.20 mm, and the average decrease in NSA was 1.90 °. Pearson's correlation test revealed that NIA was negatively correlated with the difference in FSL (R = 0.565, P < 0.001) and positively correlated with the difference in NSA (R = 0.509, P < 0.001). Binary logistic regression showed a significant correlation between NIA and the wedge effect (P < 0.001). ROC analysis indicated that the AUC for NIA was 0.813, with an optimal cutoff point of 14.85 °. IPD was positively correlated with NIA (R = 0.519, P < 0.001). Unstable fractures were associated with increased lateralization of the femoral shaft after nail insertion (P = 0.003). DISCUSSION: The NIA is positively correlated with the wedge effect in intramedullary nail fixation of intertrochanteric hip fractures. The wedge effect tends to occur when the NIA is >14.85 °, particularly in unstable fractures. Lateral deviation of the entry point is associated with an excessive NIA. Adducting the affected limb, moving the entry point slightly medial and using a medial pusher may help control the NIA to less than 14.85 ° to reduce the wedge effect. LEVEL OF EVIDENCE: III.

Characteristics of fragility hip fracture-related falls in the older adults: A systematic review.

BACKGROUND AND OBJECTIVES: With the global aging trend, the incidence of falls and hip fractures is projected to rise, leading to an increased associated burden. Over 90% of hip fractures result from falls, yet not all falls cause fractures, suggesting specific fall characteristics may contribute to hip fractures. This review provides insights into fragility hip fracture-related falls among the older adults, aiding in understanding and developing effective fall prevention strategies for this population. METHODS: Searches encompassed PubMed, OVID, EMBASE, Cochrane Library, and Web of Science, supplemented by citation checks. We included non-randomized studies detailing characteristics of fragility hip fracture-related falls in the older individuals, with or without a non-hip fracture control. Evaluated fall characteristics included height, location, direction, time, mechanism, activity during the fall, hip impact, protective responses, walking aid use, and impact surface. Results were analyzed using a narrative synthesis approach. The quality of these studies was assessed using the revised Risk of Bias Assessment tool for Non-randomized Studies 2 (RoBANS2). RESULTS: A total of 30 articles were reviewed, comprising 23 non-case control and 7 case-control studies, with a mean age of 75.6 years. Studies presented varied details on fall characteristics. Hip-fracture related falls typically occur indoors at or around standing height during daytime, often involving sideways or backward motions with inadequate protective responses. Slipping is predominant, yet lost balance and weakness/collapse are notable. Walking precedes many falls, but stationary activities (lack of forward motion, changing positions, sitting or standing still, transfer) also contribute. Low usage of walking aids and impact on hard surfaces are common features of these falls. CONCLUSIONS: This review underscores fall characteristics associated with fragility hip fractures in older adults, highlighting features more aligned with age-related physical frailty than general falls. Such insights can guide healthcare providers in implementing tailored interventions to reduce hip fractures and related challenges.

Drugs with Anticholinergic Properties and Association with Hip Fractures in Older Patients: A Danish Nationwide Cohort-Study.

Objectives: Hip fractures (HFx) resulting from falls are a significant health concern, and drugs with anticholinergic properties (DAP) increase the risk of falls. This study aimed to assess the association between use of DAP at hospital admission and HFx risk in older patients. Methods: This nationwide population-based study included all patients ≥65 years admitted to Danish geriatric wards during 2005-2014. Outcome of interest was first HFx within 2-years follow-up. The Anticholinergic Cognitive Burden (ACB) scale quantified DAP use. Cox regression analysis of data from four national registries was adjusted for activities of daily living, age, marital status, admission year, BMI, fracture history, previous admissions, dementia, anti-osteoporotic drugs, and Charlson comorbidity index. Results: 74,589 patients (62.8% female) were included, 45,463 (60.9%) received DAP at index, and 7,861 HFx occurred during follow-up. Cumulative 2-year HFx hazard was highest for ACB=0 (15.3%). Higher ACB-score was not associated with increased HFx risk in univariable nor multivariable analyses. In sensitivity analysis, use of DAP with high anticholinergic burden (≥2) did not alter results. Conclusions: In this high-incidence national cohort, higher ACB-score was not associated with increased HFx risk. Our results call for further research on association between specific DAP and risk of HFx.

Evaluation of a Blood Reserve Protocol for Hip Fracture Surgery in the Elderly.

Objective To identify the predictive factors for the need for transfusion during and after surgery to treat hip fractures in the elderly and to evaluate a protocol to guide the request for blood reserves for surgery. Methods The medical records of 172 elderly patients undergoing surgical treatment for proximal femoral fractures were collected. Data on sex, age, preoperative hemoglobin level, diagnosis, and type of surgery were tested for correlation with blood transfusion. In our sample, we determined the number of units of packed red blood cells reserved, the transfusion rate, and the cross-test:transfusion ratio. We made the same calculations in a hypothetical situation in which the request for blood reserves for our sample followed the criteria of a defined protocol. Results We found a correlation between the American Society of Anesthesiologists (ASA) classification and the occurrence of transfusions, and an inverse correlation between the hemoglobin level on admission and the number of bags transfused. A reserve of 328 units of packed red blood cells was requested for 167 surgeries. Had the proposed protocol been applied, 72 units would have been requested for 61 surgeries. Conclusion We found a correlation regarding the variables ASA classification and preoperative hemoglobin level and the occurrence of transfusion. Applying a proposed protocol to decide between requesting a reserve and only typing for elderly individuals undergoing surgical treatment for hip fracture proved suitable to reduce the number of packed red blood cell reserves.

Perioperative pain management intervention in older patients with hip fracture in an orthogeriatric unit. A controlled before/after study assessing an audit and feedback intervention (PAIN-AGE).

BACKGROUND: Postoperative pain delays ambulation, extends hospital stay, reduces the probability of recovery, and increases risk of long-term functional impairment. Pain management in hip fractured patients poses a challenge to the healthcare teams. Older adults are more vulnerable to opioid-associated side effect and it is primordial to minimize their exposure to opioids. Acetaminophen is associated with reduced opioid use so we need to focus on acetaminophen use in first-line analgesia. METHODS: We conducted a controlled before/after study to assess the ability of an audit and feedback (A&F) intervention built with nurses to improve the quality of perioperative pain management in older patients hospitalized for hip fracture in an orthogeriatric unit (experimental group) versus a conventional orthopedic unit (no A&F intervention). The primary endpoint was the percentage of patients who received 3 g/day of acetaminophen during the three postoperative days, before and after the A&F intervention. Secondary endpoints included nurses' adherence to medical prescriptions, clinical data associated with patients and finally factors associated with intervention. The significative level was set at 0.05 for statistical analysis. RESULTS: We studied data from 397 patients (mean age 89 years, 75% female). During the postoperative period, 16% of patients from the experimental group received 3 g/day of acetaminophen before the A&F intervention; the percentage reached 60% after the intervention. The likelihood of receiving 3 g/day of acetaminophen during the postoperative period and adhering to the medical prescription of acetaminophen were significantly increased in the experimental group as compared with the control group. The patient's functional status at discharge (assessed by Activities of Daily Living scores) was significantly better and the length of hospital stay significantly reduced after the A&F intervention. CONCLUSION: Our controlled before/after study showed that an A&F intervention significantly improved perioperative pain management in older adults hospitalized for hip fracture. Involving teams in continuous education programs appears crucial to improve the quality of pain management and ensure nurses' adherence to medical prescriptions.

Development and validation of a prognostic scoring system for 1-year mortality in older patients with hip fractures.

BACKGROUND: Hip fractures in older people result in increased mortality. OBJECTIVE: We developed and validated an accurate and simple prognostic scoring system for hip fractures that can be used preoperatively. DESIGN: Retrospective study. SETTING: Multicenter. PARTICIPANTS: Patients aged ≥65 years with hip fractures who underwent surgery between 2011 and 2021 were enrolled. METHODS: The significant factors were determined with logistic regression analysis, and a scoring system was developed. The patients were classified into three groups, and a log-rank test was performed to evaluate 1-year survival rates. The model was internally and externally validated using the 5-fold cross-validation and data from another hospital, respectively. RESULTS: We included 1026 patients. The analysis revealed eight significant prognostic factors: sex, body mass index, history of chronic heart failure and malignancy, activities of daily living (ADLs) before injury, hemoglobin and the prognostic nutritional index (PNI) at injury, and the American Society of Anesthesiologists Physical Status. The area under the receiver operating characteristic curve (AUC) after internal validation was 0.853. The external validation data consisted of 110 patients. The AUC of the model for the validation data was 0.905, showing outstanding discrimination. Sensitivity and specificity were 88.7% vs. 100% and 93.3% vs. 95.2% for the development and validation data, respectively. CONCLUSIONS: We developed and validated an accurate and simple prognostic scoring system for hip fractures using only preoperative factors. Our findings highlight PNI as an important predictor of prognosis in hip fracture patients.

Differences in opioid prescriptions by race among U.S. older adults with a hip fracture transitioning to community care.

BACKGROUND: Appropriate pain management can facilitate rehabilitation after a hip fracture as patients transition back to the community setting. Differences in opioid prescribing by race may exist during this critical transition period. METHODS: We conducted a retrospective cohort study of older adult U.S. Medicare beneficiaries with a hip fracture to examine whether the receipt and dose of opioids differs between Black and White patients as they transitioned back to the community setting. We stratified beneficiaries by whether they received institutional post-acute care (PAC). Outcomes were (1) receipt of an opioid and (2) opioid doses in the first 90 days in the community in milligram morphine equivalents (MMEs; also presented in mg oxycodone). We estimated relative rates and risk differences of opioid receipt and dose differences using Poisson and linear regression models, respectively, using the parametric g-formula to standardize for age and sex. RESULTS: We identified 164,170 older adults with hip fracture (mean age = 82.7 years; 75% female; 72% with PAC; 46% with opioid use after fracture). Overall use of opioids in the community was similar between Black and white beneficiaries. Black beneficiaries had lower average doses in their first 90 days in both total cumulative doses (PAC group: 165 [95% CI -264 to -69] fewer MMEs [-248 mg oxycodone]; no PAC: 167 [95% CI -274 to -62] fewer MMEs [-251 mg oxycodone]) and average MME per days' supply of medication (PAC: -3.0 [-4.6 to -1.4] fewer MMEs per day [-4.5 mg oxycodone]; no PAC: -4.7 [-4.6 to -1.4] fewer MMEs per day [-7.1 mg oxycodone]). In secondary analyses, Asian beneficiaries experienced the greatest differences (e.g., 617-653 fewer cumulative mg oxycodone). CONCLUSION: Racial differences exist in pain management for Medicare beneficiaries after a hip fracture. Future work should examine whether these differences result in disparities in short- and long-term health outcomes.

Rheumatoid arthritis increases complication risks in elderly hip fracture patients.: A Japanese nationwide medical claims database study.

OBJECTIVES: Rheumatoid arthritis (RA) is a common autoimmune disorder characterized by chronic inflammation and periarticular bone loss, leading to systemic osteoporosis and heightened fracture susceptibility, especially hip fractures among the elderly. This study aimed to evaluate the outcomes and complications associated with hip fractures in patients with RA relative to those without RA. METHODS: Using the Japanese National Administrative Diagnosis Procedure Combination (DPC) database, we examined cases of femoral neck fractures from April 2016 to March 2023. After one to three propensity score matching for age, sex, and complications, we examined the association between RA, complications, and mortality during hospitalization in elderly patients with hip fractures. RESULTS: The findings revealed that elderly Japanese RA patients with hip fractures had significantly higher complications of pneumonia than elderly hip fracture patients without RA, with a ratio of 1.232 (95% CI: 1.065-1.426, p=0.0056), and pulmonary embolism, with a ratio of 1.155 (95% CI: 1.036-1.287, p=0.009) in multivariate logistic regression analyses. Although not significantly elevated, it also found a trend toward higher mortality during hospitalization, with a ratio of 1.179 (95% CI: 0.973-1.429, p=0.096). CONCLUSIONS: A substantial study based on the Japanese DPC database revealed a significant association between RA and increased complications, including pneumonia and pulmonary embolism. On the other hand, there was a nonsignificant but higher trend for risk of mortality during hospitalization for hip fracture in elderly RA patients. Implementing preventive strategies is essential to minimizing complications in the treatment of hip fractures in patients with RA.

Enhanced recovery after surgery speeds up healing for hip fracture patients.

OBJECTIVE: To investigate the effects of enhanced recovery after surgery (ERAS) on the perioperative healing and stress response in patients with hip fractures. METHODS: A retrospective analysis was conducted on the medical records of 86 patients with hip fractures admitted to the Affiliated Hospital of Southwest Medical University between January 2022 and August 2023. Among them, 48 patients in the research group received ERAS, while 38 patients in the control group received conventional nursing. Hip joint function, pain levels, stress response, fracture healing time, incidence of complications, and nursing satisfaction were compared between the two groups. RESULTS: After nursing, the Harris scores notably increased in both groups, with the research group showing notably higher scores compared to the control group (P<0.05). The levels of cortisol and epinephrine, as well as the visual analog scale scores significantly decreased in both groups, with the research group showing significantly lower levels (P<0.05). In addition, the research group experienced significantly shorter fracture healing time (P<0.05), higher nursing satisfaction (P=0.014), and lower incidence of complications (P=0.028). Logistic regression analysis revealed that age, underlying diseases, nursing method, emotional disorders, and timing of surgery were independent factors influencing the post-nursing outcomes. CONCLUSION: The ERAS mode can effectively alleviate pain, improve hip joint function, reduce fracture healing time and complications, mitigate stress response, and accelerate postoperative recovery in patients with hip fractures. It is worthy of application and promotion in clinical practice.

Preoperative cardiology consultations for geriatric patients with hip fractures rarely provide additional recommendations and are associated with prolonged hospital stays and delayed surgery: a retrospective case control study.

OBJECTIVES: Hip fractures are increasingly common among the elderly population, who often present with a high burden of comorbidities necessitating preoperative stabilization. As a result, preoperative cardiology consultations are frequently conducted in clinical practice. The aim of this study was to investigate the additional recommendations provided by preoperative cardiology consultations and the impact of consultations on the management and outcomes of elderly patients undergoing hip fracture surgery. PATIENTS AND METHODS: This matched cohort study was performed to retrospectively assess the clinical data of patients who were treated for hip fractures at our institution between January 2016 and December 2017. Individuals who were 60 years old or older with available clinical and radiological data were included. A total of 262 patients who met these criteria were included, with 192 undergoing cardiology consultation and 70 not. Through matching for age, sex, ASA grade, fracture type, and surgery type, two groups (Group A, preoperative cardiology consultation requested; Group B, preoperative cardiology consultation not requested) of 50 patients each were formed. The duration between hospital admission and surgery, recommendations provided by cardiology consultation, type of anaesthesia and surgery, length of hospital stay, incidence of medical and orthopaedic complications, and one-year mortality status were compared between the groups. RESULTS: The mean age of Group A was 78.5 (± 7.4) years, whereas that of Group B was 78.4 (± 7.4) years (p = 0.99). Both groups included 30 female patients and 20 male patients each. There were no significant differences in anaesthesia type or the incidence of medical or orthopaedic complications between the groups. However, Group A experienced a significantly longer duration between admission and surgery (5 [1/9] days vs. 3 [0/7] days; p = 0.00) and a longer hospital stay (7 [3/15] days vs. 5 [1/19] days; p = 0.01) than did Group B. The one-year mortality rate did not significantly differ between the groups (30% vs. 20%; p = 0.36). Notably, only 3 out of 50 patients received additional treatments following cardiology consultation beyond routine recommendations. CONCLUSION: Preoperative cardiology consultations before hip fracture surgery rarely leads to a change in treatment. Additionally, these evaluations delay surgery and extend the hospital stay.

Lateral femoral wall thickness in trochanteric hip fractures: a systematic review.

BACKGROUND: Thin lateral femoral wall has been investigated as a sign of instability in trochanteric hip fractures, necessitating lateral wall reconstruction or the use of a cephalomedullary nail (CMN). Various cut-off values have been proposed to guide implant choice. This review aims to determine the clinical significance of the lateral femoral wall thickness (LWT) in trochanteric hip fractures and identify an optimal cut-off value for increased risk of lateral wall (LW) fracture when using Dynamic Hip Screw (DHS). METHODS: A comprehensive search was conducted in databases including Medline, Embase, and the Cochrane library up to July 2023. A predefined strategy was employed, with 5 eligible studies critically appraised using the methodological index for non-randomized studies (MINORS) criteria. Outcomes assessed encompassed the standardised mean difference (SMD) of LWT between the LW fracture and non LW fracture groups, aggregate LWT mean in LW fracture group, and the relation between AO/OTA fracture type with LW fracture utilising the chi-square test. RESULTS: Among 481 patients from 5 studies, 112 experienced LW fractures, while 369 did not postoperatively. Analysis indicated a significantly lower LWT in the LW fracture group (SMD -1.13, I² = 41.3%, p = 0.146). The mean LWT in the LW fracture group was 18.2 mm, with a 95% confidence interval of 17.29-19.10 mm. CONCLUSIONS: A preoperative thin lateral femoral wall is a critical predictor of fixation failure and suboptimal functional outcomes when using a DHS. Thorough evaluation of pre- and intraoperative x-rays is essential. CMN is recommended over DHS in cases with LWT measurements <19 mm.

The Impact of the COVID-19 Pandemic on One-Year Mortality in Geriatric Hip Fracture: A Retrospective Cohort Study.

Introduction: The COVID-19 pandemic has profoundly impacted global healthcare systems, necessitating substantial shifts in patient care strategies. The pandemic's onset led to drastic operational changes in hospitals, including reduced bed capacity and staffing levels, which could have further influenced the mortality outcomes for geriatric patients. The study aimed to assess the impact of the COVID-19 pandemic on 1-year mortality rates of surgically treated geriatric hip fractures. Methods: This retrospective, single-center cohort study included 346 participants aged 65 and above who underwent surgical treatment for hip fractures. We compared mortality rates between the pre-COVID and COVID eras. Data included demographics, treatment, complications, and COVID-19 status. The independent samples t test and Chi-square tests (or Fisher's exact test) were used for comparisons for era cohorts. Survival probabilities were assessed using Kaplan-Meier, while multivariate analysis identified mortality predictors. Results: 175 patients were included in the pre-COVID era, and 171 patients were included in the COVID era. During the COVID era, the 30-day mortality rate was 11.7% (compared to 13.7% in the pre-COVID era, p = 0.573), and the 1-year mortality rate was 43.9% (compared to 49.1% in the pre-COVID era, p = 0.325). The overall 1-year mortality rate was 46.5%. Patients who underwent surgery within 48 hours had a higher 1-year survival rate (60.5%) compared to those with delayed surgery (51.2%), p = 0.031. Additionally, patients not admitted to the ICU had a higher 1-year survival rate (74.7%) than those who were admitted (44.9%), p < 0.001. 70.1% of the total deaths occurred within the first 90 days. Conclusion: Elderly patients with hip fractures experienced high mortality rates before and during the pandemic. This study demonstrates that the 1-year mortality rates of geriatric hip fractures were not significantly affected by the pandemic. The findings emphasize the importance of pandemic preparedness and prompt surgeries and attentive ICU care in reducing mortality rates.

Patient Satisfaction Following Non-Operative Treatment of Geriatric Hip Fractures: A Case-Control Study.

Introduction: A minority of geriatric hip fracture patients pursue non-operative treatment. Compared with surgical patients, non-operative patients have higher mortality rates. However, patient satisfaction following non-operative vs operative treatment has not been investigated extensively. The purpose of this study was to compare satisfaction among non-operatively vs operatively treated hip fracture patients. Methods: We identified patients aged 60+ years with proximal femur fractures treated over a 10-year period. Excluded were patients with isolated greater/lesser trochanteric fractures. Patients or relatives were asked to complete a 6-question survey about their treatment satisfaction. Results: Survey responses from 56 operative and 28 non-operative patients were recorded. Overall, 91.1% of operative and 82.1% of non-operative patients were satisfied with their treatment course (P = 0.260). However, only 71.4% of non-operative patients were satisfied with treatment option explanations vs 83.9% of operative patients (P = 0.014). While only 64.3% of non-operative respondents were satisfied with the ultimate treatment outcome (vs 85.7% of operative patients, P = 0.025), 89.3% of patients in each cohort would choose the same treatment plan again. Discussion: Our findings highlight the complexity of defining patient satisfaction, particularly in a geriatric hip fracture population. Unlike previous studies, we chose a direct approach to quantifying patient satisfaction by asking participants specifically about satisfaction with treatment outcome and the overall treatment course. Additional survey questions were then included to assess factors considered important in treatment satisfaction, such as health care provider treatment explanations, post-treatment mobility, and palliative care service involvement. Conclusions: We identified significant differences between non-operatively and operatively treated geriatric hip fracture patients regarding satisfaction with the explanation of treatment options, and ultimate treatment outcomes. There was no significant difference in overall satisfaction with the treatment course or likelihood of choosing the same treatment again. Further research investigating patient satisfaction following geriatric hip fracture treatment is warranted.

Complication Rates in Intertrochanteric Fractures: A Database Analysis Comparing Sliding Hip Screw and Cephalomedullary Nail.

Objectives: In the treatment of closed intertrochanteric fractures, the two most common treatment options are intramedullary medullary nail (IMN) and dynamic hip screw (DHS), yet the best treatment method remains controversial. The purpose of this study is to determine the difference in mortality and morbidity between IMN and DHS. Secondarily, this study determines which pre-operative risk factors affect rates of morbidity and mortality. Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 2006-2016 database was used to search for patients with a closed intertrochanteric hip fracture. Bivariate analysis was performed using Pearson's Chi Square test to determine pre-operative risk factors associated with complications in fixation with IMN and DHS. Significant variables in this analysis, as well as demographic data, were analyzed via binary logistic regression. The results were recorded as odds ratio (OR) and significant differences were based on a P<0.05. Results: After adjusting for demographics and clinical covariates, patients who underwent fixation with IMN had higher 30-day mortality, reintubation, UTI, bleeding, prolonged length of stay, and non-home discharged destination rates compared to DHS. Mortality risk was increased by ascites, disseminated cancer, impaired functional status, history of congestive heart failure, and hypoalbuminemia. Bleeding risk was increased by previous percutaneous coronary (PCI) and transfusions and was decreased by impaired functional status. Myocardial infarction risk was increased by female gender. Conclusion: Our study found that IMN fixation increased risk of mortality, UTI, reintubation, bleeding, prolonged length of stay, and a non-home discharge destination compared to DHS. This study also identified patient risk factors associated with several postoperative complications. These data may better inform orthopaedic surgeons treating closed intertrochanteric fractures.

Developing a consensus-based motivational care pathway for individuals with lower limb fractures: a Delphi protocol.

Older adults with lower limb fractures often harbor concerns about losing their mobility, fearing a loss of independence. It is vital to develop strategies that foster their active engagement in the rehabilitation process. The present protocol aims to create a care pathway tailored to motivate individuals with lower limb fractures to adhere to rehabilitation. We will develop an observational, cross-sectional, and descriptive study using the Delphi data-gathering approach. Purposive sampling will recruit a panel of healthcare professionals and experts who care for patients with lower limb fractures. Aligned with the Delphi method, a series of iterative rounds will be developed to gather consensus around the motivational strategies used by health professionals in the rehabilitation of people with lower limb fractures. We will employ the Qualtrics platform for data collection and analysis, and a consensus target of 75% has been predetermined. For quantitative data analysis, we will use descriptive statistics encompassing a range of measures, including count, mean, standard deviation, median, minimum, maximum, and range. An inductive thematic analysis procedure will be employed to extract meaningful themes and patterns from qualitative data. The study results are expected to significantly impact clinical practice by creating a specialized care pathway to motivate individuals with lower limb fractures to adhere to rehabilitation. Adopting these explicit standards by professionals will ensure uniform and high-quality care.

Predictive value of prognostic nutritional index on postoperative intensive care requirement and mortality in geriatric hip fracture patients.

OBJECTIVE: The incidence of postoperative morbidity and mortality in hip fracture patients is high and is associated with nutritional deficiencies. This study investigated the predictive value of preoperative prognostic nutritional index (PNI) on postoperative intensive care unit (ICU) requirement and mortality in geriatric hip fracture patients. METHODS: Geriatric (≥65 years old) hip fracture patients who underwent surgery between January 2021 and September 2023 were evaluated retrospectively. Patients were classified according to the unit followed in the postoperative period (service group and ICU group) and 28-day mortality (mortality group and survivor group). The predictive value of PNI for ICU requirement and mortality and the factors affecting ICU requirement and mortality were investigated. RESULTS: The study included two hundred twenty-two patients, and 66.2% (n=147) were women. In the postoperative period, 47.7% (n=106) of the patients were followed in the ICU and 52.3% (n=116) in the inpatient service. The 28-day mortality of the patients was 6.8% (n=15). PNI was found to be significantly lower in patients followed in the ICU (group ICU) than in those followed in the service (group S) and in patients who died (group mortality) compared to those who lived (group survivor) (p<0.001 and p=0.029, respectively). In multivariate regression analysis, high American Society of Anesthesiologists (ASA) status and low PNI were determined to be independent risk factors for ICU requirement. Acute Physiology and Chronic Health Assessment II score was an independent predictor of mortality. In ROC curve analysis, the cut-off value of PNI in predicting mortality was 32.5, and the area under the curve was 0.660 (95% CI, 0.516-0.803). CONCLUSION: In geriatric hip fracture patients, preoperative PNI value can be used, like ASA status, in determining postoperative ICU requirements. Nutritional deficiencies are associated with adverse postoperative outcomes in this patient group, and low PNI values (<32.5) help predict in-hospital mortality.

Which factor is more associated with survival of patients with hip fracture over 90 years: Type of fracture or treatment modality?

OBJECTIVE: We aimed to analyze prognostic factors affecting the mortality and to evaluate whether the fracture type (collum femoris or intertrochanteric fracture) or treatment method (proximal femoral nail or hemiarthroplasty) affects the mortality in patients with hip fractures and older than 90 years old. METHODS: In our study, we retrospectively reviewed the patients aged >90 years and operatively treated hip fractures. Patients were categorized according to fracture type and treatment method. Finally, three groups were created. Demographic values, laboratory values were analyzed for prognostic factors and determining independent factors associated with survival for each group. RESULTS: A total of 193 patients were included with an average age of 92.5±2.4 (range, 90-104) years. There were 144 women and 49 men. There were 126 (65.2%) patients with intertrochanteric fracture and 67 (34.8%) patients with collum femoris fracture. At the time of this study, 142 (73.5%) patients had deceased. Staying in intensive care unit for collum femoris group, general anesthesia for intertrochanteric fracture treated with hemiarthroplasty group and delay to surgery and preoperative albumin level for intertrochanteric fracture treated with proximal femoral nail group were associated with poor survival. CONCLUSION: Staying intensive care unit, general anesthesia, delay to surgery and preoperative albumin levels should be carefully evaluated for patients aged over 90 years with hip fractures. Our study showed that both fracture type and treatment modality were not associated with poor overall survival of the patients aged >90 years following hip fracture surgery.

Two-year outcomes of internal fixation with femoral neck system in patients with femoral neck fracture in an Asian population.

Background: Femoral neck fractures (FNF) are one of the most common fractures, with a projected increase in incidence with population growth and ageing. The Femoral Neck System (FNS) launched in 2019 was developed specifically for fixation of FNF with the purported advantages of providing both angular and rotational stability. We report our experience with the FNS and evaluate its effectiveness and associated complications. Methods: A retrospective case series of 50 patients who underwent surgical fixation for FNF from August 2020 to October 2021 using the FNS in two Singapore tertiary institutions with at least 2 years follow-up were included. Clinical data (patients' demographics, fracture classification, intra-operative and post-operative complications) were reviewed. Radiological analysis assessed the pre- and immediate post-operative garden alignment index (GAI) and presence of femoral neck shortening at 3 months. Results: The mean age was 63.5 years (SD 16.9, range 26-92). Five (10 %), 34 (68 %) and 11 (22 %) were ASA 1, 2 and 3 respectively. Twenty-four (48 %), 16 (32 %), 4 (8 %), and 6 (12 %) patients sustained Garden's 1, 2, 3 and 4 FNF respectively. The mean operative duration was 66.2 min (SD 20.5) and length of stay was 6.9 days (SD 4.6).The post-operative improvement in garden alignment index (GAI) was a mean of 9.1° (p < 0.001) on lateral view. The mean femoral neck shortening was 1.97 mm (SD 5.3) at 3 months. There were no intra-operative complications. Post-operatively, 1 (2 %) patient required blood transfusion, 1 (2 %) patient had implant cut-out and non-union managed non-operatively, 2 (4 %) patients developed avascular necrosis and required revision to total hip replacements. There were two (4 %) cases of 1-year mortality. Conclusion: The FNS achieved good outcomes with low rates of complications. The promising results justify its continued use and further evaluation in comparison to other devices.

Unusual Pattern of Osteochondral Marginal Impaction in Acetabular Fractures: A Report of Two Cases.

Acetabular fractures could be accompanied by articular impaction injuries, affecting the outcomes if missed or treated less than optimally. Marginal impaction detected either in preoperative or intraoperatively imaging studies should be anatomically reduced using the femoral head as a template and augmenting the defect with bone graft if needed. The impacted segment articular surface looks enface during surgery, which is the classic description of such injuries. In the present report, we describe an unusual pattern of marginal impaction injuries appearance in two patients, in which the impacted fragment articular surface is facing toward the joint cavity, which is the reverse of the classic description, alluding to the probable mechanism of its occurrence, the technique for reduction, and the consequences of missing such injuries. Marginal impaction injuries should be diagnosed and treated correctly to preserve joint congruency; however, the surgeon should be aware of the possibility of an unusual pattern of marginal impaction in which the fragment could be reversed, and keeping this possibility in mind would make its diagnosis and management easier.

Vitamin D Supplementation and the Incidence of Fractures in the Elderly Healthy Population: A Meta-analysis of Randomized Controlled Trials.

INTRODUCTION: Although a well-established component of bone metabolism, the efficacy and safety of vitamin D supplementation for the prevention of fractures in elderly healthy individuals is still unclear. PURPOSE: To perform a meta-analysis comparing vitamin D supplementation with placebo and its contributions on fracture incidence. METHODS: This meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO), under protocol CRD42023484979. We systematically searched PubMed, Embase, and Cochrane Central databases from inception to November 2023 for randomized controlled trials (RCTs) comparing vitamin D supplementation versus placebo in individuals with 60 years of age or more and without bone related medical conditions such as cancer and osteoporosis. RESULTS: Seven RCTs with 71,899 patients were included, of whom 36,822 (51.2%) were women. There was no significant difference in total fracture incidence (RR 1.03; 95% CI 0.93-1.14; p = 0.56; I2 = 58%) between groups or subgroups. However, women had an increased risk for hip fractures (164 vs. 121 events; RR 1.34; 95% CI 1.06-1.70; p = 0.01; I2 = 0%). There was no significant difference in non-vertebral fractures, osteoporotic fractures development, or falls (RR 1.02; 95% CI 0.94-1.12; p = 0.6; I2 = 47%; RR 0.97; 95% CI 0.87-1.08; p = 0.63; I2 = 0%; RR 1.01; 95% CI 0.97-1.04; p = 0.66; I2 = 55%, respectively). CONCLUSION: Vitamin D supplementation does not reduce the total fracture development rate in the elderly healthy population, and it may increase the incidence of hip fractures among elderly healthy women. This finding suggests refraining from prescribing high intermittent doses of vitamin D, without calcium, to individuals aged 60 or older with unknown vitamin D serum concentration or osteoporosis status and inadequate calcium intake.