[What prognostic factors correlate with activities of daily living (Barthel Index) 1 year after para-articular hip fracture? A prospective observational study]

Long-term Outcomes in Orthogeriatric Co-management: a Literature Review

Fragility fractures of the hip are one of the most important triggers of poor health outcomes in older adults. They often result in limitations in the ability of patients to care for themselves and mortality remains high. Orthogeriatric co-management may improve outcomes for this high-risk population. However, the impact on long-term results has not yet been definitively clarified. The purpose of this study was to present the influence of orthogeriatric co-management on mortality and self-care ability, as measured by the Barthel score, one year after hip fracture in people ≥ 60 years.A systematic literature search was performed in accordance with the process steps of identification, selection, and evaluation, with a systematic search of the MEDLINE, CINAHL Complete and Cochrane Library databases in the period from February to March 2022. Articles in English and German published between 2012 and 2022 were included. Twelve studies were finally used.Six studies demonstrated a statistically significant reduction in the one-year mortality rate. Only one of four studies evaluating self-care ability showed a significant improvement when the patient was treated on a specialised ward.Orthogeriatric co-management seems to be beneficial in positively influencing one-year mortality and self-care ability. In view of the heterogeneous results, the implementation of this care model can only be recommended to a limited extent.

[Translated article] One-year mortality and associated factors in patients undergoing surgery for hip fracture

INTRODUCTION

Hip fractures are very common injuries in elderly patients and are associated with increased mortality.

OBJECTIVE

To identify the factors associated with mortality in patients after one year of being operated for hip fracture in an Orthogeriatric Program.

METHODS

We design an observational analytical study in subjects older than 65 years admitted to the Hospital Universitario San Ignacio for hip fracture who were treated in the Orthogeriatrics Program. Telephone follow-up was performed one year after admission. Data were analyzed using a univariate logistic regression model and a multivariate logistic regression model was applied to control the effect of the other variables.

RESULTS

Mortality was 17.82%, functional impairment was 50.91%, and institutionalization was 13.9%. The factors associated with mortality were moderate dependence (OR=3.56, 95% CI=1.17-10.84, p=0.025), malnutrition (OR=3.42, 95% CI=1.06-11.04, p=0.039), in-hospital complications (OR=2.80, 95% CI=1.11-7.04, p=0.028), and older age (OR=1.09, 95% CI=1.03-1.15, p=0.002). The factor associated with functional impairment was a greater dependence at admission (OR=2.05, 95% CI=1.02-4.10, p=0.041), and with institutionalization was a lower Barthel index score at admission (OR=0.96, 95% CI=0.94-0.98, p=0.001).

CONCLUSIONS

Our results shows that the factors associated with mortality one year after hip fracture surgery were: moderate dependence, malnutrition, in-hospital complications and advanced age. Having previous functional dependence is directly related to greater functional loss and institutionalization.

One-year mortality and associated factors in patients undergoing surgery for hip fracture

INTRODUCTION

Hip fractures are very common injuries in elderly patients and are associated with increased mortality.

OBJECTIVE

To identify the factors associated with mortality in patients after one year of being operated for hip fracture in an Orthogeriatric Program.

METHODS

We design an observational analytical study in subjects older than 65 years admitted to the Hospital Universitario San Ignacio for hip fracture who were treated in the Orthogeriatrics Program. Telephone follow-up was performed one year after admission. Data were analyzed using a univariate logistic regression model and a multivariate logistic regression model was applied to control the effect of the other variables.

RESULTS

Mortality was 17.82%, functional impairment was 50.91%, and institutionalization was 13.9%. The factors associated with mortality were moderate dependence (OR=3.56, 95% CI=1.17-10.84, p=0.025), malnutrition (OR=3.42, 95% CI=1.06-11.04, p=0.039), in-hospital complications (OR=2.80, 95% CI=1.11-7.04, p=0.028), and older age (OR=1.09, 95% CI=1.03-1.15, p=0.002). The factor associated with functional impairment was a greater dependence at admission (OR=2.05, 95% CI=1.02-4.10, p=0.041), and with institutionalization was a lower Barthel index score at admission (OR=0.96, 95% CI=0.94-0.98, p=0.001).

CONCLUSIONS

Our results shows that the factors associated with mortality one year after hip fracture surgery were: moderate dependence, malnutrition, in-hospital complications and advanced age. Having previous functional dependence is directly related to greater functional loss and institutionalization.

Management of pertrochanteric fractures in patients over 90 years: In-hospital mortality rate, complications and associated risk factors

PURPOSE

This study aims primarily to investigate the outcome following surgical management of pertrochanteric fractures of patients over 90 years compared to the outcome of a control group below 90 years under special consideration of the timing of surgery. The second aim was to analyze potential risk factors for early deaths in very old patients. This study allows us to draw conclusions to minimize complications linked to this particular age segment.

METHODS

The study group consisted of very old patients aged 90 years and older. Geriatric patients aged between 60 and 89 years of age were part of the control group. Type A1 pertrochanteric fractures were typically treated by dynamic hip crews, type A2 and A3 fractures by femoral nails. Full weight bearing physiotherapy was initiated on the day after surgery to improve mobility and muscle strength.

RESULTS

A total of 71 patients belonged to the study group (mean age: 92.5 years ±2.3 years), whereas 223 patients formed the control group (mean age: 79.9 ± 7.4 years). The mortality rate and the number of detected and documented complications were significantly higher in the study group (p = 0.001; p = 0.009, respectively). Despite the significantly higher complication rate in the > 90-year-old patients, there was no significant difference in the mean length of in-hospital-stay between the both groups (> 90 yrs.: 12.1d; < 90 yrs.: 13.1 d) and the timing of surgery.

CONCLUSION

The number of co-morbidities, number of daily-administered medications and the time between admission and surgery have no impact on the outcome. We noticed a longer period between admission and surgery in very old patients who survived. Patients with pertrochanteric fractures should be screened for multimorbidity and cognitive disorders in a standardized manner.

Exploring the Effectiveness of PAC Rehabilitation for Elders with Hip Surgery: A Retrospective Study

Background

Hip fractures are high risk and high-impact events in the elderly population; despite orthopedic hip surgery, the disability and mortality rate remains significant. The National Health Insurance Agency in Taiwan established a fragility fracture PAC rehabilitation program to provide functional recovery for these patients after the surgery. However, the current literature on PAC rehabilitation is outdated, and there is an urgent need for the re-evaluation of the program.

Methods

This is a retrospective cohort study that enrolled 159 patients in the PAC rehabilitation program, followed by hip repair surgery. Outcome measures were the differences in participants’ pre- and post-PAC scores in 1) Barthel index, 2) Numerical Rating Scale (NRS), and 3) Harris Hip Scores (HHS) as surrogate indicators of the functional status, followed by the analysis of subgroups, including sex, age, site of the fracture, type of procedure, and the number of comorbidities.

Results

After completing PAC rehabilitation, 86.2% of the patients successfully returned to the community with either home or out-patient rehabilitation. The re-admission rate was 3.1% and 3.8% in 14-days and in 30-days follow up, respectively. The difference in pre- and post-Barthel index, NRS, and HHS showed significant improvement (p<0.001), without significant variations between the subgroups. Additionally, the Barthel index showed a positive correlation to HHS and a negative correlation to NRS.

Conclusion

This study revealed that the current form of post-surgery fragility fracture PAC program effectively improves functional status, reduces the re-admission rate, and facilitates the patient transition back to the community. The results should improve patients’ and physicians’ confidence in such a program.

[Subtrochanteric femur fractures-epidemiology, surgical procedures, influence of time to surgery and comorbidities on complications : A risk-adjusted regression analysis of routine data from 2124 cases]

BACKGROUND

There are approximately 12,000 subtrochanteric femur fractures in Germany per year with a rising trend but studies about the epidemiology and the surgical outcome are rare. Furthermore, there are no guidelines from expert societies and there is no adequate quality assurance.

OBJECTIVE

Presentation of the epidemiology and the current treatment situation with respect to the patient collective, comorbidities, time to surgery and surgical procedures used as well as the identification of modifiable risk factors with respect to complications.

MATERIAL AND METHODS

Analysis of routine data based on an established data model in 2124 cases. The descriptive statistics contain data on basic patient characteristics, such as age, comorbidities, surgical procedure, time to surgery and mortality. In the analytical statistics the impact of risk factors (surgical procedure, time to surgery etc.) on the endpoints mortality, complications and decubitus was investigated by logistical regression analyses.

RESULTS

Of the patients 55% were operated on within the first 24h. Intramedullary osteosynthesis (89%) is the most frequently used surgical method (prostheses 2%, extramedullary procedures 5%). Within the first postoperative year 37% of the patients received a higher level of care, where the care was moved from outpatient to inpatient treatment. The mortality in the first postoperative year was 26%, while early complications were observed in 6%. A delay in surgical treatment was associated with an increased mortality and intrinsic factors, which were difficult to influence. Intramedullary osteosynthesis had the lowest mortality and revision rates.

CONCLUSION

Concerning the epidemiological data, the patient collectives of subtrochanteric fractures and femoral neck or pertrochanteric fractures were very similar. Major delays in the time to surgery of subtrochanteric fractures can be associated with increased complication rates and mortality. Therefore, programs to prevent older patients from falling have a high priority.

[One-year outcomes for proximal femoral fractures: Posthospital analysis of mortality and care levels based on health insurance data]

BACKGROUND

Proximal femur fractures are common and treatment is expensive. The aim of the present study was - after matching of hospital and health insurance data - to evaluate the influence of early operation on certain outcome parameters. Data from a German health insurance were used to identify then influence of the day of operation after admittance on the rate of mortality, decubitus, and revision surgery during the hospital stay and on the care level of the patients up to 1 year and in some cases longer after operation.

MATERIALS AND METHODS

In all, 7905 patients were included. The descriptive data, specifying the given population, described the hospital stay (occurrence, surgical procedures, early complications, secondary diagnoses, length of stay) and the course of patient recovery up to 1 year after the hospital stay (care level, late complications). The calculated data (analytical statistics) give correlations evaluating the influence of the length of the preoperative hospital stay on the outcome parameters mentioned above. Risk adjustment was performed by using secondary diagnoses.

RESULTS

The study included more women (mean age 81.5 years). Most common was the femoral neck fracture. Of the operations 77% were carried out on the first day after admission; dominating procedures were intramedullary nails and prostheses. Most common secondary diagnoses were diabetes, dementia, ischemic heart disease, and chronic heart insufficiency. Descriptive data revealed 6% early as well as late complications. In all, 50% of patients had a higher care level after operation. Almost 40% of patients changed from outpatient care to inpatient care. The time interval between admission and operation negatively influenced all outcome parameters. The relative risk to die, to develop decubitus, or to receive early revision was increased by approximately one third when patients were operated on later than the first day after admission. A total of 3172 patients died during the study period. Mortality after operation reached 9.9% within 30 days and 26.9% at 1 year. The mortality of patients operated after the first day was increased by more than 6% compared to patients treated within the first 24 h.

CONCLUSION

The present study clearly presents the importance of analysis of routine records after discharge and it demonstrates that longer periods up to 1 year and more can be evaluated. The data show that a longer time period between hospital admission and operation negatively influences all outcome parameters. The care data give impressive evidence for a significant loss of quality of life and the importance of intense postoperative rehabilitation.

[Geriatric complex treatment of proximal femoral fractures? Who profits the most?]

BACKGROUND

Geriatric complex treatment (GCT) is a new type of early rehabilitative care. The main goal is to maintain personal autonomy. GCT includes 21 treatments by physio-, occupational and speech therapists, accompanied by specialized nurses. The aim of this study was to investigate how elderly patients benefit from the GCT after hip fractures (HF).

PATIENTS AND METHODS

In all, 124 patients [≥70 years; 50 patients underwent GCT, 74 underwent standard traumatologic care (STC)] after operative treatment for HF were included. Cognitive impairment was diagnosed in 46% of GCT patients and 70% were classified as ASA III. In the STC group, 23% were cognitively impaired and 50% were classified ASA III.

RESULTS

Significantly more patients of the GCT group were both cognitively impaired and classified as ASA III. Among the cognitively impaired, the STC group reached a median of 20 points on the Barthel index, while the GCT group reached 60 points.

CONCLUSION

The GCT patients in our study were more likely to be dependent on care and have cognitive deficits. Only cognitively impaired patients were shown to benefit from GCT. In the remaining patients no difference was found, thus, only cognitively impaired patients currently undergo GCT at our clinic.

Dependence for basic and instrumental activities of daily living after hip fractures

The objective of the study is to determine basic activities of daily living (Barthel Index) and instrumental activities of daily living (Lawton-Brody Index) before and after hip fracture. Follow-up study of patients (n=100) with hip fracture, operated at Complejo Hospitalario Universitario de A Coruña (Spain). Period January/2009-December/2011. Demographic characteristic of the patients, Charlson Index, Glomerular filtration rate, Barthel index, Lawton index, type of proximal femur fracture and surgical treatment delay were recorded. Multivariate regression was performed. Informed patient consent and ethical review approval were obtained. Before fracture were independent for activities of daily living (ADL) a 38.0%, at 90 days were 15.4%. The Barthel index score decreased from 75.2±28.2 to 56.5±31.8) (p<0.0001). If we consider the age, gender, comorbidity (Charlson index), renal function, fracture type and surgical delay objectify the only independent variable to predict dependency effect is age. If we also consider the Barthel score objectify the variable that significantly modifies that score at 90 days is the baseline value of the index. The prevalence of independence for instrumental activities of daily living (IADL) at the baseline moment is 11% and at 90 days is decreased to 2.2%. There is a decrease in the independence effect in all activities. The variable predictor of independence for all activities after taking into consideration age, sex, comorbidity, fracture type, surgical delay and renal function is the baseline score of the Barthel and Lawton index.

Comparison of activities of daily living after osteoporotic hip fracture surgery in patients admitted from home and from geriatric health service facilities

With the population and proportion of the elderly increasing each year, difficulties with postoperative treatment outcomes after osteoporotic hip fracture are increasing. This study focused on activities of daily living (ADL) in patients who underwent surgery for hip fracture through an investigation of living arrangements, the presence of dementia, and other complications of aging. Information from 99 patients who lived either at home or in geriatric health service facilities was collected for this trial. Most patients were over 65 years of age and female, and about half of them had dementia. The postoperative ADL score (focusing on patients’ walking ability) was significant for those living at home than for those living in facilities. In addition, patients with dementia were divided into the following two categories: an early-rising group, comprising patients who were able to use a wheelchair within 48 hours of their operation; and a late-rising group, who did not start using a wheelchair until more than 48 hours after surgery. The ADL scores for the two groups were compared. Although the preoperative ADL scores were not significantly different between the two groups, postoperative ADL scores were significantly higher in the early-rising group than in the late-rising group, especially in patients who had undergone hemiarthroplasty. These data suggest that ADL in dementia patients following hip fracture depends on the surgical procedure performed and whether they are late or early risers after surgery.

Restoration of hip architecture with bipolar hemiarthroplasty in the elderly: does it affect early functional outcome?

INTRODUCTION

Reconstruction of the anatomic architecture correlates with functional outcome in patients receiving elective total hip arthroplasty. In theory similar rules should apply for bipolar hemiarthroplasty in femoral neck fractures. The influence of anatomic restoration after bipolar hemiarthroplasty on short-term clinical and functional outcome is explored in this study.

PATIENTS AND METHODS

Patients receiving bipolar hemiarthroplasty for intracapsular femoral neck fractures between 2010 and 2012 were included into a retrospective cohort study. Radiologic and functional outcome parameters were recorded during the acute care phase and geriatric rehabilitation. Postoperative mobilization data were recorded and co-morbidities documented for each case. Outcome parameters were obtained during geriatric rehabilitation: Barthel index, Tinetti score, Timed up and go test, Mini-Mental State Examination. The FO-ratio (ratio of femoral offset to the body weight lever arm), HC-ratio (ratio of the height of the hip center to the pelvic height) and the BWLA ratio (ratio of the body weight lever arm to the pelvic height) were obtained from postoperative radiographs.

RESULTS

A total of 193 patients with a median age of 84 (IQR = 78-94, 72% female) were analyzed. The in-hospital mortality rate was 5.7%. There was a high proportion of patients with prior co-morbidities (96% with at least one co-morbidity). During rehabilitation the Barthel index improved significantly (p < 0.001) from 40 to 55. The median Tinetti score on rehabilitation discharge was 15.5 (IQR = 10-19.5). The patients significantly improved in the timed up and go test from a median of 22 to 19 s. A significant difference (p < 0.001) was found comparing the FO ratios of the operated vs. non-operated side. None of the radiographic measures, representing the reconstructed anatomic hip geometry, significantly influenced the clinical and geriatric outcome.

CONCLUSIONS

Applying the short-term functional outcome scores used in this study, optimized anatomic restoration in hemiarthroplasty may not be a major influencing factor in a cohort of elder, multi-morbid patients.

Modified direct anterior approach in minimally invasive hip hemiarthroplasty in a geriatric population: a feasibility study and description of the technique

INTRODUCTION

The direct anterior approach (DAA) is generally accepted method for minimal invasive arthroplasty of the hip. As good results for total hip arthroplasty are already published, there is a lack of evidence for the implantation of bipolar hip hemiarthroplasty (BHH) in elderly patients with osteoporosis after femoral neck fracture.

MATERIALS AND METHODS

For hip arthroplasty using a direct anterior approach (DAA) in elderly patients with femoral neck fractures, a number of modifications of the original technique are being described. The modified DAA considers in particular the co-morbidity and the bone quality of the geriatric patient population. A consecutive series of 16 hemiarthroplasties using this technique is presented. In all 16 cases, the BHH was implanted in modified DAA technique. Mobility measured by 4-item Barthel Index, pain via visual analogue scale (VAS), duration of surgery, external length of incision and blood loss were evaluated.

RESULTS

There was no major operative complication during the procedures. The pain level decreased from 7 (preoperatively) to 0 at postoperative day 40. The Barthel Index increased from 5 at first postoperative day to 40 at day 40. Early postoperative mobilisation is efficiently accelerated. Mean operating time was 71 min; the medium skin incision length was 8 cm. The mean haemoglobin level decreased from 118 g/dl preoperatively to 101 g/dl at first postoperative day.

CONCLUSION

The described modifications of the DAA help to implant a BHH gently in elderly patients with increasing risk of complications like iatrogenic fractures, wound or prosthesis infections and haematoma. This will hopefully lead to a faster rehabilitation and lower mortality rate for patients with femoral neck fractures in the future.

Early functional results after hemiarthroplasty for femoral neck fracture: a randomized comparison between a minimal invasive and a conventional approach

BACKGROUND

A minimal invasive approach for elective hip surgery has been implemented in our institution in the past. It is widely hypothesized that implanting artificial hips in a minimal invasive fashion decreases surgical trauma and is helpful in the rehabilitation process in elective hip surgery. Thereby geriatric patients requiring emergency hip surgery also could theoretically benefit from a procedure that involves less tissue trauma.

METHODS

Sixty patients who sustained a fractured neck of femur were randomly assigned into two groups. In the minimal invasive arm, the so called "direct anterior approach" (DAA) was chosen, in the conventional arm the Watson-Jones-Approach was used for implantation of a bipolar hemi-arthroplasty.Primary outcome parameter was the mobility as measured by the four-item-Barthel index. Secondary outcome parameters included pain, haemoglobin-levels, complications, duration of surgery, administration of blood transfusion and external length of incision. Radiographs were evaluated.

RESULTS

A statistically significant difference (p = 0,009) regarding the mobility as measured with the four-item Barthel index was found at the 5th postoperative day, favouring the DAA. Evaluation of the intensity of pain with a visual analogue scale (VAS) showed a statistically significant difference (p = 0,035) at day 16. No difference was evident in the comparison of radiographic results.

CONCLUSIONS

Comparing two different approaches to the hip joint for the implantation of a bipolar hemi-arthroplasty after fractured neck of femur, it can be stated that mobilization status is improved for the DAA compared to the WJA when measured by the four-item Barthel index, there is less pain as measured using the VAS. There is no radiographic evidence that a minimal invasive technique leads to inferior implant position.

LEVEL OF EVIDENCE

Level II therapeutic study.

[Early interdisciplinary geriatric rehabilitation after hip fracture : Effective concept or just transfer of costs?]

BACKGROUND

Modern strategies for postoperative care of patients with hip fractures include early discharge from the acute care hospital to inpatient interdisciplinary rehabilitation facilities. Whether these programs are effective for the patients and improve their long-term outcomes or if they simply transfer costs, with a reduction of the inpatient days in the acute care hospital, is currently under discussion.

PATIENTS AND METHODS

This prospective study included 282 patients with hip fracture admitted to our trauma center were included into the prospective study. The mean patient age was 86+/-8 (65-110) years. All patients were treated operatively. After a mean of 12+/-9 days, the patients underwent inpatient interdisciplinary geriatric rehabilitation for a mean of 27+/-13 (4-103) days. The primary outcome measure was their activities of daily living (Barthel index) before, at the end of rehabilitation, and 1 year after trauma. In addition, patient-related variables were correlated with the Barthel index.

RESULTS

With discharge from the acute care hospital, the Barthel index was 42+/-20 points and it increased during rehabilitation to 65+/-26 points. One year later the Barthel index was 67+/-28 points. Ninety percent of patients improved their Barthel index during rehabilitation. Within 1 year, 40% of patients deteriorated in their activities of daily living. Fifty one percent of patients were reintegrated back to their homes. Patients who lived at home before trauma and were reintegrated back to their homes had a significant higher Barthel index (75+/-24) 1 year after trauma than patients who were living in a nursing care facility before the trauma (Barthel index 52+/-27). The variables of age, level of cognition, and type of fracture had no influence on the long-term outcome. An extension of rehabilitation above the mean time period did not improve the sustainable clinical outcome.

CONCLUSION

Postoperative inpatient rehabilitation programs enhance short-term activities of daily living. In particular, patients who lived at home before the trauma and were reintegrated back home benefited in perpetuity from geriatric rehabilitation. A policy for early discharge to geriatric rehabilitation is associated with extension of overall hospital stay. This association along with the related increased health care costs should be weighed against the sociofunctional effectiveness of these programs.

Predictive value of six risk scores for outcome after surgical repair of hip fracture in elderly patients

BACKGROUND

Hip fracture surgery is associated with high post-operative mortality and poor functional results: the excess mortality is 20% in the first year; of those patients who survive, only 50% recover their previous ability to walk. The purpose of this study was to assess the predictive value of six functional status and/or surgical risk scoring systems with regard to serious complications after hip fracture surgery in the elderly.

METHODS

We performed a prospective study of a consecutive series of 232 patients (aged 65 years or older) undergoing hip fracture surgery. We pre-operatively applied: The American Society of Anesthesiologists classification, the Barthel index, the Goldman index, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system, the Charlson index and the Visual Analogue Scale for Risk (RISK-VAS) scale. These scales were evaluated with respect to three variables: incidence of serious complications, the ability to walk after a 3-month period and 90-day survival. The predictive value of the different scales was assessed by the calculated area under a receiver operating characteristic curve.

RESULTS

The RISK-VAS scale, the POSSUM scoring system and the Charlson index reached a sufficient predictive value with regard to serious post-operative complications. The Barthel index and the RISK-VAS scale were those most useful for predicting ambulation at 3 months. None of the scales proved to be capable of predicting 90-day mortality.

CONCLUSIONS

A simple index such as the RISK-VAS scale was the best predictor of serious post-operative complications. The functional level before the fracture, measured with the Barthel index, had a major influence on the ambulation recovery.

[Proximal fracture of the femur in elderly patients. The influence of surgical care and patient characteristics on post-operative mortality]

In a retrospective study, 1.173 fractures of the proximal femur, which had been treated surgically, were analysed in two periods from 1975 to 1991 and from 1992 to 2000. The influence on mortality of preoperative risk factors and primary treatment with total hip replacement (THR), even in cases of pertrochanteric fractures, was analysed by stepwise logistic regression. In the later period, mortality within 90 days was 13.1%, and within 1 year 22.2%. Rejection of hemiendoprosthesis in high-risk patients with intracapsular fractures increased the mortality rate from 6.3% to 11.8%. The introduction of dynamic hip screws instead of Ender nails led to a reduction of mortality from 16.5 to 7.1%. Higher mortality after THR (27.6%) compared to osteosynthesis (15.5%) in pertrochanteric femur and lateral neck fractures was due to higher age and increased risk factors. Although the influence of some risk factors could be reduced, age, sex and morbidity influenced the outcome more than surgical treatment. THP, even after pertrochanteric fractures, is reasonable if it guarantees a quick and enduring mobilisation of the patient. Bicentric bipolar prostheses are recommended for high risk patients.

Correlation between pre-injury mobility and ASA score with the mortality following femoral neck fracture in elderly

A poor pre-injury mobility and high American Society of Anaesthiologist (ASA) grading is thought to be associated with a poor survival following surgical treatment of femoral neck fracture in the elderly. Hence there are concerns among orthopaedic surgeons about surgical treatment in this group of patients. In this retrospective study, the pre-injury mobility and ASA scores of 401 patients with fractured neck of femur treated by surgery was assessed in relation to mortality following surgery within the first 30 days of injury. Following surgery, a temporary deterioration in the ASA grading and mobility was noticed. Patients who required intensive medical care following surgery had higher mortality rate. The mortality was 15% among patients with ASA III and 40% among patients with ASA IV. 14% of 65 immobile patients, 18% of those mobile with Zimmer frame passed away after surgery for femoral neck fracture. 6.1% of ASA I scorers died compared with 40% of ASA IV scorers; this difference was statistically significant (χ²=13.883, df=1, P<0.001). Significant number of patients with ASA-IV (60%) and immobile patients (88%) survived following surgery for femoral neck fracture. Poor pre-injury mobility and high ASA scoring are associated with higher early mortality following surgery for femoral neck fracture, however, this should not preclude surgery for patients with poor pre-injury ASA grading and mobility sustaining femoral neck fracture, as significant number of our patients survived.

[On the prognosis of hip fractures. Assessment of mortality after hip fractures by analyzing overlapping segments of longitudinal data]

BACKGROUND

Data on the treatment of hip fractures in acute care settings have been collected in a report card system for quality assurance in Germany since the beginning of the 1990s. However, there are no data on the long-term outcome and long-term quality of care.

MATERIAL AND METHOD

In a retrospective study, data on 1393 patients from 1999 were collected from different sources: from the department of quality assurance at the medical association of Westfalia-Lippe, the Statutory Health Insurance Funds (AOK), and the Medical Review Board of the Statutory Health Insurance Funds (Medizinischer Dienst der Krankenkasse, MDK). Statistical analyses were performed by the Center for Clinical Studies of the University of Düsseldorf.

RESULTS

Uni- and multivariate analyses reveal the following prognostic parameters for survival after hip fracture: sex, age, nursing care dependency, living in a nursing home, risk stratification according to ASA, and postoperative complications. Timing of the operation had no affect on survival.

CONCLUSIONS

Prognostic factors for the outcome after hip fracture can only be obtained by analyzing data from the hospital stay and the post-hospital setting as well. Chances of survival can be significantly improved by rehabilitative care.

Morbidité, mortalité et autonomie des patients opérés par prothèse intermédiaire pour fracture cervicale vraie

PURPOSE OF THE STUDY

We conducted a prospective multicentric study of 203 consecutive patients who underwent hemi-arthroplasty for femoral neck fracture between May 1999 and August 2001. The purpose of the study was to assess quality-of-life among these patients one year after their surgery.

MATERIAL AND METHODS

Mean patient age was 79.6 +/- 8.6 years; 71.2% were women. Most fractures were Garden type III and IV (87.4%) and 90.9% were recent (< 21 d). The hemiarthroplasty was performed with the Intermedia implant via a posterolateral approach in 73.9% of patients with acetabular reaming for 13.7%; a skirted head was used in only 20.8%. The Robinson score (19/26 < or = 6.89) for joint motion, lifestyle, degree of osteoporosis (Singh score), and history (ASA score), as well as a psychomotor indicator (Hodkinson score) were noted preoperatively. Quality-of-life was measured at one year in the same patients using the Postel Merle d'Aubigne (PMA) score and a quality-of-life score.

RESULTS

Among the 203 patients, 38 (18.7%) were lost to follow-up and 37 died (18.2%). Eleven posterior dislocations (5.4%) were noted and four were reduced orthopedically. The PMA score was 84.7% satisfactory results (excellent, very good, good). Preoperatively 58.8% of the patients were independent and 7% were in nursing homes; one year postoperatively, these proportions were 54% and 4.8%. There was a significant difference in the PMA score between two populations defined by the preoperative Robinson score less than or greater than 20. Outcome was better for patients with a Robinson score > 20 pre-operatively. For these two populations, change in lifestyle was highly significant one year postoperatively. However, for the overall population, changes in lifestyle and joint motion were not significantly different between the pre- and postoperative evaluations. Paradoxically, 29.1% of the patients who were dependent preoperatively were not one year after surgery, which indicates that certain patients also had a better quality-of-life after their hemiarthroplasty.

CONCLUSION

Mortality after fracture of the femoral neck remains high (18.2% at one year). There were no infections requiring revision in this series, but there were eleven cases of dislocation (5.4%). The difference in joint motion and quality-of-life between the pre- and postoperative assessment was not significant for the whole population, but one third of the patients who were independent preoperatively were not at last follow-up.