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Unnanuntana A, Kuptniratsaikul V, Srinonprasert V, Charatcharoenwitthaya N, Kulachote N, Papinwitchakul L, Wattanachanya L, Chotanaphuti T. A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review. Injury 2023; 54:111039. [PMID: 37757673 DOI: 10.1016/j.injury.2023.111039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 08/21/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand. METHODS A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel. RESULTS Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan. CONCLUSION We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.
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Affiliation(s)
- Aasis Unnanuntana
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand.
| | - Vilai Kuptniratsaikul
- Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Varalak Srinonprasert
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Natthinee Charatcharoenwitthaya
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Noratep Kulachote
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Lalita Wattanachanya
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University and Excellence Center for Diabetes, Hormone and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Thanainit Chotanaphuti
- Department of Orthopedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
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Phang JK, Lim ZY, Yee WQ, Tan CYF, Kwan YH, Low LL. Post-surgery interventions for hip fracture: a systematic review of randomized controlled trials. BMC Musculoskelet Disord 2023; 24:417. [PMID: 37231406 DOI: 10.1186/s12891-023-06512-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Interventions provided after hip fracture surgery have been shown to reduce mortality and improve functional outcomes. While some systematic studies have evaluated the efficacy of post-surgery interventions, there lacks a systematically rigorous examination of all the post-surgery interventions which allows healthcare providers to easily identify post-operative interventions most pertinent to patient's recovery. OBJECTIVES We aim to provide an overview of the available evidence on post-surgery interventions provided in the acute, subacute and community settings to improve outcomes for patients with hip fractures. METHODS We performed a systematic literature review guided by the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). We included articles that were (1) randomized controlled trials (RCTs), (2) involved post-surgery interventions that were conducted in the acute, subacute or community settings and (3) conducted among older patients above 65 years old with any type of non-pathological hip fracture that was surgically treated, and who were able to walk without assistance prior to the fracture. We excluded (1) non-English language articles, (2) abstract-only publications, (3) articles with only surgical interventions, (4) articles with interventions that commenced pre-surgery or immediately upon completion of surgery or blood transfusion, (5) animal studies. Due to the large number of RCTs identified, we only included "good quality" RCTs with Jadad score ≥ 3 for data extraction and synthesis. RESULTS Our literature search has identified 109 good quality RCTs on post-surgery interventions for patients with fragility hip fractures. Among the 109 RCTs, 63% of the identified RCTs (n = 69) were related to rehabilitation or medication/nutrition supplementation, with the remaining RCTs focusing on osteoporosis management, optimization of clinical management, prevention of venous thromboembolism, fall prevention, multidisciplinary approaches, discharge support, management of post-operative anemia as well as group learning and motivational interviewing. For the interventions conducted in inpatient and outpatient settings investigating medication/nutrition supplementation, all reported improvement in outcomes (ranging from reduced postoperative complications, reduced length of hospital stay, improved functional recovery, reduced mortality rate, improved bone mineral density and reduced falls), except for a study investigating anabolic steroids. RCTs involving post-discharge osteoporosis care management generally reported improved osteoporosis management except for a RCT investigating multidisciplinary post-fracture clinic led by geriatrician with physiotherapist and occupational therapist. The trials investigating group learning and motivational interviewing also reported positive outcome respectively. The other interventions yielded mixed results. The interventions in this review had minor or no side effects reported. CONCLUSIONS The identified RCTs regarding post-surgery interventions were heterogeneous in terms of type of interventions, settings and outcome measures. Combining interventions across inpatient and outpatient settings may be able to achieve better outcomes such as improved physical function recovery and improved nutritional status recovery. For example, nutritional supplementation could be made available for patients who have undergone hip fracture surgery in the inpatient settings, followed by post-discharge outpatient osteoporosis care management. The findings from this review can aid in clinical practice by allowing formulation of thematic program with combination of interventions as part of bundled care to improve outcome for patients who have undergone hip fracture surgery.
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Affiliation(s)
- Jie Kie Phang
- Centre for Population Health Research and Implementation (CPHRI), SingHealth Regional Health System, SingHealth, Singapore, Singapore
- Program in Health Systems and Services Research, Duke-NUS Medical School, Singapore, Singapore
| | - Zhui Ying Lim
- Population Health & Integrated Care Office (PHICO), Singapore General Hospital, Singapore, Singapore
| | - Wan Qi Yee
- Population Health & Integrated Care Office (PHICO), Singapore General Hospital, Singapore, Singapore
| | - Cheryl Yan Fang Tan
- Bright Vision Community Hospital, SingHealth Community Hospitals, Singapore, Singapore
| | - Yu Heng Kwan
- SingHealth Internal Medicine Residency Programme, Singapore, Singapore
- Program in Health Systems and Services Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Lian Leng Low
- Centre for Population Health Research and Implementation (CPHRI), SingHealth Regional Health System, SingHealth, Singapore, Singapore.
- Population Health & Integrated Care Office (PHICO), Singapore General Hospital, Singapore, Singapore.
- Department of Family Medicine & Continuing Care, Singapore General Hospital, Singapore, Singapore.
- SingHealth Duke-NUS Family Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore.
- Department of Post-Acute & Continuing Care, SingHealth Community Hospitals, 10 Hospital Boulevard, Singapore, 168852, Singapore.
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Anusitviwat C, Vanitcharoenkul E, Chotiyarnwong P, Unnanuntana A. Surgical treatment for fragility hip fractures during the COVID-19 pandemic resulted in lower short-term postoperative functional outcome and a higher complication rate compared to the pre-pandemic period. Osteoporos Int 2022; 33:2217-2226. [PMID: 35809122 PMCID: PMC9540207 DOI: 10.1007/s00198-022-06485-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022]
Abstract
UNLABELLED The COVID-19 pandemic adversely affected the functional outcomes of fragility hip fracture patients. This study revealed a higher in-hospital complication rate and lower postoperative function at 3 months among patients treated during the pandemic. Therefore, modified in-hospital and post-discharge protocols should be developed for implementation during pandemic crisis periods. INTRODUCTION This study aims to investigate the in-hospital complication rate and short-term postoperative functional outcomes of fragility hip fracture (FHF) patients compared between during the COVID-19 pandemic and the same 14-month time period 1 year prior to the pandemic. METHODS Using data from the Siriraj Fracture Liaison Service registry, FHF patients treated during the COVID-19 pandemic (1 March 2020 to 30 April 2021) were time-matched with FHF patients treated during the pre-pandemic period (1 March 2018 to 30 April 2019). We collected the rate of in-hospital postoperative complications and the postoperative functional outcomes at discharge and 3 months as measured by the Barthel Index (BI) and EuroQol visual analog scale (EQ-VAS). Functional outcome measures were compared between the pre-pandemic and pandemic periods. RESULTS There were 197 and 287 patients in the pre-pandemic and pandemic groups, respectively. At the 3-month postoperative follow-up, the mean postoperative BI score and change in BI score were both significantly lower in the pandemic group indicating poorer postoperative function. Moreover, FHF patients treated during the pandemic had significantly more in-hospital complications (36.6% vs. 22.8%, p = 0.002). There was no significant difference in the 3-month EQ-VAS or change in the EQ-VAS between groups. CONCLUSION The results of this study revealed a higher in-hospital complication rate and lower postoperative function at 3 months among FHF patients treated during the COVID-19 pandemic compared to the pre-pandemic period. Therefore, modified in-hospital and post-discharge protocols should be developed for implementation during pandemic crisis periods.
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Affiliation(s)
- Chirathit Anusitviwat
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Ekasame Vanitcharoenkul
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pojchong Chotiyarnwong
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Aasis Unnanuntana
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Jarusriwanna A, Phusunti S, Chotiyarnwong P, Unnanuntana A. High-dose versus low-dose ergocalciferol for correcting hypovitaminosis D after fragility hip fracture: a randomized controlled trial. BMC Geriatr 2021; 21:72. [PMID: 33478397 PMCID: PMC7818778 DOI: 10.1186/s12877-021-02023-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Hypovitaminosis D can be observed in most fragility hip fracture patients. However, measurement of 25-hydroxyvitamin D (25(OH)D) level is costly and may not be available in some centers. Without the baseline serum 25(OH)D level, the appropriate dose of vitamin D supplementation is not known. The aim of this study was to evaluate the effectiveness and safety of vitamin D supplementation in fragility hip fracture patients compared between high- and low-dose vitamin D supplementation. Methods A total of 140 patients diagnosed with fragility hip fracture were randomly allocated to either the high-dose (60,000 IU/week) or low-dose (20,000 IU/week) vitamin D2 supplementation group for 12 weeks. The number of patients who achieved optimal vitamin D level (serum 25(OH)D > 30 ng/mL), the proportion of patients who developed hypercalcemia, and the functional outcome were compared between groups. Results Of the 140 patients who were enrolled, 21 patients were lost to follow-up during the study period. The remaining 119 patients (58 and 61 in the high- and low-dose groups, respectively) were included in the final analysis. The high-dose group had a higher rate of serum 25(OH)D restoration to optimal level than the low-dose group (82.8% vs 52.5%, respectively; p < 0.001). Approximately 3.4 and 1.6% of patients in the high- and low-dose groups, respectively, had mild transient hypercalcemia, but none developed moderate, severe, or symptomatic hypercalcemia. There were no differences in functional outcome scores between groups. Conclusions In treatment settings where baseline serum 25(OH)D level can’t be evaluated in older adults with fragility hip fracture, we recommend high-dose vitamin D2 of approximately 60,000 IU/week for 12 weeks, with subsequent switch to a maintenance dose. This regimen effectively restored serum vitamin D to an optimal level in 82.8% of patients without causing symptomatic hypercalcemia. Trial registration The protocol of this study was retrospectively registered in the Thai Clinical Trials Registry database no. TCTR20180302007 on 20 February 2018.
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Affiliation(s)
- Atthakorn Jarusriwanna
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9, Phitsanulok-Nakhon Sawan Road, Mueang Phitsanulok, Phitsanulok, 65000, Thailand
| | - Suchat Phusunti
- Chok Chai Hospital, 220 Moo 13, Omsin Road, Chok Chai, Nakhon Ratchasima, 30190, Thailand
| | - Pojchong Chotiyarnwong
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Bangkok Noi, Bangkok, 10700, Thailand.
| | - Aasis Unnanuntana
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Bangkok Noi, Bangkok, 10700, Thailand
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Wang CY, Fu SH, Yang RS, Chen LK, Shen LJ, Hsiao FY. Timing of anti-osteoporosis medications initiation after a hip fracture affects the risk of subsequent fracture: A nationwide cohort study. Bone 2020; 138:115452. [PMID: 32464276 DOI: 10.1016/j.bone.2020.115452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 05/16/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The optimal time after hip fracture to start prophylactic anti-osteoporosis medications (AOMs) remains uncertain, especially in real-world practice. Therefore, we investigated how timing of AOMs initiation affects the risk of subsequent osteoporotic fractures, and what factors influence timing of AOMs prescription. METHOD Patients ≥50 years old with diagnostic codes indicating hospitalization for hip fracture (n = 77,930) were identified from the Taiwan National Health Insurance Research Database; 9986 who were prescribed AOMs ≤1 year after a newly-diagnosed hip fracture were grouped into those who started AOMs from: ≤14 days (very early); 15-84 days (early); 85-252 days (late); and 253-365 days (very late). Associations with fracture-related hospitalizations after an index fracture were analyzed using a multivariate, time-dependent Cox proportional hazards model, and between-group differences compared by log-rank testing. Factors influencing timing of AOMs initiation were elucidated using multivariate logistic regression analyses. RESULTS Compared to AOMs initiation from 15 to 84 days, initiation after 252 days was associated with significantly increased risk of fracture-related hospitalization (HR = 1.93, 95% CI 1.29-2.89). Both sensitivity and pre-specified subgroup analyses yield similar results. Among patients with high adherence to AOMs, the increased risk of subsequent fracture-related hospitalization among very late users was profound (HR = 2.56, 95% CI 1.41-4.64). CONCLUSION Timing of AOMs initiation was significantly associated with age, index year, index hospital length of stay as well as the accreditation level and geographic region of index hospital. After adjusting factors associated with timing of AOMs initiation and patients' adherence, the anti-fracture benefit of AOMs still depends crucially on the timely initiation of AOMs.
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Affiliation(s)
- Chen-Yu Wang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Education and Medical Research, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan; Department of Pharmacy, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Shau-Huai Fu
- Department of Orthopedics, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Rong-Sen Yang
- Department of Orthopedics, National Taiwan University Hospital, Taipei, Taiwan
| | - Liang-Kung Chen
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan; Department of Geriatric Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan; Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Jiuan Shen
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.
| | - Fei-Yuan Hsiao
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.
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Validity and responsiveness of Barthel index for measuring functional recovery after hemiarthroplasty for femoral neck fracture. Arch Orthop Trauma Surg 2018; 138:1671-1677. [PMID: 30094561 DOI: 10.1007/s00402-018-3020-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION To investigate the validity of Barthel Index (BI) compared with de Morton Mobility Index (DEMMI), EuroQol-visual analog scale (EQ-VAS), 2-min walk test (2MWT), and timed get-up-and-go test (TUG), and to evaluate the responsiveness of all outcome measures for assessing functional recovery in older patients who underwent hemiarthroplasty after femoral neck fracture. MATERIAL AND METHOD Eighty-one femoral neck fracture patients who were enrolled in a study evaluating functional recovery after bisphosphonate therapy during 2013 to 2015, and who had data available at both baseline and 12 months after surgery were included in this study. RESULTS All scores improved significantly from baseline to the 1-year follow-up. BI had moderate to strong correlation with DEMMI, 2MWT, and TUG (r-value: 0.490-0.843), and mild to moderate correlation with EQ-VAS (r-value: 0.278-0.323). All outcome measurements had high effect estimates. The minimal clinically important difference (MCID) of BI at 12 months was 9.8 points. CONCLUSION Since BI was shown to have good validity (moderate to strong correlation with DEMMI and performance-based tests, and mild to moderate correlation with EQ-VAS), BI can be used to accurately assess functional recovery in patients who undergo hemiarthroplasty after femoral neck fracture.
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