Factors influencing discharge location following hip fracture

Discharge to a Skilled Nursing Facility After Hip Fracture Results in Higher Rates of Periprosthetic Joint Infection

BACKGROUND

Femoral neck fractures (FNFs) in elderly patients are associated with major morbidity and mortality. The influence of postoperative discharge location on recovery and outcomes after arthroplasty for hip fractures is not well understood.

METHODS

A multisite retrospective cohort from 9 academic centers identified patients who had FNF treated with hemiarthroplasty or total hip arthroplasty between 2010 and 2019. Patients who had diagnoses of dementia, stroke, age > 80 years, or high energy fracture were excluded. Discharge location was identified, including home-based health services (HHS), inpatient rehabilitation (IPR), or a skilled nursing facility (SNF). Rates of reoperation, periprosthetic joint infection (PJI), and mortality were compared between cohorts. Multivariate logistic regressions were performed, adjusting for age, American Society of Anesthesiologists (ASA) score, body mass index, sex, and tobacco use. Statistical significance was defined as P < .05.

RESULTS

A total of 672 patients (315 HHS, 144 IPR, and 213 SNF) were included in this study. The average follow-up was 30 months. The SNF cohort was significantly older (P < .0001) with higher ASA scores (P < .0001) than the HHS cohort. In a logistic regression model adjusting for age, ASA score, and body mass index, the SNF cohort had higher mortality rates than the HHS cohort (P = .0296) and were more likely to have PJI within 90 days (odds ratio = 4.55, 95% confidence interval = 1.40, 4.74) and within 1 year (odds ratio = 3.08, 95% confidence interval = 1.08, 8.78). Time to PJI was significantly shorter in the SNF cohort (SNF 38 versus HHS 231 days, P = .0155). No differences were seen in dislocation or reoperation rates between the SNF and HHS cohorts. No differences were seen in complication rates between the IPR and HHS cohorts.

CONCLUSIONS

Discharge to a SNF after arthroplasty for FNF is associated with increased mortality and higher rates of PJI. Hip fracture care pathways that uniformly discharge patients to SNFs may need to be re-evaluated, and surgeons should consider discharge to home with HHS when possible.

Branching Out: A Retrospective Review of Tree Fall-Related Trauma

Introduction Falls from trees (FFTs), although rare, represent a significant public health concern due to the severe consequences they can impose. Such incidents, while statistically uncommon across the wider population, have the potential to cause drastic, lasting alterations in patients' lives. The severity of these events is often substantial, highlighted by high Injury Severity Scores (ISSs) and prolonged hospital length of stay (LOS), which brings to light the urgent need for preventive strategies and heightened awareness. Our study aims to present a current epidemiological understanding of the patterns, nature, and severity of injuries caused by FFTs. Additionally, it provides an analysis and comparison of data obtained from a de-identified trauma database of patients presenting after FFTs. Methods This review presents data from a trauma registry system detailing trauma admissions from March 31, 2016, to December 27, 2021, at the Desert Regional Medical Center in Palm Springs, California, United States, a designated Level 1 trauma center. Throughout this period of nearly five years and eight months, a total of 3,148 patients were recorded to have visited the emergency department due to falls. Specifically, the study zeroes in on the subset of patients who were admitted after experiencing FFTs. From the comprehensive retrospective examination, it was noted that among the 3,148 fall incidents, there were 50 cases that involved FFTs. Results This retrospective analysis focused on 50 patients treated at the emergency department after FFTs, with a predominantly male demographic profile of 49 (98%) and an average age of 44 years. Hospitalization was required for the vast majority (44%), with approximately one-third necessitating ICU care. Surgical procedures were necessary for 35 (70%) of these cases. Upon discharge, 36 (72% of patients) were able to return home. Vertebral fractures were the most frequent injury, present in 24 (22% of admissions), followed closely by soft tissue injuries at 23 (21%). The mean ISS was 11, although those with extended hospital stays of over 10 days had higher ISS scores of 16, in contrast to an ISS of 10 for those with shorter stays. Conclusions FFTs constitute a lesser-known category of trauma-related injuries in the broader spectrum of fall-related incidents. Although relatively infrequent, these incidents result in significant injury burdens. The objective of this review is to compile and summarize the existing body of literature on FFTs. It involves an in-depth analysis of admission, discharge, and demographic data related to FFTs, highlighting the significant consequences associated with such accidents. Additionally, this review incorporates an analysis of a specialized dataset dedicated to injuries resulting from FFTs, facilitating a comparative assessment against current research in this field.

Predictive factors for home discharge after femoral fracture surgery: a prospective cohort study

BACKGROUND

Femoral fractures require protracted hospitalization and often preclude return to pre-fracture levels of mobility, function and prior residential status following hospital discharge. Early prediction of rehabilitation and discharge potential in patients with femoral fracture would optimize discharge planning.

AIM

To identify predictive factors of discharge destination during the early phase of femoral fracture rehabilitation.

DESIGN

Prospective cohort design.

SETTING

Acute and postoperative rehabilitation hospital settings.

POPULATION

Data from 109 participants (65 women [59.6%]) admitted for unilateral femoral fracture were included.

METHODS

Sociodemographic information, hip pain severity during gait (Numeric Pain Rating Scale), mobility (Elderly Mobility Scale), activities of daily living (Modified Barthel Index), cognition (Mini-Mental State Examination [MMSE]), exercise self-efficacy (Self-Efficacy for Exercise Scale), amount of physiotherapy received, and caregiver availability were assessed pre- and/or postoperatively. Discharge destination was assessed via telephone interviews 6 weeks after discharge from acute care. Receiver operating characteristic curves were used to determine optimal cut-off scores for all outcomes based on discharge destination. Outcomes demonstrating a significant area under the curve were entered as dichotomous independent variables (i.e., above or below ROC-derived cut-off values) in subsequent logistic regression analyses to determine predictors of discharge destination.

RESULTS

SEE Score ≥53 (odds ratio [OR]=5.975, 95% confidence interval [CI]=1.674-21.333, P=0.006), female sex (OR=3.421, 95% CI=1.187-9.861, P=0.023), ≥8 physiotherapy sessions (OR=4.633, 95% CI=1.559-13.771, P=0.006), MMSE Score ≥17 (OR=3.374, 95% CI=1.047-10.873, P=0.042), and caregiver availability (OR=3.766, 95% CI=1.133-12.520, P=0.030) were identified as significant predictors of home discharge.

CONCLUSIONS

Exercise self-efficacy, female sex, more physiotherapy rehabilitation training, better pre-operative cognitive function, and caregiver availability emerged as important predictors of home discharge following femoral fracture.

CLINICAL REHABILITATION IMPACT

These findings are highly translational and may be useful for informing clinical guidelines and policy decisions regarding rehabilitation potential and discharge pathway selection during early hospitalization following femoral fracture surgery.

Socioeconomically-deprived patients suffer hip fractures at a younger age and require more hospital admissions, but early mortality risk is unchanged: The IMPACT Deprivation Study

INTRODUCTION

Socioeconomic deprivation is associated with multi-morbidity and frailty, but influence on hip fracture outcomes is poorly understood. The primary aim was to investigate the association between deprivation and mortality, and secondary aims were to assess the effects on: (i) age at presentation; (ii) inpatient outcomes, and (iii) post-discharge outcomes.

METHOD

This cohort study included all patients aged >50 years admitted with a hip fracture to a high-volume centre between 01 March 2020 and 20 November 2021. Data were collected contemporaneously by specialist auditors and underwent validation using live health records after 180 days follow-up. Variables were demographics including Scottish Index of Multiple Deprivation, injury and management factors, and outcome measures including length of stay, discharge destination, readmission, and mortality status at 180 days.

RESULTS

There were 1822 patients of which 1306/1822 (72%) were female. Deprivation was independently associated with younger age at hip fracture, demonstrating a linear correlation with each deprivation level. The overall mean age was 80.7 years (range 50-102), with the mean age in the most deprived group being 77.2 years (95% CI; 75.7-78.7) versus 82.8 years (95% CI; 82.0-83.5) in the least deprived. Multivariate logistic regression showed no association between deprivation and 30- or 180-day mortality risk. Kaplan-Meier survival analysis demonstrated no difference between the most deprived versus least deprived (log-rank, p = 0.854). Deprivation had no influence on length of stay, discharge destination, or COVID-19 status, but deprived patients had an increased risk of readmission (OR 1.63, 95% CI [1.18-2.24]; p = 0.003).

CONCLUSION

Deprivation showed no linear correlation with early mortality risk (within 180 days of injury), but it was associated with an earlier age at presentation (the most deprived sustained a hip fracture 5.6 years earlier than the least deprived) which may impact overall life expectancy. More deprived patients were more likely to require further acute hospital admissions.

Factors associated with non-home discharge of patients hospitalized for hip fracture: A nationwide retrospective study using the Japanese diagnostic procedure combination database

In Japan, the length of stay in acute care hospitals has been shortened, home medical care has been promoted following national policy. However, many issues remain in promoting home medical care. The aim of this study was to clarify the profiles of patients with hip fractures, aged ≥ 65 years, who were hospitalized in acute care institutions at the time of discharge and the influence on nonhome discharge. This study used data from patients who satisfied all the following conditions: Patients aged ≥ 65 years who were hospitalized and discharged between April 2018 and March 2019; Patients with hip fractures, and; Patients who were admitted from home. The patients were classified into the home discharge and nonhome discharge groups. Multivariate analysis was conducted by comparing socio-demographic status, patient background factors, patient status at discharge, and hospital function. This study included 31,752 patients (73.7%) and 11,312 patients (26.3%) in the nonhome discharge group and home discharge group, respectively. Overall, the proportions of males and females were 22.2% and 77.8%, respectively. The average (standard deviation) age of the patients was 84.1 years (7.4) and 81.3 years (8.5) in the nonhome discharge and home discharge groups, respectively (P < .01). The following factors affected nonhome discharge: 75 to 84 years (odds ratio [OR] = 1.81, 95% confidence interval [CI] = 1.68-1.96), ≥85 years (OR = 2.17, 95% CI = 2.01-2.36), electrocardiography or respiratory treatment "(Factor A3) (OR = 1.44, 95% CI = 1.23-1.68), level of assistance with activities of daily living "(Factor B1)" (OR = 4.56, 95% CI = 4.22-4.92), and hospital where the patient-to-nurse ratio is 7:1 (OR = 2.12, 95% CI = 1.91-2.35). The results suggested that support from activities of daily living caregivers and implementing medical treatments such as respiratory care are required to advance home medical care. This study's method enables analysis focusing on aspiration pneumonia and cerebral infarction, which are common among older adults. Furthermore, specific measures for promoting home medical care for patients who are highly dependent on medical and long-term care may be developed.

Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care "Value"

BACKGROUND

Value is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNFs) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF).

METHODS

Between October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, postoperative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-squared or t-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA and 63% HA) and 132 (69%) patients discharged to SNF (14% THA and 86% HA). Patients discharged to SNF were older (P < .01), had lower Risk Assessment and Prediction Tool scores (P < .01), had higher comorbidity scores (P = .011), and had longer posthospitalization care (P < .01).

RESULTS

There were no differences in rates of inpatient minor complications (P = .520), inpatient major complications (P = .119), Intensive Care Unit admissions (P = .193), or readmissions within 30 (P = .690) and 90 days (P = .176). Costs of care at a SNF were higher than HHS (P < .01). In multivariate regressions, a lower Risk Assessment and Prediction Tool score was associated with discharge to SNF (odds ratio 0.69, 95% confidence interval 0.58-0.83, P < .001).

CONCLUSION

Among Comprehensive Care for Joint Replacement bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.

Preinjury Functional Independence is not Associated with Discharge Location in Older Trauma Patients

BACKGROUND

The purpose of this study was to evaluate the association between pre-injury Katz Index of Independence in Activities of Daily Living (Katz ADL) functional status and discharge to a facility in non-neurologically injured older trauma patients.

METHODS

Data were obtained from 207 patients in the Trauma Medical Home study cohort. Multivariable logistic regression was performed to identify factors associated with non-home discharge.

RESULTS

Average patient age was 67.9 (SD 11.1). Patients were predominantly white (89.4%) and female (52.2%) with a median ISS of 11 (IQR 9-14). The most common mechanism of injury was fall (48.3%), followed by motor vehicle crash (41.1%). Nearly all patients (94.7%) reported independence in activities of daily living prior to hospitalization for injury. Discharge disposition varied, 51.7% of patients were discharged home, 37.7% to subacute rehabilitation, 10.1% to acute rehabilitation and 0.5% to long-term acute care. There was no relationship between pre-injury independence and likelihood of discharge home (P = 0.1331). Age (P < 0.0001), BMI (P = 0.0002), Charlson comorbidity score of 3 or greater (P = 0.0187), being single (P = 0.0077), ISS ≥ 16 (P = 0.0075) and being female with self-reported symptoms of anxiety and/or depression over the past two weeks (P = 0.0092) were associated with significantly greater odds of non-home discharge.

CONCLUSIONS

Pre-injury Katz ADL is not associated with discharge disposition, though other significantly associated factors were identified. It is imperative that discussions regarding discharge disposition are initiated early during acute hospitalization. Trauma programs could potentially benefit from implementing an inpatient intervention focused on building coping skills for older patients exhibiting symptoms of anxiety or depression.

Discharge destination after hip fracture: findings from the Irish hip fracture database

PURPOSE

Although home continues to be the place from which the majority of patients are admitted, less than one third of patients are Discharged Directly Home (DDH) following hip fracture. Once ready for discharge, DDH as opposed to Discharge to an Alternative Location (DAL), i.e., community care, rehabilitation facility or long-term care, is a high priority for patients and clinicians alike. Not only is DDH integral to the quality of life of patients, it is also an essential driver of the socioeconomic cost of hip fracture care.

METHODS

We analysed 21,819 cases in the Irish Hip Fracture Database from 2013 to 2019. Descriptive and analytical statistics were conducted.

RESULTS

29% (n = 6476) of patients were DDH during the study period. On multivariate analysis, the odds of DDH decreased as age increased (OR 0.28, p < 0.01, 95% CI 0.24-0.34). Patients who were independently mobile prior to fracture were 47% more likely to be DDH (OR 1.47, p < 0.01, 95% CI 1.29-1.68). Those mobilised early post operatively were 24% more likely to be DDH (OR 1.24, p < 0.01, 95% CI 1.06-1.45). Patients who waited > 72 h prior to surgery were 30% less likely to be DDH (OR 0.70, p < 0.01, 95% CI 0.56-0.88).

CONCLUSION

The authors identified patient characteristics that increased the likelihood of DDH, i.e., younger patients independently mobile prior to fracture, who received timely surgery and early post-operative mobilisation. The Irish Hip Fracture Standards (IHFS) incorporate 2 out the 3 modifiable factors identified, which reinforces the importance of the IHFS in improving patient outcomes.

A mixed methods evaluation of a 4-week geriatrics curriculum in strengthening knowledge and comfort among orthopaedic surgery residents

BACKGROUND

In 2014, the University of Toronto Faculty of Medicine implemented a 4-week "Orthogeriatrics" rotation for orthopaedic surgery residents. We sought to assess the rotation's impact on trainees' knowledge, attitudes, and behaviours toward caring for older adults, and explore areas for improvement.

METHODS

We used a mixed methods concurrent triangulation design. The Geriatrics Clinical Decision-Making Assessment (GCDMA) and Geriatric Attitudes Scale (GAS) compared knowledge, attitudes, and behaviours between trainees who were or were not exposed to the curriculum. Rotation evaluations and semi-structured interviews with trainees and key informants explored learning experiences and the curriculum's impact on resident physician growth and development in geriatric competencies.

RESULTS

Among trainees who completed the GCDMA (n = 19), those exposed to the rotation scored higher in knowledge compared to the unexposed cohort (14.4 ± 2.1 vs. 11.3 ± 2.0, p < 0.01). The following themes emerged from the qualitative analysis of 29 stakeholders: Increased awareness and comfort regarding geriatric medicine competencies, appreciation of the value of orthogeriatric collaboration, and suggestions for curriculum improvement.

CONCLUSIONS

These results suggest that the Orthogeriatrics curriculum strengthens knowledge, behaviour, and comfort towards caring for older adults. Our study aims to inform further curriculum development and facilitate dissemination of geriatric education in surgical training programs across Canada and the world.

Early Predictors for Discharge to Geriatric Rehabilitation after Hip Fracture Treatment of Older Patients

OBJECTIVE

To investigate early predictors for discharge to a geriatric rehabilitation department at a skilled nursing home in older patients after hospitalization for hip fracture surgery.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Data from 21,176 patients with hip fracture aged ≥70 years, who were registered in the Dutch Hip Fracture Audit database between January 1, 2017, and December 31, 2019, were included.

METHODS

Patients were categorized into 3 discharge groups: home (n=7326), rehabilitation (n=11,738), and nursing home (n=2112). Age, gender, Pre-Fracture Mobility Score (PFMS), premorbid Katz index of independence in Activities of Daily Living (Katz-ADL), history of dementia, American Society of Anesthesiologists physical status classification (ASA score), type of anesthesia, fracture type, surgical treatment, and cotreatment by a geriatrician were gathered. Multinomial regression analysis was used to assess for early predictors.

RESULTS

Higher age, poor premorbid mobility, lower premorbid Katz-ADL, no history of dementia, ASA score 3-5, general anesthesia, intramedullary implant, and cotreatment by a geriatrician were independent predictors for discharge to geriatric rehabilitation vs discharge home. Identical predictors were found for discharge to a nursing home vs discharge home. History of dementia and premorbid Katz-ADL were distinguishing factors; a higher premorbid Katz-ADL and a history of dementia were associated with a higher risk of discharge to a nursing home vs discharge home. The multinomial regression model correctly predicted 86%, 38.6%, and 2.4% of the patients in the rehabilitation group, home group, and nursing home group, respectively.

CONCLUSIONS AND IMPLICATIONS

This study showed that age, PFMS, premorbid Katz-ADL, surgical treatment, ASA score, type of anesthesia, history of dementia, and cotreatment by a geriatrician were independent early predictors for discharge to geriatric rehabilitation vs discharge home in older patients after hip fracture surgery. Identical predictors were found as predictors for discharge to a nursing home vs discharge home, except for history of dementia and premorbid Katz-ADL.

Predictive validity of the functional capacity of the CUPAX questionnaire in older adults with hip fracture

BACKGROUND AND OBJECTIVES

Osteoporotic hip fracture is a relevant pathology due to its prevalence and social and health impact. The aim of this study is to explore the predictive validity of the CUPAX questionnaire on mortality, place of residence and post-fracture functionality.

MATERIALS AND METHODS

Prospective observational study. Two hundred and six patients older than 65 years were included, admitted after a hip fracture. The CUPAX questionnaire score was collected before fracture and one year later, and the place of residence and survival at hospital discharge, and after 6 and 12 months. The statistical analysis was carried out with the SAS® 9.4 and Stata® 13.1 programmes.

RESULTS

The median age of the sample was 87.0 years (80.1% women). The in-hospital and one-year mortality rate were 5.8% and 19.1%, respectively. Most of the patients were admitted from home (71.4%), and the most frequent discharge destination was a social health centre (48.2%). The percentage of retention of previous functional level in the total sample was 50%, being higher in the younger patients. The area under the curve ROC for mortality one year later was .697 (95% CI .626-.760) and .659 (95% CI .576-.741) for the discharge destination of patients admitted from home. Evaluation of functional retention one year after the fracture, identified three groups of patients based on the pre-fracture CUPAX value.

CONCLUSIONS

These findings support the clinical utility of the CUPAX questionnaire as a predictive functional tool in elderly patients with hip fracture.

Physical Therapy Management of Older Adults With Hip Fracture

Hip fracture is a leading cause of profound morbidity in individuals aged 65 years and older, ranking in the top 10 causes of loss of disability-adjusted life-years for older adults. Worldwide, the number of people with hip fracture is expected to rise significantly due to the aging population and other factors. Physical therapist management is recommended within medical, surgical, and multidisciplinary clinical practice guideline (CPGs) and is considered to be the standard of care in rehabilitation for people with hip fracture. The goal of this CPG was to review the evidence relevant to physical therapist management and to provide evidence-based recommendations for physical therapy diagnosis, prognosis, intervention, and assessment of outcome in adults with hip fracture. J Orthop Sports Phys Ther 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301.

Patient and hospital factors influencing discharge destination following hip fracture

OBJECTIVE

To compare demographics, treatment and health outcomes for individuals hospitalised with a hip fracture and examine predictors of postacute discharge destination.

METHODS

A retrospective analysis of data from the Australian and New Zealand Hip Fracture Registry of individuals aged ≥50 years hospitalised with a hip fracture from 2015 to 2018 (n = 29 881). Multinominal logistic regression was used to examine factors associated with discharge destination for individuals from private residences.

RESULTS

Advancing age, impaired cognition, reduced walking ability and poorer pre-operative health were predictors for discharge to residential aged care. The odds of discharge to a rehabilitation unit were higher for individuals with extracapsular fractures, treated at major trauma centres or at hospitals with home-based rehabilitation. Individuals in rural areas had higher odds of discharge to another hospital or ward.

CONCLUSION

In addition to well-known demographics, injury and treatment factors, non-clinical factors including geographic area of residence also affect discharge destination.

Prognostic factors for discharge to home and residing at home 12 months after hip fracture: an Anoia hip study

OBJECTIVES

Hip fracture is often associated with loss of physical function and institutionalization. The aim of this study is to describe the prognostic factors for discharge to home and residing there 12 months after a hip fracture.

METHODS

A prospective study that includes patients aged ≥ 69 years that live at home before the fracture, admitted from June 1st, 2010, to May 31st, 2013. We registered the demographic data, presurgical function and cognitive assessment, surgical waiting time, type of fracture and complications during hospitalization.

RESULTS

We included 273 patients (mean age 84.8 ± 6.1 years; 80% women), 130 (47.6%) were discharged directly to their own home. The predictors of discharge to home were a lower Geriatrics Dementia Scale score (OR 1.42; 95% CI 1.17-1.71; p < 0.001), a higher Barthel Index score at discharge (OR 1.07; 95% CI 1.05-1.10; p < 0.001) and a longer hospital stay (OR 1.14; 95% CI 1.02-1.27; p = 0.019). At 12 months, 169 (63.5%) were still residing at home. Predictors of residing at home 12 months after the hip fracture were age (OR 1.07; 95% CI 1.02-1.12; p = 0.010), the discharge Barthel Index score (OR 0.96; 95% CI 0.94-0.98; p < 0.001), the Geriatrics Dementia Scale score (OR 1.27; 95% CI 1.05-1.52; p = 0.013), the surgical waiting time (OR 3.42; 95% CI 1.077-10.89; p = 0.037) and Charlson comorbidity index (OR 1.27; 95% CI 1.05-1.55; p = 0.016).

CONCLUSION

Prognostic factors for discharging to home and remaining there 12 months after a hip fracture are those that reflect a better health condition prior to the fracture and better functionality at the hospital discharge for hip fracture.

Saving the split: the benefits of VATS thymectomy

Background

With the advent of minimally invasive techniques, the standard approaches to many surgeries have changed. We compared the financial costs and health care outcomes between standard thymectomy via sternotomy and video assisted thoracoscopic surgery (VATS).

Methods

A 3-year review [2010-2012] of the National Inpatient Sample (NIS) was performed. All patients undergoing thymectomy were included. Patients undergoing VATS thymectomy were identified. Outcomes measured were hospital length of stay (LOS), hospital charges, and mortality. Univariate and multivariate analyses were performed to control for demographics and comorbidities.

Results

The results of 2,065 patients who underwent thymectomy were analyzed, of which 373 (18.1%) had VATS thymectomy and 1,692 (81.9%) had standard thymectomy. Mean age was 52.8±16, 42.5% were male, and 65.5% were Caucasian. There was a significant interval increase in number of patients undergoing VATS thymectomy (10% in 2010 vs. 19.2% in 2012, P<0.001). Patients undergoing standard thymectomy had longer hospital LOS (6.8±6.6 vs. 3.3d±3.4 d, P<0.001), hospital charges $88,838±$120,892 vs. $57,251±$54,929) and hospital mortality (0.9% vs. 0%, P=0.01). In multivariate analysis, thymectomy via sternotomy was independently associated with increased hospital LOS B =1.6 d, P<0.001) and charges (B = $13,041, P=0.041).

Conclusions

Our study demonstrates decreased hospital length of stay and reduced hospital charges in patients undergoing VATS thymectomy compared to standard thymectomy. Our data demonstrates that the prevalence of VATS thymectomies is increasing, likely related to improved healthcare and financial outcomes.

A systematic review and economic evaluation of bisphosphonates for the prevention of fragility fractures

BACKGROUND

Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture.

OBJECTIVES

To evaluate the clinical effectiveness and safety of bisphosphonates [alendronic acid (Fosamax^® and Fosamax^® Once Weekly, Merck Sharp & Dohme Ltd), risedronic acid (Actonel^® and Actonel Once a Week^®, Warner Chilcott UK Ltd), ibandronic acid (Bonviva^®, Roche Products Ltd) and zoledronic acid (Aclasta^®, Novartis Pharmaceuticals UK Ltd)] for the prevention of fragility fracture and to assess their cost-effectiveness at varying levels of fracture risk.

DATA SOURCES

For the clinical effectiveness review, six electronic databases and two trial registries were searched: MEDLINE, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science and BIOSIS Previews, Clinicaltrials.gov and World Health Organization International Clinical Trials Registry Platform. Searches were limited by date from 2008 until September 2014.

REVIEW METHODS

A systematic review and network meta-analysis (NMA) of effectiveness studies were conducted. A review of published economic analyses was undertaken and a de novo health economic model was constructed. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years (QALYs) for each bisphosphonate treatment strategy and a strategy of no treatment for a simulated cohort of patients with heterogeneous characteristics. The model was populated with effectiveness evidence from the systematic review and NMA. All other parameters were estimated from published sources. A NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture^® (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX^® (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net benefit (INB) was estimated using non-parametric regression. Probabilistic sensitivity analysis (PSA) and scenario analyses were used to assess uncertainty.

RESULTS

Forty-six randomised controlled trials (RCTs) were included in the clinical effectiveness systematic review, with 27 RCTs providing data for the fracture NMA and 35 RCTs providing data for the femoral neck bone mineral density (BMD) NMA. All treatments had beneficial effects on fractures versus placebo, with hazard ratios varying from 0.41 to 0.92 depending on treatment and fracture type. The effects on vertebral fractures and percentage change in BMD were statistically significant for all treatments. There was no evidence of a difference in effect on fractures between bisphosphonates. A statistically significant difference in the incidence of influenza-like symptoms was identified from the RCTs for zoledronic acid compared with placebo. Reviews of observational studies suggest that upper gastrointestinal symptoms are frequently reported in the first month of oral bisphosphonate treatment, but pooled analyses of placebo-controlled trials found no statistically significant difference. A strategy of no treatment was estimated to have the maximum INB for patients with a 10-year QFracture risk under 1.5%, whereas oral bisphosphonates provided maximum INB at higher levels of risk. However, the PSA suggested that there is considerable uncertainty regarding whether or not no treatment is the optimal strategy until the QFracture score is around 5.5%. In the model using FRAX, the mean INBs were positive for all oral bisphosphonate treatments across all risk categories. Intravenous bisphosphonates were estimated to have lower INBs than oral bisphosphonates across all levels of fracture risk when estimated using either QFracture or FRAX.

LIMITATIONS

We assumed that all treatment strategies are viable alternatives across the whole population.

CONCLUSIONS

Bisphosphonates are effective in preventing fragility fractures. However, the benefit-to-risk ratio in the lowest-risk patients may be debatable given the low absolute QALY gains and the potential for adverse events. We plan to extend the analysis to include non-bisphosphonate therapies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013006883.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Predictors of direct home discharge following fractured neck of femur

INTRODUCTION Direct home discharge (DHD) following hip fracture surgery represents a challenging proposition. The aim of this study was to identify factors influencing the discharge destination (home vs alternative location) for patients admitted from their own home with a fractured neck of femur. METHODS A retrospective cohort study of prospectively collected major trauma centre data was performed, identifying 10,044 consecutive hip fracture admissions between 2000 and 2012. RESULTS Two-thirds of the patients (n=6,742, 67%) were admitted from their own home. Half of these (n=3,509, 52%) returned directly to their own home while two-fifths (n=2,640, 39%) were discharged to an alternative location; 593 (9%) died. The following were identified as independent variables associated with a higher likelihood of DHD: younger patients, female sex, an abbreviated mental test score of 10, absence of certain co-morbidities, cohabiting, walking independently outdoors, no use of walking aids, no assistance required with basic activities of daily living and intracapsular fracture. CONCLUSIONS Identifying those at risk of being discharged to an alternative location following admission from home on the basis of identified preoperative indices could assist in streamlining the postoperative care phase. Pre-emptive action may help increase the numbers of patients discharged directly home and reduce the number requiring additional rehabilitation prior to discharge home with its associated socioeconomic effect.

The effect of time to surgery on functional ability at six weeks in a hip fracture population in Mid-West Ireland

Patients with a hip fracture may be appropriately delayed for surgery as they require optimisation or clinical interventions to treat acute medical illnesses (Moja et al., 2012). Other patients are inappropriately delayed due to hospital factors (Brener, 2013; Lee & Elfar, 2014). Timely efficient admission and surgery is well documented as the best course of management for these patients. The aim of this prospective cohort longitudinal follow-up study was to establish if a relationship existed between duration of time spent in the Emergency Department (ED), time to surgery and functional ability in patients with hip fractures and to examine the effect prolonged waits may have on ability to return home. Functional ability for fifty one patients with a hip fracture was evaluated using the Barthel Index Score (BIS) on admission and at six weeks post-surgery. Data were analysed by using SPSS version 20. The findings reveal a change in BIS at 6 weeks for patients whose surgery is delayed. Patients who experienced long delays awaiting admission (>12 h) in the ED functioned less well (Kruskal-Wallis test p = 0.033). Correlation existed between time to surgery and returning to pre-fracture place of residence, (p = 0.000 Pearson chi-square), which also remained significant while controlling for age. Prolonged waits had an overall negative impact on patients' post-fracture functional ability. This study highlights the deleterious effects on functional ability when surgery is delayed.

Geriatric preinjury activities of daily living function is associated with glasgow coma score and discharge disposition: a retrospective, consecutive cohort study

The primary objective was to evaluate the associations of the Injury Severity Score (ISS), age, Glasgow Coma Score (GCS), preexisting medical conditions (PEMC), and preinjury activities of daily living (ADL) Katz score with discharge disposition in surviving geriatric trauma patients.Data were obtained from the trauma registry. The preinjury Katz ADL score was prospectively ascertained.Of 184 consecutive surviving geriatric trauma patients with an ISS of 4 to 30, age was 80 ± 8 years and 75% fell. A PEMC was present in 93%. Preinjury ADL limitation occurred in 33%. The Katz score had inverse associations with the number of PEMCs (P< .01) and dementia (P < .01). Preinjury residence was home in 93% and nursing home in 7%. Katz scores by discharge disposition were as follows: home (36%) 5.5 ± 1; nursing home (15%) 3.6 ± 2; rehabilitation (44%) 5.6 ± 1; long-term acute care (5%) 4.0 ± 3 (P < .01). Nursing home/long-term acute care discharge was independently associated (P< .01) withlower Katz score, higher age, and lower discharge GCS; dementia and the number of PEMCs had P > .05. The discharge GCS was associated with the Katz score (P < .01), head injury score (P < .01), dementia (P < .01), and admission GCS (P < .01). The discharge GCS was independently associated (P < .01) with the Katz score and admission GCS. The admission GCS was associated with the Katz score (P = .02), ISS (P < .01), head injury score (P < .01), and dementia (P < .01). The admission GCS was independently associated (P < .05) with the Katz score and ISS.The majority of geriatric trauma survivors with an ISS of 4 to 30 are not discharged home. Lower preinjury ADL function is associated with the lower admission and discharge GCS and greater care needs at discharge. Dementia and the number of PEMCs are not independent predictors of discharge disposition.

Does cognitive/physical screening in an outpatient setting predict institutionalization after hip fracture?

Background

Institutionalization after hip fracture is a socio-economical burden. We examined the predictive value of Instrumental Activities of Daily Living (IADL) and Mini Mental State Examination (MMSE) for institutionalization after hip fracture to identify patients at risk for institutionalization.

Methods

Fragility hip fracture patients ≥65 years of age (n = 584) were comprehensively examined at a geriatric outpatient clinic 4 to 6 months after surgery and followed 1 year postoperatively. A telephone interview with a structured inquiry was performed at 1, 4, and 12 months after hip fracture.

Results

Age-adjusted univariate logistic regression analysis revealed that IADL and MMSE scores measured at the outpatient clinic were significantly associated with living arrangements 1 year after hip fracture. Multivariate logistic regression analysis established that institutionalization 1 year after hip fracture was significantly predicted by institutionalization at 4 months (odds ratio [OR] 16.26, 95 % confidence interval [CI] 7.37–35.86), IADL <5 (OR 12.96, 95 % CI 1.62–103.9), and MMSE <20 (OR 4.19, 95 % CI 1.82–9.66). A cut-off value of 5 was established for IADL with 100 % (95 % CI 96 %–100 %) sensitivity and 38 % (95 % CI 33 %–43 %) specificity and for MMSE, a cut-off value of 20 had 83 % (95 % CI 74 %–91 %) sensitivity and 65 % (95 % CI 60 %–70 %) specificity for institutionalization. During the time period from 4 to 12 months, 66 (11 %) patients changed living arrangements, and 36 (55 %) of these patients required more supportive accommodations.

Conclusion

IADL and MMSE scores obtained 4 to 6 months after hospital discharge may be applicable for predicting institutionalization among fragility hip fracture patients ≥65 years of age at 1 year after hip fracture. An IADL score of ≥5 predicted the ability to remain in the community. Changes in living arrangements also often occur after 4 months.

The cause of failure to return to the pre-fracture place of residence and solution to continue medical treatment for osteoporosis following an operation for hip fracture - Periodic observation of single center

The purpose of this study was to investigate the causes of failure to return to the pre-fracture place of residence at hospital discharge following an operation for a hip fracture and to continue medical treatment for osteoporosis. Herein, we discuss methods for improving discharge protocols for these patients.

We examined patients who sustained osteoporotic fractures and were operated on for a hip fracture between 2001 and 2003 (83 males and 386 females; 81.2 ± 9.0 years old) and between 2011 and 2013 (121 males and 462 females; 83.1 ± 9.3 years old). In a follow-up study, we examined patients who moved into our related rehabilitation institution over a 3-year period, from 2011 to 2013.

The incidence of hip fractures had increased from 2001–2003 to 2011–2013 in both genders, and it tended to increase in patients greater than 80 years of age in male and 90 years of age in female. The most common destination residence after discharge from the rehabilitation institution was the pre-fracture place of residence. The Barthel Index at discharge from the rehabilitation institution was significantly lager in patients who returned to the pre-fracture place of residence compared to those who returned to nursing home and our hospital. These results suggest improved mobility and ADL level of patients enable them to return to the pre-fracture place of residence.

We propose the construction of a feedback system that aids in a medical pass to increase the ambulant consultation rate for orthopedics and prevent fragile fractures.

Factors affecting the discharge destination of hip fracture patients who live alone and have been admitted to an inpatient rehabilitation unit

[Purpose] (1) The aim of this study was to examine relations between clinical and functional assessment and discharge destination and (2) to identify the optimal cutoff point for estimating discharge to home after inpatient rehabilitation. [Subjects] The subjects were 54 hip fracture patients (15 males, 39 females; mean age 81.3 ± 7.4 years) living alone. [Methods] The patients were classified into two groups: those discharged to home and those admitted to an institution. Age, gender, side of fracture, fracture type, number of comorbidities, Functional Independence Measure motor score, and Functional Independence Measure cognitive score were compared between groups. Multiple logistic regression analysis was conducted with discharge to home as the dependent variable and age, gender, side of fracture, fracture type, number of comorbidities, Functional Independence Measure motor score, and Functional Independence Measure cognitive score as independent variables. A receiver operating characteristic curve analysis was used to identify a cutoff point for classification of the patients into the two groups. [Results] Multiple logistic regression analysis showed that the Functional Independence Measure cognitive score was a significant variable affecting the discharge destination. The receiver operating characteristic curve analysis revealed that discharge to home was predicted accurately by a Functional Independence Measure cognitive score of 23.5. [Conclusion] Information from this study is expected to be useful for determining discharge plans and for the setting of treatment goals.

Predictors of change in 'discharge destination' following treatment for fracture neck of femur

OBJECTIVES

The purpose of our study was to analyse the incidence and factors predicting the 'change in discharge destination' in patients with fractured neck of femur who were treated surgically.

MATERIALS AND METHODS

Fifteen hundred and seventy-three consecutive patients admitted with a fractured neck of femur, residing in their own home prior to admission were studied. Patients who did not have an operation (n=70) for their hip fracture were excluded from the study. Residential location in the UK is broadly categorised as:

RESULTS

A downward drift in "discharge destination" of 20% was noted after analysis. Univariate analysis revealed that age, gender, AMT score, place of fall, type of fracture, walking ability outdoor and indoor, ASA grade, medical co-morbidity requiring physician review and delay beyond 36h to surgery had a significant effect. Multiple logistic regression analysis revealed that increasing age, male gender (OR=1.67), accompaniment for outdoor mobilisation (OR=1.96), increasing ASA grade, AMT score <6 (OR=4.86), pre-operative medical condition requiring physician review (OR=2.27), delay greater than 36h for medical reasons (OR=4.38) were predictors of the change in discharge destination.

CONCLUSION

The most important predictors of the change in the discharge destination were the medical condition, cognitive and physical function of the patient at admission. Male gender and increasing age were contributory. The only clinician dependent factor that seemed to affect this change of residential status was delay to surgery secondary to medical problems. Awareness of key predictors that affect the "discharge destination" can be useful for the multidisciplinary team and patients' families to evaluate and plan for an early, satisfactory and appropriate referral to either community services or institutional care, which in turn could have a significant socioeconomic impact.

The usefulness of lean six sigma to the development of a clinical pathway for hip fractures

AIMS AND OBJECTIVES

The objective of this study was to show the usefulness of lean six sigma (LSS) for the development of a multidisciplinary clinical pathway.

METHODS

A single centre, both retrospective and prospective, non-randomized controlled study design was used to identify the variables of a prolonged length of stay (LOS) for hip fractures in the elderly and to measure the effect of the process improvements--with the aim of improving efficiency of care and reducing the LOS.

RESULTS

The project identified several variables influencing LOS, and interventions were designed to improve the process of care. Significant results were achieved by reducing both the average LOS by 4.2 days (-31%) and the average duration of surgery by 57 minutes (-36%). The average LOS of patients discharged to a nursing home reduced by 4.4 days.

CONCLUSION

The findings of this study show a successful application of LSS methodology within the development of a clinical pathway. Further research is needed to explore the effect of the use of LSS methodology at clinical outcome and quality of life.

Predicting discharge location of hip fracture patients; the new discharge of hip fracture patients score

Purpose

This paper reports on the development and validity of a new instrument, called the discharge of hip fracture patients score (DHP), that predicts at admission the discharge location in patients living in their own home prior to hip fracture surgery.

Methods

A total of 310 patients aged 50 years and above were included. Risk factors for discharge to an alternative location (DAL) were analysed with a multivariable regression analysis taking the admission variables into account with different weights based on the estimates. The score ranged from 0–100 points. The cut-off point for DAL was calculated using a ROC analysis. Reliability of the DHP was evaluated.

Results

Risk factors for DAL were higher age, female gender, dementia, absence of a partner and a limited level of mobility. The cut-off point was set at 30 points, with a sensitivity of 83.8%, a specificity of 64.7% and positive predictive value of 79.2%.

Conclusion

The DHP is a valid, simple and short instrument to be used at admission to predict discharge location of hip fracture patients.

Risk factors for failure to return to the pre-fracture place of residence after hip fracture: a prospective longitudinal study of 444 patients

INTRODUCTION

Long-term place of residence after hip fracture is not often described in literature. The goal of this study was to identify risk factors, known at admission, for failure to return to the pre-fracture place of residence of hip fracture patients in the first year after a hip fracture.

METHODS

This is a prospective longitudinal study of 444 consecutive admissions of hip fracture patients aged ≥ 65 years. Place of residence prior to admission, at discharge, after 3 and 12 months was registered. Patients admitted from a nursing home (n = 49) were excluded from statistical analysis. Multivariable logistic regression analysis was performed, using age, gender, presence of a partner, ASA-score, dementia, anaemia at admission, type of fracture, pre-fracture level of mobility and level of activities of daily living (ADL) as possible risk factors.

RESULTS

Two hundred eighty-nine patients lived in their own home, 31.8% returned at discharge, 72.9% at 3 months and 72.8% at 12 months. Age, absence of a partner, dementia, and a lower pre-fracture level of ADL or mobility were independent contributors to failure to return to their own home at discharge, 3 or 12 months. 106 patients lived in a residential home; 33.3% returned at discharge, 68.4% at 3 months and 64.4% at 12 months. Age was an independent contributor to failure to return to a residential home.

CONCLUSIONS

Age, dementia and a lower pre-fracture level of ADL were the main significant risk factors for failure to return to the pre-fracture residence. As the 3- and 12-month return-rates were similar, 3-month follow-up might be used as an endpoint in future research.

An intervention study exploring the effects of providing older adult hip fracture patients with an information booklet in the early postoperative period

AIM

To determine whether the provision of an information booklet on mobilisation improves early mobility postsurgical repair of hip fracture.

BACKGROUND

Hip fracture among older people can have long-lasting consequences with the majority of patients failing to achieve their prefracture functional status. Early postoperative mobility may have a positive effect on long-term recovery. The importance of providing postoperative information on mobility has been highlighted. It is suggested that patients remain passive in their recovery when they do not understand the importance of mobilisation.

DESIGN

The study used a pretest-post-test design of two treatments and a usual care control group.

METHODS

Eighty-three adults postsurgical repair of hip fracture, aged 65 years and older, were recruited to the study. Participants were assigned to one of three groups, a usual care group, treatment group 1 (T(1)) usual care plus basic information booklet or treatment group 2 (T(2)) usual care plus detailed information booklet. Data collection three days postsurgery and prior to discharge included the Mini-Mental State Examination, a Demographic Questionnaire, the Elderly Mobility Scale and a Numerical Pain Scale.

RESULTS

Greatest improvements in Elderly Mobility Scale scores occurred in T(1), with least changes observed in T(2). Changes did not reach significance level (p=0·105).

CONCLUSION

The results of the study suggest that the provision of basic information is preferable and highlights a deficiency of education in usual care.

RELEVANCE TO CLINICAL PRACTICE

Hip fracture patients should be provided with an educational booklet containing basic information on mobility to promote optimal recovery.

Neck of Femur Fractures in Patient's Aged More Than 85 Years-are They a Unique Subset?

Background. The UK population is ageing with the largest increase expected to occur in people aged more than 85 years (85+). We have examined the hypothesis that neck of femur (NOF) fractures in the 85+ group exhibit demonstrable key outcome measurement differences after surgery when compared to a standard NOF population. Patients and Methods. A prospective observational cohort study of the demographics, clinical features, and key clinical outcome measurements for 2 groups of patients (65-84 and 85+ years of age at presentation) was performed in a single trauma unit over a 3-year period. Results. A total of 699 patients with a median age of 78 in the 65 to 84 cohort were compared with 523 patients with a median age of 88 in the 85+ cohort. Despite a dedicated orthogeriatric service and no difference in time to surgery between the 2 groups, the 30-day and 1-year mortality rates were significantly higher in the 85+ cohort at 10% and 30%, respectively, compared with 5% and 19% in the younger patient group. In our 85+ group, 34% had evidence of significant measured cognitive impairment compared to only 19% in the 65 to 84 group (P < .001). The length of hospital inpatient stay was also longer in the 85+ cohort with a median of 20 days compared to 16 days in the younger cohort (P = .001). In the 85+ cohort, 60% of patients were discharged back to their usual (preinjury) place of residence compared to 72% in the 65 to 84 cohort (P = .001). Conclusions. Patients in 85+ group presenting with an NOF fracture represent a unique high-risk patient group. Despite adherence to published key principles of care, this group is at higher risk and as such merits focused clinical attention, with adequate patient and family member counseling with regard to prognosis and overall expectation.

The cost and consequences of proximal femoral fractures which require further surgery following initial fixation

We evaluated the cost and consequences of proximal femoral fractures requiring further surgery because of complications. The data were collected prospectively in a standard manner from all patients with a proximal femoral fracture presenting to the trauma unit at the John Radcliffe Hospital over a five-year period. The total cost of treatment for each patient was calculated by separating it into its various components. The risk factors for the complications that arose, the location of their discharge and the mortality rates for these patients were compared to those of a matched control group. There were 2360 proximal femoral fractures in 2257 patients, of which 144 (6.1%) required further surgery. The mean cost of treatment in patients with complications was £18,709 (£2606.30 to £60,827.10), compared with £8610 (£918.54 to £45,601.30) for uncomplicated cases (p < 0.01), with a mean length of stay of 62.8 (44.5 to 79.3) and 32.7 (23.8 to 35.0) days, respectively. The probability of mortality after one month in these cases was significantly higher than in the control group, with a mean survival of 209 days, compared with 496 days for the controls. Patients with complications were statistically less likely to return to their own home (p < 0.01). Greater awareness and understanding are required to minimise the complications of proximal femoral fractures and consequently their cost.

Predictors of outcome following hip fracture rehabilitation

OBJECTIVE

To determine the potential predictors of functional outcome after hip fracture rehabilitation in a large acute inpatient rehabilitation facility.

DESIGN

Retrospective chart review study.

SETTING

Large acute inpatient rehabilitation hospital.

PARTICIPANTS

Patients admitted with a primary admitting diagnosis of hip fracture (n = 753). Patients were excluded if their hip fracture was the result of high-velocity trauma and if their stay was shorter than 48 hours (196 patients).

METHODS

Independent variables included body mass index, gender, ethnicity, smoking history, alcohol consumption, past living situation, past ambulatory status, medical history, prealbumin level, medications that increase the risk of falling, and evidence of prior osteoporosis workup and treatment. These data were entered into a password-encrypted database. Univariate analyses were carried out to evaluate the relationship between independent variables and main outcomes, and multivariate analyses were performed to assess the impact of medical history of diabetes adjusting for other covariates.

MAIN OUTCOME MEASUREMENTS

Discharge location; length of rehabilitation hospital stay (LOS); Functional Independence Measure (FIM) gain, which is calculated as the FIM(discharge) - FIM(admission); and length of stay efficiency (LOSE), which is calculated as the FIM gain divided by the LOS, and measures the rate of FIM change.

RESULTS

Patients with diabetes had a worse LOSE (P = .0008). Multiple linear regression analysis revealed that patients who have a medical history of diabetes have a 0.33 reduction of LOSE compared with other patients. Predictors of better LOSE included younger age (P < .001), fewer medications that predispose to falls (P < .0001), and independent ambulation before fracture (P = .0003).

CONCLUSION

We have found several significant patient characteristics that portend a better functional outcome after hip fracture. These include younger age, female gender, absence of diabetes mellitus, independent prefracture ambulation, not living alone before fracture, and being prescribed fewer medications that predispose to falling during rehabilitation. On the contrary, one of our most interesting findings is that patients with diabetes made slower gains, had a longer LOS and were less likely to be discharged directly home from the acute rehabilitation facility. There are numerous factors that may contribute to this, and suggestions are made for future research.

Cement augmentation of intertrochanteric fractures stabilised with intramedullary nailing

We studied 80 patients (56 females) with an average age of 84 years (range 80-94). All patients were suffering from osteoporosis (1 or 2 Singh score) and had an unstable intertrochanteric fracture, defined as a fracture with three fragments or more. Patients were divided in group A (40 patients), treated by a cement augmentation technique and group B (40 patients) treated by Gamma Nail conventional technique. Augmentation was performed with MetilMetacrilate (Mendec Spine, Tecres) inserted through the cannulated cephalic screw at its apex. Such parameters were evaluated as the length of operating time, early functional recovery using the Harris hip score, assessment with radiography of the TAD index and development of implant related complications. The HHS average score was 48.2 and 49.31 after 1 month post-operation, 54.37 and 53.56 after 3 months, 54.71 and 56.42 after 6 months, 57.91 and 59.86 after 12 months, in groups A and B, respectively. The average drop of haemoglobin was 1.55 g/dL and 1.05 g/dL, in groups A and B, respectively. Except one joint penetration with the guide wire and some small amount of cement leakage, no other complications (infection, screw cut out and femoral head necrosis) were observed. We believe that in femoral intertrochanteric fractures cement augmentation could improve the mechanical stability of the implant, ensuring early functional recovery.

Assessment of the relationship between age and the effect of risedronate treatment in women with postmenopausal osteoporosis: a pooled analysis of four studies

OBJECTIVES

To quantify the effect of age on the incidence of osteoporosis-related fractures and of risedronate treatment on fracture risk in different age groups in women with postmenopausal osteoporosis.

DESIGN

Data from four randomized, double-blind, placebo-controlled, Phase III studies were pooled and analyzed.

PARTICIPANTS

The analysis population (N=3,229) consisted of postmenopausal women with osteoporosis as determined on the basis of prevalent vertebral fractures, low bone mineral density (BMD), or both.

INTERVENTION

Patients had received risedronate 5 mg daily or placebo for 1 to 3 years.

MEASUREMENTS

The endpoints of interest were the incidence of osteoporosis-related fractures, clinical fractures, nonvertebral fractures, and morphometric vertebral fractures. The effect of age on fracture risk and treatment benefit was examined using Cox regression models with age and treatment as explanatory variables. The 3-year fracture risk was estimated for patients in each treatment group at a given age.

RESULTS

Irrespective of treatment, fracture risks were greater in older patients (P<.001). On average, for every 1-year increase in age, a patient's risk for osteoporosis-related fracture increased 3.6% (95% confidence interval=2.3-5.0%). Irrespective of age, risedronate treatment reduced fracture risk 42%. Risedronate-treated patients had fracture risks similar to those of placebo-treated patients 10 to 20 years younger.

CONCLUSION

Patients treated with risedronate have a significantly lower fracture risk, similar to that of untreated patients 10 to 20 years younger.

Is there a role for bone morphogenetic proteins in osteoporotic fractures?

The central role of bone morphogenetic proteins (BMPs) in the remodelling process of the human skeleton has been identified in numerous experimental and clinical studies. BMPs appear to be key agents in the osteoblastic differentiation of mesenchymal stem cells, and more recent evidence implicates them with the cells of the osteoclastic lineage. BMP-2, BMP-4, BMP-6 and BMP-7 have been studied in the context of osteoporosis and have been associated with its pathophysiological pathways. The theoretical advantages of local or systemic treatment of osteoporotic fractures with BMPs include the potential of inducing a rapid increase in bone strength locally at the fractured area and systemically in the entire skeleton, as well as accelerating the bone-healing period. Animal models of osteoporotic fractures suggested that the induction of new bone by local or systemic use of BMP-7 should be investigated as potential bone augmentation therapy to improve bone quality in symptomatic spinal osteoporosis. As our knowledge expands, new innovations may provide clinicians with advanced biologically-based therapies for the successful treatment of osteoporotic fractures.