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Martis WR, Oughton C, Traer E, Ismail H, Riedel B. Reassessing perioperative cardiopulmonary exercise testing: point-of-care cardiac ultrasound and end-tidal pressure of carbon dioxide measurement for scalable individualised risk assessment. Br J Anaesth 2024:S0007-0912(24)00185-5. [PMID: 38670894 DOI: 10.1016/j.bja.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/06/2024] [Accepted: 03/09/2024] [Indexed: 04/28/2024] Open
Affiliation(s)
- Walston R Martis
- Department of Anaesthetics, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Anaesthetics, Monash Health, Melbourne, VIC, Australia; The Sir Peter MacCallum Department of Oncology, Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia.
| | - Chad Oughton
- Department of Anaesthetics, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Anaesthetics, Perioperative Medicine, and Pain Medicine, Northern Health, Melbourne, VIC, Australia
| | - Emily Traer
- Department of Anaesthetics, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; The Sir Peter MacCallum Department of Oncology, Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Hilmy Ismail
- Department of Anaesthetics, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; The Sir Peter MacCallum Department of Oncology, Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Bernhard Riedel
- Department of Anaesthetics, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; The Sir Peter MacCallum Department of Oncology, Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
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Kaya O, Kundakçı B, Önder C, Kurt V, Atmaca E, Tunç F. The Effect of Intraoperative Patient Positioning on the Success of Intertrochanteric Fracture Surgery in Older Patients. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:646. [PMID: 38674292 PMCID: PMC11052214 DOI: 10.3390/medicina60040646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/23/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: The incidence of hip fractures in people of advanced ages is increasing due to our aging society. Patient positioning for the intertrochanteric fractures of the femur can be performed in various ways. The aim of this study is to clinically and radiologically compare the use of the supine hemilithotomy position, the lateral decubitus position, and the traction table when performing proximal femoral nail (PFN) surgery for femoral intertrochanteric fractures in the geriatric age group. Materials and Methods: A total of 170 elderly patients with femoral intertrochanteric fractures were included in this cross-sectional study. The patients were divided into three groups (the supine hemilithotomy group, the lateral decubitus group, and the fracture table group). For the postoperative period, complications, length of stay in the intensive care unit, and length of stay in hospital were examined, while in postoperative radiographs, tip-apex distances (TADs), collodiaphyseal angles (CDAs), and Cleveland-Bosworth quadrants were examined to evaluate the placement of the lag screw in the femoral head. The quality of fracture reduction was evaluated according to the modified Baumgaertner criteria. Results: The mean age of the patients was 77.8 ± 8.8; 57.6% of patients were female. According to the modified Baumgaertner criteria, it was determined that patients with 'poor' reduction quality had an approximately ten times higher risk of cut-out than those with 'good' reduction quality (OR = 10.111, p = 0.002, 95% confidence interval; 2.313-44.207). The operative time for patients in the fracture table group was longer than that of the other groups Additionally, the CDA in the supine hemilithotomy position group was longer. Conclusions: Although PFN surgery using the traction table is longer in terms of surgical time compared to surgery performed in the lateral decubitus position and the supine hemilitotomy position, it is advantageous in terms of better TAD and CDA values and lower complication rates.
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Affiliation(s)
- Onur Kaya
- Department of Orthopaedic and Traumatology, NCR Private Hospital Mücahitler, Gazi Muhtar Paşa Blv. No:56, 27090 Şehitkamil, Gaziantep, Türkiye
| | - Buğra Kundakçı
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Cukurova University, 01330 Sarıçam, Adana, Türkiye; (B.K.); (F.T.)
| | - Cem Önder
- Department of Orthopaedic and Traumatology, Abdulkadir Yuksel State Hospital, 27100 Şahinbey, Gaziantep, Türkiye; (C.Ö.); (V.K.); (E.A.)
| | - Vahap Kurt
- Department of Orthopaedic and Traumatology, Abdulkadir Yuksel State Hospital, 27100 Şahinbey, Gaziantep, Türkiye; (C.Ö.); (V.K.); (E.A.)
| | - Emre Atmaca
- Department of Orthopaedic and Traumatology, Abdulkadir Yuksel State Hospital, 27100 Şahinbey, Gaziantep, Türkiye; (C.Ö.); (V.K.); (E.A.)
| | - Fatih Tunç
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Cukurova University, 01330 Sarıçam, Adana, Türkiye; (B.K.); (F.T.)
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Joseph EG, Serotte J, Haider MN, Pavlesen S, Anders M. Delay to Surgical Treatment in Geriatric Hip Fracture Patients. Geriatr Orthop Surg Rehabil 2023; 14:21514593231204760. [PMID: 37867607 PMCID: PMC10588415 DOI: 10.1177/21514593231204760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 03/21/2023] [Accepted: 06/20/2023] [Indexed: 10/24/2023] Open
Abstract
Background Hip fractures in the geriatric population are frequently encountered. There is increasing focus on minimizing the delay to surgery in these patients. This study was designed to evaluate factors responsible for a delay to surgery in a geriatric hip fracture population and how time to surgery affects mortality. Methods A retrospective cohort of patients sustaining low energy geriatric hip fractures in either an American College of Surgeons (ACS) verified Level 1 trauma center or a local university affiliated community teaching hospital were reviewed. The following variables were evaluated as independent risk factors for delay to surgery: demographic data, surgical details, use of cardiology resources, treatment center, and comorbidities. As a secondary objective, the effect of time to surgery on 1 year mortality was analyzed. Results 1157 patients met inclusion criteria. The following factors increased the risk of delay to surgery greater than 48 hours: male sex, treatment in a community hospital (versus trauma center), older age, multiple comorbidities (eg, cardiovascular-related conditions or other fractures), cardiology consultation, and an American Society of Anesthesiologists physical status score of 3 or 4. Cardiology consultation was the strongest independent predictor of risk for delay to surgery of >48 hours (odds ratio, 6.68; 95% confidence interval, 4.40 to 10.14; P < .001). The 1-year mortality of patients did not differ when surgical treatment occurred before 48 hours or after 48 hours (Log-rank test P = .109). Conclusion The presence of cardiovascular comorbidities and cardiology consultations can delay surgical treatments for hip fractures in patients greater than 65 years old, but the delay did not influence 1-year all-cause mortality. Level of Evidence Level IV.
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Affiliation(s)
- Elias G. Joseph
- Department of Orthopaedic Surgery, University of Tennessee Health Science Center College of Medicine, Chattanooga, TN, USA
| | - Jordan Serotte
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago, Chicago, IL, USA
| | - Mohammad N. Haider
- Department of Orthopaedic Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Sonja Pavlesen
- Department of Orthopaedic Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Mark Anders
- Department of Orthopaedic Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
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Chao TC, Lee HP, Wu JC, Hsu CJ. Analysis of Cardiac Events and the Subsequent Impact for Geriatric Patients Undergoing Hip Fracture Surgeries. J Clin Med 2023; 12:5276. [PMID: 37629317 PMCID: PMC10455102 DOI: 10.3390/jcm12165276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/02/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
Perioperative complications, particularly cardiac events, compromised surgical outcomes for geriatric patients. This retrospective study intended to investigate the occurrence and subsequent impact of cardiac events for geriatric patients undergoing hip fracture surgeries. We collected 607 patients undergoing hip fracture surgeries from January 2017 to December 2022 that received transthoracic echocardiography (TTE) pre-operatively to screen for cardiac abnormalities. Except for demographic characteristics, the researchers recorded fracture type, surgical method, American Society of Anesthesiologists (ASA) class, anesthesia type, perioperative cardiac events, and in-hospital mortality. Statistical analysis was performed using SPSS 22.0 statistics software. Throughout the whole course of the study, 16 postoperative cardiac events occurred. The cardiac events included ten arrhythmias, three acute myocardial infarctions, two heart failures, and one sudden death. Notably, 12 of 16 patients with cardiac events presented with abnormal findings on TTE, except 15 of them had a history of cardiac disease. This study disclosed 93.7% of cardiac events developed in patients with a history of cardiovascular disease. Among patients that experienced cardiac events, 75% of patients had abnormal echocardiographic findings. Pre-operative transthoracic echocardiography deserves a recommendation for geriatric patients with histories of cardiac diseases undergoing hip fracture surgeries to detect the risk of developing cardiac events earlier.
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Affiliation(s)
- Ting-Cheng Chao
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan;
- Department of Orthopaedic Surgery, Ping-Tung Christian Hospital, Pingtung 90059, Taiwan; (H.-P.L.); (J.-C.W.)
| | - Hsin-Pai Lee
- Department of Orthopaedic Surgery, Ping-Tung Christian Hospital, Pingtung 90059, Taiwan; (H.-P.L.); (J.-C.W.)
| | - Jung-Chou Wu
- Department of Orthopaedic Surgery, Ping-Tung Christian Hospital, Pingtung 90059, Taiwan; (H.-P.L.); (J.-C.W.)
| | - Chien-Jen Hsu
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan;
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Fokin AA, Wycech Knight J, Darya M, Stalder R, Puente I, Weisz RD. Two surgical pathways for isolated hip fractures: A comparative study. World J Orthop 2023; 14:399-410. [PMID: 37377993 PMCID: PMC10292054 DOI: 10.5312/wjo.v14.i6.399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/22/2023] [Accepted: 04/27/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Hip fractures (HF) are common among the aging population, and surgery within 48 h is recommended. Patients can be hospitalized for surgery through different pathways, either trauma or medicine admitting services.
AIM To compare management and outcomes among patients admitted through the trauma pathway (TP) vs medical pathway (MP).
METHODS This Institutional Review Board-approved retrospective study included 2094 patients with proximal femur fractures (AO/Orthopedic Trauma Association Type 31) who underwent surgery at a level 1 trauma center between 2016-2021. There were 69 patients admitted through the TP and 2025 admitted through the MP. To ensure comparability between groups, 66 of the 2025 MP patients were propensity matched to 66 TP patients by age, sex, HF type, HF surgery, and American Society of Anesthesiology score. The statistical analyses included multivariable analysis, group characteristics, and bivariate correlation comparisons with the χ² test and t-test.
RESULTS After propensity matching, the mean age in both groups was 75-years-old, 62% of both groups were females, the main HF type was intertrochanteric (TP 52% vs MP 62%), open reduction internal fixation was the most common surgery (TP 68% vs MP 71%), and the mean American Society of Anesthesiology score was 2.8 for TP and 2.7 for MP. The majority of patients in TP and MP (71% vs 74%) were geriatric (≥ 65-years-old). Falls were the main mechanism of injury in both groups (77% vs 97%, P = 0.001). There were no significant differences in pre-surgery anticoagulation use (49% vs 41%), admission day of the week, or insurance status. The incidence of comorbidities was equal (94% for both) with cardiac comorbidities being dominant in both groups (71% vs 73%). The number of preoperative consultations was similar for TP and MP, with the most common consultation being cardiology in both (44% and 36%). HF displacement occurred more among TP patients (76% vs 39%, P = 0.000). Time to surgery was not statistically different (23 h in both), but length of surgery was significantly longer for TP (59 min vs 41 min, P = 0.000). Intensive care unit and hospital length of stay were not statistically different (5 d vs 8 d and 6 d for both). There were no statistical differences in discharge disposition and mortality (3% vs 0%).
CONCLUSION There were no differences in outcomes of surgeries between admission through TP vs MP. The focus should be on the patient’s health condition and on prompt surgical intervention.
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Affiliation(s)
- Alexander A Fokin
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Joanna Wycech Knight
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL 33316, United States
| | - Maral Darya
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Ryan Stalder
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Ivan Puente
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
- Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL 33316, United States
- Department of Surgery, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, United States
| | - Russell D Weisz
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Department of Orthopedics, South Palm Orthopedics, Delray Beach, FL 33445, United States
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Zuelzer DA, Weaver D, Zuelzer AP, Hessel EA. Current Strategies in Medical Management of the Geriatric Hip Fracture Patient. J Am Acad Orthop Surg 2023:00124635-990000000-00694. [PMID: 37184459 DOI: 10.5435/jaaos-d-22-00815] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 04/01/2023] [Indexed: 05/16/2023] Open
Abstract
Orthogeriatric hip fractures have high morbidity and mortality rates. Modern management focuses on multidisciplinary collaboration for prompt surgical stabilization, early mobilization with multimodal pain control to avoid opioid consumption, and an enhanced recovery pathway. Despite these advances, postoperative complications and mortality rates remain higher than age-matched control subjects. The authors of this article represent the orthopaedic, anesthesia, and hospitalist medicine members of a multidisciplinary team at a single, Level 1 trauma center. Our goal was to provide an up-to-date comprehensive review of orthogeriatric hip fracture perioperative management from a multidisciplinary perspective that every orthopaedic surgeon should know.
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Affiliation(s)
- David A Zuelzer
- From the Department of Orthopaedic and Sports Medicine (Zuelzer), Department of Internal Medicine (Weaver), Department of Anesthesiology (Zuelzer and Hessel), University of Kentucky, Lexington, KY
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Schweller E, Mueller J, Santiago Rivera OJ, Villegas SJ, Walkiewicz J. Factors Associated With Hip Fracture Length of Stay Among Older Adults in a Community Hospital Setting. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00004. [PMID: 37134192 PMCID: PMC10155900 DOI: 10.5435/jaaosglobal-d-22-00195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 02/12/2023] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Hip fractures in geriatric populations constitute a heavy burden on the healthcare system. The study goal was to identify patient, hospital, and surgical factors associated with hospital length of stay (LOS) for geriatric patients with hip fractures requiring surgical intervention in a community hospital setting. METHODS This was a cross-sectional retrospective chart review of geriatric hip fractures that underwent surgical fixation at a community hospital between 2017 and 2019. The scope of the surgeries was limited to cephalomedullary device fixation or hemiarthroplasty hip fracture surgeries. Sliding hip screw or total hip arthroplasty procedures and patients who died during the index hospitalization were excluded. Median tests were conducted to examine differences between the groups. Unadjusted and adjusted truncated negative binomial regression models were used to examine the factors associated with LOS. RESULTS Bivariate analyses revealed results that the factors associated with a longer LOS were preoperative anemia (P = 0.029), blood transfusion (P = 0.022), and the number of days between admission and surgery (P = 0.001). The adjusted regression model results suggested that older patients, patients who underwent surgery more than one day after admission, current smokers, malnourished patients, patients with sepsis, and patients with a history of a thromboembolic event had statistically significant (P < 0.05) longer LOS. However, patients who live in institutions (nursing homes or assisted living) had a shorter LOS than those who live at home alone or with family (P < 0.05). DISCUSSION Older adult patients who underwent surgery with a cephalomedullary device or hip hemiarthroplasty for a hip fracture and had preoperative anemia, postoperative blood transfusions, and increased days between admission and surgery had a longer LOS. Additional factors positively associated with a longer LOS included current smokers, malnourishment, admission with sepsis, and patients with a history of a thromboembolic event. Of interest, institutionalized patients had a shorter LOS than those living at home alone or with family.
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Affiliation(s)
- Eric Schweller
- From the Garden City Hospital, Orthopedic Surgery Residency Program, Garden City, MI (Dr. Schweller, Dr. Mueller, and Dr. Walkiewicz); the Graduate Medical Education , Garden City Hospital, Garden City, MI (Dr. Santiago Rivera); and the Michigan State University College of Osteopathic Medicine, East Lansing, MI (Dr. Santiago Rivera and Dr. Villegas)
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Lim HT, Khor HM, Chandrasekaran CK, Singh S, Adnan YK, Draman MR, Ong T. Process mapping of hip fracture orthogeriatric care: Experience from a tertiary hospital in Malaysia. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2023. [DOI: 10.1177/22104917231161830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Background: Early surgical repair and mobilization postoperatively is associated with improved outcomes for older people with hip fractures. A process mapping exercise was performed to identify the delivery of this aspect of care in a tertiary center. Methods: Analysis was done on electronic health record data of those ≥65 years who had surgery over a 3-month period. Barriers to surgery within 48 h of admission, and mobilized within the day after surgery were identified. Results: Fourty-two patients had surgery where the majority were female, had an average age of 78 years, frail, and multimorbid. 10/42 (23.8%) and 9/42 (21.4%) patients were operated on and mobilized early. Eighteen (42.9%) patients had pre-operative cardiology assessment and 19 patients (45.2%) had pre-operative echocardiogram. None led to a change in the surgical management plan. Other reasons for the delay to early surgery included the need for further medical optimization, financial constraints, blood transfusion, and being on antiplatelet/anticoagulant. Barriers to early mobilization postoperatively were lack of weekend service, delayed referral to therapists, pain, hypotension, anemia, and delirium. Conclusions: Streamlining referrals, agreed clinical pathways, consolidating multidisciplinary involvement, and continuous audit would address the barriers identified in delivering early surgical repair and mobilization post-operatively.
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Affiliation(s)
- Hong Tak Lim
- Geriatric Medicine Unit, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Hui Min Khor
- Geriatric Medicine Unit, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - C.S. Kumar Chandrasekaran
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Orthopedic Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Simmrat Singh
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Orthopedic Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Yohan Khirusman Adnan
- Department of Orthopedic Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mohd Rusdi Draman
- Department of Orthopedic Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Terence Ong
- Geriatric Medicine Unit, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Streamlining orthopaedic trauma surgical care: do all patients need medical clearance? Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04743-4. [PMID: 36593366 DOI: 10.1007/s00402-022-04743-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/18/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Preoperative medical optimization is necessary for safe and efficient care of the orthopaedic trauma patient. To improve care quality and value, a preoperative matrix was created to more appropriately utilize subspecialty consultation and avoid unnecessary consults, testing, and operating room delays. Our study compares surgical variables before and after implementation of the matrix to assess its utility. METHODS A retrospective review of all orthopaedic trauma cases 6 months before and after the use of the matrix (2/2021-8/2021) was conducted an urban, level one trauma centre in collaboration with internal medicine, cardiology, anaesthesia, and orthopaedics. Patients were separated into two cohorts based on use of the matrix during the initial orthopaedic consultation. Logistic regressions were performed to limit significant differences in comorbidities. Independent samples t-tests and Chi-squared tests were used to compare means and proportions, respectively, between the two cohorts. RESULTS In total, 576 patients were included in this study (281 pre- and 295 post-matrix implementation). Use of the matrix resulted in no significant difference in time to OR, LOS, readmissions, or ER visits; however, it resulted in 18% fewer overall preoperative consults for general trauma, and 25% fewer pre-operative consults for hip fractures. Older patients were more likely to require a consult regardless of matrix use. When controlling for comorbidities, patients with renal disease were at higher risk for increased LOS. CONCLUSION Use of an orthopaedic surgical matrix to predict preoperative subspecialty consultation is easy to implement and allows for better care utilization without a corresponding increase in complications and readmissions. Follow-up studies are needed to reassess the relationships between matrix use and a potential decrease in ER to OR time, and validate its use.
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Pean C, Weaver MJ, Harris MB, Ly T, von Keudell AG. What Do Orthopedic Trauma Surgeons Want and Expect from Anesthesiologists? Anesthesiol Clin 2022; 40:547-556. [PMID: 36049881 DOI: 10.1016/j.anclin.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
From the orthopedic trauma surgeon's perspective, successful injury management hinges on fracture fixation and restoration of patient mobility in a safe and expeditious manner. Management of critically injured polytrauma patients and shared decisions regarding regional anesthetics presents a myriad of challenges for orthopedic trauma surgeons and anesthesiologists alike. As the populations age, the typical patient sustaining traumatic orthopedic injuries are increasingly frail and elderly. This trend in demographics has mandated that care for orthogeriatric patients is coordinated by multidisciplinary teams working in concert on medically complex cases to a common end. In this article, we highlight opportunities for improved communication and care integration between orthopedic trauma surgeons and anesthesiologists.
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Affiliation(s)
- Christian Pean
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Michael J Weaver
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Mitchel B Harris
- Massachusetts General Hospital, 55 Fruit Street #14, Boston, MA 02114, USA
| | - Thuan Ly
- Massachusetts General Hospital, 55 Fruit Street #14, Boston, MA 02114, USA
| | - Arvind G von Keudell
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Bispebjerg Hospital, Universtiy of Copenhagen, Bispebjerg Bakke 23, Copenhagen, KBH 2400, Denmark.
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Evaluation of a Novel Multidisciplinary Preoperative Workup Strategy for Geriatric Hip Fractures. J Orthop Trauma 2022; 36:413-419. [PMID: 34992191 DOI: 10.1097/bot.0000000000002342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the financial and clinical impact of a standardized, multidisciplinary team for surgical clearance and optimization in geriatric hip fracture patients. DESIGN Retrospective case series. SETTING Level-1 trauma center. PATIENTS One hundred twenty-four geriatric patients (age >65 years old) in the preprotocol group (cohort 1; January 2017-December 2018) and 98 geriatric patients in the postprotocol group (cohort 2; October 2019-January 2021) with operative hip fractures. INTERVENTION Implementation of a multidisciplinary team protocol consisting of Anesthesiology, Internal Medicine and Orthopedic Surgery departments for the assessment of medical readiness and optimization for surgical intervention in geriatric hip fractures. MAIN OUTCOME MEASURES Rate of cardiology consultation, need for cardiac workup (echocardiography stress testing, heath catheterization), time to medical readiness (TTMR), time to surgery, case-cancellation rate, length of stay (LOS), and total hospitalization charges. RESULTS Following implementation of the new protocol, there were significant ( P < 0.001) decreases in TTMR (19 vs. 11 hours), LOS (149 vs. 120 hours), case cancellation rate, and total hospital charges ($84,000 vs. $62,000). There were no significant differences with respect to in-hospital complications or readmission rates/mortality rates at 1 year. CONCLUSIONS Following implementation of a protocolized, multidisciplinary approach to optimizing geriatric fracture patients, we were able to demonstrate a reduction in unnecessary preoperative testing, TTMR for surgery, case cancellation rate, LOS, and total hospitalization charge-without a concomitant increase in complications or mortality. This study highlights that standardization of the perioperative care for geriatric hip fracture patients can provide effective patient care while also lowering financial and logistical burden in care for these injuries. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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12
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Bogdan Y, Vallier HA. What's New in Orthopaedic Trauma. J Bone Joint Surg Am 2022; 104:1131-1137. [PMID: 35700075 DOI: 10.2106/jbjs.22.00261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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13
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Villacres Mori B, Young JR, Lakra A, Chisena E. Team Approach: Management of Geriatric Acetabular Fractures. JBJS Rev 2022; 10:01874474-202205000-00009. [PMID: 35613307 DOI: 10.2106/jbjs.rvw.22.00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Geriatric acetabular fractures are defined as fractures sustained by patients who are ≥60 years old. With the rapidly aging American populace and its increasingly active lifestyle, the prevalence of these injuries will continue to increase. » An interdisciplinary approach is necessary to ensure successful outcomes. This begins in the emergency department with hemodynamic stabilization, diagnosis of the fracture, identification of comorbidities and concomitant injuries, as well as early consultation with the orthopaedic surgery service. This multifaceted approach is continued when patients are admitted, and trauma surgery, geriatrics, and cardiology teams are consulted. These teams are responsible for the optimization of complex medical conditions and risk stratification prior to operative intervention. » Treatment varies depending on a patient's preinjury functional status, the characteristics of the fracture, and the patient's ability to withstand surgery. Nonoperative management is recommended for patients with minimally displaced fractures who cannot tolerate the physiologic stress of surgery. Percutaneous fixation is a treatment option most suited for patients with minimally displaced fractures who are at risk for displacing the fracture or are having difficulty mobilizing because of pain. Open reduction and internal fixation is recommended for patients with displaced acetabular fractures who are medically fit for surgery and have a displaced fracture pattern that would do poorly without operative intervention. Fixation in combination with arthroplasty can be done acutely or in delayed fashion. Acute fixation combined with arthroplasty benefits patients who have poorer bone quality and fracture characteristics that make healing unlikely. Delayed arthroplasty is recommended for patients who have had failure of nonoperative management, have a fracture pattern that is not favorable to primary total hip arthroplasty, or have developed posttraumatic arthritis.
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Esper G, Anil U, Konda S, Furgiuele D, Zaretsky J, Egol K. Standardized Preoperative Pathways Determining Preoperative Echocardiogram Usage Continue to Improve Hip Fracture Quality. Geriatr Orthop Surg Rehabil 2022; 13:21514593221094730. [PMID: 35450301 PMCID: PMC9016569 DOI: 10.1177/21514593221094730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/30/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction The purpose of this study was to assess the hospital quality measures and
outcomes of operative hip fracture patients before and after implementation
of an anesthesiology department protocol assigning decision for a
preoperative transthoracic echocardiogram (TTE) to the hospitalist
co-managing physician. Materials and Methods Demographics, injury details, hospital quality measures, and outcomes were
reviewed for a consecutive series of patients presenting to our institution
with an operative hip fracture. In May of 2019, a new protocol assigning the
responsibility to indicate a patient for preoperative TTE was mandated to
the co-managing hospitalist at the institution. Patients were split into
pre-protocol and post-protocol cohorts. Linear regression modeling and
comparative analyses were conducted with a Bonferroni adjusted alpha as
appropriate. Results Between September 2015 and June 2021, 1002 patients presented to our
institution and were diagnosed with a hip fracture. Patients in the
post-protocol cohort were less likely to undergo a preoperative
echocardiogram, experienced a shorter time (days) to surgery, shorter length
of stay, an increase in amount of home discharges, and lower complication
risks for urinary tract infection and acute blood loss anemia as compared to
those in the pre-protocol cohort. There were no differences seen in
inpatient or 30-day mortality. Multivariable linear regression demonstrated
a patient’s comorbidity profile (Charlson Comorbidity Index (CCI)) and their
date of presentation (pre- or post-protocol), were both associated with
(P<0.01) a patients' time to surgery. Conclusion A standardized preoperative work flow protocol regarding which physician
evaluates and determines which patients require a preoperative TTE allows
for a streamlined perioperative course for hip fracture patients. This
allows for a shortened time to surgery and length of stay with an increase
in home discharges and was associated with a reduced risk of common index
hospitalization complications including UTI and anemia.
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Affiliation(s)
- Garrett Esper
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Sanjit Konda
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - David Furgiuele
- Department of Anesthesia, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Jonah Zaretsky
- Department of Medicine, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Kenneth Egol
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
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Preoperative echocardiogram does not increase time to surgery in hip fracture patients with prior percutaneous coronary intervention. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1013-1022. [PMID: 35279771 DOI: 10.1007/s00590-022-03245-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The purpose of this study was to (1) assess the effect of preoperative echocardiogram on time to surgery and (2) assess the outcomes of patients with a previous percutaneous coronary intervention (PCI). METHODS Demographic, clinical, quality and cost data were obtained and a validated risk predictive tool (STTGMA) was calculated for each of a consecutive series of hip fracture patients. Comparative analyses of patients who had an echocardiogram prior to surgery or a PCI prior to hospitalization were performed. RESULTS Between 2014 and 2020, 2625 patients presented to our institution with a hip fracture. From this cohort 471 patients underwent a preoperative transthoracic echocardiogram (TTE), 30 who had a history of a PCI, and an additional 26 who had a history of PCI but did not undergo a preoperative TTE. Those undergoing a preoperative TTE had similar time (days) to surgery (1.73 vs 1.77, p = 0.86) and 30-day mortality (4% vs 7%, p = 0.545) regardless of PCI history. PCI patients who underwent a preoperative TTE experienced increased rates of 1-year mortality (27% vs 10%, p = 0.007) and major complications (23% vs 12%, p = 0.08) compared to those without a PCI history. PCI patients undergoing a preoperative TTE had a similar time (days) to surgery (1.77 vs 1.48, .p = 0.397) compared to PCI patients without a preoperative TTE. Patients who underwent a preoperative TTE had higher rates of 90-day readmission (31.0% vs 8.0%, p = 0.047) and 1-year mortality (26.7% vs 3.8%, p = 0.029). CONCLUSIONS Having a preoperative TTE does not affect surgical wait times in hip fracture patients regardless of PCI history, but it may not improve mortality outcomes or reduce postoperative complications in patients with a history of a PCI.
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Katsanos S, Saranteas T, Mavrogenis AF. Orthopaedic cardiac considerations in emergency. SICOT J 2021; 7:E2. [PMID: 34738901 PMCID: PMC8570134 DOI: 10.1051/sicotj/2021051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 10/07/2021] [Indexed: 01/09/2023] Open
Abstract
Orthopaedic patients undergoing emergency orthopaedic surgery should be referred for cardiac evaluation only when they are symptomatic or when a specific cardiac intervention is expected to reduce the surgical risk. A preoperative delay of 24-48 h of emergency orthopaedic operations has been associated with increased mortality and poor functional status of the patients. Research in the preoperative setting is almost exclusively retrospective because randomized studies are difficult to be performed and pose serious ethical concerns. Moreover, inevitably, guidelines have a low level of evidence and do not always provide a straightforward framework for the preoperative care of the patients. This editorial revisits the most common clinical cardiology dilemmas for emergency orthopaedic surgery to explore controversies of current recommendations and elaborate on the role of echocardiography in the perioperative period in emergency orthopaedic surgery.
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Affiliation(s)
- Spyridon Katsanos
- Department of Emergency Medicine and Cardiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Theodosis Saranteas
- Second Department of Anesthesiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 11527 Athens, Greece
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Ranganna S, Kiefer JJ, Augoustides JG. Perioperative Transthoracic Echocardiography-Thoughtful Design and Delivery of Standardized Imaging Protocols for Anesthesiology Teams. J Cardiothorac Vasc Anesth 2021; 36:387-389. [PMID: 34922818 DOI: 10.1053/j.jvca.2021.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Shreyas Ranganna
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse J Kiefer
- Critical Care Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Advances in Geriatric Hip Fractures: Pre-Operative Considerations and Tips to Optimize Outcome. J Orthop Trauma 2021; 35:S32-S37. [PMID: 34533500 DOI: 10.1097/bot.0000000000002234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 02/02/2023]
Abstract
Geriatric hip fractures are complicated by increased morbidity and mortality, and their incidence continues to rise around the world. Frequent considerations in treating geriatric hip fractures include optimal time to surgery, need for preoperative cardiac clearance, risks of operating through anticoagulation, utilization of regional anesthesia, and collaborative care between treatment teams. This article aims to summarize these factors as well as to provide some tips and tricks that can be helpful in their surgical management.
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Prognostic factors related to ambulation deterioration after 1-year of geriatric hip fracture in a Chinese population. Sci Rep 2021; 11:14650. [PMID: 34282186 PMCID: PMC8289836 DOI: 10.1038/s41598-021-94199-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 05/31/2021] [Indexed: 12/17/2022] Open
Abstract
The objective of this study was to investigate the prognostic factors predicting the ambulation recovery of fragility hip fracture patients. 2286 fragility hip fracture patients were collected from the Fragility Fracture Registry in Hong Kong. Predictive factors of ambulation deterioration including age, gender, pre-operation American Society of Anesthesiologists grade, pre-fracture mobility, delay to surgery, length of stay, fracture type, type of surgery, discharge destination and complications were identified. Patients with outdoor unassisted and outdoor with aids ambulatory function before fracture had 3- and 1.5-times increased risk of mobility deterioration, respectively (Odds Ratio (OR) = 2.556 and 1.480, 95% Confidence Interval (CI) 2.101–3.111 and 1.246–1.757, both p < 0.001). Patients living in old age homes had almost 1.4 times increased risk of deterioration when compared to those that lived in their homes (OR = 1.363, 95% CI 1.147–1.619, p < 0.001). The risk also increased for every 10 years of age (OR = 1.831, 95% CI 1.607–2.086, p < 0.001). Patients in the higher risk ASA group shows a decreased risk of ambulation deterioration compared to those in lower risk ASA group (OR = 0.831, 95% CI 0.698–0.988, p = 0.038). Patients who suffered from complications after surgery did not increased risk of mobility decline at 1-year post-surgery. Delayed surgery over 48 h, delayed discharge (> 14 days), early discharge (less than 6 days), and length of stay also did not increased risk of mobility decline. Male patients performed worse in terms of their mobility function after surgery compared to female patients (OR = 1.195, 95% CI 1.070–1.335, p = 0.002). This study identified that better premorbid good function, discharge to old age homes especially newly institutionalized patients, increased age, lower ASA score, and male patients, correlate with mobility deterioration at 1-year post-surgery. With the aging population and development of FLS, prompt identification of at-risk patients should be performed for prevention of deterioration.
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Kamal RN. CORR Insights®: Clinician Factors Rather Than Patient Factors Affect Discussion of Treatment Options. Clin Orthop Relat Res 2021; 479:1517-1520. [PMID: 33938513 PMCID: PMC8208398 DOI: 10.1097/corr.0000000000001791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/31/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Robin N Kamal
- Assistant Professor, Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA
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