Type of surgery is associated with pain and walking difficulties among older people with previous hip fracture

Arthroplasty vs proximal femoral nails for unstable intertrochanteric femoral fractures in elderly patients: A systematic review and meta-analysis

BACKGROUND

Proximal femoral nails (PFNs) are the most common method for the treatment of unstable intertrochanteric femoral fractures (IFFs), but postoperative bed rest is required. There is a large amount of blood loss during the operation. Osteoporosis in elderly patients may cause nonunion of fractures and other complications. Arthroplasty can give patients early weight bearing and reduce financial burden, but whether it can replace PFNs remains controversial.

AIM

To compare the clinical outcomes of arthroplasty and PFNs in the treatment of unstable IFFs in elderly patients.

METHODS

A search was conducted in the PubMed, Embase, and Cochrane Library databases and included relevant articles comparing arthroplasty and PFN. The search time was limited from January 1, 2005 to November 1, 2020. Two investigators independently screened studies, extracted data and evaluated the quality according to the inclusion and exclusion criteria. According to the research results, the fixed effect model or random effect model were selected for analysis. The following outcomes were analyzed: Harris Hip score, mortality, complications, operation time, blood loos, hospital stay, weight-bearing time, fracture classification and type of anesthesia.

RESULTS

We analyzed four randomized controlled trials that met the requirements. A total of 298 patients were included in these studies. According to the AO/OTA classification, there are 20 A1 types, 136 A2 types, 42 A3 types and 100 unrecorded types. Primary outcome: The Harris Hip Score at the final follow-up of the PFN group was higher [mean difference (MD): 9.01, 95% confidence interval (CI): 16.57 to 1.45), P = 0.02]. There was no significant difference between the two groups in the rate of overall mortality [risk ratio (RR): 1.44, P = 0.44] or the number of complications (RR: 0.77, P = 0.05). Secondary outcomes: blood loss of the arthroplasty group was higher (MD: 241.01, 95% CI: 43.06–438.96, P = 0.02); the operation time of the PFN group was shorter (MD: 23.12, 95%CI: 10.46–35.77, P = 0.0003); and the length of hospital stay of the arthroplasty group was shorter [MD: 0.97, 95% CI: 1.29 to 0.66), P < 0.00001]. There was no difference between the two groups in the type of anesthesia (RR: 0.99). There were only two studies recording the weight-bearing time, and the time of full weight bearing in the arthroplasty group was significantly earlier.

CONCLUSION

Compared with PFN, arthroplasty can achieve weight bearing earlier and shorten hospital stay, but it cannot achieve a better clinical outcome. Arthroplasty cannot replace PFNs in the treatment of unstable IFFs in elderly individuals.

Reduction of trochanteric fractures in lateral view is significant predictor for radiological and functional result after six months

OBJECTIVES

The goal of our retrospective study was to determine which radiological parameter after fixation of trochanteric fractures type AO 31 A2 is most important for the position of the fracture after six months. The additional goal was to find how the end position influences mechanical failure and the mobility of the patients.

PATIENTS AND METHODS

We analysed 92 patients operated in one-year period for A 2 type trochanteric fractures with sliding hip screw or proximal femur intramedullary nail. They were divided in two groups according to the radiological position of the proximal fragment six months after the surgery. In group A we had 46 patients with satisfactory and in group B 46 patients with unsatisfactory position. In anteroposterior view we evaluated neck-shaft angle (NSA) and medial cortical support (MCS) and in lateral view anterior cortical support (ACS). Unsatisfactory position was recognized if NSA was in varus or ACS or MCS were negative. We compared the groups regarding basic patients characteristics (age, gender, ASA score, preinjury mobility, and degree of osteoporosis), type and quality of fixation, the position of the fracture (postoperatively and after 6 months), mechanical failure and mobility after 6 months. Statistical significance level was set to p ≤ 0.05.

RESULTS

Basic patients' characteristics as well as type and quality of fixation did not significantly differ between the groups. After the injury the difference between the groups in reduction quality was significant in lateral view (ACS; p=0.001), while after half a year there were significant differences in both views: NSA (p=0.003), ACS and MCS (both p<0.001). Proximal fragment position after six months statistically significant correlated with postoperative ACS in B group (r = 0.386, p = 0.008), but not with NCA nor with MCS. There were also significantly more fixation failures in group B (p<0.001) and less patients regain preinjury mobility (p=0.029).

CONCLUSIONS

In trochanteric fractures reduction in lateral view is the most important prognostic factor for favourable radiological result after half a year. Unsatisfactory position of the proximal fragment after six months influences mechanical failures and walking ability.

Risk factors for new chronic opioid use after hip fracture surgery: a Danish nationwide cohort study from 2005 to 2016 using the Danish multidisciplinary hip fracture registry

OBJECTIVE

To examine the risk factors for new chronic opioid use in elderly patients who underwent hip fracture surgery.

DESIGN

Prospective population-based cohort study.

SETTING AND PARTICIPANTS

Using Danish nationwide health registries, we identified all opioid non-user patients aged ≥65 years who had undergone hip fracture surgery from 2005 to 2016 and were alive within the first year following surgery.

MAIN OUTCOME MEASURES

New chronic opioid use defined by the dispensing of at least two prescription opioids within two of the last three quarters during the first year following surgery.

RESULTS

We identified 37 202 opioid non-user patients who underwent hip fracture surgery. Of these, 5497 (15%) developed new chronic opioid user within 1 year of surgery. Risk factors for new chronic opioid use were Body Mass Index (BMI) of <18.5 (adjusted OR (aOR) 1.22, 95% CI 1.09 to 1.36), BMI of 25.0-29.9 (aOR 1.12, 95% CI 1.04 to 1.21) and BMI of ≥30 (aOR 1.57, 95% CI 1.40 to 1.76) with BMI 18.6-24.9 as reference, a pertrochanteric/subtrochanteric fracture (aOR 1.27, 95% CI 1.20 to 1.34) with femoral neck fracture as reference, preoperative use (vs no-use) of non-steroidal anti-inflammatory drug (aOR 1.68, 95% CI 1.55 to 1.83), selective serotonin reuptake inhibitor (aOR 1.42, 95% CI 1.32 to 1.53), antidepressants (aOR 1.36, 95% CI 1.24 to 1.49), antipsychotics (aOR 1.21, 95% CI 1.07 to 1.35), corticosteroids (aOR 1.54, 95% CI 1.35 to 1.76), statins (aOR 1.09, 95% CI 1.02 to 1.18), antibiotics (aOR 1.32, 95% CI 1.22 to 1.42), antiosteoporosis drugs (aOR 1.33, 95% CI 1.19 to 1.49) and anticoagulatives (aOR 1.24, 95% CI 1.17 to 1.32). Presence of cardiovascular comorbidities, diabetes, gastrointestinal diseases, dementia, chronic obstructive pulmonary disease or renal diseases was further identified as a risk factor.

CONCLUSION

In this large nationwide cohort study, we identified several risk factors associated with new chronic opioid use after hip fracture surgery among patients who were alive within the first year following surgery. Although not all factors are modifiable preoperative, this will allow clinicians to appropriately counsel patients preoperatively and tailor postoperative treatment.

Impact of Bone Fracture on Muscle Strength and Physical Performance-Narrative Review

PURPOSE OF REVIEW

Low muscle strength and poor physical performance are associated with high risk of fracture. Many studies assessed clinical and functional outcomes of fractures. Fewer studies analyzed the impact of fractures on muscle strength and physical performance.

RECENT FINDINGS

Vertebral fractures (especially multiple and severe ones) are associated with back pain, back-related disability, lower grip strength, lower strength of lower limbs, lower gait speed, and poor balance. Patients with hip fracture have slower gait and lower quadriceps strength. Non-vertebral fractures were associated with lower strength of the muscles adjacent to the fracture site (e.g., grip strength in the case of distal radius fracture, knee extensors in the case of patellar fracture) and poor physical function dependent on the muscles adjacent to the fracture site (e.g., limited range of motion of the shoulder in the case of humerus fracture, gait disturbances in the case of the ankle fracture). Individuals with a fracture experience a substantial deterioration of muscle strength and physical performance which exceeds that related to aging and is focused on the period close to the fracture occurrence. After fracture, muscle strength increased and physical performance improved. The rate of normalization depended partly on the therapeutic approach and on the rehabilitation program. A subgroup of patients, mainly the elderly, never returns to the pre-fracture level of physical performance. The permanent decline of physical function after fracture may be related to the limitation of movements due to pain, low physical activity, poor health before the fracture, and reduced efficacy of retraining after immobilization.

Internal Fixation versus Hemiarthroplasty in the Treatment of Unstable Intertrochanteric Fractures in the Elderly: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the clinical efficacy of internal fixation versus hemiarthroplasty in the treatment of unstable intertrochanteric fractures in the elderly.

METHODS

A search was conducted in PubMed, Web of Science, Embase, and Cochrane Library databases up to April 2020. The present study compared internal fixation and hemiarthroplasty in the treatment of unstable intertrochanteric fractures in the elderly. RevMan5.3 software provided by the International Cochrane Group was used for the meta-analysis. To compare the differences in the operation time, intraoperative bleeding, length of hospital stay, superficial infection, Harris hip score, mortality within 1 year, mortality within 2 years, reoperation, incidence of deep venous thrombosis (DVT), partial weight-bearing time, non-union, and implant-related complications between an internal fixation group and an hemiarthroplasty group.

RESULTS

A total of 1300 patients were included in nine studies. The results showed that the operation time (MD = -18.09, 95% CI: -27.85--8.34, P = 0.0003), intraoperative bleeding (MD = -195.31, 95% CI: -244.8--147.74, P < 0.0001), implant-related complications (MD = 3.83, 95% CI: 1.74-8.45, P = 0.0008), and partial weight-bearing time (MD = 17.21, 95% CI: 1.63-32.79, P = 0.03) have statistical significance. However, there is not statistical significance for the Harris hip joint function scale (HHS) (MD = 5.60, 95% CI: -1.13-12.33, P = 0.10), DVT (MD = 1.02, 95% CI: 0.45-2.27, P = 0.97), length of hospital stay (MD = -1.08, 95% CI: -2.82-0.66, P = 0.22), superficial Infection (OR = 0.92, 95% CI: 0.43-1.98, P = 0.89), mortality within 1 year (OR = 0.95, 95% CI: 0.61-1.48, P = 0.81), mortality within 2 years (OR = 0.93, 95% CI: 0.61-1.43, P = 0.75), reoperation (MD = 1.80, 95% CI: 0.64-5.04, P = 0.26), and non-union (OR = 1.20, 95% CI: 0.48-3.03, P = 0.70). The result of the subgroup analysis showed no significant differences between the less than 2 years follow-up and the 2 years or more follow-up group. The only difference was for the Harris hip score: the internal fixation group was superior to the hemiarthroplasty group in the less than 2 years subgroup analysis, while there was no difference between the internal fixation group hemiarthroplasty group in the 2 years or more subgroup analysis.

CONCLUSION

Compared with the internal fixation group, those in the hemiarthroplasty group could carry out weight-bearing training early and implant-related complications were reduced, but it requires longer operation time and there is greater intraoperative blood loss. There is no difference in mortality, the incidence of DVT, non-union, HHS, reoperation, length of hospital stay, and superficial infection. Hemiarthroplasty may be a better choice for unstable intertrochanteric fractures in the elderly.

Reliability, validity, interpretability and responsiveness of the DEMMI mobility index for Brazilian older hospitalized patients

AIM

To translate and adapt cross-culturally the De Morton Mobility Index from English to Brazilian Portuguese. Furthermore, to test the content validity, reliability, construct validity, interpretability and responsiveness for older hospitalized patients.

METHODS

After we carried out the translation and the cross-cultural adaptation of the De Morton Mobility Index and its administration instructions according to international guidelines, the content validity of De Morton Mobility Index was tested by experienced physiotherapists. In the sequence, the reliability, construct validity, interpretability and responsiveness were tested in a test-retest design with 93 older patients hospitalized in ward for clinical reasons. The reliability was tested by Cronbach's alpha coefficient (internal consistency), standard error measurement (agreement), and interclass correlation coefficients (intra and inter-examiner reliability). The construct validity was tested by Pearson's correlation between the De Morton Mobility Index score and the number of steps. Interpretability was analyzed by determining the minimum detectable change and the floor and ceiling effects (frequency of maximum and minimum scoring). Responsiveness was analyzed by effect size.

RESULTS

The Brazilian version of the De Morton Mobility Index was made and adapted. The internal consistency (α = 0.89), reliability intra-(ICC = 0.94) and inter-examiners (ICC = 0.82), agreement were all adequate. The De Morton Mobility Index is validity when correlated with number of steps (r = 0.46). Floor or ceiling effects (<15%) were not observed and the responsiveness was high (ES = 3.65).

CONCLUSION

The De Morton Mobility Index has shown adequate reliability, validity, interpretability and responsiveness for the evaluation of the mobility of older hospitalized patients.

Different impacts of dementia on two-year mortality after osteosynthesis and hemiarthroplasty in treating geriatric hip fractures

BACKGROUND

Geriatric hip fractures are mostly managed by internal fixation (IF) or hemiarthroplasty (HA). Survivorship of dementia patients following these surgeries has not been extensively compared in literature. By analysis of nationwide database, this study aimed to investigate the impact of dementia on two-year mortality after IF and HA in treating geriatric hip fractures.

METHOD

From retrospective review of Taiwan's National Health Insurance Research Database, we enrolled 153,623 subjects aged 65 years and older with hospitalization for first hip fracture operated by IF (93,029 cases) or HA (60,594 cases) between 2000 and 2011. Postoperative mortality was compared between subjects with and without dementia after adjustments of age, gender, Charlson comorbidity index and hospital level.

RESULTS

The prevalence of dementia was 5.24% in the IF and 5.29% in the HA group. In the IF group, dementia increased adjusted hazard ratio of one-year (1.06, 95%CI:1.00-1.13) and two-year mortality (1.10, 95%CI:1.05-1.16). However, short and long-term mortality following HA was not significantly impacted by dementia (in-hospital OR:0.79, 95%CI:0.60-1.03; three-month HR:0.99, 95%CI:0.87-1.12; one-year HR:1.01, 95%CI:0.93-1.10; two-year HR:1.03, 95%CI:0.96-1.09). In a subgroup of dementia patients, mortality following IF was 15% higher than HA in one (p = 0.004) and two years (p < 0.001). The negative prognostic factors included female (HR:1.10; 95%CI:1.03-1.18) and aging 65-84 years (HR:1.15; 95%CI:1.00-1.32).

CONCLUSION

Dementia increased one and two-year mortality following geriatric hip fracture treated by IF, rather than HA. Dementia patients undergoing HA, especially female or 65-84 years old, sustained better one and two-year survival than those receiving IF.

[Pathological and metabolic bone diseases: Clinical importance for fracture treatment]

Pathological and metabolic bone diseases are common and relevant occurrences in orthopedics and trauma surgery; however, fractures are often treated as being the illness itself and not seen as the symptom of an underlying bone disease. This is why further diagnostics and systemic treatment options are often insufficiently considered in the routine treatment of fractures. This review focuses on osteoporosis, osteopetrosis, hypophosphatasia and Paget's disease of bone.In patients with osteoporotic vertebral or proximal femur fractures, pharmaceutical treatment to prevent subsequent fractures is an integral part of fracture therapy together with surgical treatment. Osteopetrosis is caused by compromised osteoclastic bone resorption; therefore, even in the face of an elevated bone mass, vitamin D3 supplementation is crucial to avoid clinically relevant hypocalcemia. Unspecific symptoms of the musculoskeletal system, especially together with stress fractures, are typically found in patients suffering from hypophosphatasia. In these patients measurement of alkaline phosphatase shows reduced enzyme activity. Elevated levels of alkaline phosphatase are found in Paget's disease of bone where bisphosphonates are still the treatment of choice.