Postoperative Rehabilitation after Hip Fracture: A Literature Review

Medial cortical reduction does not influence outcomes in geriatric intertrochanteric femur fractures treated with proximal femoral nail

BACKGROUND

In intertrochanteric fractures, the positive medial cortex support reduction is considered to provide a non-anatomical buttress that helps in controlled collapse.

AIM

To analyze the concept of medial cortical reduction (MCR) and its clinical and radiological association in geriatric intertrochanteric femur fractures.

METHODS

Geriatric patients who presented with AO/OTA 31A1 and 31A2 femur fractures and treated with proximal femoral nailing between July 2021 and June 2023 were include in this prospective cohort study. Based on the degree of MCR, they were divided into positive, neutral, or negative MCR groups. The demographic baseline characteristics, postoperative radiographic femoral neck-shaft angle and neck length were analyzed at 6, 12 and 24 weeks post-surgery. Functional outcomes such as modified Harris Hip Score (HHS) and time to full-weight bearing were also analyzed.

RESULTS

47 patients (Male: Famale 35:12) with mean age of 65.8 ± 4.2 years were included in this study. Twenty-two cases had neutral support, nine had negative support, and sixteen had positive support in the medial cortex post-operatively. Baseline characteristics of the three groups were comparable. No significant differences were found in the femur neck length and femur neck-shaft angle changes post-surgery between the groups. The modified HHS was not found to be significant between the groups (P = 0.883) as that of the time to full weight bearing (P = 0.789).

CONCLUSION

The type of reduction achieved based on medial cortical alignment does not affect the femur neck length shortening or varus collapse. Future randomized controlled trials are needed to validate the findings noted in the study.

Early Postoperative Gait Analysis in Elderly Patients Following Hip Fracture Surgery

Hip fractures in elderly patients significantly reduce independence and quality of life. Early postoperative gait performance remains poorly understood, particularly regarding differences between surgical treatments, such as proximal femur nailing and hemiarthroplasty. Identifying gait alterations early in rehabilitation could optimize clinical interventions. This prospective observational cohort study included 40 elderly patients hospitalized after acute hip fracture surgery. Relative peak force and step duration were assessed using the ambulant pressure biofeedback system during postoperative mobilization. Additionally, three-dimensional gait analysis evaluated spatiotemporal parameters and sagittal plane kinematics of the hip, knee, and ankle. Results demonstrated significant improvements in median peak force (45.32% to 70.00%, (p < 0.001)) and median step duration (2.96 s to 137 s, (p < 0.001)) at the end of the hospitalization period. No significant differences in step duration and peak force were observed between the different surgical procedures, proximal femur nail, and hemiarthroplasty. Three-dimensional gait analysis showed significantly reduced hip extension during terminal stance in the operated leg compared to the healthy leg. These findings highlight the utility of biofeedback systems for monitoring early rehabilitation progress and emphasize the importance of 3D gait analysis in identifying early postoperative gait deficits. Targeted interventions during hospitalization could enhance functional recovery and improve patient outcomes.

Zuyderland Hip Inference for Survival and Lifetime Expectancy (ZHISLE) following hip fracture surgery: validation of the model that demonstrated good predictive power

PURPOSE

Proximal femoral fractures are common within the elderly population and are associated with a high risk of mortality and reduced quality of life. Hemiarthroplasty or osteosynthesis (extramedullary or intramedullary) is the primary treatment option for these fractures. However, within this fragile patient population many comorbidities, among others dementia, are seen. Therefore, predicting patients with a high mortality risk after surgery may lead to adopting alternative treatment options with less risks. This paper proposes a new model to distinguish patients with high postoperative mortality risk with adequate follow-up time in combination with a wide set of useful and available variables.

METHODS

Patients treated with hemiarthroplasty or osteosynthesis for proximal femoral fractures were studied, with a follow-up period of 6 months. Patients who died within this follow-up period were compared to survivors, and predicting variables were assessed in logistic regression: The Zuyderland Hip Inference for Survival and Lifetime Expectancy (ZHISLE). The model was validated internally against a held-out dataset. Furthermore, the model performance was compared against the Almelo Hip Fracture Score (AHFS) on the same sample.

RESULTS

Out of 2463 patients undergoing surgical treatment for proximal femoral fractures, 415 (16.8%) died within 183 days. Predictors for early mortality included old age, male sex, high heartbeat, KATZ-ADL and GFI scores, C-reactive protein and urea concentrations and low albumin concentration. Our model showed satisfactory predictive and discriminatory power (ROC curve = 0.81). Internal validation was good (ROC in validation dataset = 0.81), and better than the AHFS (ROC = 0.57).

CONCLUSIONS

The ZHISLE model demonstrates good predictive power concerning mortality risk for old patients with a proximal femoral fracture. The model could benefit patients by indicating if a conservative, non-invasive policy might be a better option for those patients.

Effect of early rehabilitation on hospital stay and postoperative complications in elderly hip fracture patients: a prospective cohort study

BACKGROUND

Hip fractures in the elderly are a major global public health concern, with incidence projected to rise as populations age. Rehabilitation is critical to recovery after hip fracture surgery, but the ideal timing for initiation remains uncertain. While early rehabilitation, within 48 h post-surgery, is associated with better outcomes, its specific impact on hospital stay duration and postoperative complications is not yet conclusively established.

AIM

This study aims to evaluate the effects of initiating rehabilitation within 48 h after hip fracture surgery on hospital length of stay and postoperative complications, compared to rehabilitation started one-week post-surgery in elderly patients. It is hypothesized that early rehabilitation will significantly reduce hospital stays and decrease the rate of postoperative complications.

METHODS

In this prospective cohort study, patients aged 65 and older are divided into early rehabilitation (within 48 h) and delayed rehabilitation (after one week) groups. Data will be collected using electronic medical records (EMR), standardized clinical tools (Barthel Index, Timed Up and Go), and patient-reported outcome measures (SF-36, EQ-5D). Statistical analyses will include t-tests and chi-square tests for outcome comparison, with multiple regression adjusting for potential confounders such as age, gender, and comorbidities.

Insufficient Mechanical Loading Downregulates Piezo1 in Chondrocytes and Impairs Fracture Healing Through ApoE-Induced Senescence

Insufficient mechanical loading impairs fracture healing; however, the underlying mechanisms remain unclear. Increasing evidence indicates that Piezo1 plays an important role in fracture healing, although the effect of Piezo1 on the endochondral ossification of chondrocytes has been overlooked. This study reports that mechanical unloading down-regulates the expression of Piezo1 in chondrocytes and leads to fracture nonunion. Single-cell sequencing of calluses revealed that specific deletion of Piezo1 in chondrocytes upregulated the expression of apolipoprotein E (ApoE) in hypertrophic chondrocytes, resulting in delayed cartilage-to-bone transition due to enhanced chondrocyte senescence. Based on these results, an injectable and thermosensitive hydrogel is developed, which released an ApoE antagonist in situ at the fracture site. This hydrogel effectively attenuated chondrocyte senescence and, thus, promoted cartilage-to-bone transition as well as the fracture healing process. Overall, this data provide a new perspective on the activity of chondrocytes in fracture healing and a new direction for the treatment of fracture nonunion caused by insufficient mechanical loading.

Cross-cultural adaptation and test-retest reliability assessment of a Swedish version of the exercise adherence rating scale in patients after shoulder surgery

BACKGROUND

Adherence to prescribed home exercise is an important predictor for the long-term effectiveness of exercise therapy and therefore important to evaluate. The Exercise Adherence Rating Scale (EARS) is a valid and reliable tool to assess exercise adherence behavior, but it is not translated into Swedish. This study aimed to translate EARS into Swedish and to explore the psychometric properties in terms of test-retest reliability, internal consistency as well and possible floor-/ceiling effects.

MATERIALS AND METHODS

  A translation and cultural adaptation process followed international guidelines and resulted in EARS-Sv. A total of 30 patients who had undergone shoulder surgery were included in the study and filled out EARS-Sv at two different time points. The test-retest reliability was evaluated through the weighted kappa coefficient and Intraclass Correlation Coefficient (ICC). Cronbach's alpha was used to assess internal consistency. Floor-/ceiling effects were calculated.

RESULTS

The test-retest reliability of the questionnaire was good with ICC (0.79, CI 95%) and moderate with weighted kappa-coefficient (MD= 0.58). Cronbach's alpha was considered good (0.88). A ceiling effect was registered in all 6 items of EARS-Sv.

CONCLUSION

EARS-Sv has moderate to good test-retest reliability and good internal consistency in patients who have undergone shoulder surgery.

RHD-HA-9: A scale for nurses to assess readiness for hospital discharge in older adults following hip arthroplasty-development and psychometric testing

Background

Designing an instrument to assess discharge readiness post-hip surgery is essential due to trends showing poor patient outcomes, such as pain management issues, mobility challenges, and insufficient home support. A structured assessment tool would help ensure patients are better prepared for recovery, reducing the risk of complications and readmission.

Objective

To develop and test the psychometric properties of the Readiness for Hospital Discharge Scale (RHD-HA-9) for hip arthroplasty.

Methods

Items were generated from a comprehensive literature review and individual, face-to-face interviews with experts and patients. A cross-sectional study was conducted across four tertiary governmental hospitals to evaluate the psychometric properties of the scale. Data were collected from a total of 200 older adults who had undergone hip arthroplasty between June 2020 and February 2021. Exploratory Factor Analysis (EFA) was performed on data from 100 older adults to identify the underlying factor structure, followed by Confirmatory Factor Analysis (CFA) on a separate 100-patient dataset to validate the model. The questionnaire's internal consistency, corrected item-total correlations, inter-rater reliability, construct, concurrent, and predictive validity were assessed.

Results

The RHD-HA-9 included nine items, categorized into two factors: the physical performance of hip function and barriers to physical activity. EFA and CFA confirmed these factors, explaining 62% of the total variance. Model fit indices were acceptable (CFI = 0.97, TLI = 0.96, SRMR = 0.04), though RMSEA was 0.12. Chi-square was significant (χ2 = 0.056, df = 24, p <0.001). The scale showed excellent internal consistency (Cronbach's α = 0.89) and stability (ICC = 0.94). ROC analysis identified a cutoff of 9.5, with a sensitivity of 90.7%, specificity of 70.6%, and AUC of 0.89.

Conclusion

The RHD-HA-9 demonstrated strong psychometric properties for assessing discharge readiness in older adults following hip arthroplasty. It identifies patients who need additional support during their transition home. Nurses can use this tool to accurately assess patient needs and implement effective post-discharge care, thereby enhancing patient outcomes.

Hip Fracture in the Sportive Adult: Case Report of Complete Functional Recovery After Removal of Hardware

CONTEXT

Pertrochanteric hip fractures in sportive young adults are mainly caused by a high-energy trauma and treated in the same way as in the older population, using an osteosynthesis immediately followed by a rehabilitation program for several months. The current standard is not to remove osteosynthesis material, similar to the case of older patients.

CASE PRESENTATION

A 45-year-old male cyclist experienced a right pertrochanteric femoral fracture, treated with cephalomedullary nails. After 9 months of adequate rehabilitation, weakness of the quadriceps musculature and functional complaints persisted, objectified through an isokinetic strength test and a significantly reduced score on the Hip Disability and Osteoarthritis Outcome Score questionnaire. The patient was unable to return to his previous level of cycling performance.

MANAGEMENT AND OUTCOME

After exclusion of structural bone complications, nerve injury, and central sensitization, the functional complaints and strength deficiency were hypothesized to be related to the osteosynthesis material. Therefore, the hardware was removed 9 months after the first surgery, and the rehabilitation was continued for another 20 weeks. Very soon after the removal of the hardware, the functional complaints disappeared with a remarkable improvement of the Hip Disability and Osteoarthritis Outcome Score. The isokinetic strength test showed complete recovery of muscle strength 20 weeks after osteosynthesis removal, and preinjury cycling performance values were obtained 9 months posthardware removal.

CONCLUSION

Despite an adequate rehabilitation following a hip fracture, sporty young adults may fail to reach their previous level of functioning. Osteosynthesis removal may be indicated in this sportive population to reach complete muscle strength and functional recovery. The management of hip fractures in the sportive young adult and the identification of patients who may benefit from removal of the hardware require more research.

Ambulation recovery prediction after hip fracture surgery using the Hip Fracture Short-Term Ambulation Prediction tool

OBJECTIVE

To develop models for predicting postoperative ambulation recovery at 3 months following fragility hip fracture surgery.

DESIGN

Cross-sectional study.

SUBJECTS

Fragility hip fracture patients aged ≥ 50 years who underwent operative treatment and completed a 3-month follow-up.

METHODS

Potential predictors were collected from eligible patients, while ambulation at 3 months after injury was assessed using the modified functional ambulation classification. These factors were used to develop the Hip Fracture Short-Term Ambulation Prediction, consisting of 2 models: Model 1 for postoperative ambulation and Model 2 for preinjury status recovery.

RESULTS

Among the 275 patients, 55 (20.0%) achieved good ambulation, and 59 (21.5%) returned to their preinjury status at 3 months. Age, preinjury ambulatory status, and discharge ambulatory status were identified as significant predictors of 3-month postoperative ambulation. The tool presented (Models 1 and 2) showed strong performance (area under the curve of 0.86 and 0.85, respectively) and good internal validity.

CONCLUSIONS

Age, preinjury ambulatory status, and discharge ambulatory status significantly predict postoperative ambulation and preinjury status recovery at 3 months after fragility hip fracture surgery. The tool presented may aid clinicians in identifying patients who could benefit from targeted rehabilitation interventions during this crucial period.

Trauma center rehabilitation systems in Latin America

Trauma is a leading cause of mortality and morbidity worldwide with high rates of disability in survivors. With improvements in care, rehabilitation of the trauma patient is a cornerstone to reducing sequelae. A lack of well-established hospital rehabilitation units and standardized protocols for managing posttraumatic injuries is a common problem in Latin American countries. Future studies should seek to understand the barriers and gaps in care so that consensus and ultimately best practice guidelines can be developed and included in rehabilitation programs throughout trauma centers in Latin America.

Gait dynamic stability evaluation in patients undergoing hip joint fractures - tools to measure rehabilitation effectiveness

A hip joint fracture includes a break in the thigh (femur) or coxa bone near the pelvis. During fracture healing, stability and weight bearing by the affected limb are key indicators to measure patients' improvement. Conventionally, the rehabilitation effectiveness is monitored through clinical examinations, patients' feedback, and few studies also reported instrumented gait evaluations. A gap remains there to numerically quantify the recovery in patients' stability and weight bearing in response to rehabilitation therapies. This study introduces Nyquist and Bode (N&B) methods to analyse the instrumented gait signals further and evaluate gait stability in hip fracture patients during weight loading and unloading transitions. The centre of pressure (CoP) data was recorded using force plates for conditions: coxa hip fracture (HC), femur hip fracture (HF), and normal hip joint (NH). The time rate of CoP signals illustrated two major impulses during the loading and unloading phases which were modelled in time and frequency domains. The frequency models were further analysed by applying N&B methods and stability margins were computed for both impaired and healthy conditions. Results illustrated a significant decrease (Kruskal-Wallis's test, p < 0.001) in the intralimb walking stability of both fracture conditions. Further, Spearman's correlation between CoP velocities of fractured and intact limbs illustrated significant interlimb dependencies to maintain walking stability (p < 0.001) during weight loading and unloading transitions. Overall, the HF impairment illustrated the least intralimb walking stability and relatively greater interlimb dependencies. Clinically, these methods and findings are important to measure the recovery in patients undergoing rehabilitation after a hip joint or other lower limb impairments.

Doctor, When Should I Start Walking? Revisiting Postoperative Rehabilitation and Weight-Bearing Protocols in Operatively Treated Acetabular Fractures: A Systematic Review and Meta-Analysis

Background and Objectives: Management of acetabular fractures is aimed at anatomically reducing and fixing all displaced or unstable fractures, as the accuracy of fracture reduction has been demonstrated to strongly correlate with clinical outcomes. However, there is a noticeable gap in the literature concerning the perioperative and postoperative care of patients with acetabular fractures, which ultimately can be potential risk factors for adverse outcomes and permanent disabilities. This study aimed to systematically review the available literature regarding rehabilitation practices, including weight-bearing protocols, across time points in surgically treated acetabular fracture patients and correlate these practices with functional outcomes. Methods: We systematically reviewed the Medline and PubMed databases and the Cochrane Central Register of Controlled Trials in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were studies with adult patients (19+ years), publications from the last 10 years, articles focusing on rehabilitation or mentioning any aspect related to rehabilitation (such as weight-bearing or muscle training), and describing the surgical management of acute, isolated acetabulum fractures. Specific information was collected, including the fracture classification, time to surgery, surgical approach, surgical time, blood loss, fixation strategy, quality of reduction, postoperative rehabilitation protocol, complication rate, type(s) of complication, and outcome measurement(s). The choice(s) of surgical approach, surgical time, blood loss, and fixation strategy were stratified based on the fracture classification. The complication rate and type(s) of complication were calculated for all studies. Fractures were classified based on the Letournel classification. Results: A total of 494 articles were identified from the initial search, of which 22 (1025 patients) were included in the final review. The most common rehabilitation protocol favored isometric quadriceps and abductor strengthening exercises starting on the first postoperative day, with passive hip movement at 1-3 days postoperatively and active hip movement ranging from the first postoperative day to 4 weeks postoperatively. Partial weight-bearing with a walker or a pair of crutches was permitted from 1 to 12 weeks after surgery, and full weight-bearing was allowed depending on the patient's general condition and fracture healing state (generally at the end of 3 months). In only three studies did the patients start bearing weight in the early postoperative period (≤1 week). Meta-regression analysis was not performed due to the discrepancy between studies that reported a weight-bearing protocol ≤1 week and >1 week postoperatively. Conclusions: Our study suggests that an accelerated postoperative rehabilitation protocol, including early permissive weight-bearing, does not appear to increase the risk of loss of reduction or the rate of complications after surgical treatment of acetabular fractures. However, a proper meta-analysis was not possible, and the heterogeneity of the included studies did not allow us to conclude anything about the potential biomechanical and clinical benefits nor the negative effects related to this rehabilitation regimen in terms of functional results. There is an inconsistent use of PROMs for objectively calculating the effect size of the accelerated protocol compared with restricted weight-bearing regimes. We pose the need for higher-level evidence to proof our hypothesis.

Does post acute care reduce the mortality of octogenarian and nonagenarian patients undergoing hip fracture surgery?

BACKGROUND

With the increasing number of elderly individuals worldwide, a greater number of people aged 80 years and older sustain fragility fracture due to osteopenia and osteoporosis.

METHODS

This retrospective study included 158 older adults, with a median age of 85 (range: 80-99) years, who sustained hip fragility fracture and who underwent surgery. The patients were divided into two groups, one including patients who joined the post-acute care (PAC) program after surgery and another comprising patients who did not. The mortality, complication, comorbidity, re-fracture, secondary fracture, and readmission rates and functional status (based on the Barthel index score, numerical rating scale score, and Harris Hip Scale score) between the two groups were compared.

RESULTS

The patients who presented with fragility hip fracture and who joined the PAC rehabilitation program after the surgery had a lower rate of mortality, readmission rate, fracture (re-fracture and secondary fracture), and complications associated with fragility fracture, such as urinary tract infection, cerebrovascular accident, and pneumonia (acute coronary syndrome, out-of-hospital cardiac arrest, or in-hospital cardiac arrest.

CONCLUSIONS

PAC is associated with a lower rate of mortality and complications such as urinary tract infection, bed sore, and pneumonia in octogenarian and nonagenarian patients with hip fragility fracture.

Perioperative mental health intervention for depression and anxiety symptoms in older adults study protocol: design and methods for three linked randomised controlled trials

INTRODUCTION

Preoperative anxiety and depression symptoms among older surgical patients are associated with poor postoperative outcomes, yet evidence-based interventions for anxiety and depression have not been applied within this setting. We present a protocol for randomised controlled trials (RCTs) in three surgical cohorts: cardiac, oncological and orthopaedic, investigating whether a perioperative mental health intervention, with psychological and pharmacological components, reduces perioperative symptoms of depression and anxiety in older surgical patients.

METHODS AND ANALYSIS

Adults ≥60 years undergoing cardiac, orthopaedic or oncological surgery will be enrolled in one of three-linked type 1 hybrid effectiveness/implementation RCTs that will be conducted in tandem with similar methods. In each trial, 100 participants will be randomised to a remotely delivered perioperative behavioural treatment incorporating principles of behavioural activation, compassion and care coordination, and medication optimisation, or enhanced usual care with mental health-related resources for this population. The primary outcome is change in depression and anxiety symptoms assessed with the Patient Health Questionnaire-Anxiety Depression Scale from baseline to 3 months post surgery. Other outcomes include quality of life, delirium, length of stay, falls, rehospitalisation, pain and implementation outcomes, including study and intervention reach, acceptability, feasibility and appropriateness, and patient experience with the intervention.

ETHICS AND DISSEMINATION

The trials have received ethics approval from the Washington University School of Medicine Institutional Review Board. Informed consent is required for participation in the trials. The results will be submitted for publication in peer-reviewed journals, presented at clinical research conferences and disseminated via the Center for Perioperative Mental Health website.

TRIAL REGISTRATION NUMBERS

NCT05575128, NCT05685511, NCT05697835, pre-results.

Hip Abductor Muscle Strength Recovery: A Comparison Between Joint Replacement Surgery and Internal Fixation Surgery

Introduction Proximal femoral fractures are common fractures of the hip that are considered a major healthcare concern globally; these include subtrochanteric, intertrochanteric, and the neck of the femur fractures. Internal fixation surgery and joint replacement surgery are the two most common intervention techniques used to treat these fractures. Consequently, weakness in the hip abductor muscle post-surgery may lead to implant loosening, necessitating revision of the surgery. In light of this, this study aimed to compare hip abductor strength recovery outcomes between joint replacement surgery and internal fixation surgery. Methodology A comparative study was performed over six months at the Department of Orthopaedics and Physiotherapy. Based on the inclusion and exclusion criteria and anticipating potential dropouts, a total of 56 patients were included in the study, and their hip abductor strength was measured using a sphygmomanometer. The patients were classified into two groups: Group A or Group B as per the type of hip surgery. Group A included 29 patients who underwent joint replacement surgeries involving either cemented or uncemented total hip arthroplasty (THA) or hip hemiarthroplasty (HHA). Group B comprised 27 patients who were operated on using either proximal femoral nail (PFN) or dynamic hip screw (DHS). Results The cohort consisted of 36 males and 20 females, with a mean age of 51.71 years. The overall mean value of hip abductor muscle strength at postoperative day (POD) three in the internal fixation group was 65.06 ±5.98, which progressed to 107.51 ±24.76 after six months; in the joint replacement surgery group, it was 70.03 ±12.46 at POD three, which progressed to 113.11 ±21.27 after six months. The age-wise distribution demonstrated that the patients in the age group of 18-50 years demonstrated progressive results: from 65.33 ±4.9 at POD three to 105.95 ±22.71 after six months in the internal fixation group; from 66.82 ±7.72 at POD three to 109.59 ±22.54 after six months in the joint replacement group. Moreover, patients aged above 50 years showed progression from 64.80 ±6.98 at POD three to 103.33 ±27.30 after six months in the internal fixation group, and from 69.58 ±14.75 at POD three to 108.22 ±20.62 after six months in the joint replacement group. Conclusions Our findings revealed that joint replacement surgery resulted in greater improvements in the hip abductor muscle strength compared to internal fixation surgery in the immediate postoperative period and during follow-ups. Additionally, younger patients exhibited better strength-related outcomes in comparison to the elderly population regardless of the type of surgery.

Factors associated with concerns about falling and activity restriction in older adults after hip fracture: a mixed-methods systematic review

PURPOSE

To investigate factors contributing to concerns about falling and activity restriction in the community among older adults who had a hip fracture.

METHODS

A mixed method systematic review with a convergent segregated approach. We searched Medline, Embase, PsycInfo, PEDRo, CINAHL and the Cochrane library. Results were synthesised narratively considering physical, psychological, environmental, care, and social factors and presented in tables. Critical appraisal was completed in duplicate.

RESULTS

We included 19 studies (9 qualitative, 9 observational, 1 mixed methods) representing 1480 individuals and 23 factors related to concerns about falling and activity restriction. Physical factors included falls history, comorbidities, balance, strength, mobility and functionality. Psychological factors included anxiety and neuroticism scores, perceived confidence in/control over rehabilitation and abilities, and negative/positive affect about the orthopaedic trauma, pre-fracture abilities and future needs. Environmental factors included accessibility in the home, outdoors and with transport. Social and care factors related to the presence or absence of formal and informal networks, which reduced concerns and promoted activity by providing feedback, advice, encouragement, and practical support.

CONCLUSION

These findings highlight that to improve concerns about falling and activity restriction after hip fracture, it is important to: improve physical and functional abilities; boost self-confidence; promote positive affect; involve relatives and carers; increase access to clinicians, and; enhance accessibility of the home, outdoors and transport. Most factors were reported on by a small number of studies of varying quality and require replication in future research.

Early hip fracture surgery and rehabilitation. How to improve functional quality outcomes. A retrospective study

INTRODUCTION

Hip fractures are one of the major disability causes associated with a high morbidity and mortality rate. Early surgery and stable fixation could be associated with better pain control, possibly lower mortality rates, and early recovery of autonomy.

Effect of a Multicomponent Intervention with Tele-Rehabilitation and the Vivifrail© Exercise Programme on Functional Capacity after Hip Fracture: Study Protocol for the ActiveFLS Randomized Controlled Trial

INTRODUCTION

Hip fractures are the most common fracture leading to hospitalization and are associated with high costs, mortality rates and functional decline. Although several guidelines exist for preventing new fractures and promoting functional recovery, they tend to focus on osteoporosis treatment and do not take into account the complexity of frailty in older adults and geriatric syndromes, which are important factors in individuals at risk of suffering from frailty fractures. Moreover, most health systems are fragmented and are incapable of providing appropriate management for frail and vulnerable individuals who are at risk of experiencing fragility fractures. Multicomponent interventions and physical exercise using tele-rehabilitation could play a role in the management of hip fracture recovery. However, the effectiveness of exercise prescription and its combination with a comprehensive geriatric assessment (CGA) is still unclear.

METHODS

This randomized clinical trial will be conducted at the Hospital Universitario de Navarra (Pamplona, Spain). A total of 174 older adults who have suffered a hip fracture and fulfil the criteria for inclusion will be randomly allocated to either the intervention group or the control group. The intervention group will receive a multicomponent intervention consisting of individualized home-based exercise using the @ctive hip app for three months, followed by nine months of exercise using Vivifrail. Additionally, the intervention group will receive nutrition intervention, osteoporosis treatment, polypharmacy adjustment and evaluation of patient mood, cognitive impairment and fear of falling. The control group will receive standard outpatient care according to local guidelines. This research aims to evaluate the impact of the intervention on primary outcome measures, which include changes in functional status during the study period based on the Short Physical Performance Battery.

DISCUSSION

The findings of this study will offer valuable insights into the efficacy of a comprehensive approach that considers the complexity of frailty in older adults and geriatric syndromes, which are important factors in individuals at risk of suffering from frailty fractures. This study's findings will contribute to the creation of more effective strategies tailored to the requirements of these at-risk groups.

From Conservative Measures to Surgical Interventions, Treatment Approaches for Cubital Tunnel Syndrome: A Comprehensive Review

Cubital tunnel syndrome (CuTS) is a neuropathic condition characterized by the compression or irritation of the ulnar nerve at the elbow, resulting in a wide spectrum of symptoms ranging from pain and numbness to muscle weakness and impaired hand function. This comprehensive review delves into the diverse landscape of CuTS treatment approaches, emphasizing the importance of early intervention. The review explores how these strategies aim to alleviate symptoms and enhance patient well-being by beginning with conservative measures encompassing rest, splinting, medications, physical therapy, and lifestyle adjustments. Non-surgical medical interventions, including nerve gliding exercises, ultrasound-guided nerve injections, and orthotic devices, are considered alternative therapies for symptom relief. Surgical interventions, such as decompression procedures and emerging techniques, are discussed in detail, highlighting their indications and expected outcomes. Throughout this review, the critical role of patient-centered care is underscored, emphasizing the need for tailored treatment plans that respect individual preferences and goals. Recognizing the unique nature of each CuTS case, shared decision-making between patients and healthcare providers is advocated, ensuring that interventions align with specific patient needs. As research advances, promising developments in diagnosis, surgical techniques, and drug therapies offer hope for more effective management of CuTS, paving the way for improved symptom relief and enhanced nerve function.

Dementia and Hip Fractures: A Comprehensive Review of Management Approaches

» The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.» Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.» Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.» Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.» Coordination of care within a "orthogeriatric" team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.

Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures

PURPOSE OF REVIEW

The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities.

RECENT FINDINGS

There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.

A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review

INTRODUCTION

Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand.

METHODS

A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel.

RESULTS

Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan.

CONCLUSION

We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.

Does early post-operative exercise influence bone healing kinetics? Preclinical evaluation of non-critical sized femur defect healing

Physical exercise is a well-known modality for maintaining healthy locomotor mechanism. A detailed preclinical research on physical exercise effect on bone healing kinetics could help to improve the rehabilitation process after fracture treatment and bone remodeling. Our aim was to evaluate the effect of early post-operative exercise effect on bone microstructural changes in a rat model. Twenty Sprague Dawley male rats underwent bi-cortical 1.6 mm hole drilling in both femur diaphysis, after which (n = 10) underwent continuous treadmill training (TR) over two weeks, while the other group of rats (n = 10) was assigned to non-training (NT) control group. New bone formation labeling was performed by subcutaneous fluorochrome injections at day 5, 14 and 31. In vivo micro-computed tomography (μCT) scans were performed once a week during the 6-week post-operative period. Ten animals (five from each group) were euthanized at 3rd week while remaining animals were euthanized at 6th week. Femur samples were extracted and underwent ex vivo μCT and histological evaluation, while serum was used for evaluating alkaline phosphatase (ALP). μCT data demonstrated increased volume and surface of newly formed bone in defect area of TR group. Bone volume/Tissue volume (BV/TV) ratio and number of osteocytes showed an increase in TR group after 3-week period. Fluorochrome distances were increased between day 5 and 14 within the training group. Serum ALP level increased in both groups over 3- and 6-weeks. Post-operative exercise increases the bone healing kinetics and stimulates the new bone formation during and after the training protocol has ended.

Ambulation Distance Within 72 Hours after Surgical Management Is a Predictor of 90-Day Ambulatory Capacity in Elderly Patients with Hip Fracture

INTRODUCTION

The inability to mobilize after surgical intervention for hip fractures in the elderly is established as a risk factor for greater morbidity and mortality. Previous studies have evaluated the association between the timing and distance of ambulation in the postoperative acute care phase with postoperative complications. The purpose of this study was to evaluate the association between ambulatory distance in the acute postoperative setting and ambulatory capacity at 3 months.

METHODS

Patients aged 65 and older who were ambulatory at baseline and underwent surgical intervention for hip fractures from 2014 to 2019 were retrospectively reviewed. Consistent with previous literature, patients were divided into two groups: those who were able to ambulate 5 feet within 72 hours after surgical fixation (early ambulatory) and those who were not (minimally ambulatory).

RESULTS

One hundred seventy patients (84 early ambulatory and 86 minimally ambulatory) were available for analysis. Using a multivariable ordinal logistic regression model, variables found to be statistically significant predictors of ambulatory status at 3 months were the ability to ambulate five feet in 72 hours (P < 0.0001), ambulatory distance at discharge (P = 0.012), and time from presentation to surgery (P = 0.039). Patients who were able to ambulate 5 feet within 72 hours had 9 times the odds of being independent ambulators rather than a lower ambulatory class (cane, walker, and nonambulatory). Pertrochanteric fractures were less likely than femoral neck fractures to independently ambulate at 3 months (17.2% vs. 42.3%; P = 0.0006).

DISCUSSION

Ambulating 5 feet within 72 hours after hip fracture surgery is associated with an increased likelihood of independent ambulation at 3 months postoperatively. This simple and clear goal may be used to help enhance postoperative mobility and independence while providing a metric to guide therapy and help counsel patients and families.

Hip Fracture Care during COVID-19: Evolution through the Pandemic

INTRODUCTION

The purpose of this epidemiologic study was to analyze the care provided by our institution to middle-aged and geriatric hip fracture patients throughout the pandemic to examine for any differences compared to pre-pandemic care and across the pandemic stages.

METHODS

Consecutive patients >55 years old treated for hip fractures at our institution between October 2014 and January 2022 were analyzed for demographics, coronavirus disease 2019 (COVID-19) and vaccination status at admission, injury characteristics, hospital quality measures, and outcomes. Patients were divided into three separate cohorts: Pre-COVID-19 (PRECOV), COVID-19 Pre-Vaccine (PREVAX), and COVID-19 Post-Vaccine (POSTVAX). A sub-analysis removed COVID-19-positive patients across the study period. Comparative analyses were conducted.

RESULTS

A total of 2,633 hip fracture patients were included. For the overall cohort, there was no difference in the rate of inpatient deaths between the PRECOV, PREVAX, and POSTVAX cohorts (p=0.278). PRECOV had a significantly lower 30-day mortality rate compared to PREVAX or POSTVAX (p=0.012). Differences in complication rates for surgical site infection, urinary tract infection, and anemia (p<0.01 for all) were seen between cohorts. PRECOV had the longest length of hospital stay (p<0.01). PREVAX patients required more ICU level of care (p<0.01). When removing COVID-19-positive patients, all three cohorts had similar inpatient (p=0.872) and 30-day mortality rates (p=0.130).

CONCLUSION

The care of patients treated for hip fractures did not change throughout the pandemic at our institution. The elevated mortality rate due to the effects of COVID-19 seen in the pre-vaccine cohort decreased over time as the understanding of COVID-19 improved and the vaccine was introduced. We recommend continuation of the same hip fracture care protocols as used pre-pandemic.

Health Professionals can Sustain Proficiency in Motivational Interviewing With a Moderate Amount of Training: An Intervention Fidelity Study

INTRODUCTION

Motivational interviewing (MI) proficiency may erode quickly, limiting its effectiveness. We examined whether health professionals completing a 2-day workshop, with 3 to 5 hours of personalized coaching, and twice-yearly group reflections sustained proficiency for the duration of a hip fracture rehabilitation trial and whether intervention was implemented as intended.

METHODS

A fidelity study was completed as part of a process evaluation of the trial that tested whether physical activity increased among hip fracture patients randomly allocated to receive MI (experimental) compared with dietary advice (control) over ten 30-minute sessions. Twelve health professionals (none were proficient in MI before trial commencement) delivered the intervention for up to 952 days. Two hundred experimental sessions (24% of all sessions, 83 patients) were randomly selected to evaluate proficiency using the MI Treatment Integrity scale; along with 20 control sessions delivered by four dietitians. Linear mixed-effects regression analyses determined whether proficiency was sustained over time. Dose was assessed from all experimental sessions ( n = 840, 98 patients).

RESULTS

Intervention was implemented as intended; 82% of patients received at least eight 30-minute sessions. All motivational interviewers were proficient, whereas dietitians did not inadvertently deliver MI. Time had no effect on MI proficiency (est < 0.001/d, P = .913, 95% CI, -0.001 to 0.001).

DISCUSSION

MI proficiency was sustained in a large trial over 2.6 years by completing a 2-day workshop, 3 to 5 hours of personalized coaching, and twice-yearly group reflections, even for those without previous experience; further research needs to establish the maximum duration of training effectiveness.

A systematic review of fear of falling and related constructs after hip fracture: prevalence, measurement, associations with physical function, and interventions

BACKGROUND

Hip fracture is a common and debilitating injury amongst older adults. Fear of falling (FoF) and related constructs (balance confidence and falls efficacy) may impede rehabilitation after hip fracture. An updated systematic review to synthesize existing literature on FoF after hip fracture is needed. This review focussed on four research questions: In the hip fracture population: (1) What is the prevalence of FoF?; (2) What FoF assessment tools are validated? (3) What is the relationship between FoF and physical function?; (4) What interventions are effective for reducing FoF?

METHODS

A systematic search was undertaken in EBSCO Health, Scopus and PsychINFO in January 2021 (and updated December 2022) for articles on FoF after hip fracture. Data in relation to each research question was extracted and analysed. The quality of the studies was appraised using the 'Risk of Bias Tool for Prevalence Studies', 'COSMIN Risk of Bias checklist for Patient-reported outcome measures', modified version of the 'Appraisal Tool for Cross-sectional studies', and the 'Cochrane Risk of Bias 2' tools for each research question, respectively.

RESULTS

36 studies (37 articles) with 5099 participants were included (mean age 80.2 years and average 78% female). Prevalence rates for FoF after hip fracture ranged between 22.5% and 100%, and prevalence tended to decrease as time progressed post hip fracture. The 'Falls Efficacy Scale - International' (FES-I) and 'Fear of Falling Questionnaire - Revised' (FFQ-R) were found to be reliable, internally consistent, and valid tools in hip fracture patients. FoF after hip fracture was consistently associated with measures of physical function including balance, gait speed, composite physical performance measures and self-reported function. Ten of 14 intervention studies were considered high risk of bias. Exercise-based interventions with or without a psychological component were not effective in reducing FoF after hip fracture compared to a control condition.

CONCLUSION

FoF is prevalent after hip fracture and is consistently associated with poorer physical function. Only two instruments (FES-I and FFQ-R) have been validated for measuring FoF in the hip fracture population. However, there remains a need for larger, higher quality randomised controlled trials targeting FoF after hip fracture in order to guide clinical practice.

TRIAL REGISTRATION

PROSPERO registration: CRD42020221836.

[Result of the update of the clinical pathway for hip fracture in the elderly at a university hospital in Madrid]

BACKGROUND AND OBJECTIVES

Orthogeriatric management with clinical pathways (CP) in hip fracture (HF) has been shown to be superior to other models. We studied whether updating the CP, through prioritization of admission and surgery, improvement in the prevention and treatment of delirium, management of anticoagulants and antiplatelet agents and the use of perioperative peripheral nerve block, modifies surgical delay, stay, readmissions, mortality, suffering delirium and functional status at discharge.

MATERIAL AND METHOD

A retrospective observational study of unicenter cohorts of 468 patients with HF, 220 from 2016 (old VC) and 248 from 2019 (new VC). The variables are: intervention in the first 48hours, surgical delay (hours), stay (days), stay less than 15 days, delirium, functional loss at discharge (Barthel prefracture scale less Barthel scale at discharge), readmission at one month, and mortality at admission, month and year.

RESULTS

Median age: 87.0 [interquartile range 8.0], mostly women (76.7%). Significantly, with the new VC, there was a greater number of patients operated on in the first 48hours (27,7% vs 36,8% p=0.036), less surgical delay (72.5 [47,5-110,5] vs 64.0 [42,0-88,0] p<0.001), shorter stay (10,0 [7,0-13,0] vs 8,0 [6,0-11,0] p<0.001), greater number of discharges in 15 days (78,2% vs 91,5% p<0.001), lower delirium (54,1% vs 43,5% p=0.023). No significant changes in readmissions, functional loss at discharge, mortality at admission, 3 months or year.

CONCLUSIONS

Updating the VC brings benefits to the patient (less surgical delay, equal functional status at discharge with fewer days of admission) and benefits in management (lower admission) without modifying mortality.

Rehabilitation Outcomes Following Hip Fracture of Home-Based Exercise Interventions Using a Wearable Device-A Randomized Controlled Pilot and Feasibility Study

Although hip fractures are common and severe, there is insufficient evidence concerning which type of rehabilitation is most beneficial. The primary aim of this three-armed pilot study was to investigate any difference in outcome after hip fractures between and within groups in terms of balance, everyday activities, and health-related quality of life (HRQoL) following different home rehabilitation interventions. Further aims were to study feasibility and to suggest, if necessary, adjustments to the protocol for a future full randomized controlled trial (RCT). In total, 32 persons were included in this study. The intervention groups underwent the HIFE program with or without an inertial measurement unit, while the control group underwent standard rehabilitation. Within- and between-groups differences in outcomes and feasibility outcomes in terms of recruitment and retention rates were analyzed, and the ability to collect primary and secondary outcomes was assessed. Balance, measured as postural sway, showed no significant improvement in any group. All three groups improved in functional balance (p = 0.011-0.028), activity of daily living (p = 0.012-0.027), and in HRQoL (p = 0.017-0.028). There were no other significant changes within or between the groups. The recruitment rate was 46%, the retention rate was 75%, and the ability to collect outcome measures was 80% at baseline and 64% at follow-up. Based on the results, it is possible to, after adjusting the protocol, conduct a full RCT.

Post-fracture care program in Egypt: merging subsequent fracture prevention and improving patients’ outcomes—an initiative by the Egyptian Academy of Bone Health

Background

Despite the associated high prevalence of morbidity and mortality, osteoporotic fragility fractures remain underdiagnosed and undertreated. Furthermore, those who sustain a fragility fracture are at imminent risk of sustaining subsequent fractures. Post-fracture care (PFC) programs are systematic, coordinated care programs that recognize, evaluate, and manage older adults who sustained a fragility fracture with the goal of managing all the risk factors and preventing succeeding fractures.

Main text

This work was carried out to outline the PFC program adopted in Egypt and its applicability in standard clinical practice. A review of literature was conducted to identify an evidence-informed PFC strategies and protocols, which outlines the optimal manner to manage older adults living with fragility fractures. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist was used to guide the reporting of this review. Based on this, a PFC integrated model of care based on a patient-centered approach has been developed aiming to optimize the outcomes.

Conclusion

This manuscript described the integrated model of care adopted in Egypt to provide care for older adults presenting with fragility fractures. This will pave the way to standardize patient identification and management. Additionally, to prevent occurrence of subsequent fractures and to enhance equity of care for patients with fragility fracture and osteoporosis, expansion of such service to rural and remote areas is highly recommended.

Effect of distal interlocking of a cephalomedullary femoral nail on peri-implant fractures: A sawbone biomechanical analysis

BACKGROUND

A large proportion of hip fractures involve inter-trochanteric fractures which are managed by cephalomedullary nails. There is ongoing debate about the advantages and disadvantages of locked versus unlocked long cephalomedullary femoral nails in the treatment of intertrochanteric fractures. The objectives of our study are to evaluate the biomechanical effects of a distal interlocking bolt on the type of peri-implant fractures in a healed intertrochanteric fracture with long cephalomedullary nail fixation.

METHODS

20 femoral sawbone specimens were prepared with the TFN-ADVANCED Proximal Femoral Nailing System (TFNA) and divided into 2 groups: locked and unlocked. The specimens were subjected to axial loading force until failure. Compressive forces, strain and fracture patterns were compared between the 2 groups.

RESULTS

There was no significant difference in the mean load to failure of the unlocked specimens compared to locked specimens. However, there was significant difference in the mean compressive stress at the time of failure with the unlocked specimen (1.79±0.17 MPa) compared to the locked group (1.92±0.05 MPa) (p < 0.05). Video review analysis showed unlocked specimens consistently having basi-cervical type peri-implant fractures while locked specimens showed complex, compound fractures of the head-neck region with 2 or more fracture propagation points.

CONCLUSION

Distal-locked long cephalomedullary nails in a healed intertrochanteric fracture model are able to tolerate higher compressive stress at the point of failure but demonstrate more complex peri-implant fracture patterns in the femoral head-neck region as compared to unlocked specimens.

Gently steering - the mechanism of how motivational interviewing supported walking after hip fracture: A qualitative study

Objective

To explore how older adults perceive motivational interviewing influences their walking and physical activity after hip fracture.

Methods

Qualitative study using an interpretive description framework. Twenty-four participants aged ≥65 years living in the community after hip fracture were interviewed. Participants had received at least 8 sessions of motivational interviewing via telephone. Semi-structured interviews were transcribed verbatim and coded inductively by two researchers independently. All authors discussed findings and themes observed through the researchers' lens and mapped them to the Medical Research Council's framework for process evaluation.

Results

Motivational interviewing was described as a nuanced and subtle intervention that guided participants through their journey of recovery. Three themes described possible mechanisms of how motivational interviewing might work: connection, checking in and confidence. In the context of recovering from hip fracture psychologically and physically, a strong connection with clinicians, along with weekly checking in, were perceived to build participants' confidence to walk after hip fracture.

Conclusion

This study provided insight on participant perceptions of how motivational interviewing might work to support walking after hip fracture.

Innovation

The addition of motivational interviewing to rehabilitation is a novel way of building confidence to walk for people recovering from hip fracture.

Rehabilitation Towards Functional Independence in a Patient With Intertrochanteric Fracture and Paraplegia: A Case Report

Traumatic spinal cord injury (SCI) causes significant neurological deficits that adversely affect the quality of life of patients and caregivers. Patients with SCI present with the symptoms of weakness and loss of sensations in the limbs. Motor deficits may occur in the form of paraplegia, hemiplegia, or quadriplegia. Patients remain immobilized for a prolonged period which may lead to complications like muscle wasting, atrophy, joint stiffness, contractures, bed sores, and osteoporosis. Patients are prone to fractures owing to osteoporosis. The fractures may occur even due to trivial trauma. Our case report presents the case of a 45-year-old male patient who is already diagnosed with paraplegia having a history of SCI one-and-a-half years ago. He has recent history of intertrochanteric (IT) fracture that occurs during the transfer from bed to wheelchair. Admitted to the hospital with a complaint of a popping sound along with low back pain. Further investigation and management were started.

Clinical Effectiveness of Home-Based Telerehabilitation Program for Geriatric Hip Fracture Following Total Hip Replacement

OBJECTIVE

To compare the effectiveness of a six-month home-based telerehabilitation based on the Internet-based rehabilitation management system coupled with conventional outpatient care in elderly patients with hip fractures following total hip replacement (THR).

METHODS

Elderly patients (aged over 65 years) with first hip fractures who underwent THR between March 2018 and September 2018 in Tianjin Hospital were enrolled in this study. Patients were divided into two groups: telerehabilitation group (n = 43) and telephone group (n = 42). A Internet-based telerehabilitation management system was established and applied on patients in the telerehabilitation group. For patients in the telephone group, the rehabilitation intervention was administered through conventional outpatient care (telephone along with outpatient follow-up). Data from the Harris hip scale (HHS), functional independence measure (FIM), self-rating anxiety scale (SAS), and postoperative complications at 1, 3, and 6 months after surgery were collected and compared between the two groups.

RESULTS

A total of 85 elderly patients completed the 6-month follow-up assessment. Results showed that the HHS score was significantly higher in the telerehabilitation group than in the telephone group at 1 month (66.35 ± 4.63 vs 63.48 ± 4.49), 3 months (76.33 ± 4.52 vs 71.81 ± 3.84), and 6 months (84.23 ± 3.13 vs 77.29 ± 4.95) after surgery (P < 0.001). The FIM score was significantly higher in the telerehabilitation group than in the telephone group at 1 month (89.00 ± 5.63 vs 73.35 ± 8.70), 3 months (100.16 ± 4.56 vs 92.81 ± 5.17), and 6 months (111.70 ± 3.13 vs 98.64 ± 5.12) after surgery (P < 0.001). The SAS score was significantly lower in the telerehabilitation group than in the telephone group at 1 month (42.40 ± 3.07 vs 46.21 ± 3.53), 3 months (36.77 ± 2.26 vs 40.24 ± 1.66), and 6 months (29.26 ± 1.63 vs 33.81 ± 2.62) after surgery (P < 0.001). The overall complication rate was significantly lower in the telerehabilitation group than in the telephone group (14% vs 40.5%) (P < 0.05).

CONCLUSION

Internet-based rehabilitation management system can not only promote the physical rehabilitation of patients, but also play a positive role in psychological rehabilitation and the prevention of complications, which provides new ideas and methods for clinical rehabilitation.

Impact of concomitant upper-extremity injuries in patients with hip fractures: a systematic review and meta-analysis

INTRODUCTION

Combined hip and upper-extremity fractures raise clinical concerns because upper-extremity fractures may hinder early mobilization, thereby affecting rehabilitation and mortality. This systematic review and meta-analysis aimed to evaluate the effects of combined upper-extremity and hip fractures on rehabilitation and mortality.

MATERIALS AND METHODS

We systematically searched MEDLINE, Embase, and the Cochrane Library for studies published before March 20, 2022, that evaluated the impact of concomitant upper-extremity injuries in geriatric patients with hip fractures. The pooled analysis identified differences in the (1) length of hospital stay, (2) discharge destination, and (3) mortality rates between the isolated and combined hip fracture groups.

RESULTS

A total of 217,233 patients with isolated hip fractures (n = 203,816) and combined hip and upper-extremity fractures (n = 13,417) from 12 studies were analyzed. The average length of hospital stay was significantly longer in the combined upper-extremity fracture group than in the isolated hip fracture group (mean difference = 1.67 days; 95% confidence interval [CI] 0.63-2.70; P = 0.002). Patients in the combined upper limb fracture group were less likely to be discharged directly home (odds ratio [OR] = 0.64; 95% CI 0.52-0.80; P < 0.001) and showed significantly higher 30-day mortality (OR = 1.44; 95% CI 1.32-1.58; P < 0.001). The mortality rate after 30 days was not significantly different between the two groups.

CONCLUSIONS

Concomitant upper-extremity fractures have debilitating effects on rehabilitation and early mortality in geriatric patients with hip fractures. Therefore, more focus should be placed on the early ambulation of patients with hip fractures and simultaneous upper limb fractures to promote rehabilitation and alleviate the public health burden.

LEVEL OF EVIDENCE

III meta-analysis.

The effect of CKD on intertrochanteric fracture treated with proximal femoral nail anti-rotation: A 7-year study

Background

Intertrochanteric fracture is one of the most burdensome osteoporotic fractures in the elderly. Chronic kidney disease is associated with sarcopenia, especially in its advanced stages and, thus may impact functional status. Combining an intertrochanteric fracture with advanced CKD may diminish results after surgical fixation. This study aims to distinguish whether CKD affects the result of intertrochanteric fracture fixation in terms of mechanical and functional outcomes.

Methods

A retrospective study reviews all intertrochanteric fractures treated with PFNA fixation from 2012 to 2018. 445 patients were classified into 5 stages of CKD and divided by eGFR = 90 ml/min/1.73 m² into CKD and non-CKD group and by eGFR = 30 ml/min/1.73 m² into advanced CKD and non-advanced CKD group. The primary outcome was one year Harris Hip Score (HHS). Secondary outcomes were medical complications, surgical complications, and a 1-year mortality rate.

Results

Harris Hip Scores (HHS) were not different between non-CKD and CKD groups (eGFR <90 mL/min/1.73 m²). However, there was a difference between non-advanced CKD and advanced CKD groups (eGFR <30 mL/min/1.73 m²) (p < 0.001). Medical complications were not different, except for sepsis in CKD stage 5 compared with stage 1 (p = 0.023). Even though AO/OTA types were more severe in the advanced CKD group, surgical complications and 1-year mortality were not different.

Conclusion

Advanced stage CKD treated with PFNA fixation is associated with lower functional outcomes at one year. Sepsis is more prone to occur after surgery in CKD stage 5.

Level of evidence

Level III; Retrospective cohort study.

Liposomal Bupivacaine Associated with Cost Savings during Postoperative Pain Management in Fragility Intertrochanteric Hip Fractures

BACKGROUND

Intertrochanteric hip fractures are among the most common and most expensive diagnoses in the Medicare population. Liposomal bupivacaine is a novel preparation of a commonly used analgesic agent that, when used intraoperatively, decreases narcotic requirements and hospital length of stay and increases the likelihood of discharge to home. The purpose of this investigation was to determine whether there was an economic benefit to utilizing intraoperative liposomal bupivacaine in patients with fragility intertrochanteric hip fractures in comparison to a group of patients who did not receive liposomal bupivacaine.

METHODS

This is a retrospective observational study performed at two academic medical centers. Fifty-six patients with intertrochanteric hip fractures treated with cephalomedullary nail implant who received standard hip fracture pain management protocol were compared to a cohort of 46 patients with intertrochanteric hip fractures who received additional intraoperative injections of liposomal bupivacaine. All other standards of care were identical. A cost analysis was completed including the cost of liposomal bupivacaine, operating room costs, and discharge destination. Statistical significance was set at p < 0.05.

RESULTS

Although the length of hospital stay was similar between the two groups (3.2 days vs. 3.8 days, p = 0.08), patients receiving intraoperative liposomal bupivacaine had a lower likelihood of discharge to a skilled nursing facility (84.8% vs. 96.4%, p = 0.002) and a longer operative time (73.4 minutes vs 67.2 minutes, p = 0.004). The cost-benefit analysis indicated that for an investment of $334.18 in the administration of 266 mg of liposomal bupivacaine, there was a relative saving of $1,323.21 compared to the control group. The benefit-cost ratio was 3.95, indicating a $3.95 benefit for each $1 spent in liposomal bupivacaine.

CONCLUSIONS

Despite the increased initial cost, intraoperative use of liposomal bupivacaine was found to be a cost-effective intervention due to the higher likelihood of discharge to home during the postoperative management of patients with intertrochanteric hip fractures.

Fraturas intracapsulares do colo femoral no idoso

Currently, intracapsular femoral neck fracture (IFNF) is still a great challenge for orthopedists. In spite of the progress that has been made, a high mortality rate persists in the first year, especially in Brazil, where there is no awareness that such fractures in elderly patients should be treated as a medical emergency. The present article seeks to provide an update on the preoperative, surgical, and postoperative approaches.

Sarcopenia and Its Association With Change of Bone Mineral Density and Functional Outcome in Old-Aged Hip Arthroplasty Patients

This study aimed to investigate the relationship between sarcopenia and change in bone mineral density (BMD) and functional outcome in hip arthroplasty patients. Methods: Among the 221 patients who had undergone hip arthroplasty, 147 patients were enrolled. All patients were divided into 2 groups according to presence of sarcopenia. Bone mineral density (BMD) at hospitalization and 1-year after surgery and Barthel index was measured at the time of before injury, hospitalization, 3 months and 1-year after surgery. Results: BMD at hospitalization showed .627 ± .082 (g/cm2) in Sarcopenia and .726 ± .059 (g/cm2) in Non-sarcopenia at femur (total) site (P < .001), .531 ± .085 (g/cm2) vs .629 ± .057 (g/cm2) at femur neck site (P=.002), .715 ± .084 (g/cm2) vs .807 ± .058 (g/cm2) at lumbar (L1-L4) site (P < .001). BMD at 1-year follow-up period, Sarcopenia showed .626 ± .082 (g/cm2) and Non-sarcopenia showed .725 ± .060 (g/cm2) at femur (total) site (P < .001), .530 ± .085 (g/cm2) vs .629 ± .058 (g/cm2) at femur neck site (P < .001), .715 ± .084 (g/cm2) vs .806 ± .058 (g/cm2) at lumbar (L1-L4) site (P < .001). Change of BMD showed −.01 ± .25% for Sarcopenia and −.15 ± .47% for Non-sarcopenia in femur (total) site (P=.089), −.08 ± .63% vs −.01 ± 1.01% in femur neck site (P = .058), .00 ± .09% vs −.12 ± .33% for each group in lumbar (L1-L4) site (P = .052). Barthel index score showed 79.94 ± 5.66 for Sarcopenia and 84.74 ± 5.36 for Non-sarcopenia at pre-injury status (P < .001), 33.89 ± 4.94 vs 33.87 ± 5.36 at the time of hospitalization (P = .977), 57.42 ± 7.19 vs 60.06 ± 5.39 at 3 months follow up (P = .015), 73.86 ± 5.94 vs 80.71 ± 4.81 for each group at 1-year follow up (P < .001). Conclusions: Our study found that the sarcopenia showed lower BMD than the non-sarcopenia, but there was no significant difference of BMD change in the follow-up period. In addition, the sarcopenia showed poor functional results at all points except at the time of hospitalization.

Early Postoperative Rehabilitation Using the Hybrid Assistive Limb (HAL) Lumbar Type in Patients With Hip Fracture: A Pilot Study

Objective: To extend life expectancy after surgery, patients with hip fractures need to improve their mobility quickly through postoperative rehabilitation. Voluntary hip joint motion supported by the hybrid assistive limb (HAL) lumbar type, an exoskeleton robot suit characterized by its ability to detect the wearer’s intentions through the bioelectrical signals and assist hip extension motions at an optimal timing, may be effective to improve mobility in patients with hip joint dysfunction after surgery. We aimed to introduce rehabilitation using the HAL lumbar type in the early period after hip fracture surgery.

Methods: Patients who underwent internal fixation for hip fracture at a single institution were prospectively enrolled. They received early postoperative rehabilitation (forward and backward bending of the lumbar spine, pelvic tilt forward and backward, standing up, and squatting) using the HAL lumbar type (six times a week for 15 min per session). Five-times-sit-to-stand (FTSS) and timed-up-and-go (TUG) tests were conducted at baseline before HAL rehabilitation (pre-HAL) and after the HAL rehabilitation (post-HAL) intervention.

Results: We enrolled 14 patients (one man, 13 women) in this study. There were no adverse events, and all patients were able to complete the entire rehabilitation program. Post-HAL FTSS showed significant improvement compared with pre-HAL and had a large effect size of 1.81 (95% CI = 0.93 to 2.66) and sufficient power.

Conclusions: Robotic rehabilitation with HAL lumbar type could be introduced without adverse events, even in the early postoperative period following surgery for hip fracture. Further study is needed to develop an appropriate rehabilitation protocol using the HAL lumbar type.

Sex Differences in Recovery Across Multiple Domains Among Older Adults With Hip Fracture

BACKGROUND

Hip fractures are a public health problem among older adults, but most research on recovery after hip fracture has been limited to females. With growing numbers of hip fractures among males, it is important to determine how recovery outcomes may differ between the sexes.

METHODS

168 males and 171 females were enrolled within 15 days of hospitalization with follow-up visits at 2, 6, and 12 months postadmission to assess changes in disability, physical performance, cognition, depressive symptoms, body composition, and strength, and all-cause mortality. Generalized estimating equations examined whether males and females followed identical outcome recovery assessed by the change in each outcome.

RESULTS

The mean age at fracture was similar for males (80.4) and females (81.4), and males had more comorbidities (2.5 vs 1.6) than females. Males were significantly more likely to die over 12 months (hazard ratio 2.89, 95% confidence interval: 1.56-5.34). Changes in outcomes were significantly different between males and females for disability, gait speed, and depressive symptoms (p < .05). Both sexes improved from baseline to 6 months for these measures, but only males continued to improve between 6 and 12 months. There were baseline differences for most body composition measures and strength; however, there were no significant differences in change by sex.

CONCLUSIONS

Findings confirm that males have higher mortality but suggest that male survivors have continued functional recovery over the 12 months compared to females. Research is needed to determine the underlying causes of these sex differences for developing future prognostic information and rehabilitative interventions.

Blood transfusion practices affect CD4+ CD25+ FOXP3+ regulatory T cells/T helper-17 cells and the clinical outcome of geriatric patients with hip fracture

Hip fracture (HF) is common among older individuals and associated with high mortality, poor vitality and functional impairment. HF patients suffer whole body immunological changes and that lead to severe consequences, including immobilization, physical impairment and a high risk of complications. The objective of this study was to decipher the pattern of dynamic immunological changes, especially in two major T cell subsets, CD4⁺ CD25⁺ FOXP3⁺ regulatory T (Treg) cells and T helper-17 (Th17) cells, and their balance, during the hospital stay and to observe whether blood transfusion could influence these cells and clinical patietns' prognosis. In this study, ninety-eight consecutive HF patients were initially enrolled, and finally fifty-one patients qualified for the study, and correlation analysis of their clinical parameters was carried out to predict the meaning of their distribution in clinical practice. Our results showed that the frequency of Tregs gradually decreased, while the frequency of Th17 cells slowly increased in HF patients who received blood transfusion. The Treg frequency was inversely correlated with the level of hemoglobin (Hb), and Th17 cell frequency was positively related to fluctuations in Hb levels in HF patients after trauma. HF patients with a better prognosis and survival time showed decreased a Treg frequency and a decreased Treg/Th17 ratio. Transfusion helped reverse the imbalance in the frequencies of Tregs and Th17 cells and the Treg/Th17 ratio and especially contributed to a better outcome in HF patients with moderate-to-severe anemia. In conclusion, a higher frequency of peripheral blood Tregs and a higher Treg/Th17 ratio may be associated with unfavorable outcomes in HF patients, and blood transfusion may benefit moderate-to-severe HF patients rebalance their immune response.

Can the exercise-based and occupational therapy improve the posture, strength, and mobility in elderly Greek subjects with hip fracture? A non-randomized control trial

Objectives

The effects of a rehabilitation program on static balance, mobility, and strength of lower limbs in elderly fallers operated after a hip fracture and non-operated were studied.

Methods

Ninety-one elderly (>65 years) were divided in two groups, the Operated Group (OG, 43 fallers) and the Non-Operated Group (NOG, 48 fallers). Posture during bipedal stance (30s), mobility (Up-and-Go, Falls Efficacy Scale, Berg Balance Scale) and isokinetic strength of several muscular groups in both limbs were evaluated before and after a rehabilitation intervention, consisting in 20 sessions (3 sessions/week) including kinesiotherapy and occupational therapy.

Results

After intervention, the average velocity of Center of Pressure displacement decreased significantly for OG and NOG (p<0.005). Similarly, all other variables describing static balance, mobility (p<0.05) and isokinetic strength (p<0.005) were improved significantly for both groups.

Conclusions

The applied intervention led to improvement in static balance, mobility, and strength of lower limbs after hip fracture. Physical and Rehabilitation Medicine physicians should prescribe evidence-based rehabilitation protocols in elderly fallers because they could show just as remarkable improvements as non-operated patients when the program is carefully designed.

Biomechanics of periprosthetic femur fractures and early weightbearing

PURPOSE

The incidence of periprosthetic fractures is expected to rise increase by 4.6% every 10 years between 2015 and 2060. There are few large series examining optimal fixation constructs or the influence of early ambulation on outcome. The purpose of this narrative review is to investigate the published biomechanical considerations for periprosthetic fracture fixation, with specific consideration of early postoperative weightbearing.

METHODS

A literature review was performed to identify fracture incidences, etiology, and current trends in weightbearing after fixation. Benefits of early weightbearing, current constructs, and biomechanics are reviewed.

RESULTS

The limited data available support medical benefits and increased union rates with early mobilization. Optimal fixation constructs are not agreed upon, but mechanical studies suggest that dual implant constructs can support physiologic weightbearing loads.

CONCLUSION

Further clinical trials are required to investigate fracture union and hardware complications in dual implant construct.