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Chan JZ, Ramason R, Kwek EBK, Chua THI. Can bundled payment improve an established leading hip fracture programme? Singapore Med J 2024:00077293-990000000-00079. [PMID: 38213000 DOI: 10.4103/singaporemedj.smj-2022-033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 09/03/2022] [Indexed: 01/13/2024]
Affiliation(s)
- Juen Zhik Chan
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | - Rani Ramason
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore
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Huyke-Hernández FA, Only AJ, Sorich M, Onizuka N, Switzer JA, Cunningham BP. Outcomes After Revision Fixation With Cement Augmentation for Failed Intertrochanteric Fracture Fixation in Older Adult Patients. Geriatr Orthop Surg Rehabil 2022; 13:21514593221135480. [PMID: 36310893 PMCID: PMC9608033 DOI: 10.1177/21514593221135480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 09/17/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Intertrochanteric (IT) fractures that fail fixation are traditionally treated with arthroplasty, introducing significant risk of morbidity and mortality in frail older adult patients. Revision fixation with cement augmentation is a relatively novel technique that has been reported in several small scale international studies. Here we report a clinical series of 22 patients that underwent revision fixation with cement augmentation for IT fracture fixation failure. Methods This retrospective case series identified all patients that underwent revision intramedullary nailing from 2018 to 2021 at two institutions within a large metropolitan healthcare system. Demographics, injury characteristics, Charlson Comorbidity Index score, and surgical characteristics were extracted from the electronic medical record. Outcomes were extracted from the electronic medical record and included radiographic findings, pain, functional outcomes, complications, and mortality. Results Average follow-up after revision surgery was 15.2 ± 10.6 months. Twenty patients (90.9%) reported improved pain and achieved union or progressive healing after surgery. Most of these patients regained some degree of independent ambulation (19 patients, 86.4%), with only 5 patients (22.7%) requiring increased assistance for their activities of daily living (ADLs). One-year mortality was 13.6% (3 patients). Of the 5 patients (22.7%) that experienced complications, 2 patients (9.1%) required revision hemiarthroplasty for subsequent fixation failure. The other 3 patients did well when complications resolved. Conclusions Revision fixation with cement augmentation can be an effective, safe, cost-effective alternative to arthroplasty for the management of cases involving non-infected failed IT fracture fixation with implant cut-out or cut-through limited to the femoral head in older adult patients that have appropriate acetabular bone stock.
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Affiliation(s)
- Fernando A. Huyke-Hernández
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA,Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA
| | - Arthur J. Only
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA,Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA
| | - Megan Sorich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Naoko Onizuka
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA,Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Julie A. Switzer
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA,Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Brian P. Cunningham
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA,Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA,Brian P. Cunningham MD, Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, 6500 Excelsior Boulevard, St Louis Park, MN 55426, USA.
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3
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Usami T, Takada N, Nishida K, Sakai H, Iwata H, Sekiya I, Ueki Y, Murakami H, Kuroyanagi G. Banding with lesser trochanter fragment using nonabsorbable tape in trochanteric femoral fractures. SICOT J 2021; 7:33. [PMID: 34009117 PMCID: PMC8132597 DOI: 10.1051/sicotj/2021032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/13/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Trochanteric femoral fracture is one of the most common fractures in the elderly. Trochanteric femoral fracture with involvement of the lesser trochanter is considered unstable and recognized as having a poor prognosis. However, fixation of lesser trochanter fragment is scarce because of technical difficulties. In this study, we reported the simple surgical procedure and the effect of using nonabsorbable tape in lesser trochanter fixation. Methods: From January 2014 to December 2017, 114 patients treated with proximal intramedullary nailing for trochanteric fractures with the lesser trochanter fragment were reviewed. Among patients enrolled in this study, 73 were followed up until radiographic bone union, of which 26 were treated with lesser trochanter fragment banding (group B) and 47 without banding (group N). Radiographs and/or computed tomography images were used to evaluate bone union of the lesser trochanter fragment at three months postoperatively. Results: The bone union of the lesser trochanter fragment was achieved in 24 cases (92%) in group B and 30 cases (64%) in group N. Compared with group N, group B showed a significantly increased number of mild and moderate deformities but decreased number of severe deformity and nonunion (P < 0.001). Postoperative complications were not observed in both groups. Conclusions: From the viewpoint of increasing lesser trochanteric bone union ratio, fixation of the lesser trochanter fragment using nonabsorbable tape in the treatment of trochanteric fractures could be an effective procedure.
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Affiliation(s)
- Takuya Usami
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601 Aichi, Japan
| | - Naoya Takada
- Department of Orthopaedic Surgery, Kainan Hospital, Yatomi, 498-8502 Aichi, Japan
| | - Kazuki Nishida
- Center for Advanced Medicine and Clinical Research Nagoya University Hospital, Nagoya, 466-8560 Aichi, Japan
| | - Hiroaki Sakai
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601 Aichi, Japan
| | - Hidetoshi Iwata
- Department of Orthopaedic Surgery, Kainan Hospital, Yatomi, 498-8502 Aichi, Japan
| | - Isato Sekiya
- Department of Orthopaedic Surgery, Kainan Hospital, Yatomi, 498-8502 Aichi, Japan
| | - Yoshino Ueki
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601 Aichi, Japan - Department of Rehabilitation Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601 Aichi, Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601 Aichi, Japan
| | - Gen Kuroyanagi
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601 Aichi, Japan - Department of Rehabilitation Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601 Aichi, Japan
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4
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Transitional Care Experiences of Patients with Hip Fracture Across Different Health Care Settings. Int J Integr Care 2021; 21:2. [PMID: 33867897 PMCID: PMC8034406 DOI: 10.5334/ijic.4720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Transitions of care often result in fragmented care, leading to unmet patient needs and poor satisfaction with care, especially in patients with multiple chronic conditions. This project aimed to understand how experiences of patients with hip fracture, caregivers, and healthcare providers differ across different points of transition. Methods A secondary analysis of 103 qualitative, semi-structured interviews was conducted using emergent coding techniques, to gain an understanding of how transitional care experiences may differ across varying settings of care. Following the secondary analysis, a focus group interview was conducted to review findings. Results Seven key themes, each relating to distinct transition points, emerged from the secondary analysis: (1) Multiple providers contributed to patient and caregiver confusion; (2) Family caregivers were not considered important in the patient's care; (3) System-related issues impacted experiences; (4) Patients and caregivers felt uninformed; (5) Transitions increased stress in patients and caregivers; (6) Care was not tailored to patient needs; (7) Providers faced barriers in getting adequate information. The focus group results built upon these themes, adding some additional context to understand the current transitional care landscape. Discussion In transitions to formal care settings, similarities were related to feeling confused, while in transitions to home, similarities existed in regards to feeling unprepared. These findings support the view that models of integrated care should consider the context to which they are applied.
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5
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Trevisan C, Bedogni M, Pavan S, Shehu E, Piazzani F, Manzato E, Sergi G, March A. The impact of second hip fracture on rehospitalization and mortality in older adults. Arch Gerontol Geriatr 2020; 90:104175. [PMID: 32659601 DOI: 10.1016/j.archger.2020.104175] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Although a second hip fracture is not uncommon in the older population, the extent to which such an event may affect health-related outcomes has not been fully clarified. We aimed to evaluate the risk of new falls, functional decline, rehospitalization, institutionalization and mortality in older patients admitted for a second vs. a first hip fracture. METHODS The sample consisted of 288 older patients admitted to the Orthogeriatric Unit of Bolzano Hospital (northern Italy) and surgically treated for a hip fracture from June 2016 to June 2017. Socio-demographic data and hospitalization-related information were collected and a multidimensional assessment was made upon admission and during the hospital stay. Fifteen months after discharge, data on mobility level, functional status, institutionalization, and new falls were obtained from personal or structured phone interviews. Information on rehospitalization and mortality was obtained from local hospital registers. RESULTS One out of six patients (14.6 %) admitted was suffering a second hip fracture, of which only 16.7 % were on antiresorptive therapies. At the 15-month follow-up, individuals who had been treated for a second hip fracture were more likely than those treated for their first to have low mobility levels (OR = 4.13, 95 %CI:1.23-13.84), to be rehospitalized (OR = 2.57, 95 %CI:1.12-5.90), and to have a higher mortality (HR = 1.81, 95 %CI:1.05-3.12). CONCLUSIONS The occurrence of a second hip fracture may further affect the clinical vulnerability and mortality of older adults. These results highlight the need to implement preventive action to minimize the risk of re-fracture after the first event.
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Affiliation(s)
- Caterina Trevisan
- Department of Medicine (DIMED), Geriatrics Division, University of Padua, Italy.
| | - Marco Bedogni
- Department of Medicine (DIMED), Geriatrics Division, University of Padua, Italy
| | - Silvia Pavan
- Department of Geriatrics, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
| | - Enron Shehu
- Department of Medicine (DIMED), Geriatrics Division, University of Padua, Italy; Department of Geriatrics, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
| | - Fabrizio Piazzani
- Department of Geriatrics, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
| | - Enzo Manzato
- Department of Medicine (DIMED), Geriatrics Division, University of Padua, Italy
| | - Giuseppe Sergi
- Department of Medicine (DIMED), Geriatrics Division, University of Padua, Italy
| | - Albert March
- Department of Geriatrics, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
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Effects of Anesthesia Techniques on Outcomes after Hip Fracture Surgery in Elderly Patients: A Prospective, Randomized, Controlled Trial. J Clin Med 2020; 9:jcm9061605. [PMID: 32466360 PMCID: PMC7355551 DOI: 10.3390/jcm9061605] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/09/2020] [Accepted: 05/24/2020] [Indexed: 11/17/2022] Open
Abstract
The superiority of distinct anesthesia methods for geriatric hip fracture surgery remains unclear. We evaluated high mobility group box-1 (HMGB1) and interleukin-6 (IL-6) with three different anesthesia methods in elderly patients undergoing hip fracture surgery. Routine blood test findings, postoperative morbidity, and mortality were assessed as secondary outcome. In total, 176 patients were randomized into desflurane (n = 60), propofol (n = 58), or spinal groups (n = 58) that received desflurane-based balanced anesthesia, propofol-based total intravenous anesthesia (TIVA), or spinal anesthesia, respectively. The spinal group required less intraoperative vasopressors (p < 0.001) and fluids (p = 0.006). No significant differences in HMGB1 (pgroup×time = 0.863) or IL-6 (pgroup×time = 0.575) levels were noted at baseline, postoperative day (POD) 1, or POD2. Hemoglobin, albumin, creatinine, total lymphocyte count, potassium, troponin T, and C-reactive protein were comparable among groups at all time-points. No significant differences in postoperative hospital stay, intensive care unit (ICU) stay, and ventilator use among groups were observed. Postoperative pulmonary, cardiac, and neurologic complications; and in-hospital, 30-day, and 90-day mortality were not significantly different among groups (p = 0.974). In conclusion, HMGB1 and IL-6, and all secondary outcomes, were not significantly different between desflurane anesthesia, propofol TIVA, and spinal anesthesia.
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7
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A Percutaneous Threaded Wire as a Clamp Technique for Avoiding Wedge Deformity While Nailing Intertrochanteric Femur Fractures. J Orthop Trauma 2019; 33:e276-e279. [PMID: 30844955 DOI: 10.1097/bot.0000000000001459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Hip fractures are common injuries managed by the orthopaedic surgeon, and within the umbrella of hip fractures, intertrochanteric femur fractures constitute a significant portion of these injuries. Recent trends have shown an increased usage of cephalomedullary nails for these injuries. A known potential complication of this technique is the generation of a wedge deformity creating a varus alignment, especially when the cranial portion of the intertrochanteric fracture exits at or near the starting point of the nail. Although the biomechanics of this phenomenon are well described, few reports have shown techniques to help avoid this phenomenon. Here, we present a novel technique we have found useful to help prevent the wedge deformity incorporating commonly available instruments.
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8
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Castillón P, Veloso M, Gómez O, Salvador J, Bartra A, Anglés F. Fascia iliaca block for pain control in hip fracture patients. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017. [DOI: 10.1016/j.recote.2017.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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9
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Castillón P, Veloso M, Gómez O, Salvador J, Bartra A, Anglés F. Fascia iliaca block for pain control in hip fracture patients. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 61:383-389. [PMID: 28890120 DOI: 10.1016/j.recot.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/17/2017] [Accepted: 07/03/2017] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Pain treatment for patients with hip fracture has been based on the use of nonsteroidal anti-inflammatories and opioid derived drugs. These medications have been associated with multiple adverse effects. Fascia iliaca block is a recent pain management alternative for these patients. The objective of this study was to evaluate the effectiveness of fascia iliaca block performed in the emergency room (ER) for patients over 65years of age with hip fracture. MATERIALS AND METHODS A cohort of 216 patients, from January to December 2016, was studied prospectively. Analyzed variables were: pain upon arrival at ER, pain after fascia iliaca block, need for rescue medication, protocol compliance, delay in analgesia administration and delay for surgery. RESULTS Differences between visual analogue scale (VAS), before and after the fascia iliaca block, were statistically significant (P<.001). Pre-block VAS recorded was 6.16 (SD=2.82). The mean VAS reduction after the block was 2.99 (95%CI: 2.45-3.53%). Twenty-six percent of patients required morphine as rescue medication in the first 8hours after diagnosis. Compliance with protocol administration was of 84%. Fascia iliaca block was performed in a mean time of 16minutes (SD=10.33) after diagnosis. The median delay for surgery was 1 day (RIQ 25-75%: 1-2). CONCLUSION Fascia iliaca block is a reproducible, safe and effective technique for pain management. It is a keystone in pain treatment for patients with a proximal femur fracture at our institution. Other objectives in our pain management protocol include early analgesia administration and reduction of time to surgery.
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Affiliation(s)
- P Castillón
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España; Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, España.
| | - M Veloso
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - O Gómez
- Servei de Anestesiologia i Reanimació, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - J Salvador
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España; Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, España
| | - A Bartra
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - F Anglés
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
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Hughes JD, Bartley JH, Brennan KL, Maldonado YM, Brennan ML, Chaput CD. Rate of contralateral hip fracture after dynamic hip screw vs intramedullary nail for treatment of pertrochanteric hip fractures. Proc (Bayl Univ Med Cent) 2017; 30:268-272. [PMID: 28670054 DOI: 10.1080/08998280.2017.11929612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
A retrospective, comparative study was performed reviewing the electronic medical records and digital radiographs of patients who underwent treatment for intertrochanteric and pertrochanteric hip fractures with either a hip screw and side plate (HSSP) or intramedullary nail. A total of 430 patients were treated with HSSP, and 725 were managed with a cephalomedullary nail (CMN). Of these, 103 sustained a contralateral hip fracture. Fixation technique was not associated with a significant difference in the rate of contralateral fracture. Among the patients with a contralateral fracture, the median time to contralateral fracture was 119.28 months following HSSP and 81.97 months following CMN. Bisphosphonate use was found to be a significant predictor of contralateral fracture for all patients, but when matching using propensity scores, its use was found to be insignificant. In conclusion, there was no difference in the rate of subsequent contralateral hip fracture when comparing HSSP with CMN. Additionally, the time to second surgery between the two treatment modalities was found to be statistically insignificant. It is unclear if bisphosphonate use increased the odds of having a contralateral fracture, regardless of the surgical intervention. The difference in the bisphosphonate effect using propensity score matching suggests that the results may be due to confounding variables and bias.
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Affiliation(s)
- Jonathan D Hughes
- Department of Orthopedic Surgery, Scott & White Medical Center, Temple, Texas
| | - Justin H Bartley
- Department of Orthopedic Surgery, Scott & White Medical Center, Temple, Texas
| | - Kindyle L Brennan
- Department of Orthopedic Surgery, Scott & White Medical Center, Temple, Texas
| | | | - Michael L Brennan
- Department of Orthopedic Surgery, Scott & White Medical Center, Temple, Texas
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Murthy S, Hepner DL, Cooper Z, Bader AM, Neuman MD. Controversies in anaesthesia for noncardiac surgery in older adults. Br J Anaesth 2016; 115 Suppl 2:ii15-25. [PMID: 26658197 DOI: 10.1093/bja/aev396] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
As the population of the world is rapidly ageing, the amount of surgery being performed in older patients is also increasing. Special attention is required for the anaesthetic and perioperative management of these patients. The clinical and non-clinical issues specific to older surgical patients are reviewed, with a special emphasis on areas of debate related to anaesthesia care in this group. These issues include the role of frailty and disability in preoperative assessment, choice of anaesthesia technique for hip fracture, postoperative delirium, and approaches to shared decision-making before surgical procedures.
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Affiliation(s)
- S Murthy
- Department of Anesthesiology and Critical Care, The University of Pennsylvania, 6 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - D L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine
| | - Z Cooper
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - A M Bader
- Department of Anesthesiology, Perioperative and Pain Medicine
| | - M D Neuman
- Department of Anesthesiology and Critical Care, The University of Pennsylvania, 6 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Ishidou Y, Koriyama C, Kakoi H, Setoguchi T, Nagano S, Hirotsu M, Yamamoto T, Yokouchi M, Komiya S. Predictive factors of mortality and deterioration in performance of activities of daily living after hip fracture surgery in Kagoshima, Japan. Geriatr Gerontol Int 2016; 17:391-401. [DOI: 10.1111/ggi.12718] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 11/07/2015] [Accepted: 11/22/2015] [Indexed: 12/12/2022]
Affiliation(s)
- Yasuhiro Ishidou
- Department of Medical Joint Materials; Kagoshima University; Kagoshima Japan
| | - Chihaya Koriyama
- Department of Epidemiology and Preventive Medicine; Kagoshima University; Kagoshima Japan
| | - Hironori Kakoi
- Department of Orthopedic Surgery; Kagoshima University; Kagoshima Japan
| | - Takao Setoguchi
- The Near-Future Locomotor Organ Medicine Creation Course; Graduate School of Medical and Dental Sciences; Kagoshima University; Kagoshima Japan
| | - Satoshi Nagano
- Department of Orthopedic Surgery; Kagoshima University; Kagoshima Japan
| | - Masataka Hirotsu
- Department of Orthopedic Surgery; Kagoshima University; Kagoshima Japan
| | - Takuya Yamamoto
- Department of Orthopedic Surgery; Kagoshima University; Kagoshima Japan
| | - Masahiro Yokouchi
- Department of Orthopedic Surgery; Kagoshima University; Kagoshima Japan
| | - Setsuro Komiya
- Department of Orthopedic Surgery; Kagoshima University; Kagoshima Japan
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Impact of preoperative continuous femoral blockades on morphine consumption and morphine side effects in hip-fracture patients: A randomized, placebo-controlled study. Anaesth Crit Care Pain Med 2015; 35:37-43. [PMID: 26563608 DOI: 10.1016/j.accpm.2015.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 07/23/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Upon arrival at the emergency department, hip-fracture pain relief is usually carried out via systemic opioids. Continuous nerve blocks are efficient in the postoperative period, but have not been evaluated preoperatively. This study compared the reduction in morphine consumption and related side effects of a continuous femoral block with a single shot block in hip-fracture patients. METHODS Hip-fracture patients admitted to the emergency department received a femoral nerve catheter, with a single lidocaine injection. They were then randomized to ropivacaine (group R) or saline continuous infusion (placebo, group P) in a double-blind manner. Morphine consumption and side effects were prospectively collected until the 24th postoperative hour. RESULTS Sixty patients were included and 55 analyzed. There were no significant differences between the 2 groups regarding fracture types, delay before surgery (median [Q1-Q3]: 21.3 [14.5-29.4] versus 20.8 [15.7-36.2] hours for groups R and P, respectively; P=0.87) and catheter duration (47.5 [39.8-52.4] versus 42.5 [32.1-50.5] hours, P=0.29). Total morphine consumption was not significantly decreased in group R (5 [0-14] versus 8 [4.5-11] mg, P=0.3) and pain scores were similar (mean±SD; VAS 29±15/100 versus 33±13, P=0.3). We observed a significant reduction in morphine adverse effects (31% versus 69% for groups R and P, respectively; P<0.01), mainly nausea (31% versus 59%, P=0.03). One morphine side effect could be avoided for every 5 patients treated. CONCLUSION Preoperative continuous femoral blockades using ropivacaine reduce morphine side effects (mainly nausea) in hip-fracture patients without reducing morphine consumption.
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Niu E, Yang A, Harris AHS, Bishop J. Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States? A Survey of Orthopaedic Surgeons. Clin Orthop Relat Res 2015; 473:3647-55. [PMID: 26208608 PMCID: PMC4586189 DOI: 10.1007/s11999-015-4469-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 07/15/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND The best treatment for intertrochanteric hip fractures is controversial. The use of cephalomedullary nails has increased, whereas use of sliding hip screws has decreased despite the lack of evidence that cephalomedullary nails are more effective. As current orthopaedic trainees receive less exposure to sliding hip screws, this may continue to perpetuate the preferential use of cephalomedullary nails, with important implications for resident education, evidence-based best practices, and healthcare cost. QUESTIONS/PURPOSES We asked: (1) What are the current practice patterns in surgical treatment of intertrochanteric fractures among orthopaedic surgeons? (2) Do surgical practice patterns differ based on surgeon characteristics, practice setting, and other factors? (3) What is the rationale behind these surgical practice patterns? (4) What postoperative approaches do surgeons use for intertrochanteric fractures? METHODS A web-based survey containing 20 questions was distributed to active members of the American Academy of Orthopaedic Surgeons. Three thousand seven-hundred eighty-six of 10,321 invited surgeons participated in the survey (37%), with a 97% completion rate (3687 of 3784 responded to all questions in the survey). The survey elicited information regarding surgeon demographics, preferred management strategies, and decision-making rationale for intertrochanteric fractures. RESULTS Surgeons use cephalomedullary nails most frequently for treatment of intertrochanteric hip fractures. Sixty-eight percent primarily use cephalomedullary nails, whereas only 19% primarily use sliding hip screws, and the remaining 13% use cephalomedullary nails and sliding hip screws with equal frequency. The cephalomedullary nail was the dominant approach regardless of experience level or practice setting. Surgeons who practiced in a nonacademic setting (71% versus 58%; p < 0.001), did not supervise residents (71% versus 61%; p < 0.001), or treated more than five intertrochanteric fractures a month (78% versus 67%; p < 0.001) were more likely to use primarily cephalomedullary nails. Of the surgeons who used only cephalomedullary nails, ease of surgical technique (58%) was cited as the primary reason, whereas surgeons who used only sliding hip screws cite familiarity (44%) and improved outcomes (37%) as their primary reasons. Of those who use only short cephalomedullary nails, ease of technique (59%) was most frequently cited. Postoperatively, 67% allow the patient to bear weight as tolerated. Nearly all respondents (99.5%) use postoperative chemical thromboprophylaxis. CONCLUSIONS Despite that either sliding hip screw or cephalomedullary nail fixation are associated with equivalent outcomes for most intertrochanteric femur fractures, the cephalomedullary nail has emerged as the preferred construct, with the majority of surgeons believing that a cephalomedullary nail is easier to use, associated with improved outcomes, or is biomechanically superior to a sliding hip screw. The difference between what is evidence-based and what is done in clinical practice may be attributed to several factors, including financial considerations, educational experience, or inability of our current outcomes measures to reflect the experiences of surgeons. The educators, researchers, and policymakers among us must work harder to better define the roles of sliding hip screws and cephalomedullary nails and ensure that the increasing population with hip fractures receives high-quality and economically responsible care. LEVEL OF EVIDENCE Level V, therapeutic study.
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Affiliation(s)
- Emily Niu
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, M/C 6342, Redwood City, CA, 94063, USA.
| | - Arthur Yang
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, M/C 6342, Redwood City, CA, 94063, USA
| | - Alex H S Harris
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, M/C 6342, Redwood City, CA, 94063, USA
| | - Julius Bishop
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, M/C 6342, Redwood City, CA, 94063, USA
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15
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Neuman MD, Passarella MR, Werner RM. The relationship between historical risk-adjusted 30-day mortality and subsequent hip fracture outcomes: Retrospective cohort study. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2015; 4:192-9. [PMID: 27637826 DOI: 10.1016/j.hjdsi.2015.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 09/30/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND While 30-day risk-adjusted mortality is a performance measure for hip fracture care, it has not been shown to predict long-term outcomes. We assessed whether hospital rankings based on historical 30-day mortality predicted subsequent hip fracture outcomes. METHODS Using national Medicare data, we calculated annual hospital performance rankings based on standardized 30-day hip fracture mortality ratios. We used logistic regression to measure the association of patients' survival at 180 days with their hospital's ranking for the year prior to admission. Subgroup analyses assessed whether associations between hospital performance and 180-day outcomes were similar for community-dwelling patients as well as those living in nursing homes prior to fracture. RESULTS Out of 378,077 patients hospitalized with hip fractures between January 1, 2007 and June 30, 2009, 81,653 (21.6%) died by 180 days. Worse historical hospital performance was associated with a greater adjusted odds of 30 day mortality (odds ratio (OR), fourth vs. first quartile: 1.24, 95% confidence interval (CI): 1.18, 1.29, P<0.001) and 180 day mortality (OR, fourth vs. first quartile: 1.15, 95% CI 1.11, 1.18, P<0.001). Past hospital performance was associated with death or new nursing home placement among community dwellers (OR, fourth vs. first quartile: 1.09, 95% CI 1.05, 1.13, P<0.001), but was not associated with death or new dependence in locomotion among nursing home residents (OR 1.05, 95% CI 0.97, 1.15, P=0.229). CONCLUSIONS Better historical hospital hip fracture mortality predicts modest decreases in mortality at 180 days for subsequent patients, but is inconsistently associated with changes in functional outcomes. LEVEL OF EVIDENCE Level 3 (Non-randomized controlled cohort study).
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Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, 1119A Blockley Hall, Philadelphia, PA 19104, Unted States; Leonard Davis Institute for Health Economics, the University of Pennsylvania, United States; Department of Internal Medicine, Division of Geriatric Medicine, Perelman School of Medicine at the University of Pennsylvania, United States.
| | - Molly R Passarella
- Center for Outcomes Research, Children's Hospital of Philadelphia, United States
| | - Rachel M Werner
- Leonard Davis Institute for Health Economics, the University of Pennsylvania, United States; Department of Internal Medicine, Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, United States; Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, United States
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16
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Antonova E, Boye ME, Sen N, O’Sullivan AK, Burge R. Can Bundled Payment Improve Quality and Efficiency of Care for Patients with Hip Fractures? J Aging Soc Policy 2015; 27:1-20. [DOI: 10.1080/08959420.2015.970844] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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17
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Ireland AW, Kelly PJ. Total length of stay, costs and outcomes at final discharge for admitted patients with hip fracture: linked episode data for Australian veterans and war widows. Intern Med J 2013; 43:1280-6. [DOI: 10.1111/imj.12071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 12/17/2012] [Indexed: 11/28/2022]
Affiliation(s)
- A. W. Ireland
- Department of Veterans' Affairs; Sydney New South Wales Australia
- Sydney School of Public Health; University of Sydney; Sydney New South Wales Australia
| | - P. J. Kelly
- Sydney School of Public Health; University of Sydney; Sydney New South Wales Australia
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18
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"Just another fish in the pond": the transitional care experience of a hip fracture patient. Int J Integr Care 2013; 13:e023. [PMID: 23882170 PMCID: PMC3718274 DOI: 10.5334/ijic.1103] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 04/19/2013] [Accepted: 04/21/2013] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Miscommunication and lack of coordination can compromise care quality and patient safety during transitions in care, especially for medically complex older adults. Little research has been done to investigate care transitions from the perspective of those receiving and providing care. METHODS This study explored multiple care transitions for an elderly hip fracture patient, post-surgery. Interviews and observations were conducted with the patient, their family caregivers, and health care providers, at each point of transition between four different care settings. RESULTS FOUR KEY THEMES WERE IDENTIFIED OVER THE PATIENTS CARE TRAJECTORY: 'Missing Crucial Coversations'-Patient and family caregivers did not feel involved or informed about decisions in care; 'Who's Who'-Confusion about the role of health care providers; 'Ready or Not'-Not knowing what to expect or what is expected; and, 'Playing by the Rules'-Health system policies and procedures hinder individualized care. CONCLUSION Study findings point to the need for the health care system to engage patients and family caregivers more fully and consistently in the process of care transitions as well as the importance of understanding these processes from multiple perspectives. Recommendations for system integration are proposed with a focus on transitional care.
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