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Okike K, Prentice HA, Chan PH, Fasig BH, Paxton EW, Bernstein J, Ahn J, Chen F. Unipolar Hemiarthroplasty, Bipolar Hemiarthroplasty, or Total Hip Arthroplasty for Hip Fracture in Older Individuals. J Bone Joint Surg Am 2024; 106:120-128. [PMID: 37973035 DOI: 10.2106/jbjs.23.00486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Practice patterns regarding the use of unipolar hemiarthroplasty, bipolar hemiarthroplasty, and total hip arthroplasty (THA) for femoral neck fractures in older patients vary widely. This is due in part to limited data stipulating the specific circumstances under which each form of arthroplasty provides the most predictable outcome. The purpose of this study was to investigate the patient characteristics for which unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA might be preferable due to a lower risk of all-cause revision. METHODS A U.S. health-care system's hip fracture registry was used to identify patients ≥60 years old who underwent unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA for hip fracture from 2009 through 2021. Unipolar and bipolar hemiarthroplasty were compared with THA within patient subgroups defined by age (60 to 79 versus ≥80 years) and American Society of Anesthesiologists (ASA) classification (I or II versus III); patients with an ASA classification of IV or higher were excluded. Multivariable Cox proportional hazard regression analysis was used to evaluate all-cause revision risk while adjusting for confounders, with mortality considered as a competing risk. RESULTS There were 14,277 patients in the final sample (median age, 82 years; 70% female; 80% White; 69% with an ASA classification of III; median follow-up, 2.7 years), and the procedures included 7,587 unipolar hemiarthroplasties, 5,479 bipolar hemiarthroplasties, and 1,211 THAs. In the multivariable analysis of all patients, both unipolar (hazard ratio [HR] = 2.15, 95% confidence interval [CI] = 1.48 to 3.12; p < 0.001) and bipolar (HR = 1.92, 95% CI = 1.31 to 2.80; p < 0.001) hemiarthroplasty had higher revision risks than THA. In the age-stratified multivariable analysis of patients aged 60 to 79 years, both unipolar (HR = 2.17, 95% CI = 1.42 to 3.34; p = 0.004) and bipolar (HR = 1.69, 95% CI = 1.08 to 2.65; p = 0.022) hemiarthroplasty also had higher revision risks than THA. In the ASA-stratified multivariable analysis, patients with an ASA classification of I or II had a higher revision risk after either unipolar (HR = 3.52, 95% CI = 1.87 to 6.64; p < 0.001) or bipolar (HR = 2.31, 95% CI = 1.19 to 4.49; p = 0.013) hemiarthroplasty than after THA. No difference in revision risk between either of the hemiarthroplasties and THA was observed among patients with an age of ≥80 years or those with an ASA classification of III. CONCLUSIONS In this study of hip fractures in older patients, THA was associated with a lower risk of all-cause revision compared with unipolar and bipolar hemiarthroplasty among patients who were 60 to 79 years old and those who had an ASA classification of I or II. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kanu Okike
- Department of Orthopaedic Surgery, Hawaii Permanente Medical Group, Honolulu, Hawaii
| | - Heather A Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Priscilla H Chan
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Brian H Fasig
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Elizabeth W Paxton
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Joseph Bernstein
- Department of Orthopaedic Surgery, Philadelphia Veterans Hospital, Philadelphia, Pennsylvania
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Foster Chen
- Department of Orthopaedic Surgery, Washington Permanente Medical Group P.C., Seattle, Washington
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Shah ID, Piple AS, Schlauch AM, Crawford BD, Tamer P, Prentice HA, Grimsrud CD. Direct Anterior Versus Posterior Approach for Total Hip Arthroplasty Performed for Displaced Femoral Neck Fractures. J Orthop Trauma 2023; 37:539-546. [PMID: 37348042 DOI: 10.1097/bot.0000000000002650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVES To compare perioperative, 90-day, and 1-year postoperative complications and outcomes between the direct anterior approach (DAA) and the posterior approach for total hip arthroplasty in geriatric patients with displaced femoral neck fractures (FNFs). DESIGN Retrospective cohort study. SETTING Multicenter Health care Consortium. PATIENTS Seven-hundred and nine patients 60 years or older with acute displaced FNFs between 2009 and 2021. INTERVENTION Total hip arthroplasty using either DAA or posterior approach. MAIN OUTCOME MEASUREMENTS Rates of postoperative complications including dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. Secondary outcome measures included ambulation capacity at discharge, ambulation distance with inpatient physical therapy, discharge disposition, and narcotic prescription quantities (morphine milligram equivalents). RESULTS Through a multivariable regression analysis, DAA was associated with significantly shorter operative time ( B = -6.89 minutes; 95% confidence interval [CI] -12.84 to -0.93; P = 0.024), lower likelihood of blood transfusion during the index hospital stay (adjusted odds ratios = 0.54; 95% CI 0.27 to 0.96; P = 0.045), and decreased average narcotic prescription amounts at 90 days (B = -230.45 morphine milligram equivalents; 95% CI -440.24 to -78.66; P = 0.035) postoperatively. There were no significant differences in medical complications, dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. CONCLUSION When comparing the DAA versus posterior approach for total hip arthroplasty performed for displaced FNF, DAA was associated with shorter operative time, lower likelihood of blood transfusion, and lower 90-day postoperative narcotic prescription amounts. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ishan D Shah
- Department of Orthopaedic Surgery, St. Mary's Medical Center, San Francisco, CA
| | - Amit S Piple
- The Taylor Collaboration, St. Mary's Medical Center, San Francisco, CA
| | - Adam M Schlauch
- Department of Orthopaedic Surgery, St. Mary's Medical Center, San Francisco, CA
| | - Benjamin D Crawford
- Department of Orthopaedic Surgery, St. Mary's Medical Center, San Francisco, CA
| | - Pierre Tamer
- Department of Orthopaedic Surgery, St. Mary's Medical Center, San Francisco, CA
| | - Heather A Prentice
- Medical Device and Surveillance Department, Kaiser Permanente, San Diego, CA; and
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Gasparik AI, Lorenzovici L, Pașcanu IM, Csata Z, Poiană C, Dobre R, Bartelick MM. Predictors of mortality for patients with hip fracture: a study of the nationwide 1-year records of 24,950 fractures in Romania. Arch Osteoporos 2023; 18:69. [PMID: 37195371 DOI: 10.1007/s11657-023-01253-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/19/2023] [Indexed: 05/18/2023]
Abstract
We conducted a study evaluating incidence rates and influencing factors in Romanian hip fracture patients. Our results showed that the type of fracture and its respective surgical procedure as well as hospital characteristics correlate with mortality. Updated incidences can result in updated treatment guidelines. PURPOSE The aim of our study was to assess incidence rates for a revision-calibration of the Romanian FRAX tool and to evaluate particularities of hip fracture cases to determine patient- and hospital-related variables affecting mortality. METHODS We conducted a retrospective study using hospital reports of hip fracture codes to the National School of Statistics (NSS) from January 1, 2019, until December 31, 2019. The study population included 24,950 patients presenting to Romanian public hospitals in all 41 counties: ≥ the age of 40 with diagnostic ICD 10 codes: S72.0 femoral neck fracture, S72.1 pertrochanteric femoral fracture, and S72.2 subtrochanteric femoral fracture and procedure codes: O11104 (trochanteric/sub capital internal fixation), O12101 (hemiarthroplasty), O11808 (closed femoral reduction with internal fixation), O12103 (partial arthroplasty), O12104 (total arthroplasty). Hospital length of stay (LoS) was classified as follows: < 6, 6-9, 10-14, and ≥ 15 days. RESULTS Incidence of hip fractures was 248/100,000 among those aged 50 + and 184/100,000 within the 40 + age category. Average age of the patients was 77 years (80 for females, 71 for males); 83.7% of the patients were 65 + with equivalent urban-rural distributions. Males had a 1.7 times higher mortality risk. Each year increase in age added a mortality risk of 6.9%. In-hospital mortality was 1.34 times higher among patients living in urban areas. Hemiarthroplasty and partial/total unilateral/bilateral arthroplasty had a lower risk of mortality than trochanteric/sub capital internal fixation (p < 0.02, p < 0.033). CONCLUSION Gender, age, residence, and procedure type had significant impact on mortality. Updated incidence rates will allow the revision of Romania's FRAX model.
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Affiliation(s)
- Andrea I Gasparik
- George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Târgu Mureș, Romania
| | - László Lorenzovici
- George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Târgu Mureș, Romania
| | - Ionela M Pașcanu
- George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Târgu Mureș, Romania
| | - Zsombor Csata
- Faculty of Sociology and Social Work, Babeș-Bolyai University of Cluj Napoca, Cluj-Napoca, Romania
- Center for Social Sciences, Institute for Minority Studies, Budapest, Hungary
| | - Cătălina Poiană
- Carol Davila University of Medicine and Pharmacy of Bucharest, Bucharest, Romania
| | - Ramona Dobre
- Carol Davila University of Medicine and Pharmacy of Bucharest, Bucharest, Romania
| | - Miruna M Bartelick
- George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Târgu Mureș, Romania.
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Okike K, Royse KE, Singh G, Zeltser DW, Prentice HA, Paxton EW. Risk of Aseptic Revision and Periprosthetic Fracture Following Bipolar Versus Unipolar Hemiarthroplasty. JB JS Open Access 2023; 8:e23.00009. [PMID: 37351088 PMCID: PMC10284324 DOI: 10.2106/jbjs.oa.23.00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
Hemiarthroplasty is currently the most common treatment for displaced femoral neck fractures in the elderly. While bipolar hemiarthroplasty was developed to reduce the risk of acetabular erosion that is associated with traditional unipolar hemiarthroplasty, meta-analyses have reported similar outcomes for bipolar and unipolar hemiarthroplasty devices. The primary objective of this study was to evaluate the risks of aseptic revision and periprosthetic fracture following bipolar versus unipolar hemiarthroplasty in a large integrated health-care system in the United States. Methods We conducted a retrospective cohort study using data from the hip fracture registry of an integrated health-care system. Patients aged ≥60 years who underwent hemiarthroplasty for hip fracture between 2009 and 2019 were included. The primary outcome measure was aseptic revision, and the secondary outcome measure was revision for periprosthetic fracture. Cause-specific Cox proportional hazards regression was performed, with mortality considered as a competing event. In the multivariable analysis, estimates were adjusted for potential confounders such as age, sex, race/ethnicity, body mass index, American Society of Anesthesiologists classification, femoral fixation, surgeon volume, type of anesthesia, and discharge disposition. Results The study sample included 13,939 patients who had been treated with hemiarthroplasty by 498 surgeons at 35 hospitals. The mean follow-up time was 3.7 ± 2.9 years. The overall incidence of aseptic revision at 5 years following hemiarthroplasty was 2.8% (386). In the multivariable analysis controlling for potential confounders, bipolar hemiarthroplasty was associated with a lower risk of aseptic revision than unipolar hemiarthroplasty (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.59 to 0.94; p = 0.012). Rates of revision for periprosthetic fracture were similar between the bipolar and unipolar devices (HR, 0.79; 95% CI, 0.58 to 1.10; p = 0.16). Conclusions In this study of hemiarthroplasty for hip fracture in elderly patients, bipolar designs were associated with a lower risk of aseptic revision than unipolar designs. In contrast to prior research, we did not find any difference in the risk of periprosthetic fracture between the 2 designs. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kanu Okike
- Hawaii Permanente Medical Group, Kaiser Permanente, Honolulu, Hawaii
| | - Kathryn E. Royse
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | | | | | - Heather A. Prentice
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Elizabeth W. Paxton
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
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Okike K, Chang RN, Chan PH, Paxton EW, Prentice HA. Prolonged Opioid Usage Following Hip Fracture Surgery in Opioid-Naïve Older Patients. J Arthroplasty 2023:S0883-5403(23)00089-X. [PMID: 36773664 DOI: 10.1016/j.arth.2023.01.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/26/2023] [Accepted: 01/31/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND While the risk of long-term dependence following the opioid treatment of musculoskeletal injury is often studied in younger populations, studies in older patients have centered on short-term risks such as oversedation and delirium. This study investigated prolonged opioid usage after hip fracture in older individuals, focusing on prevalence, risk factors, and changes over time. METHODS In this retrospective cohort study of 47,309 opioid-naïve patients aged ≥ 60 years who underwent hip fracture surgery (2009 to 2020), outpatient opioid use was evaluated in 3 postoperative time periods: P1 (day 0 to 30 postsurgery); P2 (day 31 to 90); and P3 (day 91 to 180). The primary outcome was prolonged outpatient opioid use, defined as having one or more opioid prescriptions dispensed in all 3 time periods. RESULTS The incidence of prolonged opioid usage among patients surviving to P3 was 6.3% (2,834 of 44,850). Initial prescription quantities decreased over time, as did the risk of prolonged opioid usage (from 8.0% in 2009 to 3.9% in 2019). In the multivariable analyses, risk factors for prolonged opioid usage included younger age, women, current/former smoking, fracture fixation (as compared to hemiarthroplasty), and anxiety. Prolonged opioid usage was less common among patients who were Asian or had a history of dementia. CONCLUSIONS While prior research on the hazards of opioids in the elderly has focused on short-term risks such as oversedation and delirium, these findings suggest that prolonged opioid usage may be a risk for this older population as well. As initial prescription amounts have decreased, declines in prolonged opioid medication usage have also been observed.
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Affiliation(s)
- Kanu Okike
- Hawaii Permanente Medical Group, Kaiser Permanente, Honolulu, Hawaii
| | - Richard N Chang
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Priscilla H Chan
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Heather A Prentice
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
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Temporal Trends in Deep Surgical Site Infections After Six Orthopaedic Procedures Over a 12-year Period Within a US-based Healthcare System. J Am Acad Orthop Surg 2022; 30:e1391-e1401. [PMID: 36084332 DOI: 10.5435/jaaos-d-22-00280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/05/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Centers of excellence and bundled payment models have driven perioperative optimization and surgical site infection (SSI) prevention with decolonization protocols and antibiotic prophylaxis strategies. We sought to evaluate time trends in the incidence of deep SSI and its causative organisms after six orthopaedic procedures in a US-based integrated healthcare system. METHODS We conducted a population-level time-trend study using data from Kaiser Permanente's orthopaedic registries. All patients who underwent primary anterior cruciate ligament reconstruction (ACLR), total knee arthroplasty (TKA), elective total hip arthroplasty (THA), hip fracture repair, shoulder arthroplasty, and spine surgery were identified (2009 to 2020). The annual incidence of 90-day deep SSI was identified according to the National Healthcare Safety Network/Centers for Disease Control and Prevention guidelines with manual chart validation for identified infections. Poisson regression was used to evaluate annual trends in SSI incidence with surgical year as the exposure of interest. Annual trends in overall incidence and organism-specific incidence were considered. RESULTS The final study sample was composed of 465,797 primary orthopaedic procedures. Over the 12-year study period, a decreasing trend in deep SSI was observed for ACLR and hip fracture repair. Although there was variation in incidence rates for specific operative years for TKA, elective THA, shoulder arthroplasty, and spine surgery, no consistent decreasing trends over time were found. Decreasing rates of Staphylococcus aureus infections over time after hip fracture repair, shoulder arthroplasty, and spine surgery and decreasing trends in antibiotic resistance after elective THA and spine surgery were also observed. Increasing trends of polymicrobial infections were observed after TKA and Cutibacterium acnes after elective THA. CONCLUSIONS The overall incidence of deep SSI after six orthopaedic procedures was rare. Decreasing SSI rates were observed for ACLR and hip fracture repair within our US-based healthcare system. Polymicrobial infections after TKA and Cutibacterium acnes after elective THA warrant closer surveillance. LEVEL OF EVIDENCE IV.
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Do Dual-mobility Cups Reduce Revision Risk in Femoral Neck Fractures Compared With Conventional THA Designs? An International Meta-analysis of Arthroplasty Registries. Clin Orthop Relat Res 2022; 480:1912-1925. [PMID: 35767813 PMCID: PMC9473769 DOI: 10.1097/corr.0000000000002275] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/20/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Dual-mobility cups in THA were designed to reduce prosthesis instability and the subsequent risk of revision surgery in high-risk patients, such as those with hip fractures. However, there are limited data from clinical studies reporting a revision benefit of dual-mobility over conventional THA. Collaboration between anthroplasty registries provides an opportunity to describe international practice variation and compare between-country, all-cause revision rates for dual-mobility and conventional THA. QUESTIONS/PURPOSES We summarized observational data from multiple arthroplasty registries for patients receiving either a dual-mobility or conventional THA to ask: (1) Is dual-mobility use associated with a difference in risk of all-cause revision surgery compared with conventional THA? (2) Are there specific patient characteristics associated with dual-mobility use in the hip fracture population? (3) Has the use of dual-mobility constructs changed over time in patients receiving a THA for hip fracture? METHODS Six member registries of the International Society of Arthroplasty Registries (from Australia, Denmark, Sweden, the Netherlands, the United Kingdom, and the United States) provided custom aggregate data reports stratified by acetabular cup type (dual-mobility or conventional THA) in primary THA for hip fracture between January 1, 2002, and December 31, 2019; surgical approach; and patient demographic data (sex, mean age, American Society of Anesthesiologists class, and BMI). The cumulative percent revision and mortality were calculated for each registry. To determine a global hazard ratio of all-cause revision for dual-mobility compared with conventional THA designs, we used a pseudoindividual patient data approach to pool Kaplan-Meier prosthesis revision data from each registry and perform a meta-analysis. The pseudoindividual patient data approach is a validated technique for meta-analysis of aggregate time-to-event survival data, such as revision surgery, from multiple sources. Data were available for 15,024 dual-mobility THAs and 97,200 conventional THAs performed for hip fractures during the study period. RESULTS After pooling of complete Kaplan-Meier survival data from all six registries, the cumulative percent revision for conventional THA was 4.3% (95% confidence interval [CI] 4.2% to 4.5%) and 4.7% (95% CI 4.3% to 5.3%) for dual-mobility THA at 5 years. We did not demonstrate a lower risk of all-cause revision for patients receiving dual-mobility over conventional THA designs for hip fracture in the meta-analysis once between-registry differences were adjusted for (HR 0.96 [95% CI 0.86 to 1.06]). A lower proportion of dual-mobility procedures were revised for dislocation than conventional THAs (0.9% versus 1.4%) but a higher proportion were revised for infection (1.2% versus 0.8%). In most registries, a greater proportion of dual-mobility THA patients were older, had more comorbidities, and underwent a posterior approach compared with conventional THA (p < 0.001). The proportion of dual-mobility THA used to treat hip fractures increased in each registry over time and constituted 21% (2438 of 11,874) of all THA procedures in 2019. CONCLUSION The proportion of dual-mobility THAs in patients with hip fractures increased over time, but there was large variation in use across countries represented here. Dual-mobility cups were not associated with a reduction in the overall risk of revision surgery in patients with hip fractures. A randomized controlled trial powered to detect the incidence of dislocation and subsequent revision surgery is required to clarify the efficacy of dual-mobility cups to treat hip fractures. LEVEL OF EVIDENCE Level III, therapeutic study.
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Kornstein SG, Pinkerton JV, Pace DT, Singer AJ, Kingsberg SA, Ellis LE, Ashley P, Klein W. Multidisciplinary Management of Menopause: Symposium Proceedings. J Womens Health (Larchmt) 2022; 31:1071-1078. [PMID: 35980244 DOI: 10.1089/jwh.2022.0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This proceeding summarizes a symposium on multidisciplinary management of menopause held on July 30, 2021 as part of the Health of Women 2021 conference. The workshop featured presentations by national experts who provided insights into multidisciplinary approaches to the management of menopause, vasomotor symptoms and genitourinary syndrome of menopause, bone health (including osteoporosis, muscular strength, and mobility), as well as sexual and psychological health during menopause. In this study, we highlight the major points of each presentation and the resultant discussion.
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Affiliation(s)
- Susan G Kornstein
- Department of Psychiatry and Institute for Women's Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - JoAnn V Pinkerton
- Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Diane T Pace
- College of Nursing, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
| | - Andrea J Singer
- Department of Obstetrics and Gynecology, and Medstar Georgetown University Hospital, Washington, District of Columbia, USA.,Department of Medicine, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Sheryl A Kingsberg
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Lisa E Ellis
- Department of Internal Medicine and Institute for Women's Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Phoebe Ashley
- Department of Internal Medicine and Institute for Women's Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Wendy Klein
- Department of Internal Medicine and Institute for Women's Health, Virginia Commonwealth University, Richmond, Virginia, USA
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Ahmed S, Zehra N, Noordin S, Sadruddin A, Khan AH. Bridging the gaps in secondary fracture prevention at a single center in Pakistan-compliance with the IOF best practice framework. Arch Osteoporos 2021; 16:158. [PMID: 34698959 DOI: 10.1007/s11657-021-01032-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/19/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE The International Osteoporosis Foundation (IOF) formulated a set of best practice framework as an international benchmark for secondary fracture prevention (SFP) and fracture liaison services (FLS), delineating essential elements of service delivery. The aim of this audit was to assess compliance with the IOF standards for patients ≥ 50 years presenting with fragility hip fractures at a tertiary care center in Pakistan. METHODS A retrospective sample of hip fracture cases from Jan 2019 to Dec 2019, treated at the section of Orthopedic Surgery, Aga Khan University, Karachi, was conducted. After excluding high energy trauma cases and patients younger than 50 years of age, medical records were audited, using a pre-structured Performa based on IOF standards. Compliance level of 0, 1, 2, and 3 was recorded as defined by IOF. Microsoft excel was used for data analysis. RESULTS A compliance level of 3 was recorded for patient identification and fall prevention services, whereas level 1 was attained for database maintenance for 25 (100%) cases. For medication initiation, level 0 was recorded for all the cases; however, 8 (32%) cases were prescribed calcium and vitamin D supplements. For the standards, including post-fracture assessment timing, evaluation of secondary causes of osteoporosis, multifaceted assessment, medication review, communication strategy, and long-term management, a level 0 was noted for 25 (100%) cases. Moreover, no recommended assessment guidelines were followed uniformly. CONCLUSION The care gaps identified require substantial efforts to ensure adequate implementation of the overall best practice standards for SFP, necessitating the need for FLS initiation and establishment of fracture care pathway.
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Affiliation(s)
- Sibtain Ahmed
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Nawazish Zehra
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Shahryar Noordin
- Musculoskeletal and Sports Medicine, Department of Surgery, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Anum Sadruddin
- Department of Surgery, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Aysha Habib Khan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan.
- Chemical Pathology & Bone, Departments of Pathology and Laboratory Medicine, Medicine Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan.
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Sadeghi C, Prentice HA, Okike KM, Paxton EW. Treatment of Intertrochanteric Femur Fractures with Long versus Short Cephalomedullary Nails. Perm J 2021; 24:19.229. [PMID: 32663128 DOI: 10.7812/tpp/19.229] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
CONTEXT Prior studies regarding indications for long vs short cephalomedullary nails in the treatment of intertrochanteric fractures had limited sample sizes and follow-up, suggesting a need for further investigation. OBJECTIVE To evaluate the association between cephalomedullary nail length and outcomes for the treatment of intertrochanteric femur fractures. DESIGN Cohort study using Kaiser Permanente's Hip Fracture Registry. A total of 5526 patients who underwent surgical treatment with cephalomedullary nails for an intertrochanteric femur fracture (2009-2014) were identified: 3108 (56.2%) with long nails and 2418 (43.8%) with short nails. Cox proportional hazards model regression was used to evaluate risks of all-cause revision and revision for periprosthetic fracture. Linear regression was used to evaluate operative time, estimated blood loss, and length of stay. Propensity score weights were used in all models to balance nail groups on patient and device characteristics. MAIN OUTCOME MEASURES All-cause revision surgery. RESULTS No association was found in risk of all-cause revision (hazard ratio = 0.75, 95% confidence interval [CI] = 0.48-1.15) or revision for periprosthetic fracture (hazard ratio = 0.59, 95% CI = 0.23-1.48) for long nails compared with short nails. Use of longer nails resulted in 18.80 more minutes of operative time (95% CI = 17.33-20.27 minutes), 41.10 mL more of estimated blood loss (95% CI = 31.71-50.48 mL), and a longer hospitalization (8.4 hours; β = 0.35, 95% CI = 0.12-0.58 hours). CONCLUSION These findings suggest that routine use of short cephalomedullary nails is safe and effective in the treatment of intertrochanteric fractures.
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Affiliation(s)
- Cameron Sadeghi
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, San Diego, CA, USA
| | - Heather A Prentice
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California, USA
| | - Kanu M Okike
- Department of Orthopaedic Surgery, Kaiser Moanalua Medical Center, Honolulu, HI, USA
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California, USA
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Schoeneberg C, Pass B, Volland R, Knobe M, Eschbach D, Ketter V, Lendemans S, Aigner R. Four-month outcome after proximal femur fractures and influence of early geriatric rehabilitation: data from the German Centres of Geriatric Trauma DGU. Arch Osteoporos 2021; 16:68. [PMID: 33846869 DOI: 10.1007/s11657-021-00930-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/16/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study analyzed the outcome of orthogeriatric patients with hip fracture 4 months after surgery. The overall mortality rate was 12.2%. Sixty-five percent presented a degradation in walking ability, and 16% had to move to a nursing home. Early geriatric rehabilitation reduces the mortality rate and increases the rate of anti-osteoporotic treatment. PURPOSE Hip fractures are increasingly common with severe consequences. Therefore, the German Trauma Society (DGU) implemented an orthogeriatric co-management and developed the concept for certified Centre for Geriatric Trauma DGU. The patients' treatment data and the optional 120 days of follow-up were collected in the Registry for Geriatric Trauma DGU (ATR-DGU). This study analyzed these 4-month treatment results. METHODS A retrospective analysis of the ATR-DGU was conducted. Outcome parameters were the rate of readmission, rate of re-surgery, anti-osteoporotic therapy, housing, mortality, walking ability, and quality of life (QoL) 120 days post-surgery. The influence of the early geriatric rehabilitation (EGR) was evaluated using a regression analysis. RESULTS The follow-up data from 9780 patients were included. After 120 days, the mortality rate was 12.2%, the readmission rate 4%, and the re-surgery rate 3%. The anti-osteoporotic treatment increased from 20% at admission to 32%; 65% of the patients had a degradation in walking ability, and 16% of the patients who lived in their domestic environment pre-surgery had to move to a nursing home. QoL was distinctly reduced. The EGR showed a positive influence of anti-osteoporotic treatment (p<0.001) and mortality (p=0.011) but led to a slight reduction in QoL (p=0.026). CONCLUSION The 4-month treatment results of the ATR-DGU are comparable to international studies. The EGR led to a significant rise in anti-osteoporotic treatment and a reduction in mortality with a slight reduction in QoL.
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Affiliation(s)
- Carsten Schoeneberg
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Hellweg 100, 45276, Essen, Germany.
| | - Bastian Pass
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Hellweg 100, 45276, Essen, Germany
| | - Ruth Volland
- AUC, Academy for Trauma Surgery GmbH, Munich, Germany
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Daphne Eschbach
- Center for Orthopedics and Trauma Surgery, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Vanessa Ketter
- Center for Orthopedics and Trauma Surgery, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Sven Lendemans
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Hellweg 100, 45276, Essen, Germany
| | - Rene Aigner
- Center for Orthopedics and Trauma Surgery, University Hospital of Giessen and Marburg, Marburg, Germany
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12
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Molecular Mechanisms and Emerging Therapeutics for Osteoporosis. Int J Mol Sci 2020; 21:ijms21207623. [PMID: 33076329 PMCID: PMC7589419 DOI: 10.3390/ijms21207623] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/09/2020] [Accepted: 10/11/2020] [Indexed: 12/15/2022] Open
Abstract
Osteoporosis is the most common chronic metabolic bone disease. It has been estimated that more than 10 million people in the United States and 200 million men and women worldwide have osteoporosis. Given that the aging population is rapidly increasing in many countries, osteoporosis could become a global challenge with an impact on the quality of life of the affected individuals. Osteoporosis can be defined as a condition characterized by low bone density and increased risk of fractures due to the deterioration of the bone architecture. Thus, the major goal of treatment is to reduce the risk for fractures. There are several treatment options, mostly medications that can control disease progression in risk groups, such as postmenopausal women and elderly men. Recent studies on the basic molecular mechanisms and clinical implications of osteoporosis have identified novel therapeutic targets. Emerging therapies targeting novel disease mechanisms could provide powerful approaches for osteoporosis management in the future. Here, we review the etiology of osteoporosis and the molecular mechanism of bone remodeling, present current pharmacological options, and discuss emerging therapies targeting novel mechanisms, investigational treatments, and new promising therapeutic approaches.
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MODERN ASPECTS OF THE PROBLEM OF FRACTURES OF THE PROXIMAL FEMULAR. EUREKA: HEALTH SCIENCES 2020. [DOI: 10.21303/2504-5679.2020.001366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The purpose of the study is to study the current global clinical and epidemiological features of proximal hip fractures and the risks of their development and spread. The paper identifies the main aspects of the spread and treatment of fractures of the proximal femur; main world modern epidemiological characteristics of hip fractures and levels of risks of their development and spread. The relationship between comorbidities in patients with proximal hip fractures and the risk of various treatment complications is shown. The main types of treatment tactics are identified, the groups of the most common comorbidities in such patients are given. As a result of the work it was established: the percentage of fractures of the proximal thigh is 9.00–45.00 % among all skeletal fractures in the older age group and among all age categories – 17.00–24.00 %; global annual morbidity is 1.7 million people, and mortality – 11.00–23.00 % in 6 months and 22.00–29.00 % in a year; increase in the frequency of these fractures with age with doubling after 50 years every ten years; average age of patients – 75–79 years; predominance of women over men in 2-3 times; the lowest annual age-standardized cases among women are in Nigeria, South Africa, Tunisia and Ecuador, and the highest are in Denmark, Norway, Sweden and Austria, which is also typical for men; significant economic burden of treatment and high levels of fractures with osteoporosis, cardiovascular disease, diabetes, chronic obstructive pulmonary disease and more; the advantage of surgical treatment over conservative.
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Alsheikh KA, Alsebayel FM, Alsudairy FA, Alzahrani A, Alshehri A, Alhusain FA, Alsaeed A, Almubarak A, Alhandi AA. One-year postoperative mortality rate among the elderly with hip fractures at a single tertiary care center. Ann Saudi Med 2020; 40:298-304. [PMID: 32757984 PMCID: PMC7410227 DOI: 10.5144/0256-4947.2020.298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hip fractures are one of the leading causes of disability and dependency among the elderly. The rate of hip fractures has been progressively increasing due to the continuing increase in average life expectancy. Surgical intervention is the mainstay of treatment, but with an increasing prevalence of comorbid conditions and decreased functional capacity in elderly patients, more patients are prone to postoperative complications. OBJECTIVES Assess the value of surgical intervention for hip fractures among the elderly by quantifying the 1-year mortality rate and assessing factors associated with mortality. DESIGN Medical record review. SETTING Tertiary care center. PATIENTS AND METHODS All patients 60 years o age or older who sustained a hip fracture between the period of 2008 to 2018 in a single tertiary healthcare center. Data was obtained from case files, using both electronic and paper files. MAIN OUTCOME MEASURES The 1-year mortality rate for hip fracture, postoperative complications and factors associated with mortality. SAMPLE SIZE 802 patients. RESULTS The majority of patients underwent surgical intervention (93%). Intra- and postoperative complications were 3% and 16%, respectively. Four percent of the sample died within 30 days, and 11% died within one year. In a multivariate analysis, an increased risk of 1-year mortality was associated with neck of femur fractures and postoperative complications (P=.034, <.001, respectively) CONCLUSION: The 1-year mortality risk in our study reinforces the importance of aggressive surgical intervention for hip fractures. LIMITATION Single-centered study. CONFLICT OF INTEREST None.
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Affiliation(s)
- Khalid A Alsheikh
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,From the Department of Orthopedic Surgery, National Guard Health Affairs, Riyadh, Saudi Arabia.,From the Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Firas M Alsebayel
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,From the Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Faisal Abdulmohsen Alsudairy
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,From the Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdullah Alzahrani
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,From the Department of Orthopedic Surgery, National Guard Health Affairs, Riyadh, Saudi Arabia.,From the Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ali Alshehri
- From the Department of Orthopedic Surgery, National Guard Health Affairs, Riyadh, Saudi Arabia.,From the Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Faisal Ahmed Alhusain
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,From the Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdullah Alsaeed
- From the Department of Orthopedic Surgery, National Guard Health Affairs, Riyadh, Saudi Arabia.,From the Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulaziz Almubarak
- From the Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ali A Alhandi
- From the Department of Orthopedic Surgery, National Guard Health Affairs, Riyadh, Saudi Arabia.,From the Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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15
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Goh EL, Lerner RG, Achten J, Parsons N, Griffin XL, Costa PML. Complications following hip fracture: Results from the World Hip Trauma Evaluation cohort study. Injury 2020; 51:1331-1336. [PMID: 32268962 PMCID: PMC7322551 DOI: 10.1016/j.injury.2020.03.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/02/2020] [Accepted: 03/09/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Hip fractures are common in people over 60 years of age, and are associated with significant disability, morbidity and mortality. The aim of this study was to record the incidence of complications in the first 120 days following hip fracture. METHODS The World Hip Trauma Evaluation (WHiTE) study is a multicentre, prospective cohort study conducted in National Health Service (NHS) hospitals in England and Wales. Participants are 60 years and older who received operative treatment for a hip fracture. We report the incidence of complications recorded by hospital staff until discharge from hospital and by participants at 120-days post-surgery. RESULTS An analysis of 8673 consecutive participants enrolled in the WHiTE study revealed the following risks of complications within the first 120 days: signs of wound infection (3.1%); dislocation (0.5%); failure of fixation (0.6%); peri‑prosthetic fracture (0.3%); overall revision surgery (0.9%); blood loss requiring transfusion (6.1%); chest infection (6.3%); urinary tract infection (5.0%); deep vein thrombosis/pulmonary embolus (1.8%); cerebrovascular accident (0.6%); acute coronary syndrome/myocardial infarction (0.6%); acute kidney injury (1.3%). CONCLUSION The rates of complications reported here provide a reference range against which future studies might be assessed. Registration: ISRCTN63982700.
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Affiliation(s)
- En Lin Goh
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, OX3 9DU, United Kingdom; Oxford University Hospitals NHS Foundation Trust, Trauma Research, Kadoorie Centre, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Robin G Lerner
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, OX3 9DU, United Kingdom
| | - Juul Achten
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, OX3 9DU, United Kingdom
| | - Nick Parsons
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7 AL, United Kingdom
| | - Xavier L Griffin
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, OX3 9DU, United Kingdom; Oxford University Hospitals NHS Foundation Trust, Trauma Research, Kadoorie Centre, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Professor Matthew L Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, OX3 9DU, United Kingdom; Oxford University Hospitals NHS Foundation Trust, Trauma Research, Kadoorie Centre, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
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Okike K, Chan PH, Prentice HA, Paxton EW, Burri RA. Association Between Uncemented vs Cemented Hemiarthroplasty and Revision Surgery Among Patients With Hip Fracture. JAMA 2020; 323:1077-1084. [PMID: 32181848 PMCID: PMC7078801 DOI: 10.1001/jama.2020.1067] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/27/2020] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Consensus guidelines and systematic reviews have suggested that cemented fixation is more effective than uncemented fixation in hemiarthroplasty for displaced femoral neck fractures. Given that these recommendations are based on research performed outside the United States, it is uncertain whether these findings also reflect the US experience. OBJECTIVE To compare the outcomes associated with cemented vs uncemented hemiarthroplasty in a large US integrated health care system. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 12 491 patients aged 60 years and older who underwent hemiarthroplasty treatment of a hip fracture between 2009 and 2017 at 1 of the 36 hospitals owned by Kaiser Permanente, a large US health maintenance organization. Patients were followed up until membership termination, death, or the study end date of December 31, 2017. EXPOSURES Hemiarthroplasty (prosthetic replacement of the femoral head) fixation via bony growth into a porous-coated implant (uncemented) or with cement. MAIN OUTCOMES AND MEASURES The primary outcome measure was aseptic revision, defined as any reoperation performed after the index procedure involving exchange of the existing implant for reasons other than infection. Secondary outcomes were mortality (in-hospital, postdischarge, and overall), 90-day medical complications, 90-day emergency department visits, and 90-day unplanned readmissions. RESULTS Among 12 491 patients in the study cohort who underwent hemiarthroplasty for hip fracture (median age, 83 years; 8660 women [69.3%]), 6042 (48.4%) had undergone uncemented fixation and 6449 (51.6%) had undergone cemented fixation, and the median length of follow-up was 3.8 years. In the multivariable regression analysis controlling for confounders, uncemented fixation was associated with a significantly higher risk of aseptic revision (cumulative incidence at 1 year after operation, 3.0% vs 1.3%; absolute difference, 1.7% [95% CI, 1.1%-2.2%]; hazard ratio [HR], 1.77 [95% CI, 1.43-2.19]; P < .001). Of the 6 prespecified secondary end points, none showed a statistically significant difference between groups, including in-hospital mortality (1.7% for uncemented fixation vs 2.0% for cemented fixation; HR, 0.94 [95% CI, 0.73-1.21]; P = .61) and overall mortality (cumulative incidence at 1 year after operation: 20.0% for uncemented fixation vs 22.8% for cemented fixation; HR, 0.95 [95% CI, 0.90-1.01]; P = .08). CONCLUSIONS AND RELEVANCE Among patients with hip fracture treated with hemiarthroplasty in a large US integrated health care system, uncemented fixation, compared with cemented fixation, was associated with a statistically significantly higher risk of aseptic revision. These findings suggest that US surgeons should consider cemented fixation in the hemiarthroplasty treatment of displaced femoral neck fractures in the absence of contraindications.
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Affiliation(s)
- Kanu Okike
- Hawaii Permanente Medical Group, Kaiser Permanente, Honolulu
| | - Priscilla H. Chan
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Heather A. Prentice
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Elizabeth W. Paxton
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Robert A. Burri
- The Permanente Medical Group, Kaiser Permanente, San Rafael, California
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Goh EL, Gurung PK, Ma S, Pilpel T, Dale JH, Kannan A, Anand S. Direct Oral Anticoagulants in the Prevention of Venous Thromboembolism Following Surgery for Hip Fracture in Older Adults: A Population-Based Cohort Study. Geriatr Orthop Surg Rehabil 2020; 11:2151459319897520. [PMID: 31976153 PMCID: PMC6958652 DOI: 10.1177/2151459319897520] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/02/2019] [Accepted: 12/08/2019] [Indexed: 02/05/2023] Open
Abstract
Introduction Direct oral anticoagulants (DOACs) decrease the risk of venous thromboembolism (VTE) without increasing the risk of hemorrhage in elective lower limb orthopedic surgery. However, the role of DOACs in preventing VTE following hip fracture surgery in the older adults remains unclear. This study aims to evaluate the efficacy and safety of DOACs in older adults undergoing surgery for hip fracture. Materials and methods Single-center, retrospective, population-based cohort study of patients receiving either a DOAC or low-molecular-weight heparin (LMWH) for VTE prophylaxis following hip fracture surgery. Data obtained included patient demographics, comorbidities, fracture classification, time to surgery, procedure performed, and length of stay. Main outcomes assessed were incidence of VTE, incidence of major hemorrhage, and death within 30 days of surgery. Results A total of 321 patients were included. Incidence of VTE was 0% in the DOAC group and 3.4% in the LMWH group (risk ratio [RR]:0.26, 95% confidence interval [CI]: 0.02-4.34, P = .35). Hemorrhage occurred in 7.4% and 3.0% of patients in the DOAC and LMWH groups, respectively (RR: 2.47, 95% CI: 0.77-7.91, P = .13). Mortality from VTE was 0% in the DOAC group and 0.7% in the LMWH group (RR: 0.97, 95% CI: 0.05-20.02, P = .99). Mortality from hemorrhage was 1.9% in the DOAC group and 0.7% in the LMWH group (RR: 2.47, 95% CI: 0.23-26.78, P = .46). Discussion The use of DOACs for VTE prophylaxis following surgery in older adults with hip fracture was associated with a similar rate of VTE compared to LMWH. However, there was a worrying trend toward an increased risk of hemorrhage. Conclusion In the present study of a carefully selected cohort of patients, the effect of DOACs in reducing the risk of VTE following surgery for hip fracture in the older adults was comparable to LMWH. However, a trend toward increased risk of hemorrhage was noted. Larger prospective studies will be required to identify patients who will benefit the most from treatment.
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Affiliation(s)
- En Lin Goh
- Oxford University Clinical Academic Graduate School, Medical Sciences Division, University of Oxford, Oxford, United Kingdom.,Department of Trauma, Horton General Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Pratha Kumari Gurung
- Department of Trauma, Horton General Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Shaocheng Ma
- Biomechanics Research Group, Imperial College London, London, United Kingdom
| | - Timothy Pilpel
- Department of Trauma, Horton General Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - James Henderson Dale
- Department of Trauma, Horton General Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Angela Kannan
- Department of Trauma, Horton General Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sambandam Anand
- Department of Trauma, Horton General Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Beyond orthogeriatric co-management model: benefits of implementing a process management system for hip fracture. Arch Osteoporos 2018; 13:81. [PMID: 30046907 DOI: 10.1007/s11657-018-0497-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/17/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED Hip fracture is a major health care problem worldwide. Business process management systems (PMSs) have made significant contributions in health care environments to improve patient care standards. The effectiveness of PMS applied to hip fracture in older adults in the acute phase has been demonstrated. INTRODUCTION Fragility fracture is a major health care problem worldwide. Business PMSs have made significant contributions in health care environments to improve patient care standards. It is a new way of management that defines a homogeneous application procedure involving eliminating steps that add no value and developing explicit supervision criteria, in addition to identifying the appropriate managers. PURPOSE The aim of our trial was to assess the effectiveness of the PMS applied to hip fracture versus the orthogeriatric co-management model in the acute phase. METHODS All consecutive patients aged ≥ 65 who were admitted to Hospital Universitario Infanta Leonor between January 1, 2009, and December 31, 2016, for acute hip fracture surgery were included. We compared the effectiveness indicators in the acute phase between the preprocess period (orthogeriatric co-management) and the process period. RESULTS One thousand two hundred twenty-two patients were included (76.6% women). Mean age (SD) was 83.9 (6.4) years. Effectiveness management indicators are the following: length of hospital stay, time to admission to the ward from the emergency department, preoperative stay, surgery in < 48 h, and the operating room availability which were all improved in the process period with statistical significance. Effectiveness clinical indicators are the following: the numbers of patients with operated limb loading approved after surgery, discharged to home, and with osteoporosis treatment postfracture at the time of discharge which were statistically significantly higher in the process period, and the number of patients who suffered from delirium was statistically significantly lower in the process period. The number of in-hospital deaths was lower during the process period without statistical significance. CONCLUSION Our results demonstrated the effectiveness of the PMS applied to hip fracture in older adults compared with an orthogeriatric co-management model in the acute phase, based on both management indicators and clinical indicators.
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Okike K, Chan PH, Prentice HA, Paxton EW, Navarro RA. Association Between Race and Ethnicity and Hip Fracture Outcomes in a Universally Insured Population. J Bone Joint Surg Am 2018; 100:1126-1131. [PMID: 29975273 DOI: 10.2106/jbjs.17.01178] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prior studies have documented racial and ethnic disparities in hip fracture treatment and outcome, and unequal access is commonly cited as a potential mediator. We sought to assess whether disparities in hip fracture outcome persist within a universally insured population of patients enrolled in a managed health-care system. METHODS A U.S. integrated health systems registry was used to identify patients who underwent treatment for a hip fracture when they were ≥60 years of age from 2009 to 2014. Patient demographics, procedure details, and outcomes were obtained from the registry. Differences in outcome according to race/ethnicity were analyzed using multivariable regression analysis with adjustment for socioeconomic status and other potential confounders. RESULTS Of 17,790 patients, 79.4% were white, 3.9% were black, 9.4% were Hispanic, and 7.4% were Asian. Compared with white patients, black patients had a similar 1-year mortality rate (odds ratio [OR] = 0.93, 95% confidence interval [CI] = 0.79 to 1.09, p = 0.37), Hispanic patients had a lower rate (OR = 0.85, 95% = CI = 0.75 to 0.96, p = 0.01), and Asian patients also had a lower rate (OR = 0.65, 95% CI = 0.56 to 0.76, p < 0.001). There were no differences in terms of surgical delay, 90-day emergency department visits, or reoperations during the patient's lifetime (p > 0.05) between the groups. Compared with white patients, black and Hispanic patients had fewer 90-day postoperative complications (p = 0.04 and p = 0.01, respectively); 90-day unplanned readmissions were less common among Asian patients (p = 0.03) but more common among black patients (p = 0.01). CONCLUSIONS In this study of hip fractures treated in an integrated managed care system, minority patients were found to have postoperative mortality rates that were similar to, or lower than, those of white patients. These findings may be related to the equal access and/or standardized protocols associated with treatment in this managed care system. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kanu Okike
- Department of Orthopaedics, Kaiser Moanalua Medical Center, Honolulu, Hawaii
| | - Priscilla H Chan
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Heather A Prentice
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Ronald A Navarro
- Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, California
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Desai V, Chan PH, Prentice HA, Zohman GL, Diekmann GR, Maletis GB, Fasig BH, Diaz D, Chung E, Qiu C. Is Anesthesia Technique Associated With a Higher Risk of Mortality or Complications Within 90 Days of Surgery for Geriatric Patients With Hip Fractures? Clin Orthop Relat Res 2018; 476:1178-1188. [PMID: 29601378 PMCID: PMC6263607 DOI: 10.1007/s11999.0000000000000147] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Postoperative mortality and complications after geriatric hip fracture surgery remain high despite efforts to improve perioperative care for these patients. One factor of particular interest is anesthetic technique, but prior studies on this are limited by sample selection, competing risks, and incomplete followup. QUESTIONS/PURPOSES (1) Among older patients undergoing surgery for hip fracture, does 90-day mortality differ depending on the type of anesthesia received? (2) Do 90-day emergency department returns and hospital readmissions differ based on anesthetic technique after geriatric hip fracture repairs? (3) Do 90-day Agency for Healthcare Research and Quality (AHRQ) outcomes differ according to anesthetic techniques used during hip fracture surgery? METHODS We conducted a retrospective study on geriatric patients (65 years or older) with hip fractures between 2009 and 2014 using the Kaiser Permanente Hip Fracture Registry. A total of 1995 (11%) of the surgically treated patients with hip fracture were excluded as a result of missing anesthesia information. The final study sample consisted of 16,695 patients. Of these, 2027 (12%) died and 98 (< 1%) terminated membership during followup, which were handled as competing events and censoring events, respectively. Ninety-day mortality, emergency department returns, hospital readmission, deep vein thrombosis (DVT) or pulmonary embolism (PE), myocardial infarction (MI), and pneumonia were evaluated using multivariable competing risk proportional subdistribution hazard regression according to type of anesthesia technique: general anesthesia, regional anesthesia, or conversion from regional to general. Of the 16,695 patients, 58% (N = 9629) received general anesthesia, 40% (N = 6597) received regional anesthesia, and 2.8% (N = 469) patients were converted from regional to general. RESULTS Compared with regional anesthesia, patients treated with general anesthesia had a higher likelihood of overall 90-day mortality (hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.11-1.35; p < 0.001); however, when stratified by before and after hospital discharge but within 90 days of surgery, this higher risk was only observed during the inpatient stay (HR, 3.83; 95% CI, 3.18-4.61; p < 0.001); no difference was observed after hospital discharge (HR, 1.04; 95% CI, 0.94-1.16; p = 0.408). Patients undergoing conversion from regional to general also had a higher overall mortality risk compared with those undergoing regional anesthesia (HR, 1.34; 95% CI 1.04-1.74; p = 0.026), but this risk was only observed during their inpatient stay (HR, 6.84; 95% CI, 4.21-11.11; p < 0.001) when stratifying by before and after hospital discharge. Patients undergoing general anesthesia had a higher risk for all-cause readmission when compared with regional anesthesia (HR, 1.09; 95% CI, 1.01-1.19; p = 0.026). No differences according to anesthesia type were observed for risk of 90-day AHRQ outcomes, including DVT/PE, MI, and pneumonia. CONCLUSIONS We found the use of general anesthesia and conversion from regional to general anesthesia were associated with a higher risk of mortality during the in-hospital stay compared with regional anesthetic techniques, but this higher risk did not persist after hospital discharge. We also found general anesthesia to be associated with a higher risk of all-cause readmission compared with regional, but no other differences were observed in risk for complications. Our findings suggest regional anesthetic techniques may be preferred when possible in this patient population. LEVEL OF EVIDENCE Level III, therapeutic study.
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Impact of Anesthesia on Hospital Mortality and Morbidities in Geriatric Patients Following Emergency Hip Fracture Surgery. J Orthop Trauma 2018; 32:116-123. [PMID: 29461445 DOI: 10.1097/bot.0000000000001035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the impact of anesthesia type on in-hospital mortality and morbidity for geriatric fragility hip fracture surgery. DESIGN Retrospective cohort study. SETTING Integrates health care delivery system across 38 facilities in the United States. PATIENTS/PARTICIPANTS We identified 16,695 patients 65 years of age and older who underwent emergent hip fracture repairs between 2009 and 2014 through the Kaiser Permanente hip fracture registry and excluded pathologic or bilateral fractures. INTERVENTION Hip fracture surgery with general or regional anesthesia. MAIN OUTCOMES MEASURES Data on in-hospital mortality, time to death, discharge disposition, and length of stay (LOS) were analyzed among the following anesthesia types: general anesthesia (GA), regional anesthesia (RA), and intraoperative conversions from regional to general (Cv). RESULTS Compared with RA, the hazard ratio for GA for in-hospital mortality was 1.38 and 2.23 for the Cv group; the time ratio for GA-associated time to death was 0.97 and 0.89 for the Cv group. The GA-associated time ratio for LOS before discharge was 1.01, and the hazard ratio for home discharge was 0.86, but no significance was found with the Cv group. CONCLUSIONS RA may offer advantages over GA for fragility hip fracture surgeries when possible. In-hospital mortality, time to death, increased LOS, and discharge to an institute rather than home were all adversely influenced by GA. Furthermore, the previously understudied Cv group demonstrated adverse outcomes for in-hospital mortality and time to death. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Prieto-Alhambra D, Reyes C, Sainz MS, González-Macías J, Delgado LG, Bouzón CA, Gañan SM, Miedes DM, Vaquero-Cervino E, Bardaji MFB, Herrando LE, Baztán FB, Ferrer BL, Perez-Coto I, Bueno GA, Mora-Fernandez J, Doñate TE, Blasco JMI, Aguado-Maestro I, Sáez-López P, Doménech MS, Climent-Peris V, Rodríguez ÁD, Sardiñas HK, Gómez ÓT, Serra JT, Caeiro-Rey JR, Cano IA, Carsi MB, Etxebarria-Foronda I, Hernández JDA, Solis JR, Suau OT, Nogués X, Herrera A, Díez-Perez A. In-hospital care, complications, and 4-month mortality following a hip or proximal femur fracture: the Spanish registry of osteoporotic femur fractures prospective cohort study. Arch Osteoporos 2018; 13:96. [PMID: 30218380 PMCID: PMC6153683 DOI: 10.1007/s11657-018-0515-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/31/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED We have characterised 997 hip fracture patients from a representative 45 Spanish hospitals, and followed them up prospectively for up to 4 months. Despite suboptimal surgical delays (average 59.1 hours), in-hospital mortality was lower than in Northern European cohorts. The secondary fracture prevention gap is unacceptably high at 85%. PURPOSE To characterise inpatient care, complications, and 4-month mortality following a hip or proximal femur fracture in Spain. METHODS Design: prospective cohort study. Consecutive sample of patients ≥ 50 years old admitted in a representative 45 hospitals for a hip or proximal femur fragility fracture, from June 2014 to June 2016 and followed up for 4 months post-fracture. Patient characteristics, site of fracture, in-patient care (including secondary fracture prevention) and complications, and 4-month mortality are described. RESULTS A total of 997 subjects (765 women) of mean (standard deviation) age 83.6 (8.4) years were included. Previous history of fracture/s (36.9%) and falls (43%) were common, and 10-year FRAX-estimated major and hip fracture risks were 15.2% (9.0%) and 8.5% (7.6%) respectively. Inter-trochanteric (44.6%) and displaced intra-capsular (28.0%) were the most common fracture sites, and fixation with short intramedullary nail (38.6%) with spinal anaesthesia (75.5%) the most common procedures. Surgery and rehabilitation were initiated within a mean 59.1 (56.7) and 61.9 (55.1) hours respectively, and average length of stay was 11.5 (9.3) days. Antithrombotic and antibiotic prophylaxis were given to 99.8% and 98.2% respectively, whilst only 12.4% received secondary fracture prevention at discharge. Common complications included delirium (36.1 %) and kidney failure (14.1%), with in-hospital and 4-month mortality of 2.1% and 11% respectively. CONCLUSIONS Despite suboptimal surgical delay, post-hip fracture mortality is low in Spanish hospitals. The secondary fracture prevention gap is unacceptably high at > 85%, in spite of virtually universal anti-thrombotic and antibiotic prophylaxis.
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Affiliation(s)
- Daniel Prieto-Alhambra
- GREMPAL (Grup de Recerca en Epidemiologia de les Malalties Prevalents de l’Aparell Locomotor) Research Group, CIBERFES, IDIAP Jordi Gol (Universitat Autònoma de Barcelona) and Instituto de Salud Carlos III, Av Gran Via de les Corts Catalanes, 587, Atic, 08007 Barcelona, Spain ,Musculoskeletal Pharmaco and Device Epidemiology – Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD UK ,Musculoskeletal Research Unit, IMIM-Parc Salut Mar, CIBERFES, Universitat Autònoma de Barcelona, Doctor Aiguader 88, 08003 Barcelona, Spain
| | - Carlen Reyes
- GREMPAL (Grup de Recerca en Epidemiologia de les Malalties Prevalents de l’Aparell Locomotor) Research Group, CIBERFES, IDIAP Jordi Gol (Universitat Autònoma de Barcelona) and Instituto de Salud Carlos III, Av Gran Via de les Corts Catalanes, 587, Atic, 08007 Barcelona, Spain
| | - Miguel Sanz Sainz
- IIS Aragón (Instituto de Investigación Sanitaria de Aragón), Hospital Universitario Miguel Servet, Padre Arrupe, s/n, 50009 Zaragoza, Spain
| | - Jesús González-Macías
- IDIVAL (Instituto de Investigación Marqués de Valdecilla), HUMV (Hospital Universitario Marqués de Valdecilla), UC (Universidad de Cantabria), Av de Valdecilla sn, 39011 Santander, Cantabria Spain
| | - Luis Gracia Delgado
- Hospital Universitario Reina Sofía de Cordoba, Av Menendez Pidal, 14004 Córdoba, Spain
| | - Cristina Alonso Bouzón
- Geriatric Unit, Hospital Universitario de Getafe, Carr. De Madrid – Toledo, Km 12,500, 28905 Getafe, Madrid Spain
| | - Sarah Mills Gañan
- Traumatology and Orthopaedics Unit, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain
| | | | | | | | - Laura Ezquerra Herrando
- F.E.A of the Traumatology and Orthopaedics Unit, Hospital Clínico Universitario Lozano Blesa, Av. San Juan Bosco, 15, 50009 Zaragoza, Spain
| | - Fátima Brañas Baztán
- Geriatric Unit, Hospital Universitario Infanta Leonor, Gran Vía del Este, 80, 28031 Madrid, Spain
| | - Bartolomé Lladó Ferrer
- Hospital Son Llàtzer, Carretera de Manacor, PQ 4 (Son Ferriol), 07198 Palma de Mallorca, Spain
| | - Ivan Perez-Coto
- Hospital Universitario San Agustín, Camino de Heros, 6, 33401 Avilés, Asturias Spain
| | - Gaspar Adrados Bueno
- Internal Medicine Unit, Hospital Infanta Cristina, Av. de Elvas, s/n, 06080 Badajoz, Spain
| | - Jesús Mora-Fernandez
- Geriatric Unit, Hospital Clínico San Carlos, calle Prof. Martín Lagos s/n, 28040 Madrid, Spain
| | | | | | | | - Pilar Sáez-López
- Hospital Universitario Fundación Jiménez Díaz, IdiPAZ (Instituto de Investigación del Hospital La Paz), Madrid, Spain
| | - Monica Salomó Doménech
- Corporación sanitaria Universitaria Parc Tauli, Parc Taulí, 1, 08208 Sabadell, Barcelona Spain
| | - Vicente Climent-Peris
- Traumatology and Orthopaedics Unit, Hospital Públic Lluis Alcanyis de Xàtiva, Carretera Xátiva-Silla, Km 2, 46800 Xàtiva, Valencia Spain
| | - Ángel Díez Rodríguez
- Traumatology and Orthopaedics Unit, Hospital Virgen del Puerto, Paraje Valcorchero, 10600 Plasencia, Cáceres Spain
| | - Humberto Kessel Sardiñas
- Geriatric Care Unit, Complejo Hospitalario Torrecárdenas, Calle Hermandad de Donantes de Sangre, 04009 Almería, Spain
| | - Óscar Tendero Gómez
- Hospital Universitari Son Espases, Carr. de Valldemossa, 79, 07120 Palma, Islas Baleares Spain
| | - Jordi Teixidor Serra
- Hospital Universitari Vall de Hebron, Passeig de la Vall d’Hebron, 119-129, 08035 Barcelona, Spain
| | - José Ramón Caeiro-Rey
- Traumatology and Orthopaedics Unit, Complejo Hospitalario Universitario de Santiago de Compostela, Rúa da Choupana, s/n, 15706 Santiago de Compostela, A Coruña Spain
| | | | - Mariano Barrés Carsi
- Hospital Universitari i Politècnic La Fe, Av de Fernando Abril Martorell, 106, 46026 València, Spain
| | | | - Juan Dionisio Avilés Hernández
- Orthogeriatric Unit, Hospital Clínico Universitario Virgen de Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El Palmar, Murcia Spain
| | - Juan Rodriguez Solis
- Geriatric Unit, Hospital Universitario de Guadalajara, Calle Donante de Sangre, s/n, 19002 Guadalajara, Spain
| | - Oscar Torregrosa Suau
- Bone Metabolism Unit, Internal Medicine Unit, Hospital General Universitari d’Elx, Carrer Almazara, 11, 03203 Elche, Alicante Spain
| | - Xavier Nogués
- Internal Medicine Department IMIM (Hospital del Mar Medical Research), CIBER FES ISCIII, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Antonio Herrera
- Department of Surgery, Aragón Health Research Institute, University of Zaragoza, Zaragoza, Spain
| | - Adolfo Díez-Perez
- Musculoskeletal Research Unit, IMIM-Parc Salut Mar, CIBERFES, Universitat Autònoma de Barcelona, Doctor Aiguader 88, 08003 Barcelona, Spain
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Okike K, Chan PH, Paxton EW. Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Hip Fracture. J Bone Joint Surg Am 2017; 99:1547-1553. [PMID: 28926384 DOI: 10.2106/jbjs.16.01133] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prior studies have examined the relationship between surgeon and hospital volumes and outcome following hip fracture surgical procedures, but the results have been inconclusive. The purpose of this study was to assess the hip fracture volume-outcome relationship by analyzing data from a large, managed care registry. METHODS The Kaiser Permanente Hip Fracture Registry prospectively records information on surgically treated hip fractures within the managed health-care system. Using this registry, all surgically treated hip fractures in patients 60 years of age or older were identified. Surgeon and hospital volume were defined as the number of hip fracture surgical procedures performed in the preceding 12 months and were divided into tertiles (low, medium, and high). The primary outcome was mortality at 1 year postoperatively. Secondary outcomes were mortality at 30 and 90 days postoperatively as well as reoperation (lifetime), medical complications (90-day), and unplanned readmission (30-day). To determine the relationship between volume and these outcome measures, multivariate logistic and Cox proportional hazards regression were performed, controlling for potentially confounding variables. RESULTS Of 14,294 patients in the study sample, the majority were female (71%) and white (79%), and the mean age was 81 years. The overall mortality rate was 6% at 30 days, 11% at 90 days, and 21% at 1 year. We did not find an association between surgeon or hospital volume and mortality at 30 days, 90 days, or 1 year (p > 0.05). There was also no association between surgeon or hospital volume and reoperation, medical complications, or unplanned readmission (p > 0.05). CONCLUSIONS In this analysis of hip fractures treated in a large integrated health-care system, the observed rates of mortality, reoperation, medical complications, and unplanned readmission did not differ by surgeon or hospital volume. In contrast to other orthopaedic procedures, such as total joint arthroplasty, our data do not suggest that hip fractures need to be preferentially directed toward high-volume surgeons or hospitals for treatment. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kanu Okike
- 1Department of Orthopaedics, Kaiser Moanalua Medical Center, Honolulu, Hawaii 2Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
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Prentice HA, Paxton EW, Hunt JJ, Grimsrud CD, Weiss JM. Pediatric Hip Fractures in California: Results from a Community-Based Hip Fracture Registry. Perm J 2017; 21:16-081. [PMID: 28241902 DOI: 10.7812/tpp/16-081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
CONTEXT Hip fracture registries offer an opportunity to identify and to monitor patients with rare conditions and outcomes, including hip fractures in pediatric patients. OBJECTIVE To report patient demographics and surgical outcomes of pediatric patients treated surgically for hip fractures in a large integrated health care system. DESIGN Pediatric patients (< 21 years old at the time of fracture) with hip fractures were identified between 2009 and 2012 using our health care system's hip fracture registry. MAIN OUTCOME MEASURES Patient characteristics, type of fracture, surgical treatment, and short-term complications. RESULTS Among 39 patients identified, 31 (79.5%) were male, and the median age was 15 years old (interquartile range: 11-17 years). Most patients were Hispanic (n = 17, 43.6%) or white (n = 14, 35.9%). There were 8 patients (20.5%) with 15 comorbidities. Delbet Type IV (intertrochanteric) fractures were the most common fracture type (n = 22, 56.4%), and fixation method was equally distributed between intramedullary, screw and sideplate, and screws (n = 12, 30.8% for each). Most surgeries were performed by medium-volume surgeons (n = 22, 56.4%) at medium- and high-volume hospitals (n = 37, 94.9%). Three 90-day readmissions (7.7%), 1 infection (2.6%), 1 malunion (2.6%), and 1 revision (2.6%) were observed in this cohort during the study period. CONCLUSION In our series using registry data, hip fractures younger than age 21 years were more common in boys and Hispanic patients. Intertrochanteric fractures (Delbet Type IV) were the most frequently observed type in our community-based hip fracture registry. Short-term complications were infrequent.
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Affiliation(s)
- Heather A Prentice
- Research Scientist I Investigator in Surgical Outcomes and Analysis for the Southern California Permanente Medical Group in San Diego.
| | - Elizabeth W Paxton
- Director of Surgical Outcomes and Analysis for the Southern California Permanente Medical Group in San Diego.
| | - Jessica J Hunt
- Research Associate II in Surgical Outcomes and Analysis for the Southern California Permanente Medical Group in San Diego.
| | | | - Jennifer M Weiss
- Orthopedic Surgeon at the Sunset Medical Center in Los Angeles, CA.
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Muñoz-Pascual A, Sáez-López P, Jiménez-Mola S, Sánchez-Hernández N, Alonso-García N, Andrés-Sainz AI, Macias-Montero MC, Vázquez-Pedrezuela C, Pereira de Castro Juez N, Del Pozo-Tagarro P, Pablos-Hernández C, Cervera-Díaz C, Cerón-Fernández A, Vuelta-Calzada E, Perez-Jara Carrera J, González-Ramírez A, Collado-Díaz T, Idoate-Gil J, Guerrero-Díaz MT, Gutierrez-Bejarano D, Martín-Perez E. [Orthogeriatrics: The First multicentre regional register of hip fractures in Castilla y León (Spain)]. Rev Esp Geriatr Gerontol 2017; 52:242-248. [PMID: 28522074 DOI: 10.1016/j.regg.2017.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 02/12/2017] [Accepted: 03/13/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of this study is to describe the characteristics of the patients with hip fracture admitted to the Public Hospitals of Castilla y León during three monthly periods (November 2014, and October and November 2015). MATERIAL AND METHOD The Castilla y León orthogeriatrics work group created a common register to collect data on hip fractures. The study included patients 75 years-old and over hospitalised with hip fractures in the 13 public hospitals in the community during November 2014, and October and November 2015. A multicentre, prospective, and observational study was conducted, in which clinical, functional, and social variables, as well as in-hospital mortality, were collected. RESULTS The analysis included data from a total of 776 patients with a mean age of 86 (±6) years. The surgical delay was 4±2.8 days, and the mean hospital stay was 10±4.7 days. The anaesthesia risk was ASA 3±0.6. Around two-thirds (66.5%) of the patients had medical complications while in hospital, and 55.5% required a transfusion. In-hospital mortality was 4.6%. The mean pre-surgical stay was related to the overall stay: P<.001. CONCLUSIONS Hip fracture registers are an essential tool for evaluating the process and for improving the treatment quality of these patients. This is the first multicentre register of hip fracture in the elderly created in a Spanish region, and could be a good precedent reference for a future national register.
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Affiliation(s)
| | - Pilar Sáez-López
- Unidad de Geriatría, Complejo Asistencial de Ávila, Ávila, España; Instituto de Investigación Hospital Universitario La Paz, Fundación Idi Paz, Ávila, España.
| | - Sonia Jiménez-Mola
- Unidad de Geriatría, Complejo Asistencial Universitario de León, León, España
| | | | | | | | | | | | | | | | | | - Carmen Cervera-Díaz
- Unidad de Geriatría, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | | | | | | | | | | | - Javier Idoate-Gil
- Unidad de Geriatría, Complejo Asistencial Universitario de León, León, España
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Maghbooli Z, Hossein-Nezhad A, Jafarpour M, Noursaadat S, Ramezani M, Hashemian R, Moattari S. Direct costs of osteoporosis-related hip fractures: protocol for a cross-sectional analysis of a national database. BMJ Open 2017; 7:e014898. [PMID: 28400460 PMCID: PMC5775462 DOI: 10.1136/bmjopen-2016-014898] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION It is estimated that Iran accounted for about 1% of hip fracture burden of the world in 2007, but these data are based on incomplete evidence. As the country's population is ageing, it is expected that a dramatic rise in hip fracture incidence will result. There is no single national study that accurately estimates the incidence of all hip fractures in the country or identifies the direct costs for affected patients. To help fill this gap, the current study has been designed to determine the incidence of hip fracture associated with osteoporosis in the Iranian population and to assess the direct costs involved. METHODS AND ANALYSIS This is a cross-sectional analysis of 2 years of hospital admissions due to hip fracture in Iran from October 2014 to October 2016 using an electronic health record called SEPAS. SEPAS is a nationwide health information system established by Information Technology (IT) and the Statistics Department of the Ministry of Health. SEPAS has recorded more than 8.5 million inpatient hospitalizations since October 2014. Our study will identify reported hip fracture data in SEPAS among admitted adult hospital patients aged ≥50 in Iran. International Classification of Diseases ICD-9 and 10 will be used as diagnostic codes. Study factors are demographic data, types of fracture, types of treatment, duration of admission, early complications, in-hospital mortality and direct cost of fracture treatment. The accuracy of the SEPAS fracture data will be ascertained through a pilot study that compares the SEPAS data with the data directly extracted from medical records of the Shariati Hospital in Tehran during the study period. ETHICS AND DISSEMINATION The study protocol was approved by the Ethics Committee of the National Institute for Medical Research Development of Iran. Dissemination plans include academic publications, conference presentations and social media.
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Affiliation(s)
- Zhila Maghbooli
- Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Hossein-Nezhad
- Department of Medicine, Section of Endocrinology, Nutrition, and Diabetes, Vitamin D, Skin and Bone Research Laboratory, Boston University Medical Campus, Boston, Massachusetts, USA
| | - Maryam Jafarpour
- Statistics and Information Technology, Ministry of Health and Medical Education, Tehran, Iran
| | - Sima Noursaadat
- Statistics and Information Technology, Ministry of Health and Medical Education, Tehran, Iran
| | - Majid Ramezani
- Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences, Tehran, Iran
| | - Roxana Hashemian
- Boston University School of Dental Medicine, Boston, Massachusetts, USA
| | - Syamak Moattari
- Department of Health Sciences, Worcester State University, Worcester, Massachusetts, USA
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Sáez-López P, Brañas F, Sánchez-Hernández N, Alonso-García N, González-Montalvo JI. Hip fracture registries: utility, description, and comparison. Osteoporos Int 2017; 28:1157-1166. [PMID: 27872956 DOI: 10.1007/s00198-016-3834-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 11/03/2016] [Indexed: 12/30/2022]
Abstract
UNLABELLED Hip fractures (HF) are prevalent and involve high morbidity and mortality so improving their management is important. HF registries are a good way to improve knowledge about this condition and its quality of care, while at the same time reducing clinical variability, optimizing efficiency, improving outcomes, and reducing costs. INTRODUCTION Hip fractures (HF) are a prevalent fragility fracture secondary to osteoporosis that involves high morbidity and mortality. They are low-impact fractures, resulting from a fall from a standing or sitting height. Despite numerous Clinical Practice Guidelines that establish uniform recommendations for their care, great variability persists regarding clinical and healthcare outcomes. Fracture registries can help detect deficits and establish measures to improve care. The objective of this work is to analyze the contents that a HF registry should have and to compare the characteristics of some national HF registries. METHODS A literature search was conducted on several national hip fracture registries, and those that contain relevant information on the variables and their outcomes were selected. RESULTS The selected HF registries were compared using the parameters they measure as well as the outcomes in the different countries. The variables collected in the majority of the databases and those that give useful information are as follows: sociodemographic variables (age, sex, place of residence), clinical variables (function before and after HF, anesthesia risk as measured by the ASA score, type of fracture, type of surgery and anesthesia, and in-hospital and 1-month mortality), and healthcare variables (pre-operative and overall stay, presence of collaboration with orthogeriatrics or with any clinician in addition to the surgeon, secondary prevention of new fractures by assessing the fall risk, and need for osteoporosis treatment). CONCLUSION The recording of HF cases in different countries improves knowledge about handling this condition and its quality of care, while at the same time reducing clinical variability, optimizing efficiency, improving outcomes, and reducing costs. The debate on the variables that should be recorded is timely, such as organizing how to collect each measurement, and even trying to unify the national and international registries or using a current proposal such as the one from the Fragility Fracture Network.
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Affiliation(s)
- P Sáez-López
- Geriatrics Unit, Complejo Asistencial Universitario, Avila, Spain
- Orthogeriatrics Working Group of the Castilla-Leon, Cantabria, and Rioja Society of Traumatology, Complejo Asistencial Universitario, Avila, Spain
| | - F Brañas
- Geriatrics and Internal Medicine Department, Hospital Universitario Infanta Leonor, Madrid, Spain.
- Madrid Geriatrics and Gerontology Society, Madrid, Spain.
| | - N Sánchez-Hernández
- Department of Traumatology, Complejo Asistencial Universitario, Avila, Spain
| | - N Alonso-García
- Department of Traumatology, Complejo Asistencial Universitario, Avila, Spain
| | - J I González-Montalvo
- Madrid Geriatrics and Gerontology Society, Madrid, Spain
- Hospital La Paz Research Foundation, IdiPAZ, Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
- Department of Geriatrics, Hospital Universitario La Paz, Madrid, Spain
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Pitzul KB, Wodchis WP, Carter MW, Kreder HJ, Voth J, Jaglal SB. Post-acute pathways among hip fracture patients: a system-level analysis. BMC Health Serv Res 2016; 16:275. [PMID: 27430219 PMCID: PMC4950780 DOI: 10.1186/s12913-016-1524-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 07/07/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hip fractures among older adults are one of the leading causes of hospitalization and result in significant morbidity, mortality, and health care use. Guidelines suggest that rehabilitation after surgery is imperative to return patients to pre-morbid function. However, post-acute care (which encompasses rehabilitation) is currently delivered in a multitude of settings, and there is a lack of evidence with regards to which hip fracture patients should use which post-acute settings. The purpose of this study is to describe hip fracture patient characteristics and the most common post-acute pathways within a 1-year episode of care, and to examine how these vary regionally within a health system. METHODS This study took place in the province of Ontario, Canada, which has 14 health regions and universal health coverage for all residents. Administrative health databases were used for analyses. Community-dwelling patients aged 66 and over admitted to an acute care hospital for hip fracture between April 2008 and March 2013 were identified. Patients' post-acute destinations within each region were retrieved by linking patients' records within various institutional databases using a unique encoded identifier. Post-acute pathways were then characterized by determining when each patient went to each post-acute destination within one year post-discharge from acute care. Differences in patient characteristics between regions were detected using standardized differences and p-values. RESULTS Thirty-six thousand twenty nine hip fracture patients were included. The study cohort was 71.9 % female with a mean age of 82.9 (±7.5SD). There was significant variation between regions with respect to the immediate post-acute discharge destination: four regions discharged a substantially higher proportion of their patients to inpatient rehabilitation compared to all others. However, the majority of patient characteristics between those four regions and all other regions did not significantly differ. There were 49 unique post-acute pathways taken by patients, with the largest proportion of patients admitted to either community-based or short-term institutionalized rehabilitation, regardless of region. CONCLUSIONS The observation that similar hip fracture patients are discharged to different post-acute settings calls into question both the appropriateness of care delivered in the post-acute period and health system expenditures. As policy makers continue to develop performance-based funding models to increase accountability of institutions in the provision of quality care to hip fracture patients, ensuring patients receive appropriate rehabilitative care is a priority for health system planning.
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Affiliation(s)
- Kristen B. Pitzul
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
| | - Walter P. Wodchis
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario M561V7 Canada
| | - Michael W. Carter
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Department of Mechanical and Industrial Engineering, University of Toronto, 5 King’s College Road, Toronto, Ontario M5S3G8 Canada
| | - Hans J. Kreder
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Department of Surgery, University of Toronto, 2075 Bayview Avenue., MG-365, Toronto, Ontario M4N3M5 Canada
| | - Jennifer Voth
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario M561V7 Canada
| | - Susan B. Jaglal
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario M561V7 Canada
- />Department of Physical Therapy, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
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Giannoulis D, Calori GM, Giannoudis PV. Thirty-day mortality after hip fractures: has anything changed? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2016; 26:365-70. [PMID: 26943870 PMCID: PMC4856719 DOI: 10.1007/s00590-016-1744-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 01/21/2016] [Indexed: 12/26/2022]
Abstract
Bone density insufficiency is the main cause for significant musculoskeletal trauma in the elderly population following low-energy falls. Hip fractures, in particular, represent an important public health concern taking into account the complicated needs of the patients due to their medical comorbidities as well as their rehabilitation and social demands. The annual cost for the care of these patients is estimated at around 2 billion pounds (£) in the UK and is ever growing. An increased early and late mortality rate is also recognised in these injuries together with significant adversities for the patients. Lately, in order to improve the outcomes of this special cohort of patients, fast-track care pathways and government initiatives have been implemented. It appears that these measures have contributed in a steady year-by-year reduction of the 30-day mortality rates. Whether we have currently reached a plateau or whether an ongoing reduction in mortality rates will continue to be observed is yet to be seen.
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Affiliation(s)
- Dionysios Giannoulis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds, UK
| | - Giorgio M Calori
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Milan, Milan, Italy
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds, UK.
- NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, LS7 4SA, UK.
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Brox WT, Chan PH, Cafri G, Inacio MCS. Similar mortality with general or regional anesthesia in elderly hip fracture patients. Acta Orthop 2016; 87:152-7. [PMID: 26986550 PMCID: PMC4812077 DOI: 10.3109/17453674.2015.1128781] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE There is continuing confusion among practitioners with regard to the optimal choice of anesthetic type for repair of hip fractures. We investigated whether type of anesthetic was associated with short-term mortality after hip fracture surgery. PATIENTS AND METHODS We conducted a retrospective cohort study of patients with surgically treated hip fractures, performed between January 1, 2009 and December 31, 2012. Exposure of interest was anesthesia type (general, spinal/neuroaxial, and mixed). Endpoints were 30-, 90-, and 365-day post-surgery mortality. Multivariable conditional logistic regression models were used and odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS Of the 7,585 participants, 5,412 (71%) were women and the median age was 80 (IQR: 72-85) years old. Of the total cohort, 4,257 (56%) received general anesthesia, 3,059 (40%) received spinal/neuroaxial, and 269 (4%) received mixed anesthesia. Overall, the incidence of 30-, 90-, and 365-day mortality was 4% (n = 307), 8% (n = 583), and 15% (n = 1,126), respectively. When compared with general anesthesia, the 365-day odds of mortality was marginally lower in patients with spinal/neuroaxial anesthesia (OR = 0.84, CI: 0.70-1.0), but it was similar in patients with mixed anesthesia (OR = 1.3, CI: 0.70-2.3). No other statistically significant differences were observed. INTERPRETATION Regarding mortality, this study does not support specific recommendations regarding the type of anesthetic in surgery of fractured hips.
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Affiliation(s)
| | - Priscilla H Chan
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, CA
| | - Guy Cafri
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, CA
| | - Maria C S Inacio
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, CA
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