Benchmarking institutional geriatric hip fracture management: a prelude to a care quality improvement initiative

BACKGROUND

Fractures around the hip in older adults have increased in the last two decades, and the numbers are projected to rise over the next 30 years with estimates that half of them will occur in Asia. Proximal hip fractures should be operated within 48 h of injury to prevent poor outcomes. This study aims to benchmark current hip fracture care using quality improvement tools of care structure, care processes, and outcomes in a tertiary care hospital in Eastern India and determine the evidence-practice gaps and barriers to implementing the six best practices that reduce mortality and morbidity in fragility hip fractures.

METHODS

A total of 101 consecutive patients above 50 years of age with proximal femoral fractures after a trivial fall were included. Patients were divided into two groups: those operated within [Group A] and beyond [Group B] 72 h of admission. Care structure assessment included delays in admission, delay in surgery, and anesthesia risk grading. Care processes included the type of surgery performed and postoperative complications. The primary outcomes were the 30-day and 1-year mortality and the secondary outcomes included the length of stay, mobility at 6 months, return to pre-fracture independence, activity limitations, pressure sores, and readmission to the hospital.

RESULTS

Group A comprised 26 individuals, and the remaining 75 were in Group B. There were two deaths in Group A as compared to one death in Group B at 30 days; however, there were no new deaths at 1 year in Group A and 14 deaths in Group B (p = 0.187). Group B had lengthier hospital stays, poorer mobility, and higher physical and mental difficulties. No patients had re-operation on the initial fracture.

CONCLUSION

This study emphasizes the importance of early admission and fast provision of surgical fixation to reduce mortality and morbidity. Benchmarking institutional practices allows for defining the evidence-practice gaps and barriers to best practice implementation. This is an essential step to begin care quality improvement for geriatric patients with proximal femur fragility fractures.

Dual Mobile Total Hip Replacement in Super Obesity: A Case Report and Review of Literature

Introduction:

More than 13 million people in the US are morbidly obese. It is associated with various medical and anesthetic complications. Higher rate of dislocation in total hip replacement (THR) associated with morbid obesity due to thigh girth, low muscle mass and high-fat content. Morbid obesity is associated with a 38% increase in the 10-year mortality rate compare to non-obese after undergoing primary total hip arthroplasty (THA). Hip dislocation after THR is one of the earliest complications, and for every ten-point increase in BMI, the risk of dislocation increases by 113.9%.

Case Report:

We present a case report of a 69-year-old super-obese woman with a BMI of 62.2, who presented with repeated dislocation post THR. The patient was managed successfully with implant removal and implantation of dual mobile THR prosthesis.

Conclusion:

Morbid obesity with a need for arthroplasty is challenging. It needs proper planning, thorough preoperative preparation, proper intraoperative care and identification with adequate post-operative complications management. Preoperative bariatric surgery, dual mobile liner and constrained implants have shown good result in decreasing dislocation rate. The liner of dual mobile THR is efficient to prevent post-operative dislocation in morbidly obese and super-obese patients.

Metastatic Adenocarcinoma of Lungs, Mimicking Primary Scapular Tumor: A Case Report and Review of Literature

Introduction:

Cancer metastasis to the scapula and tibia is an infrequent clinical presentation. Lung cancer is one of the leading causes of death in the world. Around 80–85% of lung cancer are non-small cell lung cancer and around 30–35% of them are adenocarcinoma which metastasize to bone. Scapular metastasis is a rare event and presents with bone pain.

Case Report:

In this case report of 56-year-old male, presented with swelling to the scapula as a first symptom followed by swelling in the tibia. On further investigation, it was found to be multiple metastasis primaries as an adenocarcinoma of the lung. He was managed with palliative chemotherapy, which enhanced the patient’s quality of life, slowing down the disease process and clinical improvement.

Conclusion:

Lung cancer is the most common cancer which is progressing rapidly and spreading commonly to bones. When patients present with a mass or any suspicion of tumor, careful clinical examination and diagnostic tools often catch malignancy.

A Giant Cell Tumor of the Distal Femur Managed by Excision and Knee Arthrodesis Using a Custom Made Long Intramedullary Interlocking Nail: A Case Report and Review of the Literature

Giant cell tumors (GCTs) are primary bone tumors that occur most commonly in long bones, with half such tumors occurring in the distal femur, proximal tibia, and fibula. Around 12% of patients present with a pathological fracture indicating more aggressive disease. Arthrodesis after tumor resection is a popular choice due to its affordability and early postoperative mobilization, as well as low risks of implant loosening, infections, malignant lesions, or mortality. A free fibular graft is a popular option in limb-sparing surgery for long bone tumors. A bone graft and nail can be used to reconstruct long bones and bridge defects up to 25 cm. In developing countries, the cost of the imported mega prosthesis, around 8,500 US$, means many patients cannot afford the treatment. We describe a case of a GCT of the distal femur treated by excision of the tumor and reconstruction using a fibular bone graft, with knee arthrodesis using a custom-made long intramedullary interlocking nail fixation across the femur to the knee and the tibia. The length was achieved with 1 cm shortening post-surgery. The result was satisfactory, and partial weight-bearing was allowed three months after the surgery. At the one-year follow-up, there was no recurrence, and the patient had the full weight-bearing ability.