RESUMEN
BACKGROUND: It is a common preconception that young individuals sustaining hip fractures have alcohol and/or drug use disorder. It is important to evaluate the actual use to avoid complications and plan the rehabilitation. AIM: The primary objective was to assess alcohol and drug consumption in hip fracture patients <60 years using the validated Alcohol Use Disorders Identification Test (AUDIT) and Drug Use Disorders Identification Test (DUDIT) scores. We secondarily investigated the agreement between the instruments and the physicians' clinical evaluation of usage. MATERIAL AND METHODS: This is a sub-study of 91 women and 127 men from a multicenter cohort study of patients with an acute hip fracture treated at four hospitals in Denmark and Sweden. AUDIT and DUDIT forms were completed by the patients. In addition, the researchers made an evaluation of the patients' alcohol/drug use based on direct patient contact and information on previous alcohol/drug use from medical charts. AUDIT ranges 0-40 with 6 (women) and 8 (men) as the cut-off for hazardous use. DUDIT ranges 0-44 with cut-offs of 2 and 6 indicating drug-related problems. RESULTS: According to the AUDIT, 29 % of the patients had a hazardous alcohol use (25 % women, 31 % men), whilst the clinical evaluation identified 26 % (24 % women, 28 % men). However, there was a low agreement between "the clinical eye" and AUDIT, as the clinical evaluation only correctly identified 35 of 56 individuals with AUDIT-scores indicating hazardous alcohol use. DUDIT equaled drug related problems in 8 % (5 % women, 10 % men), the clinical evaluation depicted 8 % with drug related problems (4 % women, 10 % men). The agreement was low between "the clinical eye" and DUDIT; only 7 of 15 with DUDIT-scores indicating drug related problems were correctly identified. CONCLUSION: Hazardous alcohol consumption is more common in non-elderly hip fracture patients than in the general population. Considering both self-reported alcohol use and clinical evaluation, women have almost as high rate as men. DUDIT indicated drug related problems to be slightly more common than in the population. Still, a majority did not exhibit troublesome use of neither alcohol nor drugs. The two screening methods do not identify the same individuals, and further investigation in clinical practice is needed.
RESUMEN
BACKGROUND AND PURPOSE: Limited research has been conducted on basicervical femoral neck fractures (bFNFs). The importance of displacement in clinical outcomes remains unclear. We aimed to characterize patient demographics, degree of displacement, treatment, treatment failures, and reoperations in a cohort of fractures from the Swedish Fracture Register (SFR). METHODS: 1,260 fractures in 1,185 individuals ≥ 60 years who had a bFNF registered in the SFR at 6 orthopedic departments from 2011 to 2020 were screened through radiographic review. The final sample included 291 patients with a confirmed bFNF. The medical records of these 291 patients were reviewed. We assessed baseline characteristics, initial fracture dislocation, treatment methods, tip-apex distance, failures, reoperations, and mortality. RESULTS: The mean age was 82 years (range 60-101, 55% women). 98 (34%) were undisplaced and 193 (66%) displaced. All patients underwent operative treatment. In the undisplaced group 95 (97%) patients received internal fixation (IF) and 3 (3%) had primary hip arthroplasty. In the displaced group 149 (77%) received IF and 41 (21%) had primary hip arthroplasty. 33 (11%) suffered treatment failure. When treating an undisplaced bFNF with IF, only 3 (3%) experienced treatment failure, in contrast to the 24 (16%) failure rate for a displaced bFNF. CONCLUSION: Undisplaced bFNFs have a low failure rate when treated with IF. For displaced bFNF treated with IF the failure rate is considerably higher. There is a need for further investigation of classification, treatment, and outcome of bFNF.
Asunto(s)
Fracturas del Cuello Femoral , Fijación Interna de Fracturas , Sistema de Registros , Humanos , Fracturas del Cuello Femoral/cirugía , Fracturas del Cuello Femoral/diagnóstico por imagen , Masculino , Femenino , Suecia/epidemiología , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Fijación Interna de Fracturas/métodos , Reoperación/estadística & datos numéricos , Artroplastia de Reemplazo de Cadera/métodos , Insuficiencia del TratamientoRESUMEN
Aims: Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately. Methods: We retrieved data on all patients aged ≥ 75 years with an uFNF registered in the Swedish Fracture Register from 2011 to 2018. The database was linked to the Swedish Arthroplasty Register and the National Patient Register to obtain information on comorbidity, mortality, and reoperations. Our primary outcome, reoperation, or death at one year was analyzed using restricted mean survival time, which gives the mean time to either event for each group separately. Results: Overall, 3,909 patients presenting with uFNFs were included. Of these patients, 3,604 were treated with IF and 305 with primary arthroplasty. There were no relevant differences in age, sex, or comorbidities between groups. In the IF group 58% received cannulated screws and 39% hook pins. In the arthroplasty group 81% were treated with hemiarthroplasty and 19% with total hip arthroplasty. At one year, 32% were dead or had been reoperated in both groups. The reoperation-free survival time over one year of follow-up was 288 days (95% confidence interval (CI) 284 to 292) in the IF group and 279 days (95% CI 264 to 295) in the arthroplasty group, with p = 0.305 for the difference. Mortality was 26% in the IF group and 31% in the arthroplasty group at one year. Reoperation rates were 7.1% in the IF group and 2.3% in the arthroplasty group. Conclusion: In older patients with a uFNF, reoperation-free survival at one year seems similar, regardless of whether IF or arthroplasty is the primary surgery. However, this comparison depends on the choice of follow-up time in that reoperations were more common after IF. In contrast, we found more early deaths after arthroplasty. Our study calls for a randomized trial comparing these two methods.
RESUMEN
BACKGROUND: It is unclear whether unipolar (UHA) or bipolar (BHA) hemiarthroplasty should be the preferred treatment of femoral neck fracture (FNF). AIM: We investigated the reoperation rate at 13 years post-fracture after BHA and UHA as treatment of FNF, including a subgroup analysis of individuals who survived 5 years or more, and described the reasons for reoperation after BHA and UHA respectively. METHODS: In an observational cohort study on prospectively collected national register data, 16,216 BHA and 22,186 UHA were available for matching. A propensity score for treatment with bipolar HA was estimated using logistic regression. Matching was done using the 1:1 nearest neighbor matching without replacement. Of the 16,216 BHA patients, 12,280 were matched to a UHA control. A subgroup analysis based on the matched sample excluded individuals who died within 5 years and comprised 3,637 individuals with BHA and 3,537 with UHA. Kaplan-Meier survival analysis was used. RESULTS: In the Kaplan-Meier analysis, 92% of the BHA group was free from reoperation at 13 years (95% CI 0.91-0.93), compared to 92% in the UHA group (CI 0.89-0.94). BHA was associated with more reoperations until 3 years. Reoperation due to infection was most common after BHA, n = 212 (1.7%) compared to n = 141 (1.1%) after UHA. Dislocation led to reoperation in 192 of the BHA cases (1.6%) and in 157 of the UHA cases (1.3%). Acetabular erosion/pain occurred in 0.1% and 0.4%. Amongst those surviving ≥ 5 years, 93% of the BHA group was free from reoperation (CI 0.92-0.94) at 13 years, 92% after UHA (CI 0.90-0.94). BHA had more reoperations during the 1st year only. The causes for reoperations showed similar rates except for acetabular erosion/pain. Here the BHA group had 2 cases (0.1%), the UHA had 39 (1.1%). CONCLUSION: With a modular hemiarthroplasty relatively few patients need a reoperation. During the first years, there is a higher reoperation rate after BHA compared to UHA. Thereafter, no differences are seen. In patients who survive ≥ 5 years after the fracture there are more reoperations due to acetabular erosion after UHA, but crude numbers are extremely low, and the total reoperation rate is not affected.
Asunto(s)
Hemiartroplastia , Reoperación , Humanos , Fracturas del Cuello Femoral/cirugía , Hemiartroplastia/efectos adversos , Hemiartroplastia/métodos , Dolor/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: In patients around retirement age controversy exists as to whether to treat displaced femoral neck fracture (dFNF) with internal fixation (IF) or arthroplasty. An arthroplasty in this age group may need revision due to a long expected remaining lifetime. IF carries a higher risk of early failure but a maintained native hip if healing occurs. We aimed to determine the cumulative 5-year rate of conversion to arthroplasty after IF and implant revision after primary total hip arthroplasty (THA), respectively. PATIENTS AND METHODS: In this longitudinal cohort study, patients aged 60-69 years registered with a dFNF in the Swedish Fracture Register (SFR) 2012-2018 were cross-referenced with available data from the Swedish Arthroplasty Register (SAR) until December 31, 2019. Conversion to arthroplasty or revision were analyzed utilizing competing risk, with death as competing event. RESULTS: At 5 years, the cumulative rate of conversion to arthroplasty after IF was 31% (95% confidence interval [CI] 26-37). For primary THA, the 5-year rate of revision was 4.0% (CI 2.8-5.8). The 5-year mortality did not differ, being 20% (CI 16-27) and 23% (CI 20-28) after IF and THA, respectively. Regression analyses did not identify any risk factors for conversion arthroplasty based on the variables in the register. CONCLUSION: A follow-up of 5 years catches most reoperations after IF, resulting in a 31% conversion rate. The 4% revision rate at 5 years after primary THA should be seen as an intermediate result, as late complications may occur.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Fracturas del Cuello Femoral , Humanos , Estudios Longitudinales , Fracturas del Cuello Femoral/epidemiología , Fracturas del Cuello Femoral/cirugía , Fracturas del Cuello Femoral/etiología , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/métodos , Reoperación , Resultado del TratamientoRESUMEN
BACKGROUND: Displaced olecranon fractures with a stable elbow joint are classified as Mayo type 2a or 2b and are commonly operated with tension band wiring, i.e. two K-wires and a cerclage. Retrospective studies have reported fewer reoperations and complications with cerclage fixation alone when compared to tension band wiring, though with similar long-term results. We decided to compare tension band wiring to cerclage fixation of displaced, stable olecranon fractures in adults in a randomized controlled trial. METHODS: All patients ≥ 18 years old with Mayo type 2a and 2b fractures presenting at Skåne University hospital will be eligible for study inclusion, unless exclusion criteria are met. Two hundred participants will be included and randomized 1:1 to cerclage fixation or tension band wiring. Outpatient physiotherapist follow-up appointments will be scheduled at 2 and 6 weeks and at 3, 12, and 36 months at the Dept. of Orthopaedics. A lateral view radiograph of the elbow will be analysed at 6 months. The primary outcome of our study is the rate of reoperations. Secondary outcomes are complication rates, severity of complications, and patient-reported outcome measures (QuickDASH, Short Musculoskeletal Function Assessment, pain level, and patient satisfaction). The sample size was calculated to give 80% power for detecting a statistically significant difference in reoperation rates (with alpha-value 0.05), based on a previous retrospective study. DISCUSSION: Reoperation and complication rates after tension band wiring of olecranon fractures are high. Treatment of these injuries is debated, and several ongoing trials compare tension band wiring with plate fixation, suture fixation, and non-operative treatment. As data from retrospective studies indicate that cerclage fixation may be superior to tension band wiring, we see a need for a randomized controlled trial comparing these methods. The WOW-OK Trial aims to obtain level-1 evidence that may influence treatment choice for this type of fracture. TRIAL REGISTRATION: ClinicalTrials.gov NCT05657899 . Registered on 16 November 2022. The trial complies with SPIRIT and CONSORT guidelines. The SPIRIT figure is found in Table 2.
Asunto(s)
Articulación del Codo , Fracturas Óseas , Fractura de Olécranon , Olécranon , Adulto , Humanos , Adolescente , Olécranon/diagnóstico por imagen , Olécranon/cirugía , Articulación del Codo/diagnóstico por imagen , Articulación del Codo/cirugía , Estudios Retrospectivos , Fijación Interna de Fracturas/efectos adversos , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
OBJECTIVE: To explore timing in relation to all types of adverse events (AEs), severity and preventability for patients undergoing acute and elective hip arthroplasty. DESIGN: A multicentre cohort study using retrospective record review with Global Trigger Tool methodology in combination with data from several registers. SETTING: 24 hospitals in 4 major regions of Sweden. PARTICIPANTS: Patients ≥18 years, undergoing acute or elective total or hemiarthroplasty of the hip, were eligible for inclusion. Reviews of weighted samples of 1998 randomly selected patient records were carried out using Global Trigger Tool methodology. The patients were followed for readmissions up to 90 days postoperatively throughout the whole country. RESULTS: The cohort consisted of 667 acute and 1331 elective patients. Most AEs occurred perioperatively and postoperatively (n=2093, 99.1%) and after discharge (n=1142, 54.1%). The median time from the day of surgery to the occurrence of AE was 8 days. The median days for different AE types ranged from 0 to 24.5 for acute and 0 to 71 for elective patients and peaked during different time periods. 40.2% of the AEs, both major and minor, occurred within postoperative days 0-5 and 86.9% of the AEs occurred within 30 days. Most of the AEs were deemed to be of major severity (n=1370, 65.5%) or preventable (n=1591, 76%). CONCLUSIONS: A wide variability was found regarding the timing of different AEs with the majority occurring within 30 days. The timing and preventability varied regarding the severity. Most of the AEs were deemed to be preventable and/or of major severity. To increase patient safety for patients undergoing hip arthroplasty surgery, a better understanding of the multifaceted nature of the timing of AEs in relation to the occurrence of differing AEs is needed.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Humanos , Estudios Retrospectivos , Estudios de Cohortes , Artroplastia de Reemplazo de Cadera/efectos adversos , Articulaciones , Seguridad del PacienteRESUMEN
INTRODUCTION: Female surgeons remain a minority within the field of orthopaedics, particularly in certain specialties such as arthroplasty. There is no scientific evidence on whether the surgeon's sex affects the patient-reported outcome after orthopaedic surgery such as total hip arthroplasty (THA). We therefore aimed to investigate the association between surgeon sex and health-related quality of life after THA. METHODS: Data on primary THAs performed between 2008 and 2016 were collected from 10 hospitals in western Sweden. The data were linked with the Swedish Hip Arthroplasty Register, a regional patient register and the National Board of Health and Welfare, resulting in a data set that included surgeon-related and patient-related data. The outcome of the study was the change in health-related quality of life, measured with the 3-level version of EQ-5D (EQ-5D-3L) Index and EQ-visual analog scale (VAS), before and 1-year after THA. Mixed models, using hierarchical linear regression adjusted for patient sex, age, preoperative health-related quality of life and Charnley classification, were fitted to estimate the gain in EQ-5D-3L Index and EQ-VAS with 95% confidence intervals based on surgeon sex. RESULTS: In total, 8,383 primary THAs were done for osteoarthritis by 193 surgeons. Of those, 37 were women and 156 were men. The regression model was showed that patients operated by female surgeons had a ß-coefficient of gain in EQ-5D-3L Index of -0.001 (-0.022 to 0.021) and a ß-coefficient of gain in EQ VAS of 0.004 (-0.023 to 0.030), compared with patients operated by male surgeons. Similar results were obtained in a sensitivity analysis including attendings only. DISCUSSION: Patients undergoing primary THA reported similar gain in health-related quality of life regardless of surgeon sex. Based on our results, health-related quality of life after primary THA was not associated with the sex of the operating surgeon.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Osteoartritis de la Cadera , Cirujanos , Humanos , Masculino , Femenino , Suecia , Osteoartritis de la Cadera/cirugía , Calidad de Vida , Medición de Resultados Informados por el Paciente , Sistema de RegistrosRESUMEN
PURPOSE: We aimed to illuminate the lived experiences and the path of recovery for adults sustaining a hip fracture before the age of 60. METHODS: Participants were purposively sampled from a prospective multicenter cohort study in Sweden and Denmark, and narrative interviews were conducted with 19 individuals 0.7-3.5 years after the fracture. We used a phenomenological hermeneutic method to describe the participants' expressed essential meaning. RESULTS: The experience of sustaining a hip fracture was expressed as a painful and protracted process of regaining self-confidence, function, and independence. It also implied a sense of growing old from one day to the next. Participants were afraid of new falls and fractures, resulting in an increased wariness. When expressing fears and persisting symptoms, participants described being neglected and marginalized by the healthcare system, which was perceived as non-receptive and routinely driven by a notion that hip fractures affect only the elderly. Rehabilitation targeted towards needs different from those of elderly individuals was requested. CONCLUSION: The lived experience of sustaining a hip fracture in individuals under 60 includes substantial challenges in everyday life, even up to 3.5 years after the injury. Rehabilitation pathways tailored to the needs of younger patients are requested.
Asunto(s)
Fracturas de Cadera , Humanos , Adulto , Anciano , Persona de Mediana Edad , Estudios Prospectivos , Estudios de Cohortes , Actividades Cotidianas , DolorRESUMEN
BACKGROUND AND PURPOSE: Little is known on the use of metal artifact reduction sequence (MARS) MRI to diagnose osteonecrosis of the femoral head (ONFH) after fixation of femoral neck fractures (FNF) with conventional metal implants present. We compared MARS MRI with radiography in diagnosing ONFH. Secondarily, we determined whether signs of ONFH on MARS MRI correlate with patient-reported outcomes (PROs) via Oxford Hip Score (OHS) and pain (VAS). PATIENTS AND METHODS: 30 adults under 60 years treated with internal fixation after FNF were prospectively included (2015-2018) at 2 hospitals. They were followed up with radiography and PROs at 4, 12, and 24 months and MARS MRI at 4 and 12 months. OHS < 34 or VAS pain > 20 was considered significant. RESULTS: At 12 months, 14 patients had a pathological MRI. 3 of 14 had ONFH on radiographs at 12 months, increasing to 5 at 24 months, and 4 had unfavorable PROs. 2 of 5 patients with ONFH signs on both MRI and radiography had unfavorable PROs. 1 of 10 patients with normal MRI and radiography had unfavorable 2-year PROs. 4 patients had inconsistent MRI results, of which 1 developed ONFH. 1 patient dropped out. CONCLUSION: Information from a pathological MRI was not useful, as a majority remained free from symptoms and ONFH signs on radiographs. Furthermore, PROs did not correlate with imaging results. MARS MRI findings must be better understood before being taken into clinical practice. However, a normal MARS MRI seems to be a good prognostic finding.
Asunto(s)
Fracturas del Cuello Femoral , Necrosis de la Cabeza Femoral , Adulto , Humanos , Cabeza Femoral/cirugía , Necrosis de la Cabeza Femoral/diagnóstico por imagen , Necrosis de la Cabeza Femoral/cirugía , Radiografía , Fracturas del Cuello Femoral/diagnóstico por imagen , Fracturas del Cuello Femoral/cirugía , Medición de Resultados Informados por el PacienteRESUMEN
BACKGROUND AND PURPOSE: Hip fractures should be treated based on the best available evidence and cost-effectively to optimize the outcome for this large group of frail patients. This study examined nationwide variation in surgical methods used for hip fractures. METHODS: In this cohort study 46,243 patients ≥65 years with a trochanteric hip fracture (THF) or a femoral neck fracture (FNF) registered in the Swedish Fracture Register (SFR) between 1 January 2016 and 31 December 2020 were included. Fractures were classified according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) fracture classification system. The choice of surgical methods was assessed for each fracture type to compare national variation. RESULTS: 21,312 THFs and 24,072 FNFs (67% women) with a mean age of 83 years (SD 8) were surgically treated. In the treatment of two-fragment THFs (AO/OTA A1) departments ranged from using 90% short intramedullary nails to 98% sliding hip screws. Treating displaced FNFs (AO/OTA B3), the proportion of hemiarthroplasty ranged from 9 to 90%, and internal fixation between 0.6 to 21%, depending on the department. INTERPRETATION: A mature national fracture register permits the monitoring of treatment provided and thus serves as an important aid in assessing compliance with guidelines. The large inter-departmental variation in the surgical management of hip fractures in Sweden appears unwarranted based on the current evidence, indicating a need for updated national guidelines. Further research will have to clarify the impact of this variation on mortality and re-operation rates.
Asunto(s)
Fracturas del Fémur , Fracturas del Cuello Femoral , Fijación Intramedular de Fracturas , Fracturas de Cadera , Fracturas Femorales Proximales , Humanos , Femenino , Anciano de 80 o más Años , Masculino , Estudios de Cohortes , Fracturas de Cadera/cirugía , Fracturas del Cuello Femoral/cirugía , Fijación Interna de Fracturas , Fijación Intramedular de Fracturas/métodos , Clavos Ortopédicos , Resultado del TratamientoRESUMEN
BACKGROUND: The World Health Organization recommends a minimum of 150 min of moderate intensity exercise per week or 75 min of strenuous activity weekly for adults. Younger hip fracture patients are often assumed less active than the general population, however, knowledge on physical activity (PA) and health-related quality of life (HRQoL) in younger hip fracture patients is limited. OBJECTIVES: We aimed to 1) investigate the variation in pre-fracture PA for adult patients with hip fractures under the age of 60; and 2) to quantify the association with patient characteristics, including outcomes of HRQOL and handgrip strength. DESIGN AND METHODS: A prospective multicenter cohort study of 207 adult hip fracture patients under 60 years admitted to four study hospitals from July 2015 to December 2018. Data was collected through medical records, questionnaires, physical tests and interviews. PA level was assessed using a validated questionnaire from the Swedish National Board of Health and Welfare, providing a total score from 3 to 19. A score ≥11 corresponds to fulfillment of the WHO recommendation for weekly PA. Handgrip strength was measured in kilograms using a handheld dynamometer following a standardized protocol. Recall pre-fracture HRQoL was assessed using the EQ-5D-3L questionnaire. RESULTS: Fifty-nine percent had a PA score ≤10 out of these 46% had an ASA grade of 3 or 4, 38% had a BMI over 25 and 81% had a low energy fracture. A PA score ≤10 was associated with a lower HRQoL compared to those who had a PA score ≥11. PA score ≤10 points was associated with weaker hand grip strength and a worse health status (higher ASA-grade) p<0.001. CONCLUSION: We found that close to two-thirds of the patients had a pre-fracture PA level below WHO recommendations. Being more active was associated with better handgrip strength, HRQoL, and ASA score. Our findings indicate that individuals under 60 years who sustain a hip fracture form a heterogeneous group, some severely comorbid and others highly active and seemingly healthy. This suggests a more nuanced approach to rehabilitation, as the more active patient might need a more individualized plan than the standard program can offer.
Asunto(s)
Fuerza de la Mano , Fracturas de Cadera , Adulto , Humanos , Calidad de Vida , Estudios Prospectivos , Estudios de Cohortes , Fracturas de Cadera/rehabilitación , Ejercicio FísicoRESUMEN
BACKGROUND: Although most nondisplaced or minimally displaced femoral neck fractures are routinely treated with internal fixation, high rates of secondary surgical procedures are common, especially in the elderly population. Primary arthroplasty in elderly patients has been proposed as an alternative treatment to reduce the need for a secondary surgical procedure. The objective of this study was to describe the rate of conversion to arthroplasty within 5 years after internal fixation of nondisplaced femoral neck fractures in patients ≥60 years of age. METHODS: In this observational cohort study of prospectively collected data from the Swedish Fracture Register (SFR) between 2012 and 2018, cross-matched with the Swedish Arthroplasty Register (SAR), 5,428 nondisplaced femoral neck fractures in patients ≥60 years of age were included. Competing risk analysis was used to estimate conversion rates to arthroplasty and mortality in various age groups at 1, 2, and 5 years. RESULTS: The cumulative incidence function (CIF) for conversion to arthroplasty was 6.3% at 1 year, 8.1% at 2 years, and 10.1% at 5 years. The conversion rates within 2 years were 6.5% in 60 to 69-year-olds, 9.6% in 70 to 79-year-olds, and 7.8% in ≥80-year-olds. Women had a higher risk of conversion; the hazard ratio (HR) was 1.49 (95% confidence interval [CI], 1.19 to 1.87). The cumulative mortality was 21.3% (95% CI, 20.3% to 22.5%) at 1 year, 31.3% (95% CI, 30.0% to 32.6%) at 2 years, and 54.9% (95% CI, 53.1% to 56.7%) at 5 years. Mortality was higher in men at all time points, and the adjusted 1-year HR was 1.79 (95% CI, 1.61 to 2.00). CONCLUSIONS: One in 10 patients ≥60 years of age treated with internal fixation for a nondisplaced femoral neck fracture underwent conversion to arthroplasty within 5 years, and more than one-half of the conversions occurred within the first year. The risk of conversion was highest in women and in patients 70 to 79 years of age. These data warrant further studies in this frail patient group to identify subgroups of patients who would benefit from primary arthroplasty for nondisplaced femoral neck fractures. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Fracturas del Cuello Femoral , Masculino , Humanos , Femenino , Anciano , Preescolar , Suecia , Fracturas del Cuello Femoral/cirugía , Artroplastia , Medición de Riesgo , Fijación Interna de Fracturas/métodos , Reoperación , Artroplastia de Reemplazo de Cadera/efectos adversos , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
Although hip fractures are common and severe, there is insufficient evidence concerning which type of rehabilitation is most beneficial. The primary aim of this three-armed pilot study was to investigate any difference in outcome after hip fractures between and within groups in terms of balance, everyday activities, and health-related quality of life (HRQoL) following different home rehabilitation interventions. Further aims were to study feasibility and to suggest, if necessary, adjustments to the protocol for a future full randomized controlled trial (RCT). In total, 32 persons were included in this study. The intervention groups underwent the HIFE program with or without an inertial measurement unit, while the control group underwent standard rehabilitation. Within- and between-groups differences in outcomes and feasibility outcomes in terms of recruitment and retention rates were analyzed, and the ability to collect primary and secondary outcomes was assessed. Balance, measured as postural sway, showed no significant improvement in any group. All three groups improved in functional balance (p = 0.011-0.028), activity of daily living (p = 0.012-0.027), and in HRQoL (p = 0.017-0.028). There were no other significant changes within or between the groups. The recruitment rate was 46%, the retention rate was 75%, and the ability to collect outcome measures was 80% at baseline and 64% at follow-up. Based on the results, it is possible to, after adjusting the protocol, conduct a full RCT.
Asunto(s)
Fracturas de Cadera , Dispositivos Electrónicos Vestibles , Humanos , Estudios de Factibilidad , Fracturas de Cadera/rehabilitación , Resultado del Tratamiento , Terapia por Ejercicio/métodosRESUMEN
PURPOSE: This paper evaluates a theory-driven, interactive hand hygiene (HH) intervention, the Safe Hands project, based on theories of organizational learning and culture including leadership support, dialogue and co-creation. DESIGN: This prospective quasi-experimental study used unobtrusive overt observations to evaluate adherence to HH recommendations after implementing an infection-prevention intervention. METHODS: The primary outcome was differences in HH practices "Before aseptic/clean procedure" (WHO moment 2), "After body fluid exposure risk" (WHO moment 3) and performance of aseptic techniques. One operating room (OR) department served as the study hospital and the other as the control hospital, both at Swedish university hospitals. Adherence to HH guidelines was measured 4 times during 2015 to 2017. FINDINGS: The intervention site displayed a significant improvement in adherence to HH guidelines and aseptic techniques. WHO 2; from 23.8% to 36.2%, (P = .014), WHO 3; from 22.2% to 42.3%, (P = .002), and aseptic techniques; from 17.5% to 31.6%, (P = .003). No changes in adherence were identified at the control site. The use of contaminated gloves decreased post intervention at the study operating department. CONCLUSIONS: This study shows that implementing tailored interventions that are underpinned by theories from organizational learning and culture can improve adherence to hand hygiene in a complex setting as the OR up to 6 months post-intervention. The interprofessional co-creation of standards operating procedures addressing specific care procedures and emphasizing the importance of aseptic techniques can be an acceptable and feasible way to reduce the risks of contaminating medical devices and patients during perioperative care.
Asunto(s)
Infección Hospitalaria , Higiene de las Manos , Humanos , Estudios Prospectivos , Infección Hospitalaria/prevención & control , Adhesión a Directriz , Atención Perioperativa , Control de InfeccionesRESUMEN
BACKGROUND: Urinary retention is common in elderly patients undergoing acute hip fracture surgery. Avoiding overfilling the urinary bladder is important to avoid detrusor muscle damage and associated motility problems. The aim of this study was to analyse associations between the co-creation of a nurse-driven urinary catheterisation protocol and the incidence of bladder distension in patients undergoing hip fracture surgery. METHODS: This is a single-centre implementation intervention with a retrospective longitudinal observation design, using five measures points, spanning from June 2015 to March 2020. The intervention was theory driven and the participants, together with the facilitators and researcher, co-created a nurse-driven urinary catheterisation protocol. Data were retrieved from the hip fracture register. Uni- and multivariable logistic regressions were used for analyses of changes in bladder distension and urinary volume of ≥500 ml over the years. RESULTS: A total of 3078 patients were included over a five-year period. The implementation intervention was associated with a reduction in the proportion of patients with bladder distension of 31.5% (95% confidence interval 26.0-37.0), from year 1 to year 5. The multivariable analysis indicated a 39% yearly reduction in bladder distension, OR 0.61 (95% confidence interval 0.57-0.64, p < 0001). There was a reduction in the proportion of patients with a bladder volume of ≥500 ml of 42.8% (95% confidence interval 36.2-49.4), from year 1 to year 5. The multivariable analysis found a 41% yearly reduction in patients with a bladder volume of ≥500 ml, OR 0.59 (95% confidence interval 0.55-0.64, p < 0.0001). The intervention was associated with improved documentation of both catheter indications and removal plans. CONCLUSION: The use of predefined catheter indications and a tighter bladder scanning schedule were associated with a reduction in the incidence of both bladder distension and urine volume ≥ 500 ml in hip fracture patients. Registered nurses can play an active role in the facilitation of timely and appropriate catheter treatment in patients with hip fractures. TRIAL REGISTRATION: Clinical Trial Registry ISRCTN 17022695 registered retrospectively on 23 December 2021, in the end of the study, after data collection.
RESUMEN
BACKGROUND AND PURPOSE: Older patients with a displaced femoral neck fracture (FNF) are often treated with a cemented primary hemiarthroplasty (HA). The DAICY trial investigates whether high-dose dual-impregnated antibioticloaded cement (DIAC) including gentamicin and clindamycin can reduce the risk of periprosthetic joint infection (PJI) in comparison with low-dose single-impregnated gentamicin antibiotic-loaded cement (SIAC), in patients ≥ 60 years treated with a cemented HA for a displaced FNF. STUDY DESIGN: The trial is a national, multicenter, register-based, cluster-randomized, crossover trial. Patients ≥ 60 years with a non-pathological, displaced FNF (Type Garden 3-4/AO 31-B2 or B3) suitable for HA according to local guidelines are eligible for inclusion. Participating orthopedic departments will be randomized to start with either SIAC (control group) or DIAC treatment (intervention group) for 2 years. After 2 years, the study departments will then change to the other treatment arm for the remaining 2 years of the study. Approximately 7,000 patients will be included. The study is pragmatic in that the choice of implant brands, surgical approach and peri- and postoperative protocols follow the local routines of each participating department. All outcome variables will be retrieved after linkage of the study cohort to the following Swedish registers: the Fracture Register, the Arthroplasty Register, the National Patient Register and the Prescribed Drug Registry Outcome: The primary outcome will be periprosthetic joint infection of the index joint within 1 year after surgery. Secondary outcomes will be any reoperation on the index joint, mortality within 90 days and 1 year, resistance patterns of causative bacteria in cases of PJI, and health economics. Potential added value: This trial is designed to support or refute the efficacy of DIAC used in patients with a displaced FNF, potentially reducing PJI and resource allocation. Start of the trial and estimated duration - The DAICY trial started recruiting patients in January 2022 and will continue recruiting for approximately 4 years. Complete follow-up expected in 5 years.
Asunto(s)
Fracturas del Cuello Femoral , Hemiartroplastia , Infecciones Relacionadas con Prótesis , Antibacterianos/uso terapéutico , Cementos para Huesos/uso terapéutico , Clindamicina , Estudios Cruzados , Fracturas del Cuello Femoral/cirugía , Gentamicinas/uso terapéutico , Hemiartroplastia/efectos adversos , Humanos , Estudios Multicéntricos como Asunto , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/prevención & control , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Surgical site infection (SSI) after acute hip fracture surgery is a devastating complication associated with increased suffering and mortality. The aim of the study was to investigate early SSI, sepsis, pneumonia and urinary tract infections over five years, before and after the implementation of the Safe Hands project. METHODS: This was a single-centre observational study with a 5-year longitudinal design, investigating the effects of an infection-prevention intervention targeting the clinical care pathway of individuals with acute hip fracture. Statistical analyses were based on routinely collected patient outcome data comprising 3553 patients. The study conforms to the criteria of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). RESULTS: The incidence of early SSIs decreased from 2.5% in years 1-2 to 1.1% in years 4-5. Similar results were observed for sepsis (2.7% to 1.3%) and urinary tract infections (14.2% to 4.2%). The multivariable regression results suggest that, for every observed year, the odds of early SSIs decreased. Male gender, procedure time, sepsis and preoperative skin damage increased the odds significantly. CONCLUSIONS: Our preventive bundle, based on partnership between researchers, managers and clinicians and a strong commitment to change from the involved professions, appear to be effective in reducing the frequency of potentially devastating SSIs and other hospital acquired infections after hip fracture surgery. The use of external and internal facilitators was crucial to enable individual and organisational learning and overcoming barriers to improvements. TRIAL REGISTRATION: Clinical Trials.gov ID: NCT02983136 Registered 6 December 2016-Retrospectively registered.
Asunto(s)
Fracturas de Cadera , Sepsis , Infecciones Urinarias , Fracturas de Cadera/complicaciones , Fracturas de Cadera/cirugía , Humanos , Masculino , Sepsis/epidemiología , Sepsis/prevención & control , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/prevención & control , Infecciones Urinarias/epidemiología , Infecciones Urinarias/prevención & controlRESUMEN
BACKGROUND: To identify factors related to reproductive history and weight change associated with first incident fracture in middle-aged women. METHODS: In total, 18,326 women from the Malmö Diet and Cancer study were included in this prospective population-based cohort study. Participants were included 1991-1996 and followed to 2016. Using data from the National Patient Registry, linked with every participants' unique personal identification number, any first fracture affecting spine, thoracic cage, upper and lower extremities was identified. The association of baseline factors with incident fracture risk was analyzed using Cox regression models. RESULTS: For participating women, median age 56.0 years, the multivariable Cox regression analysis observed that early menopause (40-44 years) (hazard ratio (HR) 1.14, 95% confidence interval (CI) 1.03-1.27) but not premature menopause < 40 years (HR 1.06, 95% CI 0.91-1.24) was associated with future fracture risk. Self-reported weight loss since age 20 was also associated with future fracture risk (HR 1.39, 95% CI 1.17-1.65) whereas a daily alcohol consumption in the third quartile (5.36-11.42 g/day) compared to the lowest quartile (0-0.80 g/day) was associated with decreased future fracture risk (HR 0.88, 95% CI 0.81-0.96). The multivariable Cox regression analysis also observed that increasing age and weight at baseline, current smoking, a positive history of previous fracture and family history of fractures were associated with increased fracture risk whereas an increasing BMI was associated with a decreased fracture risk. No association to parity or period of lactation was observed nor ever-use of oral contraceptives and menopausal hormone therapy. CONCLUSION: This study shows that early menopause between 40 to 45 years and self-reported weight loss since age of 20 are relevant factors associated with increased fracture risk in middle-aged women. These factors were independent of traditional predictors of fracture risk among women and may be considered in preventive initiatives. TRIAL REGISTRATION: Clinicaltrials.gov with identifier: NCT04151732, since Nov 5th 2018.
Asunto(s)
Fracturas Óseas , Menopausia , Adulto , Estudios de Cohortes , Femenino , Fracturas Óseas/epidemiología , Fracturas Óseas/etiología , Humanos , Persona de Mediana Edad , Embarazo , Estudios Prospectivos , Factores de Riesgo , Pérdida de Peso , Adulto JovenRESUMEN
BACKGROUND: The widespread use of intramedullary nails (IMNs) compared with sliding hip screws (SHSs) in extracapsular hip fractures (AO/OTA 31-A1, 31-A2, 31-A3) has been questioned because of a higher complication rate, although the outcome might have improved through more recent implant designs and the learning curve. This study aimed to investigate if there is a difference with regard to the cumulative incidence of conversion to arthroplasty or any reoperation during the first 5 years after IMN or SHS fixation of extracapsular hip fractures. METHODS: In this nationwide, observational cohort study, individuals who were ≥60 years of age and were registered in the Swedish Fracture Register (SFR) from 2012 to 2018 due to extracapsular fracture and were primarily treated with an IMN or SHS were followed in the SFR and the Swedish Arthroplasty Register (SAR) for a minimum of 1 year. The primary outcome was the cumulative incidence of conversion to arthroplasty (conversion rate). The secondary outcome was the cumulative incidence of all reoperations (reoperation rate). Both were calculated in a competing risk analysis during the first 5 years. RESULTS: We included 19,604 individuals (70% women), with a median age of 85 years (range, 60 to 107 years). The 31-A2 fracture was most prevalent (52%), followed by the 31-A1 fracture (28%). No significant differences were seen in the 1-year conversion rate after IMN or SHS use (1.0% compared with 0.9% in the 31-A1 fractures, 1.7% compared with 1.3% in the 31-A2 fractures, and 1.3% compared with 1.5% in the 31-A3 fractures) or in the 1-year reoperation rate (1.9% compared with 1.9% in the type-A1 fractures, 3.4% compared with 2.5% in the type-A2 fractures, and 4.0% compared with 5.2% in the type-A3 fractures). Only in 31-A2 fractures were more reoperations seen after IMN use at 2 and 5 years (p < 0.05). The crude 1-year-mortality was 26.4% (5,178 of 19,604), without significant differences between implants. CONCLUSIONS: Considering conversion arthroplasty, IMNs and SHSs performed equally well in general. IMN use was associated with more reoperations than SHS use in 31-A2 fractures at 2 years. However, from a clinical perspective, the differences between the implants were small, in particular when considering the competing risk of dying. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.