Simultaneous bilateral femoral neck fracture and end-stage renal disease in a 76-year-old woman: a case report.

Hip fracture is a common occurrence in the elderly. Due to the growing demand for the specific care of these patients, we established the Orthogeriatric Unit (OGU) at San Gerardo University Hospital (Italy) in 2007. However, simultaneous bilateral femoral neck fractures among the geriatric population (those aged ≥65 years) are rarely reported in the literature. Reporting the rare case of a frail 76-year-old woman admitted with bilateral hip fracture and end-stage renal disease, we explain the important role played by the OGU and its flexible multidisciplinary approach for providing comprehensive care to patients with multimorbidity and clinical complexity. The team of geriatricians, orthopedic surgeons, anesthesiologists, and, in this case, a nephrologist, helped in the careful planning and timing of the single-step surgical repair, decided the appropriate type of anesthesia, and optimized outcomes. After a prompt evaluation of the patient, the OGU approach can achieve clinical stabilization prior to intervention. Along with a strict follow-up in the postoperative phase, this could result in a significant reduction of complications and mortality rates and an early start to a tailored rehabilitation process. We strongly suggest employing facilities with multidisciplinary teams for cases involving complex patients at short-term high risk for poor clinical outcomes. Indeed, the usual single-specialist model of care is gradually being abandoned worldwide.

Postoperative delirium and pre-fracture disability predict 6-month mortality among the oldest old hip fracture patients.

BACKGROUND: Age is one of the most robust risk factors for hip fracture. Recent projections indicate that almost half of hip fractures are occurring with an increasing trend among the "oldest old" (i.e., in those aged >85 years). AIMS: To compare clinical characteristics, outcomes, and risk factors for 6-month mortality in two groups of "oldest old" patients (group 1 = 85-89, group 2 > 90 years), after hip fracture surgery. METHODS: Observational prospective cohort study with 6-month follow-up, performed in an Orthogeriatric Unit of an academic hospital between March 2007 and November 2012. RESULTS: Two hundred seventy-five patients (group 1: N = 171; group 2: N = 104) underwent a comprehensive geriatric assessment, including demographics, clinical, functional, nutritional, and mental status. The 6-month rehospitalization and mortality rates after surgery were assessed through structured telephone interviews with patient's caregivers. Multivariate logistic regression models were used to evaluate predictors of 6-month mortality, adjusting for relevant covariates. Fifty-eight patients died at follow-up. The in-hospital and 6-month mortality rates were significantly higher for patients of group 2 than for those of group 1. After adjusting for covariates, the multivariate logistic regressions showed that severe disability (OR 2.24, 95 % CI 1.08-4.65) and postoperative delirium (POD) (OR 3.80, 95 % CI 1.72-8.39) were predictors of 6-month mortality. CONCLUSIONS: Patients aged >90 years who underwent hip fracture surgery are more likely to die at 6 months than those aged 85-89 years. Pre-fracture disability and POD are predictors of this excess of mortality.

Functional and clinical outcomes of patients aged younger and older than 85 years after rehabilitation post-hip fracture surgery in a co-managed orthogeriatric unit.

AIM: Literature investigating rehabilitation outcomes after hip surgery among individuals aged ≥85 years is sparse. We compared the characteristics and outcomes of patients aged under and over 85 years, and assessed factors potentially associated with rehabilitation success as described by the Barthel Index (BI). METHODS: From 2011 to 2014, we prospectively enrolled 328 patients (n = 152 aged <85 years, n = 176 aged ≥85 years) admitted to an orthogeriatric unit (Sondrio, Italy) with a diagnosis of hip fracture requiring surgical treatment. We excluded patients who were being treated conservatively. Outcomes included absolute functional gain (AFG; BI at discharge - BI on admission), rehabilitation effectiveness index (AFG / length of stay) and postoperative complications. RESULTS: Older patients were more functionally (mean BI on admission: 11.7 ± 9.6 vs 16.4 ± 12.2, P < 0.001) and cognitively impaired than their younger counterparts (34.1% vs 18.4%, P < 0.001). Surgery time (1.9 ± 1.2 vs 2.3 ±1.3 days, P = 0.008) and length of stay were shorter for older patients (5.7 ± 2.1 vs 6.6 ± 2.4 days, P < 0.001). There were no differences in terms of complications. Patients aged <85 years showed better functional outcomes (BI, AFG, REI) at discharge than patients aged ≥85 years (mean AFG: 38.2 ± 24.2 vs 26.1 ± 22.0, P < 0.001). BI on admission (OR 1.05, 95% CI 1.02-1.08) and cognitive impairment (OR 0.58, 95% CI 0.34-0.98) were independently associated with rehabilitation outcomes, regardless of chronological age. CONCLUSIONS: Both groups (aged <85 and ≥85 years) showed a significant functional improvement at discharge. Older patients show a residual ability to recover after surgery. A high rehabilitation efficiency - regardless of age - should be pursued even for the oldest old patients experiencing hip fracture. Geriatr Gerontol Int 2018; 18: 1194-1199.

Association Between Preoperative Malnutrition and Postoperative Delirium After Hip Fracture Surgery in Older Adults.

OBJECTIVES: To determine whether poor nutritional status can predict postoperative delirium in elderly adults undergoing hip fracture surgery. DESIGN: Prospective observational cohort study. SETTING: Italian orthogeriatric unit. PARTICIPANTS: Individuals aged 70 and older (mean age 84.0 ± 6.6, 74.5% female) consecutively admitted for surgical repair of a proximal femur fracture between September 2012 and April 2016 (N = 415). MEASUREMENTS: Participants underwent a comprehensive geriatric assessment including nutritional status, which was evaluated using the Mini Nutritional Assessment Short Form (MNA-SF). The MNA-SF-based three-class stratification was tested using multivariable logistic regression to assess its role in predicting postoperative delirium (outcome). RESULTS: Seventy-eight malnourished individuals (MNA-SF score 0-7), 185 at risk of malnutrition (MNA-SF score 8-11), and 152 who were well nourished (MNA-SF score 12-14) were compared. On average, individuals with poor nutritional status were more disabled and more cognitively impaired than those who were well nourished and those at risk of malnutrition. Moreover, those who were malnourished were more likely to have postoperative delirium. Multivariate regression analysis adjusted for age, sex, comorbidity, functional impairment, preoperative cognitive status, and American Society of Anesthesiologists score showed that those who were at risk of malnutrition (odds ratio (OR) = 2.42, 95% confidence interval (CI) = 1.29-4.53) and those who were overtly malnourished (OR = 2.98, 95% CI = 1.43-6.19) were more likely to develop postoperative delirium. CONCLUSION: This is the first study in a Western population showing that risk of malnutrition and overt malnutrition, as assessed using the MNA-SF, are independent predictors of postoperative delirium. Accordingly, nutritional status should be assessed in individuals with hip fracture before surgery to determine risk of developing delirium.

Takotsubo cardiomyopathy in an 81-year-old woman after injection of bone cement during hemiarthroplasty: An orthogeriatric case report.

INTRODUCTION: Takotsubo cardiomyopathy is a syndrome characterized by transient cardiac ischemia-like symptoms, such as chest pain, increase of myocardial necrosis markers, electrocardiographic changes, and temporary left ventricular apical ballooning without significant coronary artery disease, often triggered by a particularly stressful situation. The association between Takotsubo and hip fracture surgery has been rarely reported in the literature. PRESENTATION OF CASE: An 81-year-old woman was hospitalized with a diagnosis of right femoral neck fracture. During the surgical procedure, she displayed acute coronary symptoms a few minutes after the injection of bone cement, in the absence of coronary lesions. Due to the time relationship, bone cement implantation syndrome - not uncommon to observe - was considered in the differential diagnosis. However, the instrumental findings and the transient nature of the abnormalities guided us toward a diagnosis of Takotsubo. The treatment with Levosimendan, Amiodarone, and Metoprolol allowed gradual and satisfactory recovery of the cardiac function within a few days. The follow-up performed two and six months after surgery revealed complete cardiac recovery, and ability to walk at home comparable to the pre-fracture situation. DISCUSSION: Takotsubo cardiomyopathy is more common in women during the postmenopausal phase, especially if undergoing stressful physical or emotional stimuli. In this case, the sequence of hip fracture, pain, hospitalization, and surgery could easily be intended as a strong stressful event with high physical/psychological burden. CONCLUSION: Despite the good prognosis associated with early recognition, Takotsubo represents a life-threatening adverse event. Considering its possible pathogenesis, a "gentle care" approach and the optimization of pain control must be pursued in elderly subjects with hip fracture, aiming at reducing the stress of the hospitalization and related procedures.

Cardiovascular variability is similarly altered in coronary patients with normal left ventricular function and in heart failure patients.

OBJECTIVE: After myocardial infarction (MI), baroreflex function is impaired and heart rate (HR) variability is reduced. An impaired baroreflex has been observed also in coronary patients with no previous MI, leading to hypothesize alterations of HR variability also in these patients. The aim of the present work was, therefore, to study whether and to what extent cardiovascular variability is altered in coronary patients with no previous MI. METHODS: Thirty-two individuals were studied: eleven patients with coronary artery disease but no previous MI [coronary artery disease (CAD)], eleven patients with a reduced left ventricular ejection fraction [congestive heart failure (CHF)] and ten age-matched controls (CNT). RESULTS: Overall HR variability was significantly and similarly reduced in CAD (630 ±â€Š272 ms) and CHF patients (594 ±â€Š395 ms) with respect to CNT (1405 ±â€Š837 ms), this being the case also for the low and high frequency spectral components. Low-frequency oscillations of blood pressure (BP) were also significantly and similarly less pronounced in CAD (0.7 ±â€Š0.7 mmHg) and CHF patients (0.7 ±â€Š0.7 mmHg) compared with CNT (1.8 ±â€Š1.4 mmHg). Moreover, both CAD and CHF patients showed a significantly reduced baroreflex function and an increased pulse-wave velocity with respect to CNT. CONCLUSION: Our study shows that in coronary patients with no MI and no left ventricular dysfunction, there is a profound alteration of both HR and BP variability as in CHF patients, presumably because of a marked impairment of the autonomic modulation of the heart and blood vessels.