Effect of acute inpatient rehabilitation on outcome after fracture of the femoral neck or intertrochanteric fracture.

A study was performed to assess the impact of intensive inpatient rehabilitation on the outcome after a fracture of the femoral neck or an intertrochanteric fracture. Before 1990, our hospital did not have an inpatient rehabilitation program. On January 1, 1990, a diagnosis-related-group-exempt (DRG-exempt) acute rehabilitation program was initiated. Patients were discharged to this program after evaluation by a staff physiatrist. Before 1990, twenty-seven (9.0 per cent) of 301 patients were discharged to an outside rehabilitation facility. After January 1990, the percentage of patients who were discharged to the DRG-exempt program increased yearly, from nineteen (17 per cent) of 113 patients in 1990 to forty-one (64 per cent) of sixty-four patients in 1993; this difference was significant (p < 0.01). Before 1990, the average duration of the stay in the hospital was 21.9 days. After January 1990, the average duration for the patients who did not enter the rehabilitation program was 20.0 days whereas the average duration for those who did was 31.4 days (16.1 days for acute care and 15.6 days for the rehabilitation program). There were no differences in the hospital discharge status or in the walking ability, place of residence, need for home assistance, or independence in basic and instrumental activities of daily living at the six and twelve-month follow-up examinations between patients who had been managed before initiation of the rehabilitation program and those managed after it or between patients who had been discharged to this program after its initiation and those who had not. These results raise serious questions regarding the global cost-effectiveness of these programs for patients who have had a fracture of the femoral neck or an intertrochanteric fracture.

The effects of nutritional status on outcome after hip fracture.

OBJECTIVE: To determine the effect of nutrition on patient outcome after hip fracture. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Four hundred ninety hip fracture patients had albumin and total lymphocyte count levels determined at the time of admission and constituted the study population. These variables were examined as predictors for outcomes, including: in-hospital mortality, postoperative complications, hospital length of stay, hospital discharge status, one-year mortality rate, ambulatory ability, and independence in basic and instrumental activities of daily living twelve months after surgery. RESULTS: Eighty-seven patients (18 percent) were found to be malnourished on hospital admission based on a preoperative albumin level of < 3.5 grams/deciliter, and 280 patients (57 percent) based on a total lymphocyte count of < 1,500 cells/milliliter. An albumin level of < 3.5 grams/deciliter was predictive for increased length of stay (p = 0.03) and for in-hospital mortality (p = 0.03). A total lymphocyte count < 1,500 cells/milliliter was predictive for one-year mortality (p < 0.01). Patients with abnormal albumin and total lymphocyte count were 2.9 times more likely to have a length of stay greater than two weeks (p = 0.03), 3.9 times more likely to die within one year after surgery (p = 0.02), and 4.6 times less likely to recover their prefracture level of independence in basic activities of daily living (p < 0.01). Neither parameter was predictive for patients developing a postoperative complication, hospital discharge status (home versus nursing home), recovery of prefracture ambulatory ability, or independence in instrumental activities of daily living at twelve-month follow-up. CONCLUSION: Patients at risk for poor outcomes after hip fracture can be identified using relatively inexpensive laboratory tests such as albumin and total lymphocyte count.

Effect of piriformis versus trochanteric starting point on fixation stability of short intramedullary reconstruction nails.

Recently, a new, shorter IM nail using two 6 mm reconstruction screws for proximal fixation was introduced in two versions for femoral insertion: piriformis fossa (FAN) and greater trochanter (TAN). These nails were compared experimentally for their fixation stability, proximal load transmission, and failure strength in an unstable intertrochanteric fracture model in cadaveric femurs. Vertical and axial loads were first applied to the intact femurs. Fractures were created, subsequent fixation applied, and the femurs underwent a series of both vertical and axial loading tests. There was no significant difference in strain readings between the nails for either axial loading or cyclical loading. There was no statistically significant difference between the loads to failure for the trochanteric nails and the standard antegrade nails. The average ultimate loadfor the FAN and TAN nails were 3010 N and 2830 N respectively. These two nails performed very similarly throughout our testing.