Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture. A post hoc analysis based on the TRIFE randomized controlled trial.

OBJECTIVES: To investigate whether a liberal blood transfusion strategy [Hb levels ≥11.3 g/dL (7 mmol/L)] reduces the risk of postoperative delirium (POD) on day 10, among nursing home residents with hip fracture, compared to a restrictive transfusion strategy [Hb levels ≥9.7 g/dL (6 mmol/L)]. Furthermore, to investigate whether POD influences mortality within 90 days after hip surgery. METHODS: This is a post hoc analysis based on The TRIFE - a randomized controlled trial. Frail anemic patients from the Orthopedic Surgical Ward at Aarhus University Hospital were enrolled consecutively between January 18, 2010 and June 6, 2013. These patients (aged ≥65 years) had been admitted from nursing homes for unilateral hip fracture surgery. After surgery, 179 patients were included in this study. On the first day of hospitalization, all enrolled patients were examined for cognitive impairment (assessed by MMSE) and delirium (assessed by CAM). Delirium was also assessed on the tenth postoperative day. RESULTS: The prevalence of delirium was 10 % in patients allocated to a liberal blood transfusion strategy (LB) and 21 % in the group with a restrictive blood transfusion strategy (RB). LB prevents development of delirium on day 10, compared to RB, odds ratio 0.41 (95 % CI 0.17-0.96), p = 0.04. Development of POD on day 10 increased the risk of 90-day death, hazard ratio 3.14 (95 % CI 1.72-5.78), p < 0.001. CONCLUSION: In nursing home residents undergoing surgery for hip fracture, maintaining hemoglobin level above 11.3 g/dL reduces the rate of POD on day 10 compared to a RB. Development of POD is associated with increased mortality.

Blood transfusion and risk of infection in frail elderly after hip fracture surgery: the TRIFE randomized controlled trial.

OBJECTIVES: It is still under debate that red blood cell (RBC) transfusions might increase the risk of healthcare-associated infections after hip fracture surgery. Previously, we found that a liberal RBC transfusion strategy improved survival in nursing home residents. Our aim, therefore, was to investigate whether a more liberal RBC transfusion strategy was associated with a higher infection risk in frail elderly hip fracture patients. DESIGN: Prospective, assessor-blinded, randomized and controlled trial. SETTINGS: Orthopedic ward, Geriatric ward, and Hospital-at-home. PATIENTS: 284 consecutively hospital-admitted elderly with hip fracture from nursing homes or sheltered housing facilities were included. INTERVENTION: A restrictive RBC transfusion strategy (hemoglobin <9.7 g/dL; 6 mmol/L) compared with a liberal strategy (hemoglobin <11.3 g/dL; 7 mmol/L) administered within 30 days after surgery. MAIN OUTCOME MEASUREMENTS: Leukocytes and C-reactive protein (CRP) in repeated blood samples within 30 days, and number of all infections (pneumonia, urinary tract infection, and other infections) within 10 days. RESULTS: 88 % of the patients received a RBC transfusion. A median of 1 RBC unit (interquartile range (IQR): 1-2) was transfused for the restrictive strategy group versus 3 RBC units (IQR: 2-5) for the liberal group. Leukocytes and CRP measurements were similar for both groups. Rates of infection were 72 % for the restrictive group compared to 66 % for the liberal group (risk ratio 1.08; 95 % confidence interval 0.93-1.27, p value 0.29). CONCLUSIONS: A more liberal RBC transfusion strategy was not associated with higher risk of infection among residents from nursing homes or sheltered housing undergoing hip fracture surgery.

New compounds in the management of venous thromboembolism after orthopedic surgery: focus on rivaroxaban.

Rivaroxaban (Xarelto) is a member of a new class of oral, direct (antithrombin-independent) factor Xa inhibitors, which restrict thrombin generation both in vitro and in vivo. After oral administration the absorption is near 100%, the bioavailability is near 80%, and the elimination half-life is 5-9 hours with mixed excretion via the renal and fecal/biliary routes. The pharmacokinetics of rivaroxaban are predictable and consistent with a rapid onset of antithrombotic action within 2 hours after administration. Phase II clinical studies have been carried out in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) and a dose of 10 mg once daily for thromboprophylaxis was selected for further clinical development. The results of the phase III studies showed a significantly better antithrombotic efficacy of rivaroxaban compared with enoxaparin both in the short term (10-14 days) in TKA patients and long term (35 +/- 4 days) in THA patients with a comparable safety. Symptomatic thromboembolic events were also significantly reduced with rivaroxaban. Liver enzyme elevation was seen in patients treated with rivaroxaban, but there was no indication of an increased risk of liver toxicity compared with enoxaparin. In conclusion, rivaroxaban is a potent and safe new compound for antithrombotic prophylaxis in orthopedic surgery.

Distal radius fractures are difficult to classify.

BACKGROUND: Traditionally, distal radius fractures (DRFs) have been described using eponyms, e.g. Colles, Smith, Barton, Chauffeur. During the last half of the 20th century several classification systems for DRF have emerged. We evaluated the inter- and intra-observer agreement of the AO/OTA, Frykman and Older classification systems. METHODS: Four observers, an intern, an orthopaedic registrar, an orthopaedic consultant and a radiology consultant, independently evaluated DRF radiograms and classified the fractures according to the AO/OTA, Frykman and Older classification systems. After an interval of 6 months, radiograms of 30 randomly chosen patients were re-evaluated by the same observers. RESULTS: Radiograms of 573 DRF patients were evaluated in the study. The inter-observer reliability of the AO/OTA fracture types (A, B and C) was 'weak' (kappa = 0.45). The agreement dropped to 'minimal' (kappa = 0.24) regarding the AO/OTA groups (A2, A3, B1, B2, B3, C1, C2 and C3). The reliability of the Frykman classification system was 'weak' (kappa = 0.41), and we observed the lowest inter-observer reliability for the Older classification system (kappa = 0.10). The kappa values for the intra-observer reproducibility of the AO/OTA fracture types (A, B and C) ranged from 0.58 to 0.87. For the AO/OTA groups (A2, A3, B1, B2, B3, C1, C2 and C3) the reproducibility was lower ranging from 'minimal' to 'weak'. The intra-observer reproducibility of the Frykman system was 'weak' to 'moderate' and even worse for the Older classification system. CONCLUSION: Based on these findings the AO/OTA classification system seems to be most reliable for routine use, however, with lower kappa values concerning the agreement for the groups. The Frykman and Older classification systems cannot be recommended because of less convincing results.

Volar plating of distal radius fractures does not restore the anatomy.

INTRODUCTION: The objective of this study was to evaluate whether volar locking plating can restore the anatomical volar tilt of 12° and the anatomical length of the radius relative to the ulna. We retrospectively reviewed the radio-graphic outcome of distal radius fractures treated with two different first-generation locking plate systems; VariAx (Stryker) and Acu-Loc (Acumed). METHODS: Three independent observers evaluated radial volar tilt and ulnar variance (> 2 mm) on radiographs taken preoperatively, immediately after the operation and five weeks later. In addition, the radial inclination, distal radio-ulnar joint incongruity and articular step-off were assessed in order to describe the personality of the fracture. RESULTS: A total of 576 fracture cases were included in the study. Preoperatively, the mean volar tilt was 18 ± 6° and -15 ± 11° for volarly and dorsally displaced fractures, respect-ively. After operation, the mean volar tilt was 4.5 ± 6° without any significant changes after five weeks, p = 0.79 and no significant differences with respect to fracture type or type of plate. Thus, the anatomical angulation of 12° was not achieved at any point in time after surgery (p < 0.001). Shortening of the radius (> 2 mm ulnar variance) was still seen in 9% of the cases immediately after surgery and in 22% after five weeks. CONCLUSIONS: Volar locking plating did not restore the anatomy after distal radius fractures. The clinical implication of these findings is unclear because the functional outcome of the patients was not available. Level of evidence, level IV. FUNDING: none. TRIAL REGISTRATION: not relevant.

Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up.

BACKGROUND: Volar plating of unstable distal radius fractures (DRF) has become the favoured treatment. The complication rates vary from 3 to 36%. The purpose of the study was to estimate the complication rate of volar plating of DRF and its association with AO/OTA fracture type, surgeon experience and type of volar plate. METHODS: Retrospectively, all patients treated with volar plating of a DRF between February 2009 and June 2013 at Aarhus University Hospital, Denmark were included. AO/OTA fracture type, surgeon experience (1st year, 2nd-5th year resident or consultant), type of plate (VariAx®, Acu-Loc®) and complications were extracted from the electronic medical records. Complications were categorized as carpal tunnel syndrome, other sensibility issues, tendon complications including irritation and rupture, deep infections, complex regional pain syndrome and unidentified DRUJ or scapholunar problems. Reoperations including hardware removal were also charted. RESULTS: 576 patients with a median age of 63 years (min: 15; max: 87) were included. 78% were female and the mean observation time was 3.2 years (min: 2.0; max: 5.4). 78% (n=451) of the patients were treated with VariAx® and 22% (n=125) with Acu-Loc®. The overall complication rate was 14.6% (95% CI 11.8-17.7) including carpal tunnel syndrome or change in sensibility in 5.2% and tendon complications in 4.7%. Five flexor tendon ruptures and 12 extensor tendon ruptures were observed. The reoperation rate was 10.4% including 41 cases of hardware removal. A statistically significant association between AO/OTA fracture type C and complications was found. No statistically significant association between complication rate and surgeon experience and type of plate was observed. CONCLUSION: The majority of DRF patients treated with a volar plate suffer no complications. However, the overall complication rate of 14.6% is substantial. Intra-articular fractures, e.g. AO/OTA-type 23C1-3, had significantly higher complication rates. Neither surgeon experience, nor type of volar plate was able to predict complications.

Blood transfusion and overall quality of life after hip fracture in frail elderly patients--the transfusion requirements in frail elderly randomized controlled trial.

BACKGROUND: We examined possible associations between different red blood cell (RBC) transfusion strategies, overall quality of life (OQoL), and recovery of activities of daily living (ADL) in operated frail elderly hip fracture patients, and the possibility that OQoL was related to ADL recovery. METHODS: A prospective, assessor-blinded, randomized controlled trial was carried out among 157 elderly residents (≥65 years) from nursing homes and sheltered housing facilities with Mini-Mental State Examination scores ≥5 points. Patients were assigned to either a restrictive RBC transfusion strategy [hemoglobin (Hb) < 9.7 g/dL, 6 mmol/L] or a liberal strategy (Hb < 11.3 g/dL, 7 mmol/L) during the first 30 days after surgery. An interview-based questionnaire, the depression list (DL) assessing OQoL, and the modified Barthel Index (MBI) assessing ADL performance, were conducted on day 30 and 1 year after hip fracture surgery. Sum-scores of DL, MBI, and their changes from day 30 until 1 year (expressing recovery) were compared between RBC transfusion groups. Possible associations between changes of DL and MBI sum-scores were tested for across total patient population. RESULTS: There was no association between OQoL and RBC transfusion strategies on day 30 or at 1 year. The DL sum-score changes were similar for both groups, (ie, 1.06 points) [95% confidence interval (CI) -0.62, 2.76)] P = .21. The MBI sum-scores increased at 1 year following the liberal transfusion strategy (ie, by 6.86 points) (95% CI 0.41, 13.3) P = .03. Recoveries of OQoL and ADL were associated: ß = -0.06 (95% CI -0.11, -0.01) P = .02. CONCLUSIONS: According to our Hb threshold criteria, OQoL and RBC transfusion strategies for frail elderly hip fracture patients are not associated. However, for survivors with less severe dementia, ADL recovery after 1 year is greater following a liberal transfusion strategy than a restrictive strategy. OQoL progress and ADL recovery were associated.

Effective treatment at a Danish trauma centre.

INTRODUCTION: The trauma centre at Aarhus University Hospital, Denmark was established in 1999 and has continuously tried to improve its efficiency through regular training of personnel and auditing of selected trauma cases. The purpose of the present study was to assess the efficiency of the trauma teams to perform the initial evaluation using the time spent in the emergency room after arrival and the time to the first chest X-ray as measures for effectiveness. MATERIAL AND METHODS: This was a prospective cohort study conducted from January 2000 to December 2008 and which included all trauma patients admitted to the hospital. RESULTS: The results are based on 4,493 admissions, of which 1,102 patients (24%) had an injury severity score > 15. The median time spent in the trauma room was 50 minutes in 2000, which was steadily reduced throughout the period reaching a median time of 27 minutes in 2008 (p < 0.0001, Kruskal-Wallis test). The median time to the first chest X-ray was reduced from seven minutes in 2001 to five minutes in 2008 (p < 0.024, Kruskal-Wallis test). CONCLUSION: Utilisation of a standardised protocol for initial evaluation and treatment of trauma patients and continuous training of trauma teams may considered some of the main factors responsible for these findings. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[Tillaux fracture and fracture of the lateral malleolus with no medial soreness]. / Tillauxfraktur og lateral malleolfraktur uden medial ømhed.

Tillaux fracture is a fracture of the anterolateral tibial epiphysis most often seen in children between 11 and 16 years of age. The fracture occurs when the medial and central part of the distal tibial epiphysis is closed and the lateral part remains open. We present a case with a combination of a Tillaux fracture and an ipsilateral fracture of the lateral malleolus in a 16 year-old boy and discuss the fracture mechanism using the Lauge-Hansen ankle fracture classification system.

Coagulation activity in elderly patients with hip fracture measured by prothrombin fragment 1 + 2 in urine.

OBJECTIVE: The purpose of this study was to document the uF1 + 2 excretion in elderly patients during and after a hip fracture (HF). METHODS: The study was a prospective pilot study. Spot urine samples were collected immediately after admission and every morning until surgery. After surgery, urine samples were collected on days 1, 5, 7, 14, and at follow-up on day 90 (±10). RESULTS: A total of 24 women and 7 men with HF completed the study. The median uF1 + 2 level was significantly increased on the day of admission relative to the median level at follow-up. Maximum levels were seen on day 1 with a decreasing tendency until follow-up. Patients treated with a hemiarthroplasty had higher median uF1 + 2 levels on all days compared with patients treated with osteosynthesis. CONCLUSION: A substantial coagulation activity, indicated by high median levels of uF1 + 2, was seen at admission and during the first week after HF.

A geriatric multidisciplinary and tailor-made hospital-at-home method in nursing home residents with hip fracture.

INTRODUCTION: Nursing home residents represent a large proportion of patients hospitalized with hip fracture. Generally, residents do not achieve the same physical ability level as before their fracture and have an increased risk of death within few days after discharge. This study aims to compare 2 new approaches to geriatric intervention in residents with hip fracture. MATERIALS AND METHODS: In nursing home residents aged 65 or older with hip fracture, 85 received a newly developed standardized rehabilitation intervention undertaken by the geriatric orthopedic team (GO team) from December 1, 2006 to November 30, 2007. This standardized method was compared with a further developed tailor-made intervention method performed by the GO team in 153 residents from February 1, 2008 to January 31, 2010. Both the interventions began at hospital admission and until 30 days after surgery. Outcomes were length of hospital stay (LOS), difference in physical ability, 90-day acute readmission, 30-day mortality, and 90-day mortality. RESULTS: The tailor-made intervention method reduced the readmission rate (14% vs 26%) compared with the standardized intervention method (odds ratio [OR] = 0.47 [95% confidence interval [CI]: 0.23, 0.94]). Tailor-made intervention reduced 30-day mortality (8% vs 19%) compared with standardized intervention (OR = 0.42 [95% CI: 0.18, 0.97]). Improving 90-day survival could not be demonstrated (81% vs 73%; OR = 0.72 [95% CI: 0.37, 1.40]). Median LOS was 2 days in both the groups. A total of 7 follow-up visits were performed with tailor-made intervention versus 3 visits with standardized intervention. In both the groups, the physical ability decreased significantly within the first 30 postoperative days, with no difference between groups (ß = 1.01 [95% CI: 0.82, 1.24]). CONCLUSION: A multidisciplinary and tailor-made geriatric intervention in nursing home residents has a positive effect on readmission rate and short-term mortality. Still, it is not obvious which part of the tailor-made intervention is most crucial.

[Oram's sign for hip or pelvic disorder]. / Orams tegn på hofte- eller baekkenlidelse.

INTRODUCTION: The so-called Oram's sign states that the penis points to the side of the disorder on standard antero-posterior (AP) x-rays of the pelvis. The present study is a scientific evaluation of the sign in a relevant clinical context. MATERIAL AND METHODS: This is a retrospective study based on a blinded reading by four males and one female doctor of AP x-rays of the pelvis from 51 male patients with hip and pelvic disorders and 11 x-rays without pathology from an additional nine males and two females. The sensitivity and specificity and the positive and negative likelihood ratios were calculated together with the Kappa values for intra- and interobserver agreement. RESULTS: The sensitivity of Oram's sign for the individual reader varied between 40.3% and 25.8%. The overall sensitivity and specificity for all readers were 55% and 14%, respectively. The test performance did not show any significant variation between the male readers and the female reader. The sensitivity of Oram's sign in relation to the various pathologic findings varied between 32.1% for femoral neck fractures, 66.6% for osteoarthritis of the hip and 88.8% for pelvic fracture. Oram's sign could not be defined in 16.3% of the cases. The intra- and interobserver agreement was poor with relatively low Kappa values. CONCLUSION: Oram's sign was not useful in this study on the diagnosis of hip fractures mainly due to a low sensitivity and too low observer agreement.