Fixation Versus Replacement in Geriatric Hip Fractures: Does Functional Outcome and Independence in Self-Care Differ?

INTRODUCTION: Although there is evidence of improved functional outcomes with our "integrated care pathway" for geriatric hip fractures, we do not know if there is a significant difference in functional recovery of activities of daily living and attainment of independence in self-care between patients who underwent fixation and those treated with arthroplasty. OBJECTIVE: To determine whether such a difference exists in surgically fixed hip fractures. MATERIALS AND METHODS: Patients with hip fracture treated surgically were divided into group A (internal fixation, n = 213) and group B (arthroplasty, n = 199). Demographic data, Charlson comorbidity index (CCI) score, time to surgery, and length of stay were recorded. Inpatient complications and mortality rates were also documented. Modified Barthel Index (MBI) scores were recorded for the following intervals: prefall, discharge, 6-month, and at 1-year follow-up. RESULTS: The mean age (A: 80 years and B: 81years), CCI (A: 5.41 and B: 5.43), and length of stay (A: 13.6 days and B: 15.2 days) were not significantly different. However, there was a significant difference (P < .05) in time to surgery (A: 102.2 hours and B: 86.6 hours). Complication rates were about 6% in both groups (A = 6.57%: urinary infections = 13, wound infections = 1 and B = 6.03%: urinary infections = 10, wound infections = 1, pressure ulcer = 1). The preinjury MBI scores were significantly different (P < .05; A: 91.65 and B: 88.19), however, there was no significant difference in scores measured at discharge (A: 60.79 and B: 59.39), 6 months (A: 77.65 and B: 77.47) and 1 year (A: 80.71 and B: 83.03). Patients who underwent surgery for hip fracture had overall recovered 90.9% of their preinjury function (overall MBI at 1 year: 81.83). CONCLUSION: The MBI scores reflect the extent of attainment of independence in self-care, and actual functional recovery is gauged from the percentage of recovery of preinjury function at 1 year postsurgery. We conclude that the type of surgery may not be a significant factor in determining independence in self-care although patients who had arthroplasty had recovered more function at 1 year postsurgery than those who underwent fixation (percentage recovery of preinjury function-A: 88.1% and B: 94.1%).

Functional Improvement in Geriatric Hip Fractures: Does Vitamin D Deficiency Affect the Functional Outcome of Patients With Surgically Treated Intertrochanteric Hip Fractures.

INTRODUCTION: The "Integrated Care Pathway" for geriatric intertrochanteric (IT) fractures in Singapore's Tan Tock Seng Hospital has shown significant functional recovery in patients' activities of daily living. However, the influence of preoperative vitamin D on functional recovery remains equivocal. This retrospective study therefore aims to determine whether patients with preoperative vitamin D deficiency have poorer functional outcomes. METHOD: A total of 171 patients who had surgical treatment for IT fractures were recruited in the study. They were categorized into group A (vitamin D deficient) and group B (normal vitamin D). Charlson Comorbidity Index (CCI) score and nutritional parameters including hemoglobin, albumin, and adjusted calcium levels on admission were recorded. The Modified Barthel Index (MBI) score was used to measure functional recovery at the following time intervals: at pre-fall, at discharge after surgery, at 6 months, and at 1-year follow-up. RESULTS: The mean age of both the groups (A: 79.7 years, n = 45; B: 83.0 years, n = 126) was statistically different (P < .05). However, the mean CCI (A: 9.42 and B: 10.13), hemoglobin (A: 12.4 and B 11.1), adjusted calcium (A: 2.39 and B: 2.38), and mean albumin (A: 33.6 and B: 33.0) of the groups were not significantly different. Furthermore, the MBI scores were not significantly different for both groups at preinjury (A: 91.5 and B: 89.4), at discharge (A: 55.2 and B: 58.9), at 6 months (A: 70.9 and B: 75.1), and at 1 year (A: 75.8 and B: 79.4). CONCLUSION: In our cohort, patients with vitamin D deficiency were younger. However, vitamin D deficiency at time of injury had no significant influence on functional recovery in patients with surgically treated hip fracture in our Integrated Care Pathway. In addition, patients who had a normal vitamin D levels had similar functional scores and improvement postoperatively and at 1 year (A: 82.8% and B: 88.9%).

Inappropriate prescribing as a predictor for long-term mortality after hip fracture.

BACKGROUND: Hip fracture patients are at a higher risk for death compared to age-matched controls. While the reasons for this increased mortality risk are incompletely understood, medical comorbidities and associated medication prescribing likely play an important role in patient outcomes. Altered drug metabolism, polypharmacy and diminished physiologic reserve may all lead to adverse drug reactions and adverse outcomes. Additionally, underprescribing of efficacious medications may deprive older patients of potential therapeutic benefits. OBJECTIVE: The aim of our trial was to estimate the impact of inappropriate medication prescribing on the long-term outcome of older hip fracture patients. METHODS: The present study is a retrospective cohort study. We included all hip fracture patients who were consecutively admitted to our department from 2000 to 2004. We used the previously published STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria to assess the appropriateness of medication prescribing with an additional focus on osteoporosis medications and the total number of prescriptions. Prescriptions meeting STOPP and START criteria were considered 'positive items' and correlated with outcomes. Mortality was assessed by cross-referencing with the national death registry of the Tyrolean Institute of Epidemiology. RESULTS: During the study period, a total of 457 patients with hip fracture (mean age 80.61 ± 7.07 years; range 65-98) were evaluated. The mean number of positive combined STOPP and START items per patient was 2 ± 1.3, with ranges from 0 to 6 (STOPP items), 0 to 4 (START items) and 0 to 7 (combined STOPP/START items). Only 44 (9.6%) of patients had no positive STOPP or START items. The mean number of positive items (STOPP, START and combined) was significantly higher in non-survivors than survivors. The all-cause mortality rate at 3 years was lowest in the subjects with 1 or 0 positive items (20.5%; n = 35) and highest among those with >3 positive items (44.4%; n = 63). Inappropriate medication prescribing remained an independent risk factor with an odds ratio of 1.28 (1.07-1.52) after adjustment for sex, age, activities of daily living, comorbidities and nutrition status. CONCLUSION: Inappropriate medication prescribing is an independent predictor of long-term mortality in older hip fracture patients. It increases the relative risk of mortality in older hip fracture patients by 28%.

Long-term results of the augmented PFNA: a prospective multicenter trial.

BACKGROUND: Pertrochanteric fractures are increasing and their operative treatment remains under discussion. Failures needing reoperations such as a cut-out are reported to be high and are associated with multiple factors including poor bone quality, poor fracture reduction and improper implant placement. The PFNA(®) with perforated blade offers an option for standardized cement augmentation with a PMMA cement to provide more stability to the fracture fixation. It remains unclear if the augmentation of this implant does any harm in a longer time span. This prospective multicenter study shows clinical and radiological results with this implant with a mean follow-up time of 15 months. METHODS: In 5 European clinics, 62 patients (79 % female, mean age 85.3 years) suffering from an osteoporotic pertrochanteric fracture (AO 31) were treated with the augmented PFNA(®). The primary objectives were assessment of activities of daily living, pain and mobility. Furthermore, the X-rays were analyzed for the cortical thickness index, changes of the trabecular structure around the cement and the hip joint space. RESULTS: The mean follow-up time was 15.3 months. We observed callus healing in all cases. The surgical complication rate was 3.2 % with no complication related to the cement augmentation. A mean volume of 3.8 ml of cement was injected and no complication was reported due to this procedure. 59.9 % reached their prefracture mobility level until follow-up. The mean hip joint space did not change significantly until follow-up and there were no signs of osteonecrosis in the follow-up X-rays. Furthermore, no blade migration was assessed. CONCLUSION: This study makes us believe that the standardized augmentation of the PFNA with a perforated blade is a safe method to treat pertrochanteric femoral fractures. It leads to good functional results and is not associated with cartilage or bone necrosis.

Surgeons save bones: an algorithm for orthopedic surgeons managing secondary fracture prevention.

Postmenopausal osteoporosis has a big impact on health care budget worldwide, which are expected to double by 2050. In spite of severe medical and socioeconomic consequences from fragility fractures, there are insufficient efforts in optimizing osteoporotic treatment and prevention. Undertreatment of osteoporosis is a well known phenomenon, particularly in elderly patients. Treatment rates remain low across virtually all patient, provider, and hospital-level characteristics, even after fragility fractures. In-hospital initiation is one of the options to increase treatment rates and improve osteoporosis management. However, multiple factors contribute to the failure of initiating appropriate treatment of osteoporosis in patients with fragility fractures. These include a lack of knowledge in osteoporosis and an absence of a comprehensive treatment guideline among family physicians and orthopedic surgeons. Furthermore, orthopedic surgeons are hardly willing to accept their responsibility for osteoporosis treatment due to the fact that they are usually not familiar with the initiation of specific drug treatments. The presented algorithm offers trauma surgeons and orthopedic surgeons a safe and simple guided pathway of treating osteoporosis in postmenopausal women appropriately after fragility fractures based on the current literature. From our point of view, this algorithm is useful for almost all cases and the user can expect treatment recommendations in more than 90 % of all cases. Nevertheless, some patients may require specialized review by an endocrinologist. The proposed algorithm may help to increase the rate of appropriate osteoporosis treatment hence reducing the rates of fragility fractures.

Retinoblastoma. Cell of origin.

OBJECTIVES: To apply modern techniques of molecular cell biology and to revisit the old question of the cell of origin for retinoblastoma in hopes of gaining a better understanding of the retinoblastoma gene's antioncogenic mechanisms. METHODS: Twenty-two consecutively accessed retinoblastomas were examined with immunocytochemical techniques for numerous retinal proteins. Both single and double labeling were used. Enzyme histochemistry for carbonic anhydrase was used as well. RESULTS: Differentiated areas of the tumors contained abundant Müllerlike cells. Fleurettes stained mostly for red and green cone-specific antibodies while features of blue cones and rods predominated in areas with high cytoplasmic-to-nuclear ratios but no fleurettes. All of the differentiated neoplastic cells were either photoreceptors or Müller's cells. No other retinal cell types were found. CONCLUSIONS: The cells of retinoblastoma are capable only of bipotential differentiation, ie, Müller's cells and photoreceptors. Given this and recent findings concerning retinal embryogenesis, we argue for the rod photoreceptor as the cell of origin. A possible role for the retinoblastoma gene product is discussed.

Hepatocellular carcinoma metastatic to the orbit in an African patient.

Primary hepatocellular carcinoma rarely metastasizes to the orbit. We report a 19-year-old black man from Zimbabwe who had hepatomegaly and an orbital mass. An orbital biopsy suggested a diagnosis of hepatocellular carcinoma. Immunohistochemical stains supported the diagnosis. To our knowledge, this is only the second reported case of hepatocellular carcinoma metastasizing to the orbit and the first such reported case from Africa.

Accumulation of p53 protein correlates with a poor prognosis in human lung cancer.

Mutations in the gene coding for the p53 tumor suppressor protein are common in a variety of human cancers. To assess the role of a putative mutated p53 protein in human lung cancer, a monoclonal antibody recognizing it was used in an immunoperoxidase detection system. A total of 114 cases of Stage I and II adenocarcinomas and squamous cell carcinomas were studied. The staining pattern was always intranuclear and heterogeneous. When the median or mean survival time was compared between cases, p53 accumulation had a statistically significant negative prognostic value. This was supported by a Kaplan-Meier survival plot of p53 producers and nonproducers. In 7 of 24 Stage II cases that were negative for p53 in the primary tumor, metastatic regional lymph nodes were p53-positive. These latter cases had greatly reduced survival times. Thus, p53 accumulation in primary tumors (and regional lymph nodes) may identify a subgroup of lung cancer patients with a prognosis of more aggressive disease.

Granulocytic sarcoma presenting as an epidural mass with acute paraparesis in an aleukemic patient.

Granulocytic sarcomas are rare tumors composed of granulocytic precursor cells. They are most commonly encountered in patients with acute myelogenous leukemias and myeloproliferative disorders in blast crisis. Rarely, patients presenting with granulocytic sarcoma show no evidence of acute leukemia. The authors report an aleukemic patient with acute paraparesis from an epidural granulocytic sarcoma. Only five such cases have been reported previously. Immunoperoxidase stain for lysozyme and chloroacetate esterase stain were used to prove the myeloid origin of the tumor cells.