Fast-track care for pertrochanteric hip fracture: What impact on function and autonomy after discharge?

INTRODUCTION: Fast-track treatment of pertrochanteric fracture is being developed in traumatology. The present study hypothesis was that fast-track treatment of pertrochanteric fracture does not jeopardize patient autonomy. MATERIAL AND METHOD: A single-center prospective comparative observational study, conducted from 2014 to 2016 in the University Hospital of Angers, France, included patients presenting with isolated A1 or A2 pertrochanteric fracture on the AO classification, managed by intramedullary nailing and requiring transfer to Post-acute Recovery (PAR). The fast-track exposure group were transferred directly on postoperative day 1, while the non-exposure group received postoperative care in the surgery department before transfer to PAR. The main endpoint was difference in Parker score between admission and discharge. Secondary endpoints comprised type of walking aid at discharge and destination of discharge from PAR. RESULTS: 109 patients were initially included, with 54 patients (27 pairs) after matching. There was a significant difference in reduction in Parker score in favor of fast-track: -1.27 (95% CI: -2.27; -0.32) (p=0.012). There were no differences in amount or type of aid at discharge or discharge destination, although there was a trend toward greater discharge to the initial place of residence with fast-track. DISCUSSION: Orthopedics is heading to the fast-track. Previous studies reported shorter hospital stay, comparable survival and complications rates, and significant cost-saving. The present study addressed progression: fast-track patients showed significantly less loss of walking autonomy. CONCLUSION: Fast-track management of pertrochanteric fracture significantly reduced loss of walking autonomy, without significant impact on discharge destination or walking aids. LEVEL OF EVIDENCE: IIB, exposure/non-exposure cohort.

A rare case of Prosthetic Joint Infection associated with Coxiella burnetii.

We report here the case of a Prosthetic Joint Infection (PJI) associated with Coxiella burnetii in a 62-year-old man with a revised total hip arthroplasty. The diagnosis was performed first by 16S rDNA sequencing on hip fluid aspirate, and confirmed by specific qPCR. Q fever has been reported in few cases of Prosthetic Joint Infections, often associated with chronic evolution and iterative surgeries. This case report alerts about such an unexpected diagnosis in a patient with no known risk factors.

Fast track care for pertrochanteric hip fractures: How does it impact length of stay and complications?

INTRODUCTION: The medical and economic impact of treating pertrochanteric hip fractures is growing. We hypothesized that fast track surgery of pertrochanteric fractures would reduce the length of stay (LOS) without compromising the quality of care. MATERIALS AND METHODS: This was a prospective, observational, single-center cohort study conducted between 2014 and 2016 at the Angers Teaching Hospital in France. The enrolled patients had an isolated A1 or A2 proximal femur fracture (AO classification) that was treated surgically by intramedullary nailing and required post-acute rehabilitation (PAR) care. The exposed FT cohort was transferred into the PAR pathway on postoperative day 1. The non-exposed (control) group was provided with postoperative care in the surgery unit before transfer to PAR. The primary outcome was the total LOS (LOS in surgery+LOS in PAR). The secondary objectives were to determine the immediate survival, 1-year survival, postoperative complications and average cost of hospitalization. RESULTS: The study enrolled 109 patients initially, with 54 patients eligible for analysis after matching (27 pairs). The LOS in PAR and total LOS were 45.85±19.24 days and 48.56±19.36 days in the FT group (n=27), and 68.41±48.77 days and 77.85±48.80 days in the control group (n=27). Thus the LOS in PAR and total LOS were significantly lower in the FT group (p=0.022, p=0.003). There was no significant difference in the number of early deaths, complications, and 1-year survival without rehospitalization between cohorts. The mean cost per patient was lower in the FT cohort. DISCUSSION: The FT pathway has already been adopted in orthopedics. For patient who suffer a hip fracture, it contributes to reducing the total LOS without negatively impacting the quality of care. Early health economics studies support this care pathway. CONCLUSION: The FT approach to treating pertrochanteric fractures reduces total LOS without increasing mortality or complication rates. The 1-year survival is comparable. LEVEL OF EVIDENCE: IIB, Exposed/Unexposed cohort.

Central talar fractures--therapeutic considerations.

Talar fractures are rare and often have to be treated in the emergency department by young surgeons. Thus, important literature series, often multicentric, are generally of little interest regarding practical technical considerations. The aim of this paper is to lead the surgeon who has to treat such fractures to reflect on the goals of the treatment and the means to success. There is probably no better example than talar fractures for the application of the four AO basic principles: Anatomical reduction, stable internal fixation, preservation of the blood supply, and early active pain-free motion. After presenting the different approaches to the talus, the blood supply is described precisely, in reference to the surgical exposures. Then the many tools (tricks) to achieve the treatment goals, avoiding dangers and pitfalls, are meticulously described. Some of the goals, pitfalls, and tools are obvious, whereas some are not, but they could be just as important, if not more so.