Vitamin D and hip protectors in osteosarcopenia: a combined hip fracture preventing approach.

Osteosarcopenia is an emerging clinical condition highly prevalent in the older people. Affected subjects due to their intrinsic skeletal fragility and propensity to falls are at elevated risk of hip fractures which can increase morbidity and mortality. Strategies for attenuating the impact of predisposing factors on hip fractures are not yet well defined and should derive from multidisciplinary care and collaborations. Our aim was to narratively review available data on the preventive role of vitamin D and hip protectors on hip fractures in older patients with sarcopenia. Older subjects are at high risk of vitamin D deficiency and of falls due to several concomitant factors besides osteosarcopenia. Vitamin D protective actions against hip fractures may be mediated by both skeletal (increased mineralization) and extra-skeletal (reduced risk of falls) actions. Hip protectors may act downstream attenuating the effects of falls although their use is still not yet enough widespread due to the suboptimal compliance obtained by traditional hard devices. Concomitant use of vitamin D and hip protectors may represent an effective strategy in the prevention of hip fractures which need to be tested in ad hoc designed clinical trials.

How accurately do finite element models predict the fall impact response of ex vivo specimens augmented by prophylactic intramedullary nailing?

Hip fracture prevention approaches like prophylactic augmentation devices have been proposed to strengthen the femur and prevent hip fracture in a fall scenario. The aim of this study was to validate the finite element model (FEM) of specimens augmented by prophylactic intramedullary nailing in a simulated sideways fall impact against ex vivo experimental data. A dynamic inertia-driven sideways fall simulator was used to test six cadaveric specimens (3 females, 3 males, age 63-83 years) prophylactically implanted with an intramedullary nailing system used to augment the femur. Impact force measurements, pelvic deformation, effective pelvic stiffness, and fracture outcomes were compared between the ex vivo experiments and the FEMs. The FEMs over-predicted the effective pelvic stiffness for most specimens and showed variability in terms of under- and over-predicting peak impact force and pelvis compression depending on the specimen. A significant correlation was found for time to peak impact force when comparing ex vivo and FEM data. No femoral fractures were found in the ex vivo experiments, but two specimens sustained pelvic fractures. These two pelvis fractures were correctly identified by the FEMs, but the FEMs made three additional false-positive fracture identifications. These validation results highlight current limitations of these sideways fall impact models specific to the inclusion of an orthopaedic implant. These FEMs present a conservative strategy for fracture prediction in future applications. Further evaluation of the modelling approaches used for the bone-implant interface is recommended for modelling augmented specimens, alongside the importance of maintaining well-controlled experimental conditions.

Author Response: Nocturnal Infusion of Low-dose Dexmedetomidine and Propofol for Delirium Prevention.

How to cite this article: Ekkapat G, Chokengarmwong N. Author Response: Nocturnal Infusion of Low-dose Dexmedetomidine and Propofol for Delirium Prevention. Indian J Crit Care Med 2024;28(9):896.

Nocturnal Infusion of Low-dose Dexmedetomidine and Propofol for Prevention of Delirium Occurring in the ICU after Hip Fracture Surgery in Elderly Patients.

How to cite this article: Cong N, Wang D, Xue F. Nocturnal Infusion of Low-dose Dexmedetomidine and Propofol for Prevention of Delirium Occurring in the ICU after Hip Fracture Surgery in Elderly Patients. Indian J Crit Care Med 2024;28(9):894-895.

Surgical Treatment of Non-Displaced Subcapital Hip Fracture: Femoral Neck System vs. Cannulated Screws. Comparative Study. / Tratamiento quirúrgico de fractura subcapital de cadera no desplazada: Femoral Neck System vs Tornillos canulados. Estudio Comparativo.

OBJECTIVE: The objective of this study is to compare the outcomes of using the Femoral Neck System (FNS) (DePuy Synthes®) versus the use of cannulated screws (CS) in the surgical treatment of non-displaced subcapital hip fractures. MATERIALS AND METHODS: A retrospective cohort study was conducted on non-displaced subcapital hip fractures treated with CS or FNS between 2020 and 2023, with a minimum follow-up of one year. A total of 28 patients were included, 14 treated with CS and 14 with FNS. Demographic, radiological, clinical, and functional variables were analyzed. RESULTS: In the CS group, 64% were male, with a mean age of 66.5 years (SD 14.9) and an average follow-up of 22 months (range, 12-36 months). In the FNS group, 57% were male, with a median age of 60.8 years (SD 13.78) and an average follow-up of 16 months (range, 12-24 months). Regarding functional outcomes, no significant differences were found between FNS and CS in the Harris scale: 94.21 ± 11.55 for FNS and 96.50 ± 6.9 for CS (p=0.618). The total postoperative complications (FNS/CS) were 7.1% versus 43%, and implant failure with conversion to total hip replacement was 0% versus 43%, both significantly higher in the CS group (p=0.047; p=0.016, respectively). The FNS also presented a lower rate of avascular necrosis (0% versus 11.1%, p=0.391) and nonunion (0% versus 20%, p=0.163), although these differences did not reach statistical significance. CONCLUSIONS: Although both treatment methods, cannulated screws and the Femoral Neck System (FNS), showed similar short-term functional outcomes in the management of undisplaced subcapital femoral fractures, the FNS demonstrated a significantly lower rate of complications and reoperations. These results suggest that the FNS could be considered a safer and more effective option compared to cannulated screws.

Posterior Hip Pericapsular Block (PHPB) with pericapsular nerve group (PENG) block for hip fracture: a case series.

BACKGROUND: Pain after total hip arthroplasty (THA) for femoral neck fracture (FNF) can be severe, potentially leading to serious complications. PENG block has become an optional local analgesic strategy in hip fracture surgery, but it cannot provide effective pain relief for the posterior capsule of the hip joint. Therefore, we modified the traditional sacral plexus nerve block and named it Posterior Hip Pericapsule Block (PHPB) to complement the blockade of the relevant nerves innervating the posterior hip capsule region. Thereby, we detail the analgesic effect of PHPB combined with PENG block on five hip fracture patients and the effect on their hip motor function. METHODS: This case series was conducted from December 2023 to February 2024. We performed ultrasound-guided PHPB combined with PENG block on five patients with hip fractures. Numerical Rating Scale (NRS) pain scores at rest and maximum NRS pain scores during limb movement of the five patients were recorded within 48 h after surgery. Their hip flexion, abduction, adduction, keen flexion and quadriceps muscle strength were also recorded. Serious postoperative complications, including wound infection, hematoma formation, or nerve injury, were recorded. RESULTS: They experienced effective pain control within 48 h postoperatively, with NRS pain scores at rest decreasing from 3.0 (3.0, 4.5) to 0.0 (0.0, 1.0) and maximum NRS pain scores during limb movement from 8.0 (7.5, 8.5) to 1.0 (0.5, 2.0). They can autonomously perform hip flexion, abduction, adduction, and knee flexion within 48 h postoperatively without any signs of movement disorders or quadriceps muscle weakness. No severe postoperative complications, such as wound infections, hematoma formation or nerve damage, were observed in any of the patients. CONCLUSIONS: Ultrasound-guided PENG block combined with PHPB provided effective analgesia for hip fracture patients in the perioperative period. It maintained hip joint motor function and quadriceps muscle strength within 24 h after THA.

Early surgical care of the anticoagulated hip fracture patient within 24 hours.

INTRODUCTION: Hip fractures are still associated with high morbidity and mortality. Despite international guidelines advocating for urgent surgical treatment, delays often occur, particularly for patients on long-term antithrombotic therapy. We hypothesised that urgent surgical care for the anticoagulated hip fracture patient is not associated with severe bleeding complications. MATERIAL AND METHODS: For the period from 2015 to 2021, we retrospectively reviewed clinical records of 1142 patients with proximal femur fractures treated within 24 h of admission to our trauma centre (mean age 80.4 ± 12.4 years; 761 females, 381 males). The cohort comprised 409 femoral neck and 733 trochanteric fractures, managed with either arthroplasty (n = 297), hip-preserving techniques (n = 147), or intramedullary nailing (n = 698). Of these, 583 patients (51.1 %) were on long-term antithrombotic therapy. The primary endpoints included transfusion rate and the difference in haemoglobin (Hb) levels from pre- to postoperative. Secondary endpoints were in-patient mortality and occurrence of postoperative haematomas requiring surgical revision. A regression analysis was performed. RESULTS: The mean time to surgery was 10.3 h, with delays observed in patients on direct oral anticoagulants (DOACs). Overall, 25.9 % (n = 296) of the patients required blood transfusions. The transfusion rate was dependent on duration of the surgery, preoperative Hb level, and anticoagulation with DOACs. Similarly, the Hb difference was found to be dependent on the duration of surgery, preoperative Hb level, and anticoagulation with DOACs. In-patient mortality was 5.3 % (n = 60). Regression analysis indicated that mortality was dependent on a high ASA classification of 4 and the time to surgery, but not on the type of antithrombotic therapy. 3.1 % of the patients needed surgical revision due to postoperative haematoma with prolonged duration of surgery and antithrombotic therapy (PAI [OR = 3.7, 95 % CI: 1.1-12.7], DOACs [OR = 3.4, 95 % CI: 1.3-8.8], and VKA [OR = 5.5, 95 % CI: 1.8-17.1], p < 0.05) as independent risk factors. CONCLUSION: As postoperative haematoma and the need for transfusion are manageable situations, we conclude that immediate surgical treatment of hip fracture patients on long-term antithrombotic therapy within 24 h is feasible and patients may benefit.

Readmission and mortality before and after introduction of orthogeriatric home visits: A retrospective cohort study in hip fracture patients.

INTRODUCTION: Orthogeriatric collaboration in hip fracture patients during admission is well established, however, orthogeriatric involvement after discharge is not common. The aim of this study was to explore the association of orthogeriatric home visits with 30-day and 120-day readmission and mortality in ≥ 65-year-old patients surgically treated for hip fractures. MATERIALS AND METHODS: A cohort of patients who underwent acute hip fracture surgery in an usual care period from January 2018 to December 2018 was compared with a cohort of patients in an intervention period from June 2020 to June 2021. During the intervention period, patients were offered orthogeriatric home visits at day 2 and 9 after discharge. The home visits were performed by orthogeriatric nurses, in close collaboration with geriatricians and orthopedic surgeons based in the local hospital. Readmission was defined as ≥ 12 h hospital stay, regardless of reason. For the main analysis, we applied Cox-regression models adjusted for age, sex, New Mobility Score, Cumulated Ambulation Score regained, cognitive function, Charlson Comorbidity Index, complications, medication, discharge destination and emergency department visits. RESULTS: In total, 292 patients were included during the usual care period, and 308 patients during the intervention period. Thirty- and 120-day readmission rates were 27.7 % and 41.4 % in the usual care cohort vs. 21.8 % and 35.1 % in the home visit cohort. Adjusted Hazard Ratios for readmission in the intervention cohort after 30 and 120 days were 0.67 (CI95 %: 0.48-0.93) and 0.71 (CI95 %: 0.54-0.93) respectively. Thirty- and 120-day mortality rates were 7.2 % and 20.9 % in the usual care cohort versus 5.8 % and 13.3 % in the intervention cohort. Adjusted Hazard Ratios for mortality in the intervention cohort after 30 and 120 days were 0.68 (CI95 %: 0.35-1.31) and 0.56 (CI95 %: 0.37-0.84) respectively. CONCLUSIONS: In a period where hip fracture patients were offered two home visits after discharge, we observed lower 30- and 120- day readmission, and lower 120-day mortality, calling for more studies with a randomized design.

Propensity score matching analysis of early vs. delayed surgery for intertrochanteric fracture in older patients: a retrospective multicenter cohort study of 7414 patients with a mean 4-year follow up.

BACKGROUND: The widespread acceptance of early surgery as a treatment for acute intertrochanteric fracture (ITF) has been accompanied by ongoing controversy due to conflicting conclusions presented in previous studies. This study aims to compare the occurrence of perioperative complications and mortality, as well as functional outcomes in older patients with ITF who underwent either early or delayed surgery. METHODS: A retrospective multicenter cohort study involving 7414 patients with ITF between Jan. 2017 and Dec. 2021 was conducted. After predefined participants selection inclusion and exclusion criteria, 2323 surgically treated ITF patients were included and analyzed utilizing propensity score matching (PSM) method. Their demographics, injury-related data, surgery-related data, and perioperative adverse outcomes during hospitalization were collected and compared between the early or delayed surgery groups by PSM with a 1:4 ratio. All participants received a minimum of two-year follow-up and perioperative outcomes, functional outcomes, and survival analyses were conducted and compared. RESULTS: After adjustment for potential confounders, there were no significant difference in surgery duration, intraoperative blood loss, transfusion rate, mortality rates, functional outcomes, and perioperative complications rates including severe complications, cardiac complications, pulmonary complications, and neurological complications regardless of whether the patient was treated with early or delayed surgery (all P > 0.05). Although length of hospital stay (mean, 11.5 versus 14.4 days, P < 0.001), total hospital costs (mean, 39305 versus 42048 yuan, P < 0.001), and minor complications rates including hematological complications (31.7% versus 41.2%, P = 0.007) and nutritional/metabolic complications (59.3% versus 66.4%, P = 0.039) were lower in the early surgery group, our result indicated patients with early surgery were more inclined to receive more blood transfusion (mean, 2.8 versus 2.2 units, P = 0.004). CONCLUSIONS: Our findings suggest that a 48-hour delay in surgical intervention for older patients with an ITF does not result in a higher mortality rate, worse functional outcomes, and increased incidence of major perioperative complications when compared to early surgery. While expedited surgery is undoubtedly necessary for suitable patients, a reasonable preoperative delay of 48 h may be justified and safe for those with severe conditions, rather than strictly adhering to the current guidelines.

How to predict postoperative delirium in geriatric patients with hip fracture as soon as possible? A retrospective study.

PURPOSE: Inflammation may play a role in the mechanism of postoperative delirium (POD), a severe complication among older postoperative patients. The purpose of this study was to investigate the risk factors of POD in postoperative patients with hip fracture, especially the inflammation marker- neutrophil-lymphocyte ratio (NLR). METHODS: This retrospective investigation utilized data from the Seventh Medical Center of People's Liberation Army. 1,242 Eligible patients with hip fracture (829 females), median age 81 years, mean neutrophil-lymphocyte ratio (NLR) 5.28, were enrolled. Receiver operating characteristic (ROC) curve was performed to identify the optimal cut point of NLR for POD. The relationship between NLR and POD occurrence, NLR and POD duration were analyzed by multivariable analysis. RESULTS: ROC curve showed that the optimal cut point of NLR for POD was NLR ≥ 7.6. Multivariate logistic regression analysis showed that NLR ≥ 7.6 (odds ratio [OR] 2.75, [95% confidence interval [CI] 1.51 to 5.02], p = 0.001), stroke (OR 1.05, [95% CI 1.02 to 1.09], p = 0.005), complications, general anesthesia, long length of stay were risk factors of POD, with the largest effect for NLR ≥ 7.6. NLR ≥ 7.6 (ß 0.59, [95% CI 0.209 to 0.886], p = 0.038), older age (ß 0.054, [95% CI 0.009 to 0.099], p = 0.019), previous stroke (ß 0.908, [95% CI 0.085 to 1.731], p = 0.031), and previous heart failure (ß 1.679, [95% CI 0.448 to 2.910], p = 0.008) suggested long POD duration. CONCLUSIONS: This study demonstrates an association between NLR and postoperative delirium in geriatric hip fracture patients, and contribute new evidence to support NLR as a potential marker for prediction of POD and POD duration.

A Neck of Femur Fracture Associated With Electric Scooter Use in a Young Patient.

Since the launch of electric scooter (e-scooter) trials in the UK by the Department for Transport (DfT), there has been an upward trend in injuries involving e-scooters. We report a case of a significant orthopaedic injury in a male patient following a fall from an e-scooter. He sustained a right-sided neck of femur fracture. He was treated successfully with a dynamic hip screw. Hip fracture in the young population is rare and is often associated with higher complication rates. We emphasise the importance of prompt identification and operative management of traumatic hip fractures in young patients and raising safety awareness about the use of e-scooters.

Risk factors for mortality in periprosthetic femur fractures about the hip-a retrospective analysis.

PURPOSE: Fractures around the hip are known to be an indicator for fragility and are associated with high mortality and various complications. A special type of fractures around the hip are periprosthetic femur fractures (PPF) after Total Hip Arthroplasty (THA). The aim of this study was to investigate the mortality rate associated with PPF after THA and to identify risk factors that may increase it. METHODS: Consecutive patients (N = 158) who were treated for a PPF after THA in our university hospital between 2010 and 2020 were identified and mortality was assessed using the residential registry. Univariate (Kaplan-Meier-Estimator) and multivariate (Cox-Regression) statistical analysis was performed to identify risk factors influencing mortality. RESULTS: One-year-mortality rate was 23.4% and 2-year mortality was 29.2%. Mortality was significantly influenced by age, gender, treatment, type of comorbidity and time of surgery (p < 0.05). Surgical treatment during regular working hours (8 to 18 h) reduced mortality by 53.2% compared to surgery on call (OR: 0.468, 95% CI 0.223, 0.986; p = 0.046). For every year of age, mortality risk increased by 12.9% (OR: 1,129, 95% CI 1.078, 1.182; p < 0.001). The type of fracture according to the Vancouver classification had no influence on mortality (p = 0.179). Plate fixation and conservative treatment were associated with a higher mortality compared to revision arthroplasty (plate: OR 2.8, 95% CI 1.318, 5.998; p = 0.007; conservative: OR 2.5, 95% CI 1.421, 4.507; p = 0.002). CONCLUSION: Surgical treatment during regular working hours is associated with lower mortality compared to surgery outside these hours. In this retrospective cohort, time to surgery showed no significant impact on all-cause mortality, and revision arthroplasty was associated with lower mortality than conservative treatment or plate fixation. LEVEL OF EVIDENCE: IV (Retrospective cohort study).

Inpatient zoledronic acid in older hip fracture patients is well tolerated and safe.

Administering zoledronic acid (ZA) to older hip fracture patients during the hospital stay has faced safety concerns. However, in this study of 161 patients, no ZA-related side effects or readmissions were observed, demonstrating that ZA administration during hospitalization is safe and effective for secondary fracture prevention. PURPOSE: According to the 2022 Dutch 'Osteoporosis and fracture prevention' guideline, zoledronic acid (ZA) is the preferred osteoporosis treatment for hip fracture patients. Less than 25% of hip fracture patients visit the outpatient fracture liaison service, therefore inpatient administration of ZA during the hip fracture hospitalization is now recommended in patients > 75 years. In the OLVG Hospital, inpatient administration of ZA during hospitalization for hip fracture in older patients has been standard of care since 2020. METHODS: This single center retrospective observational follow-up study included hip fracture patients > 75 years admitted to the orthogeriatric ward of the OLVG Hospital, and treated with 5 mg of ZA intravenously on the day of hospital discharge between June 2020 and December 2022. Life expectancy estimated < 12 months, creatinine clearance < 35 ml/min, hypocalcemia, and high risk of osteonecrosis of the jaw were contra-indications. During three months of follow-up (FU) adverse events, emergency room visits, hospital readmissions, and death were recorded. RESULTS: In 161 consecutive hospitalized hip fracture patients (mean age 86 ± 6 years, 65% female, 18% nursing home) ZA was administered and no adverse events were recorded. During 3 months of FU, 8 patients (5%) visited the emergency room, 19 patients (12%) were re-admitted to the hospital, 3 with a new fracture (2 contralateral hip, 1 radius), and 17 patients (11%) died of reasons unrelated to ZA. CONCLUSION: This study shows that inpatient administration of zoledronic acid during hip fracture hospitalization is safe and feasible to prevent future fragility fractures in older hip fracture patients.

Socioeconomic and Demographic Determinants of Hip Fracture Incidence: A Comprehensive Analysis.

INTRODUCTION: Hip fracture incidence is rising globally, making it crucial to understand the demographic factors that influence their occurrence for targeted healthcare interventions. This study focuses on examining the determinants of hip fracture incidence, particularly socioeconomic status, body mass index (BMI), and gender. METHODS: The study utilised data from 570 patients recorded in the 2023 National Hip Fracture Database Audit tool. Socioeconomic status was assessed through the Index of Multiple Deprivation (IMD), based on patient postcodes. The analysis aimed to explore correlations between socioeconomic status, BMI, gender, and the incidence and types of hip fractures. RESULTS: The findings indicate that the majority of hip fractures occurred in individuals from the lowest socioeconomic deciles, with a statistically significant correlation (p < 0.05) between lower socioeconomic status and higher fracture incidence. Gender-specific disparities were observed, with males experiencing fractures at younger ages and presenting with different fracture types compared to females. Additionally, lower BMI was significantly associated with a higher likelihood of certain fracture types (p < 0.05). CONCLUSIONS: The study highlights the substantial influence of socioeconomic status, gender, and BMI on hip fracture incidence and typology. These results indicate the need for targeted prevention strategies and health policies aimed at mitigating hip fracture risks in socioeconomically disadvantaged populations. Understanding these factors can enable healthcare providers to allocate resources and interventions more effectively, reducing the incidence and impact of hip fractures in deprived areas.

Femoral Artery Pseudoaneurysm from Heterotopic Ossification after Fixation of Intertrochanteric Hip Fracture: A Case Report.

Introduction: Intertrochanteric (IT) hip fractures are increasing in prevalence due to a rise in the aging population. Cephalomedullary nailing is one of the treatment options and is becoming a treatment of choice worldwide. Complications after a hip fracture have been extensively studied and widely published. Despite numerous publications, we report a unique complication not previously seen in literature. Case Report: This case demonstrates the rare phenomenon of proximal femur heterotopic ossification (HO) after cephalomedullary nailing of an IT femur fracture causing a femoral artery pseudoaneurysm. Conclusion: Proximal femoral HO is a rare phenomenon after cephalomedullary nailing that, in this case, presented a serious complication requiring combined surgical intervention from both vascular surgery and orthopedic surgery teams. As far as the authors know, this is the only such incident in the literature.

Prognostic Factors of Hip Fracture in Elderly: A Systematic Review.

The hip fracture causes significant disabilities in many elderly people. Many studies around the world have identified various risk factors for the hip fracture. The aim of this study was to systematically investigate the risk factors of hip fractures. This study is a systematic review of risk factors for hip fractures. All published papers in English and Persian languages on patients in Iran and other countries between 2002 - 2022 were examined. The search strategy used keywords matching the mesh, including : predictors, hip fracture, and disability. Articles were selected from international databases (PubMed, Proquest ,Web of Sience, Scopus, Google scholar and Persian(Sid,Magiran), and the Newcastle Ottawa Scale was used to assess the risk of bias. The study has identified several factors that were significantly correlated with the risk of hip fracture, including age, cigarette and alcohol consumption, visual and hearing problems, low BMI levels, history of falling, weakness, and diseases such as stroke, cardiovascular disease, high blood pressure, arthritis, diabetes, dementia, Alzheimer's, Parkinson's, liver and kidney diseases, bone density, osteoporosis, vertebral fracture, and hyperthyroidism. However, the study did not find any significant correlations between the consumption of calcium and vitamin D, history of fractures, cognitive disorders, schizophrenia, and household income, and the risk of hip fracture. The results of this study reveal the determining role of some risk factors in hip fracture in older persons. Therefore, it is recommended that health policy makers provide the possibility of early intervention for some changeable factors.

Sleep and risk of hip fracture and falls among middle-aged and older Chinese.

The study aimed to assess the prospective associations between sleep duration, sleep restfulness, midday napping and hip fracture (HF) and falls in a nationally representative Chinese population. Data were from the China Health and Retirement Longitudinal Study which was conducted from 2013 to 2018. In total, 10,508 individuals without a history of HF in 2013 were included. Nighttime sleep duration, sleep restfulness and midday napping were self-reported. Logistic regression analyses were performed to examine the relationships between sleep problems and HF as well as falls, adjusting for covariates. A total of 313 (3.0%) participants reported HF, and 3899 (37.1%) experienced at least one fall event over the following 5-year period. Participants who had a short sleep duration (≤ 6) were more likely to report HF (OR = 1.27, 95% CI = 1.00-1.62) and falls (OR = 1.18, 95% CI = 1.07-1.30) than those who had a normal sleep duration (6-9 h) in the fully adjusted model. Participants having unrestful sleep were also more likely to report falls (OR = 1.23, 95% CI = 1.11-1.36) than those who had restful sleep. However, there was no significant association between midday napping and HF and falls. In conclusion, short sleep duration and sleep restfulness were independently associated with an increased risk of HF and falls, which may have important clinical and public health implications. Interventions to improve sleep quality may reduce the risk of HF and fall accidents among middle-aged and older people.

A Novel Nomogram Developed Based on Preoperative Immune Inflammation-Related Indicators for the Prediction of Postoperative Delirium Risk in Elderly Hip Fracture Cases: A Single-Center Retrospective Cohort Study.

Objective: Postoperative delirium (POD) commonly occurs in elderly individuals following hip fracture surgery, with unclear pathophysiological mechanism. Inflammation is a known factor affecting the onset of delirium. The current work aimed to examine the associations of preoperative immune inflammation-related indicators with POD occurrence in elderly cases following hip fracture surgery. Methods: The current retrospective cohort study included 437 elderly cases administered hip fracture surgery from January 2018 to December 2023. The clinicodemographic data and laboratory findings of all cases were retrospectively analyzed. Immune inflammation-related indicators were assessed, eg, MLR, NLR and PLR, as well as SII and SIRI. The bootstrap method was employed to assign cases at 7:3 to the training (48 and 258 cases in the POD and no-POD groups, respectively) and internal validation (13 and 118 cases in the POD and no-POD groups, respectively) cohorts. Next, LASSO, univariable and multivariable logistic regression analyses were applied to determine risk factors in the training cohort, based on which a nomogram model was built. The obtained nomogram was examined for accuracy by calibration plot analysis. Finally, the nomogram's clinical value was assessed by decision curve analysis (DCA), followed by internal validation based on the training cohort. Results: Of all 437 cases, 61 developed POD, indicating a POD incidence of 13.96%. LASSO regression and multivariable analyses revealed preoperative SIRI independently predicted POD in the training cohort. The developed nomogram had an area under the curve (AUC) of 0.991 (95% CI 0.983~0.998) in the training cohort versus 0.986 (95% CI 0.966~1.000) in the validation cohort. Calibration curve analysis revealed nomogram-predicted and actual probabilities were in line. DCA demonstrated the novel nomogram could confer net benefits for POD prediction in elderly cases administered hip fracture surgery. Conclusion: The immune inflammation-related indicators SIRI could predict POD in elderly cases following hip fracture surgery.

Improving agreement in assessing subtrochanteric fracture healing among orthopedic surgeons using the Radiographic Union Score for Hip (RUSH).

BACKGROUND: Prompt identification of fracture healing is crucial for medical decision-making and clinical research. This study aims to assess the effectiveness of the Radiographic Union Score for Hip (RUSH) in subtrochanteric fractures and determine the optimal scoring threshold for fracture healing. METHODS: We obtained 94 sets of X-ray films from the postoperative follow-up of 35 patients who underwent intramedullary nail fixation for subtrochanteric fractures. Six orthopedic trauma surgeons evaluated the imaging data and determined fracture healing based on subjective judgment. They then scored the X-ray images using the RUSH form. After four weeks, the same observers re-evaluated 47 randomly selected sets of radiographs. Subsequently, the observers and study designer conducted a consensus meeting where they agreed on whether the fractures had healed. We used Fleiss kappa to evaluate agreement among observers based on subjective impressions, and the intraclass correlation coefficient assessed RUSH score consistency. Regression analysis examined the relationship between scores and fracture healing consensus using a receiver operator characteristic (ROC) curve. RESULTS: Based on overall impressions, the agreement level among orthopedic trauma surgeons for determining the healing status of subtrochanteric fractures was moderate (Kappa = 0.564, 95% CI: 0.511-0.616). However, utilizing the RUSH scoring system can improve the consistency to a substantial level of agreement (ICC = 0.748, 95% CI: 0.663-0.817). Regarding intraobserver reliability, there were significant differences among orthopedic trauma surgeons in judging fracture healing based on overall impressions. However, using the RUSH scoring form, the attending group achieved better intraobserver consistency than the resident group. Regression analysis and ROC curve analysis revealed a strong correlation between the RUSH total score, cortical bone score, cancellous bone score, and consensus on fracture healing. The AUC values are 0.769 (95% CI: 0.670-0.868), 0.779 (95% CI: 0.681-0.876), and 0.771 (95% CI: 0.674-0.867), respectively. CONCLUSIONS: Our study highlights the effectiveness of the RUSH scoring system in enhancing interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing in orthopedic trauma surgeons. We propose setting 21 points as the threshold for the simplified RUSH scoring system to determine fracture healing. This system includes only eight items related to cortical bone, with a total score of 24 points.

Predictors of non-adherence to an early in-hospital rehabilitation program after surgery for hip fracture in a co-managed orthogeriatric unit.

BACKGROUND: Hip fracture is a common event in older adults, leading to an increased risk of mortality, disability, and higher healthcare costs. Early in-hospital rehabilitation after surgery within orthogeriatric units may improve outcomes with limited incident complications even in the oldest old. We aimed to determine the prevalence and predictors of non-adherence to early rehabilitation in the orthogeriatric unit of an Italian tertiary hospital and its impact on outcomes and setting at discharge. METHODS: Retrospective observational single-centered cohort study. Patients aged ≥ 65 years admitted to the orthogeriatric unit for hip fracture who underwent surgery between April 2019 and October 2020 were considered eligible if able to walk autonomously or with assistance and independent in at least 2 Basic Activities of Daily Living. Along with sociodemographic and geriatric variables, characteristics of surgery and rehabilitation, in-hospital complications and functional outcomes at discharge were collected. The primary outcome was non-adherence to the early in-hospital rehabilitation program. RESULTS: Among 283 older patients (mean age 82.7 years, 28.6% male), non-compliance with physical therapy was assessed in 49 cases (17.3%), characterized by worse pre-fracture clinical, cognitive, and functional status and showing worse outcomes in terms of mobilization at discharge. After multivariable analysis, non-adherence was independently associated with the onset of delirium (OR 5.26, 95%CI 2.46-11.26; p < 0.001) or infections after surgery (OR 3.26, 95%CI 1.54-6.89; p < 0.001) and a systolic blood pressure at admission < 120 mmHg (OR 4.52, 95%CI 1.96-10.43, p < 0.001). CONCLUSIONS: Pre-fracture poor cognitive and functional status, along with lower systolic blood pressure, seem to make some patients more vulnerable to in-hospital complications (mainly delirium and infections) and negatively affect the adherence to physical therapy and, by consequence, clinical outcomes of rehabilitation.