The Impact of the COVID-19 2020 Pandemic on Hospital Length of Stay Following Fragility Hip Fracture Surgery.

BACKGROUND: Hip fractures in elderly patients are a major cause of morbidity and mortality. Variability in length of hospital stay (LOS) was evident in this population. The coronavirus disease-2019 (COVID-19) pandemic led to prompt discharge of effected patients in order to reduce contagion risk. LOS and discharge destination in COVID-19 negative patients has not been studied. OBJECTIVES: To evaluate the LOS and discharge destination during the COVID-19 outbreak and compare it with a similar cohort in preceding years. METHODS: A retrospective study was conducted comparing a total of 182 consecutive fragility hip fracture patients operated on during the first COVID-19 outbreak to patients operated on in 2 preceding years. Data regarding demographic, co-morbidities, surgical management, hospitalization, as well as surgical and medical complications were retrieved from electronic charts. RESULTS: During the pandemic 67 fragility hip fracture patients were admitted (COVID group); 55 and 60 patients were admitted during the same time periods in 2017 and 2018, respectively (control groups). All groups were of similar age and gender. Patients in the COVID group had significantly shorter LOS (7.2 ± 3.3 vs. 8.9 ± 4.9 days, P = 0.008) and waiting time for a rehabilitation facility (7.2 ± 3.1 vs. 9.3 ± 4.9 days, P = 0.003), but greater prevalence of delirium (17.9% vs. 7% of patients, P = 0.028). In hospital mortality did not differ among groups. CONCLUSIONS: LOS and time to rehabilitation were significantly shorter in the COVID group. Delirium was more common in this group, possibly due to negative effects of social distancing.

Hip Fracture Following a Fall among Older Adults during the COVID-19 Pandemic.

BACKGROUND: Little is known regarding the impact of the coronavirus disease-2019 (COVID-19) pandemic on the incidence of hip fractures among older adults. OBJECTIVES: To compare the characteristics of patients with a hip fracture following a fall during the COVID-19 pandemic year and during the preceding year. METHODS: We conducted a retrospective cohort study of older patients who had undergone surgery for hip fracture repair in a major 495-bed hospital located in northern central Israel following a fall. Characteristics of patients who had been hospitalized in 2020 (pandemic year, n=136) and in 2019 (non-pandemic year, n=151) were compared. RESULTS: During the pandemic year, patients were less likely to have fallen in a nursing facility, to have had muscle or balance problems, and to have had a history of falls and fractures following a fall. Moreover, the average length of stay (LOS) in the hospital was shorter; however, the average time from the injury to hospitalization was longer. Patients were less likely to have acquired a postoperative infection or to have died. During the pandemic year, postoperative infection was only associated with prolonged LOS. CONCLUSIONS: The COVID-19 pandemic may have had a positive impact on the behavior of older adults as well as on the management of hip fracture patients. However, healthcare providers should be aware of the possible reluctance to seek care during a pandemic. Moreover, further research on the impact of the change in management during COVID-19 on hip fracture survival is warranted.

Hip Fractures during the COVID-19 Pandemic: Demographics, Treatment Pathway, and Outcomes.

BACKGROUND: Surgery for hip fractures within 48 hours of admission is considered standard. During the lockdown period due to the coronavirus disease-2019 (COVID-19) epidemic, our medical staff was reduced. OBJECTIVES: To compare the demographics, treatment pathways, and outcomes of patients with hip fractures during the COVID-19 epidemic and lockdown with the standard at routine times. METHODS: A retrospective study was conducted of all patients who were treated surgically for hip fracture in a tertiary center during the COVID-19 lockdown period between 01 March and 01 June 2020 and the equivalent period in 2019. Demographic characteristics, time to surgery, surgery type, hospitalization time, discharge destination, postoperative complications, and 30- and 90-day mortality rates were collected for all patients. RESULTS: During the COVID-19 period, 105 patients were operated due to hip fractures compared to 136 in the equivalent period with no statistical difference in demographics. The rate of surgeries within 48 hours of admission was significantly higher in the COVID-19 period (92% vs. 76%, respectively; P = 0.0006). Mean hospitalization time was significantly shorter (10 vs. 12 days, P = 0.037) with diversion of patient discharge destinations from institutional to home rehabilitation (P < 0.001). There was a significant correlation between the COVID-19 period and lower 90-day mortality rates (P = 0.034). No statistically significant differences in postoperative complications or 30-day mortality rates were noted. CONCLUSIONS: During the COVID-19 epidemic, despite the limited staff and the lack of therapeutic sequence, there was no impairment in the quality of treatment and a decrease in 90-day mortality was noted.

The tolerance of physiotherapy treatment in patients with COVID-19 and undergoing surgery for fragility hip fracture: An observational study.

ABSTRACT: The aim of the present work was to evaluate the tolerance of physiotherapy treatment implemented for patients with coronavirus disease (COVID-19) and undergoing hip surgeryCase-control study. During the period between March and May 2020, 9 patients were enrolled in the study with diagnosis of COVID-19 and hip fracture. In order to evaluate the tolerability of physiotherapy treatment a comparison group, involving 27 patients with a hip fracture but in the absence of suspicion of COVID-19 positivity, were put together. Blood saturation and heart rate, number of physiotherapy sessions, start of physiotherapy from surgery, number of healthcare providers, recovery of ambulation, execution of walking training and dyspnea measured by Borg scale were collected before and after each single physiotherapy session to describe the exercise tolerance of the patients.There are no significant differences between the two groups regarding basic characteristics. Average of Borg scale post treatment for COVID patients was 1.3 (DS = 1.3) compared to 0.6 (DS = 0.7) of non-COVID patients (P < .0005) but the breathing difficulty was light during the treatment, only 9% of COVID patients had a worsening superior of two points with Borg scale compared to 3% of non-COVID patients (P = .138). The incidence of walking recovery was 63% in the non-COVID patients group compared to 44.4% in the COVID group (P = .329).Physiotherapy treatment of patients with COVID-19 infection and undergoing surgery for hip fracture is well tolerated and should be encouraged and well monitored.

Does a Hand Strength-Focused Exercise Program Improve Grip Strength in Older Patients With Wrist Fractures Managed Nonoperatively?: A Randomized Controlled Trial.

OBJECTIVE: Distal radius fractures in the older population significantly impair grip strength. The aim of the study was to investigate whether a hand strength focused exercise program during the period of immobilization for nonoperatively managed distal radius fractures in this population improved grip strength and quality of life. DESIGN: This is a single-center randomized controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. Fifty-two patients older than 60 yrs who experienced distal radius fractures managed nonoperatively with cast immobilization. The intervention group (n = 26) received a home hand strength-focused exercise program from 2 and 6 wks after injury while immobilized in a full short arm cast. The control group (n = 26) performed finger range of motion exercises as per protocol. Primary outcome was grip strength ratio of injured arm compared with uninjured arm. Secondary outcome included functional scores of the 11-item shortened version of the Disabilities of the Arm, Shoulder and Hand. Outcomes were measured at 2, 6, and 12 wks after injury. RESULTS: The intervention group significantly improved grip strength ratio at both 6 and 12 wks (6 wks: 40% vs 25%, P = 0.0044, and 12 wks: 81% vs 51%, P = 0.0035). The intervention group improved the 11-item Disabilities of the Arm, Shoulder and Hand score at 12 wks; however, this was not statistically significant (25 vs 40, P = 0.066). CONCLUSIONS: A hand strength-focused exercise program for elderly patients with distal radius fractures while immobilized significantly improved grip strength.

Effect of early enteral nutrition in elderly patients with hip fracture during the perioperative period.

OBJECTIVE: This study aimed to assess the effects of early enteral nutrition (EN) in elderly patients with hip fracture. METHODS: The patients were classified into two groups (with and without EN). We compared the pre- and postoperative albumin (ALB) and inflammatory marker levels of each group and the time spent in bed and quality of life 3 months after surgery between the two groups. RESULTS: The pre- and postoperative IL-6 levels of the experimental group (61.68 ± 51.80 pg/L) were lower than those of the control group (233.11 ± 206.31 pg/L) (P< 0.001). The experimental group spent a shorter period of time in bed (38.75 ± 14.26 days) in comparison to the control group (99.71 ± 56.87 days) (P< 0.001). Quality of life was better in the experimental group than in the control group (P< 0.001). CONCLUSIONS: Early EN reduced the increment of postoperative IL-6 levels and improved healing postoperatively.

No Major Differences in Recovery After Hip Fracture Between Home-Dwelling Female and Male Patients.

BACKGROUND: Studies comparing recovery of men and women after hip fracture have reported conflicting results, some reporting worse recovery in male patients, while others found no differences between genders. METHODS: Recovery was compared in 105 male and 433 female patients with hip fractures and in age-matched groups of patients 50 years or older, who were home-dwelling and received similar rehabilitation. Residential status, walking ability, hip pain and activities of daily living function were recorded at admission and 4 and 12 months postoperatively, along with mortality and re-operations. RESULTS: No differences were observed between men and women 4 and 12 months postoperatively regarding residential status (p = 0.181 vs p = 0.883), mortality rates (p = 0.232 vs p = 0.880) or total activities of daily living scores (p = 0.546 vs p = 0.435). Walking ability was better among male patients prefracture (p < 0.001) and 4 and 12 months after fracture (p < 0.001, p = 0.031, respectively). In age-matched pair analysis, no differences were found regarding mortality, residential status, walking ability, or ADL score. Cox regression analysis identified mortality risk factors as being age, prefracture ADL score, American Society of Anesthesiologists score 4-5 and place of rehabilitation. Sex was not mortality risk factor. INTERPRETATION: Home-dwelling male and female patients had similar courses of recovery from hip fracture, although there were singular differences in specific activities of daily living functions and postoperative pain. There were no differences in mortality, even when prefracture characteristics were considered. Mortality was higher among older patients and who had high American Society of Anesthesiologists scores and low prefracture activities of daily living scores.

Frailty defined by 19 items as a predictor of short-term functional recovery in patients with hip fracture.

INTRODUCTION: Many hip fracture patients have decreased functional status inhibiting recovery to pre-fracture functional status. The prevalence of frailty in patients with hip fracture is high, but little is known how frailty is associated with functional recovery. The aim of this study was to determine whether frailty can predict functional recovery and clinical outcomes during the acute phase in hip fracture. PATIENTS AND METHODS: This study was retrospective observational study from two acute hospitals. Participants were recruited from hip fracture patients who underwent surgery. The main exposure was frailty defined using 19-item modified Frailty Index (mFI). The main outcome was functional recovery, evaluated by postoperative efficiency on the motor-Functional Independence Measure (FIM) score. Secondary outcomes included postoperative complication and discharge disposition. Multiple logistic regression analyses were performed using each outcome as a dependent variable and mFI as an independent variable. RESULTS: Sample included 274 patients (mean age 83.7 ±â€¯7.4 years, female 80.7%). Patients with higher mFI exhibited lower functional recovery, defined by efficiency on the motor-FIM score, and tended to run into complications and not return home (P < .001). In multiple logistic regression analyses, higher mFI was significantly associated with increased likelihood of lower functional recovery (odds ratio [OR], 1.60; 95% CI, 1.32-1.93; P < .001), occurrence of postoperative complication (OR, 1.32; 95% CI, 1.13-1.54; P < .001) and not returning home (OR, 1.77; 95% CI, 1.38-2.26; P < .001). CONCLUSIONS: Frailty defined by 19-item mFI can predict short-term functional recovery during acute phase following hip fracture. Frailty is also associated with postoperative complication and discharge disposition.

Tibial Shaft Fractures in Workers Compensation and No-Fault Insurance Is There a Difference in Resource Utilization?

BACKGROUND: Workers Compensation claims have been previously associated with inferior clinical outcomes. However, variation in inpatient stays for orthopedic trauma injuries according to insurance type has not been previously examined. METHODS: We investigated the differences according to insurance for tibial shaft fractures in regard to length of stay and disposition. Using the New York SPARCS database, we identified 1,856 adult non-elderly patients with an isolated tibial shaft fracture who underwent surgery. Patients were stratified by insurance type, including private, Medicaid, Workers Compensation, and no-fault, which covers medical expenses related to automobile or pedestrian accidents. RESULTS: Compared to private insurance (mean: 2.7 days), length of stay was longer for no-fault (mean: 3.9 days; adjusted difference +33%, p < 0.001) and Medicaid (mean: 3.5 days; adjusted difference +22%, p < 0.001), but not significantly different for Workers Compensation (mean: 3.5 days; adjusted difference +4%, p = 0.474). Compared to private insurance (rate: 3.5%), disposition to a facility was significantly higher for no-fault (rate: 10.1%; adjusted odds ratio [OR] = 3.3, p < 0.001) and Medicaid (rate: 7.6%; OR = 2.2, p = 0.003), but was not significantly different for Workers Compensation (rate: 6.3%; OR = 1.8, p = 0.129). CONCLUSIONS: Patients with no-fault insurance, but not Workers Compensation, are subject to longer hospital stays and are more likely to be discharged to a facility following operative fixation of an isolated tibial shaft fracture. These findings suggest that financial, social, and legal factors influence medical care for patients involved in automobile accidents with no-fault insurance.

Inferior clinical outcomes after femur fracture in the obese are potentially preventable.

INTRODUCTION: Obese patients with operative orthopedic trauma have increased risk of adverse outcomes, although the mechanisms accounting for the relationship remain unknown. This study examines the effect of body mass index (BMI) on outcomes after femur fracture fixation, and explores the mediating effects of pathophysiologic factors and clinical management. METHODS: A retrospective chart review was performed of adult patients with femur fractures undergoing surgical fixation at a Level 1 trauma center from 2010 to 2016. Demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) and mechanism of injury (MOI) were collected along with operative data and complications. Primary outcomes were hospital length of stay (HLOS), ICU length of stay (ICU-LOS), mortality, complications, and time to mobility (time first out of bed, TFOB). Bivariate correlations and multiple regression models were used to examine the relationship between BMI and outcomes. Path analysis tested whether the relationship between BMI and clinical outcomes was mediated by differences in 1) clinical management, or 2) physiologic variables. RESULTS: Of 333 patients included, the majority were male (57.4%) with a mean age of 43.4 (22.7) years and ISS of 12.5 (6.8). Predominant MOIs were motor vehicle crashes (42.8%) and falls (34.5%). There was no association between BMI category and age, ISS, or GCS. In univariate analysis, higher BMI was linked to longer HLOS (r = .12), longer ICU-LOS (r = .15), longer TFOB, (r = .18), and higher number of complications (r = .12), p < 0.05. Controlling for age and ISS, obese patients had 6.66 times the odds of respiratory failure (p = 0.021, 95% CI 1.3,33.3) and a 3.88 odds of any complication (p = 0.020, 95% CI 1.24,12.1) compared to their normal weight counterparts. For every one point increase in BMI, time first out of bed was delayed 2.3 h (p < 0.001; 95% CI 1.08, 3.62). The effect BMI on poor outcomes was accounted for by delayed mobility (longer TFOB) in a mediation model. CONCLUSIONS: Higher BMI increases the risk of longer hospital stays and systemic complications. Mediation models indicate that the adverse clinical outcomes associated with obesity are explained by delays in mobility, an intervenable factor. Clinical strategies should be directed at early mobilization to minimize morbidity.

Development of the Barthel Index 5 years after hip fracture: Results of a prospective study.

AIM: The importance of proximal femoral fractures is increasing due to demographic change. Despite appropriate care, these are associated with poor results. We are still lagging behind, and require information on the long-term functional outcome of these patients and the predictive factors involved. METHODS: Between 2009 and 2011, 402 patients aged >60 years with hip fractures were included in this prospective observational study. Patients were assessed with the Barthel Index before fracture, at discharge, and 6 months, 1 year and 5 years after surgery. In addition, a variety of parameters (sex, age, fracture type, American Society of Anesthesiologists classification, Mini-Mental State Examination, housing situation, occurrence of complications during inpatient stay and type of care) were collected to identify the possible independent predictive factors using multivariate analysis. RESULTS: The lowest Barthel Index was found at discharge (66 ± 24) for patients from an acute hospital. The Barthel Index improved within the first 6 months (86 ± 21) and decreased afterwards. The factors associated with a significantly higher point loss of the Barthel Index in the multivariate analysis were age (P-value 0.020), pre-fracture Barthel Index, (P ≤ 0.001), Mini-Mental State Examination (P ≤ 0.001) and type II complications (P = 0.001). The other values showed no significant influence on the Barthel Index. CONCLUSIONS: The present results showed that patients after a hip fracture have a great rehabilitation potential within the first 6 months after the event. More attention should be paid to type II complications and the occurrence of cognitive impairment. Both seem to be a surrogate parameter for the frailty of the patients. Geriatr Gerontol Int 2019; 19: 809-814.

The Usefulness of Basic Movement Scale in Hip Fracture Patients: Construct Validity from a Cross-Sectional Study.

OBJECTIVE: The aim of the study was to investigate the validity of using total score and to examine the constitution and characteristics of the Basic Movement Scale in postsurgery patients with hip fracture. DESIGN: The dimensionality and the threshold difficulty intervals between each score and item difficulty hierarchy of the Basic Movement Scale were examined using factor analysis and Rasch analysis in 37 patients admitted to our hospital between April and November 2015. RESULTS: For factor analysis, the contribution ratio of the first factor was 78.9%, that of the second factor was 6.5%, and there were no items that fit the Rasch analysis. The threshold was reversed at 6 of the 48 locations. The difficulty of the 12 Basic Movement Scale items was distributed roughly evenly among all 9 lots, with some deviation. There was one very easy item, and there were some items almost overlapping in difficulty. CONCLUSIONS: The results showed a unidimensional association between the items and evaluation index. The difficulty threshold of each score was approximated to the interval scale. Therefore, the Basic Movement Scale has evident construct validity and enables quantitative evaluation of physical ability, assessment of the effects of daily training, and general predictions of the feasibility of patients' clinical goals.

"Obesity Paradox" Holds True for Patients with Hip Fracture: A Registry-Based Cohort Study.

BACKGROUND: Hip fractures are associated with high mortality and reduced quality of life. Studies have reported a high body mass index (BMI) as being positively associated with survival when linked to old age and some chronic diseases. This phenomenon is called the "obesity paradox." The association between BMI and survival after hip fracture has not been thoroughly studied in large samples, nor has to what extent the association is altered by comorbidities, sex, and age. The objective of this study was to investigate the association of BMI with survival after hip fracture and with the probability of returning to living at home after hip fracture. METHODS: This cohort study was based on data from a prospectively maintained national registry of patients with hip fracture. A total of 17,756 patients ≥65 years of age who were treated for hip fracture during the period of 2013 to 2016, and followed until the end of 2017, were included. BMI was clinically assessed at hospital admission, comorbidity was measured with the American Society of Anesthesiologists (ASA) score, and the date of death was retrieved from a national database. Self-reported data on living arrangements were assessed on admission and 4 months after fracture. Multivariable regression models were used to estimate the associations. RESULTS: Despite ASA scores being similar among all BMI groups, obese patients had the highest 1-year survival and patients with a BMI of <22 kg/m had the lowest. Adjustment for potential confounders strengthened the associations. For the chance of returning to living at home, no advantage was seen for obese patients, but patients with a BMI of <22 kg/m had clearly worse odds compared with patients who were of normal weight, overweight, or obese. CONCLUSIONS: The obesity paradox appears to be true for hip fracture patients aged 65 and older. Attention should be given to patients with malnutrition and underweight status rather than to those with overweight status or obesity when developing the orthogeriatric care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Quality of life after pelvic ring fractures: Long-term outcomes. A multicentre study.

AIMS: This study was conducted to determine long-term (5-10 years) health-related quality of life (HRQOL) and ceiling effects in patients with a pelvic ring fracture. PATIENTS AND METHODS: We identified all patients with pelvic ring fractures after high-energy trauma admitted at two level 1 trauma centres in the Netherlands from 2006 to 2011. Patients were asked to complete the Majeed Pelvic Score (MPS), EuroQol-5D (EQ-5D) and Short Musculoskeletal Function Assessment (SMFA) questionnaires. HRQOL analysis used a multiple linear regression model. RESULTS: In total, 136 patients returned the questionnaires. The median follow-up period was 8.7 years. The mean MPS and EQ-5D-VAS scores were 85.1 and 74, respectively. The mean EQ-5D index scores were 0.87, 0.81 and 0.82 in Tile B, A and C patients, respectively. The mean SMFA index was 24. A ceiling effect was observed for 1/3 of the patients. After multiple linear regression analysis, no differences were identified among the various fracture types for each questionnaire, with the exception of 2 subscales of the MPS. CONCLUSION: Patients who suffer pelvic ring fractures generally have good HRQOL outcomes after 5-10 years. No significant differences were found among different fracture types. Long-term follow-up of patients with Tile C fractures is warranted.

Discharge destination following hip fracture in Canada among previously community-dwelling older adults, 2004-2012: database study.

Little is known about post-acute care following hip fracture surgery. We investigated discharge destinations from surgical hospitals for nine Canadian provinces. We identified significant heterogeneity in discharge patterns across provinces suggesting different post-acute recovery pathways. Further work is required to determine the impact on patient outcomes and health system costs. INTRODUCTION: To examine discharge destinations by provinces in Canada, adjusting for patient, injury, and care characteristics. METHODS: We analyzed population-based hospital discharge abstracts from a national administrative database for community-dwelling patients who underwent hip fracture surgery between 2004 and 2012 in Canada. Discharge destination was categorized as rehabilitation, home, acute care, and continuing care. Multinomial logistic regression modeling compared proportions of discharge to rehabilitation, acute care, and continuing care versus home between each province and Ontario. Adjusted risk differences and risk ratios were estimated. RESULTS: Of 111,952 previously community-dwelling patients aged 65 years or older, 22.5% were discharged to rehabilitation, 31.6% to home, 27.0% to acute care, and 18.2% to continuing care, with significant variation across provinces (p < 0.001). The proportion of discharge to rehabilitation ranged from 2.4% in British Columbia to 41.0% in Ontario while the proportion discharged home ranged from 20.3% in Prince Edward Island to 52.2% in British Columbia. The proportion of discharge to acute care ranged from 15.2% in Ontario to 58.8% in Saskatchewan while the proportion discharged to continuing care ranged from 9.3% in Manitoba and Prince Edward Island to 22.9% in New Brunswick. Adjusting for hospital type changed the direction of the provincial effect on discharge to continuing care in two provinces, but statistical significance remained consistent with the primary analysis. CONCLUSIONS: Discharge destination from the surgical hospital after hip fracture is highly variable across nine Canadian provinces. Further work is required to determine the impact of this heterogeneity on patient outcomes and health system costs.

The use of video games combined with conventional physical therapy in children with upper limb fractures: An exploratory study.

PURPOSE: To determine the effect of rehabilitation using video games combined with conventional therapy in children with loss of range of motion (ROM) after conservative or surgical treatment of upper limb fractures. METHODS: This retrospective observational study included 12 children (9 boys, 3 girls; mean age: 6.75 ± 2.83 y) treated with combined video game and conventional physical therapy following upper limb fracture. Children completed 60 minutes of combined therapy (20 minutes of game therapy and 40 minutes of physical therapy) two times per week until therapy was no longer warranted. The flexion and extension ROM of the elbow and wrist, pronation and supination of the forearm, and pain during rest and effort were measured at the beginning and end of treatment. RESULTS: Children experienced significantly increased extension (p< 0.001) and flexion (p< 0.01) ROM of the elbow, increased flexion ROM of the wrist (p< 0.05), and reduced pain during effort (p< 0.05) after an average of 6 weeks of combined treatment. CONCLUSION: The use of video games with conventional therapy was effective in reducing pain and recovering ROM in children with upper limb fractures.

Association between delirium, adverse clinical events and functional outcomes in older patients admitted to rehabilitation settings after a hip fracture: A multicenter retrospective cohort study.

AIM: The aim of the present study is to investigate how delirium and adverse clinical events (ACE) contribute independently and in combination to functional outcomes in older patients admitted to rehabilitation settings after a hip fracture. METHODS: This is a multicenter retrospective cohort study of patients aged ≥65 years admitted after hip fracture surgical repair to three Italian rehabilitation units. Delirium on admission was evaluated with the Confusion Assessment Method. ACE during the rehabilitation stay were recorded, including infections (i.e. urinary tract infections, other infections), non-infectious ACE (i.e. cardiovascular events, respiratory failure, pulmonary embolism) and falls. A multivariable linear regression was used to evaluate the effect of ACE and delirium on functional outcome, adjusting for covariates determined a priori. RESULTS: A total of 519 patients were included in the study. The mean ± SD age was 82.9 ± 9.4 years. ACE occurred in 277 patients (53.4%), delirium alone was present in 19 patients (3.6%). Both conditions were present in 58 patients (11.2%). Compared with patients without delirium or ACE, those with ACE or delirium were more likely to have a worse functional outcome (-6.7 Barthel Index points [-11.6; -1.7]; P = 0.008; -13.2 [-25.6; -0.8]; P = 0.038) at discharge, and patients with both conditions had an even lower Barthel Index score (-18.6 Barthel Index points [-26.9; -10.3]; P < 0.001). CONCLUSIONS: ACE and delirium are very common in older patients admitted to rehabilitation settings after hip fracture, and frequently coexist. As both ACE and delirium could impact on functional outcome, alone and in combination, a clinical geriatric approach is necessary for this population to minimize risks. Geriatr Gerontol Int 2019; 19: 404-408.

Post-operative mortality rates for neck of femur fracture at Waitemata District Health Board.

AIM: Mortality rates of up to 38% at one year have been reported following surgery for neck of femur fractures. The aim of this review is to evaluate the post-operative mortality rates and trends over time for patients with fractured neck of femur at Waitemata District Health Board. METHOD: A retrospective cohort study of all patients who received surgery following a neck of femur fracture at Waitemata District Health Board between 2009 and 2016. Inpatient data was retrieved from electronic hospital records and mortality rates from the Ministry of Health, New Zealand. Analyses included crude mortality rates and trends over time, and time-to-theatre from presentation with neck of femur fracture. RESULTS: A total of 2,822 patients were included in the study; mean age 81.9 years, 70.4% female and 29.6% male. Overall post-operative crude rates for inpatient, 30-day and one-year mortality were 3.7%, 7.2% and 23.8% respectively. Adjusted analyses showed a statistically significant decrease in mortality rates between 2009 and 2016 at inpatient (p=0.001), 30 days (p=<0.001) and one year (p=<0.001) time periods. There was also a significant association between time-to-theatre and mortality at inpatient (p=0.002), 30 days (p=0.0001), and one year (p=0.0002) time periods. CONCLUSION: Mortality rates following surgery for fractured NOF have significantly improved over recent years at Waitemata District Health Board. Reduced time-to-theatre is associated with decreased inpatient, 30-day and one-year mortality.

Pre-discharge prognostic factors of physical function among older adults with hip fracture surgery: a systematic review.

INTRODUCTION: To identify, organize, and assess the evidence level of pre-discharge prognostic factors of physical function beyond discharge after hip fracture surgery. METHODS: We performed a systematic search of four databases (PubMed, Embase, CINAHL, PsycINFO) for longitudinal studies of prognostic factors of physical function at ≥ 1 month among older adults ≥ 50 years old with surgically treated hip fracture, complemented with hand-searching. Two reviewers independently screened papers for inclusion and assessed the quality of all the included papers using the Quality in Prognosis Studies (QUIPS) tool. We assigned the evidence level for each prognostic factor based on consistency in findings and study quality. RESULTS: From 98 papers that met our inclusion criteria, we identified 107 pre-discharge prognostic factors and organized them into the following seven categories: demographic, physical, cognitive, psychosocial, socioeconomic, injury-related, and process of care. Potentially modifiable factors with strong or moderate evidence of an association included total length of stay, physical function at discharge, and grip strength. Factors with strong or moderate evidence of no association included gender, fracture type, and time to surgery. Factors with limited, conflicting, or inconclusive evidence included body-mass index, psychological resilience, depression, and anxiety. CONCLUSIONS: Our findings highlight potentially modifiable prognostic factors that could be targeted and non-modifiable prognostic factors that could be used to identify patients who may benefit from more intensive intervention or to advise patients on their expectations on recovery. Examining the efficacies of existing interventions targeting these prognostic factors would inform future studies and whether any of such interventions could be incorporated into clinical practice.