Outcomes and Risks Associated With Subsequent Contralateral Hip Fractures.

BACKGROUND: Hip fractures constitute a major public health problem for older individuals. They are associated with functional deterioration, limited mobility, and increased mortality, while contributing to economic and social hardships that are compounded by a second hip fracture. With the aging US population and increasing rates of hip fractures, it is essential to understand factors surrounding subsequent contralateral hip fractures. MATERIALS AND METHODS: This descriptive study was a retrospective review of patients 60 years and older who were identified in the institutional geriatric hip fracture database as having had an initial and subsequent contra-lateral hip fracture, with the second treated at our tertiary referral center. RESULTS: The incidence of subsequent hip fracture was 13.2%. The mean time to second hip fracture was 3.5 years after the initial injury. The first fracture tended to be a femoral neck fracture, whereas the second injury was more likely to have an intertrochanteric pattern. There was a higher complication rate after a subsequent hip fracture. Patients taking osteoporosis and adjuvant medication prior to admission for the second fracture tended to have a lower 90-day mortality rate. Patients with a history of any fracture prior to the first hip fracture, with cancer, and with osteopenia had shorter intervals to the subsequent event. CONCLUSION: Subsequent hip fractures carry high morbidity and mortality rates. Steps should be taken after the initial injury to optimize outcomes in the case of a subsequent event. Patients discharged after initial hip fracture should be maintained with osteoporosis medication. [Orthopedics. 202x;4x(x):xx-xx.].

Ninety-Day Readmission Rates in a Geriatric Hip Fracture Population, From a Bundled Care Payment Initiative Perspective.

OBJECTIVE: To determine the incidence of hospital readmission in a geriatric hip fracture population within 90 days. METHODS: Analysis of patients ≥60 years of age presenting with a fragility fracture of the hip from a prospective geriatric hip fracture program registry was performed. Demographics, diagnoses, treatments, complications, hospital events, and readmission for any cause within 30 and 90 days were collected. Readmission events were categorized as defined by Bundled Care Payment Initiative (BCPI)/Care for Joint Replacement payment model. RESULTS: The population included 305 patients. All-cause readmission at 30 and 90 days was 11.5% and 19.7%, respectively. Surgical site infection or prosthesis failure accounted for 2.6% of 90 days readmissions. Application of the BCPI rules identified 44 of 60 readmitted patients (73.3%) with causes attributable to the surgical event: medical (0.7%), hospital (12.1%), and mechanical (2.6%). Death within 30 days was the largest contributor to hospital-related events. CONCLUSIONS: This study identified a 90-day readmission rate of nearly 20% in patients with geriatric fragility fractures. Application of the BCPI definitions currently used in the Care for Joint Replacement payment model will result in more readmissions being attributed to the index surgical event than classically considered. If bundled payment models remain the future, further investigation of this population's risk factors for readmission is needed in light of these findings. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does The Use of Ethyl Chloride Improve Patient-Reported Pain Scores With Negative Pressure Wound Therapy Dressing Changes? A Prospective, Randomized Controlled Trial.

BACKGROUND: Negative pressure wound therapy (NPWT) is commonly used for surgical incisions and large wounds, particularly in the context of trauma. Research has shown that patients report that the most painful aspect of NPWT is related to foam dressing changes. This study aimed to determine whether topical use of the vapocoolant anesthetic ethyl chloride would impact patient-reported pain during these procedures. METHODS: This study was a single-blinded, placebo-controlled randomized trial in patients who were undergoing NPWT foam dressing change following surgery performed by the orthopedic trauma team. A total of 100 patients were randomized to receive ethyl chloride topical anesthetic spray or placebo (tissue culture grade water) during dressing change. The outcome measure specified prior to enrollment was a mean decrease in patient-reported pain of 1.7 points using a numeric rating scale. Baseline and procedural characteristics were collected to investigate contributions to patient-reported pain. We hypothesized that the use of ethyl chloride would decrease patient reported pain scores. RESULTS: Significantly more females were randomized to the receive vapocoolant; remaining baseline and procedural characteristics were similar between groups. The median time for NPWT drape removal was 2.0 minutes in both groups (p = 0.66). The postprocedural pain reported by patients was significantly lower in the experimental group compared with placebo (median, 5.0 vs. 7.0; p = 0.03). Multivariate analysis adjusting for potential confounders showed treatment group to be the strongest predictor of postprocedure pain (p = 0.002). Additionally, a generalized linear model suggests that treatment group was the strongest predictor of change in pain score as reported by patients prior to and immediately following dressing change. CONCLUSIONS: Use of vapocoolant spray during NPWT dressing change for orthopedic trauma wounds and surgical incisions was feasible and resulted in significant reduction in patient-reported pain associated with the procedure. LEVEL OF EVIDENCE: Therapeutic, Level I.

Establishing a Geriatric Hip Fracture Program at a Level 1 Community Trauma Center.

BACKGROUND: Traditional care of patients with geriatric hip fracture has been fragmented with patients admitted under various specialty services and to different units within a hospital. This produces inconsistent care and leads to varying outcomes that can be associated with increased length of stay, delays in time from admission to surgery, and higher readmission rates. PURPOSE: The purpose of this article is to describe the process taken to establish a successful geriatric hip fracture program (GFP) and the initial results observed in a single institution after its implementation. METHODS: All patients 60 years or older, with an osteoporotic hip fracture sustained from a low energy mechanism (defined as a fall from 3-ft height or less), were included in our program. Fracture patterns include femoral neck, intertrochanteric, pertrochanteric, and subtrochanteric femur fractures including displaced, nondisplaced, and periprosthetic fractures. Preprogram data included all patients admitted from January 1, 2012, through December 31, 2014; postprogram data were collected on patients admitted between May 1, 2016, and May 1, 2018. RESULTS: Demographic characteristics of the populations were similar. After the GFP was implemented, the proportion of patients who were treated surgically within 24 and 48 hours increased. The average number of hours between admission and surgery significantly reduced from 35.2 to 23.2 hours. Overall length of stay was decreased by 1.8 days and readmission within 30 days of discharge was lower. Reasons for readmission were similar in both timeframes. The rate of inpatient death was similar in the two groups. Mortality within 30 days of surgery appeared somewhat higher in the post-GFP period. CONCLUSION: Our program found that, with the utilization of a multidisciplinary approach, we could positively influence the care of patients with geriatric hip fracture through the implementation of evidence-based practice guidelines. In the first 2 years after initiation of the GFP, our institution saw a decrease in time from admission to surgery, length of stay, and blood transfusion requirements.