Pre-Fracture Functional Status and Early Functional Recovery are Significant Predictors of Instrumental Activities of Daily Living After Hip Fracture: A Prospective Cohort Study.

Introduction: Although the overall quality of medicine has improved in recent decades, the functional capacity in many hip fracture patients remains insufficient. The goal of the present study was to identify significant predictors of Instrumental Activities of Daily Living (IADL) measured by the Lawton-Brody scale at 3- and 6-month follow-up in patients with hip fractures admitted to a hospital. Methods: This observational cohort study included 191 patients with acute hip fractures. IADL was measured at baseline and after 3 and 6 months using the Lawton-Brody scale. Multivariable logistic regression analysis was carried out using pre-fracture functional status, sociodemographic variables, hand grip strength (HGS), surgical procedure, complications, and length of hospital stay, Short Physical Performance Battery, and Barthel Index (BI) on the fifth postoperative day as potential predictors for IADL after a hip fracture surgery. Results: The mean age of the participants was 80.3 ± 6.8 years, and 77.0% of our cohort were women. Multivariate regression analysis revealed that pre-fracture functional status and early functional recovery were independent predictors of IADL after hip fracture surgery. Conclusions: Clinicians should take steps to improve functional outcomes by changing how patients are rehabilitated in the first days after hip fracture surgery, especially for the group of patients with a lower functional status before the fracture.

The Perioperative Pain Management Bundle is Feasible: Findings From the PAIN OUT Registry.

OBJECTIVES: The quality of postoperative pain management is often poor. A "bundle," a small set of evidence-based interventions, is associated with improved outcomes in different settings. We assessed whether staff caring for surgical patients could implement a "Perioperative Pain Management Bundle" and whether this would be associated with improved multidimensional pain-related patient-reported outcomes (PROs). METHODS: "PAIN OUT," a perioperative pain registry, offers tools for auditing pain-related PROs and obtaining information about perioperative pain management during the first 24 hours after surgery. Staff from 10 hospitals in Serbia used this methodology to collect data at baseline. They then implemented the "Perioperative Pain Management Bundle" into the clinical routine and collected another round of data. The bundle consists of 4 treatment elements: (1) a full daily dose of 1 to 2 nonopioid analgesics (eg, paracetamol and/or nonsteroidal anti-inflammatory drugs), (2) at least 1 type of local/regional anesthesia, (3) pain assessment by staff, and (4) offering patients information about pain management. The primary endpoint was a multidimensional pain composite score (PCS), evaluating pain intensity, interference, and side effects that was compared between patients who received the full bundle versus not. RESULTS: Implementation of the complete bundle was associated with a significant reduction in the PCS ( P < 0.001, small-medium effect size [ES]). When each treatment element was evaluated independently, nonopioid analgesics were associated with a higher PCS (ie, poorer outcome, and negligible ES), and the other elements were associated with a lower PCS (all negligible small ES). Individual PROs were consistently better in patients receiving the full bundle compared with 0 to 3 elements. The PCS was not associated with the surgical discipline. DISCUSSION: We report findings from using a bundle approach for perioperative pain management in patients undergoing mixed surgical procedures. Future work will seek strategies to improve the effect.

TENS Improves Cisplatin-Induced Neuropathy in Lung Cancer Patients.

Background: Cisplatin-induced peripheral neuropathy is a common complication of cisplatin therapy, which develops in most patients with lung cancer. There are no effective preventive measures and once it occurs there is no effective therapy, except symptomatic. In this study, we aimed to assess the effect of transcutaneous electrical nerve stimulation (TENS) therapy on the pain intensity and the quality of life of patients with cisplatin-induced neuropathy. Material and Methods: A prospective cohort study was performed from 2013 to 2018, at the Clinical Center of Serbia. After the initial evaluation of 106 newly diagnosed patients with lung cancer, 68 patients did not have peripheral neuropathy. These 68 patients continued in the study and started the cisplatin chemotherapy. Forty of these patients developed cisplatin-induced neuropathy, which was manifested by neuropathic symptoms and proven by ENG examination. All patients with cisplatin-induced neuropathy were treated with TENS therapy. Their neuropathic pain and quality of life were evaluated using the following questionnaires at diagnosis, after cisplatin therapy and after four weeks of TENS use: DN4, VAS scale, EORTC QLQ-C30 and FACT-L. Results: Two thirds (68%) of the patients with cisplatin-induced neuropathy were male and the majority were smokers (70%). Adenocarcinoma was the most common (38%), followed by squamous (33%) and small-cell carcinoma (28%). The application of TENS therapy had a positive effect on reducing the neuropathic pain and increasing the quality of life for patients with painful cisplatin-induced neuropathy. The VAS and DN4 scores significantly decreased after TENS therapy, in comparison to its values after cisplatin therapy (p < 0.001). After TENS therapy, patients had significantly higher values in most of the domains of EORTC QLQ-C30 and FACT- L, in comparison with the values after cisplatin therapy (p < 0.001). Conclusion: The application of TENS therapy has a positive effect on reducing neuropathic pain and increasing the quality of life for patients with lung cancer and cisplatin-induced neuropathy.

Associations between early postoperative pain outcome measures and late functional outcomes in patients after knee arthroplasty.

INTRODUCTION/AIM: Early rehabilitation, return to daily life activities and function are the ultimate goals of perioperative care. It is unclear which pain-related patient-reported outcome measures (PROM) mirror treatment effects or are related with early and late functional outcomes. METHODS: We examined associations between two approaches of pain management (scheduled vs 'on demand') and PROMs on post-operative days one and five (POD1, 5) with function on POD5 and 3 months after surgery in patients undergoing Total Knee Arthroplasty (TKA) in a single centre. The scheduled pain management consisted of pain assessment and routine administration of non-opioid drugs, and a weak opioid based on severity of pain reported by patients. The 'on demand' group received non-opioids and/or a weak opioid only when asking 'on demand' for analgesics. RESULTS: On POD1, patients in the scheduled treatment group reported reduced severity of worst pain, less interference of pain with activities in-bed and sleep, and a higher proportion got out of bed. On POD5, these patients reported as well significantly less worst pain, spent significantly less time in severe pain, experienced less interference of pain with activities in bed, and felt less helpless. Furthermore, tests of function, extension and flexion ranges, Barthel index and 6 minutes walking test on POD5, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) 3 months later were significantly better in the scheduled treatment group compared to the 'on demand' treatment group. Pain related PROMs assessed at POD1 and especially at POD5 are associated with better knee range of motion, better performance in activities of daily living, and faster gait speed, as well as less pain, better performance in activities of daily living, as well as higher knee-related quality of life 3 months postoperatively. CONCLUSIONS: Our study demonstrates that severe postoperative pain after TKA might have long lasting consequences, and even small improvements in treatment, although being far from optimal, are accompanied by improved outcomes.

Incidence and Risk Factors of 30-Day Surgical Site Infection after Primary Total Joint Arthroplasty in a Middle-Income Country: A Single-Center Experience.

The data about the incidence and risk factors for surgical site infections (SSIs) following total joint arthroplasty (TJA) in middle-income countries are still scant. The aim of this study was to assess the incidence and risk factors associated with 30-day SSIs following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The study was conducted at the Clinic for Orthopedic Surgery and Traumatology, Clinical Center of Serbia (CCS) in Belgrade, from May 2016 to April 2018. All patients undergoing THA or TKA were followed throughout hospitalization until day 30 after discharge. Of the 1073 admitted patients, 459 had THA and 230 had TKA. The incidence rate of surgical site infections (SSIs) among the patients who underwent THA was 5.4%, which is 3.8 per 1000 postoperative patient-days, while the rate among those who had TKA was 4.8%, i.e., 3.4 per 1000 postoperative patient-days. Out of the 36 SSIs, 15 were deep and 21 were superficial incisional ones. Among the variables examined, the independent risk factors for SSIs after THA were the American Society of Anesthesiologists (ASA) score > 2 (RR = 3.17; 95% CI-1.26-8.02), smoking (RR = 3.14; 95% CI-1.26-7.82) and peripheral vascular disease (PVD) (RR = 6.09; 95% CI-2.35-15.77), and after TKA, only PVD (RR = 3.87; 95% CI-1.09-13.76) was the risk factor. Incidence rates of SSIs after arthroplasty are higher compared to reports from developed countries. Therefore, it is necessary to enhance infection prevention and control measures with strict control of modifiable risk factors.

Instrumental Activities of Daily Living-A Good Tool to Prospectively Assess Disability after a Second Contralateral Hip Fracture?

The aim of this study was to determine the outcome for patients who sustain a second hip fracture compared with those who sustain a first fracture, and to define the optimal measure to evaluate functional outcome after second hip fracture. METHODS: 343 patients with acute hip fractures who presented during a 12 month period were included in the study. Patients with a first (318 patients, 78.10 +/- 7.53 years) and second (25 patients, 78.96 +/- 6.02) hip fracture were compared regarding all baseline variables. Regression analysis was also performed to assess the independent relationship between the presence of a second hip fracture and observed outcome variables at discharge (physical disability, complications, length of stay, and mortality) and one-year after surgery (physical disability and mortality). RESULTS: Disability when performing instrumentalized activities of daily living (IADL) at one-year follow-up is independently related to the presence of a second hip fracture. There were no other statistically significant relationships between the presence of a second hip fracture and other observed outcome variables. CONCLUSIONS: Patients with a second hip fracture showed worse functional outcome at one-year follow-up when measured with the IADL scale. No increased short-nor long-term mortality rates were found in patients with a secondary hip fracture. IADL is a good tool to assess disability after a second hip fracture and could be thus a more reliable outcome measure when investigating differences in functional recovery in patients with a second hip fracture compared to conventionally used ADL scales.

Simultaneous Hip and Distal Radius Fractures-Does It Make a Difference with Respect to Rehabilitation?

INTRODUCTION: A minority of patients with hip fractures sustain concomitant wrist fractures. Little is known about the rehabilitation outcome in this group of patients. AIM OF STUDY: Prospective investigation of functional outcome and survival in patients with combined hip and wrist fractures compared with patients who sustain an isolated hip fracture. METHODS: 341 patients who presented with an acute hip fracture during a 12 month period were included in the study. Outcome at discharge and 4 months follow-up was compared between patients with isolated hip fractures and those patients who sustained simultaneous distal wrist fractures. RESULTS: The actual incidence of concurrent hip and wrist fractures in our cohort was 4.7%. Patients who sustained a concurrent hip and wrist fracture showed no differences regarding short- and long-term functional outcome and survival. CONCLUSION: Our results imply that patients with simultaneous hip and wrist fractures have no difference in rehabilitative outcome. Future studies should further investigate the distinctive characteristics of this patient subgroup.

Can early assessment of hand grip strength in older hip fracture patients predict functional outcome?

Decreased muscle strength is not only a risk factor for hip fracture in older patients, but plays a role in recovery of physical function. Our aim was to assess the role of grip strength measured early after hip fracture, and classified according to the EWGSOP2 criteria in predicting short- and long-term functional recovery. One hundred ninety-one patients with acute hip fracture consecutively admitted to an orthopaedic hospital have been selected. A multidimensional geriatric assessment evaluating sociodemographic variables, cognitive status, functional status and quality of life prior to fracture, as well as perioperative variables were performed. Follow-ups at 3 and 6 months after surgery were carried out to evaluate functional recovery. Multivariate regression models were used to assess the predictive role of handgrip strength. The mean age of the participants was 80.3 ±6.8 years. Thirty-five percent of our patients with clinically relevant hand grip strength weakness were significantly older, more often female, had a lower BMI, and were of worse physical health. They also had a lower cognitive level, lower Barthel index, and lower EQ5D scores before fracture. Multivariate regression analysis adjusted for age and gender revealed that hand grip weakness was an independent predictor of worse functional outcome at 3 and 6 months after hip fracture for both genders and in all age populations. Our study supports the prognostic role of hand grip strength assessed at hospital admission in patients with hip fracture. Thus, clinicians should be encouraged to include hand grip assessment in their evaluation of hip fracture patients in the acute setting in order to optimize treatment of high-risk individuals.

Prolonged pre-operative hospital stay as a predictive factor for early outcomes and mortality after geriatric hip fracture surgery: a single institution open prospective cohort study.

INTRODUCTION: The aim of this open prospective cohort study was to determine if a prolonged pre-operative hospital stay is a true predictor of higher morbidity or mortality in geriatric patients with hip fractures. MATERIALS AND METHODS: We analysed early outcome parameters, such as functional independence measure (FIM), at discharge and four months post-operatively, peri-operative nonsurgical complications, intra-hospital and one year mortality compared with prolonged pre-operative hospital stay in 308 patients from a continuous cohort of 344. RESULTS: Average pre-operative stay was 8.39 ± 5.80 days. Delaying surgery for > 72 hours was independently predictive for general complications and lower motor FIM gain at four months. All findings worsen progressively after the fifth day of delay. Pre-operative period was not found to be an independent predictor of mortality. CONCLUSION: In all observed outcome parameters except mortality, pre-operative delay > 72 hours was shown to be a true predictive factor.

Knowledge about Blood-borne Pathogens and the Prevalence of Needle Stick Injuries among Medical Students in Serbia.

INTRODUCTION: Medical students are mainly exposed to needle stick and sharp object injuries in the course of their clinical activities during studying. They are at high risk due to their undeveloped skills, restricted clinical experience, lack of knowledge and risk perception. The objectives of this study were to determine the prevalence of needle stick injuries of the fourth and final year medical students, and to estimate their knowledge about blood-borne pathogens disease transmission and standard precautions. METHODS: This cross-sectional study was conducted at the Faculty of Medicine, in February 2014. The students were invited to self-administer a questionnaire of 26 closed questions prepared for this study. RESULTS: The questionnaire was filled in and returned by 637 students. The prevalence of needle sticks and sharp object injuries was 29.5%. Needle stick injuries were the most common type of accidents, more frequent among the fourth compared to the sixth year students (p=0.002). The majority of accidents occurred in patient rooms (53%) and the emergency department (15%). 54% of participants reported an accident to the responsible person. Students without accidents had a significantly better perception of risk (3.79 vs. 3.35; p<0.05). Out of the total participating students, only 16.6% (106/637) received all three doses of Hepatitis B vaccination, while 16.2% were partially vaccinated. CONCLUSIONS: There is a need for additional theoretical and practical education of our students on blood exposure via accidents, raising the awareness of the necessity of hepatitis B vaccination, and introducing the unique/comprehensive procedure for accident reporting for students and healthcare workers in the entire country.

Length of the femoral tunnel in anatomic ACL reconstruction: comparison of three techniques.

PURPOSE: The aim of this paper was to determine whether the change in the position of the patient's leg as well as the use of flexible reamers may help in obtaining a longer femoral tunnel with minimal risk of perforating the posterior cortex. METHODS: One hundred and twenty-five patients who had undergone anatomic ACL reconstruction between 2010 and 2013 were included in this prospective cohort study. The first group was composed of patients whose femoral tunnel had been drilled with rigid reamers, while the leg being operated on was positioned on an arthroscopic leg holder (82 patients). In the second group of patients, the femoral tunnel was also drilled with rigid reamers, but the leg was positioned on the table (25 patients), while the third group was composed of patients whose femoral tunnel was drilled with flexible reamers, and the leg was positioned on a leg holder (18 patients). The length of the femoral tunnel was measured intraoperationally, while the site of femoral insertion and the position of the tunnel were read from native radiographic images. RESULTS: When the femoral tunnel was drilled on the medial aspect of the lateral condyle, the centre of the tunnel was located at 31.4 % from the most proximal point of the femoral condyle and 34.7 % from the Blumensaat line. The length of the tunnel drilled with rigid reamers on the operating table (36.1 mm) was statistically significantly greater (p < 0.05) than the length of the tunnel drilled with the same reamers, but with the leg positioned on the leg holder (32.5 mm). The length of the tunnel drilled with flexible reamers with the leg positioned on the leg holder (42.5 mm) was highly statistically significantly greater than the length of the tunnel drilled with rigid reamers (p < 0.01), and it was statistically significantly greater than the length of the tunnel drilled with rigid reamers with the leg placed on the operating table (p < 0.05). CONCLUSION: The drilling of the femoral tunnel during anatomic ACL reconstruction with the use of flexible reamers provides a longer femoral tunnel than when it is drilled with rigid reamers, without any danger of perforation of the posterior cortex. LEVEL OF EVIDENCE: III.

Effects of anodal tDCS and occupational therapy on fine motor skill deficits in patients with chronic stroke.

BACKGROUND: A growing body of evidence supports the effectiveness of using transcranial direct current stimulation (tDCS) in patients with chronic hand motor impairment resulting from stroke. OBJECTIVE: In this study, we investigate and compare the combined effects of anodal tDCS and occupational therapy (OT) to sham stimulation with OT (control) on fine motor skill deficits of chronic stroke patients. METHODS: A total of 26 stroke patients (at ≥ 9 months) were randomly assigned to an active treatment or a control group in a double-blinded, sham-controlled, parallel design study. Each group received OT for 45 min/day (10 sessions for 2 weeks). Treatment was preceded by either 20 minutes of 2 mA anodal tDCS over ipsilesional M1 or sham tDCS. A modified Jebsen-Taylor Hand Function Test (mJTHFT) was administered as primary outcome measure, and handgrip dynamometer and upper limb Fugl-Meyer (ULFM) assessments were performed as secondary outcomes. The assessment was done at baseline (T0), after the interventions on day 1(T1), day 10 (T2) and day 40 (T3). RESULTS: We observed a statistically significant effect in the tDCS group when the results were compared to the sham group. The mJTHFT times were significantly shorter immediately after treatment and at day 40. The intervention had no effect on handgrip strength or ULFM score. CONCLUSION: Fine motor skill deficits in chronic stroke survivors can be improved when intensive OT is primed with anodal tDCS over the ipsilesional hemisphere.

Estimating the effect of incident delirium on short-term outcomes in aged hip fracture patients through propensity score analysis.

AIM: We aimed to evaluate the factors contributing to delirium after hip fracture and assess the effect of incident delirium on short-term clinical outcomes. METHODS: A total of 270 non-delirious, consecutive hip fracture patients 60 years and older were included in a prospective cohort study. The patients were assessed with respect to physical status according to the American Society of Anesthesiologists classification, medical comorbidities with the Charlson Comorbidity Index, cognitive function with the Portable Mental Status Questionnaire and depression with the Geriatric Depressive Scale. Incident delirium was evaluated daily. Clinical outcomes and 1-month mortality were recorded. RESULTS: Incident delirium was present in 53.0% of patients. Patients with delirium were older (P = 0.046), had higher American Society of Anesthesiologists and Charlson Comorbidity Index scores (P < 0.001), lower Portable Mental Status Questionnaire scores and higher Geriatric Depressive Scale scores (P < 0.001, P = 0.003, respectively). After adjusting for age, multivariate regression analysis in the first model showed that patients with delirium were at higher risk of reintervention plus death (P < 0.05), complications P < 0.001), a higher severity complication score (P < 0.05) and longer length of hospital stay (P < 0.001). In the second model, after adjusting for propensity score, patients with delirium were at higher risk of reintervention plus death (P < 0.05) and longer length of hospital stay (P < 0.01). CONCLUSIONS: Patients who are older, with worse physical status, worse cognitive function and depression are more likely to develop delirium after hip fracture. Incident delirium has negative independent effects on short-term outcomes in elderly patients after hip fracture.

Early mortality after hip fracture: what matters?

BACKGROUND: Hip fractures in the elderly are followed by increased mortality, which is highest in the period immediately after the fracture. Predictors for early mortality have neither been well identified nor summarized. Identification of early postoperative mortality predictors enables the stratification of high-risk patients and can help in the development of strategies aimed at reducing risk and improving outcome after hip fracture. The primary aim of this study was to investigate the incidence of 30-day mortality. The secondary aim was to investigate factors related to early mortality. METHODS: We examined 384 elderly patients with hip fracture. Multivariate logistic regression analysis was used to explore independent prognostic factors for 30-day mortality. RESULTS: By the end of the 30-day follow-up period, 22 patients (6.4%) had died. Postoperative delirium was the only variable independently related to 30-day mortality after hip fracture. Older, male patients with a lower cognitive status had a higher chance of developing postoperative delirium. DISCUSSION: Postoperative delirium is a strong independent marker of high risk for 30-day mortality. Older, male patients with more severe cognitive impairment are at increased risk of developing postoperative delirium. Identifying patients at risk for developing postoperative delirium upon admission and early detection of delirium enable the development of targeted prevention and intervention strategies in older patients with hip fracture.

Effect of the overlap syndrome of depressive symptoms and delirium on outcomes in elderly adults with hip fracture: a prospective cohort study.

OBJECTIVES: To analyze the incidence of the overlap syndrome of depressive symptoms and delirium, risk factors, and independent and dose-response effect of the overlap syndrome on outcomes in elderly adults with hip fracture. DESIGN: Prospective cohort study. SETTING: University hospital. PARTICIPANTS: Individuals with hip fracture without delirium (N = 277; aged 78.0 ± 8.2) consequently enrolled in a prospective cohort study. MEASUREMENTS: Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive status using the Short Portable Mental Status Questionnaire upon hospital admission. Incident delirium was assessed daily during the hospital stay using the Confusion Assessment Method. Information on complications acquired in the hospital, severity of complications, re-interventions, length of hospital stay, and 1-month mortality was recorded. RESULTS: Thirty (10.8%) participants had depressive symptoms alone, 88 (31.8%) delirium alone, 60 (21.7%) overlap syndrome, and 99 (35.7%) neither condition. According to multivariate regression analysis, participants with the overlap syndrome had significantly higher incidence of vision impairment (P = .02), longer time-to-surgery (P = .03), and lower cognitive function (P < .001) than participants with no depressive symptoms and no delirium. In the adjusted regression analysis, participants with neither condition were at lower risk of complications than those with the overlap syndrome (P = .03). After adjustment, participants with the overlap syndrome were at higher risk of longer hospital stay independently (P = .003) and in a dose-response manner in the following order: no depression and no delirium, depressive symptoms alone, delirium alone, and the overlap syndrome (P = .002). CONCLUSION: Depressive symptoms and delirium increase the likelihood of adverse outcomes after hip fracture in a step-wise manner when they coexist. To reduce the risk of adverse outcome in individuals with hip fracture, efforts to identify, prevent, and treat this condition need to be increased.

Do depressive symptoms on hospital admission impact early functional outcome in elderly patients with hip fracture?

BACKGROUND: Depression is the most common mood disorder in elderly people and one of the most prevalent comorbidities in older people with hip fracture. While several authors have confirmed that depressive symptoms assessed at a later stage after hip fracture impact functional outcome and mortality, the role of depressive symptoms identified at an earlier stage after hip fracture remains understudied. The aim of the present study was to determine if depressive symptoms assessed on hospital admission impact early functional outcome after hip fracture surgery. METHODS: We studied 112 patients who underwent surgery for hip fracture during a 6-month period. Depressive symptoms were assessed using the 30-item Geriatric Depression Scale on admission to the acute setting. Multidimensional assessment included sociodemographic characteristics, general health status, cognitive status, functional status prior to injury, and perioperative variables. The primary outcome measure was motor Functional Independence Measure at discharge. RESULTS: Adjusted multivariate regression analysis revealed that the presence of moderate to severe depressive symptoms (Geriatric Depression Scale ≥ 20), older age, and female gender were independently related to motor Functional Independence Measure at discharge. CONCLUSION: Increasing levels of depressive symptoms in elderly hip fracture patients influence short-term functional outcome. We strongly support the introduction of routine assessment of this baseline comorbidity, especially in female patients. Failure to identify such patients is a missed opportunity for possible improvement of early functional outcome after hip fracture in elderly.

Predictors of severe pain in the immediate postoperative period in elderly patients following hip fracture surgery.

INTRODUCTION: The aim of this study was to identify risk factors for severe postoperative pain immediately after hip-fracture surgery. PATIENTS AND METHODS: Three hundred forty-four elderly patients with an acute hip fracture were admitted to the hospital during a 12-months period. All patients who entered the study answered a structured questionnaire to assess demographic characteristics, previous diseases, drug use, previous surgery, and level of education. Physical status was assessed through the American Society of Anesthesiologists' preoperative risk classification, cognitive status using the Short Portable Mental Status Questionnaire, and depression using the Geriatric Depression Scale. The presence of preoperative delirium using the Confusion Assessment Method was assessed during day and night shifts until surgery. Pain was measured using a numeric rating scale (NRS). An NRS ≥ 7 one hour after surgery indicated severe pain. RESULTS: Patients with elementary-level education (8 yr in school) presented a higher risk for immediate severe postoperative pain than university-educated patients (> 12 yr in school) (P < 0.05). Higher cognitive function was associated with higher postoperative pain (P < 0.01). Patients with symptoms of depression and patients with preoperative delirium presented a higher risk for severe pain (P < 0.05, P < 0.01, respectively). Multivariate analysis showed that depression and a low level of education were independent predictors of severe pain immediately after surgery. CONCLUSION: Depression and lower levels of education were independent predictors of immediate severe pain following hip-fracture surgery. These predictors could be clinically used to stratify analgesic risk in elderly patients for more aggressive pain treatment immediately after surgery.

Does early functional outcome predict 1-year mortality in elderly patients with hip fracture?

BACKGROUND: Hip fractures in the elderly are followed by considerable risk of functional decline and mortality. QUESTIONS/PURPOSES: The purposes of this study were to (1) explore predictive factors of functional level at discharge, (2) evaluate 1-year mortality after hip fracture compared with that of the general population, and (3) evaluate the affect of early functional outcome on 1-year mortality in patients operated on for hip fractures. METHODS: A total of 228 consecutive patients (average age, 77.6 ± 7.4 years) with hip fractures who met the inclusion criteria were enrolled in an open, prospective, observational cohort study. Functional level at discharge was measured with the motor Functional Independence Measure (FIM) score, which is the most widely accepted functional assessment measure in use in the rehabilitation community. Mortality rates in the study population were calculated in absolute numbers and as the standardized mortality ratio. Multivariate regression analysis was used to explore predictive factors for motor FIM score at discharge and for 1-year mortality adjusted for important baseline variables. RESULTS: Age, health status, cognitive level, preinjury functional level, and pressure sores after hip fracture surgery were independently related to lower discharge motor FIM scores. At 1-year followup, 57 patients (25%; 43 women and 14 men) had died. The 1-year hip fracture mortality rate compared with that of the general population was 31% in our population versus 7% for men and 23% in our population versus 5% for women 65 years or older. The 1-year standardized mortality rate was 341.3 (95% CI, 162.5-520.1) for men and 301.6 (95% CI, 212.4-391.8) for women, respectively. The all-cause mortality rate observed in this group was higher in all age groups and in both sexes when compared with the all-cause age-adjusted mortality of the general population. Motor FIM score at discharge was the only independent predictor of 1-year mortality after hip fracture. CONCLUSIONS: Functional level at discharge is the main determinant of long-term mortality in patients with hip fracture. Motor FIM score at discharge is a reliable predictor of mortality and can be recommended for clinical use.

Use of early indicators in rehabilitation process to predict one-year mortality in elderly hip fracture patients.

Hip fractures remain one of the most devastating injuries in the elderly. Early prediction of outcome following hip fracture potentially results in more efficient health care. The aims of this study were to explore predictors of ambulation status at hospital discharge in patients ≥65 years of age operated on for fracture of the hip, and to investigate the impact of ambulation status at hospital discharge on 1-year mortality after hip fracture. We studied 344 patients who underwent surgery for hip fracture during a 12 month period. Multivariate regression analysis was used to explore predictive factors for ambulatory status at discharge, and 1-year mortality adjusted on important baseline variables. Cumulative 1-year mortality was significantly lower for patients in the ambulatory group when compared to patients in the non-ambulatory group. Patients who were older, had severe cognitive impairment, lower functional level before injury, and in whom postoperative delirium and pressure ulcers occurred had a higher chance of not recovering their gait ability at hospital discharge, and being dead 1 year after hip fracture. Inability to walk at hospital discharge and presence of delirium are independent predictors of 1-year mortality. Every effort should be made to assure early mobilisation after hip fracture surgery, and prevention, prompt recognition and treatment of postoperative complications is important in order to facilitate better short-and long-term outcome.