RESUMO
BACKGROUND: People undergoing major orthopaedic surgery are at increased risk of postoperative thromboembolic events. Low molecular weight heparins (LMWHs) are recommended for thromboprophylaxis in this population. New oral anticoagulants, including direct factor Xa inhibitors, are recommended as alternatives. They may have more advantages than disadvantages compared to LMWHs and vitamin K antagonists (VKAs, another type of anticoagulant). OBJECTIVES: To assess the benefits and harms of prophylactic anticoagulation with direct factor Xa inhibitors compared with low molecular weight heparins and vitamin K antagonists in people undergoing major orthopaedic surgery for elective total hip or knee replacement or hip fracture surgery. SEARCH METHODS: We searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, two other databases, and two trial registers to 11 November 2023. We conducted reference checks to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing the effects of direct factor Xa inhibitors to LMWHs or VKAs in people undergoing major orthopaedic surgery. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were all-cause mortality, major venous thromboembolism (VTE), symptomatic VTE, major bleeding, and serious hepatic and non-hepatic adverse events. We evaluated the risk of bias in the included studies using Cochrane's risk of bias 1 tool. We calculated estimates of treatment effects using risk ratios (RR) with 95% confidence intervals (CIs), and used GRADE criteria to assess the certainty of the evidence. MAIN RESULTS: We included 53 RCTs (44,371 participants). Participants' average age was 64 years (range: 18 to 93 years). Only one RCT compared a VKA with direct factor Xa inhibitors. All 53 RCTs compared direct factor Xa inhibitors with LMWHs. Twenty-three studies included participants undergoing total hip replacement; 21 studies, total knee replacement; and three studies included people having hip fracture surgery. The studies' average duration was approximately 42 days (range: two to 720 days). Compared to LMWHs, direct factor Xa inhibitors may have little to no effect on all-cause mortality, but the evidence is very uncertain (RR 0.83, 95% CI 0.52 to 1.31; I2 = 0%; 28 studies, 29,698 participants; very low-certainty evidence). Direct factor Xa inhibitors may make little to no difference to major venous thromboembolic events compared to LMWHs, but the evidence is very uncertain (RR 0.51, 95% CI 0.37 to 0.71; absolute risk difference: 12 fewer major VTE events per 1000 participants, 95% CI 16 fewer to 7 fewer; I2 = 48%; 28 studies, 24,574 participants; very low-certainty evidence). Compared to LMWHs, direct factor Xa inhibitors may reduce symptomatic VTE (RR 0.64, 95% CI 0.50 to 0.83; I2 = 0%; 33 studies, 31,670 participants; low-certainty evidence). The absolute benefit of substituting factor Xa inhibitors for LMWHs may be between two and five fewer symptomatic VTE episodes per 1000 patients. In the meta-analysis with all studies pooled, direct factor Xa inhibitors appeared to make little or no difference to major bleeding compared to LMWHs, but the evidence was very uncertain (RR 1.05, 95% CI 0.86 to 1.30; I2 = 15%; 36 studies, 39,778 participants; very low certainty-evidence). ⢠In a subgroup analysis limited to studies comparing rivaroxaban to LMWHs, people given rivaroxaban may have had more major bleeding events (RR 1.94, 95% CI 1.26 to 2.98; I2 = 0%; 17 studies, 17,630 participants; low-certainty evidence). The absolute risk of substituting rivaroxaban for LMWH may be between one and seven more major bleeding events per 1000 patients. ⢠In a subgroup analysis limited to studies comparing direct factor Xa inhibitors other than rivaroxaban to LMWHs, people given these other direct factor Xa inhibitors may have had fewer major bleeding events, but the evidence was very uncertain (RR 0.80, 95% CI 0.63 to 1.02; absolute risk difference: 3 fewer major bleeding events per 1000 participants, 95% CI 5 fewer to 0 fewer; I2 = 0%; 19 studies, 22,148 participants; very low-certainty evidence). Direct factor Xa inhibitors may make little to no difference in serious hepatic adverse events compared to LMWHs, but the evidence is very uncertain (RR 3.01, 95% CI 0.12 to 73.93; 2 studies, 3169 participants; very low-certainty evidence). Only two studies reported this outcome, with one death in the intervention group due to hepatitis reported in one study, and no events reported in the other study. People given direct factor Xa inhibitors may have a lower risk of serious non-hepatic adverse events than those given LMWHs (RR 0.89, 95% CI 0.81 to 0.97; I2 = 18%; 15 studies, 26,246 participants; low-certainty evidence). The absolute benefit of substituting factor Xa inhibitors for LMWH may be between three and 14 fewer serious non-hepatic adverse events per 1000 patients. Only one study compared a direct factor Xa inhibitor with a VKA. It reported outcome data with imprecise results due to the small number of events. It showed no difference in the effects of the study drugs. AUTHORS' CONCLUSIONS: Oral direct factor Xa inhibitors may have little to no effect on all-cause mortality, but the evidence is very uncertain. Oral direct factor Xa inhibitors may slightly reduce symptomatic VTE events when compared with LMWH. They may make little or no difference to major VTE events, but the evidence is very uncertain. In the evaluation of major bleeding, the evidence suggests rivaroxaban results in a slight increase in major bleeding events compared to LMWHs. The remaining oral direct factor Xa inhibitors may have little to no effect on major bleeding, but the evidence is very uncertain. Oral direct factor Xa inhibitors may reduce serious non-hepatic adverse events slightly compared to LMWHs. They may have little to no effect on serious hepatic adverse events, but the evidence is very uncertain. Due to the high rates of missing participants and selective outcome reporting, the effect estimates may be biased.
Assuntos
Anticoagulantes , Artroplastia de Quadril , Artroplastia do Joelho , Inibidores do Fator Xa , Heparina de Baixo Peso Molecular , Fraturas do Quadril , Ensaios Clínicos Controlados Aleatórios como Assunto , Tromboembolia Venosa , Vitamina K , Humanos , Heparina de Baixo Peso Molecular/uso terapêutico , Heparina de Baixo Peso Molecular/efeitos adversos , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/uso terapêutico , Anticoagulantes/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Inibidores do Fator Xa/efeitos adversos , Fraturas do Quadril/cirurgia , Artroplastia do Joelho/efeitos adversos , Vitamina K/antagonistas & inibidores , Artroplastia de Quadril/efeitos adversos , Idoso , Viés , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Hemorragia/induzido quimicamente , Causas de Morte , Pessoa de Meia-Idade , Rivaroxabana/uso terapêutico , Rivaroxabana/efeitos adversosRESUMO
Introduction: Hospital admission due to fragility hip fracture has increased significantly in recent years. In patients with hip fracture, perioperative pain management is usually with opioids, whose dosage is difficult to adjust and have many side effects, especially in older adults. The purpose of this study was to determine the impact and the advantages of the implementation of the fascia iliaca blockade in older adults with hip fracture due to fragility included in the Orthogeriatric Clinical Care Center of the Fundación Santa Fe de Bogotá and the San José Infantil University Hospital in Bogotá, Colombia. The primary outcome of our study is the incidence of delirium during hospitalization. Methods: A retrospective observational cohort study was conducted. The data was collected from patients older than 65 years treated for a fragility fracture of the hip in two fourth-level hospitals in Bogotá, Colombia from the beginning of 2019 until the end of 2020. Results: A sample of 218 patients was obtained, of which 119 received conventional analgesic management. 99 patients underwent fascia iliaca blockade. No significant difference was found between the use of the block and the development of delirium (p = 0.442). There was a higher consumption of opioids in the conventional analgesia group compared to the block group (27.61 mg vs 16.34 mg, respectively, p = 0.003), longer duration of the surgical procedure (90.84 vs 81.08â min, respectively, p = 0.030) and longer hospital stay (6.06 vs 5.41 days, respectively, p = 0.641). Conclusions: While this study found no significant difference in the incidence of delirium, fascia iliaca blockade was associated with significant reductions in opioid consumption and shorter procedural times. These findings suggest that fascia iliaca blockade may improve pain management efficiency in older adults with hip fractures.
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Analgesia , Fraturas do Quadril , Bloqueio Nervoso , Manejo da Dor , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Analgesia/métodos , Analgésicos Opioides/uso terapêutico , Colômbia/epidemiologia , Delírio/tratamento farmacológico , Delírio/epidemiologia , Delírio/etiologia , Fáscia/inervação , Fáscia/efeitos dos fármacos , Fraturas do Quadril/cirurgia , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Estudos RetrospectivosRESUMO
Hip fracture is a public health problem recognized worldwide and a potentially catastrophic threat for older persons, even carrying a demonstrated excess of mortality. Handgrip strength (HGS) has been identified as a predictor of different outcomes (mainly mortality and disability) in several groups with hip fracture. PURPOSE: The aim of this study was to determine the association between low HGS and 1-year mortality in a cohort of older patients over 60 years old with fragility hip fractures who underwent surgery in the Colombian Andes Mountains. METHODS: A total of 126 patients (median age 81 years, women 77%) with a fragility hip fracture during 2019-2020 were admitted to a tertiary care hospital. HGS was measured using dynamometry upon admission, and data about sociodemographic, clinical and functional, laboratory, and surgical intervention variables were collected. They were followed up until discharge. Those who survived were contacted by telephone at one, three, and 12 months. Bivariate, multivariate, and Kaplan-Meier analyses with survival curves were performed. RESULTS: The prevalence of low HGS in the cohort was 71.4%, and these patients were older, had poorer functional and cognitive status, higher comorbidity, higher surgical risk, time from admission to surgery > 72 h, lower hemoglobin and albumin values, and greater intra-hospital mortality at one and three months (all p < 0.01). Mortality at one year in in patients with low HGS was 42.2% and 8.3% in those with normal HGS, with a statistically significant difference (p = 0.000). In the multivariate analysis, low HGS and dependent gait measured by Functional Ambulation Classification (FAC) were the factors affecting postoperative 1-year mortality in older adults with hip fractures. CONCLUSION: In this study of older people with fragility hip fractures, low HGS and dependent gait were independent predictive markers of 1-year mortality.
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Força da Mão , Fraturas do Quadril , Fraturas por Osteoporose , Humanos , Feminino , Masculino , Idoso , Fraturas do Quadril/cirurgia , Fraturas do Quadril/mortalidade , Fraturas do Quadril/fisiopatologia , Idoso de 80 Anos ou mais , Colômbia/epidemiologia , Força da Mão/fisiologia , Pessoa de Meia-Idade , Fraturas por Osteoporose/mortalidade , Fraturas por Osteoporose/fisiopatologia , Fraturas por Osteoporose/cirurgiaRESUMO
The FRAX® algorithm showed good accuracy in women living with DM followed in primary care. There were no differences between the ROC curve with and without adjustments for major and hip fractures. The FRAX® 10-year and FRAX® AR were better calibrated in this population. PURPOSE: An increased risk of fractures in people living with diabetes has been described. Screening instruments to calculate this risk have been proposed, including the FRAX® algorithm. Some studies suggest that minor modifications to this instrument can improve its performance. These modifications work well in other countries, but we do not know if they work in Brazil. The objective of our study was to evaluate the performance of the FRAX® algorithm with and without adjustments for women living with DM (WLDM) in primary care in Brazil. METHODS: A cohort study that included post-menopausal women attending primary care in Santa Maria, Brazil, was conducted from 2013 to 2018. The risk for major and hip fractures was calculated using the FRAX® tool. The FRAX® risk was calculated: (1) without adjustments (unadjusted FRAX®); (2) increasing the entered age by 10 years in individuals with DM (FRAX® 10 years); and (3) inserting the diagnosis of DM as rheumatoid arthritis (FRAX® AR). RESULTS: The accuracy for major fracture was 0.948 (unadjusted FRAX®), 0.947 (FRAX® 10 years), and 0.946 (FRAX® AR). For hip fractures, the accuracies were 0.989 (unadjusted FRAX®), 0.988 (FRAX® 10 years), and 0.988 (FRAX® AR). Furthermore, there were no differences between the area under the ROC curve with and without adjustments for major and hip fractures. Conversely, the FRAX® 10 years and the FRAX® AR were better calibrated, presenting a lower Chi-square. CONCLUSION: The FRAX® algorithm showed good accuracy in WLDM followed in primary care. The FRAX® 10 years and FRAX® AR were better calibrated in this population.
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Algoritmos , Fraturas do Quadril , Fraturas por Osteoporose , Atenção Primária à Saúde , Humanos , Feminino , Brasil/epidemiologia , Pessoa de Meia-Idade , Idoso , Atenção Primária à Saúde/estatística & dados numéricos , Medição de Risco/métodos , Fraturas por Osteoporose/epidemiologia , Fraturas do Quadril/epidemiologia , Estudos de Coortes , Fatores de Risco , Diabetes Mellitus/epidemiologia , Idoso de 80 Anos ou maisRESUMO
Las fracturas de cadera por osteoporosis constituyen un problema de salud y se relacionan con el aumento de la morbimortalidad. Objetivo: determinar las tasas, las causas y factores de riesgo de mortalidad en los pacientes con fracturas de cadera, en un período de seguimiento de 10 años. Metodología: estudio de cohorte, retrospectivo, realizado en pacientes ≥ 50 años pertenecientes al Plan de Salud del Hospital Italiano de Buenos Aires que se internaron por frac-tura de cadera entre el 01-7-2005 y el 31-12-2010. Se evaluaron: sexo, edad, comorbilidades y tratamiento con bifosfonato prefractura y posfractura. Se utilizaron los métodos: Chi cuadrado, media, mediana y DS, sobrevida de Kaplan-Meier y modelos de riesgo proporcionales de Cox. Resultados: se incluyeron 965 pacientes. La media de edad al momento de la fractura fue 81,6 años; el 80,7% fueron mujeres. La mor-talidad global al año fue de 14,9% y de 73,2% a los 10 años, siendo mayor en hombres (HR: 1,31; IC 95%: 1,10-1,58; p=0,003), mayor (HR: 1,10; IC 95%: 1,09-1,11; p<0,001) y aumento del puntaje (score) de Charlson (HR:1,29; IC 95%: 1,23-1,34; p<0,001). Los factores de riesgo de mortalidad según el análisis multivariable de Cox en el período son: edad, índice de Charlson, sexo masculino, fractura medial, demencia e insuficiencia cardíaca congestiva. Los bifosfonatos favorecieron la sobrevida de la población (Cox). Las causas de muerte más frecuentes fueron las infecciosas y las cardiovasculares. A los 10 años sobrevivió la población que era más joven al inicio del estudio, más sana y tratada con bifosfonatos después de la fractura de cadera. Conclusiones: de esta observación a largo plazo surge la importancia del seguimiento y tratamiento con fármacos osteoactivos después de la fractura de cadera a toda la población, especialmente a la más añosa, masculina y con comorbilidades. (AU)
Hip fractures due to osteoporosis constitute a health problem and are associated with increased morbidity and mortality. Objective: To determine the rates, causes, and risk factors for mortality in patients with hip fractures over a 10-year follow-up period. Methodology: This retrospective cohort study included patients aged ≥50 years who were part of the health plan at the Italian Hospital of Buenos Aires and were hospitalized for hip fracture between July 1, 2005, and December 31, 2010. Sex, age, comorbidities, and pre- and post-fracture bisphosphonate treatment were evaluated. Statistical methods included chi-square tests, mean, median, standard deviation, Kaplan-Meier survival analysis, and Cox proportional hazards model. Results: A total of 965 patients were included. The mean age at the time of fracture was 81.6 years, and 80.7% were women. The overall mortality rate at one year was 14.9%, increasing to 73.2% at 10 years. Mortality was higher in men (HR: 1.31; 95% CI 1.10-1.58; p=0.003), older age (HR: 1.10; 95% CI 1.09-1.11; p<0.001), and Charlson comorbidity score (HR: 1.29; 95% CI 1.23-1.34; p<0.001) at ten years of follow-up.Risk factors for mortality during the study period, according to multivariate Cox analysis, included age, Charlson index, male sex, medial fracture, dementia, and congestive heart failure. Bisphosphonates improved survival (Cox analysis). The most common causes of death were infectious and cardiovascular. Patients that survived after ten years of follow-up were healthier, younger at baseline, and showed a higher proportion of treatment with bisphosphonates after hip fracture. Conclusions: This long-term observation highlights the importance of follow-up and osteoactive drug treatment after hip fracture, especially in older, male and patients with comorbidities. (AU)
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Complicações Pós-Operatórias/epidemiologia , Assistência ao Convalescente/estatística & dados numéricos , Fraturas do Quadril/mortalidade , Comorbidade , Modelos de Riscos Proporcionais , Análise de Sobrevida , Fatores de Risco , Seguimentos , Expectativa de Vida , Fatores Etários , Difosfonatos/uso terapêuticoRESUMO
Background: Hip fractures impact the quality of life and can lead to physical dependency, particularly in older adults. Objective: To determine whether surgical treatment and other factors are associated with dependency in performing activities of daily living in elderly patients with hip fractures. Material and methods: A cross-sectional analytical study was conducted at a regional general hospital from January 2019 to December 2021. Surgically treated patients with hip fractures were included. Follow-up was conducted for 6 months after surgery, and the Barthel Index and EQ-5D questionnaires were administered. Summary statistics and association measures were used for data analysis. Results: A total of 126 patients with an average age of 78 ± 9 years were included. Patients with subcapital and basicervical fracture treated with hemiarthroplasty showed greater dependency compared to those treated with total hip arthroplasty with statistically significant differences. It was demonstrated that the greater the age the greater the dependency (p < 0.001), as well as prolonged hospital stay (p = 0.018). Cardiac disease was the comorbidity associated with increased dependency (p = 0.006). Conclusion: The type of surgery emerged as a factor associated with dependency in patients with subcapital and basicervical fractures treated with hemiarthroplasty. The length of hospital stay and the presence of cardiac disease were also associated with physical dependency.
Introducción: las fracturas de cadera afectan la calidad de vida y pueden causar dependencia física, en especial en adultos mayores. Objetivo: determinar si el tratamiento quirúrgico y otros factores están asociados a dependencia para realizar actividades de la vida diaria en pacientes ancianos con fractura de cadera. Material y métodos: estudio transversal analítico llevado a cabo en un hospital general de zona de enero 2019 a diciembre 2021. Fueron incluidos pacientes intervenidos quirúrgicamente por fractura de cadera. Después de 6 meses de la cirugía, se aplicaron los cuestionarios: Índice de Barthel y EQ-5D. Para el análisis de los datos, se utilizaron medidas sumarias y de asociación. Resultados: se incluyeron 126 pacientes con promedio de edad de 78 ± 9 años. Los pacientes con fracturas subcapitales y basicervicales tratados con hemiartroplastía presentaron mayor dependencia comparados con los pacientes tratados con artroplastia total de cadera, con diferencia estadísticamente significativa. Se demostró que a mayor edad se tiene una mayor dependencia (p < 0.001), así como una estancia hospitalaria prolongada (p = 0.018). La cardiopatía fue la comorbilidad que presentó asociación con una mayor dependencia (p = 0.006). Conclusión: el tipo de cirugía se presentó como un factor asociado a dependencia en los pacientes con fracturas subcapitales y basicervicales tratados con hemiartroplastía. El tiempo de estancia hospitalaria y la presencia de cardiopatía también se asociaron a dependencia física.
Assuntos
Atividades Cotidianas , Artroplastia de Quadril , Fraturas do Quadril , Humanos , Feminino , Masculino , Idoso , Estudos Transversais , Fraturas do Quadril/cirurgia , Idoso de 80 Anos ou mais , Tempo de Internação/estatística & dados numéricos , Hemiartroplastia , Qualidade de Vida , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: To determine the clinical, laboratory, and hospital factors associated with preoperative complications in older adults with hip fractures. METHODOLOGY: Analytical observational retrospective cohort study, whose population was older adults with a diagnosis of hip fracture treated in a hospital in northern Peru, during 2017-2019. RESULTS: 432 patients with a median age of 83 years (RIC: 77-88) were evaluated, with the female gender being the most prevalent (60.9%). The most common comorbidities included cardiovascular disease (68%) and diabetes (17.6%), and multimorbidity was observed in 47.2% of cases. The median number of geriatric syndromes was 2 (RIC: 1-5). The overall mortality rate was 3.2% (1.7-5.3). Analysis with the Poisson regression model found a significant association with MRC scale 3-5 degree (RR = 1.60), glucose on admission (RR = 1.01), and minimally significantly female sex (RR = 2.41). CONCLUSIONS: The most commonly observed complications were infectious in nature, including pneumonia, sepsis, and urinary tract infections. The MRC scale from 3 to 5 degrees increases the risk of developing a preoperative complication; the glucose levels upon admission show a clinically irrelevant association; and in females, there is a minimally significant association in older adults with hip fractures.
Assuntos
Fraturas do Quadril , Humanos , Fraturas do Quadril/cirurgia , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/complicações , Fraturas do Quadril/mortalidade , Feminino , Masculino , Idoso , Idoso de 80 Anos ou mais , Peru/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Comorbidade , Período Pré-Operatório , HospitalizaçãoRESUMO
INTRODUCTION: The optimal positioning of the cephalic screw in intertrochanteric fractures (ITFs) is crucial for minimizing the risk of cut-out. This study assesses the predictive value of the tip-to-apex distance (TAD) and tip-to-apex distance referenced to calcar (calTAD) for cut-outs in patients undergoing fixation with cephalomedullary nails. METHOD: We analyzed 158 consecutive patients aged over 65 years (mean 83.6 ± 15.9) with intertrochanteric hip fractures who underwent cephalomedullary nailing between January 2016 and July 2022. Receiver operating characteristic (ROC) curves were used to determine the optimal cut-off points for TAD and calTAD. Uni- and multivariate logistic regression analyses were conducted to identify independent predictors of cut-out, considering demographic data, comorbidities, fracture type (AO/OTA), reduction quality (according to Baumgartner classification), TAD, and calTAD. RESULTS: Cut-out occurred in 12 patients (7.5%). ROC analysis identified 18.99 mm as the optimal cut-off for TAD (sensitivity 83.3%, specificity 63.7%; area under the curve-AUC- 0.703, p = 0.009) and 24.95 mm for calTAD (sensitivity 100%, specificity 82.9%, AUC = 0.906, p = < 0.0001). Univariate analysis revealed no significant differences in demographics, fracture type, or reduction quality between patients with and without cut-outs. Multivariate analysis identified calTAD > 24.95 mm as the only independent predictor of cut-out, with an Odds ratio of 24.62 (95% Confidence Interval 27.61-68.92, p = 0.001). CONCLUSION: Our findings suggest that calTAD is a helpful measure for predicting cut-outs in intertrochanteric fracture fixation using cephalomedullary nails in the context of good fracture reduction. Surgeons should aim to keep calTAD values below 24.95 mm to reduce the risk of cut-out, as values above this threshold significantly increase the risk.
Assuntos
Pinos Ortopédicos , Fixação Intramedular de Fraturas , Fraturas do Quadril , Humanos , Fraturas do Quadril/cirurgia , Masculino , Feminino , Fixação Intramedular de Fraturas/instrumentação , Fixação Intramedular de Fraturas/métodos , Idoso de 80 Anos ou mais , Estudos Retrospectivos , Idoso , Curva ROC , Parafusos ÓsseosRESUMO
INTRODUCTION: fixation of unstable intertrochanteric fractures presents a significant challenge, especially in the context of osteoporosis. Intramedullary implants have been established as superior to plate constructs. Our aim is to compare the complications and clinical outcomes of the Proximal Femur Nail (PFN) and Proximal Femur Nail Antirotation-2 (PFNA2) in managing unstable intertrochanteric fractures. MATERIAL AND METHODS: a total of 212 patients meeting inclusion and exclusion criteria underwent fixation of trochanteric fractures using either a standard PFN (n = 110) or PFNA2 (n = 102). Their intraoperative and postoperative clinical and radiographic data were evaluated along with the quality of fixation. Data analysis was performed using the student's t-test, 2 test, and Mann-Whitney U test. RESULTS: PFNA2 demonstrated more favorable outcomes compared to PFN in terms of a better intraoperative profile, functional outcomes (PFNA2: PFN = 82:75), and fewer implant-related complications. Significant issues in the PFN group included screw back-out, guidewire breakage, and proximal protrusion of the nail tip. In contrast, locking mechanism failure and lateral screw prominence were significant problems in the PFNA2 group. CONCLUSION: PFNA2 is the preferred implant for managing osteoporotic unstable intertrochanteric fractures, given the bone's weak inherent tendency to secure the implant.
INTRODUCCIÓN: la fijación de fracturas intertrocantéreas inestables presenta un desafío importante, especialmente en el contexto de la osteoporosis. Se ha demostrado que los implantes intramedulares son superiores a las construcciones con placas. Nuestro objetivo es comparar las complicaciones y los resultados clínicos del clavo de fémur proximal (PFN) y el clavo de fémur proximal antirotación-2 (PFNA2) en el tratamiento de fracturas intertrocantéreas inestables. MATERIAL Y MÉTODOS: un total de 212 pacientes que cumplían con los criterios de inclusión y exclusión se sometieron a fijación de fracturas trocantéricas utilizando un PFN estándar (n = 110) o PFNA2 (n = 102). Se evaluaron sus datos clínicos y radiográficos intraoperatorios y postoperatorios junto con la calidad de la fijación. El análisis de los datos se realizó mediante la prueba t de Student, la prueba de 2 y la prueba U de Mann-Whitney. RESULTADOS: PFNA2 demostró resultados más favorables en comparación con PFN en términos de un mejor perfil intraoperatorio, resultados funcionales (PFNA2: PFN = 82:75) y menos complicaciones relacionadas con los implantes. Los problemas importantes en el grupo PFN incluyeron el retroceso del tornillo, la rotura de la guía y la protrusión proximal de la punta del clavo. Por el contrario, la falla del mecanismo de bloqueo y la prominencia lateral del tornillo fueron problemas importantes en el grupo PFNA2. CONCLUSIÓN: PFNA2 es el implante preferido para el tratamiento de fracturas intertrocantéreas inestables osteoporóticas, dada la débil tendencia inherente del hueso a asegurar el implante.
Assuntos
Pinos Ortopédicos , Fixação Intramedular de Fraturas , Fraturas do Quadril , Fraturas por Osteoporose , Humanos , Fraturas do Quadril/cirurgia , Feminino , Masculino , Idoso , Fixação Intramedular de Fraturas/métodos , Fixação Intramedular de Fraturas/instrumentação , Idoso de 80 Anos ou mais , Fraturas por Osteoporose/cirurgia , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Estudos RetrospectivosRESUMO
INTRODUCTION: evaluation of predictors of periprosthetic fracture in loosened femoral stems. MATERIAL AND METHODS: retrospective case-control study comparing aseptic loosened stems in two groups: cases: patients who experienced periprosthetic femoral fracture before replacement could be performed (n = 9). Controls: experienced prosthetic replacement without fracture (n = 19). RESULTS: pain intensity (VAS) was the most important aspect (p = 0.01), predominating in the controls. The simple radiological parameters did not show statistically significant findings predictive of peri-prosthetic fracture (number of Gruen zones, sum of them in mm, stress shielding, pedestal, polyethylene wear, stem subsidence). The role of complementary tests (CT and scintigraphy) for the definitive diagnosis of loosening was relevant, but not significant. The type of implant showed no differences. Overall implant survival was higher in cases than in controls (p = 0.016). This difference continues when comparing each loosened stem until fracture or replacement (p = 0.024). CONCLUSION: the main factor protecting against fracture is the replacement of a stem with clinical and radiological diagnosis of loosening. Adequate follow-up of the patient plays a determining role in this, especially when considering the greater intensity of pain in the controls, which used to guide surgeons to perform replacements before the fracture occurred. This is reinforced if we take into account that up to one third of the cases did not have regular check-ups, and therefore did not have the opportunity for replacement prior to the fracture. The role of complementary tests (CT and scintigraphy) is also very important, taking into account the low diagnostic yield obtained from simple X-rays.
INTRODUCCIÓN: evaluación de factores predictores de fractura periprotésica en vástagos femorales aflojados. MATERIAL Y MÉTODOS: estudio de casos y controles retrospectivo, comparando vástagos aflojados asépticos en dos grupos. Casos: pacientes que experimentaron fractura periprotésica femoral antes de poder efectuar recambio (n = 9). Controles: experimentaron recambio protésico, sin llegar a producirse fractura (n = 19). RESULTADOS: la intensidad del dolor (EVA) fue el aspecto más importante (p = 0.01), predominando en los controles. Los parámetros radiológicos simples no mostraron hallazgos predictores de fractura periprotésica de manera estadísticamente significativa (número de zonas de Gruen, suma de las mismas en milímetros, stress shielding, pedestal, desgaste del polietileno, hundimiento del vástago). El papel de las pruebas complementarias (TAC y gammagrafía) para el diagnóstico definitivo del aflojamiento sí fue relevante, pero sin significación. El tipo de implante no mostró diferencias. La supervivencia total del implante fue mayor en los casos respecto a los controles (p = 0.016). Esta diferencia continúa al comparar cada vástago aflojado hasta la fractura o recambio (p = 0.024). CONCLUSIÓN: el principal factor protector de fractura es el propio recambio de un vástago con diagnóstico clínico y radiológico de aflojamiento. En esto juega un papel determinante un adecuado seguimiento del paciente, sobre todo al considerar la mayor intensidad del dolor en los controles, que orientaba antes a los cirujanos a realizar recambios antes de ocurrir la fractura. Esto se refuerza si tenemos en cuenta que hasta un tercio de los casos no tenían revisiones regladas y por lo tanto no tuvieron oportunidad de recambio previo a la fractura. Resulta también muy importante el papel de las pruebas complementarias (TAC y gammagrafía) al tener en cuenta la baja rentabilidad diagnóstica extraída de las radiografías simples.
Assuntos
Prótese de Quadril , Fraturas Periprotéticas , Falha de Prótese , Humanos , Estudos Retrospectivos , Feminino , Idoso , Masculino , Estudos de Casos e Controles , Fraturas Periprotéticas/etiologia , Fraturas Periprotéticas/diagnóstico por imagem , Pessoa de Meia-Idade , Prótese de Quadril/efeitos adversos , Idoso de 80 Anos ou mais , Fraturas do Quadril/cirurgia , Fraturas do Quadril/diagnóstico por imagem , Medição de Risco/métodosRESUMO
BACKGROUND: The most common traumatic injury among older individuals worldwide is hip fracture. Higher incidence after 70 years old and women (80-85%). Hospital discharges in Mexico have little evidence. OBJECTIVE: Describe hospital discharges from hip fractures in the Mexican public health system from 2013 to 2022. MATERIAL AND METHODS: A descriptive study using open data on hospital discharges from the Mexican public health system from 2013-2022, available by the General Direction of Health Information of the Secretary of Health, focused on discharge reports for hip fractures in people aged ≥ 60 years and any sex. The study describes individual variables, hospital discharge, and the federal entities where health care was provided. RESULTS: Between 2013 and 2022, there have been 230,060 (2.11%) discharges due to hip fractures in people aged ≥ 60 years within the Mexican public health system; the highest concentration in patients with ≥ 80 years old and women (69.2%). The Mexican Social Security Institute reported the highest number of discharges (n = 126,093), with the highest percentage due to improvement (93.7%). CONCLUSIONS: Hip fracture is a problem that requires more significant care resources in Mexico.
ANTECEDENTES: La lesión traumática más común en el mundo entre personas mayores es la fractura de cadera, con mayor incidencia hacia los 70 años y en mujeres (de 80 a 85 %). OBJETIVO: Describir los egresos hospitalarios por fractura de cadera en personas mayores atendidas en el sector público de salud de México entre 2013 y 2022. MATERIAL Y MMÉTODOS: Estudio descriptivo de los datos abiertos de egresos hospitalarios del sector público de salud dados a conocer por la Dirección General de Información en Salud de la Secretaría de Salud de México. Se consideraron reportes por fractura de cadera en personas ≥ 60 años de uno u otro sexo, y se describieron variables demográficas, del egreso hospitalario y entidades federativas donde se realizó la atención. RESULTADOS: Entre 2013 y 2022 se llevaron a cabo 230 060 egresos por fractura de cadera en personas ≥ 60 años en el sector público de salud en México (2.11 %), más frecuentemente en personas ≥ 80 años y mujeres (69.2 %). El Instituto Mexicano del Seguro Social reportó mayor número de egresos (n = 126 093), con alta proporción por mejoría (93.7 %). CONCLUSIONES: La fractura de cadera es un problema preocupante que requiere mayores recursos de atención en México.
Assuntos
Fraturas do Quadril , Alta do Paciente , Humanos , México/epidemiologia , Fraturas do Quadril/epidemiologia , Feminino , Idoso , Masculino , Alta do Paciente/estatística & dados numéricos , Idoso de 80 Anos ou mais , Pessoa de Meia-IdadeRESUMO
The population has aged; there is a greater risk of osteoporosis and hip fracture. We describe the standards of care for hip fractures in various hospitals of Mexico. A total of 1042 subjects participated. The acute mortality was 4.3%. SIGNIFICANCE: Hip fracture registries provide a means to compare care and establish improvement processes. BACKGROUND: The Mexican population has aged; thus, there is a greater risk of osteoporosis, and its main consequence is hip fracture due to fragility. Its incidence is high, and it is expected to increase due to aging in our country. International guidelines provide standardized recommendations for the care of people with hip fractures, while hip fracture registries provide a means to compare care with local, national, and international clinical standards and establish improvement processes. OBJECTIVE: Describe the standards of care for hip fractures in various hospital centers of the Mexican Social Security Institute. METHODS: This was an observational, multicenter, longitudinal, and descriptive study. It included 24 hospital centers in Mexico. Informed consent was obtained. Data were recorded during the hospital stay, epidemiological data, and management, and follow-up was carried out 30 and 120 days after discharge. The information was analyzed using SPSS version 22.0. RESULTS: A total of 1042 subjects aged 79.5 ± 7.6 years participated, mostly women (n = 739; 70.9%) from the community (n = 1,021; 98.0%) and with functional independence (Barthel 80.9 ± 22.2). The transfer time to the emergency room was 4.6 ± 14.6 days. Pertrochanteric hip fracture was the most common (n = 570, 54.7%). The most common type of procedure was dynamic hip screw (DHS) (n = 399; 40.1%). Documented thromboprophylaxis was granted in 91.5% (n = 953) and antibiotic prophylaxis in 53.0% (n = 552) of the patients. The goal of 36 h for the surgical procedure was achieved in 7.6% of the subjects (n = 76), with the most frequent cause being a delay in scheduling (n = 673, 67.6%). The mean time from emergency room to surgery was 7.8 ± 7.0 days. The acute mortality rate was 4.3%. Secondary pharmacologic prevention upon discharge occurred in 64.2% of patients. At 30 days, 370 subjects (37.1%) were lost to follow-up, with a mortality of 3%, while at 120 days, 166 subjects (27.8%) were lost, with a mortality of 2.8%. CONCLUSION: In the hospital centers where the study was carried out, there are still no standards of care for hip fractures, which makes it necessary to rethink the care for this population group through a strategy focused on meeting those standards.
Assuntos
Fraturas do Quadril , Sistema de Registros , Humanos , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/mortalidade , Feminino , Masculino , Idoso , México/epidemiologia , Idoso de 80 Anos ou mais , Estudos Longitudinais , Fraturas por Osteoporose/epidemiologia , Fraturas por Osteoporose/mortalidadeRESUMO
PURPOSE: To analyse the time-to-surgery of a centre of excellence in hip fractures of the elderly and its influence on inpatient mortality and postoperative complications. METHODS: A cross-sectional cohort study was conducted. The sample universe consisted of 4,364 patients admitted to a university clinic in Chía, Colombia during the year 2018 to 2023 with ICD-10 diagnoses corresponding to femur fractures. After eliminating duplicates and application of inclusion and exclusion criteria, the final sample included was 269 patients. Qualitative and quantitative variables were analysed, such as: sex, age, age group, type of fracture, type of surgical procedure, time-to-surgery, time to discharge, inpatient mortality and postoperative complications. RESULTS: The mean time-to-surgery from admission was 70.16 h or 2.92 days (IQR 37-87). Patients were divided into three subgroups of time in which they were taken to surgery: <24 h (11.89%), 24-48 h (33.82%) and > 48 h (54.27%). The overall mortality rate was 1.85% for a total of five deceased patients, two of whom belonged to the 24-48-hour group and three to the > 48 h group. Higher rates of postoperative complications were observed in the > 48-hours group (n: 39, 14.49%), followed by the 24-48-hour group (n: 25, 9.29%) and the < 24-hour group (n: 7, 2.6%). CONCLUSIONS: Patients operated for a hip fracture in > 48 h since admission had a slightly higher rate of postoperative complications. No significant difference was observed regarding inpatient mortality when compared to the 24-48-hour group.
Assuntos
Fraturas do Quadril , Mortalidade Hospitalar , Complicações Pós-Operatórias , Tempo para o Tratamento , Humanos , Colômbia/epidemiologia , Masculino , Feminino , Fraturas do Quadril/cirurgia , Fraturas do Quadril/mortalidade , Idoso , Complicações Pós-Operatórias/epidemiologia , Estudos Transversais , Idoso de 80 Anos ou mais , Tempo para o Tratamento/estatística & dados numéricos , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Persistent inflammation is associated with adverse health outcomes, but its impact on mortality has not been investigated previously among hip fracture patients. This article aims to investigate the influence of changes in levels of cytokines in the 2 months after a hip fracture repair on 5-year mortality. METHODS: This is a prospective cohort study from the Baltimore Hip Studies (BHS) with 191 community-dwelling older men and women (≥65 years) who had recently undergone surgical repair of an acute hip fracture, with recruitment from May 2006 to June 2011. Plasma interleukin-6 (IL-6), soluble tumor necrosis factor alpha receptor1 (sTNFα-R1), and interleukin-1 receptor agonist (IL-1RA) were obtained within 22 days of admission and at 2 months. All-cause mortality over 5 years was determined. Logistic regression analysis tested the associations between the cytokines' trajectories and mortality over 5 years, adjusted for covariates (age, sex, education, body mass index, lower extremity physical activities of daily living, and Charlson comorbidity index). RESULTS: High levels of IL-6 and sTNFα-R1 at baseline with small or no decline at 2 months were associated with higher odds of 5-year mortality compared with those with lower levels at baseline and greater decline at 2 months after adjustment for age, and other potential confounders (OR = 4.71, p = 0.01 for IL-6; OR = 15.03, p = 0.002 for sTNFα-R1). Similar results that failed to reach significance were found for IL-1RA (OR = 2.40, p = 0.18). Those with higher levels of cytokines at baseline with greater decline did not have significantly greater mortality than the reference group, those with lower levels at baseline and greater decline. CONCLUSION: Persistent elevation of plasma IL-6 and sTNFα-R1 levels within the first 2 months after hospital admission in patients with hip fracture is associated with higher 5-year mortality. These patients may benefit from enhanced care and earlier intensive interventions to reduce the risk of death.
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Fraturas do Quadril , Interleucina-6 , Humanos , Masculino , Feminino , Fraturas do Quadril/mortalidade , Fraturas do Quadril/sangue , Estudos Prospectivos , Idoso , Interleucina-6/sangue , Baltimore/epidemiologia , Receptores Tipo I de Fatores de Necrose Tumoral/sangue , Idoso de 80 Anos ou mais , Biomarcadores/sangueRESUMO
INTRODUCTION: Femoral fractures in elderly individuals present significant health challenges, often leading to increased morbidity and mortality. Acute kidney injury (AKI) during hospitalization further complicates outcomes, yet the interaction between AKI severity and comorbidities, as quantified by the Charlson Comorbidity Index (CCI), remains poorly understood in this population. This study aimed to assess the associations between AKI severity and the CCI and between AKI severity and one-year mortality postfemoral fracture in elderly patients. METHODOLOGY: This study utilized data from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC-IV) database and focused on elderly patients (> 65 years) admitted with hip fractures. Patients were categorized based on AKI stage according to the KDIGO criteria and CCI scores. The primary outcome assessed was all-cause mortality one year after hospital discharge. The statistical analyses included logistic regression, Cox proportional hazards regression and moderation analysis with the Johnson-Neyman technique to evaluate associations between AKI and long-term mortality and between the CCI and long-term mortality. RESULTS: The analysis included 1,955 patients and revealed that severe AKI (stages 2 and 3) was independently associated with increased one-year mortality. Notably, the CCI moderated these associations significantly. A lower CCI score was significantly correlated with greater mortality in patients with severe AKI. The impact of severe AKI was greater for those with a CCI as low as 3, more than doubling the observed one-year mortality rate. In contrast, higher CCI scores (≥8) did not significantly impact mortality. Sensitivity analyses supported these findings, underscoring the robustness of the observed associations. CONCLUSION: This study elucidates the complex interplay between AKI severity and comorbidities and long-term mortality in elderly hip fracture patients. These findings underscore the importance of considering both AKI severity and comorbidity burden in prognostic assessments and intervention strategies for this vulnerable population. Targeted interventions tailored to individual risk profiles may help mitigate the impact of AKI on mortality outcomes, ultimately improving patient care and outcomes. Further research is warranted to explore the underlying mechanisms involved and refine risk stratification approaches in this population.
Assuntos
Injúria Renal Aguda , Comorbidade , Fraturas do Quadril , Hospitalização , Humanos , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/epidemiologia , Fraturas do Quadril/mortalidade , Fraturas do Quadril/complicações , Feminino , Masculino , Idoso , Idoso de 80 Anos ou mais , Índice de Gravidade de DoençaRESUMO
PURPOSE: Osteoporosis is a pressing public health concern among older adults, contributing to substantial mortality and morbidity rates. Low- to middle-income countries (LMICs) often grapple with limited access to dual-energy X-ray absorptiometry (DXA), the gold standard for early osteoporosis detection. This study aims to assess the performance of the FRAX® score as a population-wide screening tool for predicting osteoporosis risk, rather than fracture, in individuals aged 50 and above within an LMIC context. METHODS: This retrospective cohort study (n=864) assessed the performance of the FRAX® score for predicting osteoporosis risk using comparative c-statistics from Receiver Operating Characteristic (ROC) curves. Hazard ratios (HR) and 95â¯% confidence intervals (CI) were calculated, with p-values <0.05 indicating statistically significant. RESULTS: The 10-year FRAX® probability for hip fracture, calculated without bone mass density (BMD), exhibited significantly superior performance compared to the 10-year FRAX® probability for major fracture in predicting osteoporosis risk (AUROC: 0.71 versus 0.67, p<0.001). Within 2 to 10 years of follow-up, the 10-year FRAX® probability for hip fracture showed both greater predictive performance and net benefit in the decision curve compared to the FRAX® 10-year probability for major fracture. A newly established cutoff of 1.9â¯% yielded a negative predictive value of 92.9â¯% (95â¯%CI: 90.4-94.8â¯%) for the 10-year FRAX® probability for hip fracture. CONCLUSION: The 10-year FRAX® probability for hip fracture estimated without BMD emerges as an effective 10-year screening tool for identifying osteoporosis risk in aged 50 and older, especially when confronted with limited access to DXA scans in LMICs. MINI ABSTRACT: The Fracture Risk Assessment Tool score performance as an osteoporosis screening tool was assessed in areas with limited dual-energy X-ray access. The hip fracture probability showed better performance than major fracture probability within 2 to 10 years. The tool emerges as effective for screening osteoporosis risk in individuals over 50.
Assuntos
Absorciometria de Fóton , Densidade Óssea , Programas de Rastreamento , Osteoporose , Fraturas por Osteoporose , Humanos , Medição de Risco/métodos , Idoso , Feminino , Masculino , Estudos Retrospectivos , Osteoporose/diagnóstico por imagem , Osteoporose/complicações , Pessoa de Meia-Idade , Fraturas por Osteoporose/epidemiologia , Programas de Rastreamento/métodos , Fraturas do Quadril/diagnóstico por imagem , Fraturas do Quadril/epidemiologia , Curva ROC , Países em Desenvolvimento , Idoso de 80 Anos ou mais , Região de Recursos LimitadosRESUMO
This study, characterizing the incidence of hip fractures in Mexico, showed not only that the crude number of fractures has increased, but also there has been a decrease in fracture rates. Nonetheless, as the population ages in the coming decades, the current declines rate of could be expected to reverse. PURPOSE: This study is to examine the incidence, rates, and time trends of hip fractures from 2006 to 2019 in Mexico. Additionally, an analysis of the follow-up of the birth cohorts was carried out. METHODS: Hip fractures registered during the period of the study were obtained through the Mexican Social Security Institute (IMSS) national discharge records. The incidence per 100,000 individuals was calculated from the IMSS population at risk. A time trend analysis was conducted using linear regression, and the identification of breakpoints in linear trends. RESULTS: There was an increase of hip fractures for both sexes ≥ 60 years (43% for women and 41%, for men). However, the rates diminished from 167.8/100,000 in 2006 to 138.5 /100,000 in the population 60 and over (1.9% and 0.9% per year in women and men respectively). When the information was analyzed by age groups, hip fracture rates were similar in both sexes but higher in women. The most significant contribution to the total number of fractures is due to the groups ≥ 70 years; people born before 1937 are accounting for the burden of fractures over the total data. In contrast, the younger generations appear to have lower rates. CONCLUSION: Rates of hip fracture have steadily declined in Mexico since 2006; however, with the population aging in the coming decades, current rates declines could be expected to reverse.
Assuntos
Fraturas do Quadril , Fraturas por Osteoporose , Humanos , Fraturas do Quadril/epidemiologia , México/epidemiologia , Masculino , Feminino , Incidência , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Fraturas por Osteoporose/epidemiologia , Distribuição por Idade , Distribuição por Sexo , AdultoRESUMO
Objective: The objective of the study is to investigate the effect of pericapsular nerve group (PENG) block in early analgesia in elderly patients with hip fracture. Methods: A total of 44 elderly patients with hip fracture admitted to our hospital from August 2021 to December 2022 were selected and divided into 2 groups according to different analgesia programs. Results: At T1~T4, the resting and active visual analog scale (VAS) scores in group P were lower than group F (p < 0.05). The resting and active VAS scores at T5 in both groups were no visible differences (p > 0.05). After 30 min of block, systolic blood pressure, diastolic blood pressure, and heart rate were decreased in both groups (p < 0.05), but no obvious difference was found in the two groups (p > 0.05). Before surgery, Pittsburgh Sleep Quality Index (PSQI) and mini-mental state scale (MMSE) scores in both groups were reduced, and PSQI score in group P was lower than that in group F and MMSE score was higher than group F (p < 0.05). Conclusion: PENG technology is safe and effective in the early analgesia of elderly hip fractures. It can effectively block physiological stress response caused by acute trauma, improve pre-operative sleep quality, and reduce the incidence of cognitive dysfunction.
Objetivo: Investigar el efecto del bloqueo del grupo del nervio pericapsular en analgesia temprana en pacientes ancianos con fractura de cadera. Método: Se seleccionaron 44 pacientes ancianos con fractura de cadera ingresados en nuestro hospital entre agosto de 2021 y diciembre de 2022, divididos en dos grupos según diferentes programas de analgesia. Resultados: En T1~T4, los valores de la escala visual análoga (EVA) en reposo y con actividad en el grupo P fueron menores que en el grupo F (p < 0.05). Los puntajes de la EVA en reposo y en actividad en T5 en ambos grupos no mostraron diferencias visibles (p > 0.05). Después de 30 minutos de bloqueo, la presión arterial sistólica y diastólica, y la frecuencia cardiaca, disminuyeron en ambos grupos (p < 0.05), pero no se encontró una diferencia obvia entre ellos (p > 0.05). Antes de la cirugía, las puntuaciones del Pittsburgh Sleep Quality Index (PSQI) y de la Mini-Mental State Scale (MMSE) en ambos grupos eran reducidas, y la puntuación del PSQI en el grupo P fue menor que en el grupo F, y la puntuación del MMSE fue mayor que en el grupo F (p < 0.05). Conclusiones: La técnica de bloqueo del grupo del nervio pericapsular es segura y efectiva en la analgesia temprana de fracturas de cadera en ancianos. Puede bloquear eficazmente la respuesta al estrés fisiológico causado por un trauma agudo, mejorar la calidad del sueño preoperatorio y reducir la incidencia de disfunción cognitiva.
Assuntos
Fraturas do Quadril , Bloqueio Nervoso , Humanos , Fraturas do Quadril/cirurgia , Bloqueio Nervoso/métodos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Medição da Dor , Analgesia/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Pressão Sanguínea/efeitos dos fármacosRESUMO
BACKGROUND: Hip fractures in the older adults lead to increased morbidity and mortality. Although a low bone mineral density is considered the leading risk factor, it is essential to recognize other factors that could affect the risk of hip fractures. This study aims to evaluate the contribution of clinical characteristics, patient-reported outcomes, and muscle and aerobic capacity for hip fractures in community-dwelling older adults. METHODS: This is a retrospective cohort study with real world-data from subjects ≥ 60 years old attending an outpatient clinic in Minas Gerais, Brazil, from May 1, 2019, to August 22, 2022. Data about clinical characteristics (multimorbidity, medications of long-term use, sedative and or tricyclic medications, number of falls), patient-reported outcomes (self-perception of health, self-report of difficulty walking, self-report of vision problems, and self-report of falls) and muscle and aerobic capacity (calf circumference, body mass index, and gait speed) were retrieved from an electronic health record. The association of each potential risk factor and hip fracture was investigated by a multivariable logistic regression analysis adjusted for age and sex. RESULTS: A total of 7,836 older adults were included with a median age of 80 years (IQR 72-86) and 5,702 (72.7%) were female. Hip fractures occurred in 121 (1.54%) patients. Multimorbidity was associated with an increased risk of hip fracture (OR = 1.12, 95%CI 1.06-1.18) and each episode of fall increased the chance of hip fracture by 1.7-fold (OR = 1.69, 95%CI 1.52-1.80). Patient-reported outcomes associated with increased fracture risk were regular or poor self-perception of health (OR = 1.59, 95%CI 1.06-2.37), self-report of walking difficulty (OR = 3.06, 95%CI 1.93-4.84), and self-report of falls (OR = 2.23, 95%CI 1.47-3.40). Body mass index and calf circumference were inversely associated with hip fractures (OR = 0.91, 95%CI 0.87-0.96 and OR = 0.93, 95%CI 0.88-0.97, respectively), while slow gait speed increased the chance of hip fractures by almost two-fold (OR = 1.80, 95%CI 1.22-2.66). CONCLUSION: Our study reinforces the importance of identified risk factors for hip fracture in community-dwelling older adults beyond bone mineral density and available fracture risk assessment tools. Data obtained in primary care can help physicians, other health professionals, and public health policies to identify patients at increased risk of hip fractures.
Assuntos
Fraturas do Quadril , Fraturas por Osteoporose , Humanos , Feminino , Idoso , Idoso de 80 Anos ou mais , Pessoa de Meia-Idade , Masculino , Vida Independente , Estudos Retrospectivos , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/etiologia , Fraturas por Osteoporose/epidemiologia , Fraturas por Osteoporose/etiologia , Fatores de RiscoRESUMO
BACKGROUND: Osteoporosis increases the risk of periprosthetic fracture and loosening in hip arthroplasty. Many methods have been proposed to assess bone quality in X-rays, including both qualitative such as the Dorr classification and quantitative such as the Calcar-Canal Ratio (CCR) and Cortical-Thickness index/Canal-Bone ratio (CTI/CBR). The Canal-Diaphysis ratio (CDR) has been described as a predictor for hip fragility fractures; however, its relationship with bone mineral density (BMD) has not been described. The purpose of this study was to evaluate the correlation of the Dorr classification, CCR, CTI/CBR, and CDR with BMD of the proximal femur in patients without hip fracture. METHODS: Forty-seven patients over 45 years of age who had less than 6 months between radiographs and dual-energy X-ray absorptiometry were evaluated. Measurements of CCR, CBR, CDR, and Dorr classification were performed in all radiographs by 2 independent observers. RESULTS: The CDR had a high correlation (r = 0.74, P=<0.01) with BMD, whereas the CTI/CBR had a moderate correlation (r = 0.49, P=<0.01), and the CCR had no correlation with BMD (r = 0.06, P = .96). When evaluating the receiver operating characteristic curve, CDR showed the best performance (area under curve [AUC] = 0.75) followed by CBR (AUC = 0.73) and CCR (AUC = 0.61). The optimal cutoff value for the CDR was 0.49, with 100% sensitivity and 58% specificity. The inter- and intra-observer variability was good for all methods. No differences were found between Dorr classification of patients who had or did not have osteoporosis. CONCLUSION: Of all the analyzed methods, the CDR was found to have the best correlation with BMD. This study proposes the use of CDR as a tool for assessing bone quality when deciding the implant fixation method in hip arthroplasty.