Predictors of functional recovery after hip fracture in the elderly

Three hundred thirty-eight community dwelling, ambulatory, elderly patients who sustained a hip fracture were observed prospectively to determine which patient and fracture characteristics at hospital admission predicted functional recovery at 3, 6, and 12 months. Multiple logistic regression was performed to estimate the simultaneous contributions of the predictor variables to failure of functional recovery. Before sustaining a fracture, 16% of patients were dependent on basic activities of daily living and 46% were dependent on instrumental activities of daily living. By 1 year after fracture, 73% of the patients had recovered to their basic activities of daily living status before fracture whereas only 48% had recovered to their instrumental activities of daily living status before fracture. Patients who were age 85 years or older, who lived alone before sustaining a fracture, and who had one or more comorbidities were at increased risk of delay or failure in recovering basic activities of daily living. Only instrumental activities of daily living independence before fracture predicted failure to recover instrumental activities of daily living function by 3 and 6 months after fracture. At 1 year, patient age 85 years or older was the only predictor of failure to recover instrumental activities of daily living function that existed before fracture. Based on characteristics at admission, a group of patients at high risk for failure to recover basic activities of daily living function within 1 year of sustaining a hip fracture can be identified.     

Cardiovascular collapse after femoral prosthesis surgery for acute hip fracture

Traumatic rupture of Dupuytren's contracture is rare. It has been reported only twice in recent times and only on four previous occasions over the last millenium. These cases are reported and the forces involved in rupturing Dupuytren's contracture are discussed.     

Prognosis one year after hip fracture

This study evaluates the demography and health in a hip fracture population, and predictors of outcome one year after the fractures occurred. Physical, mental and social functioning in 109 patients who were referred from home with hip fractures were assessed retrospectively; during the hospital stay, at discharge, and after 4 and 12 months. Mobility, Katz' ADL-index and a short-version of MMSE were used in assessing their physical and mental conditions. No essential changes were found in either demography or health. The most significant predictors of outcome were age, prefracture mobility and post-fracture mental status. The proportion of patients suffering from acute confusion was considerable. The result was a higher risk of mortality, institutionalisation and poor physical outcome. It is important to pay more attention to the prevention and treatment of cases involving acute confusion.     

Functional outcome after hip fracture in Japan

One thousand one hundred sixty-nine elderly Japanese patients who sustained a hip fracture were observed prospectively. Ninety-two percent had operative fracture treatment. Hospital length of stay averaged 67 days; 81% of patients were discharged to their place of residence where they resided before sustaining the fracture. Mortality rates at 120 days, 1 year, and 2 years after injury were 6%, 11%, and 19%, respectively. At 1-year followup, ambulatory status was recovered to that of the level experienced before injury in 67% of patients.     

Intracapsular hip pressure after femoral neck fracture

A consecutive series of 34 patients with femoral neck fractures was included in a prospective study aimed at evaluating preoperative variations in intracapsular pressure after changes in hip position, hip traction, and aspiration of hemarthrosis and their influence on the development of femoral head necrosis. Patients were observed for 7 years after surgery. Before aspiration, the mean intracapsular pressure in the antalgic physiologic position was 44.4 mm Hg. There were no differences between displaced and undisplaced fractures. The pressure was a maximum (mean value, 124.8 mm Hg) with the hip in extension and inward rotation, this pressure being greater than the blood systolic pressure in most cases. Hip traction of 3 kg in the antalgic physiologic position was found to be highly effective in preventing any bone flow tamponade effect in displaced and undisplaced femoral neck fractures: the mean intracapsular pressure decreased to 28.5 mm Hg. Aspiration of the hemarthrosis induced a significant decrease in intracapsular pressure only in cases with impaired vascularity of the femoral head as measured by scintigraphy using 99mTc labeled methyldiphosphonate. Aspiration of the hemarthrosis therefore is indicated only in the above cases, although it is less effective than hip traction in the antalgic position. There was no significant correlation between intracapsular pressure and the scintigraphy ratio. Avascular necrosis of the femoral head was detected in six cases. Among these, five patients had an intracapsular pressure below their diastolic blood pressure. This could indicate that vascular damage related to the fracture could be an important cause of bone necrosis despite that blood supply can be decreased by a tamponade effect.     

Cost analysis of early discharge after hip fracture

OBJECTIVE: To ascertain the economic impact of an early discharge scheme for hip fracture patients. DESIGN: Population based study comparing costs of care for patients who had "hospital at home" as an option for rehabilitation and those who had no early discharge service available in their area of residence. SETTING: District hospital orthopaedic and rehabilitation wards and community hospital at home scheme. PATIENTS: 1104 consecutively admitted patients with fractured neck of femur. 24 patients from outside the district were excluded. MAIN OUTCOME MEASURES: Cost per patient episode and number of bed days spent in hospital. RESULTS: Patients with the hospital at home option spent significantly less time as inpatients (mean of 32.5 v 41.7 days; p < 0.001). Those patients who were discharged early spent a mean of 11.5 days under hospital at home care. The total direct cost to the health service was significantly less for those patients with access to early discharge than those with no early discharge option (4884 pounds v 5606 pounds; p = 0.048). CONCLUSIONS: About 40% of patients with fractured neck of femur are suitable for early discharge to a scheme such as hospital at home. The availability of such a scheme leads to lower direct costs of rehabilitative care despite higher readmission costs. These savings accrue largely from shorter stays in orthopaedic and geriatric wards.     

Predictors of mortality in pulmonary thromboendarterectomy

BACKGROUND: The operative mortality associated with surgical thromboendarterectomy of the pulmonary arteries has decreased at the University of California in San Diego with the application of new techniques. For universal performance of the procedure, however, those factors that contribute to the high operative mortality must be identified. We analyzed our results in 34 consecutive patients undergoing pulmonary thromboendarterectomy to determine those preoperative factors that contribute to operative mortality. METHODS: Since 1983, 34 patients with severe, surgically correctable chronic thromboembolic pulmonary hypertension who were judged to be operable by pulmonary arteriography underwent pulmonary thromboendarterectomy. No patient was excluded because of right ventricular failure or hemodynamic severity of disease; the mean pulmonary artery pressure (PAP) was 54 mm Hg, the mean pulmonary vascular resistance (PVR) was 1,094 dynes.s.cm-5, and all patients were in New York Heart Association functional class III or IV. RESULTS: Postoperative course was characterized either by swift recovery (mean length of stay, 13 days) or by rapid demise resulting from pulmonary or right ventricular failure, or both (overall operative mortality, 23%). In survivors, the mean PAP, PVR, cardiac output, and New York Heart Association functional class were significantly improved (p < 0.05). Patients who died had a significantly greater mean preoperative PAP than did those who survived (62.1 +/- 1.2 versus 49.5 +/- 2.3 mm Hg; p < 0.01) and significantly higher PVR (1,512 +/- 116 versus 949 +/- 85 dynes.s.cm-5; p < 0.01). In addition, both a PVR of more than 1,100 dynes.s.cm-5 and a mean PAP of more than 50 mm Hg could accurately predict operative mortality: operative mortality was six times greater in patients with a preoperative PVR of greater than 1,100 dynes.s.cm-5 (41% versus 5.85%) and almost five times greater in those with a mean PAP of greater than 50 mm Hg (37% versus 8%). No intraoperative factors, including the use or duration of circulatory arrest, affected outcome. CONCLUSIONS: Patients with severe hemodynamic disease (PVR > 1,100 dynes.s.cm-5 and PAP > 50 mm Hg) have a high likelihood of operative mortality and perhaps should not undergo pulmonary thromboendarterectomy, except at institutions where the operation is performed frequently.     

Functional outcome after hip fracture. Effect of general versus regional anesthesia

The effect of anesthetic technique on ambulation and functional recovery after hip fracture was studied in a series of 631 community dwelling, elderly patients. Functional recovery at followup was determined by an 11-item functional rating scale. In univariate analysis, recovery of ambulatory ability and percent functional recovery were significantly higher at 6 months for patients who had general anesthesia. When controlling for potential confounding variables, however, no differences were observed in recovery of ambulatory ability or percent functional recovery between the two groups at 3, 6, or 12 months after hip fracture.     

Bone loss after hip fracture is correlated to the postoperative degree of mobilisation

This study quantifies changes in bone mineral density (BMD) in the opposite hip and in both proximal tibiae and the correlation with the use of walking aids for patients with two types of hip fracture during the 1st year after surgery. In all, 26 women and 15 men aged 42-88 years (median 71 years) were included. Twenty-one patients had an intracapsular hip fracture (ICF) and 20 had an intertrochanteric fracture (ITF). All patients were treated with a dynamic hip screw. BMD was measured by dual X-ray absorptiometry (DXA; LUNAR, Wisconsin) within the 1st week after surgery and after 3, 6 and 12 months. Initial BMD of the non-fractured hip was significantly lower for both fracture groups compared with reference material. For both fracture types there was a significant decrease in BMD of the non-fractured hip and proximal tibia of the fractured leg during the first 3 months, which still persisted a year after surgery. Improved mobilisation between two examinations was positively correlated with changes in BMD of the proximal tibia of the fractured leg and the non-fractured hip.     

Automated evaluation of hip axis length for predicting hip fracture

The hip axis length has been shown in previous studies to be predictive of hip fracture independent of age and femoral bone density. The first studies of hip axis length were performed by manual measurement of dual x-ray absorptiometry (DXA) scan printouts. In this study, an automated analysis procedure is defined using software tools provided by the DXA manufacturer. Manual and automatic hip axis length measurements in 198 women were highly correlated (r = 0.98). Because of scaling factors of the printout, the automatic measurement was 58% longer than the manual value. Precision of the automatic measurement, based upon triplicate DXA scans of 33 women, was 0.07 cm or 0.68%. To define normative data, the hip axis length was measured from femoral DXA scans of 471 female volunteers aged 40-92 scanned on 14 different Hologic QDR-1000 systems. Mean hip axis length was 10.5 cm, with a standard deviation of 0.62 cm. No significant relationship between hip axis length and age was found (r = 0.07, P = 0.15). Based on previously reported odds ratios corrected for femoral bone density, age, height, and weight, an automatic hip axis length measurement of 11.0 cm is associated with a twofold increase in hip fracture risk compared with a woman with an average hip axis length. A hip axis length value of 11.6 cm increases hip fracture risk by a factor of 4 compared with a woman with a normal hip dimension. We conclude that the hip axis length can be easily incorporated into existing DXA hip analysis software in combination with a bone density measurement.(ABSTRACT TRUNCATED AT 250 WORDS)     

The quality circle of hip fracture care

Elderly patients with hip fractures have many medical, physical, and psychosocial challenges. Their care can become complex and require the integration of various disciplines. In this article, the author describes and explains the hip fracture preoperative assessment tool that contains various "red flag" indicators and tools used for data collection. The case manager can use this tool to assess patients before surgery and appropriately plan for discharge. Outcome results are discussed, including functional status, length of stay, and costs.     

Postoperative mortality after total hip arthroplasty. An analysis of deaths after two thousand seven hundred and thirty-six procedures

We retrospectively determined the prevalence and nature of mortality as many as ninety days after 2736 primary and revision total hip arthroplasties performed in 2002 patients by one surgeon at a teaching hospital between January 1969 and December 1996. All but seventy-one of the patients had received prophylaxis against venous thromboembolic disease. There were no intraoperative deaths, and no events during the operation could be linked directly to postoperative mortality. Eight deaths (mortality rate, 0.3 per cent) occurred within ninety days after the 2736 procedures. Four deaths (mortality rate, 0.15 per cent) occurred during the initial hospitalization. The cause of seven of the deaths was determined. Three patients died as a result of preexisting disease (severe hepatorenal disease, metastatic esophageal cancer, or severe cardiac disease), and one patient died from sepsis with a gram-negative organism during a thoracotomy eight days postoperatively. A bleeding complication that occurred while the patient was receiving warfarin therapy led to the death of two other patients; one of these deaths occurred in 1974 and the other, in 1982. At the time that these patients were managed, the desired prothrombin time was considered to be twice the control value. The remaining patient, who had had a clip placed on the inferior vena cava after a pulmonary embolus occurred in 1970, died secondary to acute, severe thrombosis of this vessel after a total hip arthroplasty in 1971. The patient for whom the cause of death was not determined had had an artificial aortic valve and had been receiving chronic warfarin therapy. She died suddenly eighty-nine days postoperatively; no autopsy was performed. No patient died as the direct result of a known pulmonary embolus. No deaths related to venous thromboembolic disease or its prophylaxis or treatment occurred after 1982 (1458 operations). We attribute this, in part, to reduced levels of warfarin prophylaxis and improved management with warfarin. The ninety-day postoperative mortality rate after 2736 procedures performed over nearly three decades was low (0.3 per cent). This span of time included the period before the introduction of many current improvements in perioperative care, such as routine intubation of patients under general anesthesia, continuous monitoring of the electrocardiogram intraoperatively, and blood-gas determinations. When the patients who died as a result of known, severe preexisting disease were excluded, the mortality rate was 0.18 per cent (five of 2733).     

Variations in the performance of hip fracture procedures

OBJECTIVE: To determine the cause and frequency of unplanned readmissions to a coronary care unit (CCU) after initial transfer to a general cardiac unit, but before hospital discharge. DESIGN: Analysis of 1776 admissions to a CCU during a 16-month period. SETTING: The CCU of a major teaching hospital in South Australia. PARTICIPANTS: All patients admitted to the CCU during the 16-month period. OUTCOME MEASURES: CCU readmissions before hospital discharge were categorized as either "planned" or "unplanned." The latter were investigated for determination of casualty and variations in patient characteristics (including age, sex, initial diagnosis, pharmacotherapy, and duration of stay in the CCU). RESULTS: Of the 1776 CCU admissions examined, 44 (2.5% of total) were unplanned readmissions before hospital discharge. Most of these (39 of 44) were related to "reactivation" of acute myocardial ischemia. Patients whose initial diagnosis was acute myocardial infarction or unstable angina pectoris were more likely to require a further unplanned CCU admission (p < 0.05); those with unstable angina pectoris had a second stay in CCU significantly longer than their first (p < 0.05). Six patients were readmitted within 6 hours of cessation of a heparin infusion (4 of the 6 without aspirin administration), and 11 patients had not received antiplatelet therapy after their initial CCU stay. Overall, a disproportionate number of men were readmitted to CCU (p < 0.05). CONCLUSIONS: In the current study, unplanned readmissions to the CCU: (1) were relatively infrequent, (2) were more protracted than initial stays in CCU, (3) may have been prevented in 15 of the 44 cases with more appropriate pharmacotherapy, and (4) involved a disproportionate number of male patients.     

Prognostic significance of hypertension and albuminuria for early mortality after acute myocardial infarction

The motile enterococci with the vanC gene have intrinsic low-level resistance to vancomycin, but have not been implicated in a nosocomial outbreak. We determined the colonization rate of motile enterococci in hospitalized and nonhospitalized patients. Perianal or stool specimens were cultured in Enterococcosel broth supplemented with 6 micrograms of vancomycin per mL. Rapid motility and pigment tests were performed on all enterococci isolated. A total of 82 motile and/or pigmented enterococci were isolated from 679 patients for a colonization rate of 12.1%. There were 43 Enterococcus gallinarum, 32 Enterococcus casseliflavus, 4 Enterococcus flavescens, and 3 Enterococcus mundtii identified. The E. gallinarum vancomycin MIC90 was 32 micrograms/mL and the E. casseliflavus vancomycin MIC90 was 8 micrograms/mL.     

Predictors of mortality in the prospective Dubbo study of Australian elderly

BACKGROUND: A study was undertaken to examine the relationship between first-contact care, an essential feature of primary care, and expenditures for frequent ambulatory episodes of care in a nationally representative sample. METHODS: A nonconcurrent cohort study was conducted using data from the 1987 National Medical Expenditure Survey. Ambulatory claims data of respondents with an identified primary care source were used to develop 20,282 episodes of care for 24 preventive and acute illness conditions. The study examined the relationship of first-contact care, defined as the use of an identified primary care source for the first visit in an episode, and ambulatory episode-of-care expenditures. RESULTS: Episodes that began with visits to an individual's primary care clinician, as opposed to other sources of care, were associated with reductions in expenditures of 53% overall ($63 vs 134, P<.001), 62% for acute illnesses ($62 vs $164, P<.001), and 20 for preventive care ($64 vs $80, P<.001). For 23 of the 24 health problems studied, first-contact care was associated with reductions in expenditures. Multivariate regression analyses that controlled for sociodemographic characteristics, health status, case-mix, length of the episode, and number of visits to the emergency room did not substantively alter these results. CONCLUSIONS: First-contact care was associated with reductions in ambulatory episode-of-care expenditures of over 50% in a nationally representative sample. These findings suggest that systems of care may reduce ambulatory expenditures.     

Estimating the costs of hip fracture and potential savings

Shaker mutant rats are characterized by the adult-onset degeneration of cerebellar anterior lobe Purkinje cells and temporally correlated development of ataxia and tremor. Normal E-13 Purkinje cells were transplanted into the anterior cerebellum in adult shaker mutant rats to study donor/host interactions in an animal with adult-onset heredodegeneration. Donor Purkinje cells from extraparenchymal transplant sites migrated radially into the host molecular layer and differentiated. Donor Purkinje cell dendrites expanded to fill the host molecular layer, spinous processes were apparent, and axonal projections into the host gray and white matter were observed. Donor Purkinje cells remaining in the extraparenchymal transplant sites differentiated if they were located relatively close to the host cerebellum. Donor Purkinje cells located intraparenchymally in the host white matter or granule cell layer survived, but were stunted in their development. The orthogonal movement of donor Purkinje cells away from transplant sites in the host cerebellum was spatially restricted. The findings from this study indicate that host cerebellar cortex with adult-onset heredodegeneration of Purkinje cells supports the survival and differentiation of transplanted normal embryonic Purkinje cells.     

Effect of a video intervention on functional recovery following hip replacement and hip fracture repair

Although much research has documented the functional outcomes in hip repair surgery, few studies have identified effective interventions to improve functional outcomes. The purpose of this study was to test the use of generic and individualized videos on patients' return to preoperative levels of independent functioning, increased physical performance, improved coping ability, and enhanced perception of ability to care for self. Two rehabilitation units in separate acute care facilities were used to recruit subjects. Data were collected on 82 participants on admission to the study, on discharge from rehabilitation, 1 week after discharge, and 3 months post discharge. The results indicate that video intervention has some benefit to persons recovering from hip repair surgery. The benefits were realized in physical performance as evidenced by a significant difference in the distance walked and time walked of participants in the treatment group.     

Medical consultation for the elderly patient with hip fracture

BACKGROUND: This article describes a family physician geriatrician's perspective on the comprehensive management of hip fracture in frail elderly patients. Primary care physicians might be called upon to provide medical consultation for these patients. METHODS: Guidelines were developed by a combination of personal experience in consulting for several hundred elderly patients with hip fracture at a large community hospital, literature review using the key words "hip fractures," "aged," and "aged, 80 and over," and educational presentations for family practice residents. RESULTS AND CONCLUSIONS: Elderly patients with hip fracture offer a prime opportunity for comprehensive geriatric assessment. Intertrochanteric fractures are almost always treated with internal fixation, whereas femoral neck fractures can be treated by either fixation or by hemiarthroplasty. Hip fracture should be regarded as a surgical urgency, and generally operation should not be delayed, even if patients have serious comorbidity. The family physician can be instrumental in preparing the patient for surgery, preventing and treating complications, and assisting in the placement and rehabilitation of patients after hospital discharge.