The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery. A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups.Aims
Methods
Infection after surgery increases treatment costs and is associated with increased mortality. Hip fracture patients have historically had high rates of methicillin-resistant A total of 13,503 patients who presented with a hip fracture over 17 years formed the study population. Multivariable logistic regression was performed to determine risk factors for MRSA and SSI. Autoregressive integrated moving average (ARIMA) modelling adjusted for temporal trends in rates of MRSA. Kaplan-Meier estimators were generated to assess for changes in mortality.Aims
Methods
Stable fractures of the ankle can be successfully treated non-operatively by a below-knee plaster cast. In some centres, patients with this injury are routinely administered low-molecular-weight heparin, to reduce the risk of deep-vein thrombosis (DVT). We have assessed the incidence of DVT in 100 patients in the absence of any thromboprophylaxis. A colour Doppler duplex ultrasound scan was done at the time of the removal of the cast. Five patients did develop DVT, though none had clinical signs suggestive of it. One case involved the femoral and another the popliteal vein. No patient developed pulmonary embolism. As the incidence of DVT after ankle fractures is low, we do not recommend routine thromboprophylaxis.
Unstable bicondylar tibial plateau fractures
are rare and there is little guidance in the literature as to the
best form of treatment. We examined the short- to medium-term outcome
of this injury in a consecutive series of patients presenting to
two trauma centres. Between December 2005 and May 2010, a total
of 55 fractures in 54 patients were treated by fixation, 34 with
peri-articular locking plates and 21 with limited access direct
internal fixation in combination with circular external fixation
using a Taylor Spatial Frame (TSF). At a minimum of one year post-operatively,
patient-reported outcome measures including the WOMAC index and
SF-36 scores showed functional deficits, although there was no significant
difference between the two forms of treatment. Despite low outcome scores,
patients were generally satisfied with the outcome. We achieved
good clinical and radiological outcomes, with low rates of complication.
In total, only three patients (5%) had collapse of the joint of
>
4 mm, and metaphysis to diaphysis angulation of greater than 5º,
and five patients (9%) with displacement of >
4 mm. All patients
in our study went on to achieve full union. This study highlights the serious nature of this injury and generally
poor patient-reported outcome measures following surgery, despite
treatment by experienced surgeons using modern surgical techniques.
Our findings suggest that treatment of complex bicondylar tibial
plateau fractures with either a locking plate or a TSF gives similar
clinical and radiological outcomes. Cite this article:
Conventional methods of treating ankle fractures
in the elderly are associated with high rates of complication. We describe
the results of treating these injuries in 48 frail elderly patients
with a long calcaneotalotibial nail. The mean age of the group was 82 years (61 to 96) and 41 (85%)
were women. All were frail, with multiple medical comorbidities
and their mean American Society of Anaesthesiologists score was
3 (3 to 4). None could walk independently before their operation.
All the fractures were displaced and unstable; the majority (94%,
45 of 48) were low-energy injuries and 40% (19 of 48) were open. The overall mortality at six months was 35%. Of the surviving
patients, 90% returned to their pre-injury level of function. The
mean pre- and post-operative Olerud and Molander questionnaire scores
were 62 and 57 respectively. Complications included superficial
infection (4%, two of 48); deep infection (2%, one of 48); a broken
or loose distal locking screw (6%, three of 48); valgus malunion
(4%, two of 48); and one below-knee amputation following an unsuccessful
vascular operation. There were no cases of nonunion, nail breakage
or peri-prosthetic fracture. A calcaneotalotibial nail is an excellent device for treating
an unstable fracture of the ankle in the frail elderly patient.
It allows the patient to mobilise immediately and minimises the
risk of bone or wound problems. A long nail which crosses the isthmus
of the tibia avoids the risk of peri-prosthetic fracture associated
with shorter devices. Cite this article:
We prospectively studied the outcome of a protocol of prophylaxis for deep vein thrombosis (DVT) in 103 consecutive patients undergoing surgical stabilisation of pelvic and acetabular fractures. Low-molecular-weight heparin (LMWH) was administered within 24 hours of injury or on achieving haemodynamic stability. Patients were screened for proximal DVT by duplex ultrasonography performed ten to 14 days after surgery. The incidence of proximal DVT was 10% and of pulmonary embolus 5%. Proximal DVT developed in two of 64 patients (3%) who had received LMWH within 24 hours of injury, but in eight of 36 patients (22%) who received LMWH more than 24 hours after the injury (p <
0.01). We conclude that LMWH, when begun without delay, is a safe and effective method of thromboprophylaxis in high-risk patients with major pelvic or acetabular fractures.
We report the outcome of 161 of 257 surgically fixed acetabular fractures. The operations were undertaken between 1989 and 1998 and the patients were followed for a minimum of ten years. Anthropometric data, fracture pattern, time to surgery, associated injuries, surgical approach, complications and outcome were recorded. Modified Merle D’Aubigné score and Matta radiological scoring systems were used as outcome measures. We observed simple fractures in 108 patients (42%) and associated fractures in 149 (58%). The result was excellent in 75 patients (47%), good in 41 (25%), fair in 12 (7%) and poor in 33 (20%). Poor prognostic factors included increasing age, delay to surgery, quality of reduction and some fracture patterns. Complications were common in the medium- to long-term and functional outcome was variable. The gold-standard treatment for displaced acetabular fractures remains open reduction and internal fixation performed in dedicated units by specialist surgeons as soon as possible.
We evaluated the cost and consequences of proximal femoral fractures requiring further surgery because of complications. The data were collected prospectively in a standard manner from all patients with a proximal femoral fracture presenting to the trauma unit at the John Radcliffe Hospital over a five-year period. The total cost of treatment for each patient was calculated by separating it into its various components. The risk factors for the complications that arose, the location of their discharge and the mortality rates for these patients were compared to those of a matched control group. There were 2360 proximal femoral fractures in 2257 patients, of which 144 (6.1%) required further surgery. The mean cost of treatment in patients with complications was £18 709 (£2606.30 to £60.827.10), compared with £8610 (£918.54 to £45 601.30) for uncomplicated cases (p <
0.01), with a mean length of stay of 62.8 (44.5 to 79.3) and 32.7 (23.8 to 35.0) days, respectively. The probability of mortality after one month in these cases was significantly higher than in the control group, with a mean survival of 209 days, compared with 496 days for the controls. Patients with complications were statistically less likely to return to their own home (p <
0.01). Greater awareness and understanding are required to minimise the complications of proximal femoral fractures and consequently their cost.
We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip.
Prospective data on hip fracture from 3686 patients at a United Kingdom teaching hospital were analysed to investigate the risk factors, financial costs and outcomes associated with deep or superficial wound infections after hip fracture surgery. In 1.2% (41) of patients a deep wound infection developed, and 1.1% (39) had a superficial wound infection. A total of 57 of 80 infections (71.3%) were due to No statistically significant pre-operative risk factors were detected. Length of stay, cost of treatment and pre-discharge mortality all significantly increased with deep wound infection. The one-year mortality was 30%, and this increased to 50% in those who developed an infection (p <
0.001). A deep infection resulted in doubled operative costs, tripled investigation costs and quadrupled ward costs. MRSA infection increased costs, length of stay, and pre-discharge mortality compared with non-MRSA infection.