Hip fractures are an increasingly common consequence of falls in older people that are associated with a high risk of death and reduced function. This review aims to quantify the impact of hip ...fracture on older people's abilities and quality of life over the long term.
Studies were identified through PubMed and Scopus searches and contact with experts. Cohort studies of hip fracture patients reporting outcomes 3 months post-fracture or longer were included for review. Outcomes of mobility, participation in domestic and community activities, health, accommodation or quality of life were categorised according to the World Health Organization's International Classification of Functioning and synthesised narratively. Risk of bias was assessed according to four items from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.
Thirty-eight studies from 42 publications were included for review. Most followed a clearly defined sample from the time of fracture. Hip fracture survivors experienced significantly worse mobility, independence in function, health, quality of life and higher rates of institutionalisation than age matched controls. The bulk of recovery of walking ability and activities for daily living occurred within 6 months after fracture. Between 40 and 60 % of study participants recovered their pre-fracture level of mobility and ability to perform instrumental activities of daily living, while 40-70 % regained their level of independence for basic activities of daily living. For people independent in self-care pre-fracture, 20-60 % required assistance for various tasks 1 and 2 years after fracture. Fewer people living in residential care recovered their level of function than those living in the community. In Western nations, 10-20 % of hip fracture patients are institutionalised following fracture. Few studies reported impact on participation in domestic, community, social and civic life.
Hip fracture has a substantial impact on older peoples' medium- to longer-term abilities, function, quality of life and accommodation. These studies indicate the range of current outcomes rather than potential improvements with different interventional approaches. Future studies should measure impact on life participation and determine the proportion of people that regain their pre-fracture level of functioning to investigate strategies for improving these important outcomes.
A significant number of patients use opioids prior to total joint arthroplasty (TJA) in North America and there is growing concern that preoperative opioid use negatively impacts postoperative ...patient outcomes after surgery. This systematic review and meta-analysis evaluated the current evidence investigating the influence of preoperative opioid use on postoperative patient-reported outcomes (PRO) after total joint arthroplasty.
A systematic search was performed using Ovid, Embase, Cochrane Library, Scopus, Web of Science Core Collection, CINAHL on February 15th, 2018. Studies reporting baseline and postoperative PRO among those prescribed preoperative opioids and those who were not prior to total knee and hip arthroplasty were included. Standardized mean differences (SMD) in absolute difference and relative change in PRO measures between the two groups was calculated using random effect models.
Six studies were included (n = 7356 patients); overall 24% of patients were prescribed preoperative opioids. Patients with preoperative opioid use had worse absolute postoperative PRO scores when compared to those with no preoperative opioid use (standardized mean difference (SMD) -0.53, 95% Confidence interval (CI) -0.75, - 0.32, p < 0.0001). When relative change in PRO score was analyzed, as measured by difference between postoperative and preoperative PRO scores, there was no group differences (SMD -0.26, 95% CI -0.56, 0.05, p = 0.10).
Patients prescribed preoperative opioids may attain worse overall pain and function benefits after TJA when compared to opioid-naïve patients, but do still benefit from undergoing TJA. These results suggest preoperative opioid users should be judiciously counselled regarding potential postoperative pain and function improvements after TJA.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
OBJECTIVES:To determine factors associated with developing nonunion or delayed healing after open fracture.
DESIGN:Prospective cohort between 2001 and 2009.
SETTING:Three level 1 Canadian trauma ...centers.
PARTICIPANTS:Seven hundred thirty-six (791 fractures) subjects were enrolled. Six hundred eighty-nine (94%) subjects (739 fractures) provided adequate outcome data.
INTERVENTION:Subjects were followed until fracture(s) healed; phone interviews and chart reviews were conducted 1 year after fracture. Patient, fracture, and injury information, and time to surgery and antibiotics were recorded during hospitalization.
MAIN OUTCOME MEASUREMENTS:Nonunion defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing at 1 year and delayed healing defined as 2 consecutive clinical assessments showing no radiographic progression or incomplete radiographic healing between 6 months and 1 year.
RESULTS:There were 413 (52%) tibia/fibular, 285 (36%) upper extremity, and 93 (13%) femoral fractures. Nonunion developed in 124 (17%) and delayed healing in 63 (8%) fractures. The median time to surgery was not different for fractures that developed nonunion compared with those who did not (P = 0.36). Deep infection Odd ratio (OR) 12.75; 95% confidence interval (CI) 6.07–26.8, grade 3A fractures (OR 2.49; 95% CI, 1.30–4.78), and smoking (OR 1.73; 95% CI, 1.09–2.76) were significantly associated with developing a nonunion. Delayed healing was also significantly associated with deep infection (OR 4.34; 95% CI, 1.22–15.48) and grade 3B/C fractures (OR 3.69; 95% CI, 1.44–9.44). Multivariate regression found no association between nonunion and time to surgery (P = 0.15) or antibiotics (P = 0.70).
CONCLUSIONS:Deep infection and higher Gustilo grade fractures were associated with nonunion and delayed healing.
LEVEL OF EVIDENCE:Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
The Good Life with osteoArthritis: Denmark (GLA:DTM) is an evidence-based program designed for individuals with symptomatic hip and knee osteoarthritis (OA). This program has reported improvement in ...pain, quality of life and self-efficacy, as well as delays in joint replacement surgery for adults with moderate to severe hip or knee OA. Evaluations of GLA:DTM implementation in several countries have focused on effectiveness, training, and feasibility of the program primarily from the provider perspective. Our objective was to examine how the GLA:DTM program was perceived and experienced by individuals with hip and knee OA to inform on-going program refinement and implementation.
Thirty semi-structured telephone interviews were conducted with participants who completed the GLA:DTM program in Alberta. An interpretive description approach was used to frame the study and thematic analysis was used to code the data and identify emergent themes and sub-themes associated with participants' experience and perception of the GLA:DTM program.
Most participants had a positive experience of the GLA:DTM program and particularly enjoyed the group format, although some participants felt the group format prevented one-on-one support from providers. Three emergent themes related to acceptability were identified: accessible, adaptable, and supportive. Participants found the program to be accessible in terms of location, cost, and scheduling. They also felt the program was adaptable and allowed for individual attention and translatability into other settings. Finally, most participants found the group format to be motivating and fostered connections between participants.
The GLA:DTM program was perceived as acceptable by most participants, yet the group format may not be useful for all individuals living with OA. Recommended improvements included adapting screening to identify those suited for the group format, providing program access earlier in the disease progression trajectory, modifying educational content based on participants' knowledge of OA and finally, providing refresher sessions after program completion.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
OBJECTIVES:To evaluate the association between time to surgery, antibiotic administration, Gustilo grade, fracture location, and development of deep infection in open fractures.
DESIGN:Prospective ...cohort between 2001 and 2009.
SETTING:Three Level 1 Canadian trauma centers.
PARTICIPANTS:A total of 736 (791 fractures) subjects were enrolled and 686 subjects (93%; 737 fractures) provided adequate follow-up data (1-year interview and/or clinical follow-up >90 days).
INTERVENTION:Demographics, injury information, time to surgery, and antibiotics were recorded. Subjects were evaluated using standardized data forms until the fracture(s) healed. Phone interviews were undertaken 1 year after the fracture.
MAIN OUTCOME MEASURES:Infection requiring unplanned surgical debridement and/or sustained antibiotic therapy.
RESULTS:Tibia/fibula fractures were most common (n = 413, 52%), followed by upper extremity (UE) (n = 285, 36%), and femoral (n = 93, 12%) fractures. Infection developed in 46 fractures (6%). The median time to surgery was 9 hours 4 minutes (interquartile range, 6 hours 39 minutes to 12 hours 33 minutes) and 7 hours 39 minutes (interquartile range, 6 hours 10 minutes to 9 hours 54 minutes) for those without and with infection, respectively (P = 0.04). Gustilo grade 3B/3C fractures accounted for 17 of 46 infections (37%) (P < 0.001). Four UE (1.5%), 7 femoral (8%), and 35 tibia/fibula (9%) fractures developed infections (P = 0.001). Multivariate regression found no association between infection and time to surgery odds ratio (OR), 0.97; 95% confidence interval (95% CI), 0.90–1.06 or antibiotics (OR, 1.0; 95% CI, 0.90–1.05). Grades 3A (OR, 6.37; 95% CI, 1.37–29.56) and 3B/3C (OR, 12.87; 95% CI, 2.72–60.95) relative to grade 1 injuries and tibia/fibula (OR, 3.91; 95% CI, 1.33–11.53) relative to UE fractures were significantly associated with infection.
CONCLUSION:Infection after open fracture was associated with increasing Gustilo grade or tibia/fibula fractures but not time to surgery or antibiotics.
LEVEL OF EVIDENCE:Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
BackgroundThe optimal rehabilitation protocol after surgical repair of an Achilles tendon rupture has not been well defined. The objective of this randomized study was to compare the effect of early ...weight-bearing with that of non-weight-bearing on early postoperative recovery following repair of an acutely ruptured Achilles tendon.MethodsBetween October 2003 and May 2006, 110 patients with a surgically repaired Achilles tendon rupture were enrolled from one of two major trauma-care tertiary hospitals. All patients were non-weight-bearing for the first two weeks postoperatively. At the two-week postoperative visit, patients were randomized to either weight-bearing or non-weight-bearing for an additional four weeks. Compliance was measured with a pressure sensor in the fixed-hinge ankle-foot orthosis given to each patient. Follow-up assessments were performed at six weeks, three months, and six months postoperatively. The primary outcome was health-related quality of life assessed with use of the RAND 36-Item Health Survey (RAND-36). Secondary outcomes were activity level, calf strength, ankle range of motion, return to sports and work, and complications.ResultsNinety-eight patients (89%) completed the six-month follow-up. At six weeks, the weight-bearing group had significantly better scores than the non-weight-bearing group in the RAND-36 domains of physical functioning, social functioning, role-emotional, and vitality scores (p < 0.05). Patients in the weight-bearing group also reported fewer limitations of daily activities at six weeks postoperatively (p < 0.001). At six months, no significant differences between the groups were seen in any outcome, although both groups had poor endurance of the calf musculature. No rerupture occurred in either group.ConclusionsEarly weight-bearing after surgical repair of an acute Achilles tendon rupture improves health-related quality of life in the early postoperative period and has no detrimental effect on recovery.Level of EvidenceTherapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
Cognitive impairment is common in the hip fracture patient population, yet few studies of functional recovery include this subgroup. The objective was to determine whether baseline cognition was a ...determinant of the rate of functional recovery over 6 months after hip fracture.
A consecutive cohort of 383 patients 65 years or older who were treated for hip fracture within a Canadian health region were grouped on cognitive status. Participants with Mini-Mental Status Examination scores <18 at 3-5 days postoperatively were classified as cognitively impaired. Primary outcome was the Functional Independence Measure. Interviews were completed within 5 days postoperatively (baseline), 1, 3, and 6 months postoperatively. Linear mixed modeling examined the pattern of recovery and the effect of cognitive status.
Of the 383 participants, 104 (27%) had Mini-Mental Status Examination scores of less than 18. The effect size for changes in the FIM over 6 months was large for those without cognitive impairment (effect size = 2.3) and smaller for those with cognitive impairment (effect size = 0.9). After adjusting for age, gender, proxy respondent, and fracture type, participants with impaired cognition recovered more slowly, never attaining comparable levels with those without cognitive impairment. The 6-month health status for the cohort was substantially lower than the health status of age-gender-matched, community-dwelling adults.
Patients with cognitive impairment who fracture their hips recover more slowly and achieve less functional recovery. Recovery is not uniform nor is it linear over the initial 6 months. The diversity of patient needs should be recognized postoperatively so that long-term recovery is optimized.
Objectives
To measure 1‐year post‐hip fracture functional recovery, health‐related quality of life (HRQL), and mortality in nursing home residents.
Design
Prospective longitudinal cohort study.
...Setting and Participants
Ambulatory nursing home residents with or without impaired cognition consecutively admitted with hip fracture to three Canadian tertiary‐care hospitals from March 2008 through November 2009.
Measurements
Participants or proxy respondents completed the Functional Independence Measure Motor score (FIMmotor) and EuroQol5D index score (EQ‐5Dindex) in the hospital (prefracture status) and 3, 6, and 12 months after fracture. Complications over the first postfracture year were also ascertained; the primary outcome was functional recovery (change in FIMmotor score).
Results
Of 92 eligible participants, 60 (64%) were enrolled. The mean age was 86.9 ± 8.1, 42 (70%) were female, and 45 (75%) had three or more comorbidities. Forty‐three (72%) walked independently with or without aids before fracture. By 12 months, 27 (45%) participants had died, and 10 (17%) had withdrawn. Of the remaining 23 participants, functional status according to FIMmotor score dropped substantially and significantly after the fracture (3 months, 34.0 ± 19.7; 6 months, 33.2 ± 19.7; 12 months, 32.0 ± 20.0; P < .001 from a baseline FIMmotor score of 50.1 ± 16.1). By 12 months after the fracture, only eight (35%) were walking independently, and 11 (48%) were no longer ambulatory. HRQL according to the EQ‐5Dindex also decreased significantly (P = .003), from 0.62 ± 0.20 before fracture to 0.42 ± 0.30 by 12 months after fracture.
Conclusion
Hip fracture for nursing home residents was associated with substantial loss of functional independence, ambulation, and HRQL. Little recovery was evident after the first 3 months; there was almost 50% mortality within 12 months.
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