Osteomalacia in elderly patients with hip fractures

The plevalence of osteomalacia was studied in 64 hip fracture patients who were admitted to Hamamatsu University Hospital for operative treatment between 1987 and 1989. Histological osteomalacia was found in 3 of the 64 patients (4.7%), suggesting that osteomalacia is not a significant predisposing factor in Japan in the development of hip fractures. This prevalence is lower than the corresponding figures in the United Kingdom and northern European countries, probably due to the more abundant exposure to sunlight in Japan.     

The outcome of fractures in very elderly patients

We compared case-mix and outcome variables in 1310 patients who sustained an acute fracture at the age of 80 years or over. A group of 318 very elderly patients (≥ 90 years) was compared with a group of 992 elderly patients (80 to 89 years), all of whom presented to a single trauma unit between July 2007 and June 2008. The very elderly group represented only 0.6% of the overall population, but accounted for 4.1% of all fractures and 9.3% of all orthopaedic trauma admissions. Patients in this group were more likely to require hospital admission (odds ratio 1.4), less likely to return to independent living (odds ratio 3.1), and to have a significantly longer hospital stay (ten days, p = 0.01). The 30- and 120-day unadjusted mortality was greater in the very elderly group. The 120-day mortality associated with non-hip fractures of the lower limb was equal to that of proximal femoral fractures, and was significantly increased with a delay to surgery > 48 hours for both age groups (p = 0.04). This suggests that the principle of early surgery and mobilisation of elderly patients with hip fractures should be extended to include all those in this vulnerable age group.     

Sequential hip fractures in elderly patients

Osteoporotic hip fractures are an increasing cause of disability to elderly patients and expenditure to the NHS. The aim of this work was to determine whether the rate of sequential hip fractures in elderly patients has changed over the past 20 years. The design was to do a retrospective study of 186 patients admitted with a diagnosis of femoral neck fracture in order to determine how many had suffered a previous contralateral hip fracture. The results indicated that the number of patients who had had previous surgery for a contralateral hip fracture was 11.8%. In conclusion, the rate of sequential hip fractures in elderly patients has not changed significantly over the past two decades.     

老年髋部骨折患者术前风险评估

背景:目前临床上有多种风险预测评估系统及相关危险因素,均可在一定程度上对患者的病情严重性进行客观评估,但尚无专门针对老年髋部骨折患者的手术风险预测系统。目的:比较老年髋部骨折患者手术风险评分系统(ORSSHF)与生理学和手术严重度评分系统(POSSUM),探索能客观而准确反映该类患者手术风险的预测方法。方法:依据统计学及POSSUM评分系统建立ORSSHF评分系统,分别应用ORSSHF和POSSUM评分系统回顾性研究2011年3月至2012年3月接受手术治疗的112例老年髋部骨折患者,男47例,女65例;年龄60～94岁,平均(74.6±6.8)岁。按术前风险评分进行分组,用统计学方法比较两种评分系统对该类患者手术并发症和死亡率的预测价值。结果:应用POSSUM和ORSSHF评分系统进行预测,发生并发症例数分别为50例和44例,死亡例数分别为6例和4例,实际发生并发症36例、死亡3例。前者预测值显著高于实际值(P<0.05);后者预测值和实际值无统计学差异。结论:POSSUM评分系统评估老年髋部骨折患者术前风险存在一定局限性;ORSSHF评分系统能较准确地评估该类患者的术前风险及预测术后并发症和死亡率,一定程度上弥补POSSUM评分系统的不足。     

Clinical characteristics and short to mid term functional outcomes of surgically treated occult hip fractures in the elderly

BackgroundOccult hip fractures in the elderly are challenging to diagnose and often result in surgical delays which may worsen outcomes. However, the minimally displaced nature of these fractures may conversely lead to better outcomes. The aim of this study was to determine if surgically treated occult hip fractures have better short to mid term functional outcomes when compared to non-occult fractures. The secondary aim was to determine if there are any differences in clinical characteristics of patients who present with occult hip fractures.MethodsThis was a retrospective cohort study of all elderly patients aged 65 years and above who presented with hip fractures in a single institution from January 2012 to December 2013. Elderly patients who presented with hip fractures were enrolled into an Ortho-geriatric carepath and were eligible for recruitment. The exclusion criteria included patients with pathological fractures and multiple injuries. Demographic and pre-injury variables were collected. The functional outcome measurement was the Modified Barthel’s Index (MBI). Patients were divided into non-occult hip fractures (Group 1) and occult hip fractures (Group 2).ResultsA total of 1017 patients were admitted during this period into the hip fracture carepath, of which 49 (4.8%) were diagnosed to have occult hip fractures. There was no significant difference between the demographics, Charlson co-morbidity index, abbreviated mental test scores or pre-morbid patient dependence between the groups. There was a significant delay to surgery for occult hip fractures when compared to non-occult fractures. (p = 0.03) Subgroup analysis showed that pre-morbidly, patients with occult inter-trochanteric fractures were significantly more independent than patients with non-occult inter-trochanteric fractures. (p = 0.03) There was no significant difference between the length of stay, surgical complications and 1-year mortality between the 2 groups. Occult inter-trochanteric fractures had better MBI scores at all time points when compared to non-occult inter-trochanteric fractures.ConclusionsDespite the significant delay to surgical intervention for patients with occult hip fractures, the short to mid term functional outcomes for this group of patients are comparable to surgically treated non-occult hip fractures. There are no distinctive clinical characteristics of elderly patients who are more likely to suffer occult hip fractures.     

老年髋部骨折患者致伤因素分析

目的通过对老年髋部骨折病例分析,了解老年髋部骨折患者致伤因素,为预防髋部骨折提供依据。方法收集北京积水潭医院2015年9月1日至2016年8月31日老年髋部骨折住院病例570例,按照年龄、性别等对致伤因素进行分析。结果老年髋部骨折病例中男性167例(293%),女性403例(707%),平均年龄795岁(60～100岁)。老年髋部骨折患者中949%为低应力骨折,且随着年龄增长脆性骨折比例逐步升高;骨折地点随着年龄增高逐步由户外为主转为室内为主;患者在户外及室内客厅发生髋部骨折的时间段均以白天为主(8:00～20:00),卧室及卫生间发生髋部骨折的时间段均以晚上为主(20:00～6:00);髋部骨折地域不同,摔倒的主要原因亦有不同;570例患者中951%合并基础疾病,随着年龄的增长合并多种基础疾病的比例也逐步升高;多元回归分析进一步得出,存在呼吸系统基础疾病、中重度营养不良以及患者基础疾病数量是髋部骨折后新发急性疾病严重程度的独立危险因素。结论老年髋部骨折致伤原因包括自身因素、药物因素以及环境因素等多方面,医疗工作人员应做好预防摔倒宣教、积极控制基础疾病、纠正骨质疏松,以期降低髋部骨折风险。     

Reduced delays in A&E for elderly patients with hip fractures

Published guidelines recommend early transfer of patients with hip fractures to hospital wards and avoidance of unnecessary delays in A&E. We describe a protocol whereby the liaison of an orthopaedic trauma co-ordinator with A&E reduced A&E-to-ward transfer times by 43%. Following introduction of the new protocol, 39% of hip fracture patients were in a ward bed within 3 h of admission to A&E compared to 4% previously. The new protocol also reduces administrative workload for the on-call orthopaedic SHOs.     

Functional outcome of patients with femoral head fractures associated with hip dislocations

Fracture of the femoral head after hip dislocation is a relatively rare injury often associated with a poor functional outcome. Twenty-six patients who sustained femoral head fractures were evaluated using radiographs, clinical examinations, and a validated outcome scoring system. The Short Form-12 was used to assess functional outcome. Patients whose fractures were stabilized with 3-mm cannulated screws and washers had a poor functional outcome. When evaluated with an odds ratio analysis, the use of Kocher-Langenbeck posterior approach was associated with a 3.2 times higher incidence of the patients having avascular necrosis develop when compared with the Smith-Petersen approach. A literature review combined with the current series confirms that the principles of early reduction of hip dislocation, early stabilization, anatomic reduction of the fracture, and rigid fixation are critical principles to attain good results. The Brumback classification system provides superior differentiation of different fracture types when compared with the Pipkin classification. The Smith-Petersen anterior surgical approach is recommended for the majority of patients with femoral head fractures. Three-millimeter cannulated screws with threaded washers are contraindicated for use in stabilizing femoral head fractures, and should not be used in any joint because of dissociation between the screw and the washer.     

老年骨质疏松性髋部骨折57例的护理体会

股骨颈和股骨粗隆间骨折是老年人常见的骨折,患者年龄多在60岁以上,其发生多与骨量丢失和骨强度降低有关,正确护理骨质疏松并髋部骨折有着重要的意义.本文报告老年(大于65岁)骨质疏松性髋部骨折的整体护理过程中的体会,认为术前心理护理、正确训练指导早期功能锻炼,术后密切观察病情、早期辅助运动、减少各种潜在诱发因素是护理工作的重要方面.     

动力髋螺钉治疗不同类型老年股骨转子间骨折

目的探讨动力髋螺钉(DHS)治疗不同类型老年股骨转子间骨折的临床疗效。方法对115例老年股骨转子间骨折患者采用DHS治疗,记录术中失血量、手术时间、术后引流量;对术后双侧髋关节功能进行Harris评分。结果患者均获随访,时间12~30(22.68±6.62)个月。不同骨折类型间在术中失血量、手术时间及术后引流量方面差异均有统计学意义(P0.05)。末次随访时患侧髋关节功能Harris评分与健侧比较:Tronzo-EvansⅠ~Ⅲ型骨折差异无统计学意义(P0.05),而Tronzo-EvansⅣ型骨折差异有统计学意义(P0.05)。结论 DHS操作简单,费用相对较低,应用于老年人Tronzo-EvansⅠ~Ⅲ型股骨转子间骨折治疗效果较好,适合广泛应用;但应用于Tronzo-EvansⅣ型骨折疗效不确切,应慎重选择。     

Management of elderly patients with hip fractures and cardiac rhythm devices

The annual incidence of hip fractures in the United States is expected to double by the year 2050. An additional challenge is that comorbidities are common in elderly patients. As indications for implantation of cardiac rhythm devices continue to broaden, the number of elderly patients with a pacemaker or an implantable cardioverter-defibrillator seen in the orthopedic surgeon's practice is likely to increase. We review the unique properties and functions of the most commonly implanted cardiac rhythm devices, provide an algorithm to assist the surgeon in gathering important patient information and developing perioperative approaches to treatment, and detail potential intraoperative complications and their prevention.     

Anti-platelet agents and surgical delay in elderly patients with hip fractures

PURPOSE: To assess the risk of surgical delay in elderly hip fracture patients on anti-platelet agents. METHODS: Records of 180 patients aged over 65 years with either an intertrochanteric or femoral neck fracture were reviewed. The clopidogrel group included 10 patients on clopidogrel alone and 11 others on clopidogrel and aspirin, whereas the control group included 69 on aspirin alone and the remaining 90 not on any anti-coagulants. The 2 groups were compared with regard to time to surgery, preoperative American Society of Anesthesiologists (ASA) score, pre- and post-operative haemoglobin levels, in-patient complication rates, duration of hospital stay, and 30-day mortality. RESULTS: In the clopidogrel and control groups respectively, the mean times to surgery were 7.2 and 2.1 days (p=0.03, t-test), the mean preoperative ASA scores were 3.35 and 2.8 (p=0.29, t-test), the mean preoperative haemoglobin levels were 119 and 115 g/l (p=0.5, t-test), the mean postoperative haemoglobin levels were 98 and 96 g/l (p=0.68, t-test), the mean durations of hospital stay were 7.4 and 3.1 days (p=0.02, t-test). The 30-day mortalities were 6/21 (29%) and 6/159 (4%) [p=0.0003, Fisher's exact test]. CONCLUSION: Surgical delay in elderly patients on anti-platelet agents with hip fracture was associated with higher mortality. Despite the risk of increased blood loss, we suggest early surgery be carried out by an experienced surgeon to expedite the operating time. Pooled platelets should be given intravenously one to 2 hours preoperatively.     

高龄陈旧性股骨颈骨折合并头颈吸收短缩的人工髋关节置换术

目的探讨对高龄陈旧性股骨颈骨折合并头颈吸收短缩行人工髋关节置换术的临床疗效及手术技巧。方法自2009-10—2012-10对高龄陈旧性股骨颈骨折合并头颈吸收短缩23例行人工髋关节置换术,手术均采用后外侧入路,在预定平面截断股骨颈,松解关节囊后进行假体置入。本组8例行全髋关节置换术,15例行半髋关节置换术。均选择生物型假体,其中初次置换生物柄17例,圆锥形生物翻修柄6例。采用髋关节功能Harris评分评估术后髋关节功能改善情况。结果 23例术后均获得平均29.5(14~50)个月随访。髋关节功能Harris评分从术前(36.35±2.11)分提高至末次随访时(89.58±4.21)分,差异有统计学意义(t=-59.08,P0.05)。术后X线片均显示股骨柄生物填充固定良好,术后3个月X线片显示均获骨性固定。结论髋关节置换术是治疗高龄陈旧性股骨颈骨折的有效手术方法,应根据髓腔形态、股骨距完整性及骨质疏松情况选择适配的股骨假体柄类型。采用髋关节复位后梯次松解法可安全、有效地对髋关节囊及周围软组织挛缩进行分层松解。     

高龄髋部骨折行人工髋关节置换术后患者再入院危险因素分析

目的:探讨高龄髋部骨折行人工髋关节置换术后患者再入院的发生率及危险因素分析。方法:回顾性分析2015年2月至2020年10月接受人工髋关节置换的高龄髋部骨折患者237例,根据患者术后3个月再入院情况分为两组,其中再入院组39例,男7例,女32例,年龄(84.59±4.34)岁;未再入院组198例,男34例,女164例,年龄(84.65±4.17)岁。将两组患者的一般资料、手术情况、髋关节Harris评分和并发症纳入单因素分析,并采用多因素Logistic回归分析患者再入院的独立危险因素。结果:再入院组中合并症(脑梗死和冠心病)的比例明显高于未再入院组(P<0.05),再入院组中术中出血量明显高于未再入院组(P<0.05),髋关节Harris评分明显低于未再入院组(P<0.05)。在并发症方面,再入院组发生感染、谵妄、关节脱位、贫血和静脉血栓形成的比例明显高于未再入院组(P<0.05)。多因素Logistic回归分析显示,高龄髋部骨折行人工髋关节置换术后患者再入院危险因素包括脑梗死、感染、谵妄、关节脱位、贫血和静脉血栓形成(P<0.05)。结论:高龄髋部骨折行人工髋关节置换术后再入院的患者并发症明显高于未再入院患者,脑梗死、感染、谵妄、关节脱位、贫血和静脉血栓形成是导致患者再入院的危险因素,临床可根据这些危险因素采取相应的干预措施,以此减低患者再入院的发生率。     

Risk factors for second hip fractures among elderly patients

Background  

Hip fractures following falls by the elderly, which increase with age, are increasing in number annually. The incidence of refracture (second hip fractures) has been reported to be 5%–10% in Japan and is expected to increase with the aging of the population in the future. Therefore, through a retrospective cohort study, we attempted to clarify the risk factors associated with second hip fractures.     

经皮加压钢板和动力髋螺钉治疗老年股骨转子间骨折的疗效比较

目的 比较经皮加压钢板(PCCP)和动力髋螺钉(DHS)治疗老年股骨转子间骨折的疗效.方法 对2007年1月至2010年1月收治的98例老年股骨转子间骨折患者(AO 31.A1-A2)进行回顾性分析,根据内固定方法不同分为PCCP组和DHS组,PCCP组53例,男10例,女43例;平均年龄78.2岁;AO分型:A1型37例,A2型16例.DHS组45例,男7例,女38例;平均年龄75.4岁;AO分型:A1型28例,A2型17例.比较两组患者的手术时间、失血量、骨折愈合时间及末次随访时Harris评分.结果 PCCP组有2例失访,51例患者术后获平均11.6个月(8～24个月)随访;DHS组有3例失访,42例患者术后获平均14.2个月(10～26个月)随访.PCCP组在手术时间、失血量、愈合时间及末次随访时Harris评分明显优于DHS组,差异均有统计学意义(P＜0.05).两组患者术后均末出现感染、骨不连、钢板螺钉断裂、股骨头螺钉切割、松动移位及股骨头坏死等并发症.结论 与DHS比较,PCCP治疗老年股骨转子间骨折具有手术时间短、切口小、剥离肌肉少、出血少、术后疼痛轻及患者能早期活动等优点.

Abstract：

Objective To investigate the clinical outcomes of minimally invasive treatment of elderly patients with intertrochanteric hip fractures with percutaneous compression plate (PCCP) as compared with dynamic hip screw (DHS) .Methods We randomised 98 patients with intertrochanteric fractures (AO31.A1-A2) to surgical treatment with either the PCCP or DHS and followed them post-operatively from January 2007 to January 2010.There were 53 cases in the PCCP group and 45 in the DHS group.The operation time, blood loss, fracture healing time and the last Harris scores were recorded and compared between the 2 groups.Results In the PCCP group 51 cases obtained a mean follow-up of 11.6 months (range, 8 to 24) and 2 were lost to the follow-up.In the DHS group 42 cases obtained a mean follow-up of 14.2 months (range, 10 to 26) and 3 were lost to the follow-up.Shorter operation time and fracture healing time, less blood loss and higher Harris scores were achieved in the PCCP group than in the DHS group.The differences between the 2 groups were statistically significant ( P ＜ 0.05) .Conclusion The minimally invasive PCCP technique can result in a lower blood loss, less post-operative pain, fewer implant-related complications and comparable surgery time than the DHS treatment.     

Functional outcome, mortality and in-hospital complications of operative treatment in elderly patients with hip fractures in the developing world

Hip fracture has been increasing in frequency for several decades, and 70–90% of patients who sustain a hip fracture survive for at least one year. Many of these survivors fail to regain their prefracture functional status. No work in this regard has been done in the developing world. Elderly patients with acute intertrochanteric fracture and fracture of the femoral neck were followed up prospectively for 12 months after surgery to record the mortality, morbidity, functional status and complications. Three hundred and forty-five patients (61% female) were assessed at six and 12 months after surgery, which included 62.9% intertrochanteric fractures and 37% femoral neck fractures. The mechanism of injury was from a fall in 67% of the cases. Nineteen patients died within six months after surgery while another eight died during the next six months. Obesity, male gender, multiple comorbidities and below normal ambulation status before fracture were identified as major determinants of bad functional outcome.