Comprehensive treatment for old patients with hip fractures

To observe the effect of comprehensive treatment for hip fracture in old people.     

Strategy for prevention of hip fractures in patients with Parkinson’s disease

Hypovitaminosis D and K due to malnutrition or sunlight deprivation,increased bone resorption due to immobilization,low bone mineral density(BMD)and an increased risk of falls may contribute to an increased risk of hip fractures in patients with Parkinson’s disease.The purpose of the present study was to clarify the efficacy of interventions intended to prevent hip fractures in elderly patients with Parkinson’s disease.Pub Med was used to search the literature for randomized controlled trials(RCTs)regarding Parkinson’s disease and hip fractures.The inclusion criteria were 50 or more subjects per group and a study period of 1 year or longer.Five RCTs were identified and the relative risk and95%confidence interval were calculated for individual RCTs.Sunlight exposure increased serum hydroxyvitamin D[25(OH)D]concentration,improved motor function,decreased bone resorption and increased BMD.Alendronate or risedronate with vitamin D supplementation increased serum 25(OH)D concentration,strongly decreased bone resorption and increased BMD.Menatetrenone(vitamin K2)decreased serum undercarboxylated osteocalcin concentration,decreased bone resorption and increased BMD.Sunlight exposure(men and women),menatetrenone(women),alendronate and risedronate with vitamin D supplementation(women)significantly reduced the incidence of hip fractures.The respective RRs(95%confidence intervals)according to the intention-to-treat analysis were 0.27(0.08,0.96),0.13(0.02,0.97),0.29(0.10,0.85)and 0.20(0.06,0.68).Interventions,including sunlight exposure,menatetrenone and oral bisphosphonates with vitamin D supplementation,have a protective effect against hip fractures elderly patients with Parkinson’s disease.     

Surgery for hip fractures: Does surgical delay affect outcomes?

Hip fractures are associated with a high rate of mortality and profound temporary and sometimes permanent impairment of quality of life. Current guidelines indicate that surgeons should perform surgery for a hip fracture within 24 hours of injury because earlier surgery is associated with better functional outcome and lower rates of perioperative complications and mortality. Proponents of early treatment argue that this approach minimizes the length of time a patient is confined to bed rest, thereby reducing the risk for associated complications, such as pressure sores, deep vein thrombosis, and urinary tract infections. Those favoring delaying surgery beyond the guideline recommendations believe that this approach is required to medically optimize patients, and therefore decrease the risk for perioperative complications. Further challenges to resolving this debate is the lack of an accepted definition of what should constitute an “unacceptable delay” for hip fracture surgery and the fact that outcomes associated with surgical delay are based on observational data alone (i.e., not randomized controlled trials). The effect of preoperative timing on mortality and other patient-important outcomes across various age groups remains controversial and warrants a large randomized controlled trial to offer clear insights into the effects associated with early versus delayed surgery among hip fracture patients.     

A modified surgical approach of the hip in children: is it safe and reliable in patients with developmental hip dysplasia?

PurposeTreatment is easier and complications are less likely to occur if developmental dysplasia of the hip (DDH) is diagnosed early. In this study, we examined the early results of open reduction using a medial approach which we had modified for DDH and analyzed the success of this technique and the associated complication rates, with a focus on avascular necrosis (AVN).Methods This is an Institutional Review Board-approved retrospective review of all patients diagnosed with DDH and treated with a modified medial approach at a single institution from July 1999 to December 2010. The patients'' charts were analyzed for clinical and radiographic features.Results Fifty-five hips of 41 patients, all of whom were treated by open reduction using a modified medial approach due to DDH, were evaluated retrospectively. The mean age of the patients at surgery was 19 (range 11–28) months, and the average follow-up was 5.5 (range 3–9.5) years. AVN was the most important complication in terms of radiological outcomes as assessed according to the Kalamchi–McEwen classification. Radiologic results were excellent or good in 51 hips (92.7 %) and fair–plus in four (7.3 %). Type 1 temporary AVN was detected in only two hips (3.6 %), and the lesions had disappeared completely in the final control graphs of these two patients. A secondary intervention was needed for two hips (3.6 %) of the same patients who were operated on due to bilateral DDH. No other complications, such as infection, re-dislocation, or subluxation, were seen in the operated patients.Conclusions We believe that treatment for DDH using a modified medial approach during early childhood is an effective and reliable method with low AVN rates. As shown here, this method achieves great success in radiological and clinical outcomes after a minimum 3-year follow-up.     

Should patients with isolated hip fractures be included in trauma registries?

BACKGROUND: Patients with isolated hip fractures are frequently excluded from trauma registries. The goal of this study was to show that patients with these injuries have higher resource use and poorer outcomes than the rest of the trauma population. METHODS: The Quebec Trauma Registry was used to identify all trauma patients from April 1, 1998, to March 31, 2003. Patients who were dead on arrival at the emergency room were excluded. Isolated hip fracture (HIP) was defined as a diagnosis of a single fracture to the neck of the femur (Abbreviated Injury Scale 1990 codes 851808.3, 851810.3, 851812.3, and 851818.3) secondary to a fall and for which the Injury Severity Score was 9 or 10 (no other Abbreviated Injury Scale code higher than 1). Patients with all other trauma diagnosis (OT) were used for comparison. Outcome variables were length of hospital stay, length of intensive care unit (ICU) stay, in-hospital complications, and status and orientation at discharge. Chi-square and Wilcoxon rank-sum tests were used. RESULTS: There were 68,422 patients: 14,426 (21.1%) HIP patients and 53,996 (78.9%) OT patients. The median Injury Severity Score was 9 for HIP (range, 9-10) and 9 for OT (range, 1-75). Mean length of hospital stay was 18.4 days for HIP compared with 11.7 days for OT (p < 0.0001). HIP patients represented 29.5% of the total hospital stay. ICU stay was required for 1,353 HIP patients (9.4%) and for 12,395 (23.0%) OT patients (p < 0.0001). Mean ICU stay was 3.9 days for HIP compared with 5.5 days for OT (p = 0.0006). In-hospital mortality was 8.5% in HIP compared with 3.7% in OT (p < 0.0001). HIP represented 62.7% of patients referred for long-term care and 39.3% of patients referred to a rehabilitation center. CONCLUSION: Patients with HIP represented 21.1% of admissions while accounting for 42% of total days of hospitalization and 38% of deaths. Patients with hip fractures have a significantly higher risk of death, prolonged hospital stay, and complication rate, and are more often transferred to a rehabilitation center or to a long-term nursing home than the rest of the trauma population despite lower severity. They require multidisciplinary care typical of the rest of the trauma population and should be included in the trauma registry if the registry is to document the full outcome and resource use of the trauma population.     

Dynamic hip screw versus proximal femoral nail for treatment of trochanteric hip fractures: an outcome analyses with a minimum 2?years of follow-up

The goal of this study is to compare the clinical and radiographical results of Dynamic hip screw (DHS) and Proximal femoral nail (PFN) for the treatment of trochanteric hip fractures. One hundred and eighty-one patients (89 male and 92 female, mean age, 77.1?years) surgically treated for trochanteric fractures were divided into two groups. Group 1: 86 hips treated with DHS and group 2: 98 hips treated with PFN. The outcome for each group was analyzed, and total operative time, time to union, complications (early and late), and mortality were recorded. The results were statistically compared. Mean follow-up was 26.8?months. The mean duration of surgery was 85.2?min for group 1 and 55.3?min for group 2. The mean time to union for group 1 was 2.09?months and 1.69?months for group 2. Early and late complication rates between treatment groups revealed no statistically significant differences. Total duration of surgery was significantly lower for PFN than it was for DHS. A comparison of time to union and overall mortality demonstrated no statistically significant differences. We detected no differences between the two treatment groups in regard to early versus late complications, time to union, and overall mortality; however, with its shorter operative period, PFN is a good alternative to the DHS. For this reason, we believed that it might be the implant of choice for the treatment of trochanteric fractures by surgeons who have an experience in interlocked femoral nailing systems.     

Operative treatment for hip fractures in patients 100 years of age and older: is it justified?

OBJECTIVES: To evaluate a unique group of elderly patients over 100 years of age who had hip fractures. DESIGN: Retrospective database analysis. SETTINGS: Academic teaching hospital. PATIENTS: All patients who had hip fractures between January 1990 and December 2001 and were over 100 years old were included. INTERVENTION: In this study, we evaluated the age, gender, type of fracture, type of treatment, background disease, rehabilitation, and time until death of all patients over 100 years, whether treated operatively or nonoperatively. RESULTS: Twenty-three patients (17 females and 6 males) were identified with ages ranging from 100 to 107 (mean: 101.8). The group had 4 subcapital and 19 pertrochanteric fractures and between 1 and 4 major background diseases. Four patients were treated nonoperatively (1 due to major pneumonia and 3 refused the operative procedure). Three of those 4 patients died in the same month of admission, and 1 patient died during the second month. Among the 19 patients who underwent operation, 17 patients have died, living between 0 and 78 months (mean: 13.8) postoperatively. Two are still alive (21 and 45 months) after the operation. Eight patients died prior to 6 months, and 11 lived more than a year after the operation. A comparison between these 2 groups showed greater major background disease in the patients who died prior to 6 months (P < 0.05). CONCLUSIONS: Most hip fractures in patients over 100 years of age are pertrochanteric. Patients with 2 or more major background diseases have an increased risk for dying in the first 6 months after the operation. Most patients having operations in this age group had a postoperative reduction in mobility status and in performing basic activities of daily living.     

Can radiographs of hip fractures predict subsequent hip fractures? A shape modelling analysis

IntroductionThe geometrical shape of the proximal femur has previously been shown to predict primary hip fractures. Hip fractures are routinely diagnosed on plain radiographs of the pelvis, and these have both hips viewable. We have investigated if statistical shape modelling of the uninvolved hip on plain radiographs, at the time of the first hip fracture episode, could predict a subsequent ‘second fracture’ on that (uninvolved) side.Materials and methods60 radiographs taken at the time of the index hip fracture were blinded and separated into two arms; patients sustaining one hip fracture only (n = 30), and those who went on to sustain a second fracture (n = 30), over the three-year follow-up period. Two separate shape models were used for these groups and compared using t-tests or Mann–Whitney U-tests, along with Cohen's d to measure the effect size of each measure.ResultsWe found no statistically significant difference in the shape of the femur between the first fracture and second fracture group (p > 0.05) and no results reached a “medium” effect size (Cohen's d <0.5).ConclusionsShape modelling is feasible and can be applied in the routine clinical setting. However, we were unable to elucidate any predictive value in this relatively small sample. A reliable radiograph-based method of identifying patients at risk of second fracture would be of value in planning prevention, service provision, and cost analysis. Further work is required and a study with more patients might exclude the type 2 error in our work.     

Are the current guidelines for surgical delay in hip fractures too rigid? A single center assessment of mortality and economics

PurposeControversy remains around acceptable surgical delay of acute hip fractures with current guidelines ranging from 24 to 48 h. Increasing healthcare costs force us to consider the economic burden as well. We aimed to evaluate the adjusted effect of surgical delay for hip fracture surgery on early mortality, healthcare costs and readmission rate. We hypothesized that shorter delays resulted in lower early mortality and costs.MethodsIn this retrospective cohort study 2573 consecutive patients aged ≥50 years were included, who underwent surgery for acute hip fractures between 2009 and 2017. Main endpoints were thirty- and ninety-day mortality, total cost, and readmission rate. Multivariable regression included sex, age and ASA score as covariates.ResultsThirty-day mortality was 5% (n = 133), ninety-day mortality 12% (n = 304). Average total cost was €11960, dominated by hospitalization (59%) and honoraria (23%). Per 24 h delay, the adjusted odds ratio was 1.07 (95% CI 0.98–1.18) for thirty-day mortality, 1.12 (95% CI 1.04–1.19) for ninety-day mortality, and 0.99 (95% CI = 0.88–1.12) for readmission. Per 24 h delay, costs increased with 7% (95% CI 6–8%). For mortality, delay was a weaker predictor than sex, age, and ASA score. For costs, delay was the strongest predictor. We did not find clear cut-points for surgical delay after which mortality or costs increased abruptly.ConclusionsDespite only modest associations with mortality, we observed a steady increase in healthcare costs when delaying surgery. Hence, a more pragmatic approach with surgery as soon as medically and organizationally possible seems justifiable over rigorous implementation of the current guidelines.     

Treatment of femoral fractures in children: is titanium elastic nailing an improvement over hip spica casting?

Purpose  

The purpose of the study was to assess the validity of surgical interference with elastic nailing in treating pediatric femur fractures in comparison with the traditional treatment method—hip spica casting.     

Bisphosphonate-associated peri-implant fractures: a new clinical entity?: A series of 10 patients with 11 fractures

Background and purpose

The current definition of atypical femoral fractures (AFFs) associated with bisphosphonate use includes only de novo fractures. However, in recent years reports of bisphosphonate-associated periprosthetic fractures involving stemmed arthroplasty implants have emerged. In a case series of peri-implant fractures in femurs with plate/screw constructs, we aimed to assess similarities with classical AFFs and how their location may have implications for the pathogenesis and management of AFFs.

Patients and methods

We retrospectively identified 10 patients with 11 peri-implant fractures.

Results

The patients were ambulant women, mean age 80 (70–92) years. Mean duration of bisphosphonate use was 5 (1–10) years. The peri-implant fractures were sustained an average of 4 years (6 months to 9 years) from the time of index surgery. They were all associated with low-energy mechanisms. 8 fractures occurred near the tip of a plate, while 3 traversed the penultimate screwhole of a plate. The peri-implant fractures showed clinical and radiological features of atypicality such as lateral cortical thickening, simple fracture pattern, and lack of comminution. The patients underwent revision surgery, with bone grafting used in all but 1 case. Radiological union was evident after 2–4 months.

Interpretation

Atypical peri-implant fractures of the femur associated with bisphosphonate use may be a new entity. Stress lesions and atypical fractures may tend to develop over stress risers along the operated femur. This finding has implications for the pathogenesis and clinical management of AFFs.Bisphosphonates form the cornerstone of antiresorptive therapy in the management of post-menopausal osteoporosis. They are used in the treatment of malignant and osteoclast-mediated metabolic bone disease. Their use in patients who have undergone total joint arthroplasty of the lower limb is associated with higher periprosthetic bone mineral density and longer implant survival (Bhandari et al. 2005). Bisphosphonates exert their therapeutic effect by reducing bone turnover and increasing overall mineralization. This translates to increased bone mineral density and bone strength, corresponding clinically to reduced risk of vertebral and non-vertebral fragility fractures (Black et al. 1996).In recent years, several published reports have described atypical femoral fractures (AFFs) of the proximal femoral diaphysis and subtrochanteric region, in association with bisphosphonate use (Goh et al. 2007, Neviaser et al. 2008, Isaacs et al. 2010). Bisphosphonates are associated with a higher age-adjusted relative risk of AFF in women than in men, which is higher in alendronate users than in risedronate users (Schilcher et al. 2015). Bisphosphonates may cause changes in bone matrix composition and bone mechanical properties, increasing the propensity for accumulation of microdamage. Impaired target remodeling would contribute to the progression of macrocracks. High interfragmentary strain from physiological loads at a thin fracture line may be a mechanical factor in lack of bone healing (Aspenberg et al. 2010).Periprosthetic/peri-implant fractures are currently excluded from the definition of AFFs. We suggest that peri-implant fractures of the femur with features of atypicality may be linked to bisphosphonate use and that they should be recognized as a clinical entity.     

A National comparison of surgical versus percutaneous drainage of pancreatic pseudocysts: 1997–2001

Case series results indicate that a surgical approach is superior to percutaneous drainage of pancreatic pseudocysts. To determine if this surgical advantage is persistent, national outcomes for both approaches were compared from 1997 through 2001. The National Inpatient Sample, a 20% sample of all nonfederal hospital discharges, was searched for patients who had a pancreatic pseudocyst diagnosis, an ICD-9 diagnosis code 577.2, and an ICD-9 procedure code of 52.01 for percutaneous drainage (PD) or 52.4 and 52.96 for the surgical approaches. Variables were compared by using either t test or x² analysis. Confounding variables were controlled for by linear or logistic regression models. No clinically significant demographic, comorbidity, and disease-specific severity-of-illness differences existed between the two groups. Significant differences in complications, length of stay (15 ± 15 versus 21 ± 22 days, P < 0.0001), and inpatient mortality (5.9% versus 2.8%, P < 0.0001) favored the surgical approach. In addition, endoscopic retrograde cholangiopancreatography use had a protective effect on mortality (odds ratio, 0.7), whereas percutaneous drainage had an increased risk of mortality (odds ratio, 1.4). This populationbased study suggests that surgical drainage of pancreatic pseudocysts, particularly when coupled with use of endoscopic retrograde cholangiopancreatography, leads to decreased complications, length of stay, and mortality in comparison with percutaneous drainage. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation).     

Operation for lung cancer in patients with idiopathic pulmonary fibrosis: surgical contraindication?

BACKGROUND: Patients with idiopathic pulmonary fibrosis have an increased incidence of lung cancer. The purpose of this study was to determine the outcome of surgical treatment of lung cancer with idiopathic pulmonary fibrosis. METHODS: From January 1992 through December 2001, 64 patients who had simultaneous lung cancer and idiopathic pulmonary fibrosis were treated. Twenty-one (33%) of them underwent surgical resection of lung cancer, and their data were reviewed. RESULTS: There were 56 men and 8 women with an average age of 69 years (range, 43 to 85 years). In the surgical group, there were no early postoperative deaths, and nonfatal complications occurred in 2 patients (10%). Among the 14 patients with stage I cancer, a second primary lung cancer developed in 5 (36%). The causes of death in the surgical group were cancer related in 7 patients, exacerbation of idiopathic pulmonary fibrosis in 7, and other in 2. Five of the 7 patients who died of a cancer-related cause had development of a second primary lung cancer. The actuarial 2-year survival rate of the surgical group was 52% overall, 58% for patients with N0 or N1 disease and 25% for those with N2 disease (p = 0.05). CONCLUSIONS: The long-term results in one surgical group were poor partly because of the high incidence of a second primary lung cancer and partly because of the poor natural history of idiopathic pulmonary fibrosis. These patients require intensive surveillance even after curative resection of lung cancer.     

Why are ambulatory surgical patients admitted to hospital?: Prospective study

Background: Once Ambulatory Surgery (AS) has been demonstrated to be an effective alternative to hospitalisation for many surgical patients, it is necessary to establish clinical indicators to evaluate objectively the quality of care that is being given. Hypothesis: The unplanned admission index (UAI) is a valid and easy indicator of the management and quality of care in ambulatory surgery units. Design: Prospective study. Setting: Public regional hospital level I (less than 200 beds). Main outcome measure: Unplanned admission index (UAI). Patients and methods: Between September 1997 and October 2000, 3502 patients were operated on in our ambulatory surgery unit. The analysed surgical services were General surgery (844 patients), Orthopaedics (646 patients), Urology (499 patients), ENT (329 patients), Ophthalmology (1007 patients) and Gynaecology (177 patients). A prospective study of all the patients was made, with analysis of the following parameters: (1) global and accumulated UAI (per months and years); (2) UAI by surgical specialities; (3) UAI by causes; (4) UAI by type of operation; (5) UAI by type of anaesthesia; (6) case-mix, according to average weight of diagnostic related groups classification (DGR). Results: The global UAI was 4.1%. By specialities, the UAI was 10.7% in Gynaecology; 6.1% in ENT; 5.9% in General surgery; 3.4% in Orthopaedics; 2.3% in Ophthalmology and 2% in Urology. The most frequent causes of unplanned admission were haemorrhage: 15.9%; more extensive surgery than anticipated: 15.3%; postoperative pain: 12.5%; nausea and vomiting: 10.4%; and drowsiness and dizziness: 6.9%. The types of operation with the highest UAI were, gynaecological laparoscopy: 50%; hysteroscopy: 26%; haemorrhoidectomy: 25%; septoplasty: 22%; strabismus surgery: 11%; orchiopexy: 11%; hydrocelectomy: 10%; inguinal hernia repair: 8%. Conclusions: (1) Classification of UAI by specific causes of admission and incorrect selection of patients may detect on-line problems and allow the application of concrete solutions to reduce the UAI index. (2) In order to compare the results amongst different ambulatory surgery units, an international classification of ambulatory patients must be applied. In the same way, an objective index to evaluate the surgical complexity and the patients' morbidity should be developed. (3) The assessment of processes and results should be based on the selection of standard indicators with systematic and periodic measurement.     

Updated Three-Column Concept in surgical treatment for tibial plateau fractures – A prospective cohort study of 287 patients

PurposeThis study introduces an updated Three-Column Concept for the classification and treatment of complex tibial plateau fractures. A combined preoperative assessment of fracture morphology and injury mechanism is utilized to determine surgical approach, implant placement and fixation sequence. The effectiveness of this updated concept is demonstrated through evaluation of both clinical and radiographic outcome measures.Patients and methodsFrom 2008 to 2012, 355 tibial plateau fractures were treated using the updated Three-Column Concept. Standard radiographic and computed tomography imaging are used to systematically assess and classify fracture patterns as follows: (1) identify column(s) injured and locate associated articular depression or comminution, (2) determine injury mechanism including varus/valgus and flexion/extension forces, and (3) determine surgical approach(es) as well as the location and function of applied fixation. Quality and maintenance of reduction and alignment, fracture healing, complications, and functional outcomes were assessed.Results287 treated fractures were followed up for a mean period of 44.5 months (range: 22–96). The mean time to radiographic bony union and full weight-bearing was 13.5 weeks (range: 10–28) and 14.8 weeks (range: 10–26) respectively. The average functional Knee Society Score was 93.0 (range: 80–95). The average range of motion of the affected knees was 1.5–121.5°. No significant difference was found in knee alignment between immediate and 18-month post-operative measurements. Additionally, no significant difference was found in functional scores and range of motion between one, two and three-column fracture groups. Twelve patients suffered superficial infection, one had limited skin necrosis and two had wound dehiscence, that healed with nonoperative management. Intraoperative vascular injury occurred in two patients. Fixation of failure was not observed in any of the fractures treated.ConclusionAn updated Three-Column Concept assessing fracture morphology and injury mechanism in tandem can be used to guide surgical treatment of tibial plateau fractures. Limited results demonstrate successful application of biologically friendly fixation constructs while avoiding fixation failure and associated complications of both simple and complex tibial plateau fractures.Level of evidenceLevel II, prospective cohort study.     

Displaced intracapsular neck of femur fractures in mobile independent patients: total hip replacement or hemiarthroplasty?

The aim of this study was to compare the outcome of total hip replacement (THR) with hemiarthroplasty in mobile and socially independent patients with displaced intracapsular fractured neck of femur. Thirty-two patients who had been treated by THR were reviewed after a mean of 3.7 years and compared with 42 patients who had been treated by hemiarthroplasty who were reviewed at 3.9 years. At follow-up none of the THRs had required revision whereas 38% of the hemiarthroplasties had required conversion to THR. Six percent of THRs had dislocated. The modified Harris Hip score rated 86% of THRs as 'good' or 'excellent,' whereas only 12% of the remaining hemiarthroplasties achieved a similar rating. Seventy-seven percent of the patients who had received a THR estimated that they could walk more than a mile compared to 27% of the remaining hemiarthroplasties. THR gave a vastly superior functional outcome compared to hemiarthroplasty in this group of patients.     

A comparison of treatment setting for elderly patients with hip fracture,is the geriatric ward superior to conventional orthopedic hospitalization?

IntroductionHip fractures in the elderly are a major cause of morbidity and mortality. The treatment settings of these patients may change their outcomes. The aim of this study is to compare the outcomes of patients with displaced femoral neck fractures who were admitted to the orthopedic vs. geriatric wards.Patients and methodsA retrospective study was conducted on 217 consecutive older patients with 219 displaced femoral neck fractures admitted either to the orthopedic or the geriatric ward between Jan. 2013 and Jun. 2015. Information regarding demographic, medical history, surgical management, hospitalization, and one year readmissions and mortality data was retrieved from electronic charts.Results102 hemiarthroplasty patients were admitted to the orthopedic ward and 117 to the geriatric ward. Patients' characteristics, including age, living arrangements, mobility status and the Charlson Comorbidity Index were similar between groups. Patients from the orthopedic ward had shorter hospitalization time (9 ± 5.1 vs. 10.8 ± 6.7 days, p = 0.022) and presented a lower in-hospital complication rates (0.6 ± 0.96 vs. 1 ± 1.9, p = 0.022), namely fewer events of urinary retentions, urinary tract infections and pneumonias (8.8% vs. 23.9%, p = 0.004, 3.9% vs. 14.5%, p = 0.010 and 2.9% vs. 12.2%, p = 0.034, respectfully). Readmission rates were similar. Neither in hospital nor one year mortality rates differed between groups.ConclusionsOur study found that geriatric care was not superior to orthopedic directed management in the treatment of elderly patients with hip fractures in terms of in-hospital complications, and hospitalization times.     

Therapeutic decisions for patients with symptomatic severe aortic stenosis: room for improvement?

Objective: Symptomatic severe aortic stenosis is an indication for aortic valve replacement. Some patients are denied intervention. This study provides insight into the proportion of conservatively treated patients and into the reasons why conservative treatment is chosen. Methods: Of a patient cohort presenting with severe aortic stenosis between 2004 and 2007, medical records were retrospectively analyzed. Only symptomatic patients (n = 179) were included. We studied their characteristics, treatment decisions, and survival. Results: Mean age was 71 years, 50% were male. During follow-up (mean 17 months, 99% complete) 76 (42%) patients were scheduled for surgical treatment (63 conventional valve replacement, 10 transcatheter, 1 heart transplantation, 2 waiting list) versus 101 (56%) who received medical treatment. Reasons for medical treatment were: perceived high operative risk (34%), symptoms regarded mild (19%), stenosis perceived non-severe (14%), and patient preference (9%). In 5% the decision was pending at the time of the analysis and in 20% the reason was other/unclear. Mean age of the surgical group was 68 years versus 73 years for medically treated patients (p = 0.004). Predicted mortality (EuroSCORE) was 7.8% versus 11.3% (p = 0.006). During follow-up 12 patients died in the surgical group (no 30-day operative mortality), versus 28 in the medical group. Two-year survival was 90% versus 69%. Conclusions: A large proportion (56%) of symptomatic patients does not undergo aortic valve replacement. Often operative risk is estimated (too) high or hemodynamic severity and symptomatic status are misclassified. Interdisciplinary team discussions between cardiologists and surgeons should be encouraged to optimize patient selection for surgery.