Influence of Time to Surgery in Ankle Fractures on the Rate of Complications and Length of Stay – a Multivariate Analysis

2018 ◽  
Vol 157 (02) ◽  
pp. 183-187
Author(s):  
Rene Burchard ◽  
Karacan Hamidy ◽  
Anke Pahlkötter ◽  
Christian Soost ◽  
Michael Palm ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Length Of Stay ◽  
Ankle Fractures ◽  
Time To Surgery

Zusammenfassung Hintergrund Mit einer Inzidenz von 9/1000 pro Jahr ist die Malleolarfraktur des oberen Sprunggelenkes eine der häufigsten Frakturen des menschlichen Skeletts. Häufig stellt sich die Frage, ob der Zeitpunkt einer operativen Maßnahme Einfluss auf die Komplikationsrate oder die Krankenhausverweildauer ausübt oder ob andere Patientencharakteristika oder Komorbiditäten darauf Einfluss nehmen. Material und Methoden Aufgrund der bisher sehr heterogenen Datenlage im Hinblick auf den optimalen Operationszeitpunkt bei Malleolarfrakturen erfolgte in der vorliegenden Arbeit eine multivariate Regressionsanalyse im Rahmen einer retrospektiven Kohortenstudie (n = 421). Ergebnisse In der multivariaten Regressionsanalyse zeigten sich keine Vorteile einer primären operativen Versorgung innerhalb von 6 Stunden gegenüber der sekundären Therapie nach ca. 1 Woche im Hinblick auf die lokale postoperative Komplikationsrate oder die Krankenhausverweildauer. Ein höheres Patientenalter bzw. ein begleitender Weichteilschaden höheren Grades waren mit einer verlängerten Krankenhausverweildauer assoziiert. Schlussfolgerung Diese aktuelle Auswertung eines 5-Jahres-Zeitraums zeigt, dass die Wahrscheinlichkeit des Auftretens einer schwerwiegenden lokalen Komplikation nach operativer Versorgung einer Malleolarfraktur weder vom OP-Zeitpunkt noch von weiteren Kovariablen wie dem Alter oder von Komorbiditäten des Patienten beeinflusst wird. Die Empfehlung der primären Versorgung innerhalb von 6 – 8 Stunden entsprechend der aktuellen S2-Leitlinie „Sprunggelenkfraktur“ sollte nach den Ergebnissen der vorliegenden Studie in einer prospektiv randomisierten Untersuchung reevaluiert werden.

scholarly journals Hip Fractures in Centenarians: Has Care Improved in the National Hip Fracture Database Era?

2017 ◽  
Vol 8 (3) ◽  
pp. 161-165 ◽  
Author(s):  
Alastair G. Dick ◽  
Dominic Davenport ◽  
Mohit Bansal ◽  
Therese S. Burch ◽  
Max R. Edwards
Keyword(s):  
Hip Fracture ◽  
Length Of Stay ◽  
Hip Fractures ◽  
District General Hospital ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Retrospective Case ◽  
Time To Surgery ◽  
Surgery Mortality ◽  
Hospital Acquired

Introduction: The number of centenarians in the United Kingdom is increasing. An associated increase in the incidence of hip fractures in the extreme elderly population is expected. The National Hip Fracture Database (NHFD) initiative was introduced in 2007 aiming to improve hip fracture care. There is a paucity of literature on the outcomes of centenarians with hip fractures since its introduction. The aim of this study is to report our experience of hip fractures in centenarians in the era since the introduction of the NHFD to assess outcomes in terms of mortality, time to surgery, length of stay, and complications. Methods: A retrospective case note study of all centenarians managed for a hip fracture over a 7-year period at a London district general hospital. Results: We report on 22 centenarians sustaining 23 hip fractures between 2008 and 2015. Twenty-one fractures were managed operatively. For patients managed operatively, in-hospital, 30-day, 3-month, 6-month, 1-year, 2-year, 3-year, and 5-year cumulative mortalities were 30%, 30%, 39%, 50%, 77%, 86%, 95%, and 100%, respectively. In-hospital mortality was 100% for those managed nonoperatively. Mean time to surgery was 1.6 days (range: 0.7-6.3 days). Mean length of stay on the acute orthopedic ward was 23 days (range: 2-51 days). Seventy-one percent had a postoperative complication most commonly a hospital-acquired pneumonia or urinary tract infection. Conclusion: Compared to a series of centenarians with hip fractures prior to the introduction of the NHFD, we report a reduced time to surgery. Mortality and hospital length of stay were similar.

scholarly journals Mortality and readmission following hip fracture surgery: a retrospective study comparing conventional and fast-track care

BMJ Open ◽  
2017 ◽  
Vol 7 (8) ◽  
pp. e015574 ◽  
Author(s):  
Kristin Haugan ◽  
Lars G Johnsen ◽  
Trude Basso ◽  
Olav A Foss
Keyword(s):  
Hip Fracture ◽  
Length Of Stay ◽  
Fast Track ◽  
Conventional Care ◽  
University Hospital ◽  
Secondary Outcome ◽  
Charlson Comorbidity Index Score ◽  
Care Group ◽  
Time To Surgery ◽  
Significant Difference

ObjectiveTo compare the efficacies of two pathways—conventional and fast-track care—in patients with hip fracture.DesignRetrospective single-centre study.SettingUniversity hospital in middle Norway.Participants1820 patients aged ≥65 years with hip fracture (intracapsular, intertrochanteric or subtrochanteric).Interventions788 patients were treated according to conventional care from April 2008 to September 2011, and 1032 patients were treated according to fast-track care from October 2011 to December 2013.Primary and secondary outcomePrimary: mortality and readmission to hospital, within 365 days follow-up. Secondary: length of stay.ResultsWe found no statistically significant differences in mortality and readmission rate between patients in the fast-track and conventional care models within 365 days after the initial hospital admission. The conventional care group had a higher, no statistical significant mortality HR of 1.10 (95% CI 0.91 to 1.31, p=0.326) without and 1.16 (95% CI 0.96 to 1.40, p=0.118) with covariate adjustment. Regarding the readmission, the conventional care group sub-HR was 1.02 (95% CI 0.88 to 1.18, p=0.822) without and 0.97 (95% CI 0.83 to 1.12, p=0.644) with adjusting for covariates. Length of stay and time to surgery was statistically significant shorter for patients who received fast-track care, a mean difference of 3.4 days and 6 hours, respectively. There was no statistically significant difference in sex, type of fracture, age or Charlson Comorbidity Index score at baseline between patients in the two pathways.ConclusionsThere was insufficient evidence to show an impact of fast-track care on mortality and readmission. Length of stay and time to surgery were decreased.Trial registration numberNCT00667914; results

scholarly journals Audit changes practice; simple education intervention can lead to better outcome for ankle fractures undergoing surgery

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0002
Author(s):  
Amin Kheiran
Keyword(s):  
Revision Surgery ◽  
Ankle Fractures ◽  
Education Intervention ◽  
Anatomical Reduction ◽  
Rater Reliability ◽  
Time To Surgery ◽  
Radiological Parameters ◽  
Patient Reported ◽  
Surgical Fixation

Category: Ankle, Trauma Introduction/Purpose: Unstable ankle fractures are common orthopaedic injuries and majority requires open reduction and internal fixation (ORIF). The goal of surgery is to achieve anatomical reduction and stable fixation of fracture. Recent literature reports malreduction rate as high as 25% to 33%. There is emerging evidence that malreduction leads to poor patient reported outcome (PROMs) and may render additional surgery. The aim of this study was to evaluate the quality of anatomical reduction and surgical fixation of ankle fractures and the effect of a simple education intervention on the adequacy of reduction of these fractures. Methods: An audit cycle was completed starting with retrospective review (phase 1) of 114 consecutive cases of ankle fracture that underwent ORIF between October 2006 and December 2007. Data was retrieved from theatre log and PACS. Age, fracture morphology, time to surgery, time to revision surgery and the quality of anatomical reduction were assessed by three surgeons using three radiological parameters (Pettrone’s criteria + Weber’s dime test). Paediatrics, pathological fractures, open fractures were excluded. The results were conveyed and interventions in the form of regional teaching and introduction of radiological criteria were implemented. Phase 2 (re-audit) was conducted with prospective review of 72 cases between December 2015 and June 2016. Inter-rater reliability was determined using kappa value. Chi- square test was used to compare malreduction rates between 2 phases. Logistic regression was performed for age, gender, time to ORIF with regards to revision surgery. P value < 0.05 was considered significant Results: Results of initial cohort showed significant rate of malreduced fixation in 25% of cases (29 out of 114). After implementation of interventions, malreduction rate reduced to 12.6% (9 out of 72). Of these nine malreduced cases, 3 cases underwent early revision surgery within the first 6 weeks of surgery. There was no significant correlation between age, gender and time to surgery, and time to revision surgery within 3 months of surgical fixation (p = 0.4). Using three radiological parameters (Weber’s dime test, tibiofibular overlap and medial clear space) the mean kappa values for inter-rater reliability was 0.786 (0.727- 0.861), representing a substantial agreement using three radiological parameters in order to avoid failure and or further surgery. Conclusion: This study demonstrates that simple education intervention locally can lead to better understanding of fixation and reduce the rate of malreduction of these fractures. We suggest using three radiological parameters in correction of corresponding anatomy of ankle mortise is a reliable tool to avoid malreduction. Malreductions were more likely to occur in complex fractures with syndesmotic injuries.

scholarly journals Association of a Modified Frailty Index with Postoperative Outcomes after Ankle Fractures in Patients Aged 50 Years and Older

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0002 ◽  
Author(s):  
Rishin Kadakia ◽  
Jason Bariteau ◽  
Catphuong Vu ◽  
Andrew Pao ◽  
Shay Tenenbaum
Keyword(s):  
Multivariate Analysis ◽  
Postoperative Complications ◽  
Assessment Tool ◽  
Frailty Index ◽  
Reoperation Rate ◽  
Ankle Fractures ◽  
Postoperative Outcomes ◽  
Improvement Project ◽  
Modified Frailty Index ◽  
Reoperation Rates

Category: Ankle, Trauma Introduction/Purpose: Frailty, a multifaceted syndrome resulting from a decrease in physiologic reserves, has been previously shown to play a significant role in elderly morbidity and mortality. The literature on frailty within orthopaedic surgery is limited currently. No study to date has assessed frailty as a predictor of postoperative outcomes in elderly patients with ankle fractures. We hypothesized that increasing frailty would be associated with increased 30-day reoperation rates and increased postoperative complications. Methods: The National Surgical Quality Improvement Project (NSQIP) was queried using the appropriate CPT codes to identify inpatients from 2005-2014 who were aged 50 years and older that sustained an ankle fracture and underwent operative fixation. Frailty was assessed using a modified frailty index (MFI), abbreviated with 11 variables from the Canadian Study of Health and Aging Frailty Index. The primary outcome was 30-day reoperation rate and secondary outcomes were postoperative surgical and medical complications, readmission rates, and length of stay. Bivariate and multivariate analysis was used to determine association between outcomes and MFI. Results: 6,749 patients were identified, and the mean age of these patients was 64.4 years. Patients with increased MFI scores had significantly higher rates of postoperative complications. In addition, increased MFI scores was also associated with increased 30 day readmissions and reoperations. Multivariate analysis also demonstrated that MFI was a stronger predictor of 30 day reoperation rates (odds ratio of 17.7, P < 0.001) than age, wound class, and ASA class. Conclusion: Frailty has the potential to be an important predictive variable of postoperative outcomes in patients aged 50 years and older who sustain ankle fractures. The modified frailty index can be a valuable preoperative risk assessment tool for the orthopaedic surgeon. Further study is necessary to examine the effect of the MFI in a larger prospective setting.

scholarly journals Segmented Linear Regression Models for Assessing Change in Retrospective Studies in Healthcare

2019 ◽  
Vol 2019 ◽  
pp. 1-9 ◽  
Author(s):  
Epaminondas Markos Valsamis ◽  
David Ricketts ◽  
Henry Husband ◽  
Benedict Aristotle Rogers
Keyword(s):  
Time Series ◽  
Hip Fracture ◽  
Linear Regression ◽  
Length Of Stay ◽  
Regression Models ◽  
Retrospective Studies ◽  
Linear Regression Models ◽  
Time To Surgery ◽  
Before And After ◽  
Group Comparisons

Introduction. In retrospective studies, the effect of a given intervention is usually evaluated by using statistical tests to compare data from before and after the intervention. A problem with this approach is that the presence of underlying trends can lead to incorrect conclusions. This study aimed to develop a rigorous mathematical method to analyse temporal variation and overcome these limitations. Methods. We evaluated hip fracture outcomes (time to surgery, length of stay, and mortality) from a total of 2777 patients between April 2011 and September 2016, before and after the introduction of a dedicated hip fracture unit (HFU). We developed a novel modelling method that fits progressively more complex linear sections to the time series using least squares regression. The method was used to model the periods before implementation, after implementation, and of the whole study period, comparing goodness of fit using F-tests. Results. The proposed method offered reliable descriptions of the temporal evolution of the time series and augmented conclusions that were reached by mere group comparisons. Reductions in time to surgery, length of stay, and mortality rates that group comparisons would have credited to the hip fracture unit appeared to be due to unrelated underlying trends. Conclusion. Temporal analysis using segmented linear regression models can reveal secular trends and is a valuable tool to evaluate interventions in retrospective studies.

scholarly journals IMPLEMENTING A GERIATRIC FRACTURE PROGRAM IN A PLURALISTIC ENVIRONMENT REDUCES LENGTH OF STAY AND TIME TO SURGERY

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S740-S740
Author(s):  
Sonja L Rosen ◽  
Kathy Breda ◽  
Carol Lin ◽  
Jeanne Black ◽  
Jae Lee ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Medical Center ◽  
Academic Medical Center ◽  
Care Physician ◽  
Geriatric Fracture ◽  
Time To Surgery ◽  
Private Practitioners ◽  
Program Success ◽  
Wilcoxon Rank Sum Test ◽  
Standardized Treatment

Abstract Geriatric-orthopaedic co-management models have been demonstrated to improve patient outcomes, but are typically implemented in closed, non-pluralistic medial systems. The Cedars-Sinai Geriatric Fracture Program (GFP) was developed through collaboration amongst a multi-disciplinary group. Cedars-Sinai is an academic medical center with a pluralistic medical staff that includes faculty, several hospitalist groups, and private practitioners. The GFP was introduced in July 2018 as a quality improvement pilot to provide standardized treatment for geriatric fracture patients. We hypothesized GFP enrollment would reduce time to surgery (TTS) and length of stay (LOS). Geriatric fracture patients were prospectively enrolled from July -December 2018. The Wilcoxon Rank- Sum test was used to compare TTS and LOS between the two patient groups. A p &lt; 0.05 was considered significant. 190 operative fractures in patients over 65 years-old were prospectively followed.56 (30%) were enrolled in the GFP, 54 (28%) were admitted to other hospitalist groups (OH), and 80 (42%) were managed by their primary care physician (PCP). There were no demographic differences between groups. Patients enrolled in the GFP had a significantly shorter LOS compared to the OH and PCP groups (4 days v 5 days v 5 days, p = 0.039) as well as a significantly shorter TTS (19.7hrs v 22.4 hrs vs 23.3 hrs, p = 0.037). Our data shows that a multi-disciplinary geriatric fracture program can be successfully implemented in a complex pluralistic environment resulting in improved patient metrics. Adherence to evidence-based protocols and close multidisciplinary teamwork are critical to program success.

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