scholarly journals The effect of remote ischaemic preconditioning on myocardial injury in emergency hip fracture surgery (PIXIE trial): phase II randomised clinical trial

BMJ ◽  
2019 ◽  
pp. l6395 ◽  
Author(s):  
Sarah Ekeloef ◽  
Morten Homilius ◽  
Maiken Stilling ◽  
Peter Ekeloef ◽  
Seda Koyuncu ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Myocardial Injury ◽  
Primary Outcome ◽  
Troponin I ◽  
Peak Plasma ◽  
Major Adverse Cardiovascular Events ◽  
Control Group ◽  
Hip Fracture Surgery ◽  
Secondary Outcomes ◽  
Fracture Surgery

Abstract Objective To investigate whether remote ischaemic preconditioning (RIPC) prevents myocardial injury in patients undergoing hip fracture surgery. Design Phase II, multicentre, randomised, observer blinded, clinical trial. Setting Three Danish university hospitals, 2015-17. Participants 648 patients with cardiovascular risk factors undergoing hip fracture surgery. 286 patients were assigned to RIPC and 287 were assigned to standard practice (control group). Intervention The RIPC procedure was initiated before surgery with a tourniquet applied to the upper arm and consisted of four cycles of forearm ischaemia for five minutes followed by reperfusion for five minutes. Main outcome measures The original primary outcome was myocardial injury within four days of surgery, defined as a peak plasma cardiac troponin I concentration of 45 ng/L or more caused by ischaemia. The revised primary outcome was myocardial injury within four days of surgery, defined as a peak plasma cardiac troponin I concentration of 45 ng/L or more or high sensitive troponin I greater than 24 ng/L (the primary outcome was changed owing to availability of testing). Secondary outcomes were peak plasma troponin I and total troponin I release during the first four days after surgery (cardiac and high sensitive troponin I), perioperative myocardial infarction, major adverse cardiovascular events, and all cause mortality within 30 days of surgery, length of postoperative stay, and length of stay in the intensive care unit. Several planned secondary outcomes will be reported elsewhere. Results 573 of the 648 randomised patients were included in the intention-to-treat analysis (mean age 79 (SD 10) years; 399 (70%) women). The primary outcome occurred in 25 of 168 (15%) patients in the RIPC group and 45 of 158 (28%) in the control group (odds ratio 0.44, 95% confidence interval 0.25 to 0.76; P=0.003). The revised primary outcome occurred in 57 of 286 patients (20%) in the RIPC group and 90 of 287 (31%) in the control group (0.55, 0.37 to 0.80; P=0.002). Myocardial infarction occurred in 10 patients (3%) in the RIPC group and 21 patients (7%) in the control group (0.46, 0.21 to 0.99; P=0.04). Statistical power was insufficient to draw firm conclusions on differences between groups for the other clinical secondary outcomes (major adverse cardiovascular events, 30 day all cause mortality, length of postoperative stay, and length of stay in the intensive care unit). Conclusions RIPC reduced the risk of myocardial injury and infarction after emergency hip fracture surgery. It cannot be concluded that RIPC overall prevents major adverse cardiovascular events after surgery. The findings support larger scale clinical trials to assess longer term clinical outcomes and mortality. Trial registration ClinicalTrials.gov NCT02344797 .

scholarly journals Topical tranexamic acid in hip fractures: a randomized, placebo-controlled double-blinded study

2021 ◽  
Vol 64 (4) ◽  
pp. E449-E456
Author(s):  
Darren Costain ◽  
Graham Elder ◽  
Brian Fraser ◽  
Brad Slagel ◽  
Adrienne Kelly ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Troponin I ◽  
Postoperative Blood Loss ◽  
Control Group ◽  
Hip Fracture Surgery ◽  
Coronary Syndrome ◽  
The Difference ◽  
Fracture Surgery

Background: Tranexamic acid (TXA) has been shown to reduce perioperative blood loss in elective orthopedic surgery. The safety of intravenous TXA in nonelective hip fracture surgery is uncertain. The purpose of this study was to evaluate the efficacy and safety of topical TXA in hip fracture surgery. Methods: Adult patients presenting to a community hospital with a hip fracture requiring surgery were randomly assigned to receive topical TXA or placebo. Hemoglobin and troponin I levels were measured preoperatively and on postoperative days 1, 2 and 3. All postoperative blood transfusions were recorded. Complications, including acute coronary syndrome (ACS), venous thromboembolism (VTE), cerebrovascular accidents (CVA), surgical site infections (SSI) and 90-day mortality, were recorded. Results: Data were analyzed for 65 patients (31 in the TXA group, 34 in the control group). Hemogloblin level was significantly higher on postoperative days 1 and 2 in the TXA group than in the control group. The difference in hemoglobin level between the groups was not statistically significant by postoperative day 3. Significantly fewer units of packed red blood cells were transfused in the TXA group (2 units v. 8 units); however, 2 of the units in the control group were given intraoperatively, and when these were excluded the difference was not significant. The incidence of ACS, CVA, VTE, SSI, transfusion and all-cause mortality at 90 days did not differ significantly between the groups. Conclusion: Topical TXA reduces early postoperative blood loss after hip fracture surgery without increased patient risk. Trial registration: Clinicaltrials.gov, no. NCT02993341.

scholarly journals Perioperative Myocardial Infarction/Myocardial Injury Is Associated with High Hospital Mortality in Elderly Patients Undergoing Hip Fracture Surgery

2020 ◽  
Vol 9 (12) ◽  
pp. 4043
Author(s):  
Carlo Rostagno ◽  
Alessandro Cartei ◽  
Gaia Rubbieri ◽  
Alice Ceccofiglio ◽  
Agnese Magni ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Hip Fracture ◽  
Hospital Mortality ◽  
Myocardial Injury ◽  
Troponin I ◽  
Cardiovascular Complications ◽  
Elevated Troponin ◽  
Hip Fracture Surgery ◽  
Hospital Stays ◽  
Fracture Surgery

Cardiovascular complications in patients undergoing non-cardiac surgery are associated with longer hospital stays and higher in-hospital mortality. The aim of this study was to assess the incidence of in-hospital myocardial infarction and/or myocardial injury in patients undergoing hip fracture surgery and their association with mortality. Moreover, we evaluated the prognostic value of troponin increase stratified on the basis of peak troponin value. The electronic records of 1970 consecutive hip fracture patients were reviewed. Patients <70 years, those with myocardial infarction <30 days, and those with sepsis or active cancer were excluded from the study. Troponin and ECG were obtained at admission and then at 12, 24, and 48 h after surgery. Echocardiography was made before and within 48 h after surgery. Myocardial injury was defined by peak troponin I levels > 99th percentile. A total of 1854 patients were included. An elevated troponin concentration was observed in 754 (40.7%) patients in the study population. Evidence of myocardial ischemia, fulfilling diagnosis of myocardial infarction, was found in 433 (57%). ECG and echo abnormalities were more frequent in patients with higher troponin values; however, mortality did not differ between patients with and without evidence of ischemia. Peak troponin was between 0.1 and 1 µg/L in 593 (30.3%). A total of 191 (10%) had peak troponin I ≥ 1 µg/L, and 98 died in hospital (5%). Mortality was significantly higher in both groups with troponin increase (HR = 1.37, 95% CI 1.1–1.7, p < 0.001 for peak troponin I between 0.1 and 1 µg/L; HR = 2.28, 95% CI 1.72–3.02, p < 0.0001 for peak troponin ≥1 µg/L) in comparison to patients without myocardial injury. Male gender, history of coronary heart disease, heart failure, and chronic kidney disease were also associated with in-hospital mortality. Myocardial injury/infarction is associated with increased mortality after hip fracture surgery. Elevated troponin values, but not ischemic changes, are related to early worse outcome.

scholarly journals Direct Oral Anticoagulants and Timing of Hip Fracture Surgery

2020 ◽  
Vol 9 (7) ◽  
pp. 2200
Author(s):  
Seth M. Tarrant ◽  
Michael J. Catanach ◽  
Mahsa Sarrami ◽  
Matthew Clapham ◽  
John Attia ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Primary Outcome ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Perioperative Outcomes ◽  
Surgical Timing ◽  
Serious Adverse Events ◽  
Hip Fracture Surgery ◽  
Geriatric Hip Fracture ◽  
Secondary Outcomes

Timely surgical intervention in hip fracture has been linked to improved outcomes. Direct Oral Anticoagulants (DOACs) are an emerging class of anticoagulants without evidence-based guidelines on surgical timing. This study aims to investigate how DOACs affect surgical timing and hence perioperative outcomes. A retrospective database/registry review was conducted for geriatric hip fracture patients aged 65 and over between 2011 and 2018. Primary outcome was 30-day mortality. Secondary outcomes included serious adverse events (SAE), transfusion and postoperative day (POD) 1 haemoglobin (Hb) levels. From a cohort of 3264 patients, 112 admitted subjects were taking DOACs; the annual proportion on DOACs increased over time. Mean time to surgery from last dose (Ts) was 2.2 (±1.0 SD) days. The primary outcome, 30-day mortality, occurred in 16 (14%) patients with secondary outcomes of SAEs in 25 (22%) patients and transfusion in 30 (27%) patients. Ts (days) did not significantly affect 30-day mortality (odds ratio (OR): 1.37, 95% confidence interval (CI): 0.80–2.33; p = 0.248), SAE (hazard ratio (HR): 1.03, 95% CI: 0.70–1.52; p = 0.885), transfusion (OR: 0.72 95% CI: 0.45 to 1.16; p = 0.177) or POD 1 Hb (OR: 1.99, 95% CI: −0.59 to 4.57; p = 0.129). Timing of surgery does not influence common surgical outcomes such as 30-day mortality, SAE, transfusion, and POD1 Hb in patients taking DOACs on admission.

Self-Efficacy Care Program for Older Adults Receiving Hip-Fracture Surgery

2021 ◽  
pp. 105477382110014
Author(s):  
Shu-Fen Su ◽  
Shu-Ni Lin ◽  
Chia-Sui Chen
Keyword(s):  
Older Adults ◽  
Hip Fracture ◽  
Hip Fractures ◽  
Self Efficacy ◽  
Short Form ◽  
Care Program ◽  
Control Group ◽  
Hip Fracture Surgery ◽  
Post Surgery ◽  
Fracture Surgery

Hip fractures decrease older adults’ physical activity and quality of life (QoL). However, no current self-efficacy care programs are managed by clinical nurses, and thus no studies have measured their effects on self-care self-efficacy (SCSE). Hence, this quasi-experimental study determined the effectiveness of a self-efficacy care program (SECP) in 104 older adults receiving hip-fracture surgery who were divided into intervention and control groups. The Strategies Used by People to Promote Health and Short Form-36 were administered pre-surgery and at 1 and 3-month intervals post-surgery. The SCSE and QoL of the SECP group were significantly better than the control group at 1- and 3-month follow-ups post-surgery. Both groups’ QoL decreased at one-month post-surgery but increased by 3-months post-surgery. The SECP group had higher psychological QoL than the control group post-surgery. This intervention increased the SCSE and QoL of older adults with hip fractures and improved post-operative care.

scholarly journals Effect of Goal-directed Haemodynamic Therapy Guided by Non-invasive Monitoring on Perioperative Complications in Elderly Hip Fracture Patients Within an Enhanced Recovery Pathway.

2021 ◽  
Author(s):  
Juan Victor Lorente ◽  
Francesca Reguant ◽  
Anna Arnau ◽  
Marcelo Borderas ◽  
Juan Carlos Prieto ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Hospital Stay ◽  
Enhanced Recovery ◽  
Perioperative Complications ◽  
Intervention Group ◽  
Control Group ◽  
Haemodynamic Instability ◽  
Hip Fracture Surgery ◽  
One Year ◽  
Fracture Surgery

Abstract Background: Goal-Directed Hemodynamic Therapy (GDHT) has been shown to reduce morbidity and mortality in high-risk surgical patients. However, there is little evidence of its efficacy in patients undergoing hip fracture surgery. This study aims to evaluate the effect of GDHT guided by non-invasive haemodynamic monitoring on perioperative complications in patients undergoing hip fracture surgery.Methods: Patients > 64 years undergoing hip fracture surgery within an Enhanced Recovery Pathway were enrolled in this single-center, non-randomized, intervention study with a historical control group and 12-months follow-up. Exclusion criteria were patients with pathological fractures, traffic-related fractures and refractures. Control group patients received the standard care given at our hospital. Intervention group patients received an individualized management strategy aimed at achieving an optimal stroke volume by fluid administration, in addition to a systolic blood pressure > 90 mmHg and an optimal cardiac index according to the patient's age and baseline metabolic equivalents. No changes were made between groups in the enhanced recovery protocols, nor in the composition of the multidisciplinary team during the study period. Primary combined outcome was perioperative complications. Intraoperatively: haemodynamic instability, sustained cardiac arrhythmias. Postoperative complications: cardiovascular, respiratory, infectious and renal complications. Secondary outcomes were administered fluids, vasopressor requirements, perioperative transfusion, length of hospital stay, readmission and one-year survival.Results: 551 patients (Control group=272; Intervention group=279). Intraoperative haemodynamic instability was lower in the intervention group (37.5% vs 28.0%; p=0.017). GDHT patients had fewer postoperative cardiovascular (18.8% vs 7.2%; p < 0.001), respiratory (15.1% vs 3.6%; p<0.001) and infectious complications (21% vs 3.9%; p<0.001) but not renal (12.1% vs 33.7%; p<0.001). Intervention group patients had less vasopressors requirements (p<0.001) and received less fluids (p=0.001) than control group. Fewer patients required transfusion in GDHT group (p<0.001). For intervention group patients, median length of hospital stay was shorter (p < 0.001) and one-year survival higher (p<0.003).Conclusions: The use of GDHT decreases intraoperative complications and postoperative cardiovascular, respiratory and infectious but not postoperative renal complications. This strategy was associated with a shorter hospital stay and increased one-year survival.Trial registration: Clinicaltrials.gov: NCT02479321

scholarly journals Preadmission Statin Prescription and Inpatient Myocardial Infarction in Geriatric Hip Fracture

2021 ◽  
Vol 10 (11) ◽  
pp. 2441
Author(s):  
Seth M. Tarrant ◽  
Raymond G. Kim ◽  
Jack M. McDonogh ◽  
Matthew Clapham ◽  
Kerrin Palazzi ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Hip Fracture ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Inpatient Mortality ◽  
Hip Fracture Surgery ◽  
Statin Prescription ◽  
Geriatric Hip Fracture ◽  
Fracture Surgery ◽  
Statin Use

Statins have been shown to reduce myocardial infarction (MI) in cardiac and vascular surgery. MI is common in hip fracture. This study aims to investigate whether statins decrease MI in hip fracture surgery and reduce mortality resulting from MI. Patients aged 65 years and above with a low-energy hip fracture were identified between January 2015 and December 2017. Demographics, comorbidities, predictive scores, medications and outcomes were assessed retrospectively. The primary outcome was inpatient MI. The secondary outcome was inpatient mortality resulting from MI, for which fatal and non-fatal MI were modelled. Regression analysis was conducted with propensity score weighting. Hip fracture occurred in 1166 patients, of which 391 (34%) were actively taking statins. Thirty-one (2.7%) patients were clinically diagnosed with MI. They had a higher inpatient mortality than those who did not sustain an MI (35% vs. 5.3%, p < 0.0001). No reduction was seen between statin use and the occurrence of MI (OR = 0.97, 95% CI: 0.45–2.11; p = 0.942) including Fluvastatin-equivalent dosage (OR = 1.00, 95% CI: 0.96–1.03, p = 0.207). Statins were not associated with having a non-fatal MI (OR 1.47, 95% CI: 0.58-3.71; p = 0.416) or preventing fatal MI (OR = 0.40, 95% CI: 0.08–1.93; p = 0.255). Preadmission statin use and associations with clinically diagnosed inpatient MI or survival after inpatient MI were not able to be established.

scholarly journals Hip fracture surgery in mixed-use emergency theatres: is the infection risk increased? A retrospective matched cohort study

2017 ◽  
Vol 99 (8) ◽  
pp. 641-644
Author(s):  
SK Agarwal ◽  
AA Khan ◽  
M Solan ◽  
M Lemon
Keyword(s):  
Hip Fracture ◽  
Laminar Flow ◽  
Surgical Site Infections ◽  
Control Group ◽  
Risk Of Infection ◽  
Hip Fracture Surgery ◽  
Mixed Use ◽  
Increased Risk ◽  
Significant Difference ◽  
Fracture Surgery

Introduction The National Institute of Health and Care Excellence recommends that people with hip fracture should have surgery on the day of, or the day after, admission. However, there remains unacceptable variation in performance around the country, with a range of 13–91% of patients meeting this target. Dedicated trauma lists have insufficient capacity in many hospitals. We occasionally employ a mixed-use emergency theatre to facilitate early surgery. Increased risk of infection has been raised as a concern owing to microbial surface contamination from a preceding unclean case and lack of laminar flow in these theatres. The objective of this study was to investigate whether there is an increased risk of surgical site infections in patients who had hip fracture surgery in a mixed-use emergency theatre. Methods Between August 2010 and July 2014, 74 patients had hip fracture surgery in a mixed-use emergency theatre without laminar flow. This group was compared with a control group of patients who had hip fracture surgery in dedicated orthopaedic theatres with laminar flow. Infection was the primary outcome measured. Results There was no statistically significant difference in the rate of infection, length of stay or 30-day mortality, readmission or reoperation rates between the two groups. Conclusions Operating on hip fractures in mixed-use theatre did not lead to an increase in infection or other complications in our series. We feel that the risk of infection can be balanced against advantages of timely operation and it may therefore be justified to use these theatres when faced with lack of time on the trauma list. A much larger series would be required to investigate the effects of confounders.

scholarly journals Feasibility and preliminary effect of anabolic steroids in addition to strength training and nutritional supplement in rehabilitation of patients with hip fracture: a randomized controlled pilot trial (HIP-SAP1 trial)

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Signe Hulsbæk ◽  
Thomas Bandholm ◽  
Ilija Ban ◽  
Nicolai Bang Foss ◽  
Jens-Erik Beck Jensen ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Strength Training ◽  
Anabolic Steroid ◽  
Nutritional Supplement ◽  
Knee Extension ◽  
Knee Extension Strength ◽  
Hip Fracture Surgery ◽  
Link Type ◽  
Secondary Outcomes ◽  
Fracture Surgery

Abstract Background Anabolic steroid has been suggested as a supplement during hip fracture rehabilitation and a Cochrane Review recommended further trials. The aim was to determine feasibility and preliminary effect of a 12-week intervention consisting of anabolic steroid in addition to physiotherapy and nutritional supplement on knee-extension strength and function after hip fracture surgery. Methods Patients were randomized (1:1) during acute care to: 1. Anabolic steroid (Nandrolone Decanoate) or 2. Placebo (Saline). Both groups received identical physiotherapy (with strength training) and a nutritional supplement. Primary outcome was change in maximal isometric knee-extension strength from the week after surgery to 14 weeks. Secondary outcomes were physical performance, patient reported outcomes and body composition. Results Seven hundred seventeen patients were screened, and 23 randomised (mean age 73.4 years, 78% women). Target sample size was 48. Main limitations for inclusion were “not home-dwelling” (18%) and “cognitive dysfunction” (16%). Among eligible patients, the main reason for declining participation was “Overwhelmed and stressed by situation” (37%). Adherence to interventions was: Anabolic steroid 87%, exercise 91% and nutrition 61%. Addition of anabolic steroid showed a non-significant between-group difference in knee-extension strength in the fractured leg of 0.11 (95%CI -0.25;0.48) Nm/kg in favor of the anabolic group. Correspondingly, a non-significant between-group difference of 0.16 (95%CI -0.05;0.36) Nm/Kg was seen for the non-fractured leg. No significant between-group differences were identified for the secondary outcomes. Eighteen adverse reactions were identified (anabolic = 10, control = 8). Conclusions Early inclusion after hip fracture surgery to this trial seemed non-feasible, primarily due to slow recruitment. Although inconclusive, positive tendencies were seen for the addition of anabolic steroid. Trial registration Clinicaltrials.gov NCT03545347.

Sign in / Sign up

Export Citation Format

Share Document