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Geriatric Fracture: Current Treatment and Future Options

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: 20 December 2024 | Viewed by 8410

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Special Issue Editors

Dr. Detlef Van der Velde

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Guest Editor

Department of Geriatric Trauma, St. Antonius Hospital, Utrecht, The Netherlands
Interests: geriatric trauma; trauma surgery; general surgery; trauma care; healthcare innovation; value-based healthcare

Dr. Henk Jan Schuijt

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Guest Editor

Department of Geriatric Trauma, St. Antonius Hospital, Utrecht, The Netherlands
Interests: geriatric trauma; older adult medicine; trauma surgery; value-based healthcare; implementation science

Special Issue Information

Dear Colleagues,

The age group of older adults is growing rapidly worldwide and is expected to continue to grow. Geriatric traumatology is a rapidly growing subspecialty within orthopedic trauma surgery, and there is increasing demand for scientific studies in this field. Medical decision-making for frail geriatric fracture patients is complex, especially toward the end of life. For example, recent studies in this field have shown that surgery may not always be the best option for very frail geriatric hip fracture patients. The “one-size fits all” approach simply does not apply in geriatric trauma.

If we are to provide patient centered for older adults with fractures, there is need for more insight into treatment options and patient (reported) outcomes, as well as costs. These insights are vital for the advancement of data-driven and value-based healthcare in this field.

For this Special Issue, we welcome authors to submit papers on current treatment options (both operative and non-operative) and patient outcomes for geriatric patients with fractures. We highly recommend research to be conducted by a multidisciplinary team. Additionally, we seek to promote inclusiveness for patients with cognitive impairment. These patients are often selectively excluded from studies in this field, while they might benefit most from them. We look forward to your submissions.

Dr. Detlef Van der Velde
Dr. Henk Jan Schuijt
Guest Editors

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Keywords

geriatric trauma
trauma surgery
orthopedic surgery
fractures
frailty
osteoporosis
older adult medicine

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Published Papers (6 papers)

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12 pages, 1426 KiB

Open AccessArticle

Variability in Care Pathways for Hip Fracture Patients in The Netherlands

by Hanne-Eva van Bremen, Thamar Kroes, Lotta J. Seppala, Emma A. Gans, Johannes H. Hegeman, Nathalie van der Velde and Hanna C. Willems

J. Clin. Med. 2024, 13(16), 4589; https://doi.org/10.3390/jcm13164589 - 6 Aug 2024

Viewed by 805

Abstract

Background/Objectives: Integrated orthogeriatric care has demonstrated benefits in hip fracture management for older patients. Comprehensive care pathways are essential for effective integrated care delivery, yet local variability in care pathways persists. We assessed the current hip fracture care pathways in the Netherlands, focusing on the variability between these care pathways and the degree of implementation of orthogeriatric care. Methods: A nationwide inventory study was conducted. A survey was sent to all hospitals in the Netherlands to collect the care pathways or local protocols for hip fracture care. All care elements reported in the care pathways and protocols were systematically analyzed by two independent researchers. Furthermore, an assessment was performed to determine which model of orthogeriatric care was applied. Results: All 71 Dutch hospitals were contacted, and 56 hospitals responded (79%), of which 46 (82%) provided a care pathway or protocol. Forty-one care elements were identified in total. In the care pathways and protocols, the variability in the description of these individual care elements ranged from 7% to 87%. Twenty-one hospitals had an integrated care model with shared responsibility, while an equal number followed an orthopedic trauma surgeon-led care model. Conclusions: These findings provide a detailed description of the hip fracture care pathways in the Netherlands. Variations were observed concerning the care elements described in the care pathways, the structure of the care pathway, and the specification of several elements. The implementation of integrated care with shared responsibilities, as recommended by the international literature, has not been achieved nationwide. The clinical implications of the variability between care pathways, such as the influence on the quality of care, need to be further investigated. Full article

(This article belongs to the Special Issue Geriatric Fracture: Current Treatment and Future Options)

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13 pages, 732 KiB

Open AccessArticle

Rehabilitation of Frail Older Adults after Hip Fracture Surgery: Predictors for the Length of Geriatric Rehabilitation Stay at a Skilled Nursing Home

by Sanne M. Krakers, Sanne Woudsma, Dieuwke van Dartel, Marloes Vermeer, Miriam M. R. Vollenbroek-Hutten, Johannes H. Hegeman and on behalf of the Up&Go after a Hip Fracture Group

J. Clin. Med. 2024, 13(15), 4547; https://doi.org/10.3390/jcm13154547 - 3 Aug 2024

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Abstract

Background: Approximately 50% of older patients hospitalized for hip fractures are admitted to a geriatric rehabilitation department at a skilled nursing home. Given the wide variation in rehabilitation stay lengths, predicting the length of stay upon hospital discharge would help manage patients’ recovery expectations and create appropriate therapy schedules. Existing literature on length of stay predictors included both acute hospital and in-hospital rehabilitation phases or involved small sample sizes. The present study aims to identify predictors for the length of geriatric rehabilitation stay in skilled nursing homes for older patients after hip fracture surgery upon hospital discharge. Methods: This retrospective cohort study was conducted from 1 October 2017 to 1 July 2023, including 561 patients. Potential predictors of the length of geriatric rehabilitation stay were first tested univariately, with variables showing p < 0.15 entered into a multivariate forward linear regression model. Results: This model identified the following independent predictors of a longer length of geriatric rehabilitation stay: Functional Ambulation Categories (FACs) 0 (B = 29.9, 95% CI 24.1–35.7), 1 (B = 18.0, 95% CI 11.8–24.2), 2 (B = 12.0, 95% CI 7.1–17.0), or 3 (B = 3.6, 95% CI −1.2–9.4) at hospital discharge vs. FAC 4, living independently with home care services (B = 5.9, 95% CI 2.5–9.3) or in a residential home prior to the hip fracture (B = 0.2, 95% CI −7.4–7.8) vs. living independently without home care services, non- or partial weight-bearing mobilization vs. full weight-bearing mobilization (B = 15.4, 95% CI 8.5–22.2), internal fixation vs. hemiarthroplasty (B = 4.7, 95% CI 1.4–7.9), in-hospital delirium (B = 7.0, 95% CI 2.2–11.7), and in-hospital heart failure (B = 7.9, 95% CI 0.5–15.3). The explained variance was 32.0%. Conclusions: This study identified FAC at hospital discharge, premorbid living situation, postoperative weight-bearing protocol, surgery type, in-hospital delirium, and in-hospital heart failure as independent predictors of the length of geriatric rehabilitation stay. Future investigations are needed to identify additional predictors, such as cognitive functioning, to better predict the length of geriatric rehabilitation stay upon hospital discharge. Full article

(This article belongs to the Special Issue Geriatric Fracture: Current Treatment and Future Options)

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11 pages, 863 KiB

Open AccessArticle

Beyond Mortality: Severely Frail Femur Fracture Patients Can Regain Independence after Surgery

by Noa H. M. Ponds, Jochem H. Raats, Devon T. Brameier, Henk Jan Schuijt, Lisa Cooper, Abigail Sagona, Houman Javedan and Michael J. Weaver

J. Clin. Med. 2024, 13(11), 3197; https://doi.org/10.3390/jcm13113197 - 29 May 2024

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Objectives: Little is known about the post-operative functional outcomes of severely frail femur fracture patients, with previous studies focusing on complications and mortality. This study investigated patient- or proxy-reported outcomes after femur fracture surgery in older adult patients with severe frailty. Methods: This was a retrospective cross-sectional study of older adult (>70 years) patients with severe frailty (defined by a Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) ≥ 0.40), who underwent femur fracture surgery at a Level 1 Trauma Center. Patients or their proxy (i.e., close relative) reported mobility, psychosocial, and functional outcomes at least 1-year after surgery. Results: Thirty-seven predominantly female (76%) patients with a median age of 85 years (IQR 79–92), and a median FI-CGA of 0.48 (IQR 0.43–0.54) were included. Eleven patients (30%) regained pre-fracture levels of ambulation, with twenty-six patients (70%) able to walk with or without assistance. The majority of patients (76%) were able to have meaningful conversations. Of the patients, 54% of them experienced no to minimal pain, while 8% still experienced a lot of pain. Functional independence varied, as follows: five patients (14%) could bathe themselves; nine patients (25%) could dress themselves; fourteen patients (39%) could toilet independently; and seventeen patients (47%) transferred out of a (wheel)chair independently. Conclusions: Despite the high risk of mortality and perioperative complications, many of the most severely frail patients with surgically treated femur fractures regain the ability to ambulate and live with a moderate degree of independence. This information can help healthcare providers to better inform these patients and their families of the role of surgical treatment during goals of care discussions. Full article

(This article belongs to the Special Issue Geriatric Fracture: Current Treatment and Future Options)

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11 pages, 662 KiB

Open AccessArticle

The Impact of Implementation of Palliative, Non-Operative Management on Mortality of Operatively Treated Geriatric Hip Fracture Patients: A Retrospective Cohort Study

by Thomas Nijdam, Tim Schiepers, Duco Laane, Henk Jan Schuijt, Detlef van der Velde and Diederik Smeeing

J. Clin. Med. 2024, 13(7), 2012; https://doi.org/10.3390/jcm13072012 - 29 Mar 2024

Cited by 1 | Viewed by 1154

Abstract

(1) Background: Hip fracture patients with very limited life expectancy can opt for non-operative management (NOM) within a palliative care context. The implementation of NOM in the palliative context may affect the mortality of the operatively treated population. This retrospective cohort study aimed to determine whether the operatively treated geriatric hip fracture population would have a lower in-hospital mortality rate and fewer postoperative complications after the introduction of NOM within a palliative care context for patients with very limited life expectancy. (2) Methods: Data from 1 February 2019 to 1 February 2022 of patients aged 70 years or older were analyzed to give a comparison between patients before and after implementation of NOM within a palliative care context. (3) Results: Comparison between 550 patients before and 485 patients after implementation showed no significant difference in in-hospital or 1-year mortality rates (2.9% vs. 1.4%, p = 0.139; 22.4% vs. 20.2%, p = 0.404, respectively). Notably, post-implementation, fewer patients had prior dementia diagnoses (15% vs. 21%, p = 0.010), and intensive care unit admissions decreased (3.5% vs. 1.2%, p = 0.025). (4) Conclusions: The implementation of NOM within a palliative care context did not significantly reduce mortality or complications. However, NOM within palliative care is deemed a more patient-centered approach for geriatric hip fracture patients with very limited life expectancy. Full article

(This article belongs to the Special Issue Geriatric Fracture: Current Treatment and Future Options)

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23 pages, 2426 KiB

Open AccessArticle

Palliative Non-Operative Management in Geriatric Hip Fracture Patients: When Would Surgeons Abstain from Surgery?

by Michael Bui, Catharina G. M. Groothuis-Oudshoorn, Annemieke Witteveen and Johannes H. Hegeman

J. Clin. Med. 2024, 13(6), 1594; https://doi.org/10.3390/jcm13061594 - 11 Mar 2024

Viewed by 1882

Abstract

Background: For hip fracture patients with a limited life expectancy, operative and palliative non-operative management (P-NOM) can yield similar quality of life outcomes. However, evidence on when to abstain from surgery is lacking. The aim of this study was to quantify the influence of patient characteristics on surgeons’ decisions to recommend P-NOM. Methods: Dutch surgical residents and orthopaedic trauma surgeons were enrolled in a conjoint analysis and structured expert judgement (SEJ). The participants assessed 16 patient cases comprising 10 clinically relevant characteristics. For each case, they recommended either surgery or P-NOM and estimated the 30-day postoperative mortality risk. Treatment recommendations were analysed using Bayesian logistic regression, and perceived risks were pooled with equal and performance-based weights using Cooke’s Classical Model. Results: The conjoint analysis and SEJ were completed by 14 and 9 participants, respectively. Participants were more likely to recommend P-NOM to patients with metastatic carcinomas (OR: 4.42, CrI: 2.14–8.95), severe heart failure (OR: 4.05, CrI: 1.89–8.29), end-stage renal failure (OR: 3.54, CrI: 1.76–7.35) and dementia (OR: 3.35, CrI: 1.70–7.06). The patient receiving the most P-NOM recommendations (12/14) had a pooled perceived risk of 30-day mortality between 50.8 and 62.7%. Conclusions: Overall, comorbidities had the strongest influence on participants’ decisions to recommend P-NOM. Nevertheless, practice variation and heterogeneity in risk perceptions were substantial. Hence, more decision support for considering P-NOM is needed. Full article

(This article belongs to the Special Issue Geriatric Fracture: Current Treatment and Future Options)

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12 pages, 541 KiB

Open AccessSystematic Review

Reverse Shoulder Arthroplasty versus Non-Operative Treatment of Three-Part and Four-Part Proximal Humerus Fractures in the Elderly Patient: A Pooled Analysis and Systematic Review

by Thomas P. Bosch, Frank J. P. Beeres, Steven Ferree, Inger B. Schipper, Roland S. Camenzind, Ruben J. Hoepelman, Björn-Christian Link, Ingmar F. Rompen, Reto Babst and Bryan J. M. van de Wall

J. Clin. Med. 2024, 13(11), 3344; https://doi.org/10.3390/jcm13113344 - 6 Jun 2024

Cited by 1 | Viewed by 1244

Abstract

Background: The treatment of complex proximal humerus fractures in elderly patients is not yet fully elucidated. Of all treatment options, reverse shoulder arthroplasty (RSA) and non-operative treatment (NOT) appear to provide the best results. Evidence to guide the choice between the two is sparse. Therefore, this review provides an overview of the available evidence on RSA versus NOT. Methods: Studies comparing complex proximal humerus fractures in patients aged >65 years treated either with RSA or NOT were included for systematic review and direct comparison via pooled analysis of patient-rated outcome and range of motion. Indirect comparison of case series and non-comparative studies on either treatment was performed separately. Results: Three comparative studies including 77 patients treated with RSA and 81 treated non-operatively were analysed. The RSA group scored better for both the Constant–Murley score (mean difference 6 points) and DASH score (mean difference 8 points). No differences were detected in ASES, PENN score, pain scores, or range of motion between treatment groups. The most common complications for RSA were infection (3%), nerve injury (2%), and dislocation (2%). Reoperation was required in 5%. In the NOT group, common complications included malunion (42%), osteonecrosis (25%), and non-union (3%); no reoperation was required. Patient satisfaction was equal in both groups. Conclusions: The functional outcomes and range of motion after RSA seemed satisfactory and potentially superior to NOT in elderly patients. Patient satisfaction was comparable despite a high malunion and osteonecrosis rate in the non-operative treatment group, which did not require re-interventions. Full article

(This article belongs to the Special Issue Geriatric Fracture: Current Treatment and Future Options)

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