Lauren A. Beaupre

Background. It is largely unknown whether functional recovery following hip fracture differs between long-term care (LTC) and community-dwelling residents. Our primary purpose was to compare recovery between these patients 6 months following hip fracture, controlling for known prognostic factors. Secondarily, we examined the contribution of residential status, in addition to patient characteristics, to functional recovery. Methods. We studied a population-based inception cohort of 451 hip fracture patients ≥ 65 years old admitted to one Canadian health region hospital between July 1999 and September 2000. Participants completed the Modified Barthel Functional Index (MBI) in hospital and again via telephone interviews 6 months postoperatively. Data were also collected on surgery and rehabilitation timing, length of hospital stay (LOS). and discharge destination. Relative change from prefracture function adjusting for known prognostic factors, and the proportion of participants returning to prefracture function were compared between the LTC and community-dwelling residents. Results. LTC residents (n = 115) were older, with lower function prefracture, more comorbidities, and increased dementia than community-dwelling residents (n = 336). Six months postfracture, 17 (22%) LTC and 180 (71%) community-dwelling residents had regained prefracture function (p <.001). LTC residents had 33% lower (−40.6, −27.2) and community-dwelling residents 11.6% lower (−14.8, −8.4) 6-month MBI scores relative to prefracture scores after risk adjustment. Residential status was significantly associated with risk-adjusted functional recovery (p <.001). Median LOS was 4 days less for LTC than for community-dwelling residents (p <.001). Twelve (10%) LTC and 266 (79%) community-dwelling residents were discharged to inpatient rehabilitation (p <.001). Conclusion. Following hip fracture, most LTC residents do not regain prefracture function irrespective of known prognostic factors. Further investigation is needed as to the extent to which personal and environmental characteristics contribute to outcome after hip fracture.

Infection after total hip replacement (THR) is a serious medical complication with significant negative ramifications for both the patient and the health care system. The prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) was designed to treat the joint infection while maintaining functional movement in the hip. We identified 28 patients treated for infected THR with the PROSTALAC system, by retrospective chart review. Preoperative and intraoperative cultures were taken to identify the causative organism. After PROSTALAC insertion, patients underwent at least 6 weeks of intravenous (IV) antibiotics. Prior to undergoing posttreatment cultures, patients were required to be antibiotic-free for a minimum of 6 weeks, with normal laboratory values. We defined resolution infection as retention of a joint prosthesis for a minimum of 2 years. Infection was identified in 28 patients in either the joint aspirate or intraoperative cultures. Of these patients, 2 failed to clear infection, requiring repeat PROSTALAC insertion. Two additional patients had positive 48-hour cultures post-second stage, treated with additional IV antibiotics. Retention of the post-PROSTALAC prosthesis is 100% at 2 years. PROSTALAC has acceptable infection resolution outcomes and appears effective for treating infected THR.

Infection after total hip replacement (THR) adversely affects patients' function and health-related quality of life (HRQL). A prosthesis with antibiotic-loaded acrylic cement (PROSTALAC) was designed to improve the function and quality of life of patients undergoing treatment for infected THR. We assessed 23 patients with the PROSTALAC implant in situ for treatment of an infected THR for function and HRQL, using standardized outcome measures. These patients were compared with a referent cohort of patients who had undergone assessment of function and HRQL before and 6 months after primary THR in the same tertiary health centres. The mean (standard deviation) Western Ontario MacMaster (WOMAC) scores for PROSTALAC patients were 70.0 (21.1), 65.8 (20.4) and 63.0 (21.1) for pain, stiffness and function, respectively. The median Harris Hip score was 62.3 (minimum 20.4, maximum 86.3) and median global hip range of motion was 100.0 (minimum 80.0, maximum 140.0) degrees. The mean WOMAC scores for pain, stiffness and function were better than they were for patients awaiting THR but not as good as 6 months after primary THR. The PROSTALAC implant allows patients to have reasonable function and quality of life during the interim treatment for deep joint infection.

Background: Hip fractures, common in the elderly population, result in significant morbidity and mortality. A study was undertaken to determine how an evidence based clinical pathway (CP) for treatment of elderly patients with hip fracture affected morbidity, in-hospital mortality, and health service utilization. Methods: A pre-post study design using two population based inception cohorts of hip fracture patients aged ⩾65 years was used. The control group (n = 678) was enrolled between July 1996 and September 1997 before implementation of the pathway and the CP group (n = 663) was enrolled between July 1999 and September 2000 following pathway implementation. Chart reviews were completed during study time frames to determine complications, mortality, and health service utilization. Results: Only nine patients (1%) in the CP group experienced postoperative congestive heart failure compared with 37 (5%) control patients (pv 36 (5%); pConclusion: Implementation of an evidence based clinical pathway reduced postoperative morbidity and did not affect in-hospital mortality or overall costs of inpatient care. The effect of changing trends in medical care cannot be ruled out, but the reduction in complications in several clinical areas lends support to the positive impact of the clinical pathway. Perioperative CP is one successful management approach for this fragile patient population as patient morbidity was reduced without negatively affecting resource utilization.

Background and Purpose. The primary purpose of this randomized controlled trial was to determine which method of mobilization—(1) standardized exercises (SE) and continuous passive motion (CPM), (2) SE and slider board (SB) therapy, using an inexpensive, nontechnical device that requires minimal knee active range of motion (ROM), or (3) SE alone—achieved the maximum degree of knee ROM in the first 6 months following primary total knee arthroplasty (TKA). The secondary purpose was to compare health-related quality of life among these 3 groups. Subjects. The subjects were 120 patients (n=40/group) who received a TKA at a teaching hospital between June 1997 and July 1998 and who agreed to participate in the study. Methods. Subjects were examined preoperatively, at discharge, and at 3 and 6 months after surgery. The examination consisted of measurement of knee ROM and completion of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Results. The 3 treatment groups were similar with respect to age, sex, and diagnosis at the start of the study. There were no differences in knee ROM or in WOMAC Osteoarthritis Index or SF-36 scores at any of the measurement intervals. The rate of postoperative complications also was not different among the groups. Discussion and Conclusion. When postoperative rehabilitation regimens that focus on early mobilization of the patient are used, adjunct ROM therapies (CPM and SB) that are added to daily SE sessions are not required. Six months after TKA, patients attain a satisfactory level of knee ROM and function.