Orthopaedic management improves the rate of early osteoporosis treatment after hip fracture. A randomized clinical trial. Development and delivery of patient treatment in the Trondheim Hip Fracture Trial. A new geriatric in-hospital pathway for elderly patients with hip fracture Use of Nonpharmacologic Interventions for Pain and Anxiety After Total Hip and Total Knee Arthroplasty Translating research into practice intervention improves management of acute pain in older hip fracture patients. Fracture prevention service to bridge the osteoporosis care gap The management of intracapsular hip fractures in the 'young elderly' internal fixation or total hip replacement? Fascia Iliaca Compartment Blockade for Acute Pain Control in Hip Fracture Patients: A Randomized, Placebo-controlled Trial Osteoporosis case manager for patients with hip fractures: results of a cost-effectiveness analysis conducted alongside a randomized trial. Comprehensive care improves health outcomes among elderly Taiwanese patients with hip fracture. Depression and osteoarthritis. The effect of emergency department crowding on the management of pain in older adults with hip fracture. Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults. Effect of osteosynthesis, primary hemiarthroplasty, and non-surgical management for displaced four-part fractures of the proximal humerus in elderly: a multi-centre, randomised clinical trial Counseling, quality of life, and acute postoperative pain in elderly patients with hip fracture Facilitated bone mineral density testing versus hospital-based case management to improve osteoporosis treatment for hip fracture patients: additional results from a randomized trial. Use of an Intramedullary Hip-Screw Compared with a Compression Hip-Screw with a Plate for Intertrochanteric Femoral Fractures. A Prospective, Randomized Study of One Hundred Patients* Comprehensive and subacute care interventions improve health-related quality of life for older patients after surgery for hip fracture: a randomised controlled trial. Effectiveness of a multidisciplinary team approach to hip fracture management. Use of a case manager to improve osteoporosis treatment after hip fracture: results of a randomized controlled trial. Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized trial. An Orthopedic-Hospitalist Comanaged Hip Fracture Service Reduces Inpatient Length of Stay Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement. Hip fracture prevention with a multifactorial educational program in elderly community-dwelling Finnish women
BACKGROUND Although osteoporosis is strongly associated with hip fractures , the initiation of osteoporosis treatment following hip fractures occurs at surprisingly low rates of between 5 % and 30 % . Currently , most patients receiving treatment have been referred back to their primary care physician for osteoporosis management . The purpose of this study was to compare the effect of osteoporosis management initiated by the orthopaedic team and osteoporosis management initiated by the primary care physician on the rates of treatment at six months . METHODS A prospect i ve r and omized trial was conducted to assess the difference in the rate of osteoporosis treatment  when an in-house assessment of osteoporosis was initiated by the orthopaedic surgeon and follow-up was conducted in a specialized orthopaedic osteoporosis clinic compared with osteoporosis education and " usual " care . RESULTS Sixty-two patients were enrolled in the study . Thirty-one patients each were in the control and intervention groups . The percentage of patients who were on pharmacologic treatment for osteoporosis  at six months after the fracture was significantly greater when the evaluation was initiated by the orthopaedic surgeon and was managed in a specialized orthopaedic osteoporosis clinic ( 58 % ) than when treatment was managed by a primary care physician ( 29 % ) ( p = 0.04 ) . CONCLUSIONS An active role by orthopaedic surgeons in the management of osteoporosis improves the rate of treatment at six months following a hip fracture Background Hip fractures are common among frail elderly persons and often have serious consequences on function , mobility and mortality . Traditional treatment of these patients is performed in orthopedic departments without additional geriatric assessment . However , studies have shown that interdisciplinary geriatric treatment may be beneficial compared to traditional treatment . The aim of the present study is to investigate whether treatment of these patients in a Department of Geriatrics ( DG ) during the entire hospital stay gives additional benefits as compared to conventional treatment in a Department of Orthopaedic Surgery ( DOS ) . Findings A new clinical pathway for in-hospital treatment of hip fracture patients was developed . In this pathway patients were treated pre- and postoperatively in DG .  Comprehensive geriatric assessment  was performed as an interdisciplinary , multidimensional , systematic assessment of all patients focusing on each patient ’s capabilities and limitations as recommended in guidelines and systematic review s. Identification and treatment of co-morbidities , pain relief , hydration , oxygenation , nutrition , elimination , prevention and management of delirium , assessment of falls and osteoporosis were emphasized .  Discharge planning  started as early as possible . Initiation of rehabilitation with focus on early mobilisation and development of individual plans was initiated in hospital and continued after discharge from hospital . Fracture specific treatment was based upon st and ard treatment for the hospital , expert opinions and a review of the literature . Conclusion A new treatment program for old hip fracture patients was developed , introduced and run in the DG , the potential benefits of which being compared with traditional care of hip fracture patients in the DOS in a r and omised clinical trial PURPOSE The purpose of this study was to compare pain and anxiety in orthopaedic patients scheduled for elective total hip or knee arthroplasty who have received a kit of nonpharmacologic strategies for pain and anxiety in addition to their regularly prescribed analgesics to those who receive the usual pharmacologic management alone . DESIGN Descriptive comparative and correlational design using surveys and chart audits . SAMPLE Sixty-five patients r and omized to receive usual care or usual care plus a kit of nonpharmacologic strategies .  FINDINGS Patients who received the kit used nonpharmacologic measures for pain and anxiety more often than patients who did not receive the kit . The kit group tended to use less opioid and have less anxiety on postoperative day 1 ( not statistically significant ) and use significantly less opioid on postoperative day 2 than the patients who did not receive the kit . There were no between-group differences in pain intensity . There were significant correlations among postoperative pain intensity , opioid use , and anxiety . The coping method of diverting attention was related to lower present ( now ) pain scores , and ignoring the pain was associated with higher worst pain . DISCUSSION Providing a kit of nonpharmacologic strategies can increase the use of these methods for postoperative pain and anxiety and decrease the amount of opioid taken . The influence of coping strategies in acute postoperative pain needs to be examined further OBJECTIVE To test an interdisciplinary , multifaceted , translating research into practice ( TRIP ) intervention to ( a ) promote adoption , by physicians and nurses , of evidence -based ( EB ) acute pain management practice s in hospitalized older adults , ( b ) decrease barriers to use of EB acute pain management practice s , and ( c ) decrease pain  intensity of older hospitalized adults . STUDY DESIGN Experimental design with the hospital as the unit of r and omization . STUDY SETTING Twelve acute care hospitals in the Midwest . DATA SOURCES ( a ) Medical records ( MRs ) of patients > or = 65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and ( b ) physicians and nurses who care for those patients . DATA COLLECTION Data were abstract ed from MRs and questions distributed to nurses and physicians . PRINCIPAL FINDINGS The Summative Index for Quality of Acute Pain Care ( 0 - 18 scale ) was significantly higher for the experimental ( 10.1 ) than comparison group ( 8.4 ) at the end of the TRIP implementation phase . At the end of the TRIP implementation phase , patients in the experimental group had a lower mean pain intensity rating than those in the comparison group ( p<.0001 ) . CONCLUSION The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture Background A care gap exists between the health care needs of older persons with fragility fractures and the therapeutic answers they receive . The Fracture Prevention Service ( FPS ) , a tailored in-hospital model of care , may effectively bridge the osteoporosis care gap for hip-fractured older persons . The purpose of this study was to evaluate the efficacy of the FPS in targeting persons at high risk of future fracture and to improve their adherence to treatment . Methods This was a prospect i ve observational study conducted in a teaching hospital with traumatology and geriatric units , and had a pre-intervention and post-intervention phase . The records of 172 participants were evaluated in the pre-intervention phase , while data from 210 participants were gathered in the post-intervention phase . All participants underwent telephone follow-up at 12 months after hospital discharge . The participants were patients aged ≥65 years admitted to the orthopedic acute ward who underwent surgical repair of a proximal femoral fracture . A multidisciplinary integrated model of care was established . Dedicated pathways were implemented in clinical practice to optimize the identification of high-risk persons , improve their evaluation through bone mineral density testing and blood examinations , and initiate an appropriate treatment for secondary prevention of falls and fragility fractures . Results Compared with the pre-intervention phase , more hip-fractured persons received bone mineral density testing ( 47.62 % versus 14.53 % , P<0.0001 ) , specific pharmacological treatments ( 48.51 % versus 17.16 % , P<0.0001 ) , and an appointment for evaluation at a fall and fracture clinic ( 52.48 % versus 2.37 % , P<0.0001 ) in the post-intervention phase . Independent of some confounders , implementation of the FPS was positively associated with recommendations for secondary fracture prevention at discharge ( P<0.0001 ) and with 1-year adherence to pharmacological treatment ( P<0.0001 ) . Conclusion The FPS is an effective multidisciplinary integrated model of care to optimize identification of older persons at highest risk for fragility fracture , to improve their clinical management , and to increase adherence to prescriptions There is a lack of consensus about how to treat intracapsular hip fractures in the ' young elderly ' ( 50 - 75 years ) . Evidence for older more mobile patients seems to point towards Internal Fixation ( IF ) for undisplaced fractures and Total Hip Replacement ( THR ) for displaced fractures . Radiographs of 263 patients from the Norfolk and Norwich University Hospital , who have suffered an intracapsular hip fracture between 2000 - 2009 were review ed . The complication and mortality rates were noted . A Hip function question naire ( Oxford hip score ( OHS ) ) and Numeric pain score ( NPS ) were sent out to patients , then methods of treatment ( IF and THR ) were compared . In displaced fractures THR compared favourably to IF , OHS ( 16.0 vs. 20.0 p 0.029 ) , NPS ( 2.0 vs. 4.0 p 0.007 ) , complications ( Odds Ratio ( OR ) 2.90 ; p 0.006 ) and death rate ( OR 3.61 ; p 0.007 ) . Although not statistically significant when stratified for age , the youngest age group ( 50 - 60 ) still achieved better function with a THR ( 13.0 vs. 18.0 ; p 0.129 ) . There was little difference in the results for undisplaced fractures . This retrospective cross-sectional study showed IF is associated with a much higher complication rate than THR for patients who sustained a displaced hip fracture . THR also showed a better functional outcome and reduced pain .  IF should be used in undisplaced fractures as there was no difference in functional outcome or complication rate . A large r and omised controlled trial is needed to confirm these results Background : Hip fracture patients are in severe pain upon arrival at the emergency department . Pain treatment is traditionally based on systemic opioids . No study has examined the effect of fascia iliaca compartment blockade ( FICB ) in acute hip fracture pain management within a double-blind , r and omized setup . Methods : Forty-eight patients with suspected hip fracture were included immediately after arrival in the emergency department , before x-ray confirmation of their fracture . Included patients were r and omly assigned to two groups of 24 . In the FICB group , the patients received an FICB with 1.0 % mepivacaine and a placebo intramuscular injection of isotonic saline . In the morphine group , the patients received a placebo FICB with 0.9 % saline and an intramuscular injection of 0.1 mg/kg morphine . Patients received intravenous rescue morphine when necessary . Results : Maximum pain relief was superior in the FICB group both at rest ( P < 0.01 ) and on movement ( P = 0.02 ) . The median total morphine consumption was 0 mg ( interquartile range , 0–0 mg ) in the FICB group and 6 mg ( interquartile range , 5–7 mg ) in the morphine group ( P < 0.01 ) . More patients ( P = 0.05 ) were se date d in the morphine group at 180 min after block placement as compared with the FICB group . Conclusion : Pain relief was superior at all times and at all measurements in the FICB group . The study supports the use of FICB in acute management of hip fracture pain because it is an effective , easily learned procedure that also may reduce opioid side effects in this fragile , elderly group of patients BACKGROUND In a r and omized trial of patients with hip fractures , we previously demonstrated that a hospital-based case manager could increase rates of appropriate osteoporosis treatment to 51 % compared with 22 % for usual care ( P < .001 ) . Alongside that trial , we conducted an economic analysis . METHODS Patients with hip fractures were r and omized to usual care ( n = 110 ) or a case manager ( n = 110 ) and followed up for 1 year . Time-motion studies were used to determine intervention costs . From a third-party health care payer perspective and over the patient 's remaining lifetime , a Markov decision-analytic model was constructed to determine  cost-effectiveness  of the intervention compared with usual care .  Costs and benefits were discounted at 3 % and expressed in 2006 Canadian dollars . RESULTS The intervention cost CaD $ 56 per patient . Compared with usual care , the intervention strategy was dominant : for every 100 patients case managed , 6 fractures ( 4 hip fractures ) were prevented , 4 quality -adjusted life-years were gained , and CaD $ 260 000 was saved by the health care system . Irrespective of the number of patients case managed , the intervention reached a break-even threshold within 2 years . The intervention dominated usual care over the entire spectrum of 1-way sensitivity analyses and was cost-saving in 82 % of probabilistic model simulations . CONCLUSIONS Compared with usual care , we found that using a case manager for patients with hip fractures increased rates of appropriate osteoporosis treatment . The intervention dominated usual care , and the analysis suggests that systems implementing an intervention similar to ours should expect to see a reduction in fractures , gains in life expectancy , and substantial cost savings . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00175175 BACKGROUND Few studies have investigated the effects of care models that combine interdisciplinary care with nutrition consultation , depression management , and fall prevention in older persons with hip fracture . The purpose of this study was to compare the effects of a comprehensive care program with those of interdisciplinary care and usual care for elderly patients with hip fracture . METHODS A r and omized experimental trial was used to explore outcomes for 299 elderly patients with hip fracture receiving three treatment care models : interdisciplinary care ( n = 101 ) , comprehensive care ( n = 99 ) , and usual care ( n = 99 ) .  Interdisciplinary care included geriatric consultation , continuous rehabilitation , and discharge planning with post-hospital services . Comprehensive care consisted of interdisciplinary care plus nutrition consultation , depression management , and fall prevention . Usual care included only in-hospital rehabilitation without geriatric consultation , in-home rehabilitation , and home environmental assessment . RESULTS Participants in the comprehensive care group had better self-care ability ( odds ratio , OR = 3.19 , p < .01 ) and less risk of depression ( OR = 0.48 , p < .01 ) than those who received usual care . The comprehensive care group had less risk of depression ( OR = 0.51 , p < .05 ) and of malnutrition ( OR = 0.48 , p < .05 ) than the interdisciplinary care group during the first year following discharge . Older persons with hip fracture benefitted more from the comprehensive care program than from interdisciplinary care and usual care . CONCLUSIONS Older persons with hip fracture benefitted more from comprehensive care including interdisciplinary care and nutrition consultation , depression management , and fall prevention than simply interdisciplinary care Depression is significant among patients with arthritis and musculoskeletal illnesses . However , the impact of depression on osteoarthritis has not been extensively studied . This article highlights the close links between these 2 prevalent chronic conditions , and the associated individual and societal burden . Results from a large clinical trial of depressed older patients with arthritis showed that a focused , collaborative depression care intervention not only decreased depression but also improved arthritis-associated outcomes , such as pain severity and arthritis-related limitations in daily activities . Relative to patients given usual care , patients receiving intervention also reported better health status and higher quality of life . Analyses of the depression interventions uncovered a reciprocal interrelation between depression and pain . Higher severity of either depression or pain decreased the benefits of systematic depression treatment and was associated with worse pain and depression outcomes . Current approaches to management of depression and arthritis do not reflect readily-available evidence -based treatment . A pilot study using a combined approach to address both depression and pain problems among elderly patients with depression and osteoarthritis suggested that benefits for depression , pain , and functional outcomes are strengthened by providing both  pain and depression care management . An integrated depression and pain program using evidence d-based pharmacologic and nonpharmacologic treatments is needed to achieve optimal depression and pain outcomes . Currently , a r and omized trial is under way to evaluate effectiveness of a combined pain and depression intervention using pharmacologic and nonpharmacologic therapies . Key intervention components in these 2 innovative and integrated depression and pain programs can guide clinicians to treat both depression and pain with more focus and intensity OBJECTIVES To evaluate the effect of emergency department ( ED ) crowding on assessment and treatment of pain in older adults . DESIGN Retrospective review of ED records from a prospect i ve cohort study . SETTING Urban , academically affiliated , tertiary medical center . PARTICIPANTS One hundred fifty-eight patients , aged 50 and older , evaluated and hospitalized from the ED with hip fracture . MEASUREMENTS Patient-related risk factors : age , sex , nursing home residence , ED triage status , dementia , Acute Physiology in Age and Chronic Health Evaluation II physiological score , and R AND comorbidity score . ED crowding risk factors : ED census and mean length of stay . OUTCOMES documentation of pain assessment , time to pain assessment , time to pain treatment , patients reporting pain receiving analgesia , and meperidine use . RESULTS Mean age was 83 ( range 52 - 101 ) , 81.0 % of patients complained of pain , mean time to pain assessment was 40 minutes ( range 0 - 600 ) , time to treatment was 141 minutes ( range 10 - 525 ) , and mean delay to treatment was 122 minutes ( range 0 - 526 ) . Of those with pain , 35.9 % received no analgesia , 7.0 % received nonopioids , and 57.0 % received opioids . Of those receiving opioids , 32.8 % received meperidine . ED crowding at census levels greater than 120 % bed capacity was significantly associated with a lower likelihood of documentation of pain assessment ( P = .05 ) and longer times to pain assessment ( P = .01 ) . CONCLUSION Older adults with hip fracture are at risk for under assessment of pain , considerable delays in analgesic administration after pain is identified , and treatment with inappropriate analgesics ( e.g. , meperidine ) in the ED . Higher levels of ED census are significantly associated with poorer pain management OBJECTIVES To model the incremental cost-utility of seven interventions reported as effective for preventing falls in older adults . DESIGN Mathematical epidemiological model populated by data based on direct clinical experience and a critical review of the literature . SETTING Model represents population level interventions . PARTICIPANTS No human subjects were involved in the study . MEASUREMENS : The last Cochrane data base review and meta-analyses of r and omized controlled trials categorized effective fall-prevention interventions into seven groups : medical management ( withdrawal ) of psychotropics , group tai chi , vitamin D supplementation , muscle and balance exercises , home modifications , multifactorial individualized programs for all elderly people , and multifactorial individualized treatments for high-risk frail elderly people . Fall-related hip fracture incidence was obtained from the literature . Salary figures for health professionals were based on Bureau of Labor Statistics data . Using an integrated healthcare system perspective , healthcare costs were estimated based on practice and studies on falls in older adults . Base case incremental cost utility ratios were calculated , and probabilistic sensitivity analyses were conducted . RESULTS Medical management of psychotropics and group tai chi were the least-costly , most-effective options , but they were also the least studied . Excluding these interventions , the least-expensive , most-effective options are  vitamin D supplementation and home modifications . Vitamin D supplementation costs less than home modifications , but home modifications cost only $ 14,794/ quality -adjusted life year ( QALY ) gained more than vitamin D. In probabilistic sensitivity analyses excluding management of psychotropics and tai chi , home modification is most likely to have the highest economic benefit when QALYs are valued at $ 50,000 or $ 100,000 . CONCLUSION Of single interventions studied , management of psychotropics and tai chi reduces costs the most . Of more-studied interventions , home modifications provide the best value . These results must be interpreted in the context of the multifactorial nature of falls Background Fractures of the proximal humerus are common injuries and account for 4–5 percent of all fractures , second only to hip and wrist fractures . The incidence is positively correlated with age and osteoporosis , and is likely to increase . Displaced four-part fractures are among the most severe injuries , accounting for 2–10 percent of proximal humeral fractures . The optimal intervention is disputed . Two previous r and omised trials were very small and involved a noticeable risk of bias , and systematic review s consequently conclude that there is inadequate basis for evidence -based treatment decisions . We aim to compare the effect of osteo synthesis with angle-stable plate with non-surgical management , and the effect of  primary hemiarthroplasty  with both osteo synthesis and non-surgical management . Methods / Design We will conduct a r and omised , multi-centre , clinical trial including patients from ten national shoulder units within a two-year period . We plan to include 162 patients . A central r and omisation unit will allocate patients . All patients will receive a st and ardised three-month rehabilitation program of supervised physiotherapy regardless of treatment allocation . Patients will be followed at least one year . The primary outcomes will be the overall score on the Constant Disability Scale , and its pain subscale , measured at 12 months . A blinded physiotherapist will carry out the assessment s. Other secondary outcomes are Oxford Shoulder Score , and general health status ( Short Form-36 ) Introduction Hip fractures represent one of the most important causes of morbidity and mortality in elderly people . Anxiety and depression affect their quality of life and increase pain severity , and have adverse effects on functional recovery . Recent World Health Organization guidelines emphasize that therapeutic regimes need to be individualized and combined with psychological support . This study was launched with the primary endpoint of assessing if and to what extent client-centered therapy affects the perception of pain , reduces anxiety and depression , and increases the quality of life of elderly patients with hip fracture . Material s and methods Forty patients were admitted to the Orthopedic and Trauma Surgery ward for hip fracture . Patients were r and omly divided into two subgroups : ( 1 ) case ( group C ) , had to receive patient-centered counseling throughout the hospitalization ; and ( 2 ) control ( group NC ) , receiving the analgesic treatment without receiving counseling .  Short Form-36-item Health Survey Question naire , State – Trait Anxiety Inventory , and Hamilton Rating Scale for Depression scores were recorded before any treatment , at discharge , and after 30 days . Pain levels were evaluated by means of Visual Analog Scale every 12 hours during the hospitalization from the day of surgery until day 5 . Results The hierarchical clustering analysis identified before any treatment were two clusters based on different physical functioning perceptions and role limitations , which were due to physical and emotional problems . Counseling did have a positive impact on quality of life on all patients , but in a more relevant way if patients were low functioning upon admittance to the ward . Anxiety and depression decreased in patients undergoing counseling , and their pain levels were lower than among patients not receiving it . Conclusion This study reveals that hip fracture patients can be clustered on the basis of Short Form-36 baseline scores . Counseling affects the evolution of mental and physical status in these patients , and the major benefit is reported in patients whose quality of life perception is worse after the trauma . Decreasing anxiety and depression levels , as well as more satisfying pain management , assessed by means of specific tests , confirm the effectiveness of counseling in elderly patients with hip fracture OBJECTIVE We previously demonstrated that a case manager intervention improved  osteoporosis  ( OP ) treatment within 6 months of hip fracture compared with usual care . The second phase of the r and omized trial compared a less intensive intervention , facilitated bone mineral density ( BMD  )  testing , with usual care and the case manager intervention . METHODS We initially r and omized 220 hip fracture patients to either an OP case manager intervention or usual care . After completing the original trial at 6 months postfracture , usual care patients were reallocated to facilitated BMD testing ; BMD tests were arranged and results sent to primary care physicians . Main outcomes ( bisphosphonate treatment , BMD tests , receipt of appropriate care ) were reascertained 1 year following hip fracture and compared with outcomes achieved by the OP case manager intervention and usual care . RESULTS Compared with usual care , facilitated BMD testing increased testing from 29 % to 68 % ( P < 0.001 ) , bisphosphonate use from 22 % to 38 % ( P < 0.001 ) , and receipt of appropriate care from 26 % to 45 % ( P < 0.001 ) . The more intensive ( 70 versus 30 minutes ) and expensive ( $ 56 versus $ 24 Canadian per patient ) OP case manager intervention led to significantly higher bisphosphonate use ( 54 % versus 38 % ; P = 0.03 ) , receipt of appropriate care ( 71 % versus 45 % ; P < 0.001 ) , and more BMD testing ( 80 % versus 68 % ; P = 0.06 ) than usual care followed by facilitated BMD testing . CONCLUSION Compared with usual care , 2 different inexpensive interventions result ed in significant increases in appropriate management of OP after hip fracture . The magnitude of improvements achieved was directly related to the intensity of the interventions One hundred elderly patients who had an intertrochanteric femoral fracture were r and omized to treatment with a compression hip-screw with a plate ( fifty patients ) or a  new intramedullary device , the intramedullary hip-screw ( fifty patients ) . All patients were followed prospect ively for one year or until death . A detailed assessment of the functional status and the plain radiographs of the hip was performed one , three , six , and twelve months postoperatively . The two treatment groups were strictly comparable . The operative time needed to insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw with the plate ( p = 0.02 ) , but use of the intramedullary hip-screw was associated with less estimated intraoperative blood loss ( p = 0.011 ) . The prevalence of perioperative complications , such as bronchopneumonia , cardiac failure , and urinary tract infection , was comparable in the two treatment groups . There were one intraoperative fracture of the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the intramedullary hip-screw . One patient had pulling-out of the compression hip-screw on the seventh postoperative day . Four patients had a trochanteric wound hematoma , without infection , after insertion of an intramedullary hip-screw . All but one of the fractures healed . The one non-union , which was in a patient who had a compression hip-screw , was treated with a hemiarthroplasty . The mortality rate was similar in the two treatment groups . The patients who had an intramedullary hip-screw had , on the average , significantly better mobility at one ( p < 0.0001 ) and three months ( p = 0.0013 ) postoperatively . This difference was no longer seen at six and twelve months , although the patients who had an intramedullary hip-screw still had significantly better walking ability outside the home at those time-periods ( p = 0.05 ) . The compression hip-screw was removed from two patients because of pain in the mid-portion of the thigh , which had begun after consolidation of the fracture . Fourteen patients who had an intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at twelve months postoperatively . Cortical hypertrophy was significantly related to the use of two interlocking screws ( p = 0.02 ) . Six of these patients also had pain in the mid-portion of the thigh , and the nail had been locked with two screws in five of them . Three of the six patients had the hardware removed because of the pain , and the symptoms resolved . A seventh patient had pain without cortical hypertrophy . The intramedullary hip-screw device was associated with significantly less sliding of the lag-screw and subsequent shortening of the limb in the region of the thigh ( p = 0.012 and 0.019 , respectively ) ; these differences were more pronounced when the unstable fractures in the two treatment groups were compared ( p < 0.001 ) BACKGROUND Elderly patients with hip fracture have been found to benefit from subacute care interventions that usually comprise usual care with added geriatric intervention , early rehabilitation , and supported discharge . However , no studies were found on the effects of combining subacute care and health-maintenance interventions on health outcomes for elders with hip fracture . OBJECTIVES To compare the effects of an interdisciplinary comprehensive care programme with those of subacute care and usual care programmes on health-related quality of life ( HRQoL ) for elderly patients with hip fracture . DESIGN R and omised controlled trial . SETTING S A 3000-bed medical centre in northern Taiwan . PARTICIPANTS Patients with hip fracture ( N=299 ) were r and omised into three groups : subacute care ( n=101 ) , comprehensive care ( n=99 ) , and usual care ( n=99 ) . METHODS Subacute care included geriatric consultation , continuous rehabilitation , and discharge planning . Comprehensive care consisted of subacute care plus health-maintenance interventions to manage depressive symptoms , manage malnutrition , and prevent falls . Usual care included only 1 - 2 in-hospital rehabilitation sessions , discharge planning without environmental assessment , no geriatric consultation , and no in-home rehabilitation .  HRQoL was measured using the Medical Outcomes Study Short-Form 36 Taiwan version at 1 , 3 , 6 , and 12 months after discharge . RESULTS Participants in the comprehensive care group improved more in physical function , role physical , general health and mental health than those in the usual care group . The subacute care group had greater improvement in physical function , role physical , vitality , and social function than the usual care group . The intervention effects for both comprehensive and subacute care increased over time , specifically from 6 months after hip fracture onward , and reached a maximum at 12 months following discharge . CONCLUSIONS Both comprehensive care and subacute care programmes may improve health outcomes of elders with hip fracture . Our results may provide a reference for health care providers in countries using similar programmes with Chinese/Taiwanese immigrant population The purpose of the current study was to evaluate the effectiveness of a multidisciplinary Hip Fracture Service in the treatment of hip fractures in elderly patients . Baseline information and hospital outcomes were compared for 510 patients over the age of 65 with hip fracture treated before and after the institution of the Hip Fracture Service .  Data included basic demographic data , admission laboratory results , surgical information , number of comorbidities , mortality , medical complications , discharge information , time to surgery , and length of stay in hospital . The demographics of the two groups of patients were similar . Patients treated as part of the Hip Fracture Service had fewer medical complications ( 36 % vs. 51 % ) , more often had surgery within 24 hours ( 63 % vs. 35 % ) , and had shorter hospital stays ( mean , 5.7 days vs. 8.1 days ) than patients treated before the Hip Fracture Service . These findings provide the rationale for a prospect i ve , r and omized trial of the service BACKGROUND Patients who survive hip fracture are at high risk of recurrent fractures , but rates of osteoporosis treatment 1 year after sustaining a fracture are less than 10 % to 20 % . We have developed an osteoporosis case manager intervention . The case manager educated patients , arranged bone mineral density tests , provided prescriptions , and communicated with primary care physicians . The intervention was compared with usual care in a r and omized controlled trial . METHODS We recruited from all hospitals that participate in the Capital Health system ( Alberta , Canada ) , including patients 50 years or older who had sustained a hip fracture and excluding those who were receiving osteoporosis treatment or who lived in a long-term care facility . Primary outcome was  bisphosphonate therapy 6 months after fracture ; secondary outcomes included bone mineral density testing , appropriate care ( bone mineral density testing and treatment if bone mass was low ) , and intervention costs . RESULTS We screened 2219 patients and allocated 220 , as follows : 110 to the intervention group and 110 to the control group . Median age was 74 years , 60 % were women , and 37 % reported having had previous fractures . Six months after hip fracture , 56 patients in the intervention group ( 51 % ) were receiving bisphosphonate therapy compared with 24 patients in the control group ( 22 % ) ( adjusted odds ratio , 4.7 ; 95 % confidence interval , 2.4 - 8.9 ; P < .001 ) . Bone mineral density tests were performed in 88 patients in the intervention group ( 80 % ) vs 32 patients in the control group ( 29 % ) ( P < .001 ) . Of the 120 patients who underwent bone mineral density testing , 25 ( 21 % ) had normal bone mass . Patients in the intervention group were more likely to receive appropriate care than were patients in the control group ( 67 % vs 26 % ; P < .001 ) . The average intervention cost was $ 50.00 per patient . CONCLUSION For a modest cost , a case manager was able to substantially increase rates of osteoporosis treatment in a vulnerable elderly population at high risk of future fractures BACKGROUND Treatment of osteoporosis following a hip fracture has been notoriously poor . Many efforts have been made to improve treatment rates . The purpose of this study was to determine whether a perioperative inpatient intervention program , involving patient education and providing a list of questions for the primary care physician , increased the percentage of patients in whom osteoporosis was addressed following a hip fracture . METHODS A prospect i ve , r and omized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted . During their hospitalization , the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures , the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment , and the importance of medical follow-up for osteoporosis management . These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician , and they were reminded about the questions during a follow-up telephone call six weeks later . The patients in the control group received a brochure describing methods for preventing falls . Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed . Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy .  RESULTS The average age in each group was eighty-two years , and 78 % of the patients were female . Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial . Fifteen ( 42 % ) of the thirty-six patients who had been r and omized to the study group , compared with only seven ( 19 % ) of the thirty-six patients in the control group , had their osteoporosis addressed by their primary physician . This difference between the groups was significant ( p = 0.036 ) . CONCLUSIONS Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions . Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management Introduction : Hip fractures are common in the elderly patients with an incidence of 320 000 fractures/year in the United States , representing a health-care cost of US$ 9 to 20 billion . Hip fracture incidence is projected to increase dramatically . Hospitals must modify clinical models to accommo date this growing burden . Comanagement strategies are reported in the literature , but few have addressed orthopedic-hospitalist models . An orthopedic-hospitalist comanagement ( OHC ) service was established at our hospital to manage hip fracture patients . We sought to determine whether the OHC ( 1 ) improves the efficiency of hip fracture management as measured by inpatient length of stay ( LOS ) and time to surgery ( TTS ) and ( 2 ) whether our results are comparable to those reported in hip fracture comanagement literature . Methods : A comparative retrospective– prospect i ve cohort study of patients older than 60 years with an admitting diagnosis of hip fracture was conducted to compare inpatient LOS and TTS for hip fracture patients admitted 10 months before ( n = 45 ) and 10 months after implementation ( n = 54 ) of the OHC  at a single academic hospital . Secondary outcome measures included percentage of patients taken to surgery within 24 or 48 hours , 30-day readmission rates , and mortality . Outcomes were compared to comanagement study results published in MEDLINE -indexed journals . Results : Patient cohort demographics and comorbidities were similar . Inpatient LOS was reduced by 1.6 days after implementation of the OHC ( P = .01 ) without an increase in 30-day readmission rates or mortality . Time to surgery was insignificantly reduced from 27.4 to 21.9 hours ( P = .27 ) and surgery within 48 hours increased from 86 % to 96 % ( P = .15 ) . Discussion : The OHC has improved efficiency of hip fracture management as judged by significant reductions in LOS with a trend toward reduced TTS at our institution . Conclusion : Orthopedic-hospitalist comanagement may represent an effective strategy to improve hip fracture management in the setting of a rapidly exp and ing patient population In a prospect i ve trial of 278 patients aged over 65 years , treatment of displaced subcapital fractures was r and omly allocated to closed reduction and internal fixation with a sliding compression screwplate , Moore hemiarthroplasty , or total hip treatment with a Howse semicaptive prosthesis . One year after operation there was little difference between the three groups in mortality ( 25 per cent ) or general complications . The revision rate within the first year was highest for internal fixation ( 25 per cent ) , but many of the replacements also required a further anaesthetic for reduction of a dislocation ( Moore , 11 per cent ; Howse 12.5 per cent ) . Total hip replacement result ed in the least pain and most mobility at 1 year , while hemiarthroplasty was worst in these respects . We conclude that internal fixation and particularly primary total hip replacement should be given serious consideration in the management of the elderly patient with a displaced subcapital fracture Summary Guidelines suggest identification of women at fracture risk by bone density measurement and subsequently pharmacotherapy . However , most women who sustain a hip fracture do not have osteoporosis in terms of bone density . The present non-pharmacological intervention among elderly women unselected for osteoporosis reduced hip fracture risk by 55 % providing an alternative approach to fracture prevention . Introduction Hip fractures are expensive for society and cause disability for those who sustain them . We studied whether a multifactorial non-pharmacological prevention program reduces hip fracture risk in elderly women . Methods A controlled trial concerning 60- to 70-year-old community-dwelling Finnish women was undertaken . A r and om sample was drawn from the Population Information System and assigned into the intervention group ( IG ) and control group ( CG ) . Of the 2,547 women who were invited to the IG , 1,004 ( 39 % ) and of the 2,120 invited to the CG , 1,174 ( 55 % ) participated . The IG participated in a fracture prevention program for 1 week at a rehabilitation center followed by review days twice . The CG received no intervention . During the 10-year follow-up , both groups participated in survey question naire by mail . Outcome of interest was occurrence of hip fractures and changes in bone – health-related lifestyle . Results During the follow-up , 12 ( 1.2 % ) women in the IG and 29 ( 2.5 % ) in the CG sustained a hip fracture ( P = 0.039 ) . The determinants of hip fractures by stepwise logistic regression were baseline smoking ( odds ratio ( OR ) 4.32 ( 95 % confidence interval [ CI ] 2.14–8.71 ) , age OR 1.15/year ( 95 % CI 1.03–1.28 ) , fall history OR 2.7 ( 95 % CI 1.24–5.9 ) , stroke history OR 2.99 ( 95 % CI 1.19–7.54 ) and participating in this program OR 0.45 ( 95 % CI 0.22–0.93 ) . Starting vitamin D and calcium supplement use was more common in the IG compared with the CG . Conclusions The results suggest that this non-pharmacological fracture prevention program may reduce the risk of hip fractures in elderly Finnish women
Overall , moderate evidence suggests that nerve blockades are effective for relieving acute pain and reducing delirium .
Low-level evidence suggests that preoperative traction does not reduce acute pain .
Nerve blockade seems to be effective in reducing acute pain after hip fracture .
Sparse data preclude firm conclusions about the relative benefits or harms of many other pain management interventions for patients with hip fracture .
BACKGROUND  Pain management  is integral to the management of hip fracture .
PURPOSE To review the benefits and harms of pharmacologic and nonpharmacologic interventions for managing pain  after hip fracture .