Morten Tange Kristensen

The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery

BACKGROUND: Perioperative anemia leads to increased morbidity and mortality and potentially inhibits rehabilitation after hip fracture surgery. As such, the optimum transfusion threshold after hip fracture surgery is unknown.

Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery: a randomized, double-blind, placebo-controlled trial.

Background:Hip fracture surgery usually carries a high demand for rehabilitation and a significant risk of perioperative morbidity and mortality. Postoperative epidural analgesia may reduce morbidity and has been shown to facilitate rehabilitation in elective orthopedic procedures. No studies exist on the effect of postoperative epidural analgesia on pain and rehabilitation after hip fracture surgery. Methods:Sixty elderly patients were included in a randomized, double-blind study comparing 4 days of continuous postoperative epidural infusion of 4 ml/h bupivacaine, 0.125%, and 50 &mgr;g/ml morphine versus placebo. Both patient groups received balanced analgesia and intravenous nurse-controlled analgesia with morphine. All patients followed a well-defined multimodal rehabilitation program. Pain, ability to participate in four basic physical functions, and any factors restricting participation were assessed on the first 4 postoperative days during physiotherapy. Results:Epidural analgesia provided superior dynamic analgesia during all basic physical functions, and patients were significantly less restricted by pain, which was the dominating restricting factor in the placebo group. Motor blockade was not a restricting factor during epidural analgesia. Despite improved pain relief, scores for recovery of physical independence were not different between groups. Conclusion:Postoperative epidural analgesia after hip fracture surgery provides superior analgesia attenuating pain as a restricting factor during rehabilitation without motor dysfunction. However, superior analgesia did not translate into enhanced rehabilitation. Future studies with multimodal rehabilitation are required to establish whether superior analgesia can be translated into enhanced rehabilitation and reduced morbidity in hip fracture patients.

Timed “Up & Go” Test as a Predictor of Falls Within 6 Months After Hip Fracture Surgery

Background and Purpose Previous studies of Timed “Up & Go” Test (TUG) scores as a predictor of falls were based primarily on retrospective data, and no prospective studies of the TUG for predicting falls in people with hip fracture are available. The purpose of this study was to determine whether TUG scores obtained upon discharge from an acute orthopedic hip fracture unit can predict falls in people with hip fracture during a 6-month follow-up period. Subjects The subjects included in this study were 79 consecutive elderly people who had hip fractures and were able to perform the TUG when discharged directly to their own homes or to assisted living facilities from a specialized acute orthopedic hip fracture unit, with 59 (75%) being able to participate in the follow-up interview. Methods In this prospective study, all subjects were contacted for a 6-month follow-up interview about falls since discharge from the hospital. The score on the TUG performed at discharge (median of 10 days after surgery) was compared with the New Mobility Score, which describes functional level before the fracture and mental status on admission, sex, type of fracture, residence, and walking aids before and after the fracture. All subjects followed a well-defined care plan with multimodal fast-track rehabilitation including an intensive physical therapy program comprising 2 daily sessions; discharge was in accordance with standardized criteria. Analyses and correlations of all variables were examined for prediction of falls, and sensitivity, specificity, predictive values, and likelihood ratios were calculated. Falls were classified as “none” or as “1 or more.” Results Among the 59 subjects in the follow-up group, 19 subjects (32%) experienced 1 or more falls in the period since discharge; 4 of these falls resulted in new hip fractures. The TUG performed at discharge with a cutoff point of 24 seconds was the only parameter that significantly predicted falls during the 6-month follow-up period, with a negative likelihood ratio of 0.1 to be a faller as a nonfaller. Discussion and Conclusion The results suggest that the TUG is a sensitive measure for identifying people with hip fracture at risk for new falls, and it should be part of future outcome measures to decide for whom preventive measures against falls should be instituted.

Anaemia impedes functional mobility after hip fracture surgery

BACKGROUND the impact of anaemia on the outcome after a hip fracture surgery is controversial, but anaemia can potentially decrease the physical performance and thereby impede post-operative rehabilitation. We therefore conducted a prospective study to establish whether anaemia affected functional mobility in the early post-operative phase after a hip fracture surgery. PATIENTS AND METHODS four hundred and eighty seven consecutive hip fracture patients, treated according to a well-defined multimodal rehabilitation programme with a uniform, liberal transfusion threshold, were studied. Hb was measured on each of the first three post-operative days, and anaemia defined as Hb <100 g/l. Functional mobility was measured with the Cumulated Ambulation Score (CAS). RESULTS the results were obtained from 170, 132 and 116 patients who were found anaemic on the first, second and third post-operative day, respectively. A significant association between anaemia and the ability to walk independently before the correction of anaemia was present on each of the 3 days separately (P<0.05). A significant correlation was also found on each day between the functional score and the Hb level. A multivariate analysis integrating the type of surgery, medical complications and prefracture function showed that anaemia at the time of the physiotherapy session was an independent risk factor for not being able to walk on the third post-operative day [OR 0.41 (0.14-0.73) P = 0.002]. CONCLUSION anaemia impedes functional mobility in the early post-operative phase after a hip fracture surgery and is an independent risk factor for patients not being able to walk post-operatively. The potential for a liberal transfusion policy to improve the rehabilitation potential in hip fracture patients with anaemia should be investigated.

Prediction of postoperative morbidity, mortality and rehabilitation in hip fracture patients: the cumulated ambulation score

Objective: To validate the cumulated ambulation score as an early postoperative predictor of short-term outcome in hip fracture patients. Design: Prospective, descriptive study. Setting: An orthopaedic hip fracture unit in a university hospital. Patients: Four hundred and twenty-six consecutive hip fracture patients with an independent walking function admitted from their own home. Rehabilitation followed a well-defined multimodal rehabilitation regimen and discharge criteria. Main outcome measure: Admission tests with a new mobility score to assess prefracture functional mobility and a short mental score for cognitive dysfunction were performed. On the first three postoperative days patients were assessed with the cumulated ambulation score consisting of a cumulated assessment of simple ambulation characteristics with a score from 0 to18 (fully mobile). The three assessments were correlated to short-term outcome parameters. Results: The cumulated ambulation score was a highly significant predictor for length of hospitalization, time to discharge status, 30-day mortality and postoperative medical complications (P < 0.001 for all). The cumulated ambulation score was superior in its association with all postoperative outcome parameters to both the New Mobility Score and the mental score. A cumulated ambulation score of ±10 correlated with a 99% survival at one month and 93% discharge to own home. Conclusion: The cumulated ambulation score is a potentially valuable score for early prediction of short-term postoperative outcome after hip fracture surgery.

Loss of Knee-Extension Strength Is Related to Knee Swelling After Total Knee Arthroplasty

OBJECTIVE To examine whether changes in knee-extension strength and functional performance are related to knee swelling after total knee arthroplasty (TKA). DESIGN Prospective, descriptive, hypothesis-generating study. SETTING A fast-track orthopedic arthroplasty unit at a university hospital. PARTICIPANTS Patients (N=24; mean age, 66y; 13 women) scheduled for primary unilateral TKA were investigated 1 week before surgery and on the day of hospital discharge 2.4 days postsurgery. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We assessed all patients for knee-joint circumference, knee-extension strength, and functional performance using the Timed Up & Go, 30-second Chair Stand, and 10-m fast speed walking tests, together with knee pain during all active test procedures. RESULTS All investigated variables changed significantly from pre- to postsurgery independent of knee pain. Importantly, knee circumference increased (knee swelling) and correlated significantly with the decrease in knee-extension strength (r=-.51; P=.01). Reduced fast-speed walking correlated significantly with decreased knee-extension strength (r=.59; P=.003) and decreased knee flexion (r=.52; P=.011). Multiple linear regression showed that knee swelling (P=.023), adjusted for age and sex, could explain 27% of the decrease in knee-extension strength. Another model showed that changes in knee-extension strength (P=.009) and knee flexion (P=.018) were associated independently with decreased performance in fast-speed walking, explaining 57% of the variation in fast-speed walking. CONCLUSIONS Our results indicate that the well-known finding of decreased knee-extension strength, which decreases functional performance shortly after TKA, is caused in part by postoperative knee swelling. Future studies may look at specific interventions aimed at decreasing knee swelling postsurgery to preserve knee-extension strength and facilitate physical rehabilitation after TKA.

Prefracture functional level evaluated by the New Mobility Score predicts in-hospital outcome after hip fracture surgery

Background and purpose Clinicians need valid and easily applicable predictors of outcome in patients with hip fracture. Adjusting for previously established predictors, we determined the predictive value of the New Mobility score (NMS) for in-hospital outcome in patients with hip fracture. Patients and methods We studied 280 patients with a median age of 81 (interquartile range 72–86) years who were admitted from their own homes to a special hip fracture unit. Main outcome was the regain of independence in basic mobility, defined as. independence in getting in and out of bed, sitting down and standing up from a chair, and walking with an appropriate walking aid. The Cumulated Ambulation score was used to evaluate basic mobility. Predictor variables were NMS functional level before fracture, age, sex, fracture type, and mental and health status. Results Except for sex, all predictor variables were statistically significant in univariate testing. In multiple logistic regression analysis, only age, NMS functional level before fracture, and fracture type were significant. Thus, patients with a low prefracture NMS and/or an intertrochanteric fracture would be 18 and 4 times more likely not to regain independence in basic mobility during the hospital stay, respectively, than patients with a high prefracture level and a cervical fracture, respectively. The model was statistically stable and correctly classified 84% of cases. Interpretation The NMS functional level before fracture, age, and fracture type facilitate prediction of the in-hospital rehabilitation potential after hip fracture surgery.

The role of pain for early rehabilitation in fast track total knee arthroplasty

Purpose. To investigate the relationship between early functional mobility and pain intensity in a fast track program after total knee arthroplasty (TKA). Methods. One hundred consecutive patients operated with TKA in an orthopaedic unit at a University hospital were prospectively studied. Measurements of independence in transfer and ambulation (Cumulated Ambulation Score), pain intensity (Verbal Analog Scale (VAS)), range of knee motion, functional mobility (‘Timed Up & Go’ (TUG) test), and walking distance were recorded daily from the first postoperative day until discharge. Results. On the first postoperative day, 90% of the patients were able to walk independently with median pain intensity of ≤5 on VAS. Of these, 78% walked > 70 m. All patients walked independently on postoperative Day 2 with pain intensity of ≤4. On the day of discharge, all patients walked with crutches with pain intensity of ≤3, walking distance > 70 m, median range of motion 10–80°, and median test time of the ‘TUG’ 19.2 s. The length of hospital stay was median 3 days. Conclusion. Pain has a limited influence on the functional recovery beyond the first postoperative day after TKA, thereby allowing early physiotherapy.

High inter-tester reliability of the new mobility score in patients with hip fracture.

OBJECTIVE To assess the inter-tester reliability of the New Mobility Score in patients with acute hip fracture. DESIGN An inter-tester reliability study. SUBJECTS Forty-eight consecutive patients with acute hip fracture at a median age of 84 (interquartile range, 76-89) years; 40 admitted from their own home and 8 from nursing homes to an acute orthopaedic hip fracture unit at a university hospital. METHODS The New Mobility Score, which evaluates the prefracture functional level with a score from 0 (not able to walk at all) to 9 (fully independent), was assessed by 2 independent physiotherapists at the orthopaedic ward. Inter-tester reliability was evaluated using the intraclass correlation coefficient (ICC1.1) and the standard error of measurement (SEM). RESULTS The ICC between the 2 physiotherapists was 0.98, 95% confidence interval (CI) 0.96-0.99 and the SEM was 0.42, 95% CI -0.40-1.24 New Mobility Score points. No systematic between-rater bias was observed (p>0.05). Patients who were scored differently by the 2 physiotherapists had significantly lower mental scores (p=0.02). CONCLUSION The inter-tester reliability of the New Mobility Score is very high and can be recommended to evaluate the prefracture functional level in patients with acute hip fracture.

Change of residence and functional status within three months and one year following hip fracture surgery

Abstract Purpose: To study the recovery of patients in terms of 18 activities of daily living and change of residence within the year following a hip fracture. Method: This prospective cohort study was carried out in a trauma service of an acute hospital in southern Spain including 159 patients with a hip fracture, 65 years or older and allowed weight-bearing after surgery. Patients or their relatives were interviewed about their residential status and functional level at pre-fracture, three months and one year after surgery, using the Functional Independence Measure. Results: Losses of function for the main activities affected were, at the first month, third month and one year relative to the pre-fracture status, 50%, 25% and 12%, respectively, for locomotion, 40%, 25% and 20%, respectively, for mobility and 27%, 17% and 15%, respectively, for self care (p < 0.001). Residential status changed mostly for patients who lived in their own home (73% before fracture to 58% at one year). Conclusions: The loss of independence in the first year after a hip fracture is substantial for specific activities. Recovery mainly takes place during the first three months after surgery. Change of residence mostly involved those patients who lived alone in their own home at pre-fracture. Implications for Rehabilitation One year after fracture, patients did not recover their previous function, and the activities most affected at the one-year follow-up were: dressing lower body, bathing/showering, transfer bathtub/shower and walking up/down stairs. After a hip fracture, most recovery of the function happens within the first three months, though some functional activities continue recovering over the first year. Rehabilitation programs cannot be based only on mobility activities, the recovery of other daily living activities should also be included.