Background: The objective of this study was to analyze the direct medical expenses of a vertebral fracture cohort (VC) and a matched cohort (MC) over 5 years preceding and following the fracture, analyze the duration of the rise in medical expenses due to the fracture, and examine whether the expenses vary with age group, utilizing a national claims database. Methods: Subjects with vertebral fractures and matched subjects were chosen from the National Health Insurance Service Sample cohort (NHIS-Sample) of South Korea. Patients with vertebral fractures were either primarily admitted to acute care hospitals (index admissions) or those who received kyphoplasty or vertebroplasty during the follow-up period (2002–2015). A risk-set matching was performed using 1 : 5 random sampling to simulate a real-world situation. Individual-level direct medical expenses per quarter were calculated for 5 years prior and subsequent to the vertebral fracture. In this analysis using a comparative interrupted time series design, we examined the direct medical expenses of a VC and an MC. Results: A total of 3,923 incident vertebral fracture patients and 19,615 matched subjects were included in this study. The mean age was 75.5 ± 7.4 years, and 69.5% were women. The mean difference in medical expenses between the two groups increased steadily before the fracture. The medical expenses of the VC peaked in the first quarter following the fracture. The cost changes were 1.82 times higher for the VC than for the MC (95% confidence interval, 1.62–2.04; p < 0.001) in the first year. Subsequently, there were no differential changes in medical expenses between the two groups (p > 0.05). In the < 70-year subgroup, there were no differential changes in medical expenses between the two groups (p > 0.05). However, in the ≥ 80-year subgroup, the cost changes for the VC were higher than those for the MC up to 5 years after time zero. Conclusions Based on our study results, we suggest that health and medical policies for vertebral fractures should be designed to last up to approximately 1 year after the fracture. Health policies should be differentiated according to age group.

To date, family medicine and internal medicine fields have been responsible for defining, researching, and development of treatments for sarcopenia, focusing mainly on diabetes and metabolic diseases. Therefore, application of current guidelines for diagnosis of sarcopenia which differ according to continent to patients with hip fractures in the orthopedic field is difficult. The purpose of this review was to understand the recent consensus on the definition and diagnosis of sarcopenia and to highlight the importance of research and future research opportunities on the management of sarcopenia in patients with hip fractures by orthopedic surgeons. The global prevalence of sarcopenia in patients with hip fractures is statistically significant. Despite establishment of various therapeutic and diagnostic criteria for osteoporosis in the clinical field, there are no clear, useful diagnostic criteria for sarcopenia in the clinical field. In particular, few studies on the evaluation and treatment of sarcopenia in patients with hip fractures have been reported. In addition, the quality of life of postoperative patients with hip fractures could be significantly improved by development of precise assessment for muscle regeneration and rehabilitation in the operating room.

Background: This study aimed to investigate nutritional or rehabilitation intervention protocols for hip fracture patients with sarcopenia and to analyze the effect of these protocols through a systematic review of studies that reported clinical results. Methods: Studies were selected based on the following criteria: (1) study design: randomized controlled trials or non-randomized comparative studies; (2) study population: patients with hip fracture; (3) intervention: nutritional or rehabilitation; and (4) reporting the clinical outcomes and definition of sarcopenia. Results: Of the 247 references initially identified from the selected databases, 5 randomized controlled studies and 2 comparative studies were selected for further investigation. The total number of patients was 497. We found 2 specific rehabilitation interventions, one medication intervention using erythropoietin, and 4 nutritional interventions using amino-acid or protein. Among the studies included in this systematic review, 2 studies did not find a clear statistical difference in assessment tools compared to controls after intervention. On the other hand, the rest of the studies positively interpreted the results for intervention. The most frequently used assessment tool for intervention was handgrip strength. Conclusions Although mainstream methods of intervention for sarcopenia include nutritional, exercise, and drug interventions, the validity of these interventions in elderly hip fractures has not been clearly proven. In addition, as most studies only reported short-term results, there is no consensus on the optimal long-term treatment.

Total joint arthroplasty (TJA) is a surgical procedure, in which parts of damaged joints are removed and replaced with a prosthesis. The main indication of TJA is osteoarthritis, and the volume of TJA is rising annually along with the increase of aged population. Hip and knee are the most common joints, in which TJAs are performed. The TJA prosthesis is composed of metal, plastic, or ceramic device. Even though TJA is the most successful treatment for end-stage osteoarthritis, it is associated with various complications, and periprosthetic joint infection (PJI) is the most serious complication after TJA. With the increasing volume of TJAs, there is a simultaneous rise in the incidence of PJI. Contamination of the surgical wound and the adherence of bacteria to the surface of prosthetic component represent the initial step in the pathogenesis of PJI. The main sources of the contamination are 1) patient's own flora, 2) droplets in the operation room air, and 3) surgical gloves and instruments. Even though modern techniques have markedly reduced the degree of contamination, TJAs cannot be done in completely germ-free conditions and some degree of contamination is inevitable in all surgical procedures. However, not all contamination leads to PJI. It develops when the burden of contamination exceeds the immune threshold or the colony forming units (CFUs) and various factors contribute to a decrease in the CFU level. Surgeons should be aware of the germ burden/CFU concept and should monitor sources of contamination to maintain the germ burden below the CFU to prevent PJI.

Background: The purpose of this study was to compare the mortality rate between patients undergoing hemiarthroplasty (HA) and those undergoing total hip arthroplasty (THA) in two age groups: patients aged 65–79 years (non-octogenerian) and patients aged ≥ 80 years (octogenarian). Methods: We identified elderly (aged ≥ 65 years) femoral neck fracture patients who underwent primary THA or HA from January 1, 2005 to December 31, 2015 in South Korea using the Health Insurance and Review and Assessment database; the nationwide medical claim system of South Korea. We separately compared the mortality rate between the HA group and THA group in two age groups. A generalized estimating equation model with Poisson distribution and logarithmic link function was used to calculate the adjusted risk ratio (aRR) of death according to the type of surgery. Results: The 3,015 HA patients and 213 THA patients in younger elderly group, and 2,989 HA patients and 96 THA patients in older elderly group were included. In the younger elderly group, the mortality rates were similar between the two groups. In older elderly group, the aRR of death in the THA group compared to the HA group was 2.16 (95% confidence interval [CI], 1.20–3.87; P = 0.010) within the in-hospital period, 3.57 (95% CI, 2.00–6.40; P < 0.001) within 30-days, and 1.96 (95% CI, 1.21–3.18; P = 0.006) within 60-days. Conclusions In patients older than 80 years, THA was associated with higher postoperative mortality compared to HA. We recommend the use of HA rather than THA in these patients.

Background: The purpose of this study was to determine whether short tapered stems reduce the rate of thigh pain through a systematic review and meta-analysis of comparative studies between short tapered stems and standard-length tapered stems. Methods: We conducted a meta-analysis of comparative studies: 1) retrospective studies and 2) randomized controlled trials (RCTs), on 2 stem designs: short tapered stem versus standard-length tapered stem. Studies were selected by means of the following criteria: 1) study design: retrospective comparative studies, prospective comparative studies, RCTs; 2) study population: patients with total hip arthroplasty or hemiarthroplasty for hip disease or hip fracture; 3) intervention: short tapered stem and standard tapered stem; and 4) outcomes; thigh pain, other clinical results. Results: Among the 250 articles that were identified at the initial search, 6 studies, 4 RCTs and 2 retrospective comparative studies, were included in this meta-analysis. In the analysis of retrospective studies, the short tapered stem reduced the risk of thigh pain compared to the standard tapered stem (risk ratio [RR] = 0.13; 95% confidence interval [CI], 0.02–0.09; Z = −2.07; P = 0.039). However, in the analysis of RCTs, the incidence of thigh pain was similar between the two stem designs (RR = 1.21; 95% CI, 0.76–1.93; Z = 0.82; P = 0.410). Overall meta-analysis including all studies showed that the short tapered stem did not reduce the incidence of thigh pain compared to the standard-length tapered stem (RR = 0.91; 95% CI, 0.59–1.40; Z = −0.44, P = 0.663). Conclusions We did not find a significant difference in the incidence of thigh pain between short tapered stem and standard tapered stem in hip arthroplasty.

Purpose: This study examined the bony morphological changes to analyze the factors affecting bony union in the treatment of elderly femoral shaft fractures with varus bowing using piriformis fossa insertion intramedullary nailing. Materials and Methods: This study included 26 patients over 60 years of age, who were admitted for femoral shaft fractures between January 2005 and December 2014 and treated with piriformis fossa insertion intramedullary nailing. Age, sex, height, weight, bone mineral density, injury mechanism, fracture type, diameter and length of the nail, postoperative lengthening of the femur, postoperative change in varus angle, contact between the lateral and anterior cortex, and the gap between the fracture line and the bony union were checked. The patients were divided into a varus group and nonvarus group, as well as a bone union group and nonunion group. Logistic regression analysis was performed to analyze the factors affecting nonunion. Results: The patients were classified into 11 in the varus group and 15 in the non-varus group and 24 in the union group and 2 in the nonunion group. The varus group showed a larger increase in leg length and varus angle reduction than the non-varus group (p<0.05). The union group had more contact with the lateral cortical bone than that of the nonunion group (p<0.05). The factor affecting bone union in regression analysis was contact of the lateral cortical bone (p<0.05). Conclusion Treatment of a femoral shaft fracture in elderly patients with a varus deformity of the femur using piriformis fossa insertion intramedullary nail increases the length of the femur and decreases the varus deformity. For bony union, the most important thing during surgery is contact of the lateral cortical bone with the fracture site.

60 years of age. A total of 588,147 participants were randomly selected for senior cohort using 10% simple random sampling. We identified senile (> 65 years old) patients who underwent hip fracture surgery from January 2005 to December 2014 and those who developed pneumonia during hospitalization from the NHIS-Senior cohort. The index date of hip fracture occurrence was defined as the date of admission to the acute care hospital. The last date of follow-up was defined as the date of death or 31 December 2015, whichever came first. A multivariable-adjusted Cox proportional hazards model was used to investigate the effects of pneumonia on all-cause mortality.RESULTS: During the enrollment period, a total of 14,736 patients, who were older than 65 years, underwent hip fracture surgeries. Among them, 1,629 patients (11.05%) developed pneumonia during the hospitalization. The pneumonia incidence was 16.39% (601/3,666) in men patients and 9.29% (1,028/10,042) in women patients. Compared to 13,107 non-pneumonia patients, adjusted relative risk (aRR) of death in pneumonia patients was 2.69 (95% confidence interval [CI], 2.14–3.38; P < 0.001) within postoperative 30-day, 3.40 (95% CI, 3.01–3.83; P < 0.001) within postoperative 90-day, 2.86 (95% CI, 2.61–3.15; P < 0.001) within postoperative 180-day and 2.31 (95% CI, 2.14–2.50; P < 0.001) within postoperative 1-year. According to patient's age, the aRR of death in pneumonia patients was 5.75 (95% CI, 2.89–11.43) in adults aged < 70 years, 5.14 (95% CI, 4.08–6.46) in those aged 70–79 years, 3.29 (95% CI, 2.81–3.86) in those aged 80–89 years and 2.02 (95% CI, 1.52–2.69) in those aged ≥ 90 years. The aRR was 3.63 (95% CI, 3.01–4.38) in men pneumonia patients, and 3.27 (95% CI, 2.80–3.83) in women pneumonia patients.CONCLUSION: The prevalence of pneumonia in elderly hip fracture patients was 11.05%. Men had higher incidence (16.39%) than women (9.29%). Compared to non-pneumonia patients, the pneumonia patients had higher 30-day to 1-year mortalities with aRR of 2.31 to 3.40. They had increased mortality in all age groups older than 65 years with aRR of 1.52 to 4.08. Both genders of pneumonia patients had higher risk of mortality (aRR, 3.63 in men and 3.27 in women) compared to non-pneumonia patients.]]>
Adult ; Aged ; Cohort Studies ; Female ; Follow-Up Studies ; Hip ; Hospitalization ; Humans ; Incidence ; Korea ; Male ; Mortality ; National Health Programs ; Pneumonia ; Prevalence ; Proportional Hazards Models

Background: The purpose of this study was to investigate the use of opioids before and after total hip arthroplasty (THA), to find out the effect of opioid use on mortality in patients with THA, and to analyze whether preoperative opioid use is a risk factor for sustained opioid use after surgery using Korean nationwide cohort data. Methods: This retrospective nationwide study identified subjects from the Korean National Health Insurance Service-Sample cohort (NHIS-Sample) compiled by the Korean NHIS. The index date (time zero) was defined as 90 days after an admission to a hospital to fulfill the eligibility criteria of the THA. Results: In the comparison of death risk according to current use and the defined daily dose of tramadol and strong opioids in each patient group according to past opioid use, there were no statistically significant differences in the adjusted hazard ratio for death compared to the current non-users in all groups (P > 0.05). Past tramadol and strong opioid use in current users increased the risk of the sustained use of tramadol and strong opioids 1.45-fold (adjusted rate ratio [aRR]; 95% confidence interval [CI], 1.12–1.87; P = 0.004) and 1.65-fold (aRR; 95% CI, 1.43–1.91; P < 0.001), respectively, compared to past non-users. Conclusion In THA patients, the use of opioids within 6 months before surgery and within 3 months after surgery does not affect postoperative mortality, but a past-use history of opioid is a risk factor for sustained opioid use. Even after THA, the use of strong opioids is observed to increase compared to before surgery.

Background: The purpose of our study was to assess the use of opioids before and after hip fracture in elderly patients in order to determine the effect of opioid use on all-cause mortality, and to analyze how the history of opioid use before fracture increases the risk of sustained use following hip fracture using a Korea nationwide cohort. Methods: Our study identified hip fracture patients from the Korean National Health Insurance Service-Senior cohort. The index date was defined as 90-days after admission to the acute care hospital that fulfilled the eligibility criteria of elderly hip fracture. Patients were classified into past user, current user, and sustained user according to the use of opioid at each period based on the time of admission and index date. The opioids were classified into strong opioids and tramadol. A generalized estimating equation model with a Poisson distribution and logarithmic link function was performed to estimate the adjusted rate ratios (aRRs) and 95% confidence intervals (CIs) to assess the association between past use and sustained use. A multivariable-adjusted Cox proportional hazard model was used to investigate the effects of strong opioid and tramadol use on all-cause mortality. Results: A total of 12,927 patients were included in our study. There were 7,384 (57.12%) opioid past-users, 11,467 (88.71%) opioid current-users, and 7,172 (55.48%) sustained users. In comparison of the death risk according to current use or the defined daily dose of the opioids or past opioid use, there were no significant differences in the adjusted hazard ratio for death in all groups, compared to the current non-users (P > 0.05). Among survivors 1 year after hip fracture, opioid past-use increased the risk of opioid sustained use by 1.52-fold (aRR; 95% CI, 1.45–1.8; P < 0.001). Conclusion Current use and past use of opioid did not increase all-cause mortality after hip fracture in elderly patients over 65 years of age. Past use of opioid before hip fracture increased risk of sustained use of opioid compared to the current opioid used without past use.