13-15 November 2020, Virtual
Extended Abstracts
Cognitive assessment using 4AT
Maria Spyraki1, Georgios Karpetas1, Evanthia Dimitriou1, Gregorios Voyagis1, Elias
Panagiotopoulos2
1 Department of Anesthesiology and Critical Care, University Hospital of Patras, Patras,
Greece
2 Department of Orthopedic Surgery, University Hospital of Patras, Patras, Greece
Delirium is a serious neuropsychiatric disorder, affecting frequently old people with
fragility fractures. It is considered as, of an acute onset, alteration of mental
status with fluctuating course, reduced awareness and disturbance of attention. In
particular, postoperative delirium consists a very compounding factor for hip fracture
patients, as it is associated with increased morbidity and mortality. Delirium constitutes
a considerable cause of patient and family distress during recovery period, increasing
the need of care- givers and having a negative impact on the overall quality of life.
The reported incidence of postoperative delirium regarding hip fracture patients ranges
from 4% to 53.3%1-3. There is a list of both predisposing and precipitating risk factors
that are related to delirium’s development. Prompt recognition of these factors can
contribute to the prevention or early identification of delirium. In spite of its
high prevalence and significant consequences, delirium often goes under- recognised
or misdiagnosed, and yet when diagnosis is made, is frequently mismanaged or goes
untreated. It is, therefore, important delirium, not only to be identified but also
to be properly managed4.
The reference standard set of criteria for the diagnosis of delirium is codified in
DSM-5, used in the clinical setting and research studies as well. Nevertheless, DSM-5
criteria require special training and extensive knowledge regarding delirium, while
hip fracture patients experience very commonly a painful condition, are immobilised
and fatigued, with minimal tolerance to repeated or prolonged testing. On the other
hand, various assessment methods and screening tools have been used, in order to overcome
DSM-5 criteria’s barriers. CAM (Confusion Assessment Method), CAM-ICU and Nu-DESC
(Nursing Delirium Screening Scale), are assessment tools suitable for the detection
of delirium postoperatively. However, the reported low sensitivities in combination
with the fact that a specially trained staff is required to perform assessment, limit
their efficacy and everyday clinical use4.
As a result, a simple, rapid and validated assessment tool for the recognition of
delirium is required. The 4 ‘A’s Test, or 4AT briefly, is a broadly used tool for
the evaluation of delirium. 4AT is recommended from the European Society of Anesthesiology
as an accurate and useful assessment tool for the recognition of postoperative delirium.
The principal advantage of the 4AT is that it can be administered very quickly, within
2 minutes, in contrast to all other existing assessment methods. Moreover, 4AT is
designed for daily use in the clinical setting by professional-level healthcare staff
from a variety of disciplines, without requiring special training. Thus, 4AT is considered
as an easy to learn, administer and score delirium assessment tool. The innovative
characteristic of 4AT is that allows scoring of patients who are drowsy or agitated
while other cognitive testing or clinical interview would exclude them. It incorporates
short cognitive tests, the Months Backwards test and the Abbreviated Mental Test-4,
resulting in the detection of moderate or severe cognitive impairment as well. 4AT
evaluates all four basic components of delirium. Altered level of alertness remains
a constant barrier for the most assessment tools, however 4AT takes this into consideration
as it is a very valuable clinical sign, highly related to delirium. Additionally,
acute onset and fluctuating course is the last feature that is assessed using 4AT,
still even no informant exists, the test can be completed as the score is derived
from the other components. 4AT is an independent of subjective judgements tool and
does not demand physical responses like drawing figures or clocks. It can be administered
everywhere, even in the emergency department, since no quiet environment is required5.
The 4 ‘A’s Test comprises one of the best-validated evaluation tools for the detection
of delirium perioperatively, reporting a pooled sensitivity and specificity of 88%,
both6,7. In the United Kingdom, 4AT is recommended, since 2017, to be administered
routinely as part of the care bundle for hip fracture patients3. In Greece 4AT has
been already translated and culturally adapted, while validation is currently in process.
References
Pioli G, Bendini C, Giusti A, Pignedoli P, Cappa M, Iotti E, et al. Surgical delay
is a risk factor of delirium in hip fracture patients with mild-moderate cognitive
impairment. Aging Clin Exp Res 2019;31(1):41-47.
Sieber FE, Neufeld KJ, Gottschalk A, Bigelow GE, Oh ES, Rosenberg PB, et al. Effect
of Depth of Sedation in Older Patients Undergoing Hip Fracture Repair on Postoperative
Delirium: The STRIDE Randomized Clinical Trial. JAMA Surg 2018;153(11):987-995.
Shelton C, White S. Anaesthesia for hip fracture repair. BJA Education 2020;20(5):142-149.
Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, et al. European
Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative
delirium. Eur J Anaesthesiol 2017; 34(4):192-214.
www.the4AT.com (accessed 01.12.2020).
Bellelli G, Morandi A, Davis DH, Mazzola P, Turco R, Gentile S, Ryan T, Cash H, Guerini
F, Torpilliesi T, Del Santo F, Trabucchi M, Annoni G, MacLullich AM. Validation of
the 4AT, a new instrument for rapid delirium screening: A study in 234 hospitalised
older people. Age and Ageing 2014;43(4): 496-502.
O’Sullivan D, Brady N, Manning E, O’Shea E, O’Grady S, O’Regan N, et al. Validation
of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and
dementia screening in older Emergency Department attendees. Age Ageing 2018;47(1):61-68.
Complications after intramedullary fixation of intertrochanteric fractures
Alexandros P. Apostolopoulos, Spyridon J. Maris, Stavros Angelis, Efthimios J. Karadimas
Trauma and Orthopaedic Department, Hellenic Red Cross Hospital, Athens, Greece
Introduction: The incidence of peritrochanteric fractures is increasing due to the
aging of the population. This represents a major issue globally since it is one the
most common injury in Orthopaedics. Most specifically, 250.000 cases occur in the
United States and 70.000 to 75.000 in the UK, annually1,2. These types of fractures
are usually seen as a result of a low energy fall from standing position, in the elderly3.
Managing extracapsular (intertrochanteric) hip fractures by using intramedullary devices
is becoming more popular since it has been associated with shorter operative time
and hospital stay, less blood transfusions requirements, minimal soft tissue disruption
and better biomechanical properties (less implant strain and shorter lever arm due
to its closer position to the femur mechanical axis), when compared to the dynamic
hip screw fixation devices1.
The aim of our study was to look at complications related to the intramedullary hip
fixation.
Patients and methods: We conducted a retrospective study including 186 patients (aged
68-103, mean age 82.3), that were managed in our department during the year 2019-2020
and had suffered an intertrochanteric fracture. All patients were managed by using
an intramedullary hip nailing system. The mean hospital stay was 10.2 days (6-27 days).
Three patients deceased on the 2nd, 4th and 8th postoperative day and were excluded
from the study. Patients were discharged from the hospital and were advised to attend
our Outpatient department 6 weeks and 12 weeks postoperatively.
Results: 95 patients out of the 186 (51.07%), attended the Outpatient Department at
6 weeks for a follow up and 72 patients at 12 weeks (38.7%). All patients were clinically
and radiologically assessed. Radiological union was assessed by using the RUSH score
(Radiographic Union Score for Hip)4 and the Tip to Apex Distance (TAD) was also assessed
(values measured: 19-26 mm, mean 23 mm)5. 90 patients presented good outcomes of fracture
healing, with maintenance of the original position of the Intramedullary Nail, within
6-14 weeks post-operatively. Three patients presented healing related complications
and two patients suffered periprosthetic fractures. More specifically, superior Cut-Out
of the lag screw was identified in two patients (1.07%) (female patients 90 and 87
years old respectively) 8 and 10 weeks following the initial surgery (Figures 1 &
2). Avascular Necrosis (AVN) of the Femoral head was found in one case (0.53%) (female,
81 years old) that occurred 12 weeks post-operatively. All three cases were revised
by removing the nail and using cemented hemiarthroplasty. Periprosthetic fractures
were observed in two patients (1.07%) (one female 73 years old and one male 88 years
old). One patient underwent nail exchange from short to long intramedullary device
and the other one underwent Open Reduction and Internal Fixation.
Discussion: Intramedullary nailing for peritrochanteric fractures has become widely
popular in recent years. There are numerous advantages compared to the dynamic hip
screw devices such as minimal blood loss and blood transfusion requirements, shorter
operation time and hospital stay, and better biomechanical properties6.
However, implant related complications may occur, and can be related to surgical techniques7-9.
Malalignment of the hip fracture, iatrogenic intraoperative fractures, impingement,
and penetration of the anterior femoral cortex are the most common primary complications
which may occur. Moreover, Avascular Necrosis of the Femoral head, cut out of the
lag screw and peri-prosthetic fractures, may also occur during the healing process10.
Conclusion: There are many advantages in managing intertrochanteric hip fractures
by using intramedullary hip devises such as shorter theatre time less blood loss and
improved biomechanical properties. However, complications such as cut out of the lag
screw and AVN and periprosthetic fracture are serious and challenging complications
that require complex revision surgery.
Figures 1 & 2
Superior cut out of the intramedullary hip nail.
References
Mavrogenis AF, Panagopoulos GN, Megaloikonomos PD, Igoumenou VG, Galanopoulos I, Vottis
CT, Karabinas P, Koulouvaris P, Kontogeorgakos VA, Vlamis J, Papagelopoulos PJ. Complications
After Hip Nailing for Fractures. Orthopedics 2016;39(1):e108-16.
British Orthopaedic Association. The care of patients with fragility fractures. 2007.
http:// www.fractures.com/pdf/BOA-BGS-Blue- Book.pdf. Accessed March 11, 2015.
Lorich DG, Geller DS, Nielson JH. Osteoporotic pertrochanteric hip fractures: manage-
ment and current controversies. Instr Course Lect 2004;53:441-454.
Chiavaras M, Bains S, Choudur H, Parasu N, Jacobson J, Ayeni O, Petrisor B, Chakravertty
R, Sprague S, Bhandari M. The Radiographic Union Score for Hip (RUSH): The use of
a checklist to evaluate hip fracture healing improves agreement between radiologists
and orthopedic surgeons. Skeletal radiology 2013;42(8):1079-88.
Geller JA, Saifi C, Morrison TA, Macaulay W. Tip-apex distance of intramedullary devices
as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip
fractures. Int Orthop 2010;34(5):719-722.
Rosenblum SF, Zuckerman JD, Kummer FJ, Tam BS. A biomechanical evaluation of the Gamma
nail. J Bone Joint Surg Br 1992;74(3):352-357.
Erez O, Dougherty PJ. Early complications associated with cephalomedullary nail for
in- tertrochanteric hip fractures. J TraumaAcute Care Surg 2012;72(2):E101-E105.
Bojan AJ, Beimel C, Taglang G, Collin D, Ekholm C, Jonsson A. Critical factors in
cut- out complication after Gamma Nailtreatment of proximal femoral fractures. BMC
Musculoskelet Disord 2013;14:1.
Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric
hip fractures. J Bone Joint Surg Am 1979;61(2):216-221.
Bhandari M, Schemitsch E, Jonsson A, Zlowodzki M, Haidukewych GJ. Gamma nails revisited:
gamma nails versus compression hip screws in the management of inter- trochanteric
fractures of the hip. A meta- analysis. J Orthop Trauma 2009;23(6):460- 464.
Balance evaluation and rehabilitation of older people in a dynamic platform
Eleftheria Antoniadou, Xristina Kalivioti, Elias Panagiotopoulos
Rehabilitation Clinic Patras University Hospital, Greece
The age-related consequences affecting all components of the complex balance control
system (vision, proprioception, vestibular function and musculoskeletal output) plus
the burden of multimorbidity and polypharmacy frequently present in this vulnarable
age category, have an impact on the postural responses in all types of perturbations.
Assessing and treating balance disorders becomes paramount due to the close link between
impaired postural responses and falls, so frequent in older people1.
In the balance evaluation process we use, apart from the anamnestic data and the clinical
examination, specific scales, with the intent to have more valid and reliable informations
on what is wrong. There is a variety of clinical tests from simple to more complex
ones, with good psychometric properties, that can give to the examiner valuable informations
but they are all subjective2. In recent years different types of posturographic analysis
are utilized in the clinical setting to have an object
ive measurement of balance, but some of the tesing protocols of this expensive machines
do not have proven psychometric values.
Balance rehabilitation is the ultimate goal when a disorder is being detected. There
is a variety of interventions3 in the literature on balance restoration with a dynamic
platform in many conditions but little is known for their value in the rehabilitation
of older people.
In this study we wanted to assess:
if the mCTSIB protocol of the Biodex Balance System (SD) has good psychometric values
and can be used as an assessment tool for balance disorders in older women living
in the community,
if the exercise protocols of the same platform are effective in balance rehabilitation
for the same population.
For the first hypothesis, 100 women over 65 years community dwellers mean age 71.8
(SD±6, ranging from 65 to 91) years, were examined using the posturography modified
Clinical test of Sensory Interaction on Balance (mCTSIB) protocol of the Biodex Balance
system SD and the Greek Mini-Best Test (miniBESTest-GR)4 to assess concurrent validity,
with 24 undergoing a second measurement after one week to test the reliability of
the method. The m-CTSIB-”Composite Score” test was significantly and positively correlated
with the mini-BESTest-GR (r=-0.652, p<0.001) indicating good validity properties.
The test-retest reliability was measured using the intra-class correlation coefficient
(ICC) using a two-way mixed-effects absolute-agreement single-measurement model, among
the two measurements of mCTSIB test (test-retest). No statistical difference was found
between the two samples (N1=100, N2=24, t=-1.755, df=122, p=0.08). ICC estimates as
0.628 with 95% confident interval=0.31-0.825. Also the mCTSIB has excellent sensitivity
(86.4%) and specificity (80.5%) (Figure 1), for the diagnosis of balance disorders
with a cutoff point 1.59. The area under the curve (AUC) is equal with 87.7% (95%
CI=81.1% - 94.5%, p<.001). With the cutoff of 1.59 the 81.8% of patients can be correctly
alloquated as having or not a balance disorder.
Figure 1
Sensitivity and Specificity of the mCTSIB test of the BBS.
For the second hypothesis, 23 women with balance disorders (miniBESTtest score under
186) were randomnly assigned to an intervention or a control group. All participants
completed an interdisciplinary Geriatric Comprehensive Assessment7 in order to diagnose
and treat any medical or other condition that could affect balance (polypharmacy,
low vitamin D levels). The experimental group included n=10 participants who completed
3 months of balance exercise, divided by 3 sections per week for half an hour per
section. During every section the patient was exposed to all different types of balance
exercise protocols of the platform, the intensity and difficulty was gradually augmented
depending on the response of the patient. The control group (n=12 in the begging,
only n=10 completed the study) was not given any type of exercise for 3 months. After
3 months both the intervention and the control group were assesed to detect for any
improvement.
A paired-samples t-test was conducted to compare miniBEST before and after the intervention
for control and experimental group. There was not a significant difference in the
scores of miniBEST-before, between the two groups (p=0.656). In control group there
was not a significant difference in the scores for miniBEST-before (M=14.20, SD=2.39)
and miniBEST-after (M=14.00, SD=3.13); p=0.509. In the experimental group there was
a significant difference in the scores for miniBEST-before (M=13.70, SD=2.54) and
miniBEST-after (M=17.60, SD=3.60); p<0.001 (Figure 2). We can conclude that the balance
escercise protocols of the BBS are an effective tool for balance rehabilitation in
community dwelling older women.
Figures 2
Comparison between the Experimental and the Control group miniBEST scores pre and
post intervention.
References
Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent nonsyncopal falls.
A prospective study. JAMA 1989;261(18):2663-8.
Visser JE, Carpenter MG, van der Kooij H, Bloem BR. The clinical utility of posturography.
Clin Neurophysiol 2008;119(11):2424-36.
An M, Shaughnessy M. The Effects of Exercise-Based Rehabilitation on Balance and Gait
for Stroke Patients: A Systematic Review. J Neurosci Nurs 2011;43(6):298-307.
Lambropoulou S, Gedicoglou AI, Michailidou C, Billis E. Cross Cultural Validation
of the Mini-BESTest into Greek. 2016;3(3):8.
Antoniadou E, Kalivioti X, Stolakis K, Koloniari A, Megas P, Tyllianakis M, et al.
Reliability and validity of the mCTSIB dynamic platform test to assess balance in
a population of older women living in the community. J Musculoskelet Neuronal Interact
2020;20(2):185-93.
Godi M, Franchignoni F, Caligari M, Giordano A, Turcato AM, Nardone A. Comparison
of reliability, validity, and responsiveness of the mini-BESTest and Berg Balance
Scale in patients with balance disorders. Phys Ther 2013;93(2):158-67.
Devons CAJ. Comprehensive geriatric assessment: making the most of the aging years.
Curr Opin Clin Nutr Metab Care 2002;5(1):19-24.
Fracture Liaison Service (F.L.S.)
Ioannis Tzellios, Apostolos Kolkas, Anastasios Korompilias, Emilios Pakos
Orthopaedic Department, University General Hospital of Ioannina
A fragility fracture is defined by the W.H.O. as “a fracture caused by an injury that
would be insufficient to fracture a normal bone”. The forces that cause these injuries
were quantified as being equivalent to those experienced from a fall from standing
height or less. It is calculated that 50% of women and 20% of men will suffer a fracture
in their remaining lifetime and 50% of those are at an increased risk of fracture
due to low bone density. A study in Greece has revealed that there were approximately
86,000 new fragility fractures in 2010, with an economic burden of 680 million € per
year, a number that will increase by 20% by 2025.
Fragility fractures have very poor prognosis. Even if they are treated adequately,
either conservatively or surgically, they lead to severe consequences, such as exceed
mortality (10-25%), inability of walking independently after a hip fracture (50%),
substantial decline from prior level of function (50%) and, of course, increased risk
for a subsequent fracture.
Positive identification of fragility fractures is critical to the care of patients
with osteoporosis. To reduce the risk of re-fracture a co-ordinated approach is needed
to identify patients most at risk. A Fracture Liaison Service (F.L.S.) is a multi
- disciplinary approach that systematically identifies, treats and refers to appropriate
services all eligible patients over 50 years old within a local population who have
suffered fragility fractures. The F.L.S. is designed to close the care gap for fracture
patients, 80% of whom are currently never offered screening and/or treatment for osteoporosis
and to enhance the communication between health care providers by providing a care
pathway for the treatment of fragility fracture patients.
According to a review by Ganda et al. in 2013, F.L.S. models were grouped in 4 main
types:
Type A identifies, investigates and initiates treatment.
Type B identifies and investigates patients, but then refers to the primary care physician
for treatment initiation.
Type C identifies patients at risk and inform them and their primary care physician,
but does not undertake any assessment or treatment of the patients.
Type D identifies at-risk patients, informs and educates them, but takes no further
part in communicating their findings to other stakeholders in the patient’s care.
The main structure of a Fracture Liaison Service is illustrated in Figure 1.
Figures 1
F.L.S structure as proposed by the International Osteoporosis Foundation.
According to this, all patients over 50 years old with a fracture resulted from minimal
trauma are addressed to F.L.S. The fragility fracture patients who agree to participate
to the program are asked to sign the informed consent form. A patient’s electronic
file is created and includes the appropriate data (hip and lumbar spine BMD, FRAX
calculation, thoracic and lumbar spine X-rays, relevant laboratory tests). The final
assessment includes a recommended antiosteoporotic treatment and a specific exercise
and educational program.
The majority of studies on F.L.S. refer very promising results. Eccles et al., in
their narrative review regarding the effectiveness of F.L.S. in the U.K., have shown
that there has been significant reduction of the risk of secondary fractures in patients
who participated in F.L.S. programs, while these were cost effective. Stephens et
al., in their study in the U.S.A., suggest that a wider adoption of an F.L.S. model
has the potential to improve care for patients with hip fracture by narrowing the
osteoporosis treatment gap. Furthermore, a prospective cohort study by Van Geel et
al. has revealed reduced risk for subsequent fragility fracture and lower risk for
mortality in patients with fragility fractures treated with oral bisphosphonates in
an F.L.S. setting. Another review by Walters et al. refers that the F.L.S. model is
associated with reduction in re-fracture risk, reduced mortality, increased assessment
of bone mineral density, increased treatment initiation and adherence to treatment
and is cost-effective.
In conclusion, and based on the majority of studies, F.L.S. is a proven model of fragility
fractures secondary prevention that improves patient’s quality of care, provides targeted
intervention, enables appropriate medicine prescribing, reduces hospital admissions,
reduces hospital and social costs, and finally improves quality of life, health and
well-being of fragility fracture patients.
References
Noordin S, Allana S, Masri BA. Establishing a hospital based fracture liaison service
to prevent secondary insufficiency fractures. International Journal of Surgery 2018;54:328e332.
Naranjo A, Molina A, Sepúlveda C, Rubiño FJ, Martín N, Ojeda S. The evolution of an
FLS in search of excellence: the experience of Gran Canaria. Arch Osteoporos 2020;15:108.
Walters S, Khan T, Ong T, Sahota O. Fracture liaison services: improving outcomes
for patients with osteoporosis. Clinical Interventions in Aging 2017;12:117-127.
Eccles E, Thompson JD, Roddam H. An evaluation of Fracture Liaison Services in the
detection and management of osteoporotic fragility fractures: A narrative review.
Radiography 2018.
Makras P, Babis GC, Chronopoulos E, Karachalios T, Kazakos K, Paridis D, Potoupnis
M, Tzavellas AN, Valkanis C, Kosmidis C. Experience gained from the implementation
of the fracture liaison service in Greece. Archives of Osteoporosis 2020;15:12.
Gupta MJ, Shah S, Peterson S, Baim S. Rush Fracture Liaison Service for capturing
‘missed opportunities’ to treat osteoporosis in patients with fragility fractures.
Osteoporosis International https://doi.org/10.1007/s00198-018-4559-9
Stephens JR, Caraccio D, Mabry DR, Stepanek KV, Jones MS, Hemsey DF, Moore CR. Implementation
of a fracture liaison service for patients with hip fracture cared for on a hospital
medicine service. Hospital Practice DOI: 10.1080/21548331.2020.1832384.
Cha YH, Ha HC, Park KS, Yoo JI. What is the Role of Coordinators in the Secondary
Fracture Prevention Program? J Bone Metab 2020; 27(3):187-199.
Svedbom A, Hernlund E, Ivergard M, Compston J, Cooper C, Stenmark J, McCloskey EV,
Jonson B, Lyritis GP, Makras P, Kanis JA. Epidemiology and Economic Burden of Osteoporosis
in Greece. Arch Osteoporos 2013;8:137.
van Geel TACM, Bliuc D, Geusens PPM, Center JR, Dinant GJ, Tran T, van den Bergh JPW,
McLellan AR, Eisman JA. Reduced mortality and subsequent fracture risk associated
with oral bisphosphonate recommendation in a fracture liaison service setting: A prospective
cohort study. PLoS ONE;13(6):e0198006.
Frailty-metrics
Dimitra Karadimou, Konstantinos Skarentzos, Georgios Drosos
Academic Orthopeadic Department, Medical School, Democritus University of Thrace,
University General Hospital Alexandroupolis, Alexandroupolis, Greece
Introduction: Frailty is a syndrome most associated with longevity characterized by
multisystem disturbance in physical homeostasis. The resulting vulnerability leads
to poor quality of life, hospitalization, falls, fractures, premature morbidity and
mortality in older people1. Pathophysiological mechanisms are not yet fully understood
and research is mainly observational upon clinical manifestations and risk-prediction.
In a longitudinal study of Trevisan et al, subject
s experienced both deterioration but also improvement of frailty state2. Special considerations
should be made on many factors that contribute for frailty onset and progression which
are demographic, psychosocial, clinical, life-style and biological3. Taking into account
the dynamic and multi-factorial nature of frailty could probably justify quantification
difficulties.
A point in history of frailty-metrics
Milestone year was 2001 when is published by Fried and colleagues the Frailty Phenotype
followed by Mitinski and colleagues Frailty Index, leading to operational definition4,5.
Frailty Phenotype is more related to “physical frailty” a term that is being used
in research to define frailty as a syndrome affecting functional ability of a person.
It compromises evaluation of muscle strength, gait speed, physical activity, self-perceived
exhaustion and weight loss. Alternatively, Frailty Index is theoretically closer to
the traditional medical frame of diagnosis-centered approach, rating accumulation
of morbidities. Both concepts have been widely used retaining their pros and cons.
Emerged research publicity from 2001 until today derived plural modification in measurement
frames but when comparison is made appears a significant effect on classification
and predictive ability6.
Frailty-metrics in health-care domains
Along with variability in psychometric properties of measurement tools feasibility
is another vast component of perplexity. In primary care for large epidemiological
studies evaluation tools should be selective, prolonged, combined with special equipment
(dynamometers, time-calculators etc.) and special educated personnel.
In acute care stabilization of the patient is most significant therefore measurement
should be easy, not time-consuming integrated in the context of medical history. It
is notable that Clinical Frailty Scale has been validated in the ED setting7.
Specialized care holds an individualized sector of healthcare; thus, evaluation of
frailty should be modified following every medical specialty needs. Geriatric medicine,
cardiology and cardiac surgery are among specialties with robust evidence in greater
prevalence of frailty whilst Orthopedic surgery and Traumatology support emerging
evidence. The FRAIL scale in a study of Gleason et al was proposed to predict adverse
postoperative outcome and perioperative management in geriatric patients with fracture8.
Frailty is not well addressed in post-acute and palliative care settings9,10. The
decline of patient’s state must be taken into consideration to guide evaluation and
management without risk enhancement. Assessment should define severity summarizing
all previous results combined with patients and family care-givers volition for quality
of life in end -life.
Conclusion: Concluding, there is not a single approach or tool to measure frailty
covering all clinical or research demands. Surely frailty evaluation should be incorporated
as standard clinical praxis for older people taking into account physical capabilities,
psychosocial, cognitive, nutritional status and comorbidity in order to provide a
holistic health-care management.
References
Ensrud KE, Ewing SK, Cawthon PM, Fink HA, Taylor BC, Cauley JA, et al. A comparison
of frailty indexes for the prediction of falls, disability, fractures, and mortality
in older men. Journal of the American Geriatrics Society 2009;57(3):492-8.
Trevisan C, Veronese N, Maggi S, Baggio G, Toffanello ED, Zambon S, et al. Factors
Influencing Transitions Between Frailty States in Elderly Adults: The Progetto Veneto
Anziani Longitudinal Study. Journal of the American Geriatrics Society 2017;65(1):179-84.
Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. Frailty: implications
for clinical practice and public health. Lancet (London, England) 2019;394(10206):1365-75.
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty
in older adults: evidence for a phenotype. The journals of gerontology Series A, Biological
sciences and medical sciences 2001;56(3):M146-56.
Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure
of aging. The Scientific World Journal 2001;1:323-36.
Theou O, Cann L, Blodgett J, Wallace LM, Brothers TD, Rockwood K. Modifications to
the frailty phenotype criteria: Systematic review of the current literature and investigation
of 262 frailty phenotypes in the Survey of Health, Ageing, and Retirement in Europe.
Ageing research reviews 2015;21:78-94.
Elliott A, Phelps K, Regen E, Conroy SP. Identifying frailty in the Emergency Department-feasibility
study. Age and ageing 2017;46(5):840-5.
Gleason LJ, Benton EA, Alvarez-Nebreda ML, Weaver MJ, Harris MB, Javedan H. FRAIL
Questionnaire Screening Tool and Short-Term Outcomes in Geriatric Fracture Patients.
Journal of the American Medical Directors Association 2017;18(12):1082-6.
Pollack LR, Goldstein NE, Gonzalez WC, Blinderman CD, Maurer MS, Lederer DJ, et al.
The Frailty Phenotype and Palliative Care Needs of Older Survivors of Critical Illness.
Journal of the American Geriatrics Society 2017;65(6):1168-75.
Roberts PS, Goud M, Aronow HU, Riggs RV. Frailty in a Post-Acute Care Population:
A Scoping Review. PM & R : the journal of injury, function, and rehabilitation 2018;10(11):1211-20.
Functional recovery and mortality rates after hip fractures. The effect of zoledronic
acid and high doses of vitamin D
Antonios A. Koutalos, George Varsanis, George I. Chalatsis, Konstantinos N. Malizos,
Theofilos Karachalios
Department of Orthopaedic Surgery & Musculoskeletal Trauma, University General Hospital
of Larissa, School of Health Sciences, Faculty of Medicine, University of Thessaly,
Hellenic republic
Introduction: Even with optimal treatment, hip fractures are associated with inferior
functional recovery and increased mortality rates1-4. While it is known that vitamin
D has a positive effect on pain, muscle strength and balance, elderly patients, especially
those with hip fractures, have a higher incidence of vitamin deficiency5. The hospitalization
of hip fracture patients is thus an opportunity to both correct any vitamin D deficiency
and start medical treatment for osteoporosis.
The purpose of the study was to evaluate whether hip fracture patients could benefit
from a combination treatment of zoledronic acid and high doses of vitamin D.
Material and Methods: Between March 2018 and December 2018, 98 consecutive patients
with hip fractures (both trochanteric and femoral neck) were recruited into our study,
applying various inclusion and exclusion criteria. After surgical treatment, patients
were separated into two groups. In group A (48 patients), 25.000 IU vitamin D per
week and 1000 mg of calcium per day were administered for two months followed by daily
doses of vitamin D and calcium. In group B (50 patients), medication was not administered
but a recommendation was made for patients to attend a primary care facility for osteoporosis
evaluation. Pre- and post- operative assessments included vitamin D measurement, Barthel
functional index for activities of daily living, AMTS dementia score, VAS pain, Charlson
Comorbidity Index and ASA score. Time to surgery and major complications were also
recorded. Time intervals for follow-up evaluation were set at 6, 12 weeks and one
year. At final follow up all patients were clinically examined and radiographs were
performed to evaluate fracture healing and possible mechanical failures. Primary outcome
end point was functional recovery at one year. Secondary outcome end point was VAS
pain and mortality.
Results: Three patients in group A and four patients in group B were lost to follow-up.
Thus, the final number of patients who were finally assessed was 45 in group A, 46
in group B. Patients demographics are shown in Table 1. Patients of both groups were
matched regarding all parameters except age.
Table 1
Patients’ demographics.
Group A (zoledronic acid plus high dose vitamin D)
Group B (control)
P value
Age (years) (mean±SD)
83.6±7.9
79.3±7.5
0.018 (t-test)*
Gender
Females (n/%)
36/80.0%
32/70.0%
0.368 (chi square)
Males (n/%)
9/20.0%
14/30.0%
Type of fracture
Neck of femur (n/%)
20/44.4%
27/58.7%
0.455 (chi square)
Pretrochanteric (n/%)
25/55.6%
19/41.3%
Charlson comorbidity index (mean±SD)
4.7±1.1
4.4±1.6
0.392 (t-test)
ASA score (mean±SD)
2.3±0.8
2.5±0.6
0.149 (t-test)
Days from admission to surgery
2.6±1.8
3.0±2.1
0.391 (t-test)
Pre-operative Barthel index score
18.0±2.8
18.8±3.5
0.286 (t-test)
Dementia (n/%)
No
36/80.0%
41/89.1%
0.282 (chi square)
Yes
9/20.0%
5/10.9%
Vitamin D at admission (ngr/ml)
7.4±5.2
8.2±6.1
0.459 (t-test)
*
statistically significant, p<0.05.
Following surgery patients of both groups showed a decline in function. Comparing
Barthel index between groups, at one year, no statistically significant (s.s.) difference
(student’s t test, p=0.850) was found (Table 2). Barthel index decreased more than
3 points in the control group only, which was both clinically and statistically significant
(Table 2). Mortality rate was s.s. higher (chi square, p=0.047) in the control group.
No s.s. differences were observed in VAS scores (t test, p=0.858) between the two
groups.
Table 2
Results between groups concerning Barthel index, VAS pain score mortality and complications.
Group A (zoledronic acid plus high dose vitamin D)
Group B (control)
P value
Post-operative Barthel index score
15.4±5.0
15.8±5.8
0.850 (t-test)
Change in Barthel index score
-2.3±2.9 (paired t test, p=0.01)
*
-3.0±4.2 (paired t test, p=0.0001)
*
VAS pain score
1.3±1.6
1.3±1.3
0.858 (t-test)
Mortality (n/%)
4 of 45/8.8 %
13 of 46/28.2%
0.047 (chi square)
*
Complications (n/%)
8 of 45/17.7%
7 of 46 / 15.2%
0.751 (chi square)
*
statistically significant, p<0.05.
Regression analysis was used in order to identify factors affecting Barthel index.
Age (Pearson correlation, p=0.038), Charlson index (Pearson correlation, p=0.00006),
pre-operative Barthel index (Pearson correlation, p<0.00001), dementia (t-test, p=0.038)
and type of fracture (t-test, p=0.076) showed s.s. correlations in univariate analysis.
Only pre-operative Barthel index (p<0.00001) and Charlson index (p=0.027) showed s.s.
correlations in multivariate analysis. Regression analysis was also used in order
to identify factors affecting mortality rate. ASA score (t-test, p=0.027), Charlson
index score (t test, p=0.021), gender (chi square, p=0.05), complications (chi square,
p=0.001) and treatment group (chi square, p=0.047) showed s.s. correlations in univariate
analysis. Treatment group (p=0.022) and complications (p=0.002) showed s.s. correlations
only in multivariate analysis.
Discussion and Conclusions: This study demonstrates that early correction of vitamin
D deficiency and administration of zolandronic acid reduces mortality and possibly
slows down functional decline after hip fracture.
Intravenous zolandronic acid has been shown to reduce mortality probably through anti-inflammatory
and immunomodulating effects6,7. The above observation was confirmed in our study.
Other studies have shown no effect when general osteoporosis treatment was assessed3,4.
Several factors have been identified as influencing mortality rates after hip fractures3,4,6,7.
In our logistic regression model we confirmed the effect of the factors treatment
and complications only. Osteoporosis treatment has been shown to have an effect on
functional recovery after hip fractures3,4. In our study we confirmed that iv zolandronic
acid and high doses of vitamin D reduce functional decline after hip fractures. Several
factors have been identified as influencing functional outcome after hip fractures3,4,8,9.
In our logistic regression model we confirmed the effect of the factors preoperative
Barthel index and Charlson index only.
References
De Joode SGCJ, Kalmet PHS, Fiddelers AAA, Poeze M, Blokhuis TJ. Long-term functional
outcome after a low-energy hip fracture in elderly patients. J Orthop Traumatol 2019;20(1):20.
Haentjens P, Magaziner J, Colon-Emeric CS, Vanderschueren D, Milisen K, Velkeniers
B, et al. Meta-analysis: excess mortality after hip fracture among older women and
men. Ann Intern Med 2010;152(6):380-90.
Makridis KG, Karachalios T, Kontogeorgakos VA, Badras LS, Malizos KN. The effect of
osteoporotic treatment on the functional outcome, re-fracture rate, quality of life
and mortality in patients with hip fractures: a prospective functional and clinical
outcome study on 520 patients. Injury 2015;46(2):378-83.
Makridis KG, Badras LS, Badras SL, Karachalios TS. Searching for the ‘winner’ hip
fracture patient: the effect of modifiable and non-modifiable factors on clinical
outcomes following hip fracture surgery. Hip Int 2019 Sep 23:1120700019878814.
Papapetrou PD, Triantaphyllopoulou M, Karga H, Zagarelos P, Aloumanis K, Kostakioti
E, et al. Vitamin D deficiency in the elderly in Athens, Greece. J Bone Miner Metab
2007;25(3):198-203.
Colón-Emeric CS, Mesenbrink P, Lyles KW, Pieper CF, Boonen S, Delmas P, et al. Potential
mediators of the mortality reduction with zoledronic acid after hip fracture. J Bone
Miner Res 2010;25(1):91-7.
Xu BY, Yan S, Low LL, Vasanwala FF, Low SG. Predictors of poor functional outcomes
and mortality in patients with hip fracture: a systematic review. BMC Musculoskelet
Disord 2019;20(1):568.
Adachi JD, Lyles KW, Colón-Emeric CS, Boonen S, Pieper CF, Mautalen C, et al. Zoledronic
acid results in better health-related quality of life following hip fracture: the
HORIZON-Recurrent Fracture Trial. Osteoporos Int 2011; 22(9):2539-49.
Mayoral AP, Ibarz E, Gracia L, Mateo J, Herrera A. The use of Barthel index for the
assessment of the functional recovery after osteoporotic hip fracture: One year follow-up.
PLoS One 2019;14(2):e0212000.
Billington EO, Burt LA, Rose MS, Davison EM, Gaudet S, Kan S, et al. Safety of High-dose
Vitamin D supplementation: secondary analysis of a randomized controlled trial. J
Clin Endocrinol Metab 2020;105(4): dgz212.
Hip fragility fractures in the elderly: the reality in Greece during the recent financial
crisis
Konstantinos Alexiou, Apostolos Fyllos, Sokratis Varitimidis, Konstantinos Malizos
Department of Orthopaedic Surgery & Musculoskeletal Trauma, Faculty of Medicine, School
of Health Science, University of Thessaly
Purpose: The present study aims at the evaluation of modifiable and non-modifiable
factors affecting quality of life and mortality in elderly patients suffering from
a low energy hip fracture.
Methods: This was a prospective controlled clinical study conducted between August
2013 and August 2016 simultaneously at a tertiary care University Hospital and a regional
General Hospital, located at the central and the north-western part of the country
respectively. Inclusion criteria were: a) age 65 years or above, b) admission for
proximal femur low-energy fracture (intracapsular, intertrochanteric or subtrochanteric
location), c) signed informed consent agreeing to participate in the study and d)
follow-up for at least 12 months or until death prior to 12 months. Exclusion criteria
were: a) patients with hip fractures with concomitant injuries, b) patients that denied
to be included in the study or failed to attend scheduled follow-ups and c) patients
suffering from multiple or pathologic fractures.
All included patients were evaluated with the Functional Independence Measure and
the Functional Assessment Measure (FIM+FAM), the 12-item Short Form survey (SF-12)
and the American Society of Anesthesiologists (ASA) physical status classification
system. Other parameters that were also recorded were time to surgery (and reasons
for delay), readmissions, mortality rate and time to death.
Results: A total of 744 patients were found eligible for inclusion in the study. Their
mean age was 83 years. Eighteen patients (2.4%) died during their hospital stay, 68
patients (9.1%) died within the first month from diagnosis and 144 patients overall
(19.4%) died within the first year since diagnosis.
• Differences between age
Patients over the age of 81 comprised 64.52% of the study population. These patients
had a higher mortality rate (23.96% vs. 10.98%, p<0.05) compared to patients under
81 years of age and significantly shorter time to death (297.6 vs. 334.1 days, p<0.001).
• Differences between hospitals
In the regional, secondary care, General Hospital, 147 patients were included in the
study, with mortality rate reaching 23.81%. Mean time to death was 293.8 days. In
the University Hospital, 597 patients were eligible for inclusion, and their mortality
rate was 18.26%. Mean time to death was 314.7 days and it did not differ significantly
between hospitals (p=0.096).
• Differences between sexes
There were 501 female and 243 male patients. During the three-year study period and
regardless of treatment, mortality rate was 23.05% for male patients, and mean time
to death was 298.3 days since fracture diagnosis. Female patients had a mortality
rate of 17.56% and mean time to death was longer compared to the male cohort (316.5
days), although it did not reach statistical significance (p=0.062).
• Type of fracture
Fracture type distribution is depicted in Τable 1. No fracture type predisposed to
higher mortality rate (p=0.245) and shorter time to death (p=0.267).
• Conservative vs. surgical treatment
Out of 744 eligible patients, 8.47% were treated conservatively. Mortality rate for
these patients was 65.08% and mean time to death was 173.7 days, since fracture diagnosis.
Patients treated surgically had a mortality rate of 15.12% and mean time to death
was significantly longer (323.7 days, p<0.001).
• Time to surgery
Patients were grouped as presented in Table 1 according to time lapse between hospital
admission and surgery. There was lower overall survival (78.7%) and shorter time to
death (313.4 days) for patients operated 48 hours or more from admission compared
to patients operated sooner (p=0.002). Reasons for delay for more than 48 hours were
lack of theatre time (62%), a medically unfit patient (34%) or lack of surgical implants
(3%).
Table 1
Factors affecting mortality rate and time to death.
Factors
Sample size
Deaths
Mortality rate
Mean Days to death (+SD)
ASA score
I
34
0
0
II
268
8
3%
III
394
100
25.4%
IV
a48
36
75%
Time to surgery
0-12 h
69
5
7.3%
349.45 (7.5)
12-24 h
154
14
9.1%
339.4 (6.8)
24-48 h
143
17
91.9%
333.7 (7.5)
>=48 h
315
67
313.422
313.4 (6.4)
Readmission (days from discharge)
0-30
45
25
55.6%
185.2 (24.8)
31-365
104
29
27.9%
296.9 (11.55)
Total readmissions
149
54
36.2%
263.2 (11.8)
No readmission
577
72
12.5%
Age
<81
264
29
10.98%
334.1 (5.9)
>=81
480
115
23.96%
297.6 (5.9)
Sex
Male
243
56
23.05%
298.3 (8.3)
Female
501
88
17.56%
316.499 (5)
Treatment
Surgical
681
103
15.12%
323.7 (4)
Conservative
63
41
65.08%
173.7 (19.9)
Type of fracture
Intracapsular
242
50
20.66%
305.9 (7.8)
Intertrochanteric
447
88
19.69%
309.7 (5.7)
Subtrochanteric
55
6
10.91%
337.65 (11.9)
Hospital
University
597
109
18.26%
314.7 (4.7)
Regional
147
35
23.81%
293.8 (11)
Total
744
144
310.6 (4.4)
• ASA
Patients were assigned an ASA physical status as presented in Τable 1. As expected,
patients assigned an ASA status IV had significantly higher mortality rate (75%, p<0.001).
• Readmission
Table 1 shows readmission and mortality rates. Patients that were readmitted shortly
after initial discharge (0-30 days) had significantly higher mortality rate (55.6%
vs. 27.9%, p=0.01) and shorter time to death (185.2 vs. 296.9 days, p<0.001). Patients
that required readmission at any point also had higher mortality rate compared to
the group of patients that did not require readmission.
• Quality of life
FIM+FAM and SF-12 are depicted in Figure 1. Overall, functional capacity and quality
of life did not differ significantly prior to fracture and 12 months postoperatively.
Differences were significant at one month and at 4 months postoperatively.
Figure 1
Depiction of FIM+FAM and SF-12 scores per hospital.
Conclusions: Female sex holds a higher risk for suffering a proximal femur fracture
over the age of 65. Lack of theatre time for safe surgical practice is a major yet
modifiable reason for surgical delay that leads to increased mortality. Comorbidity,
age over 81, readmissions and conservative treatment also increase mortality.
Suggested References
Nyholm A, Gromov K, Palm H, Brix M, Kallemose T, Troelsen A. Time to Surgery Is Associated
with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture. A Retrospective
Observational Study on Prospectively Collected Data from the Danish Fracture Database
Collaborators J Bone and Joint Surgery 2015;97(16):1333-9.
Devon R, Hiroyuki Y, Daisuke Y, Kenneth E, Zuckerman J. Delay in Hip Fracture Surgery
An Analysis of Patient-Specific and Hospital-Specific Risk Factors J Bone and Joint
Trauma 2015;29(8):343-8.
Peeters C, Visser E, Van de Ree C, Gosens T, Den Oudsten B, De Vries J. Quality of
life after hip fracture in the elderly: A systematic literature review J Injury 2016;47(7):1369-82.
Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: a worldwide projection
J Osteoporos Int 1992;2(6):285-289.
Valizadeh M, Mazloomzadeh S, Golmohammadi S, Larijani B. Mortality after low trauma
hip fracture: a prospective cohort study J BMC Musculoskelet Disord 2012;13:143.
Mariconda M, Costa GG, Cerbasi S. Factors predicting mobility and the change in activities
of daily living after hip fracture: a 1-year prospective cohort study J Orthop Trauma
2016;30(20):71-77.
Orive M, Aguirre U, Garcıa-Gutierrez S. Changes in health-related quality of life
and activities of daily living after hip fracture because of a fall in elderly patients:
a prospective cohort study Int J Clin Pract 2015;69(4):491-500.
Center J, Nguyen T, Schneider D, Sambrook P, Eisman J. Mortality after all major types
of osteoporotic fracture in men and women. An observational study. J Lancet 1999;353(9156):878-82.
Sheehan K, Sobolev B, Guy P. Mortality by Timing of Hip Fracture Surgery Factors and
Relationships at Play. J Bone and Joint Surgery 2017; 99(20):e106.
Cenzer I, Tang V, Boscardin J, Smith A, Ritchie C, Wallhagen M, Espaldon R, Covinsky
K. One Year Mortality after Hip Fracture: Development and Validation of a Prognostic
Index J Am Geriatr Soc 2016;64(9):1863-1868.
Towards an integrated primary care model in the context of the COVID-19 pandemic:
Experience gained from Greece
Christos Lionis
Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece
Greece is a country in which integrated care is still lacking, although significant
efforts have been made more recently. In 2015, Tsiachristas et al. reported on a detailed
analysis of the Greek healthcare system and its challenges for enhancing integrated
care1. Four years later, several of the interlinked integrated care prerequisites
remain particularly relevant. The integration of public health goals into PΗC could
be a first step to initiate discussion about integrated care in European settings.
This could furthermore facilitate implementation of a second level of integration
that links primary care with mental, hospital, and social care. A recently published
paper, attempted to offer a framework on how best to design and rapidly test evidence-based
approaches that can serve to address public health priorities, improve health and
well-being of the population, and support evidence-informed policy making in Greece2.
In another published work, training and empowering patients, families, caregivers,
health professionals, and policy makers to define and promote integrated care was
identified as an imperative action3.
Some few months prior the pandemic another report from Greece issued recommendations
that were designed to guide current health policy towards an effective integrated
PHC model. This report included among others the following recommendations4:
Effective human resource planning
Implementation of a fully operational e-communication, interoperable, system
Orientation of the new PHC units to address major public health
Coordinated actions for integrated chronic disease care
Emphasis on integrating public health and PHC, and information flow and exchange
Development of core competencies and implementation of a coordinated continuing education
program for PHC professionals
Interprofessional collaboration
Coordination of care by the regional and local health authorities
Towards an integrated model for frailty
In parallel with the efforts made in Greece, in Europe, a Joint Action project underlined
that an effective model of care for frailty should include a single entry point in
the community (generally in Primary Care); the use of simple frailty specific screening
tools in all care settings; comprehensive assessment and individualized care plans,
including for caregivers; several tailored interventions by an interdisciplinary team-both
in hospitals and community; case management and coordination of support across the
continuum of providers; effective management of transitions between care teams and
settings; some shared electronic information tools and technology enabled care solutions;
and, several clear policies and procedures for service eligibility and care process5.
Questions also raised on the composition of the frailty team in primary care and a
current policy paper from the NHS in the United Kingdom recommended a multi-disciplinary
team that would deliver geriatric assessments that should include as ra minimum: a
competent specialist physician in medical care of older people, a coordinating specialist
nurse with experience, a senior social worker or a specialist nurse who is also a
care manager and some dedicated appropriate therapists6. There are also questions
on the timeframe that is needed to achieve improvements in the valued outcomes of
community-based interventions from frailty. A recent Spanish study reports that a
“real-world” multidisciplinary intervention, integrating primary care, geriatric care,
and community services may improve physical function, a marker of frailty within 3
months7.
Finally, a recently published report from a European Commission collaborative and
multi-staged innovation named project VIGOUR, indicated that this approach of integration
seems robust enough to work within the challenges evoked by the pandemic and flexible
enough to take advantage of integrated care initiatives which have been tested on
a pilot level and adopt them to specific needs emerging as a result of the pandemic.
The VIGOUR project emphasizes the need for a collaboration between health and social
care services.
Conclusions: Despite the significant interest in integrated care, even prior the pandemic,
integrated healthcare service delivery, encompassing PHC, public health, social care
and evidence-based practice largely remains a neglected area in many European settings.
The interface between hospital, mental health, public and social health and primary
care remains an unfolding discussion and there is an urgent need for designing and
implementing community-based interventions and experimental work that address this
with a particular focus on frailty and people with multi-morbidity. Training and empowering
patients, caregivers, health professionals and policy makers to define and promote
integrate care is also a high priority.
References
Tsiachristas A, Lionis C, Yfantopoulos J. Bridging knowledge to develop an action
plan for integrated care for chronic diseases in Greece. Int J Integr Care 2015;15:
e040.
Lionis C, Petelos E, Papadakis S, Tsiligianni S, Anastasaki M, Angelaki A, et al.
Towards evidence-informed integration of public health and primary health care: experiences
from Crete. WHO Public Health Panorama 2018;4:491-735.
Lionis C, and Anastasaki M. Integrated health care services as a current challenge
for primary health care: reflections from Crete, Greece. Medical Science Pulse 2019;13(1):22-25.
Lionis C, Symvoulakis EK, Markaki A, Petelos E, Papadakis S, Sifaki-Pistolla D, Papadakakis
M, Souliotis K, Tziraki C. Integrated people-centred primary health care in Greece:
unravelling Ariadne’s thread. Prim Health Care Res Dev 2019;20:e113.
Hendry A, Vanhecke E, Carriazo AM, López-Samaniego L, Espinosa JM, Sezgin D, O’Donovan
M, Hammar T, Ferry P, Vella A, Bacaicoa OA, Braga M, Ciutan M, Velivasi A, Lamprini
Koula M, Van der Heyden J, Liew A, O’Caoimh R. Integrated Care Models for Managing
and Preventing Frailty: A Systematic Review for the European Joint Action on Frailty
Prevention (ADVANTAGE JA). Transl Med UniSa 2019;19:5-10.
National Health Service (NHS) England. Safe and compassionate care for frail older
people using an integrated care pathway. Available at https://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf
(Accessed December 6 2020).
Pérez Bazán LM, Enfedaque-Montes MB, Cesari M, Soto-Bagaria L, Gual N, Burbano MP,
Tarazona-Santabalbina FJ, Casas RM, Díaz F, Martín F, Góz A, Orfila F, Inzitari M.
A Community Program of Integrated Care for Frail Older Adults: +AGIL Barcelona J Nutr
Health Aging 2019;23(8):710-716.
Investigating depression during the quarantine due to the pandemic in a sample of
elderly people in Patras
Konstantinos Stolakis1, Christos Marneras2, Theodoros Tosounidis3, Elias Panagiotopoulos4
1 University of Patras, School of Medicine, Rio-Patras, Greece
2 University Hospital of Rio, Patras, Greece
3 Department of Orthopaedic Surgery, University Hospital of Heraklion, Crete, Greece
4 Rehabilitation Department, University of Patras, Rio, Greece
COVID-19 and Depression
The COVID-19 pandemic invaded suddenly in our lives and came to change our daily way
of living in such a short time. One of the measures adopted for social health protection
was that of quarantine. However, pandemic and quarantine brought about various negative
emotions, such as fear, anxiety, insecurity, changes in daily life and environment
of the elderly, while many of them were led to social and physical isolation. All
these have had a negative impact on the psychological state of these individuals and
as a result many of them developed depressive symptoms or depression.
Depression and relationship with Falls, Fragility Fractures and Osteoporosis
Depression can be a risk factor for falls and fragility fractures. This is confirmed
in various studies and meta-analyses1,2. There is a bidirectional relationship between
these three concepts, depression, falls and fractures, that create a vicious circle
that is self-perpetuating. Antidepressants in combination with depression-related
factors such as fear of falls, gait and eating disorders etc., predispose to falls
and these in turn, as fear increases, cause depression, triggering avoidance behaviours
and social isolation but also injuries or disability from possible fractures3. Finally,
depression directly affects bone metabolism through various mechanisms with a negative
impact on bone density causing the onset of osteoporosis4.
Investigating depression during the quarantine due to the pandemic in a sample of
elderly people in Patras
The survey was conducted by telephone on a sample of 55 elderly people in April 2020
in order to investigate the effect of quarantine, as a public protective health measure
of the population from the SARS-Cov2 coronavirus, in relation to the existence of
depression. The tools that were used during the telephone interview were: a) The GERIATRIC
DEPRESSION SCALE (GDS-15 items), a decimal scale in which 1 is the lowest possible
value and 10 the highest, and is used to determine health self-perception, mood self-perception
and lifestyle changes due to the pandemic and b) A Likert scale to assess the compliance
with state measures “stay at home” (1=absolute compliance and 5=no compliance).
The mean GDS value in our sample was found to be 4.61 (S=±3.24) [3.72 (SD=±2.90) for
men and 4.84 (SD=±3.31) for women]. This was significantly better in comparison with
the corresponding study5, which was conducted in a sample of 78 elderly people, who
attended the program at an Open Care Centre for the Elderly in Crete in a rural area,
before the beginning of the pandemic. The corresponding value of this study was found
to be 5.9 (SD=±4.1). However, the mean value of the GDS in our study was higher than
the reference value of the Greek population of healthy elderly, with an average age
of 79.98 years, which was 2.96 (SD=±1,66)6.
Diagram 1 shows that older people with greater number of depressive symptoms are more
likely to have low self-perception about their physical health, emotional well-being
and vice versa. These findings are related to the pandemic. These show that seniors
who believed that the onset of the pandemic has led to changes in their lifestyle
are more likely to have higher GDS-15 values and vice versa. In contrast, a significant
negative correlation (p<,01) was found between GDS-15 values and the stay of the elderly
at home.
Diagram 1
Corelations of GDS-15 with the Self perception of health and other parameters
An interesting result is the positive statistical correlation (p<0.05) between GDS-15
values and the number of people who live with the elderly of our sample. This finding
seems contradictory, as the elderly who are living alone face the problem of loneliness.
However, there are elderly people who live with their children because of their children’s
health or financial problems. Therefore, cohabitation with other people beyond the
couple is not a choice, but a necessity.
Conclusions: The study showed that about 1/3 of the sample (34.6%) were depressed
and although the mean GDS-15 (4.61) is marginally below the moderate depression, it
is above the average value (2.96), which was found in the healthy Greek population.
Older people staying home during quarantine are more vulnerable in developing depression.
This should be under concern to the health policy makers, as depression is a risk
factor for other diseases, especially falls and fractures.
This research is co-financed by Greece and the European Union (European Social Fund-ESF)
through the Operational Programme “Human Resources Development, Education and Lifelong
Learning 2014- 2020” in the context of the project “A Holistic Interdisciplinary Approach
to Treating Patients with Fragility Fractures” (MIS 5047167).
References
Whooley MA, Kip KE, Cauley JA, Ensrud KE, Nevitt MC, Browner WS. Depression, falls,
and risk of fracture in older women. Study of Osteoporotic Fractures Research Group.
Arch Intern Med 1999;159(5):484-90.
Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E. Risk factors
for falls in community-dwelling older people: a systematic review and meta-analysis.
Epidemiology 2010;21(5):658-68.
Iaboni A, Flint AJ. The complex interplay of depression and falls in older adults:
a clinical review. Am J Geriatr Psychiatry 2013;21(5):484-92.
Rizzoli R, Cooper C, Reginster JY, Abrahamsen B, Adachi JD, Brandi ML, Bruyère O,
Compston J, Ducy P, Ferrari S, Harvey NC, Kanis JA, Karsenty G, Laslop A, Rabenda
V, Vestergaard P. Antidepressant medications and osteoporosis. Bone 2012;51(3):606-13.
Alefantinou A, Vlasiadis K, Philalithis, A. Prevalence of depression in elderly people-members
of the Open Care Centre for the Elderly of a mountain village in Crete. Archives of
Greek Medicine 2016;33(3):368-374.
Fountoulakis KN, Tsolaki M, Iacovides A, Yesavage J, O’Hara R, Kazis A, Ierodiakonou
C. The validation of the short form of the Geriatric Depression Scale (GDS) in Greece.
Aging (Milano) 1999;11(6):367-72.
Management of sarcopenic patient
Markos Sgantzos
Department of Anatomy, Faculty of Medicine, School of Health Sciences, University
of Thessaly, Larissa, Greece
Aging is associated with skin sagging, kyphosis and a reduction of muscle mass and
strength; the concurrent progressive loss of functional performance that takes place
appears completely normal. The term sarcopenia which is derived from the words “sarx”
meaning flesh and “penia” meaning loss, originally described the loss of lean body
mass during “healthy” aging. In 1988, Irwin Rosenberg defined sarcopenia as the loss
of muscle mass related to aging, indicating the critical role muscles play in disability
and incapacity. As a result, sarcopenia is defined as the age-related decrease of
muscle mass and strength. In adults, low muscle strength is associated with reduced
functionality and signifies frailty. Increasing muscle strength corresponds to an
increase in functional performance, thereby reducing an individual’s vulnerability.
An individual’s functional performance becomes normal once a high level of functionality
is achieved, above which any increase is independent of the normal level of function.
Individuals greatly rely on their skeletal muscles to interact with their environments
and to carry out routine tasks in their everyday life. Sarcopenia has a significant
impact on the daily activities, functional status, disability and quality of life
in older populations. According to the revised European consensus on definition and
diagnosis of Sarcopenia, the definition and classification of this syndrome has been
modified, and it is now necessary to first evaluate an individual’s muscle strength.
If muscle strength is found to be reduced, the individual is considered a ‘probable
sarcopenia’ case; when this is combined with low muscle mass (quantity or quality),
the condition is characterized as ‘sarcopenia’. If an individual is found to have
reduced functional performance in addition to the above, then the condition is defined
as ‘severe sarcopenia’.
While age-related sarcopenia is characterized as primary sarcopenia, secondary sarcopenia
is attributed to alternate causes, including those related to specific activities,
disease or nutrition. Therefore, situations which in one way or another lead to the
above-mentioned causes - including bed rest, sedentary lifestyle, inflammatory diseases,
endocrine diseases, neurodegenerative diseases, malignancy, inadequate diet, gastrointestinal
disorders, cachexia etc. - may themselves cause secondary sarcopenia individually.
When the duration of sarcopenia is up to 6 months, it is referred to as acute sarcopenia;
however, when the duration of the condition exceeds 6 months, it is characterized
as chronic sarcopenia. A simple questionnaire (SARC-F) is utilized to begin investigating
the condition. The questionnaire refers to: strength, rising from a chair, climbing
stairs, the need for assistance in walking, and the number of falls during the past
year. A clinical suspicion for sarcopenia exists after completion of the SARC-F questionnaire,
and a cutoff value: ≥4. First, muscle strength is assessed (Grip strength or Chair
stand test). With low muscle strength “probable sarcopenia” is confirmed. Muscle quantity
or quality (DXA, BIA, CT, MRI) follows for the confirmation of “Sarcopenia” (when
muscle mass is low). In the end a physical performance assessment (gait speed, SPPB,
TUG, or 400 m walk) is conducted in order to determine a classification of “severe
Sarcopenia”.
Therapeutic approaches for the management of sarcopenia consist of nutritional supplementation
and progressive resistance exercise training. In the context of physical activity,
aerobic exercise could be included to support aerobic capacity and quality of life.
Due to the pathogenesis of sarcopenia, additional therapeutic approaches are being
considered, including regenerative therapies, testosterone, growth hormone, insulin-like
growth factor, ghrelin or vitamin-D supplementation. Many of the above-mentioned approaches
lack evidence or insufficient evidence exists for their use in sarcopenia. For the
effective treatment of disease-attributed secondary sarcopenia, it is necessary to
treat the related disease in order to treat the sarcopenia.
In conclusion, sarcopenia has a great impact on older individuals, particularly related
to their daily activities, functional status, disability and quality of life. Annual
screening of all adults over the age of 65 years should be conducted. Furthermore,
an exercise regimen should be recommended (primarily resistance exercises), as well
as increased protein intake reaching nearly 2.0 g/kg/d or greater in severe catabolic
states. The use of a leucine enriched high protein supplementation, such as whey protein,
should also be considered. Individuals should take 25-30 grams of protein with each
meal, while persons with low bioavailable vitamin D should receive adequate vitamin
D supplementation. To prevent or delay sarcopenia, the development of muscle in youth
and young adults should be maximized, among middle aged populations muscle should
be maintained, and the loss should be minimized in older populations. The use of exercise
therapy should begin at an early stage, even while patients are in the hospital. Sarcopenic
patients must remain in an exercise group for the rest of their life.
Suggested References
Bauer J, Morley JE, Schols A, Ferrucci L, Cruz-Jentoft AJ, Dent E, et al. Sarcopenia:
A Time for Action. An SCWD Position Paper. J Cachexia Sarcopenia Muscle 2019;10(5):956-61.
Chen LK, Liu LK, Woo J, et al. Sarcopenia in Asia: consensus report of the Asian working
group for sarcopenia. J Am Med Dir Assoc 2014; 15(2):95-101.
Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on
definition and diagnosis Age and Ageing 2019;48(4):16-31.
Malmstrom TK, Morley JE. SARC-F: a simple questionnaire to rapidly diagnose sarcopenia.
J Am Med Dir Assoc 2013;14(8):531-2.
Morley JE, Sanford AM. Screening for Sarcopenia. J Nutr Health Aging 2019;23(9):768-770.
Rosenberg I. Summary comments. Am J Clin Nutr 1989;50(5):1231-1233.
Rosenberg IH. Sarcopenia: Origins and clinical relevance. J Nutr 1997; 127(5 suppl):990S-991S.
Anker SD, John E, Morley JE, von Haehling S. Journal of Cachexia of Sarcopenia and
Muscle 2016;7(5): 512-514.
The necessity of multidisciplinary approach in fragility fractures
Paraskevas Georgoulas, Dimitra Karadimou, Georgios Drosos
Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace,
University General Hospital of Alexandroupolis
Introduction: Osteoporosis and fragility fractures have been recognized as a crucial
public health issue. As aging population raises concomitant fragility fractures will
increase with geometric progress producing large economic burden. Also special concerns
should be made about impact at personal health level. Osteoporosis and its subsequent
fractures are related with poor quality of life, comorbidity, polypharmacy and mortality.
The FFN’s vision is a contemporary society where patients suffering from fragility
fracture will have interdisciplinary management, optimal rehabilitation, maintaining
their independence and quality of life. In this modern approach primary prevention,
targeted intervention and secondary prevention will enhance patient’s safety diminishing
hospitalization and re-fracture possibility leading to reduction in health-care costs.
In order to fulfill this goal it is mandatory to expand cooperation among different
health-care professionals.
FFN and multidisciplinary approach
The first pillar of FFN is the multidisciplinary care of patients with acute fracture
episode such as hip, clinical vertebral and other major fragility fractures. To achieve
the pillar’s objective a non-negligible number of health professionals must be stratified.
Patients with osteoporotic fractures are mainly elderly, frail people with co-morbidities
many of them suffering sarcopenia, dementia and malnutrition1,2. Therapeutic team
should be consisted of key members such as orthopaedic surgeons, geriatricians or
general practitioners, anesthesiologists, nurses, physiotherapists, dieticians, social
workers, and other healthcare professionals depending on individual’s special needs.
The success of team’s work is directly associated with adequate collaboration and
communication among members.Regarding to the second pillar of FFN postoperative rehabilitation
must begin as early as possible. Optimally, an individualized planned rehabilitation
program should be conducted by a multidisciplinary team, including social support
and nutritional advice for a long interval after discharge. Published literature indicates
that only 40 to 60% of patients following hip fracture are presumptively to gain their
pre-fracture level of mobility3. Following a hip fracture surgery, recovery is magnified
if a realistic rehabilitation program is provided. Rehabilitation pathway includes
diagnosing and treating impairments, in addition to secondary prevention interventions
related to osteoporosis, decelerating loss of function and when this is impossible,
compensating missed functions4,5. Whereas, healthcare workers should eliminate barriers
in order to supply rehabilitation services in lower and middle income countries as
well. According to the third pillar of FFN secondary prevention following fragility
fracture is obligatory in order to secure that individuals with osteoporosis are appropriately
treated. This prerequisite needs a timely and effective identification of patients
vulnerable to present with fragility fractures. The International Osteoporosis Foundation
promoted the “Capture the Fracture” campaign aiming to improve the implementation
of well-coordinated, multidisciplinary models of care in terms of secondary fracture
prevention globally. The first pilot implementation of a fracture liaison service
in Greek healthcare setting was conducted by Makras and colleagues in a single-center,
prospective study6. In a systematic review and meta-analysis, of a total of 159 articles,
assessment and management through fracture liaison services programs seemed to benefit
patients outcomes through increasing bone mineral testing, early treatment initiation
and adherence to treatment. Subsequently a decline in rates of clinical re-fractures
and mortality was stated7. The fourth Pillar of FFN is related to the formation of
national alliances and policy changes among the related mainstream professional associations
is imperative concerning impetus to the aforementioned three pillars. The formation
of national FFNs has successfully enlarged the meaning of orthogeriatric approach
and encompasses the establishment of the national alliances of healthcare associations
advocated in the fourth, enabling, political pillar.
Conclusion: Fragility fractures, mainly hip fractures are frequently accompanied with
severe adverse clinical outcomes and are costly injuries. Fracture pandemic emerges
challenges across all healthcare systems especially in middle and low-income countries.
It is therefore an urgency to address this issue with a multidisciplinary approach
providing best results. Consequently political and economic initiative will promote
integration of excellent quality services in all levels of care contributing in the
creation of a welfare community.
References
Bougioukli S, Κollia P, Koromila T, et al. Failure in diagnosis and under-treatment
of osteoporosis in elderly patients with fragility fractures. J Bone Miner Metab 2019;37(2):327-335.
Cruz-Jentoft AJ, Bahat G, Bauer J, et al; Writing Group for the European Working Group
on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia:
revised European consensus on definition and diagnosis. Age Ageing 2019;48(1):16-31.
Dyer SM, Crotty M, Fairhall N, Magaziner J, Beaupre LA, Cameron ID, Sherrington C;
Fragility Fracture Network (FFN) Rehabilitation Research Special Interest Group. A
critical review of the long-term disability outcomes following hip fracture. BMC Geriatr
2016;16(1):158.
Diong J, Allen N, Sherrington C. Structured exercise improves mobility after hip fracture:
a meta-analysis with meta-regression. Br J Sports Med 2016;50(6):346-55.
Handoll HH, Sherrington C, Mak JC. Interventions for improving mobility after hip
fracture surgery in adults. Cochrane Database Syst Rev 2011; (3):CD001704.
Makras P, Panagoulia M, Mari A, Rizou S, Lyritis GP. Evaluation of the first fracture
liaison service in the Greek healthcare setting. Arch Osteoporos 2017;12(1):3.
Wu CH, Tu ST, Chang YF, et al. Fracture liaison services improve outcomes of patients
with osteoporosis-related fractures: A systematic literature review and meta-analysis.
Bone 2018;111:92-100.
Online exercise in the new era of digital medicine
Matina Koutroumpi
Clinical Exercise Physiologist, Private Practice
So far with the Covid 19 Pandemic 1.48 milion people have died1. A prospective study
reported that the global hip fracture incidence will increase dramatically with global
numbers up to 4.5 million by 20502. The importance of fracture and fragility incidence
has a profound impact on general function level and mobility and affects quality of
life a huge part of the global population.
Technology led to a revolution on our entertainment, education and of course health.
Online physical activity has also become a part of our everyday routine. Several studies
support that online physical activity interventions effectively promote and maintain
physical activity levels3,4. Online interventions are not the future, not even the
present, online interventions are the past. For the first time in 2010 the American
Telemedicine Association published the first telerehabilitation guidelines5. During
the 70’s the phone communication was used to access patient’s physical activity levels,
through interviews. With the video revolution during the 80’s the exercise plan was
given in the form of a VHS or a CD. Nowadays we are talking about a new era, the era
of artificial intelligence (AI). Computers can speak, hear, think, learn and if we
give them permission they even take decisions for us, such as which route to take
to avoid traffic.
For an online exercise session all you need is a fast internet connection and a tablet,
phone or PC. Moreover, many companies have produced wireless sensors such as heart
rate, blood pressure, electrocardiograms monitors and many more to increase safety
while exercising. Home online exercise appears to have increased adherence compared
to usual intervention6 and is at least as effective7. Furthermore the cost for a single
session of in-home online exercise session compared to conventional home-visit exercise
session was lower or about the same, depending on the distance between the participant’s
home and fitness centre. A favourable cost differential was observed when the participant
was more than 30 km from the provider8. While studying psychological and social wellbeing,
the results indicate that technology-supported online group-exercising which conceals
individual differences in physical skills is effective in motivating and enabling
individuals who are less fit to train as much as fitter individuals. This not only
indicates the feasibility of training together despite differences in physical skills
but also suggests that online exercise might reduce the effect of skills on adherence
in a social context9. Conclusively online home based exercise is not only feasible
even for older people but it is also associated with high levels of engagement and
participant’s satisfaction10.
Even though many project an ethical dilemma about AI, it can become our reliable fitness
partner without undermining traits that are exclusive to humans such as imagination,
empathy and intuition. Everybody should have access to high quality exercise services.
With online exercise sessions, we are a step closer to that direction, because as
stated above it is easily accessible, cheap and effective.
References
https://www.worldometers.info/coronavirus/?
Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos
Int 1997;7(5):407-13.
Müller AM, Khoo S. Non-face-to-face physical activity interventions in older adults:
a systematic review. Int J Behav Nutr Phys Act 2014;11(1):35.
Aalbers T, Baars MAE, Rikkert O. Characteristics of effective Internet-mediated interventions
to change lifestyle in people aged 50 and older: a systematic review. Ageing Res Rev
2011;10(4):487-97.
Brennan D, MBE, Tindall L, Theodoros D, Brown J, Campbell M, Christiana M, Smith D,
Cason J, Lee A. A Blueprint for Telerehabilitation Guidelines. Int J Telerehabil 2010
Fall;2(2):31-34.
Finkelstein J, & Liu J. Designing Telerehabilitation System for Multipronged Exercise
in Patients with Multiple Sclerosis. Stud Health Technol Inform 2018;254:16-23.
Tousignant M, Moffet H, Boissy B, Corriveau H, Cabana F, Marquis F. A randomized controlled
trial of home telerehabilitation for post-knee arthroplasty. J Telemed Telecare 2011;17(4):195-8.
Tousignant M , Moffet H, Nadeau S, Mérette C, Boissy P, Corriveau H, Marquis F, Cabana
F, Ranger P, Belzile L E, Dimentberg R. Cost analysis of in-home telerehabilitation
for post-knee arthroplasty. J Med Internet Res 2015;17(3):e83.
Baez M, Khaghani Far I, Ibarra F, Ferron M, Didino D, CasatiF. Effects of online group
exercises for older adults on physical, psychological and sociawellbeing: a randomized
pilot trial. PeerJ 2017;5:e3150.
Arash Harzand A, Witbrodt B, Davis-Watts M L , Alrohaibani A , Goese D, Wenger N K
, Shah A J , Zafari A M. Feasibility of a Smartphone-enabled Cardiac Rehabilitation
Program in Male Veterans With Previous Clinical Evidence of Coronary Heart Disease.
Am J Cardiol 2018;122(9):1471-1476.
Orthopaedic treatment of fragility fractures - Postoperative management
Alexandros Pastroudis, Stamatios-Theodoros Chatzopoulos, George Georgiades, Dimitrios
Begkas
6th Orhopaedic dpt, Asklepieio Voulas G.H., Greece
Worldwide, osteoporosis causes more than 8.9 million fractures annually1 and by 2050
the worldwide incidence of hip fracture is projected to increase by 310% in men and
240% in women, compared to rates in 19902. In the same time, a prior fracture is associated
with an 86% increased risk of any fracture3. Hip fracture survivors often experience
a loss in function with 40% unable to walk independently and 60% requiring assistance
a year later. All the above make aboundingly clear the need for optimization of acute
and long-term management following a fragility fracture. The aim of their treatment
is the speedy return in the patient’s pre-fracture condition. However, preexisting
conditions (cardiovascular, Parkinson, diabetes, COPD, dementia etc.) influence negatively
their outcome. In addition, already deteriorated mobility and functionality as well
lack of rehabilitation services, have a negative impact on morbidity, mortality and
functional recovery.
Care of a fragility fracture patient is best accomplished collaboratively (orthopedic,
geriatrician, nurse, physiotherapist, nutritionist, etc.), utilizing an interdisciplinary
approach. Multidisciplinary management was shown to result earlier functional independence,
reduced length of stay, and decreased future need of institutional care.
The fracture type is not the only factor influencing the decision for surgical intervention.
The condition of the patient, the potential benefit and the possibility of mobilization
post operatively are to be considered. The surgical treatment of a fragility fracture
is complicated by the poor bone quality due to the age and osteoporosis, increased
risk of non-unions, reduced osteointegration of implants, and other factors. Many
surgical options are available depending on the fracture, internal or external fixation
(for upper extremity), arthroplasties, kyphoplasty/vertebroplasty. All share the same
aim, to reduce the morbidity and mortality, provide a stable osteosynthesis with as
possible minimally invasive surgery technique to enable early mobilization and weight
bearing.
However, the management of a fragility fracture doesn’t end in the operative room,
it merely starts there! Early and late surgical complications, as well secondary fracture
prevention and rehabilitation is of outmost importance.
Wound infection is a serious complication. Host factors that influence its incidence
include, diabetes, nutrition, smoking, steroid use etc. Prophylactic antibiotics should
be used for less than 24hours. Staff, patient and family education on signs of infection
is essential4.
Perioperative thrombosis is a common event in a fracture patient. Early surgery and
early mobilization have been shown to reduce its incidence. Fondaparinux or low-molecular
weight heparin for 28 to 35 postoperative seems to be the best evidence-based recommendation5.
Pain is one of the main sequalae of a fracture and operation. Good control of postoperative
pain reduces delirium and improves patient’s ability to participate in rehabilitation.
Its assessment in the elderly patients can be challenging6. Multimodal analgesia is
of great importance in the elderly. Opioids may induce delirium, and may have increased
cerebral sensitivity to them. Nonsteroidal anti-inflammatory drugs may cause acute
kidney injury. Early surgery is likely one of the best ways to decrease pain.
Nutrition is essential in fracture patient care7. Generally, patients should be fed
orally consisting of small portions with high-caloric content. Recommended discharge
Instructions for these patients are: calcium (500 mg) and vitamin D3 (cholecalciferol
- 2000IU) supplementation daily; and 1 g/kg/Bw of Protein.
There is a post fracture care gap in secondary prevention for fracture patients. Studies
indicate that these patients: fail to be tested and treated for osteoporosis, and
go on to break another bone8. Secondary prevention methods concentrate on treating
osteoporosis, falls other comorbidities management.
Falls assessment is a key component in secondary prevention. Falls in older persons
are most often result of multiple impairments as vision, cardiovascular, neurologic,
balance, psychoactive medications, home environmental hazards, etc8.
During the recovery process, different functions recover at different rates. The goals
of rehabilitation are: to restore quality of life through mobility, prevent future
fractures by preventing falls. Rehabilitation should begin immediately after surgery.
This might include pharmacologic and nutritional interventions as well as those involving
physical rehabilitation and structured exercise.
The increase in fragility fractures together with the increase in morbidity, mortality
and their socioeconomic impact, necessitate a methodically and streamlined management
of these patients. A multidisciplinary approach will provide the solution for a tailor-made
treatment plan of the optimum outcome of the fragility fracture patients.
References
Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated
with osteoporotic fractures. Osteoporos Int 2006; 17(12):1726-33.
Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos
Int 1997;7(5):407-13.
Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, et al. A meta-analysis
of previous fracture and subsequent fracture risk. Bone 2004;35(2):375-82.
Greene LR. Guide to the elimination of orthopedic surgery surgical site infections:
an executive summary of the Association for Professionals in Infection Control and
Epidemiology elimination guide. Am J Infect Control 2012;40(4):384-6.
Marsland D, Mears SC, Kates SL. Venous thromboembolic prophylaxis for hip fractures.
Osteoporos Int 2010;21(Suppl 4):S593-604.
Gibson SJ, Helme RD. Age-related differences in pain perception and report. Clin Geriatr
Med 2001;17(3):433-56, v-vi.
Roberts KC, Brox WT. AAOS Clinical Practice Guideline: Management of Hip Fractures
in the Elderly. J Am Acad Orthop Surg 2015;23(2):138-40.
Bouxsein ML, Kaufman J, Tosi L, Cummings S, Lane J, Johnell O. Recommendations for
optimal care of the fragility fracture patient to reduce the risk of future fracture.
J Am Acad Orthop Surg 2004;12(6):385-95.
Osteoporotic vertebral compression fractures - Secondary prevention
Avraam Ploumis, George I. Vasileiadis, Ioannis Manolis, Dimitrios N. Varvarousis
Department of Physical Medicine & Rehabilitation, Division of Surgery, University
Hospital of Ioannina, University of Ioannina Medical School
Epidemiology and cost
Based on epidemiological data of the European Union (EU), Vertebral Compression Fractures
(VCFs) are the most common osteoporotic fractures (23%) (while hip fractures are less
frequent (17%)) and may occur in the absence of trauma or after minimal trauma (e.g.
bending, turning). The incidence of clinically diagnosed VCFs is 117 per 100.000 person
years1 or 438.750 clinical diagnosed VCFs per year in the EU. After the first VCF,
the risk of a subsequent VCF increases by more than 5-fold2 and is up to 15% the 1st
year3. In addition, 97,000 hospitalizations of VCFs per year are recorded4, with 10-30
day average hospital stay and 95.6 average disability days (while for hip fractures
99.1 disability days)5. 20% of the patients died the 1st year (30% for hip fractures).
The prevalence of VCFs is increasing in EU, as in 2020 23.7 million were recorded,
while in 2050 this number is estimated to reach 37.3 million6. Finally, we should
mention the long-term sequelae of untreated osteoporotic VCFs, which is pain, segmental
deformity with loss of vertebra height, progressive deformity (mainly kyphosis), loss
of function and rarely paralysis.
Biomechanics
Normally thoracic kyphosis is 20°-40° (T5-T12) and lumbar lordosis 50°-70° (T12-S1).
Posterior spinal muscles and ligaments counterbalance the increased bending moment
in case of VCF, while osteoporotic anterior spine must resist larger compressive stresses.
Osteoporotic changes in bone density and arrangement lead to thinning of vertical
trabeculae and loss of horizontal trabeculae in spine. The VCF types are wedge, concave
and biconcave fractures. Finally, factors that could affect kyphosis are the increased
axial loads and moment arm (TL region), the failure of conservative treatment and
osteoporosis.
Diagnosis
The aim is to identify the painful level and the age of VCF, to diagnose osteoporosis
or to exclude any low energy fracture, benign process and metastasis. Fracture evaluation
has to be based on history and physical exam, plain radiographs, DEXA scan, MRI, CT
scan, Bone Scan Tc 99 (in doubtful cases). Regarding MRI, it is the imaging modality
of choice [T1 - oedema increased dark signal, T2 - oedema increased bright signal,
STIR (Short Tau Inversion Recovery) is the most sensitive with fat marrow suppressed
and it increased bright signal].
Non-operative treatment and secondary prevention
The main goals of treatment are pain decrease, kyphosis avoidance, function preservation
and avoid a new VCF appearance. In addition to the osteoporosis, sarcopenia and frailty
medical treatment, avoidance of weight lifting, extensor spinal-abdominal-gluteal
muscles strengthening (by physical therapy PT), increase of extension of hip joints
(by PT), improvement of balance in order to avoid falls (by PT) are recommended. The
fracture liaison service is crucial in the follow-up of these patients. A 3-point
extension spinal brace should be used as well. If using the hyperextension brace after
standing-up there is an increase of pain or the fractured vertebra angle is above
10°, then surgery has to be considered7.
Vertebroplasty vs Kyphoplasty
Vertebroplasty stabilizes the fracture without height restoration and there is high
risk of leakage (65%) due to high pressure cement injection. On the other hand, balloon
Kyphoplasty is a procedure designed to relieve pain, stabilize the fracture, restore
vertebral height (ballon) and reduce spinal deformity. Limited surgical time with
local or general anesthesia is needed for kyphoplasty with average one-day hospital
stay and the patient returns to normal activities of daily living (no heavy lifting
for six weeks) while no bracing is required. Pain relief is observed in 90%, and low
risk of leak (10%) due to bone void creation Kyphoplasty contributes especially to
decreasing the mean difference of kyphotic wedge angle and risk of cement leakage
and increasing the vertebral body height when compared with Vertebroplasty, while
radiographic differences did not significantly influence the clinical results8. There
is no evidence of an increased risk of fracture of vertebral bodies, especially those
adjacent to the treated vertebrae, following augmentation with either method compared
with conservative treatment9.
Conclusions: Osteoporotic VCFs are common fragility fractures and have a high socioeconomic
burden due to disability. Pain and deformity are the main long-term sequela. Antiosteoporotic
medications, bracing and physical therapy are the chief treatment methods. Kyphoplasty
is used when pain and deformity are deteriorating. In order to prevent multiple vertebral
fractures, doctors must evaluate regularly both the fractures and osteoporosis during
treatment.
References
Cooper C, Atkinson EJ, O’Fallon WM, Melton LJ, 3rd. Incidence of clinically diagnosed
vertebral fractures: a population-based study in Rochester, Minnesota, 1985-1989.
J Bone Miner Res 1992;7(2):221-7.
Ross PD, Davis JW, Epstein RS, Wasnich RD. Pre-existing fractures and bone mass predict
vertebral fracture incidence in women. Ann Intern Med 1991;114(11):919-23.
National Osteoporosis Foundation.
Finnern HW, Sykes DP. The hospital cost of vertebral fractures in the EU: estimates
using national datasets. Osteoporos Int 2003;14(5):429-36.
European Commission Report on Osteoporosis in the EU.
National Foundation of Osteoporosis. EC report of Osteoporosis in the EU.
Wood KB, Li W, Lebl DR, Ploumis A. Management of thoracolumbar spine fractures. Spine
J 2014;14(1):145-64.
Wang B, Zhao CP, Song LX, Zhu L. Balloon kyphoplasty versus percutaneous vertebroplasty
for osteoporotic vertebral compression fracture: a meta-analysis and systematic review.
J Orthop Surg Res 2018;13(1):264.
Zhang H, Xu C, Zhang T, Gao Z, Zhang T. Does Percutaneous Vertebroplasty or Balloon
Kyphoplasty for Osteoporotic Vertebral Compression Fractures Increase the Incidence
of New Vertebral Fractures? A Meta-Analysis. Pain Physician 2017;20(1):E13-E28.
Pilot implementation of a primary sarcopenia early detection program and fragility
fracture risk screening of the elderly population in primary health care units of
Achaia district
Savvas Giakoumakis1, Panagiotis Antzoulas2, Georgios Vasilagkos3
1 Department of Orthopedics & Traumatology, Karamandaneio Children’s Hospital, Patras,
Greece - Medical School, University of Patras, Patras, Greece
2 Department of Orthopedics & Traumatology, Patras University Hospital, University
of Patras, Patras, Greece
3 Medical School, University of Patras, Patras, Greece
Introduction: It is well established in the literature that the main factors responsible
for primary sarcopenia are pro-inflammatory cytokines, low growth hormone, testosterone
levels, increased production of oxygen free radicals, malnutrition. Also immobility
and lack of exercise plays a significant role. However, recent studies have reported
that vitamin C, vitamin D and omega-3 fatty acid supplementations play a key role
in the prevention of sarcopenia. The purpose of this study was to raise awareness
among the aging population about the importance of regular exercise combined with
a balanced diet in the preservation of the walking capacity and self-care ability
of the elderly people, through community care programs in primary health care units.
Materials and Methods: In this study, 21 out of 39 participants of which 18 females
and 3 males between 57-74 years old, were examined and re-evaluated after three months.
The elderly population was overweight, of urban origin and middle socioeconomic status.
The participants were evaluated before and 3 months after the modification of their
daily diet and a systematic approach of exercises. They received specific exercise
instructions which included aerobic and resistance training in order to increase their
muscle mass. The physical activity was evaluated on a 2.40 m long horizontal carpet
by assessing the gait speed. In addition, the FRAX-score (Fracture Risk Assessment
Tool) was used to identify individuals at high risk of fragility fractures. The instructions
about dietary supplements included Vitamin D 2000 IU/day, ascorbic acid 1000 mg/day
and 1000 mg of omega-3 fatty acids/day (Table 1).
Table 1
Variables of the aging population evaluated on the date of screening and their percentage
of change on the 3 month follow-up.
PATIENT
AGE (years)
BODY WEIGHT BEFORE (Kg)
BODY WEIGHT AFTER (Kg)
GAIT SPEED BEFORE (m/sec)
GAIT SPEED AFTER (m/sec)
PERCENTAGE OF CHANGE IN GAIT SPEED (%)
FRAX SCORE BEFORE (MOF) (%)
FRAX SCORE AFTER (MOF) (%)
1
68
92
90
0,96
1,18
+22,91
20
20
2
74
83
82
0,92
1,28
+39,13
10
11
3
57
93
91
0,84
1,17
+39,28
2,4
2,4
4
70
80
85
0,77
0,86
+11,69
9,8
9,1
5
65
56
54
1,41
1,90
+35,71
21
22
6
60
80
77
0,94
1,20
+27,66
7,7
7,9
7
63
74
74
0,80
1,12
+40,00
5,0
5,4
8
74
67
66
0,82
1,08
+31,70
12
12
9
67
81
85
0,61
0,92
+50,82
10
9,8
10
72
66
59
1,16
0,87
-25,00
15
16
11
57
67
70
0,71
1,05
+47,88
3,9
3,8
12
74
61
65
0,60
0,60
+0,00
27
26
13
72
55
55
0,69
1,26
+82,61
13
13
14
60
75
75
0,65
0,88
+35,38
11
11
15
72
90
90
0,83
1,06
+27,71
3,4
3,4
16
74
63
65
1,12
1,09
-3,00
13
13
17
68
64
64
0,81
1,03
+27,16
15
15
18
60
68
69
0,87
1,30
+49,43
11
10
19
74
60
60
0,56
1,30
+132,14
29
33
20
71
65
65
0,92
1,10
+19,57
19
16
21
64
58
58
0,57
0,93
+63,16
27
29
AVERAGE
67,43
71,33
71,38
0,84
1,10
+36,00
13,58
13,75
(MOF)= Major Osteoporotic Fracture of elderly population under 75 years old.
Results: As Table 1 reveals, daily exercises in a systematic way combined with a diet
rich in vitamin D, C and omega-3 fats contributes to a better quality of life of the
aging population. Moreover, as evident from the increase in gait speed, the walking
speed was increased in the physical active elderly people. In addition, making vulnerable
population to participate in programs for the prevention of osteoporosis is associated
with economic benefits. However, exercise and proper nutrition failed to significantly
reduce the ten-year predicted risk of fragility fractures in the elderly. Finally,
the patients’ compliance with the treatment was rather unsatisfactory, with the instructions
for daily exercise being more widely accepted than the daily dietary supplement prescription.
Conclusions: Screening programs for primary sarcopenia and osteoporosis in the elderly
population is a means of detecting elder individuals with sarcopenia and osteoporotic
fracture risk early, thus reducing health care costs and improving their prognosis.
In addition, the implementation of a training program consisting of aerobic and anaerobic
exercises as well as the intake of dietary supplements including Vitamin D, ascorbic
acid and omega-3 fatty acids may be a feasible and safe primary health care intervention
for frail individuals in order to reduce the fracture risk and improve physical activity.
Suggested References
Abate M, Di Iorio A, Di Renzo D, Paganelli R, Saggini R, Abate G. Frailty in the elderly:
the physical dimension. Europa Medicophysica 2007;43(3):407-15.
Choi HK, Kim G-J, Yoo H-S, Song DH, Chung K-H, Lee K-J, et al. Vitamin C activates
osteoblastogenesis and inhibits osteoclastogenesis via wnt/β-catenin/ATF4 signaling
pathways. Nutrients 2019;11(3):506.
Montero-Odasso M, Duque G. Vitamin D in the aging musculoskeletal system: An authentic
strength preserving hormone. Molecular Aspects of Medicine 2005;26(3):203-19.
Kettler DB. Can manipulation of the ratios of essential fatty acids slow the rapid
rate of postmenopausal bone loss? Altern Med Rev 2001;6(1):61-77.
Kanis JA, Harvey NC, Cooper C, Johansson H, Odén A, & McCloskey EV. A systematic review
of intervention thresholds based on FRAX. Archives of Osteoporosis 2016;11(1).
Morley JE. Treatment of sarcopenia: the road to the future: Editorial. J Cachexia
Sarcopenia Muscle 2018;9(7):1196-9.
Makras P, Anastasilakis AD, Antypas G, Chronopoulos E, Kaskani EG, Matsouka A, et
al. The 2018 Guidelines for the diagnosis and treatment of osteoporosis in Greece.
Arch Osteoporos 2019;14(1):39.
Dargent-Molina P, Favier F, Grandjean H, Baudoin C, Schott AM, Hausherr E, et al.
Fall-related factors and risk of hip fracture: the EPIDOS prospective study. Lancet
1996;348(9021):145-9.
Hatori M, Hasegawa A, Adachi H, Shinozaki A, Hayashi R, Okano H, et al. The effects
of walking at the anaerobic threshold level on vertebral bone loss in postmenopausal
women. Calcif Tissue Int 1993;52(6):411-4.
Prevention of osteoporotic fractures in patients over 65 years by an outpatient clinic
based on a multidisciplinary team
Eleftheria Antoniadou, Konstantinos Stolakis, Elias Panagiotopoulos
Rehabilitation Clinic Patras University Hospital, Greece
There are important consequences in terms of morbidity and mortality for people over
65 years of age after an osteoporotic fracture1. Although prescription of an anti-osteoporotic
drug is common practice, this approach is inappropriate not only for the complex needs
of this particularly vulnerable population, but also for the prevention of any future
fractures. It is well documented that the best way to manage any health-related problem
in older people is based on the Comprehensive Geriatric Assessment (CGA)2, a holistic
tool which assesses not only biological components but also functional limitation
and psychological burden. Proper evaluation of the CGA needs an interdisciplinary
team with expertise in rating must be employed. The team members come from different
backgrounds, they may be medical doctors, physical therapists, psychologists, social
workers, nurses but also speech pathologists and occupational therapists if needed
etc.3.
Based on all the above in the Rehabilitation Department of Patras University Hospital,
an outpatient clinic was established that targets the individual needs of the geriatric
patient with the aim to reduce the impact of fragility fractures, both to patients
and health care system. The CGA was structured on balance evaluation and falls prevention
and is used as the baseline for evaluation and treatment. The protocol is structured
as follows:
Step one - medical visit, interview, and thorough clinical examination. Prescription
of blood test focusing on geriatric pathology that could have bone effects
Step 2 - based on the results of blood test, prescription of an appropriate treatment
Step 3 -functional assessment by a team using validated screening and diagnostic tools
(Frailty/Fried criteria4; Hand grip/Dynamometer; Sarc F; MNA5; MMSE; GDS; SPPB; miniBEST6;
IADL Lawton Brody; Katz Index7; FES8; Pelma analysis; Fall check list)
Step 4 - Joint team meeting to discuss the results and plan appropriate interventions
and outcome monitoring
In 8 months, we have assessed 237 patients, who were usually seen only for osteoporosis
and related follow up. By performing the CGA the treatment planning changed for 48
of them (20,25%), many of whom had been referred for further examination and consultation
with other specialties. We have detected 38 fallers (16%) and 27 (71%) of them underwent
a fall prevention program. We also detected the number of fallers that were also frail
based on the Fried phenotype, and from the 38 fallers 30 (79%) were also frail. In
this special category the compliance rate in fall prevention programs was extremely
low, only 4 out of 30 (13,33%) were compliant with the instructions. We investigated
the reason of this bad performance for those who needed more the prevention protocols,
and the discovered barriers were mainly social (literacy levels, social exclusion,
financial restrictions), which need to be considered when designing any intervention.
We have concluded that, treating only osteoporosis, in the geriatric population, is
not enough for the prevention of a fragility fracture, but we also need to address
sarcopenia, disequilibrium, malabsorption, polypharmacy, and extend our intervention
beyond a merely biological intervention to incorporate social and psychological variables.
The interdisciplinary approach based on the CGA, is an effective and valuable key
to unlock hidden and subtle conditions that will interfere with the level of care,
but unfortunately, is costly and complex as a setting and not always feasible.
References
Antoniadou E, Kouzelis A, Diamantakis G, Bavelou A, Panagiotopoulos E. Characteristics
and diagnostic workup of the patient at risk to sustain fragility fracture. Injury
2017;48:S17-23.
Gabrovec B, Antoniadou E, Soleymani D, Kadalska E, Carriazo A, Samaniego L, et al.
Need for comprehensive management of frailty at an individual level: European perspective
from the advantage joint action on frailty. J Rehabil Med 2020;52(6):jrm00075.
Gladman JRF, Conroy SP, Ranhoff AH, Gordon AL. New horizons in the implementation
and research of comprehensive geriatric assessment: knowing, doing and the ‘know-do’
gap. Age Ageing 2016;45(2):194-200.
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty
in Older Adults: Evidence for a Phenotype. J Gerontol A Biol Sci Med Sci 2001;56(3):M146-57.
Vellas B, Guigoz Y, Garry PJ, Nourhashemi F, Bennahum D, Lauque S, et al. The mini
nutritional assessment (MNA) and its use in grading the nutritional state of elderly
patients. Nutrition 1999;15(2):116-22.
Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using psychometric techniques
to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med 2010;42(4):323-31.
Cabral JF, Silva AMC da, Mattos IE, Neves Á de Q, Luz LL, Ferreira DB, et al. Vulnerabilidade
e fatores associados em idosos atendidos pela Estratégia Saúde da Família. Ciênc Saúde
Coletiva 2019;24(9):3227-36.
Gusi N, Carmelo Adsuar J, Corzo H, Del Pozo-Cruz B, Olivares PR, Parraca JA. Balance
training reduces fear of falling and improves dynamic balance and isometric strength
in institutionalised older people: a randomised trial. J Physiother 2012;58(2):97-104.
Principles of anesthesia for patients with fragility fracture
Georgios Karpetas, Maria Spyraki, Panagiotis Papalexiou, Gregorios Voyagis
Department of Anesthesiology and Critical Care, University Hospital of Patras, Patras,
Greece
Fragility fractures (FF) consist a worldwide phenomenon, affecting most commonly old
and oldest people. The majority of patients with FF in hip require in- hospital stay
and appropriate rehabilitation. Regarding anesthesia care, patients with FF, in particular
hip fractures, demand special considerations. The combination of advanced age, frailty,
comorbidity and polypharmacy increase dramatically the perioperative risk. Additionally,
painful immobilization aggravates trauma-induced stress, resulting in an overall disruption
of homeostasis. The aim of anesthesia care is to maintain homeostatic balance, facilitating
recovery and reducing perioperative complications. Anesthesiologists as members of
a multidisciplinary team, provide perioperative care, which should focus, mainly,
on providing adequate perioperative analgesia and enabling timely surgery1. Therefore,
fracture repair presupposes ensuring analgesia in the preoperative setting, because
pain management is considered of great importance. In hip fracture patients, a multimodal
analgesic approach is preferred, including peripheral nerve blocks, like fascia iliaca
compartment block, femoral nerve block or 3- in- 1 block. Peripheral nerve blocks
administered preoperatively, demonstrate additional benefits like decreasing quadriceps
femoris muscle spasm, facilitating positioning for spinal anesthesia and offering
postoperative pain relief. Peripheral nerve blocks can contribute to opioid- sparing
or opioid- free analgesia, demonstrating anti- deliriant effects2.
On the other hand, the most common dilemma in the decision- making process regarding
anesthesia care, is that of delaying surgery in favor of patient’s optimization, in
order to be “fit for surgery”. Currently, timely surgery repair within the first 36
to 48 hours of admission is recommended, however, delaying surgery may be considered
if patient’s condition could be sufficiently improved during that delay3. For this
purpose, a comprehensive preoperative evaluation should be performed, including, among
others, the assessment of cognitive function, nutrition and hydration, as well as
special medications received e.g., DOACs. Furthermore, preexisting anemia in combination
with acute blood loss due to the fracture should be evaluated and treated promptly.
Postoperative delirium is a common condition affecting almost 20-50% of hip fracture
patients, resulting in increased complication rate, prolonged hospitalization and
poor outcomes2,4. Early recognition of delirium or any other pre- existing cognitive
disorder, using a validated assessment tool, along with appropriate anti- deliriant
strategies throughout the perioperative period consist a basic pillar of anesthesia
care for hip fracture patients5. In parallel with risk stratification and patient’s
optimization, the informed consent process is one of anesthesiologist’s daily concerns,
appearing more challenging for patients with cognitive decline or dementia. However,
the role of a well- organized multidisciplinary team is crucial at this difficult
point2.
Any type of anesthesia can be used, since no clear advantages of regional or general
anesthesia have been observed. In contrary, what is proven to be beneficial is the
avoidance of hypotension. Hypotension is associated with an increased risk of complications
and mortality, as organ and tissue hypoperfusion is extremely compounding especially
for old people. In general, intraoperatively, anesthesia care should focus on maintenance
of hemodynamic stability, monitoring of depth of anesthesia, titration of anesthetic
drugs and opioid- sparing analgesia. Opioids and drugs with high anticholinergic burden
that increase the risk of delirium should be avoided2,6-8. After surgery, all patients
require adequate pain control, while early mobilization and vigilance for the occurrence
of delirium are very important. Anesthesiologists should provide adequate information
regarding the anesthetic techniques used and patient’s anticipated postoperative needs
in order to facilitate rehabilitation and multidisciplinary team’s work2,3.
References
Griffiths R, Alper J, Beckingsale A, Goldhill D, Heyburn G, Holloway J, et al. Management
of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain
and Ireland. Anaesthesia 2012;67(1):85-98.
Shelton C, White S. Anaesthesia for hip fracture repair. BJA Education 2020;20(5):142-149.
White SM, Altermatt F, Barry J, Ben-David B, Coburn M, Coluzzi F, et al. International
Fragility Fracture Network Delphi consensus statement on the principles of anaesthesia
for patients with hip fracture. Anaesthesia 2018;73(7):863-874.
Pioli G, Bendini C, Giusti A, Pignedoli P, Cappa M, Iotti E, et al. Surgical delay
is a risk factor of delirium in hip fracture patients with mild-moderate cognitive
impairment. Aging Clin Exp Res 2019;31(1):41-47.
Belrose JC, Noppens RR. Anesthesiology and cognitive impairment: A narrative review
of current clinical literature. BMC Anesthesiology 2019; 19:241.
Wesselink EM, Kappen TH, Torn HM, Slooter AJC, van Klei WA. Intraoperative hypotension
and the risk of postoperative adverse outcomes: a systematic review. British Journal
of Anaesthesia 2018;121(4):706-721.
Sieber FE, Neufeld KJ, Gottschalk A, Bigelow GE, Oh ES, Rosenberg PB, et al. Effect
of Depth of Sedation in Older Patients Undergoing Hip Fracture Repair on Postoperative
Delirium: The STRIDE Randomized Clinical Trial. JAMA Surg 2018;153(11):987-995.
Boustani M, Campbell N, Munger S, Maidment I, Fox C. Impact of anticholinergics on
the aging brain: A review and practical application. Aging Health 2008;4(3):311-320.
The role of Butterfly Bone Health Society in educating patients
Memi Tsekoura
Butterfly Bone Health Society, Greece
Butterfly Society faces osteoporosis as a family matter, although every age group
needs to be apprοached and educated differently. So, Butterfly Society is able to
show the patient education through many ways.
Education through online tools:
Butterfly’s website (www.osteocare.gr) hosts an e-library with a huge variety of informative
articles about skeletal health for the whole family.
Social media: there is a continuous presence of several informative articles and publications
in the Butterfly’s social media accounts, in order to keep patients always informed.
Youtube channel: informative videos help patients to understand better osteoporosis
and skeletal diseases.
Live chat: instant chat between patients and Butterfly Society about skeletal disorders.
Newsletter: patients can be in touch with the latest news on skeletal health through
informative newsletters.
Training patients through educational printed material: “Live Better” magazine is
a quarterly subscription magazine, where patients can reach the latest news on skeletal
health and osteoporosis. Also, Butterfly Society produces continuously informative
printed material for patients throughout Greece. There have been produced, printed
and distributed more than 100.000 copies of these informative materials.
Education via face to face events: Informative events for patients by also providing
preventive tests for osteoporosis. The last 10 years Butterfly has offered more than
35.000 free tests for osteoporosis throughout Greece in order to raise awareness for
osteoporosis. These tests followed by informative speeches from well-respected scientists.
Other social events: The last 15 years Butterfly Society organizes entertainment events
such as walks, gymnastic and nutritional events, excursions in order to keep patients
together, giving them the chance to exchange experiences on osteoporosis.
Education in cooperation with other Organizations: Educating patients is not easy
and we are not alone. We are in close cooperation with other organizations such as
International Osteoporosis Foundation and Greek Municipalities Network.
Membership: Butterfly encourage patients to become members of the Patient Society
in order to be part of a big community, which gets informed first about the latest
news on osteoporosis and skeletal health.
Educating patients is not easy. It demands patience, loyalty and unconditional giving
to every person who faces a chronic disease such as osteoporosis.
The role of musculoskeletal ultrasonography in the diagnosis of sarcopenia
Nikolaos Barotsis, Xanthi Michail, Elias Panagiotopoulos
Rehabilitation Department of the University Hospital of Patras, Rion, Greece
Introduction: Sarcopenia is associated with a significant functional decline, an increased
rate of falls, a higher incidence of hospitalization, a higher mortality rate, impaired
ability to perform activities of daily living, and a high economic burden when untreated1,2.
Commonly used ultrasound measurements in the assessment of muscle mass include muscle
thickness, cross-sectional area, fascicle length, pennation angle, and echo-intensity3.
Thickness and fascicle length values of medial gastrocnemius muscle have been advocated
as alternative measurements for diagnosing/quantifying sarcopenia4. Muscle mass prediction
equations based on multiple ultrasonographic measurements of muscle thickness have
been reported in the literature5,6.
The Ultrasonographic Measurement of Muscle Thickness in Sarcopenia
Ultrasound is a cost-effective, fast, non-invasive and widely available imaging method
that does not expose the person to ionising radiation, whereas minimal staff training
is needed to obtain images for basic measurements such as muscle thickness. The reliability
of ultrasonography for the assessment of muscle size across a number of limb sites
in healthy populations of children and adults is still under investigation.
A recent study on healthy adult volunteers examined geniohyoid, masseter, anterior
arm muscles, rectus femoris, vastus intermedius, tibialis anterior and gastrocnemius
muscle7. The measurements of muscle thickness were performed at baseline and were
repeated after 1, 6 and 24 hours, on both dominant (D) and non-dominant side (ND),
using transverse (trans) and longitudinal (long) scans. The analysis of the results
showed that the reliability of the ultrasonographically measured thickness of head
and limb muscles varies, depending on the type of section and side of the body. More
specifically the geniohyoid, anterior arm muscles (D, ND, trans, long), rectus femoris
(D, ND, trans) and tibialis anterior (ND, trans, long) showed excellent reliability
for repeated thickness measurements at 1, 6 and 24h7.
A study conducted by the Rehabilitation Department of the University Hospital of Patras,
from June 2018 until December 2019, investigated which muscles of the head, neck,
upper and lower limbs presented ultrasonographically detectable thickness changes
in sarcopenic patients8. More precisely, the objectives were to define which side
(dominant versus non-dominant) and ultrasound section (transverse versus longitudinal)
presented the most significant thickness changes in each of the studied muscle groups
of the sarcopenic patients and to evaluate the muscle thickness measurement, as a
potential predictory tool in sarcopenia.
The participants were assessed according to the EWGSOP2 criteria for the diagnosis
of sarcopenia. The handgrip strength was measured by a hand-held dynamometer and the
appendicular skeletal muscle mass by DXA. The muscle thickness was measured utilising
transverse and longitudinal ultrasound scans bilaterally (Figures 1 and 2).
Figure 1
Thickness measurement of the head and upper limb muscles. The images present the measurements
for the geniohyoid muscle (A); masseter in the transverse (B) and longitudinal section
(C); anterior arm muscles in the transverse (D) and longitudinal section (E). Images
from the archives of the Rehabilitation Department of Patras University Hospital.
Figure 2
Thickness measurement of lower limb muscles. The images present the measurements for
the medial head of gastrocnemius in the transverse (A) and longitudinal section (B);
tibialis anterior in transverse (C) and longitudinal section (D); quadriceps femoris
in the transverse (E) and longitudinal section (F). RF: rectus Femoris, VI: vastus
intermedius. Images from the archives of the Rehabilitation Department of Patras University
Hospital.
Ninety-four individuals (27 men and 67 women) with a mean age of 75.6 years (SD=6.6),
referred for sarcopenia screening to the Outpatient Sarcopenia Clinic of the Rehabilitation
Department of the University Hospital of Patras, participated in this study. The geniohyoid
and medial head of gastrocnemius thickness in all sections, and the thickness of the
rectus femoris and vastus intermedius, in specific sections, was significantly decreased
in sarcopenic patients (p<0.05). The ROC analysis of the ultrasound muscle thickness
measurements resulted in a significant association with sarcopenia.
The results of this study have shown that the ultrasonographically measured thickness
of the neck and lower limb muscles can be used for predicting sarcopenia with high
sensitivity and specificity. Specifically, the geniohyoid and rectus femoris (transverse
section - non-dominant side) seems to be the most advantageous ones8.
Future Perspectives
Further research is required to thoroughly investigate the role of ultrasonography
as a diagnostic tool for sarcopenia and to validate the optimal cut-off values for
the assessment of muscle quantity and quality. Multicentre studies will be needed
to standardise the measuring methodology and investigate in which extend it can be
used in different ethnic groups, specific population subgroups and on various types
of equipment.
The integration of machine learning techniques in musculoskeletal ultrasonography
is challenging but promising field9. Computer-aided diagnostic systems could help
in reducing examination time, while increasing the accuracy of the measurements significantly.
Moreover, computer-aided diagnostic systems could be used to acquire objective measurements,
allowing for a cost-efficient and large-scale screening of the population. The early
detection of sarcopenia in the elderly, particularly in the most vulnerable groups,
is of paramount importance.
References
Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al. Sarcopenia:
revised European consensus on definition and diagnosis. Age and Ageing 2019;48(1):16-31.
Beaudart C, Zaaria M, Pasleau F, Reginster J-Y, Bruyère O. Health outcomes of sarcopenia:
a systematic review and meta-analysis. Wright JM, editor. PLOS ONE 2017;12(1):e0169548.
Ticinesi A, Meschi T, Narici MV, Lauretani F, Maggio M. Muscle Ultrasound and Sarcopenia
in Older Individuals: A Clinical Perspective. Journal of the American Medical Directors
Association 2017;18(4):290-300.
Takai Y, Ohta M, Akagi R, Kato E, Wakahara T, Kawakami Y, et al. Applicability of
ultrasound muscle thickness measurements for predicting fat-free mass in elderly population.
The journal of nutrition, health & aging 2014;18(6):579-85.
Minetto MA, Caresio C, Menapace T, Hajdarevic A, Marchini A, Molinari F, et al. Ultrasound-based
detection of low muscle mass for diagnosis of sarcopenia in older adults. PM R 2016;8(5):453-62.
Abe T, Fujita E, Thiebaud RS, Loenneke JP, Akamine T. Ultrasound-derived forearm muscle
thickness is a powerful predictor for estimating DXA-derived appendicular lean mass
in Japanese older adults. Ultrasound in Medicine & Biology 2016;42(9):2341-4.
Barotsis N, Tsiganos P, Kokkalis Z, Panayiotakis G, Panagiotopoulos E. Reliability
of muscle thickness measurements in ultrasonography. Int J Rehabil Res 2020;43(2):123-8.
Barotsis N, Galata A, Hadjiconstanti A, Panayiotakis G. The ultrasonographic measurement
of muscle thickness in sarcopenia. A prediction study. Eur J Phys Rehabil Med 2020;
56(4):427-437.
Katakis S, Barotsis N, Kastaniotis D, Theoharatos C, Tsiganos P, Economou G, et al.
Muscle type and gender recognition utilising high-level textural representation in
musculoskeletal ultrasonography. Ultrasound in Medicine & Biology 2019;45(7):1562-73.
The role of the geriatrician in the management of fragility fractures: The UK experience
Maria-Panagiota Panourgia
Milton Keynes University Hospital, UK
Introduction: In the next 30 years the percentage of the population aged >65 years
will increase dramatically.According to the US Census Bureau, by 2050 this will reach
28% or more of the total population in Greece and the majority of European Countries.
Furthermore, hip fractures are more than 76,000 per year in the UK, with the cost
for Health and Social Services of over £1billion per year.It is well known that the
majority of the hip fracture patients are frail; with multiple comorbidities and that
post-operative complications and mortality is quite high, reaching 30-50% a year post
fracture. In the UK, since 2010 hip fractures are included within the Best Practice
Tariff (BPT) scheme, and it is strongly recommended that there is the presence of
a Consultant Geriatrician to assess and manage the medical issues of hip fractures
patients. The Geriatrician should assess these patients within 72 hours of admission
into the hospital.
The Geriatric Service
Geriatricians are Medical Doctors who specialise in the care of the elderly. The ageing
population is usually affected by the major Geriatric Syndromes (functional decline
and falls, delirium, dementia, incontinence, pressure ulcers and fragility fractures)
which can all can be considered under the umbrella of Frailty. Frailty is a medical
syndrome with multiple causes and contributors that is characterised by diminished
strength, endurance, and reduced physiological function that increases an individual’s
vulnerability for developing increased dependency and/or death.
The prevalence of frailty is 10.7% in individuals ≥65 years old and increases with
age. Frailty is also higher in women (9.6%), than in men (5.2%). The Royal College
of Physicians recommends that all people above 65 years old should be screened for
frailty. One of the best tools to assess a hip fracture patient for frailty is the
Clinical Frailty Scale.Frailty is not only a phenotype, but a condition that influences
various systems; especially the immunological and the musculoskeletal system (MSK).
Osteoporosis and fragility fracture as well as the muscle mass loss that comes with
age and sarcopenia, are the expressions of Frailty of the MSK. Following a hip fracture
the patients’ frailty increases and as a consequence, patients are more prone to develop
delirium, respiratory and urinary infections, as well as other important acute medical
complications that can lead to long hospitalisation and can increase their dependency
and their mortality.
The Consultant Geriatrician who works in an Orthopaedic ward (Orthogeriatrician) assesses
the patient within 72 hours, possibly before surgery, treats medical conditions and
helps the Orthopaedic Doctors to manage the patient. In Milton Keynes University Hospital
(MKUH) the presence of the Consultant Orthogeriatrician assisted in improving the
service, with the coordination of the Multidisciplinary Team (Nurses, Physiotherapists,
Occupational Therapists, Discharge Coordinator, Orthopaedic Doctors), a therapeutic
bundle for hip fractures to reduce pain and the involvement of the Dieticians to the
patients’ care was formed. In MKUH the presence of the Orthogeriatric Service allowed
for the patients to have a more appropriate discharge destination (Graph 1) and reduced
the 30 days mortality to 5.2%, in comparison to the 6.5% national average in 2019.
Graph 1
Milton Keynes Hospital Hip Fracture patients, Discharge Destinati.
Conclusion: Hip fractures can be a burden for the elderly. It increases their frailty
and the post-fracture one year mortality is significantly elevated. The Orthogeriatrician
is an important figure for the management of these patients as they can address the
geriatric presentations of medical complications, assess for frailty, coordinate the
MDT and offer the most appropriate care for frail older patients.
Suggested References
Morley JE, Vellas B, Abellan van Kan G, et al. Frailty Consensus: A call to action.
J Am Med Dir Assoc 2013;14(6):392-397.
Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling
older persons: a systematic review. J Am Geriatr Soc 2012;60(8):1487-92.
Clinical Frailty Scale. Available at: https://www.bgs.org.uk/sites/default/files/content/attachment/2018-07-05/rockwood_cfs.pdf
Milton Keynes Hospital Hip Fractures Mortality. Available at: https://www.nhfd.co.uk/20/NHFDcharts.nsf/vwcharts/Mortality?opendocument&org=MKH
Using interdisciplinary data to chart Longevity: An illustration for falls
Platon Tinios and Michail Chouzouris
Piraeus University, Greece
Introduction: studying longevity
The social and economic impact of longevity is linked to how active ‘Young Old’ gradually
morph into dependent ‘Old Old’1. In this, falls act both as causes and as effects
of frailty, depression, or other dysfunctions.
This transformation is complex, akin to charting an unknown planet - the ‘Planet Longevity’.
Understanding it requires interdisciplinary study founded on consistent and internationally
comparable statistical indicators. This guards against stereotypes and accommodates
the insight that future cohorts will importantly different from their predecessors.
The Survey of Health Ageing and Retirement in Europe (SHARE) is a large, freely available,
pan-European panel survey of people aged 50+. It has been in existence since 2004
and has to date collected 8 data waves2. As a longevity instrument, SHARE has four
advantages:
It is interdisciplinary, covering medicine, economics, sociology, or psychology.
It is internationally comparable, treating Europe as a notional experimental laboratory.
It is a panel survey; the same individuals are interviewed in each wave as they age.
It is calibrated to the problems of elders: proxy interviews for those unable to participate,
emphasis on cognition, use of biomarkers.
SHARE is a pioneer in Greece, providing some types of data for the first time. As
a descendent of the US Health Retirement Survey, it is part of a worldwide family
of ageing surveys. Its sample size (84 thousand in Europe, 3800 in Greece) dwarfs
other surveys and allows the investigation of research hypotheses spanning disciplines.
Using SHARE to investigate falls
Investigating how falls enter ageing process serves to illustrate using SHARE. Unlike
clinical studies, it focuses on people living in the community; international comparability
uncovers national differences whose explanation itself deserves study.
Three published studies give a flavour of results.
Komninos et al.3 use wave 1 data (2004) to define frailty as a composite of physical
indicators, to uncover differences by age and country. Almada et al.4 explain the
widely diverging prevalence of falls in wave 6 (2015). Intriguingly, Greece is an
outlier, exhibiting the lowest prevalence (3.5%), less than half the overall average
(8.2%), a finding repeated by gender and age. They use logistic regression for the
causes of falls. The large sample size allows them to extract the separate effect
of factors (controlling for other factors), such as age, gender, polypharmacy, frailty,
vertigo or depression. Macklai et al.5 shift their interest to the opposite causation:
how frailty in one wave affects other dimensions of health and well-being for specific
individuals two years subsequently (i.e. in the next wave). They find that frail individuals
in w1 saw their situation deteriorate two years later in three separate dimensions:
Mobility, need for care (ADL) and functioning (IADL), even after controlling for confounders
such as age, gender, income or chronic diseases.
Some indicative findings for Greece
To illustrate SHARE’s potential, we used wave6 to examine falls. Table 1 reports the
prevalence by age for Greece, South Europe and for the entire SHARE sample (17 countries).
Table 1
Prevalence of falls by age and gender, Greece and other countries.
Ν
Falls (%)Total
Men
Women
Median age for the total sample
Greece
55-64
1.587
1,8%
1,3%
2,1%
79 years
65-84
2.333
4,0%
2,6%
5,3%
85+
279
13,3%
11,2%
14,9%
Total
4.199
3,8%
2,7%
4,7%
South Europe
55-64
5.405
4,1%
2,9%
5,0%
76 years
65-84
8.988
9,0%
5,9%
12,0%
85+
1.205
21,4%
16,5%
25,0%
Total
15.598
8,3%
5,6%
10,6%
SHARE Total
55-64
20.982
4,1%
3,1%
4,8%
75 years
65-84
33.489
8,7%
6,0%
11,0%
85+
4.056
20,1%
16,0%
24,2%
Total
58.536
7,9%
5,6%
9,8%
Source: SHARE wave 6. South=IT,ES,PT.
Greece is an outlier, for the total and for all subcategories, while the median age
of those suffering falls is larger. Intriguingly, Greece seems to be closer to Scandinavia
than to Southern Europe. Following Macklai et al.4 we derived an indicator for frailty
and pre-frailty as a composite of five parameters. As expected, falls are closely
related to frailty. As prevalence of frailty in Greece is no different, it does not
explain fewer falls. However, as frail individuals are more subject to falls, the
Greek idiosyncrasy lies in healthy people being less susceptible to falls - perhaps
due to sedentary lifestyles.
Table 2
Frailty and pre-frailty in the SHARE sample by gender.
Greece
South Europe
SHARE_17
Men
Women
Men
Women
Men
Women
Healthy
50,1%
42,7%
49,7%
42,4%
57,4%
47,9%
Prefrail
37,8%
38,0%
37,6%
38,8%
32,9%
37,4%
Frail
12,1%
19,3%
12,7%
19,9%
9,7%
14,7%
Total (n)
2.115
2.555
8.084
9.584
30.345
36.569
% with falls
Total sample
2,7%
4,7%
5,6%
10,6%
5,6%
9,8%
Healthy
7,7%
4,7%
14.4%
10,4%
20,4%
16,3%
Prefrail
26,9%
37,4%
34,9%
36,1%
38,3%
39,2%
Frail
65,4%
57,9%
50,7%
53,6%
41,3%
44,6%
Total (N)
52
107
404
896
1.147
3.174
Source: SHARE wave 6. South=IT,ES,PT.
A logistic regression was able to explain the prevalence of falls for the entire sample
- assigning importance to frailty, health, but also to psychological variables. However,
sample size was insufficient for a convincing explanation for the Greek divergence
in falls. An explanation our intriguing findings is still wanting.
Conclusion: SHARE as an untapped resource
SHARE is relatively underused in Greece. This is due to difficulties in interdisciplinary
research, but also to the difficulties to implement evidence-based governance. Tapping
its potential, through cross-disciplinary cooperation, remains a project for the future.
References
Cavenish C. Extra Time. 10 Lessons for an Ageing World. Harper Collins, London. 2019.
Börsch-Supan A, Bristle J, Andersen-Ranberg K, Brugiavini A, Jusot F, Litwin H, Weber
G. Health and socio-economic status over the life course. First results from SHARE
Waves 6 and 7. De Gruyter, Berlin. 2019.
Komninos I, Alegakis A, & Philalithis A. Frailty in a sample form SHARE: the dynamic
of frailty in public health and health care. In A.Lyberaki, P.Tinios and A.Philalithis
(eds), Life 50+: Health, Ageing and Retirement in Greece and Europe Kritiki, Athens
2009;155-172.
Almada M, Brochado P, Portela D, Midão L, Costa E. Prevalence Of Fall And Associated
Factors Among Community dwelling European Older Adults: A Cross-sectional Study. Journal
of Frailty and Aging 2020; in press. http://dx.doi.org/10.14283/jfa.2020.44
Macklai NSJ, Spagnoli J, Junod J, & Santos-Eggimann B. Prospective association of
the SHARE operationalized frailty phenotype with adverse health outcomes: evidence
from 60+ community dwelling Europeans living in 11 countries. BMC Geriatrics 2013;
13:3. http://www.biomedcentral.com/1471-2318/13/3
Visual problems in older people and their association with fractures, falls and fear
of falls
Ioanna Marlafeka1,2, Manolis Mentis2, Giorgos Kolokythas3, Κonstantinos Stolakis4,
Eleni Giannakou2, Elias Panagiotopoulos2,4
1 General Hospital of Aegion, Greece
2 Healthy Living Lab, University of Patras, Greece
3 Municipality of Patras, Greece
4 University of Patras (European program EPANAD with MIS 5047167), Greece
Introduction: Falls are one of the most serious public health problems due to the
high prevalence in older people (32-42%), especially after the age of 70. Several
studies have linked falls to both visual problems and difficulty in moving in the
environment1-5.
Aim of the Study: The aim of this study was to investigate vision problems and how
these can affect the incidence of falls and the fear of falls in older people.
Material-Methodology: The study was exploratory, conducted in cooperation with: a)
the Healthy Living Laboratory (an informal networking and action group of the University
of Patras, aiming at developing actions to improve the quality of life of people aged
65+) and b) the Young Researchers Program of the University of Patras entitled: “Holistic
interdisciplinary approach to the treatment of patients with fragility fractures”
(MIS code 5047167). The research took place from January 2020 to March 7, 2020. The
population of the study was 190 elderly people of the 3rd Open Care Center for the
Elderly of Patras. A sample of 64 individuals, with a history of low-energy fracture
or history of falls (59.4%), was selected by screening. The research tools included
the Visual Functioning Questionnaire - 25 (V.F.Q-25)6, which was used in order to
investigate visual health-related quality of life, and Falls Efficacy Scale International
(FES-I)7 to assess fear of falls.
Results:
Table 1 presents the socio-demographic characteristics of the sample. The majority
of the sample were women (78.1%), married (70.3%), with a low personal monthly income
(52%), while the mean number of years of education was 7.39 years. 89.1% of the sample
wore glasses, 28% had chronic visual problems (cataract, glaucoma, macular degeneration),
while 14.1% had undergone eye surgery.
Table 1
Socio-demographic characteristics of the sample (n=64).
Men (%)
Women (%)
Total (%)
Gender
14 (21,9)
50 (78,1)
64 (100)
Marital Status
Unmarried
1 (1,6)
1 (1,6)
Married
12 (18,8)
33 (51,6)
45 (70,3)
Divorced
1 (1,6)
2 (3,1)
3 (4,7)
Widow
14 (21,9)
14 (21,9)
Separated
1 (1,6)
1 (1,6)
Monthly Personal Income(n=50)
Up to 300€
8 (16)
8 (16)
Up to 600€
3 (6)
15 (30)
18 (36)
Up to 900€
4 (8)
7 (14)
11 (22)
More than 900€
7 (14)
6 (12)
13 (26)
Mean (±SD)
Mean (±SD)
Mean (±SD)
Educational Level in years (n=64)
8 (4,5)
7,21 (3,31)
7,39 (3,66)
Table 2 presents the results of the study in relation to the subscales of the VFQ-25
questionnaire. The results are compared with the corresponding weighted mean values
of a research in the Greek population in relation both to the control group (healthy
population) and to a sample with cataract.
Table 2
Comparison of mean visual health values (control group and control group with cataract)
(n=62).
VFQ-25 Subscale
Μean Sample Value (±SD)
Mean value of control group (±SD) n=29
Mean value in the sample of cataract (±SD) n=18
Genaral health
60,44 (18,10)
80,3 (12,2)
57,8 (19,7)
General vision
72,98 (17,49)
90,7 (12,9)
60 (17,4)
Ocular pain
75,80 (22,84)
89,7 (12,1)
84 (20,5)
Near vision
80,62 (17,92)
96,1 (9,7)
65,6 (26,9)
Distance vision
85,01 (15,50)
96 (7,0)
74,7 (18,5)
Social Functioning
93,01 (13,59)
99,4 (3,1)
84,3 (22,9)
Mental health
80,80 (17,58)
89,7 (10,4)
67,8 (24,5)
Role limitations
80,84 (20,58)
94,8 (12,1)
68 (29,3)
Depedency
93,44 (17,25)
97,7 (7,0)
79,6 (26,4)
Driving
23,92 (19,04)
93,8 (8,0)
75 (35,4)
Color vision
92,74 (14,58)
100 (0)
86,1 (17,6)
Peripheral vision
81,45 (23,92)
95,7 (11,7)
79,4 (28,3)
These results show a generally good vision-related quality of life in the sample.
The problem is mainly located in the negative effect of vision in driving (Mean=23.92).
It should be noted that this result is also affected by the fact that 49 people of
the sample reported that they do not drive.
In relation to the effect of vision problems on the existence of falls and low-energy
fractures, the correlation with the Spearman r index showed that the sub-scale “General
Health” was found to be negatively correlated with the number of falls, ie, the higher
the values of “General Health” in the elderly of the sample, the more likely they
are to have a lower number of falls and vice versa (r= -,390, p=,002<,01).
The same negative correlation was observed with the sub-scale “General vision” (r=-,266,
p=,040<,05), with the sub-scale “Near vision’’(r=-,289, p=,028<,05) and finally with
the sub-scale ‘’Dependency’’(r=-,264, p=,042<,05).
In relation to the existence of fractures, a negative correlation was found only with
the sub-scale “Driving” (r=-,314, p=,014<,05), which means, the higher the values
in the above sub-scale, the more chances there is no fracture and vice versa.
The correlation of visual health with fear of falls showed that except for the VFQ-25
“Color vision” sub-scale, all the other categories were in a two-way negative correlation
with fear of falls, measured before quarantine due to the pandemic. This negative
correlation shows that higher values in the sub-scales are associated with less fear
of falls and vice versa. The strongest correlation was observed in the sub-scales
“Mental health” (r=-537, p<,001), “Distant activities” (r=-521, p<,001), “Near vision”
(r=-512, p<,001) and “Ocular pain” (r=-500, p<,001).
Conclusions-Suggestions: The research confirmed that there is a correlation between
good visual health and a lower number of falls and fear of falls. Driving-related
good visual Health was associated with avoiding fractures in older people who drive.
These results are in line with the international literature and reinforce the guidelines
of the World Health Organization that recommend regular sensory screening to prevent
falls and fractures in older people.
References
Deschamps T, Le Goff CG, Berrut G, Cornu C, Mignardot JB. A decision model to predict
the risk of the first fall onset. Exp Gerontol 2016;81:51-55.
Black A, Wood J. Vision and falls. Clin Exp Optom 2005;88:212-222.
Broman AT, West SK, Munoz B, Bandeen-Roche K, Rubin GS, Turano KA. Divided visual
attention as a predictor of bumping while walking: the Salisbury Eye Evaluation. Invest
Ophthalmol Vis Sci 2004;45:2955-2960.
Coleman AL, Cummings SR, Yu F, Kodjebacheva G, Ensrud KE, Gutierrez P, Stone KL, Cauley
JA, Pedula KL, Hochberg MC, et al. Binocular visual-field loss increases the risk
of future falls in older white women. J Am Geriatr Soc 2007;55:357-364.
Saftari LN, & Kwon OS. Ageing vision and falls: a review. Journal of Physiological
Anthropology 2018;37:11.
Labiris G, Katsanos A, Fanariotis M, Tsirouki T, Pefkianaki M, Chatzoulis D, Tsironi
E. Psychometric properties of the Greek version of the NEI-VFQ 25. BMC Ophthalmology
2008;8:4.
Billis E, Strimpakos N, Kapreli E, Sakellari V, Skelyon AD, Dontas I, Ioannou F, Filon
G, Gioftsos G. Cross -Cultural Validation of the Falls Efficacy Skale International
(FES-I) in Greek community-dwelling older adults. Disability and Rehabilitation 2011;33(19-20):1776-1784.
Working for the future of care: the necessity of Health Literacy
Katerina Athanasopoulou
University of Patras, Greece
The concept of Health Literacy
Health Literacy is defined as “the degree to which individuals have the ability to
obtain, process and understand basic medical information and services required to
make appropriate medical decisions”. Health Literacy includes a wide range of skills
that, once developed, contribute to better research, understanding, evaluation and
use of medical information to make informed choices, reduce health risks and improve
their quality of life. According to a model of Health Literacy, Health Literacy is
the ability of:
Accessing and obtaining health-related information.
Understanding health information and extracting clear meaning.
Critical consideration of health-related information.
Application / use of health related information.
At the core of the model are the skills associated with the development of Health
Literacy, namely access (the ability to search and find health information), comprehension,
evaluation (ability to think critically, interpret and evaluate information) and the
application (use of information for decision making and improving health). Through
practicing the above skills, the individual acquires knowledge and skills that allow
him to cope with a variety of circumstances and needs. As a patient in the context
of health care, as a person who belongs to a group at high risk for a disease in the
context of disease prevention, as a citizen in relation to health promotion in family,
workplace, community. This process of developing health literacy is not a simple and
straightforward process. In general, it is considered a lifelong process that is constantly
changing, as the conditions and health needs of the individual and his environment
change.
The following are the main benefits of developing Health Literacy on a personal and
social level:
Better knowledge of health risk factors, contributing to better disease prevention.
Health Literacy is the strongest predictor of an individual’s health compared to income,
employment status, educational level and nationality.
Better compliance with medical instructions.
Autonomy and active role in the pursuit of physical, psychological and social well-being.
Development of skills that relate to everyday life and increase of people’s control
over their health, so promoting health literacy is a critical empowerment strategy.
Choice of habits that benefit health, awareness of factors that burden it, fewer hospitalizations,
claiming of quality health care.
Improvement of the population health level and significant cost saving for the health
system.
Why developing health literacy of older people at risk of falls and fragility fractures?
Despite its benefits, Health Literacy rates are low among European countries. Even
higher rates of Health Illiteracy are found in vulnerable social groups such as people
with low socioeconomic status, with chronic diseases or older people (75+). Health
literacy is one of the main regulators for the health of the elderly, as a lack of
health-related knowledge and skills can be a significant barrier to adopting healthy
behaviors, prevention practices and better management of common chronic diseases.
As the percentage of the elderly in the general population increases, efforts are
being made to improve their quality of life so that the increase in life expectancy
is intertwined with the maximum possible well-being. This is the term of the World
Health Organization “Healthy Aging” (Healthy Aging), ie the process of developing
and maintaining the functional capacity of the elderly for a longer period of time.
Hip fractures are a major public health issue due to the increasing incidence and
associated high mortality. After the hip fracture surgery, the main purpose of the
treatment is to acquire the pre-fracture level of functionality, mobility and social
participation. Therefore, there is a need for educational interventions in patients
with hip fractures, in order to improve their functional status, quality of life and
their compliance with the medical instructions after hospital discharge. Higher health
literacy in this group of patients is associated with: a) Less and/or less severe
falls through the identification and management of risk factors, personal and environmental,
b) Reduction of fear of falls and the relative tendency to isolate and reduce activity
that characterizes individuals who are afraid of falling, c) Better compliance with
the doctor’s instructions and especially the medication instructions, d) Adoption
of appropriate health behaviors before and after the fracture or fall, e) Better understanding
of the problem and how to deal with it - empowerment of the patient, f ) Reduction
of the risk of a recurrent fracture, g) More effective management of the physical
and psychological consequences of the fall or fracture / better recovery.
Suggested References
Abrahamsen B, van Staa T, Ariely R, Olson M, & Cooper C. Excess mortality following
hip fracture: a systematic epidemiological review. Osteoporos Int 2009;20(10):1633-1650.
Chesser AK, Keene Woods N, Smothers K, & Rogers N. Health Literacy and Older Adults:
A Systematic Review. Gerontology & geriatric medicine 2016;2:2333721416630492.
HLS-EU Consortium (2012): Comparative report of Health Literacy in eight EU member
states. The European Health Literacy Survey HLS-EU. Second revised and extended version,
2014.
Kececi A, & Bulduk S. Health Education for the Elderly. Ιn C. Atwood (Ed.), Geriatrics,
InTech, 2012.
Kickbusch I, Pelikan JM, Apfel F, & Tsouros AD. Health literacy. The solid facts.
Copenhagen: WHO Regional Office for Europe, 2013.
Okan O, Bauer U, Levin - Zamir D, Pinheiro P, & Sorensen K. International Handbook
of Health Literacy: Research, Practice and Policy across the Life-span. Bristol: Policy
Press, 2019.
Sanclemente-Boli T, Ponce-Ruiz S, Álvarez-Lorenzo C, et al. Effectiveness of a multidisciplinary
educational intervention in patients with hip fracture: SWEET HOME study. Med Clin
(Barc) 2019;153(12):446-453.
Sørensen K, et al. Health literacy and public health: a systematic review and integration
of definitions and models. BMC Public Health 2012;12:80.
World Health Organization. Global strategy and action plan on ageing and health. Geneva:
World Health Organization, 2017.
Short Abstracts
Atypical femoral fractures associated with long-term bisphosphonate use. A 10-year
retrospective study.
Dimitrios Begkas, Stamatios-Theodoros Chatzopoulos, Alexandros Pastroudis
6th Orthopaedic Department, Asclepieion Voulas General Hospital, Athens, Greece
The purpose of this study was to report the clinical and radiological features and
to evaluate the results of surgical treatment of atypical femoral fractures (AFF)
associated with long-term use of bisphosphonates (BP). During the period 2006-2016,
we retrospectively examined 31 patients with a mean age of 71.2 (60-83) years, who
were diagnosed with AFF (N=34, three patients with bilateral fractures) associated
with long-term use of BP. The fractures were selected according to the criteria of
the American Society for Bone and Mineral Research. All cases were treated surgically.
The duration of treatment with BP, the preoperative and postoperative clinical and
radiological findings and the occurrence of complications were evaluated. The average
duration of follow up was 32.3 (12-72) months. The mean duration of BP treatment was
7.2 (4-10) years. Twelve (35.3%) fractures were subtrochanteric and 22 (64.7%) diaphyseal.
Antegrade intramedullary nailing (AIN) was applied to all of them. The average fracture-healing
time was 4.8 (2-9) months. In 8 (23.5%) cases there was a failure of fracture healing
and AIN was reapplied using a larger diameter nail, resulting in their healing within
4 months postoperatively. Twenty-six patients (76.5%) returned to their preoperative
motor and functional status, while 8 (23.5%) patients presented with varying degrees
of motor and functional disorders. No other complications occurred. Long-term use
of BP is directly related to the development of AFF. Surgical treatment of these fractures
is demanding and associated with an increased rate of healing failure and reduced
motor and functional capacity of patients postoperatively.
Suggested References
Cho JW, Oh CW, Leung F, et al. Healing of atypical subtrochanteric femur fractures
after cephalomedullary nailing: Which factors predict union. J Orthop Trauma 2017;31(3):138-45.
Kharwadkar N, Mayne B, Lawrence JE, et al. Bisphosphonates and atypical subtrochanteric
fractures of the femur. Bone Joint Res 2017;6(3):144-53.
Koh A, Guerado E, Giannoudis PV. Atypical femoral fractures related to bisphosphonate
treatment: issues and controversies related to their surgical management. Bone Joint
J 2017;99-B(3):295-302.
Designing a holistic interdisciplinary community model of care to improve compliance
of patients with fragility fractures through educational and strengthening processes
Konstantinos Stolakis1, Theodoros Tosounidis2, Manolis Mentis1, Katerina Athanasopoulou1,
George Kolokithas3, Georgia Dimakou4, Eleni Giannakou1, Elias Panagiotopoulos1
1 University of Patras, Greece
2 University of Crete, Greece
3 3rd Open Care Center for the Elderly, Patras, Greece
4 251 Air Force General Hospital, Greece
The global incidence of fragility fractures is rising worldwide, due to population
ageing. It has been estimated that in 2010 there were 21 million men and 137 million
women aged 50 years or more at high fracture risk and that this number is expected
to double by 2040. Prevention of fragility fractures is of major importance given
their negative impact on the elderly’s quality of life and the great costs connecting
with hospitalization and rehabilitation. The aim of the study was to develop an innovative
model for the holistic interdisciplinary approach of elderly over 65 who have a fragility
fracture history. The main purposes of the implementation of this model is to prevent
recurrent fragility fractures, reduce the factors leading to them and improving the
elderly’s physical health as well as their quality of life. Through literature review,
good practices abroad were studied, as well as Greek efforts made to deal with fragility
fractures. The intervention group consisted of 20 people. 95% were women, while the
average age was 69 years. 35% had a previous fall and 50% a fracture history. Α three-month
multilevel, digital intervention programme was designed, including:
Individual physical exercise
Nutritional education
Falls Prevention Training
The sector of physical exercise is based on the multicomponent exercise program called
VIVIFRAIL which provides each elderly person with an exercise program according to
his/her functional capacity. Nutritional education is based on an individualized nutrition
program relying on the Mediterranean Diet standards. Falls Prevention Training is
based on the provision of digital material from the Australian Guide of Falls Prevention
for older people, adapted to the educational needs of this specific team. To ensure
interaction and active participation, monthly activities and group teleconferences
have been organized. This model is in the process of implementation and its results
will be published.
Suggested References
Commonwealth of Australia. Don’t Fall For It- A guide to preventing falls for older
people. 2011.
Falaschi P, & Marsh D. Orthogeriatrics. The Management of Older Patients with Fragility
Fractures. Second Edition. Springer. 2020.
Izquierdo M, Casas-Herrero A, Zambom-Ferraresi F, et al. Multicomponent physical exercise
program VIVIFRAIL. 2017.
Detection of fall risk in general population over 65 years old
Athina-Maria Nella1, Ilias Lymberiadis2, Theodora Galani1, Zikos Kentros2,3
1 Rehabilitation Center “Iatriki Askisi”
2 Rehabilitation Center “Askisi”
3 Henry Dunant Hospital Center
Purpose of survey is to detect people in the community with balance disturbance and
to correlate a validated fall risk self-assessment questionnaire with the Time Up
and Go (TUG) assessment. Specialized clinic concerning balance problems and risk for
falling was organized in Open Care for Elderly Centers. The questionnaire used to
the CDC’s STEADI Falls Prevention Algorithm was used. It consists of twelve close-ended
questions and three of them are key questions. Medical history, neurologic and musculoskeletal
examination, TUG assessment and orthostatic vital signs were recorded. 144 people
participated, 113 women and 31 men, with average age of 70.36 years. 31.94% scored
below 4 at the questionnaire and gave negative answer at the key questions, so they
were considered of low fall risk and the rest 68.06% of high risk. 35.41% required
more than 12 seconds to perform TUG test, so they were considered of high risk. 47.96%
of the participants who had high fall risk according to the questionnaire also had
positive TUG test. There were detected 8 people who needed more than 12 seconds for
the TUG even though they had low risk according to the questionnaire. We must also
mention that 17.36% of the participants suffered from osteoporosis, 24.3% had at least
one fracture in the past and 31.25% had at least one fall during the last year. A
greater number of people with positive questionnaire rather than positive TUG test
was found. Firstly because the sample was not randomized and secondly the questionnaire
is a self-assessment tool whereas TUG is a clinical test. Falls in elderly is a major
medical issue but the use of specialized questionnaire, assessment tools, detailed
medical history and medical examination can in a great percentage detect people in
risk and with expertise intervention risk of fall can be reduced.
Suggested References
Casey C, Parker E, Winkler G, Liu X, Lambert G, Eckstrom E. Lessons learned from implementing
CDC’s Steadi falls prevention algorithm in primary care. Gerologist 2017;57(4):787-796.
Pasquetti P, Apicella L, Mangone G. Pathogenesis and treatment of falls in elderly.
Clinical Cases in Mineral and Bone Metabolism 2014; 11(3):222-225.
Rubenstein L, Vivrette R, Harker J, Stevens J, Kramer J. Validating an evidence-based,
self-rated fall risk questionnaire for older adults. Journal of Safety Research 2011;42:493-499.
Effect of early postoperative administration of bisphosphonates on healing of osteoporotic
fractures of the distal radius
Dimitrios Begkas, Stamatios-Theodoros Chatzopoulos, Alexandros Pastroudis
6th Orthopaedic Department, Asclepieion Voulas General Hospital, Athens, Greece
The purpose of this study was to evaluate the effect of early postoperative administration
of bisphosphonates on healing of osteoporotic fractures of the distal radius. Between
2011 and 2017, 120 patients (87 women and 33 men) with a mean age of 68.4 (57-82)
years, who suffered from osteoporotic fractures of the distal radius, were surgically
treated in our clinic using open reduction and internal fixation (locking plates and
screws). All of them received postoperative treatment with bisphosphonates (Alendronate
70 mg/week or Risedronate 35 mg/week). In 62 patients (group A) the bisphosphonate
treatment was administered immediately (within 2-3 days postoperatively), while in
the remaining 58 patients (group B) was delayed (3 months postoperatively). Treatment
results on fracture healing for each group were based on clinical/functional (pain
or tenderness, grip strength, wrist range of motion, Quick-Disabilities of the Arm,
Shoulder and Hand Score - QDASHS) and radiographic (anteroposterior and lateral X-rays
- radiological fracture healing time) criteria. The mean follow-up duration was 38.4
(24-60) months. Radiologically, the mean fracture healing time for group A was 3.1
(2.5-4.5) months and for group B 2.9 (2.5-4) months (p = 0.07). After the sixth post-operative
month, there was no significant difference between the two groups in improving pain
or tenderness in the fracture area, grip strength, range of motion and QDASHS. Conclusively,
the early administration of bisphosphonates after surgically treated osteoporotic
distal radial fractures does not appear to significantly affect their radiological
healing time, as well as the final clinical/functional outcome.
Suggested References
Uchiyama S, Itsubo T, Nakamura K, et al. Effect of early administration of alendronate
after surgery for distal radial fragility fracture on radiological fracture healing
time. Bone Joint J 2013;95-B(11):1544-50.
Shoji KE, Earp BE, Rozental TD. The Effect of Bisphosphonates on the Clinical and
Radiographic Outcomes of Distal Radius Fractures in Women. J Hand Surg Am 2018;43(2):115-22.
Hegde V, Jo JE, Andreopoulou P, et al. Effect of osteoporosis medications on fracture
healing. Osteoporos Int 2016;27(3):861-71.
Elderly patients with hip fractures, treatment for osteoporosis, evidence for sarcopenia
and malnutrition. A preliminary report
Ioannis E. Kougioumtzis, Stylianos Tottas, Konstantinos Tilkeridis, Athanasios Ververidis,
Georgios I. Drosos
Academic Orthopeadic Department, Democritus University of Thrace, University General
Hospital of Alexandroupolis, Alexandroupoli, Greece
Recent literature from different countries has highlighted the fact that elderly patients
with bone fragility have not been checked regarding osteoporosis on a regular basis.
Furthermore, it has been registered that most of these patients suffer from a wide
spectrum of comorbidities. Regarding our country, such data is restricted. Our aim
was to investigate the preoperative health status of the elderly patients with low
energy hip fractures who were treated in our department, in terms of sarcopenia, malnutrition
and a concurrent therapeutic protocol for osteoporosis. We prospectively collected
data concerning patients’ demographics, possible previous treatment for osteoporosis,
the amount of drugs that had been administered, history of previous fracture, body
mass index (BMI), serum vitamin D status (vit.D), serum albumin (Alb), serum calcium
(Ca), serum phosphorus (P), parathyroid hormone status (PTH) and postoperative 30-day
mortality in all consecutive patients. In our study 153 patients were included. The
average age was 81.1 years and most of them were female (n:108, 70.6%). Only 18 (7.3%)
patients were administered medication for osteoporosis. In 36 (23.5%) patients there
was a history of previous low energy fracture and in 9 (8.2%) patients there was a
history of cortisone dependent treatment. Multi drug therapy (from 6 to 11 drugs)
was registered in 54 patients (35.3%). BMI was less than 25 in 61 (58.1%) patients
and vit.D was normal in only 15 (9.8%) patients. Albumin was low (less than 3.5 gr/dl)
in 44 (28.6%) patients. In addition, Ca, P and PTH was abnormal in 50.9%, 11.8% and
21.8% respectively. The 30-day mortality rate was 6.5%. The results of our study underlined
the fact that the enhancement of primary and secondary fragility fracture prevention
in our region is of primary importance. Consequently, it is essential to establish
an orthogeriatric care unit to ensure regular checkups for our patients.
Suggested References
Kim YK, Yi SR, Lee YH, Kwon J, Jang SI, Park SH. Effect of Sarcopenia on Postoperative
Mortality in Osteoporotic Hip Fracture Patients. J Bone Metab 2018;25(4):227-233.
Steihaug OM, Gjesdal CG, Bogen B, Kristoffersen M, Lien G, Ranhoff AH. Sarcopenia
in patients with hip fracture: A multicenter cross-sectional study. PLoS One 2017;12(9):e0184780.
Malafarina V, Uriz-Otano F, Malafarina C, Martinez JA, Zulet MA. Effectiveness of
nutritional supplementation on sarcopenia and recovery in hip fracture patients. A
multi-centre randomized trial. Maturitas 2017; 101:42-50.
Falls and fractures. A comprehensive approach from the clinic for the prevention of
falls, osteoporosis and sarcopenia (IPPOS) of the University General Hospital of Patras
(U.G.H.P.)
Konstantinos Stolakis1, Zinon Kokkalis2, Panagiotis Megas2, Elias Panagiotopoulos1
1 Rehabilitation Clinic, Patras University Hospital, Patras Greece
2 Orthoapedic Department, Patras University Hospital, Patras Greece
The aim of this study was to comprehensively assess the risk factors for falls and
fractures in the study population. During the first visit to IPPOS, in 96 patients
women and men, over 65 years, the levels of vitamins D3 (vit.D3) and B12 (vit.B12)
were measured, the number of falls in last year (FNLY) as well as fragility fractures
were recorded and the ANTICHOLINERGIC-COGNITIVE-BURDEN score (ACBscore) was calculated
based on the medical history. Equilibrium was measured with the Mini-Balance-Evaluation-Systems-Test
(Mini-BESTest) and the fear of falls (FofF) with the FES-I. Anthropometric measurements
and tests of Hand Grip Strength (HGA), Walking Speed (ws), Short Physical Performance
Battery (SPPB) were performed and patients were assessed as frail, pre-frail and non-frail
according to Fried criteria (Fried Phenotype). The Linear Bivariate Correlation (L.B.C.)
did not show any statistically strong correlation between vitamin B12 levels and MiniBest,
SPPB, Hand Grip, FNLY, Fried Phenotype, and ACBscore values. In contrast, a statistically
negative correlation was found between vitamin D3 levels and FNLY (rs (93)=-0,274,
p=0.008) and Fried Phenotype (rs (89= -0.220, p=0.038). The L.B.C between the values
of the FES-I index and the values of the following variables showed a correlation
with: MiniΒest (rs(83)=-.496,p<0.001), SPPB(rs(82)=-0.343, p=0.002), HGA(rs(80)=-.235,
p=0.036), W.S(rs(82)=-.510, p<0.001), FNLY (rs(85)=0.236, p=0.030). No significant
relationship was found with: ACBscore, Vit.B12, and Vit.D3. Also, the mean value of
the FES-I index are not affected by the presence or absence of fractures after the
Mann-Whitney test for the FES-I index (Ζ=-0.214, p=0.831). The relationship between
Mini-Best and Fried Phenotype (rs (89)=-0.715, p <0.001) was also statistically significant.
Key factors influencing falls in the present study are Vit.D3, the FofF and physical
frailty, although the FofF does not appear to be affected by the presence or absence
of fractures.
Suggested References
Boustani M, et al. Impact of anticholinergics on the aging brain: a review and practical
application. Aging Health 2008;4(3):311-320.
Dhaliwal R, & Aloia JF. Effect of Vitamin D on Falls and Physical Performance. Endocrinology
and Metabolism Clinics of North America 2017;46(4):919-933.
Lewerin C, et al. Low holotranscobalamin and cobalamins predict incident fractures
in elderly men: the MrOS Sweden. Osteoporosis International 2014;25(1):131-140.
Functional Fitness MOT (FFMOT) - Assessment tool of physical abilities for the elderly
Amalia Papadopoulou-Bakrozi1, Apostolos G. Emmanouilidis2
1 Physiοtherapist (PT), Patras, Greece
2 Physiotherapist-OEP Leader, Municipality of Nea Philadelphia - Nea Chalkidona Greece
Increased physical activities (PA) in older adults can bring substantial health benefits,
reduce risk of falls and fractures.
FFMOT is an approach that aims to raise awareness of the importance of components
of fitness i.d. strength, balance, flexibility, highlight benefits of PA, engage older
people in health behavior change discussions, and direct them to proper activity resources.
Prof. Dawn Skelton and colleagues designed this tool at Glasgow Caledonian University
in 2011. FFMOT takes approximately 60 minutes/per older person and contains some elements
that are actually used in strength and balance training programs, such as sit to stand
in 30’’, single leg stance, chair sit and reach. FFMOT was mainly developed as a means
to provide information and raise awareness of the PA guidelines, particularly the
newer strength and balance one’s. According to recent PA data, only 14% of men, and
16% of women aged 65-74 years and 12% of men and 5% of women aged 75+ years meet the
strength PA guideline1. Additionally, sedentary behavior is particularly prevalent
in older populations, with an average of 9.4 hours sitting a day2. Health professionals
play a key role in encouraging older adults to increase their PA. Preliminary observational
data from the FFMOT application in Greek elderly indicate that FFMOT is attractive
and possibly feasible in the clinical setting. These data are in line with the findings
of a recent mixed-method feasibility study3. Case reports in Greece provide encouraging
signs that older people are expressing positive emotions stating that FFMOT is raising
their awareness of the opportunities to become more physically active. Preliminary
reports from Greek PTs recording the FFMOT for Greek seniors show that FFMOT can inspire
and motivate them to maintain their independence by participating in fall and fracture
prevention programs.
References
Strain T, Fitzsimons C, Kelly P, Mutrie N. The forgotten guidelines: Cross-sectional
analysis of participation in muscle strengthening and balance & co-ordination activities
by adults and older adults in Scotland. BMC Public Health 2016;16(1):1-12.
Harvey JA, Chastin SF, & Skelton DA. How Sedentary are Older People? A Systematic
Review of the Amount of Sedentary Behavior. J Aging Phys Act 2015;23(3):471-87.
de Jong LD, Peters AD, Gawler S, Chalmers N, Henderson C, Hooper J, et al. The appeal
of the functional fitness MOT to older adults and health professionals in an outpatient
setting: A mixed-method feasibility study. Clin Interv Aging 2018;13:1815-29.
Greek SARC-F: Reliability and validity of the Greek version of the Sarcopenia screening
tool in community-dwelling elderly people living in Western Greece
Maria Tsekoura1, Evdokia Billis1, John Gliatis2
1 Department of Physiotherapy, School of Health Rehabilitation Sciences, University
of Patras, Greece
2 Department of Medicine, School of Health Sciences, University of Patras, Greece
The purpose of this study was to assess in a sample of community-dwelling elderly
people the psychometric properties (reliability and validity) of SARC-F questionnaire,
a brief screening tool for sarcopenia. Reliability was assessed by inter-rater and
test-retest analyses. Test-retest reliability were tested by the intraclass correlation
coefficient (ICC) and its 95% CI. Validity was assessed by sensitivity (Se), specificity
(Sp), positive predictive value (PPV), negative predictive value (NPV) in a cohort
of elderly Greek subjects using the diagnostic criteria for sarcopenia based on the
European Working Group on Sarcopenia in Older People. For the clinical validation
phase of the SARC-F, population was divided into sarcopenic and non-sarcopenic ones.
The participants involved in this study were recruited from the University Hospital
of Patras and the 2nd Open Care Centre of Patras for the Elderly. Ethical approval
was given by the Ethical Committee of the School of Health and Welfare of the Technological
Educational Institute (TEI) of Western Greece.A total of 197 elderly participants
(71.64±7.83 years, 68.5% women) were analyzed in the clinical study. The translated
Greek version of the SARC-F demonstrated an excellent inter-rater reliability, with
an intraclass correlation coefficient (ICC) of 0.91 (95% CI 0.79-0.96), as well as
excellent test-retest reliability, with an ICC of 0.93 (95% CI 0.91-0.95). The results
showed that sensitivity of the tool was 22.9 %, and the specificity was 7.9%. Positive
predictive value was 12.91% and negative predictive value was 97.8%. Results show
that the SARC-F questionnaire may considered a suitable tool for community screening
for sarcopenia.
Suggested References
Malmstrom TK, & Morley JE. SARC-F: a simple questionnaire to rapidly diagnose sarcopenia.
J Am Med Dir Assoc 2013;14(8):531-2.
Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Writing Group for the European Working Group
on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia:
revised European consensus on definition and diagnosis. Age Ageing 2019;48(1):16-31.
Bahat G, Yilmaz O, Oren MM, et al. Cross-cultural adaptation and validation of the
SARC-F to assess sarcopenia: methodological report from European Union Geriatric Medicine
Society Sarcopenia Special Interest Group. EurGeriatr Med Springer International Publishing
2018;9(1):23-8.
Levels of vitamin D in patients with osteoporotic vertebral fractures: a retrospective
one year study
Dimitrios Begkas, Stamatios-Theodoros Chatzopoulos, Alexandros Pastroudis
6th Orthopaedic Department, Asclepieion Voulas General Hospital, Athens, Greece
Vertebral fractures are very common manifestations of osteoporosis, with one occurring
every 22 seconds in patients over 50 years of age. They are associated with an eightfold
increase in mortality and morbidity such as back pain, height loss and immobility.
Vitamin D deficiency has been identified as a contributing risk factor for osteoporotic
fractures. The aim of this study was to evaluate the levels of vitamin D (25-OH-D)
in patients with osteoporotic vertebral fractures. During the calendar year 2017,
56 patients (37 women and 19 men, mean age 74 years) were admitted to our clinic for
osteoporotic vertebral fracture (25 thoracic and 31 lumbar). At admission, they were
tested for 25-OH-D levels and risk factors for hypovitaminosis D. None of the patients
was receiving vitamin D supplements upon admission. Twelve (21%) patients were found
to have 25-OH-D levels below 10 ng/ml, 33 (59%) patients between 10 and 30 ng/ml and
9 (16%) patients above 30ng/ml. There was no statistically significant difference
in the levels of 25-OH-D between male and female patients. There was no correlation
between the fracture site and 25-OH-D levels. Forty-seven (83%) patients had at least
one risk factor for hypovitaminosis D. Conclusively, Vitamin D levels are correlated
with osteoporotic vertebral fractures. Identifying patients with risk factors for
hypovitaminosis D along with vitamin D supplementation might reduce the incidence
of osteoporotic vertebral fractures.
Suggested References
Lopes JB, Danilevicius CF, Takayama L, et al. Vitamin D insufficiency: a risk factor
to vertebral fractures in community-dwelling elderly women. Maturitas 2009;64(4):218-22.
Sakuma M, Endo N, Hagino H, et al. Serum 25-hydroxyvitamin D status in hip and spine-fracture
patients in Japan. J Orthop Sci 2011;16(4):418-23.
Maier GS, Seeger JB, Horas K, et al. The prevalence of vitamin D deficiency in patients
with vertebral fragility fractures. Bone Joint J 2015;97-B(1):89-93.
Managing peritrochanteric fractures in renal dialysis patients. Morbidity and mortality
rates and complications
Alexandros P. Apostolopoulos, Spyridon Maris, Stavros Angelis, Efthimios J. Karadimas,
Athanasios Papanikolaou
Trauma and Orthopaedic Department, Red Cross Hospital, Greece
Patients with end-stage renal failure who are on chronic haemodialysis and suffer
a neck of femur fracture have been shown to have increased morbidity and mortality
rates1,2,3. The aim of this study was to examine the mean hospital stay, the blood
transfusion rates and the morbidity and mortality of renal dialysis patients who suffered
a neck of femur fracture. We conducted a retrospective study, during the years 2015-2019.
Twenty patients that were on dialysis were included in the study (10 patients had
suffered intracapsular and 10 patients extracapsular proximal femoral fractures. Nineteen
patients were surgically managed (mean time to surgery 68.8 hours) and one patient
deceased prior to surgery. The mean hospital stay was 23.95 days (6-82 days). The
total need of blood transfusion was 86 units of RBC (4.3/patient) and 11 units of
FFP (0.55/patient). No mechanical failure was observed in the fixation group. The
inpatient mortality rate was 30.0 % whilst the one-year mortality rate was 45%. Post-operative
complications, included, haematoma of the wound in five patients, transient ischaemic
attack in one patient and NSTEMI in two patients. One patient who developed haematoma
was taken back to the operating theatre for washout and debridement of the haematoma.
(infected haematoma). Managing end stage renal dialysis patients who have suffered
neck of femur fracture is always a challenge. Bleeding, infection and increased blood
transfusion requirements are the most common complications noted. The mortality and
morbidity rates are significantly higher when compared to a non-dialysis group. A
multidisciplinary team approach is required in order to improve the outcome.
References
Swift O, Ayub A, Mathavakkannan S, de Roeck N. Outcomes following surgery for fractured
neck of femur in dialysis patients: a 5-year review from a district general hospital
in the United Kingdom. BMC Nephrol 2016;17:26.
Alem AM, Sherrard DJ, Gillen DL, et al. Increased risk of hip fracture among patients
with end-stage renal disease. Kidney Int 2000;58(1):396-399.
Karaeminogullari O, Demirors H, Sahin O, Ozalay M, Ozdemir N, Tandogan RN. Analysis
of outcomes for surgically treated hip fractures in patients undergoing chronic hemodialysis.
J Bone Joint Surg Am 2007; 89(2):324-331.
Periprosthetic Vancouver B type femoral fractures treatment with a long femoral stem:
radiological and clinical outcomes
Dimitrios Begkas, Stamatios-Theodoros Chatzopoulos, Alexandros Pastroudis
6th Orthopaedic Department, Asclepieion Voulas General Hospital, Athens, Greece
The aim of this study was to evaluate the radiological and clinical outcomes of treatment
of Vancouver B type periprosthetic femoral fractures (PFF) with a long femoral stem
(LFS). We conducted a retrospective study of 16 patients with a periprosthetic Vancouver
B1, B2 and B3 fracture that were admitted in our department between 2016 and 2018
and treated with a LFS revision. All patients were followed up at 1, 2, 3, 6 and 12
months postoperatively. Their radiological evaluation was based on plain X-Rays using
the Beals and Tower’s (BT) criteria and their clinical evaluation on Visual Analogue
(VAS), Harris Hip Score (HHS) as well there incidence of complications. Out of the
16 patients, 12 were female and 4 male. Ten fractures were around a total hip arthroplasty
(THA) and 6 around a hemiarthroplasty (HA). Their mean age was 74 (58 to 83) years.
Three fractures were classified as Vancouver B1, 6 as B2 and 7 as B3. All fractures
achieved union between 2 to 8 months (mean 4 months) postoperatively. The BT criteria
were excellent in 5 patients, good in 8 and poor in 3. The mean VAS at 2 months after
the fracture was 34.2 in comparison with 65.2 at one week after the fracture. The
mean HHS postoperatively was 71.3. All patients survived until the end of the follow
up. Three (18,7%) patients had a major complication and 6 (37.5%) a minor one. None
of the patients required a further operation. Conclusively, Vancouver B type PPF are
a major complication of THA and HA and their treatment still remains challenging.
Optimization of the surgical treatment and postoperative protocol is needed for the
optimum outcome.
Suggested References
Marsland D, Mears SC. A review of periprosthetic femoral fractures associated with
total hip arthroplasty. Geriatr Orthop Surg Rehabil 2012; 3(3):107-20.
Schwarzkopf R, Oni JK, Marwin SE. Total hip arthroplasty periprosthetic femoral fractures.
Bull Hosp Jt Dis 2013;71(1):68-78.
Corten K, Vanrykel F, Bellemans J, et al. An algorithm for the surgical treatment
of periprosthetic fractures of the femur around a well-fixed femoral component. J
Bone Joint Surg (Br) 2009;91(11):1424-30.
Polypharmacy and falls in seniors with hip fracture in Greece
Ioannis Papaioannou1, Georgia Pantazidou2, Thomas Repantis1, Andreas Baikousis1
1 Orthopedic Department of General Hospital of Patras, Greece
2 Ent Department of General Hospital of Patras, Greece
Polypharmacy is closely related with elderly’s falls, while falls are associated with
increased morbidity, mortality, undesirable events, unplanned admissions to emergency
departments, whereas fear of falling leads to isolation and resignation. The aim of
the study is to investigate the possible association of polypharmacy and falling among
older patients. We randomly selected 61 elderly patients (51 women, 10 men) with an
average age of 83,39 years, who were hospitalized in our clinic for hip fracture due
to falling. As control group, we randomly selected 60 patients (38 women and 22 men)
with an average age of 72,98 years, who were hospitalized in our department for degenerative
diseases. In the hip fracture group, we had 4,77±2,9 drugs per day per patient, while
in the control group the average was 3,6±1,85. It is worth noting that only 31,1%
of patients with hip fracture received less than four medications, while the subjects
in degenerative disease group only 41,7% received four or more medications. Hip fractured
patients are closely related with falls, as the hip fracture is a consequence of at
least one fall. It is worth noting a trend we have seen for polypharmacy of all patients.
Τhe correlation of the number of drugs consumed of each group showed a p-value of
0,085, a value very close to statistical significance and this should be noted. Several
studies have linked polypharmacy with falls and for this reason polypharmacy until
2000 was considered as an independent risk factor for falls. However, more important
seems to be the type of drugs that potentially can cause falls like anticholinergics
or sedatives. Elderly people who receive more than three drugs or drugs that induce
falls should be considered as “candidates” for fall and should be properly recognized
and consulted.
Suggested References
Dukas L, Bischoff HA, Lindpaintner LS, Schacht E, Birkner-Binder D, Damm TN, et al.
Alfacalcidol reduces the number of fallers in a community-dwelling elderly population
with a minimum calcium intake of more than 500 mg daily. J Am Geriatr Soc 2004;52(2):230-6.
Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, Staehelin HB, Bazemore MG, Zee RY,
et al. Effect of Vitamin D on falls: a meta-analysis. JAMA 2004;291(16):1999-2006.
Rejnmark L. Effects of vitamin d on muscle function and performance: a review of evidence
from randomized controlled trials. Ther Adv Chronic Dis 2011;2(1):25-37.
Primary medical challenges of treating patients with fragility fractures in the rehabilitation
setting
Ioannis-Alexandros Tzanos, Sofia Sivetidou, Aikaterini Kotroni
Physical Medicine and Rehabilitation Department, KAT Hospital, Athens, Greece
The aim of this study was to identify the main medical issues that physicians face
when treating patients that have suffered from a fragility fracture whether the patients
reside at home or in an inpatient rehabilitation facility. We performed bibliographic
research of the last 10 years in the scientific search engines: “PubMed”, “Google
Scholar”, “Uptodate” and “Cochrane Library” using the words: “rehabilitation” and
“fragility fractures”. It was found that medical management predominantly includes
pain management, pressure ulcer prevention, anticoagulation, nutritional supplements,
and delirium prevention and appropriate treatment. Other probable issues include anemia,
constipation, and urinary tract complications. It was also documented that within
the first month after the discharge from hospital in patients with a hip fracture,
readmission rates were 14%, with pneumonia the most frequent reason. Specific co morbidities,
such as fluid and electrolyte disturbances, cardiac arrhythmias, congestive heart
failure, and chronic obstructive pulmonary disease, are associated with a high rate
of readmission. In conclusion, pain management, pressure ulcer prevention, thromboprophylaxis,
nutrition and delirium prevention and treatment were highlighted as the most common
medical concerns in patients with fragility fracture during the rehabilitation phase.
References
Haentjens P, Magaziner J, Colón-Emeric CS, et al. Meta-analysis: excess mortality
after hip fracture among older women and men. Ann Intern Med 2010;152:380-390.
French DD, Bass E, Bradham DD, et al. Rehospitalization after hip fracture: predictors
and prognosis from a national veterans study. J Am Geriatr Soc 2008;56:705-710.
Boockvar KS, Halm EA, Litke A, et al. Hospital readmissions after hospital discharge
for hip fracture: surgical and nonsurgical causes and effect on outcomes. J Am Geriatr
Soc 2003;51:399-403.
Bukata SV, Digiovanni BF, Friedman SM, et al. A guide to improving the care of patients
with fragility fractures. Geriatr Orthop Surg Rehabil 2011;2:5-37.
Beaupre LA, Jones CA, Saunders LD et al. Best practices for elderly hip fracture patients.
A systematic overview of the evidence. J Gen Intern Med 2005;20:1019-1025.
Quality of life of frail elderly living in the community
Hara Pefani1, Manolis Mentis2, Katerina Athanasopoulou2
1 Hellenic Open University, Greece
2 University of Patras, Greece
Geriatric frailty is an age-related syndrome characterized by increased vulnerability
and decreased physical well-being and activity. The decrease in strength, endurance
and functionality is accompanied by increased susceptibility to stressors and dependence
in simple or complex activities of daily living. The aim of this study was to investigate
the relationship between quality of life and frailty in older people. In particular,
risk factors that may contribute to the occurrence of frailty syndrome have been studied.
100 people (54% men) aged 65 and over participated. The questionnaire formed for this
study included questions about the participants’ socio-demographic data, medical history,
habits and autonomy in their daily life, the short version of the World Health Organization
Quality of Life Questionnaire and the Simple Frailty Scale for the detection of frailty.
The majority of the elderly in this study were categorized frail (57%) or pre-frail
(27%). Significant risk factors for the occurrence of frailty syndrome and the consequent
deterioration of quality of life in the elderly were older age, low level of education,
other chronic diseases, polypharmacy, low income and non-urban living. The immediate
consequence of the ineffective management of frailty was the deterioration of the
quality of life of the elderly, which is multidimensional, as the negative impact
was on their physical health (r=-,465 ,p<0,05), mental health (r=-,365, p<0,05), social
relationships (r=-,240, p<0,05) and functionality in the environment (r=-,279, p<0,05).
Frailty had a restrictive effect on the autonomy and functionality of older people,
a negative effect that significantly affected their quality of life. Frailty and pre-frailty
are health conditions with an increasing incidence in the elderly population. With
comprehensive prevention, it is possible to improve the quality of life and maintain
the physical, mental and social functioning of older people for a longer period of
time.
Suggested References
Clegg A, Young J, Iliffe S, Rikkert M, & Rockwood K. Frailty in elderly people. The
Lancet 2013;381(9868):752-62.
Fried LP. Frailty in older adults: evidence for a phenotype. J Gerontol Biol Sci Med
Sci 2001;56.
Kojima G, Iliffe S, Jivraj S, & Walters K. Association between frailty and quality
of life among community-dwelling older people: a systematic review and meta-analysis.
J Epidemiol Community Health 2016;70(7):716-21.
The effect of femoral nerve block on the length of hospital stay for hip fracture
patients
Maria Spyraki, Georgios Karpetas, Gregorios Voyagis
Department of Anesthesiology and Critical Care, University Hospital of Patras, Patras,
Greece
Adequate perioperative analgesia in hip fracture patients contributes to lower morbidity
rates and reduced length of hospital stay (LOS)1. Perioperatively, peripheral nerve
blocks provide sufficient, opioid- sparing analgesia, reducing the risk for postoperative
complications. Femoral nerve block consists one of the analgesic methods of choice
for hip fracture patients2. The aim of the study is to investigate the effect of continuous
femoral nerve block on LOS, regarding hip fracture patients. This is a prospective
randomized clinical trial, including 30 patients (n=30) with fragility fracture of
the hip. All patients were randomly allocated, equally, into two groups: group CFNB
and group CONV. Patients of group CFNB (Continuous Femoral Nerve Block) received continuous
femoral nerve block using neurostimulator, at the Emergency Department within 4 hours
after the diagnosis, while the catheter remained for the first 24 hours postoperatively.
Patients of group CONV (Conventional) received parenteral opioid and non- opioid analgesics
(paracetamol, tramadol). LOS for all patients was recorded, defined from the day of
surgery until the day of discharge from the hospital. Group CFNB reported lower mean
LOS (10.86±2.99 days) with a maximum value of 19 days and minimum of 6 days, while
group CONV reported mean LOS 13.06±7.06 days (max=37 days/ min=7 days). In conclusion,
continuous femoral nerve block is considered to be an effective analgesic technique
for hip fracture patients during perioperative period, demonstrating positive effects
on LOS.
References
Scurrah A, Shiner CT, Stevens JA, Faux SG. Regional nerve blockade for early analgesic
management of elderly patients with hip fracture - a narrative review. Anaesthesia
2018;73(6):769-783.
Shelton C, White S. Anaesthesia for hip fracture repair. BJA Education 2020;20(5):142-149.
The impact of timing of surgery after hip fracture on patient outcomes
AIkaterini Kalampokini, Panagiotis Tsiasiotis, Michail Tsagkaris, Alexandros Makris
Anesthesiology Department, 5th Orthopedic Clinic, Asklepieion Hospital of Voula, Athens,
Greece
Hip fractures are a major public health concern in the older population. The high
incidence rate and the usually delayed management are followed by increased complications
and mortality. One main reason for delay is the use of antithrombotic agents. Aiming
to evaluate the impact of timing of surgery and the use of antithrombotics in the
postoperative course and mortality, we retrospectively studied 130 hip fracture patients,
managed by the 5th Orthopedic Clinic of our hospital within a year. Demographic data,
the use and type of antithrombotic drugs and the timing of surgery after entrance
to the hospital (<48h hours, 48-72 hours, >72 hours) were recorded. Using these data
we studied the length of hospital stay (LOS) and the mortality rate 3 and 6 months
postoperatively. Mean age of patients was 82±9,5 years. 77,7% of the patients were
females. 50 patients (38,5%) received antithrombotics, 39 of which, were operated
after 48 hours. 28 patients died (21,5%), 2 of which (1,5%) immediately postoperatively,
4 (3%) within three months and 22 (17%) within 6 months. It is noteworthy that 82,1%
of patients that died, were operated later than 48 hours, and 71.4% of them used antithrombotics.
LOS was increased proportionally to surgery delay (4,4±0,7 versus 5.4±0,9 versus 5,6±0,9
days for surgery <48 h hours, 48-72 hours, >72 hours respectively). Our study had
some limitations, being retrospective and making no clear whether increased mortality
was due to surgery delay or severe preexisting health issues. So we conclude that
delay of hip fracture management for more than 48 hours could increase mortality and
LOS. The use of antithrombotics should not lead to delay of definite management. So,
“the bad news is time flies. The good news is that we are the pilot” (Michael Altshuler).
Suggested References
Dhanwal DK, Dennison EM, Harvey NC, Cooper C. Epidemiology of hip fracture: Worldwide
geographic variation. Indian J Orthop 2011; 45(1):15-22.
Mayor A, White SM. Direct oral anticoagulants and delays to hip fracture repair. Anaesthesia
2020;75(9):1139-1141.
Grandone E, Ostuni A, Tiscia GL, Marongiu F, Barcellona D. Management of Patients
Taking Oral Anticoagulants Who Need Urgent Surgery for Hip Fracture. Semin Thromb
Hemost 2019;45(2):164-170.
The perioperative utilization of the tranexamic acid in patients with hip fracture
Ioannis E. Kougioumtzis, Stylianos Tottas, Konstantinos Tilkeridis, Athanasios Ververidis,
Georgios I. Drosos
Academic Orthopeadic Department, Democritus University of Thrace, University General
Hospital of Alexandroupolis, Alexandroupoli, Greece
Hip fractures occur usually among the general population. The vast majority are treated
operatively and may result in considerable blood loss. It is valuable to establish
a worthwhile perioperative approach. The fundamental purpose of this study was to
identify if the use of the tranexamic acid (TXA) could reduce the transfusion rate
in patients undergoing an operation for fragility hip fractures. One hundred and sixty
seven patients with hip fractures met the inclusion criteria. In those with extracapsular
fractures we used intramedullary nails and those with femoral neck fractures underwent
hemiarthroplasty. The data was prospectively collected. The principal outcome was
the perioperative serum haemoglobin decline. This was estimated as the deviation between
preoperative and final postoperative serum haemoglobin. This study further included
the demographic characteristics, the type of fracture based on a variety of classifications,
the transfusion rate and the related complications. From the 167 patients, 83 patients
were registered with intertrochanteric fractures, 67 patients with femoral neck fractures
and 17 patients with subtrochanteric fractures. Tranexamic acid was locally administered
in 69 patients and the transfusion rate was calculated. The transfusion rate was significantly
lower (p<0.05) in intertrochanteric group (36.4% vs 44.0%) and in subtrochanteric
group (33.3% vs 50.0%). On the other hand the difference was not statistically significant
in the femoral neck fractures’ group (p>0.05). Regarding postoperative complications,
such as clinical pulmonary emboli and clinical deep vein thrombosis, no statistical
significance was recorded. The postoperative complications and transfusion rate were
considerably lower in patients with locally applied TXA. We consider that the perioperative
local administration of TXA may be essential for reducing the postoperative blood
transfusion and consequently precipitate rehabilitation for patients with hip fracture,
especially those with extracapsular hip fractures.
Suggested References
Kwak DK, Jang CY, Kim DH, Rhyu SH, Hwang JH, Yoo JH. Topical tranexamic acid in elderly
patients with femoral neck fractures treated with hemiarthroplasty: efficacy and safety?
- a case-control study. BMC Musculoskelet Disord 2019;20(1):228.
Haj-Younes B, Sivakumar BS, Wang M, An VV, Lorentzos P, Adie S. Tranexamic acid in
hip fracture surgery: A systematic review and meta-analysis. J Orthop Surg (Hong Kong)
2020;28(1):2309499019887995.
Baskaran D, Rahman S, Salmasi Y, Froghi S, Berber O, George M. Effect of tranexamic
acid use on blood loss and thromboembolic risk in hip fracture surgery: systematic
review and meta-analysis. Hip Int 2018;28(1):3-10.
The relationship of hand grip strength and knee muscle strength with common functional
measures in elderly patients with sarcopenia
Maria Tsekoura, Konstantinos Fousekis, Elias Tsepis
Department of Physiotherapy, School of Health Rehabilitation Sciences, University
of Patras, Greece
The aim of this study was to examine the comparative association of upper (grip strength)
and lower extremity strength (knee strength) with common functional measures used
in the identification and assessment of sarcopenia. The study participants were 60
elderly patients (52 female, 8 male) with sarcopenia. Body composition was determined
using bioelectrical impedance analysis (Tanita BC 601), handgrip grip strength (HGS)
was measured using a standard hydraulic hand dynamometer (Saehan). An isokinetic dynamometer
was used to assess lower extremity strength (Biodex). Knee extensor and flexor strength
was assessed at isokinetic speeds of 90°/s and 180°/s. Physical performance was characterized
using gait speed, via the 4 meter test, the timed up and Go test (TUG) and the timed
sit to stand test (5 repetitions). Signed informed consent was obtained from all study
participants prior to data collection. Ethical approval was given by the Ethics Committee
of the School of Health and Welfare of the Technological Educational Institute (TEI)
of Western Greece. The age range within the study sample was 65 years to 84 years
(mean age 72.64±7.23 years). There was a fair association between left extension knee
muscle strength (180°/sec) and fast gait speed (r=0.48, p>0.05). Overall, lower extremity
muscle strength values had the strongest associations with participant functional
performance. HGS was associated with left flexion knee muscle strength (180°/sec)
(r=0.5, p>0.001) and right extension muscle strength (90°/sec) (r=0.49, p>0.05). However
HGS was not significantly associated with the other outcome measures. Significant
associations were found between most measures of lower extremity strength and functional
performance. Lower extremity strength testing may provide additional guidance regarding
assessment and clinical management of sarcopenia.
Suggested References
Roberts HC, Denison HJ, Martin HJ, et al. A review of the measurement of grip strength
in clinical and epidemiological studies: towards a standardised approach. Age Ageing
2011;40(4):423-9.
Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Writing Group for the European Working Group
on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia:
revised European consensus on definition and diagnosis. Age Ageing 2019;48(1):16-31.
Alonso AC, Ribeiro SM, Luna NMS, et al. (2018) Association between handgrip strength,
balance, and knee flexion/extension strength in older adults. PLoS ONE 13(6):e0198185.
Vitamin D deficiency and its correlation with hip fracture severity in seniors in
Greece
Ioannis Papaioannou1, Georgia Pantazidou2, Thomas Repantis1, Panagiotis Korovessis1
1 Orthopedic Department of General Hospital of Patras
2 Ent Department of General Hospital of Patras
Several studies support that vitamin D levels are associated with hip fracture severity.
This cross-sectional study included 61 consecutive individuals over 65, with mean
age 83.39, admitted to authors hospital for osteoporotic hip fracture over a year.
Demographic data, fracture type, fracture severity were evaluated and 25-hydroxy vitamin
D was measured. Fracture severity was defined as grade 3 or 4 (Garden classification)
for subcapital and A2.2, A2.3 and all A3 (AO/OTA) for intertrochanteric fractures.
Extracapsular hip fractures predominated, after being found to be 44/61. Men had mainly
intertrochanteric fracture (9/10), while women in 30% of cases had subcapital (15/50)
fractures. We found out that intracapsular fractures (8,09±4,74 ng/ml) are associated
with more severe vitamin D deficiency compared with the intertrochanteric fractures
(9,3±8,5 ng/ml). The severe hip fractures were 40 of 61 (65,6%). The vitamin D levels
in patients with severe fracture were 8,1±7,6 ng/ml, while in cases with not comminuted
fractures the vitamin D levels were higher (10,7±7,4 ng/ml). It is noteworthy that
31 out of 40 cases (77,5%) of severe comminuted fractures revealed vitamin D levels
less than 10 ng/ml. On the other hand, the group with stable hip fractures had 47,6%
of cases with vitamin D more than 10 ng/ml. Correlation between fracture severity
and status of vitamin D levels according to Horlick classification (<10 ng/ml, 10-20
ng/ml, 20-30 ng/ml, >30 ng/ml) with Spearman’s equation is very close to statistical
significance, as the p-value was found to be 0,059. Although, vitamin D levels are
not very different between patients with intracapsular or extracapsular hip fractures,
a more severe vitamin D deficiency seems to be associated with more severe osteoporotic
hip fractures. A prior vitamin D supplementation could restrict the severity of these
fractures. Comminuted fractures are associated with fixation difficulties rehabilitation
restrictions and finally functional disability.
Suggested References
Larrosa M, Gomez A, Casado E, Moreno M, Vázquez I, Orellana C, et al. Hypovitaminosis
D as a risk factor of hip fracture severity. Osteoporos Int 2012 Feb;23(2):607-14.
Buchebner D, McGuigan F, Gerdhem P, Malm J, Ridderstråle M, Åkesson K. Vitamin D insufficiency
over 5 years is associated with increased fracture risk - an observational cohort
study of elderly women. Osteoporos Int 2014;25(12):2767-75.
Zhao J, Cai Q, Jiang D, Wang L, Chen S, Jia W. The Associations of Serum Vitamin D
and Bone Turnover Markers with the Type and Severity of Hip Fractures in Older Women.
Clin Interv Aging 2020;15:1971-8.
Evaluation of patients profile who have had hip replacement surgery during 2016 in
the Orthopaedic ward of Patras university hospital
Sophia Papanikolaou1, Vassiliki Karavatselou1, Georgios Diamantakis2, Elias Panagiotopoulos2
1 Staff Nurse, “St Andrew”, Patras General Hospital, Greece
2 Department of Orthopaedics, Patras University Hospital, Greece
Introduction: Hip fractures are one of the most serious public health problems as
they result in high morbidity and mortality. There are numerous risk factors that
lead to hip fractures, such as osteoporosis, comorbidity and among them there are
factors with a deleterious effect on bone. This study is a systematic evaluation of
patient’s profile who have suffered a hip fracture.
Objectives: The aim of this study is to determine the characteristics of the patients
who have suffered a hip fracture.
Methods: The sample of the study consisted of 68,4% women and 29,7% men, with a mean
age of 82 years old who were admitted and had undergone a hip replacement surgery
during 2016 in the Orthopaedic Ward of Patras University Hospital. The criteria used
for the evaluation were the following: age, gender, comorbidity (according to ICD
10) and polypharmacy (the use of 5 and more medicines). Data were analyzed using the
Statistical Package for Social Sciences and by performing Anova test.
Results: The statistical analysis of the results indicate that the mortality risk
increases by 90% to patients above 60 years old. Women with a hip fracture who are
more than 50 years old have a mortality risk of 30,84%, whereas the same risk for
men is 25,53%. Less than one third (28,5%) of the patients die during the first year
after the fracture. Most of the patients (80% and more) had at least one comorbidity
(according to ICD-10) and 70% of them were under pharmaceutical treatment with at
least one medicine. Our findings suggest that comorbidity, age, gender and polypharmacy
are strongly associated with morbidity.
Conclusion: The systematic evaluation of risk factors such as comorbidities and polypharmacy
are important for the assessment of the subsequent risk of fracture and for the better
management of hip fracture patients.
Mortality, complications and quality of life one year after the hip fracture
George Liapis1, Maria Lagadinou2, Elias Panagiotopoulos3
1 Orthopedics Department General Hospital of Patras, Greece
2 Emergency Department University Hospital of Patras, Greece
3 Orthopedics University Hospital of Patras, Greece
Introduction: Hip fractures are low energy injuries with significant morbidity and
mortality to the individual. Furthermore, they carry a substantial burden to the health
and social services. The associated 6-month mortality is 50% and 12-month is ranging
from 14 to 58%.
Aim: The aim of our study was to conduct an epidemiological study of hip fracture
mortality in the elderly (>65 years), their immediate and distant complications (thrombosis,
pulmonary embolism, infection, pressure ulcers and new fracture) and the impact on
the quality of life for the 1st year.
Material and methods: Patients suffering from hip fracture were enrolled during the
period from 1/7/2016 to 30/6/2017 with a minimum follow up of 12 months. The data
were collected, retrospectively from notes and semi-structured interviews of the patients
or their main carers (usually first-degree relatives). The semi-structured interviews
were conducted a bespoke questionnaire in conjunction with the standardized SF-36
quality of life questionnaire.
Results: The total number of patients admitted to the Orthopedic Clinic of Patras
General Hospital over the inclusion period (1/7/2016-30/6/2017), with hip fracture
was 204. Of all responders (N = 132), the mean age was 83.9±9 years.73.5% were women
and 26.5% were men.24% (n=32) were treated with non-surgical treatment, mainly due
to serious concomitant problems or refusal of the patient or his environment to operate.
Of these patients 75% (n=24) died. Of those who underwent surgery, 25.74% died. The
total mortality of patients admitted to the hospital was 37.6%. 31 patients (23.3%)
developed an infection. 4.5% of patients developed venous thrombosis of the lower
extremities while 2.25% developed pulmonary embolism. The incidence rate of 2nd fracture
was 13.5%. Finally, the average values of most quality of life -related parameters
were low.
Conclusion: Because of hip fracture’s serious implications, both for the individual
and for the society, it is understood that the initial interventions should aim targeted
towards prevention. This could be achieved by reducing bone density decline in the
elderly population, by means of screening tests for osteoporosis, and by appropriate
treatment.