http://xoomer.virgilio.it/lusebra/NuoviFile/PrevenzioneTVP.pdf

Prevention of venous thromboembolism

https://www.chpso.org/sites/main/files/file-attachments/chest-2008-geerts-381s-453s.pdf

Prevention of Venous Thromboembolism* American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th Edition)

As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture.
This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants.  
Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures.
Multifactorial interventions assess an individual's risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined.  
Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls.
Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment.  
Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls.
Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure.
In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling.
The evidence relating to the provision of educational materials alone for preventing falls is inconclusive.

Interventions for preventing falls in older people living in the community

Prevention of Venous Thromboembolism : The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

The Clinician’s Guide to Prevention and Treatment of Osteoporosis was developed by an expert committee of the National Osteoporosis Foundation (NOF) in collaboration with a multispecialty council of medical experts in the field of bone health convened by NOF. Readers are urged to consult current prescribing information on any drug, device, or procedure discussed in this publication.

/pdf/clinician-s-guide-to-prevention-and-treatment-of-2xu0hehxcd.pdf

Clinician’s Guide to Prevention and Treatment of Osteoporosis

OBJECTIVE--To study the mortality and morbidity associated with proximal femoral fractures with reference to fracture type (intracapsular and extracapsular). DESIGN--Consecutive prospective study with 12 month follow ups. SETTING--Two British trauma receiving centres. PATIENTS--1000 consecutive acute proximal femoral fractures (fractured necks of femur) in 972 patients. RESULTS--Significantly higher mortality at one year was seen in patients with extracapsular fractures (188/490; 38%) than in those with intracapsular fractures (147/510; 29%; p < 0.01). Greater morbidity was experienced during the study period by patients with extracapsular fractures, who were less mobile and less independent at the time of their injury. CONCLUSIONS--The rise in average age of presentation with proximal femoral fracture is associated with a persistently high mortality (33%) and morbidity, greater in patients with an extracapsular fracture. Comparison with other studies, principally from outside Britain, is difficult, but despite advancing standards of care the mortality and morbidity of femoral neck fractures remains high, placing an ever increasing burden on the health service.

https://www.bmj.com/content/bmj/307/6914/1248.full.pdf

Mortality and morbidity after hip fractures.

We assessed 882 patients presenting with a proximal femoral fracture by a new mobility score and by a mental test score, to determine which was of the most value in forecasting mortality at one year. Both scores gave a highly significant prediction, but the mobility score had a greater predictive value and is easier to perform.

A new mobility score for predicting mortality after hip fracture

Background Cephalocondylic intramedullary nails which are inserted proximally to distally (cephalocondylic) have been used for the surgical treatment of extracapsular hip fractures. Objectives To compare all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. This is the third update of our original review which compared the Gamma nail with the sliding hip screw (SHS). Search strategy We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE, select orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: August 2001. Selection criteria All randomised and quasi-randomised trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. Data collection and analysis Both reviewers independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results were pooled. Main results The one trial of 230 patients comparing the Kuntscher-Y nail with the SHS, reported no major difference the outcome aside from a significantly increased number of patients with leg shortening, and a tendency for poorer recovery of mobility in the Kuntscher-Y nail group. Seventeen trials comparing the Gamma nail with the SHS were included, with data available for 2472 patients. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased re-operation rate. There were no major differences in the incidence of wound infection, mortality or medical complications between implants. Data were inadequate to determine if there were differences for other outcomes. Five trials involving 603 patients compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. Two under-reported trials tested the proximal femoral nail (PFN). The results of one study of 206 patients with a trochanteric fracture showed no advantages for the PFN compared with the SHS. The other study, involving 39 patients, comparing the PFN with the dynamic condylar plate for treating more distal and uncommon trochanteric fractures gave better intra-operative and fracture fixation results for the PFN. One trial of 60 patients reported favourable preliminary results for an experimental mini-invasive static intramedullary nail compared with the SHS. Reviewer's conclusions Further evidence is required before any conclusions can be drawn on the relative merits of either the Kuntscher-Y nail or the mini-invasive static intramedullary nail in comparison with the SHS. Given the lower complication rate of the SHS in comparison with intramedullary nails, it appears that for trochanteric fractures the SHS is superior. Further studies will be required to determine if different types of intramedullary nail produce the same results, or if intramedullary nails have advantages for selected fracture types, for example, reversed fracture lines and subtrochanteric fractures. From the evidence available, IMHS appears to have the same problems as the Gamma nail, but other theoretical advantages of the IHMS cannot be ruled out.

/pdf/gamma-and-other-cephalocondylic-intramedullary-nails-versus-3yfc8xuz4f.pdf

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults

Background
The majority of people with hip fracture are treated surgically, requiring anaesthesia

Objectives
To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults

Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (November 2003), MEDLINE (1996 to February week 2 2004), EMBASE (1988 to 2004 week 10) and reference lists of relevant articles

Selection criteria
Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in adults The primary focus of this review was the comparison of regional (spinal or epidural) anaesthesia versus general anaesthesia The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review The primary outcome was mortality

Data collection and analysis
Two reviewers independently assessed trial quality and extracted data

Main results
Twenty two trials, involving 2567 predominantly female and elderly patients, comparing regional anaesthesia with general anaesthesia were included All trials had methodological flaws and many do not reflect current anaesthetic practice Pooled results from eight trials showed regional anaesthesia to be associated with a decreased mortality at one month (56/811 (69%) versus 86/857 (100%)); however, this was of borderline statistical significance (relative risk (RR) 069, 95% confidence interval (CI) 050 to 095) The results from six trials for three month mortality were not statistically significant, although the confidence interval does not exclude the possibility of a clinically relevant reduction (86/726 (118%) versus 98/765 (128%), RR 092, 95% CI 071 to 121) The reduced numbers of trial participants at one year, coming exclusively from two trials, preclude any useful conclusions for long-term mortality (80/354 (226%) versus 78/372 (210%), RR 107, 95% CI 082 to 141)

Regional anaesthesia was associated with a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/130 (47%); RR 064, 95% CI 048 to 086) However, this finding is insecure due to possible selection bias in the subgroups in whom this outcome was measured Regional anaesthesia was also associated with a reduced risk of acute postoperative confusion (11/117 (94%) versus 23/120 (192%), RR 050, 95% CI 026 to 095)

There was insufficient evidence to draw any conclusions from a further four included trials, involving a total of 179 participants, which compared other methods of anaesthesia (a 'light' general with spinal anaesthesia; intravenous ketamine; nerve blocks)

Authors' conclusions
Overall, there was insufficient evidence available from trials comparing regional versus general anaesthesia to rule out clinically important differences Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes

Anaesthesia for hip fracture surgery in adults

To The Editor: 

Our article “Treatment of Acute Achilles Tendon Ruptures. A Meta-Analysis of Randomized, Controlled Trials” (2005; 87:2202-10), by Khan et al., was based …

Martyn J. Parker

Papers

Mortality and morbidity after hip fractures.

A new mobility score for predicting mortality after hip fracture

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults

Anaesthesia for hip fracture surgery in adults

Treatment of Acute Achilles Tendon Ruptures. A Meta-Analysis of Randomized, Controlled Trials