Abstract
A study was performed to assess the impact of intensive inpatient rehabilitation on the outcome after a fracture of the femoral neck or an intertrochanteric fracture. Before 1990, our hospital did not have an inpatient rehabilitation program. On January 1, 1990, a diagnosis-related-group-exempt (DRG-exempt) acute rehabilitation program was initiated. Patients were discharged to this program after evaluation by a staff physiatrist. Before 1990, twenty-seven (9.0 per cent) of 301 patients were discharged to an outside rehabilitation facility. After January 1990, the percentage of patients who were discharged to the DRG-exempt program increased yearly, from nineteen (17 per cent) of 113 patients in 1990 to forty-one (64 per cent) of sixty-four patients in 1993; this difference was significant (p < 0.01). Before 1990, the average duration of the stay in the hospital was 21.9 days. After January 1990, the average duration for the patients who did not enter the rehabilitation program was 20.0 days whereas the average duration for those who did was 31.4 days (16.1 days for acute care and 15.6 days for the rehabilitation program). There were no differences in the hospital discharge status or in the walking ability, place of residence, need for home assistance, or independence in basic and instrumental activities of daily living at the six and twelve-month follow-up examinations between patients who had been managed before initiation of the rehabilitation program and those managed after it or between patients who had been discharged to this program after its initiation and those who had not. These results raise serious questions regarding the global cost-effectiveness of these programs for patients who have had a fracture of the femoral neck or an intertrochanteric fracture.
There is controversy regarding the utilization and efficacy of inpatient services (acute care and rehabilitation) after a fracture of the femoral neck or an intertrochanteric fracture. Initially, implementation of the prospective-payment system led to a reduction in the amount of acute hospital care given to patients who had such fractures and resulted in an increased rate of discharge to skilled-nursing facilities3,4. More recently, patients who have such fractures have been transferred early to inpatient rehabilitation programs in an effort both to decrease the duration of the acute-care stay and to improve functional recovery. Few studies, however, have assessed the impact of these programs on the outcome after the fracture. The purpose of the present study was to evaluate the utilization of our hospital's diagnosis-related-group-exempt (DRG-exempt) rehabilitation program since its initiation and to determine its impact on the outcome after a fracture of the femoral neck or an intertrochanteric fracture.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Department of Orthopaedic Surgery, Hospital for Joint Diseases, 301 East 17th Street, New York, N.Y. 10003.
Between July 1, 1987, and June 30, 1994, 642 patients were admitted to the Hospital for Joint Diseases with a fracture of the femoral neck or an intertrochanteric fracture. To be included in this study, a patient had to be sixty-five years old or more, had to have been able to walk before the fracture, had to be cognitively intact, and had to be living in his or her own home or apartment. In addition, the fracture of the femoral neck or the intertrochanteric fracture had to be of non-pathological origin. The study was approved by the Institutional Review Board. All patients were enrolled at the time of admission to the hospital and were followed with an established protocol. Information on function before the fracture, walking ability, living situation, and cause and location of the fracture was obtained at the time of admission through an interview with the patient or a family member. Data on the hospital course were collected from the chart during hospitalization and at the time of discharge.
All patients were managed operatively and followed a similar postoperative protocol, which consisted of early mobilization on the first day postoperatively and walking with weight-bearing as tolerated. During the acute-care period, the patients were seen by a physical therapist for thirty minutes once or twice a day on weekdays and once a day on weekends and holidays. The physical therapy sessions involved gait-training, stair-climbing, transfers, range-of-motion exercises, and strengthening of the upper and lower extremities. Before discharge from the hospital, the patients were seen once by an occupational therapist for assessment and instruction in activities of daily living.
Before 1990, our hospital did not have an inpatient rehabilitation program. On January 1, 1990, it initiated a DRG-exempt acute rehabilitation program. Before being admitted to this program, a patient was evaluated by a staff physiatrist, who determined whether he or she would benefit from intensive rehabilitation and was capable of participating fully in the rehabilitation program. The decision to request a rehabilitation consultation and transfer was made by the operating surgeon.
Once they were enrolled in the rehabilitation program, patients received two hours of physical therapy seven days a week for gait-training, stair-climbing, transfers, range-of-motion exercises, and strengthening of the upper and lower extremities. They also received one hour of occupational therapy seven days a week for instruction in activities of daily living. There were weekly conferences with the patient and family, with an emphasis on establishing realistic short and long-term goals and expectations. The short-term goal was to become less dependent in activities of daily living and walking, and the ultimate long-term goal was to achieve independence in activities of daily living and walking, with or without assistive devices. Family members were encouraged to participate in the therapy sessions and were taught how to perform range-of-motion and strengthening exercises. Decisions regarding the discharge of the patient from the rehabilitation program and the need for home-care services were made by consensus of a multidisciplinary group, with input from the patient and family, and were based on the patient's achievement of his or her short-term goal or of a functional plateau without additional improvement expected in the near future.
All patients were contacted by one of two trained interviewers to obtain follow-up information at three, six, and twelve months postoperatively or until death. If a patient was not available, a family member or caregiver was interviewed. Patients were compared with regard to whether they had been treated before or after initiation of the DRG-exempt rehabilitation program. A comparison was also made between patients who had been discharged to the rehabilitation program after its initiation and those who had not been discharged to it after its initiation. The outcomes examined in this study were the hospital discharge status as well as the mortality rate, place of residence (home compared with a skilled-nursing facility), walking ability, need for home assistance, and independence in basic8 and instrumental11 activities of daily living at three, six, and twelve months postoperatively; for each appropriate outcome, it was determined whether the patient had recovered the functional level that he or she had had before the fracture. Factors that were analyzed as covariates included the age of the patient (sixty-five to eighty-four years or eighty-five years or more); gender; number of associated comorbidities (zero, one, or two, or three or more); operative risk according to the criteria of the American Society of Anesthesiologists (class I or II compared with class III or IV); type of fracture (femoral neck or intertrochanteric); walking ability before the fracture; level of independence in basic and instrumental activities of daily living before the fracture; living situation (alone or with another person) before the fracture; need for home assistance before the fracture; and type of operation (internal fixation or insertion of a prosthesis).
The walking ability before and after the fracture was classified on the basis of standard definitions of community and household ambulation5. Community ambulation meant that the patient was able to walk indoors and outdoors either independently or with assistive devices. Household ambulation indicated that the patient was limited to walking indoors either independently or with assistive devices. Non-functional ambulation essentially meant that the patient was unable to walk and was either bedbound or limited to bed-to-chair transfers with assistance. These categories were subdivided further, for purposes of a more detailed analysis9, as independent community ambulation, community ambulation with a cane, community ambulation with a walker or crutches, independent household ambulation, household ambulation with a cane, household ambulation with a walker or crutches, and non-functional ambulation.
Basic activities of daily living, adapted from the report by Katz et al., included feeding, dressing, toileting, and bathing. Instrumental activities of daily living, adapted from the report by Lawton and Brody, included shopping for food, preparing food, performing housework, doing laundry, handling banking and finances, and using public transportation. Each of the basic and instrumental activities of daily living was rated on a scale of 0 to 4 points, with 0 points indicating complete dependence and 4 points indicating complete independence in that activity. A score of 3 or 4 points indicated that the patient was independent in a specific activity and a score of 0, 1, or 2 points, that the patient was dependent. The number of basic and instrumental activities of daily living in which the patient was dependent was recorded.
The general health status was defined by the number of preexisting important comorbid conditions, including diabetes mellitus, congestive heart failure, cardiac arrhythmia, ischemic heart disease, previous cerebrovascular accident, renal disease, cancer, Parkinson disease, hypertension, chronic obstructive pulmonary disease, and the need for ongoing anticoagulation. These comorbidities were chosen as the most important ones on the basis of our experience and that reported in the literature13,16. As previous studies have shown that patients who have no, one, or two comorbidities have similar outcomes1, patients were categorized as having no, one, or two comorbidities or as having three comorbidities or more.
The classification system of the American Society of Anesthesiologists was used to assess the role of the severity of health problems at the time of admission12. Class I indicates a normal, healthy patient; class II, mild systemic disease; class III, severe systemic disease that is not incapacitating; class IV, a severe incapacitating systemic condition that is a constant threat to life; and class V, a moribund patient. No patient in this study was class V. The ratings were divided into two categories: class I or II and class III or IV. This approach has been used previously12,14.
Postoperative inpatient medical complications included myocardial infarction, cardiac arrhythmia, pneumonia, pulmonary embolism, thrombophlebitis, decubitus, urinary tract infection, allergic reaction, and deep wound infection. Minor complications, such as electrolyte imbalance, were not included in this analysis. The number of postoperative complications was categorized, as has been done previously, as none or at least one1.
The level of home assistance was categorized as none or part-time (two days a week or less) or as full-time (three days a week or more) or live-in. These social dependency levels were adapted from those described by Eastwood and have been used previously10.
Statistical Analysis
Statistical analysis was performed to evaluate the use of inpatient rehabilitation and to determine its effect on hospital discharge status as well as the mortality rate, place of residence, walking ability, need for home assistance, and independence in basic and instrumental activities of daily living at three, six, and twelve months postoperatively. The hospital discharge status and place of residence were defined as discharge to, or residence at, either home or a skilled-nursing facility. Recovery of walking ability, independence in activities of daily living, and level of home assistance were dichotomized as either a return to the level before the fracture or a decrease of at least one level. Exploratory analysis was done with use of contingency-table (chi-square) methods. To estimate the simultaneous effects of important covariates (age, gender, and so on), multiple logistic regression analysis was performed. Only the variables that added significantly to the prediction were retained in the final model. P values of 0.05 or less were considered significant.
Six hundred and nine patients met the criteria for inclusion in this study (Table I). Three hundred and one patients were managed before January 1, 1990, and 308 were managed after initiation of the DRG-exempt rehabilitation program. Patients who were managed after January 1, 1990, were more likely to have needed home assistance before the fracture (p = 0.01); no other differences were found between these two groups with regard to the characteristics of the patients before the fracture or with regard to treatment. After initiation of the rehabilitation service, patients who were transferred to this program were more likely to be female (p = 0.03), to have lived alone (p = 0.03) and needed home assistance (p = 0.001) before the fracture, and to have sustained an intertrochanteric fracture (p = 0.03) than those who were discharged after the acute-care stay.
Before initiation of the rehabilitation program, twenty-seven (9.0 per cent) of the 301 patients were discharged to an outside acute-care rehabilitation facility; the average interval from the operation to the transfer to the rehabilitation facility was 19.2 days (range, eight to forty-one days). After initiation of the rehabilitation program, the percentage of patients who were discharged to this program increased yearly, from nineteen (17 per cent) of 113 patients in 1990 to forty-one (64 per cent) of sixty-four patients in 1993; this increase was significant (p < 0.01). The average interval from the operation to the rehabilitation consultation decreased yearly, from 11.6 days in 1990 to 8.4 days in 1993; this decrease was significant (p = 0.04). The average interval from the operation to the transfer to the rehabilitation program also decreased yearly, from 14.2 days in 1990 to 12.7 days in 1993; however, this decrease could not be shown to be significant, with the numbers available. In 1990, a rehabilitation consultation was requested for thirty-one (27 per cent) of 113 patients; twenty-two (71 per cent) of the thirty-one were considered acceptable candidates for transfer to the program. Three of these twenty-two patients refused to enroll in the program. By 1993, a rehabilitation consultation was requested for forty-five (70 per cent) of sixty-four patients, and forty-three (96 per cent) of them were considered acceptable candidates. Two of these forty-three patients refused to enroll in the program. The increases, between 1990 and 1993, in the percentage of rehabilitation consultations that were requested and the percentage of patients who were considered acceptable candidates for transfer were significant (p < 0.01).
Before initiation of the rehabilitation program, the average duration of the stay in the hospital was 21.9 days (range, four to 139 days). After initiation, the patients who were not discharged to the rehabilitation program stayed in the hospital for an average of 20.0 days (range, two to 105 days) whereas those who were discharged to the rehabilitation program stayed for an average of 31.4 days (range, one to ninety-two days): an average of 16.1 days for acute care and 15.6 days for the rehabilitation program. This difference was significant (p < 0.01).
Forty-three (7.1 per cent) of the 609 patients had at least one medical complication (Table II); the patients who were discharged to the rehabilitation program were more likely to have at least one inpatient complication than those who were not discharged to the program after its initiation (p = 0.01). Eighteen patients (3.0 per cent) died during hospitalization; patients were more likely to die during hospitalization before the initiation of the rehabilitation program than after it (p = 0.03). Thirty-four patients (5.6 per cent) were discharged to a skilled-nursing facility; with the numbers available, no significant differences were found between the percentages of patients who were discharged to a skilled-nursing facility before and after initiation of the rehabilitation program or between the percentages of patients who were and were not discharged to this program after its initiation. A postoperative wound infection developed during hospitalization in ten patients (1.6 per cent), thrombophlebitis or pulmonary embolus developed in twelve patients (2.0 per cent), and nine patients (1.5 per cent) needed a revision hip procedure during hospitalization (Table II).
Data on mortality and residence were available for 588 patients (96.6 per cent) at each of the follow-up evaluations (Table III). Twenty-nine patients (4.9 per cent) died within three months postoperatively; forty-seven (8.0 per cent), within six months; and seventy-three (12.4 per cent), within twelve months. Forty-one patients (7.0 per cent) resided in a skilled-nursing facility at three months postoperatively; forty-six patients (7.8 per cent), at six months; and fifty-five patients (9.4 per cent), at twelve months. Comparison of patients who had been managed before initiation of the rehabilitation program with those who had been managed after it and comparison of those who had been discharged to the rehabilitation program after its initiation with those who had not revealed no differences in the mortality rates at three, six, or twelve months or in the percentages of patients who resided in a skilled-nursing facility.
Functional outcome data were not available for all 588 patients at every time-period. Functional outcome data were available for 408 patients (67.0 per cent of the total series of 609 patients) at three months, 440 patients (72.2 per cent) at six months, and 451 patients (74.1 per cent) at twelve months (Table IV). Men were less likely than women to have been available for assessment at three, six, and twelve months (p < 0.01); no other differences (such as in the ages of the patients, types of fracture, or number of medical comorbidities) were found between the patients who had assessment of functional outcome and those who did not.
Seventy-six (18.6 per cent) of the 408 patients who were evaluated at three months, 158 (35.9 per cent) of the 440 patients who were evaluated at six months, and 192 (42.6 per cent) of the 451 patients who were evaluated at twelve months had regained the walking ability that they had had before the fracture. Two hundred and twenty-five (55.1 per cent) of the patients who were evaluated at three months, 308 (70.0 per cent) of the patients who were evaluated at six months, and 324 (71.8 per cent) of the patients who were evaluated at twelve months had regained the prefracture level of independence in basic activities of daily living. At three months, 132 patients (32.4 per cent) had regained their prefracture level of independence in instrumental activities of daily living compared with 186 (42.3 per cent) at six months and 199 (44.1 per cent) at twelve months. Three hundred and four patients (74.5 per cent) had returned to their prefracture level of home assistance at three months; 336 (76.4 per cent), at six months; and 339 (75.2 per cent), at twelve months. The patients who had been discharged to the rehabilitation program were less likely to have recovered the prefracture level of independence in basic activities of daily living at the three-month follow-up evaluation than those who had not been discharged to the program after it had been initiated (p < 0.001); this relationship remained after potential confounders were controlled for (p < 0.001). No other differences with regard to functional outcome were found between the patients who had been discharged before and those who had been discharged after initiation of the rehabilitation program or between the patients who had been discharged to this program after its initiation and those who had not.
Ideally, DRG-exempt inpatient rehabilitation programs provide intensive inpatient rehabilitation for patients who need these services but do not place a financial burden on the institution providing that care. However, these programs have also provided an effective method for hospitals to reduce the duration of the acute-care stay while continuing to provide inpatient services. Since the initiation of the rehabilitation program at our institution, the percentage of patients in our study group who were discharged to this unit after a fracture of the femoral neck or an intertrochanteric fracture increased yearly, from nineteen (17 per cent) of 113 patients in 1990 to forty-one (64 per cent) of sixty-four patients in 1993. The percentage of patients for whom transfer to the rehabilitation program was requested and the percentage of patients who were considered acceptable candidates also increased; by 1993, forty-five (70 per cent) of sixty-four patients had a rehabilitation consultation and forty-three (96 per cent) of these forty-five were accepted for transfer. The duration of stay for acute care decreased, but the total duration of stay in the hospital increased significantly (p < 0.01).
The cost-effectiveness of intensive inpatient rehabilitation programs must be scrutinized closely. The cost of acute inpatient rehabilitation is high. The average reimbursement to our hospital after open reduction and internal fixation of a fracture of the femoral neck or an intertrochanteric fracture was $8200 during the study period while the average reimbursement after hemiarthroplasty was $14,400, regardless of the duration of hospitalization. Hospital reimbursement by third-party payers for the DRG-exempt rehabilitation program was approximately $700 a day; patients who were discharged to this program remained hospitalized there for an average of sixteen days, with an additional reimbursement of approximately $11,200.
Patients who were discharged to the rehabilitation program were more likely to have an inpatient medical complication than those who were not discharged to the program after its initiation. This higher risk of complications may be related to the increased total duration of stay in the hospital associated with transfer to the rehabilitation program. The higher rate of complications in patients who were discharged to the program may also be related to surgeon-selection bias; surgeons may have referred patients for a rehabilitation consultation when they did not think the patients would do well at home.
Patients were more likely to die during hospitalization before initiation of the rehabilitation program. The lower inpatient mortality rate reported after January 1, 1990, is probably related to improvements in perioperative medical care and not to the initiation of the rehabilitation program, as patients who died during hospitalization after January 1, 1990, did so before discharge to the rehabilitation program.
Comparison of patients who had been managed before initiation of the rehabilitation program with those who had been managed after it and comparison of those who had been discharged to this program after its initiation with those who had not revealed (with the numbers available) no differences with regard to the percentage of patients discharged to a skilled-nursing facility or the percentage of patients residing in such a facility at three, six, or twelve months. It also revealed no differences in recovery of walking ability, independence in basic and instrumental activities of daily living, or level of home assistance at the six and twelve-month follow-up evaluations. After initiation of the rehabilitation program, patients who had been transferred to this program were less likely to have recovered the prefracture level of independence in basic activities of daily living at the three-month follow-up evaluation than those who had been discharged after the acute-care stay; however, this relationship disappeared by the six-month follow-up evaluation. These results are similar to those reported by Jette et al., who found no significant differences in mortality, hospital discharge status, or pattern or level of functional recovery between patients who had received intensive inpatient rehabilitation and those who had been managed with standard rehabilitation.
It should be noted that the present study was confined to elderly patients who had a fracture of the femoral neck or an intertrochanteric fracture and had been living at home, able to walk, and cognitively intact before the fracture. While the results cannot be generalized to previously institutionalized or demented elderly patients, the population that we studied represents at least two-thirds of the elderly who have a fracture of the femoral neck or an intertrochanteric fracture6,7,9. They are also the patients who should benefit most from an intensive rehabilitation program.
All patients in this study were mobilized within forty-eight hours postoperatively and were allowed to walk bearing weight as tolerated. This negated the potential confounding effect of differing weight-bearing protocols. An additional strength of this study is that it was prospective; thus, the number of patients lost to follow-up was reduced and the inherent inaccuracies of the chart review used in retrospective studies were avoided. However, it should be noted that our follow-up data were obtained with a telephone interview. Although this method may be somewhat less reliable than direct observation of a patient, our previous study of elderly patients supported its accuracy15 and its use allowed for more efficient follow-up.
The prefracture characteristics were not identical for the two groups of patients in each comparison. Patients who were managed after January 1, 1990, were more likely to have needed home assistance before the fracture. After initiation of the rehabilitation program, patients who were discharged to this program were more likely to be female, to have lived alone and needed home assistance before the fracture, and to have sustained an intertrochanteric fracture than patients who were discharged after the acute-care stay. Furthermore, men were less likely than women to have been available for the assessment of functional outcome at three, six, and twelve months. However, multivariate analyses were performed to control for these differences in the characteristics of the patients.
A prospective, randomized study is required to evaluate most accurately the effect of inpatient rehabilitation on the outcome after a fracture of the femoral neck or an intertrochanteric fracture. It is important to emphasize that, although all of our data were collected prospectively, we did not perform a prospective, randomized study. There was an inherent bias because the request for a rehabilitation consultation and the ultimate discharge to the rehabilitation program were at the physician's discretion after discussion with the patient and family. Furthermore, the patients who were discharged to the program had been managed on the acute-care service for an average of 16.1 days. This duration is much longer than the present average duration of acute care after a fracture of the femoral neck or an intertrochanteric fracture (8.8 days), which might explain why patients did not benefit from additional inpatient rehabilitation: they had already received a substantial amount of inpatient rehabilitation.
In conclusion, use of the DRG-exempt rehabilitation program at our hospital increased yearly after its initiation; the duration of acute-care hospitalization decreased while the overall duration of hospitalization increased. Patients who were discharged to the rehabilitation program were more likely to have at least one inpatient medical complication and were less likely to have recovered their prefracture level of independence in basic activities of daily living at the three-month follow-up evaluation than patients who were not discharged to this program after it had been initiated. No other differences were found in the functional parameters either at the time of discharge from the hospital or at three, six, or twelve months postoperatively. These results raise serious questions regarding the global cost-effectiveness of these programs. Additional investigation and analysis of similar programs is warranted, as confirmation of our findings could have an effect on public policy and health-care financing.
Aharonoff, G. B.; Koval, K. J.; Skovron, M. L.; and Zuckerman, J. D.: Hip fractures in the elderly: predictors of one year mortality. J. Orthop. Trauma,11: 162-165, 1997.11162Â
1997Â
[PubMed] Â
Eastwood, H. D.: The social consequences of surgical complications for patients with proximal femoral fractures. Age and Ageing,22: 360-364, 1993.22360Â
1993Â
[PubMed] Â
Fitzgerald, J. F.; Moore, P. S.; and Dittus, R. S.: The care of elderly patients with hip fracture. Changes since implementation of the prospective payment system. New England J. Med.,319: 1392-1397, 1988.3191392Â
1988Â
Â
Fitzgerald, J. F.; Fagan, L. F.; Tierney, W. M.; and Dittus, R. S.: Changing patterns of hip fracture care before and after implementation of the prospective payment system. J. Am. Med. Assn.,258: 218-221, 1987.258218Â
1987Â
Â
Hoffer, M. M.; Feiwell, E.; Perry, R.; Perry, J.; and Bonnett, C.: Functional ambulation in patients with myelomeningocele. J. Bone and Joint Surg.,55-A: 137-148, Jan. 1973.55-A137Â
1973Â
Â
Holmberg, S., and Thorngren, K. G.: Rehabilitation after femoral neck fracture. 3053 patients followed for 6 years. Acta Orthop. Scandinavica,56: 305-308, 1985.56305Â
1985Â
Â
Jette, A. M.; Harris, B. A.; Cleary, P. D.; and Campion, E. W.: Functional recovery after hip fracture. Arch. Phys. Med. and Rehab.,68: 735-740, 1987.68735Â
1987Â
Â
Katz, S.; Ford, A. B.; Moskowitz, R. W.; Jackson, B. A.; and Jaffe, M. W.: Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. J. Am. Med. Assn.,185: 914-919, 1963.185914Â
1963Â
Â
Koval, K. J.; Skovron, M. L.; Aharonoff, G. B.; Meadows, S. E.; and Zuckerman, J. D.: Ambulatory ability after hip fracture. A prospective study in geriatric patients. Clin. Orthop.,310: 150-159, 1995.310150Â
1995Â
[PubMed] Â
Koval, K. J.; Skovron, M. L.; Polatsch, D.; Aharonoff, G. B.; and Zuckerman, J. D.: Dependency after hip fracture in geriatric patients: a study of predictive factors. J. Orthop. Trauma,10: 531-535, 1996.10531Â
1996Â
[PubMed] Â
Lawton, M. P., and Brody, E. M.: Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist,9: 179-186, 1969.9179Â
1969Â
[PubMed] Â
Owens, W. D.; Felts, J. A.; and Spitznagel, E. L., Jr.: ASA physical status classifications: a study of consistency ratings. Anesthesiology,49: 239-243, 1978.49239Â
1978Â
[PubMed] Â
Thorngren, K. G.: Optimal treatment of hip fractures. Acta Orthop. Scandinavica, Supplementum 214, pp. 31-34, 1991.Â
Â
White, B. L.; Fisher, W. D.; and Laurin, C. A.: Rate of mortality for elderly patients after fracture of the hip in the 1980's. J. Bone and Joint Surg.,69-A: 1335-1340, Dec. 1987.69-A1335Â
1987Â
Â
Zuckerman, J. D.; Koval, K. J.; Aharonoff, G.; and Skovron, M. L.: A functional recovery score for geriatric hip fracture patients: development and clinical assessment. Orthop. Trans.,20: 82, 1996.2082Â
1996Â
Â
Zuckerman, J. D.; Skovron, M. L.; Koval, K. J.; Aharonoff, G.; and Frankel, V. H.: Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J. Bone and Joint Surg.,77-A: 1551-1556, Oct. 1995.77-A1551Â
1995Â
Â