Thirty-day mortality after hip fractures: has anything changed?

Surgery on admission and following day reduces hip fracture complications: a Japanese DPC study

INTRODUCTION

The efficacy of early surgery in preventing complications among Japanese elderly patients with hip fractures requires further investigation. This study aims to use a comprehensive Japanese hip fracture case database to determine whether surgery within the day of admission and the following day reduces the incidence of complications and mortality during hospitalization in elderly hip fracture patients.

MATERIALS AND METHODS

We retrospectively analyzed the Japanese National Administrative DPC (Diagnosis Procedure Combination) database from April 2016 to March 2022. Approximately 1100 DPC-affiliated hospitals consistently provided medical records with consent for research. The study investigated the association between postoperative pneumonia, deep vein thrombosis, pulmonary embolism, and mortality during hospitalization after propensity score matching, focusing on surgeries conducted on the day of admission and the following day.

RESULTS

After one-to-one propensity score matching for age, gender, and comorbidity, we identified 146,441 pairs of patients who underwent surgery either within the day of admission and the following day or after the third day of admission. Surgery on the third day or later was independently associated with increased risks of pneumonia, deep vein thrombosis, pulmonary embolism, and mortality during hospitalization with risk ratios of 1.367 (95% CI 1.307-1.426), 1.328 (95% CI 1.169-1.508), 1.338 (95% CI 1.289-1.388), and 1.167 (95% CI 1.103-1.234), respectively.

CONCLUSION

A comprehensive study of elderly Japanese patients with hip fractures in the DPC database showed that surgery on admission and the following day is crucial for preventing complications like pneumonia, deep vein thrombosis, pulmonary embolism, and mortality during hospitalization.

Does total hip arthroplasty in elderly patients with femoral neck fractures reduce complications?: A Japanese DPC study

BACKGROUND

The global increase in femoral neck fractures due to aging and osteoporosis is a major clinical challenge. The debate on the optimal surgical intervention for femoral neck fractures remains unresolved. This large-scale study explores femoral neck fractures among the elderly, focusing on the comparative outcomes of Total Hip Arthroplasty (THA) versus Bipolar Hemiarthroplasty (BHA) in Japanese patients.

METHODS

Using the Japanese National Administrative Diagnosis Procedure Combination (DPC) database, we studied cases of femoral neck fracture from April 2016 to March 2023, and after propensity score matching by age, sex, and comorbidities, we examined the association between THA, complications, and clinical outcomes, and the usefulness of THA for elderly patients with femoral neck fracture.

RESULTS

One-to-one propensity score matching identified 7741 pairs of THA and BHA cases. There was no difference in length of stay between the THA and BHA groups. Significantly more blood transfusions were required in the THA group. There was no significant difference in mortality between the THA and BHA groups, but there was a reduced risk of pneumonia in the THA group, with a ratio of 0.547 (95% CI: 0.418-0.715). On the other hand, the THA group had a higher risk of pulmonary embolism, with a ratio of 1.607 (95% CI: 1.379-1.874). The THA group shows improved discharge rates directly home from the facility where the operation was performed, with a ratio of 1.798 (95% CI: 1.675-1.929).

CONCLUSION

The findings of this research indicate that THA is more effective than BHA in enabling elderly Japanese patients with femoral neck fractures to be discharged directly home and in preventing pneumonia, despite concerns about pulmonary embolism. These findings suggest that THA may improve functional prognosis in elderly patients with femoral neck fractures, although there is a trade-off with an increased risk of pulmonary embolism.

A Look Into How the "Blue Zone" Lifestyle May Affect Patients' Lives Before and After Hip Fracture: A Propensity-Matched Cohort Study

INTRODUCTION

Hip fractures are life-changing injuries with associated one-year mortality up to 30%. Five locations in the world have been termed "blue zones," where the longevity of the population is markedly higher than that of surrounding areas and there are 10 times more centenarians. The United States has one blue zone (Loma Linda, California), which is believed to be because of the lifestyle of the Seventh-day Adventist population living there. We hypothesized that patients from the blue zone experience low-energy, frailty-driven, osteoporotic hip fractures later in life and an increased postinjury longevity relative to non-blue zone control subjects.

METHODS

A review of patients treated for hip fracture between January 2010 and August 2020 from a single institution was conducted. Demographic data were collected, and the end point of mortality was assessed using death registry information, queried in April 2024. Groups were divided into blue zone and non-blue zone. Statistical analysis was conducted with P < 0.05 considered significant.

RESULTS

Complete data were available for 1,032 patients. The blue zone cohort sustained low-energy hip fractures 12 years later in life (83.2 versus 71.1, P < 0.01). Propensity score matching was used to account for this difference. After propensity score matching, age, body mass index, American Society of Anesthesiologists score, surgery performed, sex, mechanism, ethnicity, diabetes, chronic obstructive pulmonary disease, CHF, chronic kidney disease grade, dementia, surgical time, and drug/tobacco/marijuana use were similar between groups. Blue zone patients had lower mortality at both 1 and 2 years postoperatively (12% versus 24%, P = 0.03 and 20% versus 33%, P = 0.03, respectively), had more hypertension (76% versus 62%, P = 0.03), reported lower alcohol use (7% versus 20%, P < 0.01), and included more Seventh-day Adventists (64% versus 15%, P < 0.01).

CONCLUSION

The blue zone lifestyle affected the onset of frailty and delayed osteoporotic hip fracture by 12 years in this propensity-matched cohort study. Postoperative mortality was also markedly lower in the blue zone cohort.

The real time to surgery: Limited delay after medical optimization does not impact hip fracture surgery outcomes

INTRODUCTION

Current U.S./Canadian guidelines recommend hip fracture surgery within 48 h of injury to decrease morbidity/mortality. Multiple studies have identified medical optimization as the key component of time to surgery, but have inherent bias as patients with multiple co-morbidities often take longer to optimize. This study aimed to evaluate time from medical optimization to surgery (TMOS) to determine if "real surgical delay" is associated with: 1) mortality and 2) complications for geriatric hip fracture patients.

METHODS

A retrospective chart review of geriatric hip fractures treated from 2015-2018 at a single, level-1 trauma center was conducted. Univariate logistic regression was performed to identify association between TMOS and post-operative complication rates. For mortality, the Wilcoxon test was used to compare TMOS for patients discharged following surgery to those who were not.

RESULTS

A total of 884 hip fractures were treated operatively, with median TMOS 16.2 h (5.0-22.5, 1st-3rd quartiles). Univariate logistic regression models did not identify an association between TMOS and complication rates. For patients successfully discharged, median TMOS was 16.2 h (5.0-22.3, 1st-3rd quartiles). For the cohort of patients not successfully discharged, median TMOS was 19.1 h (10.1-25.9, 1st-3rd quartiles, p = 0.16).

CONCLUSION

"Real surgical delay", or TMOS is not associated with increased complications or with inpatient mortality for geriatric hip fracture patients. With few exceptions, our institution adhered to the 48-hour time window from injury to hip surgery. We maintain the belief timely surgery following optimization plays a crucial role in the geriatric hip fracture patient outcomes.

Aspirin prophylaxis is not associated with increased risk of venous thromboembolism in arthroplasty for femoral neck fractures: a non-inferiority study

PURPOSE

Venous thromboembolism (VTE) is a known complication of hip arthroplasty for femoral neck fractures (FNF) with various prophylactic anticoagulants utilized to decrease risk. The purpose of this study was to assess the efficacy and perioperative outcomes associated with aspirin for VTE prophylaxis following arthroplasty for FNF.

METHODS

Medical records of 1,220 patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) at an urban academic center from 2011 to 2022 were retrospectively reviewed. Patient characteristics and perioperative outcomes, including length of stay (LOS), VTE, 90-day hospital encounters, and discharge disposition, were collected. Outcomes for patients prescribed aspirin (n = 214) were compared to those prescribed non-aspirin VTE prophylaxis (n = 1006) using propensity score matching.

RESULTS

Patients who received aspirin had higher rates of THA (36.0 vs 26.7%; p = 0.008). There were no significant risk-adjusted differences in the incidence of VTE (0.5 vs 0.5%, p = 1.000) and 90-day readmissions (10.4 vs 12.3%, p = 0.646) between patients prescribed aspirin and non-aspirin VTE prophylaxis, respectively. Patients prescribed non-aspirin agents had higher rates of non-home discharge (73.9 vs 58.5%; p < 0.001) and longer LOS (143.5 vs 124.9 h; p = 0.005). Sub-analysis of patients prescribed aspirin and non-aspirin prophylaxis based on comorbidity scores demonstrated no difference in VTE incidence for low (0.0 vs 1.6%, p = 1.000) and high scores (0.0 vs 0.0%, p = 1.000), respectively.

CONCLUSION

Aspirin is not associated with increased incidence of VTE after HHA or THA for FNF. Aspirin prophylaxis should be considered in hip fracture patients to mitigate bleeding risk, particularly those with low to intermediate VTE risk.

LEVEL OF EVIDENCE

Level III, Retrospective study.

Association between anesthesia technique and death after hip fracture repair for patients with COVID-19

PURPOSE

Patients with COVID-19 undergoing hip fracture surgeries have a 30-day mortality of up to 34%. We aimed to evaluate the association between anesthesia technique and 30-day mortality after hip fracture surgery in patients with COVID-19.

METHODS

After ethics approval, we performed a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program data set from January to December 2021. Inclusion criteria were age ≥ 19 yr, laboratory-confirmed SARS-CoV-2 infection within 14 days preoperatively, and hip fracture surgery under general anesthesia (GA) or spinal anesthesia (SA). Exclusion criteria were American Society of Anesthesiologists Physical Status V, ventilator dependence, international normalized ratio ≥ 1.5, partial thromboplastin time > 35 sec, and platelet count < 80 × 109 L-1. The primary outcome was all-cause 30-day mortality. The adjusted association between anesthetic technique and 30-day mortality was analyzed using multivariable logistic regression.

RESULTS

Of 23,045 patients undergoing hip fracture surgery, 331 patients met the study criteria. The median [interquartile range] age was 82 [74-88] yr, and 32.3% were male. The 30-day mortality rate was 10.0% (33/331) for the cohort (10.7%, 29/272 for GA vs 6.8%, 4/59 for SA; P = 0.51; standardized mean difference, 0.138). The use of SA, compared with GA, was not associated with decreased mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.21 to 1.8; E-value, 2.49).

CONCLUSION

Anesthesia technique was not associated with mortality in patients with COVID-19 undergoing hip fracture surgery. The findings were limited by a small sample size.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT05133648); registered 24 November 2021.

Emergency department prediction model for 30-day mortality after hip fracture: the Spanish National Hip Fracture Registry (RNFC) cohort

INTRODUCTION

The aim of this study was to design and validate a predictive model for 30-day mortality in a cohort of patients from the Spanish National Hip Fracture Registry (RNFC) with variables collected at the Emergency Department.

METHODS

Retrospective study of a prospective database of hip fracture patients ⩾75 years old between 1 January 2017 and 30 September 2019. Patient characteristics, type of fracture and osteoprotective medication were collected at the Emergency Department. Univariate analysis compared the results between patients alive and deceased 30 days after hospital discharge. The variables associated with 30-day mortality in the regression analysis were age >85 years, male sex, indoors pre-fracture mobility, dementia, ASA score >3, pathological fracture, and vitamin D intake. A score scale was created with these variables. Discriminative performance was assessed using the area under the curve (AUC), calibration was assessed by applying Hosmer-Lemeshow goodness-of-fit test and predicted-to-observed mortality was compared.

RESULTS

A total of 29,875 hip fracture cases were included in the study. The 30-day mortality of the overall cohort was 7.7%. A scale of 0-9 points was created, with a cut-off point of 4 points for the determination of patients at high risk of mortality. The AUC was 0.886. RNFC score presented good level of calibration (p = 0.139). The predicted-to-observed ratio was 1.09.

CONCLUSIONS

The RNFC predictive model with variables collected at the Emergency Department showed an excellent predictive capacity for 30-day mortality in patients after hip fracture.

A National Database Retrospective Review of Short-Term Postoperative Mortality in the Geriatric Population: A Comparison Between Emergency Spine Fractures and Hip Fractures

BACKGROUND

Mortality rates following emergency spine fracture surgery are high, especially in the elderly. However, how the postoperative mortality rate following spine fractures compares to other geriatric fractures such as hip fractures remains unclear. Therefore, this retrospective cohort study aimed to compare 30-day mortality rates and risk factors between emergency spine fracture versus hip fracture surgery in the elderly.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried between 2011 and 2021 for emergency spine fractures and hip fractures in the elderly. Univariate analyses evaluated demographic data, perioperative factors, comorbidities, and 30-day mortality rates as the primary outcomes. A multivariable regression model was then constructed to control for significant baseline and demographic differences and evaluate independent predictors of mortality.

RESULTS

A total of 18,287 emergency hip fractures and 192 emergency spine fractures were included in our study. Univariate analysis demonstrated significant differences in female sex, body mass index (BMI), operation time, length of hospital stays, disseminated cancer, and functional dependence between spine and hip fractures. Thirty-day mortality rates were significantly higher in spine versus hip fractures (9.4% vs. 5%). Multivariate regression analysis demonstrated emergent spine fracture surgery, disseminated cancer, functional dependence, and length of stay as independent predictors of mortality in our cohort. Female sex, BMI, and operation time were protective factors for mortality in our cohort.

CONCLUSIONS

Emergency spine fractures in the elderly represent an independent predictor for 30-day postoperative mortality compared to emergency hip fractures. Disseminated cancer, functional dependence, and length of stay were independent predictors of mortality while female sex, BMI, and operation time were protective factors. These data demonstrate the severity of injury and high rates of mortality that clinicians can use to counsel patients and their families.

Admission Inflammation Markers Influence Long-term Mortality in Elderly Patients Undergoing Hip Fracture Surgery: A Retrospective Cohort Study

OBJECTIVES

Hip fractures in elderly patients are associated with a high mortality rate. Most deaths associated with hip fracture result from complications after surgery. Recent studies suggest that some inflammation biomarkers may be useful to estimate excess mortality. This study aimed to investigate the prognostic value of admission inflammation biomarkers in elderly patients with hip fracture.

METHODS

We reports on a retrospective study of elderly hip fracture patients admitted to a hospital in China between January 2015 and December 2019. A total of 1085 patients were included in the study, and their demographic and pre-operative characteristics were analyzed. The inflammation biomarkers included monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), and C-reactive protein (CRP) to albumin ratio (CAR). The predictive performance of NLR, MLR and CAR was assessed by receiver operating characteristics (ROC) curve analysis and the association between admission inflammation markers and mortality was evaluated by Cox proportional regression.

RESULTS

The 30-day, 1-year, 2-year, and 4-year mortality were 1.6%, 11.5%, 21.4% and 48.9%, respectively. The optimal cut-off values of admission NLR, MLR and CAR for 1-year mortality were 7.28, 0.76, and 1.36. After adjusting the covariates, preoperative NLR ≥ 7.28 (HR = 1.419, 95% CI: 1.080-1.864, p = 0.012) were found to be only independent risk factors with 4-year all-cause mortality, the preoperative CAR ≥ 1.36 was independently associated with 1-year (HR = 1.700, 95% CI: 1.173-2.465, p = 0.005), 2 year (HR = 1.464, 95% CI: 1.107-1.936, p = 0.008), and 4-year (HR = 1.341, 95% CI: 1.057-1.700, p = 0.016) all-cause mortality, While age, CCI score, and low hemoglobin at admission were also risk factors for postoperative all-cause mortality.

CONCLUSION

Admission CAR and NLR may be useful indicators for predicting the long-term mortality of elderly patients undergoing hip fracture surgery, and that more research is needed to validate these findings.

Risk of post-fracture pneumonia and its association with cardiovascular events and mortality in adults with intellectual disabilities

Objective

Fragility fractures are associated with an increased risk of pneumonia, which is a leading cause of death in adults with intellectual disabilities; however, the timing and complications of post-fracture pneumonia are underinvestigated. The objectives of this study were to determine the 30-day pneumonia rate post-fracture and the association of post-fracture pneumonia with mortality and cardiovascular events among adults with intellectual disabilities.

Methods

This retrospective cohort study was conducted using Medicare and commercial claims from 01 January 2011 to 31 December 2016. Incidence of pneumonia 30 days after a fragility fracture among adults ≥18 years old with intellectual disabilities (Fx cohort) was compared to the incidence among matched adults with intellectual disabilities without fractures (w/oFx cohort) and the general population of patients with an incident fragility fracture (GP+Fx). For the Fx cohort, Cox regression was used to examine the adjusted association of time-varying pneumonia (within 30 days post-fracture) with mortality and incidence of cardiovascular events 0-30, 31-365, and 366-730 days post-fracture.

Results

There was a high-early rate of pneumonia within 30 days post-fracture for young, middle-aged, and elderly adults with intellectual disabilities (n = 6,183); this rate was 2.2- to 6.1-fold higher than the rate among the w/oFx (n = 12,366) and GP+Fx (n = 363,995) cohorts (all P < 0.05). For the Fx cohort, post-fracture 30-day incidence of pneumonia was associated with an increased 30-day rate of mortality (adjusted HR [aHR] = 5.19; 95% confidence interval [CI] = 3.68-7.32), heart failure (aHR = 2.96; 95% CI = 1.92-4.56), and cerebrovascular disease (aHF = 1.48; 95% CI = 0.93-2.35; P = 0.098), with sustained effects to 1 year for heart failure (aHR = 1.61; 95% CI = 1.19-2.17) and 2 years for mortality (aHR = 1.39; 95% CI = 1.06-1.83), and without evidence of effect modification by age.

Discussion

Adults with intellectual disabilities are vulnerable to post-fracture pneumonia within 30 days, and complications arising from this, across the adult lifespan, and not only during the elderly years.

Inflammatory Index as a Predictor of Mortality in Elderly Patients With Intracapsular Femoral Neck Fracture

A femoral neck fracture is a major cause of mortality in the elderly population, and intracapsular femoral neck fractures (ICFNFs) are commonly treated with hemiarthroplasty. The 30-day mortality rate for elderly hip fracture patients ranges from 1.0% to 6.5%, and one-year mortality increases significantly to 37.3%. Identifying predictors of mortality in these patients is crucial for better management. Inflammatory indices, such as neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and monocyte-to-lymphocyte ratio (MLR), have gained popularity for assessing mortality risk in various diseases. Several studies have demonstrated the value of these indices in predicting mortality after hip fracture. The pan-inflammatory immune value (PIV), which combines hematological parameters, has been shown to predict mortality in cancer patients. However, its role in predicting mortality in ICFNF patients treated with hemiarthroplasty has yet to be explored. This study aimed to assess the association of PIV, SII, NLR, and MLR with 30-day and one-year mortality in ICFNF patients. We also investigated the impact of surgical delay time (≤24h, 24-48h, ≥48h) on these inflammatory indices and mortality. Data from 522 patients with ICFNF treated with hemiarthroplasty were retrospectively collected. We observed 30-day and one-year mortality rates of 5.24% and 21.2%, respectively. Age, gender, and American Society of Anesthesiologists (ASA) score were identified as significant predictors of mortality. Preoperative PIV, SII, NLR, and MLR were significant predictors in the evaluation of early mortality. However, postoperatively, only NLR on the third day (NLR3rd) demonstrated statistical significance. Stepwise logistic regression further confirmed NLR3rd as the most effective predictor for early mortality. For mortality occurring between 30 to 365 days, NLR3rd remained statistically significant, albeit with diminished sensitivity. No other inflammatory index demonstrated significant predictive power for mortality during this later period. Our findings suggest different inflammatory indices may have varying predictive abilities depending on the mortality period. We recommend considering NLR3rd as a valuable and reliable predictor for early mortality in ICFNF patients treated with hemiarthroplasty. Respiratory system disease and preoperative chronic obstructive pulmonary disease (COPD) were identified as risk factors for mortality in our study, in line with previous research. In conclusion, our study highlights the potential of specific inflammatory indexes, particularly NLR3rd, in predicting mortality in elderly patients with ICFNFs treated with hemiarthroplasty. Further research is needed to validate these findings and optimize risk assessment in orthopedic practice.

Predictive Value of the C-Reactive Protein to Albumin Ratio in 30-Day Mortality after Hip Fracture in Elderly Population: A Retrospective Observational Cohort Study

BACKGROUND

C-reactive protein (CRP) to Albumin ratio (CAR) has been used in multiple clinical settings to predict early mortality. However, there is a lack of evidence on the predictive role of CAR in 30-day mortality after a hip fracture. The purpose of this study was to establish a potential association between CAR and 30-day mortality and to assess if the CAR Receiving Operating Characteristics curve (ROC) can be a reliable predictor of early mortality.

METHODS

We retrospectively reviewed the charts of 676 patients (>65 years) treated for hip fracture between 2006 and 2018. All hip fractures were included. Treatment strategies included closed reduction and internal fixation, open reduction and internal fixation, hemiarthroplasty, or total joint arthroplasty. Statistical analysis included T-test, Pearson correlation for CAR and other markers, ROC curves and area under the curve, Youden Model, and Odds Ratio.

RESULTS

The 30-day mortality rate analysis showed that higher preoperative levels of CAR were associated with higher early mortality. When analyzing the area under the ROC curve (AUROC) for 30-day mortality, the reported value was 0.816. The point of the ROC curve corresponding to 14.72 was considered a cut-off with a specificity of 87% and a sensibility of 40.8%. When analyzing values higher than 14.72, the 30-day mortality rate was 17.9%, whilst, for values lower than 14.72, the 30-day mortality rate was 1.8%.

CONCLUSIONS

Patients older than 65 years affected by a hip fracture with increased preoperative levels of CAR are associated with higher 30-day mortality. Despite a moderate sensibility, considering the low cost and the predictivity of CAR, it should be considered a standard predictive marker.

The Effect of Resident Involvement in Hip Fracture Surgery: An Analysis of a Single Institution Before and After the Addition of an Orthopaedic Surgical Residency

INTRODUCTION

Hip fractures are common injuries that are associated with serious morbidity/mortality in the elderly and represent a substantial financial burden to healthcare systems. Previous studies demonstrated that resident involvement in orthopaedic surgeries is associated with increased surgical time and cost, with equivocal or worse outcomes. This study evaluated outcomes of hip fracture surgery at one institution, before and after the introduction of an orthopaedic residency program.

METHODS

A retrospective chart review divided patients who underwent hip fracture surgery between January 2015 and January 2018 into two groups based on resident involvement. Outcomes including surgical time, length of stay (LOS), readmission rate, and direct/indirect costs were compared as were the American Society of Anesthesiologists physical status score and procedure conducted.

RESULTS

Six hundred sixty-two hip fracture surgeries were performed in 36 months. Residents were engaged in 303 cases (45.8%) with no notable differences in the two groups regarding American Society of Anesthesiologists score, procedure conducted, or readmission rate. With resident involvement, surgical time was significantly longer (91.2 versus 78.9 minutes, P-value = 0.004), whereas LOS was significantly shorter (5.2 versus 5.6 days, P-value = 0.003). Finally, there were significant reductions in direct costs (8% reduction; P < 0.001) and OR implant costs (12% reduction; P < 0.001), but significant increase in indirect costs (7% increase; P < 0.001).

DISCUSSION

Surgical experience is critical in orthopaedic training. There are concerns regarding potential negative effects of resident involvement on surgical outcomes and healthcare costs. While resident involvement was associated with slightly increased surgical times and indirect costs, it also led to decreased LOS and direct costs. We believe this is the first study to compare patient outcomes at one institution before and after resident involvement. Our findings demonstrated, compared with attendings alone, resident involvement resulted in an overall improvement rather than compromise in patient care.

Intercontinental validation of a clinical prediction model for predicting 90-day and 2-year mortality in an Israeli cohort of 2033 patients with a femoral neck fracture aged 65 or above

PURPOSE

Mortality prediction in elderly femoral neck fracture patients is valuable in treatment decision-making. A previously developed and internally validated clinical prediction model shows promise in identifying patients at risk of 90-day and 2-year mortality. Validation in an independent cohort is required to assess the generalizability; especially in geographically distinct regions. Therefore we questioned, is the SORG Orthopaedic Research Group (SORG) femoral neck fracture mortality algorithm externally valid in an Israeli cohort to predict 90-day and 2-year mortality?

METHODS

We previously developed a prediction model in 2022 for estimating the risk of mortality in femoral neck fracture patients using a multicenter institutional cohort of 2,478 patients from the USA. The model included the following input variables that are available on clinical admission: age, male gender, creatinine level, absolute neutrophil, hemoglobin level, international normalized ratio (INR), congestive heart failure (CHF), displaced fracture, hemiplegia, chronic obstructive pulmonary disease (COPD), history of cerebrovascular accident (CVA) and beta-blocker use. To assess the generalizability, we used an intercontinental institutional cohort from the Sheba Medical Center in Israel (level I trauma center), queried between June 2008 and February 2022. Generalizability of the model was assessed using discrimination, calibration, Brier score, and decision curve analysis.

RESULTS

The validation cohort included 2,033 patients, aged 65 years or above, that underwent femoral neck fracture surgery. Most patients were female 64.8% (n = 1317), the median age was 81 years (interquartile range = 75-86), and 80.4% (n = 1635) patients sustained a displaced fracture (Garden III/IV). The 90-day mortality was 9.4% (n = 190) and 2-year mortality was 30.0% (n = 610). Despite numerous baseline differences, the model performed acceptably to the validation cohort on discrimination (c-statistic 0.67 for 90-day, 0.67 for 2-year), calibration, Brier score, and decision curve analysis.

CONCLUSIONS

The previously developed SORG femoral neck fracture mortality algorithm demonstrated good performance in an independent intercontinental population. Current iteration should not be relied on for patient care, though suggesting potential utility in assessing patients at low risk for 90-day or 2-year mortality. Further studies should evaluate this tool in a prospective setting and evaluate its feasibility and efficacy in clinical practice. The algorithm can be freely accessed: https://sorg-apps.shinyapps.io/hipfracturemortality/ .

LEVEL OF EVIDENCE

Level III, Prognostic study.

One-year change in handgrip strength in patients with hip fracture: a prospective comparison with hip disease

BACKGROUND

Handgrip strength (HGS) has been adopted as one of the diagnostic tools for sarcopenia and is gaining attention because of its association with osteoporotic hip fractures. Longitudinal data of HGS at multiple follow-up intervals in older hip fractures are lacking. We aimed to investigate and compare the HGS changes in patients with hip fracture within 1-year with those in patients with hip diseases.

METHODS

This prospective study was conducted between June 2018 and July 2020. The HGS was measured preoperatively, at predischarge, and at 3, 6, and 12 months postoperatively. We prospectively compared the number of patients with low muscle strength (LMS) as well as the HGS changes over time between the two groups.

RESULTS

A total of 115 consecutive patients with hip fracture (n = 58) and hip disease (57) were enrolled. The rate of preoperative LMS was higher in the hip fracture group than control (P = 0.005), but there was no significant difference in the postoperative period (P = 0.343). The mean HGS was lower in the hip fracture group at all measured time periods. The preoperative HGS increased right before discharge (15.2 kg to 17.0 kg), and plateaued thereafter 1-year in the fracture group, whereas there were no statistically significant changes in serial follow-up trends in the control group.

CONCLUSIONS

The preoperative HGS in fracture patients may have been underestimated, due to different position of the arm, insufficient practice, or pain. Subsequently, HGS was rather constant during 1-year indicating no development of general sarcopenia after treatment for hip fracture. Therefore, in hip fracture patients, the predischarge HGS might be more reliable than preoperative HGS.

Mortality Prediction in Hip Fracture Patients: Physician Assessment Versus Prognostic Models

OBJECTIVES

To evaluate 2 prognostic models for mortality after a fracture of the hip, the Nottingham Hip Fracture Score and Hip Fracture Estimator of Mortality Amsterdam and to compare their predictive performance to physician assessment of mortality risk in hip fracture patients.

DESIGN

Prospective cohort study.

SETTING

Two level-2 trauma centers located in the Netherlands.

PATIENTS

Two hundred forty-four patients admitted to the Emergency Departments of both hospitals with a fractured hip.

INTERVENTION

Data used in both prediction models were collected at the time of admission for each individual patient, as well as predictions of mortality by treating physicians.

MAIN OUTCOME MEASURES

Predictive performances were evaluated for 30-day, 1-year, and 5-year mortality. Discrimination was assessed with the area under the curve (AUC); calibration with the Hosmer-Lemeshow goodness-of-fit test and calibration plots; clinical usefulness in terms of accuracy, sensitivity, and specificity.

RESULTS

Mortality was 7.4% after 30 days, 22.1% after 1 year, and 59.4% after 5 years. There were no statistically significant differences in discrimination between the prediction methods (AUC 0.73-0.80). The Nottingham Hip Fracture Score demonstrated underfitting for 30-day mortality and failed to identify the majority of high-risk patients (sensitivity 33%). The Hip fracture Estimator of Mortality Amsterdam showed systematic overestimation and overfitting. Physicians were able to identify most high-risk patients for 30-day mortality (sensitivity 78%) but with some overestimation. Both risk models demonstrated a lack of fit when used for 1-year and 5-year mortality predictions.

CONCLUSIONS

In this study, prognostic models and physicians demonstrated similar discriminating abilities when predicting mortality in hip fracture patients. Although physicians overestimated mortality, they were better at identifying high-risk patients and at predicting long-term mortality.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Potential of Health Insurance Claims Data to Predict Fractures in Older Adults: A Prospective Cohort Study

Purpose

In older adults, fractures are associated with mortality, disability, loss of independence and high costs. Knowledge on their predictors can help to identify persons at high risk who may benefit from measures to prevent fractures. We aimed to assess the potential of German claims data to predict fractures in older adults.

Patients and Methods

Using the German Pharmacoepidemiological Research Database (short GePaRD; claims data from ~20% of the German population), we included persons aged ≥65 years with at least one year of continuous insurance coverage and no fractures prior to January 1, 2017 (baseline). We randomly divided the study population into a training (80%) and a test sample (20%) and used logistic regression and random forest models to predict the risk of fractures within one year after baseline based on different combinations of potential predictors.

Results

Among 2,997,872 persons (56% female), the incidence per 10,000 person years of any fracture in women increased from 133 in age group 65–74 years (men: 71) to 583 in age group 85+ (men: 332). The maximum predictive performance as measured by the area under the curve (AUC) across models was 0.63 in men and 0.60 in women and was achieved by combining information on drugs and morbidities. AUCs were lowest in age group 85+.

Conclusion

Our study showed that the performance of models using German claims data to predict the risk of fractures in older adults is moderate. Given that the models used data readily available to health insurance providers in Germany, it may still be worthwhile to explore the cost–benefit ratio of interventions aiming to reduce the risk of fractures based on such prediction models in certain risk groups.

Developing and validating a scoring system for measuring frailty in patients with hip fracture: a novel model for predicting short-term postoperative mortality

Objectives

Frailty is common among patients with hip fracture and may, in part, contribute to the increased risk of mortality and morbidity after hip fracture surgery. This study aimed to develop a novel frailty score for patients with traumatic hip fracture that could be used to predict postoperative mortality as well as facilitate further research into the role of frailty in patients with hip fracture.

Methods

The Orthopedic Hip Frailty Score (OFS) was developed using a national dataset, retrieved from the Swedish National Quality Registry for Hip Fractures, that contained all adult patients who underwent surgery for a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017. Candidate variables were selected from the Nottingham Hip Fracture Score, Sernbo Score, Charlson Comorbidity Index, 5-factor modified Frailty Index, as well as the Revised Cardiac Risk Index and ranked based on their permutation importance, with the top 5 variables being selected for the score. The OFS was then validated on a local dataset that only included patients from Orebro County, Sweden.

Results

The national dataset consisted of 126,065 patients. 2365 patients were present in the local dataset. The most important variables for predicting 30-day mortality were congestive heart failure, institutionalization, non-independent functional status, an age ≥85, and a history of malignancy. In the local dataset, the OFS achieved an area under the receiver-operating characteristic curve (95% CI) of 0.77 (0.74 to 0.80) and 0.76 (0.74 to 0.78) when predicting 30-day and 90-day postoperative mortality, respectively.

Conclusions

The OFS is a significant predictor of short-term postoperative mortality in patients with hip fracture that outperforms, or performs on par with, all other investigated indices.

Level of evidence

Level III, Prognostic and Epidemiological.

Characteristics of Elderly Hip Fracture Patients in Jordan: A Multicenter Epidemiological Study

Background

Elderly hip fractures represent a global health care burden. Several reports expected a massive increase in the incidence of hip fractures by the next few decades. Knowing the epidemiology of hip fractures is crucial for planning health care policies. The purpose of this study is to provide a nationwide epidemiological overview of hip ‎fractures in Jordan and to report the perioperative outcomes that may help to improve the delivered healthcare. ‎.

Methods

We conducted ‎ a retrospective study at 2 university hospitals and 2 major ‎governmental hospitals in Jordan.‎ We reviewed the records for all patients (age >55 years) who were diagnosed with hip fractures ‎over a 3 years duration (2019–2021). ‎We documented the patient’s characteristics and the perioperative data (including preoperative, intraoperative, and postoperative details including the 1-year mortality).‎

Results

The total number of included patients was 1268; more than half (53.7%) were females.‎ The mean age is ‎75 years (SD 9.7). ‎ The most common fracture type was trochanteric (66.2%)‎. ‎7% of patients had a prior contralateral hip fracture‎. The average time from admission to surgery was 2.96 days (SD 2.63). The surgery was done within 48 ‎hours for ‎56.7%‎ of patients.‎ Approximately, one-third of all patients (34.5%) received a blood transfusion.‎ The average length of hospital stay is 7.44 days (SD 5). The overall rate of postoperative thromboembolic events, readmission within 1 month, and revision ‎for the same surgery are 2.4%‎, 10.7%‎, and 3% respectively.‎ The 1-month, 6-month, and 12-month mortality rates are 4.5%, 9.1%, and 12.8% respectively.

Conclusion

The annual incidence of elderly hip fractures in Jordan is approximately 96 per 100,000 individuals. The 1-year mortality rate of hip fractures in Jordan ‎is ‎12.8%‎.‎ Both findings are ‎in the lower range of nearby Arab countries.

Post-fracture pneumonia risk and association with health and survival outcomes for adults with cerebral palsy: A retrospective cohort study

BACKGROUND

For adults with cerebral palsy (CP), fragility fractures may be a risk factor for pneumonia, a leading cause of death for this population; yet, the timing and complications are unknown. The objectives were to determine the 30-day pneumonia rate post-fracture and its association with mortality and incident cardiovascular events among adults with CP.

METHODS

This retrospective cohort study used nationwide administrative claims data from 01/01/2012-12/31/2017 from a random 20% sample of the Medicare fee-for-service and Optum Clinformatics® Data Mart. Cohorts included ≥18 years of age with CP with an incident fragility fracture (CP + Fx) and comparison cohorts: CP without fractures (CPw/oFx) and without CP with an incident fragility fracture (w/oCP + Fx). Incidence rate (IR) of pneumonia 30-days post-fracture and IR ratios were estimated by age group: 18-40, 41-64, and ≥ 65 years. For CP + Fx, Cox regression examined the association between time-varying pneumonia (within 30-days post-fracture) with mortality and incidence of cardiovascular events 0-30-days and 31-365-days post-fracture.

RESULTS

There were 3688 CP + Fx (mean [SD] age, 58.2 [14.9]; 56.4% women), 29,429 CPw/oFx (50.3 [15.8]; 45.9% women), and 363,995 w/oCP + Fx (65.9 [18.3]; 65.5% women). The IR of 30-day pneumonia for CP + Fx was similar across age groups (IR per 100 person-months, 8.4-11.0) and 1.77-16.18-fold higher (all P < 0.05) than comparison cohorts. Peri/post-fracture pneumonia was associated with an increased rate of mortality (30-day-adjusted HR [aHR] = 5.89, 95%CI = 3.54-9.81; 31-365-day aHR = 2.89, 95%CI = 2.13-3.92), congestive heart failure 0-30-days (aHR = 3.64, 95%CI = 2.01-6.57) and 31-365-days (time-dependent), myocardial infarction 31-365-days (aHR = 2.03, 95%CI = 1.11-3.71), and cerebrovascular disease 0-30-days (time-dependent), without evidence of effect modification by age, sex, or fracture site.

CONCLUSIONS

Adults with CP are particularly vulnerable to 30-day risk of post-fracture pneumonia and its complications across the adult lifespan and not just in the elderly years.

The interaction between pre-admission β-blocker therapy, the Revised Cardiac Risk Index, and mortality in geriatric hip fracture patients

BACKGROUND

An association between β-blocker (BB) therapy and a reduced risk of major cardiac events and mortality in patients undergoing surgery for hip fractures has previously been demonstrated. Furthermore, a relationship between an increased Revised Cardiac Risk Index (RCRI) score and a higher risk of postoperative mortality has also been detected. The purpose of the current study was to investigate the interaction between BB therapy and RCRI in relation to 30-day postoperative mortality in geriatric patients after hip fracture surgery.

METHODS

All patients older than 65 years who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008, and December 31, 2017, except for pathological fractures, were included in this retrospective cohort study. Patients were divided into cohorts based on their RCRI score (RCRI 1, 2, 3, and ≥4) and whether they had ongoing BB therapy at the time of admission. A Poisson regression model with robust standard errors of variance was used, while adjusting for confounders, to evaluate the association between BB therapy, RCRI, and 30-day mortality.

RESULTS

A total of 126,934 cases met the study inclusion criteria. β-Blocker therapy was associated with a 65% decrease in the risk of 30-day postoperative mortality in the whole study population (adjusted incidence rate ratio [95% confidence interval], 0.35 [0.32-0.38]; p < 0.001). The use of BB also resulted in a significant reduction in 30-day postoperative mortality within all RCRI cohorts. However, the most pronounced effect of BB therapy was seen in patients with an RCRI score greater than 0.

CONCLUSION

β-Blocker therapy is associated with a reduction in 30-day postoperative mortality, irrespective of RCRI score. Furthermore, patients with an elevated cardiac risk appear to have a greater benefit of BB therapy.

LEVEL OF EVIDENCE

Therapeutic/care management, level II.

Nottingham Hip Fracture Score: Does It Predict Mortality in Distal Femoral Fracture Patients?

Background

Patients with distal femur fractures are associated with mortality rates comparable to neck of femur fractures. Identifying high-risk patients is crucial in terms of orthogeriatric input, pre-operative medical optimisation and risk stratification for anaesthetics. The Nottingham Hip Fracture Score (NHFS) is a validated predictor of 30-day mortality in neck of femur fracture patients. In this study, we aim to investigate and evaluate the suitability of the NHFS in predicting 30-day as well as one-year mortality of patients who have sustained distal femur fractures.

Methods

Patients admitted to a level 1 major trauma centre with distal femur fractures were retrospectively reviewed between June 2012 and October 2017. NHFSs were recorded using parameters immediately pre-operatively.

Results

Ninety-one patients were included for analysis with a mean follow-up of 32 months. The mean age was 69, 56 (61%) patients were female, 10 (11%) were open fractures and 32 (35%) were peri-prosthetic fractures with 85% of patients being surgically managed. Forty-one patients were found to have an NHFS >4. Overall mortality at 30 days was 7.7% and at 1 year was 21%. Patients with an NHFS of ≤4 had a lower mortality rate at 30 days of 6% compared with those with >4 at 9.8% (p=0.422). On Kaplan-Meier plotting and log-rank test, patients with an NHFS of >4 were associated with a higher mortality rate at 1 year at 36.6% compared to patients with an NHFS of ≤4 at 8% (p=0.001).

Conclusion

NHFS is a promising tool not only in neck of femur fractures but also distal femur fractures in risk-stratifying patients for pre-operative optimisation as well as a predictor of mortality. 

Length of hospital stay following hip fracture and risk of 30 and 90 day mortality in a United Kingdom cohort

A recent study identified a length of stay (LOS) of 10 days or less following hip fracture is associated with increased risk of 30-day mortality. This effect has not been previously studied for 90-day mortality or in the United Kingdom (UK). Our aim was to investigate the effect of LOS on 30-day and 90-day mortality following hip fracture in a UK population. In this single-centre study, we retrospectively identified consecutive patients with a hip fracture from the National Hip Fracture Database over 3 years. We excluded patients who died as inpatient during their index admission. The main end-points were 30-day and 90-day mortalities and risk factors for these were examined using stepwise univariate and multivariate Cox regression analyses. Of 1228 patients, mortality at 30-days was 1.2% (15 patients) and 7.8% (96 patients) at 90-days. Mean LOS was 24 days and a total of 206 patients had a LOS of 10 days or less. Following cariate analysis, the highest risk factor for 30-day mortality was a LOS of 10 days or less with a hazard ratio of 7.26 (95% confidence interval 2.56-20.51). Other risk factors for 30-day mortality included increasing age, male gender and chest infection. A LOS of 10 days or less was not associated with increased mortality at 90-days. A short LOS was associated with higher risk of early mortality. We recommend that hip fracture patients be fully rehabilitated prior to discharge to reduce the risk of early mortality.

Outcomes after perioperative SARS-CoV-2 infection in patients with proximal femoral fractures: an international cohort study

OBJECTIVES

Studies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with perioperative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multivariate analysis.

SETTING

Prospective, international, multicentre, observational cohort study.

PARTICIPANTS

Patients undergoing any operation for a proximal femoral fracture from 1 February to 30 April 2020 and with perioperative SARS-CoV-2 infection (either 7 days prior or 30-day postoperative).

PRIMARY OUTCOME

30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality.

RESULTS

This study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68 to 3.13, p<0.001), age >80 years (OR 1.60, 95% CI 1.1 to 2.31, p=0.013), preoperative diagnosis of dementia (OR 1.57, 95% CI 1.15 to 2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18 to 2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06 to 2.48, p=0.025). Mortality at 30 days was lower in patients with a preoperative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42 to 0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220) or type of anaesthetic given (p=0.787).

CONCLUSIONS

Patients undergoing surgery for a proximal femoral fracture with a perioperative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with individualised medical and anaesthetic care, including medical optimisation before theatre. Careful preoperative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups.

TRIAL REGISTRATION NUMBER

NCT04323644.

Artificial Neural Networks Predict 30-Day Mortality After Hip Fracture: Insights From Machine Learning

OBJECTIVES

Accurately stratifying patients in the preoperative period according to mortality risk informs treatment considerations and guides adjustments to bundled reimbursements. We developed and compared three machine learning models to determine which best predicts 30-day mortality after hip fracture.

METHODS

The 2016 to 2017 National Surgical Quality Improvement Program for hip fracture (AO/OTA 31-A-B-C) procedure-targeted data were analyzed. Three models-artificial neural network, naive Bayes, and logistic regression-were trained and tested using independent variables selected via backward variable selection. The data were split into 80% training and 20% test sets. Predictive accuracy between models was evaluated using area under the curve receiver operating characteristics. Odds ratios were determined using multivariate logistic regression with P < 0.05 for significance.

RESULTS

The study cohort included 19,835 patients (69.3% women). The 30-day mortality rate was 5.3%. In total, 47 independent patient variables were identified to train the testing models. Area under the curve receiver operating characteristics for 30-day mortality was highest for artificial neural network (0.92), followed by the logistic regression (0.87) and naive Bayes models (0.83).

DISCUSSION

Machine learning is an emerging approach to develop accurate risk calculators that account for the weighted interactions between variables. In this study, we developed and tested a neural network model that was highly accurate for predicting 30-day mortality after hip fracture. This was superior to the naive Bayes and logistic regression models. The role of machine learning models to predict orthopaedic outcomes merits further development and prospective validation but shows strong promise for positively impacting patient care.

Curriculum learning for improved femur fracture classification: Scheduling data with prior knowledge and uncertainty

An adequate classification of proximal femur fractures from X-ray images is crucial for the treatment choice and the patients' clinical outcome. We rely on the commonly used AO system, which describes a hierarchical knowledge tree classifying the images into types and subtypes according to the fracture's location and complexity. In this paper, we propose a method for the automatic classification of proximal femur fractures into 3 and 7 AO classes based on a Convolutional Neural Network (CNN). As it is known, CNNs need large and representative datasets with reliable labels, which are hard to collect for the application at hand. In this paper, we design a curriculum learning (CL) approach that improves over the basic CNNs performance under such conditions. Our novel formulation reunites three curriculum strategies: individually weighting training samples, reordering the training set, and sampling subsets of data. The core of these strategies is a scoring function ranking the training samples. We define two novel scoring functions: one from domain-specific prior knowledge and an original self-paced uncertainty score. We perform experiments on a clinical dataset of proximal femur radiographs. The curriculum improves proximal femur fracture classification up to the performance of experienced trauma surgeons. The best curriculum method reorders the training set based on prior knowledge resulting into a classification improvement of 15%. Using the publicly available MNIST dataset, we further discuss and demonstrate the benefits of our unified CL formulation for three controlled and challenging digit recognition scenarios: with limited amounts of data, under class-imbalance, and in the presence of label noise. The code of our work is available at: https://github.com/ameliajimenez/curriculum-learning-prior-uncertainty.

Dual Mobility hip replacement in hip fractures offer functional equivalence and a stability advantage - A case-controlled study

BACKGROUND

Hip fracture is a common and serious injury in the elderly. Hip arthroplasty is the most frequently performed procedure for patients with an  intracapsular hip fracture. The majority of national guidelines recommend total hip arthroplasty (THA) for more active patients. Literature indicates significant stability advantages for dual mobility (DM) acetabular components in non-emergent scenarios. Evidence supporting the use of DM in hip fracture patients is limited.

AIM

We set out to ascertain if DM implants offer stability and/or functional advantages over standard THA in patients with hip fracture.

METHODS

We utilised our local National Hip Fracture Database to identify all patients undergoing either a standard or DM THA for hip fracture (n=477) We matched cohorts based on age, AMTS, mobility status pre-operatively, gender, ASA and source of admission. Our primary outcome of interest was functional status using the oxford hip score (OHS). Secondary outcome measures included  dislocation, fracture and deep infection requiring further surgery.

RESULTS

62 patient pairs were available for this study. Mean OHS for DM THA was 41.5 and for standard THA this was 42.7 (p=0.58). There were 4 dislocations in the standard THA group and 0 with DM THA. No difference was seen with infection or peri-prosthetic fracture.

CONCLUSION

This study demonstrates functional equivalence between DM and standard THA. In addition it shows a trend towards less dislocation with DM THA. Cost savings from less instability may outweigh initial prosthesis costs. This study suggests a suitably powered RCT using instability as the primary outcome measure is indicated.

Fifteen years change in acute management of hip fracture patients: 1-year mortality calls for improvements

INTRODUCTION

Over the past two decades, the average age of hip fractured patients has increased, patients are increasingly fragile and their management is more complex. Most of the literature suggest that care improvement lowered short-term mortality but there is no clear evidence whether mid- and long-term mortality rates are improving. The aim of this study was to evaluate the variations in comorbidities in hip fractured patients over 15 years, the changes in mortality and identify the predictive factors for mortality for identifying the patients at higher risk.

MATERIALS AND METHODS

Hip fractured patients admitted in hospital in 2000-2001 (192 patients) and 2015-2016 (323 patients) were retrospectively reviewed. Demographic, clinical and management data from the two cohorts were compared. Thirty-day and 1-year mortality were calculated and compare between the two cohorts. A multivariate logistic regression model were performed to identify the most significant predictors of mortality.

RESULTS

After fifteen years, mean age of hip fracture patients increased by 2.6 years with a 31% increase in comorbidity. The most prevalent comorbidities were hypertension, COPD, diabetes, arrhythmia, renal impairment and dementia. In the 2015-2016 cohort, the age-adjusted mortality at 30 days significantly declined compared to the 2000-2001 cohort (respectively 6.9% vs. 12.5%) but the age-adjusted mortality at 1-year was equivalent. Older age, reduced mobility, higher comorbidity, lateral fractures and male sex were significant risk factors for reduced survival time CONCLUSIONS: After 15 years, there was a significant improvement in 30-days mortality in hip fractured patients despite their increase in comorbidities but this advantage was not observed in 1-year mortality. This suggests the need to implement targeted and longer-term care support for males, older patients and those with greater comorbidities which are at higher risk.

Postoperative mortality in hip fracture patients stratified by the Revised Cardiac Risk Index: a Swedish nationwide retrospective cohort study

Objectives

The Revised Cardiac Risk Index (RCRI) is a tool that can be used to evaluate the 30-day risk of postoperative myocardial infarction, cardiac arrest and mortality. This study aims to confirm its association with postoperative mortality in patients who underwent hip fracture surgery.

Methods

All adults who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017 were included in this study. The database was retrieved by cross-referencing the Swedish National Quality Register for hip fractures with the Swedish National Board of Health and Welfare registers. The outcomes of interest were the association between the RCRI score and mortality at 30 days, 90 days and 1 year postoperatively.

Results

134 915 cases were included in the current study. There was a statistically significant linear trend in postoperative mortality with increasing RCRI scores at 30 days, 90 days and 1 year. An RCRI score ≥4 was associated with a 3.1 times greater risk of 30-day postoperative mortality (adjusted incidence rate ratio (IRR) 3.13, p<0.001), a 2.5 times greater risk of 90-day postoperative mortality (adjusted IRR 2.54, p<0.001) and a 2.8 times greater risk of 1-year postoperative mortality (adjusted HR 2.81, p<0.001) compared with that observed with an RCRI score of 0.

Conclusion

An increasing RCRI score is strongly associated with an elevated risk 30-day, 90-day and 1-year postoperative mortality after primary hip fracture surgery. The objective and easily retrievable nature of the variables included in the RCRI calculation makes it an appealing choice for risk stratification in the clinical setting.

Levels of evidence

Level III.

A comprehensive multidisciplinary care pathway for hip fractures better outcome than usual care?

INTRODUCTION

Hip fracture surgery is among the most performed surgical procedures in elderly patients. Mortality rates are high, however, and patients often fail to live independently following a hip fracture. To improve outcome, multidisciplinary care pathways have been initiated, but longer-term results are lacking. Aim of this study was to compare functional outcome and living situation six months after hip fracture treatment with and without a care pathway.

PATIENTS AND METHODS

A multicentre prospective controlled trial was conducted with three hospitals: in one hospital patients were treated with a care pathway, in the other hospitals patients received usual care. All patients aged ≥ 60 years with a hip fracture were asked to participate. Besides basic characteristics, health-related quality of life (EQ-5D) and performance scores of activities of daily living (Katz Index and Lawton IADL) were assessed. Differences in scores were analysed using linear regression. Propensity score adjustment was used to correct for differences between the care pathway and the usual care group. Missing data were imputed.

RESULTS

No differences in rate of return to prefracture ADL level were found between patients in the care pathway group and the usual care group. The percentage of participants in the same situation as before the fracture was the same in both treatment groups (81%). There were no significant differences in quality of life, activities of daily living or mortality (15% vs 10%, p = 0.17), but hospital stay in the care pathway group was significantly shorter (median 7 vs 10 days).

DISCUSSION

Treatment of elderly patients with a hip fracture is commonly organised in care pathways. Although short-term advantages are reported, positive effects on longer-term functional results could not be proven in our study. This study confirmed a shorter hospital stay in the care pathway group, which potentially may lead to a reduction in costs.

CONCLUSIONS

Functional outcome and living situation six months after a hip fracture is the same for patients treated with or without a care pathway.

Developing an individualised cross-sectoral programme based on activities of daily living to support rehabilitation of older adults with hip fracture: a qualitative study

OBJECTIVES

To develop an individualised rehabilitation programme for personal and instrumental activities of daily living (ADL) tasks, enabling older adults with hip fractures to perform ADL safely and independently.

DESIGN

Qualitative study inspired by the complex intervention development (Medical Research Council framework phase I) using literature search and research circles.

SETTINGS

University Hospital of Copenhagen, Herlev and Gentofte, and Herlev and Gentofte municipalities.

PARTICIPANTS

One research circle with seven older adults with hip fractures, and one with seven healthcare professionals (occupational therapists and physiotherapists).

RESULTS

Three generic categories were identified: (1) 'Challenge older adults with goal-oriented ADL tasks', (2) 'Implement strategies to enhance independent and safe performance of ADL tasks', and (3) 'Communicate the important information to the target group and across sectors'. A programme was developed and an intervention to enhance usual rehabilitation was designed comprising: an individualised intervention component consisting of five additional therapy sessions; one during hospitalisation, four in the municipality and a follow-up phone call.

CONCLUSIONS

Engaging and integrating activities into rehabilitation treatment may support rehabilitation. Our study highlighted the need for setting individual goals and challenging older adults with hip fracture by providing guidance in strategies to enhance safe and independent performance of ADL tasks. Furthermore, the need for providing older adults with hip fracture and healthcare professionals with written and oral information about goal setting during the transitional rehabilitation phase was emphasised. Including the perspectives of older adults with hip fracture and healthcare professionals added value to the rehabilitation, and thus ensured an adequate, tangible and implementable rehabilitation programme.

TRIAL REGISTRATION NUMBER

This article is the first of three articles inspired by Medicial Research Council guidelines. The next study is a feasibility study with the trial registration: ClinicalTrials.gov ID: NCT03828240. The results are right now being written in article. The third study is a randomised controlled trial with the trial registration: ClinicalTrials.gov ID: NCT04207788; Pre-results.

The risk factors of postoperative delirium in general anesthesia patients with hip fracture: Attention needed

Delirium is a common postoperative complication of patients with hip fracture, yet the risk factors for postoperative delirium in patients with hip fracture remain unclear. We aimed to evaluate the associated risk factors of postoperative delirium in patients with hip fracture, to provide evidence for formulating coping measures of postoperative delirium prevention and treatment in clinical practice.Patients undergoing surgery for hip fracture from March 1, 2018 to September 30, 2020 in our hospital were included. The related characteristics and related lab examination results were reviewed and collected. The univariate and logistic regression analyses were performed to identify the potential risk factors.A total of 462 patients were included, the incidence of postoperative delirium in patients with hip fracture was 16.02%. Logistic regression analyses indicated that history of delirium (OR = 4.38, 1.15-9.53), diabetes mellitus (OR = 5.31, 1.23-10.75), hypoalbuminemia (OR = 4.97, 1.37-9.86), postoperative hypoxemia (OR = 5.67, 2.24-13.42), and body mass index (BMI) (kg/m2) (OR = 3.03, 1.36-6.18) were the independent risk factors for the delirium in patients with hip fracture surgery (all P < 0.05). The cutoff value of postoperative blood sugar, albumin, and BMI for delirium prediction was 8.05 (mmol/L), 32.26 (g/L), and 19.35 (kg/m2), respectively, and the area under curve of postoperative blood sugar, albumin, and BMI was 0.792, 0.714, and 0.703, respectively.Those patients with a history of delirium, postoperative hypoxemia, blood glucose ≥8.05 mmol/L, albumin ≤32.26 g/L, and BMI ≤19.35 kg/m2 particularly need the attention of healthcare providers for the prevention of delirium.

Trends and Outcomes of Hip Fracture Hospitalization Among Medicare Beneficiaries with Inflammatory Bowel Disease, 2000-2017

BACKGROUND

Patients with inflammatory bowel disease (IBD) have a higher risk of hip fracture, but lower likelihood of having arthroplasties than non-IBD patients in Nationwide Inpatient Sample. Little is known about hip fracture-associated hospitalization outcomes.

AIMS

We assessed the trends in hip fracture hospitalization rates from 2000 to 2017 and estimated 30-day readmission, 30-day mortality, and length of stay in 2016 and 2017.

METHODS

We estimated trends of age-adjusted hospitalization rates using a piecewise linear regression. Medicare beneficiaries aged ≥ 66 years with Crohn's disease (CD, n = 2014) or ulcerative colitis (UC, n = 2971) hospitalized for hip fracture were identified. We performed propensity score matching to create 1:3 matched samples on age, race/ethnicity, sex, and chronic conditions and compared hospitalization outcomes between matched samples.

RESULTS

In 2017, the age-adjusted hospitalization rates (per 100) were 1.15 [95% CI = (1.07-1.24)] for CD, 0.86 [95% CI = (0.82-0.89)] for UC, and 0.59 [95% CI = (0.59-0.59)] for no IBD. The hospitalization rates for CD and UC decreased from 2000 to 2012 and then increased from 2012 to 2017. Compared to matched cohorts, CD patients had longer hospital stays (5.55 days vs. 5.30 days, p = 0.01); UC patients were more likely to have 30-day readmissions (17.27% vs. 13.71%, p < 0.001), longer hospital stays (5.59 days vs. 5.40 days, p = 0.02), and less likely to have 30-day mortality (3.77% vs. 5.15%, p = 0.003).

CONCLUSIONS

Prevention of hip fracture is important for older adults with IBD, especially CD. Strategies that improve quality of inpatient care for IBD patients hospitalized for hip fracture should be considered.

Functional Status Geriatric Scores: Single-Handed Tools for 30-Day Mortality Risk After Hip Fracture

Background

The 30-day mortality rate after hip fracture surgery has been considered as an indirect indicator of the quality of care. This work aims to appraise the Barthel Index, Katz Index, Lawton-Brody Index, and Physical Red Cross Scale registered in the Comprehensive Geriatric Assessment at admission on the of 30-day death probability after hip fracture surgery.

Methods

Prospective study including 899 hip fracture patients over 65. Bed-ridden, non-surgically treated patients, and high energy trauma or tumoral etiology fractures were excluded. Variables distribution were assessed by χ², U-Mann Whitney and we performed binary logistic regression and equal tailed Jeffreys 95% CI for risk assessment. P<0.05 was considered statistically significant.

Results

We noted a 30-day mortality rate of 5.9%. We related Barthel Index (OR=0.986 [0.975–0.996], p=0.010), Katz Index (OR=1.254 [1.089–1.444], p=0.002), Lawton-Brody Index (OR=0.885 [0.788–0.992], p=0.037), and Physical Red Cross Scale (OR=1.483 [1.094–2.011], p=0.011) with the 30-day mortality of patients after hip fracture surgery. We also validated the Barthel Index inflection point (0–55) (OR_BI(0–55)=2.428 [1.379–4.275], p=0.002) and Katz Index inflection point (A-B) (OR_KI(A-B)=0.493 [0.273–0.891], p=0.019) for the assessment of the highest risked patients.

Conclusion

The geriatric functional status scores would be useful multifunctional and standalone tools in the assessment of hip fracture patients as singly predictors of 30-day mortality.

Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade

As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.

Predicting 30-Day and 180-Day Mortality in Elderly Proximal Hip Fracture Patients: Evaluation of 4 Risk Prediction Scores at a Level I Trauma Center

This study evaluated the use of risk prediction models in estimating short- and mid-term mortality following proximal hip fracture in an elderly Austrian population. Data from 1101 patients who sustained a proximal hip fracture were retrospectively analyzed and applied to four models of interest: Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), Charlson Comorbidity Index, Portsmouth-POSSUM and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP^®) Risk Score. The performance of these models according to the risk prediction of short- and mid-term mortality was assessed with a receiver operating characteristic curve (ROC). The median age of participants was 83 years, and 69% were women. Six point one percent of patients were deceased by 30 days and 15.2% by 180 days postoperatively. There was no significant difference between the models; the ACS-NSQIP had the largest area under the receiver operating characteristic curve for within 30-day and 180-day mortality. Age, male gender, and hemoglobin (Hb) levels at admission <12.0 g/dL were identified as significant risk factors associated with a shorter time to death at 30 and 180 days postoperative (p < 0.001). Among the four scores, the ACS-NSQIP score could be best-suited clinically and showed the highest discriminative performance, although it was not specifically designed for the hip fracture population.

The dangers of ignoring underlying trends in before-and-after studies - A cautionary tale using hip fracture mortality data

BACKGROUND

Before-and-after studies are a valuable study design in situations where randomization is not feasible. These studies measure an outcome both before and after an intervention and compare the outcome rates in both time periods to determine the effectiveness of the intervention. Before-and-after studies do not involve a contemporaneous control group and must, therefore, take into account any underlying secular trends to separate the effect of the intervention from any pre-existing trend.

METHODS

To illustrate the importance of accounting for underlying trends, we performed a before-and-after study assessing 30-day mortality in hip fracture patients without any actual intervention, and instead designated an arbitrarily chosen time point as our 'intervention'. We then analysed the data first disregarding and then incorporating the pre-existing underlying trend. We did this to show that even intervention of nothing may be spuriously interpreted to have an effect if the before-and-after study design is incorrectly analysed. Our study involved a secondary analysis of routinely collected data on 30-day mortality following hip fracture in our institution.

RESULTS

We found a secular trend in our data showing improving 30-day mortality in hip fracture patients in our institution. We then demonstrated that disregarding this underlying trend showed that our intervention of nothing 'resulted' in a significant 54% decrease in mortality, from 6.7% in the 'before' period to 3.1% in the 'after' period (p < 0.0008). Though the 30-day mortality rate decreased during the 'after' period, the decrease was not significantly different from the underlying trend in the 'before' period, projected onto the 'after' period. When we accounted for the underlying trend in our analysis, the impact of the intervention (nothing) on 30-day mortality was no longer apparent (incidence rate ratio 0.75, 95% confidence interval 0.32-1.78; p = 0.5).

CONCLUSION

Our study highlights the importance of appropriate measurement and consideration of underlying trends when analysing data from before-and-after studies and illustrates what can happen should researchers neglect this important step.

A nationwide observational cohort study of the relationship between beta-blockade and survival after hip fracture surgery

PURPOSE

Despite advances in the care of hip fractures, this area of surgery is associated with high postoperative mortality. Downregulating circulating catecholamines, released as a response to traumatic injury and surgical trauma, is believed to reduce the risk of death in noncardiac surgical patients. This effect has not been studied in hip fractures. This study aims to assess whether survival benefits are gained by reducing the effects of the hyper-adrenergic state with beta-blocker therapy in patients undergoing emergency hip fracture surgery.

METHODS

This is a retrospective nationwide observational cohort study. All adults [Formula: see text] 18 years were identified from the prospectively collected national quality register for hip fractures in Sweden during a 10-year period. Pathological fractures were excluded. The cohort was subdivided into beta-blocker users and non-users. Poisson regression with robust standard errors and adjustments for confounders was used to evaluate 30-day mortality.

RESULTS

134,915 patients were included of whom 38.9% had ongoing beta-blocker therapy at the time of surgery. Beta-blocker users were significantly older and less fit for surgery. Crude 30-day all-cause mortality was significantly increased in non-users (10.0% versus 3.7%, p < 0.001). Beta-blocker therapy resulted in a 72% relative risk reduction in 30-day all-cause mortality (incidence rate ratio 0.28, 95% CI 0.26-0.29, p < 0.001) and was independently associated with a reduction in deaths of cardiovascular, respiratory, and cerebrovascular origin and deaths due to sepsis or multiorgan failure.

CONCLUSIONS

Beta-blockers are associated with significant survival benefits when undergoing emergency hip fracture surgery. Outlined results strongly encourage an interventional design to validate the observed relationship.

Admission neutrophil-to-lymphocyte ratio and monocyte-to-lymphocyte ratio to predict 30-day and 1-year mortality in geriatric hip fractures

INTRODUCTION

Elderly patients with hip fractures exhibit a high incidence of mortality and morbidity. The aim of this study was to evaluate the factors that may predict mortality in patients with geriatric hip fracture.

METHODS

Included in this retrospective study were 241 patients who were admitted to the hospital with hip fractures between May 2017 and March 2019. The effect of the modified 5-item frailty index (mFI-5) on 30-day and 1-year mortality was evaluated. In addition, admission neutrophil-to-lymphocyte ratios (NLRs) and monocyte-to-lymphocyte ratios (MLRs) were also examined.

RESULTS

The mFI-5 was not found to be a statistically significant predictive indicator for 30-day and 1-year mortality (P = 0.485 and P = 0.484, respectively). Chronic obstructive pulmonary disease or current pneumonia was found to increase mortality by 2.702 times (P = 0.002). The 30-day mortality rates of patients aged ≥80 years were significantly higher than those aged 65-79 years (P < 0.05). However, there was no statistical difference in the mortality rates between the age groups after 30 days postoperatively (P = 0.114). Admission NLRs and MLRs were significantly higher in the 30-day and 1-year mortality groups. The cut-off values of the admission NLRs and MLRs for 30-day mortality were calculated as 6.55 and 0.65, respectively, while the same cut-off values for 1-year mortality were calculated as 6.55 and 0.635, respectively.

CONCLUSIONS

Admission NLRs and MLRs are useful hematological data for the prediction of 30-day and 1-year mortality in geriatric hip fracture patients.

Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal

Introduction

Medications with anticholinergic activity (MACs) are used to treat diseases common in older adults. Evidence on the association between anticholinergic burden (AB) and increased risk of fractures and osteoporosis or reduced bone mineral density (BMD) is inconsistent. Our aim was to conduct a systematic review of observational studies on AB with fractures and osteoporosis or reduced BMD and provide methodological appraisal of included studies.

Methods

We searched MEDLINE, EMBASE, Science Citation Index and CENTRAL as well as grey literature from database inception up to August 2020. Eligibility criteria were: observational design, AB-exposure measured through a scale, fracture of any type or osteoporosis or reduced BMD as outcome, and reported measure of association between exposure and outcome. No restrictions related to time, language or type of data were applied. Eligibility and risk of bias assessment as well as data extraction were performed independently by two reviewers. Risk of bias of the included studies was assessed using the Newcastle–Ottawa Scale and the RTI Item Bank.

Results

The majority of the nine included studies had low risk of bias but heterogeneous methodology. No study used a new user design. Seven studies reported an increased risk of fractures associated with AB. In four studies using the Anticholinergic Risk Scale (ARS), adjusted risk of fractures was increased by 2–61% for ARS = 1, by 0–97% for ARS = 2, by 19–84% for ARS = 3, and by 56–96% for ARS ≥ 4; in three studies the ARS was aggregated, risk increased by 39% for ARS = 1–2 and 17% for ARS = 2–3. Two studies reported increased risk of fractures of 14 and 52% in the highest AB-category and one study reported that change in ARS of ≥ 3 during hospitalization was associated with a 321% increased risk in fractures. Two studies did not find an association between AB and fractures. The association between AB and osteoporosis or reduced BMD could only be assessed in two studies, one reporting increased risk of lower BMD at Ward’s triangle, the other reporting no association between AB and BMD T-score change at the femoral neck.

Discussion

Our study suggests an association between AB and increased risk of fractures with possible dose-exposure gradient in studies using the ARS. The low number of studies and heterogeneity of methods calls for the conduct of more studies.

Plain language summary

We conducted a study investigating the risk of fractures associated with anticholinergic burden, which is the result of taking one or more medication with anticholinergic activity. The results of our study suggest that persons who experience anticholinergic burden might have a higher risk of fractures. However, since we were only able to include nine studies, more studies conducted in a similar way are needed.

Electronic supplementary material

The online version of this article (10.1007/s40266-020-00806-6) contains supplementary material, which is available to authorized users.

Mortality in Patients with Proximal Femoral Fracture During the COVID-19 Pandemic: A U.K. Hospital's Experience

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a worldwide pandemic, with a case mortality ratio of approximately 6.4% at the time of writing (May 2020). Mortality increases in elderly patients with comorbidities. Patients with hip fracture have an average age of 80 years, with an estimated 2.8 comorbidities per patient. Evidence is lacking regarding the mortality rate of patients with hip fracture admitted during the COVID-19 pandemic. Our aim was to investigate the mortality rate among patients with a proximal femoral fracture who were admitted to our hospital during the COVID-19 pandemic.

METHODS

We conducted a retrospective review of all patients with a proximal femoral fracture admitted to Southend University Hospital in the U.K. from March to April 2020 (during the COVID-19 pandemic). Data collected included demographics (patient age, body mass index, sex), comorbidities, and blood test values along with COVID-19 diagnosis (based on positive microbiological sample and clinical and radiographic findings) and operative characteristics (time to operation, length of stay, American Society of Anesthesiologists [ASA] classification, Nottingham Hip Fracture Score). The primary outcome was the 30-day mortality rate for patients with a hip fracture who were COVID-19 positive or negative. Kaplan-Meier survival analysis was conducted along with Mann-Whitney U tests and Fisher exact tests.

RESULTS

Forty-one patients were included in the study, of whom 37 had an available SARS-CoV-2 (severe acute respiratory syndrome-coronavirus 2) swab test result. The overall 30-day mortality was 22%. Eleven patients tested positive for COVID-19. There was a significant difference in the mortality rate between those who tested positive and those who tested negative (54.5% versus 7.69%, respectively; Fisher exact test, p = 0.004) and between the operative patients who tested positive and the operative patients who tested negative (37.5% versus 4.34%, respectively; Fisher exact test, p = 0.043).

CONCLUSIONS

Patients with a proximal femoral fracture may be at higher risk for mortality during the COVID-19 pandemic. We noted that patients with a proximal femoral fracture who tested positive for COVID-19 had a higher 30-day mortality rate compared with those who tested negative. Additional research is required to ascertain the benefits of a reduction in time to operation.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mortality Rates of Patients with Proximal Femoral Fracture in a Worldwide Pandemic: Preliminary Results of the Spanish HIP-COVID Observational Study

BACKGROUND

The outbreak of coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), in December 2019 in Wuhan, People's Republic of China, has developed into an unprecedented pandemic with enormous pressure on health-care providers around the world. A higher mortality rate has been described in older infected individuals. Patients with hip fracture are a particularly vulnerable population during this pandemic because older age is associated with a higher mortality rate. Our aim was to describe the early mortality rate and demographic variables in a hip fracture sample population in Spain during the coronavirus pandemic.

METHODS

This is a multicenter, observational, retrospective, descriptive study. We collected data from 13 major hospitals in Spain from the beginning of the national state of alarm (declared on March 14, 2020, by the Spanish government) until the end of our study period on April 4, 2020. All patients who were ≥65 years of age, presented to the Emergency Department of the participating hospitals during this period with a diagnosis of proximal femoral fracture, and had a minimum follow-up of 10 days were included in the cohort. In addition to mortality, demographic and other potential prognostic variables were also collected.

RESULTS

In this study, 136 patients with a hip fracture were included. Of these patients, 124 underwent a surgical procedure and 12 were managed nonoperatively. The total mortality rate was 9.6%. Sixty-two patients were tested for COVID-19, with 23 patients being positive. The mortality rate for these 23 patients was 30.4% (7 of 23 patients) at a mean follow-up of 14 days. The mortality rate was 10.3% (4 of 39) for patients who had been tested and had a negative result and 2.7% (2 of 74) for patients who had not been tested. Of the 12 patients who were managed nonoperatively, 8 (67%) died, whereas, of the 124 patients who were surgically treated, 5 (4%) died. Results differed among centers.

CONCLUSIONS

There is a higher mortality rate in patients with a hip fracture and an associated positive test for COVID-19.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

One-year postoperative mortality rate among the elderly with hip fractures at a single tertiary care center

BACKGROUND

Hip fractures are one of the leading causes of disability and dependency among the elderly. The rate of hip fractures has been progressively increasing due to the continuing increase in average life expectancy. Surgical intervention is the mainstay of treatment, but with an increasing prevalence of comorbid conditions and decreased functional capacity in elderly patients, more patients are prone to postoperative complications.

OBJECTIVES

Assess the value of surgical intervention for hip fractures among the elderly by quantifying the 1-year mortality rate and assessing factors associated with mortality.

DESIGN

Medical record review.

SETTING

Tertiary care center.

PATIENTS AND METHODS

All patients 60 years o age or older who sustained a hip fracture between the period of 2008 to 2018 in a single tertiary healthcare center. Data was obtained from case files, using both electronic and paper files.

MAIN OUTCOME MEASURES

The 1-year mortality rate for hip fracture, postoperative complications and factors associated with mortality.

SAMPLE SIZE

802 patients.

RESULTS

The majority of patients underwent surgical intervention (93%). Intra- and postoperative complications were 3% and 16%, respectively. Four percent of the sample died within 30 days, and 11% died within one year. In a multivariate analysis, an increased risk of 1-year mortality was associated with neck of femur fractures and postoperative complications (P=.034, <.001, respectively) CONCLUSION: The 1-year mortality risk in our study reinforces the importance of aggressive surgical intervention for hip fractures.

LIMITATION

Single-centered study.

CONFLICT OF INTEREST

None.

Influence of surgical parameters on mortality after surgery for extracapsular hip fractures in the elderly

INTRODUCTION

Hip fracture is a very frequent traumatic pathology in the elderly with high mortality. Different factors have been associated with mortality after surgery (age comorbidities). There are surgical factors that are associated with mortality, but they have not been related to the different mortality rates and medical comorbidities.

OBJECTIVE

To analyze the surgical parameters with influence on mortality in surgery of extracapsular hip fractures in the elderly patient, as well as the influence of medical comorbidities of these patients on mortality, by means of the Charlson comorbidity index (CCI).

METHOD

Retrospective review of 187 patients operated on in 2015. Data were collected on age and sex, laterality and type of fracture; surgical delay, surgical time, type of osteosynthesis material, mean stay. The presence of comorbidities was determined using the JRC.

RESULTS

Mean age was 85 years. Regarding the Charlson comorbidity index in brief, 67.4% of patients had a score between 0 and 1, 23.5% of 2, and 9.1% >2. Mortality at one month and one year after surgery was 5.3% and 14.4% respectively. Forty-three complications were recorded, of which 31 were medical complications. Of the 27 patients who died in the first year, 14 (51.8%) suffered complications, 48.2% of which were medical complications.

DISCUSSION

Multivariate analysis showed significant differences with respect to age, medical complications and Charlson index abbreviated to 2 with respect to mortality. There is no association between delay and surgical time with increased mortality.

CONCLUSIONS

No association was demonstrated between the surgical parameters studied (surgical delay and time, fracture pattern and stability, reduction criteria, surgical complications) and increased short and long-term mortality. Patients with older age, comorbidities measured with abbreviated CCI and those suffering medical complications have a higher risk of mortality at the month and year of surgery.

Hip fractures in South Africa: mortality outcomes over 12 months post-fracture

With increased urbanisation and longevity in sub-Saharan Africa, the burden of osteoporosis and resultant hip fractures (HF) has increased. This study shows that 1 in 3 subjects dies post-HF, and that there are significant delays and barriers to surgery, reflecting the need to prioritise HF care in South Africa.

PURPOSE

The outcomes following hip fractures are unknown in sub-Saharan Africa. This study aimed to quantify the mortality rate (MR) following hip fractures and to identify predictors of mortality over 1 year.

METHODS

In this cohort study, demographic, clinical, and biochemical characteristics of consecutive patients with low trauma hip fractures, admitted to the five public sector hospitals in eThekwini (formerly Durban), were recorded. Cox regression analyses identified predictors of mortality at 30 days and 1 year.

RESULTS

In the 200 hip fracture patients studied, the mean age was 74.3 years (SD ± 8.8) and 72% were female. Hospital presentation was often delayed, only 15.5% presented on the day of fracture. At admission, 69.5% were anaemic, 42% had hyponatraemia, 34.5% raised creatinine, and 58.5% hypoalbuminaemia. All received skin traction before 173 (86.5%) underwent surgical fixation. Median time from admission to surgery was 19.0 days (IQR 12.3-25.0). Median hospital stay was 9.0 days (IQR 12.3-25.0). Mortality rates were 13% and 33.5% at 30 and 365 days, respectively. Over 1 year, African patients were more likely to die than Indian patients (40.9 versus 30%, HR 11.5 [95% CI 1.51, 2.57]; p = 0.012); delays to surgery predicted death (HR 1.02 [95% CI (1.00, 1.04)]; p = 0.022). In multivariate analyses, death at 1 year was most strongly predicted by an elevated serum creatinine (HR 2.43, 95% CI (1.02, 5.76), p = 0.044].

CONCLUSION

Hip fractures are associated with high MRs, in part explained by insufficient surgical capacity, highlighting the need for national efforts to improve hip fracture service provision.

Hip Fracture in Nonagenarians: Characteristics and Factors Related to 30-Day Mortality in 1177 Patients

BACKGROUND

The number of nonagenarian patients with hip fracture is increasing. The goals of this study were to describe the characteristics and in-hospital course of a cohort of 1177 nonagenarians admitted for hip fracture compared with younger patients and to identify risk factors for 30-day mortality after admission.

METHODS

This is a retrospective observational cohort study including patients aged 65 years or older admitted for hip fracture during various periods from February 1997 to December 2016. We defined 3 age groups: 65-79, 80-89, and 90 years and older. We included sociodemographic variables, baseline functional status, comorbidities, fracture and surgical characteristics, postoperative complications, length of stay, and in-hospital and 30-day mortality. Multiple logistic regression analysis was used to study risk factors for 30-day mortality in surgically treated nonagenarians.

RESULTS

Nonagenarians were more likely to be women and to have dementia and heart disease. Some 72% walked independently before the fracture. The most relevant treatable risk factor for 30-day mortality in nonagenarians (in terms of higher odds ratio [OR]) was developing respiratory infection (OR: 4.56, 95% confidence interval [CI]: 2.73-7.63). Better prefracture functional status (higher Katz score; OR: 0.83, 95% CI: 0.74-0.92) and spinal anesthesia (OR: 0.19, 95% CI: 0.05-0.68) decreased risk of 30-day mortality.

CONCLUSIONS

Nonagenarian patients with hip fracture differ significantly from younger patients concerning clinical characteristics, medical complications, and in-hospital and 30-day mortality rates. We identified several variables on which we could act to reduce 30-day mortality, such as respiratory infection, electrolyte disorders, polypharmacy, cardiac arrhythmia, and spinal anesthesia.