1
|
García-Tercero E, Belenguer-Varea Á, Villalon-Ruibio D, López Gómez J, Trigo-Suarez R, Cunha-Pérez C, Borda MG, Tarazona-Santabalbina FJ. Respiratory Complications Are the Main Predictors of 1-Year Mortality in Patients with Hip Fractures: The Results from the Alzira Retrospective Cohort Study. Geriatrics (Basel) 2024; 9:47. [PMID: 38667514 PMCID: PMC11050287 DOI: 10.3390/geriatrics9020047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/21/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction: Hip fractures pose a significant challenge for older individuals given their high incidence and one-year mortality rate. The objective of this study was to identify the primary predictors of one-year mortality in older adults hospitalized for hip fractures. Methods: We conducted a retrospective cohort study involving adults aged 70 years or older who were admitted to the hospital for fragility hip fractures between 1 January 2014 and 31 December 2021. A total of 3229 patients were recruited, with 846 (26.2%) experiencing one-year mortality. Results: Respiratory complications (HR 2.42, 95%CI 1.42-4.14; p = 0.001) were the most significant predictors of one-year mortality, followed by hospital readmission (HR 1.96, 95%CI 1.66-2.32; p < 0.001), the male sex (HR 1.88, 95%CI 1.46-2.32; p < 0.001), cardiac complications (HR 1.88, 95%CI 1.46-2.32; p < 0.001), and a diagnosis of dementia at admission (HR 1.37, 95%CI 1.13-1.66; p = 0.001). The Charlson Index and the American Society of Anesthesiologists physical status classification system also significantly increased the mortality risk. Conversely, higher hemoglobin levels at admission and elevated albumin at discharge significantly reduced the mortality risk. Conclusions: The one-year mortality rate is substantial in older adults with hip fractures who are admitted to an orthogeriatric unit. The appropriate management of anemia, nutritional disorders, and comorbidity at admission and during the follow-up could potentially mitigate long-term mortality after hip fractures.
Collapse
Affiliation(s)
- Elisa García-Tercero
- Geriatric Medicine Department, Hospital Universitario de la Ribera, Carretera de Corbera km. 1, 46600 Alzira, Spain; (Á.B.-V.); (D.V.-R.); (J.L.G.); (F.J.T.-S.)
| | - Ángel Belenguer-Varea
- Geriatric Medicine Department, Hospital Universitario de la Ribera, Carretera de Corbera km. 1, 46600 Alzira, Spain; (Á.B.-V.); (D.V.-R.); (J.L.G.); (F.J.T.-S.)
| | - Daniela Villalon-Ruibio
- Geriatric Medicine Department, Hospital Universitario de la Ribera, Carretera de Corbera km. 1, 46600 Alzira, Spain; (Á.B.-V.); (D.V.-R.); (J.L.G.); (F.J.T.-S.)
| | - Jesús López Gómez
- Geriatric Medicine Department, Hospital Universitario de la Ribera, Carretera de Corbera km. 1, 46600 Alzira, Spain; (Á.B.-V.); (D.V.-R.); (J.L.G.); (F.J.T.-S.)
| | - Rodrigo Trigo-Suarez
- Geriatric Medicine Department, Hospital Universitario de la Ribera, Carretera de Corbera km. 1, 46600 Alzira, Spain; (Á.B.-V.); (D.V.-R.); (J.L.G.); (F.J.T.-S.)
| | - Cristina Cunha-Pérez
- School of Doctorate, Universidad Católica de Valencia San Vicente Mártir, 46001 Valencia, Spain;
| | - Miguel Germán Borda
- Centre for Age-Related Medicine (SESAM), Stavanger University Hospital, 4068 Stavanger, Norway;
- Semillero de Neurociencias y Envejecimiento, Ageing Institute, Medical School, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 14186 Stockholm, Sweden
| | - Francisco Jose Tarazona-Santabalbina
- Geriatric Medicine Department, Hospital Universitario de la Ribera, Carretera de Corbera km. 1, 46600 Alzira, Spain; (Á.B.-V.); (D.V.-R.); (J.L.G.); (F.J.T.-S.)
- Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable (CIBERFES), 28029 Madrid, Spain
- Medical School, Universidad Católica de Valencia Sant Vicent Màrtir, 46001 Valencia, Spain
| |
Collapse
|
2
|
Bruce K, Mangram A, Sucher JF, Blake N, Balcome CD, Prokuski L, Dzandu J, Barletta JF, Shirah GR. Consequences of anemia in geriatric hip fractures: how low is too low? Trauma Surg Acute Care Open 2024; 9:e001175. [PMID: 38352959 PMCID: PMC10862255 DOI: 10.1136/tsaco-2023-001175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/24/2023] [Indexed: 02/16/2024] Open
Abstract
Background The transfusion threshold for low hemoglobin (Hgb) in geriatric patients with hip fractures is widely debated. In certain populations, low Hgb is associated with poor outcomes. Our objective was to evaluate the relationship between lowest Hgb and outcome to identify the Hgb threshold where poor outcomes were more prevalent. Methods This retrospective cohort study included consecutive patients with hip fractures, aged ≥60 years, evaluated at two level 1 trauma centers from 2018 to 2021. Patients who did not undergo operative fixation or had a length of stay <1 day were excluded. The primary endpoint was adverse outcome defined as the composite of myocardial infarction, stroke, new-onset arrhythmia or death. We compared lowest Hgb and possible confounders between patients with and without adverse outcomes. Classification and regression tree (CART) analysis was performed to identify the threshold for Hgb where adverse outcomes were more prevalent. Multivariate analysis was performed. Results We evaluated 935 patients. Mean age was 80±10 years; admission Hgb was 12.5±1.7 g/dL. Diabetes was present in 20%, and 20% had coronary artery disease. Adverse outcomes were noted in 57 patients (6.1%). CART identified ≤7.1 g/dL as the Hgb threshold where adverse outcomes were more prevalent (15% vs. 4.1%, p<0.001). Additionally, a greater number of adverse outcomes were noted in the subgroup of patients having both a hemoglobin ≤7.1 g/dL and advanced age (age >79 years (22%)). After controlling for age, American Society of Anesthesiologist Physical Status Classification (ASA), antiplatelet medication, admission Hgb, time to operation and blood transfusions, lowest Hgb ≤7.1 g/dL remained a risk factor for adverse outcomes. Conclusions In geriatric patients with isolated hip fractures, Hgb ≤7.1 g/dL is associated with a significantly higher rate of adverse outcomes. This risk was most pronounced in patients older than 79 years; particular care should be taken in this demographic. Level of evidence/study type Level III/prognostic and epidemiological.
Collapse
Affiliation(s)
- Kimberli Bruce
- Trauma Services, HonorHealth John C Lincoln Medical Center, Phoenix, Arizona, USA
| | - Alicia Mangram
- Trauma Services, HonorHealth John C Lincoln Medical Center, Phoenix, Arizona, USA
| | - Joseph F Sucher
- Trauma Services, HonorHealth John C Lincoln Medical Center, Phoenix, Arizona, USA
| | - Nuria Blake
- HonorHealth John C Lincoln Medical Center, Phoenix, Arizona, USA
| | - Charles D Balcome
- Trauma Services, HonorHealth John C Lincoln Medical Center, Phoenix, Arizona, USA
| | - Laura Prokuski
- HonorHealth John C Lincoln Medical Center, Phoenix, Arizona, USA
| | - James Dzandu
- Trauma Services, HonorHealth John C Lincoln Medical Center, Phoenix, Arizona, USA
| | - Jeffrey F Barletta
- Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, Az, USA
| | - Gina R Shirah
- HonorHealth John C Lincoln Medical Center, Phoenix, Arizona, USA
| |
Collapse
|
3
|
Wang Z, Zhang L, Zeng X, Nie P, Wang M, Xiong Y, Xu Y. The Nomogram Model and Factors for the Postoperative Mortality of Elderly Patients with Femoral Neck Fracture Undergoing Artificial Hip Arthroplasty: A Single-Institution 6-Year Experience. Orthop Surg 2024; 16:391-400. [PMID: 38151885 PMCID: PMC10834201 DOI: 10.1111/os.13944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 12/29/2023] Open
Abstract
OBJECTIVE Artificial hip arthroplasty (AHA) is widely accepted in elderly patients with femoral neck fractures, but it is associated with high risk of death and various postoperative complications due to old age and accompanying chronic diseases. Therefore, this study aimed to explore the risk factors for death in elderly patients with femoral neck fractures after AHA and to establish a nomogram risk prediction model, which is expected to reveal high-risk patients and improve the postoperative quality of life and survival rate of patients. METHODS Elderly patients who underwent AHA for femoral neck fractures in our hospital from September 2014 to May 2021were retrospectively analyzed. These patients were divided into a survival group and a death group according to their clinical outcomes. The following clinical data were recorded for the patients in the two groups: sex, age, underlying diseases, smoking and drinking history, preoperative nutritional risk score (NRS) and American Society of Anesthesiologists (ASA) score, as well as relevant indicators about the operation. These data were subject to univariate analysis and then logistic analysis to determine the risk factors of death. Subsequently, a nomogram risk prediction model was established and further validated with the receiver operating characteristic curve (ROC) and the Hosmer-Lemeshow test. Finally, the effects of predictive risk factors were analyzed using the Kaplan-Meier survival curve. RESULTS Follow-up was completed by 260 patients, including 206 patients in the survival group and 54 patients in the death group; the overall death rate was 20.77%, and the follow-up time, age, postoperative 1, 3 and 5-year death rates were 3.47 ± 1.93 years, 75.32 ± 9.12 years, 5.77%, 12.51%, and 25.61%, respectively. The top three causes of death in 54 patients were respiratory disease, cerebrocardiovascular disease, and digestive disease, respectively. The logistic analysis indicated that elderly patients with femoral neck fractures, the risk factors for death after AHA were age ≥ 80 years, preoperative NRS ≥ 4, HB ≤ 90 g/L, CR ≥ 110 umol/L, and ASA score ≥ 3, as well as postoperative albumin ≤ 35 g/L, the nomogram was established, and then its predictive performance was successfully validated using the ROC curve (AUC = 0.814, 95% confidence interval = 0.749-0.879) and the Hosmer-Lemeshow test (p = 0.840). Furthermore, Kaplan-Meier survival curve analysis revealed that the abovementioned six indicators were correlated with the post-AHA survival time of elderly patients with femoral neck fractures (pLog Rank < 0.05). CONCLUSION Old age, preoperatively high NRS and ASA score, anemia, poor renal function, and postoperative hypoproteinemia are the major risk factors for death in elderly patients with femoral neck fractures after AHA; they are also associated with postoperative survival. Early identification and effective interventions for optimization of modifiable risk factors are recommended to improve the postoperative quality of life and survival rates.
Collapse
Affiliation(s)
- Zewen Wang
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Lixiang Zhang
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Xiaoyan Zeng
- Department of General Surgery, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Piming Nie
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Min Wang
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Yan Xiong
- Department of Orthopaedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Yuan Xu
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| |
Collapse
|
4
|
Bhakhar A, Paul N, Verma A, Chaudhary C, Sharma A, Sarkar B. Letter to the editor for "Poorly controlled diabetes: Glycosylated hemoglobin (HA1c) levels >8% are the tipping point for significantly worse outcomes following hip fracture in the geriatric population". Injury 2023; 54:111048. [PMID: 37783062 DOI: 10.1016/j.injury.2023.111048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/10/2023] [Indexed: 10/04/2023]
Affiliation(s)
- Anurag Bhakhar
- Department of Trauma Surgery and Critical Care AIIMS, Rishikesh, India.
| | - Nirvin Paul
- Department of Trauma Surgery and Critical Care AIIMS, Rishikesh, India
| | - Aman Verma
- Department of Trauma Surgery and Critical Care AIIMS, Rishikesh, India
| | - Chetan Chaudhary
- Department of Trauma Surgery and Critical Care AIIMS, Rishikesh, India
| | - Ajay Sharma
- Department of Trauma Surgery and Critical Care AIIMS, Rishikesh, India
| | - Bhaskar Sarkar
- Department of Trauma Surgery and Critical Care AIIMS, Rishikesh, India
| |
Collapse
|
5
|
Sing D, Cummins DD, Burch S, Theologis AA. Computer-assisted Navigation in Lumbar Spine Instrumented Fusions: Comparison of In-hospital and 30-Day Postoperative Complications With Nonnavigated Fusions in a National Database. J Am Acad Orthop Surg 2023; 31:e638-e644. [PMID: 37130368 DOI: 10.5435/jaaos-d-22-01207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/11/2023] [Indexed: 05/04/2023] Open
Abstract
OBJECTIVE To compare in-hospital and 30-day postoperative complications for lumbar spine operations with and without use of computer-assisted navigation. METHODS Patients who underwent 1-level to 3-level lumbar spinal instrumentation and fusions 2011 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Emergent procedures and patients aged younger than 18 years were excluded. Patients whose surgery involved the use of computer-assisted navigation were propensity score matched 1:4 based on preoperative demographics and comorbidities to operations without the use of navigation. Multivariate analysis was done to compare postoperative complications. RESULTS In total, 8,500 patients (average age: 60.7 ± 12.9, male 3,866, female 4,634) were analyzed (1,700 navigation, 6,800 Non-Navigated). Operations with navigation had significantly fewer overall complications (24% vs. 27%, P = 0.008; odds ratio [OR] = 0.83; CI = 0.73 to 0.95), fewer minor complications (20% vs. 24%, P = 0.002; OR = 0.80; CI = 0.70 to 0.91), fewer blood transfusions (17% v. 20%, P = 0.013; OR = 0.82; CI = 0.71 to 0.95), more wound dehiscences (0.4% vs. 0.8%, P = 0.022; OR = 2.16; CI = 1.12,4.19), and shorter average lengths of hospital stays (4.8 ± 4.8 vs. 5.1 ± 5.8 days, P = 0.01). Operations with computer navigation had significantly longer average surgical times (247 ± 129 vs 221 ± 115 minutes, P < 0.001). No significant differences were observed in 30-day revision rates, readmissions, and mortality. CONCLUSION Although use of computer-assisted navigation in short-segment lumbar spine fusions (1 to 3 levels) did not decrease revision rates for screw misplacement within 30 days postoperatively, it independently reduced the frequency of blood transfusions and minor complications and decreased hospital lengths of stay compared with operations without navigation. These benefits came at the expense of increased surgical times and wound dehiscences within 30 days postoperatively. Given the inherent limitations of large national databases, these results warrant confirmation through prospective, multicenter investigations.
Collapse
Affiliation(s)
- David Sing
- From the Department of Orthopaedic Surgery, University of California San Francisco (UCSF), San Francisco, CA
| | | | | | | |
Collapse
|
6
|
Zanetti M, De Colle P, Niero M, Gortan Cappellari G, Barazzoni R, Ratti C, Murena L. Multidimensional prognostic index predicts short- and long-term mortality and rehospitalizations in older patients with hip fracture. Aging Clin Exp Res 2023:10.1007/s40520-023-02433-8. [PMID: 37178430 DOI: 10.1007/s40520-023-02433-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Multidimensional Prognostic Index (MPI), calculated on cognitive, functional, nutritional, social, pharmacological and comorbidity domains, strongly correlates with mortality in older patients. Hip fractures are a major health problem and are associated with adverse outcomes in those affected by frailty. AIM We aimed at evaluating whether MPI is a predictor of mortality and rehospitalization in hip fracture older patients. METHODS We investigated the associations of MPI with all-cause 3- and 6-month mortality and rehospitalization in 1259 older patients admitted for hip fracture surgical treatment and managed by an orthogeriatric team [age 85 years (65-109); male gender: 22%]. RESULTS Overall mortality was 11,4%, 17% and 23,5% at 3, 6 and 12 months from surgery (rehospitalizations: 15, 24,5 and 35,7%). MPI was associated (p < 0.001) with 3-, 6- and 12- month mortality and readmissions; Kaplan-Meier estimate for rehospitalization and survival according to MPI risk classes confirmed these results. In multiple regression analyses these associations were independent (p < 0.05) of mortality and rehospitalization-associated factors not included in the MPI, such as gender, age and post-surgical complications. Similar MPI predictive value was observed in patients undergoing endoprosthesis or other surgeries. ROC analysis confirmed that MPI was a predictor (p < 0.001) of both 3- and 6- month mortality and rehospitalization. CONCLUSIONS In hip fracture older patients, MPI is a strong predictor of 3-, 6- and 12- months mortality and rehospitalization, independently of surgical treatment and post-surgical complications. Therefore, MPI should be considered a valid pre-surgical tool to identify patients with higher clinical risk of adverse outcomes.
Collapse
Affiliation(s)
- Michela Zanetti
- Department of Medical Sciences, University of Trieste, Trieste, Italy.
- Geriatric Clinic, Maggiore Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy.
| | - Paolo De Colle
- Geriatric Clinic, Maggiore Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Michele Niero
- Department of Medical Sciences, University of Trieste, Trieste, Italy
| | | | - Rocco Barazzoni
- Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Chiara Ratti
- Department of Medical Sciences, University of Trieste, Trieste, Italy
- Orthopedic Clinic, Cattinara Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Luigi Murena
- Department of Medical Sciences, University of Trieste, Trieste, Italy
- Orthopedic Clinic, Cattinara Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| |
Collapse
|
7
|
Garg V, Kandhari VK, Nasim O, Joshi Y. Effect of Peri-Operative Blood Transfusion on Short and Long-Term Mortality Rates in Elderly Patients With Neck of Femur Fractures: A Retrospective Study. Cureus 2023; 15:e38825. [PMID: 37303443 PMCID: PMC10251790 DOI: 10.7759/cureus.38825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction The current reported mortality rate for elderly neck of femur fractures (eNOFF) is relatively high in the UK. eNOFF patients commonly suffer from associated cardiovascular co-morbidities and tend to have fragile physiological states and poor physiological reserves. Although some studies have shown a potential link between blood transfusion and mortality in eNOFF patients, there is no general consensus on this matter. Therefore, our study aims to explore the possible association between blood transfusion and length of hospital stay (LOHS) as well as short- and long-term mortality rates in eNOFF patients by reviewing the practice of blood transfusion. Methods This retrospective study was conducted at Wrexham Maelor Hospital, which is part of the Betsi Cadwaladr University Health Board (BCUHB), Wales. The study included patients who were 65 years of age or older and presented with neck of femur fractures. Only patients who required surgical intervention were included, and those managed non-operatively were excluded from the study. The statistical analysis was performed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, New York, United States). Furthermore, unpaired t-tests and log-rank (Mantel-Cox) tests were performed to compare the groups that received blood transfusions. Results During the study period, a total of 501 eNOFF patients were included in the primary cohort of the study, with a mean age of 81 years (ranging from 65 to 102). The majority of the patients were female (n=340). Of the 501 patients, 79 (15.8%) received a blood transfusion during their treatment. Around 52.9% of the eNOFF patients were categorized as American Society of Anesthesiologists (ASA) III, but there was no statistically significant difference in the requirement of blood transfusion between patients in ASA III, II, and IV categories, as compared to ASA I. Additionally, the mean time to surgery was higher in patients who received a blood transfusion (35.8 hours), and this difference was statistically significant (p=0.035). Moreover, the average LOHS after surgery for eNOFF was longer in patients who needed peri-operative blood transfusion (22 days), and this difference in the means was statistically significant (p=0.022). At the one-year post-surgery mark, mortality was higher in the transfused group (33%), and long-term five-year mortality rates were also higher in this group (63.2%). Conclusion Peri-operative blood transfusion may confer certain benefits in the management of eNOFF ptients. However, it should not be regarded as a panacea for improving long-term outcomes. The decision to administer blood transfusion must be made on a case-by-case basis, with careful assessment of individual clinical indications, and the potential risks and benefits taken into consideration. To achieve optimal clinical outcomes, close monitoring and follow-up of eNOFF patients, both in the short-term and long-term, are essential.
Collapse
Affiliation(s)
- Vipul Garg
- Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham, GBR
| | | | - Omer Nasim
- Trauma and Orthopaedics, Poole General Hospital, Poole, GBR
| | - Yogesh Joshi
- Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham, GBR
| |
Collapse
|
8
|
The Effect of Hematocrit on All-Cause Mortality in Geriatric Patients with Hip Fractures: A Prospective Cohort Study. J Clin Med 2023; 12:jcm12052010. [PMID: 36902799 PMCID: PMC10004393 DOI: 10.3390/jcm12052010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
OBJECTIVE The present study aimed to evaluate the association between hematocrit (HCT) levels and all-cause mortality in geriatric hip fractures. METHODS Older adult patients with hip fractures were screened between January 2015 and September 2019. The demographic and clinical characteristics of these patients were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between HCT levels and mortality. Analyses were performed using EmpowerStats and the R software. RESULTS A total of 2589 patients were included in this study. The mean follow-up period was 38.94 months. Eight hundred and seventy-five (33.8%) patients died due to all-cause mortality. Linear multivariate Cox regression models showed that HCT level was associated with mortality (hazard ratio [HR] = 0.97, 95% confidence interval [CI]: 0.96-0.99, p = 0.0002) after adjusting for confounding factors. However, the linear association was unstable and nonlinearity was identified. A HCT level of 28% was the inflection point for prediction. A HCT level of <28% was associated with mortality (HR = 0.91, 95% CI: 0.87-0.95, p < 0.0001), whereas a HCT level > 28% was not a risk factor for mortality (HR = 0.99, 95% CI: 0.97-1.01, p = 0.3792). We found that the nonlinear association was very stable in the propensity score-matching sensitivity analysis. CONCLUSIONS The HCT level was nonlinearly associated with mortality in geriatric hip fracture patients and could be considered a predictor of mortality in these patients. REGISTRATION ChiCTR2200057323.
Collapse
|
9
|
Tang Y, Kang L, Guo M, Fan L. Intertrochanteric Fracture Surgery Patients with Diabetes Mellitus are Prone to Suffer Perioperative Neurological and Endocrine/Metabolic Complications: A Propensity-Score Matched Analysis. Ther Clin Risk Manag 2022; 18:775-783. [PMID: 35967194 PMCID: PMC9365324 DOI: 10.2147/tcrm.s366846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background In older adults, the recovery after hip fracture surgery is not always to be well expected due to high risks of adverse outcomes including perioperative complications and mortality. We aimed to evaluate the intertrochanteric fracture (IF) patients with diabetes mellitus (DM) and receiving surgical fixation with intramedullary nail on the perioperative complications, total hospital costs (THC), length of hospital stay (LOS), and mortality. Methods In this retrospective cohort study, among 487 consecutive intertrochanteric fracture patients with age over 65 years and treated surgically by using intramedullary nail between Jan. 2015 and Mar. 2020, 353 patients were included, including 81 with DM and 272 without DM. After using propensity-score matched (PSM) analysis, 80 patients remained in each group. The perioperative complications, 30-day, 90-day, 1-year, and 2-year survival rates, THC, and LOS were observed and compared between two groups. Overall survival was compared by Kaplan–Meier method. Results No significant between-group differences were found in 30-day, 90-day, 1-year, and 2-year mortality rates, THC, LOS, and other perioperative complications after PSM and McNemar’s tests (all p>0.05), except for neurological complications (p<0.004) and endocrine/metabolic complications (p<0.001). At a mean follow-up time of 36.2 months, there were no statistically significant differences between the groups based on the Kaplan–Meier survival curve (p=0.171, log-rank). Conclusion IF surgery patients with DM are more prone to suffer perioperative neurological and endocrine/metabolic complications and they should be managed individually while being aware of these risks henceforth. Further high evidence clinical trials are needed to expand in DM patients with IF.
Collapse
Affiliation(s)
- You Tang
- Department of Joint Surgery, Binzhou People’s Hospital, Binzhou, People’s Republic of China
- Correspondence: You Tang, Department of Joint Surgery, Binzhou People’s Hospital, Binzhou, People’s Republic of China, Email
| | - Le Kang
- Department of Hand Surgery & Microsurgery and Foot & Ankle Surgery, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, People’s Republic of China
| | - Meng Guo
- Department of Rehabilitation, Binzhou Medical University Hospital, Binzhou, People’s Republic of China
| | - Linlin Fan
- Department of Child Healthcare, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, People’s Republic of China
| |
Collapse
|
10
|
Red Blood Cell Transfusion and Postoperative Delirium in Hip Fracture Surgery Patients: A Retrospective Observational Cohort Study. Anesthesiol Res Pract 2021; 2021:8593257. [PMID: 34853589 PMCID: PMC8629661 DOI: 10.1155/2021/8593257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/05/2021] [Accepted: 11/06/2021] [Indexed: 01/28/2023] Open
Abstract
Background Patients having hip fracture surgery are at high risk for postoperative delirium. Red blood cell (RBC) transfusion may increase postoperative delirium risk by causing neuroinflammation. We hypothesized that RBC transfusion would be associated with postoperative delirium in patients having hip fracture surgery. Methods An observational cohort study was performed using the United States National Surgical Quality Improvement Program (NSQIP) participant use files for hip fracture from 2016 to 2018. Propensity score analysis and inverse probability of treatment weighting (IPTW) were used to reduce bias from confounding. An IPTW adjusted odds ratio for developing postoperative delirium was calculated for patients who received RBC transfusion during surgery or in the 72 hours after. Results There were 20,838 patients who had eligible current procedural terminology (CPT) codes for primary hip fracture surgery and complete study data. After employing strict exclusions to balance covariates and reduce bias, 3,715 patients remained in the IPTW cohort. Of these, 626 patients (16.9%) received RBC transfusion and 665 patients (17.9%) developed postoperative delirium. IPTW adjustment led to good covariate balance between patients who received RBC transfusion and those who did not. Patients who received RBC transfusion had significantly higher odds of postoperative delirium, IPTW adjusted odds ratio = 1.21, 95% CI = 1.03 to 1.43, and P = 0.02. Discharge location also differed significantly between patients who received RBC transfusion and those who did not (P < 0.001) with in-hospital mortality or referral to hospice occurring in 1.6% of patients who received RBC transfusion and 1.3% of patients who were not transfused. Conclusion RBC transfusion is associated with increased odds of postoperative delirium after hip fracture surgery and may be associated with worse clinical outcome.
Collapse
|
11
|
Malnutrition, poor function and comorbidities predict mortality up to one year after hip fracture: a cohort study of 2800 patients. Eur Geriatr Med 2021; 13:433-443. [PMID: 34854063 DOI: 10.1007/s41999-021-00598-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Despite extensive research, a complete understanding of factors influencing mortality risk after hip fractures is lacking. Previous research has focused on static risk factors; however, to improve outcomes, attention should be directed towards risk factors that may be optimised. The present study aimed to investigate the association of 19 risk factors with mortality among patients with hip fracture treated according to a well-defined guideline. METHODS The study was a retrospective analysis of a large prospective patient cohort with all consecutive patients surgically treated for a hip fracture from January 2011 to December 2017 included (n = 2800). Variables were obtained from patient records and the Holstebro Hip Fracture Database comprising prospectively registered data on demographics, comorbidity, malnutrition (low Body Mass Index (BMI) or albumin) and hospital stay (including fracture and surgical data, biochemistry, mobilisation and discharge). Outcomes were 30-day and one-year mortality. RESULTS Patients were predominantly female (66%); median age 81.6 years. Overall mortality was 9% at 30 days and 24% at one year. Age ≥ 75 years, male gender, nursing home residence, cognitive impairment, American Society of Anesthesiologists (ASA) score ≥ 3, BMI < 20 kg/m2, albumin < 35 g/l, creatinine ≥ 100 µmol/l, a low New Mobility Score and no mobilisation were all associated with increased mortality at 30 days and one year. CONCLUSION In addition to non-modifiable risk factors, comorbidities (expressed as high ASA score and creatinine), malnutrition, and failure to achieve early post-operative mobilisation were associated with increased short and long-term mortality among patients with hip fracture: these are potentially modifiable. The effect of optimisation interventions warrants further research.
Collapse
|
12
|
Abdelnasser MK, Khalifa AA, Amir KG, Hassan MA, Eisa AA, El-Adly WY, Ibrahim AK, Farouk OA, Abubeih HA. Mortality incidence and its determinants after fragility hip fractures: a prospective cohort study from an Egyptian level one trauma center. Afr Health Sci 2021; 21:806-816. [PMID: 34795739 PMCID: PMC8568210 DOI: 10.4314/ahs.v21i2.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Fragility hip fracture is a common condition with serious consequences. Most outcomes data come from Western and Asian populations. There are few data from African and Middle Eastern countries. Objective The primary objective was to describe mortality rates after fragility hip fracture in a Level-1 trauma centre in Egypt. The secondary objective was to study the causes of re-admissions, complications, and mortality. Methods A prospective cohort study of 301 patients, aged > 65 years, with fragility hip fractures. Data collected included sociodemographic, co-morbidities, timing of admission, and intraoperative,ostoperative, and post-discharge data as mortality, complications, hospital stay, reoperation, and re-admission. Cox regression analysis was conducted to investigate factors associated with 1-year mortality. Results In-hospital mortality was 8.3% (25 patients) which increased to 52.8% (159 patients) after one year; 58.5% of the deaths occurred in the first 3-months. One-year mortality was independently associated with increasing age, ASA 3–4, cardiac or hepatic co-morbidities, trochanteric fractures, total hospital stay, and postoperative ifection and metal failure. Conclusion Our in-hospital mortality rate resembles developed countries reports, reflecting good initial geriatric healthcare. However, our 3- and 12-months mortality rates are unexpectedly high. The implementation of orthogeriatric care after discharge is mandatory to decrease mortality rates.
Collapse
Affiliation(s)
| | - Ahmed A Khalifa
- Orthopedic Department, Qena faculty of medicine and its University Hospital, South valley university, Qena, Egypt
| | - Khaled G Amir
- Orthopedic Department, Assiut University Hospital, Assiut, Egypt
| | | | - Amr A Eisa
- Orthopedic Department, Assiut University Hospital, Assiut, Egypt
| | - Wael Y El-Adly
- Orthopedic Department, Assiut University Hospital, Assiut, Egypt
| | - Ahmed K Ibrahim
- Public Health and Community Medicine Department, faculty of medicine, Assiut University, Assiut, Egypt
| | - Osama A Farouk
- Orthopedic Department, Assiut University Hospital, Assiut, Egypt
| | - Hossam A Abubeih
- Orthopedic Department, Assiut University Hospital, Assiut, Egypt
| |
Collapse
|
13
|
Amin RM, Puvanesarajah V, Chaudhry YP, Best MJ, Rao SS, Frank SM, Hasenboehler EA. Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration. World J Orthop 2021; 12:292-300. [PMID: 34055586 PMCID: PMC8152439 DOI: 10.5312/wjo.v12.i5.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/18/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery.
AIM To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients.
METHODS In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05.
RESULTS Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort.
CONCLUSION The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.
Collapse
Affiliation(s)
- Raj M Amin
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA 94305, United States
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
| | - Yash P Chaudhry
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA 19122, United States
| | - Matthew J Best
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MD 02114, United States
| | - Sandesh S Rao
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
| | - Steven M Frank
- Department of Anesthesiology, Critical Care Medicine, Baltimore, MD 21205, United States
| | - Erik A Hasenboehler
- Department of Orthopaedics, Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
| |
Collapse
|
14
|
Erivan R, Hacquart T, Villatte G, Mulliez A, Descamps S, Boisgard S. Place of residence before and place of discharge after femoral neck fracture surgery are associated with mortality: A study of 1238 patients with at least three years' follow-up. Orthop Traumatol Surg Res 2021; 107:102876. [PMID: 33652150 DOI: 10.1016/j.otsr.2021.102876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/30/2020] [Accepted: 12/09/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Femoral neck fractures constitute a major public health challenge. The risk of death after surgery depends chiefly on the patient's general health and comorbidities. No studies assessing place of residence are available. The objectives of this study were to determine whether mortality differed according to the patient's previous place of residence and to the place of discharge, and to describe the complications occurring after femoral neck fracture surgery. HYPOTHESIS After femoral neck fracture surgery, the place of discharge is associated with the risk of death, and the complication rate is high. METHODS This single-centre retrospective study included 1241 adults who sustained a true femoral neck fracture between 2006 and 2016 and were followed up for at least 3 years. The following data were collected: age at the time of the fracture, sex, hospital stay length, place of residence before and after the fracture, characteristics of the fracture, type of treatment, time from the fracture to surgery, and whether anticoagulant therapy was given. We then recorded data on mortality and complications. RESULTS The 3-year mortality rate was 36.0±1.4% (95%CI, 33.3-38.7). Place of residence before the fracture was strongly associated with mortality: the risk of death was higher in patients who lived in care homes (hazard ratio [HR], 2.18) or were hospitalised (HR, 1.78) and lower in patients who lived at home (HR, 0.46). The risk of death was also higher in patients discharged to care homes (HR, 1.82) or to hospitals (HR, 1.90) and lower in patients discharged home (HR, 0.30). All these differences were statistically significant (p<0.0001). CONCLUSION Place of residence and likely place of discharge should be evaluated as soon as the patient is admitted to the emergency department, in order to provide the best information possible to the patient and family and to establish the most appropriate treatment strategy. Patient self-sufficiency is a major parameter that should be preserved to the extent possible. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Roger Erivan
- Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, 63000 Clermont-Ferrand, France.
| | - Thomas Hacquart
- Université Clermont Auvergne, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Guillaume Villatte
- Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, 63000 Clermont-Ferrand, France
| | - Aurélien Mulliez
- Délégation à la recherche clinique et aux innovations (DRCI) - CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Stéphane Descamps
- Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, 63000 Clermont-Ferrand, France
| | - Stéphane Boisgard
- Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, 63000 Clermont-Ferrand, France
| |
Collapse
|
15
|
Guo J, Di J, Gao X, Zha J, Wang X, Wang Z, Wang Q, Hou Z, Zhang Y. Discriminative Ability for Adverse Outcomes After Hip Fracture Surgery: A Comparison of Three Commonly Used Comorbidity-Based Indices. Gerontology 2021; 68:62-74. [PMID: 33895736 DOI: 10.1159/000515526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 02/27/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Preoperative risk assessment can predict adverse outcomes following hip fracture surgery, helping with decision-making and management strategies. Several risk adjustment models based on coded comorbidities such as Charlson Comorbidity Index (CCI), modified Elixhauser's Comorbidity Measure (mECM), and modified frailty index (mFI-5) are currently prevalent for orthopedic patients, but there is no consensus regarding which is optimal. The primary purpose was to identify the risk factors of CCI, mECM, and mFI-5, as well as patient characteristics for predicting (1) 1-month, 3-month, 1-year, and 2-year mortality, (2) perioperative complications, and (3) extended length of stay (LOS) following hip fractured surgery. The secondary aim was to compare the best-performing comorbidity index combined with characteristics identified in terms of their discriminative ability for adverse outcomes. METHODS We retrospectively reviewed 3,379 consecutive patients presenting with intertrochanteric fractures at our Level I trauma center from 2013 to 2018. After eliminated by exclusion criteria, 2,241 patients undergoing hip fracture surgery by PFNA, with age ≥65 years, were included. Three main multivariate logistic regression models were constructed. Cox proportional hazards models were used to calculate hazard ratios for mortality. A base model included age, BMI, surgical delay, anesthesia type, hemoglobin record at admission, and American Society of Anesthesiologists grade (ASA) also was constructed and assessed. RESULTS Base model + mECM outperformed other models for the occurrence of major complications including severe complications, cardiac complications, and pulmonary complications [the area under the receiver operating characteristic curve (AUC), 0.647; 95% CI, 0.616-0.677; AUC, 0.637; 95% CI, 0.610-0.664; AUC, 0.679; 95% CI, 0.642-0.715, respectively], while base model + CCI provided better prediction of minor complications of neurological complications and hematological complications (AUC, 0.659; 95% CI, 0.609, 0.709; AUC, 0.658; 95% CI, 0.635, 0.680). In addition, BMI, surgical delay, anesthesia type, and ASA were found highly relevant to extended LOS. Age-group (with a 10-year interval) was indicated to be mostly associated with all-cause mortality with fully adjusted hazard ratio of 1.35 and 95% CI range 1.20-1.51. CONCLUSIONS In comparison with mFI-5 and CCI, mECM so far may be the best comorbidity index combined with the base model for predicting major complications following hip fracture. The base model already achieved good discrimination for all-cause mortality and extended LOS, further addition of risk adjustment indices led to only 1% increase in the amount of variation explained.
Collapse
Affiliation(s)
- Junfei Guo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Orthopaedic Research Institute of Hebei Province, Shijiazhuang, China
| | - Jun Di
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xian Gao
- Medical Department, First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Junpu Zha
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiuli Wang
- Department of Anesthesiology, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhiqian Wang
- Department of Geriatric Orthopedics, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qingxian Wang
- Department of Geriatric Orthopedics, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Orthopaedic Research Institute of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment (The Third Hospital of Hebei Medical University), Shijiazhuang, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Orthopaedic Research Institute of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment (The Third Hospital of Hebei Medical University), Shijiazhuang, China.,Chinese Academy of Engineering, Beijing, China
| |
Collapse
|
16
|
Canbeyli İD, Çırpar M, Oktaş B, Çoban M. Analysis of factors among 30-day and 1-year mortality rates in patients with borderline stable-unstable intertrochanteric hip fracture. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2021; 55:16-21. [PMID: 33650505 DOI: 10.5152/j.aott.2021.20071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to evaluate the possible effects of surgical procedures on mortality and to identify the possible risk factors for mortality in the management of geriatric hip fractures. METHODS A total of 191 patients (105 women and 86 men; mean age 82.26±9.681 [60-108] years) with AO/OTA 31A2.2 intertrochanteric fractures and treated with sliding hip screw, proximal femoral nail, or hemiarthroplasty were included in this retrospective cohort study. The treatment type was decided by the responsible surgeon according to the patients' pre-injury activity level, bone quality, and features of the fracture. Age, sex, type of fracture, type of surgery performed, American society of anesthesiology (ASA) grade, type of anesthesia, time to surgery, type of physical therapy, length of hospital stay, and number of comorbidities were documented. We evaluated the 30-day and 1-year mortality of patients treated with sliding hip screw (SHS), proximal femoral nail antirotation (PFN-A), or hemiarthroplasty and identified the possible risk factors for mortality. RESULTS A total of 49 patients underwent SHS, 58 underwent PFN-A, and 84 underwent hemiarthroplasty. Of these, 2 patients with SHS, 2 with PFN-A, and 11 with hemiarthroplasty died within 30 days after surgery, whereas 7 patients with SHS, 15 with PFN-A, and 23 with hemiarthroplasty died 1 year after surgery. The 30-day and 1-year overall mortality rates were 7.9% and 23.6%, respectively. Both the 30-day and 1-year mortality risks were higher in patients undergoing hemiarthroplasty than in patients undergoing SHS (p=0.068 versus 0.058). The 30-day mortality was higher in patients receiving general anesthesia than in those receiving combined spinal and epidural anesthesia (p=0.009). The 1-year mortality risk was higher in patients with ASA grade 4 than in those with grade 1 and 2 (p=0.045). Advanced age (p=0.022) and male sex (p=0.007) were also found to be the risk factors for 1-year mortality. CONCLUSION We demonstrated that higher ASA grade, male sex, general anesthesia, and hemiarthroplasty procedures are associated with higher mortality rates in elderly patients with hip fractures. Thus, we highly recommend orthopedic surgeons to consider all these factors in the management of intertrochanteric hip fractures in the geriatric population. LEVEL OF EVIDENCE Level IV, Prognostic Study.
Collapse
Affiliation(s)
- İbrahim Deniz Canbeyli
- Department of Orthopedics and Traumatology, Kırıkkale University, School of Medicine, Kırıkkale, Turkey
| | - Meriç Çırpar
- Department of Orthopedics and Traumatology, Kırıkkale University, School of Medicine, Kırıkkale, Turkey
| | - Birhan Oktaş
- Department of Orthopedics and Traumatology, Kırıkkale University, School of Medicine, Kırıkkale, Turkey
| | - Mehmet Çoban
- Department of Orthopedics and Traumatology, Kırıkkale University, School of Medicine, Kırıkkale, Turkey
| |
Collapse
|
17
|
Collin C, Bimou C, Mabit C, Tchalla A, Charissoux JL, Marcheix PS. Orthogeriatric assessment of patients over 75 years of age with a proximal femur fracture: Predictors of 6-month mortality. Orthop Traumatol Surg Res 2020; 106:1441-1447. [PMID: 33060014 DOI: 10.1016/j.otsr.2020.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Proximal femur fractures are common and dangerous in older adults, given the high short-term mortality rate. While surgical treatment is vital, medical orthogeriatric care may reduce the 6-month mortality rate; however, this has not been determined on a broad scale in France. This led us to conduct a retrospective study to answer the following questions: (1) Does delayed surgical treatment impact the 6-month mortality rate? (2) Are there correctable medical factors that impact the 6-month mortality? HYPOTHESIS Delayed surgical treatment is not an isolated risk factor for higher 6-month mortality after proximal femur fracture. METHODS We included all patients 75 years or older who had suffered a proximal femur fracture requiring surgical treatment. This allowed us to analyze the medical records of 476 patients retrospectively. We documented their comorbidities and pre-, intra- and postoperative characteristics. A univariate then multivariate analysis was done to identify risk factors for mortality at 6 months. RESULTS In the univariate analysis, time to surgery of more than 48hours increased the risk of dying at 6 months by 1.5 fold (Odds ratio (OR)=1.57/95% CI: 1-2.48/p=0.04). However, this risk factor was not significant in the multivariate analysis since it is not an independent risk factor. In the multivariate analysis, anticoagulants (OR=2/95% CI: 1.13-3.50/p=0.02), dementia (OR=2.2/95% CI: 1.32-3.59/p=0.002), peripheral artery disease (OR=2.9/95% CI: 1.10-7.70/p=0.03), 2-point drop in hemoglobin count from preoperative to postoperative (OR=1.9/95% CI: 1.05-3.12/p=0.04), male sex (OR=1.82/95% CI: 1.05-3.12/p=0.04), age above 85 years (OR=5.26/95% CI: 1.49-5.26/p=0.002) and Charlson comorbidity index≥7 (OR=2.13/95% CI: 1.29-3.52/p=0.003) were statistically associated with mortality at 6 months. DISCUSSION/CONCLUSION Our study found that the patients most at risk for dying within 6 months of a hip fracture were males, older than 85 and have associated medical conditions (Charlson index≥7). Prior anticoagulant treatment increases the time to surgery in our study and therefore increases the risk of these patients dying within 6 months. Treatment of these at-risk patients should ensure that their underlying medical conditions are not made worse, while providing treatment within 48hours. Patients taking anticoagulants must be monitored carefully to ensure surgical treatment is not delayed. LEVEL OF EVIDENCE IV, retrospective study without control group.
Collapse
Affiliation(s)
- Camille Collin
- Service d'orthopédie-traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France
| | - Charlotte Bimou
- EA 6310 HAVAE handicap activité vieillissement autonomie environnement, université de Limoges, 33, rue François-Mitterrand, 87032 Limoges, France
| | - Christian Mabit
- Service d'orthopédie-traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France
| | - Achille Tchalla
- Service de médecine gériatrique, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France
| | - Jean-Louis Charissoux
- Service d'orthopédie-traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France
| | - Pierre-Sylvain Marcheix
- Service d'orthopédie-traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France.
| |
Collapse
|
18
|
Functional treatment strategy for fragility fractures of the pelvis in geriatric patients. Eur J Trauma Emerg Surg 2020; 47:21-27. [PMID: 32862316 DOI: 10.1007/s00068-020-01484-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/24/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE We propose a functional treatment strategy for fragility fractures of the pelvis (FFP) in geriatric patients; patients with such fractures normally undergo 10 days of conservative therapy with full-weight bearing within pain limits. Conservative therapy for FFP is continued for patients who can stand with assistance, and surgical stabilization is recommended for patients with difficulty in auxiliary standing at 10 day postadmission. This study aimed to compare the outcomes of functional treatment between geriatric patients with FFP type I/II and those with FFP type III/IV, as described by Rommens et al. METHODS: We conducted a retrospective study of 84 geriatric patients who underwent functional treatment for FFP. Based on the results of the first examination, the patients were allocated to the following FFP types: type I/II (n = 53) and type III/IV (n = 31). Change in functional mobility scale described by Graham et al. from before injury to the final follow-up were compared between the groups. RESULTS There was no significant difference in the functional mobility scale (0.25 ± 0.70 vs. 0.23 ± 0.56, p = 0.889) between FFP type I/II and FFP type III/IV. CONCLUSION The outcomes of the functional treatment for FFP for the geriatric patients did not differ significantly between the radiographic classifications. Functional treatment could, therefore, be a treatment option for almost all radiographic types of FFP, especially for geriatric patients. Further investigations are warranted.
Collapse
|
19
|
Guo J, Wang Z, Fu M, Di J, Zha J, Liu J, Zhang G, Wang Q, Chen H, Tang P, Hou Z, Zhang Y. Super elderly patients with intertrochanteric fractures do not predict worse outcomes and higher mortality than elderly patients: a propensity score matched analysis. Aging (Albany NY) 2020; 12:13583-13593. [PMID: 32649313 PMCID: PMC7377837 DOI: 10.18632/aging.103466] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/27/2020] [Indexed: 12/23/2022]
Abstract
We aimed to investigate whether super elderly patients aged over 90 years had significantly worse functional outcomes, perioperative complications, and survival rates. Among 3560 patients aged over 65 years presenting with intertrochanteric fractures and treated surgically between Jan 2014 and Jan 2019, 2242 patients were included, including 206 in super elderly group and 2036 in elderly group. After using propensity score matching to minimize the effects of possible confounding variables, 192 remained in each group. No significant difference was observed in functional outcomes, perioperative complications, or 30-day, 90-day, and 1-year mortality after propensity score matching and McNemar’s tests (p>0.05). After an average follow-up of 37 months, the Kaplan-Meier survival curve showed no significant difference between the two groups in terms of cumulative survival rate (p=0.081, log-rank). Our data demonstrated progressive increases in mortality and poor outcomes with increasing Elixhauser comorbidity scores, which represented the severity index of patients preoperatively. Our study also found that there were weak correlations between five characteristics and the patient age. These results all suggested that it is not the advanced age itself but other concomitant factors, that appear to be responsible for the adverse functional outcomes, perioperative complications, and mortality in super elderly patients.
Collapse
Affiliation(s)
- Junfei Guo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei, P.R. China
| | - Zhiqian Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei, P.R. China
| | - Mingming Fu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei, P.R. China
| | - Jun Di
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei, P.R. China
| | - Junpu Zha
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei, P.R. China
| | - Junchuan Liu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei, P.R. China
| | - Guolei Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei, P.R. China
| | - Qingxian Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei, P.R. China
| | - Hua Chen
- Department of Orthopaedic Surgery, Chinese PLA General Hospital, 301 Hospital, Beijing 100853, P.R. China
| | - Peifu Tang
- Department of Orthopaedic Surgery, Chinese PLA General Hospital, 301 Hospital, Beijing 100853, P.R. China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei, P.R. China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei, P.R. China.,Chinese Academy of Engineering, Beijing 100088, P.R. China
| |
Collapse
|
20
|
Huette P, Abou-Arab O, Djebara AE, Terrasi B, Beyls C, Guinot PG, Havet E, Dupont H, Lorne E, Ntouba A, Mahjoub Y. Risk factors and mortality of patients undergoing hip fracture surgery: a one-year follow-up study. Sci Rep 2020; 10:9607. [PMID: 32541939 PMCID: PMC7296002 DOI: 10.1038/s41598-020-66614-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/22/2020] [Indexed: 12/03/2022] Open
Abstract
Hip fracture (HF) remains a main issue in the elderly patient. About 1.6 million patients a year worldwide are victims of a HF. Their incidence is expected to rise with the aging of the world’s population. Identifying risk factors is mandatory in order to reduce mortality and morbidity. The aim of the study was to identify risk factors of 1-year mortality after HF surgery. We performed an observational, prospective, single-center study at Amiens University Hospital (Amiens, France). After ethical approval, we consecutively included all patients with a HF who underwent surgery between June 2016 and June 2017. Perioperative data were collected from medical charts and by interviews. Mortality rate at 12 months was recorded. Univariate analysis was performed and mortality risk factors were investigated using a Cox model. 309 patients were analyzed during this follow-up. Mortality at 1 year was 23.9%. Time to surgery over 48 hours involved 181 patients (58.6%) while 128 patients (41.4%) had surgery within the 48 hours following the hospital admission. Independent factors associated with 1-year mortality were: age (HR at 1.059 (95%CI [1.005–1.116], p = 0,032), Lee score ≥ 3 (HR at 1,52 (95% CI [1,052–2,198], p = 0.026) and time to surgery over 48 hours (HR of 1.057 (95% CI [1.007–1.108], p = 0.024). Age, delayed surgical (over 48 hours) management and medical history are important risk factors of 1-year mortality in this French cohort
Collapse
Affiliation(s)
- Pierre Huette
- Department of Anaesthesiology and Critical Care Medicine. Amiens University Hospital. F- 80054, Amiens, France.
| | - Osama Abou-Arab
- Department of Anaesthesiology and Critical Care Medicine. Amiens University Hospital. F- 80054, Amiens, France
| | - Az-Eddine Djebara
- Department of orthopedic surgery. Amiens University Hospital. F- 80054, Amiens, France
| | - Benjamin Terrasi
- Department of Anaesthesiology and Critical Care Medicine. Amiens University Hospital. F- 80054, Amiens, France
| | - Christophe Beyls
- Department of Anaesthesiology and Critical Care Medicine. Amiens University Hospital. F- 80054, Amiens, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine. Dijon University Hospital. F- 21000, Dijon, France
| | - Eric Havet
- Department of orthopedic surgery. Amiens University Hospital. F- 80054, Amiens, France
| | - Hervé Dupont
- Department of Anaesthesiology and Critical Care Medicine. Amiens University Hospital. F- 80054, Amiens, France
| | - Emmanuel Lorne
- Department of Anaesthesiology and Critical Care Medicine. Amiens University Hospital. F- 80054, Amiens, France
| | - Alexandre Ntouba
- Department of Anaesthesiology and Critical Care Medicine. Amiens University Hospital. F- 80054, Amiens, France
| | - Yazine Mahjoub
- Department of Anaesthesiology and Critical Care Medicine. Amiens University Hospital. F- 80054, Amiens, France
| |
Collapse
|
21
|
Ko Y, Baek SH, Ha YC. Predictive factors associated with mortality in Korean elderly patients with hip fractures. J Orthop Surg (Hong Kong) 2020; 27:2309499019847848. [PMID: 31154958 DOI: 10.1177/2309499019847848] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND It is important to investigate the level of physical function impairment before fracture to predict mortality after hip fracture. This study aimed to examine the predictive factors associated with mortality depending on prefracture physical function impairment among Korean elderly patients. METHODS We included 1841 patients aged 65 years and older with hip fractures using osteoporosis-related hip fracture network data from 15 university hospitals in South Korea. The collected data included sociodemographic, nutritional, disease-related, and fracture- and surgery-related factors. For the degree of prefracture physical function impairment, ambulatory ability was classified into community, household, and nonfunctional ambulators. Binominal logistic regression was used to identify the predictive factors for mortality. RESULTS Analysis showed that mortality rate at the first follow-up after hip fracture was 4.9%, and most patients (77.7%) were community ambulators before fracture. Sociodemographic (older age, male sex), nutritional (low body mass index, low albumin level before surgery), and fracture- and surgery-related (nonsurgical management, complications after surgery) factors significantly predicted mortality, depending on the prefracture ambulatory status. CONCLUSIONS This study emphasizes that nutritional assessment and management as interdisciplinary interventions from hospitalization to follow-ups should be performed to lower malnutrition and mortality risk. Therapeutic management for comorbidities negatively affecting surgery outcomes should be prioritized to reduce postoperative complications and mortality. Surgical treatment should be encouraged if it aligns with the therapeutic goals, even in poor health status.
Collapse
Affiliation(s)
- Youngji Ko
- 1 Department of Nursing, Daegu Haany University, Daegu, South Korea
| | - Seung-Hoon Baek
- 2 Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Yong-Chan Ha
- 3 Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, South Korea
| |
Collapse
|
22
|
Nunes BKG, de Lima BR, Guimarães LCDC, Guimarães RA, Rosso CFW, Felipe LDA, Pagotto V. Survival Analysis of Hospitalized Elderly People with Fractures in Brazil Over One Year. Geriatrics (Basel) 2020; 5:geriatrics5010010. [PMID: 32092863 PMCID: PMC7151474 DOI: 10.3390/geriatrics5010010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/14/2020] [Accepted: 02/15/2020] [Indexed: 01/03/2023] Open
Abstract
Objective: This study analyzes the causes of death, survival, and other related factors in hospitalized elderly people with fractures over the course of one year. Methods: We followed 376 fracture patients for one year in a prospective cohort study to a reference hospital in central Brazil. The Cox regression model was used to analyze factors associated with survival. Results: The results indicate that the one-year mortality rate was high (22.9%). The independent factors linked to lower overall survival were as follows: patients aged ≥80 years with previous intensive care unit (ICU) admission and presence of comorbidities (diabetes mellitus [DM] and dementia). Conclusion: Our study results may contribute to a better understanding of the impact of fractures on the elderly population and reinforce the need to oversee age-groups, diabetic patients, and patients with complications during hospitalization.
Collapse
Affiliation(s)
- Brenda Kelly Gonçalves Nunes
- Faculdade de Enfermagem, Programa de Pós-graduação em Enfermagem, Universidade Federal de Goiás, Goiânia, GO 74605080, Brazil; (B.K.G.N.); (B.R.d.L.); (L.C.d.C.G.); (C.F.W.R.); (V.P.)
| | - Brunna Rodrigues de Lima
- Faculdade de Enfermagem, Programa de Pós-graduação em Enfermagem, Universidade Federal de Goiás, Goiânia, GO 74605080, Brazil; (B.K.G.N.); (B.R.d.L.); (L.C.d.C.G.); (C.F.W.R.); (V.P.)
| | - Lara Cristina da Cunha Guimarães
- Faculdade de Enfermagem, Programa de Pós-graduação em Enfermagem, Universidade Federal de Goiás, Goiânia, GO 74605080, Brazil; (B.K.G.N.); (B.R.d.L.); (L.C.d.C.G.); (C.F.W.R.); (V.P.)
| | - Rafael Alves Guimarães
- Instituto de Patologia Tropical e Saúde Pública, Departamento de Saúde Coletiva, Universidade Federal de Goiás, Goiânia, GO 74605050, Brazil
- Correspondence:
| | - Claci Fátima Weirich Rosso
- Faculdade de Enfermagem, Programa de Pós-graduação em Enfermagem, Universidade Federal de Goiás, Goiânia, GO 74605080, Brazil; (B.K.G.N.); (B.R.d.L.); (L.C.d.C.G.); (C.F.W.R.); (V.P.)
| | | | - Valéria Pagotto
- Faculdade de Enfermagem, Programa de Pós-graduação em Enfermagem, Universidade Federal de Goiás, Goiânia, GO 74605080, Brazil; (B.K.G.N.); (B.R.d.L.); (L.C.d.C.G.); (C.F.W.R.); (V.P.)
| |
Collapse
|
23
|
A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures. J Am Acad Orthop Surg 2019; 27:887-894. [PMID: 30829898 DOI: 10.5435/jaaos-d-18-00374] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population. METHODS In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation. RESULTS After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival. DISCUSSION A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL. LEVEL OF EVIDENCE Level III, retrospective cohort study.
Collapse
|
24
|
Xu BY, Yan S, Low LL, Vasanwala FF, Low SG. Predictors of poor functional outcomes and mortality in patients with hip fracture: a systematic review. BMC Musculoskelet Disord 2019; 20:568. [PMID: 31775693 PMCID: PMC6882152 DOI: 10.1186/s12891-019-2950-0] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/14/2019] [Indexed: 12/17/2022] Open
Abstract
Background Hip fracture is an important and prevalent medical condition associated with adverse outcomes. The aim of this article is to systematically review and summarise the predictors of poor functional outcomes and mortality for patients with hip fractures. Methods We conducted a systemic literature search using PubMed, EMBASE and Cochrane Library. We included English peer-reviewed cohort studies that examined predictors of poor functional outcomes (such as independence in Activities of Daily Living) and mortality for patients with hip fracture published in the past 15 years (from 1 Jan 2004 up to 30 May 2019). Two independent researchers evaluated the articles for eligibility. Consensus on the eligibility was sought and a third researcher was involved if there was disagreement. A standardised form was used to extract relevant data. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. Results We retrieved 4339 and included 81 articles. We identified two emerging predictors of poor functional outcomes and mortality for patients with hip fractures: low hand grip strength and frailty in line with an emerging concept of “physical performance”. The predictors identified in this systematic review can be grouped into 1) medical factors, such as presence of co-morbidities, high American Society of Anesthesiologists (ASA) grade, sarcopenia, 2) surgical factors including delay in operation (e.g. > 48 h), type of fracture s, 3) socio-economic factors which include age, gender, ethnicity, and 4) system factors including lower case-volume centers. Conclusions This systematic review identified multiple significant predictors of poor functional outcomes and mortality, with the hand grip strength and frailty being important emerging predictors in the most recent literature. These predictors would further inform healthcare providers of their patients’ health status and allow for early intervention for modifiable predictors.
Collapse
Affiliation(s)
- Bang Yu Xu
- Department of Post Acute and Continuity Care, SingHealth Community Hospital - Sengkang, 1 Anchorvale St, Singapore, 544835, Singapore.
| | - Shi Yan
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Lian Leng Low
- Department of Family Med & Continuing Care, Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore
| | - Farhad Fakhrudin Vasanwala
- Department of Post Acute and Continuity Care, SingHealth Community Hospital - Sengkang, 1 Anchorvale St, Singapore, 544835, Singapore
| | - Sher Guan Low
- Department of Post Acute and Continuity Care, SingHealth Community Hospital - Sengkang, 1 Anchorvale St, Singapore, 544835, Singapore
| |
Collapse
|
25
|
Wallace MA, Hammes A, Rothman MS, Trizno AA, Jones CD, Cumbler E, McDevitt K, Carlson NE, Stoneback JW. Fixing a Fragmented System: Impact of a Comprehensive Geriatric Hip Fracture Program on Long-Term Mortality. Perm J 2019; 23:18.286. [PMID: 31702983 DOI: 10.7812/tpp/18.286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
CONTEXT Geriatric hip fractures are increasingly common and confer substantial morbidity and mortality. Fragmentation in geriatric hip fracture care remains a barrier to improved outcomes. OBJECTIVE To evaluate the impact of a comprehensive geriatric hip fracture program on long-term mortality. DESIGN We conducted a retrospective cohort study of patients aged 65 years and older admitted to our academic medical center between January 1, 2012, and March 31, 2016 with an acute fragility hip fracture. Mortality data were obtained for in-state residents from the state public health department. MAIN OUTCOME MEASURES Mortality within 1 year of index admission and overall survival based on available follow-up data. RESULTS We identified 243 index admissions during the study period, including 135 before and 108 after program implementation in October 2014. The postintervention cohort trended toward a lower unadjusted 1-year mortality rate compared with the preintervention cohort (15.7% vs 24.4%, p = 0.111), as well as lower adjusted mortality at 1 year (relative risk = 0.73, 95% confidence interval = 0.46-1.16, p = 0.18), although the differences were not statistically significant. The postintervention cohort had significantly higher overall survival than did the preintervention cohort (hazard ratio for death = 0.43, 95% confidence interval = 0.25-0.74, p = 0.002). CONCLUSION Fixing fragmentation in geriatric hip fracture care such as through an orthogeriatric model is essential to improving overall survival for this patient population.
Collapse
Affiliation(s)
- Mary Anderson Wallace
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Andrew Hammes
- Department of Biostatistics and Informatics, University of Colorado, Aurora
| | - Micol S Rothman
- Division of Endocrinology, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Anastasiya A Trizno
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora
| | - Christine D Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Ethan Cumbler
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Kelly McDevitt
- University of Colorado Health, Longs Peak Hospital, Longmont
| | - Nichole E Carlson
- Department of Biostatistics and Informatics, University of Colorado, Aurora
| | - Jason W Stoneback
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora
| |
Collapse
|
26
|
Maroun G, Chaftari R, Chokr J, Maroun C, El-Jerdi M, Saade C. High comorbidity index is not associated with high morbidity and mortality when employing constrained arthroplasty as a primary treatment for intertrochanteric fractures in elderly patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1009-1015. [PMID: 30739162 DOI: 10.1007/s00590-019-02394-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 02/04/2019] [Indexed: 11/25/2022]
Abstract
AIM The aim of our study is to investigate the results of constrained total hip arthroplasty as a primary treatment of intertrochanteric fractures (ITF) in elderly patients with high comorbidities. MATERIALS AND METHODS Total hip replacement (THR) with a retentive cup was performed on 73 patients with ITF over the age of 54 years who had high comorbidities and a Charlson score above five. Short- and long-term complications were determined by follow-up. Bivariate analysis was conducted in order to determine the possible determinants of mortality and factors associated with comorbidity as measured by the Charlson comorbidities index. RESULTS Patient demographics that consisted of females (58.9%) (p < 0.04) with the mean age of both males and females demonstrated no statistical significance. The mean hospitalization time and weight bearing time were 11 and 2.67 days, respectively. Only 4.1% needed re-intervention due to re-fracture and none due to prosthesis failure. There was a statistical significance between the comorbidity index and the mortality rate. However, no statistical significance was identified between the comorbidity index and the functional status after constrained THR. CONCLUSION High comorbidity index is not associated with high morbidity and mortality when employing constrained arthroplasty as a primary treatment for ITF in elderly patients.
Collapse
Affiliation(s)
- Gilbert Maroun
- Diagnostic Radiology Department, American University of Beirut Medical Center, P.O.Box: 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon
| | - Raja Chaftari
- Department of Orthopedic Surgery, Geitaoui Lebanese Hospital, P.O.Box: 175086, Beirut, 1107 2020, Lebanon
| | - Jad Chokr
- Diagnostic Radiology Department, American University of Beirut Medical Center, P.O.Box: 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon
| | - Charbel Maroun
- Department of Orthopedic Surgery, Institut de la main Clinique Jouvenet Paris, 6 square Jouvenet, 75016, Paris, France
| | - Moussa El-Jerdi
- Department of Orthopedic Surgery, Geitaoui Lebanese Hospital, P.O.Box: 175086, Beirut, 1107 2020, Lebanon
| | - Charbel Saade
- Diagnostic Radiology Department, American University of Beirut Medical Center, P.O.Box: 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon.
| |
Collapse
|
27
|
Patel V, Champaneria R, Dretzke J, Yeung J. Effect of regional versus general anaesthesia on postoperative delirium in elderly patients undergoing surgery for hip fracture: a systematic review. BMJ Open 2018; 8:e020757. [PMID: 30518580 PMCID: PMC6286489 DOI: 10.1136/bmjopen-2017-020757] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 10/17/2018] [Accepted: 10/26/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Older patients with hip fractures who are undergoing surgery are at high risk of significant mortality and morbidity including postoperative delirium. It is unclear whether different types of anaesthesia may reduce the incidence of postoperative delirium. This systematic review will investigate the impact of anaesthetic technique on postoperative delirium. Other outcomes included mortality, length of stay, complications and functional outcomes. DESIGN Systematic review of randomised controlled trials and non-randomised controlled studies. DATA SOURCES Bibliographic databases were searched from inception to June 2018. Web of Science and ZETOC databases were searched for conference proceedings. Reference lists of relevant articles were checked, and clinical trial registers were searched to identify ongoing trials. ELIGIBILITY CRITERIA Studies were eligible if general and regional anaesthesia were compared in patients (aged 60 and over) undergoing hip fracture surgery, reporting primary outcome of postoperative delirium and secondary outcomes of mortality, length of hospital stay, adverse events, functional outcomes, discharge location and quality of life. Exclusion criteria were anaesthetic technique or drug not considered current standard practice; patients undergoing hip fracture surgery alongside other surgery and uncontrolled studies. RESULTS One hundred and four studies were included. There was no evidence to suggest that anaesthesia type influences postoperative delirium or mortality. Some studies suggested a small reduction in length of hospital stay with regional anaesthesia. There was some evidence to suggest that respiratory complications and intraoperative hypotension were more common with general anaesthesia. Heterogeneity precluded meta-analysis. All findings were described narratively and data were presented where possible in forest plots for illustrative purposes. CONCLUSIONS While there was no evidence to suggest that anaesthesia types influence postoperative delirium, the evidence base is lacking. There is a need to ascertain the impact of type of anaesthesia on outcomes with an adequately powered, methodologically rigorous study. PROSPERO REGISTRATION NUMBER CRD42015020166.
Collapse
Affiliation(s)
- Vanisha Patel
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Rita Champaneria
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Janine Dretzke
- Biostatistics, Evidence Synthesis and Test Evaluation (BESaTE), Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia and Critical Care, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| |
Collapse
|
28
|
Åhman R, Siverhall PF, Snygg J, Fredrikson M, Enlund G, Björnström K, Chew MS. Determinants of mortality after hip fracture surgery in Sweden: a registry-based retrospective cohort study. Sci Rep 2018; 8:15695. [PMID: 30356058 PMCID: PMC6200788 DOI: 10.1038/s41598-018-33940-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/06/2018] [Indexed: 11/27/2022] Open
Abstract
Surgery for hip fractures is associated with high mortality and morbidity. The causes of poor outcome are not fully understood and may be related to other factors than the surgery itself. The relative contributions of patient, surgical, anaesthetic and structural factors have seldom been studied together. This study, a retrospective registry-based cohort study of 14 932 patients undergoing hip fracture surgery in Sweden from 1st of January 2014 to 31st of December 2016, aimed to identify important predictors of mortality post-surgery. The independent predictive power of our included variables was examined using Cox proportional hazards modeling with all-cause mortality at longest follow-up as the outcome. Twelve independent variables were considered as interrelated ‘exposures’ and their individual adjusted effect within a single model were evaluated. Kaplan-Meier curves were also generated. Crude mortality rates were 8.2% at 30 days (95% CI 7.7–8.6%) and 23.6% at 365 days (95% CI 22.9–24.2%). Of the 12 factors entered into the Cox regression analysis, age (aHR1.06, p < 0.001), male gender (aHR 1.45, p < 0.001), ASA-PS-class (ASA 1&2 reference; ASA 3 aHR 2.12; ASA 4 aHR 4.79; ASA 5 aHR 12.57 respectively, p < 0.001) and PACU-LOS (aHR 1.01, p < 0.001) were significantly associated with mortality at longest follow-up (up to 3 years). University hospital status was protective (aHR 0.83, p < 0.001) in the same model. Age, gender and ASA-PS-class were strong predictors of mortality after surgery for hip fractures in Sweden. University hospital status and length of stay in the postoperative care unit were also identified as modifiable risk factors after multivariable adjustment and require confirmation in future studies.
Collapse
Affiliation(s)
- Rasmus Åhman
- Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Linköping University, Linköping, S-58185, Sweden.
| | - Pontus Forsberg Siverhall
- Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Linköping University, Linköping, S-58185, Sweden
| | - Johan Snygg
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health, Linköping University, S-58185, Linköping, Sweden
| | - Gunnar Enlund
- Department of Anaesthesia and Intensive Care, Uppsala University Hospital, 78185, Uppsala, Sweden
| | - Karin Björnström
- Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Linköping University, Linköping, S-58185, Sweden
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Linköping University, Linköping, S-58185, Sweden
| |
Collapse
|
29
|
Aigner R, Buecking B, Hack J, Eschbach D, Oberkircher L, Ruchholtz S, Bliemel C. Pre-fracture hospitalization is associated with worse functional outcome and higher mortality in geriatric hip fracture patients. Arch Osteoporos 2017; 12:32. [PMID: 28349470 DOI: 10.1007/s11657-017-0327-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/16/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED Hip fractures are common in elderly people. Despite great progress in surgical care, the outcomes of these patients remain disappointing. This study determined pre-fracture hospital admission as a prognostic variable for inferior functional outcomes and increased mortality rates in the perioperative phase and in the first postoperative year. PURPOSE The influence of a pre-fracture hospitalization on outcomes in hip fracture patients has not yet been investigated. METHODS Four hundred two patients who were surgically treated for hip fracture were prospectively enrolled. Patients with a hospital stay within the last 3 months prior to a hip fracture were compared to patients without a pre-fracture hospitalization. Postoperative functional outcomes and mortality rates were compared between groups at the time of hospital discharge and additionally at the six- and twelve-month follow-up appointments. A multivariate regression analysis was performed. RESULTS A pre-fracture hospitalization was reported by 67 patients (17%). In 63% of cases, patients were admitted due to non-surgical, general medical conditions. In 37% of cases, patients were treated due to a condition related to a surgical subject. In the multivariate analysis, pre-fracture hospitalization was an independent risk factor for reduced values on the Barthel Index at 6 months after surgery (B, -9.918; 95%CI of B, -19.001--0.835; p = 0.032) and on the Tinetti Test at 6 months (B, -2.914; 95%CI of B, -1.992--0.047; p = 0.047) and 12 months after surgery (B, -4.680; 95%CI of B, -8.042--1.319; p = 0.007). Pre-fracture hospitalization was additionally associated with increased mortality rates at 6 months (OR 1.971; 95%CI 1.052-3.693; p = 0.034) and 12 months after surgery (OR 1.888; 95%CI 1.010-9.529; p = 0.046). CONCLUSIONS Hip fracture patients with a recent pre-fracture hospital admission are at a substantial risk for inferior functional outcomes and increased mortality rates not only in the perioperative phase but also in the first postoperative year. As a simple dichotomous variable, pre-fracture hospitalization might be a suitable tool for future geriatric hip fracture screening instruments.
Collapse
Affiliation(s)
- Rene Aigner
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Benjamin Buecking
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Juliana Hack
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Daphne Eschbach
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Ludwig Oberkircher
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Christopher Bliemel
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| |
Collapse
|
30
|
Simon GI, Craswell A, Thom O, Fung YL. Outcomes of restrictive versus liberal transfusion strategies in older adults from nine randomised controlled trials: a systematic review and meta-analysis. LANCET HAEMATOLOGY 2017; 4:e465-e474. [DOI: 10.1016/s2352-3026(17)30141-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/02/2017] [Accepted: 08/02/2017] [Indexed: 01/28/2023]
|
31
|
Camurcu Y, Cobden A, Sofu H, Saklavci N, Kis M. What Are the Determinants of Mortality After Cemented Bipolar Hemiarthroplasty for Unstable Intertrochanteric Fractures in Elderly Patients? J Arthroplasty 2017; 32:3038-3043. [PMID: 28550964 DOI: 10.1016/j.arth.2017.04.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/27/2017] [Accepted: 04/20/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Primary hemiarthroplasty is proposed for the treatment of unstable intertrochanteric fractures in elderly patients with the advantages of early mobilization, acceptable functional results, and lower failure rates. The 1-year mortality rates demonstrated high variance in the literature, whereas, the factors related to 1-year mortality were not widely investigated. The main purpose of the present study was to determine predictive factors related to 1-year mortality after primary cemented calcar-replacement bipolar hemiarthroplasty performed for unstable intertrochanteric fracture. METHODS One hundred six patients with the mean age of 80.7 years were included in this retrospective study. Age, gender, body mass index, comorbid diseases, American Society of Anesthesiologists score, total hospitalization time, time from injury to surgery, operation time, estimated blood loss, postoperative mobilization time, and decrease in Koval ambulatory categories were evaluated. Univariate and multivariate analyses were performed to determine major predictors of 1-year mortality. The Kaplan-Meier survival analysis was used to construct the cumulative survival rate. RESULTS Three or more American Society of Anesthesiologists scores, presence of ≥3 comorbid diseases, and postoperative mobilization time of ≥2 days were significantly correlated with 1-year mortality. Presence of ≥3 comorbid systemic diseases was identified as the major predictive factor for 1-year mortality. The overall 5-year cumulative survival rate was 5.6%. CONCLUSION Having three or more comorbid systemic diseases has been detected as the major determinant of 1-year mortality after primary cemented calcar-replacement bipolar hemiarthroplasty performed for unstable intertrochanteric fracture in elderly patients.
Collapse
Affiliation(s)
- Yalkin Camurcu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Erzincan University, Erzincan, Turkey
| | - Adem Cobden
- Department of Orthopaedics and Traumatology, Sivas Numune Hospital, Sivas, Turkey
| | - Hakan Sofu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Erzincan University, Erzincan, Turkey
| | - Nuh Saklavci
- Department of Orthopaedics and Traumatology, Sivas Numune Hospital, Sivas, Turkey
| | - Mehmet Kis
- Department of Orthopaedics and Traumatology, Sivas Numune Hospital, Sivas, Turkey
| |
Collapse
|
32
|
Risk factors for mortality after surgery of osteoporotic hip fracture in patients over 65 years of age. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.recote.2017.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
33
|
Aranguren-Ruiz MI, Acha-Arrieta MV, Casas-Fernández de Tejerina JM, Arteaga-Mazuelas M, Jarne-Betrán V, Arnáez-Solis R. Risk factors for mortality after surgery of osteoporotic hip fracture in patients over 65 years of age. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 61:185-192. [PMID: 28363666 DOI: 10.1016/j.recot.2017.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 12/23/2016] [Accepted: 02/11/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To evaluate, from a clinical perspective, and with easily identifiable variables, those factors that influence the survival of patients admitted to a care unit designed for the comprehensive treatment of patients with hip fracture after being surgically treated. MATERIAL AND METHODS A prospective study was conducted on a cohort of patients (n=202) aged 65 years or older with a low impact hip fracture, who were surgically intervened in a tertiary hospital. An analysis was performed to determine mortality at 90 days, and at one and 2years after surgery using demographic, clinical, analytical, and functional variables. RESULTS The independent risk factors of mortality in the 3periods analysed were age (P=.047, P=.016, and P=.000 at 90 days, 1, and 2 years, respectively) and a low Barthel index (P=.014, P=.005, and P=.004 to 90 days, 1, and 2 years, respectively). Male sex (P=.004) and a high risk for anaesthesia (P=.011) were only independent risk factors of mortality at 2years after surgery. DISCUSSION AND CONCLUSION Age and dependency were the major determining factors of mortality at 30 days, 1, and 2 years after surgery for hip fracture. Both are easily measurable to identify patients susceptible to poor outcomes, and could benefit from a more thorough care plan.
Collapse
Affiliation(s)
- M I Aranguren-Ruiz
- Servicio de Gestión de la Prestación Farmacéutica, Servicio Navarro de Salud, Pamplona, España.
| | - M V Acha-Arrieta
- Servicio de Medicina Interna, Complejo Hospitalario B de Navarra, Pamplona, España
| | | | | | - V Jarne-Betrán
- Servicio de Medicina Interna, Hospital García Orcoyen, Estella, España
| | - R Arnáez-Solis
- Servicio de Medicina Interna, Complejo Hospitalario B de Navarra, Pamplona, España
| |
Collapse
|