Patients aged ninety years and older are exposed to increased risk of one-year mortality after hip fractures

Efficacy of surgical intervention over conservative management in intertrochanteric fractures among nonagenarians and centenarians: a prospective cohort study

BACKGROUND

Optimal treatment strategy for nonagenarians and centenarians with hip fractures (NCHF) remained unknown. The authors aimed to compare the outcomes of surgical and conservative management in NCHF.

METHODS

A prospective cohort study was conducted based on CPMHF database with NCHF patients hospitalized during 2014-2020. Comorbidities were evaluated by mECM score and restricted cubic spline was utilized to visually assess the dose-effect relationship between the mECM and outcomes. Propensity score matching was performed to balance baseline characteristics between nonsurgical and surgical groups. Multivariate logistic regression, Cox proportional hazard analysis, and survival analysis were employed for unfavorable outcomes (UFO) evaluation. Competing risk of death were analyzed based on Fine and Gray's hazard model and then constructed nomogram models for predicting survival rates. Subgroup analyses were used to determine potential population heterogeneity and sensitivity analyses were performed to test robustness of the results.

RESULTS

The authors found increasing trends for UFO with the increase in the mECM score, and that high mECM score (HMS, ≥3) was independently associated with a 2.42-fold (95% CI: 2.07-3.54; P =0.024) increased risk of UFO, which remained significant after considering the competing role of death and were more pronounced in nonsurgical treatment, women, no insurance, and patients with spouse (all P for interaction <0.05). Surgical intervention was identified to be significant protective factors for UFO (RR, 0.59; 95% CI: 0.46-0.75; P <0.001) and severe complications (RR, 0.63; 95% CI: 0.41-0.96; P =0.033) after propensity score matching, as well as survival (HR, 0.40, 95% CI: 0.28-0.58; P <0.001), which remained significant after considering the competing role of death and in all sensitivity analyses and were more pronounced in HMS participants ( P for interaction=0.006). Subgroup analyses revealed surgical patients with HMS had a significantly higher UFO rate (excluding death, P <0.001) while nonsurgical patients with HMS had higher mortality rate as compared to the others ( P =0.005).

CONCLUSION

Surgical treatment for NCHF yields better outcomes compared to conservative treatment.

Ultra-old patients and long-term survival after hip fracture: a real-world assessment

It's still undetermined whether ultra-old persons, aged >90 years, are able to tolerate hip fracture surgical stress while maintaining their functional reserve, and even fewer studies have investigated the role of frailty on the risk of mortality, disability, or morbidity in the ultra-old. This is a prospective study performed at the Orthogeriatrics Ward of the IRCCS Policlinico San Martino (Genoa, Italy) that consecutively enrolled 205 older adult patients with hip fractures due to low-energy trauma. Namely, 85 patients were categorized as ultra-old, and 120 patients (64-89 years) were the younger control group. Demographic data, perioperative data, and rehabilitation data were collected. Here we estimated the overall survival and related predictive variables in hospitalized ultra-old hip fracture patients based on a methodologically robust frailty stratification (Rockwood 40-item tool). The median OS for the ultra-old was 18.7 months, which also showed a doubled 1-year mortality risk. Our findings assessed that frailty in the presence of malnutrition, delayed verticalization, and post-operative respiratory complications was associated with a two-fold increase in the risk of long-term mortality, irrespective of advanced chronological age in the ultra-old. Although the higher mortality rate in these patients may be related to a priori lower life expectancy, chronological age alone is an insufficient prognostic determinant for unfavorable outcomes. Our multicomponent prognostic score can be used in combination to stratify frailty in the ultra-old for timely screening and to deliver goals of care discussions prior to surgery, potentially targeting new orthogeriatric pathways for the improvement of appropriateness and treatment intensity.

Risk factors and prognosis of postoperative delirium in nonagenarians with hip fracture

Hip fractures in nonagenarians is one of the great challenges for patients of this age, the family and the larger society. The purpose of this study was to investigate the risk factors and prognosis of postoperative delirium in nonagenarians with hip fracture. 199 Eligible patients were enrolled. Confusion Assessment Method (CAM) were used to identify the delirium. Logistic regressions were used to investigate the effect of 18 pre-existing conditions on postoperative delirium. Prognosis of postoperative delirium in nonagenarians with hip fracture were also be evaluated. The results indicated the following: (1) the prevalence of postoperative delirium among nonagenarians with hip fracture was 28.1% (56 of 199); (2) coexisting disease ≥ 4 (OR = 5.355, 95% CI = 1.394-9.074, P = 0.007), longer admission to operating time (OR = 1.514, 95% CI = 1.247-1.837, P = 0.000), and general anesthesia (OR = 2.086, 95% CI = 1.804-7.968, P = 0.032) were independent risk factors for postoperative delirium in nonagenarians with hip fracture; (3) nonagenarians with postoperative delirium had a predominantly high burden of perioperative complications, long length of stay, and postoperative mortality at 30 days follow-up and 1 year follow-up than the patients without postoperative delirium. The results could enable clinicians to improve outcome after operation in nonagenarians with hip fracture.

A New Nomogram Model for Predicting 1-Year All-Cause Mortality After Hip Arthroplasty in Nonagenarians With Hip Fractures: A 20-Year Period Retrospective Cohort Study

Background

China has become an ageing society and as it continues to age, it will face an increasing number of hip fractures in nonagenarians. However, few preoperative assessment tools to determine the postoperative mortality risk in nonagenarians with hip fracture were available. The aim of this study was to identify all-cause mortality risk factors after hip arthroplasty in nonagenarians with hip fractures and to establish a new nomogram model to optimize the individualized hip arthroplasty in nonagenarians with hip fractures.

Methods

We retrospectively studied 246 consecutive nonagenarians diagnosed with hip fracture from August 2002 to February 2021 at our center. During the follow-up, 203 nonagenarians with a median age of 91.9 years treated with hip arthroplasty were included, of which 136 were females and 67 were males, and 43 nonagenarians were excluded (40 underwent internal fixation and 3 were lost to follow-up). The full cohort was randomly divided into training (50%) and validation (50%) sets. The potential predictive factors for 1-year all-cause mortality after hip arthroplasty were assessed by univariate and multivariate COX proportional hazards regression on the training set, and then, a new nomogram model was established and evaluated by concordance index (C-index) and calibration curves.

Results

After analyzing 44 perioperative variables including demographic characteristics, vital signs, surgical data, laboratory tests, we identified that age-adjusted Charlson Comorbidity Index (aCCI) (p = 0.042), American Society of Anesthesiologists (ASA) classification (p = 0.007), Urea (p = 0.028), serum Ca2+ (p = 0.011), postoperative hemoglobin (p = 0.024) were significant predictors for 1-year all-cause mortality after hip arthroplasty in the training set. The nomogram showed a robust discrimination, with a C-index of 0.71 (95%CIs, 0.68–0.78). The calibration curves for 1-year all-cause mortality showed optimal agreement between the probability as predicted by the nomogram and the actual probability in training and validation sets.

Conclusion

A novel nomogram model integrating 5 independent predictive variables were established and validated. It can effectively predict 1-year all-cause mortality after hip arthroplasty in nonagenarians with hip fracture and lead to a more optimized and rational therapeutic choice.