'Nonagenarians' with a hip fracture: is a different orthogeriatric treatment strategy necessary?

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.

Taming Postoperative Delirium with Dexmedetomidine: A Review of the Therapeutic Agent's Neuroprotective Effects following Surgery

Postoperative delirium (POD) represents a perioperative neurocognitive disorder that has dreaded ramifications on a patient's recovery from surgery. Dexmedetomidine displays multiple mechanisms of neuroprotection to assist in preventing POD as a part of a comprehensive anesthetic care plan. This review will cover dexmedetomidine's pharmacological overlap with the current etiological theories behind POD along with pre-clinical and clinical studies on POD prevention with dexmedetomidine. While the body of evidence surrounding the use of dexmedetomidine for POD prevention still requires further development, promising evidence exists for the use of dexmedetomidine in select dosing and circumstances to enhance recovery from surgery.

Orthogeriatric co-managements lower early mortality in long-lived elderly hip fracture: a post-hoc analysis of a prospective study

OBJECTIVE

To evaluate the clinical effectiveness of orthogeriatric co-management care in long-lived elderly hip fracture patients (age ≥ 90).

METHODS

Secondary analysis was conducted in long-lived hip fracture patients between 2018 to 2019 in 6 hospitals in Beijing, China. Patients were divided into the orthogeriatric co-management group (CM group) and traditional consultation mode group (TC group) depending on the management mode. With 30-day mortality as the primary outcome, multivariate regression analyses were performed after adjusting for potential covariates. 30-day mobility and quality of life were compared between groups.

RESULTS

A total of 233 patients were included, 223 of whom completed follow-up (125 in CM group, 98 in TC group). The average age was 92.4 ± 2.5 years old (range 90-102). The 30-day mortality in CM group was significantly lower than that in TC group after adjustments for (2.4% vs. 10.2%; OR = 0.231; 95% CI 0.059 ~ 0.896; P = 0.034). The proportion of patients undergoing surgery and surgery performed within 48 h also favored the CM group (97.6% vs. 85.7%, P = 0.002; 74.4% vs. 24.5%, P < 0.001; respectively). In addition, much more patients in CM group could walk with or without aids in postoperative 30 days than in the TC group (87.7% vs. 60.2%, P < 0.05), although differences were not found after 1-year follow-up. And there was no significant difference in total cost between the two groups (P > 0.05).

CONCLUSIONS

For long-lived elderly hip fracture patients, orthogeriatric co-management care lowered early mortality, improved early mobility and compared with the traditional consultation mode.

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.

The prediction of early mortality following hip fracture surgery in patients aged 90 years and older: the Almelo Hip Fracture Score 90 (AHFS90)

The AHFS⁹⁰ was developed for the prediction of early mortality in patients ≥ 90 years undergoing hip fracture surgery. The AHFS⁹⁰ has a good accuracy and in most risk categories a good calibration. In our study population, the AHFS⁹⁰ yielded a maximum prediction of early mortality of 64.5%.

PURPOSE

Identifying hip fracture patients with a high risk of early mortality after surgery could help make treatment decisions and information about the prognosis. This study aims to develop and validate a risk score for predicting early mortality in patients ≥ 90 years undergoing hip fracture surgery (AHFS⁹⁰).

METHODS

Patients ≥ 90 years, surgically treated for a hip fracture, were included. A selection of possible predictors for mortality was made. Missing data were subjected to multiple imputations using chained equations. Logistic regression was performed to develop the AHFS⁹⁰, which was internally and externally validated. Calibration was assessed using a calibration plot and comparing observed and predicted risks.

RESULTS

One hundred and two of the 922 patients (11.1%) died ≤ 30 days following hip fracture surgery. The AHFS⁹⁰ includes age, gender, dementia, living in a nursing home, ASA score, and hemoglobin level as predictors for early mortality. The AHFS⁹⁰ had good accuracy (area under the curve 0.72 for geographic cross validation). Predicted risks correspond with observed risks of early mortality in four risk categories. In two risk categories, the AHFS⁹⁰ overestimates the risk. In one risk category, no mortality was observed; therefore, no analysis was possible. The AHFS⁹⁰ had a maximal prediction of early mortality of 64.5% in this study population.

CONCLUSION

The AHFS⁹⁰ accurately predicts early mortality after hip fracture surgery in patients ≥ 90 years of age. Predicted risks correspond to observed risks in most risk categories. In our study population, the AHFS⁹⁰ yielded a maximum prediction of early mortality of 64.5%.

Acetabular fractures treatment needs in the elderly and nonagenarians

Different treatment options for acetabular fractures in the elderly and nonagenarians exist; a consistent guideline has not been established, yet. The purpose of this study is to give an overview of how those fractures can be handled and compares two different surgical treatment methods. A total of 89 patients ≥ 18 years between 2016 and 2021 with acetabular fractures in our department received a surgical intervention with plate fixation via the Stoppa approach or a total hip arthroplasty with a Burch-Schneider ring and integrated cup. 60 patients ≥ 65 were compared in two groups, 29 patients between 65 and 79 and 31 patients ≥ 80. For comparison, data on operation times, hospitalization, complications during operation and hospital stay, blood loss and postoperative mobilization were collected. Characteristics could be found for indications for operative osteosynthesis or endoprosthetics based on the X-ray analysis. There was a tendency to treat simple fractures with osteosynthesis. Patients between 65 and 79 with an osteosynthesis had benefits in almost every comparison. Patients ≥ 80 with a plate fixation had advantages in the categories of postoperative complications, blood loss and transfusion of erythrocyte concentrates. Statistical significant differences were noticed in both groups regarding the operation time. Patients between 65 and 79 with osteosynthesis had significant benefits for postoperative complications, hospitalization, number of blood transfusions and postoperative mobilization. Finding the best supportive treatment option is difficult, and decision-making must respect fracture patterns and individual risk factors. This study shows that plate fixation via the Stoppa approach has some benefits.

Factors influencing early and long-term survival following hip fracture among nonagenarians

Background

The outcomes of nonagenarian patients undergoing orthopaedic surgery are not well understood. We investigated the 30-day mortality after surgical treatment of unilateral hip fracture. The relationship between postoperative complications and mortality was evaluated.

Methods

We performed a single-centre retrospective cohort study of nonagenarian patients undergoing hip fracture surgery over a 6-year period. Postoperative complications were graded according to the Clavien–Dindo classification. Correlation analyses were performed to evaluate the relationship between mortality and pre-specified mortality risk predictors. Survival analyses were assessed using Cox proportional hazards regression modelling.

Results

The study included 537 patients. The 30-day mortality rate was 7.4%. The mortality rate over a median follow-up period of 30 months was 18.2%. Postoperative complications were observed in 459 (85.5%) patients. Both the number and severity of complications were related to mortality (p < 0.001). Compared to patients who survived, deceased patients were more frail (p = 0.034), were at higher ASA risk (p = 0.010) and were more likely to have preoperative congestive heart failure (p < 0.001). The adjusted hazard ratio for mortality according to the number of complications was 1.3 (95% CI 1.1, 1.5; p = 0.003). Up to 21 days from admission, any increase in complication severity was associated significantly greater mortality [adjusted hazard ratio: 3.0 (95% CI 2.4, 3.6; p < 0.001)].

Conclusion

In a nonagenarian cohort of patients undergoing hip fracture surgery, 30-day mortality was 7.4%, but 30-month mortality rates approached one in five patients. Postoperative complications were independently associated with a higher mortality, particularly when occurring early.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02807-6.

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

BACKGROUND

The increase in the population over 90 years old suggests an expected surge in the number of extreme elderly patients sustaining hip fractures.

OBJECTIVE

The aim of this study is to identify factors associated with 1-year mortality and determine the conditions that are associated with an unfavorable survival outcome in nonagenarians.

DESIGN

Cross-sectional study SUBJECTS: Nonagenarian patients presenting with hip fractures between 2013 and 2018.

METHODS

Bivariate and multivariate analyses were performed to identify variables associated with mortality, and a survival analysis was conducted to determine whether the Charlson Comorbidity Index (CCI) is associated with mortality.

RESULTS

A total of 127 patients, with a mean age of 92.84 years was assessed, identifying 1-year mortality rate in 53.5% of patients. According to the bivariate analysis, requirement of postoperative vasopressor support, transfusion, decompensated heart failure and general anesthesia were associated with a higher probability of 1-year mortality after surgery. Body mass index, health status, dementia or CCI ≥ 3 were not associated with mortality. Similarly, the Kaplan-Meier survival analysis showed no difference in mortality rate of patients with CCI ≥ 3 (p = 0.282).

CONCLUSION

Patients older than 90 years with hip fractures have higher mortality rates per year than younger patients. Some associations were found, but more studies are needed to reach final conclusions, which could help identify higher-risk patients and be able to implement additional measures.