Prognostic factors for mortality after hip fracture: Operation within 48 hours is mandatory

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Development of Prediction Model for 1-year Mortality after Hip Fracture Surgery

Purpose

Hip fractures are associated with increased mortality. The identification of risk factors of mortality could improve patient care. The aim of the study was to identify risk factors of mortality after surgery for a hip fracture and construct a mortality model.

Materials and Methods

A cohort study was conducted on patients with hip fractures at two institutions. Five hundred and ninety-seven patients with hip fractures that were treated in the tertiary hospital, and another 147 patients that were treated in a secondary hospital. The perioperative data were collected from medical charts and interviews. Functional Assessment Measure score, Short Form-12 and mortality were recorded at 12 months. Patients and surgery variables that were associated with increased mortality were used to develop a mortality model.

Results

Mortality for the whole cohort was 19.4% at one year. From the variables tested only age >80 years, American Society of Anesthesiologists category, time to surgery (>48 hours), Charlson comorbidity index, sex, use of anti-coagulants, and body mass index <25 kg/m2 were associated with increased mortality and used to construct the mortality model. The area under the curve for the prediction model was 0.814. Functional outcome at one year was similar to preoperative status, even though their level of physical function dropped after the hip surgery and slowly recovered.

Conclusion

The mortality prediction model that was developed in this study calculates the risk of death at one year for patients with hip fractures, is simple, and could detect high risk patients that need special management.

Early Hip Fracture Surgery Within 24 hours did not Reduce the Mortality Rate but Resulted in Less Postoperative Opioid use and a Shorter Length of Stay: A Retrospective Study of 276 Patients From a Tertiary Private Hospital in Thailand

Introduction

The comparative results of early hip fracture surgery including mortality and postoperative complications in Thailand were not reported. Therefore, we conducted this study to compare the outcomes between patients who received hip surgery within and after 24 hours.

Methods

A retrospective study was conducted at a single center, a tertiary private hospital in Thailand. The medical records of patients who were admitted from 2018 to 2020 were reviewed. Patients aged <50 years, high-energy fracture, pathological fractures, or multiple traumas were excluded. The patients were categorized into two groups for comparison: surgery within and surgery after 24 hours groups. The outcome measures were in-hospital, 30-day, and 1-year mortality rates, length of stay, and the incidences and severities of postoperative complications.

Results

A total of 276 hip fracture patients were analyzed, with the majority (77.9%) undergoing surgery within 24 hours. Patients who underwent earlier surgery had a significantly shorter hospital stay [6 (4, 9) vs 8 (7, 13) days, P < .001]. The cumulative mortality rates at in-hospital, 30 days, and 1 year were 0%, 1.1%, and 2.5%, respectively. The most common postoperative complications observed were anemia (43.1%) and acute kidney injury (32.6%). However, there were no statistically significant differences in mortality rates (P > .05) or postoperative complications (P = .410) between the two groups.

Conclusion

While surgery within 24 hours showed some benefits, such as a shorter hospital stay and reduced pain rescue, it did not reduce mortality or major complications in hip fracture patients.

Systematic review and meta-analysis of preoperative predictors for early mortality following hip fracture surgery

Hip fractures are a global health problem with a high postoperative mortality rate. Preoperative predictors for early mortality could be used to optimise and personalise healthcare strategies. This study aimed to identify predictors for early mortality following hip fracture surgery. Cohort studies examining independent preoperative predictors for mortality following hip fracture surgery were identified through a systematic search on Scopus and PubMed. Predictors for 30-day mortality were the primary outcome, and predictors for mortality within 1 year were secondary outcomes. Primary outcomes were analysed with random-effects meta-analyses. Confidence in the cumulative evidence was assessed using the GRADE criteria. Secondary outcomes were synthesised narratively. Thirty-three cohort studies involving 462,699 patients were meta-analysed. Five high-quality evidence predictors for 30-day mortality were identified: age per year (OR: 1.06, 95% CI: 1.04-1.07), ASA score ≥ 3 (OR: 2.69, 95% CI: 2.12-3.42), male gender (OR: 2.00, 95% CI: 1.85-2.18), institutional residence (OR: 1.81, 95% CI: 1.31-2.49), and metastatic cancer (OR: 2.83, 95% CI: 2.58-3.10). Additionally, six moderate-quality evidence predictors were identified: chronic renal failure, dementia, diabetes, low haemoglobin, heart failures, and a history of any malignancy. Weak evidence was found for non-metastatic cancer. This review found relevant preoperative predictors which could be used to identify patients who are at high risk of 30-day mortality following hip fracture surgery. For some predictors, the prognostic value could be increased by further subcategorising the conditions by severity.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Correlation between preoperative CT scan of the paraspinal, psoas, and gluteus muscles and postoperative ambulatory status in patients with femoral neck fractures

BACKGROUND

This study aimed to investigate the relationship between femoral neck fractures and sarcopenia.

METHODS

This was a retrospective analysis of 92 patients with femoral neck fractures, from September 2017 to March 2020, who were classified into high ambulatory status (HG) and low ambulatory status (LG) groups. Ambulatory status was assessed before surgery, one week after surgery, at discharge, and during the final follow-up. To evaluate sarcopenia, muscle mass and fatty degeneration of the muscles were measured using preoperative CT. An axial slice of the superior end of the L5 vertebra was used to evaluate the paraspinal and psoas muscles, a slice of the superior end of the femoral head for the gluteus maximus muscle, and a slice of the inferior end of the sacroiliac joint for the gluteus medius muscle. The degeneration of the muscles was evaluated according to the Goutallier classification.

RESULTS

The cross-sectional area of the gluteus medius and paraspinal muscles was significantly correlated with ambulatory status before the injury, at discharge, and during the final follow-up.

CONCLUSIONS

Measurement of the gluteus medius and paraspinal muscles has the potential to evaluate sarcopenia and predict ambulatory status after femoral neck fractures.

Predictive factors for one-year mortality after surgery for periprosthetic femoral fracture: A retrospective multicenter (TRON group) study

BACKGROUND

Periprosthetic femoral fracture (PFF) after total hip arthroplasty (THA) or bipolar hip arthroplasty (BHA) represents a challenging situation and the treatment is associated with high rates of complications and mortality. The aims of this multicenter retrospective study were to determine 1-year mortality and to identify predictors associated with mortality, including patient characteristics and surgical factors, in patients undergoing surgery for PFF after THA or BHA.

METHODS

We collected 249 cases of PPF after THA or BHA that were treated in our 11 hospitals (named the TRON group) between January 2010 and December 2019. We excluded patients who were conservatively treated, cases in which the 1-year postoperative outcome was unknown, and Vancouver type A cases. Finally, we analyzed 161 patients. Univariate and multivariate Cox regression analyses were performed to identify factors affecting 1-year mortality. Patient-side factors such as age, BMI, fracture type, and preoperative mobility, and surgical factors such as surgical procedure, time to surgery, and operation time were analyzed respectively.

RESULTS

Eighteen of 161 patients (11.2%) died one year after surgery. The multivariate Cox regression analysis identified older age, wheelchair status before injury, and operation time as independent predictors of 1-year mortality (older age: hazard ratio [HR] 1.07, 95% CI 1.01-1.15, P = 0.048; wheelchair status: HR 5.82, 95% CI 1.01-33.47, P = 0.049; operation time: [HR] 1.01, 95% CI 1.00-1.01, P = 0.00929). Meanwhile, fracture type according to the Vancouver classification, body mass index, presence of previous fragility fractures, type of fixation, blood loss during operation, and time to surgery were not independent predictors of 1-year mortality in this analysis. ConclusionThe 1-year mortality rate after surgery for PPFs patients was 11.2%. Factors associated with older and poor activity of daily living (ADL) performance (e.g., wheelchair status before injury), and longer operative time were associated with 1-year mortality after surgery for PPF. Surgeons should carefully plan treatment according to each patient's condition.

Early surgery within 48 h was associated with reduced perioperative blood loss and red blood cell transfusion requirements in older patients with hip fracture: a retrospective study

PURPOSE

The aim of this study was to analyze the relationship between the timing of surgery and perioperative blood loss, red blood cell (RBC) transfusion rate, and RBC transfusion volume in older patients with hip fracture.

METHODS

From January 2020 to August 2022, this retrospective study enrolled older patients with hip fracture who underwent surgery in our hospital. The demographics, fracture type, type of surgery, time from injury to hospital, timing of surgery, medical history (hypertension, diabetes), duration of surgery, intraoperative blood loss, laboratory tests, and preoperative, postoperative and perioperative RBC transfusion requirements were recorded and analyzed. According to the surgical treatment within 48 h or after 48 h after admission, the patients were divided into early surgery group (ES) and delayed surgery group (DS).

RESULTS

A total of 243 older patients with hip fracture were finally included in the study. Among these, 96 patients (39.51%) underwent surgery within 48 h of admission and 147 (60.49%) underwent surgery after this time. Total blood loss (TBL) in the ES group was lower than that in the DS group (576.03 ± 265.57 ml vs 699.26 ± 380.58 ml, P = 0.003). Preoperative RBC transfusion rate, and preoperative and perioperative RBC transfusion volume in the ES group were significantly lower than those in the DS group (15.63% vs 26.53%, P = 0.046; 50.00 ± 128.15 ml vs 117.01 ± 225.85 ml, P = 0.004; 80.21 ± 196.63 ml vs 144.90 ± 253.52 ml, P = 0.027).

CONCLUSION

Timing of surgery within 48 h of admission for older patients with hip fracture was associated with reduced the total blood loss and RBC transfusion requirements during the perioperative period.

The role of neutrophil percentage to albumin ratio in predicting 1-year mortality in elderly patients with hip fracture and external validation

Objectives

This study aimed to investigate the association between the neutrophil percentage to albumin ratio (NPAR) on the day of admission and mortality 1 year after surgery in elderly patients with hip fractures.

Methods

Clinical characteristics and blood markers of inflammation were retrospectively collected from October 2016 to January 2022 in elderly patients with hip fractures at two different regional tertiary medical centers. It is divided into a training set and an external validation set. Multivariate Nomogram models such as NPAR were constructed using the least absolute shrinkage and selection operator (LASSO) regression results and multi-factor logistic regression analysis. In addition, multivariate Cox regression analysis and Kaplan-Meier survival curves were used to explore the relationship between NPAR values and mortality within 1 year in elderly patients with hip fractures. The predictive performance of the Nomogram was evaluated using the concordance index (C Index) and receiver operating characteristic curve (ROC) and validated by Bootstrap, Hosmer-Lemesow goodness of fit test, calibration curve, decision curve, and clinical impact curve analysis.

Results

The study included data from 1179 (mean age, 80.34 ± 8.06 years; 61.4[52.1%] male) patients from the Guangzhou Red Cross Hospital affiliated with Jinan University and 476 (mean age, 81.18 ± 8.33 years; 233 [48.9%] male) patients from the Xiaogan Central Hospital affiliated with Wuhan University of Science and Technology. The results showed that NPAR has good sensitivity and specificity in assessing patients' prognosis 1 year after surgery. Multivariate logistic regression models based on influencing factors such as NPAR have good discrimination and calibration ability (AUC=0.942, 95% CI:0.927-0.955; Hosmer-Lemeshow test: P >0.05). Kaplan-Meier survival curves for the training and validation sets showed that patients in the high NPAR group had a higher mortality rate at 1 year compared to the low NPAR group (P< 0.001). Multivariate Cox regression showed that high NPAR values were an independent risk factor for death within 1 year in elderly hip fracture patients (P< 0.001, HR =2.38,95%CI:1.84-3.08).

Conclusion

Our study showed that NPAR levels were significantly higher in patients who died within 1 year after surgery in both the training and validation sets. NPAR has good clinical value in assessing 1-year postoperative prognosis in elderly patients with hip fractures.

Ambulation Distance Within 72 Hours after Surgical Management Is a Predictor of 90-Day Ambulatory Capacity in Elderly Patients with Hip Fracture

INTRODUCTION

The inability to mobilize after surgical intervention for hip fractures in the elderly is established as a risk factor for greater morbidity and mortality. Previous studies have evaluated the association between the timing and distance of ambulation in the postoperative acute care phase with postoperative complications. The purpose of this study was to evaluate the association between ambulatory distance in the acute postoperative setting and ambulatory capacity at 3 months.

METHODS

Patients aged 65 and older who were ambulatory at baseline and underwent surgical intervention for hip fractures from 2014 to 2019 were retrospectively reviewed. Consistent with previous literature, patients were divided into two groups: those who were able to ambulate 5 feet within 72 hours after surgical fixation (early ambulatory) and those who were not (minimally ambulatory).

RESULTS

One hundred seventy patients (84 early ambulatory and 86 minimally ambulatory) were available for analysis. Using a multivariable ordinal logistic regression model, variables found to be statistically significant predictors of ambulatory status at 3 months were the ability to ambulate five feet in 72 hours (P < 0.0001), ambulatory distance at discharge (P = 0.012), and time from presentation to surgery (P = 0.039). Patients who were able to ambulate 5 feet within 72 hours had 9 times the odds of being independent ambulators rather than a lower ambulatory class (cane, walker, and nonambulatory). Pertrochanteric fractures were less likely than femoral neck fractures to independently ambulate at 3 months (17.2% vs. 42.3%; P = 0.0006).

DISCUSSION

Ambulating 5 feet within 72 hours after hip fracture surgery is associated with an increased likelihood of independent ambulation at 3 months postoperatively. This simple and clear goal may be used to help enhance postoperative mobility and independence while providing a metric to guide therapy and help counsel patients and families.

Factors associated with mortality after proximal femoral fracture

Proximal femoral fractures are a serious complication, especially for elderly patients. Therefore, we have aimed to answer the following research question: What is the postfracture mortality rate in the elderly population and what are associated risk factors? For this, proximal femoral fractures that occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records database. The Kaplan-Meier (KM) method with the Fine and Gray subdistribution adaptation was used to determine rates of mortality. A semiparametric Cox regression model was applied, incorporating 23 measures as covariates to identify risk factors. The estimated 1 year mortality rate was 26.8% after head/neck fracture, 28.2% after intertrochanteric fracture, and 24.2% after subtrochanteric fracture. Male sex, age over 70 years, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, chronic kidney disease, a concomitant fracture, congestive heart failure, diabetes mellitus, hypertension, insulin use, ischemic heart disease, morbid obesity, osteoporosis, tobacco dependence, and median household income were determined as risk factors for increased mortality. An early assessment of individual risk factors accessible for therapeutic treatment is crucial in the management of proximal femur fractures to aid in attempts at reducing the high mortality apparent in the elderly US population.

Morbidity and Mortality Analysis in the Treatment of Intertrochanteric Hip Fracture with Two Fixation Systems: Dynamic Hip Screw (DHS) or Trochanteric Fixation Nail Advance (TFNA)

BACKGROUND

The aim of this study was to compare the clinical outcomes, complications, and mortality of patients with intertrochanteric hip fracture treated with dynamic hip screw (DHS) vs. trochanteric fixation nail advance (TFNA).

METHODS

We evaluated 152 patients with intertrochanteric fractures concerning age, sex, comorbidity, Charlson Index, preoperative gait, OTA/AO classification, time from fracture to surgery, blood loss, amount of blood replacement, changes in gait, full weight-bearing at hospital discharge, complications, and mortality. The final indicators encompassed the adverse effects linked to implants, postoperative complications, clinical healing or bone healing duration, and functional score.

RESULTS

The study included a total of 152 patients, out of which 78 (51%) received DHS treatment and 74 (49%) received TFNA treatment. The results of this study show that the TFNA group demonstrated superiority (p < 0.001). However, it should be noted that the TFNA group had a higher frequency of the most unstable fractures (AO 31 A3, p < 0.005). Full weight-bearing at discharge also decreased in patients with more unstable fractures (p = 0.005) and severe dementia (p = 0.027). Mortality was higher in the DHS group; however, a longer time from diagnosis to surgery was also observed in this group (p < 0.005).

CONCLUSIONS

The TFNA group has shown a higher success rate in achieving full weight-bearing at hospital discharge when treating trochanteric hip fractures. This makes it the preferred choice for treating unstable fractures in this region of the hip. Additionally, it is important to note that a longer time to surgery is associated with increased mortality in patients with hip fractures.

A 7-year perspective on femoral neck fracture management in New York State-Do Level 1 trauma centers provide better care?

INTRODUCTION

Patients with femoral neck fractures are at a substantial risk for medical complications and all-cause mortality. Given this trend, our study aims to evaluate postoperative outcomes and the economic profile associated with femoral neck fractures managed at level-1 (L1TC) and non-level-1-trauma centers (nL1TC).

METHODS

The SPARCS database was queried for all geriatric patients sustaining atraumatic femoral neck fractures within New York State between 2011 and 2017. Patients were then divided into two cohorts depending on the treating facility's trauma center designation: L1TC versus nL1TC. Patient samples were evaluated for trends and relationships using descriptive analysis, Student's t-tests, and Chi-squared. Multivariable linear-regressions were utilized to assess the effect of trauma center designation and potential confounders on patient mortality and inpatient healthcare expenses.

RESULTS

In total, 44,085 femoral neck fractures operatively managed at 161 medical centers throughout New York during a 7-year period. 4,974 fractures were managed at L1TC while 39,111 were treated at nL1TC. Following multivariate regression analysis, management at L1TC was the most significant cost driver, resulting in an average increased cost of $6,330.74 per fracture.

CONCLUSION

Our results suggest that femoral neck fractures treated at L1TC have more comorbidities, higher in-hospital mortality, longer LOS, and greater hospital costs.

The use of skin traction in the adult patients with proximal femur fracture. What are the effects, advantages and disadvantages? A scoping review

BACKGROUND

Hip surgery is normally the chosen therapy for proximal femur fractures. Surgery within 24-48 h after hip fracture is recommended, but surgery may not always be performed promptly. Consequently, skin-traction is applied to reduce complications. The purpose of this review is to assess both advantages and disadvantages of skin traction.

METHODS

A scoping review was conducted. The research question was: which are the effects of skin traction, its advantages and disadvantages in adult patients with proximal femur fractures hospitalised in orthopaedic wards? The search was done in the databases PubMed, CINAHL, Cochrane, Embase, DOAJ, ClinicalTrials.gov and OpenDissertation.

RESULTS

9 records were included, skin traction effects were summarised in 7 categories: pain, pressure sores, comfort and relaxation, thromboembolism, damage from adhesive, complications and quality of care. The possible advantage is pain reduction between 24 and 60 h, the possible disadvantage is skin damage.

DISCUSSION AND CONCLUSION

The routine use of skin traction does not appear recommended, but more consistent evidence is necessary to make clinic decisions. Future RCTs could focus on the effects of skin traction 24-60 h after hospitalisation and before surgery.

Pre-operative Factors Predicting Mortality in Six Months and Functional Recovery in Elderly Patients with Hip Fractures

Introduction

This study aimed to determine on-admission and perioperative factors predicting six-month mortality and functional recovery in Vietnamese patients with hip fracture.

Materials and methods

Between April 2020 and July 2021, 118 patients participated in this prospective study. Patients' data were collected from medical records. Harris hip score (HHS) was used to evaluate the functional recovery six months after fractures. The obtained data were analysed using a univariate and multivariate model.

Results

The mean age of the participants was 79.5±9.4 years and 68.6% of the patients were female. The six-month mortality rate was 5.9% and independently associated with age (odds ratio (OR): 3.512, 95% confidence interval (CI) 1.538 - 8.019; P<0.001, patients aged >80 years vs those aged ≤80 years) and hypoproteinemia (OR: 2.859, 95% CI: 1.001 - 8.166, P=0.049). Among 111 survivors there were 66 (59.5%) of patients with a good functional recovery. Patients aged >80 years had a higher risk of poor functional outcome (OR: 3.167, 95% CI: 1.386 - 7.235, P: 0.006) compared to those aged ≤ 80 years. No significant correlations between other clinical (gender, body mass index, comorbidities, type of fractures or surgery, time until surgery) or laboratory parameters (anaemia, hyperglycemia, marked elevation of C reactive protein level, electrolyte abnormalities, elevated urea) and mortality or functional outcome were found.

Conclusion

Advanced age is the most important factor affecting both mortality and functional outcome while hypoproteinemia is associated with a higher risk of mortality in elderly patients with hip fractures.

[Result of the update of the clinical pathway for hip fracture in the elderly at a university hospital in Madrid]

BACKGROUND AND OBJECTIVES

Orthogeriatric management with clinical pathways (CP) in hip fracture (HF) has been shown to be superior to other models. We studied whether updating the CP, through prioritization of admission and surgery, improvement in the prevention and treatment of delirium, management of anticoagulants and antiplatelet agents and the use of perioperative peripheral nerve block, modifies surgical delay, stay, readmissions, mortality, suffering delirium and functional status at discharge.

MATERIAL AND METHOD

A retrospective observational study of unicenter cohorts of 468 patients with HF, 220 from 2016 (old VC) and 248 from 2019 (new VC). The variables are: intervention in the first 48hours, surgical delay (hours), stay (days), stay less than 15 days, delirium, functional loss at discharge (Barthel prefracture scale less Barthel scale at discharge), readmission at one month, and mortality at admission, month and year.

RESULTS

Median age: 87.0 [interquartile range 8.0], mostly women (76.7%). Significantly, with the new VC, there was a greater number of patients operated on in the first 48hours (27,7% vs 36,8% p=0.036), less surgical delay (72.5 [47,5-110,5] vs 64.0 [42,0-88,0] p<0.001), shorter stay (10,0 [7,0-13,0] vs 8,0 [6,0-11,0] p<0.001), greater number of discharges in 15 days (78,2% vs 91,5% p<0.001), lower delirium (54,1% vs 43,5% p=0.023). No significant changes in readmissions, functional loss at discharge, mortality at admission, 3 months or year.

CONCLUSIONS

Updating the VC brings benefits to the patient (less surgical delay, equal functional status at discharge with fewer days of admission) and benefits in management (lower admission) without modifying mortality.

Adverse events are not increased by controlled delay in surgery of acute upper extremity fractures

Management of the operative treatment of fractures is challenged by daily variation in patient flow. For upper limb fractures there has recently been an increasing tendency to temporarily discharge the patient to wait for a daytime operation to be performed during the next few days. The objective of this study was to study the safety of controlled delay in surgery. Upper limb fractures (N = 1 944) treated in a level 2 trauma center from 2010 to 2016 were identified and included in this retrospective cohort study with 5-year follow-up. Delay in surgery, inpatient time, readmissions, ED revisits and mortality were analyzed. Depending on the nature of the injury, controlled delay to surgery was implemented. Urgency of surgery was coded as green (2 days to 2 weeks) yellow (8-48 h) or red (less than 8 h). Harms and benefits to the groups were compared. Controlled delay of surgery (median delay of 5 days 7 h) was applied in 1 074 out of 1 944 fractures. The number of revisits to the emergency department (11.1% vs. 17.9-24.1%, p < 0.001) or hospital readmissions for any reason (0.99 per 100 person years in the delayed group vs. 3.74 and 4.35 in the non-delayed groups, p < 0.001) was no higher in patients with delayed (green) compared to those with non-delayed (yellow and red) operations. Inpatient time was significantly lower in the delayed group than other groups (IRR 2.31-3.36, (p < 0.001)). The standardized mortality ratio was 0.83 (CI 0.57-1.22) in the delayed group vs. 1.49 (CI 1.17-1.90) and 1.61 (CI 1.16-2.23) in the non-delayed groups. Controlled delay in upper limb trauma surgery did not lead to increased readmissions or mortality and was associated with reduced inpatient time.

Impact of COVID-19 on Timing of Hip-Fracture Surgeries: An Interrupted Time-Series Analysis of the Pre/Post-Quarantine Period in Northern Italy

BACKGROUND

To assess whether the imposition of the coronavirus disease 2019 (COVID-19) national quarantine (March 10, 2020) resulted in a shift in the proportion of patients operated for hip fracture on the day of admission, the following day and two days after admission in the region of Piedmont, northern Italy.

METHODS

Interrupted time-series analysis (ITSA) comparing hospitalization rate and timing of hip-fracture surgeries between pre- and post-quarantine period. The same data observed in Piedmont the year before were included as a control time series with no "intervention" (quarantine) in the middle of the observation period.

RESULTS

We found that 70.3% and 69.4% of hip-fracture patients received surgery within 2 days of hospital admission in the 16 weeks before and after the national quarantine, respectively. One-day surgery went from 46.0% to 46.5%, and same-day surgery from 13.3% to 12.4%. Unchanged trends were confirmed by ITSA after controlling for the 32-week time-series observed the year before. In the second week of March 2020, there was a borderline significant decrease in weekly hospital admissions for hip fractures as compared with that of the same week of March 2019 (-1.95 per 100 000, 95% CI = -4.10 to 0.21, P value = .075), followed by a weekly significant increase in the hospitalization rate (+0.14 per 100 000, 95% CI = 0.01 to 0.27, P value = .039), although the difference-in-differences of slopes failed to achieve statistical significance (0.19 per 100 000, 95% CI = -0.03 to 0.41, P value = .090).

CONCLUSION

Our study shows that the timing of hip-fracture surgery was unchanged during the lockdown period. This suggests that the healthcare systems can be resilient and able to guarantee a high-quality and safe healthcare to hip-fracture patients, even in the most challenging working conditions.

Mortality Rates in Femoral Neck Fractures Treated With Arthroplasty in South Africa

Objectives

To investigate the mortality rate for neck of femur fractures treated with arthroplasty at a tertiary level unit in South Africa and to evaluate the effect of known risk factors for mortality in neck of femur fractures treated with arthroplasty in the South African context.

Design

Retrospective cohort study. The main outcome was to determine mortality rates during in hospital stay, at 3 months, 6 months 1 year post surgery. The secondary outcome was to determine factors influencing mortality at 30 days, 6 months and 12 months post-surgery.

Results

Mortality rate was 3.3% in hospital, 5.6% at 30 days and 26.7% at 1 year. Age >79, ASA score >3, and cementing of the femur had statistically increased mortality risk (P < .001). Average length of hospital stay was 12.3 ± 5.1 days (range 3.0-41.0 days) with 73% of patients discharged back to pre-hospital home.

Conclusion

Mortality rates after femur neck fracture arthroplasty in South Africa are slightly higher at 1 year compared to international data. However, the rates are comparably low during hospital stay, 30 day and at 6 months post-surgical intervals.

The Impact of Various Anti-Osteoporosis Drugs on All-Cause Mortality After Hip Fractures: A Nationwide Population Study

Anti-osteoporosis treatment following hip fractures may reduce the overall mortality rate. However, the effects of different drugs on mortality is still unclear. This population-based cohort study aimed to identify the degree of reduced mortality after various anti-osteoporosis regimens following hip fracture surgery. We conducted this cohort study to identify patients with newly diagnosed osteoporosis and hip fractures from 2009 to 2017 using the Taiwan National Health Insurance Research Database (NHIRD). The subsequent use of anti-osteoporosis medication following hip fracture surgery was collected and analyzed. National death registration records were retrieved to determine mortality. A total of 45,226 new cases of osteoporotic hip fracture were identified. Compared with patients who did not receive further treatment, patients who had ever used oral bisphosphonates (alendronate and risedronate, hazard ratio [HR] 0.81; 95% confidence interval [CI], 0.78-0.84), ibandronate (HR 0.76; 95% CI, 0.67-0.86), zoledronic acid (HR 0.70; 95% CI, 0.64-0.76), and denosumab (HR 0.64; 95% CI, 0.60-0.68) showed lower all-cause mortality rates. Patients treated with bisphosphonates had a lower mortality risk than those treated with selective estrogen receptor modulators (HR 0.81; 95% CI, 0.75-0.87). Patients treated with zoledronic acid showed a lower mortality risk than those treated with oral bisphosphonates (HR 0.89; 95% CI, 0.82-0.97). However, patients receiving denosumab and zoledronic acid did not show a significant difference in mortality (HR 0.94; 95% CI, 0.85-1.03). Different anti-osteoporosis treatments for postsurgical patients were associated with different levels of decline in mortality. Generally, longer durations of drug use were associated with lower mortality. © 2022 American Society for Bone and Mineral Research (ASBMR).

Should the early surgery threshold be moved to 72 h in over-85 patients with hip fracture? A single-center retrospective evaluation on 941 patients

AIM

Aim of the study was to assess whether early surgery and other clinical and orthogeriatric parameters could affect mortality rate in hip fracture patients aged > 85.

MATERIALS AND METHODS

Data regarding a 42-month period were retrospectively obtained from the institutional medical records and registry data. Gender, age, fracture pattern, surgical technique, type of anesthesia, timing of surgical intervention (within 24, 48 or 72 h from admission), days of hospitalization, mortality rate divided in intra-hospital, at 30 days and at 1 year were collected for the whole population. Some additional data were collected for an orthogeriatric subgroup.

RESULTS

941 patients were considered, with a mean age of 89 years. Surgery was performed within 24, 48 and 72 h in 24.4%, 54.5% and 66.1% of cases, respectively. Intra-hospital mortality rate resulted to be 3.4%, while mortality at 30 days and 1 year resulted to be 4.5% and 31%, respectively. Early surgery within 48 and 72 h were significantly associated with a lower intra-hospital and 30-day mortality rate. In the orthogeriatric subgroup (394 patients), a significant association with a higher mortality rate was found for general anesthesia, number of comorbidities, ADL (Activities of Daily Living) < 3, transfer to other departments.

CONCLUSIONS

In over-85 hip fracture patients, the threshold for early surgery might be moved to 72 h to allow patients pre-operative stabilization and medical optimization as intra-hospital and 30-day mortality rates remain significantly lower. Advanced age, male sex, number of comorbidities, pre-operative dependency in ADL, general anesthesia, length of hospitalization and transfer to other departments were significantly related to mortality rate.

Single vs Dual-site service reconfiguration during Covid-19 pandemic - A tertiary care centre experience in hip fractures and a Scoping review

Aims and objectives

The Covid-19 pandemic has had an unprecedented effect on surgical practice and healthcare delivery globally. We compared the impact of the care pathways which segregate Covid-19 Positive and Negative patients into two geographically separate sites, on hip fracture patients in our high-volume trauma center in 3 distinct eras - the pre-pandemic period, against the first Covid-19 wave with dual-site service design, as well as the subsequent surge with single-site service delivery. In addition, we sought to invoke similar experiences of centres worldwide through a scoping literature review on the current evidence on "Dual site" reconfigurations in response to Covid-19 pandemic.

Methods

We prospectively reviewed our hip fracture patients throughout the two peaks of the pandemic, with different service designs for each, and compared the outcomes with a historic service provision. Further, a comprehensive literature search was conducted using several databases for articles discussing Dual-site service redesign.

Results

In our in-house study, there was no statistically significant difference in mortality of hip fracture patients between the 3 periods, as well as their discharge destinations. With dual-site reconfiguration, patients took longer to reach theatre. However, there was much more nosocomial transmission with single-site service, and patients stayed in the hospital longer. 24 articles pertaining to the topic were selected for the scoping review. Most studies favour dual-site service reorganization, and reported beneficial outcomes from the detached care pathways.

Conclusion

It is safe to continue urgent as well as non-emergency surgery during the Covid-19 pandemic in a separate, geographically isolated site.

Development and internal validation of a clinical prediction model using machine learning algorithms for 90 day and 2 year mortality in femoral neck fracture patients aged 65 years or above

Purpose

Preoperative prediction of mortality in femoral neck fracture patients aged 65 years or above may be valuable in the treatment decision-making. A preoperative clinical prediction model can aid surgeons and patients in the shared decision-making process, and optimize care for elderly femoral neck fracture patients. This study aimed to develop and internally validate a clinical prediction model using machine learning (ML) algorithms for 90 day and 2 year mortality in femoral neck fracture patients aged 65 years or above.

Methods

A retrospective cohort study at two trauma level I centers and three (non-level I) community hospitals was conducted to identify patients undergoing surgical fixation for a femoral neck fracture. Five different ML algorithms were developed and internally validated and assessed by discrimination, calibration, Brier score and decision curve analysis.

Results

In total, 2478 patients were included with 90 day and 2 year mortality rates of 9.1% (n = 225) and 23.5% (n = 582) respectively. The models included patient characteristics, comorbidities and laboratory values. The stochastic gradient boosting algorithm had the best performance for 90 day mortality prediction, with good discrimination (c-statistic = 0.74), calibration (intercept = − 0.05, slope = 1.11) and Brier score (0.078). The elastic-net penalized logistic regression algorithm had the best performance for 2 year mortality prediction, with good discrimination (c-statistic = 0.70), calibration (intercept = − 0.03, slope = 0.89) and Brier score (0.16). The models were incorporated into a freely available web-based application, including individual patient explanations for interpretation of the model to understand the reasoning how the model made a certain prediction: https://sorg-apps.shinyapps.io/hipfracturemortality/

Conclusions

The clinical prediction models show promise in estimating mortality prediction in elderly femoral neck fracture patients. External and prospective validation of the models may improve surgeon ability when faced with the treatment decision-making.

Level of evidence

Prognostic Level II.

What do hip fracture patients die from?

Hip fractures in the elderly are associated with an increased mortality rate, even if they are operated within the recommended time window. However, the causes of mortality vary considerably depending on the postoperative period and the patients' comorbidities. In the 30-day postoperative period, the most common causes of death are acute processes such as bacterial and aspiration pneumonia followed by myocardial infarction, cancer, gastrointestinal hemorrhage, stroke, pulmonary embolism, and acute renal failure. In the 6-month and 1-year postoperative period, chronic processes appear to be the most important causes of death, as well as decompensation of patients' chronic diseases. To enhance the literature, we performed this literature review to summarize and discuss the causes of mortality of elderly hip fracture patients depending on the postoperative period that they occur, and possibly to address the question what do hip fracture patients die from? Our aim was to perform an interesting and concise paper that the curious reader will find interesting and informative.

Outcome and technical consideration of conversion total hip arthroplasty after failed fixation of intracapsular and extracapsular hip fractures: Are they really that different?

INTRODUCTION

Conversion Total Hip Arthroplasty (cTHA) is a rescue strategy for proximal femur osteosynthesis failures. However, it is unclear whether cTHAs performed for extra-capsular fracture fixation failures (ECF) or for intra-capsular fracture fixation failures (ICF) share the same complexity and efficacy. The purpose of our study was to compare cTHAs performed on pre-existing ICFs and pre-existing ECFs, focusing on surgical complications and functional outcomes in both groups.

METHODS

An observational retrospective study was conducted on cTHA patients, treated between 2014 and 2018, divided into 2 groups: ICF-group and ECF-group. The main outcomes were: type of implant used, duration of surgery, need for transfusions, incidence of complications, functional outcomes.

RESULTS

28 patients were included (15 in the ECF group and 13 in the ICF group); the average follow-up was of 31 ± 17.3 months. No significant differences were identified in terms of the type of implant used and duration of surgery. The number of transfused patients was 4 in the ICF group and 12 in the ECF group (p = 0.02); the average transfused units were 0.4 ± 0.7 in the ICF group and 1.3 ± 0.9 in the ECF group (p = 0.01). The incidence of complications - an infection and a dislocation, both of which occurred in the ICF group - and functional outcomes did not present significant differences.

CONCLUSION

The conversion surgery on ECFs patients is technically more difficult for the surgeon and prone to greater blood loss. The outcomes are satisfactory and overlap between the two groups.

What's New in Geriatric Acetabular Fractures

The incidence of acetabular fractures in the geriatric population is growing, yet the optimal treatment algorithm remains a controversial topic among orthopaedic surgeons. This review highlights key studies published over the past 5 years on the outcomes of various treatment options for geriatric acetabular fractures. Topics include surgical timing, mortality and risk factors, nonoperative treatment, open reduction internal fixation, and acute total hip arthroplasty.

The Tyranny of Distance: How Hospital Transfer Affects Time to Surgery for Hip Fracture Patients

Introduction

In Western Australia, vast distances between hospitals can limit a patient’s access to timely surgical intervention. The aim was to examine the effect of patient location on outcomes.

Methods

Hip fracture data from all operative cases at the major Western Australian hospitals between 2015 and 2019 was retrospectively reviewed. A total of 5691 patients were separated into three groups based on hospital of first presentation - directly to the operative hospital (metropolitan), a hospital less than 2.5 hours by road from the operative centre (outer-metropolitan), or requiring transfer by air (rural). Impact of location on time to surgery, length of stay and 30-day and 120-day mortality was analysed.

Results

The mean time to surgery was 26.7 hours for metropolitan patients, 37.0 hours for outer-metropolitan, and 42.6 hours for rural patients. Outer-metropolitan patients were less likely to reach surgery within 48 hours than metropolitan patients (80.2% vs 91.5%, p<0.001), with even lower rates for rural patients (66.8%, p<0.001). Acute length of stay was longer for rural patients compared to outer-metropolitan (7.2 vs 5.8 days) and metropolitan patients (5.5 days) (p<0.001). There was no significant difference in 30-day or 120-day mortality for outer-metropolitan or rural patients compared to metropolitan patients despite requiring transfer. However, when considered as a whole group there was an increased 120-day mortality with increased time to surgery. Overall mortality was 8.7% at 30 days and 17.3% at 120 days.

Conclusion

Patients presenting outside the metropolitan area with a hip fracture have a longer time to surgery and longer length of stay. Delay for outer-metropolitan patients is disproportionately longer than transit time alone and may provide opportunities for improvement.

Sliding Hip Screw and Side Plate for Intertrochanteric Hip Fractures

For stable intertrochanteric hip fractures, treatment commonly involves the use of a sliding hip screw. Intertrochanteric hip fractures are increasingly common as the population ages and lives longer. More than 250,000 hip fractures occur per year in the United States1. The mortality rate within the first year following operative treatment ranges from 14% to 27.3%2,3. Early surgical repair within 48 hours of injury is associated with a lower risk of mortality2,4,5. The goals of surgical treatment are restoration of coronal plane alignment without varus angulation and early patient mobilization.

Description

The sliding hip screw procedure can be divided into (1) preoperative planning; (2) patient positioning; (3) C-arm setup; (4) closed reduction of fracture; (5) sterile preparation and draping; (6) lateral hip approach; (7) guide pin insertion; (8) triple-reaming the proximal aspect of the femur; (9) sliding hip screw insertion into the femoral neck and head; (10) side plate insertion, engaging the sliding hip screw, and fixation to the femur; (11) lag compression screw insertion (if appropriate); and (12) final fluoroscopic images and wound closure.

Alternatives

Intertrochanteric hip fractures must be surgically treated to avoid morbidity and increased risk of mortality. Nonoperative treatment is occasionally indicated in nonambulatory patients or those with high perioperative risk. If treated surgically, a common alternative implant option includes the intramedullary nail. Finally, for severely comminuted fractures or failed internal fixation, total hip arthroplasty may be necessary.

Rationale

Sliding hip screws are as effective as intramedullary nails and often less costly6. In general, the quality of fracture reduction is more critical than the choice of implant7. A prospective study found no significant difference in walking ability with either sliding hip screws or intramedullary nails for stable intertrochanteric fractures8.

Expected Outcomes

By 6 months, the majority of fractures will have healed; according to a prospective randomized study, 91% of stable fractures and 85% of unstable fractures had achieved radiographic union by that time9. Another study showed radiographically healed fractures in all 106 patients treated with sliding hip screws at median follow-up of 13.6 months8.

Important Tips

Watch out for comminution of the greater or lesser trochanter, which may require supplemental fixation.Prior to completely reflecting the vastus lateralis muscle, control the bleeding from any perforators with use of 2-0 silk ties. This prevents recurrent bleeding, which often occurs if only cautery is utilized to coagulate these vessels.Utilize a 4.5-mm drill hole in the lateral cortex of the femur in order to allow for minor adjustments of the anterior femoral neck guide pin; otherwise, the pin will be held tightly and continue to be bound in the same direction by the lateral cortex on repeated attempts.If the guide pin is inadvertently withdrawn along with the reamer after reaming, a lag screw may be placed backward in the newly reamed hole and the guide pin passed back through the lag screw to reposition it.Extracapsular hip fractures should be carefully scrutinized for signs of instability, such as lateral wall comminution or reverse obliquity. The fracture may displace posteriorly when the patient is supine on the fracture table.While placing the guidewire, multiple entry attempts can weaken the lateral cortex and propagate the fracture into the subtrochanteric region.Superior placement of the lag screw results in poor tip-apex distance and a higher chance of screw cut-out.Be careful to prevent guidewire penetration into the hip joint.Loss of reduction or femoral head malrotation may occur during lag screw insertion.

Acronyms & Abbreviations

AP = anteroposteriorfx's = fracturesIMN = intramedullary nailIV = intravenousPDS = polydioxanone sutureSHS = sliding hip screwTFL = tensor fascia lata.

Treatment of osteoporosis after hip fracture is associated with lower all-cause mortality: A nationwide population study

PURPOSE

Mortality after osteoporotic hip fractures is high. Postoperative care is as important as surgery itself to prevent a second fracture and improve outcomes, and the effect of anti-osteoporosis treatment after hip fractures on overall mortality is controversial. This nationwide population study aimed to determine whether anti-osteoporosis treatment might reduce overall mortality after hip fracture surgery.

METHODS

We conducted this cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan to identify patients admitted for surgery due to hip fractures from 2008 to 2018. The subsequent use and duration of anti-osteoporotic medication and other parameters were analyzed, and national death registration records were retrieved to investigate mortality.

RESULTS

A total of 59,943 patients admitted for hip fracture surgery were identified. The 22,494 patients (37.5%) who received anti-osteoporotic medication showed a lower all-cause mortality rate compared with the 37,449 patients (62.5%) who did not receive further treatment (hazard ratio (HR): 0.69, 95% confidence interval (CI): 0.67-0.70, p < 0.0001). Patients who received anti-osteoporotic medication for more than 1, 2, and 3 years exhibited propotional reductions in all-cause mortality (HR & 95%CI: 0.57 (0.54-0.60), 0.42 (0.38-0.46), and 0.29 (0.26-0.33) respectively).

CONCLUSION

Anti-osteoporosis treatment was associated with lower all-cause mortality after hip fracture surgery. A longer duration of treatment was also associated with lower mortality. Postoperative treatment for osteoporosis is crucial for patients with hip fracture.

Factors associated with mortality in older patients sustaining pelvic or acetabular fractures

INTRODUCTION

This study aimed to investigate potential factors, including delay to surgical stabilisation, affecting mortality in older patients sustaining pelvic or acetabular (PA) fractures.

MATERIALS AND METHODS

A retrospective review of the Trauma Audit and Research Network (TARN) database was performed to identify older patients (aged 65 and over) sustaining PA fractures treated surgically in a UK Major Trauma Centre (MTC) between 2015 and 2019. Chi-squared and Fisher tests were used to compare 1-year mortality rates following operative intervention between patients treated within 72 h and after 72 h. Kaplan-Meier curves were used to visualise survival probability; significant predictors of survival were found using Cox proportional hazard models.

RESULTS

Of 564 older patients with PA fractures, 70 met the inclusion criteria. The mean age was 76.1 years. The overall 1-year mortality rate was 20%. When patients were grouped by time to surgery (fracture fixation within or greater than 72 h), there was no statistically significant difference in 1-year mortality. Patients whose surgery was delayed more than 72 h were more likely to have longer hospital stays (p = 0.002) or to have suffered from polytrauma (p = 0.025). Age, Charlson Co-morbidities Index (CCI) and pre-op mobility status were associated with statistically significant differences in overall mortality. The same factors were associated with a significantly increased hazard of death in the multivariate Cox proportional hazards model. Patient gender, mechanism of injury, Injury Severity Score (ISS) > 15 and head injury were not significant predictors of mortality.

CONCLUSION

Surgical intervention within 72 h of injury did not result in decreased mortality in older patients with PA fractures. The 1-year mortality rate between older PA fractures and hip fractures was comparable. Consideration should be given to a combined multidisciplinary approach between orthogeriatric and expert PA surgeons for these patients.

For you were hungry and I gave you food: The prevalence and treatment of malnutrition in patients with acute hip fracture

Hip fractures are a common clinical problem with substantial morbidity and difficult recovery. Preexisting malnutrition has been shown to be common in those patients and a substantial risk factor for poorer outcomes, increased length of stay, and mortality. Additionally, great variability exists in reported malnutrition prevalence rates owing to the variety of nutrition screening and assessment tools utilized globally to identify malnutrition in these patients. Although previous data and a recent Cochrane review have not proven the value of nutrition supplements, we highlight several articles that show an opportunity for improvement in the nutrition care of patients sustaining hip fractures along with a multicenter randomized trial demonstrating the value of carefully designed nutrition intervention. There is also evidence that malnourished patients with hip fracture are still being undertreated. Current guidelines are reviewed, and continued efforts on the part of the clinicians to follow the guidelines as well as lowering the barriers to high-quality nutrition research is discussed.

Should we operate on all patients with COVID-19 and proximal femoral fractures? An analysis of thirty, sixty, and ninety day mortality rates based on patients' clinical presentation and comorbidity: a multicentric study in Northern Italy

PURPOSE

This study aims to evaluate 30-60-90-day mortality of operated proximal femur fractures (PFFs) suffering from COVID-19 and correlation with patients' clinical presentation and comorbidities.

METHODS

Between February 1, 2020, and December 31, 2020, patients with COVID-19 infection and surgically treated PFF were included. Patients' demographic characteristics, oxygen (O2) therapy, comorbidities, and AO type fracture were collected. Chi-square test or Fisher test and hazard ratio were used to assessing the correlation between mortality rate, patient characteristics, and COVID-19 status. Kaplan-Meyer curve was used to analyze 30-60-90-day mortality. Level of significance was set as p < 0.05.

RESULTS

Fifty-six patients (mean age of 82.7 ± 8.85 years) were included. Thirty-day mortality rate was 5%, which increased to 21% at 60 days and 90 days. Eleven patients died, eight due to AO type A-like and three due to AO type B-like fractures. No significant difference in mortality rate between patients with cardiopulmonary comorbidity or no cardiopulmonary comorbidity was found (p = 0.67); a significant difference in patients with chronic obstructive pulmonary disease (COPD) or history of pulmonary embolism (PE) and patients without COPD was found (p = 0.0021). A significant difference between asymptomatic/mild symptomatic COVID-19 status and symptomatic COVID-19 status was found (p = 0.0415); a significant difference was found for O2 therapy with < 4 L/min and O2 therapy ≥ 4 L/min (p = 0.0049).

CONCLUSION

Thirty-day mortality rate of COVID-19 infection and PFFs does not differ from mortality rate of non-COVID-19 PFFs. However, patients with pre-existing comorbidities and symptomatic COVID-19 infection requiring a high volume of O2 therapy have a higher incidence of 60-90-day mortality when surgically treated.

Should we operate on all patients with COVID-19 and proximal femoral fractures? An analysis of thirty, sixty, and ninety day mortality rates based on patients' clinical presentation and comorbidity: a multicentric study in Northern Italy

Purpose

This study aims to evaluate 30–60–90-day mortality of operated proximal femur fractures (PFFs) suffering from COVID-19 and correlation with patients’ clinical presentation and comorbidities.

Methods

Between February 1, 2020, and December 31, 2020, patients with COVID-19 infection and surgically treated PFF were included. Patients’ demographic characteristics, oxygen (O2) therapy, comorbidities, and AO type fracture were collected. Chi-square test or Fisher test and hazard ratio were used to assessing the correlation between mortality rate, patient characteristics, and COVID-19 status. Kaplan-Meyer curve was used to analyze 30–60–90-day mortality. Level of significance was set as p < 0.05.

Results

Fifty-six patients (mean age of 82.7 ± 8.85 years) were included. Thirty-day mortality rate was 5%, which increased to 21% at 60 days and 90 days. Eleven patients died, eight due to AO type A-like and three due to AO type B-like fractures. No significant difference in mortality rate between patients with cardiopulmonary comorbidity or no cardiopulmonary comorbidity was found (p = 0.67); a significant difference in patients with chronic obstructive pulmonary disease (COPD) or history of pulmonary embolism (PE) and patients without COPD was found (p = 0.0021). A significant difference between asymptomatic/mild symptomatic COVID-19 status and symptomatic COVID-19 status was found (p = 0.0415); a significant difference was found for O2 therapy with < 4 L/min and O2 therapy ≥ 4 L/min (p = 0.0049).

Conclusion

Thirty-day mortality rate of COVID-19 infection and PFFs does not differ from mortality rate of non-COVID-19 PFFs. However, patients with pre-existing comorbidities and symptomatic COVID-19 infection requiring a high volume of O2 therapy have a higher incidence of 60–90-day mortality when surgically treated.

Is preoperative balloon aortic valvuloplasty of interest for severe aortic stenosis in hip fracture surgery?

PURPOSE

In elderly patients, the discovery and management of a severe aortic stenosis (AS) prior to emergency non-cardiac surgery is a frequent and controversial issue. The objective of this study was to evaluate preoperative balloon aortic valvuloplasty (BAV) for severe AS in hip fracture surgery.

METHODS

We conducted an observational, monocentric, retrospective study from 2011 to 2018. Survival (30-day, 90-day and 180-day mortality) and the occurrence of perioperative complications were analyzed and compared between control (i.e. no BAV prior to surgery) and preoperative BAV groups in patients with hip fracture surgery and a formal transthoracic echocardiographic diagnosis of severe AS (aortic valve area < 1 cm²). Patients' allocation to the intervention and control groups was after a discussion between cardiologist, anesthesiologist and the surgeon.

RESULTS

Among the 8506 patients who underwent hip fracture surgery, 29 patients in the control group and 30 patients in the BAV group were finally included. Kaplan-Meier survival analysis demonstrated a significant decrease in mortality in the BAV group (p=0.014) despite an increase in median time to operation of about 48 hours (p<0.0001). Multivariate analysis (stepwise logistic regression) showed that postoperative delirium (OR [95%CI]: 17.5 [1.8-168]; p=0.013) and postoperative acute congestive heart failure (OR [95%CI]: 59.4 [5.0-711.1]; p=0.0013) were predictive factors of 30-day mortality with an area under ROC curve of 0.90 (95%CI: 0.80-0.97; p<0.0001).

CONCLUSIONS

preoperative BAV for severe AS could reduce the mortality of hip fracture patients despite an increase in time to operation. This improved survival could be linked to the decrease in cardiologic and neurologic adverse events. A larger prospective randomized study is necessary before generalizing our results.

Does Presence of Femoral Arterial Calcification Have an Effect on Postoperative Complication and Mortality in Patients With Hip Fracture?

Introduction In this study, we investigated the relationship between femoral arterial calcification on preoperative hip radiography and post-operative complications and all-time mortality rates in patients with hip fracture >65 years old. Methods This retrospective study was conducted by evaluating the records of patients who were operated for hip fractures. All patients were divided into two groups according to the presence of lower extremity arterial calcification (LEAC) at the femoral artery which was diagnosed using the hip radiograph. The patients with and without the presence of LEAC were assigned as groups 1 and 2, respectively. A multivariate Cox algorithm was applied to recognize whether this radiological factor is independently associated with survival. Results The study included 530 patients (540 hips; 191 males and 339 females) with an average age of 80.8 ± 7.6 years. In the study after 24.8±19.9 months (range:0-65 months) follow-up period, 336 (63.3%) patients had expired. Conversely, 194 (36.7%) patients are surviving. Survival rates at one month and one year after surgery were 89.5% and 65.7%, respectively. 234 of 540 hips (230 patients) have LEAC on the femoral artery. The survival rate at one month, one year, and overall survival were significantly higher in patients with LEAC. The postoperative infection rate was also two times higher in patients with LEAC than without LEAC (p = 0.021). Multivariate analysis demonstrated that age, treatment modality (hemiarthroplasty), and the presence of femoral arterial calcification were independently associated with poor overall survival. Conclusions In our study, we found that the presence of femoral arterial calcification on the affected side of the hip identified on hip radiograph was independently associated with poor one month, one year, and overall survival as the patients had 1.5 times higher mortality rate. Additionally, a significant correlation was found between age and survival of patients with hip fracture, especially patients >80 years old.

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

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.

Treatment of Traumatic Femoral Neck Fractures with an Intramedullary Nail in Osteoporotic Bones

PURPOSE

Sufficient anchoring of intramedullary osteosynthesis in the femoral head in a femoral neck fracture is a challenge with increasing age of the patients and decreasing bone quality. For older patients with inferior bone quality, it has not been investigated whether the application of an intramedullary force carrier, as a minimally invasive and rapid intervention, can provide a considerable benefit and reduce the postoperative complication and lethality rate. This retrospective study aimed to investigate the stability and functionality after the acute treatment of a femoral neck fracture in osteoporotic bone using an intramedullary force carrier even with higher grade fracture types.

MATERIAL AND METHODS

The retrospective analysis was based on a collective of 82 patients over 60 years of age with a femoral neck fracture treated with a gliding nail in our centre between 1999 and 2006.

RESULTS

The average time to follow-up was 69.05 months (median 71.0; minimum 27.0-maximum 108.0). Female patients made up more than two-thirds of the patient collective at 63 of the 82 patients (76.83%). The average age of the patients was 77.76 years (median 78.00; range 60.00-93.00).In 66 patients (80.49%), the implantation showed good results and no complications or further treatments. 24/82 patients of our collective had died in our re-evaluation. In no case, a pseudarthrosis or severe impaction with neck shortening occurred (loss of offset).11/82 patients had femoral head necrosis which led to total hip replacement in 8 cases, a hemiarthroplasty in 2 cases and in 1 case a remaining Girdlestone situation because of a deep infection. Another five patients also had to undergo a total hip replacement because of a central perforation of the blade in one case, breakout of the blade after another fall in another two cases and a lateral dislocation of the blade in two cases.

CONCLUSION

The use of an intramedullary force carrier in the osteoporotic bone can mean distinct advantages for the selected patient as a minimally invasive and rapid surgical method compared to extensive surgery, even in the case of severe injuries. However, the advantages and disadvantages for the patient should be considered critically.

Mortality Risk Assessment at the Admission in Patient With Proximal Femur Fractures: Electrolytes and Renal Function

In patients over 65y.o. who were surgically treated for a hip fracture, electrolytes have not been specifically studied as predictors of mortality. The main purpose of this study was to assess whether electrolytes and chronic kidney disease (CKD) stages, evaluated at admission, could represent a pre-operative prognostic factor in this population. Moreover, the role of epidemiological and clinical parameters was analyzed with and without a surgical timing stratification. This retrospective study included 746 patients. For each patient, their age, gender, fracture classification, Hb value, comorbidities, ASA class, chronic kidney disease, creatinine levels, electrolytes and surgical timing were collected. CKD-epi, MDRD, modified MDRD and BIS1 were used to obtain eGFR and CKD stages. All parameters were analyzed individually and in relation to the different surgical timing. Descriptive statistics, Chi-square test and survivability analysis with Kaplan Meier curve were used. In patients with a hip fracture non-significant association with increased mortality was shown for the following variables: Hb value, sodium values, calcium values, CKD stages and creatinine values. Otherwise altered kalemia was associated with a statistically significant increase in mortality as well as male gender, two or more comorbid medical conditions, advanced age (>75 years), higher ASA class. Surgery performed within 72h resulted in a statistically significant reduction in mortality at 6 months and, when performed in 24h-48h, a further reduction at 4 years. Age and ASA class statistically significant increased mortality regardless the surgical timing. Male patients operated after 48h from hospitalization were associated with a statistically significant increase in mortality rate. Two or more comorbidities were related to a statistically significant increased number of deaths when patients were treated after 96h. Altered kalemia values at hospitalization are associated with a statistically significant increase in mortality in patients operated after 72h from admission.

Clinical characteristics and outcomes of patients presenting with hip fractures at a tertiary care hospital in Pakistan

Osteoporosis remains under-recognized and sub-optimally managed in Pakistan, with a lack of awareness that minimal impact hip fracture is a manifestation of low bone mineral density (BMD).

PURPOSE

Hip fracture is often the first clinical presentation of osteoporosis and an opportunity to intervene and reduce future fracture risk. Our aim was to understand the current practices in Pakistan related to bone health in patients presenting with a hip fracture.

METHODS

This is a retrospective study at a tertiary care center in Pakistan of patients admitted with a hip fracture. Data collected includes previous fracture history, known preceding diagnosis of low BMD medication details, comorbidities, and DXA results.

RESULTS

Two hundred ten patients were studied. The mean age of patients was 73.1 years, with 112 (53.3%) women. Most (195 (92.9%)) had presented with a low-impact hip fracture, with 17 (8.1%) reporting previous history of fracture. None had been treated with osteoporosis medications prior to fracture. Nineteen (9%) were on calcium and vitamin D supplements prior to fracture; of the minority who were screened, all were vitamin D deficient and subsequently discharged on vitamin D supplements. No one was prescribed medications to reduce fracture risk at discharge.

CONCLUSION

This study reveals that patients admitted with minimal impact hip fractures in Pakistan are rarely evaluated for low BMD and not started on osteoporosis medications even after presenting with a typical osteoporosis-related fracture. This underscores the need for health provider education about osteoporosis as a major cause for hip fractures and the need to intervene for future fracture risk reduction.

Does early surgery prevent Postoperative ICU admission after surgery for the fracture of the hip. Nested case control study of 911 patients

Introduction

Since most hip fractures are treated surgically, it is imperative to find an optimum fracture-to-surgery time to decrease the potential complications and enhance postoperative outcomes. In comparison to the vast plethora of literature available on surgical delay and its implications on mortality, very little, if any, research is available on the impact of delayed surgery on postoperative ICU admission. The primary objective of our study is to examine the factors influencing post-surgical ICU admission in order to work on preventive strategies to reduce the potential associated morbidity.

Material and methods

Investigators did a nested case control study in a university hospital. A case was defined as a patient who had postoperative ICU admission while controls were patients who did not have postoperative ICU admission after hip fracture surgery. The primary outcome variable was postoperative ICU admission. The exposure variable was defined as the time to surgery which was categorized into two categories; early and late; the early surgery included patients who were operated within ≤ 48 h and the late included patients who had their surgery >48 h. Information on potential confounders including age, type of the procedure and comorbidities were also obtained. Result reported in-line with STROCSS criteria.

Results

A total cohort of 1084 hip fracture surgeries were performed from January 2010 to December 2018. After screening for eligibility criteria, 911 patients were eligible for the final simple logistic regression analysis (48 cases and 863 controls). Our exposure variable i.e. time from admission to surgery showed no difference between cases and controls. The odds of being treated with Hemiarthroplasty among cases admitted in ICU was 2.42 times as compared to controls (aOR = 2.42; 95% C.I. 1.21–4.86).

Conclusion

Our study did not find an association between surgical delay and post-operative ICU admission after accounting for other covariates and potential confounders.

•

There is a controversy of the benefits of early hip fracture surgery.

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Delay in surgery is postulated to carry higher risk of postoperative ICU admission.

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However, this higher risk was statistically insignificant in the current study.

Orthogeriatric assessment of patients over 75 years of age with a proximal femur fracture: Predictors of 6-month mortality

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.

Predictors of Acute Kidney Injury After Hip Fracture in Older Adults

INTRODUCTION

This study aimed to investigate the prevalence of acute kidney injury (AKI) following hip fracture surgery in geriatric patients and to identify predictors for development of AKI with a focus on possible preventable risk factors.

METHODS

In this retrospective cohort study, we reviewed electronic medical records of all patients above 65 years of age who underwent hip fracture surgery at Copenhagen University Hospital, Bispebjerg, Denmark, in 2018. Acute kidney injury was assessed according to the Kidney Disease Improving Global Outcomes guidelines. Multivariate logistic regression analyses were used to identify independent risk factors for AKI.

RESULTS

Postoperative AKI developed in 28.4% of the included patients (85/299). Acute kidney injury was associated with increased length of admission (11.3 vs 8.7 days, P < .001) and 30-day mortality (18/85 vs 16/214, P = .001). In multivariable analysis, higher age (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.08, P = .004), heart disease (OR: 1.78, 95% CI: 1.01-3.11, P = .045), and postoperative blood transfusion (OR: 1.84, 95% CI: 1.01-3.36, P = .048) were associated with AKI. Moreover, a higher postoperative C-reactive protein (199.0 ± 99.9 in patients with AKI, 161.3 ± 75.2 in patients without AKI) and lower postoperative diastolic blood pressure were observed in patients developing AKI.

DISCUSSION AND CONCLUSION

Acute kidney injury was common following hip fracture surgery and associated with longer admissions and increased mortality. Patients developing AKI were older and showed several postoperative similarities, including higher C-reactive protein, lower postoperative diastolic pressure, and the need for blood transfusion.

Do anticoagulants affect outcomes of hip fracture surgery? A cross-sectional analysis

INTRODUCTION

The management of patients with a hip fracture is affected by the use of oral anticoagulants. A cross-sectional analysis was undertaken to investigate health outcome differences in those anticoagulated compared to those not anticoagulated.

METHODS

Patients aged 50 years and over presenting to a large university hospital with hip fractures were identified from the service registry. Patient characteristics and health outcomes between those not anticoagulated were compared with those anticoagulated (warfarin and direct oral anticoagulants, DOAC).

RESULTS

200/2307 (9%) patients were anticoagulated. 84% were on warfarin, and the rest a DOAC. Compared to those anticoagulated, there was a higher prevalence of dementia (25% vs. 18%, p = 0.02) and a lower prevalence of cardiovascular disease (54% vs. 78%, p < 0.01), atrial fibrillation (10% vs. 82%, p < 0.01), and polypharmacy (55% vs. 76%, p < 0.01). Renal function was lower in the anticoagulated group. Time to operation for those not anticoagulated and anticoagulated was a median (IQR) of 25 (15) and 27 (18) hours. There was no difference in blood transfusion and hospital mortality. Postoperative complications were similar except a higher rate of renal failure (14% vs. 19%, p = 0.04) and heart failure (1% vs. 5%, p < 0.01), and a longer length of stay [median (IQR): 14 (10) vs. 16 (12) days] in the anticoagulated group. This was no longer significant after adjustment of confounders.

CONCLUSION

There was no statistically significant difference in health outcomes between those anticoagulated and those not after adjusting for patient characteristics. It was feasible to avoid significant delay in hip fracture surgery in those anticoagulated.

One-year mortality after hip fracture surgery and prognostic factors: a prospective cohort study

Older adult patients with hip fractures are 3-4 times more likely to die within one-year after surgery than general population. The study aimed to identify independent predictive factors associated with one-year mortality after hip fracture surgery. A prospective prognostic cohort study was performed. All patients aged ≥65 years, consecutively admitted in three Italian hospitals with a diagnosis of fragility hip fracture were included. Patients with periprosthetic or pathological fractures were excluded. Multivariate analysis was used to determine variables that significantly increased the risk of one-year mortality and Receiver operating characteristic (ROC) curve analysis to assess their predictive capacity on the outcome.1083 patients fulfilled the inclusion criteria and the one-year follow-up was reached in 728 patients. The 16.6% of patients died within one-year after surgery. At the multivariate analysis, advancing age (OR = 1.094, 95% CI = 1.057-1.132), higher baseline Charlson Index (OR = 1.257, 95% CI = 1.114-1.418) and Activities of Daily Living scores (OR = 1.259, 95% CI = 1.143-1.388), presence of hospital-acquired pressure ulcers (PUs) (OR = 1.579, 95% CI = 1.002-2.489) and lack recovery of ambulation (OR = 1.736, 95% CI = 1.115-2.703), were found to be independent predictive factors of one-year mortality after surgery. The area under the ROC curve of the model was 0.780 (CI95% 0.737-0.824) for one-year mortality in elderly hip fractures patients. Early ambulation and careful long-term follow-up, with attention to frailty in elderly people, should be promoted.

Epidemiology and mortality in older patients treated by reverse shoulder arthroplasty for displaced proximal humerus fractures

INTRODUCTION

Reverse shoulder arthroplasty (RSA) is rapidly becoming the preferred treatment for displaced proximal humerus fractures in older patients. However, few studies have analyzed the target population and the effect of RSA on survival, although the socioeconomic impact of this type of surgery is considerable.

PATIENTS AND METHODS

This was a retrospective epidemiological study of all patients with a displaced proximal humeral fracture treated by RSA in 14 public and private hospitals throughout France between 1995 and 2016. The French hospital discharge database (PMSI) was analyzed to isolate an 898-patient cohort who underwent RSA within 6 weeks of the fracture event. In 87% of cases, this was a 3- or 4-fragment fracture. We analyzed the epidemiological characteristics of the patients at the time of fracture, their survival (Kaplan-Meier estimate) and factors that may impact survival.

RESULTS

The mean age at the time of fracture and surgery was 79 years (46-98 years). Eighty percent of the cohort was female (sex ratio: 0.18 [p=0.0042], with 21% obesity rate [BMI>30]) and 60% of patients were ASA 1-2. The most common comorbidities were cardiovascular and neurological. The survival rate after RSA was 94% at 1 year and 73% at 5years. At the latest follow-up of 19 years, 42% of patients were still alive. In 18% of cases, the patient died within the first 15 days. The presence of comorbidities (ASA score>3-4) (p<0.004) and/or cognitive disorders (p<0.0001) were risk factors for early mortality. The time to surgery, type of fracture, associated fractures and discharge destination (return home, transfer to nursing home) had no effect on postoperative mortality in our cohort.

CONCLUSION

Despite being older (79 years) at the time of proximal humerus fracture, patients who underwent RSA treatment had a high survival rate (94% at 1 year, 73% at 5years), which is better than the survivorship reported after surgical treatment of femoral neck fractures (81-87% at 1 year, 38% at 5years). The presence of comorbidities (ASA>3-4) and/or cognitive disorders are risk factors for early mortality and should be taken into account to prevent early death.

LEVEL OF EVIDENCE

IV, Retrospective study.

[Analysis of perioperative blood loss by fast track protocol in cephalomedullary nailing for geriatric intertrochanteric fractures]

OBJECTIVE

To analyze the effectiveness of fast track protocol of geriatric intertrochanteric fracture on operative waiting time, operation time, perioperative blood loss, providing data support for clinical therapy.

METHODS

The clinical data of 240 elderly patients with intertrochanteric fracture admitted between January 2015 and December 2018 were retrospectively analyzed. They were divided into traditional protocol group (148 cases, group A) and fast track group (92 cases, group B). All patients were treated with closed reduction intramedullary nail (proximal femoral nail antirotation) surgery. There was no significant difference in gender, age, sides, fracture classification, fracture type, complications, the proportion of patients with more than 3 kinds of medical diseases, and the time from injury to admission between the two groups ( P>0.05). Analysis index included operative waiting time (hospitalization to operation time), operation time, percentage of operation performing in 48 and 72 hours, percentage of transfusion, changes of hematocrit (Hct) at different stage (admission, operation day, and postoperative 1, 3 days), blood loss by fracture and cephalomedullary nail, intraoperative dominant blood loss, total blood loss in perioperative period were recorded and compared.

RESULTS

The operative waiting time, operation time, Hct on operation day and postoperative 3 days, blood loss by fracture, transfusion volume, and total blood loss in perioperative period in group B were significantly less than those in group A ( P<0.05), and the percentage of operation performing in 48 and 72 hours in group B were significantly higher than those in group A ( P<0.05). There was no signifcant difference in Hct on admission and postoperative 1 day, intraoperative dominant blood loss, percentage of transfusion, blood loss by cephalomedullary nail between the two groups ( P>0.05).

CONCLUSION

Fast track can shorten the operative waiting time of geriatric intertrochanteric fracture, reduce the blood loss by fracture, total blood loss in perioperative period, and transfusion volume. Early operation is conducive to improve the anemia status of patients during perioperative period.

Comparison of the Efficacy and Safety of Aspirin and Rivaroxaban Following Enoxaparin Treatment for Prevention of Venous Thromboembolism after Hip Fracture Surgery

OBJECTIVE

To compare the efficacy and safety of aspirin with rivaroxaban following treatment with enoxaparin for prevention of venous thromboembolism (VTE) after hip fracture surgery (HFS).

METHODS

A total of 390 patients were enrolled in the trial. According to an odd or even number at the end of their registration number, the patients were divided into the aspirin group (n = 198) and the rivaroxaban group (n = 192). All patients were given enoxaparin subcutaneous injection after the operation and returned to the routine dose the next day until postoperative day five. The patients in the aspirin group received an additional 16 days of thromboprophylaxis with 100 mg of aspirin once daily. The rivaroxaban group was assigned to receive an additional 16 days of thromboprophylaxis with 10 mg of oral rivaroxaban once daily. Patients were followed for 90 days regarding VTE and bleeding complications.

RESULTS

The incidence of VTE in the aspirin group and rivaroxaban group was 6.6% (13/198) and 5.7% (11/192), respectively (P = 0.83). The rate of major bleeding events occurred in two (1.0%) patients in the aspirin group and in one patient (0.5%) in the rivaroxaban group (P = 1.0). A combination of major bleeding and clinically relevant nonmajor bleeding occurred in five patients (2.5%) in the aspirin group and in six patients (3.1%) in the rivaroxaban group (P = 0.77). During the 90-day follow-up, a pulmonary embolism developed in one patient (0.5%) in the aspirin group and none in the rivaroxaban group (P = 1.0).

CONCLUSIONS

Extended prophylaxis for 21 days with aspirin was equivalent to the direct oral anticoagulant rivaroxaban after hip fracture surgery with an initial 5-day postoperative course of enoxaparin. Aspirin may be an effective, safe, convenient, and cheap alternative for extended prophylaxis after hip fracture surgery.

Hip Fractures: Therapy, Timing, and Complication Spectrum

Objective

Investigation of the treatment of femur fractures and the type of femur fracture‐associated complications regarding timing of surgery and length of hospital stay.

Methods

In this retrospective cohort study, a total of 358 hip fractures were evaluated retrospectively from 1 January 2008 until 31 December 2010 at a level I trauma center in Germany. Inclusion criteria was age >18 years and a proximal femur fracture. Both sexes were evaluated. Mean age was 75.5 years, most patients were female (63.7%). Intervention was the operative treatment of proximal femur fracture. Outcome parameters were time until surgery, complications, reoperations, mortality, and length of hospital stay.

Results

Among the proximal femur fractures (n = 358), 46.6% were pertrochanteric, 11.2% subtrochanteric, and 42.2% femoral neck fractures. Operation upon hip fractures was managed regularly within 24 hours of injury (73%; mean for femoral neck: 28.3 hrs.; mean for pertrochanteric fractures: 21.4 hrs.; mean for subtrochanteric fractures: 19.5 hrs.). Delayed treatment, as well as implantation of hip total endoprosthesis (TEP), increased the overall length of hospital stay (15.4 vs 17.6 days; 18.1 vs 15.8 days). Accordingly, surgical procedures performed within 24 hours of injury resulted in a shorter hospital residence. Longest delay of operation was measured for hip fractures (28.3 hrs.).

In 351 patients, secondary injuries were detected in 94 individuals (26%), with fractures being the most common secondary injury (n = 40). We recorded postoperative complications of nonsurgical and surgical origin, and 33.6% of our patient cohort displayed complications. Complications were distributed among 118 patients. There was no significant difference in complications regarding the time of operation, with most nonsurgical and surgical complications appearing within 24 hours after operation (n = 110 vs n = 31). Nonsurgical complications, such as anemia (n = 49) and electrolyte imbalances (n = 30), were observed more frequently than surgical complications (n = 107 vs n = 34); however, these complications were reduced by delay in surgery (82.0% in 6–24 hrs. vs 74.2% in ≥24 hrs.). Anticoagulant therapy and age did not affect postoperative complications. The hospital mortality of patients was 6.2%. Follow‐up was restrained to ambulatory visits in the clinic.

Conclusions

Surgical management of hip fractures performed within 24 hours of injury minimizes hospital stay. We did not detect significant differences in the spectrum or number of complications regarding delay of surgery. Surgical complications mainly occur with rapid primary care, and medical complications can be reduced by more intensive preparation of patient and operation procedures.