Surgical treatment of hip fracture in centenarians: Complications and independent risk factors of death

Should patients with exceptional longevity be treated for osteoporosis after a hip fracture?

BACKGROUND

There are no studies focusing on treatment for osteoporosis in patients with exceptional longevity after suffering a hip fracture.

OBJECTIVE

To assess the advisability of initiating treatment for osteoporosis after a hip fracture according to the incidence of new fragility fractures after discharge, risk factors for mortality and long-term survival.

DESIGN

Retrospective review.

SETTING

A tertiary university hospital serving a population of ~425 000 inhabitants in Barcelona.

SUBJECTS

All patients >95 years old admitted with a fragility hip fracture between December 2009 and September 2015 who survived admission were analysed until the present time.

METHODS

Pre-fracture ambulation ability and new fragility fractures after discharge were recorded. Risk factors for 1-year and all post-discharge mortality were calculated with multivariate Cox regression. Kaplan-Meier survival curve analyses were performed.

RESULTS

One hundred and seventy-five patients were included. Median survival time was 1.32 years [95% confidence interval (CI) 1.065-1.834], with a maximum of 9.2 years. Male sex [hazard ratio (HR) 2.488, 95% CI 1.420-4.358] and worse previous ability to ambulate (HR 2.291, 95% CI 1.417-3.703) were predictors of mortality. After discharge and up to death or the present time, 10 (5.7%) patients had a new fragility fracture, half of them during the first 6 months.

CONCLUSIONS

Few new fragility fractures occurred after discharge and half of these took place in the first 6 months. The decision to start treatment of osteoporosis should be individualised, bearing in mind that women and patients with better previous ambulation ability will have a better chance of survival.

Outcomes of hip fracture in centenarians: a systematic review and meta-analysis

PURPOSE

Outcomes of hip fractures in centenarians remain underreported owing to the small number of patients reaching 100 years of age. This review aimed to determine outcomes of hip fracture in centenarians and to identify the most common comorbidities among centenarians with hip fracture to better characterise this population.

METHODS

Published and unpublished literature databases, conference proceedings and the reference lists of included studies were searched to the 25th of January 2023. A random-effects meta-analysis was performed. Included studies were appraised using tools respective of study design.

RESULTS

Twenty-three studies (6970 centenarians) were included (retrospective period: 1990-2020). The evidence was largely moderate to low in quality. One-year mortality following a hip fracture was 53.8% (95% CI 47.2 to 60.3%). Pooled complication rate following a hip fracture in centenarians was 50.5% (95% CI 25.3 to 75.6%). Dementia (26.2%, 95% CI 15.7 to 38.2%), hypertension (15.6%, 95% CI 3.4 to 33.1%), and diabetes (5.5%, 95% CI 1.9 to 10.7%) were the most common comorbidities among centenarians with hip fracture.

CONCLUSION

Hip fractures in centenarians typically involve complex patient presentations with diverse comorbidities. However, the current evidence-base is moderate to low in quality. Effective cross-discipline communication and intervention is suggested to promote treatment outcomes.

Clinical and Demographic Characteristics of Centenarians versus Other Age Groups Over 75 Years with Hip Fractures

Objective

The primary objective was to describe the clinical characteristics, management, and outcomes of centenarians with fragility hip fracture and compare them to other age groups. The secondary objective was to determine the variables associated with length of stay, in-hospital mortality and 30-day mortality.

Materials and Methods

This is a secondary analysis of the Spanish National Hip Fracture Registry. We included patients ≥75 years admitted for fragility hip fractures in 86 Spanish hospitals between 2017 and 2019, dividing the sample into four age groups. The variables studied were baseline characteristics, type of fracture, management, length of stay, in-hospital mortality and 30-day mortality.

Results

We included 25,938 patients (2888 were 75-79 years old; 14,762 octogenarians; 8,035 nonagenarians and 253 centenarians). Of the centenarians, 83% were women, 33% had severe dementia, 9% had severe dependency and 36% lived in residential care homes. Six out of ten had intertrochanteric fracture. Length of hospital stay was 8.6 days; in-hospital mortality was 10.3% and 30-day mortality 20.9%. Older age groups had more women, severe functional dependency, severe dementia, intertrochanteric fracture, living in care facilities and being discharged to nursing care. They had less frequent early mobilization, osteoporosis treatment and discharge to rehabilitation units. In-hospital and 30-day mortality were higher with increasing age. In centenarians, time to surgery >48 hours was independently associated with length of stay (correlation coefficient 3.99 [95% CI: 2.35-5.64; p<0.001]) and anaesthetic risk, based on an ASA score of V, was related to 30-day mortality (ASA score II [OR 0.25, 95% CI: 0.09-0.70; p=0.009] and ASA score III [OR 0.43, 95% CI: 0.19-0.96; p=0.039]).

Conclusion

Centenarians had different clinical characteristics, management and outcomes. Although centenarians had worse outcomes, nearly 4 out of 5 centenarians were alive one month after surgery.

Characteristics, comorbidity burden and outcomes in centenarians undergoing surgery in a university hospital: A case series

Introduction

As the population ages, so too does the age of those requiring surgery. People over the age of 100, centenarians, often have a greater degree of comorbidity and frailty than their younger counterparts but may also have a greater incidence of events requiring surgical intervention. There is, however, a dearth of literature describing the clinical course and practical considerations for this vulnerable population undergoing surgery. We aimed to describe the demographics of centenarians undergoing surgery, the procedures they receive, their intraoperative anaesthesia management, and their postoperative outcomes.

Presentation of cases

A retrospective cohort study was completed to understand key perioperative and intraoperative variables linked to improved outcomes. Of the 25 patients included in this study, 22 (88%) were female and the median age was 101 years. Emergency cases predominated (72%) and 44% of surgeries occurred after hours. 60% underwent an intermediate risk surgery, and no centenarians underwent high risk surgery in this study period.

Discussion

64% of patients experienced at least one episode of intraoperative hypotension, with a median 3.5 epochs per patient. 68% of patients experienced postoperative complications and 20% of patients had a complication of Clavien-Dindo severity ≥ III. In centenarians, the risk of high severity postoperative complications was independent of the intrinsic procedural risk.

Conclusion

Centenarian patients have an elevated burden of comorbidity, presenting often in the emergent setting. However, age alone should not preclude surgical intervention as expert multidisciplinary care can have acceptable outcomes.

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Centenarian patients undergoing surgery are frail

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Most centenarian patients experience postoperative complications

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Surgery in centenarians can be feasible and undertaken safely

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Appropriate patient selection leads to acceptable outcomes

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Centenarians should not be denied surgery based on age alone