Euthyroid sick syndrome in hip fractures: Evaluation of postoperative anemia

The Neutrophil-to-Lymphocyte Ratio and Preoperative Pulmonary Function Test Results as Predictors of In-Hospital Postoperative Complications after Hip Fracture Surgery in Older Adults

Purpose: This study retrospectively evaluated the usefulness of the neutrophil-to-lymphocyte ratio (NLR), prognostic nutritional index (PNI), and pulmonary function test (PFT) results as objective predictors of in-hospital postoperative complications after hip fracture surgery in older adults. Methods: The patients aged >65 years who underwent hip fracture surgery under general anaesthesia were enrolled. In-hospital postoperative complications with preoperative NLR, PNI and PFT results were evaluated. The NLR was calculated as the preoperative neutrophil count/lymphocyte count in peripheral blood. The PNI was calculated as the serum albumin (g/dL) × 10 + total lymphocyte count × 0.005 (/mm3). Results: One hundred ninety nine patients were analysed. The most common postoperative complications were respiratory complications. Compared with patients who did not have postoperative complications, patients with postoperative complications had a significantly higher NLR (8.01 ± 4.70 vs. 5.12 ± 4.34, p < 0.001), whereas they had a significantly lower PNI (38.33 ± 6.80 vs. 42.67 ± 6.47, p < 0.001), preoperative functional vital capacity (FVC; 2.04 ± 0.76 vs. 2.45 ± 0.71 L, p < 0.001), and forced expiratory volume at 1 s (FEV1; 1.43 ± 0.53 vs. 1.78 ± 0.58 L, p < 0.001). Multiple logistic regression analysis identified NLR (odds ratio [OR], 1.142; 95% confidence interval [CI], 1.060−1.230; p < 0.001) and FEV1 (OR, 0.340; 95% CI, 0.191−0.603; p < 0.001) as risk factors for postoperative complications after hip fracture surgery. Conclusion: Preoperative NLR and FEV1 are objective predictors of in-hospital postoperative complications after hip fracture surgery in older patients.

Prevention of postoperative anemia in hip hemiarthroplasty for femoral neck fractures: comparison between local haemostatic agents

Background

Tranexamic acid and fibrin sealant have been shown to be effective in reducing the need for transfusion after hip fracture surgery.

Objective

The aim of this study was to evaluate the efficacy of local haemostatic agents to reduce the need of postoperative transfusion in elederly patients after hip hemiarthroplasty.

Methods

All patients admitted to our institution with a diagnosis of proximal femur fracture from September 2018 to March 2021 were involved. Inclusion criteria were: diagnosis of femoral neck fracture, classified as AO 31B2-3, surgical treatment with hip hemiarthroplasty, hemoglobinemia on admission > 8 gr/dL. Patients were divided in four groups.

Results

EVICEL was used on 25 patients, TRANEX was used on 52 patients, standard hemostatic care was used on 73 patients, while post-surgical drain was used on 21 patients. 3 patients were transfused in the EVICEL group while 26 patients were transfused in the control group (p 0,0404), there was also statistical significant difference in the need of perioperative transfusion between EVICEL group and drain group with 10 patients transfused (p 0,0102). Statistical significant differences was found about haemoglobin variation in the first post-operative day between TRANEX group and control group (p 0,000155) and between TRANEX group and drain group (p 0,013) and also between TRANEX group and control group in the third post-operative day (p 0,0004).

Conclusion

This study demonstrates that the use of both fibrin sealant or TXA can reduce total blood loss and the need of transfusions in geriatric population with intracapsular femur fracture.

Intramedullary nailing vs modular megaprosthesis in extracapsular metastases of proximal femur: clinical outcomes and complication in a retrospective study

BACKGROUND

Extracapsular proximal femur metastasis could be treated by synthesis or resection and megaprosthesis. No universal accepted guidelines are present in the literature. The aim of our study is to analyze of patients with metastases in the trochanteric region of the femur treated by a single type of intramedullary nailing or hip megaprosthesis.

METHODS

We retrospectively reviewed all patients affected by extracapsular metastases of proximal femur. Anthropometric and anamnestic data, routine blood exams and complications were collected. VAS score and MSTS score was administered before the surgery, ad 1-6-12 months after surgery. An un-paired T test and Chi-square were used. Multiple linear regression and logistic regression was performed. Significance was set for p < 0.05.

RESULT

Twenty patients were assigned in intramedullary Group, twenty-five in megaprostheses Group. The mean operative time is shorter in intramedullary group. Differential shows a higher anemization in megaprostheses group (2 ± 2 vs 3.6 ± 1.3; p = 0.02). The patients of intramedullary group showed malnutrition (Albumin: 30.5 ± 6.5 vs 37.6 ± 6 g/L; p = 0.03) and pro-inflammatory state (NLR: 7.1 ± 6.7 vs 3.8 ± 2.4; p = 0.05) (PLR: 312 ± 203 vs 194 ± 99; p = 0.04) greater than megaprostheses group. The patients in intramedullary groups shows a higher functional performance score than megaprostheses group at 1 month follow-up (MSTS: 16.4 ± 6.3 vs 12.2 ± 3.7; p = 0.004). A multivariate analysis confirms the role of type of surgery (p = 0.001), surgery duration (p = 0.005) and NLR (p = 0.02) in affecting the MSTS. Globally eight complications were recorded, no statistical difference was noticed between the two groups (p = 0.7), no predictor was found at logistic analysis.

CONCLUSION

Intramedullary nailing guarantees a rapid functional recovery, compared to patients undergoing hip megaprosthesis who instead improve gradually over time. The selection of patients with poor prognosis allows the correct surgical indication of nailing, while in the case of a more favorable prognosis, the intervention of hip megaprosthesis is to be preferred.

The value of megaprostheses in non-oncological fractures in elderly patients: A short-term results

INTRODUCTION

The management of both hip and distal femur fractures as well as periprosthetic fractures can be challenging for orthopaedic surgeons. The use of megaprosthetic implants could provide substantial advantages in elderly population affected by complex fractures. The aim of the study was to evaluate the effectiveness of megaprosthetic implants for treating hip and distal femur fractures as well as periprosthetic fractures in elderly.

MATERIAL AND METHODS

From January 1st 2015 to December 31st 2019, patients treated for proximal or distal femoral fractures with severe bone loss or failure of previous surgery were retrospectively reviewed. Patients were divided into two group based on diagnosis: proximal femur fractures (group A) and distal femur fractures (group B). Subsequently, patients underwent hip (group A) or knee (group B) megaprosthesis. Self-assessed questionnaires were administered to all patients pre and postoperatively. Primary outcome was the Activity Daily Living. Secondary outcomes were: Instrumental Activity Daily Living, Short Form-12, Oxford knee or hip score, complications. Charlson score, Harris classification for hip or Anderson Orthopaedic Research Institute score and complication were recorded. All patients underwent a radiological follow up to rule out implant loosening and mobilization. Pre and postoperative functional score comparisons in each group were undertaken. Significance was set p ≤ 0.05.

RESULTS

Twelve patients were finally included in the study. There were 6 male and 6 females, the mean age was 72,9 years old (± 7,4); the mean BMI was 29,8 points (± 4.5). The mean follow-up was 2.9 years (± 1.4). No differences could be found between pre and postoperative evaluation in each group. No aseptic loosening, dislocation, mobilization or radiolucency were recorded during the follow-up. In group A, two surgical site infections (2/6 patients) and one pneumonia (1/6 patients) were recorded. In group B, two surgical site infections occurred (2/6 patients). All patients were treated by antimicrobial oral therapy with complete regression.

CONCLUSION

The use of hip and knee megaprosthetic implants in traumatology is a safe and viable option in elderly patients.

Risk factors analysis and nomogram construction for blood transfusion in elderly patients with femoral neck fractures undergoing hemiarthroplasty

INTRODUCTION

Elderly patients with femoral neck fractures (FNFs) undergoing hemiarthroplasty usually have poor physical condition. The main aim of this study was to identify risk factors for blood transfusion in these patients and construct a nomogram to intuitively predict the requirement of transfusion. The secondary purpose was to examine the relationship between blood transfusion and complications within 30 days post-operatively. Our hypothesis was that chronic kidney disease (CKD) and hypoalbuminemia may increase the requirement of transfusion.

METHODS

Data of 414 elderly patients undergoing hemiarthroplasty for FNFs were retrospectively collected. Univariate and multiple regression analysis were performed to identify independent risk factors for blood transfusion, which were used to construct a nomogram subsequently. The discrimination and calibration of the nomogram model were assessed with concordance index (C-index), the area under receiver operating characteristic curve (AUC), and calibration curve. Furthermore, the complications of blood transfusion within 30 days post-operatively were also analyzed.

RESULTS

Out of 414 patients, 127 (30.7%) received a blood transfusion. Independent risk factors for blood transfusion included CKD, hypoalbuminemia, pre-operative anaemia, general anaesthesia, higher American Society of Anesthesiologists score, more intraoperative blood loss, and longer surgical time. Increased hidden blood loss, deep vein thrombosis, superficial wound infection, and prolonged hospital stays were more common in transfused patients. The C-index of the nomogram model was 0.848 (95% CI = 0.811-0.885), and the AUC value was 0.859. The calibration curve showed a good consistency between the actual transfusion and the predicted probability.

DISCUSSION

We observed a transfusion rate of 30.7% in elderly FNF patients undergoing hemiarthroplasty. CKD and hypoalbuminemia were firstly identified as independent risk for blood transfusion. In addition, blood transfusion can increase the occurrence of early post-operative complications.

CONCLUSION

Targeted pre-operative intervention, such as optimizing CKD and correcting hypoalbuminemia is essential and highly regarded.

Nomogram for predicting reoperation following internal fixation of nondisplaced femoral neck fractures in elderly patients

OBJECTIVE

We aimed to evaluate risk factors and develop a nomogram for reoperation after internal fixation of nondisplaced femoral neck fractures (FNFs) in elderly patients.

METHODS

We conducted a retrospective study involving a total of 255 elderly patients who underwent closed reduction and internal fixation with cannulated screw system for nondisplaced FNFs between January 2016 and January 2019. We collected data on demographics, preoperative radiological parameters, surgery, serum biochemical markers, and postoperative rehabilitation. In addition, we performed univariate and multivariate logistic regression analyses to determine independent risk factors for reoperation, and then developed a nomogram to assess the risks of reoperation. Besides, discriminative ability, calibration, and clinical usefulness of the nomogram were evaluated using the concordance index (C-index), the receiver operating characteristic (ROC) curve, calibration curve and decision curve analysis (DCA), respectively. We employed bootstrap method to validate the performance of the developed nomogram.

RESULTS

Our analysis showed that among the 255 patients, 28 (11.0%) underwent reoperation due to osteonecrosis of the femoral head (14 cases), mechanical failure (8 cases) or nonunion (6 cases). All of the 28 patients underwent conversion surgery to arthroplasty. The multivariate logistic regression analysis demonstrated that preoperative posterior tilt angle ≥ 20°, Pauwel's III type, younger patients, preoperative elevated levels of alkaline phosphatase (ALP), preoperative hypoalbuminemia, and early postoperative weight-bearing were independent risk factors for reoperation. In addition, the C-index and the bootstrap value of the developed nomogram was 0.850 (95% CI = 0.803-0.913) and 0.811, respectively. Besides, the calibration curve showed good consistency between the actual diagnosed reoperation and the predicted probability, while the DCA indicated that the nomogram was clinically valuable.

CONCLUSIONS

Our analysis showed we successfully developed and validated a nomogram for personalized prediction of reoperation after internal fixation of nondisplaced FNFs in elderly patients. This model would help in individualized evaluation of the need for reoperation and inform strategies aimed at eliminating the need for the reoperation.