Mortality after distal femur fractures in the elderly

Effect of surgical fixation timing on in-hospital mortality and morbidity of distal femur fractures

INTRODUCTION

The literature lacks a large-scale study investigating the effect of surgical fixation timing on early mortality and morbidity outcomes in distal femur fractures. The aims of this study were to determine the effect of fixation timing on in-hospital mortality and morbidity outcomes for operatively treated distal femur fractures retrospectively using large database data.

METHODS

This study is a retrospective analysis using data from the National Trauma Data Bank. Patients were stratified into a fragility cohort (age ≥ 60, ISS < 16) and polytrauma cohort (age < 60, ISS ≥16), with both cohorts analyzed separately. Within each cohort, patients were split into three fixation timing groups: within 24 h, between 24 and 48 h, and greater than 48 h from presentation to the hospital. Fixation-timing groups were compared based on the primary outcome of in-hospital mortality rate. Secondary outcomes included hospital length of stay (LOS), ICU length of stay (ICU LOS), days on a ventilator, and complications.

RESULTS

The fragility and polytrauma cohorts included 22,045 and 5,905 patients, respectively. The in-hospital mortality rate was 1.23 % in the fragility cohort and 2.56 % in the polytrauma cohort. Multivariate analysis of the fragility cohort showed that fixation greater than 48 h from time of presentation was associated with increased mortality compared to fixation within 24 h (OR 1.89, CI: 1.26-2.83, p=0.002) and between 24 and 48 h (OR 1.63, CI: 1.23-2.15, p<0.001). In the polytrauma cohort, multivariate analysis showed no significant mortality differences between fixation timing groups. Multivariate analysis of morbidity outcomes in both cohorts showed that fixation greater than 48 h was associated with increased LOS, ICU LOS, ventilator days, and complications compared to fixation within 24 h. In the polytrauma cohort, fixation between 24 and 48 h was associated with decreased LOS, ICU LOS, and complications compared to the other two timing groups.

CONCLUSIONS

Fixation of distal femur fractures before 48 h from presentation may lead to improved mortality and morbidity in older, lower injury severity patients. No significant mortality benefit was observed in younger, polytrauma fractures. Further prospective work is needed to validate these findings.

Treatment of supracondylar femoral fractures by minimally invasive techniques vs. exposure of the fracture site: A retrospective cohort study

INTRODUCTION

Fractures of the distal femoral third are an important cause of morbidity and mortality, and their treatment is currently controversial.

OBJECTIVES

To compare the results between minimally invasive techniques versus exposure of the fracture site. Secondly, to evaluate the relationship between demographic factors, mechanism of injury and surgical delay with patient prognosis.

METHOD

Retrospective cohort study carried out between 2015 and 2021 in a tertiary hospital. Data collection was performed by reviewing medical histories, measuring demographic and hospital parameters and definitive treatment strategy. One year of follow-up was completed in all patients, assessing the occurrence of surgical complications and mortality. A stratified analysis of the variables of interest was performed among patients over 65 years of age.

RESULTS

128 fractures were recorded, with definitive osteosynthesis being performed in 117. Patients who underwent minimally invasive techniques required a shorter hospital stay (9 [7-12] vs. 12 [8.75-16] days) (p=0.007), with no differences in mortality or complications during follow-up. In those over 65 years of age, opening the fracture site was associated with an increased risk of infection compared to minimally invasive techniques (33.3% vs. 2%) (p=0.507). All the deceased were patients over 65 years of age (33.7% at one year). Surgical delay longer than 48hours increased mortality by 10% among those older than 65 years (p=0.3). High-energy trauma had a higher proportion of pseudarthrosis (27.6% vs. 6.1%) (p=0.011).

CONCLUSIONS

Minimally invasive techniques decreased hospital stay but not complications or long-term mortality.

LEVEL OF EVIDENCE

IIb.

[Translated article] Treatment of supracondylar femoral fractures by minimally invasive techniques vs. exposure of the fracture site: A retrospective cohort study

INTRODUCTION

Fractures of the distal femoral third are an important cause of morbidity and mortality, and their treatment is currently controversial.

OBJECTIVES

To compare the results between minimally invasive techniques versus exposure of the fracture site. Secondly, to evaluate the relationship between demographic factors, mechanism of injury and surgical delay with patient prognosis.

METHOD

Retrospective cohort study carried out between 2015 and 2021 in a tertiary hospital. Data collection was performed by reviewing medical histories, measuring demographic and hospital parameters and definitive treatment strategy. One year of follow-up was completed in all patients, assessing the occurrence of surgical complications and mortality. A stratified analysis of the variables of interest was performed among patients over 65 years of age.

RESULTS

128 fractures were recorded, with definitive osteosynthesis being performed in 117. Patients who underwent minimally invasive techniques required a shorter hospital stay (9 [7-12] vs. 12 [8.75-16] days) (p=0.007), with no differences in mortality or complications during follow-up. In those over 65 years of age, opening the fracture site was associated with an increased risk of infection compared to minimally invasive techniques (33.3% vs. 2%) (p=0.507). All the deceased were patients over 65 years of age (33.7% at one year). Surgical delay longer than 48h increased mortality by 10% among those older than 65 years (p=0.3). High-energy trauma had a higher proportion of pseudarthrosis (27.6% vs. 6.1%) (p=0.011).

CONCLUSIONS

Minimally invasive techniques decreased hospital stay but not complications or long-term mortality.

LEVEL OF EVIDENCE

IIb.

The Effects of Unitizing Nail-Plate Constructs in Distal Femur Fractures: A Biomechanical Study

OBJECTIVES

To assess the biomechanical differences between linked and unlinked constructs in young and osteoporotic cadavers in addition to osteoporotic sawbones.

METHODS

Intraarticular distal femur fractures with comminuted metaphyseal regions were created in three young matched pair cadavers, three osteoporotic matched pair cadavers, and six osteoporotic sawbones. Precontoured distal femur locking plates were placed in addition to a standardized retrograde nail, with unitized constructs having one 4.5 mm locking screw placed distally through the nail. Nonunitized constructs had seven 4.5 mm locking screws placed through the plate around the nail, with one 5 mm distal interlock placed through the nail alone. Cadaveric specimens were subjected to axial fatigue loads between 150 and 1500 N (R Ratio = 10) with 1 Hx frequency for 10,000 cycles. Sawbones were axially loaded at 50% of the ultimate load for fatigue testing to achieve runout, with testing performed with 30 and 300 N (R Ratio = 10) loads with 1 Hz frequency for 10,000 cycles.

RESULTS

In young cadavers, there was no difference in the mean cyclic displacement of the unitized constructs (1.51 ± 0.62mm) compared to the non-unitized constructs (1.34 ± 0.47mm) (Figure 4A), (p = 0.722). In osteoporotic cadavers, there was no difference in the mean cyclic displacement of the unitized constructs (2.46 ± 0.47mm) compared to the non-unitized constructs (2.91 ± 1.49mm) (p =0.639). There was statistically no significant difference in cyclic displacement between the unitized and non-unitized groups in osteoporotic sawbones(p = 0.181).

CONCLUSIONS

Linked constructs did not demonstrate increased axial stiffness or decreased cyclical displacement in comparison to unlinked constructs in young cadaveric specimens, osteoporotic cadaveric specimens, or osteoporotic sawbones.

Beyond Mortality: Severely Frail Femur Fracture Patients Can Regain Independence after Surgery

Objectives: Little is known about the post-operative functional outcomes of severely frail femur fracture patients, with previous studies focusing on complications and mortality. This study investigated patient- or proxy-reported outcomes after femur fracture surgery in older adult patients with severe frailty. Methods: This was a retrospective cross-sectional study of older adult (>70 years) patients with severe frailty (defined by a Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) ≥ 0.40), who underwent femur fracture surgery at a Level 1 Trauma Center. Patients or their proxy (i.e., close relative) reported mobility, psychosocial, and functional outcomes at least 1-year after surgery. Results: Thirty-seven predominantly female (76%) patients with a median age of 85 years (IQR 79-92), and a median FI-CGA of 0.48 (IQR 0.43-0.54) were included. Eleven patients (30%) regained pre-fracture levels of ambulation, with twenty-six patients (70%) able to walk with or without assistance. The majority of patients (76%) were able to have meaningful conversations. Of the patients, 54% of them experienced no to minimal pain, while 8% still experienced a lot of pain. Functional independence varied, as follows: five patients (14%) could bathe themselves; nine patients (25%) could dress themselves; fourteen patients (39%) could toilet independently; and seventeen patients (47%) transferred out of a (wheel)chair independently. Conclusions: Despite the high risk of mortality and perioperative complications, many of the most severely frail patients with surgically treated femur fractures regain the ability to ambulate and live with a moderate degree of independence. This information can help healthcare providers to better inform these patients and their families of the role of surgical treatment during goals of care discussions.

Substantial Loss of Skeletal Muscle Mass Occurs After Femoral Fragility Fracture

BACKGROUND

Femoral fragility fractures in older adults can result in devastating loss of physical function and independence. Skeletal muscle atrophy likely contributes to disability. The purpose of this study was to characterize the change in skeletal muscle mass, investigate the relationship with malnutrition and physical function, and identify risk factors for skeletal muscle loss.

METHODS

Adults ≥65 years of age who were treated with operative fixation of an isolated femoral fragility fracture were enrolled in this multicenter, prospective observational study. Skeletal muscle mass was assessed within 72 hours of admission using multifrequency bioelectrical impedance analysis, which was repeated at 6 weeks, 3 months, and 6 months. Sarcopenia was defined by sex-specific cutoffs for the appendicular skeletal muscle mass index. The Mini Nutritional Assessment was used to measure nutritional status at the time of injury. Physical function was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function domain. Linear mixed models were used to evaluate changes in skeletal muscle mass and PROMIS Physical Function scores over time and to evaluate factors associated with skeletal muscle mass changes.

RESULTS

Ninety participants (74% female) with a mean age of 77.6 ± 9.0 years were enrolled. At the time of injury, 30 (33%) were sarcopenic and 44 (49%) were at risk for malnutrition or had malnutrition. Older age was associated with lower skeletal muscle mass (age of ≥75 versus <75 years: least squares mean [and standard error], -3.3 ± 1.6 kg; p = 0.042). From the time of injury to 6 weeks, participants lost an average of 2.4 kg (9%) of skeletal muscle mass (95% confidence interval [CI] = ‒3.0 to ‒1.8 kg; p < 0.001). This early loss did not recover by 6 months (1.8 kg persistent loss compared with baseline [95% CI = ‒2.5 to ‒1.1 kg]; p < 0.001). Participants with normal nutritional status lost more skeletal muscle mass from baseline to 6 weeks after injury compared with those with malnutrition (1.3 kg more loss [standard error, 0.6 kg]; p = 0.036). A 1-kg decrease in skeletal muscle mass was associated with an 8-point decrease in the PROMIS Physical Function (model parameter estimate, 0.12 [standard error, 0.04]; p = 0.002).

CONCLUSIONS

We found that older adults with femoral fragility fractures lost substantial skeletal muscle mass and physical function. Participants with adequate baseline nutrition actually lost more muscle mass than those who were malnourished, indicating that future investigations of interventions to prevent muscle loss should focus on older adults regardless of nutritional status.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Management of Distal Femur Fractures: Replacement Versus Surgical Fixation Versus Conservative Management

INTRODUCTION

Distal femur fractures are a frequently encountered injury, especially among the ageing population. Previous studies have identified that these fractures can be managed with a variety of methods and techniques which has led to an ongoing debate and investigation to decipher the optimal approach to manage these fractures.

AIM

The purpose of this study was to compare outcomes of patients managed with either distal femur replacements (DFRs), surgical fixation (SF) or conservative management. Outcomes measured included length of hospital stay, readmission rates, 30-day mortality and Oxford Knee Score.

METHODS

A retrospective review was conducted, of patients admitted with distal femur fractures between June 2020 and October 2022 at Huddersfield Royal Infirmary Hospital. Patients with both native and peri-prosthetic joints were included. All patient's medical data, including imaging and operative records, were reviewed.

RESULTS

A total of 42 patients were identified. There were six males and 36 females with a mean age of 78 years, a median age of 76 and a range of 35-102 years. Of these fractures, 15 were peri-prosthetic, and 27 were native joints. Of the patients, 30 had an SF, five had a DFR and the remaining seven were conservatively managed. Those managed with an SF had an average length of stay of 18 days, an Oxford score of 24 and two patients were readmitted within 30 days of discharge. For the DFR, the average length of stay was 16 days, an Oxford score of 22 and no patients were readmitted within 30 days. For the conservatively managed patients 21 days, an Oxford score of 25 and two patients were readmitted within 30 days of discharge. There was no 30-day mortality across all groups.

CONCLUSIONS

From our study, we can conclude that patients who managed with a DFR had the shortest length of stay in a hospital and the lowest readmission rates when compared to alternative management techniques. There was minimal difference found between the Oxford scores between all three groups. This study shows that DFR can be a safe and reliable strategy to manage distal femur fractures. Additional research is required to further compare the outcomes of these different methods of repair.

[Translated article] One-year mortality and associated factors in patients undergoing surgery for hip fracture

INTRODUCTION

Hip fractures are very common injuries in elderly patients and are associated with increased mortality.

OBJECTIVE

To identify the factors associated with mortality in patients after one year of being operated for hip fracture in an Orthogeriatric Program.

METHODS

We design an observational analytical study in subjects older than 65 years admitted to the Hospital Universitario San Ignacio for hip fracture who were treated in the Orthogeriatrics Program. Telephone follow-up was performed one year after admission. Data were analyzed using a univariate logistic regression model and a multivariate logistic regression model was applied to control the effect of the other variables.

RESULTS

Mortality was 17.82%, functional impairment was 50.91%, and institutionalization was 13.9%. The factors associated with mortality were moderate dependence (OR=3.56, 95% CI=1.17-10.84, p=0.025), malnutrition (OR=3.42, 95% CI=1.06-11.04, p=0.039), in-hospital complications (OR=2.80, 95% CI=1.11-7.04, p=0.028), and older age (OR=1.09, 95% CI=1.03-1.15, p=0.002). The factor associated with functional impairment was a greater dependence at admission (OR=2.05, 95% CI=1.02-4.10, p=0.041), and with institutionalization was a lower Barthel index score at admission (OR=0.96, 95% CI=0.94-0.98, p=0.001).

CONCLUSIONS

Our results shows that the factors associated with mortality one year after hip fracture surgery were: moderate dependence, malnutrition, in-hospital complications and advanced age. Having previous functional dependence is directly related to greater functional loss and institutionalization.

One-year mortality and associated factors in patients undergoing surgery for hip fracture

INTRODUCTION

Hip fractures are very common injuries in elderly patients and are associated with increased mortality.

OBJECTIVE

To identify the factors associated with mortality in patients after one year of being operated for hip fracture in an Orthogeriatric Program.

METHODS

We design an observational analytical study in subjects older than 65 years admitted to the Hospital Universitario San Ignacio for hip fracture who were treated in the Orthogeriatrics Program. Telephone follow-up was performed one year after admission. Data were analyzed using a univariate logistic regression model and a multivariate logistic regression model was applied to control the effect of the other variables.

RESULTS

Mortality was 17.82%, functional impairment was 50.91%, and institutionalization was 13.9%. The factors associated with mortality were moderate dependence (OR=3.56, 95% CI=1.17-10.84, p=0.025), malnutrition (OR=3.42, 95% CI=1.06-11.04, p=0.039), in-hospital complications (OR=2.80, 95% CI=1.11-7.04, p=0.028), and older age (OR=1.09, 95% CI=1.03-1.15, p=0.002). The factor associated with functional impairment was a greater dependence at admission (OR=2.05, 95% CI=1.02-4.10, p=0.041), and with institutionalization was a lower Barthel index score at admission (OR=0.96, 95% CI=0.94-0.98, p=0.001).

CONCLUSIONS

Our results shows that the factors associated with mortality one year after hip fracture surgery were: moderate dependence, malnutrition, in-hospital complications and advanced age. Having previous functional dependence is directly related to greater functional loss and institutionalization.

Low body mass index is a risk factor for increased post-operative mortality and poor functional improvement in distal femur fractures among patients aged over 65: A multicentre (TRON) study

BACKGROUND

Distal femur fractures have been reported to have a mortality rate comparable to hip fractures, but the risk is still unknown. Recent studies have reported that low body mass index (BMI) is a risk factor for mortality in the elderly. We investigated the efficacy of low BMI for predicting the risk of mortality in distal femur fractures in patients aged over 65 within 18 months after injury and its impact on postoperative clinical outcomes and mortality.

METHODS

Data from patients followed for more than six months were obtained from our trauma research group's database. We investigated risk factors for increased mortality using Cox proportional hazards models. We divided the analysed cases into low (<18.5 kg/m²) and high (>18.5 kg/m²) BMI groups. We adjusted the background characteristics of the groups by patient matching, and evaluated the postoperative mortality, complication rate, and knee society score (KSS).

RESULTS

We identified 216 patients, including 58 (26.9%) with low BMI values. Low BMI was an independent risk factor for mortality in all models (Hazard Ratio: 2.9, p = 0.011). The overall survival rate of the low BMI group at 18 months was significantly lower than that of the high BMI group (70.7% vs. 89.1%; p = 0.003). The complication rates of the low BMI and high BMI groups were not significantly different (33.3% vs. 22.2%; p = 0.283). The mean KSS values at 3, 6, and 12 months in the low BMI group was significantly worse than that in the high BMI group (78.7 ± 16.2 vs. 84.8 ± 13.1; p = 0.035, 82.2 ± 16.9 vs. 89.7 ± 8.9; p = 0.005, 86.4 ± 13.0 vs. 91.4 ± 8.4; p = 0.020, respectively).

CONCLUSIONS

Our study indicated that low BMI was independent associated with increased mortality and impaired postoperative functional recovery in distal femur fractures of the elderly patients.