Prediction of Postoperative Outcomes Following Hip Fracture Surgery: Independent Validation and Recalibration of the Nottingham Hip Fracture Score

Systematic review of multivariable prognostic models for outcomes at least 30 days after hip fracture finds 18 mortality models but no nonmortality models warranting validation

OBJECTIVES

Prognostic models have the potential to aid clinical decision-making after hip fracture. This systematic review aimed to identify, critically appraise, and summarize multivariable prediction models for mortality or other long-term recovery outcomes occurring at least 30 days after hip fracture.

STUDY DESIGN AND SETTING

MEDLINE, Embase, Scopus, Web of Science, and CINAHL databases were searched up to May 2023. Studies were included that aimed to develop multivariable models to make predictions for individuals at least 30 days after hip fracture. Risk of bias (ROB) was dual-assessed using the Prediction model Risk Of Bias ASsessment Tool. Study and model details were extracted and summarized.

RESULTS

From 5571 records, 80 eligible studies were identified. They predicted mortality in n = 55 studies/81 models and nonmortality outcomes (mobility, function, residence, medical, and surgical complications) in n = 30 studies/45 models. Most (n = 46; 58%) studies were published since 2020. A quarter of studies (n = 19; 24%) reported using 'machine-learning methods', while the remainder used logistic regression (n = 54; 68%) and other statistical methods (n = 11; 14%) to build models. Overall, 15 studies (19%) presented 18 low ROB models, all predicting mortality. Common concerns were sample size, missing data handling, inadequate internal validation, and calibration assessment. Many studies with nonmortality outcomes (n = 11; 37%) had clear data complexities that were not correctly modeled.

CONCLUSION

This review has comprehensively summarized and appraised multivariable prediction models for long-term outcomes after hip fracture. Only 15 studies of 55 predicting mortality were rated as low ROB, warranting further development of their models. All studies predicting nonmortality outcomes were high or unclear ROB. Careful consideration is required for both the methods used and justification for developing further nonmortality prediction models for this clinical population.

Predictive Value of Machine Learning Models in Postoperative Mortality of Older Adults Patients with Hip Fracture: A Systematic Review and Meta-analysis

BACKGROUND

Some researchers have used machine learning to predict mortality in old patients with hip fracture, but its application value lacks an evidence-based basis. Hence, we conducted this meta-analysis to explore the predictive accuracy of machine learning for mortality in old patients with hip fracture.

METHODS

We systematically retrieved PubMed, Cochrane, Embase, and Web of Science for relevant studies published before July 15, 2022. The PROBAST assessment tool was used to assess the risk of bias in the included studies. A random-effects model was used for the meta-analysis of C-index, whereas a bivariate mixed-effects model was used for the meta-analysis of sensitivity and specificity. The meta-analysis was performed on R and Stata.

RESULTS

Eighteen studies were included, involving 8 machine learning models and 398,422 old patients undergoing hip joint surgery, of whom 60,457 died. According to the meta-analysis, the pooled C-index for machine learning models was 0.762 (95% CI: 0.691 ∼ 0.833) in the training set and 0.838 (95% CI: 0.783 ∼ 0.892) in the validation set, which is better than the C-index of the main clinical scale (Nottingham Hip Fracture Score), that is, 0.702 (95% CI: 0.681 ∼ 0.723). Among different machine learning models, ANN and Bayesian belief network had the best predictive performance.

CONCLUSION

Machine learning models are more accurate in predicting mortality in old patients after hip joint surgery than current mainstream clinical scoring systems. Subsequent research could focus on updating clinical scoring systems and improving their predictive performance by relying on machine learning models.

Risk scoring models for patients with proximal femur fractures: Qualitative systematic review assessing 30-day mortality and ease of use

BACKGROUND

Hip fractures are a common orthopaedic injury affecting a particularly frail and vulnerable patient cohort. They are at risk of many complications, including prolonged length of stay and mortality. Efforts to identify those at high risk may be beneficial. Over 25 risk prediction models are published for patients with hip fractures.

AIM

The primary aim of this study was to assess the performance of predictor scores in predicting 30-day mortality. The secondary aim was to assess the ease of use of these systems.

METHODS

A qualitative systematic review was performed. A search was conducted on online databases, including PubMed, CINAHL, Clinical Trials.gov, Cochrane, DARE, EMBASE, SCOPUS, and Web of Science.. The terms fragility hip fractures and risk prediction models were utilised while performing the search. These were then expanded using Boolean operators and similar terms. Search results were imported to Covidence. Primary observational studies using one or more hip fracture mortality prediction models and 30-day mortality as an outcome were included. Systematic reviews and studies on specific patient groups defined other medical conditions (e.g. COVID positive or dialysis patients) were excluded.

RESULTS

3,101 studies were screened following duplicate removal. 34 papers were included in the review, in which 23 scoring systems were reported. Six of these were pre-operative and reported in multiple studies. Most demonstrated appropriate fit and fair discrimination. Five of the six pre-operative scoring systems examined, displayed appropriate ease of use, allowing risk calculation at the time of admission.

CONCLUSION

Nottingham Hip Fracture Score remains the most extensive reported scoring system and performs fair overall with AUROCs of 0.64-0.80 and good fit in calibration across all studies. However, new systems utilise many similar predictors. There is a need for the standardisation of publications on scoring systems to allow further systematic review and meta-analyses.

Validation and updating of the Older Person's Emergency Risk Assessment (OPERA) score to predict outcomes for hip fracture patients

INTRODUCTION

Hip fractures are associated with significant morbidity and mortality in older people. Accurate risk stratification is important for planning of care, informed decision-making and communication with patients and relatives. The Older Persons' Emergency Risk Assessment (OPERA) score is a risk stratification score for older people admitted to hospital. Our aims were to validate OPERA in hip fracture patients, update the score and compare performance with the Nottingham Hip Fracture Score (NHFS).

METHODS

This dual-centre 3-year observational study (2016-2018) included acutely admitted hip fracture patients managed surgically aged ⩾65 years. The primary outcome was 30-day mortality. Secondary outcomes included residence at 120 days and 1-year mortality. Model performance was assessed using area under the curve (AUC) analysis and Brier scores (discrimination) and calibration curves. The OPERA score was updated using regression analysis with additional independent predictors and validated using bootstrap analysis.

RESULTS

2142 patients (median age 86 [80-91] years) were included with a 30-day mortality of 5.2% and a 1-year mortality of 31.4%. 30-day mortality AUC for OPERA was 0.75 (95% CI, 0.73-0.77) and for NHFS 0.68 (0.65-0.70). For 1-year mortality AUC for OPERA was 0.74 (0.73-0.75) and for NHFS 0.70 (0.69-0.71). The OPERA Score was updated to Hip-OPERA, including ASA grade. Hip-OPERA demonstrated an AUC for 30-day mortality of 0.77 (0.73-0.81) and an AUC for 1-year mortality of 0.76 (0.75-0.77). AUC for new residential care status at 120 days was 0.79 (0.78-0.80).

CONCLUSIONS

Hip-OPERA demonstrated superior discrimination to the NHFS and OPERA for 30-day mortality, 1-year mortality and residence at 120 days following hip fracture. External validation is desirable.

Correlation between admission hypoalbuminemia and postoperative urinary tract infections in elderly hip fracture patients

PURPOSE

This study aimed to evaluate the correlation between hypoalbuminemia upon admission and the incidence of postoperative urinary tract infections (UTIs) in elderly patients with hip fractures.

METHODS

A retrospective analysis was performed on the medical records of elderly patients who underwent surgical treatment for hip fractures at a level I trauma center from 2013 to 2023. Serum albumin levels were measured upon admission, and hypoalbuminemia was defined as a total albumin level < 35 g/L. Multivariable logistic regression and propensity score matching analysis were utilized to control and reduce potential confounding factors, aiming to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CI) for UTIs to determine the strength of the association.

RESULTS

This observational cohort study included 1279 patients, among whom 298 (23.3%) developed UTIs. Patients with albumin levels < 35 g/L had significantly greater odds of developing UTIs compared to those with albumin levels ≥ 35 g/L (OR 1.86, 95% CI 1.28-2.70). Further analysis, dividing albumin levels into quartiles, demonstrated that patients in the Q2 group (38.0-40.9 g/L; OR 1.38, 95% CI 0.88-2.17), Q3 group (35.0-37.9 g/L; OR 1.69, 95% CI 1.06-2.71), and Q4 group (15.3-34.9 g/L; OR 2.67, 95% CI 1.61-4.43) had notably higher odds of developing UTIs compared to those in the Q1 group (41.0-52.0 g/L).

CONCLUSIONS

The presence of hypoalbuminemia upon admission in elderly patients undergoing hip fracture surgery is strongly correlated with the occurrence of postoperative UTIs. Furthermore, this association exhibits a clear dose-response relationship.

Associated Factors of Functional Ability in Older Persons Undergoing Hip Surgery Immediately Post-Hospital Discharge: A Prospective Study

BACKGROUND

hip fractures commonly have an impact on older adults' health. Surgical treatment aims to reduce pain and promote functional ability. However, developing adverse health outcomes or complications post-hip surgery may impede older patients' recovery to return to functional ability as pre-fracture. We aimed to examine the association of personal factors and adverse health outcomes during hospitalization and post-hospital discharge on the functional ability of older people undergoing hip surgery.

METHODS

a total of 120 older people with hip fractures who were scheduled for surgery at three tertiary hospitals and met the inclusion criteria were recruited for this study. Data were obtained at admission, before discharge, and during the two-week postoperative follow-up using the Demographic, Hip Dysfunction and Osteoarthritis Outcome Score, Joint Replacement, the Confusion Assessment Method (CAM) Thai version, and Health Outcome Questionnaires. Descriptive statistics and multiple logistic regression analyses were performed to analyze the data.

RESULTS

most participants were female, with a mean age of 78.10 years (range = 60-93; SD = 8.37). The most common adverse health outcome during hospitalization was urinary tract infection, followed by delirium, pneumonia, deep vein thrombosis, and surgical site infection. At two weeks immediately post-hospital discharge, 16 participants experienced unpleasant events, including delirium, urinary tract infection, surgical site infection, and pneumonia. The significant predictors of poor functional ability at two weeks immediately post-hospital discharge were old age (OR = 1.114, p = 0.001), subtrochanteric fracture (OR = 13.48, p = 0.008), and type of surgery (OR = 4.105, p = 0.049).

Prediction of long-term mortality following hip fracture surgery: evaluation of three risk models

INTRODUCTION

Several prognostic models have been developed for mortality in hip fracture patients, but their accuracy for long-term prediction is unclear. This study evaluates the performance of three models assessing 30-day, 1-year and 8-year mortality after hip fracture surgery: the Nottingham Hip Fracture Score (NHFS), the model developed by Holt et al. and the Hip fracture Estimator of Mortality Amsterdam (HEMA).

MATERIALS AND METHODS

Patients admitted with a fractured hip between January 2012 and June 2013 were included in this retrospective cohort study. Relevant variables used by the three models were collected, as were mortality data. Predictive performance was assessed in terms of discrimination with the area under the receiver operating characteristic curve and calibration with the Hosmer-Lemeshow goodness-of-fit test. Clinical usefulness was evaluated by determining risk groups for each model, comparing differences in mortality using Kaplan-Meier curves, and by assessing positive and negative predictive values.

RESULTS

A total of 344 patients were included for analysis. Observed mortality rates were 6.1% after 30 days, 19.1% after 1 year and 68.6% after 8 years. The NHFS and the model by Holt et al. demonstrated good to excellent discrimination and adequate calibration for both short- and long-term mortality prediction, with similar clinical usefulness measures. The HEMA demonstrated inferior prediction of 30-day and 8-year mortality, with worse discriminative abilities and a significant lack of fit.

CONCLUSIONS

The NHFS and the model by Holt et al. allowed for accurate identification of low- and high-risk patients for both short- and long-term mortality after a fracture of the hip. The HEMA performed poorly. When considering predictive performance and ease of use, the NHFS seems most suitable for implementation in daily clinical practice.

Cumulated ambulation score as predictor of postoperative mobility in patients with proximal femur fractures

INTRODUCTION

The cumulated ambulation score (CAS) has been developed as an index for evaluating mobility in the early postoperative period. This study aimed to estimate the association between CAS and independent ambulation after surgery for proximal femur fractures.

MATERIALS AND METHODS

This retrospective cohort study included 223 elderly patients who underwent surgery for proximal femur fractures and had independent ambulation before the injury. Multivariable logistic regression analyses with cognitive impairment, pre-injury Barthel index, and CAS as the test variables were used to predict independent ambulation at 2 weeks (model 1) and 3 months (model 2) postoperatively. We established scoring systems based on the modeling results.

RESULTS

The number of patients with independent ambulation at 2 weeks and 3 months postoperatively was 115 and 169, respectively. Univariate analysis showed that the CAS was significantly associated with independent ambulation at 2 weeks and 3 months postoperatively. Multivariable analysis showed that models 1 and 2 had good predictive accuracies, with areas under the receiver-operating characteristic curve of 0.855 and 0.868, respectively. Among the explanatory variables, only the CAS in model 2 was not significantly associated with the postoperative ambulatory ability. Scoring systems for both models 1 and 2 also had good predictive accuracies, with cut-off scores of 3.5 for model 1 and 9.5 for model 2.

CONCLUSIONS

The CAS predicted independent ambulation at 2 weeks postoperatively; however, this relationship was limited at 3 months postoperatively. Therefore, the CAS may help estimate independent ambulation at discharge from an acute-care hospital.

Using pre-fracture mobility to augment prediction of post-operative outcomes in hip fracture

Purpose

Pre-operative scores based on patient characteristics are commonly used to predict hip fracture outcomes. Mobility, an indicator of pre-operative function, has been neglected as a potential predictor. We assessed the ability of pre-fracture mobility to predict post-operative outcomes following hip fracture.

Methods

We analysed prospectively collected data from hip fracture surgery patients at a large-volume trauma unit. Mobility was classified into four groups. Post-operative outcomes studied were mortality and residence at 30 days, medical complications within 30- or 60-days post-operatively, and prolonged length of stay (LOS, ≥ 28 days). We performed multivariate regression analyses adjusting for age and sex to assess the discriminative ability of the Nottingham Hip Fracture Score (NHFS), with and without mobility, for predicting outcomes using the area under the receiver operating characteristic curve (AUROC).

Results

1919 patients were included, mean age 82.6 (SD 8.2); 1357 (70.7%) were women. Multivariate analysis demonstrated patients with worse mobility had a 1.7–5.5-fold higher 30-day mortality (p ≤ 0.001), and 1.9–3.2-fold higher likelihood of prolonged LOS (p ≤ 0.001). Worse mobility was associated with a 2.3–3.8-fold higher likelihood of living in a care home at 30-days post-operatively (p < 0.001) and a 1.3–2.0-fold higher likelihood of complications within 30 days (p ≤ 0.001). Addition of mobility improved NHFS discrimination for discharge location, AUROC NHFS 0.755 [0.733–0.777] to NHFS + mobility 0.808 [0.789–0.828], and LOS, AUROC NHFS 0.584 [0.557–0.611] to NHFS + mobility 0.616 [0.590–0.643].

Conclusion

Incorporating mobility assessment into risk scores may improve casemix adjustment, prognostication following hip fracture, and identify high-risk patient groups requiring enhanced post-operative care at admission.

Validation of the Nottingham Hip Fracture Score in Predicting Postoperative Outcomes Following Hip Fracture Surgery

OBJECTIVE

Although several prognostic models have been developed for patients who underwent hip fracture surgery, their preoperative performance was insufficiently validated. We aimed to verify the effectiveness of the Nottingham Hip Fracture Score (NHFS) for predicting postoperative outcomes following hip fracture surgery.

METHODS

This was a single-center and retrospective analysis. A total of 702 elderly patients with hip fractures (age ≥ 65 years old) who received treatment in our hospital from June 2020 to August 2021 were selected as the research participants. They were divided into the survival group and the death group based on their survival 30 days after surgery. The multivariate logistic regression model was used to identify the independent risk factors for the 30-day mortality after surgery. The NHFS and American Society of Anaesthesiologists (ASA) grades were used to construct these models, and a receiver operating characteristic curve was plotted to assess their diagnostic significance. A correlation analysis was performed between NHFS and length of hospitalization and mobility 3 months after surgery.

RESULTS

There were significant differences in the age, albumin level, NHFS, and ASA grade between both groups (p < 0.05). The length of hospitalization in the death group was longer than the survival group (p < 0.05). The perioperative blood transfusion and postoperative ICU transfer rates in the death group were higher than in the survival group (p < 0.05). The death group's incidence of pulmonary infections, urinary tract infections, cardiovascular events, pressure ulcers, stress ulcers with bleeding, and intestinal obstruction was higher than the survival group (p < 0.05). The NHFS and ASA III were independent risk factors for the 30-day mortality after surgery, regardless of age and albumin level (p < 0.05). The area under the curve (AUC) of the NHFS and ASA grade for predicting the 30-day mortality after surgery was 0.791 (95% confidence interval [CI] 0.709-0.873, p < 0.05) and 0.621 (95% CI 0.477-0.764, p > 0.05), respectively. The NHFS positively correlated with hospitalization length and mobility grade 3 months after surgery (p < 0.05).

CONCLUSION

The NHFS demonstrated a better predictive performance than the ASA score for the 30-day mortality after surgery and positively correlated with the hospitalization length and postoperative activity limitation in elderly patients with hip fractures.

Mortality Prediction in Hip Fracture Patients: Physician Assessment Versus Prognostic Models

OBJECTIVES

To evaluate 2 prognostic models for mortality after a fracture of the hip, the Nottingham Hip Fracture Score and Hip Fracture Estimator of Mortality Amsterdam and to compare their predictive performance to physician assessment of mortality risk in hip fracture patients.

DESIGN

Prospective cohort study.

SETTING

Two level-2 trauma centers located in the Netherlands.

PATIENTS

Two hundred forty-four patients admitted to the Emergency Departments of both hospitals with a fractured hip.

INTERVENTION

Data used in both prediction models were collected at the time of admission for each individual patient, as well as predictions of mortality by treating physicians.

MAIN OUTCOME MEASURES

Predictive performances were evaluated for 30-day, 1-year, and 5-year mortality. Discrimination was assessed with the area under the curve (AUC); calibration with the Hosmer-Lemeshow goodness-of-fit test and calibration plots; clinical usefulness in terms of accuracy, sensitivity, and specificity.

RESULTS

Mortality was 7.4% after 30 days, 22.1% after 1 year, and 59.4% after 5 years. There were no statistically significant differences in discrimination between the prediction methods (AUC 0.73-0.80). The Nottingham Hip Fracture Score demonstrated underfitting for 30-day mortality and failed to identify the majority of high-risk patients (sensitivity 33%). The Hip fracture Estimator of Mortality Amsterdam showed systematic overestimation and overfitting. Physicians were able to identify most high-risk patients for 30-day mortality (sensitivity 78%) but with some overestimation. Both risk models demonstrated a lack of fit when used for 1-year and 5-year mortality predictions.

CONCLUSIONS

In this study, prognostic models and physicians demonstrated similar discriminating abilities when predicting mortality in hip fracture patients. Although physicians overestimated mortality, they were better at identifying high-risk patients and at predicting long-term mortality.

LEVEL OF EVIDENCE

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

Predictors of returning home after hip fracture: a prospective cohort study using the UK National Hip Fracture Database (NHFD)

INTRODUCTION

our objective was to describe trends in returning home after hospitalisation for hip fracture and identify predictive factors of this important patient-focussed outcome.

METHODS

a cohort of hip fracture patients from England and Wales (2018-2019) resident in their own home pre-admission were analysed to identify patient and service factors associated with returning home after hospital discharge, and with living in their own home at 120 days. Geographical variation was also analysed.

RESULTS

analysis of returning home at discharge included 87,797 patients; 57,104 (65%) were discharged home. Patient factors associated with lower likelihood of discharge home included cognitive impairment (odds ratio (OR) 0.60 [95% CI: 0.57, 0.62]), malnutrition (OR 0.81 [0.76, 0.86]), being at risk of malnutrition (OR 0.81 [0.78, 0.85]) and experiencing delay to surgery due to reversal of anti-coagulant medication (OR 0.84 [0.77, 0.92]). Corresponding service factors included surgery delay due to hospital logistical reasons (OR 0.91 [0.87, 0.95]) and early morning admission between 4:00 and 7:59 am (OR 0.83 [0.78, 0.89]). Nerve block prior to arrival at the operating theatre was associated with higher likelihood of discharge home (OR 1.07 [1.03, 1.11]). Most of these associations were stronger when analysing the outcome 'living in their own home at 120 days', in which two out of 11 geographic regions were found to have significantly more patients returning home.

CONCLUSION

we identify numerous modifiable factors associated with short-term and medium-term return to own home after hip fracture, in addition to significant geographical variation. These findings should support improvements to care and inform future research.

Preoperative and perioperative factors are related to the early postoperative Barthel Index score in patients with trochanteric fracture

Previous studies have shown that preoperative factors predict the postoperative Barthel Index score in patients with trochanteric fractures, while there is less evidence on the effects of perioperative factors on the prediction. This study aimed to assess the effects of preoperative and perioperative factors on the early postoperative Barthel Index score in patients with trochanteric fractures. Consecutive 288 patients aged ≥60 years with trochanteric fractures who could independently walk before injury were included. Patients were grouped according to the Barthel Index score measured after 2 weeks of surgery; the cut-off value was 20 points. Two logistic regression models were created to assess the effects of preoperative (model 1: dementia, walking ability before injury, and nutrition status) and perioperative (model 2: independent variables in model 1, reduction quality, and basic mobility function) factors on the Barthel Index score. Sensitivity and specificity were used to assess the predicative accuracy of the models. Poor preoperative (model 1: χ2 = 34.626, P < 0.01) and perioperative (model 2: χ2 = 43.956, P < 0.01) characteristics were significantly related to lower Barthel Index score. Sensitivity and specificity were similar between the models (model 1: 83.3% and 38.9% and model 2: 82.2% and 42.6%, respectively). Both preoperative and perioperative factors were significantly related to the early postoperative Barthel Index score after trochanteric fracture. However, only minimal increase in predictive accuracy was observed when perioperative predictors were analyzed along with preoperative factors. Both baseline characteristics and basic postoperative mobility should be considered when treating patients with trochanteric fractures.

Patients With Un-Displaced Or Displaced Intra Capsular Proximal Femur Fractures Do Not Represent A Different Patient Group And Have Similar Short And Long Term Mortality

BACKGROUND

Proximal femur fractures in geriatric patients are associated with substantial mortality. Management of intracapsular proximal femur fractures has been based on age, displacement, cognition, and pre-injury mobility. However, over the last decade, there has been a tendency to offer arthroplasty rather than internal fixation for these patients irrespective of displacement, to allow early mobilisation and negate the higher rate of reoperation due to failed internal fixation. There are no previous investigations analysing whether the severity of fracture displacement is related to different patient characteristics.

AIM

This study examines whether patients sustaining undisplaced or displaced intracapsular proximal femur fractures represent different patient groups with different pre-injury characteristics and post-operative mortality, irrespective of treatment modality.

METHODS

A retrospective series of 329 consecutive patients over the age of 55 years who sustained intracapsular proximal femur fractures, who underwent surgical management at a district general hospital over a period of 2 years (2012-2013) were identified using the national hip fracture database. Demographics, American Society of Anaesthesiologist (ASA) grade, pre-injury outdoor mobility status, cognitive status, and admission serum investigations, fracture displacement, type of surgery, and mortality rates at short term (2 years) & long-term (7-9 years) were reviewed.

RESULTS

There were 109 male and 220 female patients with a minimum follow-up of 7 years. The mean age at surgery was 81.6 years (range 55-103 years). There were 63 (19.1%) undisplaced fractures (Garden 1 &2) and, 265 (80.5%) displaced fractures (Garden 3 & 4). The median survival in this cohort was 2.95 years (95% CI 2.3-3.6). Mortality rates were 77.4% (n=257) at long-term (7-9 years) follow-up. Admission patient characteristics showed no statistically significant difference between displaced and undisplaced fracture groups. This included ASA, pre-operative cognition, and mobility status. Fracture displacement was not an independent predictor of mortality at short or long term.

CONCLUSION

In patients sustaining intracapsular proximal femur fractures, the degree of displacement is not a caveat for a different patient group. Fracture displacement is not predicted by the pre-injury level of function and does not predict short or long-term mortality.

The ASA score predicts infections, cardiovascular complications, and hospital readmissions after hip fracture - A nationwide cohort study

This study examines the association between the ASA physical status classification score at hip fracture surgery and severe postoperative complications in patients aged 60 and older. Among both men and women, ASA scores consistently predict a wide range of complications including infections, cardiovascular complications, hospital readmissions, and death.

INTRODUCTION

Hip fractures are common in aging populations and associated with poor prognosis. This study examines how the American Society of Anaesthesiologists (ASA) physical status classification is related to severe complications among hip fracture patients including infections, cardiovascular diseases, hospital readmissions, and death.

METHODS

Based on a linkage of the Swedish National Inpatient Register with the Swedish National Registry for Hip Fractures (RIKSHÖFT), this study includes patients aged 60+ with first hip fracture between 1998 and 2017. We estimated associations between ASA score and complications during the hospital stay and during 1 year after hip fracture using multivariable-adjusted logistic regression and Cox proportional hazard regression.

RESULTS

The study population included 170,193 hip fracture patients of which 24% died and 39% were readmitted to hospital within 1 year. The most common complications were urinary tract infections, pneumonia, second hip fractures, and heart failure. Among both men and women, higher ASA scores were consistently associated with higher risks for all complications included in this study. The strongest associations were observed for heart failure, myocardial infarction, pneumonia, and death.

CONCLUSION

ASA scores are routinely assessed in clinical practice and predict a wide range of postoperative complications among hip fracture patients. Since many complications may be preventable through adequate drug treatment, rehabilitation, and risk awareness, future studies should examine the mechanisms linking ASA scores to complication risk in order to improve preventive strategies. Particularly, the high risk of cardiovascular complications among patients with high ASA scores deserves clinical and scientific attention.

Validation of the Nottingham Hip Fracture Score (NHFS) in Patients with Hip Fracture: A Prospective Cohort Study in the Netherlands

Introduction

The Nottingham Hip Fracture Score (NHFS) was developed to predict 30-day mortality for patients with hip fracture. This study aimed to validate the NHFS in a cohort with sufficient statistical power.

Methods

Data were extracted from a prospective hip-fracture database (FAMMI). Patients were included between January 1, 2018 and January 11, 2021. All consecutively admitted patients ≥18 years of age with a hip fracture (ie, femoral neck fracture, intertrochanteric fracture, and subtrochanteric fracture) were included. Mann–Whitney’s U values were calculated to find potential miscalibration of the NHFS formula. Discrimination evaluation was performed using the concordance statistic as an equivalent to area under the receiver-operating curve.

Results

In total, 2,458 patients were included. Mean age was 80±12 years, and 66% were women (n=1,631). Median NHFS was 5 (4–6) and overall 30-day mortality 7.9% (n=195). Overall goodness of fit was tested with Pearson’s ?² (11.8, df 10; P=0.297). No statistically significant signs of miscalibration were found (Mann–Whitney U, P=0.08). Discrimination was tested with area under the receiver- operating curve, which was 72.1% (95% CI 68.7%–75.4%). However, observed 30-day mortality in our population of hip-fracture patients was slightly higher than the NHFS prediction.

Conclusion

The NHFS seemed to predict 30-day mortality with reasonable accuracy for patients with a hip fracture in a population within the Netherlands.

Implementing grip strength assessment in hip fracture patients: a feasibility project

Objectives:

Risk stratification scores are used in hip fracture surgery, but none incorporate objective tests for low muscle strength. Grip strength testing is simple and cheap but not routinely assessed for patients with hip fracture. This project aimed to assess the feasibility of implementing grip strength testing into admission assessment of patients with hip fracture.

Methods:

A scalable protocol and a corresponding training programme of instructional presentations and practical assessments were designed and delivered by and for physiotherapy staff. Grip strength values were collected pre-surgery on patients with hip fracture at a single centre whilst supine in bed. Implementation of the process was evaluated using narrative, quantitative and cost measures.

Results:

53 hip fracture patients with a mean age 80.6 (SD 10.4), of which 36 (67.9%) were female, were included. Testing was offered to 42/52 (81%) patients. Cognitive impairment prevented 14/42 (33%) of patients from completing testing; one patient declined testing. Of the 27 patients who completed testing, 14/27 (52%) had low grip strength as defined by EWGSOP2 criteria. The projected cost of testing for one year was £2.68-£2.82 per patient. Fidelity to the protocol was high using multiple criteria.

Conclusions:

Grip strength assessment is acceptable to physiotherapy staff and can be rapidly and cost-effectively implemented into hip fracture admission assessment.

Performance of the Nottingham Hip Fracture Score and Clinical Frailty Scale as predictors of short and long-term outcomes: a dual-centre 3-year observational study of hip fracture patients

INTRODUCTION

Hip fractures account for a growing number of hospital admissions worldwide and are associated with significant morbidity and mortality. The Nottingham Hip Fracture Score (NHFS) was developed to help risk-stratify these patients. Frailty is increasingly recognised to be a predictor of adverse outcomes. The aim of this study, using prospectively collected data from two non-specialist UK hospitals, was to report contemporaneous outcomes for patients with a hip fracture and compare the performance of the NHFS with the Clinical Frailty Scale (CFS).

MATERIALS AND METHODS

Data were collected over a 3-year period (2016-2018) from patients admitted with a hip fracture. In-patient and 1-year mortality and length of stay were compared between the NHFS, CFS and other variables. For discrimination to predict mortality, area under the receiver operating characteristic (AUC) curves were produced.

RESULTS

2422 patients (70.6% female), median age 85 (interquartile range 78-90) were included, with 93% undergoing an operation. 30-day mortality was 5.8% and 1-year mortality 23.5%. Average hospital stay was 18.0 days (Standard deviation 13.7). For in-patient mortality AUC for NHFS was 0.69 (95% CI 0.64-0.74) and for CFS 0.63 (0.57-0.69); for 1-year mortality AUC for NHFS was 0.71 (0.68-0.73) and for CFS 0.67 (0.64-0.71). Neither score predicted extended hospital stay.

CONCLUSION

Both CFS and NHFS predict 1-year survival with similar, moderate discrimination. Future research could explore whether other factors could be combined to allow better risk stratification following a hip fracture to inform patients and clinicians.

Systemic immune-inflammation index independently predicts poor survival of older adults with hip fracture: a prospective cohort study

Background

The systemic immune-inflammation index (SII), based on peripheral platelet, neutrophil and lymphocyte counts, has been proven to be a promising prognostic indicator in various diseases. Hip fracture is a common injury among the older adults, and has become a global public health problem with high mortality and disability rates. However, the relationship between SII and the prognosis of hip fracture is not yet well-known. The aim of the this study was to explore the predictive value of SII in older adults with hip fracture undergoing surgery.

Methods

This was a prospective cohort study performed from January 2014 to December 2018 at a orthopaedic center, China. The SII was calculated as platelet×neutrophil/lymphocyte counts. Univariable and multivariable Cox proportional hazard models were used to assess the association between SII and all-cause mortality.

Results

A total of 290 older adults with hip fracture were included, and the mean (SD) age was 77.6 (8.6) years, and 189 (65.2%) were female. The median (IQR) SII was 759.4 (519.0–1128.7) × 10⁹/L. After a median follow-up time of 33.4 months, 13 (4.5%), 26 (9.0%) and 54 (18.6%) patients died within the 30-day, 1-year and last follow-up, respectively. Multivariable Cox analysis revealed that each increase of 100 units of SII was associated with a 8% increased hazard of death at 1-year follow-up (HR = 1.08, 95% CI: 1.01–1.17, p = 0.033), and 9% increased hazard of death at last follow-up (HR = 1.09, 95% CI: 1.03–1.15, p = 0.003).

Conclusions

SII is associated with poor all-cause mortality in older adults with hip fracture undergoing surgery, and deserves further investigation and application in clinical practice.