Efficacy of early surgery and causes of surgical delay in patients with hip fracture

Early surgery within 48 hours of admission for hip fracture did not improve 1-year mortality in Japan: a single-institution cohort study

INTRODUCTION

Early surgery for hip fracture, within 48 hours of hospital admission, is effective in reducing mortality. However, the average preoperative waiting time for hip fractures in Japan is 4.5 days and the 1-year mortality rate after a hip fracture is 10% in Japan. This study aimed to investigate whether early surgery, within 48 hours, could reduce the 1-year mortality rate in patients with hip fractures in Japan.

METHODS

This cohort study involved 402 consecutive patients with hip fractures who underwent surgical treatment between January 2013 and September 2019. The exclusion criteria were an age of <60 years and in-hospital injury. A total of 389 patients were included in this study. The patients were divided into two groups: those who underwent early surgery within 48 hours of admission (early group) and those who di not undergo early surgery (delayed group). We compared patient characteristics and treatment outcomes between the 2 groups.

RESULTS

A comparison of patient characteristics revealed that the early group had lower hemoglobin levels (P=0.046), lower C-reactive protein levels (P = 0.031), lower numbers of patients with weekend hospitalization, lower numbers of patients with a history of using medications that may cause bleeding (P < 0.01), and who received general anaesthesia (P < 0.01). However, there were no significant differences with regard to the other variables between the 2 groups. A treatment outcome analysis showed that the early group had shorter waiting times for surgery (P < 0.01) and shorter stays in acute-care wards (P < 0.01). However there were no differences in the total hospital stay, Barthel index at discharge, home discharge rates, in-hospital mortality rates, and 1-year mortality.

CONCLUSION

Our findings indicate that early surgery did not reduce the 1-year mortality rate in older patients with hip fractures in Japan.

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.

Benchmarking institutional geriatric hip fracture management: a prelude to a care quality improvement initiative

BACKGROUND

Fractures around the hip in older adults have increased in the last two decades, and the numbers are projected to rise over the next 30 years with estimates that half of them will occur in Asia. Proximal hip fractures should be operated within 48 h of injury to prevent poor outcomes. This study aims to benchmark current hip fracture care using quality improvement tools of care structure, care processes, and outcomes in a tertiary care hospital in Eastern India and determine the evidence-practice gaps and barriers to implementing the six best practices that reduce mortality and morbidity in fragility hip fractures.

METHODS

A total of 101 consecutive patients above 50 years of age with proximal femoral fractures after a trivial fall were included. Patients were divided into two groups: those operated within [Group A] and beyond [Group B] 72 h of admission. Care structure assessment included delays in admission, delay in surgery, and anesthesia risk grading. Care processes included the type of surgery performed and postoperative complications. The primary outcomes were the 30-day and 1-year mortality and the secondary outcomes included the length of stay, mobility at 6 months, return to pre-fracture independence, activity limitations, pressure sores, and readmission to the hospital.

RESULTS

Group A comprised 26 individuals, and the remaining 75 were in Group B. There were two deaths in Group A as compared to one death in Group B at 30 days; however, there were no new deaths at 1 year in Group A and 14 deaths in Group B (p = 0.187). Group B had lengthier hospital stays, poorer mobility, and higher physical and mental difficulties. No patients had re-operation on the initial fracture.

CONCLUSION

This study emphasizes the importance of early admission and fast provision of surgical fixation to reduce mortality and morbidity. Benchmarking institutional practices allows for defining the evidence-practice gaps and barriers to best practice implementation. This is an essential step to begin care quality improvement for geriatric patients with proximal femur fragility fractures.

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.

Is There a "Black Friday" for Geriatric Hip Fracture Surgery?

OBJECTIVES

Reports show an increase in the short-term mortality rates of hip fracture patients admitted on weekends. However, there are few studies on whether there is a similar effect in Friday admissions of geriatric hip fracture patients. The aim of this study was to evaluate the effects of Friday admission on mortality and clinical outcomes in elderly patients with hip fractures.

METHODS

A retrospective cohort study was performed at a single orthopaedic trauma centre and included all patients who underwent hip fracture surgery between January 2018 and December 2021. Patient characteristics, including age, sex, BMI, fracture type, time of admission, ASA grade, comorbidities, and laboratory examinations, were collected. Data pertaining to surgery and hospitalization were extracted from the electronic medical record system and tabulated. The corresponding follow-up was performed. The Shapiro-Wilk test was applied to evaluate the distributions of all continuous variables for normality. The overall data were analyzed by Student's t test or the Mann-Whitney U test for continuous variables and the chi-square test for categorical variables, as appropriate. Univariate and multivariate analyses were used to further test for the independent influencing factors of prolonged time to surgery.

RESULTS

A total of 596 patients were included, and 83 patients (13.9%) were admitted on Friday. There was no evidence supporting that Friday admission had an effect on mortality and outcomes, including length of stay, total hospital costs and postoperative complications. However, the patients admitted on Friday had delayed surgery. Then, patients were regrouped into two groups according to whether surgery was delayed, and 317 patients (53.2%) underwent delayed surgery. The multivariate analysis showed that younger age (p = 0.014), Friday admission (p < 0.001), ASA classification III-IV (p = 0.019), femoral neck fracture (p = 0.002), time from injury to admission more than 24 h (p = 0.025), and diabetes (p = 0.023) were risk factors for delayed surgery.

CONCLUSIONS

Mortality and adverse outcome rates for elderly hip fracture patients admitted on Friday were similar to those admitted at other time periods. However, Friday admission was identified as one of the risk factors for delayed surgery.

Reasons for Surgical Delay in Patients With Hip Fracture

INTRODUCTION

15% of patients with hip fracture older than 65 years in Israel have delayed surgery. The aim of this study was to determine which patient and/or organizational factors are associated with a delay of beyond 48 hours in hip fracture repair surgery.

METHODS

A retrospective cohort study of 281 patients with hip fracture who underwent surgery during 2019-2020. Characteristics of patients with early surgery (n = 40) and patients with delayed surgery (n = 241) were compared.

RESULTS

Presence of a cardiac disease (odds ratio [OR] = 1.38), pulmonary disease (OR = 1.21), or obesity (OR = 1.18) was identified as risk factors for surgical delay. Each additional comorbidity increased the risk. Most of the documented reasons for delay were medical, with antiplatelet therapy the most common (n = 8, 20%). Unavailable operating rooms were another common reason for delays (n = 8, 20%). In addition, a higher percentage of patients with delayed surgery were admitted in August and September (42.5%).

CONCLUSIONS

It seems that most delays were for medical reasons. However, it is unclear whether allegedly clinically justified delays were indeed of benefit to the patients. Health care organizations should strive to minimize the impact of organizational factors on surgical delay.

Incidence and risk factors associated with surgical site infection after surgically treated hip fractures in older adults: a retrospective cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common complications in the traumatic orthopedics field, but remains not adequately studied after hip fractures.

AIMS

This study aims to investigate the incidence and risk factors associated with SSI after surgically treated hip fractures in older adults.

METHODS

A retrospective cohort study including 2932 older adult patients (1416 with femoral neck fracture and 1516 with intertrochanteric fracture) surgically treated from Jan 2015 to Dec 2019 due to hip fractures was performed. Their data on demographics, injury-related data, surgery-related data, and preoperative laboratory test results were collected from hospitalization medical records. Univariate analyses were used to compare between the patients with and without SSI, and multivariate logistic regression analyses were used to identify the risk factors.

RESULTS

A total of 89 patients developed SSI, with an accumulated incidence rate of 3.04% (95%CI 2.41-3.66). Staphylococcus aureus was the most common source of infection. In univariate analysis, 11 items were found to be significant in femoral neck fractures and 5 items were found to be significant in intertrochanteric fracture. In the multivariable logistic regression model, cerebrovascular disease (OR 2.17, 95%CI 1.14-4.15) and hematocrit (HCT) (< Lower limit) (OR 3.46, 95%CI 1.13-10.56) were independent risk factors for SSI in femoral neck fracture. Heart disease (OR 2.13, 95%CI 1.18-3.85) was a risk factor for SSI, while LDH (> 250 U/L) (OR 0.44, 95%CI 0.20-0.95) was a protective factor for SSI in intertrochanteric fracture.

DISCUSSION

We observed 89 cases (3.04%) of SSI in 2932 older adult patients with hip fractures in this study. Cerebrovascular disease and lower HCT were two independent risk factors for SSI in femoral neck fracture, whereas heart disease was a risk factor and LDH was a protective factor for SSI in intertrochanteric fracture.

CONCLUSIONS

Targeted preoperative management, such as predicting the probability of SSI and taking appropriate measures accordingly is essential and highly regarded. Future multicentric studies with more patients evaluated are expected to better address the risk factors for SSI in older hip fracture patients.

The Correlation Between Timing of Surgery and the Need for RBC Transfusions in the Geriatric Intertrochanteric Fracture Population

Objective:

To identify whether the timing of surgery affects red blood cell (RBC) transfusion requirements in the elderly with intertrochanteric fractures.

Methods:

We retrospectively studied all patients undergoing surgical fixation of their intertrochanteric fractures in our hospital between January 2009 and December 2018 and analyzed the relationship between the timing of surgery and RBC transfusion.

Results:

A total of 679 patients were included in this study. The need for RBC transfusion was lower in the patients who underwent surgery within 12 h after admission (timing of surgery <12 h, <12 h group) than those who underwent surgery over 12 h after admission (timing of surgery >12 h, >12 h group) (P = 0.046); lower in the the patients who underwent surgery within 24 h after admission (timing of surgery <24 h, <24 h group) than in those who underwent surgery over 24 h after admission (timing of surgery >24 h, >24 h group) (P = 0.008), and lower in the <24 h group compared to the patients who underwent surgery within 48 h after admission (timing of surgery <48 h, <48 h group) (P = 0.035). Moreover, the need for RBC transfusion was lower in the <24 h group (in the first 24 h from admission to surgery) than in the 24-48 h group (in the second 24 h from admission to surgery) (P = 0.016), and also lower in the <24 h group compared to the 48-72 h group (in the third 24 h from admission to surgery) (P = 0.047). However, there were no differences between the <12 h group and 12-24 h group, between the <12 h group and <24 h group, and between the 12-24 h group and <24 h group, respectively.

Conclusion:

Timing of surgery within 24 h contributes to the reduction of RBC transfusion in the elderly with intertrochanteric fractures.

Clinical management of hip fractures in elderly patients with dementia and postoperative 30-day mortality: A population-based cohort study

OBJECTIVES

Patients with dementia have an increased 30-day mortality after hip fracture. We investigated clinical management including time to surgery, out-of-hours admission and surgery, surgery on weekends, surgery volume per ward, and anesthesia technique for this excess mortality risk.

METHOD

This register- and population-based study comprised 12,309 older adults (age 70+) admitted to hospital for a first-time hip fracture in 2013-2014, of whom 11,318 underwent hip fracture surgery. Cox proportional hazards regression models were applied for the analysis.

RESULTS

The overall postoperative 30-day mortality was 11.4%. Patients with dementia had a 1.5 times increased mortality risk than those without (HR = 1.50 [95% CI 1.31-1.72]). We observed no time-to-surgery difference by patient dementia status; additionally, the excess mortality risk in patients with dementia could not be explained by the clinical management factors we examined.

CONCLUSIONS

Increased mortality in patients with dementia could not be explained by the measured preoperative clinical management. Suboptimal handling of postoperative complication and rehabilitation are to be investigated for their role in the witnessed increased mortality for patients with dementia.

An analysis of equity in treatment of hip fractures for older patients with dementia in acute care hospitals: observational study using nationwide hospital claims data in Japan

Background

Globally, and particularly in countries with rapidly ageing populations like Japan, there are growing concerns over the heavy burden of ill health borne by older people, and the capacity of the health system to ensure their access to quality care. Older people with dementia may face even greater barriers to appropriate care in acute care settings. Yet, studies about the care quality for older patients with dementia in acute care settings are still few. The objective of this study is to assess whether dementia status is associated with poorer treatment by examining the association of a patient’s dementia status with the probability of receiving surgery and the waiting time until surgery for a hip fracture in acute care hospitals in Japan.

Methods

All patients with closed hip fracture were extracted from the Diagnosis Procedure Combination (DPC) database between April 2014 and March 2018. After excluding complicated cases, we conducted regressions with multilevel models. We used two outcome measures: (i) whether the patient received a surgery or was treated by watchful waiting; and (ii) number of waiting days until surgery after admission.

Results

Two hundred fourteen thousand six hundred one patients discharged from 1328 hospitals were identified. Among them, 159,173 patients received surgery. Both 80–89 year-olds (OR 0.87; 95% CI, 0.84, 0.90) and those 90 years old and above (OR 0.67; 95% CI, 0.65, 0.70) had significantly lower odds ratios for receiving surgery compared to 65–79 year-olds. Those with severe dementia had a significantly greater likelihood of receiving surgery compared to those without dementia (OR 1.21; 95% CI, 1.16, 1.25). Patients aged 90 years old and above had shorter waiting time for surgery (Coef. -0.06; 95% CI, − 0.11, − 0.01). Mild dementia did not have a statistically significant impact on the number of waiting days until surgery (P = 0.34), whereas severe dementia was associated with shorter waiting days (Coef. -0.08; 95% CI, − 0.12, − 0.03).

Conclusions

These findings suggest physicians may be taking proactive measures to preserve physical function for those with severe dementia and to avoid prolonged hospitalization although there are no formal guidelines on prioritization for the aged and dementia patients.

Should advanced age be a contraindication to total hip arthroplasty in femoral neck fracture patients? A matched-control, retrospective study

Introduction

Due to demographic changes, the annual incidence of femoral neck fractures (FNF) in patients reaching the 9th and 10th decade of life is increasing. Although active and cognitively intact elderly patients could benefit from total hip arthroplasty (THA) in case of a FNF, there is no clear consensus on whether THA should be performed in this particular subgroup of patients with very advanced age. The purpose of this study was to report the complication rate, mortality, clinical outcomes and quality-adjusted life year (QALY) gained in patients treated with total THA for FNF, while having exceeded the mean life expectancy at the time of surgery, compared to a younger control group.

Materials and Methods

Patients treated with THA through a direct anterior approach (DAA) for FNF and exceeding the average life expectancy in Switzerland (age ≥ 83 y, n = 45) were matched for gender, body mass index (BMI) and ASA score with patients under the age of 83 (age = 65-83, n = 45). Perioperative complications, clinical and radiologic outcomes, as well as mortality were compared between groups.

Results

Total complication rate did not differ significantly with 22.2% in the older group compared to 17.8% in the control group. The 30-day and 1-year mortality was slightly but not significantly higher in the older group (2.2% and 8.9% vs. 2.2% and 2.2%). The average QALY gained was 3.4 years and 4.1 years for the older group and their younger counterparts, respectively.

Conclusion

THA through the DAA for FNF in cognitively intact and active patients might be a credible and safe option even after reaching mean life expectancy with excellent functional outcomes and similar surgery-related complications compared to patients younger than 83 years. Our results imply that an advanced age should not be considered a contraindication for THA in case of a FNF.

Predictive Modeling for Geriatric Hip Fracture Patients: Early Surgery and Delirium Have the Largest Influence on Length of Stay

BACKGROUND

Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares patient complexity to the logistic effects of our institution's hip fracture care pathway.

METHODS

A retrospective analysis was performed on patients enrolled into a hip fracture co-management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient-specific and system-specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016.

RESULTS

LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications.

DISCUSSION

Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program.

LEVEL OF EVIDENCE

III.

What Is the Influence of a Delay to Surgery >24 Hours on the Rate of Red Blood Cell Transfusion in Elderly Patients With Intertrochanteric or Subtrochanteric Hip Fractures Treated With Cephalomedullary Nails?

OBJECTIVES

To evaluate the influence of delay to surgery >24 hours on the rate of red blood cell transfusion in a selected population of hip fracture patients.

DESIGN

Cohort study.

SETTING

Tertiary care university hospital.

PATIENTS

A consecutive series of 987 patients (714 females) with a mean age of 86.3 (range 50-106) years operated with an intramedullary nail due to an unstable intertrochanteric or subtrochanteric hip fracture.

INTERVENTION

Patients operated with an intramedullary nail due to an unstable intertrochanteric or subtrochanteric hip fracture.

MAIN OUTCOME MEASURES

Red blood cell transfusion rate, mortality, and postoperative length of stay were analyzed. Logistic regression analysis was used to adjust for anticoagulants, acetylsalicylic acid class, fracture type, preoperative hemoglobin (Hb) value, and time to surgery. Follow-up time was 1 year.

RESULTS

There was an increased preoperative transfusion rate among patients delayed for more than 24 hours to surgery (22%), compared with those operated within 24 hours (6.1%) (P < 0.001). After adjusting for anticoagulants, acetylsalicylic acid class, fracture type, preoperative Hb value, and time to surgery, it was found that anticoagulants [relative risk (RR), 2.0; confidence interval (CI), 1.1-3.5] and surgery delayed for more than 24 hours (RR, 3.9; CI, 2.3-6.1) were significantly associated with an increased rate of preoperative transfusions, although an increasing preoperative Hb value was associated with a lower rate of transfusions (RR, 0.3; CI, 0.2-0.4).

CONCLUSION

We found an increased rate of preoperative transfusions among patients with unstable intertrochanteric or subtrochanteric hip fractures operated with an intramedullary nail that were delayed for surgery more than 24 hours.

LEVEL OF EVIDENCE

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

Reasons for delaying surgery following hip fractures and its impact on one year mortality

PURPOSE

The purposes of this study were to identify the reasons for delayed surgery following hip fractures and analyze the impact of these reasons on 1-year mortality.

METHODS

A prospective cohort study of 1234 patients with mean age of 83.1 (range 65-92, SD 8.0) who underwent hip fracture surgery compared three subgroups: (1) surgery within two days from admission (609 patients); (2) delayed surgery for medical reasons (286); and (3) delayed surgery for organizational causes (339). Medical reason was defined as the need of medical optimization of the patient prior to surgery. Pre-operative assessment was performed by the American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), Hodkinson mental status, Katz index for activities of daily living, and Short-Form (SF-12) questionnaire. Univariate analyses were used (chi-square and Fisher exact or Mantel-Haenszel tests for categorical data, and variance analysis, Student t test, or Mann-Whitney U test for continuous data). Logistic regression models were used for influence of variables on complications and one year mortality.

RESULTS

There were no significant differences in complications or one year mortality rates between patients with surgery within two days and those with delayed surgery for medical reasons. However, the patients with delayed surgery for organizational causes had significant higher rates of both complications and one year mortality compared to the other two groups (p = 0.001).

CONCLUSIONS

This study suggests that waiting time for hip fracture surgery more than two days was not associated with higher complication or mortality rate if waiting was to stabilize patients with active comorbidities at admission, compared to stable patients at admission with early surgery. Although early surgery within two days from admission is desirable for stable patients at admission, in patients with complex comorbidities, the surgery should be performed once they are optimized. However, the patients with delayed surgery for organizational reasons had a significant higher rate of post-operative complications and one year mortality compared to the other two groups.

No association between surgical delay and mortality following distal femoral fractures. A study from the danish fracture database collaborators

BACKGROUND

The purpose of this study was to investigate whether surgical delay or the educational level of surgeon is associated with early mortality in patients with distal femoral fractures.

METHODS

392 consecutive patients aged ≥50 years registered in the Danish Fracture Database for surgery of a non-pathological, closed, low-energy distal femoral fracture (AO33A-C) were included. Data included age, gender, American Society of Anaesthesiologists (ASA) score, type of fracture, educational level of surgeon and surgical delay. Educational level of surgeon was defined as "attending or above as surgeon", "attending or above as supervisor" or "below attending alone". Surgical delay was defined as hours (h) from radiological diagnostics until onset of surgery. Mortality data was provided by The Civil Registration System. Mortality rates were calculated using multiple logistical regression analysis.

RESULTS

Mean age was 76 years (range 50-101), 79% of patients were female and 65% had an extra articular fracture (AO33A). 8% were operated within 12h, 33% within 24h, 67% within 48h and 83% within 72h. Educational level of surgeon was "attending or above as surgeon" in 56% of all cases and "attending or above as supervisor" in 33%. Mortality was 7.1% at day 30 and 12.5% at day 90. The logistical regression analysis did not demonstrate any association between surgical delay or educational level of surgeon and mortality. Increasing age, male gender and ASA score >2 significantly increased both 30-day and 90-day mortality.

CONCLUSION

No association between surgical delay or educational level of surgeon and mortality was found. These findings do not support the development of guidelines for decreasing surgical delay in this population.

Effect of causes of surgical delay on early and late mortality in patients with proximal hip fracture

INTRODUCTION

The purpose of this study was to investigate the reasons for delayed surgery in patients with proximal hip fracture and to compare differences in mortality between delayed surgery cases and non-delayed surgery cases. In addition, we evaluated causal factors for delayed surgery that affected differences in mortality.

METHODS

From 2003 to 2013, 1290 patients (1290 hips) with unilateral femoral neck or intertrochanteric fractures who underwent surgery were categorized into Group Ia (402 patients, early surgery group) and Group Ib (888 patients, delayed surgery group). The delayed surgery group was categorized as Group IIa (270 patients, pre-hospital delay group) and Group IIb (618 patients, post-hospital delay group). Among 618 patients with post-hospital delay, 165 patients in Group IIIa were defined as delayed surgery cases due to patient factors, and 453 patients in Group IIIB were defined as delayed surgery cases due to hospital factors. Early and late mortality was compared between each group.

RESULTS

Of 1290 patients, 888 patients underwent delayed surgery (mean 7.5 days, range 3-167 days) after hip fracture. The cumulative mortality rate at 30, 60 days, 3, and 12 months was 0.7, 2.0, 3.0, and 9.5% in Group Ia, respectively, and 2.4, 4.5, 5.2, and 14.5% in Group Ib, respectively (p = 0.047, p = 0.027, p = 0.078, and p = 0.012, respectively). Of 618 patients with post-hospital surgery delay, the cumulative mortality rate at 30 days and 12 months was 4.8 and 21.2% in Group IIIa, respectively, and 1.8, and 12.6% in Group IIIb, respectively (p = 0.033 and p = 0.008, respectively). After adjustments, patient factors for delayed surgery (HR 2.780; 95% CI 1.012-7.640, p = 0.047) were significantly associated with death after hip fracture.

CONCLUSIONS

This study demonstrated that delayed surgery was significantly related to 30-day and 1-year mortality. Surgery delay due to drugs' hold and medical comorbidity was related to 30-day mortality after adjustment.

The influence of inpatient comprehensive geriatric care on elderly patients with hip fractures: a meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the efficacy of in-patient comprehensive geriatric care for elderly patients with hip fracture.

METHODS

Relevant literatures were searched using the following databases including PubMed, OVID, Web of science, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trails until August 1, 2015. Eligible studies were restricted to randomized controlled trials (RCTs). The available data was extracted by two independent authors and pooled through using Review manager version 5.2. For data deemed not appropriate for synthesis, a narrative overview was conducted.

RESULTS

15 trials evaluating 3458 participants were identified in our meta-analysis. Our findings indicated patients who underwent comprehensive geriatric cares showed no significant greater improvement than control in in-patient mortality (Odds risk (OR) 0.73, 95% confidence interval (CI) 0.51 to 1.05, P=0.09), 3-(OR 0.96, 95% CI 0.51 to 1.81, P=0.90), 6-(OR 1.03, 95% CI 0.73 to 1.45, P=0.86) and 12-months mortality (OR 0.93, 95% CI 0.77 to 1.12, P=0.30). The proportion of patients who were discharged from hospital to the same place of residence as before the fracture was higher in intervention group than control (OR 1.67, 95% CI 0.80 to 3.37, P=0.0003). In addition, the pooled results showed that the number of patients in intervention group who had regained the same level of activities of daily living (ADL) (43.9% vs 30.2%, 46.0% vs 29.1%) and walking ability (71.3% vs 53.2%, 68.9% vs 56.3%) as before the fracture was higher than control at 3 and 12 months after discharge, respectively.

CONCLUSION

Comprehensive geriatric care promoted the functional improvement for elderly patients with hip fracture. Meanwhile, the proportion of patients who were discharged from hospital to the same place as before fracture in intervention group was higher as compared to control. However, our finding showed no significant difference on in-patients mortality, follow-up mortality and length of stay between both groups.