New scoring system at admission to predict walking ability at discharge for patients with hip fracture

Association of preoperative nutritional status evaluated by the controlling nutritional status score with walking independence at 180 days postoperatively: a prospective cohort study in Chinese older patients with hip fracture

BACKGROUND

Malnutrition is significantly associated with unfavorable outcomes, but there is little high-level evidence to elucidate the association of malnutrition with losing walking independence (LWI) after hip fracture surgery. This study aimed to assess the association between preoperative nutritional status evaluated by the Controlling Nutritional Status (CONUT) score and walking independence at 180 days postoperatively in Chinese older hip fracture patients.

METHODS

This prospective cohort study included 1958 eligible cases from the SSIOS database. The restricted cubic spline was used to assess the dose-effect relationship between the CONUT score and the recovery of walking independence. Propensity score matching was performed to balance potential preoperative confounders, and multivariate logistic regression analysis was applied to assess the association between malnutrition and LWI with perioperative factors for further adjustment. Furthermore, inverse probability treatment weighting and sensitivity analyses were performed to test the robustness of the results and the Fine and Gray hazard model was applied to adjust the competing risk of death. Subgroup analyses were used to determine potential population heterogeneity.

RESULTS

The authors found a negative relationship between the preoperative CONUT score and recovery of walking independence at 180 days postoperatively, and that moderate-to-severe malnutrition evaluated by the CONUT score was independently associated with a 1.42-fold (95% CI, 1.12-1.80; P =0.004) increased risk of LWI. The results were overall robust. And in the Fine and Gray hazard model, the result was still statistically significant despite the apparent decrease in the risk estimate from 1.42 to 1.21. Furthermore, significant heterogeneities were observed in the subgroups of age, BMI, American Society of Anesthesiologists score, Charlson's comorbidity index, and surgical delay ( P for interaction < 0.05).

CONCLUSION

Preoperative malnutrition is a significant risk factor for LWI after hip fracture surgery, and nutrition screening on admission would generate potential health benefits.

Association of Hip Fracture With the Use of Walking Assistance Devices Post-surgery: A Retrospective Study Comparing Intertrochanteric and Subtrochanteric Hip Fractures

Background Hip fractures, including intertrochanteric and subtrochanteric fractures, are among the most common types of fractures. The dynamic hip screw (DHS) and the cephalomedullary hip nail (CHN) are the two main techniques used for the fixation of these types of fractures. This study aims to explore the association of the fracture type with the use of walking assistance devices post-surgery, regardless of the fixation technique. Methodology This study is a retrospective study based on the review of de-identified patient data from the American College of Surgeons National Surgical Quality Improvement Program database. Patients aged 65 years old or above who underwent fixation procedures for intertrochanteric or subtrochanteric fractures using CHN or DHS techniques were included in this study. Results A total of 8,881 patients were included and divided into the following two groups: 876 (9.9%) patients treated for subtrochanteric fracture, and 8,005 (90.1%) patients treated for intertrochanteric fracture. No statistical significance was detected in the use of mobility aid postoperatively between the two groups. When compared to CHN, DHS was noted to be the most employed fixation technique among patients with intertrochanteric fractures. One main finding was that patients who underwent surgery using DHS for intertrochanteric fractures were more likely to use walking assistance devices postoperatively compared to those with subtrochanteric fractures treated with the same fixation technique. Conclusions Findings suggest that the use of walking assistance devices post-surgery is independent of the type of fracture and potentially dependent on the fixation technique employed. Future studies focused on the difference in the use of walking assistance devices based on fixation techniques for patients with distinctive sub-types of trochanteric fractures are highly encouraged.

Proximal femoral fracture and female gender are risk factors for recurrent fracture: Cohort study of 292 patients over 75 years-old with iterative osteoporotic fractures

PURPOSE

The purpose of this study was to: 1/ describe the characteristics of a cohort of patients over 75 years of age hospitalized in perioperative geriatric units (UPOG) for iterative fractures; 2/ investigate the risks of institutionalization related to the first fracture; and 3/ search for potential risk factors for iterative fracture.

METHODS

This is a retrospective single-center study analyzing patients over 75 years old, hospitalized in UPOG.

RESULTS

Of the 3207 patients hospitalized, 292 patients had a refracture (9.1%), with a mean age of 85.4+/-5.8 years. Initial fractures were mainly intertrochanteric (43.2%) and the femoral neck (32.9%). Refractures occurred mainly in the first year (55.5%), with a median delay of 9.6 months. Refractures were mainly intertrochanteric (29.5%), peri‑implant (prosthesis, osteosynthesis) (28.8%), and femoral neck (26.7%). Dementia was the only factor for institutionalization after the first fracture episode (p = 0.0002). Proximal femoral fracture (PFF) and female gender were risk factors for iterative fracture (10.2% vs. 6.8%, p = 0.003; 10.7% vs. 6.8%, p = 0.005 respectively), but not age (85.4 vs. 85.8 years, p = 0.24). PFF were more likely to result in the same fracture type in the second episode (58.1% vs 7.1%, p<0.0001). The time to refracture was shorter in case of peri‑implant fracture (p = 0.0002), or discharge directly to home (p = 0.04).

CONCLUSION

PFF and female gender are risk factors for recurrent fracture, which is even more likely to occur early in case of home discharge or peri‑implant fracture.

Incidence and risk factors for bilateral proximal femoral fractures

BACKGROUND

Proximal femoral fractures (PFFs) are a public health issue due to their high frequency. The frequency of a second PFF on the other side is estimated at 10%. This estimation is controversial, however, and the risk factors have not been evaluated in a large population of French patients. The objective of this retrospective case-control study was to determine: (1) the incidence of second PFFs and (2) their risk factors.

HYPOTHESIS

The incidence of second PFFs is >2% after 1 year and >5% after 3 years.

MATERIAL AND METHODS

We conducted a case-control study in a population of consecutive patients managed surgically for PPF at the Lyon Sud Hospital between 2013 and 2014. We analysed the following clinical factors: age, sex, body mass index (BMI), institutionalisation, the Parker score, the American Society of Anesthesiologists score (ASA), comorbidities, and the use of psychoactive drugs.

RESULTS

We included 474 PFFs (trochanter, n=240 and neck, n=234) of which 36 were bilateral. The contralateral fracture occurred within 1 year of the first fracture in 6/474 (1.3%) cases and within 3 years in all 36 cases (7.6%). The case-control study comprised 49 cases with bilateral PFF and 161 controls with no second hip fracture within 3 years. Risk factors for a second hip fracture were age older than 90 years (odds ratio [OR]=5.44; 95% confidence interval [95%CI], 112-2642 (p=0.002)) and a history of heart disease (OR, 2.18; 95%CI, 1.06-4.47 [p=0.03]). A Parker score≥6 was protective (OR, 0.84; 95%CI, 0.71-0.99 [p=0.03]). Mortality after 3 years was 42% (201/474), and 13% (63/474) of patients were lost to follow-up.

DISCUSSION

Age older than 90 years, a Parker score below 6, and a history of heart disease are risk factors for a second PFF within 3 years after the first PFF.

LEVEL OF EVIDENCE

III; case-control study.

Rapid preoperative predicting tools for 1-year mortality and walking ability of Asian elderly femoral neck fracture patients who planned for hip arthroplasty

BACKGROUND

Femoral neck fractures in elderly patients typically warrant operative treatment and are related to high risks of mortality and morbidity. As early hip arthroplasties for elderly femoral neck fractures are widely accepted, rapid predicting models that allowed quantitative and individualized prognosis assessments are strongly needed as references for orthopedic surgeons during preoperative conversations.

METHODS

Data of patients aged ≥ 65 years old who underwent primary unilateral hemiarthroplasty or total hip arthroplasty due to femoral neck fracture between January 1st, 2012 and June 30th, 2019 in our center were collected. Candidate variables included demographic data, comorbidities, and routine preoperative screening tests. The main outcomes included 1-year mortality and free walking rate after hip arthroplasty. Patients were randomly divided into derivation and validation groups in the ratio of three to one. Nomograms were developed based on multivariable logistic regressions of derivation group via R language. One thousand bootstraps were used for internal validation. Those models were further tested in the validation group for external validation.

RESULTS

The final analysis was performed on 702 patients after exclusion and follow-up. All-cause 1-year mortality of the entire data set was 23.4%, while the free walking rate was 57.3%. Preoperative walking ability showed the biggest impact on predicting 1-year mortality and walking ability. Static nomograms were created from the final multivariable models, which allowed simplified graphical computations for the risks of 1-year mortality and walking ability in a certain patient. The bias-corrected C index of those nomograms for predicting 1-year mortality in the derivation group and the validation group were 0.789 and 0.768, while they were 0.807 and 0.759 for predicting postoperative walking ability. The AUC of the mortality and walking ability predicting models were 0.791 and 0.818, respectively.

CONCLUSIONS

Our models enabled rapid preoperative 1-year mortality and walking ability predictions in Asian elderly femoral neck fracture patients who planned for hip arthroplasty, with adequate predictive discrimination and calibration. Those rapid assessment models could help surgeons in making more reasonable clinical decisions and subsequently reducing the risk of potential medical dispute via quantitative and individualized prognosis assessments.

The risk-adjusted Charlson comorbidity index as a new predictor of one-year mortality rate in elderly Chinese patients who underwent hip fracture surgery

INTRODUCTION

Recently, many studies used the Charlson comorbidity index (CCI) to predict the postoperative mortality rate of elderly patients with hip fractures. However, as a predictor, CCI did not include other preoperative risk factors, resulting in decreasing its predictive value. Therefore, we performed a study to focus on two questions as follows: (1) What is the one-year mortality rate of elderly Chinese patients who underwent surgery for hip fracture? (2) Could risk-adjusted CCI act as a new predictor to predict the one-year mortality rate?

HYPOTHESIS

The risk-adjusted CCI could exhibit a good predictive value for one-year mortality of elderly Chinese patients who underwent surgery for hip fracture.

MATERIAL AND METHODS

This retrospective observational cohort study is based on data collected from July 2012 to April 2016. Patients aged 65 years and older who underwent hip fracture surgery were included. The clinical patient data were obtained, including gender, age, BMI, types of fracture, smoking, injury side, time from injury to surgery, and CCI. Stepwise, multiple logistic regression analysis was used to identify risk factors contributed to the occurrence of postoperative death at one-year follow-up. The risk-adjusted CCI scores of patients were calculated by the formula based on the coefficient regression and independent variables. Receiver operating characteristic (ROC) curve analysis was used for determining the diagnostic value of different factors.

RESULTS

A total of 445 elderly patients who underwent surgery for hip fracture, including 171 males and 274 females, were enrolled in the study cohort. The mean CCI scores of all enrolled patients were 1.20±1.62. Sixty-four patients died within one year, and the one-year mortality rate was 14.38%. The multivariate logistic regression analysis reported that age, time from injury to surgery, and CCI were associated with death after surgical treatment within one year. The risk-adjusted CCI scores of patients=0.099×age (years)+0.355×time from injury to surgery (days)+0.434×CCI scores. The predictive value of the risk-adjusted CCI was highest among these risk predictors, whose AUC value was 0.816.

DISCUSSION

The risk-adjusted Charlson comorbidity index could be used as a guide to predict one-year mortality rate in elderly Chinese patients after the surgical treatment of hip fractures.

LEVEL OF EVIDENCE

III; cohort comparative study.

Identifying factors predicting prolonged rehabilitation after simultaneous bilateral total knee arthroplasty: a retrospective observational study

Background

Rehabilitation is an effective procedure for promoting functional recovery after simultaneous bilateral total knee arthroplasty (TKA); however, it has been cited as a significant economic burden of medical care. We hypothesized that preoperative factors, including age, sex, body mass index, living alone, the knee society function score (KSS), the American society of anesthesiologists (ASA) class, hemoglobin (Hb), albumin level, mean range of motion, and the Kellgren–Lawrence grade, would predict prolonged rehabilitation utilization.

Methods

In total, 191 patients undergoing simultaneous bilateral TKA in a single hospital were enrolled. The successful compliance group included patients who completed their rehabilitation program and could return to their residence within 3 weeks after surgery (n = 132), whereas the delayed group included the remaining patients (n = 59). Logistic regression analysis was performed using preoperative factors. A prediction scoring system was created using the regression coefficients from the logistic regression model.

Results

Logistic regression analysis revealed that age (β = − 0.0870; P <  0.01) and Hb (β = 0.34; P <  0.05) were significantly associated with prolonged rehabilitation programs, whereas body mass index, living alone, KSS score, and ASA class were not significantly associated with successful completion of rehabilitation programs; however, these factors contributed to the prediction scoring formula, which was defined as follows: \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\displaystyle \begin{array}{l}\mathrm{Score}=10-\left(0.09\times \mathrm{age}\right)-\left(0.09\times \mathrm{body}\ \mathrm{mass}\ \mathrm{index}\right)-\left(0.56\times \mathrm{living}\ \mathrm{alone}\ \right[\mathrm{alone}:1,\\ {}\mathrm{others}:0\left]\right)+\left(0.03\times \mathrm{KSS}\ \mathrm{stairs}\right)+\left(0.34\times \mathrm{Hb}\right)-\left(1.1\times \mathrm{ASA}\ \mathrm{class}\right).\end{array}} $$\end{document}Score=10-0.09×age-0.09×body mass index-(0.56×living alone[alone:1,others:0])+0.03×KSSstairs+0.34×Hb-1.1×ASAclass.

The C-statistic for the scoring system was 0.748 (95% confidence interval, 0.672–0.824). The positive and negative likelihood ratios were 2.228 (95% CI, 1.256–3.950) and 0.386 (95% CI, 0.263–0.566), respectively. These results showed an increase of 15–20% and a decrease of 20–25% in the risk of prolonged rehabilitation. The optimal cutoff point for balancing sensitivity and specificity was 3.5, with 66.6% sensitivity and 78.0% specificity.

Conclusions

Older age and lower preoperative Hb were significantly associated with prolonged rehabilitation programs. We defined a new scoring formula using preoperative patient factors to predict prolonged rehabilitation utilization in patients undergoing simultaneous bilateral TKA.

Deep learning for the radiographic diagnosis of proximal femur fractures: Limitations and programming issues

INTRODUCTION

Radiology is one of the domains where artificial intelligence (AI) yields encouraging results, with diagnostic accuracy that approaches that of experienced radiologists and physicians. Diagnostic errors in traumatology are rare but can have serious functional consequences. Using AI as a radiological diagnostic aid may be beneficial in the emergency room. Thus, an effective, low-cost software that helps with making radiographic diagnoses would be a relevant tool for current clinical practice, although this concept has rarely been evaluated in orthopedics for proximal femur fractures (PFF). This led us to conduct a prospective study with the goals of: 1) programming deep learning software to help make the diagnosis of PFF on radiographs and 2) to evaluate its performance.

HYPOTHESIS

It is possible to program an effective deep learning software to help make the diagnosis of PFF based on a limited number of radiographs.

METHODS

Our database consisted of 1309 radiographs: 963 had a PFF, while 346 did not. The sample size was increased 8-fold (resulting in 10,472 radiographs) using a validated technique. Each radiograph was evaluated by an orthopedic surgeon using RectLabel™ software (https://rectlabel.com), by differentiating between healthy and fractured zones. Fractures were classified according to the AO system. The deep learning algorithm was programmed on Tensorflow™ software (Google Brain, Santa Clara, Ca, USA, tensorflow.org). In all, 9425 annotated radiographs (90%) were used for the training phase and 1074 (10%) for the test phase.

RESULTS

The sensitivity of the algorithm was 61% for femoral neck fractures and 67% for trochanteric fractures. The specificity was 67% and 69%, the positive predictive value was 55% and 56%, while the negative predictive value was 74% and 78%, respectively.

CONCLUSION

Our results are not good enough for our algorithm to be used in current clinical practice. Programming of deep learning software with sufficient diagnostic accuracy can only be done with several tens of thousands of radiographs, or by using transfer learning.

LEVEL OF EVIDENCE

III; Diagnostic studies, Study of nonconsecutive patients, without consistently applied reference "gold" standard.

The handgrip strength threshold of 16 kg discriminates successful rehabilitation: A prospective short-term study of 258 women with hip fracture

AIM

In 2019 the European Working Group on Sarcopenia in Older People (EWGSOP) indicated weakness as the key characteristic of sarcopenia and released the threshold of 16 kg for handgrip strength to define weakness in women. We aimed to externally validate the 16 kg cut-off point for predicting functional recovery in 258 women with subacute hip fracture admitted to our rehabilitation ward.

METHODS

We assessed handgrip strength by a hand-grip Jamar dynamometer at admission to inpatient rehabilitation and functional ability in activities of daily living by the Barthel index at the end of the rehabilitation course. Successful rehabilitation was defined with a Barthel index score ≥85 and highest possible recovery with a Barthel index effectiveness = 100 %.

RESULTS

A handgrip strength ≥16 kg significantly predicted both successful rehabilitation (χ2 = 23.5, P < 0.001) and highest possible recovery (χ2 = 31.05, P < 0.001). For the women with a handgrip strength ≥16 kg, the odds ratios to gain successful rehabilitation and highest possible recovery were 2.68 (95 % CI from 1.19 to 6.04; P = 0.018) and 2.81 (95 % CI from 1.47 to 5.37; P = 0.002), after adjustment for Barthel index scores before rehabilitation, age, hip-fracture type (either medial or lateral), cognitive impairment and 25-hydroxyvitamin D levels.

CONCLUSION

Our results provide an external validation of the 16 kg handgrip strength threshold recently released to discriminate functional outcomes: it significantly predicted the short-term ability to perform activities of daily living after hip fracture in women.