C-Reactive Protein to Albumin Ratio May Predict Mortality for Elderly Population Who Undergo Hemiarthroplasty Due to Hip Fracture

Preoperative Albumin and Postoperative CRP/Albumin Ratio (CARS) are Independent Predictive Factors in Estimating 1-Year Mortality in Patients Operated for Proximal Femoral Metastasis with Endoprosthesis

Background

Proximal femur resection and prosthetic reconstruction are preferred in patients with extensive bone destruction, pathological fractures, tumours resistant to radiation therapy, and patients with more proximal metastatic lesions. There is increasing evidence that the CRP/albumin ratio (CAR) is an independent marker of inflammation in various primary organ cancers and maybe a more accurate prognostic factor. We aimed to evaluate whether preoperative and postoperative CAR values could be a factor in predicting mortality in these patients. We hypothesized that CAR could predict these patients' postoperative 90-day and 1-year mortality.

Methods

The patient's age and gender, primary tumour, number of bone metastases, and presence of visceral metastases were recorded using imaging techniques such as computed tomography and bone scan or positron emission tomography. The following laboratory data were analyzed before and after surgery.

Results

The mean age of the patients was 62.67 ± 14.8; 56.9% were female (n:29), and 43.1% were male (n:22). When the results of the ROC analysis of the parameters in predicting 1-year mortality were examined, and the cut-off value for preoperative albumin was taken as ≤ 3.75, the AUC value was found to be statistically significant as 0.745 (p:0.003). When the cut-off value for postoperative CAR was taken as ≥ 87.32, the AUC value was found to be 0.7 statistically significant (p:0.015).

Conclusion

Length of stay, preoperative albumin and postoperative CAR values can be used as independent predictive values in predicting 1-year mortality in patients undergoing endoprosthesis due to proximal femur metastasis.

Association between inflammation-based prognostic markers and mortality after hip replacement

We aimed to evaluate the association between inflammation-based prognostic markers and mortality after hip replacement. From March 2010 to June 2020, we identified 5,369 consecutive adult patients undergoing hip replacement with C-reactive protein (CRP), albumin, and complete blood count measured within six months before surgery. Receiver operating characteristic (ROC) curves were generated to evaluate predictabilities and estimate thresholds of CRP-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR). Patients were divided according to threshold, and mortality risk was compared. The primary outcome was one-year mortality, and overall mortality was also analyzed. One-year mortality was 2.9%. Receiver operating characteristics analysis revealed areas under the curve of 0.838, 0.832, 0.701, and 0.732 for CAR, NLR, PLR, and modified Glasgow Prognostic Score, respectively. The estimated thresholds were 2.10, 3.16, and 11.77 for CAR, NLR, and PLR, respectively. According to the estimated threshold, high CAR and NLR were associated with higher one-year mortality after adjustment (1.0% vs. 11.7%; HR = 2.16; 95% CI 1.32-3.52; p = 0.002 for CAR and 0.8% vs. 9.6%; HR = 2.05; 95% CI 1.24-3.39; p = 0.01 for NLR), but PLR did not show a significant mortality increase (1.4% vs. 7.4%; HR = 1.12; 95% CI 0.77-1.63; p = 0.57). Our study demonstrated associations of preoperative levels of CAR and NLR with postoperative mortality in patients undergoing hip replacement. Our findings may be helpful in predicting mortality in patients undergoing hip replacement.

Admission Inflammation Markers Influence Long-term Mortality in Elderly Patients Undergoing Hip Fracture Surgery: A Retrospective Cohort Study

OBJECTIVES

Hip fractures in elderly patients are associated with a high mortality rate. Most deaths associated with hip fracture result from complications after surgery. Recent studies suggest that some inflammation biomarkers may be useful to estimate excess mortality. This study aimed to investigate the prognostic value of admission inflammation biomarkers in elderly patients with hip fracture.

METHODS

We reports on a retrospective study of elderly hip fracture patients admitted to a hospital in China between January 2015 and December 2019. A total of 1085 patients were included in the study, and their demographic and pre-operative characteristics were analyzed. The inflammation biomarkers included monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), and C-reactive protein (CRP) to albumin ratio (CAR). The predictive performance of NLR, MLR and CAR was assessed by receiver operating characteristics (ROC) curve analysis and the association between admission inflammation markers and mortality was evaluated by Cox proportional regression.

RESULTS

The 30-day, 1-year, 2-year, and 4-year mortality were 1.6%, 11.5%, 21.4% and 48.9%, respectively. The optimal cut-off values of admission NLR, MLR and CAR for 1-year mortality were 7.28, 0.76, and 1.36. After adjusting the covariates, preoperative NLR ≥ 7.28 (HR = 1.419, 95% CI: 1.080-1.864, p = 0.012) were found to be only independent risk factors with 4-year all-cause mortality, the preoperative CAR ≥ 1.36 was independently associated with 1-year (HR = 1.700, 95% CI: 1.173-2.465, p = 0.005), 2 year (HR = 1.464, 95% CI: 1.107-1.936, p = 0.008), and 4-year (HR = 1.341, 95% CI: 1.057-1.700, p = 0.016) all-cause mortality, While age, CCI score, and low hemoglobin at admission were also risk factors for postoperative all-cause mortality.

CONCLUSION

Admission CAR and NLR may be useful indicators for predicting the long-term mortality of elderly patients undergoing hip fracture surgery, and that more research is needed to validate these findings.

Accuracy of Albumin, Globulin, and Albumin-Globulin Ratio for Diagnosing Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis

Periprosthetic joint infection (PJI) is one of the most intractable orthopedic diseases, partly because of the difficulty in differentiating septic from aseptic conditions. We aimed to evaluate and consolidate the diagnostic accuracy of the quantitative assessment of serum albumin (Alb), globulin (Glb), and albumin-globulin ratio (AGR), alone or in combination with the inflammatory marker, C-reactive protein (CRP), for PJI. We searched the PubMed, CINAHL, and Cochrane Library databases for studies that quantitatively measured Alb, Glb, or AGR for the diagnosis of PJI up until the 30 April 2023. A total of 2339 patients were included from 10 studies, including 845 patients with a definitive diagnosis of PJI and 1494 with non-PJI. The pooled sensitivity, specificity, and area under the curve (AUC) in the summary receiver-operating characteristic curve were as follows: 0.625, 0.732, and 0.715 for Alb; 0.815, 0.857, and 0.887 for Glb; 0.753, 0.757, and 0.875 for AGR; 0.788, 0.837, and 0.876 for CRP; 0.879, 0.890, and 0.917 for the CRP-Alb ratio; and 0.845, 0.855, and 0.908 for the CRP-AGR ratio. Serum Alb, Glb, and AGR levels are feasible and accurate diagnostic markers for PJI, and the combination of these markers with CRP levels may potentially improve preoperative serum diagnostic accuracy. Future prospective studies are required to verify these findings because of the small numbers of included studies.

Risk Factors of the 2-Year Mortality after Bipolar Hemiarthroplasty for Displaced Femoral Neck Fracture

Purpose

This study investigates the relationship between preoperative neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-C-reactive protein ratio (LCR), albumin, and 2-year mortality in elderly patients having hemiarthroplasty for displaced femoral neck fracture (FNF).

Materials and Methods

We retrospectively reviewed 284 elderly patients who underwent hemiarthroplasty for Garden type IV FNF from September 2014 to September 2020. Using the receiver operating characteristic curve, optimal cutoff values for LCR, NLR, and albumin were established, and patients were categorized as low or high. Associations with 2-year mortality were evaluated through univariate and multivariate Cox regression analyses.

Results

Of the 284 patients, 124 patients (45.9%) died within 2 years post-surgery. The optimal cutoff values were: LCR at 7.758 (specificity 58.5%, sensitivity 25.0%), NLR at 3.854 (specificity 39.2%, sensitivity 40.0%), and albumin at 3.750 (specificity 65.9%, sensitivity 21.9%). Patients with low LCR (<7.758), high NLR (≥3.854), and low albumin (<3.750) had a statistically significant reduced survival time compared to their counterparts.

Conclusion

Lower preoperative LCR and albumin levels, along with higher NLR, effectively predict 2-year mortality and 30-day post-surgery complications in elderly patients with Garden type IV FNF undergoing hemiarthroplasty.

The Preoperative Neutrophil-Lymphocyte Ratio Is an Independent Predictive Factor in Predicting 1-Year Mortality in Amputated Diabetic Foot Patients

In this study, we aimed to evaluate the efficacy of neutrophil/lymphocyte ratio values in preoperative blood tests of patients amputated due to diabetic foot in predicting 1-year mortality. We assumed that the neutrophil/lymphocyte ratio predicted 1-year mortality in these patients. The inclusion criteria were as follows: to be diagnosed with diabetic foot, being >18 years of age, having a confirmed type 1 or type 2 diabetes mellitus diagnosis, stage 3 to 5 Wagner ulcers, and having at least 1 year of follow-up. The patients with acute traumatic injuries observed in less than 1 week, traumatic amputations, and nondiabetic amputations, and those whose data could not be obtained were excluded from the study. After the exclusion, 192 patients were included in the study. Age (p < .001), low preoperative hemoglobin (p = .024), high preoperative neutrophil (p < .001), low preoperative lymphocyte (p = .023), low preoperative albumin (p < .001), high preoperative neutrophil-to-lymphocyte ratio (p < .001), major amputation (p = .002), and were related to 1-year mortality. According to these results: (1) it was observed that a preoperative neutrophil/lymphocyte ratio value over 5.75 increases the risk of death 1.1 times and (2) it was observed that a preoperative albumin value under 2.67 increases the risk of death 5.74 times. In conclusion, the age, preoperative neutrophil/lymphocyte ratio, and albumin values of patients planning to undergo amputation surgery can be independent predictive factors in predicting 1-year mortality.

Predictive Value of the C-Reactive Protein to Albumin Ratio in 30-Day Mortality after Hip Fracture in Elderly Population: A Retrospective Observational Cohort Study

BACKGROUND

C-reactive protein (CRP) to Albumin ratio (CAR) has been used in multiple clinical settings to predict early mortality. However, there is a lack of evidence on the predictive role of CAR in 30-day mortality after a hip fracture. The purpose of this study was to establish a potential association between CAR and 30-day mortality and to assess if the CAR Receiving Operating Characteristics curve (ROC) can be a reliable predictor of early mortality.

METHODS

We retrospectively reviewed the charts of 676 patients (>65 years) treated for hip fracture between 2006 and 2018. All hip fractures were included. Treatment strategies included closed reduction and internal fixation, open reduction and internal fixation, hemiarthroplasty, or total joint arthroplasty. Statistical analysis included T-test, Pearson correlation for CAR and other markers, ROC curves and area under the curve, Youden Model, and Odds Ratio.

RESULTS

The 30-day mortality rate analysis showed that higher preoperative levels of CAR were associated with higher early mortality. When analyzing the area under the ROC curve (AUROC) for 30-day mortality, the reported value was 0.816. The point of the ROC curve corresponding to 14.72 was considered a cut-off with a specificity of 87% and a sensibility of 40.8%. When analyzing values higher than 14.72, the 30-day mortality rate was 17.9%, whilst, for values lower than 14.72, the 30-day mortality rate was 1.8%.

CONCLUSIONS

Patients older than 65 years affected by a hip fracture with increased preoperative levels of CAR are associated with higher 30-day mortality. Despite a moderate sensibility, considering the low cost and the predictivity of CAR, it should be considered a standard predictive marker.

Correlation between C-reactive protein and postoperative mortality in patients undergoing hip fracture surgery: a meta-analysis

BACKGROUND

Hip fracture is a common but devastating disease with a high mortality rate in the older adult population. C-reactive protein (CRP) is a predictor of the prognosis in many diseases, but its correlations with patient outcomes following hip fracture surgery remain unclear. In this meta-analysis, we investigated the correlation between perioperative CRP level and postoperative mortality in patients undergoing hip fracture surgery.

METHODS

PubMed, Embase, and Scopus were searched for relevant studies published before September 2022. Observational studies investigating the correlation between perioperative CRP level and postoperative mortality in patients with hip fracture were included. The differences in CRP levels between the survivors and nonsurvivors following hip fracture surgery were measured with mean differences (MDs) and 95% confidence intervals (CIs).

RESULTS

Fourteen prospective and retrospective cohort studies comprising 3986 patients with hip fracture were included in the meta-analysis. Both the preoperative and postoperative CRP levels were significantly higher in the death group than in the survival group when the follow-up duration was ≥ 6 months (MD: 0.67, 95% CI: 0.37-0.98, P < 0.0001; MD: 1.26, 95% CI: 0.87-1.65, P < 0.00001, respectively). Preoperative CRP levels were significantly higher in the death group than in the survival group when the follow-up duration was ≤ 30 days (MD: 1.49, 95% CI: 0.29-2.68; P = 0.01).

CONCLUSIONS

Both higher preoperative and postoperative CRP levels were correlated with higher risk of mortality following hip fracture surgery, suggesting the prognostic role of CRP. Further studies are warranted to confirm the ability of CRP to predict postoperative mortality in patients with hip fracture.

Evaluation of Serum Albumin and Globulin in Combination With C-Reactive Protein Improves Serum Diagnostic Accuracy for Low-Grade Periprosthetic Joint Infection

BACKGROUND

Serum immune markers can be useful in the diagnosis of periprosthetic joint infection (PJI) by detecting long-lasting abnormal immunological conditions. The purpose of this study was to examine whether serum immune markers can improve the diagnostic accuracy of PJI.

METHODS

We enrolled 51 PJI, 45 aseptic loosening, and 334 osteoarthritis patients for assessment of the discriminatory accuracy of serum markers including white blood cell count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and D-dimer, total protein, albumin (Alb), globulin (Glb), neutrophil-lymphocyte ratio, lymphocyte-monocyte ratio, platelet-lymphocyte ratio, albumin-globulin ratio (AGR), CRP-albumin ratio (CAR), and CRP-AGR ratio (CAGR). These diagnostic accuracies for low-grade PJI were also calculated in patients who had serum CRP levels < 10 mg/L.

RESULTS

Among serum markers, Alb, Glb, AGR, CRP, ESR, CAR, and CAGR had highly accurate diagnostic accuracy for PJI, with area under the curve of 0.92, 0.90, 0.96, 0.97, 0.92, 0.97, and 0.98, respectively. In low-grade PJI patients, area under the curve of CRP, ESR, CAR, and CAGR (0.69, 0.80, 0.65, and 0.82, respectively) was decreased but that of Alb, Glb, and AGR (0.90, 0.88, and 0.95, respectively) remained high, indicating the diagnostic utility of these immune markers. The sensitivity and specificity of AGR with cutoff value of 1.1 were demonstrated as 0.92 and 0.89, respectively, and with cutoff value of 1.2, 1.00, and 0.79, respectively, in the diagnosis of low-grade infection.

CONCLUSION

Our results demonstrate the potential value of Alb, Glb, AGR, and combination indices of these immune makers with CRP in improving preoperative serum diagnosis for PJI, especially in low-grade PJI.

LEVEL OF EVIDENCE

Diagnostic- Level II.

Investigation Of The Relationship Between Prognostic Nutrition Index And Mortality In Patients With Femur Fracture

Aim: The incidence of adverse postoperative outcomes in surgeries for femur fractures is high and is associated with malnutrition. In this study, it was aimed to determine the independent factors for 6-month survival in patients with femur fracture and to evaluate the predictive value of the prognostic nutrition index (PNI). Material and Method: One hundred and sixteen patients operated on only for femoral fracture were divided into survival and non-survival groups according to mortality.Demographic characteristics of the patients, operation data, fracture sites, need for intensive care unit and length of stay, postoperative hospital stay, and preoperative laboratory values, prognostic nutrition indices and mortality were evaluated. Results: Twenty-six (22.4%) of 116 patients who were operated for femoral fracture resulted in 6-month mortality. CRP, albumin, prealbumin, crp/albumin ratio and PNI values at admission were independent risk factors for postoperative mortality (p=0.014, p

The postoperative prognosis of older intertrochanteric fracture patients as evaluated by the Chang reduction quality criteria

OBJECTIVE

The aim of this study was to investigate the relationship between the Chang reduction quality criteria (CRQC) and the outcome of intertrochanteric fractures in older adults according to follow-up time.

METHODS

This was a retrospective analysis of 389 older adult patients with intertrochanteric fractures treated surgically from January 2019 to June 2021, including 130 males and 259 females aged 84.6 (77.5-89.7) years. Patient survival was determined by telephone as the time between admission to hospital for fracture and death or until the study deadline (June 1, 2022). According to the CRQC, the patients were divided into the Poor, Acceptable, and Excellent groups. Univariate and multivariate Cox proportional hazard models were used to assess the association between CRQC and all-cause mortality in older adult intertrochanteric fractures at 1 year and the total follow-up time. Further subgroup analysis was performed according to different clinical and biological characteristics to improve the accuracy of the results.

RESULTS

The mortality rates were 24.7% and 15.4% at 1 year and the total follow-up time, respectively. Both at one year and the total follow-up time, the mortality of the CRQC-Excellent group was significantly lower than that of the CRQC-Acceptable group (p.adj < 0.05) and the CRQC-Poor group (p.adj < 0.05). After multifactor adjustment, CRQC grades of Acceptable and Poor were independent risk factors affecting the overall and 1-year mortality. In addition, advanced age, ≥ 1 comorbidities, ASA 3 + 4, and prolonged preoperative waiting time were independent risk factors for survival at the total follow-up time. At 1 year, only ASA 3 + 4 and prolonged preoperative waiting time were independent risk factors for survival. Subgroup analysis according to different characteristics at the total follow-up time and at one year showed that in most subgroups, a decrease in the CRQC grade was significantly associated with an increase in all-cause mortality (p for trend < 0.05).

CONCLUSIONS

This study highlights that CRQC grades of Acceptable and Poor are associated with increased all-cause mortality in older adult intertrochanteric fractures. We should attempt to achieve good reduction of these fractures.

Low lymphocyte-to-C-reactive protein ratio relates to high 1-year mortality in elderly patients undergoing hemiarthroplasty for displaced femoral neck facture

OBJECTIVE

Lymphocyte-to-C-reactive protein (CRP) ratio (LCR) is a novel biomarker for predicting poor prognosis in many diseases. This study aims to analyze the association between preoperative LCR and 1-year mortality in elderly patients with displaced FNF undergoing hemiarthroplasty.

METHODS

Between May 2017 and May 2019, a retrospective study including 364 elderly patients undergoing hemiarthroplasty for displaced FNF was performed. LCR was defined as the ratio of preoperative lymphocyte count to CRP level. The optimal cutoff value of LCR was determined by receiver operating characteristic curve, and all patients were categorized into low-LCR group and high-LCR group accordingly. The relationship between LCR and 1-year mortality was evaluated by using univariate and multivariate Cox regression analysis. Furthermore, the complications within 30 days after surgery, length of hospital stay, and perioperative red blood cell transfusion were also analyzed stratified by LCR.

RESULTS

A total of 47 patients (12.9%) died within 1-year follow-up after surgery. The optimal cutoff value for LCR was 30,560 (specificity 76.6% and sensitivity 63.4%). Low-LCR (≤ 30,560) group had a higher mortality rate than high-LCR group (23.53% vs. 5.21%, P < 0.001). In multivariate analysis, low LCR, hypoalbuminemia, and Age-Adjusted Charlson Comorbidity Index ≥ 6 were identified as independent predictors for 1-year mortality. Moreover, low level of LCR was associated with high rate of total complications (19.6% vs. 11.4%, P = 0.029), perioperative transfusions (37.9% vs. 27.0%, P = 0.027), and longer hospital stay (7.84 ± 2.40 vs. 7.30 ± 2.32, P = 0.031).

CONCLUSIONS

The low level of preoperative LCR can effectively predict 1-year mortality and 30-day total complications after surgery in elderly patients with displaced FNF undergoing hemiarthroplasty.

Relationship between the neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio and deep venous thrombosis (DVT) following femoral neck fractures in the elderly

Purpose

This study aimed to investigate whether the neutrophil-to-lymphocyte ratio (NLR) or platelet-to-lymphocyte ratio (PLR) was associated with deep venous thrombosis (DVT) following femoral neck fractures in the elderly.

Method

This was a retrospective cohort study and used data extracted from the hospitalization electronic medical record and the laboratory biomarker reports. Patients were included if they were aged above 60 years with a definite diagnosis of femoral neck fracture caused by low-energy trauma. Duplex ultrasound scanning was routinely performed to detect the potential DVT. Two independent multivariate logistic regression models were constructed to identify the association of NLR or PLR with the risk of DVT.

Results

A total of 708 patients with femoral neck fractures were included, and 112 were found to have DVT, indicating an incidence rate of 15.8%. There were significant differences across five subgroups for NLR or PLR, in terms of age (p = 0.020, 0.006), white blood cell (p < 0.001, =0.006), hemoglobin (p < 0.001, <0.001), and albumin (p < 0.001, <0.001). BMI was tested to be significantly different across subgroups for NLR (p = 0.030) and prevalence of cerebrovascular disease for PLR (p = 0.014). The multivariate analyses demonstrated that not NLR but PLR in Q3 (range, 179–238) was associated with an increased risk of DVT, and the risk for the latter was 1.86 (95%CI, 1.07–3.36).

Conclusion

We concluded that a PLR value of 179–238 was associated with a 1.86-fold increased risk of DVT after femoral neck fracture. This study paves the way toward further exploration of inflammatory/immune biomarkers with the risk of DVT in the elderly with trauma.

C-reactive Protein-to-albumin Ratio in Spinal Epidural Abscess: Association with Post-treatment Complications

INTRODUCTION

Spinal epidural abscess (SEA) is a complex medical condition with high morbidity and healthcare costs. Clinical presentation and laboratory data may have prognostic value in forecasting morbidity and mortality. C-reactive protein-to-albumin ratio (CAR) demonstrates promise for the prediction of adverse events in multiple orthopaedic and nonorthopaedic surgical conditions. We investigated the relationship between CAR and outcomes after treatment of SEA.

METHODS

We retrospectively evaluated adult patients treated within a single healthcare system for a diagnosis of SEA (2005 to 2017). Laboratory and clinical data included age at diagnosis, sex, race, body mass index, smoking status, history of intravenous drug use, Charlson Comorbidity Index, and CAR. The primary outcome was the occurrence of any complication; mortality and readmissions were considered secondarily. We used logistic regression to determine the association between baseline CAR and outcomes, adjusting for confounders.

RESULTS

We included 362 patients with a 90-day mortality rate of 13.3% and a 90-day complication rate of 47.8%. A reduced complication rate was observed in the lowest decile of CAR values compared with the remaining 90% of patients, a threshold value of 2.5 (27.0% versus 50.2%; odds ratio [OR] 2.66, 95% confidence interval [CI] 1.22 to 5.81). CAR values in the highest two deciles experienced significantly increased odds of complications compared with the lowest decile (80th: OR 3.44; 95% CI 1.25 to 9.42; 90th: OR 3.28; 95% CI 1.19 to 9.04).

DISCUSSION

We found elevated CAR to be associated with an increased likelihood of major morbidity in SEA. We suggest using a CAR value of 2.5 as a threshold for enhanced surveillance and recognizing patients with values above 73.7 as being at exceptional risk of morbidity.

LEVEL OF EVIDENCE

Level III observational cohort study.

C-reactive protein to albumin ratio (CAR) in predicting surgical site infection (SSI) following instrumented posterior lumbar interbody fusion (PLIF)

Identification of novel markers would contribute to the individualised risk assessment and development of a risk prediction model. This study aimed to investigate the role of the C-reactive protein to albumin ratio (CAR) in predicting surgical site infection (SSI) following instrumented posterior lumbar interbody fusion (PLIF) of lumbar degenerative diseases. This study enrolled patients who underwent PLIF and instrumentation for treatment of lumbar degenerative diseases between 2015 and 2020. Electronic medical records were inquired for data collection, with follow-up register for identifying SSI cases. The optimal cut-off for CAR was determined by constructing the receiver operator characteristic (ROC) curve. Patients with high- or low-CAR value were compared using the univariate analyses, and the association between CAR and the risk of SSI was investigated using multivariate logistics regression analysis. A total of 905 patients were enrolled, twenty-nine (3.2%) had developed an SSI with 72.4% occurring during index hospitalisation, and 11 (1.2%) had deep and 18 (2.0%) superficial SSIs. An SSI was associated with additional 10.7 days of index total hospital stay (P = .001). The CAR was 0-5.43 (median, 0.05), and the optimal cut-off was 0.09 and area under the curve was 0.720 (P < .001). 336 (37.1%) patients had a CAR ≥0.09 and 22 (6.5%) developed an SSI, with a crude risk of 5.6 relative to those with a low CAR. The multivariate analyses showed CAR ≥0.09 was associated with 8.06-fold increased risk of SSI, together with diabetes (P = .018), while hypertension was identified as a protective factor (OR, 0.34; 95%CI, 0.11-1.00, P = .049). High CAR is found to significantly predict the incident SSI following instrumented PLIF of lumbar degenerative diseases, and can be considered as a useful index in practice only after it is verified by future high-level evidences.

Inflammation and nutrition based screening tests for detection of infection in cases of rapid hip destruction

Preoperative diagnosis of infection is important for appropriate surgical treatment of patients with rapid hip destruction (RHD). We investigated whether test results, including inflammatory and nutritional markers, could be used to accurately differentiate infectious and non-infectious RHD. Fifty patients with RHD who underwent total hip arthroplasty within a year of onset were observed. Infectious RHD was defined as ≥ 2 positive serological inflammatory, microbiological, or pathological evaluations. The albumin to globulin ratio (AGR), C-reactive protein (CRP)/albumin ratio (CAR), Glasgow prognostic score (GPS), modified GPS (mGPS), prognostic nutritional index (PNI), geriatric nutritional risk index (GNRI), and platelet to lymphocyte ratio (PLR) were calculated from the blood test results. In the infectious group, the white blood cell count, platelet count, CRP level, erythrocyte sedimentation rate, CAR, GPS, mGPS, and PLR were significantly higher, while the albumin level, AGR, PNI, and GNRI were significantly lower. The CRP and albumin levels showed the highest sensitivity (1.00 for both; specificity of 0.87 and 0.73, respectively) in diagnosing infectious RHD. Combining these measurements (CAR) increased the specificity to 0.92. The accuracy of other nutritional assessments was good. Thus, nutritional assessment as well as conventional assessment of the inflammatory response can improve the accuracy of preoperative diagnosis of infectious RHD.

Primary Arthroplasty or Internal Fixation in Intertrochanteric Femur Fractures: A Survey of Surgical Attitudes of Orthopedic Surgeons in Turkey

This study aimed to examine the primary arthroplasty attitudes of Turkish orthopedics and traumatology specialists and residents to patients with intertrochanteric fractures, of various ages, comorbidity situations and fracture types, using an internet-based questionnaire. Between March and April 2021, a cross-sectional survey was conducted with a total of 159 orthopedics and traumatology specialists and residents in Turkey, using an online questionnaire that consisted of 16 different patient scenarios of varying intertrochanteric fracture types, ages, and comorbidity conditions. Respondents’ preference ratio for primary arthroplasty was 24.1% in the scenarios with patients over the age of 71, while it was 8.4% in the scenarios with patients aged between 50 and 70. The ratios of primary arthroplasty preference were 12.4%, 21% and 27.3% in 2-part, 3-part and 4-part fracture scenarios, respectively. The primary arthroplasty preferences of respondents with 10 years or more of professional experience were observed to be statistically significantly different to those of the respondents with 1 to 10 years of experience in the 4-part fracture scenario where the patient was aged 71 years and above with an ASA (American Society of Anesthesiologists) score of 3–4 (p < 0.05). Despite varying opinions in the literature in recent years, primary arthroplasty can be considered a valuable alternative approach for Turkish surgeons, and in older adult patients with unstable intertrochanteric fractures, particularly those who need early mobilization and have high ASA scores.

The Association of On-Admission Blood Hemoglobin, C-Reactive Protein, and Serum Creatinine With 2-Year Mortality of Patients With Femoral Neck Fractures

Introduction

The mortality of femoral neck fracture (FNF) is high and every effort should be made to identify and manage any possible risk factors. The aim of this study was to evaluate whether on-admission hemoglobin (Hb) level, C-reactive protein (CRP), and serum creatinine were associated with 2-year mortality after FNF.

Patients and Methods

In this retrospective observational cohort study, we considered for inclusion all displaced FNF patients 65 years and above treated with hemi-arthroplasty between February 2011 and May 2015. We documented the age, sex, cognitive status, and American Society of Anesthesiologists (ASA) classification. The Hb level, CRP, and serum creatinine were measured. The medical records were followed up for 2 years. We fitted different crude and adjusted Cox proportional hazards models to examine whether Hb level <100 g/L, CRP >20 mg/L, and serum creatinine >100 μmol/L were associated with the 2-year mortality, adjusted for age, sex, and ASA class.

Results

A total of 290 patients [208 females (72%), mean age 84 years] were included in the study. More than 50% of patients had impaired cognition and ASA class 3–4. Of the 290 patients, 38.3% (n = 111) had died within 2 years after surgery. Mortality among males was 46.3% (n = 38) while mortality among females was 35,1% (n = 73), p = 0.07. We found that on-admission Hb level <100 g/L was associated with 2-year mortality (HR = 3.3, 95% CI: 1.3–8.3, p < 0.01) while CRP >20 mg/L and serum creatinine >100 μmol/L were not associated with 2-year mortality (p = 0.89 and p = 0.31, respectively).

Conclusion

On-admission Hb level <100 g/L, but not CRP >20 mg/L and serum creatinine >100 μmol/L, was associated with 2-year mortality. These results can help healthcare providers identify high-risk FNF patients who probably would benefit from optimized perioperative medical management.

Preoperative laboratory testing in elderly patients

PURPOSE OF REVIEW

Preoperative testing in elderly patients is performed to examine the patient's current medical condition in the context of evaluating vulnerabilities and predicting postoperative complications to ensure that all functions recover before surgery. This review focused on preoperative laboratory tests in geriatric patients.

RECENT FINDINGS

Preoperative complete blood count, electrolyte testing, and blood chemistry can predict postoperative complications. Preoperative elevated morning/evening salivary cortisol secretion ratio, C-reactive protein/albumin ratio (CAR), neutrophil/lymphocyte ratios, and preoperative decreased serum albumin level or 25-hydroxyvitamin D levels can predict postoperative cognitive dysfunction. Elevated brain-type natriuretic peptide or serum alkaline phosphatase levels can be biomarkers of major postoperative adverse cardiac events. Decreased preoperative estimated glomerular filtration rates and serum albumin levels can predict acute kidney injury. Hyponatremia, hypocalcemia, and low albumin/fibrinogen ratio predict postoperative complications. Hypoalbuminemia can predict surgical site infection or postoperative mortality after hip fracture surgery. A high CAR can predict anastomotic site leakage and is a risk factor for one-year mortality after hip surgery.

SUMMARY

Preoperative laboratory testing helps predict postoperative adverse complications; thus, a plan of care can be initiated.

Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture

Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms "hip fracture", "geriatric assessment", "second hip fracture", "surgery", "perioperative management" and "orthogeriatric care", in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery.