Factors Associated With Mortality After Surgical Management of Femoral Neck Fractures

Trends in Hospital Stay, Complication Rate, and Mortality in Hip Fracture Patients: A Two-Decade Comparison at a National Tertiary Referral Center

Background: Since the turn of the century, the age-adjusted incidence of proximal femoral fractures has caused a plateau or fall. However, it was anticipated that the number of patients with proximal femoral fractures would rise as life expectancy rose and the population over 80 years old expanded. The aim of this study was to compare the length of hospital stay, complication rate, and mortality in patients with proximal femoral fractures between two different time periods: 20 years ago and the present. Methods: We conducted a retrospective review of medical records of patients aged 65 years and above who underwent surgery for proximal femoral fractures between January 2000 and December 2001 and between January 2020 and December 2021. We collected information on age, gender, fracture type, length of hospital stay, and complication rate. Dates of death were obtained from the Ministry of the Interior and Safety. Results: We included 136 patients who were operated on between 2000 and 2001 and 134 patients between 2020 and 2021. The average age increased significantly from 71.6 years to 79.0 years (p < 0.001). The length of hospital stay decreased dramatically from 15.1 days to 6.0 days (p < 0.001). There was no statistically significant difference in delirium, urinary tract infection, or pneumonia. No difference was found in 30-day or 1-year mortality between the two groups. Conclusions: The complication rate and mortality between the two time periods appeared comparable, although the length of hospital stay decreased substantially. Therefore, we recommend considering expedited discharge from the acute care hospital for elderly hip fracture patients while implementing an individualized approach for better outcomes.

Predictors of long-term mortality in older patients with hip fractures managed by hemiarthroplasty: a 10-year study based on a population registry in Saxony, Germany

BACKGROUND

Mortality of patients with a femoral neck fracture is high, especially within the first year after surgery, but also remains elevated thereafter. The aim of this study was to identify factors potentially associated with long-term mortality in patients homogeneously treated with hemiarthroplasty for femoral neck fracture.

METHODS

This retrospective cohort study was performed at a single level 1 national trauma center at the university hospital of Leipzig (Saxony, Germany). The study time-window was January 1, 2010 to December 31, 2020. Primary outcome measure was mortality depending on individual patient-related characteristics and perioperative risk factors. Inclusion criteria was a low-energy femoral neck fracture (Garden I-IV) in geriatric patients 60 years of age or older that were primarily treated with bipolar hemiarthroplasty. Date of death or actual residence of patients alive was obtained from the population register of the eastern German state of Saxony, Germany. The outcome was tested using the log-rank test and plotted using Kaplan-Meier curves. Unadjusted and adjusted for other risk factors such as sex and age, hazard ratios were calculated using Cox proportional hazards models and presented with 95% confidence intervals (CI).

RESULTS

The 458 included patients had a median age of 83 (IQR 77-89) years, 346 (75%) were female and 113 (25%) male patients. Mortality rates after 30 days, 1, 5 and 10 years were 13%, 25%, 60% and 80%, respectively. Multivariate regression analysis revealed age (HR = 1.1; p < 0.001), male gender (HR = 1.6; p < 0.001), ASA-Score 3-4 vs. 1-2 (HR = 1.3; p < 0.001), dementia (HR = 1.9; p < 0.001) and a history of malignancy (HR = 1.6; p = 0.002) as independent predictors for a higher long-term mortality risk. Perioperative factors such as preoperative waiting time, early surgical complications, or experience of the surgeon were not associated with a higher overall mortality.

CONCLUSIONS

In the present study based on data from the population registry from Saxony, Germany the 10-year mortality of older patients above 60 years of age managed with hemiarthroplasty for femoral neck fracture was 80%. Independent risk factors for increased long-term mortality were higher patient age, male gender, severe comorbidity, a history of cancer and in particular dementia. Perioperative factors did not affect long-term mortality.

Correlation between preoperative CT scan of the paraspinal, psoas, and gluteus muscles and postoperative ambulatory status in patients with femoral neck fractures

BACKGROUND

This study aimed to investigate the relationship between femoral neck fractures and sarcopenia.

METHODS

This was a retrospective analysis of 92 patients with femoral neck fractures, from September 2017 to March 2020, who were classified into high ambulatory status (HG) and low ambulatory status (LG) groups. Ambulatory status was assessed before surgery, one week after surgery, at discharge, and during the final follow-up. To evaluate sarcopenia, muscle mass and fatty degeneration of the muscles were measured using preoperative CT. An axial slice of the superior end of the L5 vertebra was used to evaluate the paraspinal and psoas muscles, a slice of the superior end of the femoral head for the gluteus maximus muscle, and a slice of the inferior end of the sacroiliac joint for the gluteus medius muscle. The degeneration of the muscles was evaluated according to the Goutallier classification.

RESULTS

The cross-sectional area of the gluteus medius and paraspinal muscles was significantly correlated with ambulatory status before the injury, at discharge, and during the final follow-up.

CONCLUSIONS

Measurement of the gluteus medius and paraspinal muscles has the potential to evaluate sarcopenia and predict ambulatory status after femoral neck fractures.

The Nomogram Model and Factors for the Postoperative Mortality of Elderly Patients with Femoral Neck Fracture Undergoing Artificial Hip Arthroplasty: A Single-Institution 6-Year Experience

OBJECTIVE

Artificial hip arthroplasty (AHA) is widely accepted in elderly patients with femoral neck fractures, but it is associated with high risk of death and various postoperative complications due to old age and accompanying chronic diseases. Therefore, this study aimed to explore the risk factors for death in elderly patients with femoral neck fractures after AHA and to establish a nomogram risk prediction model, which is expected to reveal high-risk patients and improve the postoperative quality of life and survival rate of patients.

METHODS

Elderly patients who underwent AHA for femoral neck fractures in our hospital from September 2014 to May 2021were retrospectively analyzed. These patients were divided into a survival group and a death group according to their clinical outcomes. The following clinical data were recorded for the patients in the two groups: sex, age, underlying diseases, smoking and drinking history, preoperative nutritional risk score (NRS) and American Society of Anesthesiologists (ASA) score, as well as relevant indicators about the operation. These data were subject to univariate analysis and then logistic analysis to determine the risk factors of death. Subsequently, a nomogram risk prediction model was established and further validated with the receiver operating characteristic curve (ROC) and the Hosmer-Lemeshow test. Finally, the effects of predictive risk factors were analyzed using the Kaplan-Meier survival curve.

RESULTS

Follow-up was completed by 260 patients, including 206 patients in the survival group and 54 patients in the death group; the overall death rate was 20.77%, and the follow-up time, age, postoperative 1, 3 and 5-year death rates were 3.47 ± 1.93 years, 75.32 ± 9.12 years, 5.77%, 12.51%, and 25.61%, respectively. The top three causes of death in 54 patients were respiratory disease, cerebrocardiovascular disease, and digestive disease, respectively. The logistic analysis indicated that elderly patients with femoral neck fractures, the risk factors for death after AHA were age ≥ 80 years, preoperative NRS ≥ 4, HB ≤ 90 g/L, CR ≥ 110 umol/L, and ASA score ≥ 3, as well as postoperative albumin ≤ 35 g/L, the nomogram was established, and then its predictive performance was successfully validated using the ROC curve (AUC = 0.814, 95% confidence interval = 0.749-0.879) and the Hosmer-Lemeshow test (p = 0.840). Furthermore, Kaplan-Meier survival curve analysis revealed that the abovementioned six indicators were correlated with the post-AHA survival time of elderly patients with femoral neck fractures (pLog Rank  < 0.05).

CONCLUSION

Old age, preoperatively high NRS and ASA score, anemia, poor renal function, and postoperative hypoproteinemia are the major risk factors for death in elderly patients with femoral neck fractures after AHA; they are also associated with postoperative survival. Early identification and effective interventions for optimization of modifiable risk factors are recommended to improve the postoperative quality of life and survival rates.

Development of machine-learning algorithms for 90-day and one-year mortality prediction in the elderly with femoral neck fractures based on the HEALTH and FAITH trials

To develop prediction models using machine-learning (ML) algorithms for 90-day and one-year mortality prediction in femoral neck fracture (FNF) patients aged 50 years or older based on the Hip fracture Evaluation with Alternatives of Total Hip arthroplasty versus Hemiarthroplasty (HEALTH) and Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trials. This study included 2,388 patients from the HEALTH and FAITH trials, with 90-day and one-year mortality proportions of 3.0% (71/2,388) and 6.4% (153/2,388), respectively. The mean age was 75.9 years (SD 10.8) and 65.9% of patients (1,574/2,388) were female. The algorithms included patient and injury characteristics. Six algorithms were developed, internally validated and evaluated across discrimination (c-statistic; discriminative ability between those with risk of mortality and those without), calibration (observed outcome compared to the predicted probability), and the Brier score (composite of discrimination and calibration). The developed algorithms distinguished between patients at high and low risk for 90-day and one-year mortality. The penalized logistic regression algorithm had the best performance metrics for both 90-day (c-statistic 0.80, calibration slope 0.95, calibration intercept -0.06, and Brier score 0.039) and one-year (c-statistic 0.76, calibration slope 0.86, calibration intercept -0.20, and Brier score 0.074) mortality prediction in the hold-out set. Using high-quality data, the ML-based prediction models accurately predicted 90-day and one-year mortality in patients aged 50 years or older with a FNF. The final models must be externally validated to assess generalizability to other populations, and prospectively evaluated in the process of shared decision-making.

Regional medical inter-institutional cooperation in medical provider network constructed using patient claims data from Japan

The aging world population requires a sustainable and high-quality healthcare system. To examine the efficiency of medical cooperation, medical provider and physician networks were constructed using patient claims data. Previous studies have shown that these networks contain information on medical cooperation. However, the usage patterns of multiple medical providers in a series of medical services have not been considered. In addition, these studies used only general network features to represent medical cooperation, but their expressive ability was low. To overcome these limitations, we analyzed the medical provider network to examine its overall contribution to the quality of healthcare provided by cooperation between medical providers in a series of medical services. This study focused on: i) the method of feature extraction from the network, ii) incorporation of the usage pattern of medical providers, and iii) expressive ability of the statistical model. Femoral neck fractures were selected as the target disease. To build the medical provider networks, we analyzed the patient claims data from a single prefecture in Japan between January 1, 2014 and December 31, 2019. We considered four types of models. Models 1 and 2 use node strength and linear regression, with Model 2 also incorporating patient age as an input. Models 3 and 4 use feature representation by node2vec with linear regression and regression tree ensemble, a machine learning method. The results showed that medical providers with higher levels of cooperation reduce the duration of hospital stay. The overall contribution of the medical cooperation to the duration of hospital stay extracted from the medical provider network using node2vec is approximately 20%, which is approximately 20 times higher than the model using strength.

The obesity paradox and mortality after pathological hip fractures: a Swedish registry study

Background and purpose - Obesity as measured by BMI has been associated with increased survival in various diseases, a phenomenon known as the "obesity paradox." It is unknown whether obesity is associated with survival after pathological fractures. We investigated the association between BMI and survival after surgery for pathological hip fracture, to improve survival prognostication, and lay grounds for further interventional nutritional studies. Patients and methods - We analyzed prospectively collected data from Swedish nationwide registry "RIKSHÖFT." The study cohort included 1,000 patients operated for a pathological hip fracture between 2014 and 2019. BMI registered on admission was available in 449 patients. Overall patient survival was measured according to the Kaplan-Meier method. Multivariable regression was used to evaluate association with other potential factors that influence patient survival. Results - Overweight and obesity were associated with an increased postoperative survival in male patients with surgically treated pathological hip fractures. Multivariable analysis considering potential confounders confirmed this finding. The association was not that strong in women and did not reach statistical significance. Interpretation - BMI, a commonly available clinical parameter, is a good predictor of overall survival for patients operated on for pathological hip fracture. Incorporation of BMI in existent survival prognostication algorithms should be considered. Treatment of malnutrition in this frail group of patients is worth studying.

Multiple screw fixation versus cementless bipolar hemiarthroplasty for femur neck fracture using a nationwide hip fracture registry

Cementless bipolar hemiarthroplasty (BHA) recently gained popularity as a treatment for femur neck fracture (FNF), but there have been few studies comparing this with multiple screw fixation (MSF) in the elderly population. The purpose of this study is to compare (1) surgery-related parameters, (2) reoperation rate as a local complication, (3) in-hospital systemic complication rate, and (4) mortality rate at 1 year after MSF and cementless BHA in patients with FNF using nationwide data. Six-hundred sixty-six hips (aged ≥ 50 years) extracted from nationwide Hip Fracture Registry were included in this study (133 MSF and 533 cementless BHA). One hundred fifty-six hips were divided into nondisplaced FNF (Group A) and 510 into displaced FNF (Group B). We evaluated (1) surgery-related parameters (anesthesia type, time to surgery, operation time, estimated blood loss and volume of postoperative transfusion), (2) the rate of and reasons for reoperation, (3) the rate and type of in-hospital systemic complications and (4) one-year mortality rate after surgery. In Group A, MSF showed shorter operation time (p = 0.004) and lower incidence of in-hospital systemic complications (p = 0.003). In Group B, cementless BHA demonstrated lower reoperation rate than MSF (p < 0.001). In both Group A and B, cementless BHA was associated with higher estimated blood loss than MSF (p < 0.001). Based on findings in our study, MSF might be a more favorable option for nondisplaced FNF, whereas cementless BHA might be a better one for displaced FNF in patients older than fifty. Nevertheless, our nationwide study also showed that numbers of cementless BHAs were being performed for nondisplaced FNF even in teaching hospitals.

[Risk factors analysis for postoperative mortality of elderly patients with femoral neck fracture undergoing hemiarthroplasty]

OBJECTIVE

To analyze the risk factors for postoperative mortality of the elderly patients with femoral neck fracture undergoing hemiarthroplasty.

METHODS

Patients who underwent hemiarthroplasty for femoral neck fractures between January 2011 and December 2015 were enrolled as object. One hundred and nine patients who met the selection criteria were included in the study, and the clinical data were collected, including gender, age, time from admission to surgery, comorbidities, and preoperative hemoglobin level and nutritional status. Univariate analysis and Cox proportional hazard regression model were used to screen the risk factors for postoperative mortality.

RESULTS

The 1-year and 2-year mortalities were 6.4% (7/109) and 17.4% (19/109), respectively. Univariate analysis showed that the age, preoperative hemoglobin level and nutritional status were the influencing factors of postoperative mortality in the elderly patients with femoral neck fractures treated with hemiarthroplasty ( P<0.05). Multivariate analysis showed that the age≥80 years and malnutrition were the independent risk factors for postoperative mortality ( P<0.05).

CONCLUSION

To improve the clinical outcomes, perioperative risk should be comprehensively evaluated by multidisciplinary and perioperative management should be strengthened in the elderly patients with femoral neck fracture, especially those with advanced age and malnutrition, for the high postoperative mortality.