Nonagenarian hip fracture: treatment and complications

Outcomes of ultra-old vs old patients after hip fracture surgery: a matched cohort analysis of 1524 patients

BACKGROUND

Surgical management of geriatric hip fractures yields improved functional outcomes with decreased morbidity and mortality. Cohort studies have suggested that the older patients within the geriatric age group have worse outcomes with surgery, However, these studies inherently report inflated risks due to poor handling of confounders and have inadequately age-stratified their geriatric population.

AIM

This study aims to investigate the effect of age alone on the 1-year mortality and functional status of geriatric patients after hip fracture surgery.

METHODS

This is a retrospective single institution cohort study based on the prospectively-maintained registry of hip fracture patients. 2603 patients aged 60 years and above were treated surgically under a geriatric-orthopaedic hip fracture pathway from January 2014 to December 2018. Patients were split into two age groups: ultra-old (≥ 85 years) vs old (< 85 years). Baseline demographics and the ASA (American Society of Anaesthesiologists) status and the Modified Barthel's Index (MBI) were obtained at admission and 1 year after the fracture. Adverse outcomes from the fracture and surgery were recorded during a follow-up period of minimally 2 years. A 2:1 matching process based on the gender, fracture type, ASA status, CCI and MBI categories was conducted.

RESULTS

There were 1009 and 515 patients in the old and ultra-old age groups, respectively. 1-year mortality was similar for both age groups (4.0% ultra-old vs 3.6% old, p = 0.703). 30-day morbidity was similar except for higher rates of postoperative pneumonia in the ultra-old (14.0 vs 6.3%, p < 0.001). MBI scores at 1-year were lower in the ultra-old (severe dependence: 16.4 vs 10.0%; p = 0.001). Ultra-old patients were less likely to be community ambulant at 12 months (21.2 vs 36.0%) with the deterioration in ambulatory status significant after correction for baseline status (p < 0.001).

CONCLUSION

The 1-year mortality of surgically-managed geriatric hip fracture patients older than 85 years of age is not determined by age alone. Patients aged 85 years and above are at higher risk for pneumonia postoperatively. Ultra-old hip fracture patients with an intertrochanteric fracture are more likely to have poorer function at 1 year after hip fracture surgery.

Outcomes in Nonagenarians with Hip Fractures Treated Conservatively and Surgically

Introduction

We aimed to assess the clinical outcomes in nonagenarians following a hip fracture. We also further investigated the factors that influence these outcomes, such as method of treatment (operative versus conservative), co-morbidities, and pre-morbid function.

Materials and methods

We studied 65 nonagenarians that were identifiable from our hospital hip fracture database. We reviewed various parameters of these patients admitted after sustaining a hip fracture (neck of femur or intertrochanteric) and investigated how these parameters affected patient outcomes. The main outcomes studied were: inpatient morbidity, and mortality at one year.

Results

Inpatient morbidity was more likely in patients with an ASA grade of 3 to 5. Urinary tract infection was the most common medical complication. The 1-year mortality was 15.4% and was significantly influenced by advancing age. Surgically managed patients had a 1-year mortality rate (14.3%) slightly less than non-operative patients (17.4%). Post injury mobility was significantly better in those who received operative treatment with 63% of surgical cases regaining ambulatory status versus 7% of conservatively managed patients.

Conclusions

We presented the outcomes of hip fractures in an extreme age group in the population. In nonagenarians with hip fractures surgery was associated with a 1-year mortality rate of 14.3% which is comparable to the general hip fracture population and less than the mortality rate of conservatively managed patients (17.4%). The primary advantage of surgery would be that two-thirds of patients return to ambulatory status. This information is useful to counsel patients and their families especially since the elderly are often more fearful of surgical intervention.

Analysis of Factors Affecting the Third- and Twelfth-Month Mortality in Patients with Hip Fractures Aged 80 Years and Older

BACKGROUND

The purpose of this study was to evaluate the possible risk factors that are related with mortality at third and twelfth months after hip fractures in a large population of patients aged 80 years and older.

METHODS

605 patients were evaluated in terms of the localization of the fracture, gender, age, side of the fracture, the type of applied procedure, anesthesia type, hospitalization time, time to operation, comorbidities, ASA score, the values of preoperative hemoglobin, lymphocyte and neutrophil percentage, white blood cell, albumin, sodium levels. The state mortality system was used to investigate whether patients are alive or died. Statistical analysis was performed to evaluate the important factors on third- and twelfth-month mortality.

RESULTS

Male gender, neurologic-cardiac-chronic obstructive pulmonary (COP) diseases, preoperative hemoglobin level < 10 g/dL, arthroplasty and external fixator groups, ASA grade ≥ 3, delaying the surgery more than 4 days, longer hospitalization time, lower albumin levels and advanced age were found to be statistically significant factors for 3-month mortality (p values were; 0.01, 0.02, 0.01, 0.01, 0.047, 0.01, 0.02, 0.002, < 0.001, 0.002 and 0.01, respectively). Male gender, hypertension-neurologic-cardiac diseases, preoperative hemoglobin level < 10 g/dL, delaying the surgery more than 4 days, longer hospitalization time, lower lymphocyte percentage, lower albumin levels and advanced age were found to be statistically significant factors for 12-month mortality (p values were; < 0.001, 0.01, 0.01, 0.01, 0.03, 0.01, < 0.001, 0.01, 0.004 and < 0.001, respectively).

CONCLUSION

COP, advanced age, and heart disease were the most important factors in 3-month mortality. Long hospitalization time, male gender and advanced age were the most important factors affecting the 12-month mortality.Level of Evidence Prognostic level IV.

Age and clinical outcomes after hip fracture surgery: do octogenarian, nonagenarian and centenarian classifications matter?

BACKGROUND

older patients with hip fractures are arbitrarily classified as octogenarians, nonagenarians and centenarians. We have designed this study to quantify in-hospital mortality and complications among each of these groups. We hypothesised that the associations between age and in-hospital mortality and complications are continuously increasing, and that these risks increase rapidly when patients reach a certain age.

METHODS

this research is a retrospective cohort study using nationwide database between 2010 and 2018. Patients undergoing hip fracture surgery, and aged 60 or older, were included. The associations between patient age, in-hospital mortality and complications were visualised using the restricted cubic spline models, and were analysed employing multivariable regression models. Then, octogenarians, nonagenarians and centenarians were compared.

RESULTS

among a total of 565,950 patients, 48.7% (n = 275,775) were octogenarians, 23.0% (n = 129,937) were nonagenarians and 0.7% (n = 4,093) were centenarians. The models presented three types of association between age, in-hospital mortality and complications: (i) a continuous increase (mortality and respiratory complications); (ii) a mild increase followed by a steep rise (intensive care unit admission, heart failure, renal failure and surgical site hematoma) and (iii) a steep increase followed by a limited change (coronary heart disease, stroke and pulmonary embolisms).

CONCLUSION

we identified three types of association between age and clinical outcomes. Patients aged 85-90 may constitute the upper threshold for age categorisations, because the risk of in-hospital complications changed dramatically at that stage. This information can improve clinical awareness of various complications and support collective decision-making.

Contemporary Mortality Rate and Outcomes in Nonagenarians Undergoing Primary Total Hip Arthroplasty

BACKGROUND

Nonagenarians (90-99 years) have experienced the fastest percent growth in primary THA utilization recently. However, there are limited data on this population. This study aimed to determine the mortality rate, implant survivorship, clinical outcomes, and complications of primary THAs in nonagenarians.

METHODS

Our institutional total joint registry was used to identify 144 nonagenarians who underwent 149 primary THAs for osteoarthritis only between 1997 and 2017. The mean age was 92 years, with 63% being female. Mortality, revision, and reoperation were assessed using cumulative incidence with death as a competing risk and Cox regression methods. Clinical outcomes were assessed using Harris hip scores (HHSs). Cemented femoral components were used in 68%. The mean follow-up was 4 years.

RESULTS

The mortality rates were 6%, 8%, 14%, and 49% at 90 days, 1 year, 2 years, and 5 years, respectively. The 5-year cumulative incidences of any revision and reoperation were 1% and 4%, respectively. The mean HHS improved significantly from 48 preoperatively to 76 at 5 years (P < .001). The 5-year cumulative incidence of any complication was 69%, with the most common being periprosthetic femur fracture (7) intraoperatively, delirium (25) early postoperatively, and periprosthetic femur fracture (10) later postoperatively. Uncemented stem fixation was associated with a higher risk for intraoperative femur fracture (Hazard ratio 5, P = .04) but not with a higher 5-year periprosthetic postoperative femur fracture risk (P = .19).

CONCLUSION

Nonagenarians undergoing primary THA had substantial mortality rates at 90 days (6%) and 1 year (8%). While the cumulative incidence of any revision and reoperations were low at 5 years, the high complication rate is mostly due to periprosthetic fractures.

LEVEL OF EVIDENCE

Level IV, retrospective cohort.

Patients aged ninety years and older are exposed to increased risk of one-year mortality after hip fractures

BACKGROUND

The increase in the population over 90 years old suggests an expected surge in the number of extreme elderly patients sustaining hip fractures.

OBJECTIVE

The aim of this study is to identify factors associated with 1-year mortality and determine the conditions that are associated with an unfavorable survival outcome in nonagenarians.

DESIGN

Cross-sectional study SUBJECTS: Nonagenarian patients presenting with hip fractures between 2013 and 2018.

METHODS

Bivariate and multivariate analyses were performed to identify variables associated with mortality, and a survival analysis was conducted to determine whether the Charlson Comorbidity Index (CCI) is associated with mortality.

RESULTS

A total of 127 patients, with a mean age of 92.84 years was assessed, identifying 1-year mortality rate in 53.5% of patients. According to the bivariate analysis, requirement of postoperative vasopressor support, transfusion, decompensated heart failure and general anesthesia were associated with a higher probability of 1-year mortality after surgery. Body mass index, health status, dementia or CCI ≥ 3 were not associated with mortality. Similarly, the Kaplan-Meier survival analysis showed no difference in mortality rate of patients with CCI ≥ 3 (p = 0.282).

CONCLUSION

Patients older than 90 years with hip fractures have higher mortality rates per year than younger patients. Some associations were found, but more studies are needed to reach final conclusions, which could help identify higher-risk patients and be able to implement additional measures.

Operative Fixation of Hip Fractures in Nonagenarians: Is It Safe?

BACKGROUND

With the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients.

METHODS

Geriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized.

RESULTS

This study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048).

CONCLUSION

Overall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent.

Nonagenarian hip fractures: Morbidity and mortality at a single institution

OBJECTIVES

The incidence of hip fractures continues to rise dramatically, but few studies have examined these injuries in the population of individuals over 90 years of age, which is one of the fastest growing populations. We present the largest such study specifically examining hip fractures in the super-elderly.

METHODS

A review of 216 hip fracture patients over 90 years of age were examined for immediate postoperative complications and in-house, 30-day, and 1-year mortality.

RESULTS

Overall 1-year mortality was 38.1%. Statistically-significant risk factors for 1-year mortality included oncologic fracture, dementia, and CHF. Fracture classification and hospital length of stay were associated with perioperative complications including anemia and pneumonia.

CONCLUSION

The nonagenarian hip fracture is associated with a higher 1-year mortality than prior reported rates of mortality for elderly hip fractures. Factors previously reported to influence the risk of 1-year mortality in hip fractures are not observed in the super-elderly.

Hip Fracture in Nonagenarians: Characteristics and Factors Related to 30-Day Mortality in 1177 Patients

BACKGROUND

The number of nonagenarian patients with hip fracture is increasing. The goals of this study were to describe the characteristics and in-hospital course of a cohort of 1177 nonagenarians admitted for hip fracture compared with younger patients and to identify risk factors for 30-day mortality after admission.

METHODS

This is a retrospective observational cohort study including patients aged 65 years or older admitted for hip fracture during various periods from February 1997 to December 2016. We defined 3 age groups: 65-79, 80-89, and 90 years and older. We included sociodemographic variables, baseline functional status, comorbidities, fracture and surgical characteristics, postoperative complications, length of stay, and in-hospital and 30-day mortality. Multiple logistic regression analysis was used to study risk factors for 30-day mortality in surgically treated nonagenarians.

RESULTS

Nonagenarians were more likely to be women and to have dementia and heart disease. Some 72% walked independently before the fracture. The most relevant treatable risk factor for 30-day mortality in nonagenarians (in terms of higher odds ratio [OR]) was developing respiratory infection (OR: 4.56, 95% confidence interval [CI]: 2.73-7.63). Better prefracture functional status (higher Katz score; OR: 0.83, 95% CI: 0.74-0.92) and spinal anesthesia (OR: 0.19, 95% CI: 0.05-0.68) decreased risk of 30-day mortality.

CONCLUSIONS

Nonagenarian patients with hip fracture differ significantly from younger patients concerning clinical characteristics, medical complications, and in-hospital and 30-day mortality rates. We identified several variables on which we could act to reduce 30-day mortality, such as respiratory infection, electrolyte disorders, polypharmacy, cardiac arrhythmia, and spinal anesthesia.

Fewer patients undergo surgery when adding a comprehensive geriatric assessment in older patients with a hip fracture

INTRODUCTION

Geriatricians have been increasingly involved in the pre-operative process in frail elderly patients with a hip fracture which can benefit re-hospitalization, post-operative functional performance, and mortality. The objective of this study was to compare the number of older patients with hip fractures who opted for non-surgical management after the addition of pre-operative comprehensive geriatric assessment (CGA) with shared decision making by a geriatrician to usual care. Secondary objectives were: reasons for non-surgical management, duration of life, and location of death.

MATERIALS AND METHODS

A single-center, with a level 2 trauma center, retrospective study comparing care before and after introducing pre-operative CGA with shared decision making in September 2014. Patients ≥ 70 years with a hip fracture, admitted from January 2014 to September 2015, were included. The percentages of patients elected for non-surgical management and palliative care without or with CGA were compared. Differences in secondary objectives (age, sex, medical history, medication use, functional, and social status) were compared descriptively and qualitatively.

RESULTS

With pre-operative CGA significantly more patients (or representatives) elected the non-surgical management option after hip fracture (respectively, 9.1% vs 2.7%, p = 0.008). Patient characteristics were comparable. Reported reasons not to undergo surgery include aversion to be more dependent on others, and severe dementia.

CONCLUSION

The geriatrician can have an important role in decisions for non-surgical management by shared decision making in the pre-operative period in patients ≥ 70 years with a hip fracture in the emergency room.

Effect of bariatric surgery on outcomes in the operative treatment of hip fractures

INTRODUCTION

Few studies have evaluated the effect of prior bariatric surgery on outcomes following the operative treatment of hip fractures. The purpose of this study is to evaluate these metrics in a population of bariatric surgery patients compared to a control group who were operatively treated for hip fractures.

MATERIALS AND METHODS

The California Office of Statewide Health Planning & Development (OSHPD) discharge database was accessed to identify patients who sustained a hip fracture between 2000-2014. CPT codes were utilized to identify patients who had a prior history of bariatric surgery within this time period. A control cohort of patients who had undergone previous appendectomy were queried similarly. The study evaluated complication rates and inpatient mortality at 30- and 90-days postoperatively as well as 30- and 90-day readmission rates.

RESULTS

There were 1,327 bariatric and 2,127 control patients identified. Survival rates were significantly lower in bariatric patients compared to controls (87.2% vs. 91.8%, p = 0.048) at 5 years. After controlling for confounders, bariatric patients had higher 30- (OR 1.46, p = 0.005) and 90-day (OR 1.38, p = 0.011) readmission rates. There were no differences in all-cause complication and inpatient mortality rates between groups at 30 or 90 days.

DISCUSSION

Bariatric surgery patients are at increased risk of readmission after hip fracture surgery. Further research is warranted to delineate potential risk factors and mitigate readmission in these patients.

LEVEL OF EVIDENCE

III.

Influence of mobilization and weight bearing on in-hospital outcome in geriatric patients with hip fractures

INTRODUCTION

Early recovery of mobilization after a fracture of the hip is associated with improved long-term ability to walk, lower complication rates, and mortality. In this context, early mobilization and full weight bearing are favorable. The aim of this study was (1) to analyze the influence of time between operation and first mobilization on in-hospital outcome and (2) the influence of early mobilization, full weight bearing, and ASA on pain, mobility of the hip, and ability to walk during the in-hospital phase of recovery.

METHODS

This is a retrospective in-hospital study of 219 patients aged 70 years or older who were treated with surgery after a hip fracture. Data were collected by a review of medical records. The outcomes were mortality, complications, length of stay, and the Merle d'Aubigné score which evaluates pain, mobility of the hip, and ability to walk. Factors were sought in bivariate and multivariate analyses.

RESULTS

A shorter time between operation and first mobilization was significantly associated with lower in-hospital mortality and complications. Early mobilization (within 24 h after the operation) and full weight bearing had no influence on pain, mobility of the hip, and ability to walk as well as length of stay in our cohort. Fracture type and treatment influenced mobility of the hip, while age as well as physical health status affected the ability to walk.

DISCUSSION

Patients with femoral neck fractures, respectively after total hip arthroplasty, had less pain and showed better mobility of the hip and ability to walk during hospitalization than patients with trochanteric fractures; these results were irrespective of early vs. late mobilization and full vs. partial weight bearing. Foremost, a shorter time between operation and first mobilization is associated with lower complication and mortality rates.

Age Alone Does Not Predict Complications, Length of Stay, and Cost for Patients Older Than 90 Years With Hip Fractures

The purpose of this study was to analyze the perioperative complication rate and inpatient hospitalization costs associated with hip fractures in patients older than 90 years compared with patients younger than 90 years. Patients 60 years and older with hip fractures treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patient demographics, comorbidities, length of stay, procedure performed, and inpatient complications were analyzed. Total cost of admission was obtained from the hospital finance department. Outcomes were compared between patients older than 90 years and patients younger than 90 years. A total of 500 patients with hip fractures were included in this study. There were 109 (21.8%) patients 90 years and older and 391 (78.2%) patients 60 to 89 years. There was no difference in fracture pattern, operation performed, Charlson Comorbidity Index, or length of stay between the 2 groups. The mean length of stay for patients 90 years and older with hip fractures was 7.8±4.3 days vs 7.6±4.2 days for the younger cohort (P=.552). There was no observed difference in perioperative complications. Finally, there was no difference in the total mean cost of admission. Patients 90 years and older are at no greater risk for perioperative complications based on age alone. They are also no more likely to require longer or more costly hospitalizations than patients younger than 90 years. [Orthopedics. 2019; 42(1):e51-e55.].

Hip fractures in the oldest old. Comparative study of centenarians and nonagenarians and mortality risk factors

INTRODUCTION

Centenarians and nonagenarians constitute a rapidly growing age group in Western countries and they are expected to be admitted to hospital with hip fractures. The aim of this study was to compare outcomes of centenarian and nonagenarian patients following a hip fracture and to identify risk factors related to in-hospital and post-discharge mortality in both groups.

PATIENTS AND METHODS

A prospective evaluation of centenarian patients and nonagenarian controls admitted to a tertiary university hospital in Barcelona with hip fractures over a period of 5 years and 9 months. Baseline characteristics and outcomes in both patient groups were compared. Variables associated with in-hospital, 30-day, 3-month and 1-year mortality were also analyzed.

RESULTS

Thirty-three centenarians and 82 nonagenarians were included. The most relevant statistically significant differences found were: Barthel index at admission (61.90 vs. 75.22), number of drugs before admission (4.21vs 5.55), in-hospital complication rates (97 vs. 78%), readmissions at 3 months and 1 year (0 vs 11.7% and 3.4 vs. 19.5% respectively) and mortality at 3 months and 1 year (41.4 vs. 20.8% and 62.1 vs. 29.9%, respectively). Mean number of complications, rapid atrial fibrillation, mean age, and urinary tract infection were risk factors associated with mortality.

CONCLUSIONS

Centenarian patients had similar in-hospital outcomes to nonagenarians, but experienced more complications and twice the 3-month and 1-year mortality rate. The mean number of complications was the risk factor most consistently related to in-hospital and post-discharge mortality. These findings emphasize the need to improve care in very old patients to prevent complications.

Mortality by Timing of Hip Fracture Surgery: Factors and Relationships at Play

In hip fracture care, it is disputed whether mortality worsens when surgery is delayed. This knowledge gap matters when hospital managers seek to justify resource allocation for prioritizing access to one procedure over another. Uncertainty over the surgical timing-death association leads to either surgical prioritization without benefit or the underuse of expedited surgery when it could save lives. The discrepancy in previous findings results in part from differences between patients who happened to undergo surgery at different times. Such differences may produce the statistical association between surgical timing and death in the absence of a causal relationship. Previous observational studies attempted to adjust for structure, process, and patient factors that contribute to death, but not for relationships between structure and process factors, or between patient and process factors. In this article, we (1) summarize what is known about the factors that influence, directly or indirectly, both the timing of surgery and the occurrence of death; (2) construct a dependency graph of relationships among these factors based explicitly on the existing literature; (3) consider factors with a potential to induce covariation of time to surgery and the occurrence of death, directly or through the network of relationships, thereby explaining a putative surgical timing-death association; and (4) show how age, sex, dependent living, fracture type, hospital type, surgery type, and calendar period can influence both time to surgery and occurrence of death through chains of dependencies. We conclude by discussing how these results can inform the allocation of surgical capacity to prevent the avoidable adverse consequences of delaying hip fracture surgery.

The epidemiology and functional outcomes of operative fixation of extracapsular proximal femoral fractures (AO 31-A) in young adults

Proximal femoral fractures in adults under 50 years are not as common as in the elderly, but may have just as significant an impact. There is little in the literature describing the functional outcomes of fixation in this age group. Our aim was to assess the clinical and functional outcomes of operative management of extracapsular proximal femoral fractures (AO 31-A) in the young adult (<50 years). Consecutive skeletally mature patients <50 years undergoing operative fixation of these fractures were obtained from a prospective database over a 12-year period. Complications and mortality data were obtained from this database and case note review. Outcome scores were obtained via postal questionnaires. Eighty-eight patients were included in the study of which 74 (84%) had fixation with the dynamic hip screw. The mean age was 39 years (range 17-50) with a male preponderance (73.8%). Mean hospital stay was 14 days (range 2-94). Seventeen (19.3%) patients had died at a mean of 40 months from their operation date. The 1-year mortality was 4.5%. There were five complications (5.7%). SF-36 and EuroQol 5D scores showed that 5-10% had severe problems with a 20% decrease in quality of life compared to population norms. The biggest differences were in the physical function modalities. One-third had fair to poor hip function as assessed by the Oxford Hip Score. Though these injuries are relatively rare in this age group, they do have significant mortality and functional impairment reflecting a higher energy of injury rather than the frailty seen in the elderly.

Surgical delay as a risk factor for wound infection after a hip fracture

PURPOSE

Analysis of significant risk factors for mortality and for medical and orthopaedic complications.

PATIENTS AND METHODS

Observational study of a prospective consecutive cohort of 697 patients diagnosed of hip fracture from December 2012 to December 2014. Average age was 85±9years and 520 were female (75%). Intracapsular fractures (308, 44%) were treated non-operatively, (19 patients), with cannulated screws (58) or with hip arthroplasty (228 bipolar, 3 total hip atrhoplasty). Extracapsular fractures (389, 56%) were reduced and fixed with 375 trochanteric nails and 14 sliding-hip-screw-plates. Patients were controlled clinically and radiographically in outpatient clinic after 1, 3, 6 and 12months. Bivariate analysis (Pearson, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and Odds Ratio were calculated.

RESULTS

Surgical delay reached 2.1±2.2days, 1.7±1.9 in medically stable patients. Main reason for delay was anticoagulant/anti-platelet therapy. Immediate weight-bearing was begun for 72% of patients. Average time in-hospital was 12±8days and 63% returned to previous environment. Lost-to-follow-up reached 4% after 1month and 8% after 6months. After 1year, 6% of previously-walking patients were unable to walk. Mortality reached 4% while in-hospital and 14% after 1year, with older age as only significant risk factor (p=0.004), OR=1.9. Wound infection developed in 2.3% of the series, and surgical delay longer than 24hours was a significant risk factor (p=0.023), with an OR=3.48 (1.1-10.8). Fixation failed in 7.9% of cannulated screws and 1.9% of trochanteric nails (1.1% cut-out, 0.8% nail fracture), while 2.7% of arthroplasty patients suffered a prosthesis dislocation and 1.3% a periprosthetic fracture. Pyelonephritis appeared in 6.7%, pneumonia in 6.3% and cardiac failure in 2.2% of patients; significant risk factors were previous comorbidity for pneumonia (p=0.007) (OR=2.7) and cardiac failure (p=0.007) (OR=9.7), as well as older age (p=0.006) (OR=2.2) for pneumonia.

CONCLUSIONS

Surgical delay longer than 24hours has been an important risk factor for wound infection, a finding not previously described in literature. Older age is a significant risk factor for mortality and pneumonia, and previous comorbidity for cardiac failure and pneumonia.

Patient and system factors of mortality after hip fracture: a scoping review

Background

Several patient and health system factors were associated with the risk of death among patients with hip fracture. However, without knowledge of underlying mechanisms interventions to improve survival post hip fracture can only be designed on the basis of the found statistical associations.

Methods

We used the framework developed by Arksey and O’Malley and Levac et al. for synthesis of factors and mechanisms of mortality post low energy hip fracture in adults over the age of 50 years, published in English, between September 1, 2009 and October 1, 2014 and indexed in MEDLINE. Proposed mechanisms for reported associations were extracted from the discussion sections.

Results

We synthesized the evidence from 56 articles that reported on 35 patient and 9 system factors of mortality post hip fracture. For 21 factors we found proposed biological mechanisms for their association with mortality which included complications, comorbidity, cardiorespiratory function, immune function, bone remodeling and glycemic control.

Conclusions

The majority of patient and system factors of mortality post hip fracture were reported by only one or two articles and with no proposed mechanisms for their effects on mortality. Where reported, underlying mechanisms are often based on a single article and should be confirmed with further study. Therefore, one cannot be certain whether intervening on such factors may produce expected results.

Relationship between American Society of Anesthesiologists (ASA) grade and 1-year mortality in nonagenarians undergoing hip fracture surgery

This study retrospectively reviewed 327 nonagenarians who underwent hip fracture surgery at six hospitals. Functional status, postoperative complications, and 1-year mortality were evaluated, and relationships between these factors and American Society of Anesthesiologists (ASA) grade were analyzed. ASA grade was significantly associated with postoperative complications and 1-year mortality.

INTRODUCTION

Few previous studies have reported outcomes after hip fracture in nonagenarians, and these studies did not report significant associations between ASA grade and mortality. However, most of these studies included only a small number of patients from a single hospital. This study aimed to evaluate the relationships between ASA grade and functional status, postoperative complications, and mortality rate in nonagenarians undergoing hip fracture surgery.

METHODS

This study included 327 nonagenarians who underwent hip fracture surgery between January 2000 and December 2012. Patients with open fractures, subtrochanteric fractures, polytrauma, and pathological fractures were excluded. The medical records and X-rays were retrospectively reviewed. The relationships between ASA grade and functional status, postoperative complications, and 1-year mortality were analyzed.

RESULTS

There were significant associations between the ASA grade and the rates of postoperative complications and 1-year mortality (both p < 0.05). All pairwise comparisons showed significant differences in postoperative complication rates between ASA grades (all p < 0.05). All pairwise comparisons, except for grades I vs. II and grades II vs. III, also showed significant differences in mortality rates between ASA grades (all p < 0.05). There were significant associations between the preoperative ability to manage activities of daily living and the rates of postoperative complications and 1-year mortality (both p < 0.05).

CONCLUSIONS

ASA grade was significantly associated with the rates of postoperative complications and 1-year mortality in nonagenarians undergoing hip fracture surgery. The preoperative functional status was also significantly associated with these outcomes.

Postoperative delirium and pre-fracture disability predict 6-month mortality among the oldest old hip fracture patients

BACKGROUND

Age is one of the most robust risk factors for hip fracture. Recent projections indicate that almost half of hip fractures are occurring with an increasing trend among the "oldest old" (i.e., in those aged >85 years).

AIMS

To compare clinical characteristics, outcomes, and risk factors for 6-month mortality in two groups of "oldest old" patients (group 1 = 85-89, group 2 > 90 years), after hip fracture surgery.

METHODS

Observational prospective cohort study with 6-month follow-up, performed in an Orthogeriatric Unit of an academic hospital between March 2007 and November 2012.

RESULTS

Two hundred seventy-five patients (group 1: N = 171; group 2: N = 104) underwent a comprehensive geriatric assessment, including demographics, clinical, functional, nutritional, and mental status. The 6-month rehospitalization and mortality rates after surgery were assessed through structured telephone interviews with patient's caregivers. Multivariate logistic regression models were used to evaluate predictors of 6-month mortality, adjusting for relevant covariates. Fifty-eight patients died at follow-up. The in-hospital and 6-month mortality rates were significantly higher for patients of group 2 than for those of group 1. After adjusting for covariates, the multivariate logistic regressions showed that severe disability (OR 2.24, 95 % CI 1.08-4.65) and postoperative delirium (POD) (OR 3.80, 95 % CI 1.72-8.39) were predictors of 6-month mortality.

CONCLUSIONS

Patients aged >90 years who underwent hip fracture surgery are more likely to die at 6 months than those aged 85-89 years. Pre-fracture disability and POD are predictors of this excess of mortality.

Magnitude of fragility fracture risk in the very old--are we meeting their needs? The Newcastle 85+ Study

Fractures due to osteoporosis are common in older people. This study assessed the management of osteoporosis in a group of 85-year-olds and found both assessment and current treatment to be suboptimal.

INTRODUCTION

Fragility fractures are a major cause of excess mortality, substantial morbidity, and health and social service expenditure in older people. However, much less is known about fracture risk and its management in the very old, despite this being the fastest growing age group of our population.

METHODS

Cross-sectional analysis of people who reached the age of 85 during the year of 2006 was carried out. Data were gathered by general practice record review (GPRR) and a multidimensional health assessment (MDHA).

RESULTS

Seven hundred thirty-nine individuals were recruited. Mean age was 85.55 years (SD 0.44), and 60.2% were female; 33.7% (n = 249) had experienced one or more fragility fractures (F 45.2% vs M 16.3% p < 0.001); in total, 332 fractures occurred in these 249 individuals. A formal documented diagnosis of osteoporosis occurred in 12.4%, and 38% of individuals had experienced a fall in the last 12 months. When the fracture risk assessment tool (FRAX) and National Osteoporosis Guideline Group (NOGG) guidelines were applied, osteoporosis treatment would be recommended in 35.0%, with a further 26.1% identified as needing bone mineral density (BMD) measurement and 38.9% not requiring treatment or BMD assessment. Women were more likely than men to need treatment (47.4 vs 16.3%, p < 0.001, odds ratio (OR) 4.62 (3.22-5.63)) and measurement of BMD (40.0 vs 5.1%, p < 0.001, OR 12.4 (7.13-21.6)). Of the 259 individuals identified as requiring treatment, only 74 (28.6%) were on adequate osteoporosis treatment.

CONCLUSION

The prevalence of high fracture risk in the very old is much higher than the documented diagnosis of osteoporosis or the use of adequate treatments.

Functional outcome and mortality in nonagenarians following hip fracture surgery

INTRODUCTION

The world's population is ageing and the elderly population itself is growing older. This population shows a high incidence of hip fractures. We performed a retrospective study, reviewing the functional status, postoperative complications and mortality rate of nonagenarians who underwent surgery for hip fracture.

METHODS AND SUBJECTS

56 nonagenarian patients underwent hip fracture surgery in our institution between January 2000 and December 2010. Two of these patients had presented with hip fracture on separate occasions, giving a total of 58 hips for analysis. Patients with open fracture, subtrochanteric fracture, polytrauma and pathological fracture were excluded. The case notes, electronic records and X-rays for all those included in the study were reviewed. The main outcome measures were functional status, postoperative complications and mortality rate at 1 year.

RESULTS

Patients with extracapsular hip fractures were associated with higher risks of postoperative complications (60.7 %; p = 0.037), mortality (25 %; p = 0.003) and more likely to be non-ambulant at 1 year (53.6 vs 16.7 %; p = 0.003). Females were more likely to suffer postoperative complications than males (p = 0.016). 46.6 % of the patients had immediate postoperative complications and most commonly due to urological complications (29.3 %). The 1-year mortality rate was 12.1 %. A notable proportion of patients (65.5 %) remained ambulant 1 year postoperatively, although almost half of the patients (48.3 %) who could ambulate independently pre-injury required a walking aid after hip fracture surgery.

CONCLUSION

Nonagenarians have good surgical outcomes after hip fracture surgery with low mortality rate. They should be treated similarly as their younger counterparts in terms of decision for surgery. Potential decline in functional status and rehabilitation options should be shared with the patient and family at an early stage.

Mortality in centenarians with hip fractures

The proximal femur is one of the primary areas of weakness in the skeleton due to osteoporosis. With more than 50,000 Americans aged at least 100 years, an increasing number of these extremely elderly patients will present with hip fractures. A paucity of literature exists on functional outcomes and mortality rates in the centenarian population who sustain hip fractures. This study evaluated the mortality rate in centenarians who sustained hip fractures to determine whether operative intervention is safe and appropriate.The authors retrospectively reviewed 23 patients (22 women and 1 man) aged at least 100 years with hip fractures treated at their institution between 2003 and 2010. Twenty-one patients were treated operatively and 2 were treated nonoperatively. Mean Charlson comorbidity index was 2 (range, 0 to 5). The patients' medical charts or the Social Security Death Index was used to determine their dates of death. Average patient age was 101.9 years at injury and 102.8 years at death. Cumulative in-hospital, 30- and 90-day, 6- and 12-month, and 2-, 3-, and 6-year mortality rates for operatively treated patients were 15%, 20%, 30%, 45%, 60%, 70%, 90%, and 95%, respectively. Both patients treated nonoperatively died within 90 days. One patient is still alive 6 years postoperatively. Postoperative complications occurred in 9 (43%) patients.Although this patient population is a relatively small subset of the elderly population, the number of these patients is rapidly increasing. Operating on patients older than 100 years carries an acceptable mortality rate. Age alone should not preclude centenarians from undergoing operative treatment for hip fractures.