Validation of the Nottingham Hip Fracture Score in Predicting Postoperative Outcomes Following Hip Fracture Surgery

Prediction of Osteoporotic Hip Fracture Outcome: Comparative Accuracy of 27 Immune-Inflammatory-Metabolic Markers and Related Conceptual Issues

Objectives: This study, based on the concept of immuno-inflammatory-metabolic (IIM) dysregulation, investigated and compared the prognostic impact of 27 indices at admission for prediction of postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In consecutive HF patient (n = 1273, mean age 82.9 ± 8.7 years, 73.5% females) demographics, medical history, laboratory parameters, and outcomes were recorded prospectively. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were used to establish the predictive role for each biomarker. Results: Among 27 IIM biomarkers, 10 indices were significantly associated with development of PMI and 16 were indicative of a fatal outcome; in the subset of patients aged >80 years with ischaemic heart disease (IHD, the highest risk group: 90.2% of all deaths), the corresponding figures were 26 and 20. In the latter group, the five strongest preoperative predictors for PMI were anaemia (AUC 0.7879), monocyte/eosinophil ratio > 13.0 (AUC 0.7814), neutrophil/lymphocyte ratio > 7.5 (AUC 0.7784), eosinophil count < 1.1 × 109/L (AUC 0.7780), and neutrophil/albumin × 10 > 2.4 (AUC 0.7732); additionally, sensitivity was 83.1-75.4% and specificity was 82.1-75.0%. The highest predictors of in-hospital death were platelet/lymphocyte ratio > 280.0 (AUC 0.8390), lymphocyte/monocyte ratio < 1.1 (AUC 0.8375), albumin < 33 g/L (AUC 0.7889), red cell distribution width > 14.5% (AUC 0.7739), and anaemia (AUC 0.7604), sensitivity 88.2% and above, and specificity 85.1-79.3%. Internal validation confirmed the predictive value of the models. Conclusions: Comparison of 27 IIM indices in HF patients identified several simple, widely available, and inexpensive parameters highly predictive for PMI and/or in-hospital death. The applicability of IIM biomarkers to diagnose and predict risks for chronic diseases, including OP/OF, in the preclinical stages is discussed.

Validation of the Charlson Comorbidity Index for the prediction of 30-day and 1-year mortality among patients who underwent hip fracture surgery

INTRODUCTION

The aim of our study was to validate the original Charlson Comorbidity Index (1987) (CCI) and adjusted CCI (2011) as a prediction model for 30-day and 1-year mortality after hip fracture surgery. The secondary aim of this study was to verify each variable of the CCI as a factor associated with 30-day and 1-year mortality.

METHODS

A prospective database of two-level II trauma teaching hospitals in the Netherlands was used. The original CCI from 1987 and the adjusted CCI were calculated based on medical history. To validate the original CCI and the adjusted CCI, the CCI was plotted against the observed 30-day and 1-year mortality, and the area under the curve (AUC) was calculated.

RESULTS

A total of 3523 patients were included in this cohort study. The mean of the original CCI in this cohort was 5.1 (SD ± 2.0) and 4.6 (SD ± 1.9) for the adjusted CCI. The AUCs of the prediction models were 0.674 and 0.696 for 30-day mortality for the original and adjusted CCIs, respectively. The AUCs for 1-year mortality were 0.705 and 0.717 for the original and adjusted CCIs, respectively.

CONCLUSIONS

A higher original and adjusted CCI is associated with a higher mortality rate. The AUC was relatively low for 30-day and 1-year mortality for both the original and adjusted CCIs compared to other prediction models for hip fracture patients in our cohort. The CCI is not recommended for the prediction of 30-day and 1-year mortality in hip fracture patients.

Combined Systemic Immune-inflammatory Index (SII) and Geriatric Nutritional Risk Index (GNRI) predict survival in elderly patients with hip fractures: a retrospective study

PURPOSE

The Systemic Immune-inflammatory Index (SII) and Geriatric Nutritional Risk Index (GNRI) have undergone comprehensive examination and validation in forecasting the outcomes of diverse medical conditions. Nevertheless, the correlation between the combined use of GNRI and SII metrics and hip fractures has yet to be elucidated. This study aimed to determine whether the amalgamation of SII and GNRI scores constitutes an independent prognostic factor for elderly patients with hip fractures.

METHODS

We conducted a retrospective analysis of elderly patients admitted to our facility with hip fractures, encompassing both femoral neck and intertrochanteric fractures. Demographic information, experimental parameters, and postoperative complications were systematically recorded. The Geriatric Nutritional Risk Index (GNRI) and Systemic Immunoinflammatory Index (SII) were meticulously computed. Receiver operating characteristic (ROC) curves were generated, and optimal cutoff values for each parameter were determined. Subsequently, a multivariate Cox regression analysis was employed to assess the predictive utility of the SII-GNRI score in relation to 1-year postoperative mortality among elderly patients with hip fractures.

RESULTS

In a study involving 597 patients, 90 of whom experienced mortality within 1 year, it was observed that the SII-GNRI score in the group of patients who passed away was significantly higher compared to the group that survived. Following a multifactorial adjustment, it was established that a high SII-GNRI score served as an independent predictor of 1-year all-cause mortality in older patients with hip fractures. In addition to the SII-GNRI score, factors such as length of hospital stay, CCI > 2, and blood transfusion were also identified as independent risk factors for survival. Notably, the incidence of postoperative complications in patients with high SII-GNRI scores was significantly greater than in patients with low scores.

CONCLUSION

The SII-GNRI score proves valuable in predicting the 1-year survival rate for elderly patients with hip fractures who have undergone surgery.

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.

Correlation between admission hypoalbuminemia and postoperative urinary tract infections in elderly hip fracture patients

PURPOSE

This study aimed to evaluate the correlation between hypoalbuminemia upon admission and the incidence of postoperative urinary tract infections (UTIs) in elderly patients with hip fractures.

METHODS

A retrospective analysis was performed on the medical records of elderly patients who underwent surgical treatment for hip fractures at a level I trauma center from 2013 to 2023. Serum albumin levels were measured upon admission, and hypoalbuminemia was defined as a total albumin level < 35 g/L. Multivariable logistic regression and propensity score matching analysis were utilized to control and reduce potential confounding factors, aiming to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CI) for UTIs to determine the strength of the association.

RESULTS

This observational cohort study included 1279 patients, among whom 298 (23.3%) developed UTIs. Patients with albumin levels < 35 g/L had significantly greater odds of developing UTIs compared to those with albumin levels ≥ 35 g/L (OR 1.86, 95% CI 1.28-2.70). Further analysis, dividing albumin levels into quartiles, demonstrated that patients in the Q2 group (38.0-40.9 g/L; OR 1.38, 95% CI 0.88-2.17), Q3 group (35.0-37.9 g/L; OR 1.69, 95% CI 1.06-2.71), and Q4 group (15.3-34.9 g/L; OR 2.67, 95% CI 1.61-4.43) had notably higher odds of developing UTIs compared to those in the Q1 group (41.0-52.0 g/L).

CONCLUSIONS

The presence of hypoalbuminemia upon admission in elderly patients undergoing hip fracture surgery is strongly correlated with the occurrence of postoperative UTIs. Furthermore, this association exhibits a clear dose-response relationship.

The relationship between admission hyperglycaemia and urinary tract infections in geriatric patients with hip fractures

PURPOSE

This study investigated the association of admission hyperglycaemia with catheter-associated urinary tract infections (CAUTIs) and catheter-unassociated urinary tract infections (CUUTIs) in elderly patients with hip fractures.

METHODS

In an observational cohort study of elderly patients with hip fractures, glucose values were collected within 24 h of admission. Urinary tract infections were classified as CAUTIs and CUUTIs. Multivariate logistic regression analysis and propensity score matching obtained adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for urinary tract infections. Subgroup analyses were further explored to investigate the relationship between admission hyperglycemia and urinary tract infections.

RESULTS

The study included 1279 elderly patients with hip fractures, 298 (23.3%) of whom had urinary tract infections upon hospitalization (including 182 CAUTIs and 116 CUUTIs). Propensity score matching indicated that patients with glucose levels exceeding 10.00 mmol/L had significantly higher odds of developing CAUTIs (OR 3.10, 95% CI 1.65-5.82) than those with glucose levels between 4.00-6.09 mmol/L. It is worth noting that patients with blood glucose levels greater than 10.00 mmol/L have a higher susceptibility for CUUTIs (OR 4.42, 95% CI 2.09-9.33) than CAUTIs. The subgroup analyses observed significant interactions between diabetes and CAUTIs (p for interaction = 0.01) and between bedridden time and CUUTIs (p for interaction = 0.04).

CONCLUSIONS

Elderly hip fracture patients with admission hyperglycaemia have an independent association with CAUTIs and CUUTIs. The association is stronger with CUUTIs and necessitates clinician intervention if blood glucose levels at admission exceed 10 mmol/L.

Hip Fracture Post-operative Mortality and Polypharmacy: A New Risk Predictor?

Introduction Hip fractures include intra- and extracapsular fractures with hip hemiarthroplasty, intramedullary (IM nailing), dynamic hip screw (DHS) fixation and cannulated cancellous screws being the main treatment options. The Nottingham Hip Fracture Score (NHFS) is used to predict the risk of 30-day mortality with some studies investigating its use for one-year mortality. This study aims to investigate the impact of polypharmacy on post-operative hip fracture mortality and the correlation with NHFS predicted mortality. Methods A retrospective single-centre analysis was carried out on hip fracture patients aged 65 years and over who underwent operative management. Primary outcome measures were 30-day and one-year mortality along with the presence of polypharmacy. Secondary outcome measures were mortality based on procedure type, NHFSs for polypharmacy and non-polypharmacy groups, number of medications, American Society of Anesthesiologists (ASA) grade, age and gender. Polypharmacy was defined as five or more long-term medications from a selected list of drug classes. Results Thirty-day mortality was 19.3% for the polypharmacy group and 2.4% for the non-polypharmacy group (P≤0.00001), while one year mortality was 50.9% for the polypharmacy group and 2.4% for the non-polypharmacy group (P≤0.00001), the NHFS was 5.16 (±1.38) on average for the polypharmacy group and 5.07 (±1.47) for the non-polypharmacy group. Thirty-day mortality was 10/116 (8.6%) for the hemiarthroplasty patients, 3/66 (4.5%) for the DHS fixation patients and 1/32 (4.5%) for the IM nailing patients. One-year mortality was 33/116 (28.4%) for the hemiarthroplasty patients, 11/66 (16.7%) for the DHS fixation patients and 4/32 (12.6%) for the IM nailing patients. Conclusion Polypharmacy correlated with a significantly higher one-year and 30-day postoperative mortality after hip fractures with the NHFS predicting no difference in mortality. This finding could assist in decision making and help facilitate discussions with patients and family members regarding post-operative mortality risks. The NHFS may also benefit from integrating polypharmacy possibly leading to more accurate risk predictions. The IM nailing and DHS fixation patients were found to have a lower 30-day and one-year mortality than the hemiarthroplasty patients.

The role of neutrophil percentage to albumin ratio in predicting 1-year mortality in elderly patients with hip fracture and external validation

Objectives

This study aimed to investigate the association between the neutrophil percentage to albumin ratio (NPAR) on the day of admission and mortality 1 year after surgery in elderly patients with hip fractures.

Methods

Clinical characteristics and blood markers of inflammation were retrospectively collected from October 2016 to January 2022 in elderly patients with hip fractures at two different regional tertiary medical centers. It is divided into a training set and an external validation set. Multivariate Nomogram models such as NPAR were constructed using the least absolute shrinkage and selection operator (LASSO) regression results and multi-factor logistic regression analysis. In addition, multivariate Cox regression analysis and Kaplan-Meier survival curves were used to explore the relationship between NPAR values and mortality within 1 year in elderly patients with hip fractures. The predictive performance of the Nomogram was evaluated using the concordance index (C Index) and receiver operating characteristic curve (ROC) and validated by Bootstrap, Hosmer-Lemesow goodness of fit test, calibration curve, decision curve, and clinical impact curve analysis.

Results

The study included data from 1179 (mean age, 80.34 ± 8.06 years; 61.4[52.1%] male) patients from the Guangzhou Red Cross Hospital affiliated with Jinan University and 476 (mean age, 81.18 ± 8.33 years; 233 [48.9%] male) patients from the Xiaogan Central Hospital affiliated with Wuhan University of Science and Technology. The results showed that NPAR has good sensitivity and specificity in assessing patients' prognosis 1 year after surgery. Multivariate logistic regression models based on influencing factors such as NPAR have good discrimination and calibration ability (AUC=0.942, 95% CI:0.927-0.955; Hosmer-Lemeshow test: P >0.05). Kaplan-Meier survival curves for the training and validation sets showed that patients in the high NPAR group had a higher mortality rate at 1 year compared to the low NPAR group (P< 0.001). Multivariate Cox regression showed that high NPAR values were an independent risk factor for death within 1 year in elderly hip fracture patients (P< 0.001, HR =2.38,95%CI:1.84-3.08).

Conclusion

Our study showed that NPAR levels were significantly higher in patients who died within 1 year after surgery in both the training and validation sets. NPAR has good clinical value in assessing 1-year postoperative prognosis in elderly patients with hip fractures.