Mortality following surgery for geriatric hip fractures: is it the timing or the co-morbidities?

Nine-year survival after intertrochanteric fracture in elderly with chronic kidney disease

The outcome of this study was to identify 9-year survivors of intertrochanteric fracture at each stage of chronic kidney disease (CKD) and to investigate the risk factors associated with mortality following surgery with proximal femoral nail anti-rotation (PFNA). 443 elderly intertrochanteric fractures underwent PFNA fixation were recruited. Mortality rate was identified until 9 years. We compared the survival time of hip fracture in each stage of CKD. A regression analysis was used to determine the association between risk factors and one-year mortality. The overall median survival time was 7.1 years. The Kaplan-Meier curve was significantly different in each CKD stage especially in CKD5. In addition, the incidence rate of mortality was highest in CKD 5 (17.4%) and the median survival time in CKD 5 was 3.3 years. The multivariate analysis demonstrated that heart disease, operative time > 60 min, presence of pulmonary embolism, and poor to fair Harris hip score were significantly increased mortality. CKD stage 5 is associated with the highest mortality rate and the shortest median time of survival during the 9-year follow up. Patients who have high risk should focus on long-term care planning, including the counseling for their healthcare providers and families.

A retrospective chart analysis with 5-year follow-up of early care for geriatric hip fracture patients: why we should continue talking about hip fractures

BACKGROUND

Timing of surgery remains a topic of debate for hip fracture treatment in the geriatric patient population. The quality indicator "early surgery" was implemented in 2014 at the Department of Trauma Surgery of the University Hospitals Leuven to enhance timely operative treatment. In this follow-up study, we aim to evaluate the performance of this quality indicator, the clinical outcomes, and room for improvement.

METHODS

The charts of 1190 patients surgically treated for an acute hip fracture were reviewed between June 2017 and May 2022 at the University Hospitals Leuven. Primary endpoints were adherence to early surgery, defined as surgery within the next calendar day, and the evaluation of the reasons for deviating from this protocol. Secondary endpoints were length of stay (LOS); intensive care unit (ICU) admission and length of ICU stay; mortality after 30 days, 60 days, 90 days, and 6 months; and 90-day readmission rate. Pearson's Chi-square test and Mann-Whitney U test were used for data analysis.

RESULTS

One thousand eighty-four (91.1%) patients received early surgery versus 106 (8.9%) patients who received delayed surgery. The main reasons for surgical delay were the use of anticoagulants (33%), a general health condition not allowing safe surgery and/or existing comorbidities requiring workup prior to surgery (26.4%), and logistical reasons (17.9%). Patient delay and transfer from other hospitals were responsible for respectively 8.5% and 6.6% of delayed surgery. Early surgery resulted in a significantly shorter LOS and ICU stay (12 [8-25] vs. 18 [10-36] and 3 [2-6] vs. 7 [3-13] days, early vs. delayed surgery, respectively). No significant reduction was observed in ICU admission, mortality, and readmission rate.

CONCLUSION

We have been able to maintain the early surgery hip fracture protocol in approximately 90% of the patients. Comorbidities and anticoagulant use were responsible for delayed surgery in the majority of the patients. Correct implementation of the existing protocol on anticoagulant use could lead to a one-third decrease in the number of delayed surgeries. Subsequently, since the LOS and ICU stay in the delayed surgery group were significantly longer, a further increase of early surgery will lower the current economic burden.

A Case-Control Study of Hip Fracture Surgery Timing and Mortality at an Academic Hospital: Day Surgery May Be Safer than Night Surgery

Time from hospital admission to operative intervention has been consistently demonstrated to have a significant impact on mortality. Nonetheless, the relationship between operative start time (day versus night) and associated mortality has not been thoroughly investigated. Methods: All patients who underwent hip fracture surgery at a single academic institution were retrospectively analyzed. Operative start times were dichotomized: (1) day operation—7 a.m. to 4 p.m.; (2) night operation—4 p.m. to 7 a.m. Outcomes between the two groups were evaluated. Results: Overall, 170 patients were included in this study. The average admission to operating room (OR) time was 26.0 ± 18.0 h, and 71.2% of cases were performed as a day operation. The overall 90-day mortality rate was 7.1% and was significantly higher for night operations (18.4% vs. 2.5%; p = 0.001). Following multivariable logistic regression analysis, only night operations were independently associated with 90-day mortality (aOR 8.91, 95% confidence interval 2.19–33.22; p = 0.002). Moreover, these patients were significantly more likely to return to the hospital within 50 days (34.7% vs. 19.0%; p = 0.029) and experience mortality prior to discharge (8.2% vs. 0.8%; p = 0.025). Notably, admission to OR time was not associated with in-hospital mortality (29.22 vs. 25.90 h; p = 0.685). Hip fracture surgery during daytime operative hours may minimize mortalities.