The 1-year mortality of patients treated in a hip fracture program for elders

Glucose-albumin ratio (GAR) as a novel biomarker for predicting postoperative pneumonia (POP) in older adults with hip fractures

Postoperative pneumonia (POP) is a common complication after hip fracture surgery and is associated with increased mortality and other complications in elderly patients. This study aims to evaluate biomarkers, especially the glucose-albumin ratio (GAR), for predicting POP in elderly hip fracture patients. A total of 1279 elderly patients admitted to our hospital with hip fractures were included. We assessed 29 biomarkers and focused on GAR to determine its prognostic and predictive value for POP. Multivariable logistic regression and propensity score-matched analyses were conducted to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for POP, adjusting for potential confounders. Receiver operating characteristic (ROC) curves were utilized to determine the optimal cut-off of GAR for predicting POP. Among the biomarkers and combinations assessed, GAR demonstrated superior predictive capability for POP in elderly hip fracture patients. ROC analyses showed moderate predictive accuracy of GAR for POP, with an area under the curve of 0.750. Using the optimal cut-off of 0.175, the high GAR group was significantly associated with increased odds of POP (adjusted OR 2.14, 95%, CI 1.50-3.05). These associations remained significant after propensity score matching and subgroup analyses. Dose-response relationships between GAR and POP were observed. In conclusion, GAR may be a promising biomarker to predict POP risk in elderly hip fracture patients. Further studies are warranted to validate its clinical utility. However, this study has certain limitations, including its retrospective design, potential for selection bias due to the exclusion criteria, and the single-center nature of the study, which should be addressed in future prospective, multicenter studies.

Risk factors associated with 1-year mortality after osteoporotic hip fracture in Hawai'i: higher mortality risk among Native Hawaiians and other Pacific Islanders

We studied factors affecting osteoporotic hip fracture mortality in Hawai'i, a region with unique geography and racial composition. Men, older adults, higher ASA score, lower BMI, and NHPI race were associated with higher mortality. This is the first study demonstrating increased mortality risk after hip fracture in NHPI patients.

PURPOSE

To estimate mortality rates and identify specific risk factors associated with 1-year mortality after osteoporotic hip fracture in Hawai'i.

METHODS

A retrospective review of adults (≥ 50 years) hospitalized with an osteoporotic hip fracture at a large multicenter healthcare system in Hawai'i from 2011 to 2019. The Kaplan-Meier curves and log-rank tests examined survival probability by sex, age group, race/ethnicity, primary insurance, body mass index (BMI), and American Society of Anesthesiologists (ASA) physical status classification. After accounting for potential confounders, adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were obtained from Cox proportional hazards regression models.

RESULTS

We identified 1755 cases of osteoporotic hip fracture. The cumulative mortality rate 1 year after fracture was 14.4%. Older age (aHR 3.50; 95% CI 2.13-5.76 for ≥ 90 vs 50-69), higher ASA score (aHR 5.21; 95% CI 3.09-8.77 for ASA 4-5 vs 1-2), and Native Hawaiian/Pacific Islander (NHPI) race (aHR 1.84; 95% CI 1.10-3.07 vs. White) were independently associated with higher mortality risk. Female sex (aHR 0.64; 95% CI 0.49-0.84 vs male sex) and higher BMI (aHR 0.35; 95% CI 0.18-0.68 for obese vs underweight) were associated with lower mortality risk.

CONCLUSION

In our study, men, older adults, higher ASA score, lower BMI, and NHPI race were associated with significantly higher mortality risk after osteoporotic hip fracture. NHPIs are an especially vulnerable group and comprise a significant portion of Hawai'i's population. Further research is needed to address the causes of higher mortality and interventions to reduce hip fractures and associated mortality.

National Institute of Health and Care Excellence Guidelines for Displaced Intracapsular Hip Fractures: Examining Satisfaction With the Guidelines and Effects on Outcomes

BACKGROUND

The objectives of the study were to: (1) evaluate satisfaction with the new 2023 National Institute of Health and Care Excellence (NICE) criteria for selecting total hip arthroplasty (THA) over hemiarthroplasty and surgical recommendations for treatment of displaced intracapsular hip fractures; (2) describe why THA is performed when NICE criteria are not met; and (3) determine whether satisfaction with these guidelines is associated with improved outcomes.

METHODS

A retrospective chart review of patients who had a displaced intracapsular hip fracture treated with THA at a single tertiary academic center between 2010 and 2022 was performed. Preoperative patient characteristics were reviewed to determine if the indication for THA met NICE criteria. Operative details, perioperative complications, reoperation, and revision arthroplasty within 12 months of surgery were recorded.

RESULTS

Data from 196 patients (63% women; age 67 ± 10 years) were used. There were 161 THAs (82.1%) that satisfied NICE criteria. The 2 most common reasons for performing a THA when NICE criteria were not met (n = 35) included preoperative radiographic osteoarthritis (Tönnis grade ≥ 2; 48.6%) and decreased patient age (< 65 years; 31.5%). Satisfaction with the NICE criteria was associated with fewer perioperative complications (0.6 versus 37.1%; P < .001), reoperations (0.6 versus 31.4%; P < .001), and revisions (0.6 versus 28.6%; P < .001). The most common reason for revision was periprosthetic fracture, possibly secondary to the use of uncemented femoral stems (171 of 196, 87.2%).

CONCLUSIONS

Satisfaction with the new NICE criteria is associated with improved perioperative outcomes. Further studies are necessary to determine if preexisting hip osteoarthritis and younger age merit consideration in patient selection.

Trends and epidemiology of lower trunk fractures in the super elderly population in the United States from 2011 to 2020

INTRODUCTION

Fractures of the lower trunk are among the most common fractures occurring in the elderly. Super elderly individuals (i.e., those 80 years of age and older) represent a growing segment of the population and are especially prone to these fractures. The contemporary epidemiology of lower trunk fractures in the super elderly population is incompletely described in the literature.

MATERIALS AND METHODS

This descriptive epidemiology study used the National Electronic Injury Surveillance System (NEISS) to examine the incidence and recent trends of lower trunk fractures (i.e., fractures of the hip, pelvis, and lumbar spine) occurring among super elderly individuals in the United States (US) from 2011 to 2020. Annual, overall, and age-/sex-specific incidence rates (IRs) were analyzed. Average annual percent change (AAPC) estimates were calculated to indicate the magnitude/direction of trends in annual injury rates.

RESULTS

An estimated N=1,226,160 super elderly patients sustained lower trunk fractures over the 10-year study period for an overall IR of 100.2 per 10,000 person-years at-risk (PYR). Hip fractures accounted for the largest percentage of cases (IR=71.7 PYR), followed by lumbar spine fractures (IR=14.7), and pelvic fractures (IR=14.3). The incidence of lower trunk fractures among super elderly females (IR=121.5 PYR) was significantly greater than that of males (IR=65.7 PYR). The incidence of lower trunk fractures among nonagenarians and centenarians was significantly higher than that of octogenarians. Accounting for population growth yielded a significantly increasing annual incidence of lower trunk fractures in super elderly patients over the study period from 86.7 PYR in 2011 to 107.2 PYR in 2020 (AAPC=2.7, p<0.001). The annual incidence of both pelvic (AAPC=5.8) and lumbar spine (AAPC=6.9) fractures increased at a significantly higher rate than that of hip fractures (AAPC=1.4).

CONCLUSIONS

This study suggests that the annual incidence of lower trunk fractures in the oldest cohort of patients in the US (80+ years of age) increased significantly during the recent decade from 2011 to 2020, with pelvic and lumbar fractures in particular becoming increasingly common. Increased incidence rates highlight the need for future research aimed at optimizing outcomes and quality of life in this frail and ever-growing segment of the population.

Single-centre results of a randomised controlled trial comparing the Gamma3 nail and a sliding hip screw to treat AO type 31-A1 and 31-A2 trochanteric fractures

PURPOSE

The primary goal of this randomised controlled trial was to investigate whether there are differences in the outcome between the Gamma3 nail and a sliding hip screw (SHS) regarding quality of life 1 year after surgery.

METHODS

In a controlled randomised trial, we compared the Gamma3 nail (Stryker) and a SHS (Omega, Stryker) in the treatment of 193 patients with pertrochanteric fractures. The follow-up period was 12 months. The outcomes included the surgical duration, health-related quality of life measured with the EQ-5D Index and a Visual Analogue Scale (VAS), the living situation and use of walking aid before trauma and 52 weeks after surgery; the Parker Mobility Score; the Harris Hip Score; and the revision, complication and mortality rates.

RESULTS

The Gamma3 group had a significantly shorter surgical duration than the SHS group (p < 0.0001). Implant-related complications were significantly lower in the Gamma3 group (p > 0.05). The revision rate was significantly lower in the Gamma3 group based on intention-to-treat (p = 0.0336) as well as as-treated (p = 0.0302) analyses. Otherwise, we did not find significant difference between the two groups regarding the EQ-5D Index and VAS scores, the Parker Mobility Score, the Harris Hip Score, the mortality rate, the use of walking aids and the living situation.

CONCLUSION

There were no detectable differences between the groups in terms of quality of life and clinical scores 12 months after surgery. The surgical duration and revision rate were superior for the Gamma3 group.

Bone turnover markers reference database in five Southeast Asian countries

Osteoporosis is highly prevalent, particularly in developing countries. However, bone turnover marker reference ranges for management of osteoporosis in Asian population are yet to be explored and established. Thus, this study aims to develop a regional bone turnover markers (BTMs) reference database by combining country-specific reference database from five ASEAN countries: Malaysia, the Philippines, Singapore, Thailand, and Vietnam. We established a healthy reference population of 746 healthy premenopausal women aged 20 to 44 years old. Serum Procollagen 1 N-Terminal Propeptide (P1NP), Osteocalcin (OC), and Beta-Crosslaps (CTX) concentrations were measured using an automated immunoassay analyzer system, the cobas® modular analyzer systems (Roche Diagnostic Gmbh). The reference interval was defined as the central 95 % range. The estimated reference interval for CTX was 128 to 811 ng/L, OC was 9.0 to 33.0 μg/L, and for P1NP, the range was 22.8 to 96.5 μg/L. Comparison across countries showed that Singaporeans had the highest levels of median CTX along with Thais and Filipinos, who had significantly higher levels of P1NP and OC. Exploratory analysis on the associations with age showed that BTMs decreased with increasing age at 20 to 29 years old and plateaued after 30 years old. When excluding participants in their 20s, the reference interval estimated were CTX: 117-678 ng/L, P1NP: 21.6-85.8 μg/L and OC: 3.5-27.0 μg/L respectively. To the best of our knowledge, this is the first study to report BTMs reference intervals based on a healthy premenopausal Southeast Asian population which will contribute to the appropriate assessment and monitoring of bone turnover rate in the evaluation and management of osteoporosis in the Southeast Asian region. LAY SUMMARY: Osteoporosis is a common health issue, especially in developing countries. However, there is a lack of information on bone health markers specific to the Southeast Asian population. This study aimed to fill this gap by creating a reference database for bone turnover markers (BTMs) in Southeast Asian countries, including Malaysia, the Philippines, Singapore, Thailand, and Vietnam. The researchers studied 746 healthy women aged 20 to 44 years and measured blood markers related to bone health. The reference interval, representing the normal range, was determined. For example, the normal range for CTX was found to be 128 to 811 ng/L, for Osteocalcin was 9.0 to 33.0 μg/L, and for P1NP, the range was 22.8 to 96.5 μg/L. When excluding participants in their 20s, the reference intervals estimated were CTX: 117-678 ng/L, P1NP: 21.6-85.8 μg/L and OC: 3.5-27.0 μg/L respectively. Comparing the results across countries, Singaporeans, Thais, and Filipinos showed variations in their biochemical bone marker levels. Additionally, the study observed changes in the levels with age, with a decrease in BTMs observed after the age of 30. This groundbreaking study provides the first-ever reference intervals for BTMs in a healthy premenopausal Southeast Asian population. These findings will help in the proper assessment and monitoring of bone health, contributing to the management of osteoporosis in the Southeast Asian region.

The impact of ethnicity on care and outcome after hip fracture in England and Wales

Aims

To determine if patient ethnicity among patients with a hip fracture influences the type of fracture, surgical care, and outcome.

Methods

This was an observational cohort study using a linked dataset combining data from the National Hip Fracture Database and Hospital Episode Statistics in England and Wales. Patients' odds of dying at one year were modelled using logistic regression with adjustment for ethnicity and clinically relevant covariates.

Results

A total of 563,640 patients were included between 1 April 2011 and 1 October 2020. Of these, 476,469 (85%) had a coded ethnicity for analysis. Non-white patients tended to be younger (mean 81.2 vs 83.0 years), and were more commonly male (34.9% vs 28.5%; p < 0.001). They were less likely to be admitted from institutional care (12.9% vs 21.8%; p < 0.001), to have normal cognition (53.3% vs 62.0%; p < 0.001), and to be free of comorbidities (22.0% vs 26.8%; p < 0.001), but were more likely to be from the most deprived areas (29.4% vs 17.3%; p < 0.001). Non-white patients were more likely to experience delay to surgery for medical reasons (14.8% vs 12.7%; p < 0.001), more likely to be treated with an intramedullary nail or a sliding hip screw (52.5% vs 45.1%; p < 0.001), and less likely to be mobilized by the day after surgery (74.3% vs 79.0%; p < 0.001). Mortality was higher among non-white inpatients (9.2% vs 8.4% for white), but was lower at one year after hip fracture (26.6% vs 30.3%).

Conclusion

Our study identified serious problems with the quality of NHS ethnicity data. Despite this, we have shown that there is complex variation in case-mix and hip fracture morphology between ethnic groups. We have also identified variations in care received between ethnic groups, and that disparities in healthcare may contribute to poorer outcome. Inpatient mortality is higher in non-white patients, although this finding reverses after discharge, and one-year mortality is lower. Patients from ethnic minority backgrounds experience disparities in healthcare, however at one year postoperatively non-white patients have a statistically significant lower mortality after controlling for relevant clinical covariates.

Integrated model of secondary fracture prevention in primary care (INTERCEPT): protocol for a cluster randomised controlled multicentre trial

BACKGROUND

Osteoporotic fractures signal severely compromised bone strength and are associated with a greatly increased risk of refracture. Despite the availability of effective and safe medications that reduce fracture risk, 70-80% of patients are inadequately investigated or treated for osteoporosis following an initial fracture, constituting a significant 'osteoporosis care gap'. Optimal methods of bridging this gap with primary care at the forefront of secondary fracture prevention remain undetermined. This protocol describes a cluster randomised controlled trial to evaluate the effectiveness of a novel integrated model of secondary fracture prevention and management in primary care.

METHODS

The cluster randomised controlled trial involves multiple branches of a community-based radiology provider (CRP), a hospital-based secondary fracture prevention program (SFPP) and numerous primary care practices in metropolitan Sydney that refer to either the CRP or SFPP. Using natural language processing tools, patients diagnosed with a potential osteoporotic fracture will be identified by automatically screening radiology reports generated at the CRP or SFPP. The primary care practices that these patients attend will be randomised (1:1) to either the intervention or usual care. The intervention consists of (i) electronic and fax alerts informing the practice/primary care physician that their patient has been diagnosed with a potential osteoporotic fracture; (ii) provision of osteoporosis management guidelines and (iii) follow-up surveys at 4 weeks and 6 months. Practices in the usual care (control) group will receive no alerts and provide usual care. The primary outcome is the proportion of patients undergoing a bone density scan and/or filling a prescription for osteo-protective pharmacotherapy within 3 months of the initial diagnostic imaging report. Secondary outcomes are the proportion of patients: (i) undergoing an osteoporosis-related blood test within 3 months of the initial diagnostic imaging report; (ii) initiated on a chronic disease management plan within 3 months of the diagnostic report, and (iii) filling a second prescription for osteo-protective pharmacotherapy within 9 months post initial diagnostic imaging report. Outcomes will be obtained through de-identified linked data from Medical Benefits Schedule and Pharmaceutical Benefits Scheme held by the Australian Institute of Health and Welfare.

DISCUSSION

This is the first randomised trial to integrate case-detection of potential osteoporotic fractures in a hospital and community setting with direct alerts to the patient's primary care provider. This study will determine whether such an intervention is effective in improving investigation and/or treatment rates of osteoporosis in patients with a potential osteoporotic fracture.

TRIAL REGISTRATION

This study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12623000658617p.

Pulmonary Embolism Post-Femoral Neck Fracture Surgery: A Critical Predictor of Five-Year Mortality

Objectives

This study examines the impact of pulmonary embolism (PE) on mortality among patients with femoral neck fractures, exploring the predictive value of preoperative PE for postoperative occurrences and associated mortality over a 5-year follow-up period.

Methods

We analyzed 2256 patients over 60 years old admitted with femoral neck fractures, focusing on those who developed DVT or PE postoperatively. Surgical intervention aimed within 48 hours without pharmacological thromboprophylaxis, utilizing mechanical prophylaxis instead. Postoperative management included Enoxaparin administration. Data analysis employed SPSS 21, with chi-squared tests, T-tests, and multivariate logistic regression to explore mortality and PE incidence.

Results

PE was diagnosed in 1.4% of patients, with a notable mortality contrast between patients with PE (87%) and those without (59.7%) over 5 years. A history of preoperative PE emerged as a significant risk factor for postoperative PE. Despite surgical variations, no significant correlation was found between surgery type and PE incidence. Early postoperative weight-bearing and institutional rehabilitation did not significantly alter PE incidence rates.

Conclusions

The study underscores the significant mortality risk associated with preoperative PE in femoral neck fracture patients. It highlights the necessity for vigilant PE risk assessment and management, challenging assumptions about the protective role of early mobility and rehabilitation in PE incidence. Further research is essential to refine patient care strategies and improve outcomes.

Nutritional care in older adults: are we doing everything? An expert opinion review

Malnutrition is a prevalent, yet often underdiagnosed and undertreated, condition in older adults. It is characterized by weight loss and/or reduced muscle mass due to diminished caloric intake, inflammation, and/or disease burden. In return, malnutrition can lead to diminished skeletal muscle functionality and disability, among others. Malnutrition plays a crucial role in the pathogenesis of two prevalent geriatric syndromes, namely sarcopenia and frailty. The complex interplay between malnutrition, sarcopenia, and frailty significantly impacts the older population, leading to increased morbidity, mortality, hospitalization rates, quality-of-life, and healthcare costs. Given the prognostic significance of malnutrition in geriatric care, recent guidelines emphasized the role of nutritional support in vulnerable populations. A group of vulnerable populations to malnutrition, sarcopenia, and frailty are older patients with hip fractures, cancer patients, and those with sarcopenic dysphagia. This article highlights the importance of individualized nutritional assessment and treatment in the management of vulnerable populations such as older patients with hip fractures, cancer, and those suffering from sarcopenic dysphagia. It presents practical protocols and guidelines that can be instrumental in enhancing the nutritional care of these groups, thereby improving their overall health outcomes.

Sustained IL-6 and sTNF-αR1 levels after hip fracture predict 5-year mortality: A prospective cohort study from the Baltimore Hip Studies

BACKGROUND

Persistent inflammation is associated with adverse health outcomes, but its impact on mortality has not been investigated previously among hip fracture patients. This article aims to investigate the influence of changes in levels of cytokines in the 2 months after a hip fracture repair on 5-year mortality.

METHODS

This is a prospective cohort study from the Baltimore Hip Studies (BHS) with 191 community-dwelling older men and women (≥65 years) who had recently undergone surgical repair of an acute hip fracture, with recruitment from May 2006 to June 2011. Plasma interleukin-6 (IL-6), soluble tumor necrosis factor alpha receptor1 (sTNFα-R1), and interleukin-1 receptor agonist (IL-1RA) were obtained within 22 days of admission and at 2 months. All-cause mortality over 5 years was determined. Logistic regression analysis tested the associations between the cytokines' trajectories and mortality over 5 years, adjusted for covariates (age, sex, education, body mass index, lower extremity physical activities of daily living, and Charlson comorbidity index).

RESULTS

High levels of IL-6 and sTNFα-R1 at baseline with small or no decline at 2 months were associated with higher odds of 5-year mortality compared with those with lower levels at baseline and greater decline at 2 months after adjustment for age, and other potential confounders (OR = 4.71, p = 0.01 for IL-6; OR = 15.03, p = 0.002 for sTNFα-R1). Similar results that failed to reach significance were found for IL-1RA (OR = 2.40, p = 0.18). Those with higher levels of cytokines at baseline with greater decline did not have significantly greater mortality than the reference group, those with lower levels at baseline and greater decline.

CONCLUSION

Persistent elevation of plasma IL-6 and sTNFα-R1 levels within the first 2 months after hospital admission in patients with hip fracture is associated with higher 5-year mortality. These patients may benefit from enhanced care and earlier intensive interventions to reduce the risk of death.

90-Day Complication and Readmission Rates for Geriatric Patients With Hip Fracture at Different Time Points From COVID-19 Positivity: A Database Study

INTRODUCTION

Geriatric patients with hip fracture are at risk of having COVID-19 while needing fracture treatment. Understanding the associated risks of variable timing of COVID-19 before surgery may help direct care algorithms.

METHODS

Geriatric patients with documented hip fracture surgery were identified within the PearlDiver M157 database. Patients with a preoperative COVID-19 diagnosis were classified based on time from diagnosis to surgery: ≤ 1 week, > 1 to ≤ 4 weeks, > 4 to ≤ 7 weeks, > 7 to ≤ 10 weeks, and > 10 to ≤ 13 weeks. The association of COVID-19 diagnoses with 90-day complications was evaluated.

RESULTS

Overall, 263,771 patients with hip fracture were identified, of which COVID-19 within 13 weeks of surgery was documented for 976. On multivariable analysis, patients with COVID-19 infection within ≤ 1 week preoperatively demonstrated increased rates of minor adverse events (odds ratio (OR) = 1.50), all adverse events (OR = 1.59), sepsis (OR = 1.70), and pneumonia (OR = 2.35) (P ≤ 0.0007 for each). For time points greater than 1 week, there were no differences in complication rates.

DISCUSSION

Patients with COVID-19 within 1 week of hip fracture surgery demonstrated greater odds of 90-day complications. Reassuringly, patients with COVID-19 diagnoses more than 1 week preoperatively were not associated with increased odds of any assessed complication.

Patient Satisfaction Following Non-Operative Treatment of Geriatric Hip Fractures: A Case-Control Study

Introduction

A minority of geriatric hip fracture patients pursue non-operative treatment. Compared with surgical patients, non-operative patients have higher mortality rates. However, patient satisfaction following non-operative vs operative treatment has not been investigated extensively. The purpose of this study was to compare satisfaction among non-operatively vs operatively treated hip fracture patients.

Methods

We identified patients aged 60+ years with proximal femur fractures treated over a 10-year period. Excluded were patients with isolated greater/lesser trochanteric fractures. Patients or relatives were asked to complete a 6-question survey about their treatment satisfaction.

Results

Survey responses from 56 operative and 28 non-operative patients were recorded. Overall, 91.1% of operative and 82.1% of non-operative patients were satisfied with their treatment course (P = 0.260). However, only 71.4% of non-operative patients were satisfied with treatment option explanations vs 83.9% of operative patients (P = 0.014). While only 64.3% of non-operative respondents were satisfied with the ultimate treatment outcome (vs 85.7% of operative patients, P = 0.025), 89.3% of patients in each cohort would choose the same treatment plan again.

Discussion

Our findings highlight the complexity of defining patient satisfaction, particularly in a geriatric hip fracture population. Unlike previous studies, we chose a direct approach to quantifying patient satisfaction by asking participants specifically about satisfaction with treatment outcome and the overall treatment course. Additional survey questions were then included to assess factors considered important in treatment satisfaction, such as health care provider treatment explanations, post-treatment mobility, and palliative care service involvement.

Conclusions

We identified significant differences between non-operatively and operatively treated geriatric hip fracture patients regarding satisfaction with the explanation of treatment options, and ultimate treatment outcomes. There was no significant difference in overall satisfaction with the treatment course or likelihood of choosing the same treatment again. Further research investigating patient satisfaction following geriatric hip fracture treatment is warranted.

Predictive value of the early postoperative hemoglobin-to-red blood cell distribution width ratio for acute kidney injury in elderly intertrochanteric fracture patients

BACKGROUND

Hemoglobin-to-red blood cell distribution width ratio (HRR) had great predictive value for the prognosis of malignant tumors and cardiovascular disease. However, its predictive value for the occurrence of acute kidney injury (AKI) in elderly intertrochanteric fracture patients remains unclear. This study aims to analyze the correlation between the early postoperative HRR and the risk of postoperative AKI in elderly intertrochanteric fracture patients.

METHODS

We reviewed the medical records of 307 elderly intertrochanteric fracture patients in this single-center retrospective cohort study. We performed univariate analysis on the relevant parameters, and parameters with significant differences were included in the following logistic regression model for multivariate analysis. Then, we used a receiver operating characteristic (ROC) curve to evaluate the predictive value of the early postoperative HRR level for AKI in elderly intertrochanteric fracture patients. Patients were divided into a high HRR group and a low HRR group according to the cutoff point determined by ROC curve analysis. Subsequently, the relevance between postoperative HRR and AKI was further determined using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW).

RESULTS

The area under the curve of the early postoperative HRR for predicting postoperative AKI was 0.714 (95% CI: 0.618-0.809). The cutoff value was 5.44. The sensitivity was 72.7%, and the specificity was 70.8%. Patients were divided into low HRR (⩽ 5.44) and high HRR (> 5.44) groups according to the cutoff value. PSM and IPTW analysis indicated that the risk of AKI in the low HRR group was significantly higher than that in the high HRR group in both the matched cohort (OR = 6.914, 95% CI: 1.714-46.603, p = 0.016) and the weighted group (OR = 2.784, 95% CI: 1.415-5.811, p = 0.040).

CONCLUSIONS

Early postoperative HRR is an accurate, accessible, and economical blood test parameter that can predict the risk of postoperative AKI in elderly patients with femoral intertrochanteric fracture.

Impact of the American Society of Anesthesiologists (ASA) classification on hip fracture surgery outcomes: insights from a retrospective analysis

BACKGROUND

The American Society of Anesthesiologists (ASA) classification is the most used system to assess patient health status before surgery, ranging from I to V levels. This study aims to explore the impact of different ASA risk classes (ASA II [mild risk] and ASA III [severe risk]) on clinical outcomes following hip fracture surgery, including all-cause mortality and postoperative complications.

METHODS

A retrospective analysis from 2019 to 2021 across three Jordanian centers was conducted. The study included patients aged 65 and above who underwent hip fracture repair surgeries. Preoperative measures, intraoperative management protocols, and postoperative care were collected. Clinical data were extracted from electronic medical records, including demographics, fracture type, intraoperative data, and postoperative outcomes.

RESULTS

The analysis included 1033 patients, with 501 (48.5%) in the mild anesthetic risk group (ASA I-II) and 532 (51.5%) in the severe anesthetic risk group (ASA III-V). The mean age was 73 years, with a higher prevalence of males in the severe risk group. Patients in the severe risk group had more comorbidities, higher ICU admissions (15.23% vs. 6.18%), longer hospital stays (median 7 vs. 6 days), and higher rates of postoperative thromboembolic complications (3.39% vs. 1.39%) compared to the mild risk group. Additionally, the severe risk group showed higher mortality rates both in-hospital mortality (3.38% vs. 1.39%) and all-cause mortality (16.92% vs. 10.36%). Multivariate analysis identified higher ASA score as independent risk factors for increased all-cause mortality (HR = 1.64 95%CI 1.51-2.34) and thromboembolic complications (OR = 2.85 95%CI 1.16-7). Length of hospital stay was significantly associated with higher ASA score (OR = 1.04 95%CI 0.96-1.11).

CONCLUSION

The study underscores the significant impact of anesthetic risk on the outcomes of hip fracture surgeries. Patients with higher ASA scores associated with severe systemic diseases may have at increased risk of adverse outcomes.

Comparative effectiveness of denosumab vs alendronate among postmenopausal women with osteoporosis

Although clinical trials have shown that denosumab significantly increases bone mineral density at key skeletal sites more than oral bisphosphonates, evidence is lacking from head-to-head randomized trials evaluating fracture outcomes. This retrospective cohort study uses administrative claims data from Medicare fee-for service beneficiaries to evaluate the comparative effectiveness of denosumab vs alendronate in reducing fracture risk among women with PMO in the US. Women with PMO ≥ 66 yr of age with no prior history of osteoporosis treatment, who initiated denosumab (n = 89 115) or alendronate (n = 389 536) from 2012 to 2018, were followed from treatment initiation until the first of a specific fracture outcome, treatment discontinuation or switch, end of study (December 31, 2019), or other censoring criteria. A doubly robust inverse-probability of treatment and censoring weighted function was used to estimate the risk ratio associated with the use of denosumab compared with alendronate for hip, nonvertebral (NV; includes hip, humerus, pelvis, radius/ulna, other femur), non-hip nonvertebral (NHNV), hospitalized vertebral (HV), and major osteoporotic (MOP; consisting of NV and HV) fractures. Overall, denosumab reduced the risk of MOP by 39%, hip by 36%, NV by 43%, NHNV by 50%, and HV fractures by 30% compared with alendronate. Denosumab reduced the risk of MOP fractures by 9% at year 1, 12% at year 2, 18% at year 3, and 31% at year 5. An increase in the magnitude of fracture risk reduction with increasing duration of exposure was also observed for other NV fracture outcomes. In this cohort of almost half-a-million treatment-naive women with PMO, we observed clinically significant reductions in the risk of MOP, hip, NV, NHNV, and HV fractures for patients on denosumab compared with alendronate. Patients who remained on denosumab for longer periods of time experienced greater reductions in fracture risk.

Assessing fall risk in osteoporosis patients: a comparative study of age-matched fallers and nonfallers

This study aimed to investigate sway parameters and physical activity level of the age/gender-matched older adults with osteoporosis faller and nonfaller patients. By examining these factors, our objective was to understand how these faller and nonfaller groups with osteoporosis differed particularly in terms of balance capabilities and their impact on physical activity levels. We recruited 24 patients with osteoporosis: 12 who reported a fall within a year before recruitment (fallers) and 12 without falls (nonfallers). Given the close association between biochemical markers of musculoskeletal health such as serum calcium, parathyroid hormone (PTH), Vitamin D, and renal function, we compared these markers in both groups. As a result, elderly individuals with osteoporosis and with a history of falls within the preceding year indicated significantly higher sway velocity (P = 0.012*), sway area (P < 0.001*), and sway path length (P = 0.012*). Furthermore, fallers had significantly lower calcium (P = 0.02*) and Parathyroid hormone (PTH) (P = 0.02*), as well as higher Alkaline Phosphatase (ALP) (P = 0.02*) as compared to nonfallers despite similar vitamin D and creatinine levels. In conclusion, diminished biochemical factors in the osteoporosis faller group could possibly cause postural instability resulting in lower physical activity levels in the osteoporosis fall group and increasing the risk of falls.

Strategies to improve end-of-life decision-making and palliative care following hip fracture in frail older adults: a scoping review

BACKGROUND

Although surgery is the gold standard following a hip fracture, the potential for rehabilitation and survival rates are low in frail older patients. Some patients may derive more benefit from palliative care. The objectives of this review were to identify the available strategies to improve end-of-life decision-making and palliative care for frail patients with hip fractures and to synthetise their level of support.

METHODS

We conducted a scoping review of the scientific and grey literature, searching seven databases and websites of associations. We included all study designs, expert opinion articles and clinical practice guidelines (CPGs). Data were synthetised according to the Approach to Patient with Limited Life Expectancy and Hip Fracture framework. The number of research items and their level of evidence were tabulated for each of the recommended strategies.

RESULTS

Of the 10 591 items identified, 34 were eligible. The majority of included articles were original research studies (n = 15). Half of the articles and CPGs focused on intervention categories (55%) such as goals of care discussion and comfort care, followed by factors to consider in the end-of-life decision-making process (25%) and prognosis assessments (20%), mainly through the estimation of life expectancy. The level of evidence for these strategies remains low, given the limited number of prospective studies supporting them.

CONCLUSIONS

This scoping review highlighted that end-of-life care in frail older patients with a hip fracture remains understudied. The strategies identified could be prioritised for future research to improve the well-being of the target population while promoting sustainable resource management.

Geriatric Trauma: Identifying Research Gaps and Opportunities for Improvement

Geriatric trauma is a critical area of research owing to the increasing elderly population and the unique challenges associated with their injuries. This study aimed to explore the intellectual structure, growth, spatial analysis, seminal publications, most frequent keywords, trending topics, conceptual structure, and thematic evolution of geriatric trauma research (GTR). A comprehensive analysis was conducted using VOSviewer (Centre for Science and Technology Studies, Leiden University, The Netherlands) and Biblioshiny (K-Synth Srl, University of Naples Federico II, Italy) to examine a corpus of scholarly publications (N = 682) related to GTR (2004-2024). Bibliographic data were collected from the Scopus database and analyzed to highlight the key findings and trends. The analysis revealed the leading contributors to GTR. Over the years, there has been an increased interest in geriatric trauma, as demonstrated by the increasing trend in research publications. Collaboration patterns among nations were determined through spatial analysis, and insights into significant topics and their influence were offered by influential publications. Keywords used frequently as well as current issues formed part of this study's findings, which give insight into what was most focused on within the GTR. Themes and their development over time were made explicit by revealing their conceptual structures and thematic evolutions. GTR has increased significantly. Interdisciplinary approaches are suggested for future research. Furthermore, gaps need to be addressed using technological advancements that will help improve geriatric trauma management and lead to better patient outcomes.

Dysphagia is associated with increased mortality risk after hip fracture surgery

PURPOSE

This study aims to explore the prevalence of dysphagia, as well as mortality associated with dysphagia in the elderly population receiving surgical treatment for a hip fracture.

METHODS

A retrospective cohort study was completed at an academic level 1 tertiary care center. Patients older than or equal to 65 admitted with a hip fracture diagnosis from January 2015 to December 2020 (n = 617) were included. The main outcome was the prevalence of dysphagia and association with mortality. Secondary analysis included timing of dysphagia and contributions to mortality.

RESULTS

Fifty-six percent of patients had dysphagia, and the mortality rates were higher in patients with dysphagia (8.9%) versus those without dysphagia (2.6%), chi-square p = 0.001, and odds ratio 3.69 (CI 1.6-8.5). Mortality rates in patients with acute dysphagia were also higher (12.4%) than those with chronic dysphagia (5%) and chi-squared p = 0.02. Mortality rates in patients with a perioperative dysphagic event (13.9%) were higher than those with non-perioperative dysphagia (4%) and chi-squared p = 0.001. Mortality rates in patients who had acute perioperative dysphagia (21.2%) were higher than those with chronic dysphagia that presented perioperatively (6.8%) and chi-squared p = 0.006.

CONCLUSIONS

This study demonstrates high rates of dysphagia in the elderly hip fracture population and a significant association between dysphagia and mortality. Timing and chronicity of dysphagia were relevant, as patients with acute perioperative dysphagia had the highest mortality rate. Unlike other identified risk factors, dysphagia may be at least partially modifiable. More research is needed to determine whether formal evaluation and treatment of dysphagia lowers mortality risk.

Cross-sectional associations between accelerometer-measured physical activity and hip bone mineral density: the Tromsø Study 2015-2016

Positive associations between physical activity and bone health have been found in population-based studies, however, mostly based on self-reported physical activity. Therefore, we investigated the association between accelerometer-measured physical activity, measured in steps per day and minutes of moderate to vigorous physical activity (MVPA) per day, and total hip areal BMD (aBMD) measured by DXA in a general population, utilizing multiple regression models. The study participants, 1560 women and 1177 men aged 40-84 yr, were part of the seventh survey of the Tromsø Study (2015-2016). In both genders, we found a positive association between the number of daily steps and aBMD adjusted for age, BMI, and smoking status (P < .001). In women, an increase of 1000 steps per day was associated with 0.005 g/cm2 higher aBMD. For men, a polynomial curve indicated a positive association with aBMD up to 5000 steps per day, plateauing between 5000 and 14 000 steps, and then increasing again. Additionally, MVPA duration was positively associated with aBMD in both women (P < .001) and men (P = .004) when adjusted for age, BMI, and smoking status. Specifically, each 60-min increase in daily MVPA was associated with 0.028 and 0.023 g/cm2 higher aBMD in women and men, respectively. Despite positive associations, the clinical impact of physical activity on aBMD in this general population of adults and older adults was relatively small, and a large increase in daily MVPA might not be achievable for most individuals. Therefore, further longitudinal population-based studies incorporating device-based measures of physical activity could add more clarity to these relationships.

Factors that influence the mortality of patients following hip hemiarthroplasty

INTRODUCTION

Hip hemiarthroplasty (HHA) is one of the most common types of orthopedic surgery. With the prevalence and utilization of the surgery increasing year after year, this procedure is found to be associated with severe postoperative complications and eventually mortality. Thus, it is crucial to understand the factors that increase the risk of mortality following HHA.

METHODS

Using the Nationwide Inpatient Sample (NIS) database, patients undergoing HHA from 2016 to 2019 were identified. This sample was stratified into a mortality group and a control group. The data regarding patients' demographics, co-morbidities, and associated complications were compared between the groups.

RESULTS

Of the 84,067 patients who underwent the HHA procedures, 1,327 (1.6%) patients died. Additionally, the mortality group had a higher percentage of patients who were non-electively admitted (P < 0.001) and diabetic patients with complications (P < 0.001), but lower incidences of tobacco-related disorders (P < 0.001). Significant differences were also seen in age (P < 0.001), length of stay (P < 0.001), and total charges (P < 0.001) between the two groups. Preoperatively, those aged > 70 years (OR: 2.11, 95% CI [1.74, 2.56], P < 0.001) had diabetes without complications (OR: 0.32, 95% CI [0.23, 0.44], P < 0.001), tobacco-related disorders (OR: 0.24, 95% CI [0.17, 0.34], P < 0.001) and increased rates of mortality after HHA. Postoperatively, conditions, such as pulmonary embolisms (OR: 6.62, 95% CI [5.07, 8.65], P < 0.001), acute renal failure (OR: 4.58 95% CI [4.09, 5.13], P < 0.001), pneumonia (95% CI [2.72, 3.83], P < 0.001), and myocardial infarctions (OR: 2.65, 95% CI [1.80, 3.92], P < 0.001) increased likelihood of death after undergoing HHA. Patients who were electively admitted (OR: 0.46 95% CI [0.35, 0.61], P < 0.001) had preoperative obesity (OR: 0.67, 95% CI [0.44, 0.84], P = 0.002), and a periprosthetic dislocation (OR: 0.51, 95% CI [0.31, 0.83], P = 0.007) and were found to have a decreased risk of mortality following THA.

CONCLUSIONS

Analysis of pre- and postoperative complications relating to HHA revealed that several comorbidities and postoperative complications increased the odds of mortality. Old age, pulmonary embolisms, acute renal failure, pneumonia, and myocardial infraction enhanced the odds of post-HHA mortality.

Exploring the Effectiveness of Emergency Medical Services Becoming Active in Fall Prevention: A Literature Review

Falls, particularly among the elderly, are a prevalent and growing healthcare issue in the United States. Individuals who experience falls face heightened morbidity and mortality risks, along with substantial expenses associated with managing any resulting injuries. First responders frequently respond to 911 calls related to falls, with a significant portion of these cases not resulting in hospital or healthcare facility transfers. As such, many fall victims receive treatment without any preventive measures being implemented. The purpose of this review is to explore the current studies that examine whether Emergency Medical Service personnel can effectively act in fall prevention. While earlier studies present conflicting findings, recent research indicates the potential for preventive strategies that go beyond mere referrals.

Retrospective Analysis of Risk Factors in Geriatric Hip Fracture Patients Predictive of Surgical Intensive Care Unit Admission

INTRODUCTION

Although numerous risk factors and prediction models affecting morbidity and mortality in geriatric hip fracture patients have been previously identified, there are scant published data on predictors for perioperative Surgical Intensive Care Unit (SICU) admission in this patient population. Determining if a patient will need an SICU admission would not only allow for the appropriate allocation of resources and personnel but also permit targeted clinical management of these patients with the goal of improving morbidity and mortality outcomes. The purpose of this study was to identify specific risk factors predictive of SICU admission in a population of geriatric hip fracture patients. Unlike previous studies which have investigated predominantly demographic, comorbidity, and laboratory data, the present study also considered a frailty index and length of time from injury to presentation in the Emergency Department (ED).

METHODS

A total of 501 geriatric hip fracture patients admitted to a Level 1 trauma center were included in this retrospective, single-center, quantitative study from January 1, 2019, to December 31, 2022. Using a logistical regression analysis, more than 25 different variables were included in the regression model to identify values predictive of SICU admission. Predictive models of planned versus unplanned SICU admissions were also estimated. The discriminative ability of variables in the final models to predict SICU admission was assessed with receiver operating characteristic curves' area under the curve estimates.

RESULTS

 Frailty, serum lactate > 2, and presentation to the ED > 12 hours after injury were significant predictors of SICU admission overall (P = 0.03, 0.038, and 0.05 respectively). Additionally, the predictive model for planned SICU admission had no common significant predictors with unplanned SICU admission. Planned SICU admission significant predictors included an Injury Severity Score (ISS) of 15 and greater, a higher total serum protein, serum sodium <135, systolic blood pressure (BP) under 100, increased heart rate on admission to ED, thrombocytopenia (<120), and higher Anesthesia Society Association physical status classification (ASA) score (P = 0.007, 0.04, 0.05, 0.002, 0.041, 0.05, and 0.005 respectively). Each SICU prediction model (overall, planned, and unplanned) demonstrated sufficient discriminative ability with the area under the curve (AUC) values of 0.869, 0.601, and 0.866 respectively. Finally, mean hospital Length of Stay (LOS) and mortality were increased in SICU admissions when compared to non-SICU admissions.

CONCLUSION

Of the three risk factors predictive of SICU admission identified in this study, two have not been extensively studied previously in this patient population. Frailty has been associated with increased mortality and postoperative complications in hip fracture patients, but this is the first study to date to use a novel frailty index specifically designed and validated for use in hip fracture patients. The other risk factor, time from injury to presentation to the ED serves as an indicator for time a hip fracture patient spent without receiving medical attention. This risk factor has not been investigated heavily in the past as a predictor of SICU admissions in this patient population.

The real time to surgery: Limited delay after medical optimization does not impact hip fracture surgery outcomes

INTRODUCTION

Current U.S./Canadian guidelines recommend hip fracture surgery within 48 h of injury to decrease morbidity/mortality. Multiple studies have identified medical optimization as the key component of time to surgery, but have inherent bias as patients with multiple co-morbidities often take longer to optimize. This study aimed to evaluate time from medical optimization to surgery (TMOS) to determine if "real surgical delay" is associated with: 1) mortality and 2) complications for geriatric hip fracture patients.

METHODS

A retrospective chart review of geriatric hip fractures treated from 2015-2018 at a single, level-1 trauma center was conducted. Univariate logistic regression was performed to identify association between TMOS and post-operative complication rates. For mortality, the Wilcoxon test was used to compare TMOS for patients discharged following surgery to those who were not.

RESULTS

A total of 884 hip fractures were treated operatively, with median TMOS 16.2 h (5.0-22.5, 1st-3rd quartiles). Univariate logistic regression models did not identify an association between TMOS and complication rates. For patients successfully discharged, median TMOS was 16.2 h (5.0-22.3, 1st-3rd quartiles). For the cohort of patients not successfully discharged, median TMOS was 19.1 h (10.1-25.9, 1st-3rd quartiles, p = 0.16).

CONCLUSION

"Real surgical delay", or TMOS is not associated with increased complications or with inpatient mortality for geriatric hip fracture patients. With few exceptions, our institution adhered to the 48-hour time window from injury to hip surgery. We maintain the belief timely surgery following optimization plays a crucial role in the geriatric hip fracture patient outcomes.

Early mobilisation after hip fracture surgery is associated with improved patient outcomes: A systematic review and meta-analysis

INTRODUCTION

The aims of this systematic review and meta-analysis were to determine if after hip fracture surgery (1) early mobilisation is associated with improved clinical outcomes, and if so (2) are benefits directly proportional to how soon after surgery the patient mobilises.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review was conducted using four databases to identify all studies that compared postoperative early mobilisation with delayed mobilisation, in patients after hip fracture surgery. The Critical Appraisal Skills Programme checklist was employed for critical appraisal and evaluation of all studies that met the inclusion criteria.

RESULTS

A total of 13 studies, including 297,435 patients were identified, of which 235,275 patients were mobilised early and 62,160 were mobilised late. Six studies assessed 30-day mortality, of which two also investigated 30-day complication rates. Pooled meta-analysis demonstrated that there were significantly lower 30-day mortality rates (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.31-0.41, p < 0.001) and complication rates (OR 0.43, 95% CI 0.36-0.51, p < 0.001) in patients mobilising early after hip fracture surgery. Five studies investigated length of stay (LOS) and meta-analysis revealed no difference between groups (mean difference -0.57 days, 95% CI -1.89-0.74, p = 0.39).

CONCLUSION

Early mobilisation in hip fracture patients is associated with a reduction in 30-day mortality and complication rates compared to delayed mobilisation, but no difference in LOS. These findings illustrate that early mobilisation is associated with superior post operative outcomes. However, a direct casual effect remains to be demonstrated, and further work on the factors underlying delayed mobilisation is required.

Effect of operative time in outcomes following surgical fixation of hip fractures: a multivariable regression analysis of 35,710 patients

BACKGROUND

Prolonged operative time is a risk factor for increased morbidity and mortality after open reduction and internal fixation (ORIF) of hip fractures. However, the quantitative nature of such association, including graduated risk levels, has yet to be described. This study outlines the graduated associations between operative time and (1) healthcare utilisation, and (2) 30-day complications after ORIF of hip fractures.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried (January 2016-December 2019) for all patients who underwent ORIF of hip fractures (n = 35,710). Demographics, operative time, fracture type, and comorbidities were recorded. Outcomes included healthcare utilisation (e.g., prolonged length of stay [LOS>2 days], discharge disposition, 30-day readmission, and reoperation), inability to weight-bear (ITWB) on postoperative day-1 (POD-1), and any 30-day complication. Adjusted multivariate regression models evaluated associations between operative time and measured outcomes.

RESULTS

Operative time <40 minutes was associated with lower odds of prolonged LOS (odds ratio [OR] 0.77), non-home discharge (OR 0.85), 30-day readmission (OR 0.85), and reoperation (OR 0.72). Operative time ⩾80 minutes was associated with higher odds of ITWB on POD-1 (OR 1.17). Operative time ⩾200 minutes was associated with higher odds of deep infection (OR 7.5) and wound complications (OR 3.2). The odds of blood transfusions were higher in cases ⩾60 minutes (OR1.3) and 5-fold in cases ⩾200 minutes (OR 5.4). The odds of venous thromboembolic complications were highest in the ⩾200-minute operative time category (OR 2.5). Operative time was not associated with mechanical ventilation, pneumonia, delirium, sepsis, urinary tract infection, or 30-day mortality.

DISCUSSION

Increasing operative time is associated with a progressive increase in the odds of adverse outcomes following hip fracture ORIF. While a direct cause-effect relationship cannot be established, an operative time of <60 minutes could be protective. Perioperative interventions that shorten operative time without compromising fracture reduction or fixation should be considered.

Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention

OBJECTIVES

To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Three academic Level 1 trauma centers.

PATIENT SELECTION CRITERIA

Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC.

OUTCOME MEASURES AND COMPARISONS

Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality.

RESULTS

Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons).

CONCLUSIONS

Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The heart-bone connection: relationships between myocardial infarction and osteoporotic fracture

Myocardial infarction (MI) and osteoporotic fracture (Fx) are two of the leading causes of mortality and morbidity worldwide. Although these traumatic injuries are treated as if they are independent, there is epidemiological evidence linking the incidence of Fx and MI, thus raising the question of whether each of these events can actively influence the risk of the other. Atherosclerotic cardiovascular disease and osteoporosis, the chronic conditions leading to MI and Fx, are known to have shared pathoetiology. Furthermore, sustained systemic inflammation after traumas such as MI and Fx has been shown to exacerbate both underlying chronic conditions. However, the effects of MI and Fx outside their own system have not been well studied. The sympathetic nervous system (SNS) and the complement system initiate a systemic response after MI that could lead to subsequent changes in bone remodeling through osteoclasts. Similarly, SNS and complement system activation following fracture could lead to heart tissue damage and exacerbate atherosclerosis. To determine whether damaging bone-heart cross talk may be important comorbidity following Fx or MI, this review details the current understanding of bone loss after MI, cardiovascular damage after Fx, and possible shared underlying mechanisms of these processes.

Surgical intervention may provides better outcomes for hip fracture in nonagenarian patients: A retrospective observational study

Background

Hip fracture is a common disease in the elderly. Among these patients, surgical intervention for hip fracture should be carefully considered because of old age and multiple comorbidities. There are still insufficient comparisons between nonagenarian patients treated with surgery and those treated non-surgically. We studied hip fracture nonagenarian patients to compare the different outcomes between surgical and non-surgical treatments.

Materials and methods

Nonagenarian patients visiting the emergency department with hip fractures between March 2010 and December 2020 were identified. Overall survival was estimated using multivariate Cox proportional hazards models. The mortality rates, the length of hospital stay, complication and readmission rates were also recorded.

Results

A total of 173 patients who underwent surgery and 32 who received conservative treatments were included. The median survival time was 58.47 months in the OP group, which was significantly higher than the 24.28 months in the non-OP group. After adjusting for covariates, including age, sex, Charlson Comorbidity Index (CCI), injury severity score, and fracture type, the risk of death was reduced by surgery (hazard ratio [HR] = 0.427; 95 % confidence interval [CI]: 0.207-0.882; p = 0.021). CCI was also an independent risk factor for poor survival rate (HR = 1.3; 95 % CI: 1.115-1.515; p = 0.001). After adjusting for several factors, surgery within 48 h improved overall survival (HR: 2.518; 95 % CI: 1.299-4.879; p = 0.006) in operative group.

Conclusion

Our study suggests that surgical treatment may provide better survival for nonagenarian patients with hip fractures than non-operation, especially patients with less concurrent comorbidities.

Patients risk for mortality at 90 days after proximal femur fracture - a retrospective study in a tertiary care hospital

BACKGROUND

Despite improving the management of proximal femur fractures (PFF) with legal requirements of timing the surgery within 24 h, mortality rates in these patients remain still high. The objective of our study was to analyze potential cofactors which might influence the mortality rate within 90 days after surgery in PFF to avoid adverse events, loss of quality of life and high rates of mortality.

METHODS

In this retrospective, single-center study all patients with PFF aged 65 years and older were included. We recorded gender, age, type of fracture, surgery and anesthesia, time, comorbidities and medication as well as complications and mortality rate at 90 days. Separate logistic regression models were used to assess which parameters were associated with patients' mortality. The mortality rate was neither associated with timing, time and type of surgery nor time and type of anesthesia, but with higher age (OR 1.08 per year; 95% CI 1.034-1.128), lower BMI (OR 0.915 per kg/m2; 95% CI 0.857-0.978), higher CCI (OR 1.170 per point; 95% CI 1.018-1.345), dementia (OR 2.805; 95% CI 1.616-4.869), non-surgical complications (OR 2.276; 95% CI 1.269-4.083) and if mobilization was impossible (OR 10.493; 95% CI 3.612-30.479).

RESULTS

We analyzed a total of 734 patients (age ≥ 65 years) who had a PFF in 2019 and 2020 and received surgery. 129 patients (17.6%) died until 90 days at an median age of 89.7 years (range 65-101 years).

CONCLUSION

The proportion of patients who died until 90 days after surgery is still high. It is less extend influenced by surgical and anaesthesiologic factors than by patient-related factors like age or lower BMI. Physicians should be aware of the importance of avoiding adverse events and the importance of patients' mobilization to reduce mortality and improve patients' outcome.

Evaluation of the Surgical Treatment of Patients over 90 Years Old with Hip Fractures and Their Morbidity and Mortality

Objective:  Hip fractures in older adults have the highest impact on the patient's health. These injuries result in many complications, reducing functional capability, quality of life, and life expectancy. This study aimed to provide more epidemiological data on the outcomes of these fractures in nonagenarians from a large city treated at a tertiary hospital. Methods:  This study consisted of medical record reviews and interviews. Results:  In this study, 76 patients underwent 82 surgeries. The mean age of the patients was 92.5 years. Ninety percent of the subjects were female. The patients spent 10.4 days in hospital. Surgery occurred on average 2.3 days after hospitalization. Regarding fractures, 46 were trochanteric (56%), and 34 affected the femoral neck (41.5%). Forty-one surgeries used the short proximal femoral nail (50%), and 18 were partial hip replacements (22%). During hospitalization, 46 patients (55%) had no complications, excluding episodes of delirium, and seven patients (9%) died. Forty-two subjects completed the one-year postoperative follow-up period, with 56% alive and 44% dead. Conclusions:  Treating hip fractures in older patients is challenging. Our goal must focus on helping these subjects receive the quickest and least aggressive treatment possible and start mobilization early. We hope the data presented in this study can lead to a better understanding of the characteristics of our nonagenarian population with hip fractures and seek the best possible treatment for them.

Machine learning-based mortality prediction in hip fracture patients using biomarkers

The purpose of this retrospective study was to assess whether mortality following a hip fracture can be predicted by a machine learning model trained on basic blood and lab test data as well as basic demographic data. Additionally, the purpose was to identify the key variables most associated with 1-, 5-, and 10-year mortality and investigate their clinical significance. Input data included 3751 hip fracture patient records sourced from the Medical Information Mart for Intensive Care IV database, which provided records from in-hospital database systems at the Beth Israel Deaconess Medical Center. The 1-year mortality rate for all patients studied was 21% and for those aged 80+ was 29%. We assessed 10 different machine learning classification models, finding LightGBM to have the strongest 1-year mortality prediction performance, with accuracy of 81%, AUC of 0.79, sensitivity of 0.34, and specificity of 0.98 on the test set. The strongest-weighted features of the 1-year model included age, glucose, red blood cell distribution width, mean corpuscular hemoglobin concentration, white blood cells, urea nitrogen, prothrombin time, platelet count, calcium levels, and partial thromboplastin time. Most of these were also in the top 10 features of the LightGBM 5- and 10-year prediction models trained. Testing for these high-ranking biomarkers in new hip fracture patients can aid clinicians in assessing the likelihood of poor outcomes for hip fracture patients, and additional research can use these biomarkers to develop a mortality risk score.

Sex Differences in Sarcopenia in Patients Undergoing Total Knee Arthroplasty for Advanced Knee Osteoarthritis

Background and Objectives: The purpose of this study was to compare sex differences in the incidence of sarcopenia, demographic characteristics, and preoperative sarcopenic parameters in patients undergoing TKA for advanced knee osteoarthritis (OA). Moreover, we sought to compare patient-reported outcome measures (PROMs) and the predisposing factors after TKA in patients with sarcopenia by sex through subgroup analysis. Materials and Methods: From May 2020 to September 2022, a total of 892 patients who were evaluable for sarcopenia before primary TKA were enrolled. Sarcopenia was defined according to the Asian Working Group for Sarcopenia 2019 criteria. Patients were assessed according to the presence or absence of sarcopenia. After a two-to-one matched-pair analysis for subgroup analysis, 21 knees in men were matched with a corresponding number of knees in women (42), resulting in a total of 63 knees. PROMs were investigated using the Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and the Short Form-12 physical and mental component summary scores. Moreover, the postoperative complications and predisposing factors for male sarcopenia were investigated. Results: The prevalence of sarcopenia was 10.9% (97/892), and the prevalence was higher in men (19.6%, 21/107) than in women (9.7%, 76/785). In subgroup analyses, male patients had significantly inferior PROMs up to 12 months after index surgery. Moreover, there was no significant difference in the systemic complications between the two groups. Multivariate binary logistic regression analysis indicated that alcohol consumption, smoking, and higher modified Charlson Comorbidity Index (mCCI) were predisposing factors for male patients with sarcopenia. The prevalence of sarcopenia was higher in male patients undergoing primary TKA. Conclusions: When compared with the propensity-matched female group, male patients had inferior PROMs up to 12 months postoperatively. Alcohol consumption, current smoker status, and higher mCCI were predisposing factors for sarcopenia in male patients with advanced knee OA.

The Odds of One-Year Mortality in Bedridden Geriatric Patients Discharged from Acute Rehabilitation Ward Are Increased Eightfold If the Patients Have Three or More Complications

Low muscle strength, functional score at discharge, and complications during a ten-day rehabilitation hospital stay can affect mortality rates in bedridden geriatric patients. This was a prospective observational study in a cohort of 105 bedridden geriatric patients admitted to the Rehabilitation ward after a major illness or surgery. All participants had a severe dependency on another person (Barthel's Index < 60). The one-year mortality rate in this cohort was 15.2%, with further subdivision according to the number of complications: 61.5% in patients with ≥3 complications during hospitalization, 17.6% in patients with two complications, 9.5% with one complication, and 3% in patients with no complications. The Barthel Index at discharge (OR = 0.95; p = 0.003) and ≥3 medical complications (OR = 8.33; p = 0.005) during rehabilitation ward stay were significant predictors for one-year mortality. The odds of one-year mortality after discharge increased eightfold in patients with ≥3 medical complications. Sarcopenia, age, and sex were not significant predictors of mortality in this cohort. The 10-day acute rehabilitation was too short to achieve progress from severe to moderate independence in 60% of patients. The Barthel Index at discharge and a number of complications affect the mortality rate. These findings provide valuable insights into the complex dynamics of mortality and functional outcomes in bedridden geriatric patients.

Quality of Life After Hip Fracture Surgery in the Elderly: A Cross-Sectional Study

Purpose Hip fractures are common and serious injuries as they lead to high mortality and morbidity and have a significant effect on patients' lives. Additionally, these injuries have substantial socioeconomic consequences for patients' quality of life, their families, and healthcare systems. The aim of this study is to assess the quality of life (QoL) in patients after hip fracture surgery. Methods This study involved a cross-sectional survey between February 2016 and December 2019, with a sample of 199 patients who suffered a hip fracture and were treated at a tertiary care teaching hospital. The participants completed the EuroQol 5-Dimensions 5-Levels (EQ-5D-5L) questionnaire. Pearson's chi-squared test, independent sample t-test, and Pearson's correlation coefficient (r) were used in the analysis. Results We found that there is a statistically significant association between age and having problems with mobility (p=0.023), self-care (p<0.001), and usual activity (p=0.029). In addition, increased age was significantly associated with decreased EuroQol Visual Analog Scale (EQ-VAS) scores (r=-0.213, p=0.003). We also found a statistically significant association between gender and self-care, as males were more likely to report having problems with self-care when compared to females (OR: 3.63; CI 95%: 1.77-7.44; p<0.001). Conclusion Mobility, self-care, and usual activity were the most significantly affected quality of life measures and were more apparent in older age groups. Patients should be educated about the possibility of a decline in their QoL and the role of postoperative rehabilitation in improving patients' mobility. Periodic QoL screening should be done as early as possible to detect any further decrease. Future research should standardize postoperative interview intervals to improve QoL evaluation and include a control group.

Increased Neighborhood Deprivation Is Associated with Prolonged Hospital Stays After Surgical Fixation of Traumatic Pelvic Ring Injuries

BACKGROUND

The purpose of this study was to understand the role of social determinants of health assessed by the Area Deprivation Index (ADI) on hospital length of stay and discharge destination following surgical fixation of pelvic ring fractures.

METHODS

A retrospective chart analysis was performed for all patients who presented to our level-I trauma center with pelvic ring injuries that were treated with surgical fixation. Social determinants of health were determined via use of the ADI, a comprehensive metric of socioeconomic status, education, income, employment, and housing quality. ADI values range from 0 to 100 and are normalized to a U.S. mean of 50, with higher scores representing greater social deprivation. We stratified our cohort into 4 ADI quartiles. Statistical analysis was performed on the bottom (25th percentile and below, least deprived) and top (75th percentile and above, most deprived) ADI quartiles. Significance was set at p < 0.05.

RESULTS

There were 134 patients who met the inclusion criteria. Patients in the most deprived group were significantly more likely to have a history of smoking, to self-identify as Black, and to have a lower mean household income (p = 0.001). The most deprived ADI quartile had a significantly longer mean length of stay (and standard deviation) (19.2 ± 19 days) compared with the least deprived ADI quartile (14.7 ± 11 days) (p = 0.04). The least deprived quartile had a significantly higher percentage of patients who were discharged to a resource-intensive skilled nursing facility or inpatient rehabilitation facility compared with those in the most deprived quartile (p = 0.04). Race, insurance, and income were not significant predictors of discharge destination or hospital length of stay.

CONCLUSIONS

Patients facing greater social determinants of health had longer hospital stays and were less likely to be discharged to resource-intensive facilities when compared with patients of lesser social deprivation. This may be due to socioeconomic barriers that limit access to such facilities.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Distinctive Geometrical Traits of Proximal Femur Fractures-Original Article and Review of Literature

Background and Objectives: The incidence of proximal femoral fractures is escalating rapidly, generating a significant challenge for healthcare systems globally and, carrying serious social and economic implications. The primarily object of this study was to discover potential distinguishing factors between fractures occurring in the femoral neck and trochanteric region. Materials and Methods: We performed a prospective cohort study of the radiographic images of 70 people over 65 years of age who were admitted to the orthopedic department with hip fracture and who fulfilled our eligibility criteria. Neck Length (NL), Offset Lenth (OL), Hip Axis Length (HAL), Neck Shaft Angle (NSA), Wiberg Angle (WA), Acetabular Angle (AA), Femoral Neck Diameter (FND), Femoral Head Diameter (FHD), Femoral Shaft Diameter (FSD), Femoral Canal Diameter (FCD) and Tonnis classification were recorded. For the comparison of the categorical variables, Pearson's χ2 criterion was used, while Student's t-test was applied for the comparison of means of quantitative variables across fracture types. Results: There were no statistically significant variances observed while comparing the selected geometric parameters of the proximal femur with the type of fracture. This finding was reaffirmed in relation to age, gender, and Tonnis classification. However, a moderate correlation was noted, revealing comparatively reduced values of HAL, FHD, and FND in women as opposed to men. Conclusions: The inability of our research to establish the differentiative geometric factors between femoral neck and trochanteric fractures underscores the need for further investigations, which would take into consideration the intrinsic characteristics of the proximal femur.

Hospital episode-of-care costs for hip fractures: an activity-based costing analysis

Background

Despite the large impact of hip fracture care on hospital budgets, accurate episode-of-care costs (EOCC) calculations for this injury remains a challenge. The objective of this article was to assess EOCC for geriatric patients with hip fractures using an activity-based costing methodology and identify intraoperative, perioperative, and patient-specific factors associated with higher EOCC.

Material and Methods

This is a retrospective cohort study involving a total of 109 consecutive patients with hip fracture treated surgically at a Canadian level-1 trauma center from April 2018 to February 2019. Clinical and demographic data were extracted through the institution's centralized data warehouse. Data acquisition also included direct and indirect costs per episode of care, adverse events, and precise temporal data.

Results

The median total EOCC was $13,113 (interquartile range 6658), excluding physician fees. Out of the total cost, 75% was attributed to direct costs, which represented a median expenditure of $9941. The median indirect cost of the EOCC was $3322. Based on the multivariate analysis, patients not operated within the 48 hours guidelines had an increased length of stay by 5.7 days (P = 0.003), representing an increase in EOCC of close to 5000$. Higher American Society of Anesthesiology (ASA) scores were associated with elevated EOCC.

Conclusion

The cost of managing a patient with geriatric hip fracture from arrival in the emergency department to discharge from surgical ward represented $13,113. Main factors influencing the EOCC included adherence to the 48-hour benchmark surgical delay and ASA score. High-quality costing data are vital in assessing health care spending, conducting cost effectiveness analyses, and ultimately in guiding policy decisions.

Level of Evidence

Level III (3), retrospective cohort study.

Liberal intraoperative fluid management leads to increased complication rates in geriatric patients with hip fracture

PURPOSE

Fractures of the proximal femur in geriatric patients are life-changing and life-threatening events. Previous research has identified fluid volume as an independent factor contributing to trauma patients' complications. Therefore, we aimed to investigate the impact of intraoperative fluid volume on outcomes in geriatric patients undergoing hip fracture surgery.

METHODS

We conducted a retrospective single-center study with data from the hospital information systems. Our study included patients aged 70 years or older who had sustained a proximal femur fracture. We excluded patients with pathologic, periprosthetic, or peri-implant fractures and those with missing data. Based on the fluids given, we divided patients into high-volume and low-volume groups.

RESULTS

Patients with a higher American Society of Anesthesiologists (ASA) grade and more comorbidities were more likely to receive more than 1500 ml of fluids. We observed significant differences in anesthesiologic management between the two groups, with a higher rate of invasive blood pressure management (IBP) and central venous catheter usage in the high-volume group. High-volume therapy was associated with a higher rate of complications (69.7% vs. 43.6%, p < 0.01), a higher transfusion rate (odds ratio 1.91 [1.26-2.91]), and an increased likelihood of patients being transferred to an intensive care unit (17.1% vs. 6.4%, p = 0.009). These findings were confirmed after adjusting for ASA grade, age, sex, type of fracture, Identification-of-Seniors-At-Risk (ISAR) score, and intraoperative blood loss.

CONCLUSIONS

Our study suggests that intraoperative fluid volume is a significant factor that impacts the outcome of hip fracture surgery in geriatric patients. High-volume therapy was associated with increased complications.

Assessing frailty in elderly patients with hip fractures: A retrospective review comparing geriatrician and orthopedic trainee assessments

To assess the correlation of orthopedic surgery residents compared with expert geriatricians in the assessment of frailty stage using the Clinical Frailty Scale (CFS) in patients with hip fractures. A retrospective chart review was performed from January 1, 2015 to December 31, 2019. Patients admitted with a diagnosis of hip fracture were identified. Those patients with a CFS score completed by orthopedic residents with subsequent CFS score completed by a geriatrician during their admission were extracted. Six hundred and forty-eight patients over age 60 (mean 80.5 years, 73.5% female) were admitted during the study period. Orthopaedic residents completed 286 assessments in 44% of admissions. Geriatric medicine consultation was available for 215 patients such that 93 patients were assessed by both teams. Paired CFS data were extracted from the charts and tested for agreement between the 2 groups of raters. CFS assessments by orthopedic residents and geriatrician experts were significantly different at P < .05; orthopedic residents typically assessed patients to be one CFS grade less frail than geriatricians. Despite this, the CFS assessments showed good agreement between residents and geriatricians. Orthopaedic surgery residents are reliable assessors of frailty but tend to underestimate frailty level compared with specialist geriatricians. Given the evidence to support models such as orthogeriatrics to improve outcomes for frail patients, our findings suggest that orthopedic residents may be well positioned to identify patients who could benefit from such early interventions. Our findings also support recent evidence that frailty assessments by orthopedic surgeons may have predictive validity. Low rates of initial frailty assessment by orthopedic residents suggests that further work is required to integrate more global comprehensive care.

Radiomic analysis of the proximal femur in osteoporosis women using 3T MRI

Introduction

Osteoporosis (OP) results in weak bone and can ultimately lead to fracture. MRI assessment of bone structure and microarchitecture has been proposed as method to assess bone quality and fracture risk in vivo. Radiomics provides a framework to analyze the textural information of MR images. The purpose of this study was to analyze the radiomic features and its abilityto differentiate between subjects with and without prior fragility fracture.

Methods

MRI acquisition was performed on n = 45 female OP subjects: 15 with fracture history (Fx) and 30 without fracture history (nFx) using a high-resolution 3D Fast Low Angle Shot (FLASH) sequence at 3T. Second and first order radiomic features were calculated in the trabecular region of the proximal femur on T1-weighted MRI signal of a matched dataset. Significance of the feature's predictive ability was measured using Wilcoxon test and Area Under the ROC (AUROC) curve analysis. The features were correlated DXA and FRAX score.

Result

A set of three independent radiomic features (Dependence Non-Uniformity (DNU), Low Gray Level Emphasis (LGLE) and Kurtosis) showed significant ability to predict fragility fracture (AUROC DNU = 0.751, p < 0.05; AUROC LGLE = 0.729, p < 0.05; AUROC Kurtosis = 0.718, p < 0.05) with low to moderate correlation with FRAX and DXA.

Conclusion

Radiomic features can measure bone health in MRI of proximal femur and has the potential to predict fracture.

Use of hypnotic-sedative medication and risk of falls and fractures in adults: A self-controlled case series study

OBJECTIVE

To evaluate the risk of falls and fractures in users of benzodiazepines, Z-drugs, or melatonin.

METHODS

We followed 699,335 adults with a purchase of benzodiazepines, Z-drugs, or melatonin in the Danish National Prescription Registry between 2003 and 2016 for falls and fractures in the Danish National Patient Registry between 2000 and 2018. A self-controlled case-series analysis and conditional Poisson regression were used to derive incidence rate ratios (IRR) of falls and fractures during six predefined periods.

RESULTS

In total 62,105 and 36,808 adults, respectively, experienced a fall or fracture. For older adults, the risk of falls was highest during the 3-month pre-treatment period (IRRmen+70 , 4.22 (95% confidence interval, 3.53-5.05), IRRwomen + 70 , 3.03 (2.59-3.55)) compared to the baseline (>1 year before initiation). The risk continued to be higher in the later treatment periods. Contrarily, in men and women aged 40-69 years, the risk was only higher in the 3-month pre-treatment period. The incidence of falls among young men and women was slightly lower after initiation of sedating medication (treatment period, IRRmen15-39 , 0.66 (0.50-0.86), IRRwomen15-39 , 0.65 (0.51-0.83)). Analyses with fractures as outcome yielded similar results.

CONCLUSIONS

Although falls and fractures occur more often in persons using sedative-hypnotic medication, the higher risk of falls and fractures in the pre-treatment period relative to the period directly after treatment, suggests that this association is better explained by other factors that elicited the prescription of this medication rather than the adverse effects of the sedative-hypnotic medication.

In-Hospital Hip Fractures in a Large Irish Teaching Hospital: Patient Risk Factors and Outcomes

INTRODUCTION

In-hospital hip fractures follow falls during unrelated admissions. Little data in the Irish setting is available on this vulnerable subset of hip fracture patients. Our objective is to review the incidence of in-hospital hip fractures, identify risk factors, and evaluate outcomes.

METHODS

This is a retrospective observational review. We collected patient data in St. James' Hospital using the Hospital In-Patient Enquiry database and Electronic Patient Records for in-hospital hip fractures between 10/02/2017 and 22/04/2020. Comorbidity, survival, and discharge destination data were gathered.

RESULTS

We identified 40 fractures, representing 11.5% of all hip fractures treated at our center during the study period. The patients were 60-95 years old. Median age was 77 years for males and 86 years for females. Most (72.5%) were identified as fall risks, and 52% were unwitnessed falls. Many had a history of falls (67.5%), dementia (52.5%), or both (42.5%). Delirium was common (42.5%), and 75% had at least one vascular/coagulation disorder. Mortality was 10.25% at 30 days, 23.1% at 90 days, and 51.4% at 12 months. Although 70% were admitted from home, only 10% were discharged back home. 30% were admitted to a nursing home, and 55% were discharged from a nursing home.

CONCLUSION

In-hospital hip fractures accounted for 11.5% of all hip fractures treated at our center, confirming the need for a well-defined hospital protocol. Patients often present with previous falls, dementia, and cardiovascular disease. Outcomes are poor, with 51.4% mortality at 12 months and significant morbidity reflected by a loss of independent living.

Trauma (Excluding Falls) in the Older Adult

Trauma in the older adult will increasingly become important to emergency physicians hoping to optimize their patient care. The geriatric patient population possesses higher rates of comorbidities that increase their risk for trauma and make their care more challenging. By considering the nuances that accompany the critical stabilization and injury-specific management of geriatric trauma patients, emergency physicians can decrease the prevalence of adverse outcomes.

Validation of the orthopedic frailty score for measuring frailty in hip fracture patients: a cohort study based on the United States National inpatient sample

BACKGROUND

The Orthopedic Frailty Score (OFS) has been proposed as a tool for measuring frailty in order to predict short-term postoperative mortality in hip fracture patients. This study aims to validate the OFS using a large national patient register to determine its relationship with adverse outcomes as well as length of stay and cost of hospital stay.

METHODS

All adult patients (18 years or older) registered in the 2019 National Inpatient Sample Database who underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. The association between the OFS and mortality, complications, and failure-to-rescue (FTR) was determined using Poisson regression models adjusted for potential confounders. The relationship between the OFS and length of stay and cost of hospital stay was instead determined using a quantile regression model.

RESULTS

An estimated 227,850 cases met the study inclusion criteria. There was a stepwise increase in the rate of complications, mortality, and FTR for each additional point on the OFS. After adjusting for potential confounding, OFS 4 was associated with an almost ten-fold increase in the risk of in-hospital mortality [adjusted IRR (95% CI): 10.6 (4.02-27.7), p < 0.001], a 38% increased risk of complications [adjusted IRR (95% CI): 1.38 (1.03-1.85), p = 0.032], and an almost 11-fold increase in the risk of FTR [adjusted IRR (95% CI): 11.6 (4.36-30.9), p < 0.001], compared to OFS 0. Patients with OFS 4 also required a day and a half additional care [change in median length of stay (95% CI): 1.52 (0.97-2.08), p < 0.001] as well as cost approximately $5,200 more to manage [change in median cost of stay (95% CI): 5166 (1921-8411), p = 0.002], compared to those with OFS 0.

CONCLUSION

Patients with an elevated OFS display a substantially increased risk of mortality, complications, and failure-to-rescue as well as a prolonged and more costly hospital stay.

The effects of a multidisciplinary pathway for perioperative management of patients with hip fracture

OBJECTIVES

To determine if a multidisciplinary pathway focused on non-opioid pain management, delirium assessment, and resource utilization improved outcomes in geriatric hip fracture patients. The goal was to reduce opioid usage, consultation not congruent with guidelines, and increase use of regional anesthesia to reduce delirium and improve outcomes.

METHODS

An observational study was performed on hip fracture patients before and after the intervention. Hospitalists were educated on indications for preoperative cardiac consultation and specialized preoperative cardiac testing according to evidence-based guidelines with the inpatient cardiology service. Additional education on multimodal analgesia, limiting opioids, and peripheral nerve blocks was provided by the acute pain service. Pre-intervention outcomes from 1 July 20171 July 2017 to 31 May 201831 May 2018 (N = 92) were compared to post-intervention outcomes from 1 July 20181 July 2018 to 31 May 201931 May 2019 (N = 98) and included delirium, length of stay, 30-day readmission rate, time from arrival to procedure start time, time to first physical therapy session, and completion of cardiology consult time. We examined adherence, use of nerve blocks, and pre- and post-operative pain scores and opioid use.

RESULTS

Delirium was reduced from 50.0% (N = 46/92) to 28.6% (N = 28/98); p = 0.002. Postoperative opioid use (IV morphine milligram equivalents) decreased from an average of 57.2 mg (±67.7) to 42.6 mg (±58.2),P < .0001. There was a significant decrease in mean pre-operative (5.4 ± 4.14 to 5.05 ± 2.8, P < .0001) and post-operative pain scores (4.3 ± 5.2 to 3.2 ± 2.2, P < .0001). There was a significant reduction in time to cardiology consultation from 18 h] to 12 h ; p < .001).

CONCLUSIONS

A multidisciplinary collaboration between hospitalists, anesthesiologists, and cardiologists for hip fracture patients was associated with a reduction in pain and delirium and time to cardiologist evaluation. Prospective studies focusing on additional patient-centered outcomes are warranted.

Hip fractures and outcome in elderly patients in a tertiary care hospital of Sri Lanka

This study assessed how elderly patients with hip fractures were affected by factors such as comorbidities, fracture type, treatments, complications, and health-related quality of life. The majority of participants had surgery for their fracture with good prognoses despite having comorbidities. Reductions in the general level of activities related to daily living were proportionately higher even after one year.

INTRODUCTION

Hip fractures in older adults are associated with significant morbidity, mortality, loss of independence, and financial burdens. In this study, we assessed how these effects were influenced by factors such as comorbidities, fracture type, treatment methods, complications, and health-related quality of life (HRQoL) in elderly patients presented with hip fractures.

METHODS

A prospective observational study was conducted over 6 months on all patients with fall and hip fractures above 65 years of age that presented to the Accident and Emergency Department (A&E) of Provincial General Hospital Kurunegala. The subjects were followed up with for up to 1 year. Data forms were made according to the Charlson comorbidity index, the Johns Hopkins Fall Risk Assessment tool, and the International Society of Fracture Repair-International Osteoporosis Foundation (ISFR-IOF)) hip fracture outcome working group recommendations. Direct questions from these assessment guides were not used in data collection. Being able to walk independently and return to a premorbid state following surgery was considered a good outcome.

RESULTS

There were 117 patients (mean age 78 (± 7.31) years); 80% were female. Out of them, 81% had comorbidities without significant morbidity or mortality during surgery. Ninety-six (88%) had surgery for their fracture with good prognoses (p<0.05) and better outcomes due to early surgery (p=0.008). Independent walking was significantly better in intracapsular fractures than extracapsular fractures (p<0.05). Patients with post-surgical complications had significant mortality (p<0.001). Ninety-nine per cent, 81%, and 75% of patients remained dependent 1 month, 3 months, and 1 year following surgery, respectively. HRQoL was impaired in 3 months (95% SF, 12<50) and in 1 year (78.6% SF, 12 <50) following surgery. The mortality during admission, in 1 month, 3 months, and 1 year was 8.5% (10), 14.5% (17), 21.3% (25), and 35% (41), respectively.

CONCLUSION

A greater majority of hip fracture victims were female. Prognoses were good after surgery irrespective of the comorbidities with better outcomes in early surgery. Independent walking was significantly better in intracapsular fractures than extracapsular fractures. Patients with post-surgical complications had significant mortality. Significant loss of HRQoL increased in patients even after surgery, which resulted in an increased burden to families.

Risk Factors Associated with Fixation Failure in Intertrochanteric Fracture Treated with Cephalomedullary Nail

Purpose

Cephalomedullary (CM) nailing is widely performed in treatment of elderly patients with femoral intertrochanteric fractures. However, in cases of fixation failure, re-operation is usually necessary, thus determining factors that may contribute to fixation failure is important. In this study, we examined factors affecting the occurrence of fixation failure, such as age or fracture stability, after CM nailing in elderly patients.

Materials and Methods

This study was conducted retrospectively using registered data. From April 2011 to December 2018, CM nailing was performed in 378 cases diagnosed with femoral intertrochanteric fractures, and 201 cases were finally registered. Cases involving patients who were bed-ridden before injury, who died from causes unrelated to surgery, and those with a follow-up period less than six months were excluded.

Results

Fixation failure occurred in eight cases. Comparison of the surgical success and fixation failure group showed that the mean age was significantly higher in the fixation failure group compared with the control group (81.3±6.4 vs. 86.4±6.8; P=0.034). A significantly high proportion of unstable fractures was also observed (139/54 vs. 3/5; P=0.040), with a significantly high ratio of intramedullary reduction (176/17 vs. 5/3; P=0.034). A significantly higher ratio of unstable fractures compared with that of stable fractures was observed in the intramedullary reduction group (132/49 vs. 10/10; P=0.033).

Conclusion

Fixation failure of CM nailing is likely to occur in patients who are elderly or have unstable fracture patterns. Thus, care should be taken in order to avoid intramedullary reduction.