The Role of BMI in Hip Fracture Surgery

The role of subcutaneous fat and BMI in predicting surgical outcomes and patient reported outcomes in robotic-assisted total hip arthroplasty

Background

The purpose of this study was to assess if subcutaneous fat (SCF) or BMI is a predictor of surgical complications and patient reported outcomes in patients undergoing robotic-assisted total hip arthroplasty (THA).

Methods

Patients who underwent robotic-assisted primary THAs at one institution between 2018 and 2020 were included in this retrospective cohort study. Prior to surgery, computed tomography (CT) was used to measure SCF in the posterolateral quadrant of the hip. SCF was measured 3 centimeters (cm) proximal to the greater trochanter (PGT) and 3 cm inferior to the distal tip of the greater trochanter (DGT).Measurements were normalized to the size of the patient's bony anatomy by dividing the subcutaneous fat area measurement by the transverse diameter of the femur 10 cm inferior to the tip of the greater trochanter. Patients were divided into quintiles determined by SCF distribution around the mean (groups 1-5) and BMI (BMI<25, BMI 25-29.9, BMI 30-34.9, BMI 35-39.9, and >40). Ninety day outcomes and PROMIS (Patient Reported Outcome Measures Information System) scores were acquired from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database preoperatively, at 14-112 days post-operative and at the latest follow up.

Results

There were 175 patients identified with a mean age of 63.83 years (range 27-89) and a mean BMI of 30.73kg/m2 (range 18.2-48.4). Interclass correlation coefficient was greater than 0.9 in all PGT, DGT, and GT measurements. Analysis of Variance (ANOVA) found there was a significantly shorter time from incision to closure in quintiles 1 and 3 when compared to the SCF quintile 5 (p<0.05) and that there was a significantly shorter time from incision to closure in BMI categories 1, 2, and 3 when compared to BMI category 5 (BMI > 40). There were no differences between SCF and BMI as predictive of length of stay, transfusion status, infection, or PROMIS scores.

Conclusion

It can be concluded that hip SCF on axial CT images can reliably measure SCF and is predictive of time from incision to closure, but it does not show a significant difference in predicting the length of stay, infection, or PROMIS scores when compared to BMI.

Effects of body mass index on mortality in elderly patients with hip fractures

Hip fractures remain a substantial health concern, particularly among elderly individuals with osteoporosis, leading to high global mortality rates. This study aimed to analyze the association between body mass index (BMI) and postoperative mortality in patients who underwent surgery for hip fractures. A total of 680 patients treated at a single institution between January 2018 and December 2022 were included. Factors such as age, BMI, sex, Charlson Comorbidity Index (CCI), preoperative hemoglobin levels, American Society of Anesthesiologists score, anesthesia method, duration of surgery, and time from injury to surgery were assessed. Underweight status, male sex, higher CCI, and general anesthesia were significantly associated with 1-year and in-hospital mortality. Notably, underweight individuals exhibited a higher risk of mortality than normal-weight individuals, and female patients had lower mortality rates. This study underscores the importance of considering BMI, along with other demographic and clinical factors, in predicting postoperative mortality among patients with hip fractures, aiding the development of tailored management strategies to improve outcomes and reduce complications in this vulnerable patient population.

Association between operative duration and adverse outcomes after hip fracture surgery: A NSQIP matched cohort study

BACKGROUND

Prolonged operative duration is an independent risk factor for surgical complications in numerous subspecialties. However, associations between adverse events and operative duration of hip fracture fixation in older adults have not been well-quantified. This study aims to determine if prolonged operative duration of hip fracture surgery is related to adverse outcomes. We hypothesized that patients with high operative durations experience greater rates of 30-day complications.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively reviewed to identify older adults (55 years and above) who underwent hip fracture fixation between 2015-2019. Prolonged operative duration was defined as >75th percentile, and cases were matched using propensity scores based on demographic, surgical, and comorbidity factors. Univariate differences in adverse events (including readmission, reoperation, mortality, and organ-system complications) were analyzed. Multivariable mixed-effects logistic regression analyses were completed for statistically significant events.

RESULTS

A total of 8827 case-control pairs were identified for comparison. Rates of superficial surgical site infection (SSI) (p= 0.022), any SSI (p= 0.032), and any complication (p < 0.001) were elevated in those with prolonged surgical duration in univariate analyses. In multivariable models, prolonged operative time was associated with superficial SSI (OR 1.50, p= 0.019), any SSI (OR 1.35; p= 0.029) and any complication (OR 1.58; p < 0.001). In subgroup analyses, all findings persisted for IMN with operative time associated with superficial SSI (OR 1.98, p= 0.012), any SSI (OR 1.71; p= 0.019), and any complication (OR 1.84; p < 0.001). Operative time was associated only with any complication for hemiarthroplasty/internal fixation and sliding hip screw (OR 1.27 and 1.89, respectively; p < 0.001).

CONCLUSION

Our study demonstrates that duration of surgery is an independent risk factor for superficial SSI, any SSI, and any complication. Notably, our findings suggest that high operative durations may be most concerning for SSIs in IMN fixation, which is currently the most common choice for hip fracture fixation in the US. However, the rate of any complication is significantly elevated when surgical duration is prolonged, regardless of surgery type.

Development and Internal Validation of a Multivariable Prediction Model for Mortality After Hip Fracture with Machine Learning Techniques

In order to estimate the likelihood of 1, 3, 6 and 12 month mortality in patients with hip fractures, we applied a variety of machine learning methods using readily available, preoperative data. We used prospectively collected data from a single university hospital in Copenhagen, Denmark for consecutive patients with hip fractures, aged 60 years and older, treated between September 2008 to September 2010 (n = 1186). Preoperative biochemical and anamnestic data were used as predictors and outcome was survival at 1, 3, 6 and 12 months after the fracture. After feature selection for each timepoint a stratified split was done (70/30) before training and validating Random Forest models, extreme gradient boosting (XGB) and Generalized Linear Models. We evaluated and compared each model using receiver operator characteristic (ROC), calibration slope and intercept, Spiegelhalter's z- test and Decision Curve Analysis. Using combinations of between 10 and 13 anamnestic and biochemical parameters we were able to successfully estimate the likelihood of mortality with an area under the curve on ROC curves of 0.79, 0.80, 0.79 and 0.81 for 1, 3, 6 and 12 month, respectively. The XGB was the overall best calibrated and most promising model. The XGB model most successfully estimated the likelihood of mortality postoperatively. An easy-to-use model could be helpful in perioperative decisions concerning level of care, focused research and information to patients. External validation is necessary before widespread use and is currently underway, an online tool has been developed for educational/experimental purposes ( https://hipfx.shinyapps.io/hipfx/ ).

Risk factors for hospital-acquired pneumonia in hip fracture patients: A systematic review and meta-analysis

BACKGROUND

This study aimed to comprehensively assess the prevalence and risk factors for Hospital-acquired pneumonia (HAP) in hip fracture patients by meta-analysis.

METHODS

Systematically searched 4 English databases and 4 Chinese databases from inception until October 20, 2022. All studies involving risk factors of HAP in patients with hip fractures will be considered. Newcastle-Ottawa Scale was used to evaluate the quality of the included studies. The results were presented through Review Manager 5.4 with the pooled odds ratio (OR) and 95% confidence interval.

RESULTS

Of 35 articles included in this study, the incidence of HAP was 8.9%. 43 risk factors for HAP were initially included, 23 were eventually involved in the meta-analysis, and 21 risk factors were significant. Among them, the 4 most frequently mentioned risk factors were as follows: Advanced age (OR 1.07, 95% CI 1.05-1.10), chronic obstructive pulmonary disease (COPD) (OR 3.44, 95% CI 2.83-4.19), time from injury to operation (OR 1.09, 95% CI 1.07-1.12), time from injury to operation ≥ 48 hours (OR 3.59, 95% CI 2.88-4.48), and hypoalbuminemia < 3.5g/dL (OR 2.68, 95% CI 2.15-3.36).

DISCUSSION

Hip fracture patients diagnosed with COPD have a 3.44 times higher risk of HAP compared to the general hip fracture patients. The risk of HAP also increases with age, with patients over 70 having a 2.34-fold higher risk and those over 80 having a 2.98-fold higher risk. These findings highlight the need for tailored preventive measures and timely interventions in vulnerable patient populations. Additionally, hip fracture patients who wait more than 48 hours for surgery have a 3.59-fold higher incidence of HAP. This emphasizes the importance of swift surgical intervention to minimize HAP risk. However, there are limitations to consider in this study, such as heterogeneity in selected studies, inclusion of only factors identified through multivariate logistic regression, and the focus on non-randomized controlled trial studies.

A component-based analysis of metabolic syndrome's impact on 30-day outcomes after hip fracture: reduced mortality in obese patients

Introduction

Hip fractures are a common injury associated with significant morbidity and mortality. In the United States, there has been a rapid increase in the prevalence of metabolic syndrome (MetS), a condition comprised several common comorbidities, including obesity, diabetes mellitus, and hypertension, that may worsen perioperative outcomes. This article assesses the impact of MetS and its components on outcomes after hip fracture surgery.

Methods

Patients who underwent nonelective operative treatment for traumatic hip fractures were identified in the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Baseline characteristics between groups were compared, and significant differences were included as covariates. Multivariate regression was performed to assess the impact of characteristics of interest on postoperative outcomes. Patients with MetS, or a single one of its constitutive components-hypertension, diabetes, and obesity-were compared with metabolically healthy cohorts.

Results

In total 95,338 patients were included. Patients with MetS had increased complications (OR 1.509; P < 0.001), but reduced mortality (OR 0.71; P < 0.001). Obesity alone was also associated with increased complications (OR 1.14; P < 0.001) and reduced mortality (OR 0.736; P < 0.001). Both hypertension and diabetes alone increased complications (P < 0.001) but had no impact on mortality. Patients with MetS did, however, have greater odds of adverse discharge (OR 1.516; P < 0.001), extended hospital stays (OR 1.18; P < 0.001), and reoperation (OR 1.297; P = 0.003), but no significant difference in readmission rate.

Conclusion

Patients with MetS had increased complications but decreased mortality. Our component-based analysis showed had obesity had a similar effect: increased complications but lower mortality. These results may help surgeons preoperatively counsel patients with hip fracture about their postoperative risks.

Risk factors for urinary tract infection in geriatric hip fracture patients: a systematic review and meta-analysis

Background

Urinary tract infection (UTI) is a prevalent and consequential complication in hip fracture patients, leading to significant disability and heightened healthcare expenditures. Consequently, there is a critical need for a comprehensive systematic review to identify risk factors and establish early and effective preventive measures.

Methods

A comprehensive search was performed across the PubMed, Cochrane, Embase, Web of Science, and Scopus databases (up to August 31, 2023). Article screening, data extraction, and quality assessment were independently completed by two reviewers.

Results

Forty-four studies were eligible for inclusion, yielding an overall incidence rate of 11% (95% CI: 8%-14%). Our pooled analysis revealed 18 significant risk factors, including being female (OR = 2.23, 95% CI: 1.89-2.63), advanced age (MD = 1.35, 95% CI: 0.04-2.66), obesity (OR = 1.21, 95% CI: 1.11-1.31), catheterization (OR = 3.8, 95% CI: 2.29-6.32), blood transfusion (OR = 1.39, 95% CI: 1.21-1.58), American Society of Anesthesiologists ≥III (OR = 1.28, 95% CI: 1.18-1.40), general anesthesia (OR = 1.26, 95% CI: 1.11-1.43), intertrochanteric fracture (OR = 1.25, 95% CI: 1.01-1.54), hemiarthroplasty (OR = 1.43, 95% CI: 1.19-1.69), prolonged length of hospital stay (MD = 1.44, 95% CI: 0.66-2.23), delirium (OR = 2.66, 95% CI: 2.05-3.47), dementia (OR = 1.82, 95% CI: 1.62-2.06), Parkinson's disease (OR = 1.53, 95% CI: 1.46-1.61), diabetes (OR = 1.27, 95% CI: 1.13-1.43), hypertension (OR = 1.14, 95% CI: 1.03-1.26), congestive heart failure (OR = 1.35, 95% CI: 1.10-1.66), history of sepsis (OR = 7.13, 95% CI: 5.51-9.22), and chronic steroid use (OR = 1.29, 95% CI: 1.06-1.57).

Conclusion

Our study identifies numerous risk factors strongly associated with UTI, offering compelling evidence and actionable strategies for improving clinical prediction, enabling early intervention, and facilitating targeted UTI management.

Systematic review registration

identifier [CRD42023459600], https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=459600.

Risk factors for hospital-acquired pneumonia in hip fracture patients: a systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically assess the incidence and risk factors for hospital-acquired pneumonia (HAP) in hip fracture patients by meta-analysis.

METHODS

Systematically searched four English databases (PubMed, EMBASE, The Cochrane Library, and Web Of Science) and four Chinese databases (CNKI, CQVIP, Sinomed, and WAN FANG) from inception until 20 November 2023. All studies involving risk factors of HAP in patients with hip fractures were considered. Newcastle-Ottawa Scale was used to evaluate the quality of the included studies. The results were presented with the pooled odds ratio (OR) and 95% confidence interval (95% CI).

RESULTS

Of 35 articles (337,818 patients) included in this study, the incidence of HAP was 89 per 1000 cases. Twenty-three risk factors were eventually involved in the meta-analysis, and 21 risk factors were significant. Our study has identified four significant risk factors (advanced age, preoperative time, COPD, and hypoalbuminemia) associated with HAP, as follows: Advanced age as a continuous variable (OR 1.07, 95% CI 1.05-1.10), Advanced age > 70 years (OR 2.34, 95% CI 1.77-3.09), Advanced age > 80 years (OR 2.98, 95% CI 2.06-4.31), Chronic obstructive pulmonary disease (COPD) (OR 3.44, 95% CI 2.83-4.19), Time from injury to operation as a continuous variable (OR 1.09, 95% CI 1.07-1.12), Time from injury to operation ≥48 h (OR 3.59, 95% CI 2.88-4.48), Hypoalbuminemia < 3.0 g/dL (OR 3.03, 95% CI 1.93-4.73), and Hypoalbuminemia < 3.5 g/dL (OR 2.68, 95% CI 2.15-3.36). However, it is important to note that all the studies included in our research were retrospective in nature, which introduces certain limitations to the level of evidence and the ability to establish causal inferences.

DISCUSSION

Patients who have suffered hip fractures are at an increased risk of developing postoperative hospital-acquired pneumonia, which can lead to prolonged hospital stays and adverse clinical outcomes. Consequently, the identification of these risk factors offers novel insights and methodologies for healthcare professionals in terms of both prevention and treatment.

TRIAL REGISTRATION

Registration number: INPLASY2022100091.

Demystifying Statistics and Machine Learning in Analysis of Structured Tabular Data

Electronic health records have facilitated the extraction and analysis of a vast amount of data with many variables for clinical care and research. Conventional regression-based statistical methods may not capture all the complexities in high-dimensional data analysis. Therefore, researchers are increasingly using machine learning (ML)-based methods to better handle these more challenging datasets for the discovery of hidden patterns in patients' data and for classification and predictive purposes. This article describes commonly used ML methods in structured data analysis with examples in orthopedic surgery. We present practical considerations in starting an ML project and appraising published studies in this field.

Nutritional and Inflammatory Indices and the Risk of Surgical Site Infection After Fragility Hip Fractures: Can Routine Blood Test Point to Patients at Risk?

Background: Surgical site infection (SSI) after fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality. We aim to utilize several established nutritional and inflammatory indices to characterize patients at risk. Patients and Methods: A retrospective cohort study of patients 65 years and older, who underwent surgery following FHFs between January 2012 and June 2020. Those patients who presented with post-operative infection in the year after surgery were compared with patients who did not. The primary outcomes were serum albumin, protein energy malnutrition (PEM), albumin to globulin ratio, prognostic nutritional index (PNI), the systemic immune inflammation index, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, and body mass index. Results: A total of 1,546 patients, ages 82.4 ± 7.7, were included; 55 of whom presented with SSI. Demographics and comorbidities were similar. Anticoagulation treatment was more prevalent in the infected group (32.7% vs. 13.9%, p < 0.001) as were intra-capsular fractures (60% vs. 42.9%, respectively; p = 0.012). Of all indices estimated, only the PNI and the PEM were found to differ significantly (44.7 ± 9.6 and 26.1% vs. 49.4 ± 17.3 and 13.6% for the study and control groups respectively; p = 0.002 and 0.027). A logistic regression model was calculated to evaluate the contribution of fracture type and anticoagulation treatment as possible confounders. Both indices were found to be significant for infection after regression odds ratio, 2.25 for PEM; (95% confidence interval [CI], 1.089-4.344) and odds ratio, 0.97 for PNI (95% CI, 0.937-0.996). Conclusions: The PNI and the PEM were found to correlate with infection risk after FHF surgery. As both can be easily calculated from an accessible blood test, we recommend their routine use as a screening tool for tailored management of patients at risk for SSI.

Rehabilitation Prognostic Factors following Hip Fractures Associated with Patient's Pre-Fracture Mobility and Functional Ability: A Prospective Observation Study

Low physical function is associated with poor outcomes in the elderly population suffering from hip fractures. The present study aims to evaluate the prognostic tools for predicting patient recovery after hip fractures and investigate the correlation between the pre-fracture motor and functional statuses. A prospective study was performed, including 80 patients suffering from hip fractures. Patient history, previous falls, the type of fracture and overall survival were evaluated. Patient-reported outcome measures (SF-36, EQ-5D/VAS, Charlson Comorbidity Index (CCI), Short Physical Performance Battery (SPPB), Timed Up and Go (TUG) and Harris Hip Score (HHS)) were monitored before hospital discharge at 6 weeks, and 3, 6 and 12 months postoperatively. Overall, 55% of patients experienced at least one fall, and 46% of them used crutches before the fracture. The average CCI score was 6.9. The SPPB score improved from 1.4 ± 1.3 (1 week) to 4.4 ± 2.1 (48 weeks). A one-year age increase, female sex, and prior history of falls lead to 0.1-, 0.92-, 0.56-fold lower SPPB scores, respectively, at 12 months. The HHS recorded the greatest improvement between 6 and 12 weeks (52.1 ± 14.6), whereas the TUG score continued to improve significantly from 139.1 ± 52.6 s (6 weeks) to 66.4 ± 54 s (48 weeks). The SPPB and performance test can be routinely used as a prognostic tool.

Nonalcoholic Fatty Liver Disease Is Associated With Decreased Bone Mineral Density in Adults: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to investigate the effect of nonalcoholic fatty liver disease (NAFLD) on bone mineral density (BMD) and the risk of osteoporosis and osteoporotic fracture in adults. We searched PubMed, MEDLINE, Embase, CINAHL, Web of Science, Cochrane Library, and Scopus for observational studies published from inception to January 2023 that reported adjusted effect sizes of NAFLD on BMD, osteopenia/osteoporosis, and osteoporotic fracture. The data were synthesized using multilevel and random-effects models. A total of 19 studies were included; of these, nine (21,294 participants) evaluated the effect of NAFLD on BMD, six (133,319 participants) investigated the risk of osteoporosis, and five (227,901 participants) assessed the risk of osteoporotic fracture. This meta-analysis showed that NAFLD was associated with decreased BMD (mean difference -0.019 g/cm2 , 95% confidence interval [CI] -0.036 to -0.002, I2 = 93%) and increased risks of osteoporosis (adjusted risk ratio [RR] = 1.28, 95% CI 1.08 to 1.52, I2 = 84%) and osteoporotic fractures (adjusted RR = 1.17, 95% CI 1.00 to 1.37, I2 = 67%). Subgroup analyses revealed that NAFLD had a significantly detrimental effect on BMD in men and on the BMD of the femoral neck and total hip. Stratified analyses by ethnicity demonstrated that NAFLD was not associated with BMD, osteoporosis, or osteoporotic fracture in non-Asian populations. The publication bias of all included studies was low; however, there was considerable heterogeneity among the studies, warranting a careful interpretation of the findings. Overall, our results suggest that NAFLD is associated with decreased BMD and an increased risk of osteoporosis or osteoporotic fractures. Male sex and the BMD of the femoral neck and total hip may be potential risk factors for decreased BMD in adults with NAFLD. Additionally, ethnic disparities were observed between Asian and non-Asian populations regarding BMD and osteoporotic fractures. © 2023 American Society for Bone and Mineral Research (ASBMR).

Influencing factors on morbidity and mortality in intertrochanteric fractures

We aimed to evaluate the effect of the patient's clinical and paraclinical condition before and after surgery on short-term mortality and complication and long-term mortality. A retrospective cohort study was conducted and multivariate logistic regression was applied to determine the effect of demographic characteristics (sex, age, AO/OTA classification, height, weight, body mass index), medical history (hypertension, ischemic heart disease, diabetes mellitus, thyroid malfunction, cancer, osteoporosis, smoking) lab data (Complete blood cell, blood sugar, Blood Urea Nitrogen, Creatinine, Na, and K), surgery-related factors (Anesthesia time and type, implant, intraoperative blood transfusion, postoperative blood transfusion, and operation time), duration of admission to surgery and anticoagulant consumption on short-term mortality and complication and long-term mortality. Three hundred ten patients from November 2016 to September 2020 were diagnosed with an intertrochanteric fracture. 3.23% of patients died in hospital, 14.1% of patients confronted in-hospital complications, and 38.3% died after discharge till the study endpoint. ΔNumber of Neutrophiles is the primary determinant for in-hospital mortality in multivariate analysis. Age and blood transfusion are the main determinants of long-term mortality, and Na before surgery is the primary variable associated with postoperative complications. Among different analytical factors Na before surgery as a biomarker presenting dehydration was the main prognostic factor for in hospital complications. In hospital mortality was mainly because of infection and long-term mortality was associated with blood transfusion.

Is High Body Mass Index Protective or Detrimental in Surgical Fixation of Hip Fractures?: A Spline Regression Analysis of 22,388 Patients

OBJECTIVE

We aimed to characterize the association between BMI as a continuous variable and 30-day postoperative outcomes following hip fracture surgery through (1) 30-day readmission and reoperation; (2) local wound-related; and (3) systemic complications.

METHODS

The National Surgical Quality Improvement Program database (January 2016-December 2019) was queried for patients undergoing hip fracture open reduction and internal fixation. Baseline patient demographics, comorbidities, and patient outcomes were recorded. Multivariable regression models accounted for baseline demographics, comorbidities, and fracture patterns. Significant associations were analyzed using spline regression models to evaluate the continuous association between BMI and the aforementioned outcomes.

RESULTS

Spline models demonstrated a U-shaped curve for the odds of 30-day readmission and 30-day reoperation with nadirs at the BMI of 27.5 and 22.0 kg/m 2 . The odd ratios of superficial infection, deep infection, any wound complication, and inability to weight bear on POD 1 rose progressively starting at a BMI of 25.6, 35.5, 25.6, and 32.7 kg/m 2 respectively. Odds of 30-day mortality, transfusion, pneumonia, and delirium were greatest at the lowest recorded BMI (11.9 kg/m 2 ).

CONCLUSION

BMI has a U-shaped association with 30-day readmission and reoperation. Conversely, the highest risk of mortality and systemic complications (transfusion, pneumonia, and delirium) were within the lower BMI range, with diminishing risk as BMI increased. Local wound complications and systemic sepsis exhibited a third unique pattern with progressive rise in odds as BMI increased. The odds of any complications demonstrated a U-shaped pattern with a nadir in the overweight to obese I categories, suggesting that patients may be at lowest risk within this range.

LEVEL OF EVIDENCE

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

Pre-fracture ambulation capacity, Charlson comorbidity index, and dementia as predictors of functional impairment after bipolar hemiarthroplasty for unstable intertrochanteric fracture. A retrospective analysis in 158 octogenarian patients

Background: the primary purpose of this study was to assess the ambulatory capacity 12 months after surgery in patients that underwent bipolar hemiarthroplasty (BH) due to unstable intertrochanteric fractures (UITF). Secondly, to identify which preoperative variables influenced these modifications.

Methods

We retrospectively analyzed a consecutive series of patients older than 80 years with UITF treated with BH between 2010 and 2019. Ambulatory capacity was assessed before surgery, at 3 and 12 months postoperatively, using Koval's classification and the modified Harris Hip Score (mHHS). The registered variables were: gender, age, osteoporosis, Charlson comorbidity index (CCI), ASA classification, body mass index (BMI), and dementia. The identification of variables that impaired postoperative functionality was performed by uni- and multivariate analysis.

Results

158 patients were included with a median age of 87 (range 80-102) years and a follow-up of 29.2 (range 12-56) months. The 1-year overall ambulatory capacity impairment was 28.5% and significantly affected pre-fracture community walkers (p = 0.001). A CCI >4 (OR 2.72; p = 0.044), dementia (OR 14.13; p = 0.0001), and a Koval 2-3 (OR 12.84; p = 0.001) were identified as risk factors for this impairment.

Conclusion

Ambulation impairment at one year was 28.5%. The predictive characteristics found in this study help to identify patients with a greater risk of ambulation impairment and to focus rehabilitation plans to reduce this impact.

Are hip fracture patients with high or low body mass index at higher risk of missed care? A cohort study

AIM

To examine whether patients' body mass index is associated with missed hip fracture care consistent with national guideline-recommended care.

DESIGN

A nationwide, population-based cohort study using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry.

METHODS

The study population consisted of 39,835 patients ≥65 years admitted with a hip fracture and discharged between 1st of January 2012 and 29th of November 2017. National guideline-recommended care consists of preoperative optimization, early surgery, mobilization within 24 h, basic mobility assessment, nutrition screening, post-discharge rehabilitation program, and osteoporotic and fall prophylaxis. We used binomial regression to estimate the relative risk for the fulfilment of the individual measures with 95% confidence interval. Multiple imputation method was applied to handle missing values of body mass index.

RESULTS

The overall fulfilment of the individual measures ranged from 43% for pre-operative optimization to 95% for receiving a post-discharge rehabilitation program. The obese patients had a lower fulfilment of surgery within 36 h compared to patients with normal weight. No differences in fulfilment of the other measures were found. However, patients with missing data on body mass index had the highest risk of missed care. In conclusion, patients with missing BMI values had the highest risk of missed care. The obese patients had a slightly higher risk of long waiting times for surgery than normal-weighted patients.

NO PATIENT OR PUBLIC CONTRIBUTION

This study was done based on population-based data from medical registries and data was analysed by the authors only.

Obese elderly patients with hip fractures may have better survival outcomes after surgery

BACKGROUND

In recent years, there has been an increasing amount of research on the "obesity paradox". So our primary objective was to explore whether this phenomenon exists in our study, and secondary objective was to determine the effect of body mass index (BMI) on major complications, and the incidence of acute kidney injury (AKI) after hip fracture surgery after controlling for confounding factors.

METHODS

We included patients over 70 years old with hip fracture who were admitted to the Department of Orthopedics, Peking University First Hospital between 2015 and 2021. Patients were classified as underweight (UW, < 18.5 kg/m²), normal weight (NW, 18.5-24.9 kg/m²), overweight (OW, 25.0-29.9 kg/m²) and obese (OB, ≥ 30.0 kg/m²). We analyzed demographic characteristics, operation information and postoperative outcomes. Using multivariate regression with normal-weight patients as the reference, we determined the odds of 1-year mortality, major complications, and AKI by BMI category.

RESULTS

A total of 644 patients were included. Nine percent of patients died after 1 year, 18% had major postoperative complications, and 12% had AKI. There was a U-shaped relationship between BMI and the rates of major complications or AKI. However, there was a linear decreasing relationship between 1-year mortality and BMI. After controlling for confounding factors, multivariate regression analysis showed that the risk of 1-year mortality after surgery was 2.24 times higher in underweight patients than in normal-weight patients (P < 0.05, OR: 2.24, 95% CI 1.14-4.42). Compared with normal-weight patients, underweight patients had a 2.07 times increased risk of major complications (P < 0.05, OR 2.07, 95% CI 1.21-3.55), and the risk of major complications in obese patients was 2.57 times higher than that in normal-weight patients (P < 0.05, OR 2.57, 95% CI 1.09-6.09). Compared with normal-weight, underweight patients had a 2.18 times increased risk of AKI (P < 0.05, OR 2.18, 95% CI 1.17-4.05).

CONCLUSIONS

The 1-year mortality risk of patients with higher BMI was significantly reduced. Besides, compared with normal-weight patients, underweight patients and obese patients have a higher risk of major complications; low-weight and obese patients are at higher risk for AKI.

Incidence and risk factors for surgical site infection (SSI) after primary hip hemiarthroplasty: an analysis of the ACS-NSQIP hip fracture procedure targeted database

INTRODUCTION

Primary hip hemiarthroplasty (HHA) is frequently utilized to treat geriatric hip fractures, which are associated with significantly higher morbidity and mortality. While not particularly common, surgical site infection (SSI) is a major complication that frequently requires revision surgery in a frail population. The objective of this study was to determine the incidence of and risk factors for SSI after HHA in hip fracture patients.

MATERIALS AND METHODS

This retrospective cohort study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Geriatric patients (65+) who underwent HHA for non-pathologic, traumatic hip fractures between 2016-2017 were included. Demographic variables, comorbidities, operative variables, and complications were compared between "SSI" and "non-SSI" groups. Multivariate regression identified independent risk factors for postoperative SSI. Significance was set at P = 0.05.

RESULTS

A total of 6169 patients were included. The overall incidence of SSI was 1.3%. SSI was significantly associated with body mass index (BMI), preoperative functional status, congestive heart failure, chronic corticosteroid use, intraoperative time, sepsis, wound dehiscence, readmission within 30-days, and reoperation. On multivariate analysis, chronic steroid use (OR: 2.30, 95% CI: 1.13-4.70), BMI ≥ 35 kg/m² (OR: 3.59, 95% CI: 1.57-8.18), and intraoperative time ≥120 mins (OR: 2.15, 95% CI: 1.08-4.27) were found to be independent risk factors.

CONCLUSIONS

Postoperative SSI is a serious complication that is responsible for prolonged hospital stays, increased mortality, and greater healthcare costs. Here, we identified multiple risk factors for SSI after primary HHA in the US elderly population.

Association of age, sex and race with prescription of anti-osteoporosis medications following low-energy hip fracture in a retrospective registry cohort

BACKGROUND

Initiation of anti-osteoporosis medications after hip fracture lowers the risk of subsequent fragility fractures. Historical biases of targeting secondary fracture prevention towards certain groups may result in treatment disparities. We examined associations of patient age, sex and race with anti-osteoporosis medication prescription following hip fracture.

METHODS

A cohort of patients with a hip fracture between 2016-2018 was assembled from the American College of Surgeons National Surgical Quality Improvement Program registry. Patients on anti-osteoporosis medications prior to admission were excluded. Multivariable logistic regression was used to determine adjusted associations between patient age, sex and race and their interactions with prescription of anti-osteoporosis medications within 30 days of surgery.

RESULTS

In total, 12,249 patients with a hip fracture were identified with a median age of 82 years (IQR: 73-87), and 67% were female (n = 8,218). Thirty days postoperatively, 26% (n = 3146) of patients had been prescribed anti-osteoporosis medication. A significant interaction between age and sex with medication prescription was observed (p = 0.04). Male patients in their 50s (OR:0.75, 95%CI:0.60-0.92), 60s (OR:0.81, 95%CI:0.70-0.94) and 70s (OR:0.89, 95%CI:0.81-0.97) were less likely to be prescribed anti-osteoporosis medication compared to female patients of the same age. Patients who belonged to minority racial groups were not less likely to receive anti-osteoporosis medications than patients of white race.

INTERPRETATION

Only 26% of patients were prescribed anti-osteoporosis medications following hip fracture, despite consensus guidelines urging early initiation of secondary prevention treatments. Given that prescription varied by age and sex, strategies to prevent disparities in secondary fracture prevention are warranted.

An innovative scoring system for predicting an excellent Harris hip score after proximal femoral nail anti-rotation in elderly patients with intertrochanteric fracture

Typically, intramedullary and extramedullary devices are used to treat elderly with intertrochanteric fractures. The majority of previous research has focused on the association between surgical factors and mechanical failure after internal fixation. There is, however, limited evidence to demonstrate the association between functional outcomes after proximal femoral nail anti-rotation (PFNA) fixation and the non-surgical factors such as patient's comorbidities. The aim of this study is to determine the predictive factors associated with excellent outcome, as well as to develop an integrated scoring system to predict the outcome after PFNA fixation in elderly patients with an intertrochanteric fracture. A retrospective study was conducted between January 2012 and December 2018. Elderly patients with low-energy intertrochanteric fractures who underwent PFNA fixation and at least a year of follow-up were recruited. Demographics, comorbidities, cognitive status, time to operation, and surgical parameters of the patients were all identified. Excellent and non-excellent outcomes were assessed by Harris Hip Score (HHS) after a one-year follow up. Regression analysis was used to determine the predictors for an excellent functional outcome. A new integrated scoring system (ISSI; Integrate Scoring System in elderly patients with Intertrochanteric fracture) was developed and validated. 450 elderly patients were randomly divided into two cohorts: a development (N = 225) and validation cohorts (N = 225). In this study, age < 85 years, normal weight/overweight, Charlson comorbidity index (CCI) < 6, no cognitive impairment, a modified AO/OTA 31A1.3, time to operation < 6 days, and Tip Apex Distance between 20 and 30 mm were significantly associated with an excellent outcome after PFNA fixation. The range of ISSI score was between 0 to 16 and the cut-off score of 13 was found to have the highest discriminatory power to determine the excellent functional outcome where the area of ROC was 0.85. In regards to the validation cohort, the sensitivity and specificity of ISSI score was 69% and 87%, respectively, and the AUC was 0.81. The ISSI score is effortless and practical for orthopedic surgeons for predicting an outcome after PFNA fixation in elderly patients with an intertrochanteric fracture.

The epidemiological status of osteoporotic hip fractures: A bicentric comparative and retrospective study

BACKGROUND

Osteoporotic hip fractures have posed a significant burden to society, and more epidemiological data is required.

OBJECTIVE

To compare the epidemiological differences of hip fracture patients in Spain and China.

METHOD

This was a retrospective comparative study. Comparisons were made in terms of morbidity, demographic and anthropometric characteristics, length of stay, cost of hospitalization, and mortality by consulting the medical histories of osteoporotic hip fractures in two hospitals. The t test was used for measurement data, and the X2 test was used for count data. The difference is statistically significant when p< 0.05.

RESULTS

A total of 757 patients were enrolled in this study, with 426 from Virgen Macarena University Hospital (HUVM) and 331 from Xi'an Daxing Hospital (XDH). The average age was 81.4 ± 9.26 and 76.0 ± 8.08 years; the proportion of women was 74.9% and 68.0%, respectively. The incidence of osteoporotic hip fractures in Seville residents over 50 years old was approximately 239 per 100,000 residents, compared to 158 per 100,000 residents in Xi'an. The timing of surgery in Spanish patients was significantly longer than in Chinese patients, 78.7 ± 48.2 vs. 60.7 ± 43.1 hours, p= 0.000. There were 81 deaths in Spain and 43 deaths in China during the one-year follow-up period (p= 0.026).

CONCLUSIONS

In terms of incidence, demographics, surgical methods, and mortality, there are significant differences between hip fracture patients in Seville, Spain and Xi'an, China.

The impact of body mass index on mortality rates of hip fracture patients: a systematic review and meta-analysis

Obesity has been recognized as a global epidemic as approximately one-third of the world's population. Findings on early and late mortality rates between obese, overweight, and underweight vs normal body mass index (BMI) patients confirm that the obese and overweight patients were found to have lower risk and underweight patients were found to have increased risk of mortality as compared to normal weighted patients. It is unclear if the "obesity paradox" exists with survival outcomes of hip fracture patients. We hereby reviewed early (in-hospital and 30-day mortality) and late mortality (≥ 1-year) rates between obese, overweight, and underweight vs normal body mass index (BMI) patients with hip fractures. PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar were searched for studies reporting mortality rates of hip fracture patients based on BMI. We pooled crude and adjusted mortality rates in a random-effects model. Eleven studies were included. Meta-analysis indicated significantly reduced risk of early (RR: 0.64 95% CI: 0.59, 0.69 I² = 0% p < 0.00001) and late mortality rates (RR: 0.78 95% CI: 0.67, 0.91 I² = 93% p = 0.002) in obese vs normal BMI patients. Meta-analysis failed to demonstrate any statistically significant difference in early mortality (RR: 0.90 95% CI: 0.54, 1.53 I² = 44% p = 0.71) but significantly reduced risk of late mortality in overweight vs normal BMI patients (RR: 0.85 95% CI: 0.73, 0.93 I² = 84% p = 0.003). Scarce data suggested increased risk of early (RR: 1.44 95% CI: 1.08, 1.93 I² = 26% p = 0.01) and late mortality (RR: 1.23 95% CI: 1.08, 1.41 I² = 7% p = 0.002) in underweight vs normal BMI patients. Adjusted data corroborated the reduced risk of mortality in overweight (HR: 0.78 95% CI: 0.74, 0.83 I² = 0% p < 0.0001) and obese patients (HR: 0.66 95% CI: 0.60, 0.73 I² = 0% p < 0.0001). Our results indicate that the "obesity paradox" exists with survival outcomes of hip fracture patients. Obese and overweight patients were found to have lower risk and underweight patients were found to have increased risk of mortality as compared to normal weighted patients.

Analyzing the Risk Factors of Mortality after Osteoporotic Hip Fractures Using the National Health Insurance Service Sample Cohort 2.0 Database

Purpose

The purpose of this study is to determine risk factors that affect mortality following osteoporotic hip fracture in patients 50 years or older using the National Health Insurance Service (NHIS) sample cohort 2.0 database.

Materials and Methods

Data from 2,533 patients who satisfied the inclusion criteria for the NHIS sample cohort 2.0 database were used in this study. Data from patients who suffered osteoporotic hip fractures between 2002-2015 were used. An analysis of correlations between the incidence of osteoporotic hip fractures and various factors (sex, age, underlying diseases, etc.) was performed. Analysis of the associations between the mortality of osteoporotic hip fracture and the various factors with hazard ratio (HR) was performed using Cox regression models.

Results

Patient observation continued for an average of 38.12±32.09 months. During the observation period, a higher incidence of hip fracture was observed in women; however, higher mortality following the fracture was observed in men (HR=0.728; 95% confidence interval [CI], 0.635-0.836). The incidence and mortality of fractures increased when there were increasing age, more than three underlying diseases (HR=1.945; 95% CI, 1.284-2.945), cerebrovascular diseases (HR=1.429; 95% CI, 1.232-1.657), and renal diseases (HR=1.248; 95% CI, 1.040-1.497). Also, higher mortality was observed in patients who were underweight (HR=1.342; 95% CI, 1.079-1.669), current smokers (HR=1.338; 95% CI, 1.104-1.621), and inactivity (HR=1.379; 95% CI, 1.189-1.601).

Conclusion

Male gender, the presence of cerebrovascular or kidney disease, a more than three underlying diseases, underweight, a current smoker, and inactivity were risk factors that increased mortality.

Reasons for Surgical Delay in Patients With Hip Fracture

INTRODUCTION

15% of patients with hip fracture older than 65 years in Israel have delayed surgery. The aim of this study was to determine which patient and/or organizational factors are associated with a delay of beyond 48 hours in hip fracture repair surgery.

METHODS

A retrospective cohort study of 281 patients with hip fracture who underwent surgery during 2019-2020. Characteristics of patients with early surgery (n = 40) and patients with delayed surgery (n = 241) were compared.

RESULTS

Presence of a cardiac disease (odds ratio [OR] = 1.38), pulmonary disease (OR = 1.21), or obesity (OR = 1.18) was identified as risk factors for surgical delay. Each additional comorbidity increased the risk. Most of the documented reasons for delay were medical, with antiplatelet therapy the most common (n = 8, 20%). Unavailable operating rooms were another common reason for delays (n = 8, 20%). In addition, a higher percentage of patients with delayed surgery were admitted in August and September (42.5%).

CONCLUSIONS

It seems that most delays were for medical reasons. However, it is unclear whether allegedly clinically justified delays were indeed of benefit to the patients. Health care organizations should strive to minimize the impact of organizational factors on surgical delay.

Clinical Score for Predicting the Risk of Poor Ambulation at Discharge in Fragility Femoral Neck Fracture Patients: A Development Study

Surgical treatment in patients with fragility femoral neck fractures often leads to a longer length of hospital stay (LOS) and higher costs. Intensive rehabilitation is one of the choices to reduce LOS, but patient selection criteria are controversial. We intended to develop a clinical score to predict the risk of poor ambulation at discharge. This study was based on a retrospective cohort of patients diagnosed with fragility femoral neck fractures surgically managed from January 2010 to December 2019 at Chiang Mai University (CMU) Hospital. Pre-, intra-, and post-operative factors that affect rehabilitation training were candidate predictors. All patients were categorized into able or unable groups based on their ability to bear self-weight at discharge. Logistic regression was used for score derivation. Five hundred and nine patients were included in this study. Male sex, end-stage kidney disease (ESRD), cerebrovascular disease, psychiatric disorders, pre-fracture ambulation with gait aids, concomitant fracture, post-operative intensive care unit (ICU) admission or ventilator use, and urinary catheter use at second day post-operation were identified as the prognostic factors. The score showed an AuROC of 0.84 with good calibration. The score can be used for risk stratification on the second day post-operation. External validation is encouraged before clinical implementation.

The Role of Smoking and Body Mass Index in Mortality Risk Assessment for Geriatric Hip Fracture Patients

Background

Smoking, obesity, and being below a healthy body weight are known to increase all-cause mortality rates and are considered modifiable risk factors. The purpose of this study is to assess whether adding these risk factors to a validated geriatric inpatient mortality risk tool will improve the predictive capacity for hip fracture patients. We hypothesize that the predictive capacity of the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool will improve.

Methodology

Between October 2014 and August 2021, 2,421 patients >55-years-old treated for hip fractures caused by low-energy mechanisms were analyzed for demographics, injury details, hospital quality measures, and mortality. Smoking status was recorded as a current every-day smoker, former smoker, or never smoker. Smokers (current and former) were compared to non-smokers (never smokers). Body mass index (BMI) was defined as underweight (<18.5 kg/m²), healthy weight (18.5-24.9 kg/m²), overweight (25.0-24.9 kg/m²), or obese (>30 kg/m²). The baseline STTGMA tool for hip fractures (STTGMAHIP_FX_SCORE) was modified to include patients’ BMI and smoking status (STTGMA_MODIFIABLE), and new mortality risk scores were calculated. Each model’s predictive ability was compared using DeLong’s test by analyzing the area under the receiver operating curves (AUROCs). Comparative analyses were conducted on each risk quartile.

Results

A comparison of smokers versus non-smokers demonstrated that smokers experienced higher rates of inpatient (p = 0.025) and 30-day (p = 0.048) mortality, myocardial infarction (p < 0.01), acute respiratory failure (p < 0.01), and a longer length of stay (p = 0.014). Comparison among BMI cohorts demonstrated that underweight patients experienced higher rates of pneumonia (p = 0.033), decubitus ulcers (p = 0.046), and the need for an intensive care unit (ICU) (p < 0.01). AUROC comparison demonstrated that STTGMA_MODIFIABLE significantly improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.792 vs. 0.672, p = 0.0445). Quartile stratification demonstrated the highest risk cohort had a longer length of stay (p < 0.01), higher rates of inpatient (p < 0.01) and 30-day mortality (p < 0.01), and need for an ICU (p < 0.01) compared to the minimal risk cohort. Patients in the lowest risk quartile were most likely to be discharged home (p < 0.01).

Conclusions

Smoking, obesity, and being below a healthy body weight increase the risk of perioperative complications and poor outcomes. Including smoking and BMI improves the STTGMAHIP_FX_SCORE tool to predict mortality and risk stratify patient outcomes. Because smoking, obesity, and being below a healthy body weight are modifiable patient factors, providers can counsel patients and implement lifestyle changes to potentially decrease their risk of longer-term poor outcomes, especially in the setting of another fracture. For patients who are former smokers, providers can use this information to encourage continued restraint and healthy choices.

Body mass index and postoperative mortality in patients undergoing coronary artery bypass graft surgery plus valve replacement: a retrospective cohort study

Background

The relationship between body mass index (BMI) and postoperative mortality in patients who undergo coronary artery bypass graft (CABG) surgery plus valve replacement is uncertain. We aimed to investigate the association between body mass index (BMI) and postoperative mortality among patients who simultaneously underwent both CABG surgery plus valve replacement.

Methods

We retrospectively analyzed 1976 patients who underwent CABG surgery at our hospital between January 2017 and April 2021, including 202 patients who underwent valve replacement surgery during the same period. We analyzed the relationship between BMI and postoperative mortality. The relationship between BMI and postoperative mortality was assessed using smooth curve fitting and a Multiple logistic regression model.

Results

The results of smoothing curve fitting showed that BMI and postoperative mortality had a non-linear relationship, and the resulting curve exhibited a two-stage change and a breakpoint. Postoperative mortality is higher in patients that have a body mass index above 25 kg/m² compared to patients having a body mass index between 18 and 25 kg/m².

Conclusions

Our study found a non-linear relationship between BMI and postoperative mortality in patients undergoing CABG plus valve replacement after adjusting for potential confounders. The causal relationship between BMI and postoperative mortality still requires further investigations.

Inverse relation of body weight with short-term and long-term mortality following hip fracture surgery: a meta-analysis

Background

The obesity paradox, which suggests that high body weight is positively associated with survival in some diseases, has not been proven in patients with hip fracture. In this study, meta-analysis of previous studies on the impacts of body weight on postoperative mortality following hip fracture surgery in older adults was conducted.

Methods

PubMed, Embase, and Cochrane library were searched for studies investigating the correlation between mortality after hip fracture surgery and body weight. The search main items included: (“Body mass index” OR “BMI” or “body weight”) and (“hip fracture” or “hip fractures”). Studies contained data on short-term (≤ 30-day) and long-term (≥ 1 year) mortality after hip fracture and its association with distinct body weight or BMI groups were reported as full-text articles were included in this meta-analysis.

Results

Eleven separate studies were included. The definitions of underweight and obesity differed among the included studies, but the majority of the enrolled studies used the average body weight definition of a BMI of 18.5 to 24.9 kg/m²; underweight referred to a BMI of < 18.5 kg/m²; and obesity pertained to a BMI of > 30 kg/m². Based on the generalized definitions of body-weight groups from the enrolled studies, the group with obesity had lower long-term (odds ratio [OR]: 0.63, 95% CI: 0.50–0.79, P < 0.00001) and short-term (OR: 0.63, 95% CI: 0.58–0.68, P ≤ 0.00001) mortality rates after hip fracture surgery when compared with patients with average-weight group. However, compared with the average-weight group, the underweight group had higher long-term (OR: 1.51, 95% CI: 1.15-1.98, P=0.003) and short-term (OR: 1.49, 95% CI: 1.29-1.72, P<0.00001) mortality rates after hip fracture surgery.

Conclusions

Current evidence demonstrates an inverse relation of body weight with long-term and short-term mortality after hip fracture surgery in older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03131-3.

Prognostic Factors of the Inability to Bear Self-Weight at Discharge in Patients with Fragility Femoral Neck Fracture: A 5-Year Retrospective Cohort Study in Thailand

An inability to bear self-weight is one of the unfavorable results in geriatric hip fracture, which needs to be prevented. This study determines pre-operative, intra-operative, and post-operative prognostic factors of the inability to bear self-weight at discharge in patients with fragility femoral neck fracture. This retrospective study was conducted at Chiang Mai University (CMU) hospital with an observational cohort design. Electronic medical records of patients aged ≥ 50 years old with fragility femoral neck fractures between 1 January 2015 and 31 December 2019 were reviewed. Pre-, intra-, and post-operative factors were collected. Ambulation status at discharge time was classified into either ability or inability to bear self-weight. Analysis of prognostic factors was done using multivariable risk ratio regression. In total, 269 patients were recruited in this study. Significantly prognostic factors of inability to bear self-weight at discharge were end-stage renal disease (ESRD), cirrhosis, cerebrovascular disease, pre-fracture ambulatory status, having associated fractures, increasing intra-operative blood loss, and having pressure sore. These prognostic factors could be used to predict patients’ outcomes at discharge. Proper management could then be offered to the patients by the multidisciplinary care team to enhance surgical outcomes.

Low body mass index is a risk factor for increased post-operative mortality and poor functional improvement in distal femur fractures among patients aged over 65: A multicentre (TRON) study

BACKGROUND

Distal femur fractures have been reported to have a mortality rate comparable to hip fractures, but the risk is still unknown. Recent studies have reported that low body mass index (BMI) is a risk factor for mortality in the elderly. We investigated the efficacy of low BMI for predicting the risk of mortality in distal femur fractures in patients aged over 65 within 18 months after injury and its impact on postoperative clinical outcomes and mortality.

METHODS

Data from patients followed for more than six months were obtained from our trauma research group's database. We investigated risk factors for increased mortality using Cox proportional hazards models. We divided the analysed cases into low (<18.5 kg/m²) and high (>18.5 kg/m²) BMI groups. We adjusted the background characteristics of the groups by patient matching, and evaluated the postoperative mortality, complication rate, and knee society score (KSS).

RESULTS

We identified 216 patients, including 58 (26.9%) with low BMI values. Low BMI was an independent risk factor for mortality in all models (Hazard Ratio: 2.9, p = 0.011). The overall survival rate of the low BMI group at 18 months was significantly lower than that of the high BMI group (70.7% vs. 89.1%; p = 0.003). The complication rates of the low BMI and high BMI groups were not significantly different (33.3% vs. 22.2%; p = 0.283). The mean KSS values at 3, 6, and 12 months in the low BMI group was significantly worse than that in the high BMI group (78.7 ± 16.2 vs. 84.8 ± 13.1; p = 0.035, 82.2 ± 16.9 vs. 89.7 ± 8.9; p = 0.005, 86.4 ± 13.0 vs. 91.4 ± 8.4; p = 0.020, respectively).

CONCLUSIONS

Our study indicated that low BMI was independent associated with increased mortality and impaired postoperative functional recovery in distal femur fractures of the elderly patients.

Development and validation of a model for predicting mortality in patients with hip fracture

OBJECTIVE

to develop a user-friendly prediction tool of 1-year mortality for patients with hip fracture, in order to guide clinicians and patients on appropriate targeted preventive measures.

DESIGN

population-based cohort study from 2011 to 2017 using nationwide data from the Danish Hip Fracture Registry.

SUBJECTS

a total of 28,791 patients age 65 and above undergoing surgery for a first-time hip fracture.

METHODS

patient-related prognostic factors at the time of admission were assessed as potential predictors: Nursing home residency, comorbidity (Charlson Comorbidity Index [CCI] Score), frailty (Hospital Frailty Risk Score), basic mobility (Cumulated Ambulation Score), atrial fibrillation, fracture type, body mass index (BMI), age and sex. Association with 1-year mortality examined by determining the cumulative incidence, applying univariable logistic regression and assessing discrimination (area under the receiver operating characteristics curve [AUROC]). The final model (logistic regression) was utilised on a development cohort (70% of patients). Discrimination and calibration were assessed on the validation cohort (remaining 30% of patients).

RESULTS

all predictors showed an association with 1-year mortality, but discrimination was moderate. The final model included nursing home residency, CCI Score, Cumulated Ambulation Score, BMI and age. It had an acceptable discrimination (AUROC 0.74) and calibration, and predicted 1-year mortality risk spanning from 5 to 91% depending on the combination of predictors in the individual patient.

CONCLUSIONS

using information obtainable at the time of admission, 1-year mortality among patients with hip fracture can be predicted. We present a user-friendly chart for daily clinical practice and provide new insight regarding the interplay between prognostic factors.

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

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

Bipolar hemiarthroplasty in unstable intertrochanteric fractures in elderly patients. The predictive value of the Charlson Comorbidity Index in 1-year mortality

BACKGROUND

Hip fractures have a significant impact on morbidity and mortality in the elderly. Aims: We retrospectively evaluated the predictive role of the Charlson Comorbidity Index (CCI) for 1-year mortality in elderly patients with unstable intertrochanteric hip fractures (ITHF) treated with bipolar hemiarthroplasty. The secondary objective was to identify other relationships, if any, between the variables recorded and mortality.

METHODS

We included ≥75-year-old patients with unstable ITHF treated with bipolar hemiarthroplasty. We recorded patient gender, age, Body Mass Index, pre-fracture walking ability (Parker Mobility score, modified Harris Hip Score), America Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), time to surgery, time to mobilization, hospital stay, and postoperative complications. Uni- and multivariate logistic regression analysis were performed. Sensitivity and specificity were calculated using a ROC curve.

RESULTS

A total of 135 patients with a mean age of 87.34 ± 5.5 years were included. The overall 1-year mortality rate was 18.5%. The CCI (OR 1.64 CI 95% 1.21-2.23; p 0.00821) and postoperative complications (OR 3.5 CI 95% 1.19-10.23 p 0.0202) were identified as independent predictors of 1-year mortality in the univariate regression and confirmed in the multivariate regression. CCI sensitivity to predict 1-year mortality was 80%.

CONCLUSION

CCI has shown acceptable sensitivity in the prediction of 1-year mortality in elderly patients with unstable ITHF treated with bipolar hemiarthroplasty. It is of utmost importance to prevent postoperative complications due to their significant impact on 1-year mortality.

Malnutrition, poor function and comorbidities predict mortality up to one year after hip fracture: a cohort study of 2800 patients

PURPOSE

Despite extensive research, a complete understanding of factors influencing mortality risk after hip fractures is lacking. Previous research has focused on static risk factors; however, to improve outcomes, attention should be directed towards risk factors that may be optimised. The present study aimed to investigate the association of 19 risk factors with mortality among patients with hip fracture treated according to a well-defined guideline.

METHODS

The study was a retrospective analysis of a large prospective patient cohort with all consecutive patients surgically treated for a hip fracture from January 2011 to December 2017 included (n = 2800). Variables were obtained from patient records and the Holstebro Hip Fracture Database comprising prospectively registered data on demographics, comorbidity, malnutrition (low Body Mass Index (BMI) or albumin) and hospital stay (including fracture and surgical data, biochemistry, mobilisation and discharge). Outcomes were 30-day and one-year mortality.

RESULTS

Patients were predominantly female (66%); median age 81.6 years. Overall mortality was 9% at 30 days and 24% at one year. Age ≥ 75 years, male gender, nursing home residence, cognitive impairment, American Society of Anesthesiologists (ASA) score ≥ 3, BMI < 20 kg/m², albumin < 35 g/l, creatinine ≥ 100 µmol/l, a low New Mobility Score and no mobilisation were all associated with increased mortality at 30 days and one year.

CONCLUSION

In addition to non-modifiable risk factors, comorbidities (expressed as high ASA score and creatinine), malnutrition, and failure to achieve early post-operative mobilisation were associated with increased short and long-term mortality among patients with hip fracture: these are potentially modifiable. The effect of optimisation interventions warrants further research.

Life expectancy of older people living in aged care facilities after a hip fracture

To the authors’ knowledge, no study has been conducted on life expectancy for aged care facility residents with hip fracture. We assessed life expectancy of 240 residents of aged care facilities in Australia who experienced recent hip fracture treated with surgery. 149 deaths occurred over a mean follow-up of 1.2 years. Being female and having better cognition were associated with longer life expectancy. Increased age was associated with shorter life expectancy. The cumulative mortality rate within three months after hip fracture was 25.0% while the cumulative mortality rate for the whole study period was 62.1%. Life expectancy was 8.2 years, 4.8 years and 2.8 years for 70, 80 and 90-years old female patients. Life expectancy was 3.8 years, 2.2 years and 1.3 years for 70, 80 and 90 years old male patients, respectively. In conclusion, age, gender and cognition level were associated with life expectancy of hip fracture patients living in aged care facilities and their life expectancy was much shorter than that of the general Australian population.

Allogeneic Red Blood Cell Transfusion Rate and Risk Factors After Hemiarthroplasty in Elderly Patients With Femoral Neck Fracture

Objective

This study aimed to determine the rate and risk factors of allogeneic red blood cell transfusions (ABT) after hemiarthroplasty (HA) in elderly patients with femoral neck fracture (FNF).

Methods

The subjects of the study were elderly patients (≥65 years old) who were admitted to the geriatric trauma orthopedics ward of Beijing Jishuitan Hospital between March 2018 and June 2019 for HA treatment due to an FNF. The perioperative data were collected retrospectively, and univariate and multivariate stepwise logistic regression analyses were performed to determine the post-operative ABT rate and its risk factors.

Results

There were 445 patients in the study, of whom 177 (39.8%) received ABT after surgery. Multivariate stepwise logistic regression analysis showed that preoperative low hemoglobin (Hb), high intraoperative blood loss (IBL), advanced age, and a low body mass index (BMI) are independent risk factors of ABT after HA in elderly FNF patients.

Conclusion

ABT after HA is a common phenomenon in elderly patients with FNF. Their post-operative ABT needs are related to preoperative low Hb, high IBL, advanced age, and low BMI. Therefore, ABT can be reduced by taking these factors into account. When the same patient had three risk factors (preoperative low hemoglobin, advanced age, and low BMI), the risk of ABT was very high (78.3%). Also, when patients have two risk factors of preoperative low hemoglobin and low BMI, the risk of ABT was also high (80.0%).

Comparison of Two Malnutrition Assessment Scales in Predicting Postoperative Complications in Elderly Patients Undergoing Noncardiac Surgery

Background: The present study was designed to investigate the relationship between two malnutrition assessment scales, perioperative nutrition screen (PONS) and Nutritional Risk Screening 2002 (NRS2002), with postoperative complications in elderly patients after noncardiac surgery.

Methods: This was a secondary analysis of a prospective cohort study. Elderly patients (65–90 years) undergoing noncardiac surgery were enrolled in Peking University First Hospital. Malnutrition was screened by PONS and NRS2002 at the day before surgery. Multivariable analysis was employed to analyze the relationship between PONS and NRS2002 and postoperative 30-day complications. Receiver operating characteristic (ROC) curve was generated to evaluate the predictive value of PONS and NRS2002 in predicting postoperative complications.

Results: A total of 915 patients with mean age of 71.6 ± 5.2 years were consecutively enrolled from September 21, 2017, to April 10, 2019. The incidence of malnutrition was 27.3% (250/915) by PONS ≥ 1 and 53.6% (490/915) by NRS2002 ≥ 3. The overall incidence of complications within postoperative 30 days was 45.8% (419/915). After confounders were adjusted, malnutrition by PONS ≥ 1 (OR 2.308, 95% CI 1.676–3.178, P < 0.001), but not NRS2002 ≥ 3 (OR 1.313, 95% CI 0.973–1.771, P = 0.075), was related with an increased risk of postoperative complications. ROC curve analysis showed that the performances of PONS [area under the ROC curve (AUC) 0.595, 95% CI 0.558–0.633] showed very weak improvement in predicting postoperative complications than NRS2002 score (AUC 0.577, 95% CI 0.540–0.614).

Conclusion: The present study found that malnutrition diagnosed by PONS was related with an increased risk of postoperative complications. The performances of PONS and NRS2002 were poor in predicting overall postoperative complications.

Clinical Trial Registration:www.chictr.org.cn, identifier: ChiCTR-OOC-17012734.

A Bibliometric Analysis of Fragility Fractures: Top 50

Background and Objectives: The population is aging and fragility fractures are a research topic of steadily growing importance. Therefore, a systematic bibliometric review was performed to identify the 50 most cited articles in the field of fragility fractures analyzing their qualities and characteristics. Materials and Methods: From the Core Collection database in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to fragility fractures were identified in February 2021 using a multistep approach. Year of publication, total number of citations, average number of citations per year since year of publication, affiliation of first and senior author, geographic origin of study population, keywords, and level of evidence were of interest. Results: Articles were published in 26 different journals between 1997 and 2020. The number of total citations per article ranged from 12 to 129 citations. In the majority of publications, orthopedic surgeons and traumatologists (66%) accounted for the first authorship, articles mostly originated from Europe (58%) and the keyword mostly used was “hip fracture”. In total, 38% of the articles were therapeutic studies level III followed by prognostic studies level I. Only two therapeutic studies with level I could be identified. Conclusions: This bibliometric review shows the growing interest in fragility fractures and raises awareness that more high quality and interdisciplinary studies are needed.

Complications and 30-Day Mortality Rate After Hip Fracture Surgery in Superobese Patients

OBJECTIVE

Paradoxically, overweight and obesity are associated with lower odds of complications and death after hip fracture surgery. Our objective was to determine whether this "obesity paradox" extends to patients with "superobesity." In this study, we compared rates of complications and death among superobese patients with those of patients in other body mass index (BMI) categories.

METHODS

Using the National Surgical Quality Improvement Program database, we identified >100,000 hip fracture surgeries performed from 2012 to 2018. Patients were categorized as underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), obese (BMI 30-39.9), morbidly obese (BMI 40-49.9), or superobese (BMI ≥50). We analyzed patient characteristics, surgical characteristics, and 30-day outcomes. Using multivariate regression with normal-weight patients as the referent, we determined odds of major complications, minor complications, and death within 30 days by BMI category.

RESULTS

Of 440 superobese patients, 20% had major complications, 33% had minor complications, and 5.2% died within 30 days after surgery. When comparing patients in other BMI categories with normal-weight patients, superobese patients had the highest odds of major complications [odds ratio (OR): 1.6, 95% confidence interval (CI), 1.2-2.0] but did not have significantly different odds of death (OR: 0.91, 95% CI, 0.59-1.4) or minor complications (OR: 1.2, 95% CI, 0.94-1.4).

CONCLUSION

Superobese patients had significantly higher odds of major complications within 30 days after hip fracture surgery compared with all other patients. This "obesity paradox" did not apply to superobese patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a Complete Description of Levels of Evidence.

The efficiency and safety of intravenous tranexamic acid administration in open reduction and internal fixation of pelvic and acetabular fractures

PURPOSE

This study aimed to investigate the efficiency and safety of tranexamic acid use in open reduction and internal fixation of pelvis and acetabulum fractures.

MATERIALS AND METHODS

73 consecutive patients were included. 1000 mg TXA was administered intravenously to all patients before surgery. The patients were evaluated on the basis of preoperative, postoperative first and third day hemoglobin-hematocrit values, amount of drainage collected, total blood loss, transfusion rates and complications.

RESULTS

Mean operative time was 120.1 min. Average decrease in hematocrit levels between preoperative and postoperative first day was 2.1 g/dL. Average collected blood from the drain was 177 mL. Mean total blood loss was 1137 mL. Transfusion rate of the patients was 21%. Mean transfused units was 0.9 units. Three patients died within 3 weeks after the operation due to myocardial infarction, acute kidney failure and pneumonia. There were no cases of symptomatic venous or pulmonary thromboembolism during the 90 days of follow-up.

CONCLUSION

Use of TXA in pelvic and acetabular fractures was found to be effective in reducing total blood loss, hemoglobin drop and transfusion rates without increasing venous and pulmonary thromboembolism in our series.

Preoperative hypoalbuminemia: Poor functional outcomes and quality of life after hip fracture surgery

AIMS

Hip fracture patients have severe deterioration of their quality of life and function after their injury. Markers of malnutrition such as low albumin and low body mass index (BMI) have been shown to increase mortality and complication rates but their effect on recovery of quality of life and function after hip fracture surgery is unclear. The main aim of this paper is to further investigate if low albumin affects recovery after hip fracture surgery, while additionally studying low BMI as a possible risk factor for poor recovery.

PATIENTS AND METHODS

Retrospective analysis of 971 patients who underwent surgery for fragility hip fractures between January 2012 and December 2016 was performed. Demographic data, preoperative serum albumin and haemoglobin levels, BMI, Charlson Comorbidity Index (CCI), type of surgery (fixation vs replacement) and site of surgery were obtained. Patients were assessed using the Parker Mobility Scale (PMS), Harris Hip Score(HHS), Medical Outcomes Study 36-item Short-Form Health Survey (SF36) at pre-fracture, 6 weeks and 6 months after surgery. HHS was not available pre-operatively. Patients were grouped according to their albumin levels (low ≤35 g/L or normal) and BMI (underweight <18.5 or normal). Univariate and multivariate analyses were performed to examine the association between albumin and BMI and 6-month scores.

RESULTS

On univariate analysis, patients with low albumin ≤35 g/L had lower baseline PMS and SF36 Physical Functioning (PF) score. On multivariate analysis, preoperative hypoalbuminemia was associated with lower 6-month HHS, PMS and SF36 PF scores even after accounting for baseline scores and other confounders. BMI had no effect on 6-month scores.

CONCLUSION

Low albumin (≤35 g/L) is prevalent in elderly hip fracture patients and is associated with slower recovery of function and quality of life after surgery. Low albumin can be a useful prognostic tool to identify patients with poor recovery for further intervention or rehabilitation after hip fracture surgery.

Searching for the 'winner' hip fracture patient: the effect of modifiable and non-modifiable factors on clinical outcomes following hip fracture surgery

BACKGROUND

Various factors, other than the quality of surgery, may influence clinical outcomes of hip fracture patients. We aimed to evaluate the relative impact of several factors on functional outcome, quality of life, re-fracture and mortality rates following surgery for hip fractures.

METHODS

We studied 498 (62.2%) women and 302 (37.8%) men with a mean age of 81.3 years (range, 60-95) with hip fractures (femoral neck and pertrochanteric). The mean follow-up was 74 months (range 58-96). Various patient-related and surgery-related parameters were recorded and correlated to both objective and subjective mobility, functional recovery and quality of life scales. Mortality and re-fracture rates were also evaluated.

RESULTS

Using multiple regression analysis, age >80 years (p = 0.000; 95% CI, 1.077-1.143) and ASA score III and IV (p = 0.000; 95% CI, 2.088-3.396) (both non-modifiable factors) both proved to be independent (s.s.) factors affecting mortality rates. Age <80 years (p = 0.000; 95% CI, 0.932-0.974), surgery delay less (modifiable factor) than 48 hours (p = 0.046; 95% CI, 0.869-0.999), low dementia CDR index (p = 0.005; 95% CI, 0.471-0.891) (non-modifiable factor), and osteoporosis medical treatment (modifiable factor) (p = 0.006; 95% CI, 0.494-0.891) were shown to be independent (s.s.) factors affecting HOOS-symptoms. Osteoporosis medical treatment used proved to be an independent (s.s.) factor affecting HOOS-daily activities (p = 0.049; 95% CI, 0.563-1.000) and quality of life (E-Qol-5D) (p = 0.036; 95% CI, 0.737-1.325).

CONCLUSIONS

A hip fracture patient aged <80 years old, with an ASA I-II, with low dementia CDR index and on osteoporosis medication has a better chance of an improved outcome (winner patient).

Evaluation of the Drug Utilization Pattern of Pre and Post Operative Medicines used in Surgical Department: A Prospective Observational Study

Background:

Surgery is the art of treating lesions and malformations of the human body which involves various surgical techniques. Various classes of drugs are being used in the surgery but unfortunately, the drug utilization pattern of these drugs particularly in developing countries like India is still unsatisfactory. Thus, there is a need to conduct drug utilization studies of various medicines used in the surgical department.

Objective:

The main objective of the current study is to evaluate the drug utilization pattern of pre and post- operative medicines used in surgery to promote the rational use of medicines.

Material and Methods:

A prospective observational study was carried out over a period of 6 months (November 2017 to April 2018) from in Global Hospital, Jalandhar, Punjab, India. A consent form has been designed and filled by the patients after explaining the aims and objectives of the study. The case record form (CRF) has been designed to collect all the relevant information from the surgery patients.

Results:

A total of 271 cases have been reported and evaluated. 58.0% of patients were female and 42.0% of patients were male. The most common surgery was nailing, plating and knee replacement. In pre and post-operative procedures, the most common medicines prescribed were a combination of antimicrobials and antacids followed by anti-emetics, analgesics.

Conclusion:

The prescribed medicines were less from the National Essential Medical List (EML) which should be increase in future.

The Effect of Obesity on Operative Time and Postoperative Complications for Peritrochanteric Femur Fractures

Introduction The high prevalence of obesity among adults in the United States presents significant challenges to orthopedic surgeons. Obesity has been shown to increase operative time and complications in both elective and nonelective orthopedic surgeries. Despite this, there is a lack of literature evaluating the effect obesity has on operative time and postoperative complications following peritrochanteric fracture surgery. Methods and Materials We performed a retrospective review of patients who underwent isolated operative stabilization of a peritrochanteric femur fracture at our urban level one trauma center between 2010 and 2018. Patients were divided into an obese group, as defined by a body mass index (BMI) equal to or greater than 30 kg/m2, and a nonobese group, as defined by a BMI less than 30 kg/m2. Operative timing variables including time to surgery, operative time, total operating room (OR) time, anesthesia time, and fluoroscopy time were collected. Postoperative variables evaluated including the presence of a major postoperative complication within 90 days of surgery, the need for repeat surgery within 90 days, and the need for surgery due to an infection within 90 days were collected. Results A total of 175 patients were included in this retrospective review. Thirty-seven patients were included in the obese group, and 138 were included in the nonobese group. Obesity was associated with a significantly (p = 0.002) longer operative time, total OR time (p = 0.0001), anesthesia time (p = 0.00006), and fluoroscopy time (p = 0.0001). There was no significant difference (p > 0.05) in postoperative variables between the obese and nonobese group. The 90-day major postoperative complication rate was 10.8% in the obese group and 10.9% in the nonobese group. Both repeat surgery and surgery for infection within 90 days were 2.7% in the obese group and 1.4% in the nonobese group. Conclusion The treatment of peritrochanteric femur fractures in obese patients is associated with a significantly longer operative time, total OR time, anesthesia time, and fluoroscopy time, but no difference in major postoperative complications when compared to nonobese patients.

Predictors of Medical Serious Adverse Events in Hip Fracture Patients Treated With Arthroplasty

AIM

Patients with hip fractures are often frail with multiple comorbidities and at risk of medical serious adverse events (SAEs). We investigated the HEALTH trial patient population to ascertain predictors of SAEs.

METHODS

We performed a multivariable Cox regression analysis. Occurrence of SAEs was included as the dependent variable with 31 potential prognostic factors being included as independent variables.

RESULTS

One thousand four hundred forty-one patients were included in this analysis. Three hundred seventy (25.6%) patients suffered from an SAE. The most common events were cardiac (38.4%, n = 105), respiratory (20.8%, n = 77), and neurological (14.1%, n = 77). The majority of SAEs (50.8%, n = 188) occurred in the first 90 days after hip fracture with 35.4% occurring in the first 30 days (n = 131). Body mass index (BMI) between 18.5 and 24.9 compared with BMI between 25 and 29.9 [hazard ratio (HR) 1.32, P = 0.03] and receiving a total hip arthroplasty compared with a bipolar hemiarthroplasty (HR 1.36, P = 0.03) were associated with a higher risk of a medical SAE within 24 months of femoral neck fracture. Age (P = 0.09), use of femoral cement (P = 0.59), and use of canal pressurization (P = 0.37) were not associated with a medical SAE.

CONCLUSION

Total hip arthroplasty is associated with more SAEs in the immediate postoperative period, and care should be taken in selecting patients for this treatment compared with a hemiarthroplasty. A higher BMI may be protective in hip fracture patients while age alone does not predict SAEs and neither does the use of femoral cement and/or pressurization.

LEVEL OF EVIDENCE

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

The Association between High Body Mass Index and Early Clinical Outcomes in Patients with Proximal Femur Fractures

BACKGROUND

Fractures of the proximal femur constitute daily work in orthopedic trauma surgery. With the continuous increase of obesity in the general population, surgeons face several known technical challenges. The aim of this study was to investigate the association of high body mass index (BMI) in patients with proximal femur fractures with intra- and postoperative adverse events, as well as with functional outcomes after successful surgery.

METHODS

In this retrospective, single-center cohort study, 950 patients who sustained a fracture of the proximal femur (femoral neck fracture or trochanteric fracture) and underwent surgical treatment at our level I trauma center between 2003 and 2015 were included. Patient-specific data were obtained in regard to demographics, comorbidities, and fracture morphology. In-hospital postoperative complications (i.e., need for revision surgery, wound site infection, pneumonia, urinary tract infection, necessary transfusion, and deep-vein thrombosis) were analyzed, along with the length of hospitalization and overall mortality rate. Functional outcome was assessed using the Barthel index and the patient's ability to walk on crutches. Mortality rate and need for revision surgery were assessed over a two-year time period. Any adverse event was correlated to one of the four WHO's BMI groups.

RESULTS

The cohort included 80 (8.4%) underweight patients, 570 (60.0%) normal weight patients, 241 (25.4%) overweight patients, and 59 (6.2%) obese patients. We found more femoral neck fractures (506, or 53%) than trochanteric fractures (444, or 47%). In bivariate analysis, no significant difference was found in regard to overall mortality or postoperative complications. Hospitalization time (LOS) differed between the underweight (12.3 ± 4.8 days), normal (13.6 ± 7.8 days), overweight (14.2 ± 11.7 days), and obese patients (16.0 ± 9.7 days) (p = 0.040). Operation time increased stepwise with increasing BMI: underweight = 85.3 ± 42.9 min; normal weight = 90.2 ± 38.2 min; overweight = 99.9 ± 39.9 min; obese = 117.2 ± 61.5 min (p < 0.001). No significant difference was found by analyzing functional outcomes. However, patients with intermediate BMI levels (18.5-30 kg/m2) tended to achieve the best results, as represented by a higher Barthel index score and the patient's ability to walk on crutches.

CONCLUSION

Increased BMI in patients with proximal femur fractures is associated with both longer operation time and length of hospitalization (LOS). Postoperative mobilization and functional outcomes appear to follow a reversed J-curve distribution (with overweight patients showing the best functional results), whereas both obese and underweight patients have associated poorer function.

One-year mortality rate after fragility hip fractures and associated risk in Nan, Thailand

Objectives

Fragility hip fracture is a common secondary complication of osteoporosis, which leads to significant morbidity and mortality. The incidence and prevalence of hip fractures have increased over recent decades. This study established an objective to determine the mortality rate and potential risk factors in fragility hip fracture patients.

Methods

Electronic medical records were retrospectively reviewed. A total of 1412 patients, aged 50 years and over, who sustained and received treatment for hip fractures between 2014 and 2018 were subsequently identified. Mortality rate data were retrieved from the official statistics registry for the provincial population. The mortality rates and potential risk factors for mortality were examined using Kaplan-Meier estimates and multivariate Cox proportional hazard models.

Results

The overall 1-year mortality rate of fragility hip fracture patients was 19%. Compared with the age-matched population in Nan province, hip fractures increased the mortality rate by 6.21 times. Additionally, the mortality of hip fracture patients was significantly higher among those with age above 80 years, nonambulatory status before fracture and upon hospital discharge, end-stage renal disease, delirium, and pneumonia.

Conclusions

Patients who sustained hip fractures had approximately 6 times higher mortality. Effective strategies for hip fracture prevention as well as improvement in the standard of care are crucial steps towards reducing mortality in patients with hip fracture.

Factors affecting the incidence of surgical site infection after geriatric hip fracture surgery: a retrospective multicenter study

Background

Geriatric hip fracture is a common type of osteoporotic fracture with high mortality and disability; surgical site infection (SSI) can be a devastating complication of this injury. By far, only a few studies identified easily remediable factors to reduce infection rates following hip fracture and less researches have focused on geriatric patients. The objective of this study was to identify potentially modifiable factors associated with SSI following geriatric hip fracture surgery.

Methods

This retrospective, multicenter study involves three level I hospitals. A total of 1240 patients (60 years or older) underwent hip surgery with complete data were recruited between January 2016 and June 2018. Demographics information, medications and additional comorbidities, operation-related variables, and laboratory indexes were extracted and analyzed. Receiver operating characteristic (ROC) analysis was performed to detect the optimum cut-off value for quantitative data. Univariate and multivariate logistic analysis model were performed respectively to identify the independent predictors.

Results

Ninety-four (7.58%) patients developed SSI in this study, and 76 (6.13%) had superficial infection, while 18 (1.45%) were diagnosed with deep infection. Results of univariate and multivariate analysis showed age > 79 years (OR, 2.60; p < 0.001), BMI > 26.6 kg/m² (OR, 2.97; p < 0.001), operating time > 107 min (OR, 2.18; p = 0.001), and ALB < 41.6 g/L (OR, 2.01; p = 0.005) were associated with an increased incidence of SSI; drainage use (OR, 0.57; p = 0.007) could reduce the incidence of wound infection for patients after geriatric hip fracture.

Conclusion

Accurate modifiable variables, operating time > 107 min, serum albumin < 41.6 g/L, BMI > 26.6 kg/m², and age > 79 years could be applied to distinguish geriatric patients with high-risk of postoperative surgical site infection.