Complications and their risk factors following hip fracture surgery

Early surgical treatment using regional clinical pathways to reduce the length of postoperative hospital stay in hip fracture patients: A retrospective analysis using the Japanese Diagnosis Procedure Combination database

Hip fracture is a common injury in older adults; however, the optimal timing of surgical treatment remains undetermined in Japan. Therefore, this retrospective study aimed to ascertain the rate of early surgery among hip fracture patients and investigate its effectiveness, along with "regional clinical pathways" (patient plan of care devised by Japanese clinicians), in reducing the length of hospital stay (LOS) postoperatively. We hypothesized that performing early surgery along with a regional clinical pathway is effective to reduce the postoperative LOS and complications among hip fracture patients. We examined the data of patients diagnosed with femoral neck and peritrochanteric fractures retrieved from the Japanese Diagnosis Procedure Combination database between April 2016 and March 2018. Patients were divided into the early (43,928, 34%; surgery within 2 days of admission) and delayed (84,237, 66%; surgery after 2 days of admission) surgery groups. The difference in postoperative LOS between the two groups was 3 days (early vs. delayed: 29 days vs. 32 days). The early surgery group had more cases of intertrochanteric fractures (57% vs. 43%) and internal fixation (74% vs. 55%) than did the delayed surgery group. In contrast, the delayed surgery group had more cases of femoral neck fractures (43% vs. 57%) and bipolar hip arthroplasty (25% vs. 42%) or total hip arthroplasty (1.2% vs. 3.0%). Moreover, the early surgery group showed a lower incidence of complications, except anemia (12% vs. 8.8%). Logistic regression analysis using the adjusted model revealed that early surgery and implementation of regional clinical pathways reduced LOS by 2.58 and 8.06 days, respectively (p<0.001). Early surgery and implementation of regional clinical pathways for hip fracture patients are effective in reducing postoperative LOS, allowing regional clinical pathways to have a greater impact. These findings will help acute care providers when treating hip fracture patients.

What can they expect? Decreased quality of life and increased postoperative complication rate in patients with a fracture-related infection

BACKGROUND

By gaining insight into the Quality of Life (QoL) status and occurrence of complications, critical facets in the care for patients with Fracture-Related Infection (FRI) can be mitigated and measures can be taken to improve their outcome. Therefore, the aims of this study were to 1) determine the QoL in FRI patients in comparison to non-FRI patients and 2) describe the occurrence of other complications in both FRI and non-FRI patients.

METHODS

An ambidirectional cohort study was conducted in a level 1 trauma centre between January 1st 2016 and November 1st 2021. All patients who underwent surgical stabilisation of an isolated long bone fracture were eligible for inclusion. To avoid confounding, only patients with an Injury Severity Score (ISS) <16 were included. Data regarding patient demographics, fracture characteristics, treatment, follow-up and complications were collected of both non-FRI and FRI patients. QoL was assessed through the use of five-level EuroQol five-dimension (EQ-5D-5L) questionnaires twelve months post-injury.

RESULTS

A total of 134 patients were included in this study, of whom 38 (28%) FRI patients and 96 (72%) non-FRI patients. In comparison to non-FRI patients, FRI patients scored significantly worse on the QoL assessment regarding the index value (p = 0.012) and the domains mobility (p<0.001), usual activities (p = 0.010) and pain/discomfort (p = 0.009). Other postoperative complications were more often reported (p<0.001) in FRI patients (66%, n = 25/38) compared to non-FRI patients (27%, n = 26/96). During the median follow-up of 14.5 months (interquartile range (IQR) 9.5-26.5), 25 FRI patients developed a total of 49 distinctive complications besides FRI. The complications nonunion (18%, n = 9/49), infection other than FRI (e.g. line infection, urinary tract infection, pneumonia) (18%, n = 9/49) and implant failure (14%, n = 7/49) were the most frequently described in the FRI group.

CONCLUSION

Patients who suffered from an FRI have a decreased QoL in comparison to those without an FRI. Moreover, patients with an FRI have a higher rate of additional complications. These findings can help in patient counselling regarding the potential physical and mental consequences of having a complicated course of recovery due to an infection.

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

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

A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review

INTRODUCTION

Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand.

METHODS

A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel.

RESULTS

Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan.

CONCLUSION

We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.

Timing of Adverse Events Within 90 Days of Hip Fracture Surgery: A Database Study

INTRODUCTION

Hip fracture surgery is associated with notable morbidity. Understanding the timing of adverse events can inform strategies for prevention and management. Owing to database limitations, many studies have limited postoperative follow-up to 30 days. However, adverse events may not have plateaued by this time. This study evaluated adverse events after hip fracture surgery out to 90 days.

METHODS

Hip fracture surgeries in patients 65 years or older were identified in the 2010 to 2020 Q3 M91Ortho PearlDiver data set using administrative codes. The 90-day incidence and time of diagnosis of 10 common adverse events were determined and used to calculate median, interquartile range, and middle 80% for time of diagnosis. The number of events occurring before and after 30 days was also determined.

RESULTS

A total of 258,834 hip fracture surgery patients were identified. On average, 70% of adverse events occurred in postoperative days 0 to 30 and 30% occurred in days 31 to 90. The percentage of events in days 31 to 90 ranged from 8% (transfusion) to 42% (wound dehiscence). Compared with patients with a 0- to 30-day adverse event, those with 31- to 90-day adverse events had higher average Elixhauser Comorbidity Index scores (8.6 vs. 7.8, P < 0.001) and a slightly greater proportion of men (31.5% vs. 30.2%, P < 0.001).For specific adverse events, the time of diagnosis (median; interquartile range; middle 80%) were as follows: transfusion (2 days; 1 to 4 days; 1 to 24 days), acute kidney injury (5; 2 to 26; 1 to 55), cardiac event (9; 3 to 35; 1 to 64), urinary tract infection (13; 3 to 39; 1 to 65), hematoma (14; 6 to 28; 3 to 52), pneumonia (15; 5 to 39; 2 to 66), venous thromboembolism (16; 5 to 40; 2 to 64), surgical site infection (23; 14 to 37; 7 to 56), sepsis (24; 9 to 48; 3 to 71), and wound dehiscence (26; 15 to 41; 7 to 64).

DISCUSSION

Nearly one-third of 90-day adverse events after hip fracture surgery were found to occur after postoperative day 30. An understanding of the timing of adverse events is important for improving patient counseling and optimizing patient care.

The high-risk hip fracture patient and the palliative care consult : A retrospective study to investigate risks of complications and the utility of a palliative care consult in hip fracture patients undergoing surgical fixation

We evaluated the utility of a palliative care consult (PCC) in high-risk hip fracture patients. The main result was that a PCC reflects certain risk factors for post-surgical complications and is associated with a delay to surgery in the high-risk patient population that it served.

PURPOSE

The objective of this study was to identify risks of complications in surgically managed hip fractures and determine the utility of a PCC in this population, particularly regarding time to the operating room (OR).

METHODS

Retrospective cohort at a Level I academic trauma center.

RESULTS

Four hundred sixty-two patients were treated surgically for hip fracture. Decreased pre-injury ambulatory status (OR 2.18, 95% CI 1.13-4.20, p = .02), time to OR > 48 h (OR 4.76, 95% CI 1.43-15.87, p = .011), and obtaining a pre-operative PCC (OR 3.03, 95% CI 1.34-6.85, p = .008) were independent risk factors for post-surgical complications. Multivariate risk factors for obtaining a PCC included older age (OR 1.1, CI 1.0-1.1, p = .007), pre-injury ambulatory status (OR 2.2, CI 1.3-3.9, p = .005), renal failure (OR 3.1, CI 1.1-9.0, p = 0.032), and higher ASA category (OR 2.6, CI 1.2-5.5, p = .014). A delay of more than 48 h was associated with being male ( OR 4.6, CI 1.4-15.0, p = .013) or having obtained a PCC (OR 5.5, CI 1.4-22.7, p = .017).

CONCLUSIONS

Obtaining a PCC can reflect risks of complications and mortality. It is a valuable resource for use in high-risk patients who are inherently at risk for delays to surgery and should be used judiciously.

Adaptive Risk Modeling: Improving Risk Assessment of Geriatric Hip Fracture Patients Throughout their Hospitalization

INTRODUCTION

The purpose of this study was twofold: 1. To assess how adaptive modeling, accounting for development of inpatient complications, affects the predictive capacity of the risk tool to predict inpatient mortality for a cohort of geriatric hip fracture patients. 2. To compare how risk triaging of secondary outcomes is affected by adaptive modeling. We hypothesize that adaptive modeling will improve the predictive capacity of the model and improve the ability to risk triage secondary outcomes.

METHODS

Between October 2014-August 2021, 2421 patients >55 years old treated for hip fracture obtained through low-energy mechanisms were analyzed for demographics, injury details and hospital quality measures. The baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for hip fractures (STTGMA_HIP) was calculated in the emergency department setting. A new mortality risk score (STTGMA_{HIP_ADPTV}) was created including inpatient complications. Each models' predictive ability was compared using DeLong's test. Patients were grouped into quartiles based on their respective STTGMA_{HIP_ADPTV} and comparative analyses were conducted.

RESULTS

AUROC comparison demonstrated STTGMA_{HIP_ADPTV} significantly improved the predictive capacity for inpatient mortality compared to STTGMA_HIP (p < 0.01). STTGMA_{HIP_ADPTV} correctly triaged 80% and 64% of high-risk patients with inpatient and 30-day mortality compared to 64% and 57% for STTGMA_HIP. STTGMA_{HIP_ADPTV} quartile stratification demonstrated that the highest risk cohort had the worst mortality outcomes and hospital quality measures. Patients whose risk classification changed from minimal risk using STTGMA_HIP to high risk using STTGMA_{HIP_ADPTV} experienced the highest rate of mortality, readmission, ICU admission, with longer lengths of stay and higher hospital costs.

DISCUSSION

Adaptive modeling accounting for inpatient complications improves the predictive capacity and risk triaging of the STTGMA_HIP tool. Real-time modulation of a patient's mortality risk profile can inform their requisite level of medical management to improve the quality and value of care as patients progress through their index hospitalization. STTGMA_{HIP_ADPTV} can better identify patients at risk for developing complications whose mortality and readmission risk profile increase significantly, allowing their new risk classification to inform higher levels of care. While this may increase length of stay and total costs, it may improve outcomes in both the short and long-term.

LEVEL OF EVIDENCE

III.

Patient body mass index modifies the association between waiting time for hip fracture surgery and in-hospital mortality: A multicenter retrospective cohort study

BACKGROUND

Patient body mass index (BMI) plays an important role in stress exposure, especially in elderly patients with hip fracture. However, how BMI modifies the relationship between the waiting time for surgery and mortality remains unclear.

METHODS

We investigated the association between waiting time and mortality using a nationwide multicenter database of patients undergoing hip fracture surgery. The primary outcome was in-hospital mortality and secondary outcomes were complications. We performed prespecified subgroup analysis with stratification by BMI.

RESULTS

Overall, 305,846 patients (mean age, 83.5; standard deviation [SD], 8.2); women, 79.5% (n = 243,214) were included in our study. A cubic spline curve revealed two inflection points in the association between waiting time and mortality, and we statistically divided patients into three groups accordingly: the reference group (80,110 patients [26.2%] who waited 1 day for surgery), the delayed group (184,778 patients [60.4%] who waited 2-6 days for surgery), and the extremely delayed group (40,958 patients [13.4%] who waited more than 6 days for surgery). Multivariable logistic regression models showed that the odds of mortality in the delayed group was 14% higher than that in the reference group (adjusted odds ratio [aOR], 1.14; p = 0.002), whereas the odds of mortality in the extremely delayed group was 52% higher than that of the reference group (aOR, 1.52; p < 0.001). Patients with lower BMI were more negatively affected by delayed surgery compared to patients with normal BMI (p for interaction = 0.002). Respiratory disorders were most frequent and the spline curve was accordant with in-hospital mortality.

CONCLUSION

Patients underwent surgery within 1 day, particularly with lower BMI, had a lower mortality than normal BMI. To optimize limited health care resource, patient's BMI should be considered for hip fracture management, and further investigation in prospective study should be needed to address causal relationship.

LEVEL OF EVIDENCE

Therapeutic Level III.

Pre-Operative Medications as a Predictor for Post-Operative Complications Following Geriatric Hip Fracture Surgery

Background

Fragility hip fractures are a common orthopedic injury seen in Emergency Departments, with variable outcomes that can range from average to devastating. Currently, few reliable metrics to predict which patients will suffer post-operative complications exist. The aim of this study was to determine if the number and type of pre-operative medications can help predict post-operative complications.

Methods

A prospectively collected database of hip fracture patients was retrospectively reviewed. Patients with isolated greater trochanteric fractures, periprosthetic fractures, or re-fractures were excluded. Pre-operative baseline characteristics as well as number and type of post-operative complications were reviewed. Any complication within 6 months of surgery and complications that could be directly attributable to the surgical procedure within 2 years of surgery were examined. Major complications (return to the operating room, deep infection, pulmonary, cardiac, and hematologic) and minor medical complications were assessed. A multivariate regression model was performed to identify independent risk factors.

Results

Three-hundred ninety-one patients were included. A majority were aged 80–90 and female, and lived at home prior to presentation. Overall, 33.7% of patients suffered a complication within a 2-year follow-up period. Mortality rates were 5.4%, 10.0%, and 14.9% over 30 days, 1 year, and 2 years, respectively. After assessing this relationship while controlling for age, sex, injury type, pre-operative residence, ambulatory status, ASA score, and CCI score, the relationship remained significant for both an increased number of complications (P = .048) and a higher likelihood of having a complication (P = .008). Cardiovascular (P = .003), pulmonary (P = .001), gout (P = .002), or diabetes (P = .042) medications were associated with a higher likelihood for experiencing a complication.

Conclusions

Our study suggests that there is a strong and linear relationship between the number and type of pre-operative medications taken and risk of post-operative complications. This exists for up to 8 medications, at which point further increase does not contribute to an increased risk of complication. This relationship exists even after controlling for confounding variables and can be used by surgeons to better counsel patients and families regarding their specific risk for suffering perioperative complications.

[EXPLORATORY EXAMINATION FOR THE FACTORS RELATED TO VOIDING DYSFUNCTION IN PATIENTS AFTER SURGERY FOR PROXIMAL FEMORAL FRACTURES]

(Purpose) While urinary retention and urinary tract infections accompanying residual urine are often experienced following proximal femoral fractures (femoral neck fractures and trochanteric fractures) in clinical practice, the pathology of the onset of voiding dysfunction for this disease is unclear since the nervous system associated with urination is not damaged due to the fracture not reaching the pelvis. Therefore, we exploratorily examined the factors related to voiding dysfunction in proximal femoral fractures. (Subjects and method) Among the patients who underwent surgery for proximal femoral fractures, we examined the relation between the proportion of cases in which withdrawing urine was required for residual urine after removing the urethral catheter and the differences in the fracture sites, pain, the ability to maintain a sitting position, the strength to bend the hip joints, and the volume of the iliopsoas muscle. (Results) The proportion of cases in which withdrawing urine was required was higher in the group suffering trochanteric fractures than the group suffering femoral neck fractures (41% vs. 11%), while the strength to bend the hip joints was lower. Regarding trochanteric fractures, compared to the group in which no urine was withdrawn, the group in which urine was withdrawn included more of the unstable type in which the fracture reached the lesser trochanter, which is the femoral insertion of the iliopsoas muscle (56% vs. 82%), in addition to having a significant decrease in the strength to bend the hip joints. Regarding trochanteric fractures, compared to the group without injury in lesser trochanter, the group with injury in lesser trochanter had a higher proportion of cases in which withdrawing urine was required (23% vs. 51%), in addition to the iliopsoas muscle thereof having been atrophied (-15.7% vs. -35.2%). (Conclusion) As factors related to voiding dysfunction following surgery for proximal femoral fractures, the relation between fracture sites, the strength to bend the hip joints associated with maintaining posture, the presence of injuries in the lesser trochanter, and the volume of the iliopsoas muscle were suggested. Therefore, it is possible that the proportion of cases in which the withdrawal of urine was required increased with the increase in residual urine due to the decrease in the ability to maintain a urinating posture until the bladder is completely empty.

Cost-Effective Analysis of Dual-Energy Computed Tomography for the Diagnosis of Occult Hip Fractures Among Older Adults

OBJECTIVE

Early and accurate diagnosis of hip fractures minimizes morbidity and mortality. Although current guidelines favor magnetic resonance imaging (MRI) for the diagnosis of occult hip fractures, a new technology called dual-energy computed tomography (DECT) seems an effective alternative. This article investigates a potentially cost-effective strategy for the diagnosis of occult hip fractures in older adults in Singapore.

METHODS

A decision tree model was developed to compare costs from a payer's perspective and outcomes in terms of quality-adjusted life-years (QALYs) of different imaging strategies for diagnosing occult hip fracture, comparing MRI with DECT supplementing single-energy computed tomography (SECT) and SECT alone. Model inputs were obtained from local sources where available. Sensitivity analyses are performed to test the robustness of the results.

RESULTS

The MRI strategy was dominated by the DECT strategy, whereas DECT supplementing SECT provided 0.30 more QALYs at an incremental cost of SGD106.41 with an incremental cost-effectiveness ratio of SGD352.52 per QALY relative to SECT alone. DECT seemed a cost-effective strategy at a willingness-to-pay threshold of SGD50 000 per QALY.

CONCLUSION

DECT supplementing SECT is a cost-effective imaging strategy to diagnose occult hip fractures among older adults in Singapore and should be included in clinical pathways to expedite timely treatment and considered for reimbursement schemes.

Outcomes of Femoral Neck Fractures in Young Patients and the Factors Associated With Complications: A Multicenter Study From Malaysia

Background and objective Femoral neck fractures are relatively rare in young adults, but they result in prolonged loss of function in these patients, thereby placing a huge burden on a country's healthcare and economy. Femoral neck fractures in young adults are normally treated with head salvage surgery. However, primary head replacement surgeries have been gaining traction recently to expedite the recovery of these patients. In this study, we aimed to investigate the outcomes in young patients with femoral neck fractures and factors associated with their complications. Patients and methods Patients with femoral neck fractures who underwent surgery in three tertiary hospitals [Hospital Tengku Ampuan Afzan (HTAA), Hospital Sultan Haji Ahmad Shah (HOSHAS), and Hospital Kuala Lipis] in Pahang state in Malaysia were reviewed and included in this study. The demographic profile of the patients, injury patterns, intervention details, functional outcomes, and complications were analyzed. The comparison between the sociodemographics, clinical assessment, and complication outcomes was analyzed using statistical software. Results The complications were associated with the mechanism of injury, capsulotomy, and type of fixation. A total of 46 patients were included in the study. Most of the patients were found to have severe displacement based on Garden and Pauwels classification. The majority of the patients underwent femoral head salvage surgeries. Almost half of the patients sustained complications and were unable to achieve weight-bearing status at six months postoperatively. Conclusion Despite a relatively short follow-up period in our study, femoral neck fractures in young adults were found to be associated with a high rate of complications. Primary head replacement surgeries should be considered in high-risk patients with femoral neck fractures.

Subcuticular Barbed Suture and Skin Glue Wound Closure Decreases Reoperation and Length of Stay in Geriatric Hip Fractures When Compared With Staples

INTRODUCTION

Patients with geriatric hip fracture are notoriously frail and at risk for complications. Persistent postoperative wound drainage can lead to prolonged hospital stay, increased risk for infection, and need for revision surgery. The purpose of this study was to determine the effect of wound closure technique, barbed monofilament subcuticular suture and skin glue versus staples on rates of intervention for wound drainage and length of hospital stay after geriatric hip fracture fixation.

METHODS

A retrospective review of isolated hip fractures in patients older than 60 years at a single institution over a 3-year period was done. Hip fractures included femoral neck, intertrochanteric, and subtrochanteric femur fractures treated with internal fixation or arthroplasty. Skin closure technique, at the discretion of the operating surgeon, included either barbed subcuticular monofilament suture and skin glue or staples. Charts and radiographs were reviewed to determine patient characteristics, Charlson Comorbidity Index, type of wound closure, length of stay, and interventions for persistent wound drainage.

RESULTS

There were 175 patients in the barbed suture and skin glue group and 211 patients in the staples group. The barbed suture group had an average postsurgical length of stay of 5.0 days which was significantly lower than the staples group (7.0 days, P < 0.00001). In the staples group, 17 patients (8%) required incisional negative pressure wound therapy due to wound drainage with five patients (2.4%) returning to the operating room secondary to persistent wound drainage. No patients were observed in the barbed suture group that required intervention for wound drainage.

DISCUSSION

Barbed suture and skin glue closure is associated with markedly shorter hospital stay and fewer interventions for wound drainage when compared with staples after surgical treatment of geriatric hip fractures.

Loss of pre-fracture basic mobility status at hospital discharge for hip fracture is associated with 30-day post-discharge risk of infections - a four-year nationwide cohort study of 23,309 Danish patients

BACKGROUND

The loss of pre-fracture basic mobility status is associated with increased mortality and any readmission after hip fracture. However, it is less known if the loss of pre-fracture mobility has impact on acquiring a post-discharge infection.

PURPOSE

To examine if the loss of pre-fracture basic mobility status at hospital discharge was associated with hospital-treated or community-treated infections within 30-days of hospital discharge after hip fracture.

METHODS

Using the nationwide Danish Multidisciplinary Hip Fracture Registry from January 2014 through November 2017, we included 23,309 patients undergoing surgery for a first-time hip fracture. The Cumulated Ambulation Score (CAS, 0-6 points) was recorded using questionnaire at admission (pre-fracture CAS) and objectively assessed at discharge. The loss of any CAS-points at discharge compared with pre-fracture CAS was calculated and dichotomized (yes/no). Using Cox regression analyses, we estimated the hazard ratio (HR) with 95% confidence interval (CI) of any hospital-treated infection, hospital-treated pneumonia or community-treated infection adjusted for sex, age, body mass index, Charlson Comorbidity Index, residential status, type of fracture, and length of hospital stay (LOS).

RESULTS

Total of 12,046 (62%) patients lost their pre-fracture CAS status at discharge. Among patients who had lost their pre-fracture CAS, 6.0% developed a hospital-treated infection compared to 4% of those who did not lose their pre-fracture CAS. Correspondingly, 9.2% versus 6.2% developed a community-treated infection. The risk of 30-day post-discharge infection increased with increasing loss of any CAS points. The adjusted HRs for patients who had lost their pre-fracture CAS status, compared to patients who did not, was 1.34 (CI: 1.16-1.54) for hospital-treated infection, 1.35 (CI: 1.09 - 1.67) for pneumonia and 1.36 (CI: 1.21-1.52) for community-treated infection.

CONCLUSION

In this large national cohort study, we found that loss of pre-fracture basic mobility status upon hospital discharge was strongly associated with 30-day post-discharge risk of developing infection. These findings suggest a clinical importance of carefully focusing on regaining the pre-fracture basic mobility before discharging the patient.

Hospital variation in the risk of infection after hip fracture surgery: a population-based cohort study including 29,598 patients from 2012-2017

Background and purpose - Understanding the key drivers of hospital variation in postoperative infections after hip fracture surgery is important for directing quality improvements. Therefore, we investigated variation in the risk of any infection, and subgroups of infections including pneumonia and sepsis after hip fracture surgery.Methods - In this nationwide population-based cohort study, all Danish patients aged ≥ 65 undergoing surgery for an incident hip fracture from 2012 to 2017 were included. Risk of postoperative infections, based on data from hospital registration (hospital-treated infections) and antibiotic dispensing (community-treated infections), were calculated using multilevel Poisson regression analysis. Hospital variation was evaluated by intra-class coefficient (ICC) and median risk ratio (MRR).Results - The risk of hospital-treated infection was 15%. The risk of community-treated infection was 24%. The adjusted risk varied between hospitals from 7.8-25% for hospital-treated infection and 16-34% for community-treated infection. The ICC indicated that 19% of the adjusted variance was due to hospital level for hospital-treated infection. The ICC for community-treated infections was 13%. The MRR showed a 2-fold increased risk for the average patient acquiring a hospital-treated infection at the highest risk hospital compared with the lowest risk hospital. For community-treated infection, the MRR was 1.4.Interpretation - Our results suggest that 20% of infections could be reduced by applying the top performing hospitals' approach. Nearly a 5th of the variation was at the hospital level. This suggests a more standardized approach to avoid postoperative infection after hip fracture surgery.Hip fracture is a leading cause of hospital admission among the elderly. The 30-day mortality following hip fracture surgery has been approximately 10% during the last few years in Denmark (Pedersen et al. 2017). Higher mortality after hip fracture has been associated with a range of hospital factors (Kristensen et al. 2016, Sheehan et al. 2016) and patient factors in observational studies (Roche et al. 2005). Furthermore, variation in 30-day mortality after hip fracture surgery has been observed between Danish hospitals, but not fully explained (Kristensen et al. 2019).

Should concurrent infections be treated before performing hip arthroplasty for hip fracture?

Aims

A systematic literature review focusing on how long before surgery concurrent viral or bacterial infections (respiratory and urinary infections) should be treated in hip fracture patients, and if there is evidence for delaying this surgery.

Methods

A total of 11 databases were examined using the COre, Standard, Ideal (COSI) protocol. Bibliographic searches (no chronological or linguistic restriction) were conducted using, among other methods, the Patient, Intervention, Comparison, Outcome (PICO) template. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for flow diagram and checklist. Final reading of the complete texts was conducted in English, French, and Spanish. Classification of papers was completed within five levels of evidence (LE).

Results

There were a total of 621 hits (526 COre; 95 Standard, Ideal) for screening identification, and 107 records were screened. Overall 67 full-text articles were assessed for eligibility, and 21 articles were included for the study question. A total of 46 full-text articles were excluded with reasons. No studies could be included in quantitative synthesis (meta-analyses), and there were many confounding variables including surgeons’ experience, prosthesis models used, and surgical technique.

Conclusion

Patients with hip fracture and with a viral infection in the upper respiratory tract or without major clinical symptoms should be operated on as soon as possible (LE: I-III). There is no evidence that patients with coronavirus disease 2019 (COVID-19) should be treated differently. In relation to pneumonia, its prevention is a major issue. Antibiotics should be administered if surgery is delayed by > 72 hours or if bacterial infection is present in the lower respiratory tract (LE: III-V). In patients with hip fracture and urinary tract infection (UTI), delaying surgery may provoke further complications (LE: I). However, diabetic or immunocompromised patients may benefit from immediate antibiotic treatment.

Cite this article: Bone Joint Res 2020;9(12):884–893.

Daytime versus after-hours surgery outcomes in hip fracture patients: a systematic review and meta-analysis

BACKGROUND

Several studies found that hip fracture patient outcome is greatly influenced by the time from admission to surgery. To avoid surgical delay, surgery for hip fracture may be performed at night or weekends. However, after-hours surgery may lead to a reduction in support staff and to surgeon fatigue, which ultimately increases mortality and complications. Therefore, we wanted to compare the outcomes of daytime and after-hours surgery in hip fracture patients.

METHODS

A literature search was performed in the Cochrane Library, and the Web of Science, PubMed, Embase, and Springer databases from inception to December 2019. Relevant studies comparing the results of operations performed at different time periods were included. The main clinical outcomes included total complications, mortality, blood loss, surgical time, and length of hospitalization. Data were pooled, and a meta-analysis was completed.

RESULTS

Nine retrospective cohort studies and one randomized controlled trial met the inclusion criteria; the studies included a total of 583,290 patients. We found no significant differences in mortality, surgical time or blood loss between daytime and after-hours surgery in hip fracture patients (P > 0.05). Of note, the patients who underwent after-hours surgery had fewer surgical complications (P < 0.001) and a shorter length of hospitalization (P = 0.021) than those who underwent daytime surgery.

CONCLUSION

After-hours surgery for hip fracture is safe. To avoid surgical delay, after-hours surgery is still a viable and even necessary option.

Mortality and the Risk Factors in Elderly Female Patients With Femoral Neck and Trochanteric Fractures

BACKGROUND

The main purpose of this study is to exhaustively explore risk factors, including age, gender, and several clinical indices, for mortality in elderly patients with femoral neck fracture and to evaluate some of them using survival analyses.

METHODS

This was a retrospective study tracking 1 year for vital prognosis. Data were collected at post-operation from medical records of the cases. Survival analysis was conducted to investigate the risk factors for death, including albumin, urinary retention, activity of daily living (ADL), and cognitive disorder.

RESULTS

We recruited 318 patients with a history of hip surgery carried out at Toyama Municipal Hospital, in which 39 patients died for 1 year after discharge. The results showed a significant decrease in survival rate in low albumin, positive urinary retention, and low ADL (P < 0.01, by log-rank test). The hazard ratios (95% confidence interval) of albumin, urinary retention, ADL, and cognitive disorder were 0.36 (0.19 - 0.69), 0.4 (0.2 - 0.8), 0.29 (0.15 - 0.58) and 0.65 (0.32 - 1.29), respectively.

CONCLUSIONS

This study demonstrated that albumin, urinary retention and ADL were the important risk factors for mortality, and suggested that the postoperative management of albumin, urinary retention and ADL is important, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.

Conservative vs Surgical Treatment of Impacted Femoral Neck Fracture in Patients 75 Years and Older

OBJECTIVE

To evaluate the safety and effectiveness of conservative treatment (CST), internal fixation (IF), and hemiarthroplasty (HA) in treating patients older than 75 years with impacted femoral neck fracture (IFNF).

DESIGN

A randomized clinical trial to compare clinical outcomes of CST, IF, and HA in IFNF patients older than 75 years with a 1:1:1 ratio.

SETTING

Nanjing First Hospital, Nanjing Medical University, Nanjing, China.

PARTICIPANTS

A total of 154 patients with IFNF aged between 75 and 97 years.

INTERVENTION

Patients with IFNF were allocated to CST, IF, and HA. They all received a 36-month follow-up.

MEASUREMENTS

All patients were evaluated by Harris hip score (HHS) (primary outcome) for hip function, European Quality of Life-5 Dimensions (EQ-5D) index scores for health-related quality of life, and visual analogue scale score for hip pain. Operation duration, blood loss, mortality, union rate, complications, and reoperation were also recorded. Assessors were blind to the type of treatment.

RESULTS

The baseline parameters of the three groups were similar. IF group had much lower blood loss than HA group (P < .05), while no significant difference in operative duration was found between the two groups (P > .05). HHS in HA group was significantly higher at 1, 3, and 6 months (P < .05), but no significant difference in HHS was found between CST and IF groups at any of the time points during the overall follow-up (P > .05). EQ-5D index score was higher in HA group at each follow-up within 1 year (P < .05), but the difference was not significant at 2- and 3-year follow-up (P > .05). There was no significant difference in mortality among the three groups at each follow-up point (P > .05). The nonunion rate was 11.76% (6/51) in CST group and 9.80% (5/51) in IF group and showed no significant difference (P > .05).

CONCLUSION

CST may be a feasible way for IFNF in the older patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04219943. J Am Geriatr Soc 68:2214-2221, 2020.

Medical and economic consequences of perioperative complications in older hip fracture patients

Patients suffering from complications during inpatient treatment after hip fracture surgery are associated with a worse mid-term outcome. While surgically treatable complications only delay the healing process, internal complications seem to worsen the outcome in the long run. All complications come with significant increased costs during the hospital stay.

PURPOSE

Due to the demographic changes, the importance of hip fractures is still increasing nowadays. Not only surgical but also medical complications represent a major challenge in the treatment of those patients. Nevertheless, only few is known about the functional, medical, and economic consequences of complications.

METHODS

A total of 402 hip fracture patients ≥ 60 years were observed prospectively at a German university hospital. Complications were assessed during the inpatient stay and classified by Clavien and Dindo. Afterwards their influence on acute care costs was examined as well as their influence on the mortality, health-related quality of life (HRQL) (EQ5D), functional capacities (Barthel index), and mobility (Tinetti score) in the follow-up periods of 6 and 12 months.

RESULTS

Complications that required surgical revision/treatment (type III) were associated with an increased 6 months' mortality, while type II and IV complications did not influence mortality after 6 and 12 months. Six months after surgery, HRQL, Barthel score, and Tinetti score were reduced in patients suffering from all different types of complications. After 12 months however, HRQL, Barthel score, and Tinetti score following type II and IV complications remained reduced, while the scores improved in patients suffering from type III complication. All types of complications led to significantly increased acute care costs.

CONCLUSIONS

The results of the present study emphasize the crucial role of perioperative complications in older patients with hip fractures. Therefore, special attention has to be given to the prevention of those complications, e.g., with orthogeriatric treatment models, which have been shown to be effective in the reduction of complications.

Epidemiological and clinical study of hip fracture in hospitalized elderly patients in Shanghai, China

In this study, we attempted to determine the epidemiology and clinical characteristics of hip fracture in the elderly. We find that elderly people with hip fracture have multiple comorbidities and suffer numerous complications.

INTRODUCTION

We attempted to explore the epidemiology and clinical characteristics of hip fracture in the elderly.

METHODS

One thousand five hundred thirty-nine patients aged over 65 years were included in the retrospective study. From the medical records, information was gathered about pre-fracture conditions, as well as fracture type, surgical details, laboratory indicators, postoperative complications, length of stay, outcomes, and costs of hospitalization. Binary logistic regression was used to screen for potential risk factors for perioperative complications and postoperative death, and general linear models were used to determine factors that influenced the cost of surgical treatment.

RESULTS

The average age of hip fracture patients in our study was 82.20 ± 6.82 years old, and the male-to-female ratio was 1:2.82. In 1356 patients who underwent hip surgery, the incidence of perioperative complications was 6.71% (91/1356), and the postoperative mortality rate was 1.11% (15/1356). Factors associated with perioperative complications were male sex, heart function class III or higher, serum albumin < 35 g/L, respiratory diseases, and perioperative blood transfusion (P < 0.05). Perioperative blood transfusion was an independent risk factor for postoperative death after hip fracture in the elderly (P < 0.05). The main factors that influenced hospitalization expenses related to elderly hip fracture patients were type of surgery, method of anesthesia, length of stay, perioperative complications, and outcomes (P < 0.05).

CONCLUSIONS

Elderly people with hip fracture have multiple comorbidities and suffer numerous complications. Thus, randomized intervention studies should focus on prevention of complications that might be avoidable.

[Effect of early preoperative mobilization on rehabilitation of the elderly patients with hip fractures after operation]

OBJECTIVE

To evaluate the effect of early preoperative mobilization on the rehabilitation of the elderly patients with hip fractures after operation.

METHODS

The clinical data of 16 elderly patients with hip fractures between February 2017 and April 2018 who met the selection criteria was retrospectively analyzed. There were 8 males and 8 females, with an average age of 80.3 years (range, 69-90 years). There were 8 cases of intertrochanteric fracture and 8 cases of femoral neck fracture. The preoperative American Society of Anesthesiologists (ASA) scored 2.94±0.43. There were 3 cases of cardiovascular and cerebrovascular diseases, 6 cases of essential hypertension, 5 cases of respiratory diseases, 3 cases of diabetes, and 2 cases of other system diseases. The time from injury to admission was 4 hours to 14 days with an average of 39.5 hours. On the day of admission or on the first day after admission, the patient started to exercise on the floor underwent analgesia treatment. And the patients were treated with closed reduction (9 cases) or artificial hip arthroplasty (7 cases). The time from admission to operation was 4 to 25 days, with an average of 7.4 days. At the time of admission, after the first ground movement before operation, on the second day after operation, and at last follow-up, the Barthel Index was used to assess the patients' self-care ability, and Barthel effectiveness (BE) was calculated. The complications were observed and recorded during follow-up.

RESULTS

All 16 patients underwent operation successfully. The hospital stay was 8 to 24 days, with an average of 14.1 days. All patients were followed up 2.5-16.0 months with an average of 6.5 months. One patient developed postoperative pulmonary infection; the remaining patients had no surgical-related complications. No patient died during the follow-up. The Barthel Index scored 30.63±5.56 at admission, 53.13±9.50 after the first ground movement before operation, 60.63±6.09 on the second day after operation, and 96.25±4.84 at last follow-up. There were significant differences in Barthel Index scores between different time points ( P<0.05). The BE was 0.23±0.06 after the first ground movement before operation, 0.30±0.04 on the second day after operation, and 0.66±0.06 at last follow-up. There were significant differences in BE between different time points ( P<0.05).

CONCLUSION

For elderly patients with hip fractures who have long waiting time before operation, early preoperative mobilization has a positive impact on patients' activities of daily living.

Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis

We aimed to assess the impact of timing of surgery in elderly patients with acute hip fracture on morbidity and mortality. We systematically searched MEDLINE, the Cochrane Library, Embase, PubMed, and trial registries from 01/1997 to 05/2017, as well as reference lists of relevant reviews, archives of orthopaedic conferences, and contacted experts. Eligible studies had to be randomised controlled trials (RCTs) or prospective cohort studies, including patients 60 years or older with acute hip fracture. Two authors independently assessed study eligibility, abstracted data, and critically appraised study quality. We conducted meta-analyses using the generic inverse variance model. We included 28 prospective observational studies reporting data of 31,242 patients. Patients operated on within 48 hours had a 20% lower risk of dying within 12 months (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.66-0.97). No statistical significant different mortality risk was observed when comparing patients operated on within or after 24 hours (RR 0.82, 95% CI 0.67-1.01). Adjusted data demonstrated fewer complications (8% vs. 17%) in patients who had early surgery, and increasing risk for pressure ulcers with increased time of delay in another study. Early hip surgery within 48 hours was associated with lower mortality risk and fewer perioperative complications.

Upper gastrointestinal bleeding in neck of femur fracture patients: a single tertiary centre experience

This study aimed to identify the incidence of perioperative acute upper gastrointestinal bleeding (UGIB) in our hip fracture patients; to evaluate the characteristics, management and clinical outcomes of these patients; and to explore risk factors and protective factors. Of the 1691 consecutive patients admitted for surgical management of hip fractures, 11 (0.65%) had UGIB and a further four patients for each case were selected as controls for evaluation of risk factors and protective factors. Pre-existing peptic ulcer disease was identified as a risk factor for acute UGIB (odds ratio 7.9; 95% confidence interval: 1.1-54.9). This study reported a very low incidence of UGIB in hip fracture patients. Despite being a high-risk population, timely endoscopic evaluation can be safely undertaken to optimise patient outcome. When risk factors such as history of peptic ulcer disease are present, additional precaution including gastro-protective agent and nutritional support should be undertaken.

Deep vein thrombosis in bilateral lower extremities after hip fracture: a retrospective study of 463 patients

Objective

To investigate the incidences of deep vein thrombosis (DVT) before and after operation in inpatients with hip fractures in both lower extremities.

Patients and methods

We collected the clinical data of 463 patients with lower extremities fractures who presented at Xi'an Honghui Hospital between July 1, 2014, and October 31, 2016 and met all the inclusion criteria. Doppler ultrasonography was used to diagnose DVT. The patients were examined preoperatively and postoperatively and divided into the thrombosis and non-thrombosis group according to the ultrasonographic findings. We divided the DVT cases into central, peripheral, and mixed thromboses.

Results

The incidence of preoperative DVT was 34.98%, and the prevalence of DVT on the uninjured side was 13.60%. This composition ratio increased to 57.23% postoperatively, and the prevalence of DVT on the uninjured side was 25.05%. Age (odds ratio [OR], 1.03; 95% CI: 1.01-1.04; P=0.002), venous thrombosis at admission (OR, 4.05; 95% CI, 2.30-7.13; P=0.000), and the days between the fracture and the operation (OR, 1.10; 95% CI, 1.02-1.20; P=0.020) were the independent risk factors of preoperative DVT. Coronary heart disease (OR, 1.85; 95% CI: 1.18-2.89; P=0.007), venous thrombosis at admission (OR, 22.35; 95% CI: 6.78-73.60; P=0.000), days between fracture and operation (OR, 1.06; 95% CI: 1.01-1.11; P=0.021), and blood loss (OR, 1.002; 95% CI: 1.000-1.003; P=0.014) were independent risk factors of postoperative DVT.

Conclusion

The actual incidence of DVT after hip fracture may be underestimated. The incidences of preoperative and postoperative DVTs and the incidence of DVT on the uninjured limb were high.

Incidence and risk factors of medical complications and direct medical costs after osteoporotic fracture among patients in China

We analyzed the incidence of medical complications after osteoporotic fractures and estimated its risk factors and cost impacts. Osteoporotic fractures can result in lots of serious medical complications, which is associated with patients' baseline characteristics such as patients' disease history and significantly increased patients' direct medical costs.

PURPOSE

The purpose of the study is to investigate the incidence and identify the risk factors of medical complications after osteoporotic fracture, and quantify patients' economic burden.

METHODS

Data were obtained from the Tianjin Urban Employee Basic Medical Insurance database (2009-2014). Patients aged ≥ 50 years, had ≥ 1 diagnoses of hip or vertebral fracture between 2010 and 2012, and continuously enrolled from 12 months before to 24 months after the first identified fracture were included. The incidence of medical complications was estimated within 12 months before and after fracture. Direct medical costs were measured and compared between patients with at least one medical complication and without any medical complications. Logistic regression was applied to identify risk factors for any medical complications.

RESULTS

Three thousand seven hundred nineteen patients were identified; 45.0% had hip fracture, and 56.2% had vertebral fracture. After osteoporotic fracture, the accumulative incidence of the most common medical complications including constipation (25.6%, RR 1.38 [1.28, 1.48]), stroke (25.2%, 1.16 [1.09, 1.24]), pneumonia (17.0%, 1.55 [1.40, 1.73]), urinary tract infection (16.3%, 1.23 [1.12, 1.36]), and arrhythmia (11.8%, 1.39 [1.23, 1.56]) was significantly higher than that before fracture. Advanced age; male sex; retirement status; diagnosis of hypertension, chronic heart disease, cerebrovascular disease, hemiplegia, or Parkinson's disease; and higher direct medical costs at baseline were significant predictors of complications. The all-cause direct medical cost during 24-month follow-up was $5665. Medical complications significantly increased patients' direct medical costs.

CONCLUSIONS

Osteoporotic fractures led to amount of medical complications, which significantly increased patients' economic burden. Complications correlate to various factors such as patients' disease history.

NHSLA litigation in hip fractures: Lessons learnt from NHSLA data

Hip fractures are a major cause of trauma related death, usually occurring in vulnerable elderly patients. There are an estimated 70,000 hip fractures in the UK per year with numbers set to rise. The estimated annual cost to the healthcare economy is in the region of £2 billion. A 17-year review examining litigation related to hip fractures was undertaken. Under a freedom of information request, data was obtained relating to all orthopaedic claims made to the NHS Litigation Authority (NHSLA) between 1995 and 2012. Data was filtered to identify cases involving hip fractures examining litigation trends related to this specific area. 10263 NHSLA orthopaedic cases were identified, of which 13.3% (n=1364) cases related to the hip and femur. Hip fractures made up 16.7% (n=229). The total cost of hip fracture litigation was over £7 million with an average cost per case of £32,700. The commonest reasons for litigation were diagnostic errors (30.6%), issues with care (24.9%) alleged incompetent surgery (15.7%) and development of pressure sores (5.7%). This study highlights the main causes of litigation in patients sustaining hip fractures, with diagnosis in the emergency department and ward presenting a significant problem. In addition, the data identifies a range of care related issues, as well as several surgical factors and highlights the importance of pressure area care. We discuss these and make suggestions on how to improve practice in this area with the aim of improving patient care and reducing litigation.

The effect of 'Out of hours surgery Service' in Israel on hip fracture fixation outcomes: a retrospective analysis

BACKGROUND

'Out of Hours Surgery Service' (OHSS) was implemented in Israel, amongst other reasons, in order to reduce the time interval between hospital admission and surgery and consequently improve outcomes. The OHSS is currently operated in the public hospitals in Israel. In this study we compared the data of patients before and after OHSS implementation to determine its efficacy in improving patient care.

METHODS

This is a retrospective observational study of 792 adult patients who underwent hip fracture surgery between 2002 and 2007 in a single hospital. The study population included two groups: patients that were operated before the implementation of the OHSS (2002-2004) and after the implementation of the OHSS (2005-2007). Data regarding all patients was collected using the institution's computer program. The following variables were analyzed: patients' demographics, time interval from hospitalization to surgery, causes for delaying surgery, post-operative length of hospitalization and mortality.

RESULTS

Patients in the post-OHSS group had more illnesses and higher ASA classification than those in the pre-OHSS group. The post-OHSS group had a significantly decreased length of stay in the hospital before and after the surgery. After adjusting for ASA score and age, the post-OHSS group was found to have decreased post-operative hospitalization and lower post-operative mortality. Surgery was delayed in pre-OHSS period mainly due to operating rooms unavailability.

CONCLUSION

Implementation of OHSS facilitated operating room availability, thus early operation and reduced post-operative mortality. In accordance with other studies, patient's outcome is greatly influenced by the time from admission to hip fracture surgery.

Increased Mortality in Elderly Patients with Sarcopenia and Acetabular Fractures

BACKGROUND

Sarcopenia is a condition of clinically relevant loss of muscle mass and function. Acetabular fractures in elderly patients are common and difficult to treat. This study aimed to determine if sarcopenia is common in elderly patients with acetabular fractures and correlates with lower-energy mechanisms of injury, higher rates of complications, and higher mortality than patients with normal muscle mass.

METHODS

The Rhode Island Hospital Trauma Database was queried for patients who were ≥60 years of age from 2005 to 2014 using the International Classification of Diseases, Ninth Revision, code for closed acetabular fracture, 808.0. Charts were retrospectively reviewed for demographic data, operative intervention, mechanism of injury, mortality, comorbidities, and other factors. Computed tomography (CT) was used to determine the muscle cross-sectional area and to calculate the skeletal muscle index.

RESULTS

The database revealed 192 patients coded for acetabular fracture; of these, 181 were correctly diagnosed. Ninety-nine patients had recorded body mass index (BMI) and adequate CT scans to measure the skeletal muscle index. Forty-two patients (42.4%) had sarcopenia, and 57 patients (57.6%) did not have sarcopenia. There were no significant differences in demographic characteristics between the groups with the exception of BMI and sex. BMI was higher in patients who did not have sarcopenia (31.7 kg/m) than it was in patients with sarcopenia (23.6 kg/m) (p < 0.001). Male sex was significantly greater (p = 0.0104) in patients with sarcopenia at 76.2% (32 of 42 patients) than in patients without sarcopenia at 50.9% (29 of 57 patients). Fractures in patients without sarcopenia were associated with a higher-energy mechanism of injury in 78.9% of cases compared with 52.4% of cases of patients with sarcopenia (p = 0.005). Sarcopenia was significantly associated (p = 0.0419) with increased 1-year mortality (28.6%) compared with the absence of sarcopenia (12.3%). This association was even stronger if in-hospital mortality was excluded (p = 0.00074). Finally, anterior column fractures were more likely (p = 0.017) to be sustained by patients with sarcopenia at 47.6% (20 patients) than by patients who did not have sarcopenia at 24.6% (14 patients).

CONCLUSIONS

Sarcopenia is common in elderly patients with acetabular fractures and is associated with lower-energy mechanisms, anterior column fractures, and higher risk of 1-year mortality.

LEVEL OF EVIDENCE

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

Cranberry juice concentrate does not significantly decrease the incidence of acquired bacteriuria in female hip fracture patients receiving urine catheter: a double-blind randomized trial

Background

Urinary tract infection (UTI) is a common complication among patients with hip fractures. Receiving an indwelling urinary catheter is a risk factor for developing UTIs. Treatment of symptomatic UTIs with antibiotics is expensive and can result in the development of antimicrobial resistance. Cranberries are thought to prevent UTI. There is no previous research on this potential effect in patients with hip fracture who receive urinary catheters.

Aim

The aim of this study is to investigate whether intake of cranberry juice concentrate pre-operatively decreases the incidence of postoperative UTIs in hip fracture patients that received a urinary catheter.

Design

This study employed a randomized, placebo-controlled double-blind trial.

Method

Female patients, aged 60 years and older, with hip fracture (n=227) were randomized to receive cranberry or placebo capsules daily, from admission, until 5 days postoperatively. Urine cultures were obtained at admission, 5 and 14 days postoperatively. In addition, Euro Qual five Dimensions assessments were performed and patients were screened for UTI symptoms.

Result

In the intention-to-treat analysis, there was no difference between the groups in the proportion of patients with hospital-acquired postoperative positive urine cultures at any time point. When limiting the analysis to patients that ingested at least 80% of the prescribed capsules, 13 of 33 (39%) in the placebo group and 13 of 47 (28%) in the cranberry group (P=0.270) had a positive urine culture at 5 days postoperatively. However, this difference was not statistically significant (P=0.270).

Conclusion

Cranberry concentrate does not seem to effectively prevent UTIs in female patients with hip fracture and indwelling urinary catheter.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Adverse cardiac events in 56,000 orthopaedic trauma patients: Does anatomic area make a difference?

PURPOSE

Postoperative cardiac events in orthopaedic trauma patients constitute severe morbidity and mortality. It is therefore increasingly important to determine patient risk factors that are predictive of postoperative myocardial infarctions and cardiac arrests. This study sought to assess if there is an association between anatomic area and cardiac complications in the orthopaedic trauma patient.

PATIENTS AND METHODS

From 2006-2013, a total of 361,402 orthopaedic patients were identified in the NSQIP database using Current Procedural Terminology (CPT) codes. Of these, 56,336 (15.6%) patients were identified as orthopaedic trauma patients broken down by anatomic region: 11,905 (21.1%) upper extremity patients (UE), 29,009 (51.5%) hip/pelvis patients (HP), and 15,422 (27.4%) lower extremity patients (LE) using CPT codes. Patients were defined as having adverse cardiac events if they developed myocardial infarctions or cardiac arrests within 30days after surgery. Chi-squared analysis was used to determine if there was an association between anatomic area and rates of cardiac events. Multivariate logistical analysis was used with over 40 patient characteristics including age, gender, history of cardiac disease, and anatomic region as independent predictors to determine whether anatomic area significantly predicted the development of cardiac complications.

RESULTS

There were significant differences in baseline demographics among the three groups: HP patients had the greatest average age (77.6 years) compared to 54.8 years for UE patients and 54.1 years in LE patients (p<0.001). HP patients also had the highest average ASA score (3.0) (p<0.001). There was a significant difference in adverse cardiac events based on anatomic area: 0.27% (32/11,905) UE patients developed cardiac complications compared to 2.15% (623/29,009) HP patients and 0.61% (94/15,422) LE patients. After multivariate analysis, HP patients were significantly more likely to develop cardiac complications compared to both UE patients (OR: 6.377, p=0.014) and LE patients (OR: 2.766, p=0.009).

CONCLUSION

There is a significant difference in adverse cardiac events following orthopaedic trauma based on anatomic region. Hip/Pelvis surgery appeared to be a significant risk factor in developing an adverse cardiac event. Further studies should investigate why hip/pelvic patients are at a higher risk of adverse cardiac events.

Predictors of Infective Outcomes Following Hip Fracture: A Cohort Study

Objectives: This study sought to assess the value of differing pre-operative measures in prediction of post-operative non-surgical site infection (NSSI) and length of hospital stay following hip fracture surgery. Methods: All patients admitted during a one year period with a hip fracture to our department were included in the study (n=207). Primary outcome measures were ten independent risk factors correlated to the development of non-surgical site infection following surgery for hip fracture. Secondary outcome measures were duration of hospital stay and inpatient mortality. Results: The patients who had severe cognitive impairment had a 71.0% risk of developing non-surgical site infection. Patients who had multiple medical co-morbidities also had increased risk of developing non-surgical site infection at 59.1%. Patients who developed NSSI on average stayed in hospital 13.1 days longer than patients who did not (31.6 vs. 18.5, p < .001). Conclusions: This study demonstrates the importance of reducing post-operative infection in hip fracture patients in view of reducing morbidity, mortality and cost. These patients can be stratified by risk factors and interventions can be employed in view of reducing inpatient post-operative infection rates in this cohort.

Adverse Events in Orthopaedics: Is Trauma More Risky? An Analysis of the NSQIP Data

OBJECTIVES

As our healthcare system moves toward bundling payments, orthopaedic trauma surgeons will be increasingly benchmarked on perioperative complications. We therefore sought to determine financial risks under bundled payments by identifying adverse event rates for (1) orthopaedic trauma patients compared with general orthopaedic patients and (2) based on anatomic region and (3) to identify patient factors associated with complications.

DESIGN

Prospective.

SETTING

Multicenter.

PATIENTS/PARTICIPANTS

A total of 146,773 orthopaedic patients (22,361 trauma) from 2005 to 2011 NSQIP data were identified.

INTERVENTIONS

Minor and major adverse events, demographics, surgical variables, and patient comorbidities were collected.

MAIN OUTCOME MEASUREMENTS

Multivariate regressions determined significant risk factors for the development of complications.

RESULTS

The complication rate in the trauma group was 11.4% (2554/22,361) versus 4.1% (5137/124,412) in the general orthopaedic group (P = 0.001). When controlling for all variables, trauma was a risk factor for developing complications [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.57-1.81]. After controlling for several patient factors, hip and pelvis patients were 4 times more likely to develop any perioperative complication than upper extremity patients (OR: 3.79, 95% CI: 3.01-4.79, P = 0.01). Lower extremity patients are 3 times more likely to develop any complication versus upper extremity patients (OR: 2.82, 95% CI: 2.30-3.46, P = 0.01).

CONCLUSIONS

Our study is the first to show that orthopaedic trauma patients are 2 times more likely than general orthopaedic patients to sustain complications, despite controlling for identical risk factors. There is also an alarming difference in complication rates among anatomic regions. Orthopaedic trauma surgeons will face increased financial risk with bundled payments.

LEVEL OF EVIDENCE

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

Does integrity of the lesser trochanter influence the surgical outcome of intertrochanteric fracture in elderly patients?

BACKGROUND

Most surgeons do not fix the lesser trochanter when managing femoral intertrochanteric fractures with intramedullary nails. We have not found any published clinical studies on the relationship between the integrity of the lesser trochanter and surgical outcomes of intertrochanteric fractures treated with intramedullary nails. The purpose of this study was to evaluate the impact of the integrity of the lesser trochanter on the surgical outcome of intertrochanteric fractures.

METHODS

A retrospective review of 85 patients aged more than 60 years with femoral intertrochanteric fractures from January 2010 to July 2012 was performed. The patients were allocated to two groups: those with (n = 37) and without (n = 48) preoperative integrity of the lesser trochanter. Relevant patient variables and medical comorbidities were collected. Medical comorbidities were evaluated according to the American Society of Anesthesiologists classification and medical records were also reviewed for age, sex, time from injury to operation, intraoperative blood loss, volume of transfusion, operative time, length of stay, time to fracture union, Harris Hip Score 1 year postoperatively, and incidence of postoperative complications. Postoperative complications included deep infection (beneath the fascia lata), congestive heart failure, pulmonary embolus, cerebrovascular accident, pneumonia, cardiac arrhythmia, urinary tract infection, wound hematoma, pressure sores, delirium, and deep venous thrombosis. Variables were statistically compared between the two groups, with statistical significance at P<0.05.

RESULTS

Patients with and without preoperative integrity of the lesser trochanter were comparable for all assessed clinical variables except fracture type (P < 0.05). There were no statistically significant differences between these groups in time from injury to operation, volume of transfusion, length of stay, time to fracture union, Harris Hip Score at 1 year postoperatively, and incidence of postoperative complication (P > 0.05). The group with preoperative integrity of the lesser trochanter had significantly less blood loss (107.03 ± 49.21 mL) than those without it (133.96 ± 58.08 mL) (P < 0.05) and the operative time was significantly shorter in the former (0.77 ± 0.07 hours) than the latter (0.84 ± 0.11 hours) group (P < 0.05).

CONCLUSIONS

The integrity of the lesser trochanter has no significant influence on the surgical outcome of intramedullary nail internal fixation of femoral intertrochanteric fractures.

Pertrochanteric hip fracture: a "routine" fracture with a potentially devastating vascular complication

Vascular injuries in conjunction with low-energy geriatric hip fractures, although uncommon, can be life-threatening. Furthermore, vascular injuries are usually iatrogenic, related to malpositioning of percutaneous reduction aids, aberrant drilling, or poorly sized implants. The authors describe an older woman who had a low-energy pertrochanteric hip fracture. She was noted preoperatively to have an isolated decrease in hemoglobin of 4.7 g/dL in the 2.5 days before surgery. Fracture reduction was performed with closed and percutaneous techniques with the limb free-legged on a radiolucent flat-top table. On reduction of the distal fragment (which was translated proximal and medial), extremely brisk bleeding was noted from the fracture site. Vascular control was obtained with subvastus exposure through the fracture site to gain access to the medial aspect of the thigh. A pulsatile traumatic laceration in the profunda femoral artery was identified, and the ends were ligated. The fracture was then fixated internally. Careful analysis of preoperative imaging showed the distal fracture fragment in immediate proximity to the calcified profunda femoral artery, transecting it at the time of injury and resulting in the significant increase in hemoglobin noted preoperatively. This case is an unusual vascular injury associated with a very common geriatric fracture pattern. To the authors' knowledge, there are only 2 cases in the English language literature of acute vascular injury as a result of a proximal femur fracture fragment. Given the routine nature of geriatric hip fractures, the orthopedic surgeon must be familiar with the appropriate diagnosis and management of this major complication.

Treatment of femoral neck fracture with a minimal invasive surgical approach for hemiarthroplasty - clinical and radiological results in 180 geriatric patients

Purpose :

The Direct Anterior Approach (DAA) is well established as a minimal access approach in elective orthopaedic hip surgery. For the growing number of elderly patients with femoral neck fractures treated with Bipolar Hip Hemiarthroplasty (BHH), only a few results do exist. The study shows the clinical and radiological outcome for 180 patients treated by a modified DAA with BHH.

Materials and Methods :

The data of 180 geriatric patients with medial femoral neck fractures were evaluated retrospectively. The general and surgical complications, mobilisation using the Timed Up and Go test (TUG), the social environment pre- and postoperative and the radiological results have been compared with established approaches for geriatric hip surgery.

Results :

After joint replacement, 18 (10%) patients were developed pneumonia, of which 3 (1.7%) died during hospitalisation. In 7 cases (4%), surgical revision had to be carried out: three times (1.7%) because of a seroma, three times (1.7%) because of subcutaneous infection, and one time (0.6%) because the BHH was removed, owing to deep wound infection. One dislocation (0.6%) occurred, as well as one femoral nerve lesion (0.6%) occured. 88.3% of patients were mobilised on walkers or crutches; the Timed Up and Go Test showed a significant improvement during inpatient rehabilitation. 83% were discharged to their usual social environment, 10% were transferred to a short-term care facility and 7% were relocated permanently to a nursing home. 3/4 of patients had a cemented stem alignment in the range between -5° and 5°, while 2/3 of patients had a maximum difference of 1 cm in leg length.

Conclusion :

Using the modified DAA, a high patient satisfaction is achieved after implantation of a BHH. The rate of major complications is just as low as in conventional approaches, and rapid mobilisation is possible.