Long-term survival of femoral neck fracture patients aged over ninety years: Arthroplasty compared with nonoperative treatment

The Superior Approach in Hemiarthroplasty for Femoral Neck Fracture: A Comparative Analysis with the Posterior Approach

Purpose

The concept of a superior approach (SA) involves the use of a tissue-sparing posterior approach (PA), with exposure of the piriformis muscle and gluteus medius/minimus muscles. The objective of this study was to clarify the features of hip hemiarthroplasty (HA) using a SA in regard to early recovery and mid-term outcomes, with a comparison of the outcomes of SA-HAs and HAs using a PA (PA-HAs).

Materials and Methods

A total of 120 HAs for treatment of primary femoral neck fracture with a healthy opposite hip joint were performed in our hospital from 2013 to 2018. Propensity score matching in regard to age, sex, body mass index, walking ability before injury, place of residence, time to surgery, and American Society of Anesthesiologists-Physical Status was performed for 79 patients with SA-HAs and 41 patients with PA-HAs. The final analysis included 34 patients who underwent SA-HAs and 34 patients who underwent PA-HAs.

Results

The duration of surgery was 57.1 minutes and 72.1 minutes (P=0.001) for SA-HAs and PA-HAs, respectively. The scores for walking ability at postoperative one week were 4.9±1.4 and 4.2±1.0 (P=0.021) for SA-HAs and PA-HAs, respectively. The Barthel index (BI) at the start of rehabilitation was 26.2±18.7 and 17.4±16.3 (P=0.042) for SA-HAs and PA-HAs, respectively. The 4-year complication-free survival rates were 74.2% and 56.3% for SA-HAs and PA-HAs, respectively (P=0.310).

Conclusion

SA-HA can be performed without torsion of the muscles and ligaments around the hip joint. Early recovery of walking ability and BI was a significant feature of SA-HAs.

The Prognostic Significance of Surgical Treatment for Excessive Elderly Soft Tissue Sarcoma Patients over 90 Years Old: A Clinicopathological Study of 16 Cases

OBJECTIVES

The incidence of soft tissue sarcomas (STSs) among older patients is increasing. Although surgical treatment of elderly patients with STS has been reported to improve their prognosis, most of these studies included patients with STS aged <85 years. This study aimed to analyze the clinical features and prognostic factors of STS in elderly patients aged ≥90 years.

SUBJECT AND METHODS

We retrospectively identified patients aged ≥90 years with STS who were treated at our two hospitals between 1994 and 2022. Data on clinical information and detailed assessments were collected. We evaluated the features and factors affecting the prognosis of patients with older-extremity STS. In addition, we compared the clinical courses and results of patients treated with surgery and radiotherapy for primary tumors.

RESULTS

Among 454 patients with STS, 16 were aged ≥90 years. Kaplan-Meier curves for overall survival showed a significantly poorer prognosis in patients who did not receive surgical treatment (p = 0.0348) and those who received radiotherapy (p = 0.0070). Moreover, we investigated the difference in prognosis between surgical treatment and radiotherapy, excluding two cases with distant metastasis at initial diagnosis and one case with no treatment. Kaplan-Meier curves for overall survival showed a significantly better prognosis in patients who underwent surgical treatment (p = 0.0161). Univariate analysis revealed that only primary tumor size was a significant predictor of poor prognosis (p = 0.0426).

CONCLUSION

In patients with STS aged ≥90 years old, aggressive surgical treatment may improve the prognosis more than radiotherapy.

Efficacy of surgical intervention over conservative management in intertrochanteric fractures among nonagenarians and centenarians: a prospective cohort study

BACKGROUND

Optimal treatment strategy for nonagenarians and centenarians with hip fractures (NCHF) remained unknown. The authors aimed to compare the outcomes of surgical and conservative management in NCHF.

METHODS

A prospective cohort study was conducted based on CPMHF database with NCHF patients hospitalized during 2014-2020. Comorbidities were evaluated by mECM score and restricted cubic spline was utilized to visually assess the dose-effect relationship between the mECM and outcomes. Propensity score matching was performed to balance baseline characteristics between nonsurgical and surgical groups. Multivariate logistic regression, Cox proportional hazard analysis, and survival analysis were employed for unfavorable outcomes (UFO) evaluation. Competing risk of death were analyzed based on Fine and Gray's hazard model and then constructed nomogram models for predicting survival rates. Subgroup analyses were used to determine potential population heterogeneity and sensitivity analyses were performed to test robustness of the results.

RESULTS

The authors found increasing trends for UFO with the increase in the mECM score, and that high mECM score (HMS, ≥3) was independently associated with a 2.42-fold (95% CI: 2.07-3.54; P =0.024) increased risk of UFO, which remained significant after considering the competing role of death and were more pronounced in nonsurgical treatment, women, no insurance, and patients with spouse (all P for interaction <0.05). Surgical intervention was identified to be significant protective factors for UFO (RR, 0.59; 95% CI: 0.46-0.75; P <0.001) and severe complications (RR, 0.63; 95% CI: 0.41-0.96; P =0.033) after propensity score matching, as well as survival (HR, 0.40, 95% CI: 0.28-0.58; P <0.001), which remained significant after considering the competing role of death and in all sensitivity analyses and were more pronounced in HMS participants ( P for interaction=0.006). Subgroup analyses revealed surgical patients with HMS had a significantly higher UFO rate (excluding death, P <0.001) while nonsurgical patients with HMS had higher mortality rate as compared to the others ( P =0.005).

CONCLUSION

Surgical treatment for NCHF yields better outcomes compared to conservative treatment.

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

Background

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

Materials and methods

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

Results

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

Conclusion

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

Current surgical status of hip fracture among elderly in China

OBJECTIVE

Hip fracture patients are recommended to undergo surgery within 24-36 h. The present study aimed to analyze the current status of hip fracture surgery among the elderly in China.

METHODS

The baseline information, such as the patient's age, gender, place of residence, place of treatment, fracture type, admission, and operation time, of hip fracture patients >65-years-old were retrieved from the hospital quality monitoring system (HQMS) database from 2013 to 2017 and analyzed.

RESULTS

A total of 304,279 patients >65-years-old with hip fractures were included in this study. The average length of hospital stay was 15 days, and the average waiting time for surgery after admission was 96 h. The average surgery rate of elderly hip fractures in China was 59.6 %, of which the lowest was recorded in the Northwest China (46.4 %).

CONCLUSIONS

The major issues in diagnosing and treating elderly patients with hip fractures in China are the long waiting time for surgery and the low surgery rate.

Outcomes of ultra-old vs old patients after hip fracture surgery: a matched cohort analysis of 1524 patients

BACKGROUND

Surgical management of geriatric hip fractures yields improved functional outcomes with decreased morbidity and mortality. Cohort studies have suggested that the older patients within the geriatric age group have worse outcomes with surgery, However, these studies inherently report inflated risks due to poor handling of confounders and have inadequately age-stratified their geriatric population.

AIM

This study aims to investigate the effect of age alone on the 1-year mortality and functional status of geriatric patients after hip fracture surgery.

METHODS

This is a retrospective single institution cohort study based on the prospectively-maintained registry of hip fracture patients. 2603 patients aged 60 years and above were treated surgically under a geriatric-orthopaedic hip fracture pathway from January 2014 to December 2018. Patients were split into two age groups: ultra-old (≥ 85 years) vs old (< 85 years). Baseline demographics and the ASA (American Society of Anaesthesiologists) status and the Modified Barthel's Index (MBI) were obtained at admission and 1 year after the fracture. Adverse outcomes from the fracture and surgery were recorded during a follow-up period of minimally 2 years. A 2:1 matching process based on the gender, fracture type, ASA status, CCI and MBI categories was conducted.

RESULTS

There were 1009 and 515 patients in the old and ultra-old age groups, respectively. 1-year mortality was similar for both age groups (4.0% ultra-old vs 3.6% old, p = 0.703). 30-day morbidity was similar except for higher rates of postoperative pneumonia in the ultra-old (14.0 vs 6.3%, p < 0.001). MBI scores at 1-year were lower in the ultra-old (severe dependence: 16.4 vs 10.0%; p = 0.001). Ultra-old patients were less likely to be community ambulant at 12 months (21.2 vs 36.0%) with the deterioration in ambulatory status significant after correction for baseline status (p < 0.001).

CONCLUSION

The 1-year mortality of surgically-managed geriatric hip fracture patients older than 85 years of age is not determined by age alone. Patients aged 85 years and above are at higher risk for pneumonia postoperatively. Ultra-old hip fracture patients with an intertrochanteric fracture are more likely to have poorer function at 1 year after hip fracture surgery.

Prevalence and correlative factors of hyperhomocysteinemia in elderly patients with femoral neck fracture: A cross-sectional study

Aims

The occurrence of hyperhomocysteinemia (HHcy) in elderly patients with femoral neck fracture (FNF) draws little attention from surgeons preoperatively. The aim of our study was to determine the prevalence and correlative factors of HHcy in elderly patients (≥65 years) with FNF prior to surgery.

Methods

We retrospectively investigated 286 elderly FNF patients aged 65–98 years admitted to our institution from September 2020 to September 2021. Categorical variables were compared using the Chi‐squared test, and continuous variables were compared using the Mann–Whitney U test. Univariable and multivariable logistic regression were used to determine the associations of variables with the odds of HHcy.

Results

Among the 286 elderly FNF patients, the prevalence of HHcy was 30.77% and the mean Hcy level was 14.52 ± 10.49 μmol/L. The mean Hcy level and the prevalence of HHcy in male patients were significantly higher than that in female patients (16.41 ± 9.58 μmol/L vs. 14.00 ± 10.69 μmol/L, p = 0.002; 43.55% vs. 27.23%, p = 0.014). Multivariate analysis indicated that being male patient (OR 2.187, 95% CI 1.187–4.028, p = 0.012), hypertension (OR 1.993, 95% CI 1.141–3.479, p = 0.015), and low HDL‐C (OR 2.979, 95% CI 1.353–6.558, p = 0.007) were significant correlative factors of HHcy among elderly FNF patients.

Conclusions

This study found a high prevalence of HHcy in elderly FNF patients, with being male patient, hypertension, and low levels of HDL‐C as the significant correlative factors after adjusting for age and other covariables. However, further large‐scale studies in wider regions are warranted to confirm these findings.

Hyperhomocysteinemia (HHcy), which have been associated with increased cardiovascular, cerebrovascular, and thromboembolic diseases in elderly patients, are frequently neglected by orthopedic surgeons in their clinical practices. Using the descriptive statistical analysis and logistic regression model, we found a high prevalence (30.77%) of HHcy among elderly patients with femoral neck fracture (FNF), with being male patient, hypertension, and low levels of HDL‐C as the significant correlates after adjusting for age and other covariables. The current findings may help to the preoperative assessment and optimization of patient with FNF.

Sex differences in short- and mid-term survival in femoral neck fracture patients aged over 90 years: A retrospective cohort study

OBJECTIVES

The primary purpose of this retrospective study was to evaluate the sex differences in short- and mid-term mortality in femoral neck fracture patients aged >90 years treated operatively and nonoperatively over a 10-year period.

METHODS

From January 2007 to December 2016, all femoral neck fractures patients (aged over 90 years) admitted to our hospital were included for evaluation. The survival time and mortality rate were compared between patients treated by arthroplasty and those treated nonoperatively. Additionally, a Cox proportional hazards model was built to explore the treatment effect difference between the arthroplasty group and the nonoperative group with sex-stratified subgroups.

RESULTS

The difference in the survival distribution between the nonoperative and arthroplasty groups were significant for women (P = 0.002) but not for men (P = 0.6222). The adjusted hazard ratio (95% confidence interval) of nonoperative treatment to arthroplasty was 3.93 (1.86, 8.31). The adjusted risk ratios of nonoperative treatment to arthroplasty for males and females were 1.24 (0.58, 2.67) and 34.04 (8.68, 133.47), respectively. The data also showed higher short- and midterm survival rates in women than in men among the arthroplasty group, especially within the first 1-3 years after injury.

CONCLUSIONS

Arthroplasty can significantly improve short- and mid-term survival in femoral neck fracture patients aged over 90 years, especially females. The most significant difference in mortality between the two sexes was observed within the first three years following the fracture.