Rapid preoperative predicting tools for 1-year mortality and walking ability of Asian elderly femoral neck fracture patients who planned for hip arthroplasty

Predictive factors of gait recovery after hip fracture: a scoping review

OBJECTIVE

This scoping review aimed to identify predictive factors influencing gait recovery post-hip fracture surgery among adults aged 65 and older.

DESIGN

A systematic search of MEDLINE, Embase and CINAHL databases was conducted, focusing on studies assessing predictive factors of gait recovery within one month to one-year post-surgery. Two independent reviewers carried out study selection, quality assessment and data extraction using the Quality in Prognosis Studies Tool to gauge evidence levels.

RESULTS

About 10,627 articles were initially identified. After duplicates were removed, 7665 were screened based on title and abstract, then 796 based on full text; 138 articles were finally included.The review identified a total of 77 predictive factors. However, just under half (34) of these were supported by studies with a low risk of bias. Higher-level evidence-supported factors were age, pre-fracture independence in daily activities, cognitive impairment, delirium, orthogeriatric multidisciplinary co-management, specific surgical interventions, allowing weight-bearing, comorbidities, nutritional status, rehabilitation treatments and polypharmacy.

CONCLUSION

The identified factors influencing gait recovery include both non-modifiable factors [such as younger age, pre-fracture independence in activities of daily living, absence of cognitive impairment, fewer comorbidities and lower anaesthetic risk] and modifiable factors, including rehabilitation treatments, organisational factors, absence of delirium, orthogeriatric co-management, surgical factors such as implant type and unrestricted weight-bearing, better nutritional status and strength, and reduced polypharmacy. We believe the latter should be prioritised in managing patients with hip fractures to achieve optimal recovery.

Effect of Early Mobilization on Gait Recovery One Year After Hip Fracture Surgery: A Single-Center Cohort Study

PURPOSE

To investigate the effects of early mobilization on walking independence and gait recovery one year after hip fracture surgery.

MATERIALS AND METHODS

This cohort study included 104 patients aged ≥65 years. Patients were divided into two groups: early mobilization (EM; postoperative mobilization on the day after surgery) and late mobilization (LM; postoperative mobilization ≥2 days after surgery) groups. Multivariate logistic regression analysis was performed to investigate the effect of EM on independent walking and recovery to pre-injury walking status one year postoperatively. Independent walking was defined as a walking functional independent measure (FIM) of ≥5.

RESULTS

The number of older patients able to walk independently at discharge and one year postoperatively after hip fracture surgery was 63 (60.6%) and 66 (63.5%), respectively. Multivariate logistic regression analysis revealed that EM was associated with independent walking at one year postoperatively (odds ratio, 3.79; 95% confidence interval, 1.30-11.06; P=0.001). However, EM was not associated with recovery to pre-injury walking status one year postoperatively (P=0.22).

CONCLUSIONS

Early postoperative mobilization significantly increased the likelihood of independent walking one year after hip fracture surgery in older adults. Patients who mobilized early were nearly four times more likely to achieve this outcome, underscoring the importance of EM in postoperative care. Further studies are needed to confirm these findings and address barriers to implementing EM in clinical practice.

Preoperative transthoracic echocardiography does not lead to decreased postoperative mortality but with increased time to surgery and length of stay in Chinese geriatric hip fracture patients

PURPOSE

The present study aimed to investigate the influence of preoperative TTE on postoperative short-term mortality, surgery delay, as well as other economic and clinical outcomes in Chinese geriatric hip fracture patients.

METHODS

This retrospective, matched-cohort study enrolled geriatric hip fracture patients (≥ 60 years) who underwent surgical interventions at our center between 2015 and 2020. The primary exposure was inpatient preoperative TTE. Demographic and clinical data that were reported as risk factors for postoperative mortality were retrieved from the medical data center as the covariates. The primary clinical outcomes were all-cause mortality at 30 days, 90 days, 180 days, and 1 year. Time from hospital presentation to surgery, length of stay (LOS), inpatient cost, frequency of cardiology consultation and coronary angiography (CAG) were also assessed. The propensity score matching (PSM) was performed in a ratio of 1:1.

RESULTS

447 patients were identified and 216 of them received a preoperative TTE (48.3%). After successfully matching 390 patients (87.2%), patients receiving TTE showed significantly higher 30-day mortality (6.6% vs 2.0%, P = 0.044). But no significant difference was found in 90-day, 180-day, and 365-day mortality as well as the 1-year accumulated survival rate. Receipt of TTE was also associated with significant increases in LOS (13.6 days vs 11.4 days, P = 0.017), waiting time for surgery (5.9 days vs 4.3 days, P < 0.001), and lower proportion of receiving surgery within 48 h (7.2% vs. 26.2%, P < 0.001). According to the multivariable logistic analysis, only ejection fraction (30 days, 90 days), aorta diameter (30 days, 90 days, 180 days, 365 days), left ventricular posterior wall diameter (90 days, 180 days, 365 days), aortic valve velocity (90 days) and mitral valve A-peak (90 days, 180 days) were association with postoperative mortality among the 17 parameters in the TTE reports. Besides, TTE has no influence on the frequency of preoperative cardiology consultation.

CONCLUSION

Preoperative TTE does not lead to decreased postoperative mortality but with increased time to surgery and length of stay in Chinese geriatric hip fracture patients. The predictive ability of TTE parameters is limited for postoperative mortality.

Development of a Clinical Prediction Rule to Determine Walking Independence in Older Adults With Hip Fractures

INTRODUCTION AND AIM

 Accurate determination of walking independence in older adults after hip fracture surgery is crucial for selecting appropriate walking strategies and providing fall prevention guidance. We developed and validated a clinical prediction rule (CPR) to determine level-surface walking independence and community walking independence in older adults with hip fractures.

METHODS

In a multicenter, cross-sectional study, we investigated 289 older inpatients with hip fractures. A backward stepwise logistic regression analysis was performed to develop a CPR for determining level-surface walking independence and community walking independence. The independent variables incorporated the patients' walking and balance evaluations at discharge, including the Berg Balance Scale (BBS), the Timed Up and Go (TUG) test, and maximum walking speed (MWS), as well as age and cognitive function evaluations. We used a bootstrap internal validation for the CPR's internal validation.

RESULTS

At their hospital discharge, 171 patients had achieved level-surface walking independence, and 51 had achieved community walking independence. As the level of walking independence decreased, patients tended to be older, with lower BBS scores and slower TUG times and walking speeds. As diagnostic factors, the level-surface walking model included age, BBS, and cognitive decline; the community walking model included BBS, TUG, and MWS. The diagnostic accuracy, represented by the area under the curve (confidence interval), was 0.88 (0.84-0.92) for the level-surface walking model and 0.81 (0.74-0.87) for the community walking model. Internal validation confirmed that the models' discrimination accuracy was good, and no model overfitting was observed.

CONCLUSIONS

We developed a moderately accurate CPR to determine walking independence in hip fracture patients. CPR can be a useful indicator for determining an individual's walking independence at present, but external validations with other samples are necessary.

Independent Walking Disability After Fragility Hip Fractures: A Prognostic Factors Analysis

Introduction

Up to one-third of patients with fragility hip fractures are totally dependent in the year following the injury which leads to later morbidity and mortality. Understanding the related factors that affect patients' ambulation helps health care providers prepare for the treatment plans to improve their functional outcomes. This study aimed to evaluate the factors associated with independent walking disability in the early postoperative period after fragility hip fractures.

Material and methods

This retrospective cohort study involved 394 patients with fragility hip fractures with either intertrochanteric, subtrochanteric, or femoral neck fractures from January 2018 to June 2023. The related factors including preoperative demographics, perioperative, and postoperative factors, were collected and analyzed. The endpoint was the independent walking disability of patients at 6 weeks after surgery.

Results

110 patients (27.9%) were disabled, whereas 284 patients (72.1%) could walk independently at postoperative 6 weeks. The multivariable risk ratio regression analysis showed that patients with age ≥80 years (RR 1.65; 95% CI 1.21-2.25; P = 0.001), pre-fracture walking with the gait aid (RR 2.03; 95% CI 1.53-2.69; P < 0.001), having ≥2 underlying comorbidities (RR 1.63; 95% CI 1.19-2.23; P = 0.002), preoperative hypoalbuminemia (RR 1.74; 95% CI 1.32-2.29; P < 0.001), and presence of the postoperative medical complication (RR 2.04; 95% CI 1.37-3.02; P < 0.001) were significantly associated with independent walking disability at the early postoperative period of 6 weeks.

Conclusions

Post-hip fracture surgery patients with the presence of postoperative medical complication have the highest risk of independent walking disability. Health care providers should concentrate on high-risk patients, correct the modifiable factors, and minimize any postoperative complications to improve functional recovery and decrease morbidity related to non-ambulation after fragility hip fractures.

Systematic review of multivariable prognostic models for outcomes at least 30 days after hip fracture finds 18 mortality models but no nonmortality models warranting validation

OBJECTIVES

Prognostic models have the potential to aid clinical decision-making after hip fracture. This systematic review aimed to identify, critically appraise, and summarize multivariable prediction models for mortality or other long-term recovery outcomes occurring at least 30 days after hip fracture.

STUDY DESIGN AND SETTING

MEDLINE, Embase, Scopus, Web of Science, and CINAHL databases were searched up to May 2023. Studies were included that aimed to develop multivariable models to make predictions for individuals at least 30 days after hip fracture. Risk of bias (ROB) was dual-assessed using the Prediction model Risk Of Bias ASsessment Tool. Study and model details were extracted and summarized.

RESULTS

From 5571 records, 80 eligible studies were identified. They predicted mortality in n = 55 studies/81 models and nonmortality outcomes (mobility, function, residence, medical, and surgical complications) in n = 30 studies/45 models. Most (n = 46; 58%) studies were published since 2020. A quarter of studies (n = 19; 24%) reported using 'machine-learning methods', while the remainder used logistic regression (n = 54; 68%) and other statistical methods (n = 11; 14%) to build models. Overall, 15 studies (19%) presented 18 low ROB models, all predicting mortality. Common concerns were sample size, missing data handling, inadequate internal validation, and calibration assessment. Many studies with nonmortality outcomes (n = 11; 37%) had clear data complexities that were not correctly modeled.

CONCLUSION

This review has comprehensively summarized and appraised multivariable prediction models for long-term outcomes after hip fracture. Only 15 studies of 55 predicting mortality were rated as low ROB, warranting further development of their models. All studies predicting nonmortality outcomes were high or unclear ROB. Careful consideration is required for both the methods used and justification for developing further nonmortality prediction models for this clinical population.

Systematic review and meta-analysis of preoperative predictors for early mortality following hip fracture surgery

Hip fractures are a global health problem with a high postoperative mortality rate. Preoperative predictors for early mortality could be used to optimise and personalise healthcare strategies. This study aimed to identify predictors for early mortality following hip fracture surgery. Cohort studies examining independent preoperative predictors for mortality following hip fracture surgery were identified through a systematic search on Scopus and PubMed. Predictors for 30-day mortality were the primary outcome, and predictors for mortality within 1 year were secondary outcomes. Primary outcomes were analysed with random-effects meta-analyses. Confidence in the cumulative evidence was assessed using the GRADE criteria. Secondary outcomes were synthesised narratively. Thirty-three cohort studies involving 462,699 patients were meta-analysed. Five high-quality evidence predictors for 30-day mortality were identified: age per year (OR: 1.06, 95% CI: 1.04-1.07), ASA score ≥ 3 (OR: 2.69, 95% CI: 2.12-3.42), male gender (OR: 2.00, 95% CI: 1.85-2.18), institutional residence (OR: 1.81, 95% CI: 1.31-2.49), and metastatic cancer (OR: 2.83, 95% CI: 2.58-3.10). Additionally, six moderate-quality evidence predictors were identified: chronic renal failure, dementia, diabetes, low haemoglobin, heart failures, and a history of any malignancy. Weak evidence was found for non-metastatic cancer. This review found relevant preoperative predictors which could be used to identify patients who are at high risk of 30-day mortality following hip fracture surgery. For some predictors, the prognostic value could be increased by further subcategorising the conditions by severity.

Predictive Value of Machine Learning Models in Postoperative Mortality of Older Adults Patients with Hip Fracture: A Systematic Review and Meta-analysis

BACKGROUND

Some researchers have used machine learning to predict mortality in old patients with hip fracture, but its application value lacks an evidence-based basis. Hence, we conducted this meta-analysis to explore the predictive accuracy of machine learning for mortality in old patients with hip fracture.

METHODS

We systematically retrieved PubMed, Cochrane, Embase, and Web of Science for relevant studies published before July 15, 2022. The PROBAST assessment tool was used to assess the risk of bias in the included studies. A random-effects model was used for the meta-analysis of C-index, whereas a bivariate mixed-effects model was used for the meta-analysis of sensitivity and specificity. The meta-analysis was performed on R and Stata.

RESULTS

Eighteen studies were included, involving 8 machine learning models and 398,422 old patients undergoing hip joint surgery, of whom 60,457 died. According to the meta-analysis, the pooled C-index for machine learning models was 0.762 (95% CI: 0.691 ∼ 0.833) in the training set and 0.838 (95% CI: 0.783 ∼ 0.892) in the validation set, which is better than the C-index of the main clinical scale (Nottingham Hip Fracture Score), that is, 0.702 (95% CI: 0.681 ∼ 0.723). Among different machine learning models, ANN and Bayesian belief network had the best predictive performance.

CONCLUSION

Machine learning models are more accurate in predicting mortality in old patients after hip joint surgery than current mainstream clinical scoring systems. Subsequent research could focus on updating clinical scoring systems and improving their predictive performance by relying on machine learning models.

Bone turnover biomarkers predict one-year all-cause mortality and walking ability in geriatric hip fracture patients

PURPOSE

To investigate the utility of serum C-terminal cross-linking telopeptides (β-CTX) and procollagen type I N propeptide (PINP) for predicting one-year mortality and walking ability in Chinese geriatric hip fracture patients who underwent surgical interventions.

METHOD

Elderly patients (≥ 60 years) who underwent surgical interventions for unilateral low-energy hip fracture from 2015 to 2020 in our center were included. Demographic data was retrospectively retrieved from the electronic medical database. The PINP and β-CTX concentrations were measured before the surgery. The patients were divided into two groups according to the outcome of mortality and walking ability after hip surgery, respectively. β-CTX and PINP were divided into four grades based on quartiles [Quartile(Q)1-4] for further analysis. All the variables with p < 0.1 in univariable analysis were included in a multivariable model.

RESULTS

In univariable analysis, the levels of serum β-CTX (p = 0.007) and PINP (p = 0.025) was associated with one-year mortality, while the association between levels of serum β-CTX (p = 0.072) or PINP (p = 0.055) with one-year disability was marginally significant. After adjustment for confounders, the relative risk [OR (95 % CI), Q4 v sQ1, p-value] of one-year mortality and one-year disability were 7.28 (2.08-29.78, p = 0.003) and 3.97 (1.44-11.69, p = 0.009) for β-CTX and 5.87 (1.70-23.80, p = 0.008) and 3.48 (1.30-9.93, p = 0.016) for PINP, respectively. The coefficient of determination, AUC and bias-corrected C-index of predictive models based on previously reported predictors were significantly improved after integrating β-CTX or PINP.

CONCLUSION

Higher serum β-CTX and PINP are independently associated with an increased risk of one-year mortality and disability in patients with hip fractures. The application of BTMs improves the performance of currently available predictive models.

Preoperative Vitamin D Deficiency is Associated with Increased One-Year Mortality in Chinese Geriatric Hip Fracture Patients - A Propensity Score Matching Study

BACKGROUND

Vitamin D deficiency is a common comorbidity in geriatric hip fracture patients. However, there is still an ongoing debate regarding the influence of preoperative Vitamin D status on postoperative mortality in hip fracture patients.

METHODS

Elderly patients (≥60 years) who underwent surgical interventions for unilateral hip fracture from 2015 to 2020 in our center were included. We retrospectively retrieved the demographic data from the electronic medical database. Preoperative serum total 25-hydroxy-Vitamin D was set as the independent variable and patients were classified as the Vitamin D deficiency (<20ng/mL) and the control groups consequently. Clinical outcomes include all-cause mortality, walking ability, and major postoperative complications in the first postoperative year. Propensity score matching (PSM) was performed in a ratio of 1:1 in the two groups for further comparison.

RESULTS

A total of 210 patients were included and 121 patients (57.6%) were diagnosed with Vitamin D deficiency. Patients in the Vitamin D deficiency group were much older and therefore preferred peripheral nerve block, and had significantly higher proportions of females, preoperative dementia, higher ASA grade, and lower baseline serum albumin level. Overall, 79 patients were identified in the Vitamin D deficiency and control groups after PSM, respectively. Patients diagnosed with Vitamin D deficiency showed a significantly higher one-year mortality (21.5% vs 6.3%, P=0.011) and a much lower one-year independent walking rate (67.1% vs.84.8%, P=0.016) after the matching. Regarding the dataset before PSM and after PSM, the AUC for serum Vitamin D for predicting one-year mortality was 0.656 (P=0.006) and 0.695 (P=0.002), respectively.

CONCLUSION

Our retrospective PSM-design study provides new evidence that Vitamin D deficiency was associated with a significantly higher mortality and poor walking ability in the first year after surgical intervention based on southern Chinese populations.

Development and internal validation of a conventional ultrasound-based nomogram for predicting malignant nonmasslike breast lesions

BACKGROUND

The aim of this study was to develop a conventional ultrasound (US) features-based nomogram for the prediction of malignant nonmasslike (NML) breast lesions.

METHODS

Consecutive cases of adult females diagnosed with NML breast lesions via US screening in our center from June 1st, 2017, to April 17th, 2020, were retrospectively enrolled. Candidate variables included age, clinical symptoms, and the image features obtained from the conventional US. Nomograms were developed based on the results of the multiple logistic regression analysis via R language. One thousand bootstraps were used for internal validation. The area under the curve (AUC) and the bias-corrected concordance index (C-index) were calculated. Decision curve analysis (DCA) was also performed for further comparison between the nomogram and the Breast Imaging Reporting and Data System (BI-RADS). The study has not yet been registered.

RESULTS

A total of 229 patients were included in the study after exclusion and follow-up. The overall malignant rate of NML breast lesions was 31.0%. Age, clinical symptoms, echo pattern, calcification, orientation, and Adler's classification were selected to generate the nomogram according to the results of the multivariable logistic regression analysis. The bias-corrected C-index and the AUC of our nomogram were 0.790 and 0.828, respectively. The DCA showed that our model had larger net benefits in a range from 0.2 to 0.7 when compared with the BI-RADS.

CONCLUSIONS

We developed a prediction model using a combination of age, clinical symptoms, echo pattern, calcification, orientation, and Adler's classification for malignant NML breast lesion prediction that yielded adequate discrimination and calibration.

A clinical model for predicting knee replacement in early-stage knee osteoarthritis: data from osteoarthritis initiative

BACKGROUND

Knee osteoarthritis (OA) progresses in a heterogeneous way, as a majority of the patients gradually worsen over decades while some undergo rapid progression and require knee replacement. The aim of this study was to develop a predictive model that enables quantified risk prediction of future knee replacement in patients with early-stage knee OA.

METHODS

Patients with early-stage knee OA, intact MRI measurements, and a follow-up time larger than 108 months were retrieved from the Osteoarthritis Initiative database. Twenty-five candidate predictors including demographic data, clinical outcomes, and radiographic parameters were selected. The presence or absence of knee replacement during the first 108 months of the follow-up was regarded as the primary outcome. Patients were randomly divided into derivation and validation groups in the ratio of three to one. Nomograms were developed based on multivariable logistic regressions of derivation group via R language. Those models were further tested in the validation group for external validation.

RESULTS

A total of 839 knees were enrolled, with 98 knees received knee replacement during the first 108 months. Glucocorticoid injection history, knee OA in the contralateral side, extensor muscle strength, area of cartilage deficiency, bone marrow lesion, and meniscus extrusion were selected to develop the nomogram after multivariable logistic regression analysis. The bias-corrected C-index and AUC of our nomogram in the validation group were 0.804 and 0.822, respectively.

CONCLUSION

Our predicting model provided simplified identification of patients with high risk of rapid progression in knee OA, which showed adequate predictive discrimination and calibration.

KEY POINTS

• Knee OA progresses in a heterogeneous way and rises to a challenge when making treatment strategies. • Our predicting model provided simplified identification of patients with high risk of rapid progression in knee OA.