Outcome after conservatively managed intracapsular fractures of the femoral neck

Girdlestone resection arthroplasty for femoral neck fractures has poorer outcomes than hemiarthroplasty in frail patients with increased risk for arthroplasty-related complications: a retrospective case study of 21 patients

BACKGROUND AND PURPOSE

Hemiarthroplasty (HA) is the usual treatment for displaced femoral neck fractures (FNF) in elderly patients. Patients may be unsuitable for HA due to secondary conditions such as systemic infections or severe neurological conditions, which is why Girdlestone resection arthroplasty (GRA) may be an option. We aimed to determine (1) patient survival in matched patient groups treated with either GRA or HA and (2) functional outcomes.

PATIENTS AND METHODS

21 patients treated with GRA for FNF in a German university hospital were retrospectively reviewed (2015-2019). After matching for age and comorbidities, a control group of 42 HA patients was established. Patient survival was determined by a Kaplan-Meier analysis. The mean follow-up (FU) was 1.5 (0-4.4) years. Function at FU was documented using the modified Harris Hip Score (mHHS) and the National Hip Fracture Database (NHFD) mobility score.

RESULTS

The 1-month-mortality was 19% in the GRA group and 12% in the HA group; the 1-year mortality was 71% and 49%, respectively (P = 0.01). The mHHS at FU was lower in the GRA group than in the HA group (22 [range 0-50] vs. 46 [11-80]). 82% of patients in the GRA group were bedridden post-surgery as opposed to 19% in the HA group.

CONCLUSION

Patients with HA after FNF had higher survival and better functional outcomes when compared with GRA in matched patient groups. Considering this, GRA for FNF should be selected restrictively.

The impact of fixation type for intertrochanteric femoral fracture on patient survival

BACKGROUND

Intramedullary (IM) nail fixation for intertrochanteric fractures is potentially associated with improved postoperative function but may have an increased mortality risk compared to sliding hip screw (SHS) fixation. This study investigated postoperative mortality risk between surgical fixation type for intertrochanteric fracture in patients aged 50 years and older using linked data from the Australian Hip Fracture Registry and National Death Index.

METHODS

Descriptive analysis and Kaplan-Meier survival curves performed unadjusted analysis of mortality and fixation type (short IM nail, long IM nail and SHS). Multilevel logistic regression (AMLR) and Cox modelling (CM) performed adjusted analysis of fixation type and mortality following surgery. Instrumental variable analysis (IVA) was conducted to minimize the effect of unknown confounders.

RESULTS

The 30-day mortality was 7.1% for short IM, 7.8% for long IM and 7.8% for SHS fixation (P = 0.2). The AMLR demonstrated significant increase in 30-day mortality risk for long IM nail compared to short IM nail (OR = 1.2, 95% CI = 1.0-1.4, P < 0.05) but no significant difference for SHS fixation (OR = 1.1, 95% CI = 0.9-1.3, P = 0.5). No significant difference between groups and postoperative mortality was demonstrated by the CM at 30-days nor 1-year nor by the IVA at 30-days.

CONCLUSION

Despite a significant increase in 30-day mortality risk for long IM nail compared to short IM nail fixation in the adjusted analysis, this was not demonstrated in the CM nor IVA indicating the role of confounders influencing the regression findings. There was no significant association in 1-year mortality between long IM nail and SHS compared to short IM nail fixation.

Mobility and Hip Function Among Geriatric Patients With Displaced Neck of Femur Fractures Treated With Arthroplasty

Background

Neck of femur fractures result in impaired function for older people. Despite surgery, many patients experience a decrease in functional level and poorer health status after the injury. The objectives of this study were (1) to determine the short-term mobility and hip function of geriatric patients who underwent hip replacement surgery for a displaced neck of femur fracture in our local population and (2) to identify factors which affect the functional outcome of these patients.

Methods

Patients aged 60 years and above, who were admitted for neck of femur fracture from January 2017 to December 2020, and treated surgically with arthroplasty, were included. Information on patient demography, comorbidities, perioperative data, mobility, hip function and complications were retrospectively collected. Outcome measures used were independent ambulation and recovery of pre-fracture mobility at 1 year after surgery while hip function was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total, pain, stiffness, and physical function scores. Factors associated with these outcomes were analyzed.

Results

168 patients with a mean age of 75.2 (SD 8.4) years met the inclusion criteria. 32.1% of patients regained their pre-fracture mobility and 59.6% remained independent 1 year after surgery. Logistic regression analysis identified age, gender, surgical procedure, and time to surgery as significant contributors to recovery of pre-fracture mobility. Older age and increasing requirement for postoperative ambulatory aid resulted in worse WOMAC total and physical function scores. No significant differences were observed in patient-reported hip function between those who had a total hip arthroplasty and those who had a hemiarthroplasty.

Conclusion

Most geriatric patients with displaced neck of femur fractures did not regain pre-fracture mobility despite surgical treatment with arthroplasty.

Outcomes for non-operatively managed fracture neck of femur patients: A single-institution study

BACKGROUND

The majority of neck of femur (NOF) fractures are treated operatively in the United Kingdom. The literature reports the advantages of operative management for these patients. However, whilst a subset is treated non-operatively, there is currently no clear guidance for the selection and subsequent management of these patients. This study aims to explore the incidence, demographics, inpatient stay, use of imaging and outcomes of patients who have non-operatively managed NOF fractures.

METHODS

A 6-year retrospective review (2013-2019) of all non-operatively managed NOF fractures at a tertiary teaching hospital and major trauma centre was conducted. Electronic patient records, radiographs and National Hip Fracture Database (NHFD) data were used to obtain information. We noted demographic details, fracture classification, rationale for non-operative management, mortality, clinical frailty score (CFS), use of imaging and analgesia requirements. Patients who were repatriated or transferred to other sites for specialist surgery were excluded.

RESULTS

3.2% (99/3132) of NOF fractures were managed non-operatively. The two commonest reasons for non-operative management were either 'comfortable mobilisation' (n = 44) or 'patient frailty/medically unwell' (n = 50). 74% (37/50) of the patients in whom operative risk was thought to outweigh benefit died within the 30 days of admission and 1-year mortality for this group was 92% (46/50). Of the "comfortable mobilisation" subgroup only 18% (8/44) of this patient subgroup subsequently required surgical intervention for failed non-operative management. The 30-day mortality for this cohort was 6.8% with a 1-year mortality rate of 25% (11/44).

CONCLUSION

For a select group of patients whose fractures are stable enough to allow them to mobilise comfortably, non-operative management resulted in a 25% 1-year mortality rate and average length of stay of 10.1 days. This is comparable to statistics for overall NOF fracture management in the literature according to the NHFD January 2021 report. 82% of this group of patients were successfully managed without an operation indicating that there is a place for the consideration of non-operative management in a small select subgroup of hip fracture patients with minimally displaced, stable fractures. Further analysis is necessary to assess the functional outcomes of this subgroup, as well as the potential cost implications.

Mortality rates for hip fracture patients managed surgically and conservatively in a dedicated unit in Singapore

INTRODUCTION

At our hospital, an unusually high proportion of patients and families opted for conservative management of hip fractures. This study aimed to compare the mortality rates of patients with hip fractures treated conservatively to that of operatively managed patients in a dedicated hip fracture unit.

MATERIALS AND METHODS

Retrospective analysis was done for patients who were treated for hip fractures between January 2015 and October 2017 in a Hip Fracture Unit at a tertiary hospital. Patients were managed non-operatively or surgically after discussion with the multi-disciplinary team.

RESULTS

233 patients were treated conservatively and 781 underwent operative management for hip fractures. Patients managed non-operatively had a higher inpatient, 30-day and 1-year mortality rates. Inpatient mortality was 6.01% for conservatively managed compared to 0% for operative management. 30-day mortality for conservatively managed patients was 8.58% as compared to 0% for operatively managed patients, and 1-year mortality was 33.05% as opposed to 8.96%. There was an association seen with the type of management of hip fractures and that of inpatient death (p = 0.000), death in 30 days (p = 0.000) and death in 1 year (p = 0.000). The type of management was a predictive factor in 1-year mortality (p = 0.000). The average number of co-morbidities in conservatively managed patients was 5.2 compared to surgically managed patients of 4.0. Conservatively managed hip patients had a higher prevalence of stroke, chronic kidney disease and ischemic heart disease. Complications during hospital stay were comparable for both groups. The mean length of hospital stay was similar for both groups.

CONCLUSION

Surgical intervention for hip fractures is associated with lower inpatient, 30-day and 1-year mortality rates. However, patient co-morbidities and pre-morbid conditions should also be considered.

LEVEL OF EVIDENCE

IV.

Outcomes after perioperative SARS-CoV-2 infection in patients with proximal femoral fractures: an international cohort study

OBJECTIVES

Studies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with perioperative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multivariate analysis.

SETTING

Prospective, international, multicentre, observational cohort study.

PARTICIPANTS

Patients undergoing any operation for a proximal femoral fracture from 1 February to 30 April 2020 and with perioperative SARS-CoV-2 infection (either 7 days prior or 30-day postoperative).

PRIMARY OUTCOME

30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality.

RESULTS

This study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68 to 3.13, p<0.001), age >80 years (OR 1.60, 95% CI 1.1 to 2.31, p=0.013), preoperative diagnosis of dementia (OR 1.57, 95% CI 1.15 to 2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18 to 2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06 to 2.48, p=0.025). Mortality at 30 days was lower in patients with a preoperative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42 to 0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220) or type of anaesthetic given (p=0.787).

CONCLUSIONS

Patients undergoing surgery for a proximal femoral fracture with a perioperative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with individualised medical and anaesthetic care, including medical optimisation before theatre. Careful preoperative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups.

TRIAL REGISTRATION NUMBER

NCT04323644.

Effect of Nonsurgical Versus Surgical Management on Geriatric Hip Fracture Mortality of Hispanic-American Male Veterans

Introduction

The effect of surgical vs nonsurgical management on hip fracture mortality of Hispanic-American male veterans has not been rigorously studied. Hence, we examined the mortality and life expectancy effect of nonsurgical vs surgical management after hip fracture in a geriatric Hispanic-American male veterans’ population.

Material and Methods

This was a retrospective cohort study of Hispanic-American male veterans who were 65 years of age or older and suffered a femoral neck or intertrochanteric fracture from January 2008 to December 2015. Analysis between a surgical cohort (cannulated screw fixation, hemiarthroplasty, total hip arthroplasty, or cephalomedullary nail) and a non-surgical cohort was performed. In-hospital, 30-day, one-year, and two-year mortality were compared between both groups.

Results

Out of 268 patients with hip fracture, 159 (59.2%) were treated surgically and 109 (40.8%) non-surgically. The overall in-hospital (9.2% vs 1.9%, P = .009), 30-day (17.4% vs 5.0%, P = .002), one-year (48.6% vs 23.3%, P < .001), and two-year (63.3% vs 36.5%, P < .001) mortality rate was found to be higher for the nonoperative group. The average life expectancy of the nonoperative cohort was significantly shorter than those who were managed surgically (216 days vs 260 days, P < .001).

Discussion and Conclusion

This study shows a higher mortality rate and lower life expectancy in geriatric male patients who were treated nonsurgically in a Veterans Health Affair hospital facility that mostly serves Hispanic-American veterans. Our results provide an expansion to the findings of other geriatric studies on hip fracture with focus in a Hispanic-American veteran male population.

Mortality Following Hip Fracture Surgery During COVID-19 Pandemic Compared to Pre-COVID-19 Period: A Case Matched Cohort Series

Introduction:

This study aims to report on clinical outcomes and 30-day mortality of patients with neck of femur fracture during COVID-19 pandemic and compare the outcomes in a cohort during the same period prior to the pandemic.

Material and Methods:

The study included 66 patients with hip fracture over the age of 60 years, presented between 1st March and 15th May 2020 and matched with the patients with hip fractures (75 patients) managed during the corresponding period in 2019 as control. Data was collected on demographics, comorbidities, COVID-19 status, procedures and mortality and complications.

Results:

Thirty-day mortality following hip surgery was 13.6% during COVID-19 pandemic with all the mortalities in patients with ASA Grade 3 and 4. Mortality was considerably high for intracapsular fracture (20%) but highest in cemented hemiarthroplasty (20%). One third of the hip fractures operated in COVID-19 designated theatre died within 30 days of surgery. Thirty-day mortality rate for COVID-19 positive hip fracture patients were 55.5%. There has been higher 30-day mortality for hip surgeries during COVID-19 pandemic with positive correlation between patient’s COVID-19 test status and 30-day mortality following hip surgeries.

Conclusion:

There is strong association between 30-day mortality and the designated theatre (Clean/COVID) where the patients were operated on with higher mortality for intracapsular neck of femur fractures with significant mortality associated with cemented hemiarthroplasty particularly among symptomatic or COVID-19 positive patients. Therefore, adoption of a multidisciplinary approach is recommended to optimally balance the risk-benefit ratio for planning of management of hip fractures while considering patient’s peri-operative outcomes.

Nonoperative hip fracture management practices and patient survival compared to surgical care: an analysis of Estonian population-wide data

A notable proportion of hip fracture patients receive nonoperative management, but such practice is seldom analysed. Although highly variable reasons underpin hip fracture nonoperative management, none of these practices conclusively outweigh the superiority of operative management. Nonoperative management should be only considered when surgery is not an option.

PURPOSE

Reasons underpinning hip fracture (HF) nonoperative management (NOM) are seldom analysed. This study aims to identify the reasons behind NOM and assess the accuracy of these decisions using these patients' survival compared with those treated with operative management (OM).

METHODS

This is a retrospective cohort study based on population-wide administrative health data, including patients aged ≥ 50 with an index HF diagnosis between January 2009 and September 2017. NOM patients were subgrouped according to their expected prognoses, and their survival up to 36 months was compared with those treated surgically.

RESULTS

From a total of 11,210 included patients, 6.8% (766) received NOM. Varying reasons lead to NOM, dividing them further into five distinct subgroups: (I) 46% NOM decision due to poor expected prognosis with OM; (II) 29% NOM decision due to poor expected prognosis for mixed reasons; (III) 15% NOM decision due to good expected prognosis with NOM; (IV) 8.0% NOM decision due to patient's refusal of OM; and (V) 1.3% NOM decision due to occult HF. Only poor prognosis and patients who refused OM (I, II, IV) had worse survival than OM patients. However, a relatively high proportion of the poor prognosis patients survived 1 year (29%).

CONCLUSION

Although there was high variability in reasons underpinning HF NOM, none of these practices conclusively outweigh OM's superiority. NOM should be considered with utmost care and only for patients for whom OM is out of the question - well-defined medical unfitness or carefully considered refusal by understanding the increased mortality risk.

Outcome of nonoperative treatment for hip fractures in elderly patients: A systematic review of recent literature

Many studies have shown that surgical management still leads to the best outcomes in elderly patients with hip fractures, with some studies showing non-inferiority of nonsurgical management as compared to surgery in fragility fractures. Evidence-based guidelines on whether to operate on these patients are lacking. A systematic literature search was conducted regarding outcomes of nonoperatively treated hip fractures in elderly patients with various comorbidities. A structured literature review of multiple databases (PubMed, Web of Science, EMBASE, and Cochrane library) referenced articles from 2000 to 2020. A total of 596 patients from 11 published studies were identified. Mean age was 83.3 years. Overall 328 (69.7%) complications occurred in 470 patients with nonsurgical treatment. Pneumonia and urinary tract infections were the most common complications which occurred in 53 (16.1%) and 46 (14.0%) patients, respectively. Hip fracture patients who were treated nonoperatively had a higher in-hospital (17.1% vs. 4.4%; p < 0.001), 30-day (31.4% vs. 10.2%; p < 0.001), and 1-year (48.5% vs. 19.9%; p < 0.001) mortality compared to a matched group of operatively treated patients (n = 1464). Of the 110 patients whose reported cause of death was nonoperative care, 44 (40%) was due to pneumonia. Patients with nonoperative treatment following hip fracture were associated with substantially higher complication and mortality compared with patients who were treated operatively. Our study will help health-care providers and caregivers to enable more informed decision-making for families and patients confronted with a hip fracture.

Femoral Neck Fracture in a Hemodialysis Patient after Liver Transplantation: A Case Report

Background

Surgical treatment of femoral neck fractures is usually performed as an urgent procedure so that restoration of the ability to stand and walk can be achieved as quickly as possible. However, orthopedic surgeons need to be aware of undertreated or untreated diseases in their patients. Organ transplant recipients require immunosuppressive agents and steroids postoperatively. Hemodialysis patients also exhibit immunological deterioration and are included among immunocompromised patients. We report a case in which conservative treatment was chosen for a hepatic transplant recipient on hemodialysis who suffered a femoral neck fracture because signs of inflammation of unknown etiology were intermittently seen.

Case

The patient was a 70-year-old man who had undergone liver transplantation from a living donor as treatment for hepatocellular cancer and hepatic failure with cirrhosis. Dialysis for end-stage renal failure was initiated at approximately 1 year postoperatively. Cyclosporine was administered as an immunosuppressive agent. The patient subsequently fell off a bicycle and was unable to walk because of right hip pain. He was brought to our hospital by ambulance, and a right hip radiograph revealed a femoral neck fracture. His white blood cell count and C-reactive protein levels were intermittently elevated with unknown etiology. Conservative treatment was finally adopted, although a bipolar hip arthroplasty was planned. At 5 months after the injury, the patient was able to walk alone in a stable manner using a pair of crutches and was discharged.

Discussion

Conservative treatment for a femoral neck fracture, which generally requires surgery, may be acceptable in organ transplant recipients on hemodialysis.

Prognosis of nonoperative treatment in elderly patients with a hip fracture: A systematic review and meta-analysis

OBJECTIVE

Hip fractures in frail elderly patients are associated with significant mortality and morbidity. Surgery remains the predominant treatment of choice, despite the poor prognosis. Limited research has been done with regards to nonoperative management of frail elderly patients with a hip fracture and therefore the natural course is relatively unknown. This systematic review aimed to provide an overview of the prognosis of nonoperative management in frail elderly patients with a hip fracture in terms of mortality, complications, mobility, and quality of life (QoL).

DESIGN

A systematic review of the literature was conducted in PubMed, EMBASE, and Cochrane Central. In addition, a meta-analysis was performed. The primary outcome measurement was 30-days mortality.

RESULTS

A total of 4,318 studies were screened. In total eighteen studies matched the eligibility criteria; with low to moderate quality. Approximately two-thirds of the patients were managed nonoperatively due to medical reasons and one-third due to non-medical reasons. Pooled mortality rates after 30 days, six months and one year were 36%, 46%, and 60%, respectively. 33% of the patients developed in-hospital complications. At six months post trauma, 9.6% of the patients were able to mobilize. Data on quality of life (QoL), functional outcome, pain, comfort during nursing care, and costs were not reported.

CONCLUSION

Nonoperative management of frail elderly patients with a hip fracture is associated with a poor prognosis. Heterogenous study cohorts and limited outcomes were reported. Current literature shows a lack of evidence of the true prognosis of nonoperative management of frail elderly patient with a hip fracture and a limited life expectancy. Results of this review can be used to aid decision making and improve expectation management.

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.

Outcomes of an accelerated nonsurgical management protocol for hip fractures in the elderly

The majority of hip fractures in elderly patients are managed surgically with superior outcomes. However, for patients who refuse surgery or are deemed medically unfit, traction used to be the mainstay of nonsurgical treatment, which is associated with prolonged hospitalization and inpatient complications from immobility. This study, therefore, aims to evaluate the outcomes of an early wheelchair mobilization protocol as an alternative nonsurgical treatment option. This is a retrospective study of 87 elderly patients who were managed nonsurgically for their hip fractures over a 1-year period. The accelerated rehabilitation protocol did not have them on traction but were instead mobilized with assistance as soon as possible after admission. Variables collected electronically include patient demographics, fracture characteristics, inpatient mobilization milestones, inpatient complications, Modified Functional Ambulation Classification (MFAC), Modified Barthel Index (MBI) scores, and radiological findings. Patients who were younger, could sit up earlier and had a shorter length of stay, were able to ambulate better at 6 months ( p value < 0.05). Patients with femoral neck fractures and shorter length of stay had better MFAC scores. A total of 58% of patients with radiological follow-up had displacement of their fractures with age, type of fracture, and length of stay as predictors ( p value < 0.05) The Charlson's score, day to sitting up, and day to transfer affect fracture healing ( p value < 0.05). The mean length of stay was 17 days and the 1-year mortality was 18%. Surgical therapy remains the preferred choice of management for patients with hip fractures. Early wheelchair mobilization leads to a shorter length of stay compared to traditional traction methods and comparable 1-year mortality rates with operative management. Despite this, complication rates remain high and only 48% of patients achieved ambulation by 1 year, with healing in only 24% of fractures.

Nonoperative Geriatric Hip Fracture Treatment Is Associated With Increased Mortality: A Matched Cohort Study

OBJECTIVE

To report the mortality data and life expectancy of geriatric hip fracture patients who underwent nonoperative management and compare that with a matched operative cohort.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS

Geriatric (65 years of age and older) femoral neck or intertrochanteric fracture (OTA/AO 31A and 31B) patients.

INTERVENTION

Operative treatment with either arthroplasty, cannulated screws, sliding hip screw device, or cephalomedullary nail compared with nonoperative cohort.

MAIN OUTCOME MEASUREMENTS

In-hospital, 30-day, and 1-year mortality.

RESULTS

Two hundred thirty-one patients, comprising 154 operative and 77 nonoperative patients, were compared. There were no significant differences among age, sex, fracture location, Charlson Comorbidity Index, preinjury living location, dementia, and history of cardiac arrhythmia between the 2 cohorts. Nonoperatively managed patients were found to have a significantly higher percent in-hospital (28.6 vs. 3.9; P < 0.0001), 30-day (63.6 vs. 11.0; <0.0001), and 1-year (84.4 vs. 36.4; P < 0.0001) mortality. The mean life expectancy after a hip fracture for the nonoperative cohort was significantly shorter than the operative group (221 vs. 1024 days; P < 0.0001).

CONCLUSIONS

Nonoperatively treated hip fracture patients had an 84.4% 1-year mortality that was significantly higher than a matched operative cohort. Our results demonstrate the bleak overall prognosis for nonoperatively treated geriatric hip fractures as well as the associated reduction in mortality with surgical treatment. Our findings offer helpful information by providing updated mortality data when discussing nonoperative hip fracture management with patients and their family.

LEVEL OF EVIDENCE

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

Palliative Care in the Hip Fracture Patient

Introduction:

Older patients with hip fracture have a 20% to 30% mortality rate in the year after surgery. Nonoperative care has higher 1-year mortality rates and is generally only pursued in those with an extraordinarily high surgical risk. As the population ages, more patients with hip fracture may fall into this category. The orthopedic surgeon is typically the main consultant responsible for deciding between surgery and conservative management, and the reasoning behind one decision over the other is often poorly understood. We undertook a review to determine decision-making tools for surgery in high-risk patients with hip fracture.

Materials and Methods:

A review was conducted using PubMed to determine articles published using the terms palliative care, conservative care, nonoperative, hip fracture, orthopedic procedures, fracture fixation, and surgery. Our search resulted in 13 articles to review. These were further screened to determine tools for use in surgical decision-making.

Results:

Several potential decision-making tools were found in our search. The potential tools to identify patients who would benefit from nonoperative treatment included the Palliative Performance Scale for severe dementia, the Lawton Instrumental Activities of Daily Living and Katz Activities of Daily Living scales for prefracture immobility, a combination of clinical signs and laboratory tests to determine risk of imminent death, and the Charlson Comorbidity Score for additional serious comorbidities. No tools have been prospectively tested in a clinical setting.

Discussion:

Evaluation of each patient using a variety of decision making tools should help the orthopedic surgeon determine which patients would be better suited to non-operative management. After determining the benefit of non-operative care, they must effectively allow the fracture to heal while ameliorating pain. Palliative care physicians can fulfill this role by providing support and symptom relief.

Conclusions:

Surgical decision-making for hip fracture repair in the elderly patients is not straight forward. Several tools may be helpful to the surgeon in determining who may be better suited for nonoperative care or a palliative care referral. Prospective data do not exist in these decision-making tools.

Charlson Comorbidity Index Predicts 5-Year Survivorship of Surgically Treated Hip Fracture Patients

Introduction:

This study aims to assess the correlation of the age-adjusted Charlson comorbidity index (ACCI) with 5-year mortality in a surgically treated hip fracture population.

Materials and Methods:

A retrospective analysis was performed on 1057 patients aged 60 years and above who underwent surgery for hip fracture with a minimum of 5-year follow-up (92.2% 5-year follow-up rate) in a tertiary hospital. Manual review of patients’ electronic hospital records was performed to record demographic data, comorbidities, and length of stay. Mortality data were extracted from the hospital’s electronic medical records and corroborated with the National Electronic Health Record.

Results:

Of the 1057 patients, 283 (26.8%) were male. The majority of patients were 80 years of age and above (42.5%), with the oldest patient operated on age 102 with a mean age of 77.8 (8.6) years. Four hundred eighteen (39.5%) patients sustained extracapsular intertrochanteric fractures. The mean follow-up duration was 8 years and 3 days with an overall survivorship of 37.2%. A multiple regression model constructed with ACCI, age, gender, and fracture pattern demonstrated satisfactory predictive ability with a concordance statistic of 0.68. Patients with a higher ACCI category (≥6) had an increased 5-year mortality rate (41.8%) with an odds ratio of 13.6 (6.7-31.8, P < .001) compared to those with an ACCI category of 3 and below (89.3%).

Discussion:

The study demonstrates that ACCI correlated with 5-year mortality after surgical treatment of hip fracture. This information is pertinent in the counseling of patients with regard to their midterm survival following hip fracture surgery and may inform policy makers of the varied midterm survival rates in patients with differing ACCI scores and educate the allocation of health-care resources.

Conclusion:

The ACCI correlates with 5-year mortality after surgical treatment of hip fracture.

Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)

BACKGROUND

Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation.

DESIGN

Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study.

SETTING

Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge.

PARTICIPANTS

Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area.

INTERVENTIONS

Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers.

RESULTS

Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported.

CONCLUSIONS

Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22464643.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

Blood loss in trochanteric fractures: multivariate analysis comparing dynamic hip screw and Gamma nail

INTRODUCTION

Anaemia in patients with trochanteric fracture is associated with increased morbidity and mortality and it is an independent risk factor for functional mobility of patients. Several authors have reported the blood loss following operative treatment comparing different fixation systems but few authors have evaluated many associated variables that could influence the perioperative blood loss.

PURPOSE

To evaluate the blood loss in patients that had their trochanteric fracture stabilized with dynamic hip screw (DHS) or Gamma nail. Multivariate analysis of different variables that can influence blood loss was carried out (type of fracture, antiaggregant or anticoagulant therapy, time to surgery). The hypothesis was that there is no difference in terms of blood loss in patients with trochanteric fracture treated with DHS or Gamma nail considering all these variables.

MATERIALS & METHODS

Perioperative blood loss was evaluated in 417 consecutive patients treated for trochanteric fracture with DHS or Gamma nail between January 2010 and March 2013. The perioperative blood loss was calculated using the Lisander formula modified by Foss-Kehlet based on pre- and post-operative haemoglobin values and transfusion rates. Univariate and multivariate analysis were performed integrating the following variables: type of fracture (A1 vs A2), antiaggregant/anticoagulant therapy vs no therapy, time to surgery (<24 vs >24 hours from trauma), type of implant (DHS vs Gamma nail).

RESULTS

A significant blood loss (p <0.05) was observed between A1 and A2 fracture types (1247ml vs 1796.7ml), antiaggregant/anticoagulant therapy and no therapy (1592.7ml vs 1470.2ml), time-to-surgery <24 and >24 hours from trauma (1584.4ml vs 1323.9ml), DHS and Gamma nail (894.7ml vs 1720.6ml). At multivariate analysis, in the A1 fracture groups the DHS showed a significant lower blood loss compared to Gamma nail (p < 0.05).

CONCLUSIONS

According to the perioperative blood loss, DHS should be used in A1 fractures while Gamma nail can be taking in account for the unstable A2 fractures.

Do we need orthogeriatrics in Poland? Changes in the age structure and location of hip fractures

Background

Patients with hip fractures present a great challenge for surgeons due to multimorbidity, polypharmacy as well as difficulty in communicating. These could be attributed to a recent trend in the aging patient population (80 years and older) as compared to the past. The aim of this study is to analyze age structure and location in male and female patients’ population with hip fracture over 50.

Materials and methods

Hospital records between 2005 and 2014 with ICD-10 codes S72,0, S72,1 and S72,2 were included in the analysis. All fractures occurred in citizen aged 50 years and over living in the district of Tarnowskie Góry and the city of Piekary Śląskie in Poland.

Results

Within the study period, 1258 hip fractures were registered. The mean age of the patients was higher every year, starting from 77.27 ± 9.52 in 2005 to 80.80 ± 9.65 years in 2014 (p < 0.01). The average age also increased in both gender groups from 73.85 ± 8.30 to 77.89 ± 9.52 years in male and from 78.14 ± 9.66 to 81.98 ± 9.49 years in female, respectively. The median age value was changed from 78.00 to 83.00 years in the total population. We noted a significant increase in female with trochanteric fracture; however, the level of neck fracture was almost the same. In men, crude rates for both trochanteric and cervical fractures slightly increased.

Conclusions

As the age of patients increases, fractures were shown to be more complicated. Given the scale of the phenomenon and its determinants, we emphatically conclude orthogeriatrics is needed in Poland.