Predicting life expectancy after geriatric hip fracture: A systematic review

Assessment of Surgical and Non-surgical Outcomes in Patients with Dementia and Hip Fractures

INTRODUCTION

The aging population is associated with increased osteoporosis and risk of hip fractures. Cognitive decline has recorded exponential increases in the last decades, with the rise in life expectancy.

MATERIAL AND METHODS

We conducted a prospective study on 65 patients over 65 years old associated with dementia and hip fractures. We used pre-and post-treatment variables such as age, type of fracture, type of treatment, Charlson Comorbidity Index (CCI), EQ-5D-5L score, and the Harris hip score (HHS) to assess pain, mobility, and mortality. We performed follow-ups at 6 months, 1 year, 2 years, and 3 years.

RESULTS

Patients with dementia typically arrive at the hospital without any previous analgesic treatment and receive lower doses due to poor pain recognition. The 6-month mortality rate was 48.22% and increased to 78.46% at 3 years. The best survival rates were in patients with bipolar prosthesis and Gamma nails, with a 3-year survival rate of 40% and 50%, respectively.

CONCLUSIONS

Patients with dementia have a higher mortality rate compared to cognitively intact patients and the treatment decisions require a multidisciplinary team and individualized recommendations for each patient, due to high surgical risk in the elderly.

Subtype consideration in hip fracture research: patient variances in inter- and intra-classification levels highlight the need for future research deliberation. A 2-years follow-up prospective-historical cohort

Current research on elderly patients with hip fractures often neglects specific subtypes, either grouping all fracture types or overlooking them entirely. By categorizing elderly patients based on fracture subtypes, we observed diverse baseline characteristics but found no discrepancies in measured outcomes. This emphasizes the need for caution in future research dealing with different or broader measured outcomes that were not covered by the scope of this research.

PURPOSE/INTRODUCTION

Existing research in elderly patients with hip fractures often overlooks the distinct subtypes or lumps all fracture types together. We aim to examine the differences between hip fracture subtypes to assess if these differences are meaningful for clinical outcomes and should be considered in future research.

METHODS

Patients above 65 years who underwent hip fracture surgeries during a three-year period were retrospectively reviewed. Cases were grouped based on fracture subtype: non-displaced femoral neck (nDFN), displaced femoral neck (DFN), stable intertrochanteric (sIT), and unstable intertrochanteric (uIT).

RESULTS

Among the 1,285 included cases, the nDFN-group had lower ASA scores (p = 0.009) and younger patients (p < 0.001), followed by the DFN-group (p = 0.014). The uIT-group had a higher proportion of female patients (72.3%, p = 0.004). Differences in preoperative ambulation status were observed (p = 0.001). However, no significant associations were found between fracture type and postoperative outcomes, including ambulation, transfusions, complications, reoperations, or mortality. Gender and preoperative ambulation status were predictors of mortality across all time frames. ASA score predicted mortality only within the first year after surgery. Age and gender were predictors of postoperative blood transfusions, while age and preoperative ambulation status were predictors of postoperative complications.

CONCLUSIONS

Variations in baseline characteristics of hip fractures were observed, but no significant differences were found in measured outcomes. This indicates that the hip fracture group is not homogeneous, emphasizing the need for caution in research involving this population. While grouping all types of proximal femur fractures may be acceptable depending on the outcome being studied, it's essential not to extrapolate these results to outcomes beyond the study's scope. Therefore, we recommend consider hip fracture subtypes when researching different outcomes not covered by this study.

Femoral shaft fractures in eldery patients - An epidemiological risk analysis of incidence, mortality and complications

OBJECTIVES

This work aimed at answering the following research questions: (1) What is the incidence of femoral shaft fractures in the geriatric population in the U.S.? (2) What is the rate of mortality, mechanical complications, nonunion and infection, and what are the associated risk factors?

STUDY DESIGN AND SETTING

In this cross-sectional study, femoral shaft fractures occurred between January 1, 2009, and December 31, 2019, were identified from Medicare records. Rates of mortality, nonunion, infection, and mechanical complications were calculated with the Kaplan-Meier method with Fine and Gray sub-distribution adaptation. Semiparametric Cox regression was applied with twenty-three covariates to determine risk factors.

RESULTS

Between 2009 through 2019 the incidence of femoral shaft fractures decreased by 12.07% to 40.8/100,000 inhabitants (p = 0.549). The 5-year mortality risk was 58.5%. Male sex, age over 75 years, chronic obstructive pulmonary disease, cerebrovascular disease, chronic kidney disease, congestive heart failure, diabetes mellitus, osteoporosis, tobacco dependence, and lower median household income were significant risk factors. The infection rate was 2.22% [95%CI: 1.90-2.58] and the union failure rate 2.52% [95%CI: 2.17-2.92] after 24 months.

CONCLUSION

An early assessment of individual patient risk factors may be beneficial in the care and treatment of patients with these fractures.

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

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

Methods

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

Results

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

Conclusion

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

Median survival following geriatric hip fracture among 17,868 males from the Veterans Health Administration

Background

The expected value of treatments for geriatric femoral neck fracture is influenced by the predicted duration of survival after injury. Specifically, total hip arthroplasty is more suited for patients likely to live long enough to reap its longer-term benefits. For predicting short- and medium-term survival, there are many tools available, but for longer-term survival prognosis the current literature is insufficient. Our hypothesis is that patient age at the time of injury correlates with median life expectancy and survival rates, and these values can anchor a prediction regarding a given patient's life expectancy. We therefore sought to determine median and fractional survival rates at 30 days, and 1, 2, 5 and 10 years after surgery for a large cohort of elderly patients with hip fracture as a function of age.

Methods

17,868 male patients, 65-89 years of age, treated surgically for hip fracture within the Veterans Affairs system were assessed. From this set, 10,000 patients were randomly selected, and their ages at surgery and death (if any) were recorded at least 10 years post-operatively. Median and fractional survival rates were recorded at 1 month and 1, 2, 5, and 10 years. The mathematical relationship between age and median survival was determined. All findings from the 10,000-patient cohort were compared to corresponding values of the remaining 7,868 patients, to assess the predictive power of the initial observations.

Results

The median survival rate for the entire cohort was 2.2 years, with 90.4% of the group surviving at 30 days. The percentage of the cohort surviving at 1, 2, 5 and 10 years after treatment was 64.5%, 52.3%, 27.1% and 8.9% respectively. Median survival was approximately (13 - (0.13 × age-at-time-of-surgery) years for patients of all ages.

Conclusions

Median survival after geriatric hip fracture can be accurately predicted by the patient's age at the time of injury. Median survival and fractional survival at key milestones can help estimate life-expectancy and thereby help guide treatment.

Surgical versus non-surgical treatment of humeral SHAFT fractures compared by a patient-reported outcome: the Scandinavian Humeral diAphyseal Fracture Trial (SHAFT)-a study protocol for a pragmatic randomized controlled trial

BACKGROUND

The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection, and nonunion. The purpose of the study is to compare patient-reported outcomes after surgical and non-surgical treatment for humeral shaft fractures.

METHODS

A pragmatic randomized controlled trial (RCT) is planned with two study groups (SHAFT-Young and SHAFT-Elderly). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder, and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analog score, Constant-Murley score including elbow range of motion, and anchor questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening, and peri-implant fracture), major adverse cardiovascular events, and mortality.

DISCUSSION

The SHAFT trial is a pragmatic multicenter RCT, that will compare the effectiveness of the main strategies in humeral shaft fracture treatment. This will include a variety of fracture morphologies, while taking the dilemmas within the population into account by splitting the population by age and providing the orthopedic society with an interval for early crossover surgery.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04574336 . Registered on 5 October 2020.